RE (“Executive analysis, from afar’’): The criteria for a mental disorder that psychiatrists use place strong weight on an individual’s internal reward system and on society’s external response to their behaviors: If these behaviors don’t cause the individual distress and impairment, and society allows the individual to be successful, then the behaviors are considered healthy. As Dr. Allen Frances says of Donald Trump, “people trying to diagnose Trump as having a mental disorder are wrong.’’ Frances notes that Trump “apparently gets pleasure, not distress, from [activities such as late-night, angry tweets], and they made him president.’’

But a mental disorder can severely distort an individual’s internal reward system, so that they may experience at least short-term pleasure in response to behaviors that ultimately may be destructive toward both themselves and their community. And when a society is itself sick — damaged, angry, and vulnerable — it may enable these behaviors, so that external checks also fail, and we may end up with disastrous legacies from individuals judged to be healthy.

Psychiatrists should explicitly acknowledge that both internal and external reward systems are unreliable and subject to their own disorders. Until this is done, psychiatric guidelines are of limited use in evaluating the ultimate effects of the behaviors of individuals on themselves and their communities.

Nicholas Newell

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