Gupta: 'Competent' or 'crazy' misses the point of presidential mental health
Story highlights
- An accurate diagnosis of mental illness is a serious and laborious undertaking
- Half of US presidents between 1776 and 1974 had clinical evidence of mental illness during their lifetimes
(CNN)The
discussion around the health of President Trump has reached a new level
of urgency this week because he will be an outpatient at Walter Reed
Medical Center today, undergoing a battery of tests to determine whether
he is "fit to lead," a colloquial term many use but with little
clinical basis.
Almost
everywhere I go, including the hospital where I practice, nearly
everyone wants to weigh in about the mental health of Trump, and perhaps
because I am a neuroscientist and medical reporter, I have become a
repository of these opinions (though I will tell you the mind is a much
more difficult thing to probe than the brain).
Some
of the opinions have been cringeworthy, like the time a fellow
physician asked whether I thought the president was "crazy" in a crowded
elevator full of patients, any one of whom could be suffering from
debilitating mental illness. Many of the armchair diagnoses have been
misguided, even if well-intentioned, and all have been thus far
unsubstantiated.
Particularly
bothersome is the commingling of the president's questionable
behavioral traits with serious mental illness. It is, as Dr. Allen
Frances, the chairman of the DSM-IV task force that defines the criteria of various mental conditions, said, an insult to the mentally ill.
The point is, there can be major pitfalls with these sorts of distant diagnoses.
For starters, they are typically wrong.
An
accurate diagnosis of mental illness is a serious and laborious
undertaking. Many patients see at least three mental health care
professionals over several months to arrive at any diagnosis.
Even
after sustained contact with a patient, most responsible psychiatrists
will follow up with family members and close acquaintances to gather as
much information as possible. They want to be as certain as possible, as
any doctor would be with the diagnosis of, say, cancer or a stroke.
Unlike those diseases, though, mental illness has no particular brain
image or blood test that can easily make the case. It takes time and
expertise by someone who has been trained to find the clues and avoid
the traps -- and that excludes the vast majority of us, including me.
Trump's 'diagnosis'
Frances
doesn't believe that Trump has narcissistic personality disorder, a
popular amateur diagnosis on the internet. This is particularly
important because Frances also happens to be the Duke University
professor who wrote the criteria defining the disorder.
I
have often responded to those sharing their opinions with a smile and a
shrug when approached by people wanting to have the "Trump is crazy"
discussion. It is not out of lack of interest but because, after the
umpteenth time, I know that the discussion often sadly leads to
worsening misconceptions about the mentally ill.
Point
is, even if Trump was diagnosed with a mental illness, that is not
necessarily a barrier to holding a job or even higher office. It was in
1972 when Thomas Eagleton was dropped as a Democratic vice presidential
candidate after it was revealed that he had been hospitalized for
depression. We seem hardly enlightened since then.
Fully half of US presidents between 1776 and 1974 had clinical evidence of mental illness
during their lifetimes (half of them while in office), according to a
2006 study in the Journal of Nervous and Mental Disease. Half of those
were depressed, including James Madison, Dwight Eisenhower and, perhaps
most famously, Abraham Lincoln, who also suffered from psychosis. Lyndon
Johnson, Theodore Roosevelt and John Adams were among the fifth of US
presidents with bipolar disorder. And another fifth were alcoholics,
including Richard Nixon, whose staff, according to an NPR interview with
one of the study's authors, had to make sure he didn't make important
decisions in the evening.
A separate study in the Journal of Personality and Social Psychology from 2012 took it a step further when it concluded that John Kennedy was a psychopath
but added that "certain features of psychopathy are tied to successful
interpersonal behavior." In particular, it was the trait of "fearless
dominance" -- a brashness accompanied by a compulsion to dominate social
situations, a higher willingness to take risks and an immunity to
anxiety -- that was "associated with better presidential performance,
leadership, persuasiveness and crisis management," according to the
study authors.
Fearless dominance.
When you consider the qualities of a good leader, trust, intellect,
curiosity, empathy and discipline probably come to mind, but "fearless
dominance" is a frightening term these experts think should be added to
the list.
Terms matter when we talk about mental health.
When Dr. Bandy X. Lee, a Yale psychiatrist, briefed mostly Democratic members of Congress in early December, she raised a different term: "dangerousness."
It
is not a true psychiatric diagnosis but one that has been medicalized
nonetheless. According to J.C. Segens' "Dictionary of Modern Medicine,"
it is "the state of being dangerous and possibly causing mental or
physical harm to others."
Based
on "public records, tape recordings, video tapes and his own public
speeches, interviews and 'tweets,' " Lee told congressional members, it
is "obvious" Trump meets the criteria for dangerousness. And she feels
compelled to inform the public. She is the organizer of the Duty to Warn
conference and has written a book, "The Dangerous Case of Donald
Trump."
That makes many of her
colleagues uncomfortable, because they abide by the 1973 Goldwater Rule,
which prohibits psychiatrists from opining about the mental health of
an individual they have not personally examined. Lee, and a handful of
other psychiatrists, instead seem to take cover under a separate
professional guideline, the controversial Tarasoff Rule of 1976, which
obligates psychiatrists to notify potential victims if they believe
their patient is a real threat. It is that "duty to warn," Lee told me
over the phone, that has motivated her to break from the rank-and-file
psychiatrists.
In this case, she is claiming that the patient is Trump and the potential victims are everyone else on the planet.
Of course, Trump is not Lee's patient, and she has never examined him.
For
its part, the American Psychiatric Association offered a rebuke to Lee
and others who continue to diagnose from afar. "A proper psychiatric
evaluation requires more than a review of television appearances, tweets
and public comments. Psychiatrists are medical doctors; evaluating
mental illness is no less thorough than diagnosing diabetes or heart
disease," it said in a statement this week.
What presidents are tested for
When
Trump is examined today for his annual physical, he will undergo a
battery of tests. There's no guarantee which ones they will be and no
requirement that results be released.
Most
presidents have released one- to two-page summaries including height
and weight, blood lipid levels and even running speed. George W. Bush,
we were told, smoked occasional cigars and ran 3 miles 4 times a week.
Only candidate John McCain released his full medical records in 2008,
and he invited me to review them in a secure room for a few hours. While
McCain's records included detailed reports around his mental health,
virtually none of the others I have seen in the past 16 years of
reporting on presidential health made mention of the cognitive or mental
health of the presidential patient. The current White House has
telegraphed that mental health testing is probably not something the
president will even undergo.
If his doctors want to probe the brain and mind of Trump and he agrees, a few useful tests could be performed.
The Mini-Mental State Examination is a five- to 10-minute validated exam that has been around since 1975. It consists of 11 questions
that focus on five specific areas of cognitive function: orientation,
registration, attention and calculation, recall, and language. A low
enough score could indicate that the patient is cognitively impaired.
A
neuropsychiatric evaluation is much more thorough: up to eight hours,
with many cognitive-based questions. The goal is to investigate any
changes in the brain that might impact behavior. It can also help
identify the early stages of dementia and make clear if a patient is
able to conduct the normal activities of daily living.
And
although a brain scan, such as a CT or an MRI, would not be able to
diagnose a mental illness, it would probably uncover an organic problem
such as a tumor, hydrocephalus or types of dementia including vascular
or frontotemporal dementia, which in certain locations can greatly
impact the behavior, memory and judgment of a patient.
Lee
believes Trump should also have a capacity exam, by force if necessary.
Capacity, a medical term, is mostly synonymous with the legal term
competence. A capacity exam is not precisely defined, but it is one of
the most common reasons a doctor like me, a neurosurgeon, will consult
with a psychiatrist: I want help in determining whether a patient has
the ability to provide consent for an operation.
The
question I am typically trying to answer: Can the patient make an
informed decision about having surgery? The question Lee is hoping to
answer: Can the president make informed decisions about the welfare of
the population?
At
no other time in US history has a group of mental health professionals
been so collectively concerned about a sitting president's
dangerousness, according to Lee.
But
other than a clear-cut diagnosis of dementia, it's difficult to see how
a mental health diagnosis leads to removing a president from office, no
matter his fearless dominance or perceived dangerousness.
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