It is a question that has dogged Donald Trump – fairly or otherwise – since he was elected president: is he mentally fit for office?
The question has been raised again by the release of a new book by New York journalist Michael Wolff, which chronicles the first year of the Trump White House.
The book – the accuracy of which has been disputed by the White House and queried by others – paints the president as impatient and unable to focus, prone to rambling and repeating himself.
Mr Trump has hit back against Mr Wolff’s account, claiming on Twitter to be a “very stable genius” whose “two greatest assets have been mental stability and being, like, really smart”.
But the president’s manner and speaking style have led to armchair diagnoses of a host of ailments, from Alzheimer’s to narcissistic personality disorder – a controversial practice that has divided the medical profession.
What are people saying?
The current flurry of speculation has been triggered by the book Fire and Fury, in which Mr Wolff writes that during the course of his access to the White House preparing the book, he witnessed people around President Trump become aware that “his mental powers were slipping”.
Mr Wolff said – during the marketing campaign for the book’s sale – that Mr Trump, 71, repeated himself often. Repetition can be caused by poor short-term memory, as well as by other factors. It can be a sign of dementia, which affects 5-8% of people aged 60 and over worldwide, according to the World Health Organization.
“Everybody was painfully aware of the increasing pace of his repetitions,” wrote Wolff. “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 Wolff did not give any other context for the alleged repetitions. Mr Trump has blasted the book, calling it “phony” and “full of lies” and saying he did not authorise any access to the White House for Mr Wolff.
Critics of the book have also questioned its sourcing. They have asked whether Wolff himself witnessed the events he describes, and called some of its content gossip.
What have they said before?
Psychologists had previously speculated about symptoms they purported to see in Mr Trump’s behaviour.
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”. But it’s worth remembering that none of these people have treated Mr Trump, nor do they have close-up information on his state of mind.
Anyone who has treated him would be going against ethics standards and, in most cases, federal law if they disclosed any details.
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, however many voices call for it.
Has mental health been an issue for previous presidents?
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.
So what’s the evidence with Mr Trump?
It is worth reiterating, there is no real evidence as nobody speaking publicly has examined the president.
But some have suggested that Mr Trump may have symptoms which would point to 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.
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Wolff’s book has prompted some to ask if Mr Trump might be suffering from cognitive decline.
Repetition of stories and the way Mr Trump speaks have been put forward to back up the claims.
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, some 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.