My response to: We must not confuse Trump's bad behavior with mental illness by Allen Frances



The title is somewhat misleading because in general mental health professionals are not suggesting that Trump suffers a mental illness, as it is commonly understood. They are suggesting that he does indeed meet the diagnostic criteria for narcissistic personality disorder and that he may well be developing dementia. This is not to use these diagnoses as terms of abuse - they are relevant because they may feed into the legal process whereby it is determined whether or not Trump should be removed from office.


Frances' position is absurd. In one paragraph he says that he supports the Goldwater rule and in the next he flouts it. The fact that he does so in order to defend Trump is irrelevant. He is clearly debating the diagnosis of somebody he has never met and adduces various facts in the public domain to support his own thoughts on the subject.


I do not support the Goldwater rule. Nor, as a UK doctor am I bound by it. Frances has previously made the argument that Trump does not meet the criteria for narcissistic personality disorder because he is not distressed or impaired. Many mental health professionals find this extremely unconvincing. We have no hesitation in diagnosing sociopathic personality disorder in patients we have assessed who only cause distress to others. Besides, many would argue that Trump is indeed impaired by his personality disorder, with his low approval ratings, his legal and financial problems and the widely accepted view that he is the worst ever American president. It is very noteworthy that Frances fails to deny that Trump otherwise meets the criteria for narcissistic personality disorder in spades and indeed, without have assessed Trump in person, mentions his "extravagant narcissism".


The concerns that he may be developing dementia stem not from Trump's ignorance but from the fact that he appears to be performing far less well than he used to. If we compare his verbal communication now, even in the context of a calm interview rather than one of his rally rants, we see that his vocabulary is impoverished and the complexity of sentence structures diminished. This is just one example of the features of his functioning which appear characteristic of early dementia and which mean that he should undergo a formal assessment process.


It is not in itself stigmatising of mental illness to say that Trump is impaired by a personality disorder and possibly early dementia. The possibility of dementia is especially important because it will progress. An argument can be made that Trump was elected by people who were aware of his personality flaws. But if he has progressive dementia then he might have been competent when elected but not now. In any event, my own professional view is that he is indeed impaired by mental disorder (not mental illness) and that he should undergo a formal assessment with a view to removal from office if judged appropriate.


Prof David Curtis MA MD PhD FRCPsych

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