⬅ Donald Trump: Psychiatric Definitions

Personality Disorders

The medical diagnoses usually applied to Trump's mind are illnesses known as "personality disorders." These diseases, of which there are 10 types, are the bread and butter of psychiatric practice in contemporary America 1. All have several characteristics in common:

[Personality disorders are] pervasive, maladaptive, and chronic patterns of behavior, thinking, and feeling, ultimately leading to distress and dysfunction. Patients with personality disorders suffer from distorted perceptions of reality and abnormal affective behavior, manifesting in maladaptive coping mechanisms and distress. 2

The psychiatric profession groups personality disorders into three clusters, unimaginatively called A, B, and C.   Cluster-B, which is particularly relevant to Trump, is sometimes labeled the "dramatic/emotional/erratic" cluster and includes antisocial, narcissistic, histrionic, and "borderline" personality disorders 3. Commonly, patients will have more than one diagnosed disorder from within a cluster.

Assessment of Dr. Mary Trump

Trump's niece, Dr. Mary L. Trump 4a, is a well-trained and experienced Ph.D. psychologist 4b. Although she certainly harbors biases against her uncle, she also knows him far better than any other mental health professional ever will. She assesses possible diagnoses for her uncle as follows:

Narcissistic personality disorder:
I have no problem calling Donald a narcissist -- he meets all nine criteria [listed in the DSM-5 book] 4b... [But] this is far beyond garden-variety narcissism; Donald is not simply weak; his ego is a fragile thing that must be bolstered every moment because he knows deep down that he is nothing of what he claims to be. 4c

Antisocial personality disorder:
A case could be made that he also meets the criteria for antisocial personality disorder, which in its most severe form is generally considered a sociopathy but can also refer to chronic criminality, arrogance, and disregard for the rights of others. 4d

Dependent personality disorder: [from Cluster-C]
Donald may also meet some of the criteria for dependent personality disorder, the hallmarks of which include an inability to make decisions or take resposibility, discomfort with being alone, and going to excessive lengths to obtain support from others. 4e

Other:
Dr. Trump entertains the possibility of "a long undiagnosed learning disability that for decades has interfered with his ability to process information" 4e, as well as a co-morbid sleep disorder 4e.

She summarizes:

Donald's pathologies are so complex and his behaviors so often inexplicable that coming up with an accurate and comprehensive diagnosis would require a full battery of psychological and neuropsychological tests that he'll never sit for. 4d

Testifying to the accuracy of this statement is the large number of relatively minor, but still unfathomable, behaviors noted elsewhere on this page: his caffeine hyper-consumption, his multiple personal fears, his germaphobia, his sexual bravado as expiation for the cowardice of his illegal draft evasion, his sensitivity about his hand size, his laughable hair style, his overabundant skin make-up, and so on.

The Diagnosis

Despite Mary Trump's warning about the difficulty in diagnosing her uncle, Dr. Zebra offers the following, which has been leavened by long discussions with an astute psychiatrist.

Mr. Trump's psychiatric illness is best identified as "a mixed, severe personality disorder with sociopathic and borderline features." Specifically, it is a mixture of antisocial personality disorder and borderline personality disorder.

• "Sociopathic" refers to a severe degree of antisocial personality disorder -- a disease that psychiatrists formally diagnose in adults who have a "pervasive pattern of disregard for and violation of the rights of others," as described by the standard textbook of mental disorders, "The DSM-5."
• "Borderline" does not refer to features that are on the verge of being abnormal. It refers instead to a defined list of clearly abnormal features that are not always present. It forms part of Trump's diagnosis because antisocial personality disorder does not alone account for all of the abnormal behaviors he displays.
• Although it is tempting to apply narcissistic personality disorder to Mr. Trump, his illness, as Mary Trump observes, is larger than that. His antisocial features swallow (and exceed) his narcissism.

To diagnose antisocial personality disorder the DSM-5 requires that three or more of the following behaviors must be present: (Use the checkbox squares to tally your assessment of Trump.)

• Failure to conform to social norms concerning lawful behaviors;
• Deceitfulness, repeated lying, or conning others for pleasure or personal profit;
• Impulsivity or failure to plan;
• Irritability and aggressiveness;
• Reckless disregard for the safety of self or others;
• Consistent irresponsibility, failure to sustain consistent work behavior, or honor monetary obligations; or
• Lack of remorse, being indifferent to or rationalizing having hurt, mistreated, or stolen from another person.

For pointers to the full DSM-5 criteria of all personality disorders, see → SEE BELOW.

Delusions

It is relevant to Mr. Trump's recent history, and typical of personality disorders, that a challenging environment will accentuate the disorder's symptoms, in particular, delusional thinking. Psychiatrists define a delusion as "a fixed idea at variance with reality, unamenable to change, with the exception of religion." SEE BELOW

Mr. Trump's supremely challenging 2020 -- impeachment, epidemic, economic collapse, riots, defeat in the election, defeats in the courts -- likely hardened his self-interested deluded beliefs, so much so that he became mentally incapable of taking any action contravening them. This equates to a gross impairment of judgment, which was nowhere more apparent than in his videotaped message during the heinous riot at the Capitol on Jan. 6, 2021, in which he expressed sympathy and support for the rioters seeking to keep him in office.

Impact

President Woodrow Wilson suffered a stroke in 1919 that left him partially paralyzed and mentally damaged. Mr. Trump is no less paralyzed than Wilson, but instead of being medically unable to move a limb, he is medically unable to move his mind to the common good, or, indeed, to move it to any good other than his own. No pill can cure this paralysis.

The framers of the 25th Amendment may not have had in mind a psychiatric illness specifically like Mr. Trump's, but they certainly had in mind debilitating neuro-psychiatric disease -- which his became. Thus, the Vice President and the Cabinet had a Constitutional duty to remove Mr. Trump from office. They also had a moral duty to make sure this unfortunate man gained access to medical treatment.

Comment: Dr. Zebra learned something from the case of Donald Trump. For too long I believed that Trump could not possibly be genuine in his shabby attempts at peddling falsehoods and cons. I thought he was simply wrapping cynical artifice around a hidden core of rationality. But, as the diagnosis illuminates, his perpetual self-serving hucksterism is genuine. His disease has placed it at the core of his being, making it difficult for psychologically normal people to understand him and his actions. Just as every historian writing about the last 18 months of Wilson's presidency must start with Wilson's stroke, every historian who writes about the Trump presidency must start with Trump's psychiatric illness. Dr. Zebra apologizes to his psychiatrist friends with whom he disagreed for years. You were right.

Personality disorders disqualify a person for service in the US Air Force 5a.

Diagnostic Criteria: Personality Disorders

Every so often, the American Psychiatric Association publishes a book that becomes the diagnostic bedrock for the psychiatry profession. Called The Diagnostic and Statistical Manual of Mental Disorders, and most recently published in its 5th edition in 2013, it is commonly abbreviated as "DSM-5" 6.

The DSM-5's criteria for personality disorders are the same as in the previous edition (the DSM-4, published in 2000). Reference 3 reprints the DSM-4/DSM-5 criteria and is freely available on the internet.

Definition: Delusions

The DSM-5 has two definitions of "delusion" -- one in the glossary, and one in the section on schizophrenia. The main text (above) alludes to the glossary definition. Here is the schizophrenia definition, which notably does not require the delusion to be false.

Delusions are fixed beliefs that are not amenable to change in light of conflicting evidence. Their content may include a variety of themes (e.g., persecutory, referential, somatic, religious, grandiose).

• Persecutory delusions (i.e., the belief that one is going to be harmed, harassed, and so forth by an individual, organization, or other group) are most common.
• Referential delusions (i.e., belief that certain gestures, comments, environmental cues, and so forth are directed at oneself) are also common.
• Grandiose delusions (i.e., when an individual believes that he or she has exceptional abilities, wealth, or fame) and erotomanic delusions (i.e., when an individual believes falsely that another person is in love with him or her) are also seen.
• Nihilistic delusions involve the conviction that a major catastrophe will occur, and
• somatic delusions focus on preoccupations regarding health and organ function.

[[ Elided: definition of "bizarre delusions" and its examples ]]

The distinction between a delusion and a strongly held idea is sometimes difficult to make and depends in part on the degree of conviction with which the belief is held despite clear or reasonable contradictory evidence regarding its veracity.

The last sentence of the definition is of special interest, as it may explain why so large a fraction of the American population could adhere to Trump's delusions.