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Bandy X. Lee M.D., M.Div.
Bandy X. Lee M.D., M.Div.
Health

Mental Health Experts Declare the Need to Evaluate

We need a proper, not a sham, examination.

In the context of Mental Health Awareness Month, authors of The Dangerous Case of Donald Trump gathered in Washington, DC (Lee, 2018), where a topic of discussion was the recent disqualification of White House physician Rear Admiral Ronny Jackson. One public discourse they contributed to centered around Jackson's false reassurances to a worried public in declaring his boss and commander-in-chief mentally fit based on a 10-minute, inadequate and inappropriate cognitive screen (Lee and Eisen, 2018). Now the doctor is not only withdrawn from nomination as Veterans Affairs secretary but also removed from serving as the president’s personal physician (Johnson, 2018). Mental health professionals believe that his mental health screen should be nullified, too.

First, the brief screen he administered, known as the Montreal Cognitive Assessment, or MoCA, was not an appropriate test for the conclusion he drew from it: that the president was “very sharp” and “absolutely … fit for duty,” not just for the remainder of this term, but for another four years if reelected (Vitali, 2018). Generally used as a screen for Alzheimer’s and similar symptoms, the MoCA has only moderate to good sensitivity in detecting cognitive impairment. Even patients clinically diagnosed with Alzheimer’s dementia can score up to 30 out of 30 points on the MoCA (Trezpacz et al., 2015). For this reason, some researchers in Alzheimer’s Disease Neuroimaging Initiative consortium emphasize that the MoCA is only a screening instrument and thus does not replace neuropsychological assessment for confirming the absence of mild cognitive impairment or dementia.

Not only that, individuals with known severe mental illness may also achieve normal MoCA scores. This has been shown with hospitalized schizophrenia patients (Gierus et al., 2015). Therefore, scoring in the normal range on the MoCA does not rule out the presence of serious mental illness and is not a good measure of psychological impairment.

Determination of the president’s actual cognitive status would have required a full history by someone with training in mental health and a standardized battery of tests, such as the Minnesota Multiphasic Personality Inventory, Wisconsin Card Sorting Test, the California Verbal Learning Test, the Stroop Test, and the Wechsler Adult Intelligence Scale. A magnetic resonance imaging (MRI) and an amyloid positron emission tomography (PET) scan of the brain should have been considered, given the observable symptoms and his family history. The MoCA examination was simply not sufficient under any circumstances to support the declaration that the military doctor had “absolutely no concerns about [Trump’s] cognitive ability or neurological functions” (Jackson and O’Donnell, 2018).

We have seen many concerning signs in Trump’s cognitive abilities: whether specialist or not, many have noticed a decline in Donald Trump's ability to form complete sentences, to stay with a thought, to use complex words, and to refrain from repetitions and tangents. Marked decline, especially with a family history of dementia, warrants comprehensive testing.

Neurologically, we have witnessed at least one episode of slurred speech which, in the worst scenario, could signal a stroke. He showed other neurological signs that we can call “primitive”: awkwardly grabbing a glass with both hands or using his free hand to steady a small water bottle.

Psychologically, Trump has shown a susceptibility to aggression. He has engaged in extensive cyberbullying, boasted of sexual assaults, incited violence in others, and repeatedly taunted hostile nations and allies alike. He has also exhibited impulsivity, paranoid responses, a loose grip on reality, a lack of empathy, and a tendency to go into an attack mode when stressed. We now see how Trump’s irrational and self-destructive acts undermine his legal cases as well as his own public image.

When one causes damage to self or to others in illogical ways irrespective of consequences, then there is a need to question the person’s capacity. A capacity examination determines whether a person will be able make decisions without undue interference from impulsivity or lack of touch with reality. It tests whether a person can take in important facts and advice, process that information, and weigh consequences before making sound, rational, and reality-based decisions. A capacity evaluation does not require consent.

Prior to Dr. Jackson’s disqualification, the same group that had warned of the inappropriateness of his cognitive screen and his lack of independence had been requested to prepare a brief for his Senate hearing (See below). The questions that have gone into the brief are now being converted into criteria for a comprehensive mental health evaluation. Furthermore, the same professionals have been invited to outline the requirements for an expert panel that would be capable of impartially assessing fitness for duty, based purely on medical criteria. Their recommendations will be given to the nongovernmental National Academy of Medicine for review and appointment of panelists, if appropriate.

We believe that there is good reason to establish a fitness-for-duty exam for all presidential and vice-presidential candidates, just as there is for military officers. Such an exam can assure that proper testing will be done before leaders assume office, so that no one will be elected to a position in which they do not have the capacity to serve. Because full capacity is difficult to establish from a distance, and certainly for those who are untrained, the long “vetting” process of a presidential campaign does not substitute for proper examination.

However, we mental health experts who contributed to The Dangerous Case of Donald Trump believe the current situation is an emergency. The American people should take mental health matters as seriously as legal ones and demand that the president receive a proper mental health test. Mental impairment does not exonerate him from criminal wrongdoing, but the combination may augment the dangers.

Our nation is full of highly qualified, well-trained forensic mental health professionals who can carry out a proper examination. This is not to decide who can or cannot be president but to ensure that the commander-in-chief meets the bare minimal level of functioning to serve in office. The people have a right to demand it—to be correctly informed about the exact conditions of this presidency, learn about the unhealthy dynamics that can occur, and elect not to be drawn into them but to retain the ability to choose a life-affirming course.

Sample Questions for Rear Admiral Dr. Ronny Jackson at His Hearing before the U.S. Senate

At the White House press briefing on January 16, 2018, you reported on President Trump’s physical examination, which you performed on January 12, 2018. You mentioned at the time that you performed a cognitive assessment because the president asked you to.

1. What kind of mental health exam did the president request?

2. Why did you choose the Montreal Cognitive Assessment (MoCA)?

3. You said you did not believe that a full cognitive assessment was indicated based on your daily interactions with the president. How accurate are passing, day-to-day interactions for assessing cognitive function?

4. What does a cognitive workup entail?

5. You emphasized that the president’s score of 30 out of 30 on the MoCA ruled him out for Alzheimer’s and that there was no possibility of overlooking something. How sensitive is the MoCA?

You stated at the press briefing that you believe Mr. Trump is “mentally very sharp, very intact,” that: “absolutely he is fit for duty and will remain fit for duty for the remainder of this term and for the remainder of another term if he is elected.”

6. On what basis did you make these declarations?

7. What would you define as the limits and boundaries of your expertise?

8. Can a military doctor give an independent opinion about his commander-in-chief?

9. What is involved in evaluating someone for mental fitness?

10. Under what conditions would you consider consulting a mental health professional?

Numerous mental health experts have expressed concerns over Mr. Trump’s psychological signs and his proneness for impulsive behavior, based on objective signs that anyone can easily observe. They include the following: his engagement in verbal aggression, boasting of sexual assaults, incitement of violence in his followers, showing an attraction to violence and powerful weapons, and repeated taunting of hostile nations and allies alike. He has also exhibited impulsivity, recklessness, paranoid ideations, a tenuous apprehension of reality, a lack of empathy, and a persistent concern with power/control.

11. What is your response to these signs?

12. Reality testing is an essential part of a mental status examination. How did you assess this in your examination?

13. Impulse control is an essential capacity of executive functioning. What was your assessment of the president’s impulse control?

14. In many personality disorders, the person evaluated would not feel subjective distress, but the disorder would only be apparent in behavior and ideation he does not directly express to you. How would you determine if the president had a severe personality disorder that could affect his fitness?

15. Assessing dangerousness is an underpinning of all mental health evaluations. What are the criteria for assessing dangerousness?

(Names of the Brief Preparation Working Group members are available upon request: dangerouscase.org.)

References

Gierus, J., Mosiołek, A., Koweszko, T., Wnukiewicz, P., Kozyra, O., and Szulc, A. (2015). The Montreal Cognitive Assessment as a preliminary assessment tool in general psychiatry: Validity of MoCA in psychiatric patients. General Hospital Psychiatry, 37(5), 476-480.

Jackson, D., and O’Donnell, J. (2018). White House doctor: Trump healthy, passed cognitive assessment, but needs to lose weight and exercise. USA Today. Retrievable at: https://www.usatoday.com/story/news/politics/2018/01/16/white-house-doc…

Johnson, E. (2018). Ronny Jackson won’t return to old job as Trump’s physician. Politico. Retrievable at: https://www.politico.com/story/2018/04/29/ronny-jackson-trump-doctor-55…

Lee, B. X. (2018). Mental health experts speak of an increasingly dangerous era. Psychology Today. Retrievable at: https://www.psychologytoday.com/us/blog/psychiatry-in-society/201805/me…

Lee, B. X., and Eisen, N. (2018). On Trump’s mental fitness, the experts are silenced and the public’s in the dark. USA Today. Retrievable at: https://www.usatoday.com/story/opinion/2018/01/19/trumps-mental-fitness…

Trezpacz, P. T., Hochstetler, H., Wang, S., Walker, B., and Saykin, A. J. (2015). Relationship between the Montreal Cognitive Assessment and Mini-Mental State Examination for assessment of mild cognitive impairment in older adults. BMC Geriatrics, 15(1), 107.

Vitali, A. (2018). White House doctor deems Trump mentally ‘very sharp,’ in ‘excellent’ health. NBC News. Retrievable at: https://www.nbcnews.com/politics/white-house/wh-doctor-deems-trump-ment…

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About the Author
Bandy X. Lee M.D., M.Div.

Bandy Lee, M.D., is a forensic psychiatrist at Yale School of Medicine and project group leader for the World Health Organization Violence Prevention Alliance. She also authored the textbook Violence.

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