This post is a critique of psychiatry’s spurious personality disorder diagnoses. It is neither a defense, nor a condemnation, of Mr. Trump. In my view, it is right and proper that we the people should comment freely on, and criticize, our political leaders, as we deem appropriate. But assigning spurious psychiatric labels is problematic for two reasons. Firstly, it adds nothing useful to the discussion. Secondly, it affords unwarranted validity and reliability to what are nothing more than loose collections of inherently vague thoughts, feelings, and behaviors, with no explanatory significance.
The point is not whether Mr. Trump “has narcissistic personality disorder”, but rather that there is no such thing as narcissistic personality disorder.
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On December 17, Richard Greene, a Communication Strategist, posted an article on the Huffington Post titled Is Donald Trump Mentally Ill? 3 Professors Of Psychiatry Ask President Obama To Conduct A Full Medical And Neuropsychiatric Evaluation.
In this article, Mr. Greene reproduces (with the authors’ permission) a letter that was sent to President Barack Obama on November 29, 2016. Here’s the text of the letter:
“President Barack Obama
The White House
1600 Pennsylvania Avenue NW
Washington, DC 20500
November 29, 2016
Dear President Obama,
We are writing to express our grave concern regarding the mental stability of our President-Elect. Professional standards do not permit us to venture a diagnosis for a public figure whom we have not evaluated personally. Nevertheless, his widely reported symptoms of mental instability including grandiosity, impulsivity, hypersensitivity to slights or criticism, and an apparent inability to distinguish between fantasy and reality lead us to question his fitness for the immense responsibilities of the office. We strongly recommend that, in preparation for assuming these responsibilities, he receive a full medical and neuropsychiatric evaluation by an impartial team of investigators.
Judith Herman, M.D.
Professor of Psychiatry
Harvard Medical School
Nanette Gartrell, M.D.
Associate Clinical Professor of Psychiatry
University of California, San Francisco (1988-2011)
Assistant Professor of Psychiatry, Harvard Medical School (1983-87)
Dee Mosbacher, M.D., Ph.D.
Assistant Clinical Professor
Department of Community Health Systems
University of California, San Francisco (2005-2013)”
Mr. Greene’s article contains a link to an interview given by Lynne Meyer, PhD, whom Mr. Greene describes as “a Psychologist specializing in personality disorders, brilliantly explaining how such a disorder might help us understand Mr. Trumps comments and behaviors and the challenges that likely lie ahead for our country.”
Mr. Greene then lists the DSM-5 criteria for narcissistic personality disorder.
“If someone does have ‘Narcissistic Personality Disorder’ they can, indeed, wake up, see a Tweet or a news report from a foreign leader criticizing him, mocking him, calling him ‘weak’ or threatening his ego in any way and order some kind of impulsive, vindictive, punishing, immediate response that could include an unhinged order to attack that foreign leader or foreign country with military force, even including the authorization of nuclear weapons.
It is extremely likely that there would be some kind of impulsive, angry diplomatic response.
Because someone afflicted with this incurable and progressive ‘Narcissistic Personality Disorder’ simply cant help himself.”
Note that the APA’s pseudo-diagnosis narcissistic personality disorder is being presented here as a valid entity, an incurable and progressive affliction. Note also the contention that if a person has this disorder, he simply can’t help himself.
Earlier in the article Mr. Greene had stated that he had been interviewing psychiatrists and psychologists about Donald Trump’s alleged “Narcissistic Personality Disorder”, and that:
“Virtually every mental health professional I interviewed told me that they believed, with 100% certainty, that Mr. Trump satisfied the DSM criteria of this incurable illness and that, as a result, he is a serious danger to the country and the world.”
Mr. Greene continues his article with a summary of the psychological and behavioral characteristics of “people with NPD”, and a summary of the concerns expressed by the mental health professionals that he had interviewed.
The article closes with an extended quote from “a clinical psychologist”, essentially endorsing and expanding on the points made by Dr. Meyer in the earlier interviews. These anonymous comments are fairly extreme, e.g.:
“The point about him getting worse in the future also cannot be overstated. An increasing paranoia combined with growing sadistic vindictiveness is pretty much a given. We have seen it consistently in other leaders, past and present, with this character defect.”
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But the essential core of the article is the second (and longer) video interview with Dr. Meyer. As mentioned earlier, Dr. Meyer is a psychologist, but it is clear from her comments that she endorses the psychiatric “diagnostic” system and the ontological and explanatory status of this so-called diagnosis. It should also be noted that Dr. Meyer couches her responses in hypothetical terms and does not state or imply that Mr. Trump meets the criteria for this “disorder”.
Here’s an extended quote from the interview. The interviewer is presumably Mr. Greene.
Q. I’d like you to share whether narcissistic personality disorder is the same thing as someone being a bit egotistical or quote unquote narcissistic.
A. Well to answer that question, no. When you have a trait that is a little bit narcissistic, that is not a diagnosis. So in order to make a diagnosis, you’d have to have five or more criteria, and that would be about one percent of the population which have NPD, which is narcissistic personality disorder. And when you have this diagnosis, it’s a pervasive disorder, it’s hardwired in the brain. And with narcissistic personality disorder it’s very highly untreatable, it’s very difficult to treat because narcissists don’t like to have anybody have an opinion that is not theirs, they don’t like interpretations, and in fact they are very fragile. They are the most unlikely people to seek out psychotherapy because of their grandiosity, sense of self-importance. And they actually create a world around them that’s a little bit delusional, they lose track of reality, especially if they have people around them feeding their sense of self-importance.
Q. So if someone were hypothetically the President of the United States and the Commander in Chief with sole and exclusive and unfettered access to thousands of nuclear weapons and the entirety of the United States military, would that be a problem if they were suffering from narcissistic personality disorder?
A. If they had the true diagnosis, the concern would be their lack of stability and especially their impulsivity and they’re quick to anger. So I would be very concerned that in a moment of rage or impulsivity, they would react because they are reactive, they’re thin-skinned, and they would do something destructive.
Q. So it’s not outside of the realm of possibility, without being totally paranoid here, that if someone were the Commander in Chief and they had narcissistic personality disorder which is not just a trait, it’s as you said an actual diagnosis. And if a foreign leader said something very negative about them, criticized them for not being strong enough, for being weak, for whatever, that they could go into some sort of impulsive reaction and potentially use or misuse their power over the military and over the release of weapons and even nuclear weapons. Is that completely out of the question?
A. No it’s absolutely in the realm of possibility that they would use their power to punish or be destructive and without thinking they would react, because they are wounded. We have a concept called narcissistic rage which is when you go against the narcissist they usually retaliate, and that’s part of the condition. They can be retaliatory.
The central problem here is that the “diagnosis” of narcissistic personality disorder is being presented as a reality something “hardwired into the brain” which has both explanatory significance, and predictive validity. In fact, the criteria for this disorder, like all DSM entries, are merely a loose collection of vaguely defined thoughts, feelings, and behaviors. There is no evidence that these activities even if they could be reliably identified in specific individuals constitute a coherent entity. In fact, the polythetic aspect of the “diagnosis” (five out of nine) virtually guarantees that the “diagnosis” is not a coherent entity. Individuals who score “yes” on items 1, 2, 3, 4, and 5 will inevitably differ markedly from those scoring “yes” on items 5, 6, 7, 8, and 9. And that’s even conceding that these items can be applied in a reliable and consistent fashion, which they can’t.
Let’s look at some of the DSM-5 criteria for this so-called disorder.
“Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.” (p 669)
It is obvious that this criterion cannot be rated against a simple yes or no standard. What does preoccupied mean? What is unlimited success? How can we even know other people’s fantasies?
Here are two more criteria:
“Requires excessive admiration.”
“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).”
In effect, the “diagnoser” must shoe-horn his/her assessment of the individual into a yes or no judgment, then count the yeses. So essentially we have five (or more) pieces of garbage data, which through the mindless alchemy of psychiatry become an incurable illness, “hardwired in the brain”.
The fact that a “diagnosis of narcissistic personality disorder” has no explanatory usefulness is highlighted by the following hypothetical conversation.
Wife: Why is my husband so self-important; why does he have such a sense of entitlement?
Psychiatrist: Because he has an illness called narcissistic personality disorder.
Wife: How do you know he has this illness?
Psychiatrist: Because he is so self-important and has such a sense of entitlement.
Narcissistic personality disorder is just a label. It explains nothing. The only evidence for the “illness” is the very behavior it purports to explain.
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DSM-5’s general definition of a personality disorder is:
“an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.” (p 645)
The reality, however, borne out by decades of research, indicates clearly that behavior is “enduring” only when the circumstances and context that maintain the behavior are equally enduring. When our circumstances change, our perceptions and our actions change, and this general adaptability usually outweighs any tendencies that might exist to stay mired in the habits of the past. Although we are usually willing servants to our habits, we are not their slaves.
In his book Personality and Assessment, (1968, reprinted 1996), Walter Mischel, PhD, having reviewed two decades of research on this matter, concludes:
“Global traits and states are excessively crude, gross units to encompass adequately the extraordinary complexity and subtlety of the discriminations that people constantly make. Traditional trait-state conceptions of man have depicted him as victimized by his infantile history, as possessed by unchanging rigid trait attributes, and as driven inexorably by unconscious irrational forces. This conceptualization of man, besides being philosophically unappetizing, is contradicted by massive experimental data. The traditional trait-state conceptualizations of personality, while often paying lip service to man’s complexity and to the uniqueness of each person, in fact lead to a grossly over-simplified view that misses both the richness and the uniqueness of individual lives. A more adequate conceptualization must take full account of man’s extraordinary adaptiveness and capacities for discrimination, awareness, and self-regulation; it must also recognize that men can and do reconceptualize themselves and change, and that an understanding of how humans can constructively modify their behavior in systematic ways is the core of a truly dynamic personality psychology.” (p 301)
There is no evidence that the individuals to whom psychiatry attaches the label narcissistic personality disorder are somehow exceptions to this general finding. There is no evidence that these individuals’ brains are “hardwired” for inflexibility. But psychiatrists, busy and preoccupied as they have been in the invention and promotion of spurious, but medical-sounding, diagnoses, have chosen to ignore this large corpus of psychosocial research, and to provide instead a medical façade to the long-standing human activity of name-calling.
The point of all this is that psychiatry’s “personality disorders” are not valid ways to conceptualize or categorize behavior. They have an appearance of face validity, but the labels add nothing to our understanding of the thoughts, feelings, and behaviors in question. And in fact, the personality disorder labels have two very negative effects. Firstly, they create the impression that the behaviors in question have been explained. In mental health case discussion, for instance, one often hears statements like: he’s arrogant and demanding because he has narcissistic personality disorder; or he keeps very much to himself because he has schizoid personality disorder; etc. In fact, narcissistic personality disorder and schizoid personality disorder are just labels which explain nothing. Genuine understanding of human actions requires a detailed knowledge of the individual obtained through lengthy and painstaking dialogue, in a context of mutual trust and respect. It is definitely not something that can be derived from fifteen-minute “med checks” four times a year. Nor is it something that can be obtained by someone who views people through the distorting lens of psychiatric “diagnoses”.
Seven months ago, on June 9, 2016, the eminent psychiatrist Allen Frances, MD, architect of DSM-IV, stated categorically that Donald Trump did not have narcissistic personality disorder, or for that matter any personality disorder. So much for the reliability of psychiatric diagnoses.