The New York Times recently published a now widely-circulated letter authored by psychiatrist Dr. Allen Frances. This letter was written as a response to an earlier publication signed by 33 mental health professionals expressing their informed opinions that Donald Trump is not mentally fit to serve as president.
Dr. Frances dissents to this judgment, arguing that Trump does not meet diagnostic criteria for mental illness and that asserting so is stigmatizing to true sufferers. I’ve seen several friends and acquaintances cite Dr. Frances’ letter to back up their belief that Trump is not ill, but simply malevolent. I fully agree that mental illness cannot and should not be equated to evil, and that stigma against sufferers is a serious issue–and one that I am personally affected by on a regular basis. But as a person with higher education in psychology, I take exception with some of the claims and assertions that Dr. Frances employs to reach this conclusion.
Most amateur diagnosticians have mislabeled President Trump with the diagnosis of narcissistic personality disorder. I wrote the criteria that define this disorder, and Mr. Trump doesn’t meet them.
Firstly, Dr. Frances’ involvement with the formulation of the diagnostic criteria is overstated. Contrary to what the majority of the headlines I’ve seen on this will have you believe, no one individual writes the DSM criteria for any disorder, no matter how experienced and knowledgeable they may be. This page from the American Psychiatric Association describes how the diagnoses found in the Diagnostic and Statistical Manual are developed and updated. The diagnostic criteria contained in each edition of the DSM are formed by committee of experts based on the cumulative results of research conducted by dozens or hundreds of individual research teams and institutions. Dr. Frances was part of this committee for the DSM-IV (he headed it, in fact), but he was not by any means the sole author of the criteria as his letter insinuates. Further, the edition of the DSM he worked on was published in 1994, and the criteria for many diagnoses–including NPD–have since been updated in the newest edition, the DSM-V (2013).
Like any other science, psychology is a highly collaborative field and no one expert may establish theory without consensus from dozens or hundreds of other researchers, statisticians, practitioners and other experts. It seems that Dr. Frances relies on the relative ignorance of the average NYT reader about the internal dealings of clinical psychology and psychiatry in order to establish himself as the premier authority on this matter.
He goes on:
[Trump] may be a world-class narcissist, but this doesn’t make him mentally ill, because he does not suffer from the distress and impairment required to diagnose mental disorder. […] Mr. Trump causes severe distress rather than experiencing it.
Many mental health experts (I suspect most but I can’t say for certain due to lack of polling data at my disposal) would disagree with Dr. Frances that mental illness cannot be diagnosed unless the individual in question experiences personal emotional distress. Social workers and clinical psychologists often go by the maxim, “Mental illness negatively impacts one’s ability to live, to work, and to love.” The negative impact often takes the form of emotional distress, but not necessarily. Emotional distress is not an absolute requirement for mental illness. Most illnesses will cause emotional distress in one form or another so it can be a good indicator, but not all illnesses conform to this characteristic, and the degree of severity matters.
For example, people with mild to moderate bipolar disorder sometimes shun treatment because during hypomanic or manic episodes the person feels exuberantly happy, requires little sleep and can be extremely productive at work. It’s a positive experience for them, and mood stabilizing medication removes these highs (as well as the not-so-pleasant lows) from the person’s emotional experience in order to achieve a stable average. The average manic episode does not cause emotional distress–more severe ones might due to psychotic symptoms, but that’s another topic–but it does cause a negative impact on the person’s life by increasing impulsiveness. People in manic episodes are prone to engaging in behaviors like compulsive shopping, excessive gambling, unsafe sex, reckless driving and other risky behaviors—which of course, negatively impacts their ability to live, to work and to love.
The first page of this document published by the American Psychiatric Association in 2012 lays out the characteristics of personality disorders in general as found in both the DSM-IV and V. Even within the framework of the DSM-IV (the edition Dr. Frances worked on), distress was not a requirement for a personality disorder diagnosis. Criterion C in the DSM-IV criteria states that:
The enduring pattern [of inner experience and behavior] leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
“Or impairment” being the operative words there; according to the DSM-IV distress was sufficient but not necessary for the diagnosis of a personality disorder. The most recent edition of the DSM does not contain any references to distress, which you can confirm yourself by following the above link. I am not privy to the exact reasons why it was dropped, but typically criteria are removed from the DSM because they are not found to lead to increased accuracy of diagnosis.
The criteria specific to narcissistic personality disorder, found on pages 9 and 10 of the above document, also do not specify that the affected individual must experience personal emotional distress in either the DSM-IV or the DSM-V. I believe Dr. Frances might benefit from a refresher course in the criteria which he and the media would have you believe he personally and solely authored.
Furthermore, how can Dr. Frances be sure that Mr. Trump does not, in fact, experience any emotional distress? This seems to be an assumption based on Dr. Frances’ personal interpretation of Trump’s character and success in his career. I find it curious that despite having not seen Mr. Trump in a professional psychological setting or even knowing him personally, Dr. Frances is willing to make a positive claim about his mental state, the very action that he cautions other mental health professionals against. He also seems to assume that a mentally ill person would not be able to maintain a high-pressure or high-prestige career, which is in itself stigmatizing. In fact, financial success is positively correlated with narcissistic traits, so narcissists might actually be more likely to hold high-power positions than non-narcissists.
I am not taking the positive position that Trump does in fact suffer from NPD–in fact, neither are the authors of the letter he’s responding to, which never mentioned NPD or any other specific illness. I am simply asserting that Dr. Frances’ objections to the professional opinions of other mental health experts are not well-founded, and that if he wishes to demonstrate the veracity of his claim, he should provide more convincing evidence.
There is one aspect of the letter that I can agree with, though:
It is a stigmatizing insult to the mentally ill (who are mostly well behaved and well meaning) to be lumped with Mr. Trump (who is neither).
Setting aside the last parenthetical, I fully support Dr. Frances’ efforts to separate mental illness from ill intent. The vast majority of people with people mental illness are far more likely to be the victims of violence than to perpetrate it, and if they do hurt anyone, it will most likely be themselves. Behavior varies widely between diagnoses, so of course it’s counterfactual and unfair to treat your loved one with depression as if they might commit a shooting the next time they have a bad day. Even if Trump does have some flavor of illness, that doesn’t make all, or even most, other people with mental illness equivalent to him. When I worry about being a burden on my loved ones because of the thoughts and behaviors my illnesses cause, my therapist tells me that it’s not a person’s illness that makes them a “bad person”, but their actions.
Dr. Frances is certainly correct that even if Trump’s actions are influenced by some psychological malady, they do not excuse them. If Trump is ill, there’s still a monumental and vital difference between him and your average mentally ill person. Most people with mental illness are self-aware, take personal responsibility when their illness negatively affects others, and actively seek methods of self-improvement. Dr. Frances and I agree that Trump does not fit this description.