Ride or die.
Support The Bulwark.
  Join Now

How Has Donald Trump’s Mental State Affected His Presidency?

What we knew about his psychology four years ago, and what we know today.
July 1, 2020
Featured Image
US President Donald Trump delivers remarks in front of the media in the Rose Garden of the White House in Washington, DC on June 1, 2020. - US President Donald Trump was due to make a televised address to the nation on Monday after days of anti-racism protests against police brutality that have erupted into violence. The White House announced that the president would make remarks imminently after he has been criticized for not publicly addressing in the crisis in recent days. (Photo by Brendan Smialowski / AFP) (Photo by BRENDAN SMIALOWSKI/AFP via Getty Images)

It seems so clear now.

In June 2016—roughly seven weeks before Donald Trump formally received the Republican nomination for president—I wrote an extended essay in the Huffington Post assessing his behaviors. The title was self-explanatory: “Too Sick to Lead: The Lethal Personality Disorder of Donald Trump.”

By then, Trump had supplied us with overwhelming evidence of an ineradicable pathology which utterly disqualified him for the presidency. But few political observers wanted to touch such a volatile subject.

His party feared him. The media put him in their customary analytical boxes, parsing his every move as if he were something grander, yet more normal, than a mentally disordered demagogue bereft of principles and starved for adulation. And those mental health professionals who dared address the obvious were chided by their peers for psychoanalyzing a man they had never met.

But we had met him—ceaselessly, for decades, and never more than in the year before June 2016, when cable news frequently broadcast his appearances in their entirety. His character disorder was klieg-lit; central to Trump’s pathology was his uncontrollable need to flaunt it.

Most remarkable about his psychological illness is the utter consistency of his behaviors. My descriptions of his pathology, and how it would operate in office, are as applicable today as they were four years ago. Save for factual references specific to 2016, I need not change a word. This owes nothing to my special insight, and everything to Trump’s inability to be anything other than what he was and always will be: a man far too disturbed to occupy the White House.

That he does underscores the core issue in 2020: Will a critical swath of voters, despite all we’ve learned about his unfitness for the presidency, return this man to power?

No longer can we rationalize away his disabling instability—not for tax cuts, or judges, or ideology writ large. By deliberately averting their eyes from the incessant manifestations of his feral inner landscape, the GOP and much of the news media became complicit in his Electoral College victory—and the damage he has inflicted on our democracy and society.


To capture Trump’s singular abnormality, I opened my June 2016 article by describing a telling example from his past: his disturbingly bizarre and infantile practice of pretending to be someone else while calling a reporter to brag about his own romantic life. After describing an audiotape of Trump’s pseudonymous 1991 phone call to People magazine boasting about his supposed romantic involvement with several ultra-famous women—made despite the fact that he was living with his future wife Marla Maples—I pointed out that this behavior was not merely “self-aggrandizing” but also “gratuitously cruel, heedless of all but self, reckless in his lust for attention” and, therefore, that it reflected on Trump’s “psychological fitness to be president.”

With this indubitably aberrant practice as preface, I argued that there is “only one organizing principle” that can make sense of Trump’s “wildly oscillating utterances and behavior—the clinical definition of narcissistic personality disorder.”

The Mayo Clinic describes it as “a mental disorder in which people have an inflated sense of their own importance, a deep need for admiration and a lack of empathy for others.” This is bad enough in selecting a spouse or a friend. But when applied to a prospective president, the symptoms are disqualifying.

With Trump ever in mind, try these. An exaggerated sense of self-importance. An unwarranted belief in your own superiority. A preoccupation with fantasies of your own success, power and brilliance. A craving for constant admiration. A consuming sense of entitlement. An expectation of special favors and unquestioning compliance.

A penchant for exploiting or disparaging others. A total inability to recognize the needs of anyone else. An incapacity to see those you meet as separate human beings. An unreasoning fury at people you perceive as thwarting your wishes or desires. A tendency to act on impulse. A superficial charm deployed to disguise a gift for manipulation.

A need to always be right. A refusal to acknowledge error. An inability to tolerate criticism or critics. A compulsion to conform your ever—shifting sense of “reality” to satisfy your inner requirements. A tendency to lie so frequently and routinely that objective truth loses all meaning.

A belief that you are above the rules. An array of inconsistent statements and behaviors driven by your needs in the moment. An inability to assess the consequences of your actions in new or complex situations. In sum, a total incapacity to separate the world from your own psychodrama.

Recognize anyone? . . .

The annals of business are filled with such people, some of whom wind up in jail, others of whom die rich. But however puissant they become in their chosen realm, their sickness of mind and spirit cannot ruin a country. That power is reserved for presidents.

Indeed, Trump’s rise simply swells his unwarranted belief that he can stride the world like a colossus—naked of judgment, knowledge, temperament or preparation. This reflects a fatal deficit in those who suffer this disorder—they cannot see themselves as they are.

To the contrary, their grandiosity is a defense against feelings of inadequacy too deep and painful to acknowledge. By the consensus of mental health experts, this emotional impairment has a last fatal ingredient—there is no cure. For a man like Donald Trump, life offers no lessons, no path forward save to continue as you have until, like Icarus, you fly too close to the sun.

This disability involves far more than a set of discrete character flaws, however grave, including those which suggest a lack of trustworthiness. We survived the dishonesty and paranoia of Richard Nixon, after all, albeit at considerable cost and only after forcing him from office.

But in many ways Nixon was well-equipped for the presidency, capable of navigating the larger world and understanding complex situations and people—as in China and its leaders. He did not reflexively substitute a grossly inflated sense of self for knowledge, strategy or preparation. His tragedy, and ours, was that his crippling inner wounds outstripped his proven strengths.

Donald Trump is altogether different—and infinitely more dangerous. He is afflicted with a comprehensive and profound character disorder which leaves no corner of his psyche whole. And this dictates—and explains—every aspect of his behavior.

Take his recourse to bullying and slander. “I’m a counterpuncher,” he rationalizes. “[I]’ve been responding to what they did to me.” Now we understand, Donald—your enemies made you do it.

Really? So Heidi Cruz made him ridicule her looks on Twitter? That handicapped reporter made him imitate his disabilities at a rally? . . . And on and on—the list of enemies he must demean is infinite.

A recent example typifies his psychological imbalance. Speaking at a rally in San Diego, he tried to shame an otherwise obscure federal judge in the city, who is presiding over a lawsuit against Trump University. Trump called the Indiana-born judge a “Mexican,” a “hater of Donald Trump” and a “very hostile person” who had “railroaded” him. Heedless of his position or his audience, Trump wallowed in his personal grievances so long that his listeners grew restive. And so, yet again, the campaign for president descended into the poisonous murk of Trump’s inner world.

This astoundingly graceless and unpresidential behavior is far too pointless and indiscriminate to qualify as strategy or tactics. The common thread in all this lashing out—often at those who can’t fight back—is that it has nothing to do with issues, or anything else one would expect from a normal candidate. It is another symptom of Trump’s pathology—the visceral reflex to humiliate and degrade anyone who displeases him, no matter the context or situation.

Take the media. Where, one might ask, would Trump be without its constant and credulous attentions? But, like everyone else, the media can never do enough to feed his needs. He threatens the owners of newspapers with reprisals by the federal government, talks of changing libel laws to facilitate lawsuits for statements which affront him, proposes revoking FCC licenses for media which ruffle him. CNN is “very unprofessional”; like so many others, Fox has treated him “very unfairly.”

He refers to the media which cover him as “scum.” He singles out by name reporters who dare to challenge him. . . . After all, Trump says, he’s “fighting for survival”—ever victimized by hostile forces who fail to recognize his innate superiority.

Opposition of any kind enrages him. He incites reprisals against protesters. He threatened violence in Cleveland as payback for the GOP’s “unfairness.” He fuels anger against Hispanics, Muslims, and other minorities whom he perceives as inimical. And never—not once—does he take any responsibility for stirring these toxic pots. For one of the symptoms of his disability is an absence of conscience or accountability.

So what did women do to him, one wonders? The offense was obviously grave, for his misogyny is endless and, it seems, uncontrollable. One can but identify the same symptoms which drive his comprehensive impulse to demean—the need to dominate, displeasure at feeling thwarted and, of course, a profound lack of empathy for anyone but himself.

But for “Trump,” ever beset, his empathy is boundless. His view of others vacillates wildly based solely on their deference—or lack of it. . . .

Which brings us to a central problem of Trump’s warped psychology—he believes that filling the presidency requires nothing but the wonder of himself. This gives the lie to GOP’s most craven rationalization of its own capitulation: that a suddenly docile Trump will, as president, defer to a cadre of wise and experienced advisers drawn from the party establishment.

This is pernicious nonsense. Consistent with his character disorder, Trump proudly insists that his chief adviser is himself. Even were he so inclined, in order to learn from others he must know enough to discern good advice from bad. But such is his pathology that he feels no need to learn much of anything from anyone. And so, from the beginning, he has plunged us down the bottomless rabbit hole of his intellectual emptiness.

His ignorance and grandiosity form a lethal compound. He disowns NATO, unaware that he is playing into Putin’s hands . . . and imagines negotiating one-on-one with North Korea’s psychotic leader. . . . Oblivious to the appalled reaction around the globe, he promises to compel the respect of world leaders through “the aura of personality.”

His equally spurious domestic “proposals,” such as they may be, reflect nothing but the unreality of his own self-concept. . .

But to talk of Trump in terms of issues is to flatter him. Most of what he says is provisional, ever subject to change, and based on nothing but his needs at the moment. . . .

One can forecast the inevitable day-to-day damage to our country—the lashings out, the abuses of power, the mercurial and confidence-destroying lies and changes of mind, the havoc his distorted lens would wreak upon our institutions and our spirit. But most dangerous of all is the collision between a volatile world, a leader unable to perceive external reality, and the often-unbearable pressures of the presidency. That Trump’s judgment would crack time and again is certain—the only question is how dangerous the moment.

So how have we fallen prey to a man who, by the damning evidence of his own behavior, is psychologically unfit to be president? When did boasting top coherence; mindless posturing become strength; a talent for ridicule supplant experience or judgement; a gift for scapegoating surpass wisdom or generosity? Why must we even contemplate someone with this stunted inner landscape as the world’s most powerful man?

Why, indeed? But that was then—2016. In 2020 America’s electorate has experienced three and a half years of the most aberrant presidency in our history. We have no excuses left.

Our president’s sickness is ever on display. According to the Washington Post, as of May 29 Trump had made more than 19,000 false or misleading claims in a little over 1,200 days in office. During this time, we have witnessed his manipulation of the Justice Department, attacks on the rule of law, refusal to honor congressional subpoenas, fascination with authoritarian leaders, assertions of unlimited power, and attempts to solicit or compel electoral assistance from foreign governments.

Hungry for attention, he subjects us to a constant stream of scurrilous tweets, false accusations, rank divisiveness, unhinged conspiracy theories, blatant racial innuendos, shameless denials of reality, reflexive self-pity, unbounded grandiosity, puerile insults to real or imagined enemies, and claims of superior expertise in a multitude of areas where his abysmal ignorance is manifest. His sole concern is for himself.

This confluence of anti-social behaviors would be shocking in a relative or coworker; in a president, they are frightening and disorienting. Since his inauguration, Trump has debased the coinage of the presidency, eroded the boundaries on presidential misconduct, and poisoned the well of civic decency. His crippling dysfunction is now ours.


These behaviors have caused an increasing number of mental health professional to issue warnings about Trump’s psychological condition. In 2017, forensic psychiatrist Bandy X. Lee edited a book, The Dangerous Case of Donald Trump, that included essays from dozens of psychiatrists, psychologists, and mental health professionals. And last December, two weeks before Trump’s impeachment, Dr. Lee submitted to Congress a petition, with 650 other psychiatrists, psychologists, and mental health professionals as co-signatories, which included this disturbing admonition:

What makes Donald Trump so dangerous is the brittleness of his sense of worth. Any slight or criticism is experienced as a humiliation and degradation. To cope with the resultant hollow and empty feeling, he reacts with what is referred to as narcissistic rage. He is unable to take responsibility for any error, mistake, or failing. His default in that situation is to blame others and to attack the perceived source of his humiliation. These attacks of narcissistic rage can be brutal and destructive.”

Further, Lee explained to the London Independent, Trump was “doubling and . . . tripling down on his delusions”; “ramping up his conspiracy theories”; and “showing a great deal of cruelty and vindictiveness” in his “accelerated, repetitive tweets.”

Recent examples include his vicious allegations that, twenty years ago, Joe Scarborough murdered a woman who worked in his Florida congressional office. In reality, she died of a heart attack when Scarborough was 500 miles away. But Trump’s cruelty caused her anguished widower to implore Twitter to delete his sadistic tweets.

A related sign of emotional instability is Trump’s obsession with projecting dominance and strength—the underside of which is a debilitating admixture of neediness and insecurity.

Recent examples abound. Some would be seriocomic were he not America’s president:

  • As reported by Ashley Parker and Josh Dawsey in the Washington Post, Trump sidetracked a cabinet meeting with a lengthy re-enactment of his supposedly stellar performance—three years prior—on a cognitive screening test.
  • After taking refuge in an underground bunker when protesters ringed the White House, he furiously denied it—claiming to have been conducting a snap inspection tour.
  • When a videotape captured his halting descent down a ramp after speaking at West Point, Trump delivered a rambling fifteen-minute revisionist history at his rally in Tulsa—blaming, among other things, slippery shoes.

Other examples are alarming, indeed ominous. His constant calls to “dominate” the streets during protests following the death of George Floyd. His threats to deploy active duty troops on American soil. His misuse of military personnel to clear peaceful protesters near Lafayette Square—all so that he could hold a borrowed Bible aloft in front of a damaged church, a videotaped piece of authoritarian theater.


The gnawing hunger of Trump’s misshapen psyche dominates Carl Bernstein’s appalling new account for CNN of the president’s conversations with foreign leaders, detailing in the starkest terms the consequences of investing someone of his pathology with the power of the American presidency.

Writes Bernstein:

Trump was so consistently unprepared for discussion of serious issues, so often outplayed in his conversations with powerful leaders like . . . Vladimir Putin and Turkish president Recep Erdoğan, and so abusive to leaders of America’s principal allies, that the calls helped convince some senior U.S. officials—including his former secretaries of state and defense, two national security advisers and his longest-serving chief of staff—that the president himself posed a danger to the national security of the United States . . . [and] to conclude that the president was often “delusional,” as two sources put it, in his dealings with foreign leaders.

Central to these conversations was Trump’s disabling absorption with himself: “Trump incessantly boasted to his fellow heads of state, including . . . North Korean dictator Kim Jong Un, about his own wealth, genius, ‘great’ accomplishments as president, and the ‘idiocy’ of his Oval Office predecessors. . . . In his phone exchanges with Putin . . . the president talked mostly about himself . . . [while] obsequiously courting Putin’s admiration and approval.” Adds Bernstein: “The common, overwhelming dynamic that characterizes Trump’s conversations with both authoritarian dictators and leaders of the world’s greatest democracies is his consistent assertion of himself as the defining subject and subtext of the calls.”

But for allies, Trump’s manner was the opposite of his pandering to the authoritarians: bullying, abusive, and riven with grievances. “Everything was always personalized,” a source told Bernstein, “with everybody doing terrible things to rip us off—which meant ripping ‘me’—Trump—off.” With females, Trump added a withering misogyny. “His most vicious attacks,” Bernstein relates, “were aimed at women heads of state. In conversations with both [Theresa] May and [Angela] Merkel, the president demeaned and denigrated them in diatribes described as ‘near-sadistic.’”

Other consistent features of these phone calls were Trump’s ignorance and dissociation from reality. “Two sources,” Bernstein reports, “compared many of the president’s conversations with foreign leaders to Trump’s recent press ‘briefings’ on the coronavirus pandemic: free form, fact-deficient stream-of-consciousness ramblings, full of fantasy and off-the-wall pronouncements based on his intuitions, guesswork, the opinions of Fox News TV hosts and social media misinformation.”

Bernstein concludes by quoting a senior official who summarizes the grip of Trump’s personality disorder on his conduct of foreign affairs: “There was no sense of ‘Team America’ or of . . . certain democratic principles and leadership of the free world. . . . The opposite. It was like the United States had disappeared. It was always ‘Just me.’”


But, for now, all else is overshadowed by Trump’s catastrophic mishandling of COVID-19—a case study in the literally lethal consequences of his hydra-headed disorder. This is precisely what I meant when, in 2016, I wrote about the dangerous collision between “volatile world, a leader unable to perceive external reality, and the oftenunbearable pressures of the presidency.” Trump need not precipitate a nuclear exchange for his warped psychology to cause tens of thousands of needless American deaths.

It has. Last month disease modelers at Columbia estimated that we would have incurred roughly 36,000 fewer fatalities had Trump initiated social distancing one week earlier, and 54,000 deaths had it started two weeks earlier. Instead, fearful that acknowledging the seriousness of the coronavirus would have adverse political consequences, Trump chose misleading the public over protecting lives.

Inexorably, the deadly pandemic overwhelmed Trump’s self-created alternate reality—in which denying its lethality substituted for action. So he substituted yet another fantasy: that his proactive leadership in fighting the virus had saved countless lives and defeated the pandemic.

Even as the death toll mounted, he urged state governments to reopen the economy—dismissing life-saving public health measures recommended by his own government. COVID-19, he told Sean Hannity, is “fading away.” A week later, we suffered the greatest number of new cases since the pandemic began.

Events in the real world provide a roadmap of Trump’s delusions. The coronavirus spiked in the states that were the swiftest to reopen. The European Union has banned Americans as threats to public health. Contradicting Trump, Anthony Fauci warned Congress that “the virus is not going to disappear,” adding that “we are still in the middle of a serious outbreak.”

No matter to Trump. In his imaginary America, the real problem became that we were testing too much, thereby increasing the count of new cases.

By then, as his pathology dictates, Trump had put blame for the pandemic on China, the World Health Organization, the media, Barack Obama, the intelligence community, and the CDC. And he had discovered the real victim of COVID-19: himself. In Vanity Fair, Gabriel Sherman reported Trump telling a confidant: “This is so unfair to me! Everything was going great. We were cruising to reelection!”

Instead, the pandemic has underscored Trump’s complete indifference to other human beings. And not just the vulnerable, the sick, and the dead. He insisted that West Point graduates return to hear his commencement speech in the middle of a pandemic. He scheduled large indoor rallies in Tulsa and Phoenix, surefire super-spreaders, so that he could bask in adoring crowds.

When public health officials in Charlotte inquired about health measures for the GOP convention, Trump moved it to Jacksonville—simply to ensure himself a jam-packed arena filled with unmasked faces, risk be damned. Over a three-week period of public statements amid the pandemic back in April, the Washington Post reported, Trump spoke for some thirteen hours—of which he spent two hours attacking others, forty-five minutes praising himself and his administration, but just four-and-a-half minutes expressing rote sympathy for coronavirus victims and front-line workers.

Further, the Post related in late May, “The coronavirus pandemic has spawned a whole new genre of Trump’s falsehoods. The category in just a few months has reached 800 claims, with his advocacy for hydroxychloroquine as a possible cure, based on minimal and flimsy evidence, already reaching Bottomless Pinocchio status.” As Trump’s confidant told Sherman: “He lives in his own fucking world.”

In that world, Trump is free from the constraints of constitutional democracy.


To stave off defeat, he and his party are striving to prevent the universal voting by mail necessitated by the pandemic, while groundlessly asserting that the mail-in balloting currently available guarantees massive voter fraud by the Democratic Party. Already, Trump is claiming that the 2020 election “will be, in my opinion, the most corrupt election in the history of our country, and we cannot let this happen.”

This is insane. But an increasingly serious body of opinion anticipates that Trump will try to maintain power by denying the legitimacy of the November election. This captures how completely Trump’s sickness has consumed us—expecting our president to subvert American democracy is becoming our new normal.

The problem of Trump transcends party or ideology, and so does our need to be rid of him. For there is no constitutional guarantee against a president too mentally ill to respect its terms—and a party too craven to stop him.

Until further notice, we have both.

Richard North Patterson

Richard North Patterson is a lawyer, political commentator and best-selling novelist. He is a former chairman of Common Cause and a member of the Council on Foreign Relations.