Medical Examiner

We’ve Misdiagnosed the Problem With Donald Trump

It’s not what’s in his head that matters. It’s what’s in ours.

Republican presidential candidate Donald Trump speaks during a campaign rally at the MidFlorida Credit Union Amphitheatre on October 24, 2016 in Tampa, Florida.
Donald Trump during a campaign rally on Monday in Tampa, Florida.

Joe Raedle/Getty Images

Lately, I have been having dreams about Donald Trump. In one, I’m in the audience as he walks out onto the debate stage, and the version of Hillary Clinton who follows him out is bald and deranged. In another, I’m waiting for Kanye West to perform at Madison Square Garden, but Trump does instead. No matter the dream, I wake up feeling the same way: scared.

And waking life is scary enough. During the last presidential debate, the country watched Trump scoff at one of the basic tenets of our democracy, the peaceful transfer of power. His campaign now runs on paranoia and delusion—and in the spare moments when it’s not paranoid or delusional, it’s merely incoherent. When asked in the second debate to explain his boasts about sexually assaulting women, Trump basically answered that it doesn’t matter because ISIS is worse. “No one has more respect for women than I do,” he said in the final debate. Some in the audience laughed, and maybe there was catharsis in that laughter, but I wanted to throw something at my television screen.

It’s Trump’s denialism that sets me off. It’s so casual—as casual as when he told Billy Bush that he can touch women against their will because he’s a star. He lives in an alternative reality, one in which the widespread backlash against him simply doesn’t exist. What could make someone so disturbingly unaware? So confident in his right to the presidency? Could it be that he is actually unable to grasp objective truth? Might he actually be mentally ill?

Several people, spanning media and medicine, have tried to answer these questions, psychologizing Trump or at least discussing the propriety of psychologizing Trump. Can we blame the candidate’s apparent insanity on an actual psychological condition? Are we watching the manifestation of a severe case of narcissistic personality disorder?

There have been cautiously speculative stories in the New York Times, here on Slate, in Vanity Fair and the Washington Post and the Atlantic, all of them seeming to grow from the same unspoken wish: to explain away the crazy by labeling it as a real disorder. We like to put a name to our monsters. Diagnosing Trump, whether doing so without examining him is proper or not, helps.

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This isn’t the first time narcissistic personality disorder has been employed as a means of understanding a scary political movement. The godfather of personality disorder analysis, Theodore Millon, was drawn to the field in part by Nazis and fascists. Born in Manhattan in 1928 to Jewish immigrants from Eastern Europe, Millon addressed his doctoral dissertation to “a theme of great concern at that time, which had to do with post-Second World War concerns regarding the Nazi Fascistic kind of mentality,” as he told fellow psychologist Michael Shaughnessy. “I did a research study on assessing the characteristics of authoritarian or fascistic personalities.”

He would go on to develop the Millon Clinical Multiaxial Inventory—the MCMI, currently in its fourth edition—which is considered the gold standard for the assessment of personality disorder pathology. Reading his analysis of narcissistic personality disorder now, you wonder if he was actually writing this from the press pen at a Trump rally. (Millon died in 2014.) Consider this analysis from his 2011 treatise, Disorders of Personality: Introducing a DSM/ICD Spectrum From Normal to Abnormal:

Narcissists are neither disposed to stick to objective facts nor to restrict their actions within the boundaries of social custom or cooperative living. … Free to wander in their private world of fiction, narcissists may lose touch with reality, lose their sense of proportion, and begin to think along peculiar and deviant lines.

Were narcissists able to respect others, allow themselves to value others’ opinions, or see the world through others’ eyes, their tendency toward illusion and unreality might be checked or curtailed. Unfortunately, narcissists have learned to devalue others, not to trust their judgments, and to think of them as naïve and simpleminded. Thus, rather than question the correctness of their own beliefs they assume that the views of others are at fault. Hence, the more disagreement they have with others, the more convinced they are of their own superiority and the more isolated and alienated they are likely to become. … They are increasingly unable to assess situations objectively, thereby failing further to grasp why they have been rebuffed and misunderstood. Distressed by these repeatedly and perplexing social failures, they’re likely, at first, to become depressed and morose. However, true to their fashion, they will begin to elaborate new and fantastic rationales to account for their fate. But the more they conjecture and ruminate, the more they lose touch, distort, and perceive things that are not there. They may begin to be suspicious of others, to question their intentions, and to criticize them for ostensive deceptions …

I received these excerpts from a psychologist, one who did not want to publicly speculate on Trump’s mental condition but who was alarmed at the prospect of someone seemingly afflicted with a severe case of this disorder assuming the presidency. (The American Psychological Association has an ethical standard discouraging members from making armchair diagnoses of a person they have not examined face-to-face, akin to the American Psychiatric Association’s much-debated Goldwater Rule.)

Elsewhere, Millon writes:

Deficient in social controls and self-discipline, the tendency of CEN narcissists to fantasize and distort may speed up. The air of grandiosity may become more flagrant. They may find hidden and deprecatory meanings in the incidental behavior of others, becoming convinced of others’ malicious motives, claims upon them, and attempts to undo them. As their behaviors and thoughts transgress the line of reality, their alienation will mount, and they may seek to protect their phantom image of superiority more vigorously and vigilantly than ever. Trapped by the consequences of their own actions, they may become bewildered and frightened as the downward spiral progresses through its inexorable course. No longer in touch with reality, they begin to accuse others and hold them responsible for their own shame and failures. They may build a “logic” based on the relevance and entirely circumstantial evidence and ultimately construct a delusion system to protect themselves from unbearable reality.

In the last debate, when Trump proclaimed he would “keep us in suspense” about whether he’d accept the outcome of the election, Clinton replied with a plainly rehearsed summation of her opponent’s routine denialism. It felt almost as if she’d been reading Millon herself:

You know, every time Donald thinks things are not going in his direction, he claims whatever it is, is rigged against him. The FBI conducted a year-long investigation into my e-mails. They concluded there was no case; he said the FBI was rigged.

Millon: Rather than question the correctness of their own beliefs they assume that the views of others are at fault:

He lost the Iowa caucus. He lost the Wisconsin primary. He said the Republican primary was rigged against him.

They are increasingly unable to assess situations objectively, thereby failing further to grasp why they have been rebuffed and misunderstood:

Then Trump University gets sued for fraud and racketeering; he claims the court system and the federal judge is rigged against him.

They may find hidden and deprecatory meanings in the incidental behavior of others …

There was even a time when he didn’t get an Emmy for his TV program three years in a row and he started tweeting that the Emmys were rigged against him …

… becoming convinced of other’s malicious motives, claims upon them, and attempts to undo them

This is—this is a mindset. This is how Donald thinks. And it’s funny, but it’s also really troubling.

That’s exactly how I feel about reading Millon. The Times’ devastating analysis of Trump’s mental tics falls into place. The monster has a name. Diagnosis—even unofficial diagnosis—is comforting. And once you know what’s wrong, you can start to treat the problem.

Except you can’t treat it, not in this case. For one thing, there is no accepted treatment for narcissistic personality disorder. But in a larger sense, it turns out that Trump’s mental health is not the thing most in need of treatment.

* * *

Back in June, writer Maggie Koerth-Baker adjudicated for FiveThirtyEight the question of whether it was appropriate to diagnose a presidential candidate with a mental illness. She wrote:

The basis of diagnosing a mental health disorder is that the person feels disordered. Human behavior and personality exist on a spectrum and the thing that makes the difference between, say, somebody who is a bit scatterbrained and somebody with ADHD is that the latter is debilitated by the symptoms they experience and has trouble functioning in society. And it’s hard to make a case for that being true of somebody successfully running for president of the United States. “Whether you like him or not, he seems to function,” [Northwestern University psychologist Dan] McAdam said.

Whether or not you believe a person must feel disordered to receive treatment for a mental illness (I don’t), whether or not Donald Trump actually has narcissistic personality disorder (who knows), there is one important truth in this passage: Donald Trump certainly seems to function.

And not only function. He excels. We can theorize all we want about the disorders that allow him to act in ways both divorced from reality and indifferent to the lives and rights of other human beings. But Trump is not encumbered by his pathological behavior. In fact he is often celebrated for it. You could argue that his pathologies helped him win one of our two major parties’ nominations for president.

This says more about us than it does about Trump and any mental disorder he might have.

Psychologist Nigel Barber, assessing Trump’s mental health in Psychology Today, offered a telling caveat: “Some of the DSM criteria are less relevant to Trump given his birth to money and life as a plutocrat that guarantee contact with high-status persons and being fawned over as a VIP.” Barber still diagnosed Trump with narcissistic personality disorder, while allowing that the privilege into which Trump was born may exempt him from some of the diagnostic conventions of the mental health world.

I’d go further than Barber: I think the privilege into which Trump was born has exempted him from the operating rules of civilized society. Whether he’s bragging about sexual assault, denying reality during the debates, or promising to reject the democratic process itself if it does not happen to favor him, the thread that connects them all is privilege. The impunity he has enjoyed is chilling, and so is his blithe certainty that it will always be there for him. The privilege he derives from his gender and his fame and his father and his class and his race seems to have granted him a lifetime pass. The result of such a life is a man whom we cannot help but pathologize.

But Trump’s own pathologies are nothing next to the pathologies of a society that allowed him to reach the doorstep of the highest office in the land, to live on this earth for 70 years and never once be held accountable for his failings with other people. A society that lets a man like this live and prosper is sick.