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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  • Dr. Frances,

    I do remember studying the Personality Disorders as including that the symptoms must be debilitating to the patient’s own life.

    He must be Bipolar Type II though, yes? He has all the DIGFAST criteria and certainly has no problems functioning, but he does it without ever resting (ie. his early morning Tweets)

  • I am not a doctor, but will pit my personal experience against dusty writings any day. Lived it, damned near didn’t survive. Signs and symptoms are so distinctive they can’t be confused for anything else. No doubt in my mind he’s a psychopath taking everything into account. It’s all there. Such a threat to public safety and our democracy gives me the right as a citizen to sound the alarm while politicians sit on their hands.

  • You must be joking. Or working for the NSA. You’re doing the exact thing professionals have warned against and taken a pledge against, namely the Goldwater rule. Making a pat diagnosis based on no personal interactions or observations whatsoever. #fail

    • Perhaps Dr. Frances should have said that he is not making an official diagnosis from afar, but that he is using his observations to caution and to exercise his professional Duty To Warn. There is no need for you to be so harsh.

    • Nevertheless, he did make a public diagnosis and DID break the Goldwater Rule. Shameful! That and he clearly made a bad diagnosis to boot.

  • “Narcissist: psychoanalytic term for the person who loves himself more than his analyst considered to be the manifestation of a dire mental disease whose successful treatment depends on the patient learning to love the analyst more and himself less.” — Thomas Szasz

  • You cannot declare a diagnosis of “not mentally ill” because you have not examined him. In the same way other psychiatrists cannot declare a diagnosis because they haven’t examined him, neither can you declare a lack of diagnosis. Basic logic.

    • More concerning is the fallacy that “the mind” is a thing that can be “examined” and “treated.” That’s why no psychiatric diagnosis can be validated by any physical test, and why “mental illness” diagnoses can appear and disappear as if by magic. It’s why Dr. Frances said that trying to define a mental disorder is “bulls–t.” It’s why actual brain diseases — not disapproved behaviors — are treated by neurologists.

      As psychologist Robert Baker put it: “The assumption that mental health is synonymous with physical health is a catastrophic mistake and a glaring failure to understand the basic nature of the human being.”

      “Examination” is the psychiatric expropriation of medical language, which refers to nothing more than observing and engage in conversation. After the examination comes the pretense that drugs solve life’s problems.

  • Very well communicated Dr. Frances. I have referred to the DSM(s) often in the past and admire the way they are written.
    Perhaps the issue in this case is that we should never have such a narcissistic person like Trump in such a high position of leadership. I don’t know if Hitler had similar traits but I can’t help think that possibility existed as well.

    Mike Heck

  • I’m not a doctor and unqualified to debate the topic. All I have is my personal experience and what Mayo Clinic and other professionals have written. I encountered a sociopath 30 years ago and it still haunts me. It was indescribably destructive for life, mind, and family. Since then I learned sociopath and psychopath are used interchangeably for antisocial personality disorder. There is no mistaking those signs and symptoms. Clinicians sometimes differ in their opinion of a definition. For me, it’s all too real. When I see it now, I have to say something. And I see it in Trump. The danger is incontrovertible. That’s all I have to offer.

  • There are many discrepancies between the DSM-V (2013) and the DSM-III (1978). Various criteria have changed and been altered. And I’m sure the Ethical Principles of Psychologists and Code of Conduct would have something to state about the violation of Standard 5.04.

  • I read the article prepared to dispute, but the author has made a believer out of me. But i dissagree on one point. I strongly believe Trump’s tarnished dialog and inability to articulate is quite deliberate. It reflects the class in which, and from where, he regards his constituents. He “knows” they are ignorant and this is how he relates and holds them.

    • Linda Lee, the one redeeming quality that I can give to Trump is that he recognized the great discontent and anger in our country about our political system. And he exercised that knowledge by stirring up the anger, thus creating his “base”. All he needs to do to keep his base riled up is to simply use his narcissism to denigrate anyone and everything to make himself look bigger and better, thus confirming and validating their votes.

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