Gage Skidmore / CC BY-SA 2.0

Does Donald Trump only say crazy things, or does he say crazy things because he actually is crazy? In a speech delivered on the third day of the Democratic National Convention, former New York City Mayor Michael Bloomberg openly questioned the GOP candidate’s sanity on prime-time television.

More importantly, if less sensationally, the issue of Trump’s emotional stability has also been raised by a growing number of influential and highly respected mental-health practitioners. They have done so out of a sense of urgency, even in the face of a code of conduct promulgated by the American Psychiatric Association that cautions psychiatrists against making public statements about public figures whom they have not formally evaluated.

Ordinarily, as someone licensed to practice law rather than psychology, I’d stay out of the debate and remain in my comfort zone of traditional legal and political commentary, committed to exposing the policy shortcomings of both major-party candidates and their surrogates. But Donald Trump has secured the GOP nod for president. He’s one election away from being the commander in chief of the most powerful nation the planet has ever seen. As such, he, like Democratic presidential nominee Hillary Clinton, deserves heightened scrutiny, both as to policy and personality.

This column is about Trump. There will be future ones on Clinton. And here’s my take, with no punches pulled: If Trump is elected our 45th president, he could well be the most profoundly disturbed occupant of the Oval Office since Richard Nixon, our 37th, whose extreme paranoia brought us Watergate and precipitated the most far-reaching constitutional crisis of the late 20th century. 

Some readers, particularly on the progressive left who by orientation are predisposed to policy critiques, may not be comfortable with my approach. Some may even ask if it isn’t a waste of time to examine the psyche of a president or a presidential hopeful, noting that even a paranoid Nixon agreed to end the Vietnam War and opened the door to normalized relations with China. So why not just stick to policy?

To such doubters, I would say that few people, including world leaders, rarely represent pure evil or insanity. Most are capable of the occasional act of goodness or kindness or wisdom, even if by accident. But to gain a more complete understanding of any person—especially someone on the national stage, who once in office will be subject to the external pressures of social and political movements and public opinion and be responsible for the well-being of millions—a more nuanced and dialectical methodology is required that takes account of both the objective and subjective realms of human interaction. 

So comfort be damned. As we head for the general election in November, when it comes to the former reality-TV show host, I’m not going to be content to focus simply on what the Republican standard-bearer has to say about Mexican rapists, building a wall, Fox News’ Megyn Kelly “bleeding from her whatever,” New Jersey Muslims cheering the fall of the World Trade Towers, being the “only one” who can save America from chaos, crime and radical Islamic terrorism, or any of the other abject falsehoods, outbursts and calumnies he’s uttered or tweeted.

I’ve decided to probe the why behind such seeming lunacy. To do that, I’ve done something positively un-Trumpian: I’ve consulted the experts and dug deeply into the public record.

Here’s what I’ve found thus far:

A consensus has emerged that Trump suffers from narcissistic personality disorder (NPD). Unless you’ve tuned out of politics completely in this election year, you’ve no doubt heard the word “narcissist” bandied about in connection with Trump, along with labels like “bombastic,” “hyperbolic” and “politically incorrect,” and criticisms that he lacks the temperament and judgment to be president.

But NPD is more than a label, or a momentary mood or affect. It’s a sickness.

The Mayo Clinic, in a website entry posted before Trump’s current presidential bid was a twinkle in anyone’s eye or a nightmare in anyone’s mind, defines it thusly:

Narcissistic personality disorder is one of several types of personality disorders. Personality disorders are conditions in which people have traits that cause them to feel and behave in socially distressing ways, limiting their ability to function in relationships and other areas of their life, such as work or school.

If you have narcissistic personality disorder, you may come across as conceited, boastful or pretentious. You often monopolize conversations. You may belittle or look down on people you perceive as inferior. You may feel a sense of entitlement—and when you don’t receive special treatment, you may become impatient or angry. You may insist on having ‘the best’ of everything—for instance, the best car, athletic club or medical care.

At the same time, you have trouble handling anything that may be perceived as criticism. You may have secret feelings of insecurity, shame, vulnerability and humiliation. To feel better, you may react with rage or contempt and try to belittle the other person to make yourself appear superior. Or you may feel depressed and moody because you fall short of perfection.

Many experts use the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, to diagnose mental conditions. This manual is also used by insurance companies to reimburse for treatment.

DSM-5 criteria for narcissistic personality disorder include these features:
● Having an exaggerated sense of self-importance.
● Expecting to be recognized as superior even without achievements that warrant it.
● Exaggerating your achievements and talents.
● Being preoccupied with fantasies about success, power, brilliance, beauty or the perfect mate.
● Believing that you are superior and can only be understood by or associate with equally special people.
● Requiring constant admiration.
● Having a sense of entitlement.
● Expecting special favors and unquestioning compliance with your expectations.
● Taking advantage of others to get what you want.
● Having an inability or unwillingness to recognize the needs and feelings of others.
● Being envious of others and believing others envy you.
● Behaving in an arrogant or haughty manner.

Although some features of narcissistic personality disorder may seem like having confidence, it’s not the same. Narcissistic personality disorder crosses the border of healthy confidence into thinking so highly of yourself that you put yourself on a pedestal and value yourself more than you value others.

In a Vanity Fair article published in November, a group of six mental health professionals weighed in on the subject of Trump’s narcissism and gave the diagnosis an unequivocal thumbs-up. One interviewee, a clinical psychologist who lectures on manipulative behavior, went so far as to say of Trump: “He’s so classic that I’m archiving video clips of him to use in workshops because there’s no better example. … Otherwise, I would have had to hire actors and write vignettes. He’s like a dream come true.”

But identifying Trump as an NPD sufferer is only the first step toward inventorying his personality. Not all versions of NPD are the same.

To some commentators—lay and expert alike, including, most recently, Libertarian Party vice presidential candidate William Weld—Trump presents as a “malignant” narcissist, commonly described as someone who mixes a blend of narcissism, antisocial personality disorder, aggression, lack of empathy and sadism.

Malignant narcissists take special pleasure in the humiliation of others, often in response to perceived threats and disparagements. They frequently respond with over-the-top vitriol of their own.

The New York Times keeps a running tab on Trump’s verbal abuse in a feature titled “The 250 People, Places, and Things Donald Trump Has Insulted on Twitter: A Complete List.” Psychologically speaking, many of Trump’s barbs appear to be a form of “projection,” a primitive defense mechanism long ago identified by Sigmund Freud, whereby a person ascribes negative feelings about themselves to others. A good example—as a projection of Trump’s own racism—might be his bizarre allegation that federal Judge Gonzalo Curiel, who is presiding over the Trump University litigation in San Diego, is biased against him because of his Mexican heritage. 

Other experts see Trump as more of a “thin-skinned” narcissist—one who, because of severe insecurity, is easily insulted, easily hurt and lashes out at perceived enemies in order to receive reassurance and affirmation from supporters. Among those who espouse the thin-skinned assessment is Justin Frank, a Washington, D.C.-based psychiatrist and psychoanalyst and a professor at George Washington University. Frank is also the author of two popular profiles on our last two presidents—“Bush on the Couch” and “Obama on the Couch.”

Frank, who has never treated Bush, Obama or Trump, explained how he goes about his trade, utilizing the techniques of “applied psychoanalysis,” in an hour-long interview in March with San Francisco radio host Peter Collins.

“I look for patterns and do a lot of careful study,” Frank told Collins. “I look for what pops up over and over again to really understand people. Trump is a piece of work as a person.”

Trump’s narcissism, Frank continued, also combines with elements of other traits, such as paranoia, an inability to process facts, and attention-deficit disorder. Referring to Trump’s loopy boast that he consults primarily with himself on foreign affairs, Frank remarked, “He’s not interested in hiring anybody smarter than himself because there isn’t anybody, and he’s paranoid enough that he wouldn’t want anybody smarter.”

Regarding the GOP candidate’s thought processes and unwillingness to admit to making any mistakes, Frank said, “Trump takes a preconception [for example, that Mexican rapists are streaming across the border] and turns it into an absolute fact, whereas most people have experiences that can change their preconception into a new conception. You can’t argue with a narcissistic person [like him] on content.”

In Frank’s view, Trump’s limited vocabulary—his overuse use of words like “amazing,” “huge” and “winner” to describe himself, and terms like “loser” and “disgusting” to smear his foes—is typical of youngsters struggling with ADD and lack of impulse control. Like such children, he added, Trump engages in the “childlike quality” of “magical thinking” when it comes to his policy proposals. The fact that his proposals lack detail or make no objective sense is of little consequence, because his programs will be “great,” as if wishing will make it so.

Frank departs, however, from other observers on the question of whether Trump is a pathological liar. Because of his magical, childlike thinking, “Trump actually believes what he says at the moment,” Frank maintained. “He lives in digital, not analog time. He doesn’t think about what he said an hour ago.”