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Diagnosing Patient X
What’s wrong with our reticence to talk about Donald Trump’s mental health
Patient X presents as an older, affable, well-to-do executive. Several minutes into a cordial conversation he reveals the FBI is out to get him and that the government has been listening in on his conversations. Unprompted, he speaks with serious conviction on several conspiracy theories. Despite having the resources to prove or disprove these paranoid delusions, he chooses to cite supporting evidence gleaned from cable news. His suspicion toward strangers necessitates a small inner circle and prohibits a fulfilling social life. He has difficulty sustaining long-term romantic relationships and has few close friends.
Blatant symptomatic displays of mental illness are uncomfortable to watch, even when they happen at a safe distance. We pick up pace and pretend to look at our phone to avoid the street-corner schizophrenic and cringe at the crazies on TV. But mental illness symptoms are most uncomfortable when they unfold up close and personal, in real life. Knowing how to respond can be so difficult — it’s the one illness we all want to ignore and wish away. As convenient as that sounds, it’s rarely a good strategy.
In order to justify avoidance and relinquish responsibility, we perpetuate the idea that mental illness is different from other physical illnesses, ergo a layperson isn’t qualified to comment. Psychiatrists are the only people qualified to diagnose, treat, and even recognize a mentally ill person. And even then, diagnosis must be made after an in-depth personal interview, and never, never from afar.
In truth, it doesn’t take psychiatric training to identify mental illness any more than one needs a medical degree to identify the flu. Granular details or nuance in diagnoses aren’t necessary when it’s plain to see someone is emotionally distressed and in need of help.
Even the lexicon around mental illness is overly solemn and mysterious. We go to the dentist and doctor for cheery “check-ups,” but to see a psychiatrist requires an ominous “psychiatric evaluation.” And far from technical or mysterious, psychiatric evaluations are based purely on observation of obvious behavior and self-reported symptoms. They generally take 15 minutes to an hour. To qualify for a psychiatric diagnosis, symptoms are cross-referenced with criteria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). The DSM-V reads more like a cookbook than a medical journal. If the patient is exhibiting enough symptoms to index, a diagnosis (or comorbid diagnosis) is made. Note that the reigning diagnostic tool is only on its fifth edition, updated every 10 years or so. The first edition was published in 1952, when psychiatric practices and diagnosis became standardized and frontal lobotomies were still a thing. Despite scientific advances, modern psychiatry is still a pretty ham-fisted branch of medicine that isn’t much concerned with laser-like accuracy or nuance.
Patient X’s quality of life is degrading. He insists that there is nothing wrong with him despite showing physical symptoms of distress: erratic sleeping patterns, emotional volatility, overeating, a steady decline in work attendance and productivity, avoidance of responsibilities, and difficulty focusing. He is unreliable and unable to follow projects through to completion. He shows very little impulse control, especially when agitated. He routinely disparages or insults his colleagues with an absence of remorse and marked presence of sadistic glee. He is caught lying daily on both insignificant and important subjects and denies the lies even when presented with inscrutable facts showing the contrary. He cycles quickly through support staff, oblivious of his contributions to an unhealthy, unstable work environment.
The emotional lives of other people are generally considered off-limits because they happen in an unseen, semi-inaccessible, inner realm. Thoughts and feelings — and the brain where they both live — are private. But prostate cancer also resides in an extremely private part of the body, and men speak openly about the state of their prostate. It’s difficult to justify the double standard: Anal gland cancer is empathy-eliciting conversational fodder, but brain chemistry isn’t.
“The brain is just another organ like the lungs, heart or liver,” says Lisa Weinstock, MD, assistant professor of psychiatry and behavioral sciences at psychiatrist at New York Medical College. “The brain has a lot of jobs, some of them are to keep your emotions straight and to make sure you’re not hearing voices that aren’t there. There’s still a stigma surrounding dysfunction of this one organ, but there really shouldn’t be.”
Patient X refers to himself in the third person. He displays abnormal rigidity in his personal presentation. His eccentric, meticulous haircut has not evolved in over 30 years; he wears the same suit in one of two colors and spends excessive time and effort cultivating an artificial tan. He washes hands frequently and cringes when circumstances require him to shake hands with someone who he perceives as dirty. His home, office, and vehicles are stocked with hand sanitizer. He only drinks with a straw to avoid touching his lips to a potentially “contaminated” surface. His fear of being poisoned leads him to favor mass-produced food from chain restaurants, purchased in random patterns.
Despite being both chronic and fatal, society downgrades and discounts the emotional pain that stems from a mental illness. On a scale from “hangnail” to “Ebola,” emotional pain is relegated to the hangnail side of the spectrum. Statistically, every person in American knows someone who has attempted or succeeded in killing themselves. Still, psychiatry is the one branch of medicine that is only sought out in the most extreme cases, and usually post-psychiatric incident. As a society, we value our teeth (checked twice a year) more than our sanity.
The lack of gravity assigned to mental illness conveniently justifies the reluctance to help or offer support. If it’s not serious, there is no need to intrude into the private recesses of someone’s synapses. Yet we live in a culture where if one finds themselves physically incapacitated, unconscious, or unable to self-advocate, family and friends — even random strangers on the street — are generally quick to help. Upon discovering a colleague unconscious in the next cube over, it’s unthinkable to ignore them and go about your coffee run. Again, a medical degree isn’t needed to know that consciousness happens in the brain, and unconsciousness means there is something wrong in that brain. But if the same colleague is exhibiting psychotic behavior, which also resides in the brain and indicates something is going wrong in that brain, we’re reluctant to help and look for excuses to intentionally disregard.
Patient X is sexually promiscuous and holds dehumanizing views on women. He flaunts his extramarital affairs, cavorts with prostitutes, porn stars and has a penchant for inappropriately younger women. He minimizes pedophilia, incest, and domestic abuse, and makes inappropriate remarks about his own daughter.
Everyone experiences mental illness at some point in their life. Tragedy begets depression, success begets narcissism, and pretty much anything can be a legitimate trigger for anxiety. All mental illnesses are measured on an incremental sliding scale, “healthy” on one end and “malignant” on the other. Yes, there is such a thing as healthy depression. It would be unhealthy if one didn’t show symptoms of depression (lethargy, extreme melancholy, lack of appetite) after the death of a loved one. And it’s healthy to feel grandiose, important, or superior after a big win. It is unhealthy to construct delusions that facilitate a constant state of “winning.” Long-lasting or catatonic depression are clearly malignant.
Psychology/psychiatry is the only medical field where a DIY approach to diagnosis and treatment is perpetuated by a multimillion-dollar self-help industry. We know a lot about healing in different organs and would never expect a cut artery, multi-fractured break, or diabetes to heal itself, but nothing less is expected from a brain. And worse yet, blame is misplaced on the afflicted personally — not their compromised brain — for not being able to get it together.
There is a class of mental illness that is resistant to any treatment.
Some mental illnesses are only treatable by rebalancing brain chemicals. Some are only treatable by cognitive behavioral therapy. But there is a class of mental illness that is resistant to treatment. The famous Cluster B personality disorders — Antisocial (aka Psychopathic), Narcissistic, Histrionic, and Borderline Personality Disorders — are impervious to treatment in their malignant manifestations. Like all mental illnesses, the B-Cluster Personality Disorders fall on an incremental scale. In their most benign state, symptoms can be beneficial. Hollywood is full of functional histrionics and executives in cut-throat industries often register on the psychopathy scale.
Just a touch of the most serious, treatment-resistance mental illness is not necessarily an impediment to a successful social and professional life — except in the military, where B-Cluster Personality Disorders are disqualifiers. An organization that, even in its lowest ranks, requires the ability to handle great responsibility for the well-being or safety of other people. Assuming responsibility for others is beyond the capacity of someone suffering from a B-Cluster personality disorder, just like calculus is beyond the capacity of a cat.
Patient X’s self-perception is simultaneously hero and victim. He blames outside influences as the source of his irritation. His persecution delusions necessitate an all-or-nothing defensive posture. He is quick to draw excessive attention to his perceived strengths. He is blind to his lack of self-awareness and emotional immaturity.
Eccentrics make the world more interesting, but some would argue that crazy can’t be in charge. How does one tell the difference? Those suffering from low-level chronic or temporary mental illness recognize their diminished capacities and they suffer. Malignant mentally ill people do not recognize their disordered thinking, and they don’t suffer. Instead their behavior makes the people around them suffer.
They don’t recognize their thinking as disordered, so they don’t suffer. Instead their behavior makes the people around them suffer.
Questions of presidential sanity are not new. A study conducted by Duke University in 2006 and published in the Journal of Nervous & Mental Disorders cites psychiatric symptoms (or neurodegeneration, in the case of Ronald Reagan) in almost half of all American presidents. Depression, anxiety, and substance abuse touched dozens of presidents, and at least ten of them had their battles with mental illness while in office.
Before this administration, America has never had someone with a B-Cluster personality disorder at the helm. Although hidden from the public at the time, it was clear to all cabinet members that Nixon’s alcoholism and paranoia negatively affecting his critical thinking. While his poor judgement and disordered thinking would have certainly checked off boxes under “antisocial behavior disorder,” Nixon conceded to spare himself the humility of an embarrassing criminal and impeachment trial, which is a sign that his disordered thinking likely did not qualify as malignant on the mental illness spectrum.
Within one 20-minute interview, Patient X displays symptoms of two thought disorders (Word Poverty Illogicity and Knight’s Move Thinking), five cognitive distortions (black and white thinking, over generalization, control fallacies, magical thinking, personalization), and behavioral symptoms indicative of B-cluster personality disorders: delusions, paranoia, detachment from reality, obsessive thoughts, general anxiety, occasional rage, and occasional confusion.
There is no brain chemistry test to check serotonin levels. MRIs don’t catch psychiatric disorders and PET scans can reveal indicators, but they are far from conclusive.
A debate on “is he or isn’t he” is best preceded by an examination of why we deny mental illness when it presents clearly in our friends, family, colleagues, and president?
Despite the Goldwater Rule (which forbids psychologist and psychiatrists from making an official and binding diagnosis on someone they haven’t examined), distance and objectivity make spotting a mental illness easier. “Distance is actually an advantage when making a diagnosis,” according to Dr. Weinstock. “A doctor can’t be objective without it.” We’re more likely to justify deviant behavior in friends and family because of their close proximity, in a “oh that’s just Kevin being Kevin” kind of way.
But in the face of obvious, serious symptoms, not acting is tantamount to allowing someone bleed out. No one likes a confrontation, and confronting someone about their mental state is awkward any way you slice it. But the fear of unpredictable escalation isn’t enough to justify evading confrontation. Consider the alternative: Do we wait until they hurt themselves? Hurt others? Or do we wait until they destroy a country? We are responsible, not the afflicted, because we are the ones who understand that harm and suffering are inevitable.
Colleagues are worried about the increasing violence in Patient X’s remarks. From a shooting spree on 5th Avenue, to exacting revenge on perceived rival, to advocating for more torturing, physical violence, ethnic cleansing, civilian genocide, and nuclear holocaust. He believes the law does not apply to him. His actions are erratic, and stress exacerbates his agitation. His emotions are volatile, extreme and consistently on the anti-social end of the emotional spectrum: rage, paranoia, defensiveness, indignation, vindictive to audacious claims of would-be heroism.
Q: When are we as a friend, co-worker, spouse, or citizen responsible for the mental well-being of another?