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.


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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  • 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:


      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 —


      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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