James Hamblin MD, a senior editor at The Atlantic, writes, “It is best not to diagnose the president from afar, which is why the federal government needs a system to evaluate him up close.” As readers know, I have weighed in on the urgency of ignoring the supposed ethical standard called the ‘Goldwater Rule’ in the face of Trump’s malignant narcissism and the imminent danger it represents to our health and survival. Can we diagnose this personality disorder from afar? I have argued that such potent narcissism, being an unquenchable thirst for adulation, plays itself out largely on the public stage and can accurately be recognized from afar.
Should it be taken into account in assessing Trump’s fitness? Such psychiatric luminaries as Allen Frances, a leading author of the first edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) to include personality disorders, argue along the lines 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.” I beg to differ, and would venture to say that most mental health professionals practice with a different understanding. Some psychiatric symptoms function to defend the sufferer from the experience of their own distress and in so doing cause those around them to suffer. Narcissistic personality disorder is among those. One role frequently played by the mental health profession has been to evaluate and treat people who have not voluntarily sought relief from their own suffering when it is necessary for the protection of those around them. And Trump’s conduct causes a clear and present threat to the health and wellbeing of people across this country and the world.
A further specious argument against attributing Trump’s difficulties to mental illness is that it stigmatizes the mentally ill. I fight strongly against the stigmatization of my patients, but frankly this is a false syllogism. You see how it works: “Trump is execrable or evil. Trump is mentally ill. Therefore all mentally ill people are execrable or evil.” But let us not be politically correct. Because patients with mental health dificulties are suffering and usually courageous people struggling against great odds, and on aggregate do no more harm to others than those without illness, it does not mean that none of them ever, anywhere, do any harm. While the long raging debate about whether evil and malevolence are per se evidence of mental illness has never been (and will probably never be) resolved, that does not mean that evil is never done by those with a mental health diagnosis.
Yet psychiatric concern, especially in today’s hyperpolarized world, is too easily dismissed as partisanship. But how about something more objective and incontrovertible than a psychiatric diagnosis? While diagnosing a mental disorder and particularly a personality disorder will always be a judgment call, Dr Hamblin’s article describes another cause for alarm — observable evidence of Trump’s neurological dysfunction. Viewers of his speeches have noticed minor but suggestive abnormalities in his movements and at least one incident of garbled speech, which could have represented either dysarthria — interference with the articulation of sounds from anywhere in the speech-producing machinery — or aphasia — problems at the level of the brain’s control of language, e.g. from a transient ischemic attack or an acute stroke. But, more important, there is clear evidence in the public record, the significance of which cannot be disputed, of a drastic deterioration in Trump’s verbal fluency and impoverishment of his vocabulary over the years. It is chilling to compare the examples, as this article does, from interviews he gave in the 1980s or 1990s with almost any section of any statement he has made in the last few years (except when he is kept to task delivering speeches written by others presumably neurologically intact). Of course, verbal fluency predictably declines with age. (I am sure you would notice the phenomenon across the 18 years of posts here on FmH, for example.) But experts agree that the decline in Trump’s linguistic sophistication is far in excess of the normal regression of cognitive function expected with age.
Why should we be alarmed? So what if his stories, or even his sentences, don’t have beginnings, middles, and ends? if his associational leaps are rarely clear? This is not the folksy simplicity and vernacular that, say, GW Bush adopted to appear to be a Texas man of the people instead of from an Eastern patrician clan. This is evidence of a progressive process of cognitive impairment, more than not likely to be a dementia, i.e. one that affects far more than language alone, iindiciative of cognitive impairment in skills such as deployment of attention and concentration, resistance to distraction, control of impulsivity, concept formation, judgment, problem-solving and decision-making. Many of these can be objectively assessed and measured by neuropsychological examinations accepted as standards.
I was one of a number of health professionals taking note of the evidence of Ronald Reagan’s dementia by the time he was running for reelection. Perhaps you saw me, dressed in my white coat, interviewed on the Boston evening news when he gave a speech here at City Hall Plaza at which a number of us demonstrated. It is now common knowledge that he was mentally disabled during his term in office but at the time it was a public outrage to talk about the Emperor’s nakedness. And, even though the evidence now regarding Trump is far more definitive and unavoidable, and the consequences of ignoring it far more dire, the taboo appears to remain as strong.