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.
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).
Like it or not, psychology is a ever developing science. It is also teeming with academics who like to argue their point, whatever it is. Butting heads is a time honored tradition.
One piece of DSM-IV cluster B he’s referring to is this. The way NPD and BPD are written in the DSM-IV they are mutually exclusive. Not so in the DSM V. In the DSM V the two dx are more nebulous and there can be overlap. The science has changed.
Personality disorders are still heavily argued and discussed such that there will probably be more changes to them when the DSM-VI happens.
I do agree, there should always be a discouragement from armchair diagnosing for the exact reasons he is stating. And why real diagnoses remain with doctors and not randos on the internet. But what Frances states does not extend to denying what appears to be a highly disfunctional problem that has gone even further off the rails after 8 yrs. That does even more people a disservice, especially now. It would also be weird from a guy, who from the title of his book, is going so far as to question the sanity of an entire nation.
You don’t have to ignore the elephant in the room. That’s an active choice. So is not ignoring the elephant in the room. Media spent a lot of time ignoring that elephant, which is probably, in part, why we are on the bad timeline right now. It is also why everyone with at least one functional limb should probably point to it now.
No one was quiet about Biden. Should no one have mentioned the word Dementia after the Trump Biden debate? Would it have been helpful to ignore it, for the reasons Frances states? Where would we be now if dementia hadn’t been heavily discussed?
Let me reiterate that Allen Frances is in no way “the guy who invented the diagnostic criteria for NPD.” He lead a team that synthesized decades of research into the diagnostic criteria for NPD.
Allen Frances is a brilliant physician, and he’s also only one man airing an opinion about whether or not he believes Donald Trump meets the DSM-IV criterion of experiencing clinically-significant distress across multiple areas of functioning. People should absolutely consider Allen Frances’ opinion, but just because he’s Allen Francis doesn’t make it automatically right.
For example, what happens when someone denies up and down ever having any problems despite blatant evidence to the contrary? Or does having so much money that you never experience social or occupational consequences exempt one from having a personality disorder?
Donald Trump has left a wake of destroyed social and occupational relationships everywhere he has gone his entire life. He has faced continual legal ramifications for his actions for decades, but has always been in such a position of power as to avoid real consequences. Donald Trump, who, Allen Francis notes, “demonstrates in pure form every single symptom described in the DSM for Narcissistic Personality Disorder,” clearly experiences clinically significant distress related to NPD mitigated by wealth and power.
I respect Allen Frances’ work and his opinion. I respect his perspective that psychiatric diagnoses should not be thrown around as political weapons and his distress that they are being used as such. I disagree in this instance, where Allen Francis himself describes Donald Trump as demonstrating in pure form every single symptom, that this is not relevant to discuss, because it literally affects the course of this country and the well-being of people I love. Donald Trump has clinically-diagnosable Narcissistic Personality Disorder. That needs to be part of the conversation when considering whether we should put him back in the White House.
Allen Frances is a psychiatrist who wrote the rules for diagnosing personality disorders in the Diagnostic and Statistical Manual of Mental Disorders. The DSM is the No. 1 tool mental health professionals have for making diagnoses.
Frances, a professor emeritus at Duke, doesn’t mince words about what he thinks of mental health professionals who are now using the DSM to diagnose President Donald Trump with a mental disorder. “What’s going on is bullshit,” he says
“Everyone has a personality,” Frances says. “It’s not wrong to have a personality; it’s not mentally ill to have a personality. It’s only a disorder when it causes extreme distress, suffering, and impairment.”
Trump’s willingness to lie and endless self-promotion are traits that have, so far, worked out largely to his advantage. He’s president of the United States, after all.
Psychologists don’t have such a rule, and Frances — who supports the Goldwater Rule and generally thinks mental illnesses are overdiagnosed — worries that when the petitioners and others call Trump mentally ill, they stigmatize people with psychological problems. They can also distract from the more objective criticisms you can make of his presidency. “Call him a liar, call him evil, call him a threat to democracy, call him impulsive, call him ignorant — these labels are all absolutely true — but saying he has a mental disorder doesn’t really add force to the argument,” Frances says.
Dr. F. Perry Wilson: You authored the DSM criteria for narcissistic personality disorder. This is something that many people have attributed to President Trump. You are not one of them. Do you stand by the assertion that he does not have this disorder?
Dr. Allen Frances: Well, Trump is absolutely a world-class narcissist. He has every criteria met except for two. **In addition to having the features of being grandiose, unempathic, self-involved, selfish, all the things that go into being Trump, you have to have distress or impairment, significant distress or impairment. **
Trump is a man who causes immense distress in others, but doesn’t seem to experience it very much himself. Although he’s created tremendous impairment for our country and for his business colleagues, he, himself, has been very well rewarded in politics and also in business for being a narcissist. I think that it’s reckless for people to attribute the damage he’s causing to mental illness. He’s much more bad than mad.
To lump Trump with the mentally ill is a tremendous insult to them. It stigmatizes them. Most people who are mentally ill are well meaning and well behaved, and really fine people. Trump is none of those. So that when we confuse mental illness with bad behavior, we, first of all, insult the mentally ill, and secondly, we underestimate just how evil Trump is and how dangerous.
I don’t think anyone is denying that these things are said. The argument is Frances is one physician and academic of many with an opinion on the matter.
Doctors and academics argue and debate. It’s kind of a thing.
https://www.statnews.com/2017/09/06/donald-trump-mental-illness-diagnosis/
Like it or not, psychology is a ever developing science. It is also teeming with academics who like to argue their point, whatever it is. Butting heads is a time honored tradition.
One piece of DSM-IV cluster B he’s referring to is this. The way NPD and BPD are written in the DSM-IV they are mutually exclusive. Not so in the DSM V. In the DSM V the two dx are more nebulous and there can be overlap. The science has changed.
Personality disorders are still heavily argued and discussed such that there will probably be more changes to them when the DSM-VI happens.
I do agree, there should always be a discouragement from armchair diagnosing for the exact reasons he is stating. And why real diagnoses remain with doctors and not randos on the internet. But what Frances states does not extend to denying what appears to be a highly disfunctional problem that has gone even further off the rails after 8 yrs. That does even more people a disservice, especially now. It would also be weird from a guy, who from the title of his book, is going so far as to question the sanity of an entire nation.
You don’t have to ignore the elephant in the room. That’s an active choice. So is not ignoring the elephant in the room. Media spent a lot of time ignoring that elephant, which is probably, in part, why we are on the bad timeline right now. It is also why everyone with at least one functional limb should probably point to it now.
No one was quiet about Biden. Should no one have mentioned the word Dementia after the Trump Biden debate? Would it have been helpful to ignore it, for the reasons Frances states? Where would we be now if dementia hadn’t been heavily discussed?
Let me reiterate that Allen Frances is in no way “the guy who invented the diagnostic criteria for NPD.” He lead a team that synthesized decades of research into the diagnostic criteria for NPD.
Allen Frances is a brilliant physician, and he’s also only one man airing an opinion about whether or not he believes Donald Trump meets the DSM-IV criterion of experiencing clinically-significant distress across multiple areas of functioning. People should absolutely consider Allen Frances’ opinion, but just because he’s Allen Francis doesn’t make it automatically right.
For example, what happens when someone denies up and down ever having any problems despite blatant evidence to the contrary? Or does having so much money that you never experience social or occupational consequences exempt one from having a personality disorder?
Donald Trump has left a wake of destroyed social and occupational relationships everywhere he has gone his entire life. He has faced continual legal ramifications for his actions for decades, but has always been in such a position of power as to avoid real consequences. Donald Trump, who, Allen Francis notes, “demonstrates in pure form every single symptom described in the DSM for Narcissistic Personality Disorder,” clearly experiences clinically significant distress related to NPD mitigated by wealth and power.
I respect Allen Frances’ work and his opinion. I respect his perspective that psychiatric diagnoses should not be thrown around as political weapons and his distress that they are being used as such. I disagree in this instance, where Allen Francis himself describes Donald Trump as demonstrating in pure form every single symptom, that this is not relevant to discuss, because it literally affects the course of this country and the well-being of people I love. Donald Trump has clinically-diagnosable Narcissistic Personality Disorder. That needs to be part of the conversation when considering whether we should put him back in the White House.
https://www.vox.com/policy-and-politics/2017/2/10/14551890/trump-mental-health-narcissistic-personality
https://www.youtube.com/watch?v=QdaBsfu44ps
Is that enough proof for you, or do you need angels to descend from the heavens to confirm what all these journalists are saying?
I don’t think anyone is denying that these things are said. The argument is Frances is one physician and academic of many with an opinion on the matter.
Doctors and academics argue and debate. It’s kind of a thing.