It is considered unethical and unprofessional for psychiatrists to hand out opinions about public personalities from afar. This rule was broken recently, with regards to, of course, Donald Trump.
Letter to the editor
A letter to the editor in The New York times, signed by Lance Dodes, an addiction psychiatrist, former Harvard assistant professor (and 34 other professionals) on the 13th Feb 2017 stated:
“Silence from the country’s mental health organizations has been due to a self-imposed dictum about evaluating public figures (the American Psychiatric Association’s 1973 Goldwater Rule). But this silence has resulted in a failure to lend our expertise to worried journalists and members of Congress at this critical time. We fear that too much is at stake to be silent any longer.”
“Mr. Trump’s speech and actions demonstrate an inability to tolerate views different from his own, leading to rage reactions. His words and behavior suggest a profound inability to empathize. Individuals with these traits distort reality to suit their psychological state, attacking facts and those who convey them (journalists, scientists).”
“In a powerful leader, these attacks are likely to increase, as his personal myth of greatness appears to be confirmed. We believe that the grave emotional instability indicated by Mr. Trump’s speech and actions makes him incapable of serving safely as president.”
A strongly-worded response to the letter
A pretty badass response came in the next day, 14th Feb 2017: a follow-up letter to the editor from Allen Francis, who wrote much of the DSM IV, including the diagnostic criteria for Narcissistic Personality Disorder. Much as the DSM IV has its flaws, this guy is really on point, in my more than humble opinion:
“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.”
“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.”
Should psychiatrists stay silent?
Looking down from her moral high ground on the 2 lads in a newspaper fight is the president of the American Psychiatric Association, Maria A Oquendo, who pointed out that while she could understand the desire to “get inside the mind” of a presidential candidate, having psychiatrists comment publicly about people they have not examined threatens to erode the public’s confidence in the profession.
“Simply put, breaking the Goldwater rule is irresponsible, potentially stigmatizing, and definitely unethical,” she wrote.
As for me, I believe that, psychiatrists shouldn’t be analysing living political figures – as psychiatrists. As people with opinions, however, I feel they should be heard – just like anyone else. They also happen to be very good at analysing people’s behaviour. It is up to the reader to understand that this is not an excerpt from Trump’s personal medical files, instead it is just another opinion made legitimate by our commitment to free speech.
What is this psychiatric condition they are debating about?
Narcissistic personality disorder is a mental disorder in which people have an inflated sense of their own importance, a deep need for admiration and a lack of empathy for others. But behind this mask of ultraconfidence lies a fragile self-esteem that’s vulnerable to the slightest criticism. For those of you not familiar with the DSM, it is a (the?) diagnostic guide for psychiatrists. We are currently of the 5th edition. Here are the criteria for NPD:
The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose narcissistic personality disorder, the following criteria must be met:
A. Significant impairments in personality functioning manifest by:
1. Impairments in self functioning (a or b):
a. Identity: Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal may be inflated or deflated, or vacillate between extremes; emotional regulation mirrors fluctuations in self-esteem.
b. Self-direction: Goal-setting is based on gaining approval from others; personal standards are unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations.
AND
2. Impairments in interpersonal functioning (a or b):
a. Empathy: Impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- or underestimate of own effect on others.
b. Intimacy: Relationships largely superficial and exist to serve self-esteem regulation; mutuality constrained by little genuine interest in others‟ experiences and predominance of a need for personal gain
B. Pathological personality traits in the following domain:
1. Antagonism, characterized by:
a. Grandiosity: Feelings of entitlement, either overt or covert; self-centeredness; firmly holding to the belief that one is better than others; condescending toward others.
b. Attention seeking: Excessive attempts to attract and be the focus of the attention of others; admiration seeking.
C. The impairments in personality functioning and the individual‟s personality trait expression are relatively stable across time and consistent across situations.
D. The impairments in personality functioning and the individual‟s personality trait expression are not better understood as normative for the individual‟s developmental stage or socio-cultural environment.
E. The impairments in personality functioning and the individual‟s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).
A millennial's musings 
I feel like clinicians should be able to comment and offer their opinions with carefully worded disclaimers that they are in no way based on actual clinical interactions but rather on assumptions, speculation, and observation of socially observable behavior. I think any time there’s a way for a clinician to illustrate what they see as an example of a clinical concept they should take that opportunity to make it accessible to the public who’s not had the opportunity to study psychology academically. But it should be done carefully, with (perhaps excessive) disclaimers attached. That’s just my opinion. I get why they don’t, and I understand the reasoning. I just think that the public loves to learn about psychology. It’s interesting. So if you can provide accessible education in popular forums, why not? I use my column to do that often. Carefully, but often.
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Exactly, I agree.
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Upon reading the exchange I’m prone to interpret that this DSM poses a rather constrictive set of constraints. I look at the Drumpf’s behavior, and have read much of the analysis and consider that he, as we all, are composites of what this DSM must label as “disorders”.
The Drumpf surely exhibits narcissistic behaviors. As well as sociopathic tendencies too. Those, in concert with the bloviating incoherence of his speech, must certainly point to a whole bevy of personality traits, none of which one would admire.
The fact that the balance of his behavior falls on the wrong side of rational, empathic or even consistent would seem to me to invite anyone to comment — the more expert the better.
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I agree. Freedom of speech is freedom of speech!
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I am asking because I am not sure of my facts, but is it not a fact that many CEO’s have narcissistic and/or sociopathic tendencies, if not a confirmed diagnosis? A President is in a way a CEO, even if he is a humanitarian too. And Trump does not come from a political background. Surely the medical opinion should not have been considered a far reach at all.
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You’re right. The point the second psychiatrist is making is that Trump has tendencies of a narcissist, but he isn’t mentally ill. In other words, there is a difference between narcissism and NPD, the same way there is a difference between being a bad person and being mentally ill.
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The thorny issue is the DSM concept of Axis II “personality disorders” rather than Axis I disorders such as depression, schizophrenia, etc. Frankly, I would say that most politicians (as well as public figures, such as high level business people, entertainers, althletes) have to have narcissistic traits to excel to the positions of prominence. That does not mean that they have an Axis II Narcistiic Personality Disorder (I recall that President Clinton was labeled such for his rationalization about his sexual behavior).
From my early years as a therapist (occupational), I recall an article from the DSM 2 days called “The Manic Game”, or something like that. It was about the personality features that people who were in manic states were likely to display. I shall has to see if I can find that in my files.
As to narcisism in various Axis I diagnosis, I have observed that many people experience their distorted thinking (as viewed from those of us who believe that we have some insight about ourselves) in self-referential manner. Obviously, those in a manic state are all-about-me, in their impulsive and destructive spending sprees, sexual exploits, business deals, etc. Yet, I also see self-centeredness as a theme in paranoid delusions (e.g. they are out to get me because I am so important). Depression has a self-centered characteristis (e.g. I feel rotten because my beliefs about life are not upheld by my experiences). I suspect that there are neurochemical-pathway phenomenon going on that link narcisism to other brain functions.
To deal with my own dispair about our state of affairs, I recently pulled out a 1970’s French movie, “The King of Hearts”. It is a hilarious social commentary on the Liberation of France at the end of WWI, in which the Germans and Brits inihilate each other and the towns people who survive are those who escape back into the local asylum. Of course, there was no DSM to reference then.
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That’s very interesting. I completely agree with you in terms of your use of the DSM.
As for a strong sense of self, I am not sure whether it’s a good or bad thing. It would seem obvious to magnanimously assume that it’s a negative, but why does it exist then? I always wonder what animals’ sense of self is like.
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