By Vince Greenwood, Ph.D., founder of DutyToInform.org

Shortly after Trump’s election in 2016, many mental health professionals spoke out about what they saw as the new president’s unfitness for office. Many associated Trump’s behaviors with particular psychological vulnerabilities that, in turn, predicted dangerousness. By doing so, they were flirting with violation of an ethical provision of the American Psychiatric Association (APA) called the Goldwater Rule (the American Psychological Association has also supported this rule). The Goldwater Rule prohibits professionals from diagnosing anyone they have not personally examined. In March of 2017, no doubt in response to those speaking out about the new president, the APA not only reaffirmed the Goldwater Rule provision about diagnosing at a distance, but asserted that members should not offer any kind of opinion on public figures, even if was based on evidence and observable behavior.

However, this did not prevent many in the mental health community from trying to educate the public about Trump’s possible psychopathology, Goldwater Rule and the recent APA gag order on the books or not. Bandy Lee, a Yale University psychiatrist and world expert in violence prevention, provided leadership by organizing a coalition of concerned mental health professionals, The World Mental Health Coalition, and editing a book, The Dangerous Case of Donald Trump, that contained articles spelling out “the clear and present danger” that Trump’s mental health posed to the nation. The book became a New York Times bestseller (all royalties were donated to the public good).

In a similar vein, John Gartner, a psychologist and former instructor at Johns Hopkins, posted a petition on Facebook in January 2017 that called for Trump’s removal from office because of his dangerously unstable mental condition. In short order, over 60,000 mental health professionals signed the petition. Gartner went on to found Duty To Warn, an organization of mental health professionals dedicated to educating the public about Trump’s unfitness for office. He also edited Rocket Man: Nuclear Madness and the Mind of Donald Trump, which contained thoughtful discussions on Trump’s fitness for office.

A handful of writers and public intellectuals made unique contributions to delineating Trump’s psyche. Tony Schwartz, Michael Wolff, and George Conway had a history of access to Trump. As a result, they shared a wealth of perceptions and insights about Trump that aligned with many of the critiques coming from the mental health community.

Did this effort have an impact? In the run-up to the 2020 election, there was clearly a strong interest in material about Trump’s psyche, as measured by the number of books sold on the topic and articles shared. Thanks to the efforts of The World Mental Health Coalition and Duty To Warn, expert commentary about Trump’s psychiatric vulnerabilities and his fitness for office were ushered into the national conversation.

And then, of course, Trump lost.

Most political analysts felt the election had been primarily a referendum on Trump. Biden was not considered a particularly strong candidate, and the record-breaking turnout was seen as largely due to negative appraisals of Trump. Substantive portrayals of his pathologies and their dangerousness undoubtedly contributed to the large voter turnout that helped defeat him. So many voters considered the election an existential moment for the country, and the psychological commentary validated that concern. It certainly seemed that the effort from the mental health community was one of the factors contributing to Trump’s defeat.

And yet… for many of us in that community, it seemed like our findings should have had an even greater impact. After all, many of us had spelled out pathologies that demonstrated that Trump was unfit for office, clinically dangerous, and really was an existential threat. Given that, how could the election have even been close? How could Trump have garnered more votes (other than Biden) than any presidential candidate in history?

A quick answer is tribalism. It is folly to suggest that reasoned arguments about Trump’s fallibilities could have any impact in Magaland. Indeed, research suggests such arguments would only embolden the support of his base. Hell, Joe Biden could bring peace, prosperity, and good health outcomes to every corner of the globe, and part the Red Sea to boot, and it wouldn’t result in the slightest uptick in his poll numbers. And Trump, as he accurately noted, could murder someone on the streets of Manhattan without concern of losing support from his followers.

Tribalism is a force more potent than reasoned argument. We know this. But tribalism is an insufficient answer as to why our findings didn’t have more sway. We had shown that Trump was a public health menace and someone who was incapable of passing a fitness of duty test for any number of professions, much less the presidency. There was sufficient evidence that he suffered from a condition associated with recklessness and dereliction.

Given that, how could any moderate Republican vote for him (virtually all did) or any independent voter for Chrissake? Why wasn’t the conversation about Trump’s psychiatric condition more front and center in the country’s mainstream media and collective consciousness? Why isn’t it now?

There remains a gap between the deadly implications of Trump’s psychiatric disabilities and the country’s appreciation of that reality. The gap remains consequential. The existential threat himself has been voted out of office but still lurks. The former and, potentially future, emperor — exposed by mental health professionals to have no clothes — is still elegantly robed in the eyes of too many. His poll numbers don’t look great at the moment, but we’ve seen this movie before. His approval/disapproval ratings were noticeably worse than Hilary’s right up to election day in 2016. He remains the leading candidate for the Republican nomination.

The purpose of this essay is to try to close that gap, to inform all those not blinded by the blazing politics of tribal warfare that the ‘dangerous case of Donald Trump’ deserves the following clear verdict: he meets diagnostic criteria for a psychological disorder of destructive personality traits that leaves him demonstrably unfit for higher office. This is not a close call.

This argument will first be presented by delineating four reasons that explain the gap between the dangerous reality of Trump’s condition and the public’s understanding of it. Then, I will argue that, while these reasons have some merit, there are substantive challenges to each of them. Hopefully, these challenges can help us deliver the message — that Trump is a danger — with more force and clarity. I hope this can strengthen the message of mental health professionals as we move forward.

Looking back on the efforts of mental health professionals to educate the public about Trump in the 2017–2020 time period, I identified four reasons that compromised our message’s receptivity. They are listed below in the voice of a Trump supporter and skeptic of mental health professionals:

  1. This whole business of diagnosing Trump is fraudulent because you haven’t even interviewed him. You are violating your own ethical standards (see the Goldwater Rule) in the service of a witch hunt.
  2. You provide so many diagnoses of the guy I can hardly keep up with them. You’d really have us believe he has all these disorders? That stretches credulity beyond the breaking point.
  3. By the standards of your profession, he does not qualify for any diagnosis. You are just tarring him with a diagnosis because you hate him. You think he is an autocrat. Fine, but here’s the thing: we live in a democracy. We elected him in 2016, and we very well may do it again in 2024.
  4. Admit it, you mental health types are biased. You’re nothing but lefties who condemned the man and wanted him out of office, and so went in search of so-called pathology to justify your mission.

And now let’s go through them one by one.

A clinical interview of the patient is considered essential in providing a bona fide psychiatric diagnosis. Licensed mental health professionals will gather information about the patient’s history and symptoms, conduct a mental status examination, and perhaps administer psychological tests. They will then use their knowledge of psychopathology to determine whether the patient meets the criteria for a particular disorder, as enumerated in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V).

The key to making a valid and reliable diagnosis revolves around gathering sufficient and relevant information for each patient. There are three sources of information to draw upon in making a diagnosis:

  • Data from the patient (the clinical interview)
  • Data from informants (e.g., family, friends, business associates, etc. and, if the public official is high-profile like Trump, well-researched biographies)
  • Data from archival sources (e.g., speeches, taped interviews, tweets, court records, real-time video observations)

For virtually all diagnostic categories in DSM-V, the most critical and targeted information comes from the clinical interview.

The interview enables the examiner to synthesize the information put forward in order to narrow down the diagnostic options and ask pointed questions about symptoms and other domains related to DSM-V criteria. Most critically, the examiner can conduct a mental status exam to evaluate the patient’s attentiveness, quality of thought, mood and affect, and level of insight and judgment.

To forswear the clinical interview as an instrumental part of ascertaining a diagnosis can seem like an abdication of our professional training and undermine our credibility with the public. While all the contributors to The Dangerous Case of Donald Trump condemned the APA’s gag order in March of 2017, most accept the Goldwater Rule stricture that you cannot diagnose a patient without an interview. In the prologue to the first edition of the book, Judith Lewis Herman and Bandy Lee note:

The clinical approaches we use to evaluate patients require a full examination. Formulating a credible diagnosis will always be limited when applied to public figures observed outside this intimate frame; in fact, we would go so far as to assert that it is impossible.

In his article Should Psychiatrists Refrain From Commenting On Trump’s Psychology, Leonard Glass worries about mental health professionals repeating some of the mistakes as in the original Goldwater episode where political bias seemed to win out. He comes down on the side that mental health experts have a right to comment on Trump’s behavior and possible dangerousness, but not to offer a diagnosis.

“I do respect the difference between, on the one hand, making a diagnosis of a public person one hasn’t examined and, on the other, offering a professionally informed perspective. Diagnosing is intrinsically more specific and requires a more substantial level of confidence rooted in the professional procedures and discipline in which a more definitive conclusion is grounded. Offering a definitive medical diagnosis without a thorough personal evaluation and he consent of the person being assessed can quickly degenerate into speculation and name-calling, which discredits the clinician for making the less than optimally founded diagnosis. Nonetheless, one can acknowledge the limitations of relying on publicly available evidence and the lack of certainty inherent in that foundation and still offer valuable professional perspectives on the apparent psychological impediments of a public figure.” (pg. 147)

There are exceptions to even very good rules. The use of a clinical interview to diagnose Psychopathic Personality Disorder (PPD) in not only unnecessary, but contraindicated. There is empirical support that the clinical interview detracts from the examiner’s ability to arrive at a valid and reliable diagnosis for this particular disorder. There is a thorough and empirically-supported diagnostic process to ascertain if someone has PPD, but it does not demand an interview. All reasonable objections to ‘diagnosing at a distance’ simply do not apply to this disorder.

There are two main reasons for this assertion.

First, the information gained from a psychopath during an interview is worse than a distraction. A core feature of psychopaths is deceitfulness. They lie casually and reflexively. They are not just unreliable reporters of their history or symptoms but are active dissemblers. Even if you could give a psychopath truth serum, their hard-wired traits of glibness, lack of insight, arrogance, and grandiosity would still lead you down a rabbit hole (think of Trump’s Q and A sessions with reporters).

One would hope that a seasoned diagnostician who has studied PPD would not be fooled or misled by a psychopath. But the leading pioneers in the field emphasize they are not exempt from the ‘malignant charms’ of the psychopath. Robert Hare notes in Without Conscience:

“Know what you are dealing with. This sounds easy but in fact can be very difficult. All the reading in the world cannot immunize you from the devastating effects of psychopaths. Everyone, including the experts, can be taken in, conned, and left bewildered by them.”

There are many fine, scholarly reasons to interview a psychopath, and doing so might help in a diagnostic formulation, but it is not a requirement. Trying to elicit reliable information from a psychopath can run the risk of getting disoriented in a funhouse of mirrors.

Second, a thorough, reliable, and valid diagnostic process has been achieved through the use of the Hare Psychopathy Checklist. The Checklist can be administered if there is sufficient data from informed sources and archival data. The diagnostic process is driven by data and not contingent on a personal interview. The diagnostic process is rigorous. Specialized training to understand, administer, and score the Checklist is a prerequisite. The Checklist requires the examiner to gather, cull, and synthesize data across 20 behavioral, affective, lifestyle, and life history domains. The examiner must then conform to a scoring system to maintain the consistency and reliability of the diagnostic process. I believe it is fair to say that the demands placed on the evaluator of PPD are greater than those involved in diagnosing most conditions in DSM-V.

I am not saying it is generally acceptable to diagnose a public figure or anyone else at a distance. A clinical interview conducted by a trained professional is instrumental in arriving at virtually every diagnosis in DSM-V.

But I am saying without reservation that an appropriately trained professional can evaluate anyone for PPD from a distance if the data from archival sources and collateral sources is sufficient. Also, you should trust that evaluation since it rests on solid reliability and validity metrics. The Goldwater Rule does not restrict a professional trained to administer the Hare Psychopathy Checklist from diagnosing this particular, fateful condition.

There are a couple of reasons why this objection is reasonable. Serving up a range of diagnoses and psychological explanations for Trump’s dangerousness (The Dangerous Case of Donald Trump offered at least a dozen diagnoses) makes it difficult for the public to develop a clear and concise appraisal of Trump. The narrative of Trump’s psychiatric vulnerabilities and accompanying dangerousness, with so many formulations, is fragmented. Information overload kicks in and, understandably, people tune out.

Unfortunately, the politically engaged mental health community might have, ironically, replicated a “flooding the zone” phenomenon that served to deflect criticism from Trump. “Flooding the zone” occurred during his presidency when the public (and media) were overwhelmed with so many instances of Trump’s unfitness or malfeasance that the impact of any particular incident was diminished. What would have stopped the presses with previous presidents, didn’t even make it into the news cycle with Trump.

The public is not only overwhelmed by so many diagnoses put forth but also, again understandably, skeptical. This is what happened in the Goldwater episode. He was tagged with so many diagnoses and (pejorative) psychological descriptors that mental health professionals came across as politically biased. No doubt, many believed Goldwater was clinically dangerous. But also, many, no doubt, were gunning to shoot down his candidacy. Since mental health professionals did not do the rigorous diagnostic work on Goldwater, their assertions about his unfitness were viewed (justifiably) with skepticism. Rather than Goldwater being looked at with suspicion, mental health professionals were instead.

In contrast, the contributors to Dangerous Case of Donald Trump and Duty To Warn presented thoughtful and well-reasoned arguments on Trump’s psychopathology and unfitness. Nevertheless, the point remains that, in terms of communicating with the public, the more diagnoses we offer for Trump, the less each one registers. More is less.

If it were the case that Trump really did suffer from a surfeit of diagnoses, we would simply have to live with the challenge of trying to communicate his psychopathology concisely and clearly. After all, Bandy Lee and John Gartner developed platforms that encouraged substance over anti-Trump polemics. If the clinical picture of Trump is inherently complex, multifactorial, and a bit overwhelming, so be it.

However, it isn’t. A primary diagnosis of PPD is the ‘signal’ to all of the ‘noise’ of his aberrant behavior.

Donald Trump doesn’t suffer from an abundance of psychiatric conditions. He suffers fundamentally from one condition: Psychopathic Personality Disorder (PPD). That is his primary diagnosis.

A few of the other diagnoses ascribed to Trump are valid (i.e., he certainly appears to meet the inclusion criteria for them as laid out in DSM-V). But these diagnoses are secondary to the core pathology of PPD. Several other diagnoses put forward for Trump are unwarranted because, upon closer inspection, he does not appear to meet the diagnostic criteria for them.

PPD is the primary diagnosis for two reasons: Trump meets the demanding diagnostic criteria of the disorder, and the defining features of the disorder account for the symptoms in some of the other diagnoses put forward for Trump. Understanding PPD enables us to cut through the dizzying breadth and flamboyance of his aberrant behavior. It enables us to drain the floodplains and see the underlying landscape. PPD is the Trump whisperer.

To back up this assertion, we must evaluate the legitimacy of the other diagnoses that have most often been put forth for Trump. This will require getting in the weeds a bit. Let’s start with the most popular alternative.

Two things can be true at once: Donald Trump certainly appears to meet the diagnostic criteria for Narcissistic Personality Disorder (NPD); however, presenting him to the public as a clinical narcissist results in a profoundly misleading picture. Let me try to unpack this paradox.

First, it seems undeniable he displays NPD. I realize I just stated we should be wary about diagnosing virtually any condition in DSM-V from a distance (again, Psychopathic Personality Disorder is an exception to this rule of thumb). But, c’mon, look at the criteria:

A pervasive pattern of grandiosity (fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood, as indicated by at least five of the following:

Has a grandiose sense of self-importance (e.g., exaggerates achievements, expects to be recognized as superior without actually completing the achievements)

Is preoccupied with fantasies of success, power, brilliance, beauty, or perfect love.

Believes that they are “special” and can only be understood by, or should only associate with, other special people (or institutions)

Requires excessive admiration

Has a sense of entitlement, such as an unreasonable expectation of favorable treatment or compliance with his or her expectations

Is exploitative and takes advantage of others to achieve their own ends

Lacks empathy and is unwilling to identify with the needs of others

Is often envious of others or believes that others are envious of them

Shows arrogant, haughty behaviors and attitudes

It seems like these criteria were written with the former president in mind. If they ever put out a Pictionary edition of DSM-V, you could put Trump’s face above the NPD entry. With all of the archival data and information from informed sources on Trump, it seems pretty reasonable to affix him with the NPD diagnosis, even without the benefit of an interview.

But second, to present Trump to the public as primarily a clinical narcissist takes us far afield from the defining features of his personality and paints a false picture of the extent of his dangerousness.

Narcissistic Personality Disorder should be regarded as a secondary diagnosis to Trump’s primary diagnosis of Psychopathic Personality Disorder. His narcissistic features deserve attention and explication but need to be placed in the context of his core PPD pathology.

Consider the following analogy to appreciate the difference between primary and secondary diagnoses:

There are different types of leukemia (blood cancers). The diagnosis of leukemia is typically made by a hematopathologist who examines the patient’s blood microscopically. Normally, this specialist would see circulating leukemia blasts — immature red blood cells — produced by the bone marrow, crowding out the healthy blood cells. The pathologist may see some reddish, linear structures within the blast. These structures, called Auer rods confirm a formal diagnosis of Acute Myeloid Leukemia (AML). AML is a fateful diagnosis. AML must be treated quickly and aggressively. Even with successful short-term treatment, the survival rate five years out from initial diagnosis is discouraging.

Anemia is one of the expected complications of AML. Anemia is acondition in which you lack enough healthy red blood cells to carry adequate oxygen to your body’s tissues. The main symptom of anemia is fatigue. Anemia does not cause AML; it is the result of AML. Virtually everyone with AML develops anemia, whereas only a tiny percentage of those with anemia have AML. Anemia needs to be identified and addressed in its own right. However, no one would highlight anemia over the severe, governing disease process of AML.

Narcissistic Personality Disorder is to Psychopathic Personality Disorder as anemia is to AML. It is a feature of the graver condition. All of the core traits of the NPD diagnosis — failure to empathize, grandiosity, and the need for admiration — are incorporated into the PPD diagnosis. These core NPD traits are nestled in the three clusters of traits that comprise Psychopathic Personality Disorder. PPD encompasses a significantly more comprehensive range of destructive personality traits than NPD. If you drew a Venn diagram of the two disorders and their key traits, the PPD circle would fully encapsulate the NPD circle.

The clinical bottom line of the two disorders is telling. Clinical narcissists have a conscience and some ability to form a loving bond with others. Psychopaths do not. Narcissists fear disapproval from others and limit their behavior accordingly. Psychopaths do not. Narcissists experience the inhibitory emotions of guilt, shame, and fear. Psychopaths do not. Both narcissists and psychopaths are very deceitful, but for very different aims: the narcissist to fuel his grandiosity to get acclaim; the psychopath to get his way and win. Compared to psychopaths, narcissists don’t typically display traits of dereliction, inability to defer gratification, high-risk tolerance, failure to accept responsibility, proneness to boredom, hostility, inability to plan, sensation-seeking, and callousness. The psychopathology associated with PPD is more extensive, specific, and severe than NPD. To emphasize the narcissistic features in an individual who has been diagnosed with PPD would be like putting anemia on the same plane of pathology as someone diagnosed with Acute Myeloid Leukemia (AML).

Emphasizing Trump’s narcissistic features has two regrettable consequences. First, the emphasis on narcissism undersells his level of dangerousness. Second, it muddles our understanding of his deeper psychology which, in turn, compromises our ability to communicate clearly to the public about his psychopathology.

Narcissists can be hell to live with, but there is little in the research to indicate they are particularly dangerous (thank goodness, since in America, approximately six in one hundred qualify for the diagnosis). The core traits of narcissism are problematic but not particularly menacing. One of the critical psychological components of a narcissist involves their fragile feeling of self-esteem. This fragility is seen as driving much of their inflated sense of self-importance and efforts to secure attention and admiration. Because of their need for attention and fear of disapproval, narcissists will impose certain limits on their behavior. They loathe to incur the wrath of others. Like almost all of us, they want and need love and connection.

(It seems relevant to note here: as an interested consumer of the Trump biographies, I have observed that many authors assume Trump suffers from this underlying fragility. This fragility, in turn, presumably fuels his arrogant and deceitful behavior. However, I never seem to find passages where he actually displays this fragility. Whereas there are many hundreds of anecdotes where he reveals the core psychopathic traits. As psychopathy expert Martha Stout notes, all psychopaths are narcissists, but few narcissists have the depth of PPD pathology.)

Psychopaths, like Trump, are not in the game of pursuing love or security. Thus, they do not feel any obligations to others. It is all winning; win at all costs; keep winning. Combine that with the inability to experience guilt, shame, or fear, and you have an individual with no sense of limits on their behavior. Anything goes to achieve their egocentric prerogatives. Psychopaths are a much smaller group (approximately one in 140 qualify for the diagnosis) but more dangerous by a significant magnitude.

For a few years, I tried to believe we would be able to dodge bullets with Trump in the White House. It was maddening to have someone in the Oval Office who was so unfit, but the collateral damage seemed short of catastrophic. Then came his response to Covid and his shattering of so many democratic norms. So, inevitably, the predictable danger associated with his personality disorder became manifest. Our body politic can live with narcissists (always has, no doubt always will); but is in peril with psychopaths.

To truly see Trump, to understand ‘where he is coming from’, requires a clear understanding of the secondary nature of his narcissistic features to his core psychopathic pathology. The primacy of his psychopathic traits was demonstrated in response to Covid. Again, narcissists have a fragile sense of self. They desire love and approval. They have a conscience. Psychopaths have a rigid, arrogant sense of self. They operate only in the gear of domination and win at all costs. They are remorseless. Psychopathic traits explain why Trump could not collaborate or delegate authority during the crisis. He blew off task force meetings and took over daily press briefings where he displayed ignorance and insensitivity. He could have been collaborative rather than combative and derelict. It was no contest because of his trait structure. He refused to wear a mask and mocked those who did; he tweeted out support to protestors who flaunted social distancing guidelines, and he peddled exaggerations about the administration’s achievements and bogus treatments. Trump treated the crisis as a media spectacle that he was determined to dominate from the outset. His remorselessness and callousness explain his doling out of ventilators and protective equipment to governors based on their political leanings and sycophancy, and his holding of super spreader events. Narcissistic drives would have veered away from such behavior since it would have risked disapproval.

Trump was revealed as a puppet dancing on psychopathic strings in his behavior on January 6: the casual incitement to violence, the bottomless deceit in his speech, the apparent glee he took in watching on TV as “his people” descend on the Capitol, the lack of concern for injury or worse to Mike Pence and members of Congress, the obliviousness as to what it might all mean for our democracy.

Also, it is misleading to think of Trump as someone who suffers from psychopathy and narcissism or, worse, as a narcissist with “malignant” features. No, he is a diagnosed clinical psychopath who, yes, possesses narcissistic features as one part of that disorder. Do not think of him as some kind of preening peacock, although that is tempting to do. Recognize he is a cold-blooded snake (however colorful) who can’t help but strike with venom.

Mark Twain once said, “The difference between the right word and the almost right word is the difference between lightning and a lightning bug.” That’s the way I feel about psychopathy and narcissism after my journey thru The Sociopath Next Door, The Mask of Sanity, Without Conscience, and The Psychopath Whisperer. I believe you would feel the same if you also undertook that journey.

Malignant narcissism, a kind of diagnosis, has been cited frequently by mental health professionals and public intellectuals to deconstruct Trump’s extreme behavior. The term “malignant narcissist” was first introduced by the famous social psychologist and humanist Erich Fromm in his book The Heart of Man: Its Genius for Good and Evil. Fromm claimed that malignant narcissism was a “severe mental illness” signified the “quintessence of evil.” He used the construct to explore the psychology of Hitler, Stalin, and other monsters of history. Otto Kernberg, a psychoanalyst, elaborated on the concept in several writings. He defined malignant narcissism as the toxic brew of four personality conditions: narcissistic, antisocial, paranoid, and sadistic. John Gartner, the founder of Duty To Warn, applied the term to Trump in a number of articles, including a chapter in Dangerous Case.

The term seemed to catch on to a degree in the popular culture, particularly so in the community of those concerned with Trump’s mental health and dangerousness. The term certainly may have helped raise awareness of the gravity of his personality structure. It is an ominous-sounding descriptor that communicated concisely that Trump, because of his psychopathology, should be viewed more as a menace than some political maverick.

But malignant narcissism is only ‘a kind of diagnosis’. It is not a formal diagnosis listed in DSM-V. More critically, in contrast to PPD, it has no scientific underpinnings. It has never been operationalized in a way you can measure it. Thus, it has not generated any research that might enable us to understand its cardinal features, etiology, course, response to treatment, or the structure of its four key features or, well, anything. Since it has no scientific foundation, it places those of us in the activist wing of the mental health profession in a precarious position to try to defend malignant narcissism as a reliable, valid, and well-delineated condition.

Since we can’t rely on a foundation of empirical findings, we can only make clinical judgments based on inferences and theory. For example, what is clinical sadism in this model? Blue Tribers would point to separating children from families at the border or Trump mocking those wearing masks as obvious examples. But Red Tribers would look at the same behavior and label it “strong.” Likewise, for paranoia. Blue Tribers would note Trump’s accusation of Obama taping his calls or those thousands of Arabs in New Jersey cheering on the 9/11 attackers as delusional. Red Tribers would chuckle at Trump’s deliberate trolling of the libs. It is maddening to acknowledge, but without an empirical footing, Red Tribers would be standing on the same scientific ground as Blue Tribers in these arguments.

Perhaps, the descriptor “malignant narcissism” was put out there as simply a way of getting the idea of Trump’s pathology and associated dangerousness across. But why settle for that when we can have the more significant sway that comes with the authority of a diagnosed condition of PPD that brings rich and empirically-generated detail with it. Also, look at the four conditions that make up malignant narcissism. Except for paranoia, they sure sound like PPD, albeit in a slightly paler form. Indeed, Kernberg himself came to view what he termed “pathological narcissism” as a spectrum, with Psychopathy pioneer Hervey Cleckley’s antisocial character being at the extreme end of pathology, and malignant narcissism in a somewhat less severe position.

In the future, I would argue for downplaying the usage of the term “malignant narcissism” and becoming more unified about the diagnosis of PPD. What we might lose as an apt descriptor, we gain in empirical standing and irrefutability.

Delusional Disorder and Paranoid Personality Disorder are two diagnoses sometimes attributed to Trump, although much less so than narcissism. I am lumping them together because they are typically put forth in the context of pointing to various Trump utterances that, well, sound pretty delusional and paranoid. Examples include the charge that Obama tapped his phone at Trump Tower, that the crowds at his Inauguration were larger than any in history, that Supreme Court justice Antonin Scalia was murdered, and of course, the fact-free charges of voter fraud (Suitcases of votes coming in the back door! Dead people casting ballots! The machines!).

These assertions, along with many others, are bananas, and, understandably, terms like “delusional” and “paranoid” would be used to describe him. However, our job is to use such terms only as serious clinical constructs, not as adjectives. Regarding these terms, I must say the oft-repeated observation, “the press takes him literally, but not seriously; his supporters take him seriously, but not literally,” is on target.

Based on all the collateral data we have on Trump, plus what we have seen and heard with our own eyes and ears the past six years, plus our knowledge of the different nature of paranoid versus psychopathic pathology, we can make quick work of rejecting these diagnoses. However, I think it might be helpful to elaborate a bit on the specious nature of these diagnoses to highlight some of the detail about Trump’s psychopathology. Such a delineation, I hope, will contribute to our ability to convey to the public what a different and dangerous creature the 45th president was and continues to be.

Delusional disorder is a rare condition (prevalence rate of one in 500) where one displays delusions — defined as beliefs held despite indisputable factual evidence to the contrary — in the absence of any other major mental illness such as schizophrenia or bipolar disorder. The quality of the delusional thinking is the giveaway as to why Trump does not fit this diagnosis. For someone with this disorder, the delusions are fixed, held with absolute certainty, and intense, central to the person’s identity.

However, Trump’s so-called delusional thinking dwells in a different realm. Trump’s beliefs are not fixed or rigid but incontinent and erratic. His flaunting of reality is not intense and circumscribed to a few persecutory or grandiose ideas but casual and voluminous (tens of thousands of documented lies at this point). Trump will pick up on any outrageous claim that serves his interest and run with it, not because he believes it, but because it serves his interest. The source of Trump’s “delusional” thinking is not his psychiatric disability but what he may have heard on Fox and Friends that morning or have been fed by one of his fevered sycophants, such as Rudy Giuliani or Mike Flynn.

Trump’s “delusional” thinking is opportunistic and wielded as a weapon, rather than paranoid and held on to secretly. Trump wasn’t brooding over Obama being a Muslim born in a foreign country, but blaring it out so he could become a rising star with the Republican base. Trump is a casual and self-serving liar, not a delusional paranoid.

Paranoid Personality Disorder is in what is called the Axis 2 section of DSM-V, which is reserved for personality disorders. For DSM-V, a personality disorder is defined as an “enduring pattern of inner experience and behavior…that is inflexible and pervasive, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.” There are eleven personality disorders listed in DSM-V.

Here are the definition and criteria for Paranoid Personality Disorder, with my shorthand appraisal vis a vis Trump in parentheses.

TABLE 1. DSM-5 Criteria for Paranoid Personality Disorder

A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by (or more) of the following:

Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her. (I see some, but not much, of this with Trump. Remember, he does, in fact, have a lot of enemies)

Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates. (He demands loyalty, but that is not the same as “unjustified doubts” about others’ loyalty)

Is reluctant to confide in others because of unwarranted fear that they will use the information maliciously against him or her. (Tony Schwartz, his ghostwriter, noted Trump was open and transparent but simply had little insight into himself)

Reads hidden demeaning or threatening meanings into benign remarks or events. (I have not seen much of this)

Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights). (Very much meets this criterion)

Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or counterattack. (He certainly reacts angrily and counterattacks, but usually in response to criticism that is apparent)

Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner. (I don’t see this anywhere in the information from collateral sources)

Does not occur exclusively during the course of schizophrenia, a bipolar disorder or a depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological effects of another medical condition.

As you can see, I do not think Trump meets the threshold of four of the criteria needed for this diagnosis.

Nevertheless, I thought it might be helpful to spell out some of the differences between the personality features of a paranoid character versus a psychopathic character. I do this in part to provide a more granular feel for the two conditions, but mostly to reinforce the assertion that Trump is in the PPD camp (you are encouraged to picture him as you go through the descriptors). The material is broken down into the three main domains of personality functioning — behavioral, affective, and cognitive — and two subsidiary domains of attention and sense of inner self.

  • Manner is guarded, brooding, secretive
  • Distant
  • Defensive vigilance (in a crouch)
  • Circumspect
  • Hesitant in speech
  • Anxious around high status others
  • Focus with others is to protect self
  • Highly defended

  • Cold
  • Sensitive pride
  • Stolid mood
  • Looks to reduce stimulation
  • Tries to regulate emotions
  • Delusions are threat-based (“out to get me”) or shame-based (“my body smells”)
  • Can be dysphoric

  • Train of thought is rigid
  • Views self as powerless, vulnerable to harm
  • Delusional thinking revolves around theme of malevolence
  • Rigidly pursues a line of thought
  • Preoccupied about being controlled

  • Scans environment for threat
  • Looks for clues
  • Focus is acute, probing
  • Lives mostly in the past, the world of betrayals and wounds

  • Constricted
  • Has convictions
  • Has a narrative of course of life
  • Whims are threatening, need to be suppressed

  • Manner is unrepressed, spontaneous, transparent
  • Extreme extraversion
  • Take the offensive (chin and chest thrust forward)
  • Boastful
  • Says things ‘off the top of his head’
  • Comfortable with high status others
  • Focus with others is to win the transaction
  • Immediately acts out

  • Labile, but superficial
  • Remorselessness
  • Baseline is bored, easily aggravated
  • Abrupt mood changes
  • Seeks stimulation
  • Unregulated emotional expression
  • Emotion associated with “delusion’ is often self-aggrandizing (“it was a landslide!”)
  • Rarely dysphoric

  • Train of thought is incontinent
  • Views self as powerful, able to prevail against others
  • Lies revolve around egocentric needs
  • Struggles to pursue a line of thought
  • Controlling

  • Scans environment for opportunities
  • Looks for way to ‘win the moment’
  • Focus is undifferentiated, reactive
  • Prisoner of the moment (“must always be closing”)

  • Empty, all attention directed outward
  • Has campaigns, not convictions
  • No coherent narrative of life, one episodic event after another
  • Whims are everything, immediately acted upon

As you ponder this more comprehensive list of paranoid vs. psychopathic features, I trust you see Trump solidly in the psychopathic camp. Indeed, he is quite a different creature than the paranoid. But not just the paranoid. He meets the demanding diagnostic criteria for PPD and therefore is quite the different creature than over 99% of us. And a distinctly more dangerous one.

A number of mental health professionals have asserted that Trump meets diagnostic criteria for ASPD. You can see why when you look at the criteria:

There is a pervasive pattern of disregard for and violation of the rights of others occurring since the age 15 years, as indicated by (or more) of the following:

failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest

deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure

impulsivity or failure to plan ahead

irritability and aggressiveness, as indicated by repeated physical fights or assaults

reckless disregard for safety of self or others

consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations

lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

The individual is at least 18 years old

There is evidence of Conduct Disorder with onset before age 15 years.

The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode.

Yet, I would urge us not to consider using ASPD as a primary diagnosis for Trump. I recommend that, not because I don’t think Trump meets diagnostic criteria for ASPD (most reasonable people would acknowledge that he does), but because it has a perverse effect on communications to the public about his psychology. Of course, the term “antisocial personality disorder” sounds terrible and is an ominous diagnosis. But it actually undersells the breadth and depth of his psychopathology. That’s because ASPD is a paler form of Psychopathic Personality Disorder. The ASPD diagnosis places more emphasis on overt antisocial behavior but less on the psychological, emotional, and behavioral traits that the pioneers of the condition identified as being at the heart of the disorder.

The terms psychopathy, antisocial personality disorder, and sociopathy are used interchangeably in the culture. However, as diagnosticians, we cannot abide by such casual usage. Sociopathy is not even a formal diagnosis in DSM-V, nor is it associated with any scientific studies. Diagnosed PPD and ASPD are not distinctly different animals, but one is a lion and the other is its cub. All diagnosed psychopaths meet the diagnostic criteria for ASPD. The opposite is not always the case. In prevalence studies conducted at maximum-security facilities, almost all inmates meet the criteria for Antisocial Personality Disorder, but only 22% — 25% meet the criteria for Psychopathic Personality Disorder.

In an earlier article on President Trump and PPD, I tried to (humorously) make an analogy of these two diagnoses to the drug market in Albuquerque, New Mexico, as portrayed in the hit TV show, Breaking Bad. In that show, Walter White, the antihero protagonist — after he receives a diagnosis of stage three lung cancer and wants to find a way to obtain financial security for his family — transforms (“breaks bad”) from a meek high school chemistry teacher to a drug kingpin in Albuquerque. A big part of his success in the drug market is his skill as a chemist. He concocts an exceptionally pure form of crystallized methamphetamine that blows away the competition. His crystal meth has a blue tinge to it and earns the moniker “the blue stuff” on the streets of Albuquerque.

Psychopathy is the “blue stuff” of Antisocial Personality Disorder.

And ASPD not only undersells the gravity of Trump’s pathology, but also underreports its features. PPD is the condition that has generated so much research, significantly more than on any other personality disorder. Suppose we casually use ASPD as the primary diagnosis rather than the empirically-soaked PPD. In that case, we lose access to all the scientific research that enables us to speak with more authority and precision about Trump and the danger he poses.

Finally, I would be remiss if I didn’t note that DSM-V posits two criteria that are deemed necessary to consider the diagnosis of any personality disorder: that the person displays “clinically significant distress or impairment in social, occupational, or other important areas of functioning.” With his pre-wired inability to experience the distress of certain negative emotions and high level of functioning (in the eyes of many), is Trump, therefore, a legitimate candidate for a diagnosis of any personality disorder?

This question leads us to the third reasonable objection to affixing Trump with a psychological diagnosis.

Dr. Allen Frances, professor emeritus of the Department of Psychiatry at Duke University School of Medicine, served as chair of the American Psychiatric Association task force overseeing the development and revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). He is credited with determining the criteria for Narcissistic Personality Disorder. He is a leader in the field of psychiatric diagnostics. Thus, it is noteworthy that he is also one of the staunchest critics of those of us who have tried to affix Trump with a diagnosis. His opinion carries weight.

Frances’ objections are twofold: one technical and one more philosophical. His technical objection revolves around the threshold criterion in DSM-V that to allow a diagnosis of any personality disorder, the individual must display “clinically significant distress or impairment in social, occupational, or other areas of functioning.” Frances, certainly no fan of the former president, asserts (reasonably, I believe): “I wrote the criteria that define this disorder (Narcissistic Personality Disorder), and Mr. Trump doesn’t meet them. He may be a world-class narcissist, but this doesn’t make him mentally ill, because he does not suffer from the distress and impairment required to diagnose a mental disorder.”

Frances’ contention that Trump’s manifest symptoms of NPD (and Antisocial Personality Disorder (ASPD), for that matter) don’t result in clinically significant distress or impairment is entirely defensible. As Frances notes, Trump causes distress in others, not himself; and rising to the level of POTUS is not exactly a marker of impairment of functioning. Technically, it would seem that Trump does not qualify for a diagnosis of personality disorder in DSM-V.

But here’s the thing: Psychopathic Personality Disorder (PPD) is not one of the ten personality disorders included in the DSM-V. The task force decided on the much broader category of ASPD that, as you remember, emphasizes unlawful behavior that would typically check the box for the “impairment of functioning” criterion needed for the possible diagnosis of a personality disorder. Since it is not in the DSM-V, PPD is not subject to the “clinically significant distress” or “impairment of functioning” requirements.

This qualifier should in no way be viewed as a compromise of the rigorous diagnostic process to ascertain if someone merits a diagnosis of PPD. Just the opposite. Lack of distress is one of the defining features of the condition PPD. There is strong agreement that psychopaths have brain abnormalities that contribute to what is often termed as “emotional deficit,” the inability to experience the (distressing) emotions of fear, shame, and guilt. The lack of distress for this disorder, and probably for only this disorder, is actually one of the vital inclusion criteria! Likewise, it is well established that clinical psychopaths can be pretty successful in the vocational arena and possess good social standing. One of the Mt. Rushmore psychopathy experts, Robert Hare, wrote a book called Snakes in Suits about psychopaths who were quite successful at work and adept at hiding their true nature from others. This should not be surprising since one of the core traits of psychopathy is the drive to dominate, which often finds its expression in work. Psychopaths often have a keen, opportunistic intelligence that enables them to get ahead and slither their way up the social hierarchy.

Dr. Frances’ objection to affixing Trump with a diagnosis of one of the personality disorders in DSM-V is valid since Trump doesn’t display distress or impairment. However, this objection does not apply to PPD. Indeed, when we consider the particular pathology of PPD, the absence of these threshold criteria (especially “clinically significant distress”), if anything, is suggestive of the presence of psychopathy.

There was controversy over which diagnosis — PPD or ASPD — should be included in DSM. Ultimately, the Personality Disorder Advisory Committee chose the broader ASPD (prevalence rate of 3% to 4%) rather than the narrower PPD (prevalence rate a bit less than 1%). Key constructs in psychopathy such as “emotional deficit” and “lack of empathy” did not fit the Advisory Committee’s desire for specific, operational criteria for each diagnosis. The Committee chose to emphasize antisocial and behavioral characteristics rather than psychological traits, perhaps so DSM-V could have more clinical utility with criminal populations. But just because PPD is not included in DSM-V does not make it disappear. It rests companionably alongside the Manual, indeed rests on an empirical foundation firmer than exists for the great majority of disorders in DSM-V.

This brings us to the second concern Frances has over giving Trump a diagnosis. He argues that Trump should be viewed as “bad,” not “mad”. To appraise Trump as mentally ill is to “pathologize” or “medicalize” his “evil” (Frances’ word). Frances is clearly appalled by Trump (see his Twilight of American Sanity) but insists that his fitness for office should be handled politically, not psychologically.

I agree with Frances that we should keep the resolution of the Trump phenomenon in the political arena. We elected him, witnessed his conduct, might elect him again, and it is our collective responsibility to contend with him in the political arena. A panel of mental health experts should not resolve the Trump issue. However, I’m afraid I have to disagree with Frances on the characterization of Trump as simply “bad,” not “mad”. Trump does suffer from a fateful mental health condition. And it is our duty as mental health professionals to inform the public about such findings. Affixing a valid diagnosis is not “medicalizing,” but the application of the tools of our scientific training. The spirit of the effort is not anti-democratic but rather aims to inform the citizenry.

The nub of the conflict between Frances’ view and many in the politically activist psychology camp revolves around the validity of Psychopathic Personality Disorder. Well, what can I say? It exists; it is a real thing. It has a heart, lungs, eyes, ears, fingers, and toes: the diagnostic equivalent of which is solid reliability and validity psychometrics on the measurement of the disorder; empirical findings that address the etiology of the disorder and its underlying brain abnormalities; the course of the condition; the voluminous detail on its clinical features; and its (abysmal) response to treatment. It has standing as a valid diagnostic entity. Therefore, the remaining issue is whether Trump meets the diagnostic criteria for the condition. Well, he does (see here).

It is our duty to spell out the significance of this genuine condition. Perhaps the most significant implication of the diagnosis involves the inevitable harm that comes to those in the psychopath’s orbit. In an earlier paper, I analogized the tripartite trait structure of PPD (remorselessness, drive to dominate, and impulsivity) to a car. This car has no brakes (remorselessness, i.e., no inhibitory emotions of guilt, shame or fear), no steering wheel (impulsivity), and only able to operate in one gear (drive to dominate). Trump was leasing such a car (his presidency). For a while, it seemed we were avoiding a crackup. But this wasn’t due to any kind of control by Trump. It resulted from his impulsivity trait structure (e.g., inability to plan, inattention to detail, dereliction, etc.). His executive dysfunction provided a partial brake to his other destructive traits. The GOP establishment tried to fill the breach caused by his dereliction, but little got done during his presidency. We seemed to be avoiding catastrophe.

Then along came Covid.

In this crisis, his impulsivity did not serve as a check on his callousness and remorselessness; tragically, it had a synergistic effect. A study by Lancet, a British medical journal, concluded that 40% of the 500,000 deaths from Covid in 2020 were avoidable due to Trump’s response to the pandemic. He is responsible for as many deaths as occurred in World War II, the Korean War, and the Vietnam War combined. He is responsible for this massive killing field (I realize nearly half the country shrugs off this calamity, but that doesn’t change the facts on the ground).

This outcome is horrific. But it is not simply the result of “badness” on the part of the former president. It is more deeply understood as an expression of the “madness” that is the psychopathology of PPD.

Let’s start with the traits of the impulsivity cluster within PPD — particularly those under the descriptor “irresponsibility’, such as fecklessness, disorganization, inattention to detail, failure to plan, low frustration tolerance, and dereliction. As elaborated in the psychopathy research literature, the flavor of the irresponsibility traits is mostly about not getting the job done, and not following through on one’s obligations or promises. Psychopaths avoid responsibility because they recognize they have neither the skills nor the temperament to handle complex problems. They are wired to be disorganized, unfocused, easily bored, and undisciplined. This set of traits leaves them overmatched in trying to take on a thorny or complex issue that requires sustained focus. These traits help explain the general workings and daily chaos in the Oval Office, as detailed in the litany of richly sourced accounts of the Trump White House.

Thus, the federal nonresponse to Covid was entirely predictable. The crisis demanded discipline and hard work, and Trump was not about to wade into those waters. Golf weekends or coronavirus task force meetings? No contest. Oversee a coordinated federal response? Ha! He stopped attending coronavirus task force meetings and became bored with the daily press conferences as soon as it became clear they were hurting his poll numbers. As we look back, it is clear there was never even a plan of a plan. There was chaos and neglect all the way through.

The cognitive infrastructure and the set of executive functioning skills needed in a President to develop a detailed and comprehensive response to Covid — a response that would not leave the rest of the civilized world aghast — was simply not there. He was overmatched. We paid the price.

Perhaps the primary culprit in the disastrous response to Covid is the “emotional deficit” mentioned earlier. Psychopaths display structural abnormalities in their brains that result in functional deficits in their ability to experience:

  • fear and alarm
  • empathy and compassion
  • shame and guilt

As a diagnosed psychopath, Trump was devoid of these feeling states. Without access to such emotions to help guide his perceptions and reactions, Trump’s callous and remorseless behavior in the face of the crisis was inevitable.

Trump’s inability to process emotions related to threat situations helps us understand his sluggish response to Covid-19. In January, when he was getting alarming reports about the virus from the intelligence agencies and senior officials, he dismissed them. He compared the virus to the common flu and called it a “hoax”. In February, he took no action to develop testing or provide supplies for the looming health care crisis. He seemed blind to the scale of the risk. He was genuinely whistling past the graveyard, not out of fear but rather its absence.

Trump’s lack of empathy and compassion sealed America’s poor outcome with the virus. Only a psychopath would react to the alarming numbers of deaths as disembodied facts. Only a psychopath could respond to the wrenching images coming out of Europe at the beginning of the pandemic with all the intensity and depth of someone binging a series on Netflix.

Lacking any gear of compassion, Trump barreled forward in the only gear he possessed: win-at-all-costs-political-domination. He refused to wear a mask and mocked those who did; he tweeted out support to protestors who flaunted social distancing guidelines; he doled out ventilators and protective equipment to governors based on their political leanings and sycophancy to him; he peddled exaggerations about the administration’s achievements and bogus treatments; and he conducted rallies and White House events that became super-spreader events.

Trump has no capacity for shame or guilt that might have served as a brake on his impulse to deceive and divide. We now know from Trump’s interview responses to Bob Woodward for his book Rage that he was fully briefed in January of 2020 about the lethality and transmissibility of the virus. And yet he lied shamelessly to the public from the beginning about the threat (“the 15 people (infected) within a couple of days is going to be down close to zero, that’s a pretty good job we’ve done”, “It’s going to disappear. One day like a miracle, it will disappear”, “This is a flu. This is like the flu”.)

A core feature of psychopathic shamelessness is the refusal to take responsibility. This trait was on full display throughout America’s regrettable response to Covid, “Nothing more could have been done. Nothing more could have been done. I acted early. I acted early,” he blathered to Woodward.

This is bad behavior. No doubt. Historically abominable behavior. And Trump the man, bears responsibility. It is also true he is afflicted with the condition that governs his emotional life and behavior. He is behind the wheel of a car with no steering or brakes and can operate in only one gear. A Desantis, a Cruz, or a McConnell might be behind the wheel of a car hurtling down the road, scattering vulnerable populations, eligible voters, or rival tribe members. But they would have some measure of control, some moral agency. Trump has none.

Trump is a puppet on a string; actually, the three strings of impulsivity, remorselessness, and drive to dominate trait clusters. He is not evil pathologized. He has a condition that, OK, might be considered evil. Hervey Cleckley called his painstaking and pioneering work on psychopathy The Mask of Sanity. It is an apt title.

We have a duty to inform. We need to explicate Trump’s condition to the public. Hopefully, we can avoid another cataclysm.

This is a reasonable objection, not only by Republican partisans but any fair-minded person. We know bias exists, and we know it can color our appraisal of information, people, and events. As a profession, we have studied bias and have a descriptor for its research: confirmation bias. Confirmation bias is the tendency for people to favor information that confirms their existing beliefs or hypotheses. We know that confirmation bias is more likely with people in emotionally charged situations that might tap into their cherished beliefs.

We know that confirmation bias is an unconscious process that can express itself in three ways:

  1. We tend to favor information that confirms our existing beliefs, hypotheses, or expectations. Thus, we give more weight to evidence confirming our beliefs, and less weight to evidence that might disprove them.
  2. We can display bias by gathering or recalling information selectively.
  3. We tend to interpret such information selectively in a way that validates our pre-existing beliefs.

And we know that it is not easy to counteract this reflexive bias in our thinking system. Daniel Kahneman, co-author of the acclaimed Thinking, Fast and Slow, noted that the more rational and reflective system in our brains is, for the most part, a slave to the faster, more intuitive, but often biased system. Furthermore, self-awareness about the primacy of our more reflexive, possibly biased system, does not automatically or quickly lead to an objective re-appraisal of a situation or information. It may be noble to claim we are unbiased, but we should be cautious about doing so.

Nevertheless, I would contend there is a viable rebuttal to the charge of bias in the specific case of Donald Trump and the diagnosis of Psychopathic Personality Disorder.

Consider the following vignette:

A doctor of internal medicine is buzzed in her office by the receptionist who asks if the doctor can field a question from a patient on the phone. She agrees and asks the name of the patient. It is a man she has treated for over 20 years. She has worked thru several medical issues with him over that time, although none of them were particularly serious. She feels she has gotten to know this patient, who has always been open and appreciative in his dealings with her. She has come to admire and like him. When she hears his complaint of fatigue, which has escalated over the past few weeks to a feeling of exhaustion and episodes of gasping for breath when he climbs the stairs to his bedroom, she instructs him to report to the lab the following day for a full workup and schedules him an appointment for the day after that. When he arrives for his appointment, he is immediately escorted to her office. This exceptional efficiency tweaks his anxiety. The doctor gets right to it. His white blood cell (WBC) count was abnormally high, close to 100,000, whereas the norm is more comparable to 7,000. The count is so high that it effectively rules out the diagnosis of an infection or other relatively benign or acute condition. She tells him he has leukemia (from the Greek, leukos= white, haima= blood, and ia= condition), a blood cancer.

The doctor informs him she has already sent the blood test results to a hematopathologist and received a report back. As she pulls out a whiteboard and draws some figures on it, the doctor explains there are different types of leukemia. The hematopathologist examined his blood microscopically and saw circulating leukemia blasts, immature blood cells produced by the bone marrow that were crowding out his healthy blood cells. The doctor points to an oval figure on the whiteboard that portrays some reddish, linear structures within the blast. These structures, called Auer rods, indicate a myeloid malignancy. His formal diagnosis is Acute Myeloid Leukemia (AML). This is not good news. Of the different types of leukemia, this is one of the least favorable (the survival rate two years out from diagnosis for a man his age is 12%). The doctor spells out the following steps she will take with her patient. She then escorts him to the door and embraces him. It is one of the most painful consultations she can remember.

This vignette aims not to educate you about leukemia, but to underscore the constraints imposed on the doctor by the scientific rigor of the diagnostic process. Her greatest wish would have been not to provide this differential diagnosis of AML. But an empirically-supported assessment process left her no choice. If such a process is available for a particular disorder, then all subjectivity, bias, or wish fulfillment regarding that diagnosis is negated. An evaluator may want a particular conclusion, such as a more benign diagnosis for their patient. Still, if it exists for a specific condition, a valid and reliable diagnostic process will dictate the conclusion.

In the case of Trump, an evaluator with liberal political views may very well want a diagnosis that informs the public about his dangerousness and unfitness for office. In contrast, a staunch conservative wants the opposite. Whatever. The validity of the diagnostic process sidelines the wishes or biases of the evaluators, and their hands are tied if that process is objective and rigorous. This is true for the diagnosis of acute myeloid leukemia and many other conditions. One of those conditions is Psychopathic Personality Disorder (PPD).

Microscopes don’t distort the architecture of aberrant blood cells that generate the diagnosis of AML. Admittedly, the assessment process of Psychopathic Personality Disorder does not possess the acuity provided by a scanning electron microscope. But something approaching that. It is a process more extensive and rigorous than what is required for diagnosing conditions in DSM-V. It is a process that involves training over and beyond what one receives in graduate school or psychiatric residency.

Please note: the diagnosis of PPD is contingent upon receiving a clinically significant score on the Psychopathy Checklist-Revised (PCL-R) or the Psychopathy Checklist: Screening Version (PCL:SV). Thus, formal training in the administration and scoring of these checklists is needed to operate in the “boundaries of competence” outlined in the American. Psychological Association code of ethics. In my case, that included a week-long workshop run by Stephen Hart, Ph.D., an expert in the assessment of psychopathy using the PDL-R and PCL:SV.

Highlights of this training included:

  • Overview of theory and research on psychopathy and its measurement
  • How to collect and evaluate the quality of relevant collateral information
  • How to deal with conflicting data
  • Provision of extensive definitions and behavioral examples of checklist items
  • Use of case examples to learn to apply the scoring system
  • Feedback on videotaped case studies to increase inter-rater reliability on the checklists
  • Discussion of uses and misuses of the psychopathy checklists

These training objectives for assessing PPD can also be read like a list of good practices to counteract confirmation bias. An emphasis on objectivity in collecting and analyzing information helps mitigate selectivity bias. And interpretive bias is not much in play with this diagnosis. There is no interpretive next step if someone meets the cutoff score to diagnose PPD. The next step is to follow the wealth of empirically-derived information generated by the 62,717 studies (through February 2020, as noted by Google Scholar) that used the checklists to study PPD.

We can’t abolish confirmation bias, and we certainly can’t abolish political passion. But a valid, reliable, and rigorous diagnostic process for a specific disorder can deliver the objective goods. If you believe in the scientific method, it should earn your trust. No matter what political tribe you belong to, the microscope, or, in the case of the assessment of PPD, something damn close to it, doesn’t lie.

Here, and elsewhere, I have tried to make an evidenced-based argument that our profession should coalesce around a diagnosis of Psychopathic Personality Disorder for Donald Trump. Because of the nature of that diagnosis, such a consensus could substantively counter those who criticize our efforts to affix the former president with a psychological diagnosis. More importantly, I believe it is the truth, or certainly the closest version to some Platonic ideal of the truth as we are ever going to get in the admittedly less-than-perfect science of psychopathology.

I have no particular authority to issue a decree on Donald Trump’s mental health. Nevertheless, here it is.

— — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — —

DIAGNOSTIC DECREE ON Donald TRUMP’S MENTAL ILLNESS

To back up this proclamation, we need to provide affirmative answers to three questions:

  1. Is Psychopathic Personality Disorder a distinct condition with a sufficient knowledge base that enables us to speak with precision about those that display PPD?
  2. Can you reliably diagnose PPD?
  3. Does Trump meet diagnostic criteria for PPD?

This essay has tried to provide affirmative and detailed answers to these questions. Here is a summary of these arguments.

  1. Is Psychopathic Personality Disorder a distinct condition?

Psychopaths appear to have been with us from antiquity through medieval times to the present. Descriptions from Greek and Roman mythology, the Bible, and classical literature are remarkably consistent in revealing the presence of those that were intellectually intact, but lacked the capacity for moral reasoning.

No culture or station in life is immune from this condition. Psychopaths are found in pre-industrial societies, past and present, as well as in modern states. They are found among the wealthy as well as the impoverished.

The advent of modern psychiatry — especially the establishment of reliability and validity in the clinical diagnosis of disorders — has enabled us to confirm the descriptions from classical literature: that there is a distinct clinical entity we now label Psychopathic Personality Disorder that is stable across history, culture, and socioeconomic status. PPD is also stable across the lifespan of the individual who displays it. Psychopathic personality disorder is not just a term of disapprobation for (mostly) men behaving badly, but a diagnosis that reflects a real world, clearly defined psychopathology with predictable consequences.

The development of the Psychopathy Checklist (PCL-R) led to a surge of research (over 69,000 studies through February 2020 as noted by Google Scholar) and detailed understanding of the condition. Psychopathic Personality Disorder is one of the best understood and most thoroughly validated conditions in the field of psychopathology. If someone warrants this diagnosis, we would know a good deal about the etiology and course of their disorder, their probable neurological abnormalities, the possibility of ameliorating the condition, and the fine details of its fundamental characteristics, including the extent of the dangerousness associated with it.

We have learned that PPD is a condition that is specific, severe, and undeviating as a primary color.

2. Is Psychopathic Personality Disorder a condition that can be reliably diagnosed?

Yes. The Psychopathy Checklist is a valid and reliable tool to diagnose PPD.

The Checklist was designed by Robert Hare, a Canadian psychologist, and his colleagues. They developed the checklist by listing over 100 behavioral, emotional, interpersonal, and lifestyle traits that had been observed in criminal populations, and, from the descriptions of Hervey Cleckley, considered the pioneer in the study of psychopathy and author of Mask of Sanity in the 1930’s. In that book, he detailed the psychopath’s often “brilliant and charming” manner, which masked a predatory nature and a lack of conscience. Through statistical analysis and studies to establish reliability and validity, Hare was able to winnow the original list of traits to 20 items, which he published in 1991. The original checklist (PCL — R) was developed with a criminal population in British Columbia. The clinical version (PCL:SV), with 12 items, was developed with civilian populations and published in 1995. Both checklists were utilized in the assessment of former President Trump.

Robert Hare wrote a book-length manual in which he provided extensive definitions and behavioral examples for each item on the Checklist in order to facilitate consistency and reliability in ratings. Statistical reliability (the degree to which different clinicians using the Hare Checklists come to the same diagnosis) and validity (the checklists are in fact assessing a distinct entity called psychopathy) of the checklists have solid psychometric support (in addition to the comprehensive review in the Hare technical manual, see Current Issues in the Assessment and Diagnosis of Psychopathic Personality Disorder). In addition to its solid psychometric qualities, the PCL-R and PCL-SV emphasize long-standing and stable behavioral and personality traits. The rating system for each checklist requires culling life history data that can identify chronic, persistent, and entrenched traits (as opposed to flamboyant criminal behavior) that we now understand are at the heart of the condition.

The Checklists are not only reliable, but also “rigorous” instruments. Training is required to administer the Checklists. There are demanding criteria for the breadth and quality of the information (life history data points) needed to make an assessment. In the case of Trump, this included:

  1. Information from his childhood, adolescence, and young adulthood. The condition of psychopathy expresses itself early in life. Data is needed from these earlier stages of development to make an assessment.
  2. Information in which the trait is expressed in overt behavior (e.g., an instance of his lying is privileged over an accusation of his lying).
  3. Information that reflects his typical functioning and lifelong patterns vs. descriptions of more flamboyant, occasional behavior.
  4. Information that is well-resourced, substantiated, and has some type of external validation.
  5. Behavior that lends itself to coding and thus quantification (e.g., number of documented lies, lawsuits, or grandiose statements).

The evaluator then culls all this informational data and links it to each specific item on the Checklist. This enables us to generate a data-rich rating for each item, and then an overall score.

Collecting relevant information on Trump, albeit overwhelming at times, was not difficult. There is extensive informant data because of the many biographies and investigative reporting on the man. There is also a wealth of archival data, in large part due to the televised nature of celebrity figures and POTUS. There are thousands of hours of videotape available for behavioral observations of relevant Checklist items.

If you have sufficient high-quality data, you do not need an interview to make the diagnosis of PPD with the psychopathy Checklists. Indeed, given the psychopaths ability to lie casually and persuasively, there is some evidence that an interview detracts from an objective evaluation for PPD.

3. Does Trump meet diagnostic criteria for PPD?

He most certainly does.

As noted above, there is voluminous data on Trump that enables a trained evaluator to score him on the Checklist. I am going to present the scores for Trump on the shorter clinical Psychopathy Checklist: Screening Version since the norms for it were derived from a non-criminal population.

Each item on the Checklist is assigned a score of 0 (trait definitely not present), 1 (there is some data to support the trait, but it is not overwhelming), or 2 (trait definitely present). The designation of a 2 for an item deserves some elaboration. Hare emphasizes that a perfect match is not necessary to justify a rating of 2, but rather a “reasonably good match in most essential respects: the behavior is generally consistent with the flavor and intent of the item, even if only a few of the characteristics are displayed, providing that, in the rater’s opinion, they are sufficiently extreme in intensity, frequency or duration.”

Here are the ratings for Trump:

Hare Psychopathy Checklist — Screening/Clinical Version (PCL:SV)

  1. Superficial/glib — 2
  2. Grandiose/boastful — 2
  3. Deceitful — 2
  4. Lacks remorse — 2
  5. Lacks empathy — 2
  6. Doesn’t accept responsibility — 2

7. Impulsive — 2

8.Poor behavioral controls — 2

9.Lacks goals — 0

10. Irresponsible — 2

11. Adolescent antisocial behavior — 1

12. Adult antisocial behavior — 1

Total = 20

A “perfect” score (very rare) on the PCL:SV would be 24. A score of 20 places one in the moderate to severe range of PPD. Less than 1% of the population produces such high scores. Please note the average score in the general population on the HCL:SV is 3! Trump’s score of 20 is higher than the average score for those incarcerated for serious crimes, or for those receiving psychiatric treatment in either a forensic or civil inpatient facility.

Open and shut case. Donald J. Trump meets the rigorous criteria for the diagnosis of Psychopathic Personality Disorder. It is our duty to inform the public about the dangerous implications of that fateful diagnosis.

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Vince Greenwood, Ph.D., is a clinical psychologist who lives and works in Washington D.C. He founded DutyToInform.org.

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