Trump accused of ‘malignant narcissism’ – but how accurately can you diagnose someone you’ve never met?

Self-absorbed. Arrogant. Boastful. It does not take a mental health professional to recognise these features as narcissistic. Most of us, regardless of our educational background, are confident to label someone we’ve never met as narcissistic.

Other behavioural features associated with narcissism can be similarly obvious, including a grandiose sense of self, an excessive need for attention and admiration, a lack of empathy and lashing out when criticised.

Public figures have often been subject to speculations as to whether their behaviour meets a mental health diagnosis. Ahead of the US presidential elections, Donald Trump’s mental fitness has, once again, been called into question. This time, 200 mental health professionals have signed an open letter warning the public of Trump’s “malignant narcissism”.

The letter, organised by an anti-Trump political group, argues that Trump poses “an existential threat to democracy” in the US. Citing the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, the mental health professionals argue that Trump meets the diagnostic criteria for narcissistic, antisocial and paranoid personality disorder. These are “all made worse by his intense sadism, which is a symptom of malignant narcissism,” they claim.

Malignant narcissism is considered a combination of the above personality disorders, in addition to the sadistic urge to inflict pain towards others while gaining pleasure from doing so. For instance, the letter states: “According to first-hand accounts, Trump watched the violence he unleashed on January 6 for three hours on TV with ‘glee’, watching his favorite parts ‘over and over’ on ‘rewind’.”

Even though Trump has not been formally assessed by a psychologist as having any of the diagnoses put forward in the letter, it argues that it is “easy to see that Trump meets the behavioral criteria for antisocial personality disorder”.

The signatories argue that thousands of hours of media coverage of Trump’s behaviour have demonstrated a lifetime pattern of “failure to conform to social norms and laws, repeated lying, reckless disregard for the safety of others, irritability, impulsivity, irresponsibility and lack of remorse”. Other psychologists have come to similar conclusions.

The Goldwater rule

A rule set forth by the American Psychiatric Association, known as the Goldwater rule, considers it unethical to diagnose people a psychiatrist has not personally assessed.

The rule is named after Barry Goldwater, a former US senator and 1964 Republican presidential candidate who was labelled “psychotic” and “schizophrenic” by psychiatrists who responded to a survey from Fact magazine. Goldwater successfully sued the magazine for libel and won a $75,000 punitive settlement (£57,779).

The 200 signatures on the open letter about Trump believe they can justify overriding this ethical duty on the grounds that the public should be warned about Trump’s behaviour.

However, it can be argued that clinicians do not need to render a diagnosis to warn us that a public figure poses a risk to our safety. Media coverage about Trump’s danger is abound and people can draw their own conclusions without the need to put a label on it.

This is because speculative diagnoses can do more harm than good. The casual use of mental health terminology can quickly become pejorative, as the press has demonstrated in relation to Trump but also other celebrities.

Speculative diagnoses about Trump’s mental illness on social media have ranged from obsessive–compulsive disorder to delusional disorder, with little consideration that these conditions are merely conjecture. And more importantly, they shame and belittle people who are, in fact, diagnosed with these conditions.

Accuracy

But how accurately can a mental health professional diagnose someone who isn’t their patient? Would you trust a diagnosis from a doctor you had never met? Probably not.

That said, there are some benefits to external perspectives when it comes to psychiatric evaluations. Studies show that other people (spouses, close friends, neighbours) often provide a more reliable assessment of someone’s personality than self-assessments, especially in relation to narcissistic features.

Research using self-report measures show that narcissistic people tend to distort their responses to enhance themselves. For studies of personality, self-reported answers along with a psychologist’s evaluation and assessments by friends and family would give the best insight.

Social media offers yet another layer. A study in 2015 showed that a computer model could more accurately assess someone’s personality based on their Facebook posts than their closest friends – or even a spouse. And for Trump, there are thousands of social media posts to draw on.

But regardless of how accurate these observations may be, making public speculations about someone’s mental health and labelling them with a personality disorder diagnosis at a distance is unethical and, at worst, may have legal implications.