“I’m not a psychiatrist, but….” is becoming a typical phrase used when TV hosts and guests describe Trump’s deteriorating behavior and his losing touch with reality. Above are some terms just from the articles on my Duty to Warn page this week (right) which essentially say that Trump is demonstrating near-psychotic, or fully psychotic, symptoms.
When psychotherapists assess patients they quickly determine whether they are grounded in reality. In fact, on some standard forms there is the heading called mental status which includes ability to engage in reality testing.
Most people going to see a therapist do so because of distressing problems. The first session is usually straight-forward. Still, the therapist has to determine in there is a more serious disorder. This can be done within minutes in the course of conversation. However, it may take paying special attention to the following (from Wikipedia):
Thought content
A description of thought content would describe a patient's delusions, overvalued ideas, obsessions, phobias and preoccupations. Abnormalities of thought content are established by exploring individuals' thoughts in an open-ended conversational manner with regard to their intensity, salience, the emotions associated with the thoughts, the extent to which the thoughts are experienced as one's own and under one's control, and the degree of belief or conviction associated with the thoughts.[38][39][40]
A delusion can be defined as "a false, unshakeable idea or belief which is out of keeping with the patient's educational, cultural and social background ... held with extraordinary conviction and subjective certainty",[41] and is a core feature of psychotic disorders. The patient's delusions may be described as persecutory or paranoid delusions, delusions of reference, grandiose delusions, erotomanic delusions, delusional jealousy or delusional misidentification. Delusions may be described as mood-congruent (the delusional content in keeping with the mood), typical of manic or depressive psychoses, or mood-incongruent (delusional content not in keeping with the mood) which are more typical of schizophrenia. Delusions of control, or passivity experiences (in which the individual has the experience of the mind or body being under the influence or control of some kind of external force or agency), are typical of schizophrenia. Examples of this include experiences of thought withdrawal, thought insertion, thought broadcasting, and somatic passivity. Schneiderian first rank symptoms are a set of delusions and hallucinations which have been said to be highly suggestive of a diagnosis of schizophrenia. Delusions of guilt, delusions of poverty, and nihilistic delusions (belief that one has no mind or is already dead) are typical of depressive psychoses.
The question we have to answer about Trump is “how impaired is his reality testing?” In other words, what is his thought content?
If he believes things that demonstrably are not true we have to dig deeper to see how far these delusions go.
Does he “merely” believe conspiracy theories that go along with his need to protect his self-concept?
As pathological and dangerous as this is, it is possible that at times it is even more serious.
If someone decompensates into fully blown psychosis they may also listen to hallucinatory voices in their head. Sometimes they hear what are called “command hallucinations” which, as the name conveys, tell them to do dangerous things.
It would be very difficult without face-to-face interaction to determine if this happened to Trump. Those close to him, unless they were in full denial, would be able to pick this up. It is generally possible to discern when someone is actually hearing a voice that isn’t there because you can observe them listening to someone who isn’t there.
I hope Gen. Kelly or others will be able to act on this if it happens.