When 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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  • Disclaimer. I am not an expert in forensic diagnosis, or fitness for duty assessments like psychiatrist David Reiss, who does “fitness for duty” evaluations for police departments and is a contributor to “The Dangerous Case of Donald Trump.” He said that the president “likely would not qualify to be an Air Force officer entrusted with a nuclear weapon.”

    I have diagnosed uncountable clients in my 40-year career prior to retirement but only a few represented a major challenge.

    With someone who is not trying to deceive the therapist diagnosis is fairly easy. I never did fitness for duty or forensic evaluations. Therapists experienced in these kinds of assessments have vast experience working with less than candid clients and outright liars.

    No client ever came close to approaching the difficulty even an experienced therapist would have in assessing Trump’s fitness to be president to the level that would be necessary to present in a hearing called in the Senate to determine whether the 25th Amendment temporary removal is justified. It would be more difficult to remove Trump from office than to deny an unstable police officer the right to carry a gun and badge, let alone stop someone from working in a nuclear missile command center, yet Trump has the ability to start a nuclear war,

    Trump would have every reason to attempt look good in a mental health assessment with his presidency at stake. In the examiners benefit, he has no idea how to fake a psychiatric assessment. He simply doesn’t know what “normal” (non-pathological) behavior is.

    If anyone felt constrained by the Goldwater rule they would refrain from making any diagnosis whatsoever unless they interviewed him and of course gave permission to release their assessment and recommendations to the public. Freed from the constraints of the Goldwater Rule here’s what I’d want done.

    I would want Trump to authorize the clinician to contact all his prior medical professionals, anyone who taught him in school, and just about anyone else who had interactions with him, and instruct them to fully release any written information they had on him and, crucially, to discuss with me their impressions of him.

    I would want the examiner to be able to talk to just about anyone they deemed to have relevant information including family members. I would also want the examiner or a designated top expert or experts to conduct a complete battery of psychological tests possible to included neuropsychological tests many of which the layman is not familiar with. These tests would include those which assess his problem-solving ability in addition to those generally used to tease of indications of psychopathology.

    Depending on recommendations from other evaluators I might also want a referral to a behavioral neurologist to look for signs of cognitive impairment such as early-onset dementia. I’d want to use any other expert who would help.

    Then the primary clinician would meet with a group of top experts in psychological, psychiatric, and neurological assessment for consultation to make a plan as to how to proceed with the in-person examination.

    I would want the option of having a co-therapist conducting the interview or more likely several interviews. The possibility of having marital and family assessments must be left open.

    I don’t see the in-person assessments as being antagonistic, in fact, every effort would be made not to deliberately provoke Trump. However, he would have to be presented with numerous examples of his potentially diagnostically relevant behavior and asked to explain what he was feeling and thinking at the time.

    Self-awareness and insight into his own motivations would all be evaluated.

    He would be asked to explain the reasoning behind his grandiose statements. He would be asked what he was feeling and thinking when he made them.

    He would be asked to explain what he feels when people insult or attack him.

    He would be asked what he felt when incited people to act out their own aggressive feelings.

    His contradictory statements, and of course his outright lies would have to be brought up without deliberately provoking him. His explanations would be duly noted. The clinician should attempt to follow Trump’s internal logic.

    The clincian wold look for:

    impaired reality testing,
    delusions,
    tangential thinking, speech and thought,
    loose associations,
    and paranoid ideation
    perseveration
    derailment

    All efforts would have to be made not to get him defensive or anger him so if he did respond this way it would not be because of the clinician setting him up.

    If Trump managed to be on his best behavior and not erupt into episodes of rage only then would I want the clinician to push him gradually by confronting him with his most blatant contradictions and lies to see whether or not he had an impulse control disorder.

    Additions:

    From a psychotherapist friend:

    To engage the cognitive is often to reduce the amygdala’s emotional activity. Asking him to co-create a four-generation family diagram with the clinician can be inherently calming in its focus on collecting facts of multigenerational family functioning. Repetitive intergenerational patterns, including patterns of strength (he will respond to that), sibling birth order, how, as a child, he observed adults responding to one another when anxious, traumas in past and current generations, etc. should be part of the assessment. Context is key to any thorough assessment. One must see the self in the family system and the family system in the self!

    ————-

    Here’s a list of possible indications of cognitive impairment and decline which would have to be assessed. It is from Trump’s troubling behavior raises questions his medical exam didn’t answer, by John Gartner, David Reiss and Steven Buser published Jan. 22, 2018 in USA Today:

    ►Declining complexity of thought, rambling speech, difficulty completing a thought

    ►Markedly declining vocabulary over recent years, with over-reliance on superlatives

    ►Episodes of slurred speech

    ►Failure to recognize old friends (link corrected)

    ►Perseveration of thought (perpetual repetition of the same concepts)

    ►Decreased fine motor coordination

    ►Difficulties reading, listening and comprehending

    ►Suspect judgment, planning, problem-solving, and impulse control

    • I think that you are complicating this question unnecessarily.

      The constitutional question is simple, turning on “ability to discharge the powers and duties of the office”. If Trump can’t do that, various other office-holders are given the power and duty to remove him by the 25th Amendment. He very obviously can’t do that. He has no apparent interest in politics or public policy. It isn’t clear that he has made any of the decisions his handlers attribute to him. He is breathtakingly free with very public expressions of stark and idiosyncratic opinions on a range of political and public policy questions, but his handlers clearly treat those as merely opinions, not orders. His press secretary has told us that directly, his tweets are just his opinions. He apparently tries to give orders, but those are generally so obviously foolish, that his handlers just ignore him. According to Woodward, they can get around having to execute his orders by the simple expedient of taking documents out of his inbox and destroying them. He can’t or won’t follow through on his stark opinions, he can’t translate them into functional decisions. He can’t execute, and therefore cannot be the Chief Executive.

      We have very public inability to function in the discharge of powers and duties. No medical diagnosis needs to be added to that.

      It is true that dementia (a group or category of diagnoses) is almost certainly the cause of this dysfunction in office. And though it is true that no medical diagnosis is necessary to resolve the political problem created by a president who is unable to discharge the duties and powers of his office, of course, because our system of govt is a republic, and govt is a public matter, every relevant light should be shed on the cause of a dysfunction that requires the result of the 2016 presidential election to be overturned by means of the 25th.

      But you don’t need any sort of testing of cognitive ability abstracted from functional results in the patient’s life, to make the diagnosis. Dementia is present if these two criteria are met:
      1) continuing and progressive cognitive impairment
      2) causing dysfunction in the patient’s life
      I use the CDR, a semi-structured inventory of six functional areas of the patient’s life, in an interview with the patient and at least one relative, to make the diagnosis of dementia. If I find dysfunction, at a relatively even level across the six functional areas, that began at least a year ago, and is not subject to dramatic remissions and exacerbations, then the patient is demented. Lab work is a safety play against infectious or metabolic problems that might mimic dementia, and imaging is needed to decide what kind of dementia is present, but formal cognitive testing is only needed if somebody or other wants a foolish pseudo-criteria looked at and reported, to meet some foolish administrative requirement.

      Trump’s case of dementia is almost unique, in that he is almost uniquely (for an office holder) willing to express his frank opinions, in an office that gets an almost unique level of attention to the office holder. We are able to compare his freely expressed thoughts to the resulting performance discharging his powers and duties in pursuit of his executing those opinions in public policy, and we see that not only can he not get anything done, he doesn’t even, in most cases, seem to understand that he hasn’t gotten a thing done. Without interviewing the patient or a family member, we have three of the functional areas of the CDR covered — Memory, Judgement and Problem Solving, and Community Affairs. It would be nice to sit down with this patient and a family member and fill in the other three, but we already have enough for a diagnosis.

      Who cares if Trump won’t cooperate with filling in the other three areas of the CDR? Still less should anyone care if he refuses neuro-psych testing, or lab work, or imaging. He’s dysfunctional in his office, and we don’t need any of those things to establish that. He needs to be removed from that office. He may still be quite functional in a less demanding life situation, and he is quite welcome to go back to that less demanding life. Of course, at this point, his astonishingly bad judgement in leaving his simpler life as titular head of a rather shady business enterprise to expose himself to the public scrutiny a president is subjected to, may very lead to the custodial care of a prison — a real lifestyle simplification.

  • Just on MSNBC, there was a discussion about the matter of what they called “senility” would be most likely to convince Pence et al that invoking the 25th was justified. In part, I think this is something that the public would be more accepting of than saying that his erratic behavior is due to a mental illness which despite a supposedly enlightened society still has a stigma associated with it. I am in the majority of mental health therapists who think Trump is a malignant narcissist. Friday I wrote: Distinguished shrinks weigh in on the anonymous N.Y. Times OpEd, and so do I here: https://www.dailykos.com/stories/2018/9/7/1793807/-Distinguished-shrinks-weigh-in-on-the-anonymous-N-Y-Times-OpEd-and-so-do-I

  • Trump doesn’t have dementia. Though I am a retired NP, my judgment isn’t based on medical knowledge, it’s based on having lived in NYC for 30 years where the media tirelessly promoted this jackass that nobody in the city cared about. Notice he not only had to resort to foreign banks, he also had to resort to foreign countries for two of his wives. Meanwhile, he was living in a city with millions of attractive young women who would have nothing to do with him – with the exception of Marla Maples. When a woman inserts herself into her married lover’s family vacation & confronts his wife, I think we can tell what a special kind of person Maples is.

    Trump has always been a liar, a fraud, a dissembler, an egomaniac, venal, an agent of chaos, unempathetic and wildly boorish. The lazy NYC media was thrilled to have him, particularly as the 24 hour news cycle became the standard. Trump filled dead airtime, he was the go-to person when reporters had a looming deadline and a crippling hangover. “I’ll call Trump,” was the Hail Mary of “journalism.”

    He has always gotten up before a crowd and made meandering, self-promoting speeches that seem endless. Before someone hit on the idea of a Trump university, he made money from lectures in hotel conference rooms, ostensibly telling people how to be successful in real estate, but ending up giving an extemporaneous diatribe about whoever Trump happened to hate the most on that particular day.

    The only reason he had his fingers in so many pies is because of how bad he is at business. If he was good at real estate, he would only need to be in real estate. Jared Kushners family doesn’t try to sell Kushner brand steaks, ties, vodka, an airline, a failed NFL grab. They’re successful in real estate, that’s why.

    Trump started out with a $9M loan from his father (which he claims was $1M), needed his father to buy $2.5M in chips to keep his casino solvent and STILL lost the casino. Why did Trump lose his casinos? Because he’s mentally disturbed and should not be in charge of anything. He lost $1B dollars in the early 1990s. He’s declared bankruptcy 6 times. The only reason you still hear from him is the credulousmess of Americans. We in NYC knew he needed that TV show to pay off creditors. We know he won’t show his tax returns because he’s in massive debt to lenders. He borrows from Petr to pay Pavel. If he hadn’t been lauded by the media for all these years he’d have been locked up a long time ago. His disturbed, chaotic mind has always been this way. He doesn’t read, he has no interest in anything outside of himself and his family, no curiosity about other people or history, geography, diplomacy. He only cares about money and vengeance. Now that he isn’t being covered by lazy media hacks in NYC to make a deadline, people start noticing his rallies and his tweets are nothing but repetitive performance art. If you keep seeing the same shtick over and over again, you start to wonder about the performer. Maybe he’s not so good after all. Maybe he’s just some guy who got lucky, like Milton Berle, and was able to make a career out of 5 ml of talent.

    The dithering, slurring, repetitive, juvenile, revenge-seeking Trump you see today is who he has always been. It’s just that PT Barnum was right – there’s a sucker born every minute. There is always a group of people in the top bracket of intelligence; then there is a majority in the middle, and at the bottom you’ve got about 33% of your population. They’re the Trump voters. Gullible, greedy, incurious people who admire bling and bluster.

    His head problems are mental, not physical. And our problem is that our society has become so greedy it will excuse any kind of behavior in its admiration of the wealthy (and those who aren’t wealthy but are good at the pretense).

  • Oh please, one more article declaring Trumpt to have brain damage or mental illness without the benefit of history and physical, family informants, cognitive testing, lab tests or imaging. Please stop the arm chair diagnosis. Go to work for a totalitarian regime where political opponents are declared mentally ill and sent away for “rehabilitation.”

  • ” .. I have written extensively about him on Daily Kos.”

    DK – proven (D) front.

    You’re a politician. That shows.

    Want to test someone? Test Obama’s math abilities — you should find, they are sub-marginal, like all (D).

  • “Ford Vox” is not the name of any board-certified neurologist or psychiatrist on the the American Board of Psychiatrists and Neurologists (ABPN) website.
    A Google search states he is a physiatrist. Ford Vox, M.D. should clearly state that he is a physiatrist, because his self-designation as a “brain specialist” is misleading. I would refer a patient suspected of mild, early dementia to a neurologist for diagnosis, not to a physiatrist, who usually treat more severe, established cases of neurological injury or disease, where the diagnosis is often clearly evident.

  • Disinhibition and socially inappropriate behavior do suggest early fronto-temporal dementia. However, President Trump has functioned at a very high level, based on his economic results. He offers a rational and cogent game plan for immigration reform for the many Americans who do not want to be overwhelmed with poor migrants, as has affected Europe. Unemployment is at record lows, including Black unemployment. I have the following questions:
    1) Are you a board-certified neurologist?
    2) What form of testing or examination could you offer, compared with what the President has had?
    3) What do you make of his score of “30 out of 30”, evidently a perfect mini-mental status test score?
    4) Please reply, I believe the debate would be instructive.

    • If Trump, or any patient, had a copy of the test like the Montreal Cognitive Assessment Test (MoCA) in advance and practiced taking it, I do not think the results would be valid. Trump is known to lie whenever he thought it would make him look good. We are asked to trust he wouldn’t cheat on a cognitive test at a time when his mental functioning is being questioned? Put another way, why would Trump risk having his cognitive test confirm the speculation that he was unfit to be president?

      If I was a Trump advisor and wanted to help him put aside the rampant speculation about his being in the early stages of dementia, I would have suggested he ASK to be tested during his physical.

      Then I would check online to determine which were the most likely tests would be used. The MoCA is one of two commonly used tests, the other being the Mini–Mental State Examination (MMSE).

      Trump could have taken the tests repeatedly until he could answer all the questions.

      I would have suggested Trump get a couple of questions wrong to avoid suspicion, but of course he would probably ignore this advice wanting to brag about getting 30 out of 30 right.

      It is certainly possible Trump was concerned about the possibility he might actually be suffering cognitive decline, and gone into the test with no prior knowledge. In this case we have evidence that his cognition isn’t as impaired as has been suggested by some observers, or isn’t impaired at all.

    • 1. PhD (neuroscience),MD. One particular expertise is in neuroprotection. A couple treatment modalities coming out of our work are now in clinical trials for neurodegenerative diseases. One in phase-3. I got this stuff.

      Interestingly, I attended the same medical school as Trumps doc. So we likely both sat thru the same neuro course, more or less. He carefully retains “plausible deniability” concerning the near certainty that Trump or his handlers had seen the test before.

      2) Like to see a “real” neuro workup, not just a screening test intended to primarily measure memory and to distinguish between FTD and alzheimers. . Including MRI and Pet-scans looking for frontal lobe atrophy or impairment. As it was, only one question (concerning “abstraction”) on the MOCA is directly relevant to frontal lobe function. And that only consists of two elementary similes.

      3) Google “moca” for a copy of the test. Someone in the Whitehouse certainly did. With what is at stake, do you really think Trump or his handlers didn’t get a copy? The “right” answers are either obvious or stated explicitly.

      Trump is an actor, used to memorizing lines from a script. I can see he and his handlers going thru as many repetitions as possible to get things just right. In fact, I’m now considering memorizing the answers myself, just in case. Likely, so would you.

      Coming back to the “abstraction” question. The John Dickerson interview shows Trump blowing right thru a metaphor, giving a completely concrete interpretation. Which is inconsistent with Trump “passing” this part of the test. Admittedly more sophisticated than what the MOCA uses. So may represent more subtile organicity.

    • 1) The American Board of Psychiatrists and Neurologists (ABPN) website does not verify either of the following persons as board-certified in either specialty: “Vox, Ford” and “Brown, Hal”, which can be verified at the following link:

      https://application.abpn.com/verifycert/verifyCert.asp?a=1

      2) Your statement “Trump is known to lie whenever he thought it would make him look good” is, prima facie, unprofessional, unscientific, defamatory and biased. I urge you to retract it, or to provide citations.

    • There are two ABMS-associated “neurology” boards, representing the overlap between the fields of psychiatry and neurology, particularly with reference to “Organic” brain syndromes. That is, brain diseases associated with actual death or atrophy of brain tissue, as in Alzhemers or FTD, etc. No one specialty has a monopoly on these.

      One is the “ABN” or American Board of Neurology. This is composed of “real” neurologists, the guys who treat Parkinsons, stroke, etc..

      The other is the American Board of Psychiatry and Neurology (ABPN), the psychiatrist board. Mainly, ABPN docs treat “functional” psychiatric diseases, with a significant overlap over into treatment and diagnosis of organic brain syndromes. Which is where “”neurology” comes in. BTW, my daughter-the-doctor is ABPN-certified.

    • To Dr. Keller: I never said I was an MD – I am a member of the mental health profession proving the majority of outpatient psychotherapy in the United States, clinical social work. I do not write about anything that would require medical expertise to opine on. I said he could have cheated and did not offer an opinion of whether he suffered from a cognitive disorder.

      Ford Vox never identifies himself as a psychiatrist or neurologist. He is clear in what his job entails as a brain injury physician, and although he doesn’t say he’s a physiatrist I’ll take your word for it. Unlike most internists a physiatrist working in a setting like where Dr. Vox works treats people with a wide range of neurological disorders every day.

      I agree with Brainstorm, who said what I did with fewer words: “Trump is an actor, used to memorizing lines from a script. I can see he and his handlers going thru as many repetitions as possible to get things just right. In fact, I’m now considering memorizing the answers myself, just in case. Likely, so would you.”

      I do not think Trump can take credit for this: “President Trump has functioned at a very high level, based on his economic results.” I hardly think the state of the ecomony is due to the president functioning at a very high level, although he takes sole credit for everything good about the economy and conveniently ignores everything bad about it (jobs still moving to other countires for example).

      I do, however, think as do you that “he offers a rational and cogent game plan for immigration reform for the many Americans who do not want to be overwhelmed with poor migrants, as has affected Europe” since this is a rational and cogent plan if you are a white nationalist – or to put it politely as Trump does, believe in America First.

      I stand by what I wrote and challenge Dr. Keller or anyone else to state what in my proposition says that cheating on his cognitive assessment is not a possibility. To quote Reagan, I say “Доверяй, но проверяй” – or trust but verify. This would require the president taking a customized MoCA with all the questions changed. (Okay, obviously I do not trust the president.)

      About me: I am a retired licensed independent clincial social worker who practiced outpatient psychotherapy mostly with adults for over 40 years. In this capacity I diagnosed countless patients. I was the director of a small mental health center, as well as a clincial supervisor for numerous staff and interns. My opinions about Donald Trump, and my clincial impressions of him, can easily be found if you Google Trump and my name. I have written extensively about him on Daily Kos.

  • Today President Trump responded to the back and forth comments about the nuclear button.

    To better protect the United States he ordered his contractors to build a much bigger button and said North Korea would pay for the cost.

    He used the metaphor “it will be a “wall” of a button.

    • Here is arguably the most definitive evidence that something “ain’t quite right” with the president. Mainly, because interpreting a metaphor this concretely would not be part of any scripted role by a clever actor, the other alternative for Trumps behavior. A real “Oh sh!t” moment for me when I read it.

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

      PRESIDENT DONALD TRUMP: Sure. Sure.

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

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

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