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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  • Look, as someone who has been diagnosed with ADD, Depression, and Anxiety Disorder, I am aware if the stigma that comes with the media coverage for extreme cases. I also know that the following sentences can offset that. The media usually only covers extreme cases of mental illness, therefore it is a poor example of what mental illness usually looks like. mentally ill does not mean insane.

    There were very good, important, influential people who had mental illness. There were quite a few bad ones too. I agree that the presence of mental illness alone should not be a deciding factor on presidential eligibility, but the kind of mental illness should. A president who’s willing to do anything to preserve him/herself and hold themselves above all others regardless of any vows they made is a very dangerous thing. Turning a blind eye to mental illness will do no one any favors. We should be aware of the stigma and damage it may cause, and avoid using it to label. But it should not be ignored or underestimated either.

  • This article is actually a sad example of how even so-called experts who work on the DSM itself can be blatantly wrong. It is troubling how easily we dismiss the psychotic behavior of Trump. It actually blows my mind how we can completely look past clearly insane behavior, and shame on you for posting this article. The period for giving him the benefit of the doubt is long past. Something should have been done months ago and opinions like this are part of the reason why there hasn’t been.

  • I think it is also dangerous to assume he is not mentally ill. Where do we draw the line? Apparently someone can demonstrate all the traits of a mentally ill person, and still not be mentally ill just because they hold a position of wealth or power. I think this is a very wrong view, and sets a bad precedent for the future. When people act insane, why can’t we assume that they might be and need help no matter their position? He does a lot more than just believe in conspiracy theories. He needs serious psychological help and it is obvious. To say that he isn’t mentally ill would be to say he doesn’t need help and therapy, which is completely untrue. The insanity of his actions speak for themselves.

    It also doesn’t unfairly stigmatize anyone with mental illness. If someone acts like Trump, I would hope they would get help too. Mental illnesses are very individualistic, and the DSM has had so many over generalizations and diagnosis that have later shown to be incomplete or completely wrong. How can someone demonstrate all the traits and then somehow we make an excuse because “That’s just Trump”. It is completely ridiculous, he needs help along with many other people in the GOP. Sadly he’ll never get it because psychopaths or people with disorders generally aren’t willing to be treated unless forced.

    This line of dialog is dangerous. We CANNOT assume he is not mentally ill just because of his position of power and the people around him that have taught him conspiracy theories. And again how you try to say it stigmatizes other people with illnesses is blatantly false. It is sad that even experts can mis-characterize something that is clearly a case of mental illness just because it involves politics and power.

    • “When people act insane…” And there you have it. So-called mental illness is a label put on behavior of which the labeler disapproves. Nothing more. No science. No biology. It’s quackery, but much more dangerous, akin to witch dunking.

    • I think the point was to say someone acting insane has some form mental illness, but someone with mental illness is not necessarily insane.

  • Personality disorders ARE mental illnesses and this does NOT unfairly stigmatize people with other types of mental illnesses. In fact, claiming so unfairly stigmatizes people with personality disorders!
    Also, have you never heard of the Goldwater Rule? If you haven’t had Trump in your office, what on Earth are you doing publicly diagnosing him?

    • What you believe you could never prove or disprove. If a claim can’t be falsified, which no diagnosis can, then it is something other than science. Psychiatry is the tool long used to suppress and dispense with objectionable people. It’s a powerful method of social control of the unwanted. By its very nature it stigmatizes, as that is its purpose.

  • You need to get off the DSM committee if you think that Trump can’t possibly have NPD. Or do you think there have been no new discoveries on NPD since 1978? His self-perceived grandiosity is legendary and so is his willingness to hurt others. He’s planning a parade for himself estimated to cost between 10-30 million dollars! It’s true that not everyone who is full of himself or herself has NPD but Trump has unabashedly -even proudly- had very public illicit affairs. He threatens foreign leaders! He can’t control his rages enough to stop himself from blurting out offensive words and statements unbecoming of any politician, especially a president. You have the audacity to claim that “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” when he clearly cannot control his rage. Furthermore, that is NOT even true of NPD. A person with NPD does not have to feel significant stress because they lack empathy. Their “feelings” are largely made up of anger, rage and feelings of superiority. He literally fits the DSM for narcissism perfectly. Besides, eliminating NPD from the DSM would be a crime against humanity. To pretend that people who manipulate and abuse others due to lack of empathy and selfish reasons are not sick and in need of treatment is a slap in the face to every one of us who has been traumatized or even physically abused by someone with NPD. These people cause quite a lot of harm to others in our society and ignoring that is ignoring people who suffer PTSD and CPTSD due to relationships with people with NPD. NPD is mental illness just as sure as PTSD is and all of us need and deserve access to treatment. I am not here to hate on Trump or to hate on anyone with a personality disorder, I believe everyone who is mentally ill deserves a society that offers treatment. By saying “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,” YOU stigmatize people with NPD! What? They aren’t good enough to receive attention and treatment like people who suffer other types of mental illness? You stigmatize them as being undeserving of attention, understanding or treatment. It’s appalling that, as a psychiatrist, you would publicly diagnose a public figure who has never set foot in your office and you know full well that a clinician should not publicly diagnose anyone without having seen that individual. How exactly do you have any idea how significant his stress or impairment is? You should be ashamed! Are you not familiar with the Goldwater rule?

    https://www.npr.org/sections/health-shots/2016/08/13/489807468/psychiatrists-reminded-to-refrain-from-armchair-analysis-of-public-figures

    https://www.psychiatry.org/news-room/apa-blogs/apa-blog/2016/08/the-goldwater-rule

  • How are you supposed to know if he is or isn’t turbulent or if he demonstrates narcissistic/psychopathic rage if no one records his actions and behaviors in his bedroom with the door shut? He could keep it cool out in public- but clearly demonstrates his insecurity and petty anger through Twitter and God knows how he possibly treats his kids and wife 🤦‍♀️

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