Davos and Dementia

Dan and I talked about Carney’s speech, which you should watch in full if you haven’t already. I’ve appended it below. I have more to say about that speech, but I’ll put it in a separate newsletter.

Dan and I also discussed Trump’s mental state, and the reaction of those in attendance. He and I have a significant disagreement about how to understand Trump’s behavior. We were already well over our allotted 15 minutes, so I decided to write about it.

I’ve written here about Trump’s psychopathology and his growingly obvious dementia, and don’t want to reprise every point I’ve made. But some bear repeating—all the more so because if Dan isn’t yet convinced, and Congress isn’t yet convinced, I have to keep working on it.

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I’m going to begin by asking you to do something unpleasant. It’s directly relevant to the argument. I’d like you to watch this—the whole thing, from start to finish:

Your instinct will be to skip it, or to stop after five minutes. (Or who knows? Perhaps you’ll be riveted by the soaring oratory.) But I’m asking you to watch it through because, as I said to Dan, far too many people are kidding themselves about the severity of Trump’s condition. They can do so because they’re never forced to listen to him for more than a soundbite at a time, and because the media never (to my knowledge) gives readers or viewers a full and accurate portrait of the situation.

That’s not because the news media are engaged in a conspiracy to hide his decline. Most outlets aren’t, anyway. It’s a combination of failings. Journalists don’t realize how significant his symptoms are or what they mean, and they’re too incurious to ask; or they feel that it’s somehow unserious to discuss the president’s mental health. As I wrote:

The taboo against precisely describing the president’s speech and behavior and then accurately telling the public what this suggests is policed most strictly by the prestige media, where the fear of appearing unseemly or unserious has curdled into a refusal to apply the analytical tools journalists routinely deploy everywhere else. … This pattern of failure in the media isn’t an accident. At elite outlets, “seriousness” has come to mean a particular tone; this is understood as an injunction against saying the thing that would sound unspeakable if said plainly. The New York Times’ editors instinctively sense that writing precisely about the president’s cognition would be tabloid journalism, no matter how carefully and soberly it’s done. This is a category error. They’re confusing clinical description with sensationalism, because the topic itself feels lurid. The result is euphemism—“meandering,” “freewheeling,” “discursive”—without analysis.

Above all, journalists know full well that no one of sound mind would sit through an hour of Trump’s insane discourse. (I’ll be astonished if more than 10 percent of you are willing to do it, despite my pleas.) So print journalists try to extract a coherent quote from the jumble of garbled sounds that tumble out of Trump’s mouth, because they know a newspaper article has to have a point. Broadcasters find a sound clip, one that sounds like it might have a meaning, and run with it—time is money, on television, and you’re just not going to put this on people’s screens for an hour.

So do me a favor, just this once: Watch it through. Do it so that you see exactly what that collection of assembled economists, diplomats, business leaders, and government officials saw. I’m sure that many or even most of them had not previously grasped how serious this situation really is. They too had been seeing Trump refracted through a news media that reflexively endeavors to bring order to this chaos.

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I am confident in saying that Trump is suffering from at least two distinct pathologies: a severe personality disorder, and, growingly, dementia, probably of the fronto-temporal variety. As for the objection that I’m not a doctor and haven’t examined him, I repeat what I wrote:

True. But so what? I’m not offering him medical care. The relevant medical literature isn’t sacred scripture interpretable only by sages who have passed through a secret initiation and emerged bearing the stethoscope of true revelation. It’s a body of publicly available knowledge, written in ordinary language. Medicine isn’t necromancy, and neurology isn’t a mystery cult. The literature exists precisely so that observable phenomena can be compared with known patterns by anyone willing to look.

But if you’re only willing to take the word of a qualified medical or mental health professional, the number who are saying this publicly is rapidly mounting. More than two hundred, for example, signed this open letter to The New York Times:¹

We, the undersigned licensed medical and mental health professionals concur:

From our years of training and experience, we are convinced that, while a definitive diagnosis would require further testing, Donald Trump is showing unmistakable signs strongly suggesting dementia, based on his public behavior and informant reports that show progressive deterioration in memory, thinking, ability to use language, behavior, and both gross and fine motor skills.

1) Decline from baseline:

Overall, he shows a shocking decline in verbal fluency from his previous baseline. He was once highly articulate, with a sophisticated vocabulary, and spoke in polished paragraphs. Now, his vocabulary is impoverished, he often has difficulty finishing a thought, sentence or even a word. Typical of dementia patients he perseverates and overuses superlatives and filler words.

People who worked closely with Trump during his administration are reporting a shocking deterioration in just 4 years.

2) Memory:

Forgetting names and dates is normal for people who are aging (like Joe Biden). But the Dementia Care Society says “confusing people and generations” is a sign of advanced dementia. Recently, Trump confused Nikki Haley and Nancy Pelosi. Eight times he said he was running against Obama. He didn’t look like he was joking. An example of confusing generations: Trump said his father was born in Germany, when that was his grandfather. Michael Wolff wrote Trump not infrequently failed to recognize old friends.

3) Language

Trump shows formal signs of disordered speech we typically see only in organically impaired patients. Trump is verbalizing an increasing number of “phonemic paraphasias.” Using non-words in place of real words that may include a fragment of the actual word. For example saying “mishuz” instead of missile, or “Chrishus” instead of Christmas. Sometimes he just uses sounds that don’t resemble words at all.

Trump evidences “semantic aphasia” where he uses words in the wrong way. For example, “the oranges of the investigation.”

Trump evidences “tangential thinking” where he drifts from one unrelated thought to another, and sometimes tries to confabulate them into a story. But the narrative is literally incoherent. With increasing frequency he degenerates into literal incoherence, where no one can tell what he was trying to say.

4) Motor:

Trump shows evidence of a “wide based gait” commonly found among patients with dementia. He swings his right leg in a semi-circle as if it were a dead weight. He also shows deterioration in fine motor coordination, for example having difficulty drinking a bottle of water.

5) Behavior:

He is showing marked deterioration in impulse control and judgement.

This represents a unique danger because of Trump’s pre-existing Malignant Narcissistic Personality Disorder. As he continues to deteriorate he will become even more erratic, impulsive, paranoid, and aggressive than he already is. A demented malignant narcissist as president of the United States would have unimaginably catastrophic consequences.

Not only is Trump unfit, but he is cognitively incapable of carrying out the duties of president. Under normal circumstances, relatives of such a patient would be seeking consultation with experts, and considering long term care, as he continues to deteriorate.

We feel an ethical obligation to warn the public, and urge the media to cover this national emergency.

More than three thousand clinicians signed a petition to the same effect.

Here’s yet another petition, this one signed by 70,000 mental health professionals:

We, the undersigned mental health professionals, believe in our professional judgment that Donald Trump manifests a serious mental illness that renders him psychologically incapable of competently discharging the duties of President of the United States. And we respectfully request he be removed from office, according to article 4 of the 25th amendment to the Constitution, which states that the president will be replaced if he is “unable to discharge the powers and duties of his office.”

The psychologist who organized the petition, John Gartner, has said:

… [T]he Trump situation is “from a psychiatric point of view the absolute worst-case scenario … if I were to take the DSM (Diagnostic and Statistical Manual of Mental Disorders) and try to create a Frankenstein’s monster of the most dangerous and destructive leader and had freedom to create any combination of diagnosis and symptoms,” Trump would be the result.

That’s because it’s not a single condition at work, according to Gartner. Rather, Trump is something more than a narcissist and shows signs of a quartet of conditions that add up to “malignant narcissism,” which Gartner described as an “old-fashioned term” that was originally devised to characterize Hitler. The quartet, Gartner said, consists of narcissism, paranoia, and anti-social personality disorder, with a dash of sadism thrown in. It is not an official diagnosis, but Gartner said that it’s especially apt in Trump’s situation. …

Each aspect of the quartet of “malignant narcissism,” Gartner said, is part of a diagnosis in the DSM. For all diagnoses, the DSM offers a summary topic sentence, followed by a list of criteria, and a person must meet some minimum number of these criteria to be diagnosed. Gartner had these at his fingertips and walked me through an example of antisocial disorder, which he asserted is the most serious of the quartet that he thinks Trump manifests. As he stepped through each criterion, Gartner cited examples of Trump’s behavior that he has observed—that anyone can have observed, he said—and concluded that with many such examples, Trump does in fact meet the criteria for this disorder.

And Gartner went a step further. “I doubt that interviewing Donald Trump would give them (a professional) a lot of information,” he said. “He runs circles around people, changes topic, never answers questions, I’m not sure that they would get a good deal” more from him. But, he argued, “We have tons of information about his behavior, his words, people who know him well, who have observed his behavior … we have so much information that it is screamingly obvious that he meets these diagnostic criteria.”

Want another one? Here’s an op-ed by Morton Tavel, MD, a professor emeritus at Indiana University School of Medicine. He summarizes the opinions of “27 nationally recognized psychiatrists and psychologists” who contributed to a book about Trump’s psychopathology:

In order to quantify the seriousness of Trump’s mental disorder, the psychiatrists used a “psychopathic check list,” generally used to grade the severity of impairments, which was applied to evaluate Trump. This assessment included a wide variety of factors such as egocentricity, pathological lying, lack of remorse or guilt, lack of empathy, impulsiveness, sexual infidelity, and several others. As a frame of reference, the average score for someone in the general population is 5, with an average for felons in a maximum-security prison setting, 22. A score of 30 or more places one into serious mental disorder, and Trump was found to exceed this level by the experts, falling in the range of 34. The authors concluded that “Trump’s is a life destined to inflict harm and suffering on others. With the support of thousands of studies on his condition, we have to warn that Donald Trump, because of his hard-wired and immutable traits, is more dangerous than even his harshest critics exclaim.”

… Given all these facts, how could the average person understand and react to Trump? A common mistake is to assume that he is “sane,” that is, possessing human qualities common to all, such as the ability to listen to reason and draw conclusions from cogent facts, and to modify his/her behavior accordingly. Trump possesses none of these qualities, and we should not be misled by this erroneous interpretation

Another one? Here’s a statement from the World Mental Health Coalition:

We are a group of medical and mental health professionals with expertise in aging, mental fitness, and how these relate to the capacity for leadership and ensuring our national security. We feel an obligation to express concerns about the manifestations of poor cognitive function in former President Donald J. Trump.

While we cannot make a formal diagnosis without direct examination, his repeated public behaviors and speeches demonstrate strong evidence of significant cognitive decline, aligned with common signs of an early dementia, and include:

• Deterioration in language skills, such as simpler vocabulary, incomplete and incoherent sentences, grammatical errors, and paraphasias (substituting words)

• Impaired memory/recall, such as confabulation, where memory gaps are filled with false or fabricated details

• Tangential thinking, where speech often drifts to unrelated topics in an erratic manner

• Inappropriate or vague statements that lack connection to reality

• Perseveration, where thoughts or ideas are repeated without a relevant trigger

• Rigidity in thinking, evidenced by an inability to adapt or revise opinions, often manifesting as “doubling down”

• Amplification of maladaptive personality traits, such as paranoid (invented threats), narcissistic (excessive focus on self), or antisocial (criminal and dangerous) personality traits

• Disinhibition in speech, such as the frequent use of vulgar, profane language or hate speech

• Disinhibition in behavior, such as impulsive decision making or aggression and violence

We believe these observable and repeated behaviors warrant public awareness of their implications.

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I don’t, personally, require a physician’s imprimatur to believe it.² It’s the medical literature itself that makes me certain I’m seeing in Trump a severe (and dangerous) personality disorder. It is the medical literature, too, that makes me reasonably sure that its effects are now being exacerbated by a disorder of the frontal lobe.

But if you want to hear this from yet another physician—I listed many in those articles—they’re multiplying rapidly. Frank George, for example, is a psychologist, neurologist, and former Senior Fellow and laboratory director at the NIH. He has, specifically, taught classes on abnormal psychology at the undergraduate and graduate levels. He has devoted his Substack to explaining what we’re seeing:³

… This isn’t guesswork pulled from thin air. This is the conclusion drawn from analyses by hundreds of clinical and research experts in mental health. Frontotemporal dementia (FTD) refers to a group of disorders caused by progressive nerve cell loss mainly in the brain’s frontal lobes (the areas behind your forehead) and/or its temporal lobes (the regions behind your ears). Brain regions impaired in FTD are the ones responsible for self-monitoring, impulse control, and reality-checking. The nerve cell damage caused by FTD leads to loss of function in these brain regions, and in bvFTD, the nerve cell loss is most prominent in areas that control conduct, judgment, empathy and foresight.

A key symptom found in FTD is confabulation. This is seen when a person creates confident, detailed fabrications that fill gaps without any awareness they’re false. As the brain’s frontal lobes and their networks degenerate, one effect is that a person’s ability to evaluate whether a memory is accurate weakens. In fact, confabulation is used as a key indicator for FTD. Confabulation is much less frequent in Alzheimer’s, because Alzheimer’s primarily affects memory-storage regions (like the hippocampus), causing forgetting rather than inventing.

A result of confabulation, disturbing but true, is that Trump could likely “ace” a lie detector test (as opposed to a cognitive test) because he truly believes what he says. FTD patients believe their invented story is true. For example, he really believes it when he confabulates about ending seven, or is it eight(?), wars. He also thinks it’s a great honor to get that hilarious FIFA “Participation Trophy.” FTD is the dementia that causes a rise in inappropriate behaviors. …

There’s also typical physical symptoms seen with FTD. … Here’s the two main physical symptoms we often see with Trump, and how they reveal cognitive symptoms.

1. An awkward gait often shown by disposition or swinging of a limb, like when Trump swings his right leg when he walks. These are not seen with Alzheimer’s.

2. Patients with FTD also sometimes tilt forward. This is not seen with Alzheimer’s.

This is the symptom

So is this…

And this.

'Trump will not make it to the end of this term compos mentis' | Psychologist analyses Trump

As George stresses, however, the main disorder, and the one that in combination with FTD is so uniquely dangerous, is malignant narcissism—a shorthand for the uniquely dangerous combination of pathological narcissism (or Narcissistic Personality Disorder), paranoia (Paranoid Personality Disorder), sociopathy (Antisocial Personality Disorder), and sadism. He continues:

Watching Trump is witnessing a malignant narcissist without the brain’s guardrails—judgment, restraint, empathy—leaving an unhinged finger on the big button and a hunger for validation, control and vengeance. That’s what makes this moment so volatile, and so dangerous. For years, clinicians and researchers, myself included, have been sounding the alarm on Trump’s malignant narcissism (MN)—his grandiosity, paranoia, total lack of empathy, and need for vengeance.

… Here’s where it gets even more dangerous. MN and FTD feed off each other. FTD erodes impulse control, self-monitoring, and reality-testing—the brakes a malignant narcissist desperately needs but never had much of to begin with. Meanwhile, without the inhibition, the malignant narcissism thrives unchecked: rage, paranoia, reckless decisions. It’s not just additive—it’s synergistic. You’re seeing it in action every day.

… FTD on its own is tragic. Together, they make a uniquely combustible threat. The grandiosity that once had a shred of calculation now comes out as unfiltered delusion. The sadism breaks free to wreak vengeance and cruelty on perceived enemies and innocent victims. This is why you’re suddenly hearing a lot more people talk about Trump’s cognition. The MN made his behavior impossible to ignore; the FTD makes his decline undeniable and frightening.

He lists the symptoms we can all see:

1. Confabulation. … Watch for: highly specific claims that are clearly false. Malignant narcissism twist: the invented memories are usually grandiose, self-serving, or feeding off a vengeance.

2. Phonemic Paraphasias. Speech sounds scrambled (“Obamna,” “United Shates”). Malignant narcissism twist: he never self-corrects. Instead he blames equipment, pretends it’s intentional, or calls someone “stupid.”

3. Tangential/disorganized speech. Losing the thread, drifting into non sequiturs. Malignant narcissism twist: he reframes it as “the weave,” demands applause, and calls it genius.

4. Impulse-control failures. The frontal lobes can’t filter impulses. Malignant narcissism twist: hostility, threats, public rage, sending sycophants to do his dirty deeds, persecution narratives.

I will add that he is at family risk for Alzheimer’s. But he is augmenting, not diminishing, and the progression of symptoms, especially over the past several months, are strongly consistent with FTD. In addition to confabulations, current diagnostic criteria for the bvFTD variant describe that behavioral disinhibition may manifest as “socially inappropriate behavior,” “loss of manners/decorum,” or “impulsive, rash or careless actions” [reference here].

“…First, there may be a compromise of the frontal structures responsible for inhibiting the impulse (i.e., “loss of brakes”), or there may be a hyperactivation of the structures that generate the impulse (i.e., “excess gas”) …” — Rascovsky K., et.el.

“Behavioral disinhibition is one of the most prominent and disturbing manifestations of bvFTD.” — Rascovsky K., et.el.

Also, Trump often shows instances of possible Progressive Nonfluent Aphasia. also typically linked to FTD. There are many examples of this, for instance, mispronouncing words like “United States” as “United Shersh,” “mishes” for “missiles,” “cricious” for “Christmas,” and “Cricket Joe” for “Crooked Joe,” and devolving into word salad ramblings and overuse of simple words like “thing.”

I’ve written about all of these in more depth if you’d like to look at examples and compare them to the descriptions in the medical literature. It’s important to grasp that these syndromes are synergistic. As George puts it:

The pathological narcissistic traits have always been there—it’s part of his core personality. Alone, either FTD or malignant narcissism can cause serious disruption. Together, they create a volatile, destabilizing, and uniquely dangerous person. On its’ own, malignant narcissism is considered to be the most severe personality disorder, blending grandiosity, sociopathy, lack of empathy, paranoia, and sadism.

By itself, FTD can cause havoc and embarrassment when words and actions that would normally be suppressed get released. It is behaviorally and neurologically akin to that drunk friend saying: “Hold my beer.” When FTD develops in someone with MN, the frontal lobe degeneration strips away what little behavioral control and social inhibition existed. The result is:

Loss of Inhibition effects:

• Frontal disinhibition: the usual MN “pause before you blow up” is gone. The rage that malignant narcissists usually weaponize strategically now fires off more impulsively, more often, and more intensely.

• Loss of empathy is completed. MNs already lack genuine empathy, but FTD strips away even the shallow “faked” empathy.

• Amplified rage: Narcissistic injury becomes even more unrestrained due to reduced frontal inhibition.

Impulsivity/Vindictiveness Effects:

• Hyper-vindictiveness: A malignant narcissist’s desire for revenge is no longer tempered by calculation. Every slight becomes an urgent, disproportionate vendetta.

• Increased impulsivity: FTD erodes strategic thinking. The person may act on destructive urges without concern for long-term consequences.

• Social inappropriateness as a weapon: Loss of shame can make humiliation of perceived enemies even more brazen and crude.

• Paranoia on steroids: FTD-related rigidity and MN’s baseline paranoia leads to a flood of baseless accusations, conspiracy thinking, and delusional beliefs about enemies.

• Impulse control collapse means vindictiveness is immediate and overblown. The shift is from “punish with purpose” to “punish because I can.”

The symptoms of MN and FTD overlap! We are watching a personality disorder and a neurodegenerative disease synergize into a rapidly escalating loss of judgment, restraint, and empathy. The result is someone more impaired, impulsive, cruel, and detached from reality than either condition alone would produce. And it’s going to get worse.⁴

In our discussion, Dan waved this away with the suggestion that “everyone has a disorder these days.”

No.

No, they don’t.

Yes, some people claim to have psychiatric disorders for attention, sympathy, or to serve some other agenda. The woman who can’t get on an airplane without her emotional support anteater is not really suffering from Ekbom’s Syndrome. The kid whose mom demands he be allowed to call her for help during the final exam because he’s got Maternal Dependency Syndrome needs to be told that his affliction is his mom—and he’ll either finish the exam in an hour, on his own, like everyone else, or he’ll flunk.

That some people brandish spurious diagnoses does not mean there’s no such category as mental illness, nor does it mean that the diagnostic criteria are so vague as to be meaningless, nor does it mean that there’s no difference between sociopathy and “being a dick.” To suggest so is exactly the species of anti-intellectualism Dan deplores—akin to insisting, “When I was a kid, everyone got measles and we were just fine.”

There is a very significant difference between “being a dick” and “having a personality disorder.” Understanding this is essential because personality disorders cause people to behave in predictable ways, and because the disease becomes more dangerous under certain conditions. The difference between “normal aging” and frontal lobe dementia is that the latter is vastly more serious, and progressive—sometimes rapidly progressive. The interaction of these syndromes is putting the entire world in far more danger than most people grasp. This shouldn’t be minimized. The full ramifications of this must be made clear to a public—and a Congress—that still does not realize that Trump isn’t just a dick, and he isn’t just aging. He’s out of his mind, and there is no limit to what he might do.

These disorders have been studied extensively. They are discrete nosological entities. There are thousands upon thousands of clinical case studies in the literature. They have physical correlates: Narcissistic Personality Disorder, for example, is associated with faulty signaling in a shrunken anterior insular cortex, which regulates emotions and empathy.

Clinicians have been desperately trying to make the public aware that what we’re seeing is not just a really stupid guy who’s a dick. But they’re up against the same species of resistance to medical expertise that caused people to dismiss virologists when they said, “This is not just the flu.” Let’s not encourage that.

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Why does it matter? Why shouldn’t we treat this as, “everyone gets a diagnosis these days?” Aren’t these shrinks merely pathologizing their political enemies, much as the Soviets did in sending dissidents to psychiatric prisons? Are these terms just elaborate insults disguised in medical terminology?

There are several answers to these questions, and they reinforce each other. First, and most importantly, neurological decline in a president entails massive, unacceptable risk. We tend to think about “fitness for office” in the vocabulary of personality—strength, empathy, prudence, ambition, etc.—because that’s the vocabulary of the political press. But cognition isn’t personality. It’s more like infrastructure. It’s the substrate through which judgment is exercised.

A president with a malignant personality disorder is dangerous because he will do terrible things. A president with dementia is dangerous in an orthogonal way—unable to deliberate, unable to remember, unable to inhibit his impulses, unable to integrate incoming information, and unaware of his own deficits.⁵ Combine the two pathologies and the danger is multiplicative, not additive.

It’s less important to worry about DSM-labeling than about the impairment of Trump’s executive function—the cognitive machinery that governs planning, inhibition, time-sequencing, and abstraction. One more time: The American president has the legal authority to order a nuclear strike on warning—a decision that might need to be made in minutes, under uncertainty, and without consultation. This alone makes the “Oh come on, everyone’s got a diagnosis” dismissal unserious.

It’s important for us to point this out because the implications of this are obviously not clear to voters, who tend to assume that dementia means “sweet forgetfulness,” when in reality, front-temporal dementia is often accompanied by paranoia and persecutory ideation, emotional lability and rage, impaired language production (implicating the Broca’s area), confabulation to fill memory gaps, rigidity of schemas, anosognosia (a lack of awareness of one’s deficits), and a reduced capacity for understanding other perspectives. In the psychoanalytic and clinical literature, malignant narcissism describes a constellation of features in which narcissistic grandiosity, paranoid projection, and primitive rage coexist in an unstable equilibrium. Dementia destabilizes that equilibrium.

To say “everyone has a diagnosis these days” misses a crucial point: Everyone does not have frontal-temporal deficits interacting with a personality organized around grievance, entitlement, and sadistic omnipotence fantasies. That is not common. That is not normal aging. That’s a specific, documented clinical profile with well-studied behavioral correlates.

Trump’s deficits aren’t steady-state. Good days and bad days are common in early frontal dementia. That’s why “But look, here’s a clip where he sounds fine!” isn’t a counterargument. (Yes, and here’s the EEG of an epileptic between seizures: that doesn’t negate the diagnosis.) The trajectory is what matters.

When Dan says “everyone has a diagnosis these days,” my answer is this: Everyone is not entrusted with nuclear launch authority, diplomatic crisis management, covert action oversight, pandemic response, and emergency economic stabilization during market panics. The critical question isn’t whether Trump is a dick. It’s whether the man who commands the only nuclear arsenal to have been used in war is cognitively impaired. And he is. His speech is not just vulgar—it’s neurologically disorganized. His aggression isn’t just political—it’s limbic.

Our lives depend, absurdly, on the fallible brains of our leaders. When those brains begin to fail, the refusal accurately to name what we’re seeing—and the dismissal of whole fields of established scientific research—makes us complicit in misdiagnosis. In politics as in medicine, misdiagnosis leads to catastrophic treatment plans.

There’s a category error in saying “he’s just a jerk.” Jerkhood is a personality trait. It doesn’t metastasize. Frontal-lobe degeneration isn’t a personality trait, it’s a process. It has a slope. It accelerates. It strips away inhibition, abstraction, time-sequencing, and empathy, and it rarely plateaus.

The question with Trump isn’t, “Is this who he really is?” It’s “What will this look like twelve months from now, when the circuitry that once constrained his worst traits is further degraded?” We’re not watching a fixed character. We’re watching a progressive neurological event unfolding in a man who has nuclear release authority.

Most psychiatric traits don’t guarantee worsening. Dementia does. The relevant literature emphasizes three properties of FTD patients that are germane to the presidency: Decline is progressive; insight decreases as severity increases; and behavior disinhibits as frontal systems fail. It gets worse, the patient can’t tell, and the brakes fail first.

JFK could afford Addison’s disease; FDR could (barely) afford end-stage heart failure in the last months of the war. Neither condition degraded judgment plus inhibition plus abstraction plus time-pressure cognition. Dementia does.

Trump is already compensating by collapsing his thinking into repetitive grievance loops because he no longer has the cognitive buffer to handle novelty. That’s why his speeches now sounds like a Spotify playlist stuck on repeat: The brain conserves energy by operating in scripts.

If the frontal lobe is failing, the future is worse than the present—a lot worse.

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In their reporting on Davos, journalists again, tried to make Trump seem saner than he is. I spotted one headline, for example, that read: “Four takeaways from Trump’s Davos speech.” But there is one and only one takeaway that matters. The president of the United States is insane. He’s incapable of competently performing any job, no less carrying out the duties of the presidency. His symptoms do not suggest a benign species of mental illness. He is dangerous to everyone on this planet. He must be removed from office immediately, be it by the 25th Amendment or impeachment.

The audience saw how impaired he is with their own eyes. They also know that despite the existence of constitutional mechanisms to remove a dangerously impaired president, we haven’t removed him. We’re allowing him to endanger not only us, but the entire world. That’s what they’ll never forget, and that’s why Carney was right to say that this is a permanent rupture.

1. The letter appears to no longer be available on the website, which is very unhelpful. Dr. Frank George, a neurologist, has reproduced it here.

2. It’s easy enough to find a few hundred physicians and mental health professionals who will sign a petition, as we know from the duly-credentialed authorities who signed one, at the height of the pandemic, urging people to take to the streets because racism was a more severe threat to public health than Covid. Although for what it’s worth, I believe many of the signatures on that open letter were fraudulent. I tried looking up the names: I found no one who correlated to any of the names I checked. Some of them were clearly made up. Other signatories were specialists in non-medical disciplines. The whole thing looked, on close inspection, like a hoax of some kind.

3. I wish he wrote in a more adult manner. His incessant use of bullet points, capitalized words, bold type, and italics works does not underscore the gravity of his message; it undermines it.

4. George also suggests that many more psychiatrists would be saying this were they not intimidated:

… Many of us who work in mental health practice, education and research have known about his condition for years. Some of us have been speaking out since his first term and prior to his second term. But it was too few to be heard loudly. And some even objected, which made the battle harder. Why did some professionals, who basically agreed with us, object to our voices? [Because of a] 60-year old ethics rule that is ending up doing more harm than good to the psychiatric profession, and to the world.

The Goldwater Rule was adopted by the American Psychiatric Association in 1973 to prevent psychiatrists from offering professional opinions about public figures they had not personally examined or received consent from.

… When people invoke the Goldwater Rule as if it were handed down on stone tablets, it helps to remember what psychiatry looked like when it was written. … Back then, in the DSM-II era and earlier, psychiatry and psychotherapy were purely subjective and operating with shockingly loose boundary standards by today’s norms. … Diagnostic criteria were vague, impressionistic, and heavily psychoanalytic, i.e., Freudian. Evidence-based work barely existed, reliability between clinicians was poor, and “diagnosis” often meant one psychiatrist’s gut feeling after a short interview and a long cigar.

Fast-forward to today, and the DSM-5. Today, we rely on longitudinal data, objective analysis, behavioral observation, neurobiology, and population-level research. We routinely study personality structure, risk patterns, and psychopathology without ever sitting across from the individual in question. That’s not reckless — that’s how good science has evolved. Pretending that 1970s ethics rules map cleanly onto 21st-century biological, psychological and socio-cultural science is wrong. It isn’t caution. It isn’t ethics. It’s chicken shit.

There is a deep historical irony embedded in the Goldwater Rule. Barry Goldwater was not an authoritarian populist. In the 1980s and 1990s, he repeatedly warned that the growing influence of the religious right and populism posed a serious threat to democracy, famously criticizing leaders who sought power through grievance, moral absolutism, and mass emotional manipulation. He’d likely be horrified to see his party not based on ideology but on dominance, spectacle, and loyalty tests. The irony is tragic: a rule created to protect public figures from reckless psychiatric speculation ended up muting responsible psychological commentary. That silence helped normalize the rise of disordered personalities that earlier clinicians would have warned about en masse.

I agree. I’ve followed this debate closely. I see no merit at all in the injunction against psychiatrists and other professionals speaking about this publicly. Indeed, this posture is obviously unethical. This man is a danger to every human being alive. They know it. Their credentials ensure that their voices will be more trusted than mine will be. They have a responsibility to say in public what they and I know to be true.

5. This should not be confused with “unbelievably stupid” or “ignorant.” These he may be, but a president can be ignorant without being off-the-scale dangerous. What makes him dangerous is the mental illness.