Tuesday will be Power Plant Day, and Bridge Day, all wrapped up in one, in Iran. There will be nothing like it!!! Open the Fuckin’ Strait, you crazy bastards, or you’ll be living in Hell - JUST WATCH! Praise be to Allah. President DONALD J. TRUMP
Malignant narcissism, as Kernberg described it, is not simply vanity gone mad. It is a constellation: grandiose narcissism braided with antisocial features, paranoid vigilance, and ego-syntonic aggression, cruelty that feels right to the person enacting it. The malignant narcissist does not merely need admiration; he needs enemies, and he enjoys their pain. He lies fluently, exploits reflexively, and experiences remorse mainly as a rhetorical move. His grandiosity is defensive architecture: beneath it sits a brittle self that cannot survive ordinary reflection, so reflection is outsourced to blame.
Behavioral-variant frontotemporal dementia (bvFTD) is something else entirely, but uncanny in its phenotypic rhyme. It is a neurodegenerative disease of the frontal and anterior temporal lobes, the very territory that governs empathy, inhibition, social appraisal, and self-monitoring. Its early signs are often mistaken for personality change rather than illness: disinhibition, apathy toward loved ones, loss of empathy, perseverative speech, stereotyped phrases repeated like incantations, dietary rigidities and hyperorality, coarsening of taste and judgment, and, diagnostically central, anosognosia, the patient's genuine inability to perceive his own deficits. He is not denying the decline; he cannot see it.
Cross the two and you do not get addition. You get resonance. The pre-existing narcissistic architecture offers the disease a scaffolding already built for its symptoms. Grandiosity that was once a defense becomes a symptom that needs no defending, because the monitoring apparatus that once whispered careful has been eaten by the disease. Paranoia that was once strategic — useful for keeping underlings frightened — loses its modulation and becomes ambient, untethered, exhausting. The lying, which was always constant, now blurs with confabulation: he cannot always tell which of his claims he is manufacturing and which he is misremembering, and this does not trouble him, because nothing troubles him in that register anymore. Insight was always thin; now it is neurologically unavailable.
Language coarsens and contracts. The vocabulary narrows to a few hundred favored words, cycled and recycled. Superlatives proliferate because gradations require cognitive work the frontal lobes can no longer perform: things are the greatest, the worst, the most beautiful, the most unfair. Stereotyped phrases become verbal tics, deployed regardless of context. Sentences lose their subordinate clauses and then lose their verbs. Tangentiality increases; the speaker wanders from the prompt and cannot find his way back but experiences the wandering as eloquence.
Emotionally, the affective range collapses toward two poles: grievance and triumph. The capacity for even performative warmth erodes, because performance requires the modeling of another mind, and that modeling is exactly what the anterior temporal lobe is losing. What remains is reactive, reflexive, and loud. The hyperorality of bvFTD: the craving for sweets, for fast food, for fixed culinary rituals, becomes a quiet tell amid the noise.
Now install this person in the presidency.
The office does not correct him; it amplifies him. Structural checks are external, and the machinery failing inside his skull is the machinery that would have metabolized those checks into self-restraint. He cannot be shamed, because shame requires a recognition of other people's perspectives that is being neurologically dismantled. He cannot be embarrassed by contradiction, because working memory is too short to hold the prior claim alongside the present one. His staff becomes a loyalty filter rather than an advisory body, because paranoia plus cognitive decline demands constant reassurance, and reassurance is incompatible with candor. The competent peel away; the compliant and the opportunistic remain. Decision-making concentrates around whoever was in the room last.
"Stable genius" is the phrase that gives the game away. It is not a boast in the ordinary sense. It is a symptom, specifically, anosognosia spoken aloud. A cognitively intact narcissist would never need to say it; the claim would be implicit in his competence. The man who says it is reporting, accurately, what he perceives from inside a brain that can no longer audit itself. He is not lying about his stability. He genuinely cannot see the instability. This is what makes the declaration both pitiable and dangerous: pitiable because it is, at the neural level, a kind of blindness; dangerous because the blindness is not corrective but expansive, and because the office he holds converts private delusion into public policy.
The through-line of such a person, examined dramaturgically, is a life-long refusal of ordinary accountability finally meeting a disease that makes accountability neurologically problematic. He was always exempt in his own eyes; now the exemption is confirmed by pathology. What had been character becomes symptom, and the distinction stops mattering to him, though it matters enormously to everyone governed by him.
Clinically, the combined picture is diagnostically difficult precisely because the personality structure camouflages the disease. Observers assume continuity, he has always been like this, and miss the trajectory. The signs are in the deltas: the shrinking vocabulary, the tightening rituals, the increasing perseveration, the flattening of even the performative emotions, the dietary fixations, the loss of what little empathic mimicry once existed. Neuroimaging would likely show frontal and anterior temporal atrophy; neuropsychological testing would show executive dysfunction disproportionate to memory loss, which is the bvFTD signature. But such testing requires consent, and consent requires insight, and insight is the first casualty.
The public, meanwhile, watches a man who has always been cruel become cruel in a new register, less calculated, more automatic, more repetitive, more untethered. They argue about whether he is evil or ill, as though the categories were exclusive. They are not. Malignant narcissism is a moral-psychological formation. bvFTD is a disease. When they meet in one person, you get a leader who is simultaneously culpable and compromised, whose worst instincts are now neurologically disinhibited, and who will, with perfect sincerity, describe himself as stable while the ground gives way beneath him.
It is a tragedy for the person. It is a catastrophe for the polity that elected him.
Addendum: Further Decline, Narcissistic Injury, and the Midterms
A follow-up to “The Malignant Narcissist with Frontotemporal Dementia: A Clinical Sketch.” September 29, 2026.
My earlier post described a malignant narcissist who develops behavioral-variant frontotemporal dementia and holds the presidency. This addendum adds what has become publicly observable since then, revises the diagnostic speculation, and considers what the coming months may bring as the midterms approach and his approval falls.
I have not examined Donald Trump. Nobody outside his medical care has the imaging, sleep study, or neuropsychological testing a diagnosis would require. What follows is a clinician’s reading of public behavior, not a diagnosis. I know the Goldwater rule and its reasons. I am writing anyway because I think the public risk now outweighs the professional one.
What has changed
He falls asleep in public. By late May, The New Republic counted at least eight on-camera episodes this year, and they have continued, most recently at an Oval Office announcement on September 28. Snopes reviewed video of a June 4 event and confirmed that he nodded off five times within about sixteen minutes. He denies dozing, and his communications staff has mocked the people who post the clips.
His speech has continued to deteriorate. He has told the same joke about a third term three times, and by one count he has repeated the same misattributed story about the deaths of American service members eight times. He drifts from topic to topic and loses the thread of his sentences. He calls this “the weave” and says it is deliberate. A person with anosognosia would say the same thing.
He is less able to restrain himself. Delivering a eulogy for a Republican senator, he went off script to say that not everybody had liked the man. Earlier in his career he usually aimed his insults where they would do him some good. This one served no purpose.
His political standing has fallen with it. Polling averages put his approval around 37 to 38 percent, and several late-September polls have it at 32 or 33. The Wall Street Journal found the lowest pre-midterm approval for any president in its polling back to 1990. Republican support has slipped. The country is at war with Iran, most voters think the economy has gotten worse, and the election is five weeks away.
A revised differential
I leaned on bvFTD in the first post because its symptoms overlap so much with malignant narcissism: loss of empathy, disinhibition, perseveration, stock phrases, and lack of insight. The sleepiness does not fit. Excessive daytime sleepiness is not typical of bvFTD, and the disease usually begins in the fifties or sixties, not near eighty.
Other possibilities now deserve at least equal weight. Obstructive sleep apnea could explain the sleepiness and much of the inattention, and it is treatable. In dementia with Lewy bodies, fluctuating alertness is a core feature. Alzheimer’s disease is the most common cause of dementia at his age and fits the confusion of names and places better than bvFTD does. Vascular cognitive impairment is possible. In a man of eighty, a combination of these is more likely than any one alone. Whatever the cause, what matters here is the functional picture: fluctuating attention, weaker executive control, and perhaps diminished awareness of the change.
His character predates all of this. The neurology determines what he is losing; the narcissistic structure shapes how the loss looks from outside.
How he is likely to function
If his alertness fluctuates, decisions will be made in his good hours and carried out, reinterpreted, or reversed by whoever is around him in the others. His staff will spend more of its time managing him: scheduling around his energy, shortening briefings, and deciding what he sees. A cabinet chosen for loyalty is badly suited to this work, because loyalty selects against people who will tell him he is tired or wrong.
He will look better at rallies than in meetings. A friendly crowd can carry him through an hour on stage. A policy briefing gives him nothing to feed on and asks for sustained attention.
The midterms as degradation
For a malignant narcissist, losing an election is a public degradation, a loss of status he will not accept. After 2020 he denied the result, looked for people to blame, demanded loyalty, and pressured officials to overturn it. I expect the same moves after a bad midterm.
Decline changes how those moves play out. He is less able to plan and sustain a long campaign against institutions. He is also less able to stop himself from acting on impulse. The risk moves away from scheming and toward sudden reactions.
If Democrats win the House, he will face subpoenas, oversight hearings, and possibly impeachment, and he will experience each one as a new humiliation. The riskiest stretch may be the months after the election rather than election night.
Is the United States in danger?
I think it is.
The country is at war, and the president alone can order the use of nuclear weapons. A commander whose attention fluctuates and whose aides were chosen for compliance is a real hazard in a crisis that requires sustained judgment at any hour.
There is also the problem of drift. When a president is impaired, power moves to the aides who manage him. They are unelected, and the public cannot tell who is actually deciding.
And there is the danger after a defeat, when the wish to regain status through some dramatic act meets weakened inhibition.
The constitutional remedy is hard to use. Section 4 of the Twenty-Fifth Amendment requires the vice president and a majority of the cabinet to declare the president unable to serve, and if he contests it, two-thirds of both houses of Congress must agree. His cabinet will not start that process, and he cannot see why anyone would want to.
There are real safeguards. The courts still function. States run elections, and the midterms will happen. Military officers are bound by law, not only by orders. The bureaucracy is slow, which sometimes protects the country. An impaired president can do damage but has trouble sustaining a campaign. The country has also survived an incapacitated president before: after Woodrow Wilson’s stroke in 1919, his wife and physician concealed how disabled he was for the rest of his term.
There are reasonable arguments against my reading. Many voters see a tired eighty-year-old, not a demented one, and point out that he has always talked this way. His physician reports a perfect score on the MoCA, a standard cognitive screen. Critics have predicted his collapse for years and been wrong. I think the trend now outweighs these points, but I hold that view with less than full confidence.
What I think I am seeing
I believe I am watching a man whose alertness and verbal control have declined over the past year, on top of a character that has not changed. I am fairly confident that the decline is real and goes beyond what his long-standing speaking style would explain. I am much less confident about its cause, and I would not be surprised if a thorough workup found something treatable, such as sleep apnea, contributing to it.
My evidence has real limits. I am working from clips, and clips are selected: the moments of dozing and confusion circulate widely, while the hours in which he performs adequately do not. At least one widely shared video of him asleep was an AI fake. Many of my sources are openly hostile to him. Any eighty-year-old may nod off in a long afternoon meeting, and a single episode means little. What persuades me is the accumulation over time, not any one event.
Several things would change my view. A normal sleep study and neurological examination with imaging would weaken the case for a degenerative process. Stability in his public performance over the next several months would also count against it. On the other side, I would take it as confirmation if his public schedule contracts, if aides begin announcing decisions about the war that he would once have announced himself, or if officials with independent standing continue to leave. Short of an examination, these are the best evidence available, and none of it amounts to proof.
I ended the first post by calling this a tragedy for the person and a catastrophe for the polity. I would now say the catastrophe is possible but not settled. Much depends on whether the people around him are willing to see what he cannot.
References
American Psychiatric Association. The Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry, Section 7.3 (“the Goldwater Rule”).
Berg, A. S. (2013). Wilson. New York: G. P. Putnam’s Sons.
Dorn, S. (2026, September 24). Trump’s approval rating hits new lows in 3 polls this week. Forbes. https://www.forbes.com/sites/saradorn/2026/09/24/trumps-approval-rating-hits-low-in-third-poll-this-week/
Fact check: Videos show Trump appearing to fall asleep during Oval Office coal industry announcement. (2026, June 5). Snopes, via Yahoo News. https://www.yahoo.com/news/politics/articles/fact-check-videos-show-trump-234900903.html
Trump is losing it and must be removed. (2026, June). The Hill (opinion). https://thehill.com/opinion/white-house/5914003-trump-decline-25th-amendment/
Izzo, J., & Esposito, J. (2026, April 24). Did Trump fall asleep during meeting? Separating satire from real footage. Snopes. https://www.snopes.com/fact-check/trump-asleep-meeting-claim/
Kernberg, O. F. (1984). Severe Personality Disorders: Psychotherapeutic Strategies. New Haven: Yale University Press.
Mary Trump says Trump is showing signs of cognitive decline. (2026, July 30). Yahoo News / The Daily Beast. https://www.yahoo.com/news/politics/articles/mary-trump-says-trump-showing-090215805.html
McKeith, I. G., et al. (2017). Diagnosis and management of dementia with Lewy bodies: Fourth consensus report of the DLB Consortium. Neurology, 89(1), 88–100.
Olmsted, E. (2026, May 27). Trump falls asleep again after he says medical checkup went perfectly. The New Republic. https://newrepublic.com/post/210989/trump-falls-asleep-cabinet-meeting-medical-checkup
Rascovsky, K., et al. (2011). Sensitivity of revised diagnostic criteria for the behavioural variant of frontotemporal dementia. Brain, 134(9), 2456–2477.
Rhetoric of Donald Trump. Wikipedia (accessed 2026, September 29). https://en.wikipedia.org/wiki/Rhetoric_of_Donald_Trump
Donald Trump appears to struggle to keep his eyes open at ‘historic’ event. (2026, September 29). Reality Tea. https://realitytea.com/2026/09/29/donald-trump-appears-sleeping-oval-office-event
Donald Trump health fears rise after psychiatrist reportedly spots ‘abnormal and pathological’ concerns. (2026, September). International Business Times UK. https://ibtimes.co.uk/donald-trump-health-fears-rise-after-psychiatrist-reportedly-spots-abnormal-pathological-concerns-1822090
Suter, T. (2026, September 28). Trump approval slips to historic low in Wall Street Journal survey. The Hill. https://thehill.com/homenews/campaign/6114659-trump-approval-record-low
Trump keeps losing his train of thought. Cognitive experts have theories about why. (2024, August 7). STAT. https://www.statnews.com/2024/08/07/trump-mental-health-linguistic-analysis-suggests-potential-cognitive-decline-experts-say/
An empirical analysis of popular press claims regarding linguistic change in President Donald J. Trump. (2018). PMC6258767. https://pmc.ncbi.nlm.nih.gov/articles/PMC6258767/
U.S. Constitution, Amendment XXV, Section 4.
Perfectly on point. Absolutely nailed it.
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