D

iagnosing 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.

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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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  • I believe that over-reliance on clinical diagnosis is not helpful. The emerging patterns of thought from the President of the United States are very worrisome. His irrational, poorly-thought-out, delusional, self-absorbed statements and actions have risen to a level requiring serious consideration of impeachment.

  • The topic itself and discussion following are wholly inappropriate for a “science-based” magazine. This serves merely as the spouting of political rhetoric from a disgruntled group. I believe many of the same sentiments could be discussed relative to the last president, but were not?

    It is apparent more editorial overview is warranted

  • Dr Frances’ misinformed believe that a person’s illness has to cause them clinical distress before it can be called a mental illness is silly. If that were the case, Jack the Ripper would not have been called mentally ill, or Charles Manson.
    It doesn’t take a self absorbed doctor who calls himself an “expert” to diagnose Trump, it only takes common sense. Apparently that is something Dr Frances is lacking.

    • The surprise is that you didn’t declare Dr. Frances to be mentally ill.

      The amusing irony is that Frances was, by virtue of being lead editor of DSM-IV, arguably the most powerful psychiatrist in the world. (DSM is the “psychiatric bible,” which determines what is “mental illness” and what is not.)

      That he lacks common sense I agree, but that’s because he admits on the one hand that psychiatric diagnosis is nonsense, while engaging in that diagnosis on the other.

  • Trump is Not a mirror of the American soul. The general consensus is not mirroring their lives in the American era of the years gone by. Look back at the men in America – in the early 1950’s. There is when a man like Trump ruled the roost, made pathetic comments derogatory of women, would not tolerate racial rights. THAT is why he is wrought, rather vehement to make America ‘great again’. He wants to make ‘his’ America and his life the 1950’s Again. He is stranded in a Time that he lives in his mind. * An eye opening read is found in an article by Tony Schwartz in the May 10th Washington Post publication. https://www.washingtonpost.com/posteverything/wp/2017/05/16/i-wrote-the-art-of-the-deal-with-trump-his-self-sabotage-is-rooted-in-his-past/?utm_term=.5bd13efe0c42

  • Disagree that Trump’s narcissism doesn’t “cause him distress”; his uncontrollable need to respond to even the smallest perceived slight from detractors far and wide is one of the things that has derailed his Presidency thus far. Rewarding or punishing his underlings based on their perceived loyalty takes precedence over political or practical considerations, including the effectiveness of the people involved, or potential impacts on Trump’s agenda and, ultimately, his legacy. And Vanity Fair editor Graydon Carter, who famously labeled Trump a “short-fingered vulgarian” in Spy magazine back in the early ’90s, has stated that he _still_ receives periodic letters from Trump, containing publicity shots with Trump’s hands circled in gold Sharpie, and messages like, “See? Not so small!” Trump’s narcissism not only causes him distress, it consumes him, and may very well define him – and his Presidency.

    • I agree with you. Dr Frances is not the “expert” he thinks he is. If Dr Frances assessment were true, then Jack the Ripper and Charles Manson would not be considered mentally ill.

    • People are labeled “mentally ill” because — and only because — their behaviors are bad or disapproved of. The so-called mentally ill have included homosexuals, women who don’t achieve orgasm (anorgasmic), women who enjoy sex too much (nymphomania), slaves who wanted to escape (“drapetomania”), epileptics, people who masturbate, and scores of other healthy people. In the past people would have been labeled “heretics,” and “witches,” but medicine is now much more powerful than religion in the West, so religious stigmas have been replaced by pseudomedical stigmas. For many years psychiatry has been aggressively trying to replace morality and religion with medicine. Psychiatry fulfills the age-old need to scapegoat and persecute unwanted persons that used to be left to religion. It is pretended that psychiatry is scientific, but no “mental illness” has a proven physiologic or biochemical basis, and if one has been found (as in the case of epilepsy), it is no longer considered a mental illness and is no longer treated by psychiatrists (or allied professionals).

      Charles Manson and Jack the Ripper are/were evil people, and there is zero evidence that they suffered from illnesses. It’s particularly amusing that Jack the Ripper gets a psychiatric diagnosis since nobody even knows for certain who he was. But then no proof is required when making a diagnosis of “mentally ill,” and that proves the point made by Dr. Frances, and much more cogently by Thomas Szasz.

  • So you are doing the “appeal to authority” fallacy as your headlie?

    Well; You are NOT the only person with knowledge about mental health-care in the world..

    and you are misappropriating a lot of things, and evaluating things where you do not have all the data (or ignoring data)..

    Have you heard about the expression “enabler”? I claim you are one of many of Trumps enablers. Also YOU are the one that is the cause of stigmatizing mentally ill people.. when you say “Confusing Trump’s behavior with mental illness unfairly stigmatizes those who are truly mentally ill, underestimates his considerable cunning,”, then YOU are the person claiming that “If someone is mentally ill, the person in question can NOT be cunning at all”.. There are PLENTY of mentally ill people whom are highly intelligent.. there are differences between different ailments, but YOU seem to want to claim that talking about one person and HIS specific ailment, and how HE deals with it should automatically reflect on ALL people with ailments.. The fact that YOU clump people together in this manner is evidence that you shouldn’t be certified in mental health care.. NO you should __NOT__ go out and stifle discussions on whether someone is mentally fit to lead the nation.

    .. and if Trump did what he did because of his “cunningness” then all backlash he gets (which is EASILY PREDICTABLE) is also a result of his “cunningness”, and if he CHOSE this backlash because he is this cunning.. then he do not need you to try to stifle the VALID debate over the fact that you idiots in the USA have let your ideals (where you confuse being aggressive with being an indicator of strength, confusing bullying with being a strong leader, confuse selfishness with selfreliance, refusing to listen to others with resilience, etc.. basically egocentricity and hostility as a way of life) trick you to elect a CLEARLY mentally deficient man to office..

    First of all… “To qualify for narcissistic personality disorder, an individual’s selfish, unempathetic preening must be accompanied by significant distress or impairment. “……. Have you measured his distress? or have you measured his impairment?..

    secondly; NO, there is no guarantee that an ailment HAS to be something that “impairs” the person suffering from it.. there are many serial killers whom were FULLY functional members of society and enjoying their lives, and there was NO impairment for them to have families, jobs, or even friends that THOUGHT they “seemed normal”.. the ONLY impairment they got was when society FOUND OUT and SOCIETY created the impairment… Something CAN be a mental illness even if it doesn’t prevent someone from enjoying their life, or enjoying what they do…

    BUT.. even more importantly..what IS an impairment?.. Many people with various mental illnesses do their best to HIDE their impairments from society.. I suggest that he has had MANY impairments that comes from his narcissism.. The thing is; There are MANY situations we know of when Trump lost.. people seem to forget about these.. but he has lost a marriage.. he has lost deals.. friends.. and work partners.. We just do NOT have the information to know for sure which is the result of his (obvious and easily proven) sociopathy/narcissism, or if they are “normal” downfalls because he is an asshole… Many people meet obstacles in life and are able to have a life that doesn’t crash totally just because there were impairments..

    Actually; Trump Fucked his finances up.. he ASSUMED to be able to manipulate people in florida and lost a LOT of money in the process.. The fact that someone “fails” in their manipulations isn’t an indicator of whether narcissism exists or not.. but what IS is whether they work through it or hide it…. If you look as his ACTUAL result as a leader, then you will see that it is always OTHER people that are paying for his successes, NOT his own skill… he did a BIG nose dive, and the ONLY reason he was able to survive was because of OTHER people still willing to invest in him because of his REPUTATION… the familiarity of the Trump name.. Not because of his internal abilities..

    Just as society can be the ones that create an impairment.. society can also be the factor that makes an actual impairment less prominent.. I say less prominent, because if you don’t WANT to be stupid and ignorant, Trumps failures as a business leader are OBVIOUS…

    The thing is.. being insane do _NOT_ mean you have to be stupid,.. it do NOT mean that it is impossible to achieve results (look at Hitler.. and just to say; there is ENOUGH evidence to prove that Hitler thought of himself as a LITERAL Messiah)..

    How to recognize an ailment is from behavior.. and Trump shows ALL the telltale signs of narcissism.. the only “caveat” is that people shouldn’t diagnose without actually doing some tests.. but.. let’s be fair; If you have watched all of the clips available of Trump, and followed his career and family life.. there is no doubt that this man ONLY lives according to his own head.. at no point have he taken in anything, but he is a bulldozer because he KNOWS he knows better than ANYONE.. (unless possibly the “anyone” say EXACTLY what he himself would’ve said)..

    What you are NOT supposed to use to “give someone a clean bill of health” is the CONSEQUENCES of (ill) behaviour.. There are many diagnosed people whom are “functional” in society.. sometimes even HIGHLY functional…. There are people whom CLEARLY are Autistic.. they have been easily diagnosed BY health care professionals doing DEEP studies….., BUT.. they are able to live their lives.. autistic people aren’t ill-willing..

    However; Delusions of grandeur, and narcissism.. are issues within the sociopathic range.. And if there is something Trump ALREADY proven is that he cares FUCK ALL about EVERYONE around him, he NEVER cared about ANY life he ruined even if when he seen it with his own eyes, he can just ignore it… this means he lacks empathy.,. which makes him a sociopath.. (and today sociopath doesn’t really exist any longer, it might be in common use, but it is really just another word for “a psychopath who is skilled in hiding his psychopathic nature”)..

    Amusingly enough; There are many psychopaths/sociopaths that never were diagnosed or suspected of having this problem.. because their problem is not that they WANT to harm others… they just lack the empathy to prevent them.., but they might have OTHER reasons (practical reasons) to behave normally, and never ever get to the point where something makes it seem better to “break” social rules.. They feel content with their lives without breaking them, hence.. it is all good.

    The way to diagnose narcissism is from behaviour… and one of the things that lifts the “veil” of narcissism is the fact that they think they are better than others, but this is also a weakness.. They can not stand being questioned.. so.. One of the EASIEST ways to recognize a narcisist is whether he can (or can not) take criticism.. are you familiar with all the IRRATIONAL situations where Trump has thrown a HISSY FIT (that no sane person would throw after the age of three) because someone questioned a MINOR thing?..

    Trump is throwing out his own staff at a high rate because of them not being completely loyal.. he is alienating ALL of the rest of the world(you might THINK he hasn’t but that is because the rest of the world DO know of something called “diplomacy” and to not CREATE problems.. unlike Trump).. IF this is the result of “cunning” I will pray to God to remove all cunningness from my being..

    • Amazing comment! You should have written this article! What country are you from?

      I agree that people like this Author are enabling a madman that represents the single greatest threat to global security since Hitler. It’s plainly obvious on a fundamental level, regardless of mental health training, that Trump falls nowhere in the spectrum of normality. The fact that people can’t see this is because they don’t want to see it OR they are seeking to benefit from it (more on this below).

      I would like to suggest that trump does have 1 major impairment (while im not DSM trained, I have a parent that has untreated borderline personality disorder) which is Trumps extreme susceptibility to manipulation. Lets look at Russia. The Russians knew exactly how to play Trump. Trump wanted to build in Russia, but the Russians withheld their full affection and attention from Trump for years. They knew his wealth and influence could be valuable one day so they no doubt did a psych work up on him and discovered the same thing we all see: Trump’s irrational need for nonstop attention, approval, and flattery, especially from powerful white men (to me, Trump’s need resembles the behavior of a drug addict…he will do ANYTHING to get his fix). knowing how badly he wanted/needed their approval, the Russians slowly gave Trump their favor in small doses, but they always withheld enough back to keep Trump literally begging for more. Russia started Trump off with low level mobsters and dirty money financiers, then moved him up to Russian entertainers, and a few oligarchs, but they always kept Putin and his inner circle at arms length, which they knew would drive Trump crazy, to the point that when Russia was ready to fully bestow their favor, trump would be ready to risk everything for it (just like an addict). This final moment came during the campaign when the Russians had trump believe they were going to allow him to build a building in Russia and he signed a letter of intent. No sane person running for president would have made this reckless of a play, but the only thing Trump could see was this great power had finally decided to bestow their greatest honor on him, so he took it.

      I also agree with idea that impairment shouldn’t be directly tied to a person’s success. My parent that suffers from BPD is super high functioning and was the administrator of several institutions. The problem was my parent created so much conflict and stressful conditions that people stopped wanting to work for my parent….this is an impairment! And Trump demonstrates this very same impairment everyday. So I would suggest that impairment must always include a person’s effect on those around him.

      Finally, a lot of people pretending that trump is perfectly sane are either insane themselves or seeking to manipulate trump like Russia has. Take Steve Bannon for instance. He called Trump a “blunt instrument” for the alt right…think about what that description says…blunt instruments can’t be reasoned with or enlightened. They can’t educated or grow. They have one purpose, to force their will on other things. This discription is decidedly anti-human, but the real message is that an instrument is to be used by others, thus Bannon is describing Trump as having no agency over himself. Bannon knows that trump’s mental illness makes him a tool to be used, and Trump is too self-absorbed to even understand this!

  • This is an armchair diagnosis too. The point is that he might or might not be mentally fit, but this can only be decided based on proper diagnostic procedure.

    • Anna, what, in your opinion, constitutes proper diagnostic procedure in this case? I, too, was raised by a parent with untreated borderline personality disorder, and spent many hours if not months and years of therapy trying to understand the dynamics in our family. Donald Trump has been in the public eye for decades, covering the news media with far more information and examples of his behavior and character than a few hours of psychiatric office evaluation ever provides from the majority of patients. If you and others cannot see by now what this individual is made of and what drives him, you are seriously – and deliberately – missing obvious signs. The very idea that someone cannot be mentally ill if they are able to function in society, has been promoted by our court system, in which perpetrators of the most heinous crimes are debated to be “guilty” or “not guilty by reason of insanity” by the simple fact of how they can function overall; how aware they were of what they were doing, did they have preconceived motives, etc. etc. Look at Ted Bundy, a classic example. He was cunning enough to go to law school to learn how to deceive the system, yet would you not say he was mentally ill? Would YOU have been able to diagnose him through proper diagnostic procedure when he was able to deceive even his closest friends and co workers? I think it’s time we re-evaluate what constitutes “proper diagnostic procedure” and allow more common discernment in situations like those of our current POTUS, who has clearly given us more than enough examples of the workings of his mind. What more do you need?

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