Donald Trump has spawned a new industry, what might be called Trumpology — the study of his mental state and personality. Numerous pundits have suggested that the Republican presidential nominee has some kind of mental illness or medical condition that explains his boastfulness, intemperate outbursts and thin-skinned response to criticism. A recurring theme among these commentators is that Trump displays textbook signs of what psychiatrists call “narcissistic personality disorder.”
Not that Hillary Clinton has been spared the long-distance psychiatric evaluations. A recurring meme on conservative blogs is that she suffered brain damage during a fall several years ago. Trump himself mocked his Democratic opponent on Saturday for her comment that she had “short-circuited” when discussing the FBI investigation of her use of a private email server while secretary of state. Trump pointed to his head and said, referring to Clinton, “The people of this country don’t want somebody who is going to short-circuit up here.” He later added, “She is a totally unhinged person. She’s unbalanced. And all you have to do is watch her, see her, read her.”
But psychiatric kibitzing is a slippery business. Largely lost in the conversation about Trump is the fact that a personality disorder is not a mental illness, strictly speaking. A candidate could be a narcissist, but that wouldn’t make him “crazy,” as most people understand the word.
And though Trump’s critics say he provides a steady stream of evidence that he’s obsessed with his popularity, craves affirmation and has many other attributes of a narcissist, “narcissistic personality disorder” is such an ambiguous condition that the American Psychiatric Association nearly eradicated it six years ago from its official diagnostic manual.
That happened as the APA was revising the Diagnostic and Statistical Manual of Mental Disorders, which included 10 personality disorders. An expert working group wanted to get rid of five of them, including narcissistic personality disorder.
The ensuing debate exposed a basic truth about the entire category: Personality disorders are not mental illnesses in the way that depression and schizophrenia are, for example. Mental illnesses are conditions of the mind, fundamentally disrupting a person’s inner thoughts and feelings, and usually have a biological origin. Brain scans can discern physical changes often associated with mental illnesses. Medication can treat them in many cases.
By contrast, personality disorders are not amenable to drug therapy. Nor have neuroscientists found any obvious biological underpinning or any gene associated with them. There also are no physical tests for a diagnosis.
Clinical psychologists and psychiatrists had long used a checklist approach. The fourth edition of the diagnostic manual listed nine common traits for narcissistic personality disorder, including “a grandiose sense of self-importance” and “requires excessive admiration” and “lacks empathy.” Generally, a person demonstrating at least five of those traits could be diagnosed with the disorder.
In 2010, some experts felt that too many of those markers overlapped with the traits seen in other personality disorders. Another objection: There were just so many narcissists in American society that labeling the condition as a disorder made no sense, they said.
Other psychiatrists pushed back, however, and the plan to drop narcissistic personality disorder was abandoned. In fact, all 10 disorders remained when the DSM-5 was published in 2013 — including paranoid, borderline and dependent personality disorders.
All human beings have personality traits. A personality disorder reflects long-standing patterns of behavior that developed early in life and differ significantly from the societal norm. There is no specific point at which self-absorption and grandiosity become pathological.
Long-distance psychiatry is necessarily fraught, and the leaders of the profession frown on it. In 1973, the APA adopted the “Goldwater Rule,” which referred to a 1964 controversy in which many psychiatrists participated in a survey asking whether presidential candidate Barry Goldwater was mentally fit to be president. In a blog post last week titled “The Goldwater Rule: Why Breaking it is Unethical and Irresponsible,” APA President Maria A. Oquendo reiterated that psychiatrists shouldn’t offer opinions about candidates they have not personally examined.
The rule states, in full:
On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.
Part of the difficulty of diagnosing personality disorders comes because so many people, at one time or another during their lives, exhibit some of the characteristics. Moreover, the prefrontal cortex of the brain, which controls executive function, can shrink with age, and an elderly person can experience personality changes that resemble a personality disorder, including a tendency to be a know-it-all or reflexively negative.
Personality disorders are difficult to treat. Narcissists, for example, don’t generally show up at a psychiatrist’s office complaining of arrogant self-centeredness and an inability to accept the idea that they might be wrong about something. When they do seek help, it’s because their personality disorder makes them more susceptible to issues like depression and anxiety.
Peter Freed, a psychiatrist at Columbia University and the Personality Studies Institute in New York City, says he treats a lot of “covert narcissists.” They come in for “rage, depression, bad relationships,” and it typically takes many years before they realize that their core problem is narcissism.
“People are in treatment with me for eight to 10 years. It’s like learning a religion — a religion of one, letting go of an omnipotent god of one,” Freed said.
(The Washington Post)