The DSM is basically the ‘Bible’ of mental health professionals in the United States. "The Diagnostic and Statistical Manual of Mental Disorders (DSM–5) is the product of more than 10 years of effort by hundreds of international experts in all aspects of mental health. Their dedication and hard work have yielded an authoritative volume that defines and classifies mental disorders in order to improve diagnoses.” (https://www.psychiatry.org/psychiatrists/practice/dsm) Here, an MD takes the components of the DSM definition of an “Anti-Social Personality Disorder” and applies them to the long personal history of what we know about President Trump. The result produces the shocking realization that our President is emotionally impaired and a text book example of a DSM mental disorder. This diagnosis was made during the 2016 Presidential campaign. Nothing that characterizes the President since that campaign changes this diagnosis. The value of the diagnosis is that it helps us understand more of his behavior and contributes to better forecasts of what he is likely to to do in the future.
Donald Trump: Sociopath?
Taking His Biographer's Claim Seriously
By James Hamblin, MD
This week, the co-author of Donald Trump’s autobiography said in The New Yorker that if he were writing The Art of the Deal today, it would be a very different book with a very different title: The Sociopath.
To title a person’s life story with that label is a serious accusation, and one worth considering. The stakes are high. Tony Schwartz, the writer of the best-selling book, said that he “genuinely believe[s] that if Trump wins and gets the nuclear codes, there is an excellent possibility it will lead to the end of civilization.” In that light, Schwartz said he feels “deep remorse” at having “put lipstick on a pig.”
That seemed to me to be something of a contradiction to the charge of sociopathy, as pigs have been found to show signs of empathy. If you call a pig by name, it will come and play with you, reciprocating affection like a dog. So which is it, pig or sociopath?
I’m not here to be Trump’s doctor. He has a doctor, and his name is Harold Bornstein—the fellow who wrote in his official doctor’s note, “I can state unequivocally [that Trump] will be the healthiest individual ever elected to the presidency.”
Bornstein’s willingness to make such a claim suggests that Trump’s health may not have undergone legitimate scrutiny. Unless the doctor has been alive since 1789 to personally examine the health of every sitting president, it would seem that he would approve of our exercise in remote appraisal of his patient.
And in the context of an election where Trump has repeatedly, strategically branded people with single words that seem to have proven influential—“Little Marco,” “Lyin’ Ted,” and “Crooked Hillary”—would “Sociopathic Donald” be an intellectually honest equivalent?
Labeling people from afar is an inherently flawed endeavor, of course, especially with regard to mental health. Many psychologists and psychiatrists say that their work could never be done remotely, and should never be attempted outside of the standard, one-on-one approach to diagnosis. Many regard anything less as patently unethical. But certain extenuating circumstances seem to make this exercise worthwhile.
Psychiatrists often bestow labels knowing less about the facts of people’s lives and actions than we collectively know today about Donald Trump’s. We’re also legitimized in this endeavor by the fact that sociopathy and psychopathy—which are similar, and sometimes used interchangeably—are not formal psychiatric diagnoses. The terms “sociopath” and “psychopath” do tend to be thrown around casually by people in need of an insult that carries an air of empiricism. “My boss is a sociopath” is to say that this is not just an opinion or judgment, but a fact. But different people define the terms differently, with understandings converging around the feature of lacking “a conscience.”
The closest thing to psychopathy or sociopathy in The Diagnostic and Statistical Manual (DSM)—the book that defines every mental illness and outlines how mental-health professionals should make the diagnosis—is either Narcissistic Personality Disorder or Antisocial Personality Disorder.
Other analysts have focused on the applicability of Narcissistic Personality Disorder, which the Mayo Clinic defines by “an inflated sense of [one’s] own importance, a deep need for admiration and a lack of empathy for others. But behind this mask of ultra-confidence lies a fragile self-esteem that’s vulnerable to the slightest criticism.” One psychologist, Ben Michaelis, called Trump “textbook Narcissistic Personality Disorder.” Psychologist George Simon called Trump “so classic that I’m archiving video clips of him to use in workshops because there’s no better example of his characteristics.”
To more wholly assess the claim of sociopathy, then, it may be more illustrative at this point to consider the Antisocial Personality Disorder side of the picture, which focuses on deceit, manipulation, disregard for the rights of others, and failure to take responsibility for one’s actions.
According to the DSM, Antisocial Personality Disorder should be diagnosed in a person who meets two criteria about the way they function in the world, and criteria about their personal traits. In the realm of the latter, the person must also demonstrate two other traits: antagonism and disinhibition.
Antagonism can be characterized by hostility, manipulativeness, deceitfulness, or callousness. It’s worth considering these one by one.
Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults; mean, nasty, or vengeful behavior.
As one recent example, Fox News debate moderator Megyn Kelly said that she “may have overestimated his anger management skills” when, in response to perceived unfair questioning, Trump called her a “bimbo” with “blood coming out of her eyes, blood coming out of her wherever.”
In a much more prolonged example, writer McKay Coppins wrote a profile of Trump in which he called Mar-a-Lago a “nice, if slightly dated, hotel,” and incurred years of backlash. “He had tweeted about me frequently in the weeks following its publication—often at odd hours, sometimes multiple times a day—denouncing me as a “dishonest slob” and “true garbage with no credibility,”Coppins recalls. “For two years, Trump continued to rant about how I’m a scumbag, or a loser, or ‘just another phony guy.’”
This degree of hostility is not unique to the last few years, nor can it be dismissed as TaylorSwifting (performative melodrama), as he has a record of retaliation in private as well. In the late 1980s, the satirical magazine Spy began to use Trump as a symbol of the gaudy decadence and ostentatious vulgarity of New York City during the era. Editor Graydon Carter noted at one point that Trump had small fingers, and the magazine—known for inventing pithy epithets for people and using them repeatedly—came to introduce Trump as a “short-fingered vulgarian.”
Even though Spy went out of publication more than a decade ago, Carter still hears from Trump about the insult. “He'll send me pictures, tear sheets from magazines—and he did it as recently as April,” Carter said earlier this year on NPR. “With a gold Sharpie, he'll circle his fingers and in his handwriting say, ‘see, not so short.’”
(Carter sent it right back with a note saying that the fingers were actually quite short. “I know it just gives him absolute fits,” Carter said. “And now that it's become sort of part of the whole campaign rhetoric, I'm sure he wants to just kill me with those little hands.”)
See also: Most everything that Trump has said on Twitter.
Manipulativeness: Frequent use of subterfuge to influence or control others; use of seduction, charm, glibness, or ingratiation to achieve one’s ends.
I think this might alternatively be defined as politics. That’s not a joke.
Steve Becker, a psychotherapist who specializes in Narcissistic Personality Disorder, has written that “we’ve reached the point where we expect our politicians to behave like psychopaths.” We view psychopathic traits as acceptable, perhaps necessary, and even advantageous attributes of politicians. “Trump’s ‘psychopathy,’ incidentally, is expressive in a less ‘compartmentalized’ form than that of most candidates,” Becker writes, “meaning he’s really more than a ‘political psychopath’—he’s really just broadly, flat-out a psychopath.”
Manipulativeness is also somewhat inherent to the art of the deal, insofar as deal-making is about getting people to give you what you want. Though, here as in politics, just because a trait is typical within a system does not make it non-diagnostic—a concept we’ll address in just a bit.
Seduction is also worth noting, as it has become an area of study and fascination such that entire books like The Game are written on the subject. Some may be worth reading if only as a form of inoculation against psychopaths and casual pickup artists alike. Game, as they say, recognizes game.
Deceitfulness: Dishonesty and fraudulence; misrepresentation of self; embellishment or fabrication when relating events.
When the matter of the size of Trump’s hands being small came up during a debate this year, he said, “Nobody has ever hit my hands. I've never heard of this one. Look at those hands. Are they small hands?”
He had heard about his hands before. Of the more consequential statements put to the test on the fact-checking site Politifact, 56 percent of Trumps statements are false or mostly false. Another 19 percent are “pants on fire.” Some of them he continues to repeat. Just this weekend, Trump insisted again on 60 Minutes that he opposed the Iraq War from the start. The Washington Post’s Fact Checker and Politifact have proven that false, with BuzzFeed even having published a 2002 interview in which Trump supports the invasion.
Callousness: Lack of concern for feelings or problems of others; lack of guilt or remorse about the negative or harmful effects of one’s actions on others; aggression; sadism.
Trump intends to ban immigration by Muslims, including refugees and the people who are being oppressed and kill by ISIS. After the Orlando shootings, he tweeted, “Appreciate the congrats for being right on radical Islamic terrorism …” And maybe most fitting here is his unwillingness to apologize for most anything, including his insults to Kelly (only eventually addressing the issue and saying “you’ve been called a lot worse”). Even after an episode of clear plagiarism this week on the part of his campaign in Melania Trump’s speech, which could have been forgiven, he gave no indication of guilt or remorse.
The other of the two personality traits, disinhibition, is characterized by impulsivity, irresponsibility, and risk taking.
Impulsivity: Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing and following plans.
When Trump was supposed to introduce his vice-presidential candidate Mike Pence this week, his remarks protracted into 28 minutes of self promotion, absorbing the energy and attention of the crowd. As David Brooks described it this week in The New York Times, “The Pence announcement was truly the strangest vice-presidential unveiling in recent political history. Ricocheting around the verbal wilds for more than twice as long as the man he was introducing, Trump even refused to remain onstage and gaze on admiringly as Pence flattered him. It was like watching a guy lose interest in a wedding when the bride appears.”
Irresponsibility: Disregard for—and failure to honor—financial and other obligations or commitments; lack of respect for—and lack of follow through on—agreements and promises.
One obligation of a presidential candidate is to disclose his income taxes, which Trump has not.
Risk taking: Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard for consequences; boredom proneness and thoughtless initiation of activities to counter boredom; lack of concern for one’s limitations and denial of the reality of personal danger
Risky business moves over the decades aside, the very act of continuing to run for president is a risk. Earlier this year, The Economist’s research firm Economist Intelligence Unit ranked a Trump presidency among the top ten global risks, tied with “the rising threat of jihadi terrorism destabilizing the global economy.”
The other domain of Antisocial Personality Disorder is personality functioning, which involves two criteria. First, either one of the following:
Identity: Ego-centrism; self-esteem derived from personal gain, power, or pleasure.
Self-direction: Goal-setting based on personal gratification; absence of prosocial internal standards associated with failure to conform to lawful or culturally normative ethical behavior.
Trump is rather candid about these points. He is rich and powerful, and his business endeavors are primarily undertaken to achieve that end. “I don’t lose! I’ve never been a loser. I like to win!”
“In general, many candidates who run for president are driven in large part by ego,” psychiatrist Robert Klitzman told Vanity Fair, after clarifying that he could not comment on Trump’s specific mental state without meeting him. “I hope that does not preclude their motivation to govern with the best interests of the public as a whole in mind. Yet for some candidates, that may, alas, be a threat.”
And the final element in diagnosing antisocial personality disorder is impaired interpersonal functioning in one of two domains:
Empathy: Lack of concern for feelings, needs, or suffering of others; lack of remorse after hurting or mistreating another.
Intimacy: Incapacity for mutually intimate relationships, as exploitation is a primary means of relating to others, including by deceit and coercion; use of dominance or intimidation to control others.
The realm of intimacy is beyond the purview of public inquiry, though some thought it telling that when Melania Trump spoke of her husband on Monday night, she delivered an endorsement that could have come from anyone. She said nothing of him as a husband, lover, or father to her child—the insight that many were hoping she would provide. On Tuesday, his daughter Tiffany was somewhat more illustrative, saying that her father would write notes to her on her report card.
Using dominance or intimidation to control others, though, shows up time and again in Trump’s history. He has done this particularly to journalists, and entire newspapers and magazines. In one incident, he sent The New York Times’ Gail Collins a copy of her column, having circled her photo and scrawled “The Face of a Dog!”
He has attempted to silence not just media, but protesters at his rallies, implying support for violent retaliation and publicly suggesting that he may pay the legal fees of one assault suspect.
These examples could go on, and maybe should, as the news cycle tends to help us forget these stories. They are especially important as Trump has disclosed very little in the way of policy on which to judge what his presidency would look like, placing further burden on evaluation of his character.
It’s useful to note that two caveats in the DSM apply to any personality disorder. The first is that these impairments only qualify for a diagnosis if they “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).”
One can’t rule these things out from afar. A famous case study in psychopathy complicated by exogenous chemistry, Adolf Hitler used high-dose amphetamines, which can produce many of the symptoms described above. Historians have noted that the drug use correlates with the escalating brashness in his military strategy. But Trump’s personality patterns have been present in news stories and biographical accounts for decades, and he has remained “high-functioning,” a clinical term meaning that his life hasn't fallen apart due to any sort of drug abuse in all that time, which would be rare.
The other caveat in making this diagnosis, according to the DSM, is that the impairments in personality functioning and personality trait expression do not constitute disease if they are “better understood as normative for the individual’s developmental stage or sociocultural environment.”
If this were a “developmental stage” for Trump, it would be one occurring late in life and lasting a long time. But the effect of “sociocultural environment” is a major caveat, and often a matter of subjectivity. It’s the rare case where any psychiatric diagnosis is not relative to a sociocultural environment, ADHD and Internet Gaming Disorder being good examples.
It may be a little of both, a man with some “sociopathic” proclivities in society riddled with fear and hatred that is enabling his behavior.
Personality disorders are, to reiterate, diagnoses to be made by experts. Everyone shows some of these signs occasionally, which can lead people to unfairly appraise themselves and others, as writer Jon Ronson warns in The Psychopath Test. Still, there could be predictive value in having a more empiric rubric than simply labeling people “disgusting losers,” “crooked,” or “lying.” Among complex cognitive and behavioral concepts, basic tenets are not beyond the understanding and consideration of the general electorate. The lens of psychological and psychiatric science may be a useful one to continue holding to those seeking so much power.