dsm-heroI worked with a few older, white, misogynistic, ill-informed, amoral, racist, conspiracy theory loving, less qualified, cruel surgeons when I trained. They were privileged, white males so they failed up and because they were a product of an older time their misogyny and racism was sadly not that different from the background. Their privilege was either from money, a 2nd or 3rd son who was not going to get the family business so being a doctor was a good option that brought respect and wealth which they deserved. Sometimes their privilege was a respected physician father, so basically if they spelled their name correctly on the application they got into medical school. Some of these men were competent surgeons (you can teach anyone with basic manual dexterity to physically operate) and others were not. The ones who were technically not proficient were covered by residents, medical students, nurses, and even other surgeons. There was a time that being a man was the only requirement for a job and this was not unique to medicine.

Some of these asshole (because that is the best summary of the litany of character flaws) surgeons may well have had mental health issues. I suspect some drank too much and others may have had anxiety or depression, but their mental health issues did not make them cruel or racist or drive them to pinch my ass. Their character, or lack thereof, and upbringing did that. Yes, they were grandiose, but every person who thinks they are better than they are is not manic. Delusions don’t make you racist, being a racist does.

I have also worked with a few older, white, male surgeons who clearly had mental health issues. One had PTSD from war service and a couple who seemed pretty clearly to have bipolar disease. These men were kind, and tolerant, and skilled surgeons who did not pinch bottoms. One of them specifically lectured us on treating every hospital employee, from cleaning person to Chief of Staff with the same level of respect.

Mental health disorders and character are very different things, something many people seem to forget in their desire to explain Trump’s behavior.

It is not possible to Diagnose a Mental Disorder Remotely

While somethings can be diagnosed with a degree of certainly by observation, mental health conditions cannot. The ethics of playing remote diagnostician aside, no one impaired medically enough to be disqualified from the Presidency by any health issue could get through televised debates and addressing congress so just let it go.

Don’t confuse ignorance and self-importance and racism with mental health conditions

Trump has false beliefs, but not because he is delusional  because he is surrounded by sycophants and gets his information from Breitbart and Fox News. He’s wearing blinders on purpose because it is convenient. My dad is a hydro-electric engineer and doesn’t believe in global warming (sun cycles or something). My dad also doesn’t want to believe in global warming and so never reads anything except articles that support his bias. My dad is willfully misinformed, not delusional.

Trump is grandiose for sure, but he is not unrealistically powerful or important. He is also ostentatious with vulgar tastes. His brand is extreme. Nothing he does or says is out of character.

Trump has a long history of racism that predates his run for office. Brushing that off as a mental health condition is not only insulting and stigmatizing to those with mental health conditions,

What about a personality disorder?

“He’s a classic narcissistic personality disorder!” I hear that all the time. One has to be distressed and impaired and of course if one manages to get through debates and an election and get to be President one isn’t impaired in the way the criteria mean. Don’t believe me? That’s what the doctor who wrote the criteria says as well.

Lots of people are narcissists, but that doesn’t make them impaired it just means they have an elevated sense of self. I suspect that trait is common in Washington.

There is no DSM-V for privileged, asshole, ignorant, racist, cruel, misogynistic, short-tempered, self-centered, anti semitic, xenophobic, dictator aspiring, con man. 

Explaining Trump’s behavior with a mental health diagnosis is insulting to those who truly have those conditions. It is also the ultimate in white male privilege. Imagine, people saying you can’t be as bad as you clearly are because of a health condition beyond your control! No one thought Hillary Clinton’s use of a private e-mail server was because she had a narcissistic personality disorder, it was because she was wrong, had poor judgement, or was #crooked.

Talking about Trump’s imagined mental health issues detracts from his policies, appointments, racism, fascism, and complete lack of preparation for office. Trump is our Barnum, so this distraction suits his agenda.

There are lots of people like Trump and they represent the Pandora’s box of humanity’s ills, but they are not psychiatrically unwell.

Yes, Trump is unqualified to be president. Not because of his mental health, he is simply unqualified.






Join the Conversation


    1. If you meant to say that “I guess I am part of the problem..” – then I am glad to see that I am not the only white male who took this to paint that broad brush. While yes, there are jerks and boors who happen to be white males (the “pinching bottoms” comment for example) I do wish people would remember the vast majority of us white males are not racist, misogynist, privileged butt holes.

      1. Generalizing statements can be accurate and inaccurate simultaneously. I did intend to identify myself as part of that specified group, yet I do sympathize with her commentary given my knowledge of its existence. Maybe more people need to step up and address the issues being presented here?

      2. As do I – and those individuals and issues should be addressed in whatever manner needs to be done. Thank you – for both comments.

  1. Dr. Jen, I truly enjoy both your blog and your twitter feed, particularly your political philosophy. All that is well and good and I’m impressed by your dedication to your patients and your profession. I do however want to make clear there are degrees of difficulty between an emergency C-section, ruptured ectopic or other OB-GYN emergencies and a Type I Aortic dissection. With the later you need to make good decisions, good incisions and have a great team with you. Obviously my comment is in reference to your statement “(you can teach anyone with basic manual dexterity to physically operate)”. I am by no means attacking you personally, but please have more respect for the surgeons who went before you.

    1. Are you trying to be insulting? My breadth of surgical experience does extend beyond OB/GYN you know.

      Teaching the skill of surgery is manual dexterity and that skill is not that hard. Like anything it is repetition. The hard is in choosing the right patient and making correct intraoperative and post operative decisions.

      Of course some surgeries are more technically challenging, for example microsurgery. However, almost anyone can learn any technical skill with enough time a practice.

      How is the technical skill of suturing the aorta any different than the technical skill of quilting by hand? Sewing an aorta is more stressful with high stakes if you make a mistake, but that is not what I am talking about.

      The person who first told me surgery skill is repetition is someone who was a MASH surgeon. He told me they trained medics to open and close chests and to close many minors wounds.

      By the way, you need a good team to make good decisions and good incisions with a c-section too.

    2. Have you heard of this bloke Dr. Ben Carson? Fantastic brain surgeon. He also thinks vaccines are dubious, that the pyramids were Joseph’s grain silos, and that slaves were somehow immigrants. I’d trust him in an instant to fix my baby’s brain if she needed it, but I’d be horrified to find him teaching her history.

  2. Sinclair Lewis wrote a novel in the mid 1930s titled “It Can’t Happen Here”, about a political character amazingly like Donald Trump. Same xenophobia, racism, sexism, and overwhelming thirst for power. Read it; it’s alarmingly similar to what we are experiencing today.

  3. Thanks. I’ve been thinking the same thing – that you can’t diagnose anyone over the TV.

    He really is every bit as bad as he seems and it’s not because he has a mental disorder, or at least, as you say, not one in the DSM. Perhaps in the next update?

    I see people pushing a fantasy of getting him disqualified under 25th amendment and sometimes I wonder if they are not actually the delusional ones. There’s a lot of work to be done between now and the next election (2018) and anything not related to decreasing his Congressional support is pretty much wasted effort.

  4. This is a great post. While I agree we should not be diagnosing the president over the TV and internet, I respectfully disagree with your conclusions. I’m not ready to dismiss his alarming behavior to him merely being an asshole without a lot more data. I am not a mental health specialist, but have enough background in the area (multiple graduate degrees in nursing, a minor in psychology, one memorable summer working on a forensic psychiatry unit, and parenting a child who just recently had bipolar I added to his alphabet soup of diagnoses) to recognize when something is well outside the norms and needs to be evaluated further.

    Psychiatric symptoms differ from normal human experience primarily in their number, degree, and frequency. We all get depressed, euphoric, irritable at times, have irrational beliefs, and cling to delusions. That is why DSM specifies minimum frequencies or amounts of time for a symptom to be present, and requires that a minimum number of symptoms to be present at the same time to apply a diagnosis. Displaying 3 of the symptoms of narcissistic personality disorder suggests you are merely an asshole; displaying all 9 on a regular basis indicates the need for a diagnostic interview (assuming one could be persuaded to attend one) to help determine if a diagnosable illness exists.

    Being distressed by the symptoms is necessary for diagnosis and treatment, and that is one area where data is lacking. One of the big stumbling blocks in psychiatric care is that many people don’t have the personal insight to admit their symptoms bother them. Often, mental health professionals have to rely on outward behavior (such as compulsive handwashing in someone with OCD) as manifestations of internal distress. For all we know, the deflection and early morning Twitter rants are DJT’s more obvious manifestations of distress, but we have no way of knowing for sure without that psych evaluation.

    Impairment is the other area where we can’t get a clear picture. For someone with obvious symptoms of psychosis, suicidal ideation, or violent outbursts, they can easily reach that state where they are considered a “danger to themselves or others” and earn an involuntary admission to a psychiatric facility. If you think back to those incompetent surgeons you mentioned, they were probably arrogant bastards, and some of them may very well have met the symptom criteria for a psychiatric diagnosis had they been evaluated by an expert. Was their performance impaired? Yes. Were they a danger to others? Yes, specifically, their patients. However, they got away with their incompetence because a host of residents, nurses, and other surgeons covered for them when the surgeon screwed up because they didn’t want the patient to suffer. The technical term for this is enablement. I know of one surgeon who hired a physician assistant to follow him around all day and cover for him because he could no longer manipulate his coworkers to enable him anymore (he didn’t last long after that point). In extreme cases, enablement can continue until someone dies or you are caught breaking laws. In that forensic psychiatry unit I worked on, there were several patients who, because they were master manipulators, were able to outwardly function in society for a long time before they were caught. Only one was a serial killer. Money and power can buy you a lot of enablement, and the president has had both for a long time.

    Keep in mind that just because a person doesn’t seek treatment, or won’t admit they have a problem, doesn’t mean there is no diagnosable problem. Some disorders are more difficult to diagnose. Depending on how well a person can mask or deny their symptoms, or manipulate others into enabling them, they can remain out in society for a very long time, and have the potential to do a lot of damage along the way. In the case of the president, we should leave diagnosing him to the professionals. However, based on the visible signs, and the potential for harm, I think the professionals need to have a chance to evaluate him. I, for one, would be relieved if they concluded he was merely an asshole.

  5. Trump may be mentally ill. He may not be mentally ill. I agree that diagnosing him from a distance is irresponsible and bad medicine. However, I don’t think the people publicly diagnosing him are trying to excuse his behavior in any way. A lot of the conversation about mental illness in the media just seems to be the usual, horrible misuse of technical terms as everyday words — “narcissist” has become a catchall word for self-centered asshole, and I don’t think it’s used here to excuse anyone or get anyone off the hook for racism or sexism. In fact, sometimes it sounds like the opposite, that his critics are saying “no, this is not just ‘the usual hate,’ there’s something even crazier about this guy’s hate.”

    Your article is right on the money, though, in suggesting that things like patriarchy and racism are much better explanations than specific medical conditions. That sounds more like the standard “horse not zebra” approach.

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