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    STAT

    Analyzing the president, from afar

    Carolyn Kaster/Associated Press

    There it was again: This past week, even as he unveiled policies affecting momentous issues from oil pipelines to immigration, President Trump seemed fixated on. . . less portentous topics.

    He tweeted that “daughter Ivanka has been treated so unfairly” after Nordstrom declined to order more from her clothing and accessories line. He slammed a “so-called judge” for blocking the 90-day travel ban on people from seven Muslim-majority countries. Then he claimed that thousands of Massachusetts residents voted illegally in New Hampshire.

    And this was after Trump claimed 3 million illegal voters cost him the popular vote, and insisted his inauguration crowd was “the biggest ever. . . . This crowd was massive.”

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    In early January, Trump had told “60 Minutes” that after he was sworn in he would be “very restrained” on Twitter, “if I use it at all.” That has not happened. Is it deliberate? Or does his behavior reflect a personality trait such as narcissism, some kind of obsession that is driving compulsive behavior, or both?

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    STAT, a national online health and medicine publication owned by Boston Globe Media, interviewed 10 psychiatrists and psychologists — some supporters of Trump, some not — about the president’s behavior and what it might say about his personality and mental health. All are respected in their field and close observers of Trump. They based their views on his books, public statements, appearances, and tweets, but emphasized that they have no firsthand knowledge of Trump.

    As a result, they can’t rule out that the president’s actions are part of an intentional political strategy, and not a reflection of particular mental states. After all, his confrontational style and egotism — adorning buildings around the globe with his name — served him well in business and brought him to the White House.

    Still, the analyses were strikingly consistent. Several of the experts, for instance, advanced the view that, as New York University psychologist John Montgomery put it, Trump shows “compulsive ‘more-than’ behavior,” meaning a desperate need to keep from feeling, even fleetingly, that he might not be superior to everyone else.

    “I think it completely fits with him making up the millions-of-illegal-votes idea. . . and not being able to accept the clear data about Obama’s [first] inauguration having a far bigger crowd,” said Montgomery, who voted for Hillary Clinton.

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    A sharply contrary perspective was offered by Dr. Robert Pyles, a Massachusetts psychiatrist and Trump supporter, who said the president’s behavior is within the normal range: “My liberal colleagues feel frightened and betrayed, so they go to this hysterical extreme of saying Trump has narcissistic tendencies, but what political leader doesn’t?”

    But without exception, the mental health professionals said that would-be diagnosticians, including pundits and political foes, are misguided in asserting that Trump has a mental disorder — for one fundamental reason. According to decades-old criteria established by the American Psychiatric Association, a diagnosis of mental illness requires that someone’s behavior, emotions, or beliefs have two key attributes: They cause the individual to suffer distress and, most important, impairment.

    “Trump doesn’t meet DSM criteria” for any mental disorder, said Dr. Allen Frances, a professor emeritus of psychiatry at Duke University who oversaw the creation of a previous edition of the APA’s Diagnostic and Statistical Manual of Mental Disorders, considered the bible of psychiatry. “I wrote the criteria and should know how they are meant to be applied: Personality disorder requires the presence of clinically significant distress and/or impairment. The armchair, amateur diagnosticians seem either to be unaware of this requirement, or carelessly choose to ignore it.”

    The APA’s “Goldwater Rule” prohibits psychiatrists from making public comments on the mental health of anyone they have not treated, but some psychiatrists believe that the rule restricts their right of free speech and argue that it is acceptable to discuss a public figure’s behavior with the appropriate caveats.

    The threat of ‘less than’

    Although Trump does not meet psychiatry’s basic criteria for a diagnosable disorder, many of the experts said his public behavior offers a window into his emotional makeup and what drives him — the realm of psychology rather than psychiatry.

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    The experts see three key psychological traits: Trump’s apparent anger and his resulting confrontational behavior (and the related delight he seems to take in attacking those who challenge or criticize him), his evident narcissism, and his seemingly compulsive need to tweet. According to Ben Michaelis, a psychologist in private practice in New York City and not a Trump supporter, Trump “has an intense focus on his popularity, and the idea that somehow someone would be greater than him bothers him. It doesn’t take a mental health professional to figure that out.”

    ABC’s David Muir asked Trump about spending much of his Jan. 21 speech at the CIA’s memorial wall talking about the “crowd size at the inauguration, about the size of your rallies, about covers on Time magazine,” and wondered, “When does all of that matter just a little less. . . now that you’re the president?”

    Trump didn’t answer directly. Instead, he described the speech as “a home run” that received “the biggest standing ovation since Peyton Manning had won the Super Bowl.” That, too, fits the idea that Trump cannot abide feeling “less than,” in Montgomery’s words. Many critics took issue with the CIA speech, he noted, “so Trump makes up a completely absurd and counter-factual story about how great it was, another ‘more than’ compensation for feelings of ‘less than.’ ”

    Psychiatrists who voted for Trump have also wondered about his behavior. “I see personality traits there that, if he came to me [for therapy], I wouldn’t be shocked,” said Dr. Janis Chester, a psychiatrist in Delaware. “But he couldn’t be what people say and have kids who are so wholesome and so connected to him even after his divorces from their mothers.”

    “Anger seems to be a very prevalent emotion for Trump,” said psychologist Dan McAdams of Northwestern University, who is not a Trump supporter. Although psychology generally considers anger a negative emotion and one that is unpleasant to feel, “for Trump it is also positive,” he said, “because it gives him a sense of righteousness.”

    Inflated self-regard

    Accounts of Trump’s childhood describe how he “wanted to be No. 1” and had a deep “need to excel.” Although that describes countless people who go on to stellar achievements in business, politics, sports, or other fields, McAdams and others see something more extreme in Trump.

    Every psychiatrist and psychologist who spoke to STAT mentioned what they perceive to be Trump’s inflated self-importance and self-regard, and his need for the attention and adulation of others, and to feel dominant and superior.

    There are two common views of where that narcissism may come from, McAdams said. Some psychologists trace it to not receiving enough attention as a child. “In this view, the child’s need to be the center of attention and the apple of someone’s eye wasn’t gratified,” McAdams said. “So they’re desperately trying to get that experience as an adult.”

    A competing view, with stronger scientific evidence, is that a child who “gets reinforced like crazy for being the center of attention” becomes emotionally addicted to that adulation, McAdams said. Trump’s father, Fred, told Donald, according to biographies, “You’re my favorite, you’re a killer,” McAdams noted. “Rather than satisfying and soothing” one’s emotional and psychological need to be the focus of attention and valued, he said, “that pours gasoline on the fire,” stoking the need to “seek glorification over and over because they can’t get enough.”

    Hence the chest-thumping tone of Trump’s postelection victory rallies and the apparent need to keep himself the center of attention through provocative tweets. “It’s affirmation that he needs,” said McAdams.

    But when narcissists do not receive the admiration, attention, love, and adulation they need, when they begin to feel that their greatness is not being recognized and paid obeisance, they typically feel either rage or an intolerable, jump-out-of-their-skin anxiety.

    “The obvious thing with Trump is that he can’t tolerate psychological pain,” said psychologist Gary Greenberg, a therapist in Connecticut, author of the 2013 expose “The Book of Woe: The DSM and the Unmaking of Psychiatry,” and not a Trump supporter. “He has to immediately eject the pain; he can’t sit with it.” That is typical of a compulsion, he added, in which “you have to act on what you feel. You wake up at 3 a.m. and you have to say something.”

    Enter Twitter.

    A compulsive behavior is not necessarily evidence of a disorder. Whether it’s checking one’s phone constantly, playing video games, shopping, or any other behavior that can be taken to extremes, “it’s a mental disorder only if it doesn’t provide a pleasurable reward or benefit” and if it does cause that requisite duo of distress and impairment, Duke’s Frances said.

    But although Trump’s — and other prolific tweeters’ — embrace of 140-character communication is not compulsive in the clinical sense, it probably reflects a milder compulsion. A compulsion is an action that “is forced on a person” because it is the only way they can relieve unbearable anxiety, said Frances, who has been critical of Trump’s policies and actions.

    In this understanding, the anxious person seizes on whatever behavior can defuse the anxiety. Many people, but especially narcissists, feel anxious about being dissed or insulted or verbally attacked in public; most can only wish they had a platform to strike back. Trump does. At his first postelection press conference last month, Trump assailed what he called “fake news” stories about him and said that although many people are victimized by such stories, “I have this great megaphone, I can fight back.” And he has, such as when he tweeted about Meryl Streep after her anti-Trump speech at the Golden Globe Awards.

    Experts doubt that Trump will change: At age 70, he is probably set in his ways, and his patterns of behavior have brought him huge success. That’s a key reason why “people trying to diagnose Trump as having a mental disorder are wrong,” said Frances. From Trump’s late-night, angry tweets to his denying that he did or said something caught on video, “he apparently gets pleasure, not distress, from these things, and they made him president,” Frances said. The tweeting, in particular, “makes perfect sense, and he’s rewarded for it,” with attention and, from his fans, cheers.

    Frances warned, however, that this is a potential pitfall of psychoanalysis from afar: No outsider can know whether Trump, alone with his thoughts and emotions at 3 a.m., is feeling significant enough distress to place him that much closer to meeting the criteria for a mental disorder.

    What an outsider can tell, though, is that far from impairing him, these behaviors vaulted Trump into the highest office in the land. That criterion alone rules out mental illness. “He’s crazy like a fox,” said Frances.