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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  • Bullshit. You’re seeing what you want to see and interpreting it through the lens of your biases. I know a “one dog study” when I see it.

    • Doctors approach every patient’s case individually, making use of multiple bits of data and deductive logic. Simply-stated, medicine is mainly “If it looks like a duck, flies like a duck, and sounds like a duck, it’s probably a duck, rule-out goose”. Just like (say) fixing cars or TV’s, also “One dog studies”.

      Thus, Trump’s unusual behavior might represent an actor playing a scripted part, or alternatively, someone with frontal lobe impairment. So, to rule out “script” you look for something that would not be scripted.

      Your frontal lobes are involved in “abstracting”. one example of which is interpreting metaphors. So neurologists use interpretation of metaphors as a handy proxy for frontal-lobe function. Inability to abstract is unlikely to be scriped. Thus, we can rule-out that interpretation, leaving us with frontal lobe impairment.

      This alone is enough to justify a further workup in pretty much any random patient. It is not “making a diagnosis”, which could be one of several things. In fact, in cases like this, the final diagnosis may involve imaging studies.

    • Doctors approach every patient’s case individually, making use of multiple bits of data and deductive logic. Simply-stated, medicine is mainly “If it looks like a duck, flies like a duck, and sounds like a duck, it’s probably a duck, rule-out goose”. Just like (say) fixing cars or TV’s, also “One dog studies”.

      Thus, Trump’s unusual behavior might represent an actor playing a scripted part, or alternatively, someone with frontal lobe impairment. So, to rule out “script” you look for something that would not be scripted.

      Your frontal lobes are involved in “abstracting”. one example of which is interpreting metaphors. So neurologists use interpretation of metaphors as a handy proxy for frontal-lobe function. Inability to abstract is unlikely to be scriped. Thus, we can rule-out that interpretation, leaving us with frontal lobe impairment.

      This alone is enough to justify a further workup in a random patient. It is not “making a diagnosis”, which could be one of several things. In fact, in cases like this, the final diagnosis may involve imaging studies.

    • Obama crew (D) ran wild with taxpayer funds, pushing the taxpayer debt from $10 TRILLION to $20 TRILLION, in eight years.

      To many, it is OBAMA crew (D) who need a “brain specialist.”

  • Almost certainly NOT alzheimers. Inability to intrepret metaphors with clinical history says Trump’s frontal lobe function is dysproportionately-impaired. Alzheimers is generally much more global.

    This is supported by presidents gross disregard for social and interpersonal norms and apparent inattention to consequences, which admittedly could just be part of the “act”. Why I look at things like “interpretation of metaphors as a less-ambiguous sign.

    Orginating as a frontal lobe issue, FTD works its way back, producing temporal symptoms such as word-finding and language issues. We may be seeing these already, along with arguable motor symptoms.

    Eventually, FTD affects the whole brain, producing a syndrome virtually- identical with alzheimers in it later stages. When I was in training, “Pick’s”, another name for FTD, was thought rare. Now it seems about 10-15% of “Alzheimers” and roughly half of Alzheimers under age 65.

    FTD has a significant hereditary component. So the death of Trups father from “alzheimers” is significant. Final diagnosis would require a full neurowork-up, most likely including imaging studies looking for frontal lobe atrophy, hopefully to include PET-scans for frontal and temporal lobe function.

    In any case, there is enough here that were it a random patient showing up it a neruologist’s office, he would definitely be getting a work-up.

    • B, how should a wild pack of over-spenders (D) who double the taxpayer debt in eight years, be “cared for?”

      For many, they ought to be jail. Now. Today.

  • What if an MRI scan showed a benign tumor on his brain in an area related to self-control or analytical judgement? Maybe that’s what we wanted when we voted. You vote on the whole package, and you get what you deserve. I’ve been an Alzheimer’s caregiver for the last six years, I’ve watched a few Trump press conferences, and he doesn’t look even close to MCI or AD. I know what that looks like, and he doesn’t have it. From what I’ve heard from an FTD caregiver, I’ll admit that’s a possibility, but I think it’s more likely he’s been a loose cannon (to put it politely) all of his life.

    • Mark Thorson: You say: “I think it’s more likely he’s been a loose cannon (to put it politely) all of his life.” If I may add in agreement that his previous relatively small cannons caused much damage to people … financially, in terms of their dignity, … His new set of cannons are the biggest the World has known. Assessment of danger is based on previous activity, coupled with an assessment of present availability of tools to cause further damage. I take it that we largely agree.

  • Lots of the symptoms are the same … Degen. Brain Disease … Severe PD coupled with nastiness … TBI Confabulation can look a lot like fake news and path. lying … I listed these: 1. Such people are generally incapable of understanding and responding in an emotionally empathic way to how another feels. Winning appears to be all. They may well, in an intellectual way, be able to know how others react or even what they might be thinking but this has little bearing on how they treat these others who remain objects, like pieces on a Chess board to be moved about in order to win the game.
    2. This Black-and-White thinking effectively splits the World into friend and foe, into those who support him and all those others who are against him. Such a person may, indeed, grow to be incapable of bigotry for to be bigoted or racist or sexist, one must feel allegiance to a group and these so-afflicted appear to develop few such allegiances. Still and all, they may have no qualms about using bigotries for their own purposes.
    3. Lacking the need to evaluate how their actions may impact others, these people react more quickly and with less skepticism about the correctness of their actions.
    4. Such individuals have not yet developed a respect for others’ thinking, relationships or efforts, leading them to place little value in the accomplishments of others. As such, they tend not to recognize the necessity for maintaining extant organizations, government structures, conventional practices, laws, or alliances between others. They may appear civilized but are not safely socialized.
    5. Due to the above (1-4), their thinking is focused but lacks nuance. They demonstrate no apparent ability to see more than one not-unreasonable view: a monomania, of sorts. These views, additionally, can flip to their opposite, since what makes any new attitude acceptable to them is under the control of a “my will be done” syndrome, no matter what that will may be.
    6. Finally, (following on 1-5, above) they display a limited capacity to distinguish the real from the wished for or imagined, and demonstrate a ready willingness to distort the truth.

  • I am going to guess that you are leftist liberal and any objective mental health care professional would not make such a statement without seeing a person first.

    Dr. Michael White

    • And you went to what medical school? The fact that you do not call yourself MD or DO makes me wonder.

      Neuropsych diseases have few if any physical symptoms. So preliminary assessments are quite possible on the basis of well-documented statements, changes in behavior and mental status. There is a plethura of such in the case of Trump.

      My favorite example is when Trump blows right thru interpretation of a metaphor during his interview with John Dickerson. First thing on many mental status exams. Under the clinical circumstances, likely indicative of some frontal lobe impairment, r/o frontotemporal dementia, r/o alzheimers.

    • ” .. My favorite example is when Trump blows right thru interpretation of a metaphor ..”

      My God, you’ve never seen TV news in NYC? They’re all like that — Bloomberg, de Blasio, Cuomo, Sharpton.

      Reality — nothing is better.

    • If deficits in “Interpetation of metaphors” (here, likely signifying frontal-lobe impairment) are common among media types, why was John Dickerson so clearly confused and flustered when Trump blew right thru the one Dickerson tossed out in the interview? Seemed to have no clue as to what he was witnessing.

  • I worked for 35 years as a physician assistant. I have seen patients with early and full blown dementia. I have been concerned about Trumps brain for awhile. If he were you grandfather, and you had seen his decline in vocabulary, his articulateness, and his emotional control, there would be no question you would want him evaluated. If he were your neighbor and you observed some of these things you would want to talk to his family. I have thought for awhile that he has frontotemporal dementia. A typical history is increasingly alienating behavior which ends up with divorce and job losses before the neurological diagnosis is finally made. Yes he is emotionally unfit, but more importantly his brain function is declining and he needs to be evaluated.

  • Reply to Imnot Georgel
    Who is Georgel and why are you not him/her?

    It’s about time someone replied with numerous insults and ad hominems!

    I’ve seen it done to others over and over (not on this site) but this is the first time for me!
    How refreshing when you say:
    1. You show no understanding
    2. You also don’t seem to understand
    3. You just don’t know what you are talking about.

    Did you know that the elites that you want to use in high positions have a generally negative definition?

    Merriam Webster:
    1
    : giving special treatment and advantages to wealthy and powerful people
    elitist colleges
    an elitist country club
    2
    : regarding other people as inferior because they lack power, wealth, etc.
    She’s an elitist snob.

    Maybe we are tired of elitists in high positions and that’s one of the reasons Trump got elected.

    Maybe the backhoe operator would relate well to people in other countries and do very well. Do you need to insult all backhoe operators? It’s unlikely (but possible) that a backhoe operator would do well. The Prime Minister of Canada used to be high school teacher.

    Trump was a TV personality and businessman.

    You quoted me a bit out of context re trying to “take out” the N. Korean regime. I didn’t use the word regime, I said arms and Kim being unstable could press the nuclear button at any time almost on a whim.

    “Should we placate him and walk on eggshells while each day he grows stronger and stronger until he reaches his goal of having a huge nuclear arsenal capable of reaching and destroying the US and other countries?

    The US should have taken out his military arms years ago.”

    You make some good points but we cannot allow N Korea or Iran to start or continue nuclear programs and enlarge and strengthen them to the point where they can destroy the US and other countries.

    That’s why I said we should have taken out his military arms years ago, before they even had a nuclear weapon.

    Haven’t they talked about negotiation for 25 years or so?

    You talk about all the casualties a war would cause but can we allow N Korea to continue to develop better and better weapons which will eventually be able to destroy the US and S Korea you talk about?:

    https://www.rollingstone.com/politics/features/timeline-of-the-north-korean-nuclear-threat-w496701
    “Most ominous was the July 28th launch of the Hwasong-14 ballistic missile 2,300 miles into space at a steep trajectory that ended with a splash down in the Sea of Japan. Experts believe if the missile had been given a flatter (horizontal) trajectory, it could have reached as far as Chicago. With only a modest performance boost, New York and Washington D.C. would be within range.

    Any missile crashing down on an American city is a terrifying prospect, but North Korea is also working at top speed to arm its missiles with nuclear warheads. From 2006 to 2016, North Korea conducted five successful nuclear tests. It is currently estimated to have eight to ten nuclear bombs. North Korea, a remarkably unstable country, is about ready to join the ranks of countries with a global nuclear reach.”

    You offer criticism but no solution. It’s either negotiate and stop them that way or take out their military and stop them that way.

    Negotiation has failed for years and resulted in their military becoming much, much stronger. We can continue to try negotiation and that’s fine, and maybe it will succeed but for how long should we try while they work on more powerful arms to destroy us?

    • The unstated main reason we have done nothing militarily about Kim is that he has long been able to dump a nuke on any staging areas for an invasion. Could use a bomber, if necessary.

      Yeah, we could probably intercept. But even one getting thru would be catastrophic to any invasion force. So few commanders would take the chance. This also includes any amphibious invasion.

      Nobody much talks about this, but it is why many retired generals, etc. say we are well and truly stuck. We would not have been able to invade Iraq had Saddam had nukes. It takes a while to assemble an invasion force and meanwhile it is very vulnerable to a nuke.

    • Mr. Vox, I want HRC to take a lie detector test. Ditto, her goofy husband.

      I want BHO, tribal Chief Eliza. Warren, and all elected (D) to take a math test on budget deficits. And if they can’t score 80%, all of BHO’s “pen-and-phone” orders are immediate voided. I don’t think they can do it.

      Happy, now? Good.

  • There is a reason we want elites in the Special Forces and teaching at Ivy League schools and it is the same reason we don’t appoint the backhoe operator as Secretary of State or an ambassador. In diplomacy and negotiation, superior use of language (both in subtlety and specificity) are a huge advantage as is self control and planning.

    You show no understanding of the situation in N. Korea, nor the role that both Russia and China have played for decades. You also don’t seem to understand the consequences of either nuclear war or trying to “take out” the N. Korean regime. First of all, tens of millions of S. Koreans would die from conventional artillery and war as well as possibly many Americans, Japanese and others. Second, neither China nor Russia would stand by and allow us to do that, just as they engaged in the Korean War 65 years ago.

    You just don’t know what you are talking about.

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