With reports that a giddy commander in chief is running around the White House like a kid freed of any adult supervision, having dispatched every moderate who hasn’t resigned in hopes of saving a shred of his integrity, Donald Trump now appears to be in a state of mania as he escalates his efforts to bolster his fragile ego before he goes into the cage with special counsel Robert Mueller—or fires him.

This was exactly what the contributors to the book The Dangerous Case of Donald Trump warned about six months ago. The psychiatric professionals who contributed to the book have monitored and come to know Trump’s character better than most clients they have treated or people they have interviewed. As the special prosecutor’s noose tightens around the president and his cultish family, it is increasingly clear that he is an imminent danger to the public, and this impinges on professionals’ duty to society. Sheehy wrote about the book and its genesis in these pages last October (Sheehy and Sword also contributed to the book).

Lawmakers with experience as prosecutors or foreign affairs experts are sounding red alerts about how far out of control is this tormented tweeter. In this White House it’s now every man for himself. As authors of the book warned, Trump trusts no one. Predictably, that has taught everyone who works for him that they can’t trust their boss. Praised today, fired tomorrow.

The authors of the book warned that the Trump effect was creating a “malignant normalcy,” a collective psychological anesthesia in the face of people’s free-floating fears about the stability of this president. Last fall, it was the kind of hush that falls before an impending hurricane or an October Surprise. The book warned that the worst was ahead.

Trump’s paranoia, exaggerated by the real and imminent threat of prosecution for obstruction of justice, money laundering, and physical intimidation of women he has bought for sexual pleasure, is reaching a break point. Democratic Sen. Richard Blumenthal warns of a “catastrophic crisis” pitting an unhinged president against the rule of law and the future of democracy.

“It’s an onrushing train heading straight at us,” warned Sen. Chris Coons this week. The Democrat from Delaware likely has inside knowledge from his seat on the Senate Foreign Relations Committee.

Even more ominous are the coded words of former CIA Director John Brennan, who this week told MSNBC that “perhaps the Russians have something” on Trump, and “Mr. Trump knows better than any one of us why the Russians might have something on him.”

And this Sunday will bring the anticipated Stormy Daniels 60 Minutes segment. What will that do to this fragile man’s psyche? Her descriptions of Trumps pathetically “generic” sex play could strike the most wounding blow to his studly reputation.

Our question: Will the president approach a psychiatric breakdown before, or after, he fires Mueller?

One thing we are certain of is Trump’s extreme present hedonism—living in the moment. His decisions are made on impulse, driven by impulse, with no thought of future consequences or reflection on past mistakes. Unlike most of us who worry about the impact of our most controversial actions, Trump responds recklessly to assuage his ego needs.

In an extreme present hedonist, attempts to bolster a fragile ego can lead to dehumanizing others in order to feel superior. We saw this in Trump’s humiliating dismissal of Secretary of State Rex Tillerson and his derision of FBI Deputy Director Andrew McCabe as he deprived the career civil servant of his pension. It’s all meant to cast them as “weak,” his favorite condemnation. Trump continues relentlessly to smear the most loyal of his appointees, such as Attorney General Jeff Sessions, who was first to publicly lie for him on the Russia probe, before the Senate Intelligence Committee.

Inherently low in self-esteem, the extreme present hedonist will say or do anything at any time to self-aggrandize and shield himself from revelations of his nefarious activities.

If one knows anything about what really sets off a malignant narcissist when he is close to being cornered, charged as guilty, and unmasked as the Strong Man he pretends to be—a weak man with a hollow ego—the answer is simple. He unravels. He decompensates. His behavior may become manic.

Another trait seen in the extreme-present hedonist is bullying. Trump displays a total lack of empathy and compassion, which leads to the aggressive bullying behavior that Mr. Trump has used to intimidate his rivals, rattle his advisers, and warn his Cabinet and congressional lawmakers of disloyalty. He uses bullying (along with payoffs) to silence his sexual playmates and victims of sexual aggression, as well as to insult women of stature like Oprah (branding her “insecure”). Oh, yes, and he loves to bully world leaders.

Two days ago, he summarily replaced his national security adviser, Lt. Gen. H.R. McMaster, with John Bolton, the former UN ambassador, whose white shrub of a mustache had previously turned off Trump as unable to pass the Apprentice star’s TV screen test. But only weeks ago, Bolton had told The Wall Street Journal he favors preemptive strikes against both North Korea and Iran.

That suited Trump’s taste for war as the ultimate distraction from his troubles with the law. Bolton is a virtual twin of Trump in his extreme paranoia about the “deep state.” The prospect of Trump and Bolton, twin paranoids, running the foreign policy of the United States is a threat to the rest of the world.

To verify the symptoms of mania, Sheehy sought out Dr. Jeffrey Lieberman, c hairman of psychiatry at Columbia University’s medical school and a former president of the American Psychiatric Association who has produced 10 books on mental illness and psychiatry. This conversation took place in the summer of 2016.

“Manic personalities are imbued with a sense of self-importance, grandiosity, and mission,” Dr. Lieberman said, taking care to add that this is true of most people who seek the presidency. Granted, anyone with the audacity to assume that he or she has what it takes to lead the world’s superpower will exhibit an excess of narcissism and its offspring—a sense of entitlement—along with a grandiosity of ambition and some degree of messianic belief that she or he is the ideal rescuer-protector for the times. But early on, Donald Trump crashed through the sound barrier on all such temperamental traits.

Dr. Lieberman elaborated on the fragmented thinking process of a person suffering from mania. They jump from subject to subject, not following a line of logical reasoning, no thematic consistency. They need less sleep, or don’t sleep at all.

The average person doesn’t need a Ph.D. to peg Trump in ordinary words as “a raging, overbearing, egotistical, obnoxious boor,” as professor Lieberman observed. But what goes on in the brain of a manic temperament is more dangerous than just obnoxious. “There is a biochemical disturbance in a part of their brain that involves regulating moods,” Lieberman said. “Instead of being able to re-stabilize a highly emotional state, they remain in a period of excess. That state can persist for days, weeks, or even months.”

This sounds like a dead ringer description of the state of Trump’s mind in recent months as he sleeps less and tweets more—up to as many as a dozen times a day—to create a perpetual disarray in government and a constant distraction from what he most fears.

Before speaking further, the properly cautious Dr. Lieberman read me the Goldwater Rule, which cautions medical professionals not to comment clinically on people in the public domain without having personally treated them. This “rule” was created almost 50 years ago by a trade organization, the American Psychiatric Association (of which Lieberman is a past president) before the DSM manual of psychiatric diagnoses was published and long before the internet existed.

Notwithstanding the above, when asked if he had ever seen or heard a candidate for the presidency who was as grandiose in stating his unique self-importance, he said: “Not [in] an American candidate.” Asked what world leaders might match Trump for mania, internationally or historically, he offered only two competitors: Italy’s hyper-narcissistic former president, Silvio Berlusconi, and the fascist Benito Mussolini.

Two months after Trump’s inauguration in January 2017, the American Psychiatric Association (APA) tightened its rule to forbid psychiatrists from making any comment on any aspect of a public figure, even in an emergency; a de facto gag order. While much of America began speaking openly about the mental state of their president, the actual professionals in the field of psychiatry were prohibited from doing so because of the gag rule.

The revolt of the shrinks against this rule began almost a year ago, in April of 2017. A normally apolitical Korean-American professor of law and psychiatry at Yale University, Dr. Bandy X. Lee, called a town meeting to debate the APA rule vs. the ethical duty of “witnessing professionals” to warn and protect America first.

The Yale School of Medicine supported the conference, but Lee withdrew its name for her alma mater's protection. The expected audience shrank to fill a few scattered rows. Dr. Lee was addressing the APA's new "violation of free speech” by expanding the Goldwater Rule into a gag rule.

Howard Covitz, a Philadelphia psychoanalyst and former director of the Institute for Psychoanalysis and Psychotherapy, pointed out that the Goldwater Rule, as it now stands, has no limits. “Hypothetically, a president could be hallucinating and running on the White House lawn buck naked, screaming ‘Bring me my nuclear codes!’ and the new rule would continue to gag professionals from speaking up.”

A dozen top psychiatrists engaged in debate and wound up with a clear majority in favor of going public with their concerns, despite the new rule. Yale’s Dr. Lee joined ranks with Harvard’s Dr. Judith Herman, both women believing that the Trump presidency rises to a historic turning point in the nation’s necessary response to an evident mental health crisis in the Oval Office. The key question, said Herman, “is whether mental health professionals are engaging in political collusion with state abuses of power, or in resistance to them.”

Dr. Lee doubled down by recruiting 27 mental health professionals and commentators who agreed that the APA was colluding with the Trump White House to silence mental health professionals. St. Martin’s Press agreed to publish the book, and the authors took no compensation. With its debut on Amazon on Oct. 3, Dangerous Case shot to the top of that best seller list and within weeks appeared high on the best seller list of The New York Times Book Review.

By November, a fusillade of attacks by Dr. Lieberman began to scare off the media. Ironically, it was Lieberman who denounced the book in the most disrespectful terms as “not a serious, scholarly, civic-minded work but simply tawdry, indulgent, fatuous, tabloid psychiatry.”

While evidencing no hint of having read the book, he branded the authors as having made a “diagnosis” of Trump without personal examination, when they carefully address this issue in the book and explain why they are not breaking ethical guidelines. “Dangerousness” addresses the need for a psychiatric evaluation and is not a diagnosis; it is a human failing of serious concern in a leader. Meanwhile, Lieberman himself proposed a specific diagnosis of Trump in the popular magazine Vice.

To this day, the APA has not reconsidered its gag rule, although some members have resigned in protest. This week has seen Trump go rogue in attacking Vice President Joe Biden as “crazy” and “weak,” his favorite projections on others of qualities he may fear in himself.

Forget the psychiatrists for the moment. How do Trump’s extreme present hedonism, dehumanization, and bullying affect every day Americans? Sheehy jokingly suggested over a year ago that she and many others were suffering from TAD: Trump Anxiety Disorder. The American Psychological Association (i.e. not the American Psychiatric Association) has recently reported that the nation’s stress level is now worse than at any time in memory—worse than during World War II and Vietnam, the Cuban Missile Crisis, and the Sept. 11 terrorist attacks.

With mounting evidence of the president’s likely guilt of high crimes and/or lying about payoffs to silence his female accusers of sexual hedonism, we never know if we are out of the dystopian nightmare where the next tweet could be a nuke. Even if this president goes down, his normalization of clearly unacceptable behavior is the harbinger of a violent culture that will afflict our nation for at least another generation.

Rosemary Sword is co-developer of Time Perspective therapy with psychologist Philip Zimbardo, Stanford professor emeritus and author of Stanford prison experiment.

Gail Sheehy is a journalist and author of 17 books, including Passages and Character: America’s Search for Leadership.

Correction: Due to an editing error, an earlier version of this piece misidentified the professional organization that imposed the gag rule on psychiatric professionals. It is the American Psychiatric Association, not the American Psychological Association. The Beast regrets the error.