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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  • Sounds to me that the good Doctor made a viable diagnosis for the possibility of removing President Trump from office under the 25th amendment to the US Constitution!

  • Please submit this as an editorial to the New York Times, the Washington Post, and any other newspaper you can find. It’s too important to be hidden away in a publication with limited range. Yes, the President is ill, that’s been obvious from the start. I’m constantly amazed at what he gets away with that any other candidate or public servant would be immediately banished for – how in the world did we get to this place?

  • Thank you, Dr. Vox!! This is a most interesting and convincing explanation of how and why this man could possibly speak and act the way he does. Thank you for having the knowledge and courage to write and publish this article.
    By the way, I love to listen to your Medical Minute segments in WABE. I especially like the way you clearly explained complicated medical issues in a non-judgmental way.
    Dan

  • also see: The Malignant Personality (Konrad, ’99):

    “These people are mentally ill and extremely dangerous. The following precautions will help to protect you from the destructive acts of which they are capable. First, to recognize them, keep the following guidelines in mind:

    (1) They are habitual liars. They seem incapable of either knowing or telling the truth about anything. (trump named “king of the whoppers” by factcheck. org)

    (2) They are egotistical to the point of narcissism. They really believe they are set apart from the rest of humanity by some special grace. (trump “i alone can fix it”, “i know more than the generals”, “i know things other people don’t know”)

    (3) They scapegoat; they are incapable of either having the insight or willingness to accept responsibility for anything they do. Whatever the problem, it is always someone else’s fault. (trump – mexicans are “rapists”, muslims are “terrorists”; the “crooked media”, “the system is rigged”; “i inherited a mess (all obama’s fault)”)

    (4) They are remorselessly vindictive when thwarted or exposed. (trump’s attacks on cruz’s wife & father, the khans, morning joe & mika, megyn kelly, carly fiorina, ms. universe, john lewis, meryl streep, the free press, etc. etc.)

    (5) Genuine religious, moral, or other values play no part in their lives. They have no empathy for others and are capable of violence. Under older psychological terminology, they fall into the category of psychopath or sociopath, but unlike the typical psychopath, their behavior is masked by a superficial social facade.” (trump making fun of disabled reporter, calls to ‘beat the crap out of ’em’ at his rallies, sexual predation & misogyny, support of torture, and the list goes on and on and on…)

    also known as malignant narcissism, antisocial personality disorder (ASPD), dissocial personality disorder (DPD), narcissistic personality disorder (NPD), sociopathy, psychopathy – although each may place a different emphasis on particular symptoms they are all basically describing the same pathology.

  • I agree 100% with your hypotheses. I do agree, based on all available observations, about predementia. I also think there are some possible mental health diagnoses I think might be concomitant. This is NOT a diagnosis and I have never evaluated 45. Here are some things that come to mind not in any particular order and not sure what is primary, secondary, tertiary, etc.

    ASPD with NPD and BPD features (or NPD with ASPD and BPD features) ODD/CD, ADHD, schizoid, bipolar dx., maybe OCD.

    Once again, I have never evaluated him and this is just an educated guess.

  • I have always said that Trump remind me of the character in the movie “Network”. The sad thing is if Trump has dementia his base will still want him as president. Interesting to know why so many people think a person with obvious mental health issues would make a good president.

    • You have put your finger on the more enduring issue. The President will retire in his own sense of success and dignity. The public psyche that put him in office will again be showing up at the polls in 2020, 2024, etc.

  • New Comment. Not illegal to speculate on mental health of public figure. Why not lack of “theory of mind”, child like mannerisms, impulsivity, lack of regards for others, rigid narcissism and disinterest of other’s opinion being Autism Spectrum Disorder?

  • Trump has shown himself unable to spell the simple words he would clearly have had to be able to spell as a University graduate. His need to be tested should have been obvious to everyone a long time ago.

  • His disengaged and reckless (very!) behavior combined with underlying malignant narcissism wholly justifies his removal from office. He simply doesn’t know right from wrong as most 1st graders would. His timely removal is the only real solution…

    • Reckless, Malignant Narcissism, does not know right from wrong.
      President Obama promise to clean Wall Street, rehired Timothy Geithner nothing happen, The Wall is ready to collapse again, they are ready to start walking down the street. VA 20-26 veterans commit suicide every day, for 8 years, The National Debt double, North Korea now is ready to launch ICBM, Iran received 40 Billion Dollars Cash. We Americans love everyone, I do not need LGBT organization to love them and respect them, just do not let me offend you with my Heterosexuality, Let keep separated church and state as our Constitution says. President Trump, was elected by all of us, let him do His Job. We allow Obama to do His. We have the right our Elected President, needs the same rights as Obama did. PERIOD. PERIOD. PERIOD.

  • The author made no conclusions regard diagnosis. In fact, he mentioned regard his hypothesis of possible diagnoses (neurocognitive defects) that he may be incorrect and there is the possibility nothing is wrong. He outlined observations and made his case. Other interpretations are clearly possible. If there are different points of view; make the case.

    • Dear Scharazard Gray, every one who wrote and publish this article are Highly Qualified Medical Doctors. I am also one of them. We know no Physician can do any Diagnosis until patient is medically evaluated, starting with the proper medical history and physical exam. None of these Physicians have done this indispensable requirement. I do not care, what they said. Hippocratic Oath.. do no harm.. They are harming our President, they are braking the law, President can sue them if he wants to. Dr. Vargas

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