This year’s contentious presidential election may have reached a new level of antagonism, as candidates, surrogates, and supporters have turned to aggressively questioning the mental and physical health of the opposition candidate. It hardly gets more personal than that.

U.S. Rep. Karen Bass, a California Democrat, along with many others, have used social media to assert that Republican nominee Donald Trump meets the diagnostic criteria for Narcissistic Personality Disorder, as defined in the latest edition of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual (DSM-5).

This June Hillary Clinton made a speech in San Diego questioning Donald Trump’s temperament saying, “I will leave it to the psychiatrists to explain his affection for tyrants.”

For his part Donald Trump called the Democratic nominee “unstable,” and “unhinged” and at a rally in New Hampshire, he said, “She’s got problems.” Trump has also claimed that “Crooked Hillary lacks the mental and physical stamina to take on ISIS.”

Trump surrogate, former New York City mayor Rudy Gulianni, tweeted that Clinton looked “tired” and “sick.” Gulianni is a leader of the so-called “healthier movement,” which is challenging Clinton’s health, much the same way the “birther movement” contested President Obama’s citizenship in the last presidential election.

Among those suggesting there is a media conspiracy to hide Clinton’s health problems are Fox News’ Sean Hannity, TV’s Dr. Drew, pharmacy executive Martin Shkreli, and Trump spokesperson Katrina Pierson. Through various conservative outlets it has been suggested that Clinton has disorders ranging from autism and dementia to Parkinson’s Disease and aphasia. Much has been made of the 2012 concussion Clinton sustained. There has even been a forged version of Clinton’s personal physician’s statement circulating on the internet.

Trump’s heath statement has been no less controversial. Loaded with superlative claims, such as “physical strength and stamina are extraordinary” and lab tests results were “astonishingly excellent.” His Park Avenue physician Dr. Harold Bornstein recently defended his statement saying that it was written in a hurry.

Mental health controversies are not new to politics. Stigma regarding mental illness in elections is unfortunately par for the course. In the past, any acknowledgement of mental health issues threatened one’s political career. Former Obama presidential advisor David Axelrod has said that fair or not, the disclosure of a mental health problem immediately creates a “crisis of confidence” in the public’s eye.

In 1973 Thomas Eagleton was the vice-presidential pick of Democratic nominee George McGovern. A few weeks later Eagleton withdrew when it became known that he had been treated with electroshock therapy for depression.

Former Florida Sen. Lawton Chiles’ use of Prozac became a major issue in his gubernatorial race and a number of military veterans running for Congress have had to confront the stigma surrounding post-traumatic stress disorder (PTSD).

In the 2000 presidential primary John McCain’s mental stability was questioned by opponents in light of his traumatic prisoner-of-war experiences. He released his medical records — an action he had to later repeat to demonstrate that he had recovered from cancer.

CODE OF ETHICS

Perhaps the most significant mental health-related incident occurred in the 1964 campaign when Fact Magazine published an article titled, “The Unconscious of a Conservative.” The magazine surveyed over 12,000 psychiatrists, asking them if Republican candidate Barry Goldwater was psychologically fit to be president. A total of 1,189 psychiatrists said that Goldwater was unfit to assume the presidency. In response, Goldwater filed a libel suit and won $75,000 in damages.

This episode tarnished the reputation of psychiatry, such that in 1973 the APA added Section 7.3 to its code of ethics. This section states: “On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”

This new requirement, known informally as “The Goldwater Rule,” only applies to psychiatrists who are members of the APA. Sanctions may include a reprimand, suspension, or expulsion from the Association.

As the current controversy regarding the mental fitness of candidates has intensified, the APA has issued a warning, cautioning psychiatrists to refrain from making unwarranted public comments. On their website APA President Maria Oquendo wrote, “The unique atmosphere of this year’s election cycle may lead some to want to psychoanalyze the candidates, but to do so would not only be unethical, it would be irresponsible.”

The Goldwater Rule, however, is not law, nor is it a requirement for other mental health professionals, such as psychologists. Some professionals believe they can abide by the letter of the Goldwater Rule by simply not making a diagnosis, even if they violate the intent of the rule.

Some have argued that the Goldwater Rule encroaches upon psychiatrists’ First Amendment Rights, while others, like psychiatrist Jerome Kroll, from the University of Minnesota, say that “it’s disingenuous to ask psychiatrists to tiptoe around the diagnosing of public figures while still commenting …”

Last year writer Alex Thompson from POLITICO Magazine posed the question, is it possible that America could elect a president with a mental illness? His answer was, “Yes! In fact, we probably already did.”

In a 2006 study, Duke University psychiatrists studied biographies, medical studies, and first party accounts to evaluate the mental status of U.S. presidents from Washington to Nixon. They concluded that 49 percent met DSM criteria for psychiatric disorders. Depression was the most common diagnosis, followed by anxiety, bipolar disorder, and alcohol abuse.

— Terry L. Stawar, Ed.D., lives in Georgetown and is the CEO of LifeSpring Health Systems, a community behavioral health center and federally qualified health center headquartered in Jeffersonville. He can be reached at tstawar@gmail.com.