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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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  • “He may not be crazy, but we certainly were for electing him.” Who is the “we” who voted for Trump.

    There are millions of us who did not vote for Trump. I’m one of them. His campaign was despicable with all that chanting “Lock her up” referring to Hilary Clinton. It’s painful and terrifying to read the news day after day about Trump’s ignorant and dangerous decisions.

  • More politcal garbage and you call this a scientific publication. You should be embarrassed and ashamed of yourselves

  • Political comments not appropriate,welcome or meaningful with any degree of accuracy and really lessen the stature of this publication; for a supposedly scientific publication, this is a recurring theme, almost daily-regrettable,contemptible

  • Interesting article. Yet, no mention of Trump’s delusional obsession with the size of the inaugural crowd, Obama’s bugging of Trump HQ, his penchant for bullying his opponents, and tweeting baseless comments unworthy of the POTUS. Crazy like a fox, or a departure from reality? Are these not signs of a lower level of mental illness, e.g., neurosis?

  • This should be done before elections. I don’t think so that this is now the right way to criticize trump because he is now our president and we all should give respect to him. Although, the majority of the people dislikes him but then how he elected on elections and now we are saying that he is not appropriate according to a psychological evaluation. Don’t know what’s going on!
    Carlene Cromedy – Manager at https://www.themarioninstitute.org/

    • Unfortunately, you like many Trump followers, appear to have the “good German” syndrome. It is always time to speak up when dangerously dysfunctional behaviors can be observed, especially when they impact the welfare of a nation. It doesn’t matter if it is before an election or afterwards. Please stop advocating for the silence of passivity….that is what allows dictators gain power.

  • Many people, like D Trump, with characterlogical mental illnesses, called personality disorders, are in massive denial about their psychological problems. They have structural fault lines in their psyche and show deficits in empathy, reasoning, reality testing and morality. They are in massive denial about the harm they cause others and maintain delusional grandiosity about their superiority. They externalize all problems and blame others/circumstances. If relationships occur, they are master-slave oriented since they must be dominant and adored. (Yes, there is likely early and deep insecurity, loss and neglect but it is buried so deeply, it is rarely uncovered.) Their emotional intelligence is primitive and lacking in insight. Curiosity is rarely evident. We rarely see them in therapy.

    • Exactly! You only see the people they harm seeking help to understand. Trump is very disordered. His pre-frontal cortex seems to be very underdeveloped. I have read that the amygdala of those with NPD tend to be much smaller in size as well which would explain a lot about his all around strange behavior. I would be very interested in seeing a functional MRI scan of his brain or lack thereof. He often speaks like a adolescent would. I would be equally interested in seeing his IQ test results. To me he seems to be very much a dullard. Whatever the case may be, we are all in danger as long as he is allowed a Twitter account. He is so insecure that he must undo EVERYTHING possible that the former president did, good or bad. Don’t even get me started on how he is handling the N. Korea situation. Yes, we all should pray diligently because this guy is not presidential material. He doesn’t have diplomatic bone in his body. Apparently, his advisers are afraid to advise for fear of hearing “You’re Fired!!!!!” God help us all.

  • I don’t care what you wrote, when, or what you used as the basis of your criteria. Mr. Donald J. Trump is not mentally stable given the position he is in. The “position he is in” being the operative and deciding factor. If you used another factor and did not consider the position he is in, you should have your head examined. Just saying.

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