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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.

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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).

  • I have a background in clinical psychology. I am not sure I understand why you think that Trump does not suffer from narcissistic personality disorder. People with personality disorders don’t experience distress as a result of their condition. In fact, they don’t believe there is anything wrong with them. That is why they rarely seek therapy. So I find it bizarre that you see lack of distress as an indicator that he does not suffer from this disorder. In terms of impairment (your second criterion), I think his narcissistic behavior impairs just about every aspect of his interpersonal life and his ability to find fulfillment and happiness. So in fact, the diagnosis seems appropriate and valid. If I am missing something please explain.

    • Charles S.
      Thank you for stating this, I agree that NPD is pervasive in all aspects of the person’s life, so in pretending to be how they think a perfect person would be or act they put on a ’false persona’, an illusion that allows them to have a cool demeanor & not take on any blame, guilt or remorse because in their simulation of the ‘false persona’ they uphold that perfect image & protect it at all costs or they would have a ‘narcissistic injury’…that glimpse of reality where they see the fake puppet show they are putting on & controlling from behind a curtain & feel they’re fake ness has been exposed to the people they deal with. To get this glimpse of reality they would have to feel overwhelmed, so over half the people in their everyday crowd would have to say that they know he is portraying an illusion that he wants all including himself to accept as reality. This isn’t going to happen in the powerful position he is in. Thus even under seemingly enormous pressure his delusion is enough for him to believe that he is omnipotent, superior, special, entitled & has no reason to lose face, freak out emotionally, stress out or feel humiliated as long as he thinks that over half of the United States supports him & he can blame-shift any perceived guilt or wrong doing on fake news or a scape goat around him & uphold his delusional puppet show that a lot of people (flying monkeys) buy into.

    • I would say that 99% of use would be in severe distress if we behaved as Trump does. We would be unemployable.

      Trump is in a very unique position because he has others in power that are willing to prop him up for their own gain.

      It could be that he is cunning enough to manipulate people and pull this all off. I am not buying that though. Often times he digs himself a hole that serves no useful purpose and only manages to cause him more distress. He has done things that most of us would assume to be the final straw. I don’t think he calculates what he can get by with and what he can’t.

      When he goes to the hospital to see people who are wounded as a result of a mass shooting and he makes it about himself (crowd sizes, how much he is loved, etc.) that serves no useful purposes. He does it because he feels he is victimized and thinks everyone else will feel the same. It’s not planned. He is just lucky to be the one person who can get by with antisocial behavior over and over.

  • Seems like this Narcissists and mentally ill old man is trying to correct the foolish mistakes that the past 4 Presidents abd House and Senate have created. The past Presidents didnot want to rock the boat and were only thinking of their legacy and Libraries that would be built to commemorate the sorry Bastards. How ironically Narcissistic is that?

    • I think your comment is merely a personal opinion that has absolutely ZERO FACT to it. How in the world would you know what those presidents were concerned about? Its idiotic assumptions like yours that tend to confuse the underinformed members of the populace.

  • I’ve watched off-the-cuff interviews with Trump from the 70’s. Google “Trump AND Howard Stern interview.” Trump’s speech patterns are light years more skilled than his rambling, disjointed, nearly-incoherent stump speeches (presumably based on a professionally written speech) show me a man with significant neurological impairments. You don’t have to be a mental health professional to recognize Trump’s recent inability to use “origin” (instead of “orange”) numerous times to understand that he’s at least suffering some kind of mental dysfunction.
    Of course, I’m not a mental health professional who has managed to remain “apolitical” over the most politically divisive period since the Civil War, either.

    • A lot of mixing neurological impairment, mental disorder, personality disorder. Making diagnoses without any neuro-imagining, past medical or psychological history, alcohol or drug history, family history. No formal psychological, neurological,or personality testing. All these speculation diagnoses are not professional diagnoses.

  • stupidity is reflected in the many comments by those unhappy with an election result that has factually resulted in great improvements in the country as a whole ( except for the emergence of a “hateful resistance ” of well funded groups and naive,gullible followers played by their puppeteers like a well tuned orchestra;brilliant,clever, dispicable and purely political)

    • By great improvements I assume you mean the economy

      Trump received a booming economy from Obama, which he promptly took credit for. Economic indicators have been steadily improving for years, the rate of improvement did not increase when Trump took office.

    • There are sour grapes every time someone loses an election, but in this case that is not the issue in question. Trump is special and different from most (all?) other politicians on the republican side today. It should be possible (but seems to be perplexingly hard for a lot of people) to divorce the policies he (and the people around him) advocates from judgements on his personality and mental faculties.

      First of all, there is a long delay from a policy is enacted to the effect on the economy is felt, so he can’t claim credit for much of what’s good (or bad) in the US today. Clearly, wanting changes in border security or tax codes or trade agreements are not indications of personality disorders or dementia, even if they in Trumps case represent quite radical policy changes. I would even say that things like the bizarre claims of election fraud to the tune of 4 million votes or insistence that his inauguration crowds were bigger than Obama’s may not necessarily be indicative of mental illness – as the article points out – since he may not actually believe it. It would, however, be a fairly gross lie, and the fact that he can say such things with a straight face over and over would indicate that he does not feel shame.

      Narcissism is pretty evident in everything he does… he insists his deals are “the greatest and biggest”, that his words are “the best”, his calls are “perfect”, his wisdom “great and unmatched”… he thinks he deserves the Nobel Peace Prize and that the only reason he hasn’t been awarded it is that the process is “unfair”. And that’s just the last month. If this guy doesn’t have Narcissistic Personality Disorder, the term has no meaning.

      It is also pretty evident from his public appearances that he: a) probably has quite poor eyesight and struggles with reading teleprompters (which I won’t hold against him) and b) has early stage dementia, as evidenced by his poverty in vocabulary and regular confusion when performing tasks he is not familiar with.

      Agree or disagree with his policies, he clearly is not fit to serve as president. Pence should take over until the next election.

  • Somethings in your comment are confusing to me. When you say “reflexion”, do you mean like “looking in a mirror and seeing a reflection of yourself”? Are you implying that the majority of Americans are stupid. I believe that if one is “stupid”, one does not wake up from being asleep and then being “not stupid”.

  • With increasing age there is increasing risk of neurocognitive dysfunction and disorder. Please don’t mistake personality style from personality disorder. Alas, the DSM appears to be suffering from diagnostic inflation. Who is responsible for that? Did Duke University just pay an enormous fund of money to the Federal Govermant for using falsified research results. Was Duke University Department of Psychiatry and Behavioral Sciences part of this?

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