He has been called McNasty and Senator Hothead, but John McCain has called his fellow senators far worse. Newsweek reported that he “erupted out of the blue” at Budget Committee Chairman Pete Domenici, saying, “only an a–hole would put together a budget like this.” He called Sen. Chuck Grassley a “f—ing jerk” and capped a profane tirade during last year’s amnesty debate by screaming “f— you” at Sen. John Cornyn. Then there was the scuffle on the Senate floor with Strom Thurmond when the South Carolina senator was a less-than-spry 93.

No one is immune from his outbursts. A pair of Arizona physicians, Robin Silver and Bob Witzeman, went to meet McCain to discuss their concerns about a telescope project he wanted to fund. “He jumped up and down, screaming obscenities at us for at least 10 minutes,” Silver told CounterPunch’s Jeffrey St. Clair. “He shook his fists as if he was going to slug us.”

Even McCain’s family comes under fire. In The Real McCain, Cliff Schecter writes:

In his 1992 Senate bid, McCain was joined on the campaign trail by his wife, Cindy. … At one point, Cindy playfully twirled McCain’s hair and said, ‘You’re getting a little thin up there.’ McCain’s face reddened, and he responded, ‘At least I don’t plaster on the makeup like a trollop, you c—.’ McCain’s excuse was that it had been a long day.

Asked about her husband’s temper on “The View,” Cindy McCain said people mistake his passion for rage. But others are less accommodating. Former Phoenix mayor Paul Johnson has been quoted as saying that McCain is “in the area of being unstable.” Republican senator Bob Smith told the Washington Post, “His temper would place this country at risk in international affairs, and the world perhaps in danger. In my mind, it should disqualify him.” During the 2000 campaign, McCain’s hometown newspaper warned of his “volcanic” temper.

This round, the most notable voice questioning the senator’s fitness is conservative George Will, who recently wrote, “For McCain, politics is always operatic, pitting people who agree with him against those who are ‘corrupt’ or ‘betray the public’s trust,’ two categories that seem to be exhaustive—there are no other people. … It is arguable that McCain, because of his boiling moralism and bottomless reservoir of certitudes, is not suited to the presidency.” Beyond bad manners, Will hints at a dark stream running beneath McCain’s outbursts—impulsive, defiant, unforgiving, narcissistic.

There is something almost medieval about the way McCain cloaks himself in virtue and treats anyone who questions him as unworthy of public trust. His crusade for campaign-finance reform is a case in point. McCain manipulated the press into bestowing on him the “reformer” mantle and waged a scorched-earth campaign over something relatively superficial, as if it would by itself save America’s troubled democracy. His passion outpaced any perceived benefit. But when McCain gets a notion, he seems to listen only to his inner voices—and staffers and sycophants who echo them. He is always angry at someone, or he is looking for something to be angry about.

McCain’s most devoted supporters hardly disagree—they just think that’s how heroes act. And the candidate himself is dismissive, citing a temperamental streak running through his whole story: “As a young man, I would respond aggressively and sometimes irresponsibly to anyone whom I perceived to have questioned my sense of honor and self-respect.”

But the country faces a more difficult question: Is John McCain’s pattern of volatile behavior simply a matter of style and personality, or is there some underlying cause that makes these well documented traits “driven” and thus dangerous?

Much of the speculation about McCain’s mental status is irresponsible, even defamatory. But there is enough to justify looking through all the smoke to see if his anger is fed by flames he cannot control. Evaluating McCain through this lens makes sense to me. I have worked for a decade as a psychotherapist in a multidisciplinary rehabilitation program for victims of Traumatic Brain Injury. The question with McCain, as with any other possible TBI patient, is about where personality leaves off and organically driven behaviors, if existent, begin. Are his closed-minded, free-reigning passions for causes like campaign finance reform or, more recently, earmarks evidence of determination, a virtue, or obsessiveness, a fearsome attribute in a president?

As we explore explanations for some of Senator McCain’s actions, it is important to bear in mind that any professional who would render a definitive diagnosis on an individual he has not interviewed or tested is prostituting his credentials. But when someone places his life in the hands of voters, it is reasonable to examine behaviors in light of diagnostic criteria. It must be understood that my explanations cannot possibly be certain. That said, I believe it is highly likely that John McCain suffers from Traumatic Brain Injury (TBI) and Post Traumatic Stress Disorder (PTSD). The question I face as a citizen, and would invite readers to weigh, is one of probability and the degree of risk associated with the level of probability.

One of the great difficulties encountered by many TBI patients is the invisibility of the organic damage and the subtlety of the effects of even moderate brain injury. Indeed, many clinicians who work with TBI have come to view brain damage as a continuum we all fall on—it’s just a matter of the relative extent of damage and severity of the symptoms. In our program, we treat many men and women who are high-functioning individuals, but seem just a bit “off.” Their peers have to “walk on eggshells” so they don’t “set them off” or “get them going.” But moderate TBI is not necessarily a barrier to material success or political power.

There are three signal characteristics of moderate TBI: emotional disregulation (volatility), perseveration (inability to let go of thoughts and feelings or see them in broader perspective), and concrete thinking (abstractions and nuance are compressed into right or wrong, good or evil, people are either “for me or against me”). The difference between these attributes as personality characteristics or organically driven compulsions is subtle. How far do they deviate from appropriate behaviors, and are they moderated or exacerbated by time and the aging process? Where is the all-important line between emotional control and disregulation?

Obviously, there are batteries of sophisticated tests, and even diagnostic imaging that can rule TBI in or out, but John McCain has made it clear he will not only not co-operate, he will not abide discussion of anything of this nature. In the absence of his willingness to deal with such matters, we are forced to rely on his public record.

It speaks clearly: John McCain possesses, even trumpets, these characteristics. In addition, his biography records protracted episodes of violent abuse of intensity sufficient to make it all but impossible for him to have escaped without organic—and psychological—damage to his brain. It is sad that any such damage would have been incurred in honorable service to his country, but what is at stake is far too important for these possibilities to be ignored.

Details of John McCain’s years as a prisoner of war are spare, and the campaign has not made his intelligence debriefs or his Navy personnel file available. But in a 1973 interview with U.S. News & World Report, McCain described the days that led to what he called his “breaking point”: “[T]he guards, who were all in the room—about 10 of them—really laid into me. They bounced me from pillar to post, kicking and laughing and scratching. After a few hours of that, ropes were put on me and I sat that night bound with ropes. … For the next four days, I was beaten every two to three hours by different guards. … I had been reduced to an animal during this period of beating and torture.” (This came after two years in solitary confinement and deprivation so severe his weight dropped to 100 pounds.)

The North Vietnamese kept detailed records of prisoner interrogations, but they have never been released, so it is impossible to know how long McCain was unconscious or how many times he was concussed. He said that after the bout that broke him, “it was one round of rough treatment after another. Sometimes I got it three or four times a week.” He hasn’t detailed the sessions but speaks of “repeated, severe treatment.”

Even minor concussions, in sequence, can cause major damage to brain tissue. Torturers tend to inflict as much pain as possible on the body, with blows to the head restrained until the victim has reached the limits of endurance, but then he is knocked unconscious so as to recover his faculties in the most disorienting circumstances possible. Accounts of torture at the hands of the Vietnamese Communists indicate that they tended to rely on physical beatings and psychological torment rather than mechanical or electrical devices. If, as he says, he was broken into submission, in addition to the physical trauma, McCain would have experienced systematic and cruel manipulation of his psyche. It is impossible to experience torture at a level sufficient to cause a highly indoctrinated and motivated professional naval aviator to abandon his beliefs and commitments to his country and, as McCain maintains, experience no serious or enduring damage.

Yet he insists that simply disowning what happened to him in Vietnam, apparently through willpower or virtue, means that it had no effect. Clinicians call this “magical thinking.” It is not only impossible from a medical standpoint, it is counterintuitive, not to mention illogical from any sensible point of view. What is reasonable on a psychological basis is that the more traumatic the experience, the stronger the denial system that protects it is, and McCain’s denial system is well articulated.

Working through traumatic events in a therapeutic context requires confronting and dismantling the denial system in a manner that makes it safe for the psyche to re-experience these events, process them in a healthy manner, and dispose of the horrifying images that rampage through the subconscious to distort mood and compel behavior. But like many who are afflicted with such maladies, both organic and psychological, John McCain, according to a recent Atlantic piece has “no time for this Psycho stuff.” His inability to retrieve a more appropriate term is itself a revealing, almost Freudian, giveaway of his level of resistance to addressing these issues.

For example, while he was being tortured his hair went white, a physical manifestation of extreme duress, but he accepts no psychological effects. That would be great, if it could be true, and indeed it may be so in some alternate universe. But in the one we inhabit, something that dramatic can only result in major psychological trauma, which has inevitable effects on the human mind. In a clinical setting, McCain’s position is called “cognitive dissonance” — belief in contradictory things. That is, he was traumatized, but he is somehow immune from the effects of trauma that would be inevitable for anyone else.

It is entirely consistent with this kind of denial for Senator McCain to take a high public profile in matters related to TBI and PTSD in veterans returning from Iraq or Afghanistan. This behavior tends to reinforce the delusional system that insists one is entirely unique and therefore whole and undamaged. This is a destructive thing in relational and familial systems of individuals; it would be unspeakably dangerous if it were part of the makeup of a president.

History provides many examples of rulers with such traits. In fact, John McCain shares just about every important characteristic of temperament, attitude, and behavior with most of the Plantagenet kings, who embodied the characteristics of the knight errant that he evokes as virtues.

Under the Plantagenets, the long-suffering people of England were stuck with nearly 300 years of virtually continuous, ruinous, and fruitless wars of almost no conceivable purpose beyond demonstrating that they were boss in France. (It turned out they weren’t.) Similarly, McCain buys unconditionally into the idea that a diverse world—particularly the Islam-believing, oil-producing component—must recognize that the president of the United States is in charge.

It’s one thing to believe something like that. The question is how much violence you are willing to expend in pursuit of such a notion. The Plantagenet answer was simple: we will use all the blood and treasure we can extort from the people we control in pursuit of power over people who resist us. John McCain gives the same answer, without ambiguity or qualification.

From the time of Henry II until very recently, it was assumed that the peculiar Plantagenet temperament was inherited rather than acquired—they were called “Devil’s spawn,” and their rages and obsessions were Shakespearian in intensity. But insights derived from modern understanding of concussions, coma, strokes, sepsis, and the damage they do to brain tissue—and the effects these incidents have on human emotions and behavior—casts these particular rulers in a very different light.

Coming of age in Plantagenet times involved putting an iron bucket over your head and flailing about with broadswords, clubs, maces, and an assortment of heavy objects in the direction of other young men similarly accessorized, until you or your opponent broke major bones or lost consciousness. Then, with everybody revived—except those who were dead, fractured, or in a coma—the practice was to put the iron bucket back on your head, get on your horse, and charge at each other with maximum velocity until someone was unhorsed, generally landing on his head, which was still encased in that iron bucket.

We know enough about the damage blows can do to heads encased in high-tech football helmets or struck frequently with padded gloves. Imagine the brain damage a prince had to acquire before he was deemed fit to be king.

In the Tudor case of Henry VIII, we have an individual whose life has been chronicled in such tedious detail that we can identify with specificity what clinicians call “precipitating events.” We know that, in addition to any damage done in training, he was unhorsed in a tournament trying to impress Anne Boleyn. This left him unconscious, probably in a coma, for several days, as did another fall from a horse while riding in the country, shortly before he had Boleyn beheaded. Although this man was afflicted by numerous ailments, a recent publication by the Congress of Neurological Surgeons maintains that his remarkable cognitive and emotional degeneration was substantially due to progressively more severe organic brain damage incurred during the course of his violent life.

When the warlords of the Dark Ages evolved into the nobility of Medieval Europe, rule by functional but obsessive rage-filled men was the norm. This may explain why pre-Enlightenment queens like Elizabeth I or Isabella of Castile stand out remarkably from most of their male counterparts in terms of competence, flexibility, imagination, and mental and emotional stability and why queen consorts, from Eleanor of Aquitaine to Catherine de Medici, so often ran the show.

In this context, perhaps one of the greatest gifts of the Enlightenment may be that the path to political leadership no longer required sustaining brain damage. America has had famously temperamental presidents, even in recent years. George Stephanopoulos described Bill Clinton’s “purple rages,” confessing that he was so unnerved by the outbursts that he broke out in hives and began taking an antidepressant. But even famously feisty presidents like Nixon and LBJ were scarcely pathological. By my analysis, only Andrew Jackson approaches the morbidity of the symptoms of TBI presented by John McCain.

Far from diminishing, the behaviors that marked McCain’s Senate career—unregulated anger, impulsivity, inability to tolerate ambiguity—would surely stalk his White House, and on a grander scale. Difficulties with abstract thinking breed obsessive behaviors and tendencies to personalize issues in very concrete terms in lieu of dealing with nuance and complexity. It is difficult enough for political leaders to keep perspective when dealing with foreign leaders whose motives are often obscure and complex. If one is given to personalizing such things, the miscalculations could have horrifying outcomes. And if the behaviors are organic in etiology, they will not abate on some sort of presidential learning curve.

In my clinical work with TBI patients with moderate symptoms, I am invariably struck by the level of frustration they encounter on a daily basis. It’s a terrible, multi-layered bind. Unless it is severe, brain injury is a closed wound. Since victims appear undamaged, everyone around them expects—and they themselves often expect—normal skill sets, behaviors, and emotional ranges. The energy it takes to compensate for functional deficits is extraordinary, and the absence of affirming feedback breeds a sense of isolation that morphs over time into deep-seated resentment. It is much, much easier to stay focused on one thing, which accounts for the characteristic obsessiveness. Execution is often driven by resentment and anger rather than objective circumstances. This breeds a toughness that can endure enormous amounts of stress before decompensation—which is almost always extremely violent in nature—occurs.

This is where it gets frightening. Coming into the presidency of the United States at this time in our history with frustrations and disinhibitions derived from TBI and PTSD constitutes a perfect storm. We have seen how the essentially normal (if not particularly impressive) brain and psyche of George W. Bush became obsessive, error-prone, isolated, and even delusional when confronted with the awesome power and duties of the presidency. The responses of an unhealthy or damaged brain to the ego-distortions, pressures, complexities, and especially the decision-making powers of the presidency are the stuff of horror fiction. No points of agreement on policy or program can justify that kind of risk.

A PET scan is a value-neutral picture of the human brain in action that any properly trained neurologist can evaluate through scientific method—no bias, no subjectivity as would be found in the notes of some shrink or in an article like this. A scan of John McCain’s cranium would answer all these questions. He will never submit to this, but our descendents may wish we had insisted.

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