Diagnosing President Donald Trump’s alleged mental disorder has become a popular pastime, not just among mental health professionals but also among politicians, journalists, pundits, comedians, and ordinary people gathered at coffee breaks. Trump’s consistently bizarre sayings and doings have triggered a bill to establish a commission “on presidential capacity” and a suggestion that the president be removed from office via the 25th Amendment on the grounds that he is mentally unfit to be president.

A recent Time poll indicates that many Americans think that Trump is unfit for office. I also believe we made a terrible mistake electing him. But Trump’s disagreeable traits in no way indicate that he is mentally ill. Instead, they reveal him to be the ruthless self-promoter he has always been, now poorly cloaked in fake populist clothing.

Before I go any further, you should know that I am a lifelong political inactivist, shamefully missing in action from the tumultuous political events of the last 50 years. It took the travesty of a Trump presidency to get me fully engaged.


Confusing Trump’s behavior with mental illness unfairly stigmatizes those who are truly mentally ill, underestimates his considerable cunning, and misdirects our efforts at future harm reduction. And the three most frequent armchair diagnoses made for Trump — narcissistic personality disorder, delusional disorder, and dementia — are all badly misinformed.


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Trump is an undisputed poster boy for narcissism. He demonstrates in pure form every single symptom described in the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for narcissistic personality disorder, which I wrote in 1978. But lots of successful people are extremely narcissistic without being mentally ill — think most celebrities, many politicians, and a fair percentage of writers, artists, lawyers, doctors, and professors. To qualify for narcissistic personality disorder, an individual’s selfish, unempathetic preening must be accompanied by significant distress or impairment. Trump certainly causes severe distress and impairment in others, but his narcissism doesn’t seem to affect him that way.

My long experience with psychiatric diagnosis has taught me a recurring and painful lesson: Anything that can be misused in the DSM will be misused, especially when there is an external, nonclinical reward for doing so. We decided to include narcissistic personality disorder in the DSM-III 40 years ago purely for clinical reasons. We never imagined it would be used as ammunition in today’s political warfare.

It’s also important to note that narcissistic personality disorder holds a fragile place in the diagnostic universe. It came quite close to being eliminated when the fifth edition of the DSM was published in 2013, and will be excluded from the forthcoming revision to the International Classification of Diseases, a set of codes used by physicians and other health care providers to classify diagnoses, symptoms, and procedures.

Some presidential observers base their diagnosis of delusional disorder on Trump’s being an avid consumer and creator of conspiracy theories. He learned his art from a master: his mentor, Roy Cohn, who was the brains behind Sen. Joseph McCarthy’s attempt to control our government through Communist witch hunts in the 1950s. Conspiracy theorists are a dime a dozen, while those with delusions are more rare. Up to half of all Americans believe in strange conspiracy theories. They are wrong, but not delusional. Having a delusion means being a minority of one.

Confusing Trump’s behavior with mental illness unfairly stigmatizes those who are truly mentally ill, underestimates his considerable cunning, and misdirects our efforts at future harm reduction.

Also keep in mind that Trump’s conspiracy theories have been, and continue to be, essential to his political success. His long-standing claim that President Obama was not born in the United States launched Trump’s presidential run, his “crooked Hillary” claims helped win him the election, and “fake news” holds his base in his thrall. Trump is crazy like a fox.

The dementia diagnosis is based on the supposed poverty and perseveration in Trump’s current speech patterns compared to his earlier ones. I would attribute this to the number of stump speeches Trump has given. Abraham Lincoln could find creative ways of repeatedly saying the same thing, but Trump has never achieved Lincoln’s eloquence. He uses the same words over and over again because they successfully work up the crowd.

Convincing proof that Trump is not demented is his undiminished creative and canny skills at blaming, bare-knuckle political fighting, and self serving.

Buried in the noisy debate about Trump’s mental health is the misinformed and noxious assumption that mental illness somehow automatically disqualifies someone for high leadership position. If this were policy, Abraham Lincoln and Winston Churchill both would have been lost to history due to their battles with depression.

Assigning psychological disorders to Trump is not only wrong but futile. Vice President Pence, the Cabinet, and Congress would never invoke the 25th Amendment because it would amount to political suicide for everyone concerned and for the Republican Party. Any psychological fitness exam would also be inherently biased and unreliable. My guess is that Trump will eventually be removed from power, but via the appropriate investigative and political process, not a psychiatric evaluation.

I believe that Trump is a mirror of the American soul, a surface symptom of our deeper societal disease. He may not be crazy, but we certainly were for electing him. We mustn’t waste this Trumpian dark age. If we don’t learn from it, we will keep making the same mistakes.

Allen Frances, M.D., was chair of the Department of Psychiatry and Behavioral Sciences at Duke University and also chaired the task force responsible for revising the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. He is the author of “Twilight of American Sanity: A Psychiatrist Analyzes the Age of Trump” (William Morrow, September 2017).

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  • Thanks to the President’s insatiable need to be seen and heard daily, the entire world has had the opportunity to psychoanalyze him in depth.

    Pundits and experts have been spinning their words to support their diagnostic opinion. To resolve this dilemma, please fill in this sentence’s blank. Everyone will be correct.

    Donald Trump has a severe _______________ disorder making him unfit to perform the duties of President of the United States.

  • Subjective observation and collection of symptoms may seem very convincing. But how was this information acquired? Have you inquired about insight or lack of insight. Are you sure this isn’t the result of another mental disorder or medical illness? Are you sure this isn’t the result of medication or a substance of abuse? Do you have any neuroimaging. Do you have any family history. Are there recurrent thoughts, urges, or images that at sometime have felt to be unwanted or ntrusive. Do they cause anxiety or distress. Are there repetitive behaviors or mental acts that the individual feels driven to perform in response to the thoughts, urges, or images or according to rules that must be applied rigidly. Are these behaviors or mental acts intended to prevent or reduce anxiety or distress? Or are they clearly excessive? Do they care she distress or impairment in important areas of functioning?

  • Evidence of significant cognitive decline. Documentation by standardized neuropsychological testing. Any neuro-imaging? Many people may have personality styles or traits but not a personality disorder. You will need more substantiating confirmation before a suspected diagnosis is an actual diagnosis.

  • Some psychiatrist you are. I suppose you wrote the Manuel yourself, a narcissistic personality me thinks. I don’t need to tell me he is deranged and has dementia.

  • Let me ask this….. if you knew someone who washed their hands incessantly, checked the stove or the lock 20 times before being able to walk away, arranged items on a table or desk over and over again, and/or had rituals that had to be completed at certain times or in certain ways and if they got screwed up had to be started all over again (among the many other possibilities)… how long would it take you to decide that it was pretty likely that person had obsessive-compulsive disorder? Or would you need a psychiatrist’s diagnosis?

    The latter is always preferable. But sometimes things are blindingly obvious.

  • Being appalled by someone’s behavior and making a psychiatric diagnosis is not the same. Making a psychiatric diagnosis requires more than hearing in the media behaviors that could be checked off on a Diagnostic checklist. But I’m sure you knew this. You cannot just listen to a journalist presenting to you subjective
    interpretations of reported stories.

  • It is now March 2019 and I am wondering if your opinion is the same as it was when you wrote this….I am appalled by this man’s behaviors and they all seem to point to progressive dementia…..your thoughts???

  • Without psychotropic treatment the patient complains of demons and is planning to commit suicide. With psychotropic treatment he does not complaing of demons and is not planning to commit suicide. In both cases he has no job, no family, and impaired self care. He has “3 hots and a cot”. He enjoys watching tv and smoking cigarettes. He says his life is fine and has no complaints. Success? There is no law against complaining of demons. There is no law of declining psychotropic treatment or psychosocial treatment.

    • Szasz said that if someone came to him and claimed to be Jesus, he would respond, “Congratulations!” Everyone lies, but some lies are so offensive to the social norm they will get you a diagnosis. (This is where Trump comes in.)

      If you enjoy drugs whose use is not approved by government, you earn a mental illness diagnosis. You are not allowed to enjoy marijuana, opioids, cocaine, amphetamine, etc. There is a “law of declining psychotropic treatment or psychosocial treatment.” You can, and millions are, forcibly drugged and required to attend “therapy” against their will. You can even still be coercively subject to electroconvulsive therapy.

  • The patient hears demons telling him to jump in front of a bus. The patient has significant impairment in work, interpersonal relations, self care or ther important areas of functioning. His sensorium is clear. His speech is clear and coherent. Any question he has a mental disorder, or mental illness if you prefer? Certainly psychotropic treatment has is I ndicated. Also social skills training. How to decide his quality of life is satisfactory. What if he just smokes cigarettes and watches tv, but isn’t complaining of demons telling him to commit suicide. What more needs to be done to achieve desired “quality work of life”?

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