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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  • Really tired of this hubris on Frances’s part. He’s jealous that “amateurs” got it right long before he even looked. Most mental health experts have little experience with NPD because most Narcissist won’t seek therapy or diagosis unless forced to- and then they’re the worst patients. Anybody who’s been victimized by someone with NPD and has any mental health insight likely understands it better than Frances ever will.

    The incredible statement that Trump doesn’t experience distress is jaw-dropping, and is at the crux of Frances’s argument. He’d admit that Trump meets every other criteria.

    Frances clearly doesn’t like that NPD exists in the first place. That strikes me as something worthy of a few therapy sessions on Dr. Frances’s part.

    Nobody should flaunt their position over the scientific accuracy of their words.

    And mot of the mental health community agrees with me, not Dr. Frances.

    Change the Goldwater rule, and submit the profession to public scrutiny. It can take it and survive.

  • Numerous other professional assert strongly that Trump does have a pronounced sociopathic narcissistic disorder. Quite simply, at several conferences phychology professionals have asserted exactly that, and how dangerous it is for him to be in the place of power that he is.
    However, other than the clinical diagnosis part, many non-professionals would find it disconcerting for a “professional” to not be able to catch this one, given how obvious it should be. Even the GOP staff and congressmen around him have been caught making note of his psychological issues. Just list all the behavioral traits and note the contexts and frequency/consitency and compare to your DSM. I guess that this is why it is so easy to get a professional witness to contradict almost any professional mental health diagnosis, and what still makes psychology a soft science.

  • No I don’t agree he absolutely has brain problems! Normal people don’t behave like him. Just the lying alone shows how dimented he is! He is a sick person and he sure has a lot of enablers!

  • But isn’t the common case for most individuals diagnosed with NPD is that everyone around them is left broken, penniless, or emotionally drained while they remain unscathed? According to many articles on the inner workings of the White House, everyone’s job is to cater to Trump’s needs rather than helping serve our country. He is surrounded by enablers telling him how great he is while 62% of Americans think he is not.
    It’s possible Trump is not mentally ill but there is definitely something wrong with him, and it definitely interferes with his ability to perform his duties. He’s a pathological liar. He makes personal attacks on Twitter. He attacks groups he needs to cooperate with for the security of our nation. He attacks families of killed military soldiers. He is uninformed and doesn’t care. He cannot explain any policies coherently because he knows nothing about them–he is leaving the work to everyone else only to take the credit later. Can you honestly say Trump is fulfilling his duties as a world leader with a straight face?

  • how can you call yourself a psychiatrist? Really? He’s gone out of his way to promote himself and degrades people in the process. He ignores facts and constantly projection what he thinks of himself onto other people, all the time. He ignore reality and refuses to let the election (the past go) and goes on a tirade of how great he is when events have passed. In vids, he is shown to not care about other people’s feelings at all and have absolute authority. He brought in a cabinet in office and promised to drain the swamp, yet most have left or resigned or were fired. Its been one chaos after another sir. And you can tell me he is fit to be commander In chief and isn’t mentally ill. Id like to meet you face to face. I have my own issues and all but can see this clearly like most American’s the fact you cant disturbs me and the university you teach. Also, you bring attention to the DSM. You help with that. It concerns me with your thinking process. Further, NOBODY is a “expert”. We all learn and grow and if your not aware in your high chair, psychology and neuroscience will grow way beyond what we know now.

  • You say that his Narcissism has never affected his business in a negative way and that is why he does not have narcissistic personality disorder. However it has, if he had grown his fathers wealth at SP500 rates he would actually be worth over 10 billion.

    He was unable to competently manage his finances. at least 4 business bankruptcies, a failed public company, the 90s. his narcissism and arrogance has costed him greatly over the years. But being narcissistic he will never admit it.

    • If Trump’s a narcissist, you’re a fool. In point of fact, Trump has a pretty broad and diversified financial empire that’s extroidinarily profitable in recent years. Trump may not be a financial market maker , but he’s been pretty savy as a developer and marketeer.

    • So, are you saying he is a fool and Trump is a Narcissist and therefor contradicting your own opinion, or that he is not a fool and therefor Trump is a narcissist (and again, contradicting your own opinion). I guess either way you are wrong or a fool!

  • “We mustn’t waste this Trumpian dark age. If we don’t learn from it, we will keep making the same mistakes.”
    Great suggestions yet to end on such a note without solutions seems unfinished.
    So, how exactly do you believe we not “waste this” and “learn from it”

  • You are confusing the concepts of mental illness and competence. As a diagnostic professional, you should be aware of the differences. Capacity and competence are not diagnostic concepts; they are legal and/or statutory. One may may not be competent to stand trial yet not be mentally ill. One may be mentally ill, yet competent to stand trial. One may be mentally ill and competent to fulfill vocational obligations. Yet, one may also be incompetent to fulfill vocational obligations but not mentally ill. This is very basic, my professional colleague.

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