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Wednesday, November 22, 2017

Excerpted from The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President (Thomas Dunne Books, 2017).

Donald Trump is so visibly psychologically impaired that it is obvious even to a layman that “something is wrong with him.” Still, putting a name to that disturbance has been a challenge for two reasons. First, because of the Goldwater gag order, discussed extensively in Part 2 of this book, which has forced mental health professionals to censor themselves, despite how alarmed they might be; and second, Trump’s is a genuinely complex case. Like the story of the blind men and the elephant, many writers have tried to analyze and diagnose Trump, and have gotten pieces of the elephant right. What is missing is the whole elephant. There are a lot of things wrong with him—and together, they are a scary witch’s brew.

One of the most recurrent debates, and a genuine mystery, is to what extent is Trump just a really bad person and to what extent is he really crazy? Psychoanalyst Steven Reisner has written in Slate, “This is not madness. Impulsivity, threats, aggression, ridicule, denial of reality, and the mobilization of the mob that he used to get there [to the presidency] are not symptoms. It is time to call it out for what it is: evil.” According to this view, Donald Trump is “crazy like a fox.” That is, his abnormal persona is an act, a diabolical plan to manipulate the public’s worst instincts for fun, power, and profit.

When Trump tweeted about his imaginary inauguration crowd size and about Obama having tapped his phones, was there any part of him that believed this “denial of reality”? If so, then Michael Tansey (“Why ‘Crazy Like a Fox’ versus ‘Crazy Like a Crazy’ Really Matters”), who writes about Trump having delusional disorder, may be right that Trump is not crazy like a fox but “crazy like a crazy.”

My old boss Paul McHugh, longtime chairman of psychiatry at Johns Hopkins University School of Medicine, used to say that “a dog can have both ticks and fleas.” I will argue that Trump can be both evil and crazy, and that unless we see how these two components work together, we will never truly understand him. Nor will we recognize how much danger we are in.

Bad: Malignant Narcissism

“The quintessence of evil” was how Erich Fromm described malignant narcissism, a term he introduced in the 1960s. Fromm, a refugee from Nazi Germany, developed the diagnosis to explain Hitler. While Fromm is most well known as one of the founders of humanistic psychology (whose basic premise, ironically, is that man’s basic nature is good), the Holocaust survivor had a lifelong obsession with the psychology of evil. Malignant narcissism was, according to Fromm, “the most severe pathology. The root of the most vicious destructiveness and inhumanity.”

The modern figure most associated with the study of malignant narcissism is my former teacher Otto Kernberg, who defined the syndrome as having four components: (1) narcissistic personality disorder, (2) antisocial behavior, (3) paranoid traits, and (4) sadism. Kernberg told the New York Times that malignantly narcissistic leaders such as Hitler and Stalin are “able to take control because their inordinate narcissism is expressed in grandiosity, a confidence in themselves, and the assurance that they know what the world needs.” At the same time, “they express their aggression in cruel and sadistic behavior against their enemies: whoever does not submit to them or love them.” As George H. Pollock, the late president of the American Psychiatric Association, wrote, “the malignant narcissist is pathologically grandiose, lacking in conscience and behavioral regulation[,] with characteristic demonstrations of joyful cruelty and sadism.”

Much has been written in the press about Trump having narcissistic personality disorder. Yet, as critics have pointed out, merely being narcissistic is hardly disqualifying. However, normal narcissism and malignant narcissism have about as much in common as a benign and malignant tumor. The latter is far rarer, more pathological and dangerous, and, more often than not, terminal. It’s the difference between life and death.

Narcissism

Narcissistic personality disorder is described by Craig Malkin in his essay “Pathological Narcissism and Politics: A Lethal Mix.” Trump finds himself to be uniquely superior (“Only I can fix it”), and appears to believe that he knows more than everyone about everything, despite his lack of experience, study, intellectual curiosity, or normal attention span. Since he took office, an amusing video montage has made its way through social media in which, in the course of three minutes, Trump brags about being the world’s greatest expert in twenty different subject areas. “No one knows more about [fill in the blank] than me,” he repeats over and over.

Antisocial Personality Disorder

Lance Dodes describes antisocial personality disorder, or ”Sociopathy.” Antisocials lie, exploit, and violate the rights of others, and they have neither remorse nor empathy for those they harm.

While we will not give a final diagnosis here, the fact-checking website PolitiFact estimated that 76 percent of Trump’s statements were false or mostly false, and Politico estimated that Trump told a lie every three minutes and15 seconds.

We have ample evidence of Trump’s pervasive pattern of exploiting and violating the rights of others. According to New York State attorney general Eric Schneiderman, Trump University was a “straight up fraud . . . a fraud from beginning to end.” Also, dozens of lawsuits attest to Trump’s pattern and practice of not paying his contractors. Finally, there is Trump’s pattern of serial sexual assault, which he bragged about on tape even before a dozen women came forward, whom he then called liars.

Trump is allergic to apology and appears to feel no remorse of any kind. It is as if being Trump means never having to say you’re sorry. When political consultant Frank Luntz asked Trump if he had ever asked God for forgiveness, Trump said, “I’m not sure I have . . . I don’t think so.” His unrepentance notwithstanding, he also boasted that he had “a great relationship with God.”

And empathy? Even Trump’s former mentor, the notorious Roy Cohn, lawyer for gangsters and Joseph McCarthy, said that when it came to his feelings for his fellow human beings, Trump “pisses ice water.”

Paranoia

Paranoia is not a diagnosis but, rather, a trait that we see in some conditions. When Donald Trump was asked to document his false claim that “thousands and thousands” of New Jersey Muslims openly celebrated the attacks of 9/11, he cited a link to Infowars, the website of radio talk show host Alex Jones. Jones, nicknamed “the king of conspiracies,” believes that the American government was behind the September 11 attacks, that FEMA is setting up concentration camps, and that the Sandy Hook school shooting was a hoax. Yet, according to Trump, Jones is one of the few media personalities he trusts. “Your reputation is amazing,” Trump told Jones when he appeared as a guest on Jones’s show on December 2, 2015. Trump vowed that if he were elected president, “you will find out who really knocked down the World Trade Center.”

In the same week, both the New York Times and the Washington Post  ran front-page stories on Trump as a conspiracy theorist. Before the election, Right Wing Watch accumulated a list of 58 conspiracies that Trump had proclaimed or implied were true. Of course, that list has grown since then. Many are truly bizarre. For example, not only is Obama a Muslim born in Kenya but, according to Trump, he had a Hawaiian government bureaucrat murdered to cover up the truth about his birth certificate (“How amazing, the state health director who verified copies of Obama’s birth certificate died in a plane crash today. All others lived,” Trump said); Antonin Scalia was murdered (“[T]hey say they found a pillow on his face, which is a pretty unusual place to find a pillow”); later, fake news websites sponsored by the Russians laid this “murder” at Hillary’s feet; and Ted Cruz’s father aided the Kennedy assassination, the mother of all conspiracy theories (“What was he doing with Lee Harvey Oswald shortly before the death? Before the shooting? It’s horrible”).

And still the world was shocked when Trump accused Barack Obama of illegally wiretapping Trump Tower. Why were we surprised?

When you combine these three ingredients, narcissism, antisocial traits, and paranoia, you get a leader who feels omnipotent, omniscient, and entitled to total power; and who rages at being persecuted by imaginary enemies, including vulnerable minority groups who actually represent no threat whatsoever. With such a leader, all who are not part of the in-group or who fail to kiss the leader’s ring are enemies who must be destroyed.

Sadism

Because he is a sadist, the malignant narcissist will take a bully’s glee in persecuting, terrorizing, and even exterminating his “enemies” and scapegoats. When a protester was escorted out of a Trump rally, Trump famously said, “I’d like to punch him in the face,” in a tone that suggested it would genuinely bring him great pleasure. Narcis- sists often hurt others in the pursuit of their selfish interests:

A notable difference between normal narcissistic personal- ity disorder and malignant narcissism is the feature of sadism, or the gratuitous enjoyment of the pain of others. A narcissist will deliberately damage other people in pur- suit of their own selfish desires, but may regret and will in some circumstances show remorse for doing so, while a malignant narcissist will harm others and enjoy doing so, showing little empathy or regret for the damage they have caused.

We often see Trump “punch down,” demeaning and humiliating people weaker than he. In fact, a substantial portion of the 34,000 tweets he has sent since he joined Twitter can be described as cyberbullying. Sometimes he will send the same nasty tweet six times across a day’s news cycle in order to maximally humiliate his victim.

Erich Fromm saw evil up close, thought about it throughout his life, and applied his genius to boil it down to its psychological essence. A malignant narcissist is a human monster. He may not be as bad as Hitler, but according to Fromm, he is cut from the same cloth. “The Egyptian Pharaohs, the Roman Caesars, the Borgias, Hitler, Stalin, Trujillo—they all show certain similar features,” Fromm writes.

Malignant narcissism is a psychiatric disorder that makes you evil. What’s scary is that’s not even the worst of it.

Mad

Before the 2016 election, I wrote an article for the Huffington Post warning about Trump. At that point, in June 2016, there was still a strong hope that Trump would “pivot” and become more presidential—a hope based on the assumption that while he might be a wicked opportunist and a con man, he was still a rational actor, and thus would change tack when it was in his own best interest. I wrote, “[T]he idea that Trump is going to settle down and become presidential when he achieves power is wishful thinking. Success emboldens malignant narcissists to become even more grandiose, reckless, and aggressive. Sure enough, after winning the nomination, there has been no ‘pivot’ towards more reasonable behavior and ideas, just the opposite. He has become more shrill, combative, and openly racist.” After riding his angry base to the White House, to alter his behavior to a saner presentation after the election would have been in Trump’s best interest. As Rob Reiner put it on Real Time with Bill Maher, “People don’t understand why Trump doesn’t just stop acting mentally ill? Why can’t he just stop being mentally ill?” Why? Because his illness is not a ruse. It can’t just be turned off when it’s convenient.

According to Fromm, “malignant narcissism is a madness that tends to grow in the life of the afflicted person.” In The Heart of Man, Fromm argues that malignant narcissism “lies on the borderline between sanity and insanity.” In more benign forms of narcissism, “being related to reality curbs the narcissism and keeps it within bounds,” but the malignant narcissist recognizes no such bound- aries. His grandiose fantasy trumps reality.

The thing that distinguishes the malignant narcissistic leader from a run-of-the-mill psychotic patient is his power to coerce and seduce others to share his grandiose and persecutory delusions.

“This Caesarian madness would be nothing but plain insanity,” Fromm writes, “were it not for one factor: by his power Caesar has bent reality to his narcissistic fantasies. He has forced everyone to agree he is god, the most powerful and wisest of men—hence his megalomania seems to be a reasonable feeling.”

According to Fromm’s description of the disorder, Trump lives on the border of psychosis. Does he ever go over the border? Is it all for effect, to rile up his base, deflect blame, and distract from his shortcomings, or does Trump actually believe the crazy things he says? If you take Donald Trump’s words literally, you would have to conclude that he is psychotic.

A delusion is technically defined as a “rigidly held, demonstrably false belief, which is impervious to any contradictory facts.” Is he “crazy like a fox,” asks Michael Tansey, or simply “crazy like a crazy?” With Trump, it’s often genuinely difficult to know, but as Tansey makes frighteningly clear, this is not a trivial academic distinction. Literally, the fate of the entire world may depend on the answer:

Surpassing the devastation of climate, health care, education, diplomacy, social services, freedom of speech, liberty, and justice for all, nothing is more incomprehensible than the now-plausible prospect of all-out nuclear war . . . Because of this existential threat, it is absolutely urgent that we understand the differences between a president who is merely “crazy like a fox” (shrewd, calculating, the truth is only spoken when it happens to coincide with one’s purposes) versus what I have termed “crazy like a crazy” (well- hidden-core grandiose and paranoid delusions that are disconnected from reality).

Insight into this question comes from, of all sources, Joe Scarborough, host of the popular MSNBC show Morning Joe. After Trump claimed that Trump Tower had been bugged by Barack Obama, Scarborough tweeted, “His tweets this weekend suggest the president is not crazy like a fox. Just crazy.”

Some of Trump’s false claims can be seen as giving him a perverse strategic advantage. For example, his claim that Obama was not born in the United States appealed to the racist portion of the electorate who were already inclined to see a black president as foreign and illegitimate. Other false statements of his seem more blatantly crazy, precisely because they offer him no discernible strategic advantage. Take his false claim that he had the biggest inaugural crowd in history. On the first day of his presidency, he lost credibility with the entire world with that demonstrably false claim—as Groucho Marx said, “Who are you going to believe, me or your lying eyes?”—when there was no longer any need to motivate his base, which was already ecstatically celebrating his inauguration. He needed to broaden his base and shore up his authority as president, but did the opposite.

On Morning Joe on April 3, Joe Scarborough and Donny Deutsch, both of whom had known Trump personally for over a decade, came to two conclusions: first, that Trump must suffer from a mental illness, because his behavior since ascending to the presidency had been so irrationally self-destructive; and second, that Trump had gotten dramatically worse since he was inaugurated.

Scarborough: People, stop tweeting at me “How could you not have known?” We’ve known this guy for ten, eleven, twelve years. We had misgivings, but it’s safe to say neither you [Donny Deutsch] nor I thought it would be this bad. We were concerned. Really, really concerned, but never thought this guy would be this much of a petulant brat. We didn’t think he would wake up every day and hit his hand with a hammer.

Deutsch: I also think it’s time. I know the psychiatric community has the Goldwater rule about not diagnosing from a distance. I just think he’s not a well guy. Period.

Scarborough: During the campaign, he would do things that were offensive to us [that energized his base], but that’s not like hitting your hand with a hammer. What he’s doing now is not in his self-interest. Then you start saying how well is he [pointing to his own head] when he’s doing things that any sane rational person would know would hurt him politically?

For these same reasons, Michael Tansey suggests that Trump may meet DSM-V criteria for delusional disorder, which require evi- dence of a delusion lasting longer than a month in the absence of a more serious psychotic disorder such as schizophrenia or bipolar disorder type 1, which would in themselves explain the presence of delusional thinking.

Trump doesn’t show signs of being schizophrenic, but we should explore where he fits on the bipolar spectrum. He definitely has the hypomanic temperament I wrote about in my two books, The Hypomanic Edge: The Link Between (a Little) Craziness and (a Lot) of Success in America (2005) and In Search of Bill Clinton: A Psychological Biography (2008). Hypomanic temperament is genetically based, running in the families of people with bipolar relatives, but it represents a milder and more functional expression of the same traits as mania. Historically, hypomanic temperament has received little attention compared to bipolar disorder, but the founders of modern psychiatry, Eugen Bleuler, Emil Kraepelin, and Ernst Kretschmer, first described these personalities early in the twentieth century. In a 2005 article in The New Republic, I summarized the traits of hypo- manic temperament as follows:

Hypomanics are whirlwinds of activity who are filled with energy and need little sleep, less than 6 hours. They are restless, impatient and easily bored, needing constant stimulation and tend to dominate conversations. They are driven, ambitious and veritable forces of nature in pursuit of their goals. While these goals may appear grandiose to others, they are supremely confident of success—and no one can tell them otherwise. They can be exuberant, charming, witty, gregarious but also arrogant. They are impulsive in ways that show poor judgment, saying things off the top of their head, and acting on ideas and desires quickly, seemingly oblivious to potentially damaging consequences. They are risk takers who seem oblivious to how risky their behavior truly is. They have large libidos and often act out sexually. Indeed all of their appetites are heightened.

This description sounds an awful lot like Trump who reports, “I usually sleep only four hours a night,” which by itself is usually a pretty reliable indicator of hypomania Indeed, he boasts about it: “How can you compete against people like me if I sleep only four hours?” He claims to work seven days a week and, in a typical eighteen-hour day, to make “over a hundred phone calls” and have “at least a dozen meetings.” He also tweeted, “Without energy you have nothing!”—hence his taunt of Jeb Bush as “a low energy person,” by contrast, a charge that proved quite effective. Like most hypomanics, Trump is easily distracted. We could add attention deficit disorder to the Trump differential, except attention deficit disorder almost always goes with the territory for hypomanics. “Most successful people have very short attention spans. It has a lot to do with imagination,” Trump wrote with Meredith McIver in Think Like a Billionaire in 2004. He is correct. The same rapidity of thought that helps engender creativity makes it difficult for one to stay on one linear track of ideas without skipping to the next. Like most hypomanics, Trump trusts his own ideas and judgment over those of anyone and everyone else, and follows his “vision, no matter how crazy or idiotic other people think it is.”

One of my dictums when working with hypomanic patients is that “nothing fails like success.” If they succeed in achieving one of their wildly ambitious goals, there is often a noticeable uptick in their hypomania, sometimes even precipitating a full-blown hypomanic episode, which, unlike hypomanic temperament, is a diagnosable disorder. They become more aggressive, irritable, reckless, and im- pulsive. Now seemingly confirmed in their grandiosity, they drink their own Kool-Aid and feel even more invincible and brilliant. They pursue even bolder, riskier, and more ambitious goals, without listen- ing to dissent, doing their due diligence, or considering contradictory facts. Their gut is always right. Once, Trump was asked whom he went to for advice. With a straight face, he said, “Myself.” Trump is Trump’s most trusted adviser. In the same vein, with the increase in grandiosity comes a corresponding increase in paranoia over the fools and rivals who might nay-say the hypomanic’s insights, impede his progress, or destroy him out of jealousy or ignorance.

In fact, this is a pattern for Trump. In 1988, after the publication of his best-selling book The Art of the Deal, Trump’s celebrity really took off. His response was an increase in his hypomania, according to Politico writer Michael Kruse in his article “1988: The Year Trump Lost His Mind”:

[H]is response to his surging celebrity was a series of manic, ill-advised ventures. He cheated on his wife, the mother of his first three children. In business, he was acquisitive to the point of recklessness. He bought and sold chunks of stocks of companies he talked about taking over. He glitzed up his gaudy yacht, the yacht the banks would seize less than three years later. He used hundreds of millions of dollars of borrowed money to pay high prices for a hotel and an airline—and his lenders would take them, too. And he tus- sled for months with game-show magnate Merv Griffin for ownership of his third casino in Atlantic City, the most expensive, gargantuan one yet, the Trump Taj Mahal, which led quickly to the first of his four corporate bankruptcy filings.

During that period, Trump the storied dealmaker went on a buying binge, and made impulsive, ill-advised investments, often paying the asking price without negotiating at all. As Kruse wrote in his Politico piece:

That spring, though, he purchased the Plaza Hotel because he openly coveted the Manhattan landmark, so much so that he paid more for it than anybody anywhere ever had spent on a hotel—$407.5 million—[for] a hotel that wasn’t turning enough profit to service the debt to which Trump [was] committed.

And in the fall, he agreed to buy the Eastern Airlines [sic] Shuttle, which he wanted to rename the Trump Shuttle, for a sum that analysts and even his own partners considered excessive—more than the airline itself thought the shuttle was worth. . . .

“It was not a lengthy financial analysis,” [said] Nobles [president of Trump Shuttle], describing it as “back-of-the- envelope” and “very quick. . . . Donald said, ‘I really want to buy it.’”

Trump could be the poster child for the dictum that when it comes to hypomanics, nothing fails like success. Kruse continued:

If Trump’s current campaign is the culmination of a lifelong effort to turn his name into a brand, his brand into money and all of it into power, 1988 was the first sustained look at what the man who is the shocking favorite to be the Republi- can Party’s nominee does when he gets ahold of it. It was the year when Trump’s insatiable appetites and boundless ego— this early, spectacular show of success—nearly did him in.

Fast-forward 28 years, to 2016, when Trump once again achieved success beyond anyone’s wildest imaginings. He became addicted to rallies, where he excited crowds with his hypomanic charisma, and where they in turn threw gasoline on the fire of his hypomanic grandiosity. This culminated in the Republican National Convention, at which Trump made a grandiose statement that encapsulates it all: “Only I can fix it.”

David Brooks is not a mental health professional, but he astutely commented on what appeared to him to be Trump’s increasing hypomania:

He cannot be contained because he is psychologically off the chain. With each passing week, he displays the classic symptoms of medium-grade mania in more disturbing forms: inflated self-esteem, sleeplessness, impulsivity, ag- gression and a compulsion to offer advice on subjects he knows nothing about.

His speech patterns are like something straight out of a psychiatric textbook. Manics display something called “flight of ideas.” It’s a formal thought disorder in which ideas tumble forth through a disordered chain of associa- tions. One word sparks another, which sparks another, and they’re off to the races. As one trained psychiatrist said to me, compare Donald Trump’s speaking patterns to a Robin Williams monologue, but with insults instead of jokes.

Trump’s first hypomanic crash resulted only in a few bankruptcies, but while he is president, the consequences could be on a scale so vast it’s difficult even to contemplate.

Let’s put these two moving parts together, bad and mad. Trump is a profoundly evil man exhibiting malignant narcissism. His worsening hypomania is making him increasingly more irrational, grandiose, paranoid, aggressive, irritable, and impulsive. Trump is bad, mad, and getting worse. He evinces the most destructive and dangerous collection of psychiatric symptoms possible for a leader. The worst-case scenario is now our reality.

Often as therapists we are called on to help our patients see that their life circumstances are not as catastrophic as they might feel. In the case of Trump, however, our job is the opposite: o warn the public that the election of Donald Trump is a true emergency, and that the consequences most likely will be catastrophic.

It’s a catastrophe that might have been avoided if we in the mental health community had told the public the truth, instead of allowing ourselves to be gagged by the Goldwater rule. “See some- thing, say nothing” appears to be the APA’s motto when it comes to national security. History will not be kind to a profession that aided the rise of an American Hitler through its silence.

John D. Gartner, Ph.D., is a clinical psychologist. He taught in the Department of Psychiatry at Johns Hopkins University Medical School for 28 years. He is the author of In Search of Bill Clinton: A Psychological Biography and The Hypomanic Edge: The Link Between (a Little) Craziness and (a Lot of) Success in America. He practices in Baltimore and New York.

Copyright © 2017 by John D. Gartner from The Dangerous Case of Donald Trump (Thomas Dunne Books). Copyright © 2017 by Bandy X. Lee.

 

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