Aug 18 2016

Diagnosing Mental Illness in Presidential Candidates

trump-duh-e1453305835771CBS News Sunday Morning contributor Nancy Giles says that, in her opinion, Donald Trump is “clinically insane.” I have to wonder how “clinically insane” is different from regular “insane.”

I think the implication here is that this is a real psychiatric diagnosis of insanity, and not just a colloquial use of the word, like “that’s crazy.” Giles is implying that Trump has a mental illness, not just that she vehemently disagrees with his attitudes and temperament.

Meanwhile, there are conspiracy theories on the right about Clinton’s health and her “bizarre behavior,” with wild speculations about seizures and Parkinson’s disease.

A recent editorial on Medscape Psychiatry by Nassir Ghaemi asks a very interesting question, Is Psychoanalyzing Our Politicians Fair Game?

Armchair vs Professional

There is a range of behaviors going on here, and to some extent they need to be considered separately. Ghaemi was writing exclusively about psychiatrists (and to some extent psychologists) and their duties to patients, the profession, and as citizens.

There are also TV doctors, like Dr. Drew, who are weighing in on the question of Clinton’s health. There are many non-professionals, like Giles and just about everyone else, who feel free to offer their completely uneducated opinion about the clinical diagnosis of people they only know from their media profile.

Is it all fair game?

You could look at this a number of ways. If you are running for the job of president, then everything about your life is, arguably, fair game. You want to be the most public figure in the country, with tremendous power and responsibility, and the public have the right to know everything about you so they can properly decide if you are fit for the job.

Presidential candidates typically release their medical records, and their tax returns – information that are otherwise considered private. The public have a right to know if the person they are going to put into a stressful and demanding job for the next 4-8 years is likely to die or be incapacitated with health issues.

Mental illness, however, is a special case. Although this is certainly improving, there is still an unfair stigma attached to mental illness. Psychiatric diagnoses and also vague colloquial terms like “crazy” and “nuts” are used as insults. Someone with an anxiety disorder controlled with medication may be no less fit for office than someone with migraines controlled with medication, but the two diagnoses are likely dramatically different in their impact on public opinion.

As Ghaemi also points out in detail, psychiatric diagnoses exist on a spectrum from scientifically solid to vaguely pragmatic. Schizophrenia, for example, is a well established diagnosis with some clear features and we understand a fair amount about its pathophysiology (although it is a complex category of diseases). Narcissistic personality disorder, on the other hand, lacks the same level of scientific validity. It was almost removed from the DSM V for lack of evidence, but was kept in for pragmatic reasons.

Is it fair to give a public figure a diagnosis that is not even scientifically valid?

For psychiatrists there is the Goldwater Rule, which constrains psychiatrists from publicly commenting on the mental health of public figures. The general public has no such constraints, only decency.

What I see happening for the general public is that people tend to fall for the temptation of framing their personal opinions in clinical terms, to give them more apparent weight. Just throw the word “clinically” in front of your opinion, or use a sciencey sounding label, to give the impression you know what you are talking about, rather than just making stuff up.

My Opinion

If I had to summarize my overall opinion on this issue, I would have to separate it out into the two categories of professional vs non-professional.

For professionals, I tend to agree with Ghaemi but I would be a bit more conservative than him. Mental health professionals should exercise extreme caution in publicly commenting on the mental health of public figures. As a rule of thumb, they should just not do it.

One reason for caution that Ghaemi only touched on is that professionals still have political opinions, which may be strong. It is likely that their political opinions will color, and even severely bias, their professional opinions. They may not be able to maintain the professional detachment necessary when evaluating someone who may be president and who either agrees or disagrees with their ideology. So just don’t do it.

However, I do agree with Ghaemi who concludes that in extreme cases there may be a duty as a citizen to comment on the mental health of a public figure. Professionals should only comment if they have access to sufficient documentation to inform their opinions, and if they restrict their opinions to scientifically valid and uncontroversial diagnoses.

For non professionals my opinion is a lot simpler – stop. Do not make armchair diagnoses of public figures. Chances are, you have no idea what you are talking about. The risk is even greater that you are just following your political bias, you are likely using a mental illness diagnosis as a pejorative, and you are likely just psychologizing the usual range of human behavior.

But here’s the thing – you don’t have to couch your opinions in fake clinical terms you don’t really understand. Just give your opinion of someone’s behavior and temperament in non-clinical terms.

It’s OK to say that Trump is a self-serving, ambitious, childish egomaniac with a thin skin, a penchant for bullshit, and an apparent utter disregard for facts and expertise. That is clearly just your opinion from his public behavior.

Don’t say, however, that Trump has a narcissistic personality disorder, is a pathological liar, is “clinically” anything, or is a psychopath. These are diagnoses that you are not qualified to make, you likely don’t have a working knowledge of the scientific basis for these diagnoses and their utility and accuracy in clinical use.

Further, you don’t know Donald Trump. You know his public persona, and largely what the media choose to show.

I would further argue that you just diminish your own opinions and persuasiveness by using clinical terms you don’t have the qualifications to use. This gives others the opening to just dismiss your opinions as armchair diagnoses.

Finally, using mental illness diagnoses as a pejorative or political attack just further stigmatizes mental illness. I know it is difficult to change habits of everyday speech, but we should make an attempt to stop using clinical mental health terms as insults.

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