Trump’s Executive Function Disorder

In recent months, psychologists, psychiatrists, and psychoanalysts have argued that the Goldwater Rule, which forbids mental health experts from analyzing persons they have not examined, should be modified in the Age of Trump. When psychologists speak anonymously, the usual diagnosis of Trump is “narcissism.” John Gartner, a professor who taught at Johns Hopkins, raised the ante with “malignant narcissism.” Pundits and even Republican politicians have in the summer of Trump’s mercurial discontent judged Trump to be incompetent and unfit for the office he holds. Many citizens just believe he’s crazy.

Trump’s emotional lability and televised rants have certainly brought disorder to the Executive branch of the government, but my title — “Executive Function Disorder” — is a medical term that names a set of cognitive processes and that gives us a better, deeper understanding of Trump than the more generalized “narcissism,” though it can be a symptom of EFD. The term is interesting because it has its origin in human organizations: an “executive” knows the components of the organization and makes judgments intended to sustain and improve the organization. In the brain, the executive functions are “higher order” cognitive processes that synthesize and govern other, more fundamental kinds of cognition. Executive functions have been described as “metacognitive,” thinking about thinking to best utilize the brain’s multiple ways of perceiving, organizing, and responding to the world. The functions are somewhat localized in the prefrontal cortex, but they are not limited to that area. These functions are often diminished in persons with dementia, but EFD and dementia, which some experts believe Trump has, are not the same, for EFD can result from various causes.

Neurologists have devised tests to measure executive functioning, but I doubt that Trump would submit to any of them, so we are limited to observation of his behavior and his expression. In offering my “diagnosis,” I understand that I must eventually pass the “So what” test: so what if Trump suffers from EFD? How would recognition of that fact lead to his vacating an office for which many citizens think he is mentally and emotionally unfit? Consider the following paragraphs, and then I’ll get to the possible consequences of an EFD diagnosis.

Neuroscientists differ on just which processes should be termed “executive,” but the following definition, from a very well-sourced Wikipedia entry, is a good summary of current thinking on EFD:

Executive dysfunction appears to consistently involve disruptions in task-oriented behavior, which requires executive control in the inhibition of habitual responses and goal activation. Such executive control is responsible for adjusting behavior to reconcile environmental changes with goals for effective behavior. This offers a parsimonious explanation for the common occurrence of impulsive, hyperactive, disorganized, and aggressive behavior in clinical patients with executive dysfunction.

Trump has been called the “two-minute man” by one of his staffers. Many who have presented him with information describe his attention span as very limited. His daily briefings must be short, bullet-pointed, and, if possible, filled with graphics. Some who have observed him in meetings or have interacted with him have suggested Trump may suffer from ADHD, one of the subsets of EFD. His Twitter storms demonstrate that he has problems staying “task oriented” and on message if something on Fox News diverts his attention.

A healthy executive function will inhibit “habitual responses” as wasteful cognitive energy. Anyone who observes Trump off the teleprompter can see that his mind moves habitually through a very limited set of familiar responses and ideas. There are reports from intimates and staffers that he is obsessed with the Russian investigation, and will interrupt discussions of other subjects to habitually return to the investigation. He appears to use slogans — “Build the wall”; “Lock her up” — not just for rhetorical effect but because the phrases are easily accessible because habitual. I have discussed elsewhere the impoverished nature of Trump’s language, his diction and sentence formation (when actual sentences are formed). Supple and subtle language is how we can think about our thinking, our cognition. The kind of reductive and repetitive language that Trump uses when not reading what someone else has written for him implies a deficit in executive function.

Executive functions enable one to adjust his or her behavior to “environmental changes,” to new circumstances, conditions, and facts. Set aside the fact that Trump seems to care little for facts. Consider the three responses to Charlottesville: first was his “many sides” assertion. Then the begrudging monotone-read statement modifying the first response. And finally the rant, described as “unhinged” by several observers, that defended his initial response. He could not force himself to stick with the adjustment. In more general terms, his inability or unwillingness to learn how the governing environment works, how the Executive branch collaborates with the Legislative branch, diminishes his ability to turn his goals into laws. For those who oppose his goals and policies, his inability is welcomed. But how would Trump respond to a significant international crisis? That is the question that haunts many, including James Clapper, former Director of National Intelligence, who has explicitly questioned Trump’s fitness for office.

Clinical patients with EFD are “impulsive, hyperactive, disorganized, and aggressive.” So are some teenaged boys. But EFD tends to increase in older adults even if memory is essentially intact. That Trump displays these behaviors is obvious to the most casual observer of his actions and rallies. He impulsively tweets and speaks off the cuff, and he aggressively defends whatever he has done or said in the past, even as he sometimes denies the fact that he is defending. It is not only his speeches that are disorganized. He is the chief executive of a government that has changed in a very few months its national defense advisor, its spokesperson, its communications director, its chief of staff, and its primary political advisor, Stephen Bannon. Some of these changes have been reported to be impulsive, based on emotional responses rather than executive functioning.

If these symptoms of EFD — inattention, habitual responses, impulsivity, aggression — are present, the person will have difficulty “self-monitoring,” standing back from or above his or her thoughts and actions and evaluating their efficacy or social acceptability or morality. Trump revels in assaulting what he thinks of as political correctness. But he sometimes seems unable to monitor or control his behavior, which leads him into the self-destructive actions and statements that so many observers have remarked. His rant defending his comments on the events in Charlottesville indicates a mind unable or unwilling to examine itself and the effects of its communiqués to the outside world. Did Trump really mean there were many “fine people” among the neo-Nazis and Klansmen? Or was that statement a kind of brain fart, an error in diction, that he could not see as unacceptable to most Americans? It is this lack of “self-monitoring” that journalists describe as “unhinged,” a euphemism for “mentally ill.” The judgment may be accurate, but I believe that “cognitively ill” — or EFD — is a more precise medical description of Donald Trump.

When demonstrating in front of Trump Tower, I’m asked if I think Trump will be impeached or assassinated. I think neither, but if the cognitive decline — noted by those who have studied tapes of him decades ago — continues there may be good scientific grounds to remove him through the 25th Amendment. The tests for psychological illness can be vague. The tests of cognitive functioning are quite specific, concrete, and persuasive. Let’s see if Trump can do the “Stroop Task” or pass the “Wisconsin Card Sorting Test.” Let’s see if he can think outside the box of his familiar slogans and clichés. Let’s see if his executive functions are sufficiently intact for him to be the head of the Executive branch. A Democrat in the House of Representatives, Zoe Lofgren, has introduced a resolution in Congress that would require just such testing.

Two New York Times columnists — David Brooks and Charles M. Blow — represent the harsh opposition to Trump’s presidency on, respectively, moral and psychological grounds. I share their outrage, but if underneath and in a way causing Trump’s moral vacuity and emotional lability is a neurological condition, a limitation or deficit caused by aging, then Trump is, in the simplest terms, a sick man who deserves sympathy. But he does not deserve and should not occupy the desk in the oval office. Bannon was called “Trump’s brain.” Now that Bannon no longer does some of Trump’s thinking for him, the country cannot risk having as its chief executive a man with Executive Function Disorder. Those who know Trump most intimately in the White House — his family, his vice president, and cabinet — should discuss implementing the procedures of the 25th Amendment.

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