WASHINGTON—There is an elephant in the election.

It was tiptoed around for a full year by Republicans and Democrats and the media alike. And then, on Wednesday, Michael Bloomberg hoisted it onto the stage of the Democratic National Convention.

His plea for Hillary Clinton: “Let’s elect a sane, competent person.”

The compliment barely disguised an extraordinary allegation. The billionaire former mayor of New York City was suggesting that Donald Trump is not sane himself.

Bloomberg’s remark was a sign of a quiet shift over the last month in the mainstream discussion of the Republican presidential nominee. Once unmentionable, questions about Trump’s mental health have started to bubble into respectable American forums as he has inched closer to the nuclear codes of the world’s mightiest military while behaving stranger than ever.

It’s a delicate thing to ask, but the fate of humankind is at stake. Is Donald Trump … OK?

“Donald Trump is not of sound mind,” conservative Stephen Hayes wrote two weeks ago in the Weekly Standard.

“Have we stopped to appreciate how crazy Donald Trump has gotten recently?” liberal Ezra Klein wrote last week on Vox.

He “appears haunted by multiple personality disorders,” conservative David Brooks wrote last week in the New York Times.

“We can gloss over it, laugh about it, analyze it, but Donald Trump is not a well man,” Stuart Stevens, chief strategist to Mitt Romney’s 2012 campaign, wrote last week on Twitter.

Stevens, the most prominent political figure to persistently broach the subject, conceded that he is “no doctor or psychiatrist.” But he said in an interview that the available evidence leads to two possible conclusions: either Trump has a substance abuse problem, which appears unlikely, or “there is something definitely off about him.”

“At best, this is a very damaged person,” Stevens said. “And there’s probably something more serious going on.”

Trump’s campaign vehemently disagrees.

“I’m sure you saw Mr. Trump’s medical report released in December of last year, which described him as perhaps the healthiest individual to ever be elected President (paraphrasing) — I refer you to that,” spokeswoman Hope Hicks said in an email.

But that brief report explicitly addressed only physical matters like blood pressure, not mental health. And its extreme grandiosity, unprecedented in a campaign medical report, was precisely the kind of eyebrower-raiser that has caused apprehension about his stability.

He boasts of his own unparalleled magnificence. He creates and promotes wild conspiracy theories. He tells easily disprovable lies. He fails to finish sentences before he gets distracted by unrelated thoughts. He appears to fly into a wounded rage at mild criticism.

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His conduct this summer has been even more erratic than his conduct before. At a rally early last month, Trump became distracted and then angered by a mosquito. At a rally on Thursday, he ranted about his desire to “hit” Bloomberg. When a fire marshal stopped letting people into a rally on Friday, Trump baselessly accused him of being a Clinton agent.

“Trump is crazy. And you can’t fix crazy,” Kevin Sheekey, a Bloomberg adviser, told The New York Times on Thursday.

The armchair pathologizing, and breezy use of the C-word, has upset disabled people and their advocates. David Perry, a disability rights journalist, said that “the casual association of behaviour we find objectionable or erratic with mental illness spreads stigma.”

“He’s a liar, he’s a bigot, he makes bad decisions, he’s erratic and unpredictable. That’s what we need to know. Do we need to then extend a diagnosis to go along with that, to make it really objectionable?” Perry said.

“It hasn’t really worked in eroding Trump’s popularity, but it certainly makes people who actually have these conditions feel very uncomfortable — feel that the message is: ‘If you have a mental health condition, you are not fit to be president.’ And frankly, I suspect we’ve had lots of presidents with mental health conditions, and we’ll probably have lots more.”

Abraham Lincoln lived with depression. Each of Richard Nixon and John F. Kennedy took a cocktail of anxiety medication. Aides to Lyndon B. Johnson, who experienced severe mood swings, were so concerned about his mental state that they consulted psychiatrists.

U.S. psychiatrists are now prohibited by their professional association from publicly assessing public figures. The most common amateur diagnosis of Trump is narcissistic personality disorder, a condition characterized by an “inflated sense of their own importance,” “a deep need for admiration and a lack of empathy for others,” and “a fragile self-esteem that’s vulnerable to the slightest criticism,” the Mayo Clinic said.

Dan McAdams, a psychology professor at Northwestern University, would not diagnose Trump with any ailment, and he said most people running for high office must have a “healthy dose” of narcissism. But he added: “It does seem to be the case that he’s kind of off the map.”

“Putting his name on everything, talking about himself all the time: this is beyond the pale,” said McAdams, who conducted a detailed personality assessment of Trump for the Atlantic. “I don’t want to argue that it’s a clinical condition … but if there’s a continuum, in terms of narcissistic personality characteristics within a relatively normal population, he’s really way off on the extreme end.”

Scott Lilienfeld, a psychology professor at Emory University, co-conducted a study of narcissism in the 42 presidents up to George W. Bush. High levels of the grandiose variety of narcissism, he found, have been associated with superior crisis management, public persuasiveness and overall success — but also with abuse of power, ethics scandals and impeachment resolutions.

It’s the Goldilocks principle: there appears to be a presidential “sweet spot,” Lilienfeld said, between helpful narcissism and damaging narcissism. While he would not specifically discuss Trump other than to say he is almost certainly sane — “I don’t think he’s out of touch with reality, I think he knows what he’s doing, he probably doesn’t hear voices or have delusional thinking” — he suggested that voters ask themselves a question.

“Is this individual’s narcissism so high that it might be at the upper end of the curve where it’s no longer just healthy self-confidence, which is probably good to some degree, or is it at the point where it could really cause problems?”

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