A common claim is that Trump is “delusional” and “out of touch with reality.” For example, psychiatrist Bandy Lee stated in an interview that Trump “seemed further to lose his grip on reality by denying his own voice on the Access Hollywood tapes.” I was surprised to read this assessment from a psychiatrist given Trump’s history of lying. Trump’s denial does not prove or even suggest he had lost his grip on reality. The term delusional is sometimes used to mean that one is making statements that are untrue. However, this is not how delusional is typically defined in the field of mental health. In mental health, a delusion refers to a belief that is false, psychotic and held by one person.

Some people have erroneously pointed to Trump’s claim that his inauguration was the most well-attended in U.S. history as an example of a delusion. Anyone who has followed Trump through the decades knows he is a liar, a conman, and a conspiracy theorist. However, this was a lie — not a delusion — created by Trump and perpetuated by his then press secretary Sean Spicer. Trump’s proclivity for conspiracies can be traced back to his relationship with his lawyer and mentor Roy Cohn in the 1970s. Cohn had a penchant for conspiracies and introduced Trump to Roger Stone. In 2011, Trump began expressing doubts that President Obama was born in the U.S. And the rest is history.

The most frequent diagnosis ascribed to Trump is narcissistic personality disorder. He has also been diagnosed as having malignant narcissism and sociopathy, but neither of these are listed in the Diagnostic Statistical Manual of Mental Disorders, fifth edition (DSM-5). It is hard to refute that Trump has narcissistic traits and that he does not meet the criteria for narcissistic personality disorder set forth in the DSM-5. The problem is that the diagnosis of narcissistic personality disorder does not tell us much that is unique about the person. Millions of people in the world meet the DSM-5 criteria for this diagnosis. A personality disorder is a chronic, relatively stable and fixed condition that begins in early adulthood, continues throughout the lifespan, and it is not necessarily a mental illness unless it becomes exacerbated by stress, another mental disorder, or other factors. Like most DSM-5 diagnoses, narcissistic personality disorder lacks scientific validity, clinical utility, and inter-rater reliability. Moreover, the criteria for narcissistic personality disorder are based on deviations from cultural norms rather than an illness that can be identified through objective (i.e., independent) tests. Thus far research on individuals who have been diagnosed with narcissistic personality disorder has not conclusively identified brain anomalies that can reliably be attributed to this condition.

It has also been speculated that Trump is in cognitive decline and that he has early onset dementia. This speculation may have some merit because Trump’s father was diagnosed with Alzheimer’s disease and some decline in cognitive function is age-appropriate for anyone at age 71. On October 12, 2017, Trump neglected to sign a healthcare executive order until Vice President Pence told him “Mr. President, you need to sign it.” On December 6, the White House attributed Trump’s slurred speech to his being thirsty. These and other cases do not prove that Trump has significant cognitive decline let alone early signs of dementia or Alzheimer’s disease. We may learn after he leaves office, like we did with President Reagan, that indeed Trump had Alzheimer’s disease. We may learn this while he is still in office, but I doubt it. For now, we can only speculate.

What Now?

Trump’s legacy will be defined, in part, by speculations that he was unstable and unfit for office. I have always thought it is highly unlikely that he will ever voluntarily submit to a mental health evaluation or that he will be forced to have one until he had his first annual medical examination as president on January 11, 2017, by White House physician Dr. Ronny Jackson. On January 16, 2018, Jackson provided a detailed report in which he said that Trump is overweight and that he could benefit from lowering his cholesterol, improving his diet and begin an exercise regimen. The report also stated that Trump was administered a cognitive screening tool at the president’s request. He scored 30 out of 30 on the Montreal Cognitive Assessment (MoCA). According to Dr. Jackson, Trump showed no signs of dementia and overall the president was in “excellent health.” Referrals were not made to neurology or psychiatry. Dr. Jackson reported that Trump explicitly requested the cognitive screening to allay concerns that he has dementia. If speculations about Trump’s mental health persist, someday Trump might agree to an evaluation by a psychiatrist, psychologist or other mental health professional for the same reason. But I doubt it.

It is unlikely Trump will ever be removed from office through the 25th amendment of the U.S. Constitution. Anyone who knows its protocol knows it is a high bar. First, the Vice-President and a majority of Trump’s cabinet must declare Trump no longer capable of performing his duties. Next, Trump may dispute this finding. And the process goes on. Mandatory mental health evaluations for Trump have been proposed. Dr. Bandy Lee stated there are doctors and legal groups who have said they would help involuntarily commit Trump if the White House reports he becomes an immediate danger to himself or others. Dr. Lee notes that lawyers have volunteered to file for a court paper so White House security staff would cooperate with such an intervention. However, she has also acknowledged: “But we have declined, since this will really look like a coup, and while we are trying to prevent violence, we don’t wish to incite it through, say, an insurrection.”

As psychologist Dr. Grohol has suggested, it may be a good idea for all U.S. presidents to be required to have an annual mental health evaluation. Granted there are all sorts of considerations for such mandated mental health evaluations, including lack of reliability of mental health evaluations and how to proceed if evaluations find a candidate unfit. Nevertheless, these proposals do not apply to Trump. Claims that Trump is “unfit” for office are also vague because they do not necessarily address the question of mental illness. I, too, think Trump is “unfit” for office, but only because he is dangerous, unpredictable, racist and for many other reasons. It is unlikely that Trump’s mental health diagnosis, if he has one, will be ever be known, and the odds of Trump being removed from office due to his mental status are minuscule to nil. And mental illness is not in itself a reason to remove a president from office. Many individuals function effectively with a mental illness.

The good news is that a growing number of prominent mental health professionals are getting the word out that opponents of Trump should focus on political, rather than, medical interventions. In particular, psychiatrist Dr. Allen Frances, who wrote the final draft of the section on personality disorders in the American Psychiatric Association’s Diagnostic Statistical Manual of Mental Disorders (DSM) has stated that although Trump is dangerous, he is not mentally ill. Frances has noted that the diagnosis of narcissistic personality disorder was included in the DSM’s third edition in 1980 “only as clinical tool, not as a [a] political weapon” and it was almost removed from the most current edition, the DSM-5. In his recent book Twilight of American Sanity: A Psychiatrist Analyzes the Age of Trump, Frances argues that Trump isn’t crazy but, rather, he is a symptom of a society gone mad.

Rather than speculate if Trump is mentally ill, I suggest that people who oppose him focus their efforts on political action to block his initiatives. Some readers may disagree with my political opposition to Trump. The purpose of this article, however, has not been to debate Trump’s politics insomuch as to establish an argument against diagnosing him as mentally ill.