The Dangerous Case of Donald Trump

by Bandy X. Lee

  When insisting that the Fake Media created the feud between him and the intelligence community, such a person would fail a reliable lie detector test because he would know he was lying.

  The most jarring evidence yet of DT’s “crazy like a crazy” delusional disorder came with his early morning tweets (subsequently deleted) in March that his Trump Tower phones had been wiretapped by a “bad (or sick!) Obama”; the tweets included insane comparisons to Watergate and McCarthyism. DT’s actions immediately generated bipartisan criticism, and there was a complete lack of evidence from anyone, anywhere, that he had been targeted for surveillance. The suspicion that one is being wiretapped is an absolutely classic expression of paranoid delusions.

  When insisting that the Fake Media created the feud between him and the intelligence community, DT would unequivocally have passed a lie detector test because he believed the delusion was actually true. “Crazy like a fox” defines a person whose apparent external irrationality masks underlying rational thinking. “Crazy like a crazy” characterizes a person whose apparent external rationality masks underlying irrational thinking.

  Returning to our historical examples of nuclear emergencies, is there anyone who could possibly believe DT would have shown Brzezinski’s grace under pressure had he himself received that 3:00 a.m. call? If, indeed, Trump harbors grandiose and paranoid delusions (for which there is mounting evidence), he would have launched missiles faster than he fires off paranoid tweets on a Saturday morning.

  Given the thirteen days of excruciating tension during the very real nuclear threat of the Cuban Missile Crisis, is there anyone who possibly believes that DT could have demonstrated JFK’s composure, wisdom, and judgment, especially in the face of unanimous pressure from his military advisers? If DT were indeed merely “crazy like a fox,” it would still be a huge stretch—but, increasingly, that appears not to be the case.

  Michael J. Tansey, Ph.D. (www.drmjtansey.com), is a Chicago-based clinical psychologist, author, and teacher. He is a graduate of Harvard University (A.B., 1972, in personality theory) and Northwestern University Feinberg School of Medicine (Ph.D., 1978, in clinical psychology). In addition to his full-time practice, he was an assistant professor teaching and supervising students, interns, residents, and postdoctoral fellows. He has been in private practice for more than thirty-five years, working with adults, adolescents, and couples. Along with a coauthored book on empathy and the therapeutic process, he has written numerous professional journal articles as well as twenty-five blogs for the Huffington Post.

  References

  Chang, Laurence; Kornbluh, Peter, eds. (1998). “Introduction.” The Cuban Missile Crisis, 1962: A National Security Archive. http://nsarchive.gwu.edu/nsa/cuba_mis_cri/declass.htm.

  CNN.com video. 2017. January 21. www.youtube.com/watch?v=4v-Ot25u7Hc.

  Keneally, Meghan. 2016. “5 Controversial Dictators and Leaders Donald Trump Has Praised.” ABC News.com, July 6.

  Maddow, Rachel. 2016. The Rachel Maddow Show. MSNBC, October 27.

  Sagan, Scott. 2012. The National Security Archive, George Washington University, Washington, DC, March 1.

  Sarlin, Benjy. 2016. NBC News, October 7.

  Stephanopoulos, George. 2016. This Week with George Stephanopoulos. ABC News, July 31.

  Wright, David. 2015. TK. Union of Concerned Scientists. November 9, http://blog.ucsusa.org/david-wright/nuclear-false-alarm-950.

  COGNITIVE IMPAIRMENT, DEMENTIA, AND POTUS

  DAVID M. REISS, M.D.

  Obviously, it is difficult to conceive of a more stressful, demanding job than being POTUS. Leaving aside all the serious, critical, and snarky questions we hear regarding presidential “vacations,” golf outings, and so on, the office demands the ability to be emotionally and cognitively alert and intact, and fully “on duty” at a moment’s notice, 24/7. Potentially, the lives and well-being of millions of people are at stake in any number of the presidential decisions required to be developed over time, with appropriate advice and counseling, or within minutes, without any prior notice regarding the specific details or options.

  It goes without saying that the position of POTUS inherently requires an almost inhuman degree of cognitive clarity at all times, regardless of the personal situation or circumstances of the man or woman holding the office. It is not surprising that the idea of a “dual presidency,” at least some division of tasks, has been considered at different times (Rediff.com n.d., Smith 2015) (including, briefly, during the last election cycle) (Lerer 2016), although implementation of the idea has never seemed practically or politically possible.

  In general, the populace values exuberance, energy, and experience as essential qualities in a POTUS, some would say with each cycle which traits are considered of primary importance at different times. Historically, longings for an experienced leader and the seeking of a “paternal,” even “grandfatherly,” presidential persona and political presence have often yielded male candidates who are in their senior years, with Donald Trump being the oldest person to be sworn in as POTUS.

  With age comes experience and, it is hoped, wisdom—but also, medically, concerns regarding cognitive decline. It is now recognized that while some neurological functioning has peak efficiency during earlier adult years (e.g., physical reaction time), in general, cognitive functioning remains remarkably intact until quite late in the life cycle (with minor deterioration during the seventies and a more measurable decline after age eighty, but such decline certainly is not universal) of the healthy older adult (Levin 2016, Ramer 2013). Thus, the key issue to be addressed is not age-related cognitive decline but illness-related cognitive decline and decline related to other non-age-dependent physiological factors (the use of prescribed medications, a history of past or present substance abuse, a history of injury to the head, etc.). In general, older persons are more likely to be using multiple prescribed medications than younger persons, and many medications may have a subtle negative impact upon cognition, but that is not an age-related issue in and of itself.

  Therefore, concerns regarding the cognitive abilities of a POTUS can be divided into five general areas: (1) innate, baseline, intellectual/cognitive skills and ability; (2) impairment due to an ongoing neurological deterioration (Alzheimer’s disease or other types of dementia); (3) impairment caused by acute illness (especially in older individuals; even a urinary tract infection can negatively impact cognition); (4) toxic effects of prescribed medications or use of illicit substances; and (5) cumulative effects of head trauma and/or use of licit or illicit toxic agents (an issue that has received much more attention, clinically and publicly, vis-à-vis sports-related concussion injury).

  Baseline Intellectual and Cognitive Skills

  The current political system sets no intellectual or cognitive standards (or physical/medical well-being standards) for someone to become POTUS. Clearly, this is a vulnerability. Equally as clearly, the question of where any “line should be drawn” regarding health or, in particular, intellectual and cognitive prowess, as well as how and by whom those parameters would be measured, in my opinion, make it practically unlikely that any such standards will ever be implemented. In essence, we rely upon the candidates to voluntarily divulge their medical history (which Trump did not do with any indication of clinical validity), and we rely upon the voting populace to determine if a candidate’s intellectual abilities “measure up,” an inherently flawed system, as the populace has access only to prepackaged presentations and observations of a candidate in debates and while he or she is giving speeches—hardly an adequate database for accurately gauging intellectual ability.

  Based upon the limited information available, persons with professional training could provide public opinions regarding a candidate’s intellect, but the database that even professionals can use remains inadequate and incomplete, and differentiation between objective and clinically “solid” opinions versus politically based propaganda is an insurmountable problem.

  At the current time,
I view this as a problem without any solution in the near future.

  Impairment Due to an Ongoing Neurological Deterioration

  In the vernacular, the term Alzheimer’s is often used nonspecifically to refer to dementing illness, which is not clinically accurate, as deterioration of cognitive functioning can occur due to multiple different degenerative neurological disease processes. However, with regard to the issue at hand, the important question is whether a degenerative process is present, not necessarily a specific diagnosis. Other than in certain relatively uncommon acute illnesses, cognitive decline due to degenerative neurological disorders is a relatively slow process that can begin insidiously. As just noted, but not commonly appreciated, absent other factors, “normal aging” is a very infrequent cause of significant cognitive impairment prior to true “old age” (i.e., above eighty years). It is not unusual for early indications of a degenerative process to be “excused” or minimized as age-related and not seen as particularly significant acutely (which they may not be) or recognized as implying a problematic prognosis.

  This is an area in which sophisticated clinicians may notice, even from public appearances and interactions, that a person is exhibiting indications suggestive of an early stage of a dementing process. Without a full medical history and without formal testing, no diagnosis can be provided based upon such observation, but certainly a trained observer can identify cause for concern and suggest the prudence of obtaining a formal evaluation.

  However, it is obviously problematic for many reasons to rely upon unsolicited opinions from practitioners whose level of expertise, objectivity, and ulterior motivations may be suspect (legitimately or defensively/manipulatively). This is, in fact, what has occurred regarding the candidacy and election of Donald Trump. Multiple experts have voiced concern, some referring to an inherent “duty to warn.” Multiple differing opinions have been expressed, ranging from denial of any evidence necessitating concern; to suggestions of the need for a formal evaluation; to speculation about, provision of, and even rumor of specific diagnoses.

  Objectively, I personally do not see how any informed clinician would not notice a significant difference between the cognitive performance of Trump in videos from fifteen years ago to his current presentation. Objectively, I personally do not see how any informed clinician cannot conclude that there is reason for concern and/or a formal evaluation.

  Yet, at the same time, the videos from the past were produced under very different situations (vis-à-vis planning, scripting, stress, and in some cases, editing), and it has been my stance that the promulgation of anything beyond a general warning, along with education regarding the “differential diagnoses” (i.e., possible causes for the apparent change), is not clinically supported without additional data, as well as being ethically questionable.

  Thus, in my opinion, it has been appropriate and, in fact, prudent for clinicians to speak out regarding their concerns of possible neurological deterioration, but the public discussion has been so muddied that serious and legitimate concerns voiced have had no practical impact.

  Although the presidency of Donald Trump is still young and, in the view of many, including me, quite problematic, with very high and dangerous risks present, in essence we have probably already “dodged a bullet” at least once. During the first 1984 debate between Ronald Reagan and Walter Mondale, Reagan obviously experienced a moment of disorganization. A brief lapse can happen to anyone under stress and need not be assumed to indicate the presence of pathology (e.g., Rick Perry’s forgetting “the third department” he wished to disband during the 2012 primary debate). In retrospect, Reagan’s “becoming lost” appeared more significant. There were already public concerns regarding his medical status, and it was later reported that friends and family were well aware that a degenerative disease was progressing (Corn 2011). Yet, there was no significant expression of public concern by clinicians, and the issue was, out of (in my opinion, misplaced) “politeness,” not seriously raised within the political discourse. Perhaps if clinicians had spoken up, there could have been a reasonable call for appropriate medical records or evaluation. It might have backfired, and the election could have been determined on the spot, but personally, I always wonder what might have happened if, in the second debate, in a sincere and diplomatic manner, Mondale had directly raised the question to Reagan: “Sir. The last time we met, you appeared to have a moment of significant confusion. What would the consequences be if that occurred during a national emergency?” It is conceivable that Reagan could have deftly deflected the question, and Mondale would have been pilloried, his campaign essentially ended. Yet, it is also conceivable that if Reagan had some awareness of his difficulties, the question could have led to his becoming acutely disturbed and discombobulated—perhaps revealing his vulnerability and swinging the election in the other direction. We will never know, and thankfully whatever neurological impairment Reagan suffered while in office did not (to anyone’s knowledge) ever lead to any inappropriate action, behavior, or decision. Nonetheless, that is not a risk the country should look forward to taking again.

  While neurological degenerative disease can occur even at relatively young ages, this is quite uncommon, and perhaps the wisest course would be for there to be a legal imperative for candidates above a certain age to undergo neuropsychological testing to rule out the process of a progressive illness. It would still be problematic to determine exactly what tests should be administered, who should administer them, and where a “cut-off” for eligibility/determination of “fitness to serve” should be set. It is conceivable that a bipartisan effort based upon clinical knowledge could at least set standards for disqualifying a candidate for whom there is objective medical evidence of a progressive disorder.

  Short of such a procedure, in my opinion, qualified professionals should not hesitate to carefully, judiciously express any concerns they may have, providing as much educative information as possible—while appreciating that, practically, the situation will remain confusing and controversial to a large segment of the population and that pernicious manipulation by unscrupulous clinicians cannot be avoided.

  Impairment Caused by Acute Illness and Toxic Effects of Prescribed Medications or Illicit Substances

  Any number of medical conditions can negatively impact cognition in any person, regardless of age—although, in general, as age progresses, vulnerability to cognitive impairment increases. Similarly, many medications very legitimately and appropriately prescribed for medical purposes can result in side effects ranging from mild word-finding difficulties (not uncommon with anticholinergic agents) to more significant cognitive slippage or confusion and even overt delirium. It goes without saying that those risks are higher with use of specific psychotropic medications and, of course, illicit drugs or alcohol. Acute side effects are very often reversible, while some agents (definitely alcohol; other illicit drugs; controversially, some rather common medications generally considered benign) may result in irreversible cognitive problems.

  However, practically, identifying these issues in a candidate does not appear to be nearly as problematic as addressing the question of a degenerative process. Simply by the release of objective and clinically sound medical records, including a toxicological screen and consideration of potential medication side effects (with formal neuro-psychological testing performed if indicated by the clinical history and findings), issues of acutely impaired cognitive functioning can be identified and often remedied. Or, at least such as in the possibility of illicit drug use, or mild, insignificant side effects (e.g., some simple word-finding difficulties due to use of anti-hypertensives) be made public. If any such findings cannot be remedied, then the situation would essentially fall into section (2) as described above.

  Cumulative Effects of Head Trauma and/or Use of Licit or Illicit Toxic Agents

  It is now recognized and generally accepted that a history of even “mild” head trauma, especially if there have been multiple events, as well as past
use of licit or illicit psychoactive agents, can produce acute cognitive impairment that lasts longer than was previously thought and can trigger an ongoing cognitive deterioration (the specific mechanism of which is not yet well understood). Increasing evidence is being obtained from those who participated in contact sports (and even relatively non-contact sports that involve use of the head, e.g., soccer; as well as victims of domestic violence or abuse that involved blows to the head), can suffer from increasing cognitive difficulties as they age, even years after the injuries/exposure occurred and even if acute symptomatology did not seem particularly severe. While the medical details regarding CTE (Chronic Traumatic Encephalopathy) (Boston University CTE Center 2017) remain controversial and under investigation, it cannot be denied that many persons with a history of head trauma or substance abuse suffer from cognitive decline that is not related to Alzheimer’s Syndrome or other “typical” degenerative neurological disorders. However, determining the presence and severity of any such decline (and establishing a prognosis) is somewhat more complicated than determining the presence or absence of a well-established disease process.

  Thus, this is not an issue that is practically different than described in (2) above, but it is an area of a person’s medical history that (to this day) often remains overlooked and deserves appropriate consideration and evaluation within any review of a candidate’s medical history.

  Summary

  No reasonable person would want someone with compromised cognitive/intellectual functioning to serve as POTUS. However, to date, there is no process or procedure (beyond voluntary release of medical records) that provides the public with any reliable knowledge regarding whether a candidate for the office of POTUS suffers from cognitive impairment or is at high risk for cognitive degeneration.