An old paper on presidential mental health gets new attention

January 11, 2018 by Sarah Avery And Eric Ferreri, Duke University
The 2006 paper on presidential mental health explored issues faced by Grant, Lincoln, Wilson, Johnson, Nixon and others. Credit: Duke University

Twelve years ago, publishing in a journal most people had never heard of, a group of faculty from the Duke Department of Psychiatry and Behavioral Sciences suggested that 18 of America's first 37 presidents met the criteria for a serious psychiatric disorder, based on a review of biographical information.

The study "got zero attention" at the time, said co-author and current Duke psychiatry professor Marvin Swartz.

But in the current swirl of a presidency that is shattering norms, "Mental Illness in U.S. Presidents Between 1776 and 1974" is suddenly at the forefront of the national dialogue, fueling debate over President Donald Trump's fitness for office and the ethics of making those claims.

"It was a very different time when that was published in 2006," Swartz said. "Our point was that presidents are people like anyone else, and they have mental health diagnoses at about the same prevalence as the general public, and it's just something to be aware of."

The study, which originally appeared in The Journal of Nervous and Mental Disease, is now being cited by journalists as an academic case for assessing the of presidents based on something other than a personal psychiatric examination. In recent weeks, Swartz and his study have been cited by National Public Radio and the Washington Post.

In their paper, Swartz and his co-authors laid out three criteria used to determine whether presidents exhibited psychiatric disorders, as gauged by a review of the : Symptoms met the diagnostic definition; symptoms were persistent; symptoms altered personality, relationships or work capacity, and were evident to others and treated.

This kind of approach is part of a subfield of psychiatry known as psychohistory, which traces its roots back to Sigmund Freud. But it also appears to be at odds with the American Psychiatric Association's "Goldwater Rule." The association issued the rule in 1973 as an ethical guideline after psychiatrists were successfully sued for publically claiming that presidential candidate Barry Goldwater was unfit for office.

"The Goldwater situation was a huge embarrassment for psychiatry," said Swartz, who is leading a grand rounds debate with psychiatry faculty later this month to discuss the Goldwater Rule.

"You don't want psychiatrists going off and publically opining about things they might may not have expertise in for a political purpose," Swartz said. "It's one thing as a citizen, but if you're speaking out as a psychiatrist, you must follow ethical guidelines."

Professional guidelines require that psychiatrists must perform an examination to make a diagnosis, not conjecture from afar. The second tenant requires patient consent to disclose the diagnosis.

"Swartz said he recently reached out to the ethicist at the American Psychiatric Association to determine whether the 2006 paper was in violation of the rule, and learned that while the paper should have not made any diagnoses, its conclusions were adequately qualified to be acceptable.

As for the current interest in the paper, Swartz said the theme may be lost in current debate about Trump. "This was not a flamboyant paper. It was a very sober and serious review. And when you look at the president's through history, you can't connect mental illness with a lack of fitness of duty. Those are two different things, and certainly have nothing to do with the 25th Amendment, which is invoked by the president's cabinet, not a bunch of psychiatrists."

The stigma of mental illness

As journalists continue to cite Swartz's 12-year-old journal article, they're also beating a path to Allen Frances' door these days.

Frances, who in the last week has been quoted in the New York Times and was interviewed on CNN, MSNBC and a host of other television and radio programs, uses the current media interest to defend the mentally ill and also the integrity and accuracy of psychiatric diagnosis.

"The current rush to medicalize Trump's behavior confuses it with mental disorder, stigmatizing those suffering from real who are almost always very well behaved," he said. "And I also have to protect against the misuse of psychiatric diagnosis as a political weapon—the medicalization of politics. We must keep our diagnostic system within its appropriate borders as a clinical, educational and research tool—not allow it to become a cudgel to attack politicians we don't like."

An emeritus professor at Duke and former chair of its department of psychiatry, Frances was also chair of the task force that produced the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, often called the bible of psychiatry. A vocal critic of the president, Frances has used the media pulpit to cast doubt on the frequent claims that Trump's behavior should be attributed to one or more mental disorders—dementia, delusional disorder or narcissistic personality.

"It's amazing to me how Trump has suddenly turned so many people into diagnostic experts, who are perfectly confident in explaining his actions in psychiatric, not political, terms," said Frances, the author of "The Twilight of American Sanity: A Psychiatrist Analyzes the Age of Trump." "People should focus much less on Trump's presumed craziness, much more on how crazy we are to have elected him and to allow him to ruin our country. Psychological name calling is an inappropriate and impotent tool for opposing Trump. Only effective political action can tame him."

Explore further: Goldwater Rule 'gagging' psychiatrists no longer relevant, analysis finds

Related Stories

Goldwater Rule 'gagging' psychiatrists no longer relevant, analysis finds

December 5, 2017
The rationale for the Goldwater Rule—which prohibits psychiatrists from publicly commenting on the mental health of public figures they have not examined in person—does not hold up to current scientific scrutiny, a new ...

Somatic symptom disorder: New condition could classify millions of people as mentally ill

March 19, 2013
Millions of people could be mislabeled as mentally ill when psychiatry's bible of diagnoses is updated in May, warns a senior doctor in this week's BMJ.

Experts say psychiatry's diagnostic manual needs overhaul

May 16, 2012
The Diagnostic and Statistical Manual of Mental Disorders (DSM), long the master reference work in psychiatry, is seriously flawed and needs radical change from its current "field guide" form, according to an essay by two ...

Society considers people with mental illnesses to be more dangerous than they are

April 3, 2017
How dangerous does the general public consider mentally ill people to be? Scientists at the University of Basel and the University Psychiatric Clinics Basel have investigated the factors that influence social stigma. The ...

New diagnostic model for psychiatric disorders proposed

April 5, 2017
University of Otago researcher Associate Professor Martin Sellbom is part of a group of 50 leading international psychologists and psychiatrists who have put forward a new, evidence-based, system for classifying mental health ...

Changes to psychiatry's 'bible' could widen definition of ADHD

April 12, 2013
(HealthDay)—When the latest version of what is considered the "bible" of psychiatry is unveiled in May, experts believe several changes in it will broaden both the definition and diagnosis of attention-deficit/hyperactivity ...

Recommended for you

Inherited IQ can increase in early childhood

January 18, 2018
When it comes to intelligence, environment and education matter – more than we think.

Modulating molecules: Study shows oxytocin helps the brain to modulate social signals

January 17, 2018
Between sights, sounds, smells and other senses, the brain is flooded with stimuli on a moment-to-moment basis. How can it sort through the flood of information to decide what is important and what can be relegated to the ...

Reducing sessions of trauma-focused psychotherapy does not affect effectiveness

January 17, 2018
Posttraumatic Stress Disorder (PTSD) patients treated with as few as five sessions of trauma-focused psychotherapy find it equally effective as receiving 12 sessions.

How past intentions influence generosity toward the future

January 17, 2018
Over time, it really is the thought that counts – provided we know what that thought was, suggests new research from Duke University's Fuqua School of Business.

Baby brains help infants figure it out before they try it out

January 17, 2018
Babies often amaze their parents when they seemingly learn new skills overnight—how to walk, for example. But their brains were probably prepping for those tasks long before their first steps occurred, according to researchers.

Tracking the impact of early abuse and neglect

January 17, 2018
Children who experience abuse and neglect early in life are more likely to have problems in social relationships and underachieve academically as adults.

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.