No political figure has ever mobilised, and frustrated, the mental health profession as much as President Trump.
Prior to Mr Trump’s inauguration, 3 professors of psychiatry called for a ‘neuropsychiatric evaluation’. Shortly after, with the first wave of chaos from executive orders and bizarre preoccupation with having won the majority vote, several social media comments started to trickle in, and continue to from several mental health clinicians, myself included. American psychiatrists are professionally barred from providing an arms-length diagnosis (known as the Goldwater rule, instituted by the American Psychiatric Association after Senator Goldwater was grilled in the media by psychiatrists speculating on his fitness for office), however several senior clinicians (such as John Gartner of John Hopkins University Medical School) have chosen to ignore it, citing their overriding civic duty.
The consensus diagnosis appears to be narcissistic personality disorder. The personality disorders refer to a group of conditions where people exhibit unusually exaggerated behaviours on a longstanding basis, often related to serious childhood disturbances. Things took an unusual turn recently when the principal author of the DSM criteria for the disorder, Professor Allen Frances, himself denied the diagnosis was appropriate. He cited that Trump does not exhibit distress secondary to his narcissistic behaviours, which he regards as an essential component of the syndrome. He opines instead that Mr Trump merely has an abhorrent personality, rather than an unwell one.
There are a number of problems. The first, and most obvious issue, is that none of the clinicians have actually formally interviewed Mr Trump. The second, subtler issue, is that most literature regarding personality disorders is prejudiced towards discussions of 20-40 year olds, which is when they tend to present most frequently for mental support. There is very little literature to advise an appropriate personality diagnostic approach for any 70 year old, let alone an arms-length assessment of the President of the United States.
History has had scant opportunities for mental health professionals to assess senior politicians. In 1939, the famous psychoanalyst Carl Jung had the singular opportunity to meet Hitler. Coolidge and Segal wrote, “Jung said Hitler never laughed, and it appeared as if Hitler was sulking and in a bad mood. Jung viewed him as sexless and inhuman, with a singleness of purpose: to establish the Third Reich, a mystical all-powerful German nation, which would overcome all of Hitler’s perceived threats and previous insults in Germany’s history.” At that time, despite Jung’s serious concerns and, unusual for him, outright fear, there was no framework in place to respond to the signals.
Mr Trump’s political opponents have unsurprisingly maintained this as an issue. Senator Al Franken has stated that “a few” Republican senators are concerned about the President’s mental health. Senator Sanders has called him a pathological liar, and not without clear reason. “When somebody goes before you and says that 3 to 5 million people voted illegally … nobody believes that. There is not a scintilla of evidence to believe that, what would you call that remark? It’s a lie. It’s a delusion.”
The obviousness of these observations is probably responsible for the worldwide outrage from the mental health fraternity, simultaneously muzzled by the ethical constraints of the profession. Perhaps Dr Greenhalgh of the British Medical Journal provides the most reasonable stance. As a general practitioner, she wrote, “When referring a patent to a hospital colleague, for example, I do not declare that patient X is suffering from disease Y; rather, I propose that the signs seem to point in that direction and that I would value an expert opinion and specialist diagnostic tests…I believe that there is no absolute bar to a doctor suggesting that in his or her clinical opinion, it would be in the public interest for a particular public figure to undergo “occupational health” checks to assess their fitness to hold a particular office.”
There is possibly much for the world, as well as for Mr Trump personally, should he ever undergo a psychiatric examination. History may see it as the single most beneficial act that mental health could have ever achieved.
And it will never happen.