The release of a new book about the Trump presidency has reignited debate about whether or not the US president is mentally ill.
A debate that has existed since before he took office, it has now reached fever pitch, moving from allegations of clinical narcissism to speculation that his brainpower may be decreasing with age or dementia.
What are people saying?
In his book, Fire and Fury, journalist Michael Wolff writes that President Donald Trump is showing worsening signs of mental decline.
“Everybody was painfully aware of the increasing pace of his repetitions,” he writes in Hollywood Reporter.
“It used to be inside of 30 minutes he’d repeat, word-for-word and expression-for-expression, the same three stories – now it was within 10 minutes.”
Mr Trump has blasted the book, calling it “full of lies”.
Mr Wolff adds his voice to those of various psychologists who have spoken out publicly about the symptoms they purport to see in Mr Trump.
Several books came out on the topic within months of the Trump inauguration: The Dangerous Case of Donald Trump by Bandy X Lee; Twilight of American Sanity by Allen Frances and Fantasyland by Kurt Andersen.
Dr Lee, who is a psychiatry professor at Yale, told a group of mostly-Democrat senators last month that Mr Trump was “going to unravel, and we are seeing the signs”.
Why would it matter?
In theory it could cost Mr Trump his job.
Under the 25th amendment to the US Constitution, if the president is deemed to be “unable to discharge the powers and duties of his office”, the vice-president takes over. His cabinet and the vice-president together would need to kick-start the process, so it’s unlikely to happen, but increasing numbers of voices seem to be clamouring for it.
Has anything like this happened before?
Yes – presidents have suffered from mental ill health going right back to Abraham Lincoln, whose clinical depression prompted several breakdowns.
More recently Ronald Reagan, who was president from 1981 to 1989, suffered confusion and seemed unsure of where he was at times – he was diagnosed with Alzheimer’s five years after he left office.
The 25th amendment has never been used to depose a sitting president.
Is this debate fair?
Well, there’s the question. When the debate reared its head before, Dr Frances said it was unfair to people suffering from mental illnesses.
“Bad behaviour is rarely a sign of mental illness, and the mentally ill behave badly only rarely,” he said.
“It is a stigmatising insult to the mentally ill (who are mostly well behaved and well meaning) to be lumped with Mr Trump (who is neither).”
Others have echoed this, with one columnist saying the debate would “make people with mental-health needs more likely to stay closeted”.
But professionals who have given their opinion on Mr Trump’s psychological state say they have done so in order to warn the nation.
In speaking out they have in fact broken their industry’s own ethics – the decades-old Goldwater Rule prohibits psychiatrists from giving diagnosis about someone they have not personally evaluated.
Given the rule against diagnosing from afar, some argue that there should be a system in place for diagnosing Mr Trump up close.
“A president could be actively hallucinating,” writes the Atlantic, “threatening to launch a nuclear attack based on intelligence he had just obtained from David Bowie, and the medical community could be relegated to speculation from afar.”
In fact there is a law in the works for a committee to be required to assess the president’s health – the Oversight Commission on Presidential Capacity (OCPC) Act.
And despite the amount of space given to the topic of the president’s mental health, many commentators recoil from it. Carlos Lozada writes in the Washington Post: “There is something too simple about dismissing his misdeeds as signs of mental illness; it almost exonerates him, and us.”
“If we don’t like someone’s politics we rail against him, we campaign against him, we don’t use the psychiatric system against him,” writes former Harvard Law School professor Alan Dershowitz, saying that is “just dangerous”.
He said that people who thought the 25th Amendment would end the Trump presidency were putting “hope over reality”.
Only a “major psychotic break” would result in that, he said.
So what’s the evidence with Mr Trump?
In the past, some suggested that Mr Trump had Narcissistic Personality Disorder (NPD).
People with this condition often show some of the following characteristics, according to Psychology Today:
- Grandiosity, a lack of empathy for other people and a need for admiration
- They believe they are superior or may deserve special treatment
- They seek excessive admiration and attention, and struggle with criticism or defeat
But the man who wrote the diagnostic criteria for NPD, Allen Frances, said a lack of obvious distress stopped him from saying Mr Trump had the condition.
“Mr Trump causes severe distress rather than experiencing it and has been richly rewarded, rather than punished, for his grandiosity, self-absorption and lack of empathy,” he wrote.
- Experts debate Trump’s mental health
Now, though, people have moved on to discussing whether Mr Trump might be suffering from cognitive decline.
They point to his repetition of stories, as mentioned in Mr Wolff’s new book, and to the way he speaks.
When neurological experts compared clips of Mr Trump in the past with more recent footage, they found his manner of speaking had totally changed. In the past he spoke in long and complicated sentences, following thoughts through and using long adjectives while in more recent clips, he used fewer and shorter words, missed words out, rambled, and was more likely to use superlatives like “the best”.
This could be due to a neurological condition like Alzheimer’s, the experts said, or it could be a symptom of nothing more sinister than age.
Those who say the president is concealing cognitive decline point to a few other incidences where he seemed not to have full control over his own movements. There was one instance in December where he was giving a speech and lifted a glass, awkwardly, with both hands.
During another speech, he slurred through some of his words, which the White House blamed on a dry throat but some said could be a sign of something more serious.
Motor function is driven by the brain’s frontal lobe, which loses volume with age but also gets affected by a specific, relatively rare, type of dementia.
According to the National Health Service (NHS) in the UK, frontotemporal dementia has symptoms including “acting inappropriately or impulsively”, “appearing selfish or unsympathetic”, “overeating”, “getting distracted easily” and “struggling to make the right sounds when saying a word”.
Next week the president will undergo his first medical examination – a physical – since taking office.
How are Republicans responding to the debate?
“It’s disgraceful and laughable,” said Sarah Huckabee Sanders, the White House press spokeswoman.
“If he was unfit, he probably wouldn’t be sitting there, wouldn’t have defeated the most qualified group of candidates the Republican Party has ever seen.”
But others have been more forthright. Following in the footsteps of Jeb Bush’s assertion during the race for the presidency that “the guy needs therapy”, Tennessee senator Bob Corker said in August that Mr Trump had not demonstrated the “stability” he needed for the role.
There was only one Republican lawmaker at the Bandy X Lee talk earlier this month – he or she has not yet been identified.