Photo: Pool/Getty Images

By now, you’ve probably read an article or two about how Donald Trump has some psychological disorder — narcissistic personality disorder is the most commonly cited one — and how this can help explain his mental state and behavior. Science of Us has published several articles in this vein, including two in which I interviewed Wendy Behary, a therapist who works with clients with NPD, and who believes the condition provides a helpful framework for understanding Trump.

Behary is far from the only mental-health expert to have made such claims. There’s a Change.org petition with 23,500 petitions and counting called “Mental Health Professionals Declare Trump is Mentally Ill And Must Be Removed,” though it’s hard to know how many of the signatories are actual mental-health professionals. And a few days ago, the New York Times ran a letter to the editor co-signed by 35 “psychiatrists, psychologists and social workers” in which the clinicians argued that Trump was unfit for office due to his psychological state (though they didn’t name a specific disorder). “Mr. Trump’s speech and actions demonstrate an inability to tolerate views different from his own, leading to rage reactions,” they wrote. “His words and behavior suggest a profound inability to empathize. Individuals with these traits distort reality to suit their psychological state, attacking facts and those who convey them (journalists, scientists).”

Other therapists view such speculation as inappropriate. Their side of the debate got its loudest voice this week in another letter to the Times, from Allen Frances, who was chairman of the task force that wrote the DSM-IV. “I wrote the criteria that define [narcissistic personality] disorder, and Mr. Trump doesn’t meet them,” Frances argued. “He may be a world-class narcissist, but this doesn’t make him mentally ill, because he does not suffer from the distress and impairment required to diagnose mental disorder.” He went on to claim that “It is a stigmatizing insult to the mentally ill (who are mostly well behaved and well meaning) to be lumped with Mr. Trump (who is neither).”

There’s a historical component to this controversy, explained Sherry Amatenstein, a New York–based therapist and one of the signatories to the Change.org petition, in Vox. “Since public calls to diagnose Republican presidential candidate Barry Goldwater in the 1960s, the mental health community has stuck to a code: Do not diagnose a person in the public eye, only in a diagnostic setting, no matter how tempting,” she wrote. “It’s a good rule: Mental illness carries a stigma and it’s irresponsible, as well as ethically wrong, to impugn someone’s reputation based on an uninformed opinion. I’ve stood by it.” But she went on to argue that while in normal times, the so-called “Goldwater Rule” is important, Trump’s behavior warrants an exception. Given his actions in office, “It seems there is no impulse control or apparent ability to consider feedback from anyone who disagrees with him. This is not normal. It is extremely dangerous.”

This debate isn’t an easy call, and there are a lot of eminently qualified people on both sides. Maybe the easiest way to reconcile the conflicting claims is to focus less intently on the question of whether Trump qualifies, in a narrowly defined way, for the specific diagnosis of NPD, and more on what we know about people who are deeply narcissistic, whether or not they meet some clinical threshold.

To focus too much on NPD might cause us to miss the forest for the trees. Take Frances’s letter, for example. Nowhere does he argue that Trump doesn’t exhibit the specific symptoms of NPD — rather, he says that whatever Trump has, it doesn’t appear to have caused him distress or impairment, which is a traditional gateway criterion for any mental-health diagnosis in the DSM. But can anyone be certain of this? “We don’t know if he suffers from distress,” Behary told Science of Us, responding to Frances’s letter. “We don’t know what happens behind the curtain. We don’t know if there is a vulnerability and fear that comes out in his darkest moments.” She highlighted some of Trump’s fixations, such as his belief that millions of “illegals” contributed to Hillary Clinton’s popular-vote victory, as possible signals that he is experiencing distress — he has just managed to mostly keep it hidden from view.

But even setting aside that possibility, it’s worth remembering that every step of Trump’s life, he has had the safety net of a rich family and power to fall back on. Think about it this way: Many women claim Trump sexually assaulted them, but didn’t feel comfortable reporting him at the time of the alleged assaults, because of how powerful he was. He settled, for $25 million, a lawsuit over the misleading and exploitative scam that was Trump University — an amount he could easily cover. He has been sued by countless contractors for not paying them — but again, was able to simply pay what needed to be paid in the end, or countersue with an army of lawyers. Had Donald Trump been just about anyone other than Donald Trump, his own behavior would have hurled him into financial or legal ruin several times over — and he did go bankrupt on multiple occasions, but was always able to get back on his feet thanks to his access to money and credit — in which case there would be a long trail of self-inflicted damage.

So if the goal is to understand what Trump has done in the past and what he’s likely to do in the future, does it matter if his actions have caused him distress? Maybe not. That’s the argument Josh Grubbs, a Bowling Green State University clinical psychologist who studies narcissistic personalities, made as part of a broader tweetstorm questioning Frances’s letter:

But, here's the thing, as someone who studies narcissistic personality more than I study NPD, I don't care if there is personal impairment. — Josh Grubbs (@JoshuaGrubbsPhD) February 16, 2017

The actions/reactions of the narcissistic personality are consistent, regardless of whether distress or impairment warrant diagnosis of NPD — Josh Grubbs (@JoshuaGrubbsPhD) February 16, 2017

If it walks like a duck, quacks like a duck, and waddles like a duck... then it's a probably an orange narcissistic duck. — Josh Grubbs (@JoshuaGrubbsPhD) February 16, 2017

Frances also echoed the oft-repeated line that to talk about NPD and Trump is to stigmatize the mentally ill. Generally speaking, this is a valid, important concern given that mentally ill people do face all sorts of stigmatization and victimization. It’s just hard to see how it applies here. If people were pointing to Trump to make the argument, People with mental illness shouldn’t be given rights or power, full-stop, or People who have politics different from my own must be mentally ill, those would be offensive and wrongheaded arguments. Those don’t seem to be the most common claims, though — rather, clinicians and others are arguing that giving someone with NPD, or whatever it is that Trump has, this much power could be extremely dangerous.

When you break it down, this isn’t very different from saying that someone with major, untreated depression who is suicidal shouldn’t be flying airliners, or that someone with untreated schizophrenia that causes them to constantly be tormented by voices shouldn’t be teaching young children. Some forms of mental illness, if they’re not under control, clearly are disqualifying when it comes to certain positions. No one would seriously deny this, and these claims aren’t generally seen as stigmatizing in some big, broad, damaging way, so it’s strange to think they couldn’t apply to someone as powerful as the president as well.

Either way, while Trump certainly seems to exhibit most of the hallmarks of NPD, no one can know for sure that he would or wouldn’t meet the threshold if he were examined in a formal diagnostic setting. But again, it might not really matter. We do know, with certainty given the huge pile of evidence that has accured, that Trump is deeply narcissistic — much more so than past presidents. And since, as Grubbs suggests, deeply narcissistic people act in certain somewhat predictable ways regardless of whether or not they meet the threshold for NPD, this could be a good midway approach to trying to understand Trump’s actions: Focus more on the trait itself, and its potentially dangerous ramifications in extreme cases, and less on hypothetical diagnoses.