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).

  • What a lot of double-speak! Dr. Frances wants to mince words and have it both ways; he says #Tramp is a #Narcissist but is not mentally ill because it doesn’t trouble him any. FFS! I’m not a psychologist, but I know cray-cray when I see it!

    • Hi,

      I think this person is really in the dark. The only think I could tell from his writing is that Trump fits to a tee, but he doesn’t experience distress. Rather he causes distress. That’s what the npd person does best. And they can and do “suffer” internally. I have seen Trump with very thin-skin reactions.

      I think “pure evil” might be a good assessment though, sorry to say.

  • I find it amusing to read these ultra liberal posts; including this author who claim to be professionals, yet are quick to diagnose someone they’ve never met, nor engaged in one session to determine such a diagnosis! While the author continues to badger Trump with being a “poster boy” for NPD, he contradicts himself by saying “Trump is not mentally ill” So, which is it? Until you have actually had (at least) 6 months time with said person, had in depth conversations with him/her, and determined that said person meets all criteria, you should probably stop with your armchair diagnosis, indoctrinating the minds of your readers, just because you do t like his policies. I was no fan of D. Trump, but considering what he’s had to endure, even before he became president, I can’t blame him for the “chip on his shoulder” being accused of racism (show me an actual video) he’s been enduring such hatred, celebrities threatening to blow up the whites house, and killing him…the list goes on, but you liberals target him, because you are the actual mentally ill! It’s called pride. It always leads to iniquity, and all of you are suffering from something we like to call “sore losers” You talk about characteristics of narcissism; but you failed to mention some of those characteristics which your favorite president obama was certainly guilty of. Donald Trump was not elected to be charming; we all know he’s definitely not charming (in other words FAKE) but obama certainly took the cake on charm. Donald Trump was not elected for his excellent public speaking skills, but everyone was blown away by obamas ability to be articulate, and deceptive to large crowds, while he made his way into American government like the Trojan horse. Boy, your obama was good looking, charming, and funny! He hung out with all the superstars, and was worshipped by many. Obama supporter are the delusional ones. Dare anyone say anything I’ll of barack, well they will slander you for the rest of your life! At least Trump supporters will call him out, when he is wrong. Let’s not forget how barack came into his presidency claiming he “inherited” a bad economy; what did he do to make it better? I won’t hold my breath on that. Obama, much like satan, or the devil, was the great deceiver, the liar, the charming prince, cloaked in “Hope and Change” who captured his fans with a lovely smile, cute jokes, seemingly nice disposition and an agenda to destroy our nation from the inside out. If I were you people, I would take your focus off the man who is actually doing the job he was elected to do, and focus on your Congress people. Are you really going to tell me that you think Nancy Pelosi is mentally stable? Are you going to tell me that you think AOC is mentally stable, how about you Illhan Omar or Rashida Tlaib, Maxine Waters, Kamala Harris, and the myriad of racists who made actual racist statements. Democrats who support these people, are infected with such pride, they can’t even admit that they’re wrong! But you people continue to attack the man who has made a difference! Like his personality or not, he’s getting the job done! My suggestion for you is to sit down and do some self assessing; swallow your pride and focus on the real enemy of the American people which unfortunately has become the democratic party.

    • Your response is beyond ridiculous. The writer does NOT think Trump has NPD or a mental illness. He thinks that he’s a jerk. That’s what I got. Having said that, let’s not kid ourselves. Trump has made multiple racist, sexist, bigoted comments. I don’t feel for him at all. I feel he’s a sociopath. And for the record, I think Hillary is a liar. It’s on video. Google the shit both of these people have said and figure it out yourself. Liberal. Liberal. Liberal. That’s all I saw. You are a T supporter.

    • “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.” This is a quote from the author. He said that T-man didn’t fit this, which in his view, is mandatory for a diagnosis. I think he’s full of it, because “distress” is hard to define. And the person that needs to swallow pride is T-man. He has a real complex about everything. He had severe distress based on the size of his hands being discussed. Obsessed with is shows that he has issues. Who the hell cares about his hand size? I know I don’t. And it says nothing about a person. Many great pianists have small hands or stubby ones. But he couldn’t hack that. I suppose that’s liberal propaganda too. Why don’t you critique both sides if you aren’t into T-man?

    • You know, the more I think about this, the more I don’t give a damn whether Donald Tяump fits your textbook definition or not. He is easily the most dangerous narcissist/sociopath/psychopath since Hitler/Stalin/Pol Pot, and he is as malignant and malicious as a metastasized renal carcinoma.

      As far as protecting poor malignant narcissists from stigma because they are “mentally ill”:
      when your mental illness makes you a danger to all of society, the right thing to do is not to coddle you, it is to put you down. Paleontologists tell us that proto-human females put us through a “domestication event” a few million years ago, when they stopped letting themselves be raped by the dominant males and started choosing less aggressive males, reserving their sexual favors for (mostly) one male, in return for that male sticking around and bring food to her and the kids. Apparently our canines are connected to our testosterone levels; in choosing males with less, they chose males with smaller canines, which is why we don’t have much in the way of fangs today.

      I think we need to put Homo”sapiens” through another domestication event: some scientists suggest that psychopathy might have a genetic component? If we can identify a gene for psychopathy, we could test children at birth, sterilize psychos, tattoo a little warning on their foreheads, and in a generation we might not have to deal with them any more. If psychopaths aren’t raising children, we will have fewer sociopaths to deal with. And consider the damage Hitler Stalin Trump et. al. have done and continue to do: If malignant narcissism also has a genetic component, if we could positively identify them, is it really so harsh to suggest we drown them at birth?

    • Hey Lauren, your comments should be removed. I AM A CONSERVATIVE, and women should remain in the shadows. The other women here are liberal,s and there is nothing I can do about it, so hush, and go back to the kitchen.

  • An interesting consideration and I respect your experience and expertise.

    Early in 2019 I met someone who clearly has a covert NPD. It was so blatantly obvious it astonished me she’s been “successful” in life – she’s highly dysfunctional. But she’s from a life of privilege, as is Mr. Trump. Anyway, things were unravelling for her and she was locked in a serious bout of narcissistic rage. I imagine she remains dangerous and I’ve managed to put 1,000 miles between myself and her. Covert NPD can be terrifying and I pity the people who have to deal with her in their lives.

    Trump meanwhile clearly is a model example of someone with a NPD, so your notes were very interesting. It’d be interesting to see you write a followup piece in early 2020. Now the impeachment stuff is on the way.

  • Did Trump pay for this favorable result?

    Trump exhibits dementia and is narcissist.

    I have worked with both DX’s

    • A real narcissist is a man who threatens to find the American people if they don’t purchase his health care plan. I believe you know who I’m talking about.

  • As an adult child of one who had NPD, I disagree with you. I think he fits it perfectly. Now, he might have more than one PD. He might also have APD, but the hold he has on the public shows me his disorder. I don’t believe the social scientists fully know what’s going on with this one. I love sociology and social psychology, so I’m not knocking the social sciences, but this is more complex. It’s hard to study a subject matter that doesn’t wish to be studied. They think they are well, and they refuse to get treatment, stating that they have no issue. My whole life was destroyed from this type of man. Some could see it, but most thought he was great at the uni he taught at. It got worse as he aged, and I think he starting losing some friends. His teacher reviews show me that some students couldn’t take it. My brother has this also.

    Even if you wrote or helped write up the description, there are those of us that lived every day of our lives with people like *rump. I can’t use his name. We know that these people cause more distress than they feel and that distress is hard to measure. For instance, if one loses friendships and acts as though he doesn’t understand why or acts as though he doesn’t care, everyone either feels sorry for him, blames those who left, or doesn’t see that this is a form of “distress” for one with NPD. I’ve seen the weakness in this person. In my life, I’ve seen very few like my father. My father detested the current president, but he was like him. The different was that my father was much more intelligent. If they remove this diagnosis from the DSM, that is just pure stupid. It’s getting worse in society, not better. Taking that out will affect a significant number of victims of such people. At the same time, I never had a psychologist, social worker, or doctor really help me cope, let alone help or at least tell my father. They didn’t understand the “animal” they were dealing with. I tried to explain it, and I recall my therapist losing control after he talked about himself in our meet-and-greet for 45 minutes, leaving me 5 to talk to her. She swore so much, and I asked her what was wrong after she did. She said, “Are you kidding me? He talked incessantly about himself.” I told her that I had warned her. She needed to step up and say, “Ok, it was lovely meeting you.” Better yet, she could have had him come in at the end of the appointment. However, like most, he seemed fragile to her and she didn’t want to or have the guts to confront him. It’s easy to say that a client should “let go,” but live with this type and you find out what it’s like. It’s not the same to clinically evaluate anyone. For you to really conclude about this guy in WA DC, as a doctor, you’d need to examine him. Watching him on tv isn’t really enough. That goes with your title of a provider. Personally though, I feel I have the experience of decades of watching my father and brother enough to make the judgement call. Plus, I’m not a counselor or doctor.

    I agreed with some of what you said, but I wouldn’t say that this is a typical mental illness either. He has NO place in office, and he won’t be removed via the process due to the majority in the Senate. We should have a fitness test. I have suffered with serious illness, in part due to my father, and the other is from pathogen-induced effects on my brain and body. I don’t think even I should be in office. And one could argue some other candidates, like JFK, should never have been in office. I’m liberal, but I’m able to to see the flaws in my candidate of choice. Hillary has lied in an age when we have cameras all around. She has pathologically lied and shouldn’t have been allowed to run. Anyone who says she was shot at by snipers and then says she was sleep-deprived might make serious errors. Or she’s just a liar. I know politicians lie, but she has taken it to new levels. I have real reasons for disliking her and former president Bill Clinton–not that the guy in office didn’t take advantage of the situation. Many already hated Hillary and felt she was corrupt.

    We need some new and better candidates, and I think if a person demonstrates enough nasty behavior publicly and weird statements, he/she/they should be disqualified. Change needs to happen!

  • We only see some of his behaviors. It is probably a good thing we don’t see everything or people would never fall asleep at night.

    • Very true. I wasn’t very certain if he reached NPD level in 2017, but can’t be more sure today. Classic NPD. I always felt his children looked nervous, now I know why.

  • Trump was sent to military school after he hit a teacher — something psychopathic children do. You can’t convince me that this guy isn’t a psychopath. What is scary, aside from all of the chaos he is causing, is that he has access to nuclear weapons.

    Dude, remind me not to make an appointment.

    • Went to an anti-Trump rally the night the senate made him an autocrat. My sign said:

      PLEASE
      TAKE THE
      NUCLEAR FOOTBALL
      AWAY FROM THE
      MALINANT NARCISSIST

      We stuck it out in the cold for an hour or so. One guy in a big pickup laid on his horn and flipped us off as he went by; and a city bus driver with an angry face made big sweeping motions with his right arm as though to sweep us off the bridge, the sidewalk of which we were occupying. Other than that every reaction I saw was positive. And funny how even a car horn can express either solidarity or rage, depending on how it’s applied.

      I’d say the responses we got were encouraging. But then I remember that Tяump’s “approval rating” (among who?) They never ask me….) went up to 48% after the senate crowned him, and I despair for my people again.

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