Some Foolish Psychiatric Diagnoses

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PSYCHIATRIC VIEWS ON THE DAILY NEWS

For yesterday’s April Fool’s Day video, I foolishly left out the foolishness that can arise with what are called psychiatric diagnoses, and I am not even talking about the validity of some diagnostic classifications. Often when my sense of diagnostic foolishness occurs, the reason is some social utility by those in power, though in some basic way, the social influence is everywhere in our DSM. A British journal editorial even wonders if the American conception of depression is more of a culture-bound syndrome than universal.¹ For example, the Buddhist concept of dukkha, meaning detachment from desire, may be of value in providing an alternative spiritual and psychological conception of depression.

The sociocultural influence on psychiatric diagnosis is one reason we have the so-called Goldwater Rule in our ethical principles. Occasionally, psychiatrists ignore this rule with the rationale that accurate projection of danger to society is more ethically important than the risk of publicly misdiagnosing or humiliating a public figure.² I agree.

There are many examples of psychiatric and medical diagnoses being based on a social cause. Take drapetomania, a diagnosis referring to the madness a slave must have had if they tried to run away!³ Imagine that! Or, in more modern times when homosexuality appeared in the first DSM in 1952 and thereafter in various iterations until our current DSM-5 in 2013. Moreover, for the transgender individuals, there is still a category of gender dysphoria, although the dysphoria is generally due to social obstacles and dangers than to their preferred gender identity expression.

Certain diagnoses have been used by authoritarian countries in modern times to punish individuals who protested the government in one way or another.⁴ In the former Soviet Union in the 1970s and 80s, the diagnosis of “sluggish schizophrenia” was used to justify involuntary hospitalization for dissenters. China has done so similarly, using such a diagnosis of “political monomania,” defined as an irrational failure to agree with the state, with treatment often also being enforced hospitalization, accompanied with the culturally misuse of acupuncture with electrified acupuncture. Iran authorities diagnose protesters with antisocial behavior and “re-education” intervention.

Although “concerned psychiatrists” in the United States successfully helped to reduce Soviet abuse of psychiatry back then, even before that, some stigmatizing diagnoses were used in the United States against Barry Goldwater in 1964 when he was running for President. In a magazine poll, some of his alleged diagnoses included⁵:

• Chronic psychosis
• A megalomaniac, grandiose omnipotence
• Anal character
• Various variations on homosexuality
• The same pathological makeup as Hitler, Castro, Stalin, and other known schizophrenic leaders

All these and more diagnoses were provided, despite what appeared to be normal functioning as a Senator both before and after he ran for President. He even seemed to play a major role in President Nixon’s resignation.

After 9 years, in 1973, around the same time we were addressing the Soviet misuse of psychiatry, the American Psychiatric Association produced the Goldwater Rule with the ethical principle of not publicly diagnosing public figures. Over the years since, it has been retained and even strengthened in 2017.

What could be interpreted as an updated drapetomania for Black Americans appeared during the Civil Rights era. One prominent psychiatrist analyzed how Malcom X and others were diagnosed from afar with “prepsychotic paranoid schizophrenia,” with the prepsychotic part being the political addition to an actual DSM diagnosis.⁶ In general, Black men of the time were overly diagnosed with paranoid schizophrenia.

More recently, the controversy over whether psychiatrists can diagnose President Trump from afar has been turned on its head.⁷ For those unduly preoccupied with him, some Republican senators from Minnesota want to add “Trump Derangement Syndrome” to the state’s definition of mental illness. The proposed bill describes that the “syndrome” would be characterized by “acute onset of paranoia in otherwise normal persons that is in reaction to the policies and presidencies of President Donald J. Trump.” This syndrome was actually put into motion by the late commentator and psychiatrist Charles Krauthammer, who coined the term “Bush Derangement Syndrome” in 2003 and later adjusted it as the “Trump Derangement Syndrome.”In 2017, he said:

“What distinguishes Trump Derangement Syndrome is not just general hysteria about the subject, but additionally the inability to distinguish between legitimate policy differences on the one hand and signs of psychic pathology on the other...”

Can we clearly and convincingly distinguish by now?

This variable use of psychiatric diagnoses, official and unofficial, seems to leave us with confusion and a conundrum. There seem to be both political medical diagnoses and psychiatric medical diagnoses, and occasionally they overlap. Who else but psychiatrists and other mental health care professionals can help us tease out which is which? We cannot very well do that if there is a gag order preventing us from confidently speaking out.

While he was alive, the late psychiatrist Jerrold M. Post, MD, was apparently viewed as an exception to the Goldwater Rule due to his work for the government, so he provided psychological profiles of many leaders, including Trump.⁸ Moreover, it is not just a mental disorder per se that is of concern, but it depends on whether a certain disorder fits the societal needs of the time.⁹ But a psychiatric perspective on past President Biden, his confusing withdrawal, and the role of his inner circle, has been left to nonpsychiatrists so far.¹⁰

With the power of the American presidency, nothing less than the safety of our country and the world, as well as the mental health of the public, can be at stake. It would seem that we have to wisely reconsider and revise the Goldwater Rule. At the very least, a panel of experts in political psychiatry should be designated for the medias to call upon. Otherwise, we have politicians and pundits becoming psychiatric diagnosticians. In the meanwhile, we courageously need to get out in public and explain these diagnostic concerns and meanings.

Dr Moffic is an award-winning psychiatrist who specialized in the cultural and ethical aspects of psychiatry and is now in retirement and retirement as a private pro bono community psychiatrist. A prolific writer and speaker, he has done a weekday column titled “Psychiatric Views on the Daily News” and a weekly video, “Psychiatry & Society,” since the COVID-19 pandemic emerged. He was chosen to receive the 2024 Abraham Halpern Humanitarian Award from the American Association for Social Psychiatry. Previously, he received the Administrative Award in 2016 from the American Psychiatric Association, the one-time designation of being a Hero of Public Psychiatry from the Speaker of the Assembly of the APA in 2002, and the Exemplary Psychiatrist Award from the National Alliance for the Mentally Ill in 1991. He presented the third Rabbi Jeffrey B. Stiffman lecture at Congregation Shaare Emeth in St. Louis on Sunday, May 19, 2024. He is an advocate and activist for mental health issues related to climate instability, physician burnout, and xenophobia. He is now editing the final book in a 4-volume series on religions and psychiatry for Springer: Islamophobia, anti-Semitism, Christianity, and now The Eastern Religions, and Spirituality. He serves on the Editorial Board of Psychiatric Times.

References

1. Dowrick C. Depression as a culture-bound syndrome: implications for primary care. Br J Gen Pract. 2013;63(610):229-230.

2. Lee B, ed. The Dangerous Case of Donald Trump: 37 Psychiatrists and Mental Health Experts Assess a President. St. Martin’s Griffin; 2019.

3. Moffic HS. Cultural psychiatric services: past present, and future. Psychiatric Times. 2003;20(10).

4. Gainty C. The dark side of psychiatry - how it has been used to control societies. The Conversation. April 1, 2025. Accessed April 3, 2025. https://theconversation.com/the-dark-side-of-psychiatry-how-it-has-been-used-to-control-societies-248493

5. Levin A. Goldwater Rule’s origins based on long-ago controversy. Psychiatric News. 2016;51(17).

6. Metzl J. The Protest Psychosis: How Schizophrenia Became a Black Disease. Beacon Press; 2011.

7. McCloud C. One state wants to classify ‘Trump derangement syndrome’ as a mental illness. 7 things to know. USA Today Network. March 20, 2025. Accessed April 3, 2025. https://www.yahoo.com/news/one-state-wants-classify-trump-202857000.html

8. Post J, Doucet S. Dangerous Charisma: The Political Psychology of Donald Trump and His Followers. Pegasus Books; 2020.

9. Ghaemi N. A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness. Penguin Books; 2012.

10. Whipple C. Uncharted: How Trump Beat Biden, Harris, and the Odds in the Wildest Campaign in History. Harper; 2025.