It is best not to diagnose the president from afar, which is why the federal government needs a system to evaluate him up close.





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President Donald Trump’s decision to brag in a tweet about the size of his “nuclear button” compared with North Korea’s was widely condemned as bellicose and reckless. The comments are also part of a larger pattern of odd and often alarming behavior for a person in the nation’s highest office. Trump’s grandiosity and impulsivity have made him a constant subject of speculation among those concerned with his mental health. But after more than a year of talking with doctors and researchers about whether and how the cognitive sciences could offer a lens to explain Trump’s behavior, I’ve come to believe there should be a role for professional evaluation beyond speculating from afar. I’m not alone. Viewers of Trump’s recent speeches have begun noticing minor abnormalities in his movements. In November, he used his free hand to steady a small Fiji bottle as he brought it to his mouth. Onlookers described the movement as “awkward” and made jokes about hand size. Some called out Trump for doing the exact thing he had mocked Senator Marco Rubio for during the presidential primary—conspicuously drinking water during a speech. (Joshua Roberts / Reuters)

(Mark Wilson / Getty) By comparison, Rubio’s movement was smooth, effortless. The senator noticed that Trump had stared at the Fiji bottle as he slowly brought it to his lips, jokingly chiding that Trump “needs work on his form. Has to be done in one single motion, and eyes should never leave the camera.” Then, in December, speaking about his national-security plan in Washington, D.C., Trump reached under his podium and grabbed a glass with both hands. This time he kept them on the glass the entire time he drank, and as he put down the glass. This drew even more attention. The gesture was like that of an extremely cold person cradling a mug of cocoa. Some viewers likened Trump to a child just learning to handle a cup.

Then there was an incident of slurred speech. Announcing the relocation of the American embassy in Israel from Tel Aviv to Jerusalem—a dramatic foreign-policy move—Trump became difficult to understand at a phonetic level, which did little to reassure many observers of the soundness of his decision. Experts compelled to offer opinions on the nature of the episode were vague: The neurosurgeon Sanjay Gupta described it as “clearly some abnormalities of his speech.” This sort of slurring could result from anything from a dry mouth to a displaced denture to an acute stroke.

Though these moments could be inconsequential, they call attention to the alarming absence of a system to evaluate elected officials’ fitness for office—to reassure concerned citizens that the “leader of the free world” is not cognitively impaired, and on a path of continuous decline. Proposals for such a system have been made in the past, but never implemented. The job of the presidency is not what it used to be. For most of America’s history, it was not possible for the commander in chief to unilaterally destroy a continent, or the entire planet, with one quick decision. Today even the country’s missileers—whose job is to sit in bunkers and await a signal—are tested three times a month on their ability to execute protocols. They are required to score at least 90 percent. Testing is not required for their commander in chief to be able to execute a protocol, much less testing to execute the sort of high-level decision that would set this process in motion. A president could be actively hallucinating, and the medical community could be relegated to speculation from afar. The lack of a system to evaluate presidential fitness stands to become only more consequential as the average age of leaders increases. The Constitution sets finite lower limits on age but gives no hint of an upper limit. At the time of its writing, septuagenarians were relatively rare, and having survived so long was a sign of hardiness and cautiousness. Now it is the norm. In 2016, the top three presidential candidates turned 69, 70, and 75. By the time of the 2021 inauguration, a President Joe Biden would be 78. After age 40, the brain decreases in volume by about 5 percent every decade. The most noticeable loss is in the frontal lobes. These control motor functioning of the sort that would direct a hand to a cup and a cup to the mouth in one fluid motion—in most cases, without even looking at the cup. Related Stories Evaluating Trump's Psyche in Public

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The Bizarre Words of Donald Trump’s Doctor These lobes also control much more important processes, from language to judgment to impulsivity. Everyone experiences at least some degree of cognitive and motor decline over time, and some 8.8 percent of Americans over 65 now have dementia. An annual presidential physical exam at Walter Reed National Military Medical Center is customary, and Trump’s is set for January 12. But the utility of a standard physical exam—knowing a president’s blood pressure and weight and the like—is meager compared with the value of comprehensive neurological, psychological, and psychiatric evaluations. These are not part of a standard physical. Even if they were voluntarily undertaken, there would be no requirement to disclose the results. A president could be actively hallucinating, threatening to launch a nuclear attack based on intelligence he had just obtained from David Bowie, and the medical community could be relegated to speculation from afar.

Even if the country’s psychiatrists were to make a unanimous statement regarding the president’s mental health, their words might be written off as partisan in today’s political environment. With declining support for fact-based discourse and trust in expert assessments, would there be any way of convincing Americans that these doctors weren’t simply lying, treasonous “liberals”—globalist snowflakes who got triggered? The downplaying of a president’s compromised neurological status would not be without precedent. Franklin D. Roosevelt famously disguised his paralysis from polio to avoid appearing “weak or helpless.” He staged public appearances to give the impression that he could walk, leaning on aides and concealing a crutch. Instead of a traditional wheelchair, he used an inconspicuous dining chair with wheels attached. According to the FDR Presidential Library, “the Secret Service was assigned to purposely interfere with anyone who tried to snap a photo of FDR in a ‘disabled or weak’ state.” Documenting the reality of Roosevelt’s health status fell to journalists, who had been reporting on his polio before his first term. A 1931 analysis in Liberty magazine asked, “Is Franklin D. Roosevelt Physically Fit to Be President?” and reported on his paralysis: “It is an amazing possibility that the next president of the United States may be a cripple.” Once he was elected, Time described the preparation of the White House: “Because of the president-elect’s lameness, short ramps will replace steps at the side door of the executive offices leading to the White House.”

Today much more can be known about a person’s neurological status, though little of it is as observable as paraplegia. Unfortunately, the public medical record available to assuage global concerns about the current president’s neurological status is the attestation of Harold Bornstein, America’s most famous Upper Manhattan gastroenterologist, whose initial doctor’s note described the 71-year-old Trump as “the healthiest individual ever elected to the presidency.” Trump has exhibited a “clear reduction in linguistic sophistication over time.” The phrasing was so peculiar for a medical record that some suggested that Trump had written or dictated the letter himself. Indeed, as a key indicator of neurological status, Trump’s distinctive diction has not gone without scrutiny. Trump was once a more articulate person who sometimes told stories that had beginnings, middles, and ends, whereas he now leaps from thought to thought. He has come to rely on a small stable of adjectives, often involving superlatives. An improbably high proportion of what he describes is either the greatest or the worst he’s ever seen; absolutely terrible or the best; tiny or huge. The frontal lobes also control speech, and over the years, Donald Trump’s fluency has regressed, and his vocabulary contracted. In May of last year, the journalist Sharon Begley at Stat analyzed changes in his speech patterns during interviews over the years. She noted that in the 1980s and 1990s, Trump used phrases such as “a certain innate intelligence” and “These are the only casinos in the United States that are so rated.” I would add, “I think Jesse Jackson has done himself very proud.”

He also more frequently finished sentences and thoughts. Here he is with Larry King on CNN in 1987: Larry King: Should the mayor of the city be someone who knows business? Donald Trump: Well, what we need is competence. We don’t have that. We have a one-line artist. That’s all he is … Or on Oprah in 1988: Oprah Winfrey: What do you think of this year’s presidential race, the way it’s shaping up? Trump: Well, I think it’s going to be very interesting. I think that probably George Bush has an advantage, in terms of the election. I think that probably people would say he’s got, like, that little edge in terms of the incumbency, etcetera, etcetera. But I think Jesse Jackson has done himself very proud. I think Michael Dukakis has done a hell of a job. And George Bush has done a hell of a job. They all went in there sort of as semi-underdogs—including George Bush—and they’ve all come out. I think people that are around all three of those candidates can be very proud of the jobs they’ve done. Compare that with the meandering, staccato bursts of today. From an interview with the Associated Press: People want the border wall. My base definitely wants the border wall, my base really wants it—you’ve been to many of the rallies. Okay, the thing they want more than anything is the wall. My base, which is a big base; I think my base is 45 percent. You know, it’s funny. The Democrats, they have a big advantage in the Electoral College. Big, big, big advantage … The Electoral College is very difficult for a Republican to win, and I will tell you, the people want to see it. They want to see the wall. Ben Michaelis, a psychologist who analyzes speech as part of cognitive assessments in court cases, told Begley that although some decline in cognitive functioning would be expected, Trump has exhibited a “clear reduction in linguistic sophistication over time” with “simpler word choices and sentence structure.”

This is evident even off camera, as in last week’s post-golf sit-down with The New York Times at his resort in Florida: The tax cut will be, the tax bill, prediction, will be far bigger than anyone imagines. Expensing will be perhaps the greatest of all provisions. Where you can do something, you can buy something … Piece of equipment … You can do lots of different things, and you can write it off and expense it in one year. That will be one of the great stimuli in history. You watch. That’ll be one of the big … People don’t even talk about expensing, what’s the word, “expensing.” [Inaudible.] One-year expensing. Watch the money coming back into the country, it’ll be more money than people anticipate. But, Michael, I know the details of taxes better than anybody. Better than the greatest CPA. I know the details of health care better than most, better than most. And if I didn’t, I couldn’t have talked all these people into doing ultimately only to be rejected. Now here’s the good news. We’ve created associations, millions of people are joining associations. Millions. That were formerly in Obamacare or didn’t have insurance. Or didn’t have health care. Millions of people. That’s gonna be a big bill, you watch. It could be as high as 50 percent of the people. You watch. So that’s a big thing … The paper said that the transcript was “lightly edited for content and clarity.” If Trump’s limited and hyperbolic speech were simply a calculated political move—he repeated the phrase “no collusion” 16 times in the Times interview, which some pundits deemed an advertising technique—then we would also expect an occasional glimpse behind the curtain. In addition to repeating simplistic phrases to inundate the collective subconscious with narratives such as “no collusion,” Trump would give at least a few interviews in which he strung together complex sentences—for example, to make a case for why Americans should rest assured that there was no collusion.

Though it is not possible to diagnose a person with dementia based on speech patterns alone, these are the sorts of changes that appear in early stages of Alzheimer’s. Trump has likened himself to Ronald Reagan, and the changes in Trump’s speech evoke those seen in the late president. Reagan announced his Alzheimer’s diagnosis in 1994, but there was evidence of linguistic change over the course of his presidency that experts have argued was indicative of early decline. His grammar worsened, and his sentences were more often incomplete. He came to rely ever more on vague and simple words: indefinite nouns and “low imageability” verbs such as have, go, and get. After Reagan’s diagnosis, former President Jimmy Carter sounded an alarm over the lack of a system to detect this sort of cognitive impairment earlier on. “Many people have called to my attention the continuing danger to our nation from the possibility of a U.S. president becoming disabled, particularly by a neurologic illness,” Carter wrote in 1994 in the Journal of the American Medical Association. “The great weakness of the Twenty-Fifth Amendment is its provision for determining disability in the event that the president is unable or unwilling to certify to impairment or disability.” Indeed, the 1967 amendment laid out a process for transferring power to the vice president in the event that the president is unable to carry out the duties of the office because of illness. But it generally assumed that the president would be willing to undergo diagnostic testing and be forthcoming about any limitations.

This might not happen with a person who has come to be known for denying any hint of weakness or inability. Nor would it happen if a president had a psychiatric disorder that impaired judgment—especially if it was one defined by grandiosity, an obsession with status, and an intense aversion to being perceived as weak. Nor would it happen if the only person to examine the president was someone like Bornstein—whose sense of objective reality is one in which Trump is healthier than the 42-year-old Theodore Roosevelt (who took office after commanding a volunteer cavalry division called the Rough Riders, and who invited people to the White House for sparring sessions, and who, after his presidency, would sometimes spend months traversing the Brazilian wilderness). It was for these reasons that in 1994, Carter called for a system that could independently evaluate a president’s health and capacity to serve. At many companies, even where no missiles are involved, entry-level jobs require a physical exam. A president, it would follow, should be more rigorously cleared. Carter called on “the medical community” to take leadership in creating an objective, minimally biased process—to “awaken the public and political leaders of our nation to the importance of this problem.” To attribute Trump’s behavior to mental illness risks devaluing mental illness. More than two decades later, that has not happened. But questions and concern around Trump’s psychiatric status have spurred proposals anew. In December, also in the Journal of the American Medical Association, mental-health professionals proposed a seven-member expert panel “to evaluate presidential fitness.” Last April, Representative Jamie Raskin introduced a bill that would create an 11-member “presidential capacity” commission. The real-world application of one of these systems is complicated by the fact that the frontal lobes also control things such as judgment, problem-solving, and impulse control. These metrics, which fall under the purview of psychiatrists and clinical psychologists, can be dismissed as opinion. In a hospital or a doctor’s office, a neurologist may describe a patient with Parkinson’s disease as having “impaired impulse control.” The National Institute on Aging lists among the symptoms of Alzheimer’s “poor judgment leading to bad decisions.”

These are phrases that can and do appear in a person’s medical record. In the public sphere, however, they’re easily dismissed as value judgments motivated by politics. The Harvard law professor Noah Feldman recently accused mental-health professionals who attempt to comment on Trump’s cognition of “leveraging their professional knowledge and status to ‘assess’ his mental health for purposes of political criticism.” Indeed, thousands of mental-health professionals have mobilized and signed petitions attesting to Trump’s unfitness to hold office. Some believe Trump should carry a label of narcissistic personality disorder, antisocial personality disorder, or both. The largest such petition has more than 68,000 signatures—though there is no vetting of the signatories’ credentials. Its author, the psychologist John Gartner, told me last year that in his 35 years of practicing and teaching, “this is absolutely the worst case of malignant narcissism I’ve ever seen.” Many other mental-health professionals are insistent that Trump not be diagnosed from afar by anyone, ever—that the goal of mental-health care is to help people who are suffering themselves from disabling and debilitating illnesses. A personality disorder is “only a disorder when it causes extreme distress, suffering, and impairment,” argues Allen Frances, the Duke University psychiatrist who was a leading author of the third edition of the Diagnostic and Statistical Manual, which was the first to include personality disorders.

This is consistent with the long-standing, widely misunderstood rule in the profession that no one should ever be diagnosed outside the confines of a one-on-one patient-doctor relationship. The mandate is based on a legal dispute that gave rise to the American Psychiatric Association’s “Goldwater Rule,” which was implemented after the politician Barry Goldwater sued Fact magazine for libel because a group of mental-health professionals had speculated about Goldwater’s thought processes in its pages. The rule has protected psychiatrists both from lawsuits and from claims of subjectivity that threaten trust in the entire enterprise. After more than a year of considering Trump’s behavior through the lens of the cognitive sciences, I don’t think that labeling him with a mental illness from afar is wise. A diagnosis such as narcissistic personality disorder is too easily played off as a value judgment by an administration that is pushing the narrative that scientists are enemies of the state. Labeling is also counterproductive to the field in that it presents risks to all of the people who deal with the stigma of psychiatric diagnoses. To attribute Trump’s behavior to mental illness risks devaluing mental illness. Judiciousness in public statements is only more necessary as the Trump administration plays up the idea of partisan bias in its campaign against “the media.” The consistent message is that if someone is saying something about the president that depicts or reflects upon him unfavorably, the statement must be motivated by an allegiance to a party. It must be, in a word, “fake”—coming from a place of spite, or vengeance, or allegiance to some team, creed, or party. Expertise is simply a guise to further a hidden political cause. Senator Lindsey Graham recently told CNN that the media’s portrayal of Trump is “an endless, endless attempt to label the guy as some kind of kook not fit to be president.” Bias will color any assessment to some degree, but it needn’t render science useless. (Of course, Graham himself has called Trump a “kook” who is “not fit to be president.” That was in 2016, though, during the Republican presidential primary, when the two were not yet allies.) That sort of breathless indictment—followed by a reversal and a condemnation of others for making the same statement—may not be rare among politicians, but it is a leap to assume that doctors and scientists would similarly lie and abandon their professional ethics out of allegiance to a political party. When judgment is compromised with bias, it tends to be more subtle, often unconscious. Bias will color any assessment to some degree, but it needn’t render science useless in assessing presidential capacity.