By George Drinka, MD, with Ginevra Drinka, PhD candidate
Be sure to check out Part 1.
Returning again to the Goldwater rule regarding the idea that psychiatrists should not diagnose a patient without having interviewed him, I think it best to discuss diagnosis possibilities, prognosis, and treatment options from the perspective of an unlikely hypothesis. Let us imagine for a moment that a psychiatrist named Dr. Muir has interviewed the new president and with his permission videotaped their discussion and then turned to me as a consultant. After pondering both the tape and the transcript of the interview, I would have shared with Dr. Muir my concerns about possible delusions and then driven the matter further.
By definition a delusion is “a false belief based on incorrect inference about external reality that is firmly held despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary.”[i] In many of the instances described above, including crowd size at the inauguration, massive voter fraud all against him, the efficacy of torture, and the portability of Iraqi oil, we find ample evidence that the facts are not as Mr. Trump insists they are.
But what about the phrase “despite what almost everyone else believes?” Let me add another component of the definition: the delusional state is “not held by other members of the operating culture.”[ii] Here is where we must pause and ask a few questions: Is not most of what Mr. Trump obsesses over in this interview simply the beliefs of the so-called Alt Right? Are not these very unusual and even dangerous ideas the ones which Mr. Trump swallows and now presents as his own fixed beliefs? Is he not just mouthing their beliefs?
To the contrary, for at least three of the fixed beliefs cited above and on which Mr. Trump perseverates do not grow out of Alt Right positions. Rather, the fixed beliefs of Mr. Trump to which I refer do not directly concern members of any cultural group like the Alt Right. Rather they concern mostly Mr. Trump. Crowd size, getting Iraqi oil out of the country years ago, and fabulous numbers of fraudulent votes all being cast for Hillary are primarily private idees fixes of Mr. Trump. Probably many of his supporters agree with him on these issues. Indeed they now admire him as a kind of cult leader in their culture war against the elite world that is conspiring against Mr. Trump. But in these instances at least, Mr. Trump has created the delusional material himself rather than simply mouthing the strange beliefs of others.
For a psychiatrist, delusions constitute a very serious symptom. Is there another way of explaining away these strange and false statements of our new president?
One way of explaining Mr. Trump’s poor reality testing, of playing so loose with the truth, is that he is actually lying, prevaricating, acting as a fabulist. Indeed, in other settings before he was president, Mr. Trump was well known to play loose with the facts, often for personal gain. But in the interview with Muir he seems insistent on what he says. He seems sincere, even ardent in pushing forward his points. In fact, he perseverates in these arguments, even getting irritated with Mr. Muir for challenging him. In short, they seem like not just the lies of a scoundrel. Further, when Mr. Muir offers facts that contradict his fervently held beliefs, Mr. Trump does what many delusional patients tend to do. He doubles down. He belittles Mr. Muir by throwing in ABC’s low rating. He tries to turn the tables by positing a conspiracy against him by the media, of which Mr. Muir is a member. When a delusional patient feels cornered and challenges the doctor, we are taught to back off, cool things down, and move on to another subject. And Mr. Muir does just that.
A recent article in the New York Times of January 25[iii] offers us extensive descriptions of how Mr. Trump has been dishonest, conniving and manipulative in his long business dealings, and we can expect the same from him as President. But in the Muir article we witness not simply his intentionally lying and exaggerating but rather his expressing a series of firmly held beliefs not supported by reality that arguably only fit his need of self-aggrandizement, not financial gain, but which will certainly impact negatively on his capacity to lead.
Once a physician accepts at least provisionally that certain utterances by a patient seem like delusions, he or she considers whether the delusions stand as a diagnosis on its own or as part of a larger clinical syndrome such as Schizophrenia, Bipolar or Manic-depressive disorder, or Organic Brain Syndrome.
The diagnosis of organic brain syndrome can be explored further via the administration of a battery of well-known psychological tests, meant primarily to measure cognitive levels of functioning. If unusual test results are gleaned, the referral to a neurologist is indicated.
In terms of schizophrenia and bipolar diagnoses, which are in the bailiwick of psychiatry, further psychiatric interviews would be indicated along with perhaps projective tests in order to delve more deeply into Mr. Trump’s grandiosity and paranoia. Also, his apparent difficulty with abstracting as described above is a symptom of schizophrenia whereas his purported history of sleeplessness, poor anger control and hyper-sexuality are well-known symptoms of bipolar disorder.
But let us assume that these further studies were not definitive and so the diagnosis of a simple Delusional Disorder seems like the best diagnostic fit, where would we go from here?
A good idea would be to attempt to characterize the subtypes of delusions from which Mr. Trump seems to suffer: delusions of grandeur and of persecution. On the one hand, the fact that he already believes just five days into office that he is capable of being more presidential than anyone with the exception of Lincoln is clearly a grandiose statement. Other statements about huge crowd size at the Inauguration and the cheering throng at the CIA headquarters also fit this subtype of delusions of grandeur. On the other hand, he also claims that many groups, including much of the mainstream media, were publishing unfair photos of the Inauguration crowd in order to hurt him. Likewise, the casting of 3 to 5 million fraudulent votes involves a vast conspiracy against him. These delusional statements manifest both the grandiose and paranoid components at once, the two sides of the Trumpian delusional coin.
Once we suspect that the President suffers from delusions of grandeur and persecution, we must ask this question: What is to be done? First and foremost, if my ideas gain any traction, those allied with him will work to marginalize this idea as the delusion of a member of the coastal elite. They will ring the wagons around their hero. But this President, so weighted down with serious pathology, will certainly manifest his deep incompetence very quickly. He will lose support on all sides, not because of his mental incapacity per se but because these mental problems will tend to manifest themselves in the real world through actions. Slowly a consensus will grow among leaders, citizens and professional organizations like the APA that the President has a severe mental illness and that the implications are dire: He will be unable to function properly as President.
Is the President treatable? What we know about both bipolar disorder and schizophrenia is that certain medications and intensive therapy can ameliorate the symptoms of the condition but not cure it. With Organic Brain Syndrome, treatments are only palliative. The symptoms usually worsen over time. With regards to a delusional disorder per se, most medications are ineffective, and indeed with most delusional disorders, the doctor/patient relationship often becomes strained because the patient sees the doctor as part of the plot against him. Often the patient ends treatment abruptly.
I submit that only when the vast majority of the population and our leaders face squarely the severity of Trump’s psychiatric problems, will the public effectively clamor for the president to undertake a thorough evaluation. If he refuses, then the only two ways to proceed are either impeachment or the invoking of the 4th clause of the 25th Amendment of the Constitution.[iv] The impeachment route is a cumbersome and perilous one. First, House of Representatives would vote to impeach Mr. Trump for high crimes or misdemeanors. Then a public Senate trial would ensue, and two-thirds of all Senators would vote to remove him from office.
Another way forward involves invoking the 4th clause of the 25th Amendment. This amendment, added to the Constitution after the assassination of John Kennedy, outlines how the nation confronts a president deemed too incapacitated to serve and removes him or her from office. The sooner this Constitutional amendment of the Constitution is invoked, the better for the nation, since waiting too long and becoming involved in partisan fighting over a President capable of delusional, chaotic, and destructive actions could leave us at risk for him wreaking a whirlwind of utter devastation on the nation and the world in one angry instant.
Dr. George Drinka is a child and adolescent psychiatrist and the author of The Birth of Neurosis: Myth, Malady and the Victorians (Simon & Schuster). His new book, When the Media Is the Parent, is a culmination of his work with children, his scholarly study of works on the media and American cultural history, and his dedication to writing stories that reveal the humanity in us all.
[i] Diagnostic and Statistical Manual of Mental Disorders: DSM-5. (2013). Arlington, VA: American Psychiatric Association.
[iii] Barstow , D. (2017, January 28). ‘Up Is Down’: Trump’s Unreality Show Echoes His Business Past. Retrieved February 4, 2017, from https://www.nytimes.com/2017/01/28/us/politics/donald-trump-truth.html
[iv] The Constitution of the United States of America. (1995). Bedford, MA: Applewood Books.