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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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  • This is not helpful. By stating he does not satisfy any mental illness, you are quietly validating is aberrant behavior. See, not be done with it.

    He clearly has a character disorder. I maintain he is illiterate and most likely suffers Asberger’s syndrome. Total lack of empathy and recognition of acts that affect other human beings.

    The real issue is his fitness to assume the office. He is unfit and incompetent.

    The DSM is not a static manual. It is an evolving compendium illustrating the shortcomings of all these diagnoses.

    Thomas Szaz used to say how can you diagnose mental illness in a sick society.

    • “Thomas Szaz used to say how can you diagnose mental illness in a sick society.”

      Szasz said no such thing. Something like that is attributed to him, but neither said nor believed such a thing.

  • Well… If the Orange One doesn’t meet the criteria of a narcissist and psychopath, nobody does.
    Why don’t you write a fairy tale about how Kundalini is demon possession instead?
    I’m sure you will make it a laugh….Just take the right kind of drugs when you write it. Perhaps you will be perceived as a very stable genius.

  • Allen Francis started out speaking out against the vitriol stating that “Trump is not insane” and that those attacking him and making diagnosis are wrong.

    Now he’s nothing less than the same exact thing, a wolf in sheeps clothing. Shame on this leftwing hack.

    • Dr. Frances is not afflicted with intellectual or moral consistency. Given that he is a psychiatrist, that is not surprising.

  • You need to differentiate between narcissistic personality style and narcissistic personality disorder. If a question please see Len Sperry, DSM-IV-TR, personality disorders. His narcissistic personality style is healthy.

    • Mental health is the favorite quackery of the “modern” world, hands down. The minute differentiation of behaviors then classified as diseases will one day seem as absurd as the the claim that Jews poisoned wells.

  • Dr. Frances, you seem to contradict yourself in your title which says that Trump does not meet the criteria. Later in the article you say “He demonstrates in pure form every single symptom described in the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for narcissistic personality disorder.” I assume that you imply also that simple narcissism can meet that criteria. I also think that you are not actually diagnosing from afar, but rather are exercising your duty to warn.

  • As an LCSW I’ve been extremely fascinated/horrified by the pathological personality traits that Trump displays daily. If anything, I think Narcissistic PD is about as close as one can get to a plausible dx, though I was always on the “clusters” bandwagon (vs specific personality d/o) for the DSM-V as there is so much overlap. Does he exhibit Cluster B traits? Absolutely. I don’t buy the dementia thing AT ALL; I’ve worked in medicine my entire career, and have seen many pts with dementia – Dr. Frances is absolutely correct that he is too “organized” to fit this type of disorder.

    I would only quibble with one point on NPD (or let’s call it Cluster B PD, if that better suits the nuance) – the point re: dx causing “significant distress or impairment” which is present for most psychiatric disorders in the DSM. By definition, an individual who is PATHOLOGICALLY narcissistic (in the clinical sense, not the colloquial definition that would apply to most politicians/actors/etc), DOES NOT RECOGNIZE there is any problem! They DON’T seek treatment, because the belief that they have “special inside knowledge” or abilities is so entrenched that to elucidate any sort of impairment/distress would entail too much cognitive dissonance to function. Also, I’m not sure we can say for sure he does NOT experience any kind of internal distress – he very well might – but his narcissism would never allow any hint of that shown in public as that would shatter the perception of himself as all-knowing/extraordinarily special/beyond comprehension of the rest of us mere mortals.

    I agree with the notion that we shouldn’t throw around the idea of the 25th amendment as a solution to the Trump problem due to a supposed mental illness. This would indeed be a slippery slope, and there are many talented, qualified individuals who are able to manage their psychiatric d/o (e.g., depression, PTSD) adequately enough not to disqualify them from public service. I agree that by his own nature (given how removed he is from the idea that the public may not approve of his actions) Trump’s presidency will implode either under it’s own weight, or be halted by our democratic institutions that do not view right/wrong through his narcissistic lens.

  • While I agree that Trump is not mentally ill, it does not preclude the possibility that his narcissism is dangerous. And the 25th Amendment does not specify mental illness as necessary criteria. But I also agree that the 25th Amendment or impeachment would throw the country into a constitutional crisis. I believe that Trump will probably resign as he gets closer and closer to being cornered by the special prosecutor. That will probably happen sooner rather than later. Thanks for your great article.

    -Mike

  • My experience tells me that in addition to his B Complex PD’s, it is his social and emotional regression related to spectrum behaviors that are most dangerous to his decision making ability….He has the appearance of structural dissociation that goes with PTSD, Aspergers Syndrome, or Bipolar, with the Dr Jekell Mr Hyde split between left and right brain functioning. I think Dr Frances is correct in that Trump is a symptom of the deep dysfunction of our society. I have observed young children in schools for over 40 years, and I believe the social and emotional regression in the US that is causing a new form of codependency, in addition to spiritual annihilation, is perpetuated by the cold and callous school environment in elementary schools. Those early developmental years have become punishment for children, where “authoritarians” obsessively focus on performance while ignoring children’s basic social and emotional needs. Until we recover our child rearing ability in this country that allows children to make healthy attachment to others, and restore adults to having the ability for empathic understanding, and skills to validate children, then we can expect more generations of the same, only worse.

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