Physicians handcuffed diagnosing Trump mentally ill

In December 2016, several distinguished physicians composed a letter to President Obama questioning Trump’s  mental stability. They recommended a complete neuropsychiatric and medical evaluation. The letter was reported in the British Medical Journal and published in its entirety by the Huffington Post.  It’s a 4 sentence letter and raises the concern of  “widely reported symptoms of mental instability” in Trump.  These psychiatrists cannot offer diagnostic possibilities citing the Goldwater rule of 1973 in which the American Psychiatric Association issued a provision to their code of ethics.  The rule restrains psychiatrists from venturing a diagnosis for public figures whom they have not evaluated personally.

There are widespread concerns amongst physicians that the leader of the free world is mentally unbalanced. With or without a formal diagnosis the mental stability of our now Commander-in-Chief is in question. In an ideal world we could formally evaluate our President’s sanity. Harvard professors question Trump’s ability to “discern fantasy from reality.”

Imagine.

  • There are “widely reported symptoms of mental instability” and experts in Psychiatry question Trump’s ability to discern fantasy from reality.

Rest assured, Trump supporters, there will be no stampede of physicians coming forward.  Professional standards preclude that from happening.  We’d be admonished by the medical powers that be and the truth is – we’ve already been admonished.  Put it in perspective. When a full professor from Harvard can go no further than a private note stating “there are widely reported symptoms of mental instability”, the rest of the country’s 800,000 non-crimson-H employed physicians can’t say squat. These leading experts, however, have spoken for many physicians.

  • When a full professor from Harvard can go no further than a private note stating “there are widely reported symptoms of mental instability”, the rest of the country’s 800,000 non-crimson-H employed physicians can’t say squat.

Ironically,  if physicians watching television saw a suspicious pinpoint black spot on Trump, we could  scream for evaluation with impunity. Physicians would climb over each other to question that dot and offer differential diagnoses despite “not evaluating him personally.” We’d be applauded and sign our names proudly for the savvy pick-up. Careers boosted.

Know that many  physicians believe our new President has impaired cognition but will not come forward.  We’ve been witness to Trump destroying lives with a tweet. We’ve been witness to hundreds of hours of  aggressiveness and vindictiveness in interviews, rallies, and debates – written, spoken, and off mic “comments”.  Many physicians have grave concerns.  Physicians question his mental health and cognitive function but ethically cannot offer a diagnosis without personally examining him. It’s not best practice. Patients that are an imminent danger to themselves or others can be involuntarily committed to psychiatry units. When a patient is an imminent danger to themselves or others,  restraints can be used. Many physicians are ethically torn between offering a diagnosis without a personal exam versus raising the flag for the impression that Trump is an imminent danger. Either decision risks loss of livelihood for a physician. I applaud the practitioners courageous enough to come forward.

  • Let that sink in. Three  expert practitioners from Harvard and UCSF  wrote to President Obama questioning the leader of the free world’s  mental stability. Expert physicians question Trump’s fitness for office.

Evaluation for mental instability cannot occur without our new President’s consent and  would be useless without his full cooperation.  Should the President heed these physicians’ recommendations and undergo  neuropsychiatric evaluation, the results could not be released without his consent. Fat chance. All that we know of our new President’s health is described in a one page document said  to have been dictated in 5 minutes by his primary care physician, a gastroenterologist, while  standing at a curb.  There’s been an appearance on the Dr. Oz show.  In total  we’ve been offered that  the new president is prescribed a medication for elevated cholesterol,  is overweight, and considers  rally speeches an adequate form of exercise. Terrific.

  • Physicians won’t publicly offer diagnoses of impaired cognition and malignant narcissism for Trump but many of us believe it.

We do not know if the new President is fit to undertake leading the free world.

Experts in the field of Psychiatry question Trump’s ability to distinguish between fantasy and reality.

Mental illness and cognitive disorders  can be fatal. They can be fatal in the same way that the flu is fatal. Folks’  immediate causes of death are often from complications of the illness and not the illness itself.  Commonly it’s a pneumonia and towards the end there is air hunger.  Next comes the “death rattle” and when we hear it, we know it.  We feel it.

And America, it’s getting harder to breathe.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Why I miss Barbara Bush

 

It’s not uncommon for medical professionals to consider diagnoses in people of whom they’ve not formally evaluated.   This habit  has been called  “diagnosing at the mall”.  Paint me guilty of looking at a thin stranger with a tremor  and wondering about hyperthyroidism, Grave’s disease, or thyroiditis. My eyes move to their neck to get a peek of their thyroid gland.  Then I think of Barbara Bush and wonder some more. I remember Mrs. Bush emphatically protesting that  she was not trying to lose weight.  Hearing that, I reflexively questioned her thyroid.   In short order she was formerly diagnosed with Grave’s disease (an illness that results in hyperthyroidism).  I looked closely at her stare and indeed her eyes were just slightly prominent.  Weight loss.  Tremor.  It all fit. I’m a physician. It’s what we do.

The truth is that it’s remarkably common for both physicians and non-physicians to do it. We wonder if someone is OCD, passive aggressive or depressed.  How often do any of us wonder if we’re coming down with Alzheimer’s disease when we can’t remember why we walked into a room or lost keys or not remembered a conversation? None of us are diagnosing.  We’re questioning.  We all do it.

Enter President Elect Trump.

A number of articles  tackle the possibility of Trump having Narcissistic Personality Disorder (NPD).  Some of the signs of NPD  include grandiosity, exploitation of others, lack of empathy, envy,  and arrogance. Some of these signs and symptoms overlap with other diagnoses.   One less well-known medical diagnosis is behavioral variant frontotemporal dementia (bvFTD).  In a subset of patients  bvFTD,  patients  demonstrate some or all of the following: impulsiveness, inappropriate social/sexual behavior, lack of empathy, distractibility, disinhibition and/or  lack of insight.  It was with these diagnostic criteria in mind that the questions flowed.  You’ve likely had similar observations and questions.  Why doesn’t  Trump  read from a teleprompter for more than a few sentences?  Can he? Was it really twelve women that  came forward? Did he?

Remarkably, we have observations of Trump in the physical, written and verbal realms.  I no longer question whether he filters his communications. I now question whether he  has that ability.  He rages when he perceives the slightest criticism.  Following his  outbursts, there appears no remorse.  I recall no apologies to the Khan family, Senator McCain, Megyn Kelly,  Nancy O’Dell nor Arianne Zucker. Regardless of the offense, he seems unashamed.  I now question  if  he’s devoid of the insight that he even should be ashamed. Could it be that simple?  Maybe he just doesn’t get it.
Despite the name “dementia”,   memory dysfunction is less prominent early in the course of frontotemporal dementia than with Alzheimer’s.  In fact, the prominence of increased emotionality, inability to modulate mood, impulsiveness and inappropriate social behavior point more to  behavioral variant frontotemporal dementia. I question frontotemporal dementia in Trump but then recall no observations of  diminished memory (save for the innumerable “I don’t remember” responses during testimony in previous lawsuits).  Or have I?

Does cognitive dysfunction explain Trump’s  performances in the debates?   He spoke in brief, repetitive phrases,  and became disorganized and intemperate quickly.

Does Trump have a diminished ability to spontaneously craft thoughtful and coherent responses in an intelligible manner?  Is that why he hasn’t held a press conference in months? It would seem unfortunate for a reporter to be better versed in current events than the president-elect.  Can he even process a multipart question,  distill effective and organized communications then move on to the next question?

It’s only more recently that I’ve questioned why Trump has a family member close by at confidential meetings.  Like others, I wondered whether he was self dealing business opportunities.  With FTD in mind, I now question whether the answer is simpler and less self profiting. Does he need a handler with him to negotiate the complexities of appointing a cabinet and maneuvering foreign relations?

We have no alternative than to keep questioning and observing.  The clinical course of   dementia can be rapid.  What if it’s true?  Dementia  progresses. It progresses relentlessly and unapologetically.  Most of us have observed it.  Executive function and decision-making skills fail.  Worsening impulse control overwhelms. It’s catastrophic and heartbreaking.
And so I miss Barbara Bush.  I’m relieved she is well.