NYTimes Letter: Chairman of DSM-IV committee says Trump isn't crazy, just a dangerous asshole

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https://www.nytimes.com/2017/02/14/opinion/an-eminent-psychiatrist-demurs-on-trumps-mental-state.html?ref=todayspaper&_r=0

To the Editor:

Fevered media speculation about Donald Trump’s psychological motivations and psychiatric diagnosis has recently encouraged mental health professionals to disregard the usual ethical constraints against diagnosing public figures at a distance. They have sponsored several petitions and a Feb. 14 letter to The New York Times suggesting that Mr. Trump is incapable, on psychiatric grounds, of serving as president.

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. He 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 and has been richly rewarded, rather than punished, for his grandiosity, self-absorption and lack of empathy. 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).

Bad behavior is rarely a sign of mental illness, and the mentally ill behave badly only rarely. Psychiatric name-calling is a misguided way of countering Mr. Trump’s attack on democracy. He can, and should, be appropriately denounced for his ignorance, incompetence, impulsivity and pursuit of dictatorial powers.

His psychological motivations are too obvious to be interesting, and analyzing them will not halt his headlong power grab. The antidote to a dystopic Trumpean dark age is political, not psychological.

ALLEN FRANCES

Coronado, Calif.

The writer, professor emeritus of psychiatry and behavioral sciences at Duke University Medical College, was chairman of the task force that wrote the Diagnostic and Statistical Manual of Mental Disorders IV (D.S.M.-IV).

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Translation: “I know better than to diagnose psychological problems in someone I’ve never met, but I’m going to do it anyway.”

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Ouch. His pathos isn’t even interesting.

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Exactly. How is saying “I can state with authority that this person I’ve never met or examined is free of mental illness” any more responsible than saying “I can state with authority that this person I’ve never met or examined does have a mental illness”?

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The key to Frances’ POV:

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).

It’s a bit of driving trollies, maybe, but he’s got a point that it’s not an illness, in the DSM guidelines, if The Resident isn’t actually suffering ill effects. It’s us who suffer. This might be a philosophical point the DSM committee needs to revisit.

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Have we received a second opinion from a proctologist yet?

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I appreciate that he’s trying to destigmatize mental illness, but it’s hard for me to believe that he’s right that “the mentally ill behave badly only rarely.” I think it’s probably a lot more true that people with mental illnesses behave badly at approximately the same rate as people without mental illnesses. I’d even buy that it’s a little less, but basically having a mental illness doesn’t stop you from being a raging asshole.

But the first part of the sentence, “Bad behaviour is rarely a sign of mental illness,” is very much true. And the big point - that Trump causes distress in others and is rewarded for doing so - is well taken.

Somewhere out there there is someone who will tell you getting cancer was the best thing that ever happened to them. That doesn’t mean they weren’t sick. If we systemically promoted people with scoliosis to positions with billion dollar salaries and gave them undue political power, it wouldn’t mean that their spines weren’t curved. If we are going to use a disease model to talk about different ways of thinking and feeling, then I don’t see how we can do that without accepting that sometimes getting a disease can be good for someone, even if we still think the disease is bad.

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The worst word you can label Trump by Trump’s standards. Boring.

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He 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.

Bingo.

This is the one thing so many seem to get wrong about clinically defined mental illness. The appending ‘D’ in an acronym for an a DSM diagnosis (MDD, ADHD, SAD) stands for ‘disorder’ which is a formal term in psychiatry. If a person with anxiety, distractibility, or emotional lability doesn’t express any sense of suffering and shows no impairment of global functioning, they do not have a disorder.

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I think we’ve got a problem with the terminology. I have a friend who experiences multiple distinct personalities inside their head that seem to have a relatively equitable arrangement for sharing control of things and getting what they want out of life. That person does not have Dissociative Identity Disorder, because their situation doesn’t cause them problems or distress. However, reading books about dissociative identity disorder helped them overcome some of their internal struggles that were making their lives more difficulty (if not rising to a level they’d describe as “distress”). The organization of their personality isn’t a problem for them, but a similar organization is problematic for others.

I self-diagnose as having Borderline Personality Disorder (my psychologist, after humouring me for a long time on the subject, recently had an epiphany on the matter and I think now agrees with me). I only identified that after reading a long paper on the treatment of BPD that discussed a theoretical underlying organization that leads to BPD. The thing is, I don’t present as having BPD in a way that would meet the definition, and the majority of people I interact with wouldn’t suspect I have any kind of disorder because I seem to get along fine day to day, going to work, raising children, and so on.

But that underlying organization really does cause me a lot of trouble and distress, and I wouldn’t understand myself nearly as well as I do if I hadn’t come across descriptions of BPD that fit my internal problems so well.

Psychiatric diagonoses strike me as diagnosing a person without working legs as having can’t-go-up-the-stairs disorder. The distress is created by the interaction between the underlying organization and the outside world. We look at what an individual can’t do that most people disorders can do. So you’re much more likely to be diagnosed as mentally ill if you are unemployed than if you are employed. Presumably people with late stage cancer are also unlikely to be employed, but we don’t use that to diagnose the illness.

If we looked at these issues through a neurodiversity lens, I’d think that me and my doesn’t-have-DID friend are pretty far out on the same spectrum (whatever spectrum that is). But if we talked to psychiatrists my friend would be told they have no disorder and I be told I’ve got dysthymia (which is a bullshit diagnosis).

Here’s the post from NIMH saying something similar:

https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis.shtml

To bring it all back around to Trump, I think the thing we ought to take away is that we should stop asking if he has a particular disorder, and instead say that reading about NPD seems to help in understanding Trump’s behaviour. There’s a set of terminology used to talk about narcissist behaviour that is useful in talking about Trump. We all know how Trump acts because we’ve been exposed to it so much. Looking for a bucket to put that manner of acting into won’t help. Looking to understand what motivates that way of acting and what future actions you can predict from it might.

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I think he’d take boring over disliked.

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Could he differentiate boring from disliked?

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It’s my layperson understanding that the DSM still does not include “Psychopathy” as a disorder in part because many of the classic traits of psychopathy are impossible to measure objectively. So it seems that Trump could show every indication of being a psychopath without actually meeting the criteria for diagnosable mental illness according to the chairman of the DSM-IV committee.

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More a Typhoid Mary.

I have a close relative who told me he did not suffer the effects of stress, but was aware he was a carrier.

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In that case, maybe we need a new entry in the ol’ DSM-IV: Trump Personality Disorder.

“All the indications are positive for extreme TPD! Worst case I’ve ever seen! Get me the guillotine/elephant enema/other extremely painful treatment, STAT!”

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Are there any combination proctologist/phrenologists out there? You could get two opinions with a single examination…

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Just call him “low energy” since he seems to have trouble doing his job when he’s sleepy.

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These are the criteria for Narcissism in the DSM IV:

A. A pervasive pattern of grandiosity (in fantasy or behavior), need for
admiration, and lack of empathy, beginning by early adulthood and
present in a variety of contexts, as indicated by five (or more) of the
following:

  1. Has a grandiose sense of self-importance (e.g., exaggerates
    achievements and talents, expects to be recognized as superior
    without commensurate achievements).
  1. Is preoccupied with fantasies of unlimited success, power,
    brilliance, beauty, or ideal love.
  2. Believes that he or she is “special” and unique and can only be
    understood by, or should associate with, other special or high status
    people (or institutions).
  3. Requires excessive admiration.
  4. Has a sense of entitlement, i.e., unreasonable expectations of
    especially favorable treatment or automatic compliance with his
    or her expectations.
  5. Is interpersonally exploitative, i.e., takes advantage of others to
    achieve his or her own ends.
  6. Lacks empathy: is unwilling to recognize or identify with the
    feelings and needs of others.
  7. Is often envious of others or believes that others are envious of
    him or her.
  8. Shows arrogant, haughty behaviors or attitudes.

Narcissism is a personality disorder, not a mental illness. I don’t see why the requirement to be suffering from it should apply either, and it isn’t in the DSM criteria for the disorder. These are the general criteria for a personality disorder, which do mention distress or impairment:

A. An enduring pattern of inner experience and behavior the deviates
markedly from the expectations of the individual’s culture. This
pattern is manifested in two (or more) of the following areas:

  • Cognition (i.e., ways of perceiving and interpreting self,
    other people and events)
  1. Affectivity (i.e., the range, intensity, liability, and
    appropriateness of emotional response)
  2. Interpersonal functioning
  3. Impulse control

B. The enduring pattern is inflexible and pervasive across a broad
range of personal and social situations.
C. The enduring pattern leads to clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
D. The pattern is stable and of long duration, and its onset can be
traced back at least to adolescence or early adulthood.
E. The enduring pattern is not better accounted for as a manifestation
or consequence of another mental disorder.
F. The enduring pattern is not due to the direct physiological effects
of a substance (e.g., a drug abuse, a medication) or a general
medical condition (e.g., head trauma).

The DSM V actually removed the requirement for distress and focuses on impairments in relationships, but still; how do we know that he’s not experiencing distress or impairment? Why wouldn’t distress to others, multiple failed relationships with partners and children or distress over criticism from people with no power over him be relevant? Why is impairment an issue anyway, when many disabled people argue that their disability is social rather than inherent? Trump has managed to be very successful financially and politically (particularly in relation to his actual ability), but this wouldn’t be the case if people didn’t have any respect for his grandiose claims.

I realise that armchair diagnoses and using mental illness as an insult are not helpful, but this seems to be going the opposite way. My own diagnoses don’t mean that I am doomed to a life of social isolation and misery, but they are relevant and will affect me throughout my life. America just seems to be a very comfortable and supportive environment for a rich narcissist to be in.

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I have a problem with the requirement that the patient suffer distress, lots of bipolar and Borderline personalities rampage through life leaving a trail of chaos and don’t seem to suffer for it. My sister in law is a rampaging bitch my clinical psych PhD mom has diagnosed as Borderline. She is very successful in her career, but treats every interaction with people as a deathmatch, which most people aren’t willing to play and let her win. If a member of her immediate family crosses her she will give them the silent treatment for months. Her own father loudly said “thank you” when my brother said “I do”. But she seems perfectly happy as long as she’s in control, which she is. Trump has some of this control profile too.

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I think it’s easy to underestimate how much distress people feel, though. If a clinical psychologist was willing to say BPD then they’ve been through a checklist (at least mentally). Try to pick five of the following where you wouldn’t say a person undergoes distress:

  1. frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5. [distress]
  2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation [maybe not?]
  3. identity disturbance: markedly and persistently unstable self-image or sense of self [maybe not?]
  4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, Substance Abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5. [maybe not?]
  5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior [distress]
  6. affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) [distress]
  7. chronic feelings of emptiness [distress]
  8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights) [maybe not?]
  9. transient, stress-related paranoid ideation or severe dissociative symptoms [distress]

I can only get to four without being sure the person experiences distress, and a couple of the ones I say “maybe not” for are really stretching it. Some people take their negative feelings out on themselves and some people take their negative feelings out on others (i.e., almost everyone does both). People with a lot of distress who are very oriented towards taking that out on those around them still actually experience the distress, though it’s considerably harder to feel sympathy for them because they are raging assholes.