Sunday, April 16, 2017

The Pathology of Narcissism




The Pathology of Narcissism

This is long and intense, but an interesting read.

"...he spent that first full day in office focused not on the problems 
facing our country but on the problems facing him: his lackluster 
inauguration attendance and his inability to win the popular vote."




Trump and the Pathology of Narcissism

Diagnosing the president was off-limits to experts – until a textbook case entered the White House

By Alex Morris


At 6:35 a.m. on the morning of March 4th, President Donald Trump did what no U.S. president has ever done: He accused his predecessor of spying on him. He did so over Twitter, providing no evidence and – lest anyone miss the point – doubling down on his accusation in tweets at 6:49, 6:52 and 7:02, the last of which referred to Obama as a "Bad (or sick) guy!" Six weeks into his presidency, these unsubstantiated tweets were just one of many times the sitting president had rashly made claims that were (as we soon learned) categorically untrue, but it was the first time since his inauguration that he had so starkly drawn America's integrity into the fray. And he had done it not behind closed doors with a swift call to the Department of Justice, but instead over social media in a frenzy of ire and grammatical errors. If one hadn't been asking the question before, it was hard not to wonder: Is the president mentally ill?
It's now abundantly clear that Trump's behavior on the campaign trail was not just a "persona" he used to get elected – that he would not, in fact, turn out to be, as he put it, "the most presidential person ever, other than possibly the great Abe Lincoln, all right?" It took all of 24 hours to show us that the Trump we elected was the Trump we would get when, despite the fact that he was president, that he had won, he spent that first full day in office focused not on the problems facing our country but on the problems facing him: his lackluster inauguration attendance and his inability to win the popular vote.
Since Trump first announced his candidacy, his extreme disagreeableness, his loose relationship with the truth and his trigger-happy attacks on those who threatened his dominance were the worrisome qualities that launched a thousand op-eds calling him "unfit for office," and led to ubiquitous armchair diagnoses of "crazy." We had never seen a presidential candidate behave in such a way, and his behavior was so abnormal that one couldn't help but try to fit it into some sort of rubric that would help us understand. "Crazy" kind of did the trick.
And yet, the one group that could weigh in on Trump's sanity, or possible lack thereof, was sitting the debate out – for an ostensibly good reason. In 1964, Lyndon B. Johnson had foreshadowed the 2016 presidential election by suggesting his opponent, Barry Goldwater, was 
too unstable to be in control of 
the nuclear codes, even running 
an ad to that effect that remains 
one of the most controversial in 
the history of American poli
tics. In a survey for Fact magazine, more than 2,000 psychiatrists weighed in, many of them 
seeing pathology in Goldwater's supposed potty-training woes, 
in his supposed latent homosexuality and in his Cold War paranoia. This was back in the Freudian days of psychiatry,
 when any odd-duck characteristic was fair game for psychiatric dissection, before the Diagnostic and Statistical Man
ual of Mental Disorders cleaned 
house and gave a clear set of 
criteria (none of which includes 
potty training, by the way) for a 
limited number of possible dis
orders. Goldwater lost the election, sued Fact and won his suit.
 The American Psychiatric Asso
ciation was so embarrassed that 
it instituted the so-called Goldwater Rule, stating that it is "un
ethical for a psychiatrist to offer 
a professional opinion unless he 
or she has conducted an examination" of the person under question.
All the same, as Trump's candidacy snowballed, many in the mental-health community, observing what they believed to be clear signs of pathology, bristled at the limitations of the Goldwater guidelines. "It seems to function as a gag rule," says Claire Pouncey, a psychiatrist who co-authored a paper in The Journal of the American Academy of Psychiatry and Law, which argued that upholding Goldwater "inhibits potentially valuable educational efforts and psychiatric opinions about potentially dangerous public figures." Many called on the organizations that traffic in the psychological well-being of Americans – like the American Psychiatric Association, the American Psychological Association, the National Association of Social Workers and the American Psychoanalytic Association – to sound an alarm. "A lot of us were working as hard as we could to try to get organizations to speak out during the campaign," says Lance Dodes, a psychoanalyst and former professor of psychiatry at Harvard Medical School. "I mean, there was certainly a sense that somebody had to speak up." But none of the organizations wanted to violate the Goldwater Rule. And anyway, Dodes continues, "Most of the pollsters said he would not be elected. So even though there was a lot of worry, people reassured themselves that nothing would come of this."
But of course, something did come of it, and so on February 13th, Dodes and 34 other psychiatrists, psychologists and social workers published a letter in The New York Times stating that "Mr. Trump's speech and actions make him incapable of safely serving as president." As Dodes tells me, "This is not a policy matter at all. It is continuous behavior that the whole country can see that indicates specific kinds of limitations, or problems in his mind. So to say that those people who are most expert in human psychology can't comment on it is nonsensical." In their letter, the mental health experts did not go so far as to proffer a diagnosis, but the affliction that has gotten the most play in the days since is a form of narcissism so extreme that it affects a person's ability to function: narcissistic personality disorder.
The most current iteration of the DSM classifies narcissistic personality disorder as: "A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts." A diagnosis would also require five or more of the following traits:
1. Has a grandiose sense of self-importance (e.g., "Nobody builds walls better than me"; "There's nobody that respects women more than I do"; "There's nobody who's done so much for equality as I have").

2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love ("I alone can fix it"; "It's very hard for them to attack me on looks, because I'm so good-looking"). 
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 ("Part of the beauty of me is that I'm very rich").
4. Requires excessive admiration ("They said it was the biggest standing ovation since Peyton Manning had won the Super Bowl").

5. Has a sense of entitlement ("When you're a star, they let you do it. You can do anything. Grab them by the pussy"). 
6. Is interpersonally exploitative (see above).

7. Lacks empathy, is unwilling to recognize or identify with the feelings
and needs of others ("He's not a war hero . . . he was captured. I like people that weren't captured").

8. Is often envious of others or believes that others are envious of him or her ("I'm the president, and you're not").

9. Shows arrogant, haughty behaviors or attitudes ("I could stand in the middle of 5th Avenue and shoot somebody, and I wouldn't lose any voters").
NPD was first introduced as a personality disorder by the DSM in 1980 and affects up to six percent of the U.S. population. It is not a mood state but rather an ingrained set of traits, a programming of the brain that is thought to arise in childhood as a result of parenting that either puts a child on a pedestal and superficially inflates the ego or, conversely, withholds approval and requires the child to single-handedly build up his or her own ego to survive. Either way, this impedes the development of a realistic sense of self and instead fosters a "false self," a grandiose narrative of one's own importance that needs constant support and affirmation – or "narcissistic supply" – to ward off an otherwise prevailing sense of emptiness. Of all personality disorders, NPD is among the least responsive to treatment for the obvious reason that narcissists typically do not, or cannot, admit that they are flawed.
Trump's childhood seems to suggest a history of "pedestal" parenting. "You are a king," Fred
 Trump told his middle child, while 
also teaching him that the world
 was an unforgiving place and that 
it was important to "be a killer." Trump apparently got the message: He reportedly threw rocks 
at a neighbor's baby and bragged
 about punching a music teacher in
 the face. Other kids from his well-
heeled Queens neighborhood of Jamaica Estates were forbidden from playing with him, and in school
 he got detention so often that it
 was nicknamed "DT," for "Donny Trump." When his father found 
his collection of switchblades, he
 sent Donald upstate to New York Military Academy, where he could be controlled while also remaining aggressively alpha male. "I think his father would have fit the category [of narcissistic]," says Michael D'Antonio, author of The Truth About Trump. "I think his mother probably would have. And I even think his paternal grandfather did as well. These are very driven, very ambitious people."
Viewed through the lens of pathology, Trump's behavior – from military-school reports that he was too competitive to have close friends to his recent impromptu press conference, where he seemed to revel in the hour and a half he spent center stage, spouting paranoia and insults – can be seen as a constant quest for narcissistic supply. Certainly few have gone after fame (a veritable conveyor belt of narcissistic supply) with such single-mindedness as Trump, constantly upping the ante to gain more exposure. Not content with being the heir apparent of his father's vast outer-borough fortune, he spent his twenties moving the Trump Organization into the spotlight of Manhattan, where his buildings needed to be the biggest, the grandest, the tallest (in the pursuit of which he skipped floors in the numbering to make them seem higher). Not content to inflict the city with a succession of eyesores bearing his name in outsize letters, he had to buy up more Atlantic City casinos than anyone else, as well as a fleet of 727s (which he also slapped with his name) and the world's third-biggest yacht (despite professing to not like boats). Meanwhile, to make sure that none of this escaped notice, he sometimes pretended to be his own publicist, peppering the press with unsolicited information about his business conquests and his sexual prowess. "The most florid demonstration of [his narcissism] was around the sex scandal that ended his first marriage," says D'Antonio. "He just did so many things to call more attention to it that it was hard to not recognize that there's something very strange going on." (The White House declined to comment for this article.)
Based on the "Big Five" traits that psychologists consider to be the building blocks of personality – extroversion, agreeableness, openness, conscientiousness and neuroticism – the stamp of a narcissist is someone who scores extremely high in extroversion but extremely low in agreeableness. From his business entanglements to his preference for the rally format, Trump's way of putting himself out in the world is not meant to make friends; it's meant to assert his dominance. The reported fear and trembling among his White House staff aligns well with his long-standing habit of hiring two people for the same job and letting them battle it out for his favor. His tendency to hire women was spun as a sign of enlightenment on the campaign trail, but those who've worked with him sensed that it had more to do with finding women less threatening than men (a reason that's also been posited as to why Ivanka is his favorite child). Trump has a lengthy record of stiffing his workers and dodging his creditors. And nothing could be more disagreeable than the way he's dealt with detractors over the years, filing hundreds of frivolous lawsuits, sending scathing letters (like the one he sent to New York Times columnist Gail Collins with her photo covered by the words "The face of a dog!"), and, once it was invented, using Twitter as an instrument of malice that could provide immediate narcissistic supply via comments and retweets. In fact, while studies have found that Twitter and other social-media outlets do not actually foster narcissism, they have turned much of the Internet into a narcissist's playground, providing immediate gratification for someone who needs a public and instantaneous way to build up their false self.
That Americans weren't put off by this disagreeableness may have come as a surprise, but in a country that has turned its political process into a glorified celebrity marketing campaign, it probably shouldn't have. America was founded on the principles of individualism and independence, and studies have shown that the most individualistic nations are, predictably, the most narcissistic. But studies have also shown that America has been getting more narcissistic since the Seventies, which saw the publication of Tom Wolfe's seminal "Me Decade" article and Christopher Lasch's The Culture of Narcissism. In 2008, the National Institutes of Health released the most comprehensive study of NPD to date and found that almost one out of 10 Americans in their twenties had displayed behaviors consistent with NPD, versus only one in 30 of those over 65. Another study found narcissistic traits to be rising as quickly as obesity, while yet another showed that almost one-third of high school students in America in 2005 said that they expected to eventually become famous. "If there were no Kardashians, there would be no President Donald Trump," says Keith Campbell, a professor of psychology at the University of Georgia who co-authored the book The Narcissism Epidemic. "And Trump decided to do it Kardashian-style, with no filter. When Trump and Kanye had that meeting in Trump Tower, I was like, 'I should just quit. My work here is done.'"

Still, Campbell would not label Trump with NPD. A final DSM criterion for the disease is that it must cause "significant" distress or impairment, which has been a sticking point for many mental-health professionals. "He's a billionaire who's president of the United States," points out Campbell. "He's functioning pretty highly."
Others maintain that making diagnoses without a formal interview is not just unethical, but impossible – that the public actions of a public persona may not align with who that person is when they're alone at home. After Dodes' op-ed appeared in the Times, Allen Frances, the psychiatrist who wrote the NPD criteria for the DSMIV, followed up with a letter to the editor the very next day, arguing that it was unfair and insulting to the mentally ill to lump them with someone like Trump, and that doing so would give the president a pass he doesn't deserve. "No one is denying that he is as narcissistic an individual as one is ever likely to encounter," Frances tells me. "But we tend to equate bad behavior with mental illness, and that makes us less able to deal with the bad behavior on its own terms."
Others have been less circumspect, implying that if the DSM wouldn't diagnose someone like Trump with NPD, then maybe it's the DSM that's wrong. "It's just that one pesky impairment thing," says Josh Miller, Campbell's colleague and a professor and director of the clinical training program at the University of Georgia who specializes in psychopathy and narcissism. "Maybe the DSM isn't thinking about this in exactly the right way by ignoring when something causes such widespread problems to those around them." More specifically, Miller believes that Trump's wealth could have shielded him from impairment that would otherwise be more pronounced. "He gets to present himself as an incredible businessman despite multiple bankruptcies, despite lots of signs that he is not as astute or as successful as he might be otherwise," Miller says. "We might know more about his relational functioning if his ex-wives didn't sign the sort of thing where getting a nice sum of money from a divorce is contingent upon not discussing the person's behavior. He's able to keep sycophants around him because of his money. If he was your average politician, it might be that the impairment would be much, much more apparent."
At the very least, the growing debate over Trump's mental health raises the question of what having an NPD president would mean. "I hated President Bush, but it never occurred to me or any of my colleagues that he was mentally ill," says John Gartner, a psychologist who taught in the department of psychiatry at Johns Hopkins University Medical School for 28 years and who has been one of the most vocal critics of upholding the Goldwater Rule in this case, going so far as to say that Trump suffers from "malignant narcissism," a term for the triumvirate of narcissistic, paranoid and antisocial personality disorders (with a little sadism thrown in for good measure) that was invented to describe what was wrong with Hitler. "Even though I disagree with everything he believes in, I would be immensely relieved to have a President Pence," Gartner says. "Because he's conservative. Not crazy."
Of course, having a mental illness, in and of itself, wouldn't necessarily make Trump unqualified for the presidency. A 2006 study published in theJournal of Nervous & Mental Disease found that 18 of the first 37 presidents met criteria for having a psychiatric disorder, from depression (24 percent) and anxiety (eight percent) to alcoholism (eight percent) and bipolar disorder (eight percent). Ten of them exhibited symptoms while in office, and one of those 10 was arguably our best president, Abraham Lincoln, who suffered from deep depression (though, considering the death of his son and the state of the nation, who could blame him?).
The problem is that, when it comes to leadership, all pathologies are not created equal. Some, like depression, though debilitating, do not typically lead to psychosis or risky decision-making and are mainly unpleasant only for the person suffering them, as well as perhaps for their close friends and family. Others, like alcoholism, can be more dicey: In 1969, Nixon got so sloshed that he ordered a nuclear attack against North Korea (in anticipation of just such an event, his defense secretary had supposedly warned the military not to act on White House orders without approval from either himself or the secretary of state).
When it comes to presidents, and perhaps all politicians, some level of narcissism is par for the course. Based on a 2013 study of U.S. presidents from Washington to George W. Bush, many of our chief executives with narcissistic traits shared what is called "emergent leadership," or a keen ability to get elected. They can be charming and charismatic. They dominate. They entertain. They project strength and confidence. They're good at convincing people, at least initially, that they actually are as awesome as they think they are. (Despite what a narcissist might believe, research shows they are usually no better-looking, more intelligent or talented than the average person – though when they are, their narcissism is better tolerated.) In fact, a narcissist's brash leadership has been shown to be particularly attractive in times of perceived upheaval, which means that it benefits a narcissist to promote ideas of chaos and to identify a common enemy, or, if need be, create one. "They're going to want attention, and they're going to get attention by making big public changes and having bold leadership," says Campbell. "So if things are going well, a narcissistic leader's probably not what you want. If things aren't going well, you're like, 'Eh, let's roll the dice. Let's get this person out there to just make some big changes and shake things up.' And then we pray to God it works."
It doesn't always. Ironically, for 
a man who ran on the platform to 
"Make America Great Again," narcissists may have a better chance 
of getting elected when things are going poorly, but they actually appear to perform better when things are going well – and they can take the credit. One of the questions on the Narcissistic Personality Inventory, which is used to assess narcissistic personality traits, asks respondents to choose between two statements: (1) The thought of ruling the world frightens the hell out of me, and (2) If I ruled the world, it would be a better place. Narcissists obviously tend to pick the latter, but that overconfidence actually works against them: One of the highest predictors of success is conscientiousness, but if you think you're already the best, then why would you bother to take the time to get better? It's easier, instead, to point fingers. "Narcissistic people externalize blame," says Miller. "I mean, Trump's going to fire [Sean] Spicer, and then it's going to be the Cabinet. When is he going to say, 'I should have read that more carefully. I should have taken more time to know what this treaty was'? That is not part of a narcissistic individual's makeup, to assume responsibility for their own missteps."
Despite the obvious risks, having a narcissistic president doesn't always end in disaster. "Democracy's always based in trying to work through conflict," says Sean Wilentz, a professor of history at Princeton and contributor to Rolling Stone. "And a person who has a dominant personality sometimes can actually be very effective." LBJ, who scored the highest in that study that ranked the narcissistic tendencies of U.S. presidents, had the aggressiveness necessary to push through the Civil Rights Act, but he also didn't (or wouldn't) do an about-face to get the country out of Vietnam. When a group of reporters pressed him for an explanation of this, he reportedly unzipped his pants, pulled out his penis and declared, "This is why."
Likewise, Andrew Jackson, who ranked third, was considered the nation's first demagogue – a rabble-rouser who fought at least a dozen duels throughout his life, who contemporaries thought would trash the White House with his unruly mob, and whose "jackass" tendencies were the inspiration for the symbol of the Democratic Party – but he paid off the national debt and pushed the nation's expansion westward (though his Indian Removal Act led to the deaths of tens of thousands along the Trail of Tears). "Narcissistic leaders are really good and bad, meaning that they often get a lot done, but they're also viewed as ethically challenged," says Campbell. Meanwhile, "nice guy" presidents like Jimmy Carter are well-liked, but they aren't viewed as particularly potent.
So how might Trump measure up? According to the 2013 study, while run-of-the-mill narcissism conveyed some benefits, NPD traits usually did not, and were furthermore "related to numerous indicators of negative performance: having impeachment resolutions brought up in Congress, facing impeachment proceedings, placing political success over effective policy, and behaving unethically." Nixon, probably our most unethical president, was ranked second in the study, but even he knew to conduct attacks covertly. His form of narcissism was more adaptive, more Machiavellian. In fact, many narcissists see the world as a chess game in which they must think ahead in order to maintain the advantage they feel they deserve. For this reason, impulsivity is not considered a classic trait of narcissism. Trump's obvious rashness, then, allows for an unfortunate combination of traits. "The impulsivity and the lack of deliberate forethought about things," warns Miller, "paired with the overconfidence, are the most troubling parts for me."
Another problem for narcissists on the more extreme end of the spectrum is that the skills needed to get elected are not, and have never been, identical to the skills needed to govern. "Just because you get a big job doesn't mean that you can't have a psychiatric disability that interferes with your ability to confidently perform it," points out Gartner. Individuals with NPD are notoriously bad at regulating their behavior or tailoring it to the situation at hand. "Every situation feels like a competition to win," explains Aaron Pincus, a professor of psychology at Penn State who researches pathological narcissism. "Every situation feels like a stage in which to show people that 'I'm superior, better, and they're going to admire me for it.'" As former Democratic Congressman Barney Frank describes his impression of Trump, "I have never seen anybody in public life so focused exclusively on the trivial aspects of his own persona. I certainly have never seen anything like it in a person with a lot of responsibility."
This makes narcissists particularly vulnerable to sycophants, or at least those who feed their narcissistic supply by telling them what they want to hear. Whether Steve Bannon actually is the evil mastermind he's been made out to be doesn't change the fact that even Republicans seem wary of Trump's susceptibility to him. Unelected officials gaining power through a destabilizing characteristic of a mental disorder is the sort of thing our political system was set up to combat. "It's a sign, actually, of how severely we need functioning parties," Wilentz says. "Because when they work, they are in fact a check on the emergence of this kind of character. You can't get where Trump is now in a functioning party system. It took this particular political crisis, which was a political crisis, to produce a president who has this trait. Normally, we can weed them out."
For many in the mental-health field, the most troubling aspect of Trump's personality is his loose grasp of fact and fiction. When narcissism veers into NPD, it can lead to delusions, an alternate reality where the narcissist remains on top despite clear evidence to the contrary. "He's extremely quick, like nanoseconds quick, to discern anything that could conceivably threaten his dominance," says biographer Gwenda Blair, who wrote The Trumps: Three Generations of Builders and a President. "He's on it. Anything that he senses – and he has very sharp senses – that could suggest that he is anything except 200 percent total winner, he's got to stomp it out immediately. So having those reports, for example, that he did not win the popular vote? He can't take that in. There has to be another explanation. It has to have been stolen. It has to have been some illegal voters. It can't be the case that he lost. That's not thinkable."
But having verifiable facts be "unthinkable" is, Dodes explains, "a serious impairment 
of what we call 'reality 
testing,' so it creates an obvious risk for somebody whose job it is to
 gather information and 
make decisions. It creates an inability to know 
where you have gone
 wrong because you can't 
let yourself self-correct
 by hearing contrary evidence." This is particularly true when the information is viewed as an ego blow, which goes a long way toward explaining Trump's first day in office, his blustering assertions of superiority, the speed with which he turns on former allies, and his selection of a wealthy and inexperienced Cabinet – a so-called narcissistic bubble from which anyone or anything that questions his dominance is ejected.
"When it comes to negative information about themselves, narcissists devalue it and they denigrate it and they don't accept it," says Pincus. "They'll push it away, they'll distort it, they'll blame it on somebody else, they'll lie about it, because they need to see that superior, ideal image of themselves, and they can't tolerate the idea that they have any flaws or imperfections or somebody else might be better than them at something." This not only means that Trump has no qualms about lying (a PolitiFact tally of candidates' statements during the 2016 campaign found that only 2.5 percent of the claims made by Trump were wholly true and that 78 percent were mostly false, false or "pants on fire"), but it also means that he will continue to cater to his minority base, which, Pincus continues, "happen to have his ear and tell him he's great. Then he's shocked when courts and states have a different opinion, and he has to denigrate the courts and the states rather than question his own position." It means that he will continually recast negative events in his favor: "All four corporate bankruptcies, were they a sign of failure for him during the debates?" asks Blair. "No, they were a sign he was smart." And he will continue to double-down on delusions, like having been wiretapped by Obama, despite all evidence to the contrary.
That's what concerns Wilentz. "We've had some very troubled presidents in our past, but their troubles are things like alcoholism, paranoia, you know, sort of garden-variety psychological maladies," he tells me. "This is different. This shows a dissociation from reality. We just haven't seen anything like this before." Gartner's take is even more pointed: "He's acting crazy, and he's mad that other people aren't seeing and believing what he's making up in his own head."
This dissociation from reality, paired with Trump's knee-jerk need to assert his dominance, has led many mental-health professionals to feel that, no matter what the specific diagnosis, the traits themselves are enough to render Trump unfit for office, and that a shrink's "duty to warn" overrides the Goldwater Rule in this instance. "Psychiatrically, this is the worst-case scenario," says Gartner. "If Trump were one step sicker, no one would listen to him. If he were wearing a tinfoil hat, if he were that grotesquely ill, he wouldn't be a threat. But instead, he's the most severe and toxic form of mental illness that can actually still function. I mean, in his first week in office, he threatened to invade Mexico, Iran and Chicago. And thank God someone finally stood up to Australia, you know? Glad someone had the balls to put them in their place."
Indeed, it was Gartner's fear that "Trump is truly someone who can start a war over Twitter" that led him to start a petition on January 26th that called on mental-health professionals to "Declare Trump Is Mentally Ill and Must Be Removed," invoking Section 4 of the 25th Amendment to the Constitution, which states that the president should be replaced if he is "unable to discharge the powers and duties of his office." Gartner's petition currently has 40,947 signatures. Congresswoman Karen Bass' petition, #DiagnoseTrump, has 36,743.
Not that any of these petitions are likely to make a difference. In order for Section 4 to be invoked, Congress or the vice president along with a majority of Trump's handpicked Cabinet would have to call for his removal, which has never happened under any presidency. And even if Trump did something that warranted impeachment, 25 Republicans in the House would have to break ranks to pass the resolution on to the Senate, where two-thirds of that body would have to condemn him, meaning that no fewer than 19 Senate Republicans would need to vote in favor of an ouster. Many of those Republicans come from districts where #MAGA is practically gospel, meaning that these numbers are not just daunting, they're all but unthinkable.
On June 29th, 1999, Trump gave a eulogy at his father's funeral at Marble Collegiate Church in Manhattan. Others spoke of their memories of Fred Trump and his legacy as a man who had built solid, middle-class homes for thousands of New Yorkers. But his middle son, according to most accounts, used the time to talk about his own accomplishments and to make it clear that, in his mind, his father's best achievement was producing him, Donald.
Presidents unite nations under narratives of what they stand for, whether true or false. But a president with NPD would stand for nothing but himself, offering no narrative other than the "false self" he created. An NPD president would expect Americans to go along with his rhetoric and ignore that behind the self-aggrandizing, the unyielding drive for more and more confirmation of the myth of his own greatness, he may only have his own emptiness to offer. "'We're going to do this thing, it's going to be fantastic, amazing,'" Pincus paraphrases. "But there's no substance to what he says. How are you going to do that? How is that going to be achieved?"
The answer is we don't know. The White House leaks portray an angry man who wanted to become president, but never really wanted to be president. Trump may have stormed into the Oval Office poised to make sweeping changes, but unlike LBJ or Jackson or even Nixon, he doesn't have the political expertise or historical perspective to see the long game. The rumblings in Congress suggest widespread fears that Trump will view policy through the prism of pathology rather than in any rational, methodological, bipartisan way. So far, as Barney Frank points out, even with a Republican House and Senate, "Trump hasn't done very much." His immigration bans have been blocked, his budget has been ridiculed, and his rage against the GOP to repeal and replace Obamacare, or else (and with a plan that would take health care away from millions of Americans while making it more expensive for most of the rest of us), turned into nothing more than a game of chicken – which he lost – with House Republicans. "Trump's time horizon with regard to things that affect him appears to be about 13 minutes," Frank says. "There is an inverse relationship between people who are more focused on how things affect them personally than on public policy and their effectiveness in Congress. You can't work with those people."
If Trump does have NPD, and the setbacks to his agenda keep coming, his magical thinking about the limitlessness of his power will only continue to clash with reality, and many in the mental-health field believe that would only exacerbate the problem. "I think we're actually looking at a deteriorating situation," says Gartner. "I think he's going more crazy." As Dodes' letter to The New York Times states, Trump's attacks against "facts and those who convey them … are likely to increase, as his personal myth of greatness appears to be confirmed." Still, no matter how monumentally he fails in the next four years, says biographer Gwenda Blair, "there's no doubt he's going to think he's done a great job. That isn't even open to question." 



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