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.

advertisement

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).

Leave a Comment

Please enter your name.
Please enter a comment.

  • Find his use of verbal cues maddening as they remain unconnected until much later when motivations may become clearer. The way he handles each interaction, and his facial expressions reveal much about how passionate he is, or isn’t, even if disguised, and how he manages rote program driven responses is revealing.

  • I didn’t vote for Trump. I think he’s a jackass and an embarrassment.

    But people who compare him to Hitler, or think he’s a new level of atrocity in the American presidency are fools.

    In my lifetime, we have had presidents who were responsible for the deaths of hundreds of thousands of innocent people (Johnson, Nixon, GWBush). That is the highest crime a president can commit, and Trump doesn’t register on that metric. Only a moron would rate his speeches and tweets more offensive than the actual butchering of people.

  • I’m a Canadian man I read a book “House of Trump and house of Putin “ and watch CNN i can’t believe that this sick man is president of the USA I’m amazed that everything written in this book is happening. When DrFrances mentions on CNN interview that he’s as dangerous as Hitler and other dictators its scary and a fact.Trump is very sick and hopefully will be removed from office in 2020 .God forbid he’s voted in again he will destroy everything the Americans have been working for.

  • Bizarrely, Frances attempts to take down the strawman, according to which Trump has narcissistic personality disorder. Alas, the claim at issue in popular discussion of the president’s obvious mental disorders is that Trump is a malignant narcissism. Trump’s a narcissist and a psychopath; he loves himself and hates everyone else (too much). Trump has no capacity for empathy, and that neatly disposes of Frances’ pitifully weak defense, that Trump can’t have narcissistic personality disorder because he doesn’t suffer from his narcissism. Trump doesn’t suffer from it because he can’t feel shame or bad about anything he does, because he’s also (obviously) a psychopath.

    Remember when Trump gave a creepy smile and a thumbs-up for a photo with that infant survivor of the El Paso shooting? That’s psychopathy. Remember when Trump did everything he’s ever done or said over the last fifty years? That’s narcissism. Put them together and you get the real-life monstrosity of a dictator.

    Also, Trump’s wealth insulates him from the negative consequences of his narcissistic thoughts and actions, which helps account for his lack of suffering. To that extent, American psychiatry entails that only poor people can have mental illnesses, since they have much less control over their environment.

    But if Trump ever gets his comeuppance in politics, he might suffer at that point. Couldn’t a psychiatrist have practiced a little something known as preventative medicine, predicting that Trump’s apparent malignant narcissism would eventually lead him at least indirectly to suffer? For example, even if such a monster lacks the capacity to feel bad about his actions, were he to hurt others, get caught, and end up in prison he might suffer indirectly from that loss of personal freedom.

  • One correction (was thinking about criteria for Antisocial Personality Disorder – another possible diagnosis for Mr. Trump):

    “Occurred since age 15 – check” should read “Beginning in early adulthood – check”

    Mr. Trump has a lifetime of this behavior dating back to early adulthood (see numerous publications/interviews in which he exhibited these patterns early in his adult life).

  • With all due respect, if Donald Trump does not meet the DSM V criteria for Narcissistic Personality Disorder then the diagnosis is meaningless.

    Pervasive pattern of grandiosity – check
    Lack of empathy – check
    Grandiose sense of self importance (exaggerates achievements and talents…etc) – check
    Is preoccupied with fantasies of…brilliance… – check
    Believes that he is “special”… – check
    Requires excessive admiration – check
    Has a sense of entitlement – check
    Is interpersonally exploitative – check
    Is often envious of others… – check
    Shows arrogant, haughty behaviors or attitudes – check
    Occurred since age 15 – check

    His dysfunction CLEARLY causes him significant distress as evidenced by his erratic behavior and his emotional statements in response to perceived “slights” against him (among other evidence). His ability to function in both professional and personal situations is impaired by his disorder.

    As an aside, I also do not buy the argument presented by certain members of our profession that a diagnosis cannot be made in this case because he is not “my” patient/is not in treatment. This is done all the time!: for example, patients are transported involuntarily to ER settings evidencing dysfunctional behaviors who refuse to participate in evaluations. Patients are routinely given diagnoses based entirely upon observed behavior/statements made by the patient combined with collateral information from friends and family. In the case of Mr. Trump, we have unprecedented quantities of information regarding his mental state as he is constantly sharing his thoughts and feelings through “tweets” and other media. We have countless videos documenting his behavior combined with collateral information from those who work with him.

    Without question, Mr. Trump is SEVERELY personality disordered and clearly meets all criteria for Narcissistic Personality Disorder (as much as any person ever met these criteria).

  • Um , the president is mentally ill. His object constancy is completely out of whack. I’m a layman. How can you not see this?

    • Do you also diagnose cancer and epilepsy? The cliche is that “mental illness is like any other illness,” but most people do not diagnose any other illness based on observing a person’s behavior on television, nor do physicians who are not shrinks.

  • These comments seem to imply most of you yourselves have problems not only in diagnostic skill but in merely evaluating the real world and politics. I recommend reading daily the Wallstreet Journal and other well-researched papers and journals and turn off CNN and CNBC.

  • Your classification paradigm, “To qualify for narcissistic personality disorder, an individual’s selfish, unempathetic preening must be accompanied by significant distress or impairment.” seems needlessly narrow and quite probably idiosyncratic. My own observation of this president’s mental state is that he is continuously distressed, to the point of constantly making vehement, punitive, and potentially hurtful comments about his “enemies”.
    This distress has a profound retributive component, causing others great pain, regardless of their culpability. What puzzles me is that you don’t see fit to classify his obvious ongoing and dangerous levels of distress as a precise match to your own definition, “…must be accompanied by significant distress or impairment.”, to diagnose him with narcissistic personality disorder.
    Please explain.

  • Whilst I see what you are saying here, Dr. Frances, I’m fairly confident you see things quite differently at this point. No person with experience in dementia patients would not recognize the quite obvious signs. And as we have seen more of his behaviors, there can be no denying something is VERY wrong with our president.

    I have many years of diagnostic experience and neuropsychological diagnosis. It is so blatantly obvious to me that our president absolutely is a very strong candidate for personality disorder(s) and for dementia. Listen to his language, watch his find and gross motors, watch how many times he loses track of who is in the room, of what is being said, of why he is at a function or event. Check YouTube for videos of him wandering off in the same way that had families bring grandpa to me for assessment. Even his eye movements tell a story… it’s ALL there for anyone to see and hear. And now we see he is having difficultly with reality.

    We have conservative media creating a version of reality that you and I know is utter fiction. That harms us all – not only Americans. We are seeing a massive rise in hate crimes, obviously inspired by his hateful and racist rhetoric. We see, because of his severe limitations of cognition and moral character, a wholesale abuse of migrants fleeing extreme danger. We are witnessing 42% of Americans sink into a comfortable tribalism that tells them white people are the true Americans.

    What are you waiting for? A florid psychosis? Do you want to see him forget his name? He already looks like a stage 3, maybe 4 dementia patient to me. I’ve diagnosed hundreds of them. You know diagnosis is largely about observable behaviors. Well, Dr. Frances… observe!

    This is a true emergency. If we mental health experts don’t speak up, we are abdicating a sacred duty we have to protect the public. We must not stand silent. You see a person completely devoid of conscience, in obvious severe and accelerating cognitive decline, and a person with a cruel sadism to the extent that we all can see his schadenfreude.

    I hope our representatives write a law that all presidential nominees are screened for mental and neurological impairment. It was obvious to most mental health professionals from the start that something was very wrong with him. It’s only gotten worse.

    It’s time for you to amend this, Dr. Frances. It is now so egregious, no mental health expert can, in good conscience, remain silent. I hope you will do so.

    • Dementia is evidence of brain damage, so it is no more a “mental illness” than is epilepsy (though psychiatrists imprisoned epileptics) or chronic traumatic encephalopathy. There is no test for early state dementia that produces results on which all neurologists would agree. That’s because people exhibiting what might be symptoms are sent for things like psych evaluations rather than being given biological or anatomical tests. It’s all very subjective and “mental health experts” really have nothing useful to offer.

A roundup of STAT’s top stories of the day in science and medicine

Privacy Policy