What is Mental Illness? Donald Trump and the Psychiatrists Who Would Diagnose Him By Richard Makover, MD on 1/18/18 - 4:18 PM

Recently, the American electorate has been treated to the awkward spectacle of mental health professionals proclaiming that President Donald Trump is mentally ill. These pundits have ignored the ethical standard against diagnosing someone you’ve never met, based only on public scrutiny, and have exhibited both grandiosity (they believe themselves saviors of the Republic) and lack of insight (they fail to recognize how their personal politics taint their judgment). They show an evident contempt for our democracy and the 60 million voters who chose Trump over his rivals. (Full disclosure: I didn’t vote for any of the listed candidates; instead, I wrote in my choice: George Washington.)

In a New York Times OpEd (1/12/18), Jeffrey A. Lieberman, Chairman of Psychiatry, Columbia University College of Physicians and Surgeons, said:

… when psychiatrists engage in clinical name calling about the president’s mental status without adequate evidence and proper evaluation, they are damaging the credibility of the entire field. Psychiatry has had a checkered past: Witness its collusion in Nazi eugenics policies, Soviet political repression and the involuntary confinement in mental hospitals of dissidents and religious groups in the People’s Republic of China. More than any other medical specialty, psychiatry is vulnerable to being exploited for partisan political purposes.

A recent book, The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President (St. Martin’s Press, 2017), accuses the President of such things as “impulsivity,” “pathological narcissism,” “paranoia,” and “sociopathy.” But what about other Presidents and Presidential candidates who these same diagnosticians would no doubt admire?
  • Barack Obama may have impulsively criticized as racist a white police officer responding to a possible burglary at a black professor’s home but had to publicly apologize through the “beer at the White House” photo op. Although a minor episode, it raised the issue of racial animus with the first President of color.
  • Lyndon Johnson refused to end the Vietnam war because, he said, “I will not be the first U.S. President to lose a war.” Tens of thousands of Americans and perhaps hundreds of thousands of Vietnamese were subsequently injured or killed because of Johnson’s apparent pathological narcissism.
  • Hillary Clinton may have revealed her paranoia when she defended her husband, Bill, as the target of a “vast right-wing conspiracy.” Perhaps this earlier instance of a secretive, suspicious nature presaged her later use of the infamous private email server.
  • And speaking of Bill Clinton, does any President more clearly show sociopathy than him? Consider a few of many possible examples: his purported history as a sexual predator, his questionable connections to the Chinese People’s Liberation Army, and even his apparent theft of White House property at the end of his term.

All of these alleged signs of mental illness fall under the category of character traits, an even more ambiguous area of diagnosis. After all, everyone has a personality, and it is only a matter of degree whether any of our mannerisms interfere with daily function enough to be considered problematic. Successful people often have strong character traits that may help or hinder them. All of the politicians above, including Donald Trump, have lifelong histories of functioning at very high and effective levels. To call any of them mentally ill begs the question: what is mental illness?

Leaving aside the political contretemps, we must recognize how difficult it is to define mental illness. The DSM5 attempts to categorize various observations and behaviors into a useful taxonomy. These categories are described as “disorders” rather than illnesses and they are constantly reshuffled with additions and subtractions in each revised edition. For example, before 1974 homosexuality was a disorder and afterwards it was not. The current edition includes gender identity disorder (or “transsexualism”) for the first time. So, in this sense, mental illness is whatever a large committee says it is. This approach is useful for research and to facilitate communication among providers, but it isn’t science.

Adding to the difficulty is the observation that a behavior considered abnormal in one part of the world is accepted as normal elsewhere. In the United States, taking one’s own life is almost always considered a sign of mental illness. Yet the Hindu practice of sati in which a wife throws herself onto her husband’s funeral pyre still occurs today, and Islamic fundamentalists blow themselves up like the Japanese kamikaze pilots of World War II. These acts are considered, within their own cultures, as honorable, not “sick.” Suicidal behavior, then, can sometimes be an illness and other times not, depending on the cultural context. I could give many other examples, but the point is that human societies vary and there is no universal standard for mental illness. The only definition that covers all of it is: mental illness is a marked deviation from cultural expectation. Although accurate, this definition is so broad as to be almost meaningless, and it has little practical utility.

In everyday practice, we rely on those who seek our help to define their own mental disability. Behaviors others might consider abnormal can be acceptable to an individual. Some live with phobias by restructuring their lives to avoid anxiety triggers. Others may accept low-level chronic depression as normal, as in the old blues song, “been down so long it looks like up to me.” Narcissistic, dependent and even antisocial personality traits may be tolerable unless they lead to significant interpersonal or societal dysfunction. People who come to a psychotherapist usually can tell us what they consider “abnormal,” and maybe that’s all the definition we need.

File under: Law & Ethics