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.

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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.

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 think this article misses a very important and not-particularly subtle component: A narcissist with substantial resources will have a tremendous advantage in coping with their mental distress. Trump has vast amounts of money, power, legal, PR, advisors, sycophants, etc. He ALWAYS launches an attack from real or imagined slights from literally anyone on the planet earth regardless of their social status, he manipulates others to support his baldfaced lies, he threatens anyone with litigation, he (effectively) uses Twitter to spread his falsehoods across the globe…… and so on. He transparently cannot control his worst impulses, he often appears to ignore sound advice (the number of ppl that have bailed out from his cabinet is unprecedented. Thusly, he has virtually unlimited resources that he uses to assuage his distressed mind. That he’s very savvy in self-promotion and is without a doubt very cunning is not incompatible with the fact that he’s high up on the narcissism spectrum. With respect I don’t think I’d readily agree with Steven’s comment below that suggests Trump’s behavior is much different from decades ago. I lived in NY back in the 90s; Trump has always been kind of a joke within the business world but desperately craved to be esteemed by the elite crowd for his perceived genius, his impulsive and reckless management style – or lack of – imploded the majority of the businesses he touched (Trump Shuttle, anyone – to name but one highly-publicized one), more and more information about his voluminous propensity for lying – particularly about his finances – back then is now becoming known, he was always well-known for not paying legitimate invoices for goods and/or services and dragging thousands of people/companies into court – or threatening to – and was often forced to settle (despite still publicly claiming he ‘never’ settles), numerous broken marriages, all his wives were a result of cheating on his previous wife – Melania not excluded (given the evidence that strongly suggests Trump surely cheated on her multiple times); three of his four children appear to have at least somewhat of a sycophantic relationship with him (not necessarily Tiffany) and it’s well-established that narcissists can get along best with others that have narcissistic traits or at the least derive benefits from the relationship (also ala’ the GOP). I’d argue that Trump’s inclinations at that time simply weren’t subject to the massive scrutiny that he now receives in public office. He gave plenty of interviews back then (classicly full of lies mixed with some truth), but there really wasn’t anyone that had the wherewithall to dispute them – except those business associates he’d already screwed and the untold numbers of employees whose jobs were disrupted by the perpetual failing businesses – but all of whom were surely under threat of NDA’s and the costs of legal battles. Trump’s pretty much always been known as a selfish axx-hat, albeit a very shrewd one.

  • Expert you say? Trump is exemplifying all signs of Narcissistic Borderline Personality Disorder. I’m assuming it was self-inflicted. Copious amounts of cocaine in his younger life partying with young girls, I would assume is the reason. I honestly don’t understand how you could say with a straight face he doesn’t show (ANY) signs of mental illness. His behavior is obviously much different than it used to be 40 years ago. His needs to feel special and important, delusions of grandeur, forced acceptance from everyone around him, paranoia, his back and forth contradictions, the obsession with conspiracies, feeling things are unfair to him, refusal to apologize when he’s wrong, or taking simple ownership for what he says and does. As time goes on it’s becoming more obvious. I honestly would not be surprised if he’s already been diagnosed with NBPD years ago. Being an expert I’m sure you’ve already noticed this.

  • The severity of Mr. Trump’s narcissism and antisocial behaviors significantly impair his ability to function as President and pose a clear threat to our republic. This is not hyperbole.

    Mr. Trump’s distorted world view resulting from the severity of his disorder(s) routinely reaches psychotic levels. He is extremely disconnected from reality as evidenced by his repeated denial of patent information/objectively verifiable facts (ex. crowd size at his inauguration, evidence of extreme climate change). He blatantly dismisses any challenges to his world view as “fake news” and fires anyone in his administration who significantly challenges his fragile psyche/causes too much cognitive dissonance. He is increasingly isolating himself from these challenges and his administration now suffers from extreme Group Think which will lead to more self-serving decisions (a vicious cycle).

    He clearly evidences numerous traits common to a myriad of horrid historical figures. For example, he repeatedly singles out groups of migrants who are dissimilar to his white/European ancestry for acts of cruelty including those leading to death as they are vermin unworthy of US citizenship (sound familiar?).

    The severity of his pathology is extremely dangerous and should in no way be dismissed or normalized. The stage is set for his malignant narcissism to carry this country to extremely dark places which rival the worst seen in history. We’re already heading down this road.

  • Mr. Frances,
    Your article means well if you omit everything related to narcissistic personality disorder.

    Verifiable facts directly contradict your requisite qualification when you state that “unempathetic preening must be accompanied by significant distress or impairment.“ & further state…”Trump’s narcissism doesn’t seem to affect him that way.”

    Let’s be real, you know just as many others both qualified professionals and rational everyday citizens, this man has narcissistic personality disorder. Your own professional credibility is diminished and so many other great points you made are lost when this obvious personality disorder he demonstrates is unqualified by your opinion letter.

    Does it make him unfit for office. Arguably No. But let’s not attempt to compare heathy levels or even excessive levels of narcissism high powered execs & celebrities have with this man.

    It’s sad for Trump and so many others who have this disorder and when you state that you’re qualified & he doesn’t meet the criteria, when he clearly does qualify for narcissistic personality disorder.

    You’re making the actions he and many others with this mental illness appear to have some level of normal behavior that doesn’t need treatment. This poor president of ours needs help. Just call it what it is.

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