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 has made him a constant subject of speculation among those concerned with his mental health.
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.
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 per 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.
The lack of a system to evaluate presidential fitness only stands to become more consequential as the average age of leaders increases.
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.
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.
The downplaying of a president’s compromised neurologic status would not be without precedent. Franklin Delano 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.”
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 neurologic 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.
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.”
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 like “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 like 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.”
Nor would it happen if the only person to examine the president was someone like Harold Bornstein—whose sense of objective reality is one in which Donald 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.”
The real-world application of one of these systems is complicated by the fact that the frontal lobes also control things like 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 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 “poor judgment leading to bad decisions.”
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.
The rule has protected psychiatrists both from lawsuits and from claims of subjectivity that threaten trust in the entire enterprise.
However, labeling Trump with a mental illness from afar is wise. A diagnosis like 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 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 President Donald Trump is “an endless, endless attempt to label the guy as some kind of kook not fit to be president.”
That sort of breathless indictment—followed by a reversal and 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.
A presidential-fitness committee—of the sort that Carter and others propose, consisting of nonpartisan medical and psychological experts—could exist in a capacity similar to the Congressional Budget Office. It could regularly assess the president’s neurologic status and give a battery of cognitive tests to assess judgment, recall, decision-making, attention—the sorts of tests that might help a school system assess whether a child is suited to a particular grade level or classroom—and make the results available.
Such a panel need not have the power to unseat a president, to undo a democratic election, no matter the severity of illness. Even if every member deemed a president so impaired as to be unfit to execute the duties of the office, the role of the committee would end with the issuing of that statement. Acting on that information—or ignoring or disparaging it—would be up to the people and their elected officials.
Of course, the calculations of the Congressional Budget Office can be politicized and ignored—and they recently have been. Almost every Republican legislator voted for health-care bills this year that would have increased the number of uninsured Americans by 20-some million, and they passed a tax bill that will add $1.4 trillion to the federal deficit. A majority of Americans did not support the bill—in part because a nonpartisan source of information like the CBO exists to conduct such analyses.
That math and polling can be ignored or disputed, or the CBO can be attacked as a secretly subversive entity, but at least some attempt at a transparent analysis is made. The same cannot be said of the president’s cognitive processes. We are left only with the shouts of experts from the sidelines, demeaning the profession and the presidency.