Monday, January 22, 2018

'How broke that brain?' Understanding President Trump's mental health - what his exam did not tell us

Ever since Trump got on the list of presidential candidates (and I think long before) there have been questions about his mental fitness for the job he now holds. For example, SNL revisits Trump’s cognitive test results and asks, ‘How broke that brain?’

“There’s been questions about the president’s mental fitness, and the White House has, of course, pushed back on that,” says a reporter, played by Kate McKinnon. “Since you’ve examined him personally, my question is: How broke that brain?”

The rest of this post is less barbed. To start, in it’s email summary over the weekend, succinctly reported on the cognitive assessment part of Trump’s recent physical exam.

It was only under mounting public pressure that the White House allowed Rear Admiral Ronny Jackson to publicize the details of his examination of Trump, and those results haven’t clarified much for those hungry for a better sense of the president’s physical and cognitive fitness. … although Trump passed his physician’s cognitive assessment with flying colors, his ability to differentiate a lion from an elephant probably doesn’t say much about his appetite for consuming the vast amounts of information necessary to make complex policy decisions.

And there is another angle, The test that Trump passed does not measure personality characteristics, such as narcissism. Let me explain.

What is NOT wrong with Trump

First let’s look at the cognitive test he was given. Here’s the information from a Canadian site, Donald Trump aced the Montreal Cognitive Assessment: here’s what the test looks like.

Developed in Montreal in 1996, it was designed to measure “mild cognitive dysfunction” according to the Canadian Partnership for Stroke Recovery.

The MoCA test Trump took includes exercises to the likes of remembering a list of spoken words; listening to a list of random numbers and repeating them backward; naming as many words that begin with, say, the letter F as possible within a minute; accurately drawing a cube; and describing concrete ways that two objects – like a train and a bicycle – are alike.

According to administration and scoring instructions, the MoCA exam is a rapid screening test and assesses different cognitive functions like attention, concentration, language and conceptual thinking.

The test itself take about 10 minutes and the total possible score is 30 points. A score of 26 or above is considered normal. Trump scored a perfect 30, according to Jackson.

In general, patients with good or average memory forget one of the five words and can still be within the normal range, said Dr. James Mastrianni, an expert in memory disorders and other neurodegenerative conditions at the University of Chicago Medicine.

“It’s a screening assessment that we use routinely in the clinics to determine whether someone has some degree of cognitive impairment or not,” he said.

“If they score poorly on that assessment, then usually there is more detailed evaluation that follows. But if they score well that usually indicates there is pretty good cognitive function. They are essentially intact,” Mastrianni added.

The standard version of the test is “pretty good” but “not definitive” said Dr. Ronald Petersen, an Alzheimer’s disease expert at the Mayo Clinic in Rochester, Minnesota. Petersen said he could not comment specifically on the president’s cognitive health.

You can take the test here. However:

The test does not assess the president’s psychiatric fitness and the president did not undergo a psychiatric evaluation, according to his doctor.

Steve Benen (MSNBC/MaddowBlog) reports on Trump’s misplaced boast about passing a cognitive test.

… as long as Trump is talking about this, it’s probably taking a moment to understand what his high score is all about.

“If you look at the test, it’s pretty hard to see how you could not score a 30,” a Washington Post piece explained yesterday, adding, “Yes, Trump passed with flying colors, as any adult with normal cognitive function probably would.”

We’re talking about an exam, known as MoCA, that’s used to identify evidence of dementia, mental deterioration, and neurodegenerative diseases. Those who take it may be asked, for example, to draw a clock or describe the similarities between oranges and bananas.

I’m glad Trump was able to do well on the test, but let’s be clear: we’re talking about being able to clear a very low bar for an adult in a position of enormous responsibility. The idea of a president bragging, even jokingly, about getting 30 out of 30 on the exam is comparable to a president boasting about knowing the alphabet.

So here’s the dangling question.

Trump’s score is not evidence of a towering intellect. On the contrary, as New York’s Jon Chait put it, “[W]hile Trump’s behavior may not be medical symptoms of a debilitating mental disease, it is clear evidence of a mind that’s totally unfit for the presidency. What excuse does he have for his behavior?”

The MoCA is diagnostic of mental deterioration as explained in this Washington Post article: Why you may be misunderstanding the mental test that Trump passed with flying colors.

Studies have shown that this test can be used to spot problems with the brain’s executive functioning even before other signs of mental decline are apparent. There are questions about the proper scoring method and about the extent to which educational differences may be apparent, but, generally, there’s a reason that the test is included.

The point is not that the test is easy. The point is that an inability to complete aspects of the test reveals different types of mental decline. The clock test is about executive brain function: memory, planning ahead. The different parts of the MoCA are labeled according to what they test, with the clock test falling under “visuospatial/executive.” Questions about the current year and date are under “orientation.” The request to identify a drawing of a camel is under “naming.” In the test’s scoring instructions, it explains what is covered: “attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations and orientation.”

Hang onto that list of cognitive functions. I’ll return to it in a moment. Phillip Bump, the Post author, continues:

Yes, Trump passed with flying colors, as any adult with normal cognitive function probably would. And that’s the point. There’s every indication from Tuesday’s report that Trump maintains normal cognitive function. That he passed the test is just like you successfully singing the alphabet song. Sure, it’s easy — unless you have that can’t-say-H disease. Here, the MoCA test is easy — unless you have the sort of impairment that Trump was said to have suffered by any number of public critics.

You’re supposed to get 30 out of 30 — and when you don’t, that’s when the doctors learn something.

Bump updates his post.

The original post above was meant to explain to readers why the seemingly easy nature of the test was not a reason that Trump’s passing it should be pooh-poohed. After all, the lingering question was one of Trump’s cognitive abilities and whether or not he was affected by the early stages of mental decline, perhaps in the form of dementia. Mocking as easy a test meant to detect that particular thing is as dumb as mocking someone for passing a blood test.

But the flip side of this is that this is not a test you should brag about — any more than you should brag about passing a blood test. [No one] should see Trump’s perfect score on the test as indicating anything other than “this person’s brain is not showing obvious signs of deterioration.”

What IS wrong with Trump

OK, so Trump is not gorked. His brain is not the neurological equivalent of Swiss cheese. What then is wrong with this guy?

At the psychological level, here is my nomination: Narcissistic Personality Disorder: Rethinking What We Know.

… Persons with NPD are aggressive and boastful, overrate their performance, and blame others for their setbacks; current editions of DSM portray them as arrogant, entitled, exploitative, embedded in fantasies of grandeur, self-centered, and charming but emotionally unavailable …

Prototypical persons with NPD present with many interpersonal problems … Romantic relationships are typically shallow, and narcissistic persons build and maintain them with difficulty. Conflicts at work are the rule rather than the exception, as are problems with commitment when faced with negative feedback.

Feelings of grandiosity and fantasies of power and success are certainly important but are not the core theme in a narcissistic stream of consciousness …

NPD manifests as anger triggered by feelings of social rejection and tendencies to derogate those who give negative feedback. Persons with NPD often feel hampered in pursuing goals and blame others for being inept, incompetent, or hostile. States in which the self-image is extremely negative are important but are so hard to bear that fighting with others and blaming them for any personal flaws is a more suitable defensive maneuver. …

In persons with NPD, self-experience patterns coalesce into self-other relational schemas: the dominant motives are concerns with social rank/antagonism, and the need to be admired and recognized by others as being special; the dominant image is of an “other” person unwilling to provide attention. The main schema is the “self” who desires to be recognized or admired and the “other” who is dominant and critical. In one schema, the self reacts with overt antagonism or by resorting to a metaphorical ivory tower. Another prominent schema is the self that needs attention while the other rejects and again criticizes the self, which, in turn, steers the self to compulsive self-soothing and denial of attachment needs. In general, such persons spend much time ruminating about issues of antagonism/social rank and avoid forming or thinking about attachments, thus concealing their vulnerable self. Empirical support has been found for the possibility that patients with NPD or narcissistic traits tend to seek self-enhancement, to overreact when they perceive others are setting limits, and to self-soothe.

Remember that list of cognitive functions? “attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations and orientation.” I challenge you to find any mention of any of these functions in the passages quoted above on narcism. Similarly, I challenge you to find any mention of the characteristics of someone with NPD in this list of cognitive functions.

So: what the MoCA tells us about Trump’s mental function totally misses what is really wrong with him. In my opinion, the descriptors for NPD apply to Trump. To confirm that hypothesis, we would have to have Trump undergo a comprehensive psychiatric workup - and that is as likely to happen as the release of his tax records.

What this Narcissistic president costs America

Leonard Pitts Jr. reviews Trump’s accomplishments: One year later Trump continues race to the bottom

And here we are, one year later.

If you are groping for markers by which to measure how profoundly we have been changed since Inauguration Day, here’s one you might want to consider:

In January of 1998, reports surfaced of a sexual affair between President Bill Clinton and a 24-year-old White House intern. It would mushroom into the biggest story of the year.

In January of 2018, reports surfaced of an alleged payoff by lawyers for the present president to silence a porn star from talking about their alleged sexual affair. It wasn’t even the biggest story of the day.

You’d be hard-pressed to find a more visceral illustration of how our sensibilities have been bludgeoned into submission in the last year. Surprises no longer surprise. Shocks no longer shock. We have bumped up against the limits of human bandwidth and find ourselves unable to take it all in.

One simply cannot keep up with, much less respond with proper outrage to, all of this guy’s scandals, bungles, blame-shifting, name-calling and missteps, his sundry acts of mendacity, misanthropy, perversity and idiocy. It’s like trying to fill a teacup from Niagara Falls. It’s like trying to read the internet.

One year later, we’ve seen a procession of feuds that would impress a Hatfield, a McCoy or a ’90s rapper, running beefs with Mitch Connell, Elizabeth Warren, Bob Corker, Jeff Flake, Jeff Sessions, Dick Durbin, Colin Kaepernick, James Comey, Joe Scarborough, Mika Brzezinski, CNN, The New York Times and reality, to name just a few.

One year later, the man who promised to “work so hard” for the American people is setting new standards for presidential laziness, a short workday, hours of television and endless golf.

One year later, the man who bragged of having “the best words” has pundits parsing the difference between “s-house” and “s-hole” as descriptors of Africa, El Salvador and Haiti.

One year later, the man who asked African-Americans “what the hell” they had to lose by voting for him, is praised by tiki-torch-wielding white supremacists — “very fine people,” he says — and his name is chanted as a racist taunt by white mobs.

One year later, we live in a state of perpetual nuclear standoff, a Cuban Missile Crisis that never ends.

But hey, at least the stock market is doing well. It did well under President Obama, too, but nobody seems to remember that.

Not that a bull market mitigates — or even addresses — the sense of ongoing upheaval, of constant chaos, that have become our new American norm. This guy is flat-out exhausting.

Give him this much, though. He has banished apathy, made fools of those people who once declared with pontifical certitude that we should “blow up” the system and said voting didn’t matter because there was no difference between the parties. More, he’s galvanized a powerful resistance that has claimed upset victories from Alabama to Wisconsin and left Gumby-spined Republicans looking over their shoulders. That resistance might even save this country, assuming the guy leaves us anything to save.

All this better fits the president as suffering from a personality disorder, not one experiencing cognitive deficits. Pitts concludes:

If that sounds bleak, well, that’s where we stand. Indeed, one year later, both our despair and our hope are encompassed in the same five syllables.

One down. Three to go.

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