It is time to take the mental condition of President Donald Trump a lot more seriously. Always having what appears to be only a tenuous grasp of reality, the president is showing signs of mental and emotional deterioration at a most dangerous time. Dust off the 25th Amendment, and ask the American Psychiatric Association and the American Psychological Association to put together a panel of their best and brightest to issue an opinion to Vice President Mike Pence and the cabinet on whether the president is mentally able to “discharge the powers and duties of his office.”

I have done a variety of things in my life, from working in an underground iron ore mine and in a cardboard box factory, to serving in the Army and then practicing law. The most useful part of my career, however, for understanding what is going on in Washington, D.C. (or at Mar a Lago, as the case may be) was the time that I spent as a psychiatric social worker, trained at the University of Pittsburgh.

For years I screened psychiatric patients brought to the emergency room or mental health clinic at Ft. Meade, Maryland. I saw plenty of psychotic patients in my work there, listening to them describe various types of bizarre ideation. Sometimes the signs are subtler than others, and some patients are more guarded than others, and then you must listen carefully until a patient begins to describe what is obviously a delusion around which a patient has organized a part of his or her life. With President Donald Trump, the signs are right out in the open.

Like almost everyone else familiar with psychopathology, I believe that our president has narcissistic personality disorder. John Gartner, Ph.D, a psychologist who taught at the Johns Hopkins University School of Medicine for 20 years, has described Mr. Trump’s condition as “malignant narcissism” and believes that it renders him dangerous and unfit to be president. It is a condition that could worsen if dementia begins to affect the president, who is 71 years old and has a family history that includes Alzheimer’s Disease.

Many other mental health professionals have joined Dr. Gartner in recommending that Mr. Trump be removed from office under the 25th Amendment, warning that his condition makes it almost impossible for him to distinguish reality from fancy and to control his impulses. Dr. Gartner describes Mr. Trump’s condition as lying in the grey area between sanity and insanity. Dr. Gartner is a serious clinician and scholar. Read his article in USA Today if you want to feel a chill run down your spine.

Today’s tweets from the president indicate that the president may be decompensating – i.e., his mental state going from bad to worse, to the edge of psychosis. The first tweet goading Senate Majority Leader Mitch McConnell to “try harder” on repealing and replacing the Affordable Care Act was bad enough, displaying profound naivete and an abysmal lack of judgment.

The second tweet doubling down on his threats against North Korean dictator Kim Jong Un was well over the edge. Throw in his statement at a press conference thanking Russian President Vladimir Putin for helping Mr. Trump trim the payroll by throwing 755 U.S. diplomats out of Russia and you are starting to build a pretty good case that the president is going off his rocker.

The apparent failure of Mr. Trump’s first threat to intimidate North Korea apparently was more than Mr. Trump’s ego could withstand. After Mr. Trump warned North Korea that further threats to attack the United States would be met with “fire and fury” the regime turned right around and threatened to launch a strike on Guam, describing the fire and fury comments from the president as a “load of nonsense.” Mr. Trump responded by doubling down on his threat, tweeting today that perhaps his first threat was not “tough enough,” and making clear that the door remains open for a preemptive strike by the United States.

No rational person would have believed that, given the apparent failure of his first threat to end the bellicose language from North Korea, the logical thing to do was to try to make an even bigger, more ominous threat. Mr. Trump truly believes that can lie, bully or bluster his way out of every situation. Mr. Trump’s reflex in almost every situation is to up the rhetorical ante. In this case not only is it irrational, it is highly dangerous.

The biggest threat of a nuclear war comes from a perception by Kim Jong Un that a preemptive nuclear attack on his country is imminent. There is nothing to indicate that the dictator is suicidal and the Chinese certainly have told him in no uncertain terms, if his sycophants have not, that precipitating a nuclear exchange with the U.S. would lead to the devastation of North Korea. There is, however, a very real danger that the young and unstable Kim Jong Un could panic if he believes that all is about to be lost and initiate a nuclear attack – what diplomats euphemistically refer to as a “miscalculation.”

Mr. Trump’s joking reference to the expulsion of U.S. diplomats was almost as bizarre. There is of course his persistent reluctance to criticize Russia and Putin, but making light of what is not a humorous situation was inappropriate, and almost pathologically so. The attempt by Russia to interfere in our election, and their disproportionate response to our sanctions, are not funny. Mr. Trump displayed an almost fawning weakness in the face of Russian hostility on one hand, and an exaggerated, overaggressive reaction to North Korean rhetoric on the other. Something is wrong.

The so-called Goldwater Rule has discouraged psychiatrists from joining other mental health professionals in speaking out about Mr. Trump’s mental illness. The Goldwater Rule was promulgated as an ethical principle by the American Psychiatric Association in 1973 in response to concerns about liberal psychiatrists being asked to render their opinions on the mental fitness of conservative presidential candidate Barry Goldwater in 1964. In general, the principle prohibits psychiatrists from rendering public opinions on patients that they have not examined and who have not authorized them to make such statements.

The rule was recently challenged by the American Psychoanalytic Association, which stated that it no longer considered its members bound by the restriction. The American Psychiatric Association, however, tightened the rule in March, clarifying that the rule is broken by an analysis of behavior even if no diagnostic label is used. Regardless, I think we are going to see more psychiatrists speaking out, under what mental health professionals refer to as the “duty to warn.”

Barry Goldwater was a perfectly sane man who lived a very normal life, but who happened to have political views that were out of the mainstream at the time. It was an abuse by politically-motivated psychiatrists to allow themselves to be drawn into an attempt to question his mental stability.

This is different. President Trump is not normal, and one could argue that experts with knowledge in human behavior have a duty to share their concerns with members of the public, and especially with those persons who have the power to remove the president from office.  And to do so before it’s too late.

August 10, 2017