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Fluctuations, Exacerbations, and Decline in Functioning — Where is Trump Headed?

By David M. Reiss, M.D. and Seth D. Norrholm, Ph.D.

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Many persons have noted the significant difference in the quality of Trump’s physical, cognitive, and language/linguistic presentation in public both recently and over the last few decades. Similarly, many persons have noted that Trump presents very differently depending upon whether he is “talking off the cuff”, such as at his rallies, “going off script,” or (apparently) reading from a teleprompter.

Differences can easily be observed in Trump’s emotional state: at times “high-energy”, activated; at times flat, blunted, seeming uninvolved or uninterested; in Trump’s sophistication of use of language and choice of words; in Trump’s ability to stay on topic; and in Trump’s ability to answer questions with direct, cogent, or meaningful responses.

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On Thursday, August 29, 2019, this President re-established the U.S. Space Command during a largely scripted Rose Garden appearance in which he showed flat affect, slowed speech delivery, and an apparent lack of engagement with the subject matter. Photo: SpaceNews, Sandra Erwin

We doubt that few would disagree that, overall, Trump’s presentation and the level of Trump’s communicative abilities appear to be deteriorating. Some have suggested, or even concluded on TV news, talk radio, and social media, that these observations represent definite indications of deterioration of Trump’s cognitive abilities and/or a descent into dementia (some have even suggested specific types of dementing illness they believe to be present).

We definitely believe that based upon his observed behaviors, it is clinically indicated that Trump undergo a full and comprehensive neuropsychological evaluation. Based upon public disclosures, this has not occurred. The only information revealed to the public has been that Trump was administered a basic screening protocol (that reportedly, he himself had specifically chose and requested, which clinically renders the results invalid and/or unreliable). To be clear, the instrument that the President was administered, the Montreal Cognitive Assessment or MOCA, is used as a screening tool for cognitive decline/dementia and clinically informs the degree to which a patient’s cognitive debilitation requires enhanced treatment such as assisted living or skilled nursing. A “passing” grade, as trumpeted by this President, in most adults is achieved by correctly identifying animals and following simple task instruction.

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The Montreal Cognitive Assessment, or MOCA, is widely used to screen for severe cognitive deficits including impairments that may necessitate enhanced treatment interventions including assisted living. Most neuropsychiatrically healthy individuals will “pass” the screener if they demonstrate an ability to follow basic directions and to identify where and “when” they are at present. Nevertheless, the President touted his performance as a false indicator of his “intelligence”

At the same time, we are concerned that many of the opinions being voiced regarding specific diagnoses and Trump’s prognosis are based upon personal experience of people who have suffered through the cognitive/behavioral deterioration of a loved one (also called anecdotal evidence). While we have no doubt that behaviors exhibited by Trump are similar to symptoms observed in persons suffering from dementia, we are concerned that while no specific diagnosis can be definitively ruled out, the public behaviors displayed by Trump may be explicable by multiple individual or combined issues other than (albeit possibly including) a degenerative neurocognitive disorder.

Of course, many of the older videos of Trump speaking were scripted or edited; for most, Trump was probably well-prepared as to what he wanted to say; and during those interviews, Trump was expecting little, if any, challenge or confrontation. This had long become par-for-the-course by the malignantly narcissistic Trump and his abused and/or sycophantic court. Those interviews were conducted under circumstances of minimal stress (and often, in a jovial manner). That was obviously very different from the circumstances under which we now observe Trump. Simply put, Howard Stern, the shock jock, is not conducting the interviews anymore and there is no giggling Robin.

It is well known that stress and anxiety can temporarily impact cognitive performance. We also have no information regarding any possible concurrent medical issues with which Trump is dealing, or any medications that Trump is being prescribed (for any reasons) — all of which may impact cognitive functioning, apart from the presence of a degenerative disease process. In fact, within the last “medical report” released, by Sean Conley, D.O., enigmatically (emphasis added), “Dr. Conley did not provide the list of the medications that Trump is taking. Instead, he only mentioned an increase in Trump’s dose of a cholesterol-lowering medication, rosuvastatin, to 40 mg a day”; and questions have been posed regarding who actually wrote the report, “…the authorship of this report is questionable for several reasons, one of which is the sentence ‘The president is very grateful for the outstanding care he received today, and he especially wants to thank the doctors, nurses, enlisted and civilian staff who participated.’ It would be unheard-of for a doctor to praise himself in such a statement. Odder still is the subsequent assertion that Trump is ‘in very good health and I anticipate he will remain so for the duration of his Presidency, and beyond.’ This sort of long-term prediction is atypical for any reputable physician, much less one whose only charge is to assess the president’s ability to execute the duties of the office.”

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Sean Conley’s memorandum addressed to then Press Secretary Sarah Sanders included bizarre and inappropriate language that physicians routinely do not include in an objective, clinical report. This language includes self-praise and a fair bit of prognostication.

While there is very good reason for concern, it must be realized that multiple different disorders or syndromes can present with similar behavioral manifestations and superficial symptomatology:

1) There is insufficient clinical data available to provide any definitive diagnosis or prognosis (it is possible to list “differential diagnoses” of possible conditions, but there is no clinical basis for going further than that); and

2) the fact that Trump’s presentation varies, at times from day-to-day, could represent overall deterioration but also could represent fluctuations and exacerbations that occur due to situational circumstances that are reversible.

In fact, if we look at the overall pattern, it has not been unusual for Trump to appear slow, flat, uninvolved, and distant (suggestions of significant impairment) on one occasion; but a few days later, at a “rally” (while still illogical, tangential, and quite impulsive and irrational), Trump’s energy, affect and mood have returned to baseline.

In summary, there is currently a clear indication for comprehensive evaluation, but there is no observation or data that can definitively state that whatever Trump’s underlying pathology, the fluctuations we are seeing are not, quite possibly, consistent with exacerbations and recoveries that are all inherent to Trump’s long-standing baseline level of dysfunction. Of course, even going back to the older videos, despite some significant differences,

1) Trump was never known to be a “deep thinker” or to have a high-level fountain of knowledge;

2) Trump was never known to express carefully considered comprehensive opinions, taking into account different perspectives or points of view; and,

3) Trump was never known to have particularly good impulse control while speaking, not infrequently tangentially moving into at best problematic and often overtly inappropriate or offensive territory.

Yes, “Houston, we have a problem…”

No, the problem is not likely to improve or become any less dysfunction or any less dangerous.

We firmly believe that there is sufficient information to state that Trump is unfit to serve as POTUS. But until we have additional validated, objective clinical data, no person can offer any definitive diagnosis and we are all left in an ominous dark place as to Trump’s prognosis, and the dangers we face during the remainder of Trump’s time in office.

About the Authors:

David M. Reiss, M.D. (Twitter: @DMRDynamics) has been a practicing psychiatrist for more than 30 years, specializing in “front-line” adult and adolescent psychiatry. He has evaluated and treated over 12,000 persons of diverse social and cultural backgrounds, from every occupational field. Dr. Reiss has been recognized internationally for expertise in character and personality dynamics. He is often interviewed and quoted in the print, Internet and radio/TV media, nationally and internationally, to help the public understand the psychological aspects of current events. Dr. Reiss was a co-author on the New York Times bestselling book, “The Dangerous Case of Donald Trump.” He is an authority on issues regarding social and political phenomena, medical and mental health treatment, PTSD, violence in society, and the functioning of the current mental health system.

Seth D. Norrholm, PhD (Twitter: @SethN12) is an Associate Professor of Psychiatry and Behavioral Sciences at Emory University School of Medicine, a full-time faculty member in the Emory Neuroscience Graduate Program, and a member of the Emory Clinical Psychology Graduate Program. Dr. Norrholm has spent 20 years studying trauma-, stressor-, anxiety-, depressive-, and substance use-related disorders and has published over 90 peer-reviewed research articles and book chapters. The primary objective of his work is to develop “bench-to-bedside” clinical research methods to inform therapeutic interventions for fear and anxiety-related disorders and how they relate to human factors such as personality, genetics, and environmental influences. Dr. Norrholm has been featured on NBC, ABC, PBS,,, The Huffington Post,, USA Today, WebMD, The History Channel, and Scientific American.

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