Diagnostic Criteria For Evaluating The Mental Illness of DT -- You Make the Call

Spanning four decades of writing, teaching, and practicing as a clinical psychologist, I have had an unwavering aversion to attaching labels to those I work with. People are not diagnostic entities. Similarly, I do not practice clinical psychology outside of my office with my family, friends, or others. Worse still, I have always felt that it is beneath the dignity of my profession to psychoanalyze people I've never met who happen to be in the public eye.

DT's hideous actions over the last week have generated such outrage and disgust that, like so many others, I feel compelled to speak out. His barely contained rage that he'd "like to hit [DNC speakers] so hard their heads would spin and they'd never recover," though deeply concerning, is nothing new. His claim on Friday to have "a better temperament than anyone running for president in American history -- because I'm a winner and I win," would be laughable were it not for the fact that he actually believes it.

But DT crossed a line in displaying all-time lows in disturbed and shocking behavior by his despicable attacks against Khizr and Ghazala Kahn -- Muslim-American immigrants and Gold Star parents of Humayun Kahn who died heroically in Iraq in 2004 while sacrificing himself to save many others. Their dignified and heartbreakingly eloquent DNC rebuke of DT for his bigotry regarding American Muslims ignited a concerted attack from him that exposes the composure and empathy of an agitated hornet's nest. Given the horrifying stakes involved in our presidential election, I feel compelled to speak out -- not as a citizen but as a professional psychologist -- against the menace of DT and to warn the American people about the devastating consequences were he to become the most powerful man on the planet.

Terms like megalomaniacal, narcissistic, psychopathic, sociopathic, unstable, and insane fill the media. Though I will not diagnose the man myself, I will instruct the public in the surprisingly simple psychological criteria used by professional diagnosticians such that each of us can make our own independent, informed decisions. I will then comment on what we can most certainly expect were this man to be elected.

The gold standard for clinically diagnosing mental illness is the Diagnostic and Statistical Manual, a handbook for psychologists, psychiatrists, and other mental health professionals, based on careful scientific research into the full array of psychopathological disorders. DSM diagnoses are required for insurance treatment reimbursement. Although the manual is revised every couple of years, I will be referring to the DSM-5, published in 2011, because of its exceptionally clear language, easily understood by an average 8th grader with a dictionary.

The pertinent category from the DSM delineates a spectrum of seven different "personality disorders." The distinguishing feature of any personality disorder is that the "psychological impairments ... are relatively stable across time and consistent across situations." There is no personality disorder with someone who is temporarily responding to a situational crisis -- such as a death, job loss, or relationship break-up -- with uncharacteristic traits not seen before or after the crisis..

Among the seven varieties of character disorders, two may be especially useful for the public to consider. First, "Narcissistic Personality Disorder" in which the following criteria must be met:

-- Excessive reliance on others for self-definition and bolstering self-esteem (Note: When I am adored in the manner I know I deserve, I am on top of the world; when I am criticized, slighted, or shamed, my world shatters).

-- Impaired empathy, insufficient ability to recognize or identify with the feelings and needs of others; excessively vigilant to the reactions of others, but only if perceived as relevant to self.

-- Intimate relationships are largely superficial and exist only to serve self-esteem ... with little genuine interest in others' experience and dominated by the need for personal gain. (Note: While there may be an appearance of love or closeness, people are valued only as an appendages and reflections of self, not recognized as an autonomous individuals).

-- Extreme antagonism characterized by feelings of either overt or covert entitlement; self-centeredness; firmly holding to the belief that one is better than others; extreme condescension.

-- Excessive attempts to be the focus of the admiration and attention of others.

Beyond the DSM, the personality researcher, Theodore Millon, has identified five subtypes of NPD. His category of malignant narcissism includes the following traits: guiltless, remorseless, cruel, spiteful, hateful, jealous, suspicious and vengeful.

There can be considerable overlap between and among personality disorders. The second relevant diagnosis is Anti-Social Personality which includes both Sociopath and Psychopath, with the latter defined as a more serious disturbance. ASP characteristics include:

-- Self-esteem derived from personal gain, power, or pleasure

-- Absence of prosocial internal standards associated with failure to conform to lawful or culturally normative ethical behavior.

-- Lack of empathy for the feelings, needs, or suffering of others; lack of remorse after mistreating someone.

-- Exploitation as a primary means of relating to others, including by deceit, coercion, and intimidation.

-- Manipulative and frequent use of subterfuge, charm, seduction, glibness or ingratiation to influence or control others and achieve one's ends.

-- Deceitful, dishonest, and fraudulent misrepresentation of self; embellishment and fabrication of events.

-- Callous lack of concern for feelings and problems of others; lack of guilt or remorse about harmful impact on others; aggression and cruel behavior.

-- Persistent or frequent anger or irritability in response to minor slights or insults; mean, nasty, or vengeful behavior.

-- Disregard for -- and failure to honor -- financial and other obligations; lack of respect for -- and lack of follow-through on -- agreements and promises.

-- Acting on the spur of the moment in response to immediate stimuli.

-- Boredom proneness and thoughtless actions to counter boredom.

A more severe diagnosis than sociopath, a psychopath is considered to be more shrewd and calculating to minimize risks to themselves, though the distinction between the two diagnoses is somewhat blurred. Psychopathic dishonest or criminal activity is carefully planned, whereas some consider the sociopath to be more impulsive with little foresight for the risks or consequences of their behavior.

Lastly, in her DNC acceptance speech, Hillary Clinton pointed out that we have all been inclined "to excuse DT as an entertainer putting on a show ... We laugh it off because he could not possibly mean all the horrible things he says ... But there is no other DT. This is it."

Although I agree with Ms. Clinton that DT genuinely has meant everything he has said -- at least at the moment he says it before he changes his mind as soon as five minutes later -- I believe she is wrong in saying what you see is what you get. To some extent, we all monitor our public versus our private selves, even DT for all his overt outrageousness. Behind closed doors, away from the cameras, given his psychological make-up, we can be sure that his behavior and reactivity is much, much worse. Would you have wanted to be Melania in private with DT after she had brought shame on him for plagiarizing her speech? We might envision a 70-year-old version of a frustrated 2-year-old's nuclear meltdown. Now imagine him with the nuclear codes with no one having the ability to restrain him.

In an imminent follow-up, I will examine the nature of genuine empathy versus scanning, DT's delusions regarding the birthplace of President Obama and the wild celebration of "thousands and thousands of Muslims" on 911, his staggeringly grandiose self-portrayal, his affection for Putin and admiration for Saddam and Kim Jong-il, and the terrifying, apocalyptic potential should he control the levers of power.

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