"People who boast about their I.Q. are losers." -- Stephen Hawking
Several times on this blog, I've explored the possibilities of what may be impairing President Trump. Though he has boasted about his I.Q., we know that he is, in reality, quite impaired in his language and his cognition. I am a Speech-Language Pathologist, and as my profession deals with speech, language, and cognitive impairments of all kinds, I have looked at his unusual cognitive-communication patterns and have thrown out some hypotheses.
April 24, 2017: A Case for Dementia. I looked at his language from a clinical perspective, how his language is full of "empty" words with a lot of nonsense and confabulation.
July 15, 2017: The Language Butcher. I examined the simplicity of his language and also his butchering syntax, making him often unintelligible.
December 7, 2017: "God Bless the United Shashe." I analyze his slurred speech. It became concerning to me, as dysarthria is almost always due to a neurological issue.
December 26, 2017: When the well is dry, they know the worth of water. I looked at his funny way of drinking water and analyzed it clinically. With this emerging motor symptom, I tried to couple it with his cognitive-linguistic symptoms to come up with a possible diagnosis.
January 7, 2018: Concern should drive us into action and not into a depression. I noted Michael Wolff's writing, in his tell-all book Fire and Fury: Inside the Trump White House, about Trump's habits of perseveration of ideas. Wolff quotes staffers that say he tends to tell the same story several times over and over.
January 19, 2018: Thinking: the talking of the soul with itself. I looked again at his cognitive abilities and the probable sham of his cognitive screening done as part of his physical exam by Dr. Ronny Jackson.
May 1, 2018: Truth is stranger than fiction. I noted some more unintelligible ramblings.
I've continued to think about it, and this week I was hit by a couple of things. Please refer to my post of last December, When the well is dry, they know the worth of water. I'm sorry that the videos that I embedded are no longer available, but you'll recall his odd two-handed hold on his water bottle or water glass and the funny way he tipped his head down and up to drink water.
In that December post, I outlined a few possibilities of neurological problems that are characterized with both speech and language difficulties and with motor difficulties. One disease I considered and dismissed was Amyotrophic Lateral Sclerosis. I wrote:
I'll consider ALS (Amyotrophic Lateral Sclerosis, or Lou Gehrig's disease) only briefly. A horrible progressive motor neuron disease, ALS typically does not have a cognitive component. An in fact, over the years I have found, as have many in the medical community I have recently learned, that patients with ALS are the nicest people you ever hope to meet. "Niceness" in these patients is so prevalent that some physicians can practically use the characteristic as part of their differential diagnosis process! No, he decidedly does NOT have ALS.
I was left in December believing that he suffers from Frontotemporal Dementia, saying, "I am liking the diagnosis Frontotemporal Dementia. It accounts for his lack of empathy, his forgetfulness, his inappropriate actions, his lack of judgment, his speech and language difficulties, his getting lost, his lack of insight into his difficulties, as well as his motor difficulties."
Well, today I believe I was too quick to dismiss ALS. My new theory is that Donald Trump indeed suffers from Amyotrophic Lateral Sclerosis.
I was hit hard by something as I watched the news on Monday.
I was watching ABC Nightly News on November 5, 2018, and I caught something that possibly only a Speech-Language Pathologist would notice. Please look carefully at Trump speaking at about 2:03 and about 2:12.
Right after he says, "you can forget it" at about 2:03, his upper lip has a tiny tremor (also called a fasciculation). You may have to play it a couple times. It is quite subtle, but it was immediately obvious to me. Again at 2:12, while he is saying, "a lot of people, a lot of people <right here is a fasciculation of his lips> my opinion..." This one is a little easier to see. It looks like both lips tremor briefly.
Caveat: Fasciculation of the lips can be attributed to many things, including stress and fatigue. But coupled with all of his other speech, language, and cognitive symptoms, it really jumped out at me. Fasciculations of the lips or tongue are common in ALS patients, and can be the very first symptom.
I wanted to see if I could spot other incidents. I searched and reviewed several more clips of speeches. I found this news conference from today. I moved the slider to a random spot, and immediately I spotted a little twitch in his left chin/neck at about 1:44:20 after he said, "build the embassy." I've started the video below just before the moment.
Again, it's subtle, but it's there. I moved the slider to a couple other random spots and didn't see any more, but I'll continue to review his speeches to collect more data to refine my hypothesis.
In addition to these small fasciculations, we return to his speech problems. One shocking incident was his pronunciation of "anonymous" while talking about the New York Times Op/Ed that purported that there was a mutinous attitude within the White House.
And, earlier, his extremely concerning slurring of "United Shashe," which I discussed in my blog on December 7, 2017: God Bless the United Shashe.
Dysarthria (slurred speech) is a hallmark of ALS. Many times, speech problems are the presenting symptom of ALS, with symptoms extending out to the extremities over time.
The reason I had dismissed ALS as a cause of his difficulties was primarily that it was my belief that ALS rarely had a cognitive disorder component. I started exploring ALS diagnosis a bit more. I learned that, contrary to my previous belief and experience, within the last 10-15 years it has become understood that up to 50% of ALS patients have cognitive disorders, and up to 25% of patients develop a full-blown dementia. And further, the type of dementia that typically strikes ALS patients is Frontotemporal Dementia. Just as I had predicted in my post.
The ALS Association outlines cognitive-communication behaviors that are associated with this subset of ALS patients:
- Behavior becomes embarrassing, childlike, inappropriate, or uncharacteristic
- Person seems to have lost “a filter” with regard to making comments or expressing opinions
- Person begins eating sweets, or only one type of food to the exclusion of a more balanced diet
- Person loses table manners and begins stuffing their mouth with food
- Decreased attention to hygiene such as toileting, bathing, grooming, or changing clothes on a regular basis
- Loss of judgment with regard to making decisions or making a decision that reflects a strong departure from views the person expressed in the past
- Lack of concern for others, one’s own illness and symptoms, and/or no view of the future
- Inability to concentrate or to shift focus from one activity to another
- Fixation on a single idea or activity with a need to repeat the concern or repeat the activity
- Increased aggression
- Says “no” when means “yes,” or becomes less reliable with yes/no responses
- Feels like there is a disconnect between having the thought to move and being able to move the intended body part
- Writes or says words in the wrong order or without respect to grammar
- Thinks of the word he/she wants to use but cannot get it out in conversation
- Loss of spelling or loss of word meaning
- Says sentences that convey little meaning
- Cannot follow instructions to complete physical therapy/occupational therapy/speech therapy exercises, stretches, or guidelines such as swallowing precautions
- Difficulty remembering what he/she intends to do
The Mayo Clinic outlines these behavioral symptoms in patients with Frontotemporal Dementia:
- Increasingly inappropriate actions
- Loss of empathy and other interpersonal skills
- Lack of judgment and inhibition
- Apathy
- Repetitive compulsive behavior
- A decline in personal hygiene
- Changes in eating habits, predominantly overeating
- Oral exploration and consumption of inedible objects
- Lack of awareness of thinking or behavioral changes
We don't know all of his behaviors while off-camera, but we can easily observe many of these behaviors in Donald Trump.
There are language components to Frontotemporal Dementia, including Primary Progressive Aphasia or generalized difficulties with language expression or comprehension in both spoken and written modalities. We are all very aware of his speech and language difficulties, as I've outlined in previous posts, and we know he has difficulty reading, too, as I outlined in my post A Case for Dementia.
In addition, cognitive changes may precede the physical manifestations of ALS according to studies. In my original musings of his difficulties, I said that there weren't any physical symptoms, but now they are becoming more apparent.
The physical manifestations of ALS can start out very subtly. Now I wonder if his aversion to closing his umbrella -- and thus abandoning it on his way onto Air Force One -- was a hesitation on his part, knowing that the fine motor task would be difficult, and would demonstrate his motor difficulties to the world.
The main trouble, to my mind, with the ALS diagnosis is what I noted before: That the overwhelming majority of ALS patients are so extraordinarily nice that physicians can practically use "niceness" or "agreeableness" as a diagnostic trait. This study corroborates anecdotal observations, which I have also noticed in my own patients through the years. Trump is nothing like any of the ALS patients I've had. I've always been struck at how nice ALS patients are. However, as in any disorder, there are outliers. And if the dementia aspect is strong in this one, it could also account for his mean and hateful ways. Disagreeableness, paranoia, and other negative social behaviors are also a hallmark of dementia. I've read that in person Trump is quite charming, so perhaps his more public persona is more difficult to mask, or perhaps a mental health issue is overlaying a neurological issue.
Read more about ALS at the National Institutes of Health website or at Medscape.
I will continue my forensic detective ways as I watch his behaviors closely. The "pathologist" in me is always at work. If you see anything odd, send it my way. I'm sure I will continue to update my thoughts! It's also possible that Parkinson's disease or another neurological disease can account for his speech, language, cognitive, and motor symptoms. He should get a thorough neurological workup by an unbiased agency. His previous health exams by his gastroenterologist and by the White House physician were not legitimate and did not focus on his neurological health.
In the meantime, back to the greater political picture. I'll post my post-election thoughts soon.
Thanks for reading!
