W

hen President Trump slurred his words during a news conference this week, some Trump watchers speculated that he was having a stroke. I watched the clip and, as a physician who specializes in brain function and disability, I don’t think a stroke was behind the slurred words. But having evaluated the chief executive’s remarkable behavior through my clinical lens for almost a year, I do believe he is displaying signs that could indicate a degenerative brain disorder.

As the president’s demeanor and unusual decisions raise the potential for military conflict in two regions of the world, the questions surrounding his mental competence have become urgent and demand investigation.

Until now, most of the focus has been on the president’s psychology. It’s now time to think of the president’s neurology — and the possibility of an organic brain disorder.

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Every day of my working life, I evaluate people with brain injuries. It falls to me to make decisions about what is normal and what is not, what can improve and what will not, whether or not my patients can work, what kind of work they can do, and pretty much everything else.

In turning my attention to the president, I see worrisome symptoms that fall into three main categories: problems with language and executive function; problems with social cognition and behavior; and problems with memory, attention, and concentration. None of these are symptoms of being a bad or mean person. Nor do they require spelunking into the depths of his psyche to understand. Instead, they raise concern for a neurocognitive disease process in the same sense that wheezing raises the alarm for asthma.

Here’s the evidence on which I base my conclusion that it would be prudent for the president to be tested for a brain disorder.

Language and executive dysfunction

Language is closely tied with cognition, and the president’s speech patterns are increasingly repetitive, fragmented, devoid of content, and restricted in vocabulary. Trump’s overuse of superlatives like tremendous, fantastic, and incredible are not merely elements of personal style. These filler words reflect reduced verbal fluency. Full transcripts of the president’s interviews with outlets like the New York Times and Time reveal the extent of his disorganized thought patterns.

The problem becomes especially apparent in the transcript format, where his thinking is no longer camouflaged by visual accompaniments to communication like facial expressions and gesticulations. Some outlets have sought to protect the president, forgiving his lapses by declining to publish full transcripts. When Politico published a leaked transcript of the Wall Street Journal’s July interview, we learned that the president’s intellectual curiosity rises to the level of introductory geography: “You call places like Malaysia, Indonesia, and you say, you know, how many people do you have? And it’s pretty amazing how many people they have.”

The president made that remark in response to a question about the ideal corporate tax rate, demonstrating the degree to which his thinking drifts. The problems with language expression extend to language interpretation, the likely source of the president’s gross misunderstanding of London Mayor Sadiq Khan’s message to his city in the wake of a terror attack in June.

Dysfunction of social cognition and behavior

Some of the president’s most concerning behaviors suggest a decline in social cognition: reduced insight and awareness into the thoughts and motivations of other people, coupled with symptoms like impulsivity and disinhibition that make him behave rudely and create needless controversy.

The decision to fire FBI Director James Comey in the middle of the investigation into Russian meddling in the 2016 election is an example of an impulsive decision that was greatly damaging to the president himself, assuming he was not actually trying to cover up his own complicity in the matter under investigation. Contradicting his own communications staff by disclosing that the Russia investigation was one reason he fired Comey is an example of disinhibited behavior. Rashly threatening Comey with a recording he did not have is reflective of poor emotional control.

Trump’s easy Twitter trigger finger, most recently retweeting British far-right videos he apparently knew nothing about simply because the social media platform promoted these videos in his feed, reflects poor impulse control. Numerous problematic moments in the Trump presidency, such as his volunteering top secret Israeli intelligence to the Russian ambassador or volunteering that his immigration restrictions were indeed a “travel ban,” reflect an inability to contain himself.

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We saw this most recently with his inability to make it through a simple White House ceremony honoring Navajo code talkers without making an ethnically derogatory reference to an opposition political figure.

The president’s decision to launch into a fight with a Gold Star wife and mother who lost their soldier in Niger is also reflective of impaired social cognition. It could also signal memory decline, since it seemed as though he had not learned from a similar imbroglio during the campaign.

Episodes like these often occur because of impaired frontal lobe brain systems. These typically provide some degree of restraint from saying the first thing that crosses your mind. In a healthy brain, these ideas must make their way through multiple layers of checks and balances that take into account the social propriety and appropriateness of the audience for a given remark. Such frontal impairment often does not stop at troublesome communication, but has physical manifestations such as childlike facial expressions and physical restlessness, both features we see in Trump.

Dysfunction in memory, attention and concentration

The integrity of other primary cognitive domains like memory, attention, and concentration are tied up in all of the problems I mention above. Memory impairment is specifically implicated in episodes like forgetting to sign orders — not once, but twice — that were the purposes of the press events the president was attending. Attention and focus are key to forming memory; the lack of either makes it more likely to forget why one was in a room in the first place.

The persistence of fixed beliefs about the crowd size at his inauguration, President Obama having a fraudulent birth certificate, or millions of undocumented people voting for Hillary Clinton suggest either a shocking willingness to lie, which falls into the behavioral dysregulation category, or a memory disorder that hobbles the president with fixed delusions that cannot be swayed by contradictory information. The New York Times opinion section has catalogued an astounding collection of the president’s lies so extensive that such lying implicates the cognitive systems that undergird one’s hold on what has happened in one’s life.

If the president is questioning whether the “Access Hollywood” videotape of himself celebrating a lifestyle rife with misogyny and sexual assault is really him, that worries me more about a memory disorder than a particularly poor effort at gaslighting.

Moving forward

The clinical task is to distinguish the president’s symptoms from normal aging. Typically, that’s accomplished with standardized neuropsychological testing that would help compare the president to peers of similar age and education. It’s perhaps useful to think of how many 71-year-olds in your life display similar behaviors, thoughts, and speech patterns as the ones we are witnessing in Trump.

If I were to make a differential diagnosis based on what I have observed, it would include mild cognitive impairment, also known as mild neurocognitive disorder or predementia. About 16 percent of people the president’s age fall into this category. Mild cognitive impairment comes in various flavors as the precursor to a variety of different full-blown dementias. The key distinguishing characteristic between mild cognitive impairment and dementia is whether the decline is starting to interfere with essential daily functioning. In a billionaire typically surrounded by assistants, who is now the president surrounded by more assistants, whether Trump can perform his necessary daily tasks on his own may be difficult to assess.

The symptoms I’ve observed raise the concern for mild cognitive impairment preceding frontotemporal dementia, which is particularly heavy on the behavioral symptoms like those the president displays, as well as more typical Alzheimer’s dementia, or dementia with Lewy bodies. Though advanced testing such as brain imaging, as well as genetic testing and cerebrospinal fluid analysis, are not required to make the diagnosis, all of this testing is warranted in the president’s case if cognitive testing is consistent with mild cognitive impairment or dementia.

It’s entirely possible that the president does not have predementia or is not progressing toward dementia. But he is definitely behaving as such.

If an individual with these symptoms was in an average job in an average community surrounded by an average family, he or she would most likely be seen by a doctor. In the clinical evaluation of dementia, the concerns expressed by family members and the patient themselves are essential: They explain the changes observed over recent years, and that history is a prime ingredient in formulating the differential diagnosis.

The uniqueness of the megalomaniacal media personality that Trump has built himself into, followed by the presidency and its attendant cadre of fawning assistants, have most likely prevented him from getting proper assessment.

The president’s apparent symptoms are advancing and warrant medical evaluation by relevant specialists. Given the sensitivity of his case, an independent panel would be appropriate. It’s entirely possible that the president does not have predementia or is not progressing toward dementia. But he is definitely behaving as such.

In either scenario, I do not think this is an individual who is fit to serve the office.

Why I wrote this article

The president is sick. That’s the impression shared by a growing number of Americans — including me, as both a citizen and as a physician.

I am not a psychiatrist, and I have always taken some solace while writing about various public figures in the news that I am not governed by the Goldwater rule, which prohibits psychiatrists from dispensing free-form psychoanalysis about public figures they’ve never personally examined. But according to the American Medical Association, a variation of that rule now applies to all physicians. In a largely unreported addition to the AMA Code of Medical Ethics this fall, the AMA now has its own variation of the Goldwater rule: Physicians should refrain “from making clinical diagnoses about individuals (e.g., public officials, celebrities, persons in the news) they have not had the opportunity to personally examine.”

The statement seems out of the blue, as the Goldwater rule has been around since 1973 without the rest of medicine ever joining in. The AMA has unfortunately chosen a time to issue its own prohibition precisely at a moment when physician insight into a public figure is needed more now than ever before.

I sought to better understand the source of this restriction, so I spoke with AMA media representative Robert Mills, who told me that the media ethics guidance derived from concern about Dr. Mehmet Oz. A medical student member, citing Oz’s endorsement of fringe medical practices that seemed to be influencing Americans broadly, suggested that the association resolve to provide stricter media guidance to physicians that would help discourage them from portraying themselves as all-knowing media authorities.

That’s a noble idea, but capping dialogue about public figures seems rather peripheral and worthy of deeper consideration than given by the paragraph in the broader statement. Dr. Matthew Wynia, who was formerly Director of the AMA Institute for Ethics and now directs the University of Colorado’s Center for Bioethics and Humanities, told me that he considers the AMA’s new position, emphasizing the importance of in-person examination, “misplaced” given the way medicine is practiced in 2017.

In Trump’s case, we have no relevant testing to review. His personal physician issued a thoroughly unsatisfying letter before the election that didn’t contain much in the way of hard data. That’s a situation many people want to correct via an independent medical panel that can objectively evaluate the president’s fitness to serve. But the prospects for getting Congress to use the 25th Amendment in this way seem poor at the moment.

What we do have are a growing array of signs and symptoms displayed in public for all to see. It’s time to discuss these issues in a clinical context, even if this is a very atypical form of examination. It’s all we have. And even if the president has a physical exam early next year and releases the records, as announced by the White House, what he really needs is thorough cognitive testing.

Before biting the bullet, I also spoke with Dr. Dennis Agliano, who chairs the AMA’s Council on Ethical and Judicial Affairs, the panel that wrote the new ethical guidance. He advised me to be careful: “You can get yourself into hot water, since there are people who like Trump, and they may submit a complaint to the AMA,” the Tampa otolaryngologist told me. Ultimately, he reassured me that I should just do what I think is right.

Which is warn the president that he needs to be evaluated for a brain disease.

Ford Vox, M.D., is a medical journalist and commentator who practices brain injury medicine in Atlanta.

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  • On MSNBC tonight: Shoehorned between all the news coming out of the blockbuster Washington Post article was on short segment addressing Trump’s mental health, albeit in a mocking manner by Chris Hayes. Go to the last two minutes of this video in the Thing 1, Thing 2 segment. Hayes noted an oddity in Trump’s speech today about cutting regulations when he said the word scraping instead of what was obviously written in from of him, the word scrapping.

    “We’re scraping and recalling doing a job getting rid of the job killing regulations that threatened the auto workers and devoted their jobs over the years.” What could be going on his his mind – how can someone scrape regulations.

    The amazing MSNBC archive searchers found nine examples.

    Is this a type of speech impediment? Or is this a sign of mental deterioration? I don’t know. http://www.msnbc.com/all-in/watch/donald-trump-s-signature-teleprompter-trick-1117046339563

    • Hal Brown: ““We’re scraping and recalling doing a job getting rid of the job killing regulations that threatened the auto workers and devoted their jobs over the years.” What could be going on his his mind – how can someone scrape regulations.”

      Trump has adjusted the script. Scraping as one scrapes off paint before repainting. Flaky paint comes off and the good stuff stays.
      Flaky regulations get scraped up and recalled.
      I suggest Trump thought that “scrapping and recalling,” could be perceived as being more radical than he believes things will be.

  • 45?
    Can’t find that anywhere.
    All I can think of is the TV series “Get Smart,” the agents like 86 and 99, and KAOS the international organisation of evil.

    • I suppose you would label him as already going a bit soft for having his young children playing in his office while he was working?

  • Thanks for writing this. Very interesting.

    I’ve been assuming that Trump is literally mentally ill, but cognitive impairment is a legitimate alternative. My question is, when you start issuing tweets that are flatly untrue and ridiculous, how much does the root cause really matter?

  • I too long interpreted Trump as just an actor, playing a part. Then I read the following interchange with John Dickerson where the Pres completely blows a metaphor, with all that implies in terms of frontal lobe function, abiet sometimes indirectly. https://www.yahoo.com/news/four-bizarre-moments-donald-trumps-cbs-interview-145345587.html

    JOHN DICKERSON:(Throwing out a metaphor) George W. Bush said the reason the Oval Office is round is there are no corners you can hide in.

    PRESIDENT DONALD TRUMP:(totally- concrete) Well, there’s truth to that. There is truth to that. There are certainly no corners. And you look, there’s a certain openness. But there’s nobody out there. You know, there is an openness, but I’ve never seen anybody out there actually, as you could imagine.

    JOHN DICKERSON: (dumbfounded) But he– what he meant was it’s– all comes —

    PRESIDENT DONALD TRUMP: Sure. Sure.

    JOHN DICKERSON: (floundering) –back to you.

    PRESIDENT DONALD TRUMP: (again completely concrete) Sure. It does. But I think that’s true anyway. But it does, there’s no question.
    county

    • Brainstorm wrote (and I intersperse comments):

      Brainstorm
      “DECEMBER 13, 2017 AT 9:50 AM
      I too long interpreted Trump as just an actor, playing a part. Then I read the following interchange with John Dickerson where the Pres completely blows a metaphor,”

      Trump has not blown a metaphor.

      “with all that implies in terms of frontal lobe function,”

      Very astute functioning.

      “abiet sometimes indirectly. https://www.yahoo.com/news/four-bizarre-moments-donald-trumps-cbs-interview-145345587.html

      which does not give all the bits you say. Only the first bit. Who knows if you have made up “county?”

      JOHN DICKERSON:(Throwing out a metaphor) George W. Bush said the reason the Oval Office is round is there are no corners you can hide in.”

      Implying Bush may have wanted a place to hide and found he couldn’t.

      “PRESIDENT DONALD TRUMP:(totally- concrete) Well, there’s truth to that. There is truth to that. There are certainly no corners. And you look, there’s a certain openness.”

      Trump is now referring to his own approach.

      “But there’s nobody out there.”

      “Out there” meaning on that limb of needing to hide. In Trump’s experience no one is trying to hide. Including himself. Trump goes over it again just in case it has not sunk in:

      ” You know, there is an openness, but I’ve never seen anybody out there actually, as you could imagine.”

      Perhaps he might have used “and” rather than “but.”

      By “As you could imagine” Trump is saying, I think people realise my intention is a whole new open approach, unlike past admins. People trying to hide are on the outer in my admin and I have never seen anyone out there.

      “JOHN DICKERSON: (dumbfounded) But he– what he meant was it’s– all comes —

      PRESIDENT DONALD TRUMP: Sure. Sure.”

      Trump not waiting for the word, “out” after “it all comes” he is implying it’s obvious and does not require pride.

      “JOHN DICKERSON: (floundering) –back to you.

      PRESIDENT DONALD TRUMP: (again completely concrete) Sure. It does.”

      does have no corners to hide.

      “But I think that’s true anyway.”

      Thinking of the past admins is obvious.

      “But it does, there’s no question.”

      In other words see what has been coming out about past admins are more is going to come out, ie 9/11.

      “county”

      Should that be “counting” or waiting”?

    • Brian. Do you even have a clue what I am talking about, or for that matter, what this is about? In any case, clearly, you did not go to my medical school.

      The first question on most mental status exams is “Interpret a metaphor”. Typically– “Tell me what ‘a rolling stone gathers no moss’ means to you”. A “concrete” interpretation such as Trump gave (or for that matter, what you claim he gave, which is also very concrete) can signify a number of things, most of which can be ruled out.

      E.g., Trump is not autistic, nor does he likely have schizophrenia, etc. In a 70 y/o man who was previously highly functional, the first thing you think of is some frontal lobe problem. This is consistent with his other hypofrontal behavior.

      Particularly in view of his family history of “alzheimer’s”, the specific diagnosis that comes immediately to mind is frontotemporal dementia or FTD. The “temporal” part of this disease presents with various speech and language deficits. Which is why Trumps recent stumbles in this regard have raised such a fuss. One more data point. Could also explain odd episodes like “covfefe”, etc., which may represent the typical word-finding deficit in temporal lobe diseases.

      Interestingly, the speech stumbles have finally gotten the presidents handlers to promise to get him a physical. This may signify that they realize they cannot keep this a secret much longer as the disease progresses and are working to establish plausible deniability and a smooth extraction for themselves by being the ones to make the pres’ condition official.

      Age-related dementias are invariably-progressive and likely we will find out soon enough. My wild guess is that the Pres is about half-way thru the typical 8-year course, which is typically when the symptoms begin to become prominent.

    • Brianstorm, to me it appears to be you having the problem not understanding that Trump is replying to the metaphoric content. I am sorry I do have a difficulty understanding how you think he was talking as if Bush’s statement were concrete.

    • Bush’s Statement was a metaphor. Trump’s reply was totally concrete, as was your interpretation of Trump’s reply.

      It is also true that Trump recently interpreted another metaphor, “Prime the pump”, abstractly. But this was only sort of and after thinking about it for a while. Neurologists sometimes use a series of gradually more obtuse metaphors to narrow in on degree of impairment. So Trump still has some frontal lobe function. OTOH, he seemed to think he had just discovered the phrase, when there are old videos of him using it exactly correctly and he does have a bidness degree from Warton. So this goes to possible memory impairment.

      Which is worrisome in view of the other evidence for some sort of frontal lobe issue. Were it your uncle Elmo presenting like this, it would be off for MRI plus PET scans (maybe also cat scans) r/o cortical atrophy. Which is all anyone is calling for. If Trump were a company president, his Board of Directors would insist.

      This is not psychobabble BS, but a real “organic” brain disease, where brain tissue progressively dies off. It will be very interesting to see what comes out of the imaging studies. Anyway, it is out of our hands. Again, these are progressive diseases, untreatable and with a dismal outcome. See it happen. Ain’t pretty.

    • Brianstorm: “Bush’s Statement was a metaphor. Trump’s reply was totally concrete, as was your interpretation of Trump’s reply.”

      Trump was replying for the public who may not understand metaphor.
      And to be totally concrete do you think Trump to be replying about physical places to hide in the Oval Office?

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