Changing the conversation about Donald Trump’s fitness for office from whether he has a personality disorder to whether he has an organic brain disorder.
For a long while there has been an ongoing debate about whether Donald Trump suffers from a personality disorder that might contribute to his being unfit the President of the United States. Psychiatrists have ethical constraints in what they say because of the so-called Goldwater rule, barring them from commenting on the mental health of political figures that they have not personally interviewed.
I am a clinical psychologist, not a psychiatrist. I feel the need to speak out that the behavior of Donald Trump is abnormal and we should caution against normalizing it. The problem with settling on his behavior being simply that of a bad person or con man is it doesn’t prepare us for just how erratic his behavior can be.
I’ll refrain from making a formal psychiatric diagnosis. I actually think that in clinical practice, a lot of mental health professionals too casually make diagnoses of personality disorders for patients (or privately, even for colleagues) they find difficult or annoying. If they ever gave these people a structured interview, I suspect they would be found to fall below the threshold for any particular personality disorder.
Changing the conversation
But now an article in Stat has changed the conversation to whether Donald Trump suffers from personality disorder to whether he is developing an organic brain disorder.
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.
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.
In addition to being a medical journalist, the author Ford Vox of the article is a neurorehabilitation physician who is board-certified physical medicine and rehabilitation physician with additional subspecialty board certification in brain injury medicine.
I was alerted by the possibility of a diagnosis of frontotemporal dementia by a tweet by Barney Carroll. He is a senior psychiatrist whom I have come to trust as a mentor on social media, even though we’ve never overlapped in the same department at the same time.
And then there was this tweet about the Stat story, but I could judge its credibility because I did not know the tweeter or her source:
I followed up with a Google search and came across an article from August 2016, before the election:
It’s called Pick’s Disease, or frontotemporal dementia
Look at the symptoms, all of these which fit Trump quite closely:
- Impulsivity and poor judgment
- Extreme restlessness (early stages)
- Overeating or drinking to excess
- Sexual exhibitionism or promiscuity
- Decline in function at work and home
- Repetitive or obsessive behavior
And especially these, listed earlier in the article:
Then I followed up with more Google searches, hitting MedLine Plus, the website maintained by the National Institutes of Health’s Web site for patients and their families and friends and produced by the National Library of Medicine.
Pick disease is a rare form of dementia that is similar to Alzheimer disease, except that it tends to affect only certain areas of the brain.
People with Pick disease have abnormal substances (called Pick bodies and Pick cells) inside nerve cells in the damaged areas of the brain.
Pick bodies and Pick cells contain an abnormal form of a protein called tau. This protein is found in all nerve cells. But some people with Pick disease have an abnormal amount or type of this protein.
The exact cause of the abnormal form of the protein is unknown. Many different abnormal genes have been found that can cause Pick disease. Some cases of Pick disease are passed down through families.
Pick disease is rare. It can occur in people as young as 20. But it usually begins between ages 40 and 60. The average age at which it begins is 54.
The disease gets worse slowly. Tissues in parts of the brain shrink over time. Symptoms such as behavior changes, speech difficulty, and problems thinking occur slowly and get worse.
Early personality changes can help doctors tell Pick disease apart from Alzheimer disease. (Memory loss is often the main, and earliest, symptom of Alzheimer disease.)
People with Pick disease tend to behave the wrong way in different social settings. The changes in behavior continue to get worse and are often one of the most disturbing symptoms of the disease. Some persons have more difficulty with decision making, complex tasks, or language (trouble finding or understanding words or writing).
The website notes
A brain biopsy is the only test that can confirm the diagnosis.
However, some alternative diagnoses can be ruled out:
Your doctor might order tests to help rule out other causes of dementia, including dementia due to metabolic causes. Pick disease is diagnosed based on symptoms and results of tests, including:
Assessment of the mind and behavior (neuropsychological assessment)
Examination of the brain and nervous system (neurological exam)
Examination of the fluid around the central nervous system (cerebrospinal fluid) after a lumbar puncture
Head CT scan
Tests of sensation, thinking and reasoning (cognitive function), and motor function
Back to Ford Vox in his Stats article:
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.
Good luck, Dr Vox, but at least we have a reasonable hypothesis on the table. As Barney Carroll says “Time will tell.”