Diagnosing Trump: A Reply

The issues of diagnosis are much more complicated than some imply.

Posted Jan 08, 2018

In multiple venues, the psychiatrist Dr. Allen Frances has made a strong public case that to diagnose Donald Trump with Narcissistic Personality Disorder (NPD) is an amateur error. Since he wrote the criteria in the DSM, his expert opinion rightfully carries much weight. However, as a fellow professional who believes the so-called amateurs have a case to make, I would like to offer some reflections about why this is much more complicated issue than Frances’ arguments suggest.

Let’s start with the fact that Dr. Frances acknowledges that Trump meets many if not all of the standard descriptions of NPD, such as being grandiose and having the need to feel special, having poor empathy and exploiting others, feeling entitled and envious, and so forth. Frances states that “Trump is all this in spades,” and a “world class narcissist.” So far so good, as it means he and I are seeing the same behavior.

But Frances goes on to point out that there is a very important criterion that is missing that many overlook, which makes diagnosing Trump misguided. The criterion is that the features associated with NPD must “cause clinically significant distress or impairment.”

Instead of distress or impairment, Dr. Frances argued that Trump has been rewarded by “fame, fortune, women, and now political power.” And because of this and because he is not in distress about it (at least as far as we know), then, case closed. No diagnosis. The issue is not that he is “mad,” Frances tells us, but that he is “bad.” He is incompetent and ineffective. But don’t call him “crazy.” (Frances is very critical of Trump as a politician).

My problem with this analysis is that the issues are far more complex. In his clear rejection of diagnosing Trump and his characterization of those who do as “amateurs,” he is giving the public the impression that those in the know are in clear agreement on this issue because of professional consensus.

He is wrong. I am an expert clinician and diagnostician, and the issues are enormously complicated. It is worth noting that I am a clinical psychologist rather than a psychiatrist and the two professions often see these issues differently. But my message is that these issues are unresolved among mental health professionals.

To understand why the issues are complicated, let me start with the concept of mental disorder itself as a very murky one. That is, there is no generally agreed upon definition of what constitutes a mental disorder, and Dr. Frances should tell the public as much. After all, he is well aware that this is the case.

Consider that a few years ago, he, along with James Phillips, invited 23 scholars from a broad range of disciplines to respond to the question “What is a mental disorder?” (Phillips et al., 2012). Frances’s opening summary captures the essence of the discussion that followed: “When it comes to defining the term ‘mental disorder’ or figuring out which conditions qualify, we enter Humpty Dumpty’s world of shifting, ambiguous, and idiosyncratic word usages. This is a fundamental weakness of the whole field of mental health” (Phillips et al., 2012, p. 24).

Dr. Frances then argued—with a touch of sarcasm—that a mental disorder is “what clinicians treat and researchers research and educators teach and insurance companies pay for. In effect, this is historically how the individual mental disorders made their way into the system” (Phillips et al., 2012, p. 24). Frances’s definition is not intellectually satisfying, and has implications that are quite problematic. By his definition, if we deemed red hair to be a problem and treated people for the distress of having red hair, then being a red head would be a mental disorder.

Dr. Frances’ conception that mental disorders are what mental health professionals treat connects to his analysis of Trump. Note that, for Frances, one of the big issues is that Trump is not in distress and is not seeking treatment. Indeed, let’s use this point to generate a thought experiment that shows why the issues are much murkier than Frances’ suggests. To see this clearly, all we need to do is imagine Trump having a mental breakdown. So, let’s say the special counsel finds some stuff that Trump did wrong and he gets impeached, and that creates more problems and then Melania asks for a divorce, and, lo and behold, Trump starts feeling worse and worse. Not an impossible future to imagine.

Let’s say ultimately Trump sucks it up and decides to go to see a psychiatrist like Dr. Frances, and reports that he feels lousy. He is alone and his life was ruined relative to how he hoped it would turn out. And he is now thinking about killing himself. Now, according to Dr. Frances’ analysis, Trump definitely is “crazy.” That is, now he would be an absolutely clear case of an NPD. In fact, it would be more or less a textbook case of a “world class narcissist” who has crashed and burned.

My point is that, according to Frances, it is only if Trump starts to become miserable about an aspect of who he is that he is “crazy.” This is not something that every scholar on the concept of mental disorders is comfortable with, especially when it comes to the personality disorders. Many see the problem with these conditions being a lack of insight, which makes all these issues very fuzzy.

Indeed, I ask readers to reflect on this implication. Does the idea that Trump has an NPD only after he starts feeling bad about it make good sense to you? Consider, for example, that a direct quote from Trump is that he does not like to analyze himself because he might not like what he sees. According to Frances's conception of “crazy,” if all of a sudden Trump had what some of us might call an enlightened moment of insight, and started to reflect on himself and who he was and how he treated people and then started to feel miserable, then he would indeed be diagnosable because he would see himself in a new light and feel bad about how he treated others.

That might be the definition of “crazy” to Frances. But to me, the issues are very complicated. The idea that Trump would feel “bad” about being “bad,” should not necessarily be the thing that causes us to label him as “mad.”  

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