Allen Frances wrote an Op-Ed in the New York Times ‘An Eminent Psychiatrist Demurs on Trump’s Mental State’ expressing the opinion that Donald Trump does not meet the criteria for narcissistic personality disorder. He bases this view upon the assertion that he cannot have the condition because he does not suffer from distress and impairment. His argument has three flaws:
He claims authority for his view because he wrote the criteria for narcissistic personality disorder for the DSM-IV. This is just a drafting exercise and his claim that he knows what the condition is because he wrote the criteria undermines a vast literature on the subject. The claim is a tautology along the lines of “I know I am right because I said so”.
Secondly, the general criteria for personality disorder requires “distress and impairment in social, occupational, or other important areas of
functioning”. He is no position to claim that Trump does not experience this. Narcissistic personality disorder is usually egosyntonic, meaning that narcissists like the way that they are. They believe that everybody else is also obsessed with obtaining admiration, and if they have achieved this aim then everybody else is envious of them. They rarely seek therapy and, when they do, they resist and manipulate the therapist who they see as undermining what makes them great. Psychiatrists who only treat patients who voluntarily consult them have systemic sample bias–all their patients self-identify as distressed and impaired. If people with egosyntonic personality disorders do not so self-identify, why did Frances include such conditions in DSM-IV at all?
Lastly, he criticises those psychiatrists who breach the ethical constraints against diagnosing celebrities at a distance. And yet he is also doing this. He supposes that Trump does not suffer distress, but he cannot know this without examining him. Narcissism is a defence mechanism that conceals an inner state of rage, emptiness and intense envy. His assertion that Trump does not experience this is diagnosing at a distance. He also cannot say that Trump is not impaired. Trump is unique among narcissists in that his wealth has enabled him to purchase the admiration that he craves, and he has been able to mask his impairment by acquiring unlimited sycophants and fixers. But his brief career in politics is already revealing that his unreasonable belief that he knows more about foreign policy than the State Department and more about security threats than the CIA is leading to undeniable severe impairment.