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December 19, 2017

Dec. 18, 2017 to

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Sunday, Dec. 31, 2017
The hotest NON-CLINICAL PSYCHIATRIC story of the year

The hottest non-clinical story in psychiatry by far was the Trump Goldwater rule controversy. This pitted the American Psychiatric Association leaders against some of their own preeminent members, the American Psychoanalytic Association, and hundreds if not thousands of other mental health professionals including Robert Jay Lifton and Phillip Zimbardo who believed they had an ethical responsibility to warn that Trump suffered from a constellation of immutable personality characteristics which made him unfit, even dangerous, to be president. 

There certainly were other stories, here’s the list from the email newsletter Psychiatric Times - I include it here having read numerous comments on articles which dismiss, even disparage, psychiatry as a pseudoscience and worse. One of the authors cited below is Ronald Pies who wrote Inside the minds of Trump’s ‘true believers’


Tardive Dyskinesia: Finally Some Good News, by Allan Tasman, MD — We’ve been waiting since 1953, the year chlorpromazine was introduced to the US as a revolutionary treatment for schizophrenia, for an active treatment for tardive dyskinesia (TD) that the FDA judged to be effective. This year, the FDA approved valbenazine as the first-line treatment specifically indicated for TD. Dr. Tasman reminds us that of course, it isn’t cheap; much like many recent breakthrough medications, it has an annual cost likely to be in the tens of thousands of dollars. — Hearing Voices and Psychiatry’s (Real) Medical Model, by Ronald W. Pies, MD — Critics misconstrue the nature of the medical model used in clinical psychiatry—and often overlook the seminal contributions psychiatrists have made to the psychological understanding of “hearing voices.” What is “the real medical model” in psychiatry? — Warning: Antidepressants May Cause Messaging Manslaughter, by James L. Knoll IV, MD and George David Annas, MD — Neither time nor science has given pause to the trend of condemning widely used and beneficial medications—antidepressants. This legal strategy continues. Attorneys use “experts” to testify that these medications can produce all manner of illegal behaviors—from murderous rage to callous lack of empathy to manipulative criminal behaviors. Here, the authors give a brief update on the research in this area, along with an illustrative criminal case that received international media attention—the case of Commonwealth v Michelle Carter—more popularly known as the “texting suicide case.” — What Do Climate Change and Physician Burnout Have in Common?, H. Steven Moffic, MD — Although we are experts in addressing trauma of all kinds, the psychological toll of climate-related events will require a different paradigm for approaches to disaster psychiatry. In terms of ethical priorities, taking care of ourselves is secondary to taking care of patients, even though our own well-being correlates with quality of care. American psychiatry is on the cusp of recognizing and tackling both physician burnout and climate change. — ECT: History of a Psychiatric Controversy, by Greg Eghigian, PhD — History of Psychiatry Editor Greg Eghigian interviewed Jonathan Sadowsky, PhD, author of Electroconvulsive Therapy in America: The Anatomy of a Medical Controversy. ECT has had—and continues to have—both its champions and detractors. And historians who have written on the subject have largely fallen into the same pattern, seeing it either as a technology of social control or as an instance of unmitigated progress. How did Dr. Sadowsky’s your book differ from these? — Not Enough Seating? Time for a Beating!!, by Harvey Roy Greenberg, MD ---Overbooking airline seats and bumping travelers from a flight is legal. So is compelling a passenger to surrender a seat when an insufficient number accept compensation for leaving. The practice backfired when Dr. David Dao refused to give up his seat on United Express Flight 3411 out of Chicago bound for Lexington in April. Dao maintained he needed to get home to take care of his patients. After attendants couldn’t persuade him to deplane, Chicago Airport Security was summoned. And the rest is history. — Clinical Conundrum: Approaching Bipolar Diagnosis Four Ways, by James Phelps, MD— In an informal reader survey, respondents who identified as practicing psychiatrists and psychiatric nurse practitioners are using 4 different diagnostic approaches to bipolar disorder. When given descriptions of how to look for bipolar disorders in new patients, no single approach was the clear winner. Can you imagine surgeons using 4 different approaches to the diagnosis of appendicitis? — Clozapine, Mortality, and Self-Harm in Treatment-Resistant Schizophrenia, by Brian Miller, MD, PhD, MPH — Clozapine is the “gold-standard” antipsychotic for patients with treatment-resistant schizophrenia. However, it remains underutilized for several reasons, including concerns about potential adverse effects and the need for serial blood monitoring. — New Diagnostic Codes for Substance Use Disorders and Avoidant/Restrictive Food Intake Disorder, by Michael First, MD — Several updates to ICD-10-CM affect the diagnostic codes used by mental health practitioners. One important update involves the codes for substance use disorders. — Assisted Outpatient Treatment Enters the Mainstream, by E. Fuller Torrey, MD — Dr. Torrey reviews common misconceptions about assisted outpatient treatment--and how this tool can help selected mentally ill patients who are most difficult to treat.— Can Diet Treat Depression?, by Chris Aiken, MD — Although supported by basic science, it’s still a sea change to think that diet can treat depression. A new clinical trial puts that idea to the test.

From the lead New York Times story:
TRUMP’S WAY
From TRUMP, A YEAR

OF REINVENTING
THE PRESIDENCY

In ways that were once unimaginable, President
Trump has discarded the conventions and
norms established by his predecessors. Will
that change the institution permanently?
….. dispensing with the carefully modulated messaging of past chief executives in favor of no-holds-barred, crystal-breaking, us-against-them, damn-the-consequences blasts borne out of gut and grievance.

...He has appealed to base instincts on racereligion and gender as no president has in generations. And he has rattled the nuclear saber more bombastically than it has been since the days of Hiroshima and Nagasaki.
In case you missed it.

… Mr. Trump to construct and promote his own narrative, one with crackling verve but riddled with inaccuracies, distortions and outright lies, according to fact checkers. 

…. “Trump is arguing that we need to take care of my enemies. I really can’t think of any precedent.”

…. He is testing the proposition that a president can still effectively remake the country without securing or even seeking a broader mandate.

… But he has bristled at the restraints imposed on the presidency as few have, lashing out at judges, lawmakers, investigators and journalists who anger him and expressing frustration that he is not supposed to use the F.B.I. as he sees fit. 

…. Presidents are human, too, a blend of varying degrees of idealism, generosity, empathy, ambition, ego, vanity, jealousy and anger, but they generally hide their unvarnished traits behind an official veneer. Call it decorum, call it presidential. Mr. Trump essentially calls it fake, making no effort to pretend to be above it all, except to boast that he is stronger, richer, smarter and more successful than anyone else. To him, the presidency is about winning, not governing.

… Mr. Trump repeatedly jumps the guardrails that his predecessors heeded. 

… He called various targets of his ire “crazy,” “psycho,” “short and fat,” “crooked,” “totally inept,” “a joke,” “dumb as a rock,” “disgusting,” “puppet,” “weak and out of control,” “sleazy,” “wacky,” “totally unhinged,” “incompetent,” “lightweight” and “the dumbest man on television.” Among others.

…. Mr. Trump’s decisions, announced over Twitter, often seem like spur-of-the-moment reactions to something he has seen on television.

…. Over 72 hours, Mr. Trump had nonetheless demonstrated that he had brought his personal mottos, “always get even” and “hit back harder than you were hit,” to the White House.

…. “This is a man, Trump, who has no compunctions about attacking people in ways that diminish the office of the president.”

…. “Trump is at war, but I don’t think he’s thought through the war,” he said. “This is not healthy when a president bashes certain institutions or questions the motivations of certain people, though some probably deserve it. Nor is it healthy when the media and the elite question the president’s very character.”

… “The good news is he’s been so incompetent and he’s got such a short attention span.//


Saturday, Dec. 30, 2017
This would be a balanced article had it not concluded with quotes
 from a psychiatrist using the examples of doctors who
gave cover to  Nazi eugenics policies and those who helped
 confine dissidents in China (he left out Russia). The opposing
 view is omitted, which is that psychiatrists should have
 been expressing outrage at the psychopathic Hitler. 
Excerpts: The president of the United States is not well. That is an uncomfortable thing to say, but it is an even worse thing to ignore. 
Consider the interview Trump gave to the New York Times on Thursday. It begins with a string of falsehoods that make it difficult to tell whether the leader of the free world is lying or delusional.
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It would be comforting, on some level, to believe that Trump is simply lying, that he is trying to convince us of what he knows to be untrue. It is scarier to believe that Trump is delusional, that he has persuaded himself that Democrats have said things they’ve never said, that his base has strengthened when it has actually weakened, that it’s really his opponents under investigation for collusion, that his campaign has been cleared of wrongdoing when the circumstantial case for collusion has only grown stronger.
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Over the course of reporting on the Trump White House, I have spoken to people who brief Trump and people who have been briefed by him. I’ve talked to policy experts who have sat in the Oval Office explaining their ideas to the president and to members of Congress who have listened to the president sell his ideas to them. I’ve talked to both Democrats and Republicans who have occupied these roles. In all cases, their judgment of Trump is identical: He is not just notably uninformed but also notably difficult to inform — his attention span is thin, he hears what he wants to hear, he wanders off topic, he has trouble following complex arguments. Trump has trouble following his briefings or even correctly repeating what he has heard.
↓↓↓↓↓↓↓
Imagine how we would react to literally any other president speaking like this. Trump has bludgeoned us into becoming accustomed to these kinds of comments but that, too, is worrying. 
This is the president of the United States speaking to the New York Times. His comments are, by turns, incoherent, incorrect, conspiratorial, delusional, self-aggrandizing, and underinformed. This is not a partisan judgment — indeed, the interview is rarely coherent or specific enough to classify the points Trump makes on a recognizable left-right spectrum. As has been true since he entered American politics, Trump is interested in Trump — over the course of the interview, he mentions his Electoral College strategy seven times, in each case using it to underscore his political savvy and to suggest that he could easily have won the popular vote if he had tried.

I am not a medical professional, and I will not pretend to know what is truly happening here. It’s become a common conversation topic in Washington to muse on whether the president is suffering from some form of cognitive decline or psychological malady. I don’t think those hypotheses are necessary or meaningful. Whatever the cause, it is plainly obvious from Trump’s words that this is not a man fit to be president, that he is not well or capable in some fundamental way. That is an uncomfortable thing to say, and so many prefer not to say it, but Trump does not occupy a job where such deficiencies can be safely ignored.
Trump’s Sea of Love:



Friday, Dec. 29, 2017
Main Stories - fallout from the NY Times interview:


Excerpt: …. you have to read the whole interview to really get it. This simply is not a man in full control of his mental faculties. He’s always been narcissistic and blowhardish, but over the course of the interview he’s completely unable to stay focused on a topic for even a few seconds. He veers off into his Electoral College win constantly. He stops to insist there’s no Russian collusion at least a dozen times. He displays no knowledge of anything. It’s like talking to a third-grader.


Excerpts:
THE PRESIDENT* EXHIBITS THE KIND OF STUBBORNNESS YOU SEE IN PATIENTS WHEN YOU TRY TO RELIEVE THEM OF THEIR CAR KEYS.
In this interview, the president* is only intermittently coherent. He talks in semi-sentences and is always groping for something that sounds familiar, even if it makes no sense whatsoever and even if it blatantly contradicts something he said two minutes earlier. To my ears, anyway, this is more than the president*’s well-known allergy to the truth. This is a classic coping mechanism employed when language skills are coming apart. (My father used to give a thumbs up when someone asked him a question. That was one of the strategies he used to make sense of a world that was becoming quite foreign to him.) My guess? That’s part of the reason why it’s always “the failing New York Times,” and his 2016 opponent is “Crooked Hillary." 
In addition, the president* exhibits the kind of stubbornness you see in patients when you try to relieve them of their car keys–or, as one social worker in rural North Carolina told me, their shotguns. For example, a discussion on health-care goes completely off the rails when the president* suddenly recalls that there is a widely held opinion that he knows very little about the issues confronting the nation. So we get this.
↓↓↓↓↓↓↓

So, no, I don’t particularly care whether (NYT interviewer) Michael Schmidt was tough enough, or asked enough follow-up questions. I care about this.
I’m always moving. I’m moving in both directions. We have to get rid of chainlike immigration, we have to get rid of the chain. The chain is the last guy that killed. … [Talking with guests.] … The last guy that killed the eight people. … [Inaudible.] … So badly wounded people. … Twenty-two people came in through chain migration. Chain migration and the lottery system. They have a lottery in these countries. They take the worst people in the country, they put ‘em into the lottery, then they have a handful of bad, worse ones, and they put them out. ‘Oh, these are the people the United States. …” … We’re gonna get rid of the lottery, and by the way, the Democrats agree with me on that. On chain migration, they pretty much agree with me. 
We’ve got bigger problems.



Excerpt: (emphasis added)


In a panel discussion about the interview, that took place on the Mar-a-Lago golf course, Johnston and reporter John Harwood marveled at the multiple references to “me,” “my” and “I” from the president. 

“I think this interview is profoundly disturbing,” Harwood said. “If you read it and think about it. The way the president speaks in such grandiose terms about himself suggests a level of delusion. ‘I saved coal.’ ‘I was treated better than anyone in the history of China.’ ‘I did things that Ronald Reagan couldn’t do.’ ‘The news media has to keep me president because the entire media system would fall apart without me.’ This suggests a level of mental functioning which is not particularly acute and when he starts talking about the Russia investigation and he says 16 times ‘there’s been no collusion, absolutely no collusion, everyone agrees there’s no collusion.’ And some point you’re just kind of babbling and this is the president of the United States and it cannot be reassuring to even people who support his policies to hear him speak in this way.”

Harwood noted that Trump doesn’t seem to be aware of what he’s giving away in interviews liked. 


“Anyone who speaks about himself in the kind of terms that he does, ‘absolute right to control the Justice Department, ‘I know more than the greatest CPA.’ These are statements that are obviously cartoonishly ridiculous. And the fact that the president would feel free to say them to The New York Times suggests that he is not perceiving his own best interests or the interests of the white house.”

Wait, there’s more. No wonder Trump hates CNN:

On CNN’s New Day, host Alysin Camerota and Bill Weir were unable to contain their laughter at a portion of New York Time interview with Donald Trump, where the president insisted he knew more about taxes and the GOP’s healthcare plan than anyone.


Thursday evening, the Times published an interview conducted with Trump after a reporter found him unattended at his Trump International Golf Club, leading to a rambling, and at times bizarre, 30-minute interview.
Among the topics covered were taxes and healthcare, with the president claiming, “I know the details of taxes better than anybody. Better than the greatest C.P.A. I know the details of health care better than most, better than most.”
Reading from the transcript, host Weir laughingly made his way through Trump’s verbatim comments, where he bumbled his way through, “And if I didn’t, I couldn’t have talked all of these people into doing ultimately only to be rejected.”
“This is not you messing up this read,” co-host Camerota added.”It is the grammar where it gets a little tricky.”
“A bit of an off-ramp I wasn’t seeing. A man with good grasp of the English language,” Weir snarked as Camerota continued to laugh.  From Raw Story
Snippets -- links to other articles 

Donald Trump Is Forging An America As Greedy, Deceitful And Cruel As Its President







I was struck by two of the photos of Trump in this NY Times article. 
Click image to read article - NY Times subscription may be necessary
In this one he seems more interested in scowling at the photographers than anything else.
Click image to enlarge
Here he looks like he’d rather be anywhere else than among world leaders who don’t recognize his greatness.
Click image to enlarge
From a month ago:

Donald Trump and the Success of the Narcissistic Sociopath

Psychological studies and evolutionary biology show that an overconfidence and brash leadership style is both dangerous—and can work.

I have a small army of about 5,000 contributors to a Duty to Warn Facebook group about Trump locating articles I miss with my own Google search and my own perusal of the Internet every morning. Sometimes it takes adding a new word to Trump in a Google search to discover more material about Trump’s personality. For example here’s what comes up when you search Trump and erratic:
Click above to search



Thursday, Dec. 28, 2017


Link above
Excerpt:


Ralph Northam, a pediatric neurologist who was recently elected governor of Virginia, distinguished himself during the gubernatorial race by calling President Donald Trump a “narcissistic maniac.” Northam drew criticism for using medical diagnostic terminology to denounce a political figure, though he defended the terminology as “medically correct.”1 The term isn’t medically correct — “maniac” has not been a medical term for well over a century — but Northam’s use of it in either medical or political contexts would not be considered unethical by his professional peers.
For psychiatrists, however, the situation is different, which is why many psychiatrists and other mental health professionals have refrained from speculating about Trump’s mental health. But in October, psychiatrist Bandy Lee published a collection of essays written largely by mental health professionals who believe that their training and expertise compel them to warn the public of the dangers they see in Trump’s psychology. The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President rejects the position of the American Psychiatric Association (APA) that psychiatrists should never offer diagnostic opinions about persons they have not personally examined.2 Past APA president Jeffrey Lieberman has written in Psychiatric Newsthat the book is “not a serious, scholarly, civic-minded work, but simply tawdry, indulgent, fatuous tabloid psychiatry.” I believe it shouldn’t be dismissed so quickly.  CONTINUED
From the Trenches: Letters to Local Papers:


Dec. 27 -- To the Editor:
During the year of 1968 when I slogged through the swamps of South Vietnam with my M-16 I woke up every morning with a sick feeling of dread in the pit of my stomach, knowing that something terrible could happen at any moment. I wake up every day now with a similar feeling of dread, caused not by Viet Cong soldiers with weapons but with a mentally ill president with his hands on the triggers of much larger weapons. Continued — Seacoast OnLine New Hampshire 
Reprise:

Lies, Self-Deception, and Malignant Narcissism by Stephen Diamond, PhD, in Psychology Today (Oct. 17, 2017)

Excerpts:

Narcissistic personality disorder—which, in my view, exists on a spectrum the more severe pole of which is sociopathy or what I have previously termed psychopathic narcissism—is one of the more popular and predominant diagnoses attributed to Donald Trump by mental health professionals in the book, here at PT, and by others who have observed his behavior both before and during his presidency.  Assuming Mr. Trump, who had sufficient support and popularity to win the presidency, meets full diagnostic criteria for this personality disorder—which, in the absence of a thorough face-to-face evaluation by a seasoned diagnostician is somewhat speculative—this begs the questions: What makes the narcissistic personality so irresistibly attractive to certain people? What renders some individuals especially susceptible to the narcissist's considerable charms? And why do those who fall under the narcissist's spell support whatever he or she says or does without question?

Pathological or malignant narcissism is something that manifests by a matter of degree, ranging from the relatively harmless narcissism of self-absorption and self-aggrandization to the extreme toxic narcissism of the predatory psychopathic narcissist. Narcissists, who not unlike psychopaths or sociopaths, know how to effectively manipulate people through flattery, lying, conning, and deception, can be legendarily charming, making them highly attractive to adoring others. Narcissists desperately need such adulation from others, and go to great lengths to incessantly seek such "narcissistic supplies." And those that actively adore them, fulfilling and feeding the narcissist's insatiable appetite for attention and adulation, need the narcissist as much as the narcissist needs them. It is a symbiotic relationship. So who are they? 
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In truth, we all deceive ourselves about a great many matters, from bad behavior, to how we feel, to the ever-present existential fact of death. Such self-deception is fundamentally related to Freud's broad conception of the unconscious--the unknown aspects of our psyche—and specifically to Jung's notion of the shadow: those unacceptable traits and tendencies in ourselves we hide from both others and ourselves. This very capacity to deny our own selfishness, fears, cruelty, and complicity in evil—unconsciousness—is itself a treacherous sort of self-deception. Which is why growing gradually more conscious during the course of psychotherapycan be a shocking, painful and sobering process. Jung noted the therapeutic importance of consciously tolerating the "tension of opposites" we today term "cognitive dissonance," and that such unadulterated confrontation with the truth about oneself is almost always initially experienced as an insult to or defeat of the ego—a devastating blow to our narcissism. No wonder we so fervently resist this process. It takes considerable courage and commitment to be brutally honest with oneself. But it is precisely this willingness to stop our chronic self-deception and face the truth that finally sets us free.

Weds., Dec. 27, 2017
Trump’s 60 Worst Tweets For Diagnostic purposes only

Narcissism Runs: Wild Dept.
Trump rams greatness down our throats  Washington Post (More about the Ego Coin)
In this holiday season, a familiar question arises: Is President Trump trying to undermine democracy, or is he just irredeemably vain?
It’s a toss of the coin — specifically, Trump’s commemorative “Challenge Coin,” which just had its public debut.
Typically, these coins are simple copper-and-silver designs with the presidential seal and signature. But Trump’s is thicker, bright gold and with a built-in stand. Beyond the garish presentation, it defaces the presidential seal: The eagle looks right instead of left, it no longer holds the 13 arrows representing the original states, and the national motto — “E pluribus unum,” which translates to “ Out of many, one” — is gone. Instead, both sides of the coin display Trump’s campaign motto, “Make America Great Again,” and his name appears four times.
Dana Milbank begins with biting satire in this, but then ends with this:

In a Christmas video, Trump briefly captured the meaning of the day when he spoke of renewing “the bonds of love and goodwill between our citizens.” But even in this message, he managed to find division. He highlighted the belief that the Old Testament prophet Isaiah prophesied that Jesus would be the Messiah. Jews dispute that interpretation. 

The holiday wasn’t yet over when Trump tweeted that “tomorrow it’s back to work in order to Make America Great Again (which is happening faster than anyone anticipated)!” The next morning, he resumed attacks on Obamacare and a “Crooked Hillary pile of garbage.”

Contrast that with another head of state’s Christmas message. Britain’s Queen Elizabeth II spoke of the resilience of London and Manchester after terrorist attacks, mentioned the victims of Caribbean hurricanes, hailed charities and volunteers, and delivered a unifying Christmas theme about the baby Jesus, “whose only sanctuary was a stable in Bethlehem. He knew rejection, hardship and persecution, and yet it is Jesus Christ’s generous love and example which has inspired me through good times and bad.” 


I write this on Boxing Day, a holiday for many of the Commonwealth nations of the former British empire, with a twinge of envy. I don’t wish that the queen would take us back. But I regret that our head of state, with his jingoistic talk of greatness, squanders American goodness.

Today’s Quotes

That is not how a great nation speaks and acts; it is how a rich, callous nation that has philosophically regressed to the mid-20th Century speaks and acts.
It reflects the attitude of a would-be autocrat whose narcissism blinds him to the fact that the world has changed in ways that he is compelled to deny because he cannot be in charge of it.
He lives in his own Potemkin world in which “ … America is in the game and America is going to win,” as he declared last week. The distorted world he imagines is one of zero-sum calculations; of disconnected “wins” and “losses.” 
The real world comprises a process that will go on even if America, deliberately or ignorantly, continues to isolate itself. And that real world has other powerful, wealthy nations whose leaderships understand that foreign aid is in their own interest, not just a handout; that reciprocity is a value.
For the first time in more than century, America has a viable challenger to its world leadership. China awaits as Trump fumbles it away. Wichita Eagle
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Democrats, aiming for major gains in Congress in 2018 have Trump’s egocentric, disastrous decision making to thank for making their jobs slightly easier. Unable to admit when he screwed up, Trump instead is blaming Sessions.
Based on those instincts and his narcissism, Trump is setting himself up to blame a lot of people for other losses to come. ShareBlue
The Narcissistic Apples Don’t Fall Fall From The Tree Dept:

'Little entitled brats': Tiffany and Ivanka Trump blow kisses in bikinis but Twitter can't help cringing

Signs of diminished brain function: 

Desus and Mero Discuss Donald Trump's Strange Relationship with Water

Here's what happens when a Diet Coke fanatic switches to tap.



Read more here: http://www.kansas.com/opinion/opn-columns-blogs/article191614299.html#storylink=cpy

It isn’t a satire, click image above.


Duty to Warn founder Dr. John Gartner and Rachel Montgomery wrote about them:

What Donald Trump’s tweets reveal about his mental health


From his obsession with “the haters and losers” to his episodes of mania and delusion, it’s all there on Twitter

 Now his Tweets could get help Trump impeached:


Trump’s Tweets Could Be Witness Intimidation: Analysts

Sr. Fellow Brookings, CNN Commentator & Chair CREW. Former US Amb. Prague & Obama WH Ethics Czar.


While on the subject of Trump’s Tweets, not only does he bask in the imagined glow of his wonderfulness, he also gives vent to his malignant narcissistic bullying:

What happens when Trump targets you on Twitter


Five Americans named by the president on social media talk about the unexpected fallout in their real lives.
Not a link

I try mightily to get his attention with my own Tweets. Alas, to no avail…


 



Tuesday, Dec. 26, 2017
From Business Daily Africa a psychiatrist weighs on on Trump:
The American Psychiatrist Association subsequently declared it unethical to offer an opinion on the mental health of a public figure, one they had not examined.
The American authors decided to break this rule and decided to warn Americans and the world about their president. They considered it their moral and civic duty “to warn” as in their view, their duty to society supersedes their professional neutrality.
Their conclusion is that their subject is a “dangerously complex mad man”. They find that he has “a lack of trust that exceeds paranoia”. His impulsivity is described as “unbridled and extreme present hedonism”.
Many other opinions on Trump and his mental health have been offered by many others, but the man continues to tweet away as President. As long as he has not been examined and found to be mentally ill, then he is presumed to be fit for office.
This now brings us to another, even more complex subject of the meaning and significance of a diagnosis of a mental illness.

Dec. 25, 2017 

This is from a website called Brinkwire. My disagreement is posted in the one and only comment.
  Sunday, Dec. 24, 2017


Wishful thinking with deference to Dickens:


“The hour itself,” said Trump, triumphantly, “and nothing else!” 
He spoke before the hour bell sounded, which it now did with a deep, dull, hollow, melancholy ONE. Light flashed up in the room upon the instant, and the curtains of his bed were drawn. 
The curtains of his bed were drawn aside, I tell you, by a hand. Not the curtains at his feet, nor the curtains at his back, but those to which his face was addressed. The curtains of his bed were drawn aside; and Trump, starting up into a half-recumbent attitude, found himself face to face with the unearthly visitor who drew them: as close to it as I am now to you, and I am standing in the spirit at your elbow.

Sat. Dec. 23, 2017


Just Saying:

This is the current Medal of Freedom, click to enlarge. Loose the
stars and put a portrait of Trump? Why not?

Trump’s insatiable need for praise would be cartoonish were it not symptomatic of malignant narcissism. Consider: 

Click image to enlargeChallenge coins clockwise from bottom: President Trump’s, Vice President Mike Pence’s, Vice President Joe Biden’s and President Barack Obama’s. Presidential challenge coins have traditionally been handed out to service members in commemoration of special achievements and milestones.

Trump Gives Presidential Challenge Coin a Makeover, and It Shows (NY Times)  "The Washington Post reported that the coin may soon be handed out to supporters and campaign donors in addition to military service members."

"The banner at the bottom of the coin is designed as a rocking-horse-style base to allow it to be positioned upright. But some might say that, even without that feature, the coin already stands on its own."
Excerpt: 
What’s big and shiny and gold and features Donald J. Trump’s name splashed across the front? No, it’s not a new development on the West Side of Manhattan. It’s the redesigned presidential challenge coin. 
A custom dating back 20 years, presidential challenge coins have traditionally been handed out to service members in commemoration of special achievements and milestones. President Trump’s coin, which many saw on Friday for the first time, is unmistakably different from its predecessors. 
Gone is the national motto, E pluribus unum, meaning “out of many, one.” In its place appears the president’s campaign slogan, “Make America Great Again,” which the administration has also used on official White House documents. 
The traditional presidential seal has been replaced by an eagle looking rightward, with President Trump’s signature beneath it. Instead of holding the customary 13 arrows representing the original states, or an olive branch, the eagle is perched behind a red, white and blue shield, with 13 stars around its wings. 
Many social media users expressed outrage, calling the coin “tacky” and a disgrace.

For the Record:

Why Mental Health Is A Poor Measure Of A President (Note: I post links even when I disagree with the premise conclusions of the article)


Recommended Reading

This is well worth reading as we attempt to understand the continuum of narcissism in famous world leaders from Alexander the Great and Napoleon to Trump. Perhaps in the next DSM it will be called "narcissism spectrum disorder" starting with what is now narcissistic personality disorder listing a cutoff short of full NPD to be considered a psychiatric illness, all the way to full-bore Trumpian malignant narcissism.

Excerpt -

Weaknesses of the Narcissistic Leader

Narcissists are usually not at ease with, or sometimes even aware of, their emotions, indeed they are often described as unemotional. They tend only to listen for the kind of information they are seeking at the moment. They generally don’t learn well from others unless they view that person as an equal superior being. They don’t like to teach per se but they do believe heartily in indoctrination and making speeches. They will try to dominate meetings with subordinates as well as equals. One of the significant weaknesses of a narcissistic leader is that his faults become even more magnified the more successful he becomes.


Sensitive to Criticism. Due to their extreme sensitivity to even the slightest comment that they view as negative, narcissistic leaders tend to shun all emotions. Narcissistic leaders typically keep others at a distance and can become quite emotionally isolated. They can put up a wall of emotional armor as thick as Fort Knox. Given their difficulty with knowing or acknowledging their own feelings, they are most uncomfortable with other people expressing theirs, especially if theirs are negative feelings. Narcissists are ‘thin-skinned and bruise easily’. This is certainly one of the reasons why narcissistic leaders prefer not to know what people think of them. They genuinely do not care what others think unless it has become a problem for them. Furthermore, they cannot tolerate dissent especially among those closest in command next to them. Although narcissistic leaders (not dictators) might say that they want teamwork, what they really want is a group of people who agree with them.

Friday, Dec. 22, 2017

Another major article from U.S. News and World Report, which was the first major magazine to publish a story (called “Temperament Tantrum” by senior writer Susan Milligan) about Trump’s fitness for office on Jan. 27, 2017:

We're Having the Wrong Debate on Trump's Mental Health (or are we? HB)

By psychiatrists Bandy Lee and James Gilligan
Excerpt: 

The issue of whether Donald Trump is mentally ill has been much debated since the beginning of his campaign. We believe that this debate misses the point. The critical question is not whether the president is mentally ill, but whether he is dangerous. 
This is what we outline in "The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President." One does not have to be "mentally ill," as both law and psychiatry define it, in order to be dangerous. In fact, most mentally ill people do not commit serious violence but are rather more likely to be its victims. Regarding dangerousness, psychiatrists are not only permitted but legally obligated to warn potential victims when they have reason to conclude that someone represents a significant risk of harm to them.

Editors Note:

Those who are closely following the Duty to Warn movement may have noticed that among mental health professionals who have come out publicly saying Trump is not fit to be president there are similar but different ways the case is presented. The particular names associated with each are familiar to those reading my website which has links to just about every article published about the subject. 
What the authors all have in common is more important by far than their different explanations as to why Trump should not be president: he is dangerous, and this dangerousness is evidenced by his own statements and behavior.

You don’t need to be a psychotherapist to understand that the best predictor of future behavior is past behavior. Psychotherapists are similar to historians studying living powerful leaders and trying to anticipate their behavior. Both look for recurring patterns and how an individual learns from the consequences of their decisions. In fact, there is even a specialty crossing both fields which is called psychohistory.

An article was just published in U.S. News and World Report entitled “We’re Having the Wrong Debate on Trump’s Mental Health: The critical question is not whether the president is mentally ill. It's whether he is dangerous.” 

I do not think that authors make a compelling case for issuing a warning about his being dangerous. This is because without a diagnosis it I think it presents weak evidence that he may act out on his inflammatory oral rhetoric and in his often impulsive Tweets. In fact, aside from his bragging, we only have he said-she said evidence of actual violent behavior against women, his ex-wife and the women he assaulted. 

Based on what they present just as plausibly can be explained as performance, as bluster, and at times as brilliant strategy on the political and the world stage. 

One might say that all the world is a stage and that Trump is the best qualified to lead the United States in playing on that stage. This is what Trump supporters have been saying in one way or another.

If, on the other hand, we diagnose Trump as being a malignant narcissist, we have far more to justify our grave concern that he is dangerous because this is a psychological syndrome comprising an extreme mix not only of narcissism, but also of antisocial personality disorder, aggression, and sadism. Because we can look the situations that could lead him to make a dangerous decision because his psychological defenses no longer serve to protect the fragile ego hidden beneath his grandiose self-identity.

 HB


Under Trump, George Orwell’s Dystopian Nightmare Arrives a Few Decades Later than “1984?”  Blue Virginia

Excerpt:

It doesn’t matter to his supporters that Trump’s idea of “science” or “facts” or “truth” is whatever he happens to be thinking at the moment, that his actual cognition from what we know through his twittering, speeches, and comments rejects empirical data as “not important” because it’s “not his.” Trump’s is the only opinion that has weight, the only view that to Trump is important; all other views to him are insignificant by comparison –even when those other views are based on years of painstaking scientific research and analysis.
This is how a narcissistic personality perceives the world. And this is how Trump perceives the world: simply through his ego asserting itself.  And since, as psychiatrists, philosophers, sages, and holy men through the centuries have related “the ego is only a self-construct — without actual existence, a non-thing of personal fiction, a projection of the mind upon the world, an idea without substance” — it’s easy to see that Trump’s perception of the world lacks any grounding in reality.
Trump’s narcissism is of a particular brand — malignant narcissism. From what we know of the disorder, this implies that Trump’s perception of the world is one of both constant scrutiny for possible antagonists, and also offensive pursuit against those he believes most critical of him (therefore “dangerous”).  The latter must be dealt with by diminishment or removal — belittling them by name calling, denigrating by calling them “insignificant” or “weak” or “little” or “nothings,” or by seeking revenge on them and attacking them with lawsuits, police action, or economic sanctions in order to erase their criticism.

Thurs. Dec. 21, 2017

Here’s one I missed, from Sept. 6th. I try to find all articles referencing Trump’s mental health and make sure they are archived here. This is an interview with psychiatrist Allen Francis who takes credit for writing the diagnostic criteria for narcissistic personality disorder in the DSM-5. 

He’s the psychiatrist who has said unequivocally that Trump does not meet the criteria for NPD because his symptoms are not bothersome to him. I managed to contact him by email to discuss why he won’t accept the diagnosis of malignant narcissism instead, and he said it was a closed subject with him.
His contention is that Trump isn’t mad, he’s bad. What he seems not to be willing to accept is that Trump is both mad and bad. He thinks that "Trump is a mirror on our soul and this is a shock treatment kind of moment where we should be wondering about ourselves."

He is also among a group of mental health professionals who have said that to suggest Trump is mentally ill stigmatizes those who are struggling with psychiatric disorders.
He has recently published a book
Twilight of American Sanity: A Psychiatrist Analyzes the Age of Trump and is definitely not pro-Trump. He says he began to write the book two years ago and never thought Trump would be president.



Misdiagnosing Trump: Doc-to-Doc with Allen Frances, MD



Perry Wilson and Allen Frances discuss the president as a mirror on America's soul




Excerpts: Trump is absolutely a world-class narcissist. He has every criteria met except for two. In addition to having the features of being grandiose, unempathic, self-involved, selfish, all the things that go into being Trump, you have to have distress or impairment, significant distress or impairment.
Trump is a man who causes immense distress in others, but doesn't seem to experience it very much himself. Although he's created tremendous impairment for our country and for his business colleagues, he, himself, has been very well rewarded in politics and also in business for being a narcissist. I think that it's reckless for people to attribute the damage he's causing to mental illness. He's much more bad than mad.
↓↓↓↓↓↓↓↓
To lump Trump with the mentally ill is a tremendous insult to them. It stigmatizes them. Most people who are mentally ill are well meaning and well behaved, and really fine people. Trump is none of those. So that when we confuse mental illness with bad behavior, we, first of all, insult the mentally ill, and secondly, we underestimate just how evil Trump is and how dangerous.
Excerpt:


A recent Backpage Editorial in these pages labeled President Trump as an “oddity” who stomps around angrily “like a petulant toddler.” These descriptions, while accurate, understate his psychopathology in extremis.
Psychiatrists and psychologists have diagnosed Donald Trump from afar. The most common diagnostic label they have applied has been “narcissistic personality disorder.” His uncontrolled lying, his unquenchable thirst for admiration, his demand of unwavering loyalty from government officials he has appointed to his family, friends and voters, his over-the-top self-aggrandizing remarks, his lack of empathy or sympathy, his humorlessness, his shifting of attitudes and political positions, his begrudging the successes and achievements of others, his disparagement of weaknesses in others, thus inflating his own fragile self-esteem (for example, his public humiliation of Attorney General Jeff Sessions), his own sense of entitlement (augmented by his holding the most powerful office in the world), snobbishness and patronizing attitudes, and many more similar personality characteristics.
Donald Trump is not psychotic. Despite his ongoing outlandish comments and being totally unaware of world affairs, denial of scientific findings, and lack of much knowledge of how government works or even the job requirements of a U.S. President, he is not mentally ill in the legal sense of the term. His social and vocational functioning are obviously very much impaired as a result of his narcissistic, near-total focus on his own image and status.
I contend that most Trump voters were unaware of these personal deficiencies when they made their election choice at the time. His masterful manipulation of the media gave him an enormous advantage over his many primary opponents and his one general election foe.
____________________
Dr. Franzini is a clinical psychologist, speaker and writer. His new book is Just Kidding: Using Humor Effectively.

Duty to Warn publicity:
The American Prospect is a daily online and quarterly print American political and public policy magazine dedicated to American liberalism and progressivism. Based in Washington, D.C.The American Prospect says it aims "to advance liberal and progressive goals through reporting, analysis, and debate about today's realities and tomorrow's possibilities."

Weds. Dec. 20, 2017

A reader fact checked the story below. In fact it is recycled from a September 2016 conspiracy story. Infowars host Alex Jones devoted a segment to what he described as the revelation of a plot to kill Republican presidential nominee Donald Trump. In truth, the segment was a re-airing of a commentary that same day on Russian state television by host Dmitry Kiselyov
Here’s the Alex Jones video.


The insane part of this is that we have to wonder how Trump, known to read Alex Jones and presumably to have talked to him on the phone at least once, will react to this. I doubt Trump is in the throws of a psychotic delusional state, but there are times when his reality testing is suspect. I doubt he will believe the gut instinct of Alex Jones, but the mere fact that I am wondering about this gives me pause.


Morning preview:

Trump’s Narcissism

Though the Electoral College gave Trump the election, his debilitating narcissism prevents him from accepting the fact he lost the popular vote. This makes him even crazier. Though Trump and his reactionary cronies can't currently use Jim Crow's literacy tests, poll taxes and physical threats, they still ...


The worrisome departure is Trump himself because he feels obligated to insult world leaders and provoke international conflict using his Twitter feed based on the whims of his all-consuming narcissism. "America First", in Trump's worldview, is markedly different than what the staffers in his administration ...


Trump's secretary of energy, Rick Perry has a history of campaigning for office by demonstrating that he was anti-LGBT. A number of Trump's nominations to the federal bench have extensive records of animus towards the LGBT community. Trump's narcissism was evident after the Pulse Nightclub ...

Tuesday, Dec. 19, 2017

Trump blasted after inviting NRA boss for White House Christmas party on anniversary of Sandy Hook mass shooting - (Just saying)

“Not only did (Trump) ignore the five-year remembrance completely — not even a single tweet — he slapped us all in the face by having none other than NRA President Wayne LaPierre at his White House Christmas party that night,” Hockley said in a statement to The News. “The appalling lack of humanity and decency has not gone unnoticed.”


From the U.K: Trump sparks fresh dementia concerns after he drinks small glass of water with two hands like a child - just days after he slurred his words during Jerusalem speech



  • Twitter went into meltdown on Monday after the president took an awkward swig of water while unveiling his new national security strategy
  • Trump cradled the glass in both hands, like a young child, for the sip
  • Move sparked concerns Trump may have a serious degenerative disorder which can cause shaky hands
  • Sandra F Woodward wrote that Trump 'holds that water glass like my 3 year old grandson. I really think Trump has dementia and is reverting 2 childhood action'
  • 'His motor skills are degenerating,' added Joseph Fedorko‏
  •  In November, he picked up a bottle of Fiji water in both hands and sipped it awkwardly during a press conference at the White House
  • And earlier this month, speculation was rife after Trump began slurring through part of his speech announcing changes to America's Israel policy
 Right Wing Watch reports that Paul McGuire and Troy Anderson — who are co-authors of an upcoming book called “Trumpocalypse: The End-Times President, a Battle Against the Globalist Elite, and the Countdown to Armageddon” — are trying to personally lobby Trump to declare an official call for national repentance, in which Americans will be encouraged to ask God for forgiveness of their sins. AlerNet


Click above for article







Monday, Dec. 18, 2017

Evening Edition:
You may be directed to a link to subscribe before you can read this.
As you’ve no doubt heard, Centers for Disease Control and Prevention (CDC) had been banned from using the words "vulnerable," "science-based," "fetus," "transgender," "diversity," "entitlement," and, my particular favorite, "evidence-based.”


Personal Bias Should Not Rule Health Policy 

A lot of attention has been focused on whether President Trump and his supporters and family members connived with the Russians to win the presidency.
For that matter, censorship and denial of science would be following in the steps of other world leaders who also sought to ban science in the name of ideology when it came to matters where the science did not suit their politics.
Donald Trump bemoans fake news. But one might think that he seems to like fake science. If there's an issue with bathrooms or healthcare coverage or admission to the armed forces for the transgendered, then mandate them out of existence. Want to impose your views on those who disagree about abortion, emergency contraception, and research on embryos? Make sure no one uses anything but the word "baby" to describe a fetus or an embryo. Tired of those who keep reminding you and anyone who will listen that coal is a hugely dirty and polluting energy source? Then no more facts or evidence allowed.

The comments to this articles proved interesting and disturbing. While most applauded the publication of the article, there were some who were obviously Trump supporters. I felt I have to respond:

I applaud Medscape for making this exception to your usual fare of medical articles to address this public health crisis. Many commenters try to excoriate you, these two for example:  

"Wow. Medscape has hit the skids too..” and  "I joined medscape for credible medical science which has the potential for plenty of debate on its own without the obvious one sided political commentary that has become too common.  The editorial board should be purged and replaced with people that want to report news and not advance agendas! 

When politics turns anti-science it effects the health of the nation. What else is the definition of a public health emergency. 

Conflict of interest: I was one of the first mental health professionals to write about Trump being a malignant narcissist, and to publish many articles on the subject on Daily Kos: https://www.dailykos.com/blog/Trumpology 
For the record, this is also from Medscape. I disagree with all of the article, but agree with many of the comments. 


Ed. Comment: Clinicians consider the degree to which someone can engage in accurate reality testing, even when the facts lessen or undermine their self-image, to be an indication of good mental health. Case in point, we have to wonder about Trump’s reality testing about the Russian investigation. While believing he’ll be vindicated in a glorious way is good for us since then he won’t fire Mueller, it has to be added to the long list of factors pointing to Trump being a malignant narcissist whose previously functional psychological defenses are breaking down. HB

 Excerpt: Until those next signs emerge, Trump is boasting to friends and advisers that he expects Mueller to clear him of wrongdoing in the coming weeks, according to sources familiar with the conversations. The President seems so convinced of his impending exoneration that he is telling associates Mueller will soon write a letter clearing him that Trump can brandish to Washington and the world in a bid to finally emerge from the cloud of suspicion that has loomed over the first chapter of his presidency, the sources said. 



This account of how Trump and his senior staffers are privately grappling with the Russia investigation is based on interviews over the past week with nearly three dozen White House officials, lawmakers, outside advisers, friends of the President and sources familiar with the Mueller probe. It depicts a president genuinely convinced of his innocence and advisers preparing for him to explode early next year if the probe doesn't end as neatly as Trump expects.

In private conversations, Trump still speaks dismissively of the Russia investigation, referring to it as "bulls---" and proclaiming "I don't know any Russians!" multiple sources told CNN.

We’ve read much this before, but

here’s what an article in The Christian Post has to say about Trump’s fitness to serve:


This article begins noting the recent polling which showed that "Fifty-one percent of believe that Trump is "mentally unbalanced," while 44 percent said that they think the president is "mentally stable" and 5 percent said they were "not sure.” It then goes on to explain what Tony Schwartz (Art of the Deal author) and pundit Andrew Sullivan has said.  

Click to enlarge - Note:  It took him 10 minutes
before his thoughts and prayers
(yeah, right, like he has such human reactions) 
the “presidential” Tweet went out. HuffPost
has a story on this.

Duty to Warn’s Bandy Lee, editor best seller “The Dangerous Case of Donald Trump” is quoted, including: "Just some of the signs that have raised red flags include: verbal aggressiveness, boasting about sexual assaults, inciting violence in others, an attraction to violence and powerful weapons and the taunting of hostile nations with nuclear power. Specific traits that are highly associated with violence include: impulsivity, recklessness, paranoia, a loose grip on reality and poor understanding of consequences, a lack of empathy and belligerence toward others, rage reactions and a constant need to demonstrate power. Such traits interfere with the ability to think rationally, to take in needed information or advice, to weigh consequences and to make sound, logical decisions based on reality,


Where the article is different from many others posted on this website is that it presents the opinions of several prominent people who have different opinions:



Danielle Pletka, senior vice president of of Foreign and Defense Policy Studies at the American Enterprise Institute, responded by saying that she thinks Republicans are "going to keep talking privately about the president."
"But I think it serves nobody to stand up and say, 'I think the president's crazy.' He's the president of the United States. And that kind of thing is just, there's no political upside for Republicans, because then the next question is, 'Okay, you think he's crazy, you think he's on drugs, you think there's something wrong with him?'" she said. "These are all the whispers we hear in Washington. Then the next question is, 'So what are you going to do about it?' And the answer is, from them is, 'We don't want to do anything about it.'"
CIA Director Mike Pompeo called such claims “absurd” interesting only because he may actually have his own suspicions about Trump’s collusion with Russia.

Susan Collins gave a lawyerly response when asked: "First of all, let me say my conversations with the president have given me no reason to be concerned in that regard.” In other words, she only said she hasn’t observed signs of mental illness while talking with the president. 


As would be expected hard-core Trump supporters Mollie Hemingway and Peter Roff think the entire question is part of an anti-Trump conspiracy.



"It is a campaign based on anonymous leaks, so it is very hard to determine how much to take seriously," Hemingway, a senior editor at The Federalist, said. "In general, it is people who haven't accepted the reality of Donald Trump winning the election who are making this claim. ... Nobody should be evaluating each other's mental health, particularly not people who are still struggling to accept reality a year after it happened. "
Peter Roff, a contributing editor to US News & World Report, wrote in an op-ed that the claims of mental instability are seemingly part of a "consistent effort to undermine presidential legitimacy" that "has hardened the partisan divisions in the country."

Reminding us that historians are thinking of the 25th Amendment solution, here's an article from The George Washington University History News Network trying to answer this question:

When (and if) Donald J. Trump leaves office – via impeachment, criminal indictment and conviction, resignation, or the 25th amendment – Mike Pence, his Vice President will become President. Mike Pence does not have a secret agenda – he is all out there: “My Christian faith is at the very heart of who I am,” he said during one of the vice presidential debates. And he means that. Welcome to Christian Theocracy. 


Editorial Comment:

The Daily Beast begins this article,

Frustrated Donald Trump Plots Counterpunches and Talks Lawsuits


With the following:
"President Donald Trump increasingly believes that he is surrounded by enemies intent on his political destruction."  
This could be written about many or most presidents in the modern era, in fact, probably most since the Founding Fathers. Certainly Obama, Bush 1 and 2, and Clinton were surrounded by enemies bent on their political destruction. This comes with the job.

Most Duty to Warn therapists think that Trump, at the very, least resides in the shadow area between  having a persecution complex, not a particular unusual array of disturbing beliefs with insecure people, and his being close to having a delusional paranoid disorder.

The key to defining the psychiatric significance of paranoid-leaning (in the 1950’s and ’60’s we’d use the term neurotic) and a person having outright paranoid beliefs is how real the beliefs are, and how rationally a person responds to them.

If Trump is becoming paranoid to the extent that he is highly suspicious of the motives of people in his inner circle who are, in reality, totally supportive of him and just trying to giving him helpful advice he doesn’t want to hear, this moves the needle closer to the delusional disorder side.

With what shrinks call a “full-blown” paranoid delusional disorder, Trump would not only feel strong anxiety over people plotting against him, but he’d hear auditory hallucinations expressing these opinions.

In most instances a face-to-face psychological assessment would be required to determine this unless he decompensated on live-TV.  All competent clinicians with experience doing diagnostic evaluations  with those who might be psychotic or suffering from Parkinson’s hallucinations, dissociative disorder, or dementia are adept at picking up the signs that their patient is hearing an inner voice.

Trump is certainly prone to believing the conspiracy theories he read, or perhaps hears on the phone, from the likes of Alex Jones.

At this juncture we Duty to Warn therapists, and now experts on organic disorders such as dementia, have grave concerns about whether Trump is mentally fit to be president.

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