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On a third-down play last season, the Washington Redskins quarterback Alex Smith stood in shotgun formation, five yards behind the line of scrimmage. As he called his signals, a Houston Texans cornerback, Kareem Jackson, suddenly sprinted forward from a position four yards behind the defensive line. To hear more feature stories, see our full list or get the Audm iPhone app. Jackson’s timing was perfect. The ball was snapped. The Texans’ left defensive end, J.J. Watt, sprinted to the outside, taking the Redskins’ right tackle with him. The defensive tackle on Watt’s right rushed to the inside, taking the offensive right guard with him. The result was a huge gap in the Redskins’ line, through which Jackson could run unblocked. He quickly sacked Smith, for a loss of 13 yards. Special-teams players began taking the field for the punt. But Smith didn’t get up. He rolled flat onto his back, pulled off his helmet, and covered his face with his hands. He was clearly in excruciating pain. The slow-motion replay immediately showed the television audience why: As Smith was tackled, his right leg had buckled sharply above the ankle, with his foot rotating significantly away from any direction in which a human foot ought to point. The play-by-play announcer Greg Gumbel said grimly, “We’ll be back,” and the network abruptly cut to a break. There was nothing more to say.

Even without the benefit of medical training, and even without conducting a physical examination, viewers knew what had happened. They may not have known what the bones were called or what treatment would be required, but they knew more than enough, and they knew what really mattered: Smith had broken his leg, very badly. They knew that even if they were not orthopedists, did not have a medical degree, and had never cracked open a copy of Gray’s Anatomy. They could tell—they were certain—something was seriously wrong. And so it is, or ought to be, with Donald Trump. You don’t need to be a weatherman to know which way the wind blows, and you don’t need to be a mental-health professional to see that something’s very seriously off with Trump—particularly after nearly three years of watching his erratic and abnormal behavior in the White House. Questions about Trump’s psychological stability have mounted throughout his presidency. But those questions have been coming even more frequently amid a recent escalation in Trump’s bizarre behavior, as the pressures of his upcoming reelection campaign, a possibly deteriorating economy, and now a full-blown impeachment inquiry have mounted. And the questioners have included those who have worked most closely with him. No president in recent memory—and likely no president ever—has prompted more discussion about his mental stability and connection with reality. Trump’s former chief of staff John Kelly is said to have described him as “unhinged,” and “off the rails,” and to have called the White House “Crazytown” because of Trump’s unbalanced state. Trump’s former deputy attorney general, Rod Rosenstein, once reportedly discussed recruiting Cabinet members to invoke the Twenty-Fifth Amendment, the Constitution’s provision addressing presidential disability, including mental disability.

Read more: Donald Trump’s 50 most unthinkable moments Rosenstein denies that claim, but it is not the only such account. A senior administration official, writing anonymously in The New York Times last September, described how, “given the instability many witnessed, there were early whispers within the cabinet of invoking the 25th Amendment”—but “no one wanted to precipitate a constitutional crisis.” And NBC News last week quoted someone familiar with current discussions in the White House warning that there is “increasing wariness that, as this impeachment inquiry drags out, the likelihood increases that the president could respond erratically and become ‘unmanageable.’” In September, a former White House official offered a similar assessment to a Business Insider reporter: “No one knows what to expect from him anymore,” because “his mood changes from one minute to the next based on some headline or tweet, and the next thing you know his entire schedule gets tossed out the window. He’s losing his shit.” Even a major investment bank has gotten into the mix, albeit in a roundabout way: JPMorgan Chase has created a “Volfefe Index”—named after Trump’s bizarre May 2017 “covfefe” tweet—designed to quantify the effect that Trump’s impulsive tweets have on interest-rate volatility. The bank’s press release understatedly observed that its “volatility fair value model” shows that “the president’s remarks on this social media platform [have] played a statistically significant role in elevating implied volatility.”

The president isn’t simply volatile and erratic, however—he’s also incapable of consistently telling the truth. Those who work closely with him, and who aren’t in denial, must deal with Trump’s lying about serious matters virtually every day. But as one former official put it, they “are used to the president saying things that aren’t true,” and have inured themselves to it. Trump’s own former communications director Anthony Scaramucci has on multiple occasions described Trump as a liar, once saying, “We … know he’s telling lies,” so “if you want me to say he’s a liar, I’m happy to say he’s a liar.” He went on to address Trump directly: “You should probably dial down the lying because you don’t need to … So dial that down, and you’ll be doing a lot better.” That was good advice, but clearly wishful thinking. Trump simply can’t dial down the lying, or turn it off—even, his own attorneys suggest, when false statements may be punished as crimes. A lawyer who has represented him in business disputes once told me that Trump couldn’t sensibly be allowed to speak with Special Counsel Robert Mueller, because Trump would “lie his ass off”—in effect, that Trump simply wasn’t capable of telling the truth, about anything, and that if he ever spoke to a prosecutor, he’d talk himself into jail. Trump’s lawyers in the Russia investigation clearly agreed: As Bob Woodward recounts at length in his book Fear, members of Trump’s criminal-defense team fought both Trump and Mueller tooth and nail to keep Trump from being interviewed by the Office of Special Counsel. A practice testimonial session ended with Trump spouting wild, baseless assertions in a rage. Woodward quotes Trump’s outside counsel John Dowd as saying that Trump “just made something up” in response to one question. “That’s his nature.” Woodward also recounts Dowd’s thinking when he argued to Trump that the president was “not really capable” of answering Mueller’s questions face to face. Dowd had “to dress it up as much as possible, to say, it’s not your fault … He could not say what he knew was true: ‘You’re a fucking liar.’ That was the problem.” (Dowd disputes this account.) Which raises the question: If Trump can’t tell the truth even when it counts most, with legal jeopardy on the line and lawyers there to help prepare him, is he able to apprehend the truth at all?

Behavior like this is unusual, a point that journalists across the political spectrum have made. “This is not normal,” Megan McArdle wrote in late August. “And I don’t mean that as in, ‘Trump is violating the shibboleths of the Washington establishment.’ I mean that as in, ‘This is not normal for a functioning adult.’” James Fallows observed, also in August, that Trump is having “episodes of what would be called outright lunacy, if they occurred in any other setting,” and that if he “were in virtually any other position of responsibility, action would already be under way to remove him from that role.” Trump’s erratic behavior has long been the subject of political criticism, late-night-television jokes, and even speculation about whether it’s part of some incomprehensible, multidimensional strategic game. But it’s relevant to whether he’s fit for the office he holds. Simply put, Trump’s ingrained and extreme behavioral characteristics make it impossible for him to carry out the duties of the presidency in the way the Constitution requires. To see why first requires a look at what the Constitution demands of a president, and then an examination of how Trump’s behavioral characteristics preclude his ability to fulfill those demands. The Framers of the Constitution expected the presidency to be occupied by special individuals, selfless people of the highest character and ability. They intended the Electoral College to be a truly deliberative body, not the largely ceremonial institution it has become today. Because the Electoral College, unlike Congress and the state legislatures, wouldn’t be a permanent body, and because it involved diffuse selections made in the various states, they hoped it would help avoid “cabal, intrigue and corruption,” as Alexander Hamilton put it in “Federalist No. 68,” and deter interference from “these most deadly adversaries of republican government,” especially “from the desire in foreign powers to gain an improper ascendant in our councils.”

Though the Constitution’s drafters could hardly have foreseen how the system would evolve, they certainly knew the kind of person they wanted it to produce. “The process of election affords a moral certainty,” Hamilton wrote, “that the office of President will never fall to the lot of any man who is not in an eminent degree endowed with the requisite qualifications.” “Talents for low intrigue, and the little arts of popularity,” might suffice for someone to be elected to the governorship of a state, but not the presidency. Election would “require other talents, and a different kind of merit,” to gain “the esteem and confidence of the whole Union,” or enough of it to win the presidency. As a result, there would be “a constant probability of seeing the station filled by characters pre-eminent for ability and virtue.” This was the Framers’ goal in designing the system that would make “the choice of the person to whom so important a trust was to be confided.” Read more: The presidency is the hardest job in the world Hamilton’s use of the word trust in The Federalist Papers to describe the presidency was no accident. The Framers intended that the president “be like a fiduciary, who must pursue the public interest in good faith republican fashion rather than pursuing his self-interest, and who must diligently and steadily execute Congress’s commands,” as a recent Harvard Law Review article puts it. The concept is akin to the law of private fiduciaries, which governs trustees of trusts and directors and officers of corporations, an area that has been central to my legal practice as a corporate litigator. “Indeed,” as the Harvard Law Review article explains, “one might argue that what presents to us as private fiduciary law today had some of its genesis in the law of public officeholding.” The overarching principle is that a fiduciary—say, the CEO of a corporation—when acting on behalf of a corporation, has to act in the corporation’s best interests. Likewise, a trustee of a trust must use the assets for the benefit of the beneficiary, and not himself (a fundamental rule, incidentally, that Trump apparently couldn’t adhere to with his own charitable foundation).

In providing for a national chief executive, the Framers incorporated the very similar law of public officeholding into his duties in two places in the Constitution—in Article II, Section 3 (the president “shall take Care that the Laws be faithfully executed”), and in Article II, Section 1, Clause 8, which requires the president to “solemnly swear (or affirm) that I will faithfully execute the Office of President of the United States.” That language—particularly the words faithfully execute—was in 1787 “very commonly associated with the performance of public and private offices,” the Harvard Law Review article points out, and “anyone experienced in law or government” at that time would have recognized what it meant, “because it was so basic to … the law of executive officeholding.” In a nutshell, while carrying out his official duties, a president has to put the country, not himself, first; he must faithfully follow and enforce the law; and he must act with the utmost care in doing all that. But can Trump do all that? Does his personality allow him to? Answering those questions doesn’t require mental-health expertise, nor does it really require a diagnosis. You can make the argument for Trump’s unfitness without assessing his mental health: Like James Fallows, for example, you could just ask whether Trump would have been allowed to retain any other job in light of his bizarre conduct. At the same time, the presence of a mental disorder or disturbance doesn’t necessarily translate to incapacity; to suggest otherwise would unfairly stigmatize tens of millions of Americans. Someone battling a serious psychological ailment can unquestionably function well, and even nobly, in high public office—including as president. The country, in fact, has seen it: Abraham Lincoln endured “no mere case of the blues”; he suffered such “terrible melancholly,” said one of his contemporaries, that “he never dare[d] carry a knife in his pocket.” Many historians speculate that he suffered from what we would now diagnose as clinical depression. Yet Lincoln’s mechanisms for coping with his lifelong affliction may have supplied him with the vision, the creativity, and the moral fortitude to save the nation, to achieve for it a new birth of freedom. As a writer in this magazine once put it: Lincoln’s “political vision drew power from personal experience … Prepared for defeat, and even for humiliation, he insisted on seeing the truth of both his personal circumstances and the national condition. And where the optimists of his time would fail, he would succeed, envisioning and articulating a durable idea of free society.”

More than a diagnosis, what truly matters, as Lincoln’s case shows, is the president’s behavioral characteristics and personality traits. And understanding how people behave and think is not the sole province of professionals; we all do it every day, with family members, co-workers, and others. Nevertheless, how the mental-health community goes about categorizing those characteristics and traits can provide helpful guidance to laypeople by structuring our thinking about them. Read more: Donald Trump is not well And that’s where the Diagnostic and Statistical Manual of Mental Disorders comes into play. The DSM, now in its fifth edition, “contains descriptions, symptoms, and other criteria for diagnosing mental disorders,” and serves as the country’s “authoritative guide to the diagnosis of mental disorders.” What’s useful for nonprofessionals is that, for the most part, it’s written in plain English, and its criteria consist largely of observable behaviors—words and actions. That’s especially true of its criteria for personality disorders—they don’t require a person to lie on a couch and confess his or her innermost thoughts. They turn on how a person behaves in the wild, so to speak. If anything, a patient’s confessions in an office may disadvantage a clinician, because patients can and do conceal from clinicians central aspects of their true selves. If you can observe people going about their everyday business, you’ll know a lot more about how they act and behave.

And Donald Trump, as president of the United States, is probably the most observable and observed person in the world. I’ve personally met and spoken with him only a few times, but anyone who knows him will tell you that Trump, in a way, has no facade: What you see of him publicly is what you get all the time, although you may get more of it in private. Any intelligent person who watches Trump closely on television, and pays careful attention to his words on Twitter and in the press, should be able to tell you as much about his behavior as a mental-health professional could. One scholarly paper has suggested that accounts of a person’s behavior from laypeople who observe him might be more accurate than information from a clinical interview, and that this is especially true when considering two personality disorders in particular—what the DSM calls narcissistic personality disorder and antisocial personality disorder. These two disorders just happen to be the ones that have most commonly been ascribed to Trump by mental-health professionals over the past four years. Of these two disorders, the more commonly discussed when it comes to Trump is narcissistic personality disorder, or NPD—pathological narcissism. It’s also more important in considering Trump’s fitness for office, because it touches directly upon whether Trump has the capacity to put anyone’s interests—including the country’s and the Constitution’s—above his own.

Narcissus, the Greek mythological figure, was a boy who fell so in love with his own reflection in a pool of water that, according to one version of the story, he jumped in and drowned. Psychiatrists and psychologists now use the term narcissism to describe feelings of self-importance and self-love. As Craig Malkin, a clinical psychologist who has written extensively on the subject, has explained, narcissism is a trait that, to some extent, all human beings have: “the drive to feel special, to stand out from … other[s] … to feel exceptional or unique.” A certain amount of narcissism is healthy, and helpful—it brings with it confidence, optimism, and boldness. Someone with more than an average amount of narcissism may be called a narcissist. Many politicians, and many celebrities, could be considered narcissists; presidents seem especially likely to “rank high in extroverted narcissism,” Malkin writes, although they have varied greatly in the degree of their narcissism. But extreme narcissism can be pathological, an illness—and potentially a danger, as it was for Narcissus. “Pathological narcissism begins when people become so addicted to feeling special that, just like with any drug, they’ll do anything to get their ‘high,’ including lie, steal, cheat, betray, and even hurt those closest to them,” Malkin says. The “fundamental life goal” of an extreme narcissist “is to promote the greatness of the self, for all to see,” the psychologist Dan P. McAdams wrote in The Atlantic. To many mental-health professionals, Donald Trump provides a perfect example of such extreme, pathological narcissism: One clinical psychologist told Vanity Fair that he considers Trump such a “classic” pathological narcissist that he is actually “archiving video clips of him to use in workshops because there’s no better example” of the characteristics of the disorder he displays. “Otherwise,” this clinician explained, “I would have had to hire actors and write vignettes. He’s like a dream come true.” Another clinical psychologist said that Trump displays “textbook narcissistic personality disorder.”

Not everyone agrees that Trump meets the diagnostic criteria for NPD. Allen Frances, a psychiatrist who helped write the disorder’s entry in the DSM, has argued that a mental “disturbance” becomes a “disorder” only when, as the DSM puts it, the affliction “causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.” The idea behind this threshold is to separate “mild forms” of problems from pathological ones, “in the absence of clear biological markers or clinically useful measurements of severity for many mental disorders.” In Frances’s view, that dividing line disqualifies Trump from having a disorder, particularly NPD. Trump “may be a world-class narcissist,” he has written, “but this doesn’t make him mentally ill, because he does not suffer from the distress and impairment required to diagnose mental disorder. Mr. Trump causes severe distress rather than experiencing it and has been richly rewarded, rather than punished, for his grandiosity, self-absorption and lack of empathy.” But from the perspective of the public at large, the debate over whether Trump meets the clinical diagnostic criteria for NPD—or whether psychiatrists can and should answer that question without directly examining him—is beside the point. The goal of a diagnosis is to help a clinician guide treatment. The question facing the public is very different: Does the president of the United States exhibit a consistent pattern of behavior that suggests he is incapable of properly discharging the duties of his office?

Even Trump’s own allies recognize the degree of his narcissism. When he launched racist attacks on four congresswomen of color, Senator Lindsey Graham explained, “That’s just the way he is. It’s more narcissism than anything else.” So, too, do skeptics of assigning a clinical diagnosis. “No one is denying,” Frances told Rolling Stone, “that he is as narcissistic an individual as one is ever likely to encounter.” The president’s exceptional narcissism is his defining characteristic—and understanding that is crucial to evaluating his fitness for office. Read more: Is something neurologically wrong with Donald Trump? The DSM-5 describes its conception of pathological narcissism this way: “The essential feature of narcissistic personality disorder is a pervasive pattern of grandiosity, need for admiration, and lack of empathy that begins by early adulthood and is present in a variety of contexts.” The manual sets out nine diagnostic criteria that are indicative of the disorder, but only five of the nine need be present for a diagnosis of NPD to be made. Here are the nine: 1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements). 2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. 3. Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions). 4. Requires excessive admiration. 5. Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations). 6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends) 7. Lacks empathy: is unwilling to recognize or identify with the feelings or needs of others. 8. Is often envious of others or believes that others are envious of him or her. 9. Shows arrogant, haughty behaviors or attitudes. These criteria are accompanied by explanatory notes that seem relevant here: “Vulnerability in self-esteem makes individuals with narcissistic personality disorder very sensitive to ‘injury’ from criticism or defeat.” And “criticism may haunt these individuals and may leave them feeling humiliated, degraded, hollow and empty. They may react with disdain, rage, or defiant counterattack.” The manual warns, moreover, that “interpersonal relations are typically impaired because of problems derived from entitlement, the need for admiration, and the relative disregard for the sensitivities of others.” And, the DSM-5 adds, “though overweening ambition and confidence may lead to high achievement, performance may be disrupted because of intolerance of criticism or defeat.”

Finally, (7) Lacks empathy: is unwilling to recognize or identify with the feelings or needs of others? One of the most striking aspects of Trump’s personality is his utter and complete lack of empathy. By empathy, psychologists and psychiatrists mean the ability to understand or relate to what someone else is experiencing—the capacity to envision someone else’s feelings, perceptions, and thoughts. The notorious lawyer and fixer Roy Cohn, who once counseled Trump, said that “Donald pisses ice water,” and indeed, examples of Trump’s utter lack of normal human empathy abound. Trump himself has told the story of a charity ball—an “incredible ball”—he once held at Mar-a-Lago for the Red Cross. “So what happens is, this guy falls off right on his face, hits his head, and I thought he died … His wife is screaming—she’s sitting right next to him, and she’s screaming.” By his own account, Trump’s concern wasn’t the poor man’s well-being or his wife’s. It was the bloody mess on his expensive floor. “You know, beautiful marble floor, didn’t look like it. It changed color. Became very red … I said, ‘Oh, my God, that’s disgusting,’ and I turned away. I couldn’t, you know, he was right in front of me and I turned away.” Trump describes himself as saying, after the injured man was hauled away on a makeshift stretcher, “‘Get that blood cleaned up! It’s disgusting!’ The next day, I forgot to call [the man] to say is he okay … It’s just not my thing.”

And then there was 9/11. Trump gave an extraordinary call-in interview to a metropolitan–New York television station just hours after the Twin Towers collapsed. He was asked whether one of his downtown buildings, 40 Wall Street, had suffered any damage. Trump’s immediate response was to brag about the building’s brand-new ranking among New York skyscrapers: “40 Wall Street actually was the second-tallest building in downtown Manhattan, and it was actually, before the World Trade Center, was the tallest—and then when they built the World Trade Center, it became known as the second-tallest. And now it’s the tallest.” (This wasn’t even true—a building a block away from Trump’s, 70 Pine Street, was a little taller.) That human empathy isn’t Trump’s thing has been demonstrated time and again during his presidency as well. In October 2017, he reportedly told the widow of a serviceman killed in action “something to the effect that ‘he knew what he was getting into when he signed up, but I guess it hurts anyway.’” (Trump later claimed that this account was “fabricated … Sad!” and that “I have proof,” but of course he never produced any.) On a less macabre note, on Christmas Eve last year, Trump took calls on NORAD’s Santa Tracker phone line, which children call to find out where Santa Claus is as he makes his rounds. Trump asked a 7-year-old girl from South Carolina: “Are you still a believer in Santa? Because at 7, it’s marginal, right?”

According to Woodward’s Fear, when Trump’s first chief of staff, Reince Priebus, resigned, he found out about his replacement when he saw a tweet from Trump saying that he had appointed John Kelly as the new chief of staff—moments after Priebus and Trump had spoken about waiting to announce the news. Kelly was appalled, and that night apologetically told Priebus, “I’d never do this to you. I’d never been offered this job until the tweet came out. I would have told you.” His predecessor, though, wasn’t surprised. “It made no sense, Priebus realized, unless you understood … ‘The president has zero psychological ability to recognize empathy or pity in any way.’” Priebus apparently isn’t the only White House staffer to have learned this; in February 2018, when Trump met with survivors of the Parkland, Florida, school shooting and their loved ones, his communications aide actually gave him a note card that made clear that “the president needed to be reminded to show compassion and understanding to traumatized survivors,” as The New York Times put it. The empathy cheat sheet contained a reminder to say such things as “I hear you.” One aide to President Obama told the Times that had she and her colleagues given their boss such a reminder card, “he would have looked at us like we were crazy people.” Most recently, in July of this year, in a stunning scene captured on video, Trump met in the Oval Office with the human-rights activist Nadia Murad, a Yazidi Iraqi who had been captured, raped, and tortured by the Islamic State, and had won the Nobel Peace Prize in 2018 for speaking out about the plight of the Yazidis and other victims of genocide and religious persecution. Her voice breaking, she implored the president of the United States to help her people return safely to Iraq. Trump could barely look her in the eye. She told him that ISIS had murdered her mother and six brothers. Trump, apparently not paying much attention, asked, “Where are they now?” “They killed them,” she said once again. “They are in the mass grave in Sinjar, and I’m still fighting just to live in safety.” Trump, who has publicly said that he deserves the Nobel Peace Prize, seemed interested in the conversation only at the end, when he asked Murad about why she won the prize.

Another equally unforgettable video documents Trump visiting Puerto Rico shortly after Hurricane Maria, tossing rolls of paper towels into a crowd of victims. He later responded vindictively to charges that his administration hadn’t done enough to help the island, prompting the mayor of San Juan to observe that Trump had “augmented” Puerto Rico’s “devastating human crisis … because he made it about himself, not about saving our lives,” and because “when expected to show empathy he showed disdain and lack of respect.” In October 2018, a gunman burst into Shabbat morning services at a Jewish synagogue in Pittsburgh and sprayed worshippers with semiautomatic-rifle and pistol fire. Eleven people died. Three days later, the president and first lady visited the community, and the day after that, the first thing Trump tweeted about the visit was this: “Melania and I were treated very nicely yesterday in Pittsburgh. The Office of the President was shown great respect on a very sad & solemn day. We were treated so warmly. Small protest was not seen by us, staged far away. The Fake News stories were just the opposite—Disgraceful!” Similarly, after gunmen killed dozens in the span of a single August weekend in Dayton, Ohio, and El Paso, Texas, Trump went on a one-day sympathy tour that was marked by attacks on his hosts and on political enemies, and an obsessive focus on himself. Read more: The fight to make meaning out of a massacre