Even during Donald Trump’s first term, his cognitive and psychological traits attracted attention. Those around him noted that he struggled to concentrate on a single subject for long, and his public remarks and behavior caused such concern among psychiatrists that, in 2017, 27 mental health professionals collectively published a book titled The Dangerous Case of Donald Trump, warning that his mental condition, combined with the powers of the presidency, posed a threat to global security. Trump is set to turn 80 before his current term is out, and his condition is clearly not improving: his speech is increasingly incoherent, he often makes crude jokes at inappropriate moments (like when he mimed oral sex with a microphone), and he frequently resorts to profanity. His already limited vocabulary continues to shrink, while both his speech and actions are becoming more impulsive. According to several experts, these may be signs of early dementia — which, in combination with his narcissistic personality and lack of empathy, could prove to be an extremely dangerous concoction.
On Friday, April 11, Donald Trump underwent a five-hour medical examination. “President Trump exhibits excellent cognitive and physical health and is fully fit to execute the duties of the Commander-in-Chief and Head of State,” declared his personal physician, Sean Barbabella, following the exam.
Trump also took the Montreal Cognitive Assessment (MoCA) and scored a perfect 30 out of 30. That evening, aboard Air Force One, he boasted to reporters: “I got every answer right.” One media outlet after another reported that the president had “successfully passed a cognitive test.”
The problem is, the Montreal Cognitive Assessment isn’t a test in the clinical sense — it’s a basic set of screening questions. The entire set fits on a single sheet of paper and takes about ten minutes to complete. Statistically, it’s a useful tool for identifying dementia in the general population. But its sensitivity is too low for even a perfect score to rule out serious cognitive impairment.
The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President, The Psychology of Trump Contagion: The Science of Understanding and Resisting Trump’s Rule, and The More Dangerous Case of Donald Trump: 37 Psychiatrists and Mental Health Experts Assess a President.
Narcissism is divided into «grandiose» (when a person’s self-esteem is extremely high) and «vulnerable» (when self-esteem is low or unstable).
The American Psychiatric Association developed a nine-item checklist for identifying narcissistic personality disorder. Five items are considered sufficient for diagnosis. A person with this disorder:
1. has a grandiose sense of self-importance, often exaggerates achievements and talents;
2. is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love;
3. believes that they are special and unique and should associate only with other special (for example, high-status) people;
4. requires excessive admiration;
5. has a sense of entitlement, expecting especially favorable treatment;
6. exploits other people;
7. lacks empathy, is unwilling to recognize or identify with the feelings and needs of others;
8. is often envious of others or believes others are envious of them;
9. shows arrogant, haughty behaviors or attitudes toward others.
There’s no indication that Trump’s recent medical exam included a real cognitive test, said American psychiatrist Bandy Lee in an interview with The Insider:
“The Montreal Cognitive Assessment does not rule out dementia (it rules out who needs to be in a nursing home; people with dementia and hospitalized with a 30/30 schizophrenia score). […] There are cases where a person wears a ‘mask of sanity’ and appears perfectly functional — but it’s just a disguise.”
Dr. Lee taught for 17 years at the Yale School of Medicine, authored a textbook on violence prevention, worked on U.S. prison reform, and served as a UN consultant on countering violence against children. Since 2017, she has focused on Trump’s mental health, publishing three books and numerous articles on the subject.
Condition worsening
Bandy Lee says she first noticed signs of neurocognitive issues in Donald Trump back in 2017, and that the president’s condition has steadily declined since then. In 2024, the World Mental Health Coalition, which Dr. Lee chairs, issued a statement signed by fifty prominent forensic psychiatrists, neuropsychologists, and dementia experts.
The manifesto, published on Nov. 3, 2024 and titled “Statement on Cognitive Decline in the Presidential Election,” lists the symptoms of Trump’s deterioration: simpler vocabulary, incomplete and incoherent sentences, grammatical mistakes and paraphasias (a speech disorder in which people substitute, rearrange, or distort words), inappropriate or vague statements that lack connection to reality, and “perseveration” — the compulsive repetition of the same thoughts or ideas regardless of context. The statement also notes his growing use of profanity and hate speech, as well as increasingly pronounced signs of “grandiose” narcissism.
As for the paraphasias, some of Trump’s invented words went viral even during his first term — such as the mysterious covfefe, the product of a late-night tweet. “Despite the constant negative press covfefe,” he wrote. The intended word was likely coverage. The tweet was deleted the next morning, but covfefe became a meme, appearing on protest signs and in advertising campaigns.
The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President, The Psychology of Trump Contagion: The Science of Understanding and Resisting Trump’s Rule, and The More Dangerous Case of Donald Trump: 37 Psychiatrists and Mental Health Experts Assess a President.
Narcissism is divided into «grandiose» (when a person’s self-esteem is extremely high) and «vulnerable» (when self-esteem is low or unstable).
The American Psychiatric Association developed a nine-item checklist for identifying narcissistic personality disorder. Five items are considered sufficient for diagnosis. A person with this disorder:
1. has a grandiose sense of self-importance, often exaggerates achievements and talents;
2. is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love;
3. believes that they are special and unique and should associate only with other special (for example, high-status) people;
4. requires excessive admiration;
5. has a sense of entitlement, expecting especially favorable treatment;
6. exploits other people;
7. lacks empathy, is unwilling to recognize or identify with the feelings and needs of others;
8. is often envious of others or believes others are envious of them;
9. shows arrogant, haughty behaviors or attitudes toward others.
Some of Trump’s invented words went viral even during his first term
During last year’s presidential race, new examples of paraphasia surfaced — along with commentary from scientists. Harry Segal, a senior lecturer in psychology at Cornell University, has observed signs of early dementia in the president:
“What’s alarming is how the rate of Trump’s bizarre speech and political decisions have been increasing. He gave an answer about childcare to the Economic Club of New York so incoherent that even his supporters were concerned… Trump has shown evidence of dementia for the past year as indicated by his strange gait, phonemic paraphasia…and decline in the complexity of his words and concepts. This limited capacity explains his poor debate performance.”
Segal believes this is why Trump refused to debate Kamala Harris a second time — and why his speeches have become more impulsive.
Psychologist John Gartner said in a recent interview that he has compiled dozens of examples of verbal errors made by the president since retaking office: “What happens is that someone is trying to say a word and then they get the first part out but they have to end it or create one because they can’t remember the rest. Trump will say something like ‘mishiz’ for missiles, or “Chrishus” for Christmas, because he can’t complete the word.”
Gartner believes the media intentionally sanitize Trump’s quotes by cutting out the most nonsensical parts. There’s a term for this — “sanewashing” — that gained popularity during Trump’s first four years in the Oval Office. But just because the problem was visible eight years ago does not mean that it has not gotten worse since.
A month before the 2024 election, The New York Times set out to analyze Trump’s public speeches to see how they’ve changed over the years. The analysis found that his rally speeches in 2024 had become nearly twice as long — averaging 82 minutes compared to 45 in 2016. He also used profanity 69% more often.
Trump has always used more negative than positive language, but in 2016, negative words outpaced positive ones by only 21%. In 2024, the gap grew to 31%. Several former associates interviewed by the paper confirmed that Trump’s speaking style has changed significantly. Former deputy White House press secretary Sarah Matthews put it this way:
“I don’t think anyone ever considered Trump a brilliant orator, but his recent speeches really seem less coherent. He’s become even more disjointed, and there are some noticeably confused moments. When he was running against Biden before, it may not have been as obvious.”
The medical news outlet STAT conducted its own studies. In 2017, it compared Trump’s speech patterns with his public appearances from the 1980s. In a follow-up analysis, experts found that since 2017, Trump’s speaking style had deteriorated further. The Independent reported that “while the experts noted that they couldn’t give a diagnosis without conducting an examination, several of them said some of the changes in the former president’s speaking style were possible signs of cognitive decline.”
In the summer of 2024, researchers compared his current style to speeches from his first term. “Experts noted a further decline in Trump’s linguistic complexity, and while none of them said they could make a diagnosis without an examination, some stated that certain changes in his speech patterns may be potential signs of cognitive impairment,” the authors wrote cautiously.
Putin and the “Death Spiral”
Bandy Lee believes that Trump’s speech issues are connected with his memory lapses, profanity, and hate speech. For her most recent book, co-authored with 36 other mental health professionals, Lee used a tool known as the Hare Psychopathy Checklist. It assesses biographical and observable facts — from lack of empathy and early behavioral problems to promiscuity and absence of realistic long-term goals. The checklist is filled out by a clinician based on publicly known information about the subject.
Each criterion scores up to 2 points, for a maximum total of 40. A score of 30 or higher is typically used to diagnose psychopathy. Convicted criminals generally score between 22 and 24, while the average for the general population is 5 to 6. Trump received a 36, which Lee describes as “dangerously high.”
The situation, Lee warns, is only getting worse with time, as all psychiatric symptoms are biopsychosocial, meaning they are influenced by the person’s social environment. Chief among those influences, she says, is the people around Trump. Today, Lee argues, he is surrounded by sycophants whose primary function is to reinforce his delusions so that he can deny his incompetence and unfitness.
The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President, The Psychology of Trump Contagion: The Science of Understanding and Resisting Trump’s Rule, and The More Dangerous Case of Donald Trump: 37 Psychiatrists and Mental Health Experts Assess a President.
Narcissism is divided into «grandiose» (when a person’s self-esteem is extremely high) and «vulnerable» (when self-esteem is low or unstable).
The American Psychiatric Association developed a nine-item checklist for identifying narcissistic personality disorder. Five items are considered sufficient for diagnosis. A person with this disorder:
1. has a grandiose sense of self-importance, often exaggerates achievements and talents;
2. is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love;
3. believes that they are special and unique and should associate only with other special (for example, high-status) people;
4. requires excessive admiration;
5. has a sense of entitlement, expecting especially favorable treatment;
6. exploits other people;
7. lacks empathy, is unwilling to recognize or identify with the feelings and needs of others;
8. is often envious of others or believes others are envious of them;
9. shows arrogant, haughty behaviors or attitudes toward others.
Trump is surrounded by sycophants whose main role is to repeat his false beliefs
Strangely enough, Trump does care about other people — but only a very specific kind. His inclination toward Putin and other autocrats, according to Lee, has deep internal roots. It’s not that “dictators understand him,” she says, but that they can give him something ordinary people cannot: limits and structure. Dr. Lee explains the paradox this way:
“Trump is at a different developmental stage, which in moral psychology we call, ‘preconventional,’ where ‘might makes right.’ Right now, the president has the power to defy any law, any expertise, and any concern regarding reality, and he will continue to make more and more arbitrary decisions that bring on calamities — until we stop him from the outside… I have seen this with many violent offenders: in truth, they feel comforted when limits are set on them and we contain them, because like toddlers they are actually testing to see if a parental figure will hold them and guide them. This is why Donald Trump is drawn to brutal dictators such as Vladimir Putin, whom he will remain ever loyal to, no matter the malevolent intents, because he feels safe there.”
Bandy Lee has substantial experience working with dangerous offenders and gang leaders. As a forensic psychiatrist, she spent years dealing with such people and sees many parallels between gang behavior and that of the current president: in their language, demeanor, and methods of manipulating followers. And those followers, in turn, see in the gang leader the same thing the U.S. president seeks in Putin: an external restraining force and a sense of security, Lee explains.
The rule of silence
The American Psychiatric Association (APA) has forbidden its members from making psychiatric diagnoses of public figures from a distance. This restriction is known as the Goldwater Rule and, like many traditions in the U.S., it stems from a legal precedent. In 1964, Fact magazine published a special issue analyzing the mental health of Republican presidential candidate Barry Goldwater. He sued the publication — and won.
Such ground rules also exist beyond the jurisdiction of U.S. law. The Madrid Declaration of ethical standards in psychiatry similarly stresses that “psychiatrists should not make public statements about the presumed psychopathology of any person.” Still, this is a legal and ethical guideline, not a conclusion grounded in science.
In 2017, Bandy Lee’s public remarks — and those of her supporters — sparked intense debate over the wisdom of the Goldwater Rule. Psychiatrists argued that there is another ethical imperative at play: to warn society of danger. After all, the U.S. president not only stewards the world’s most powerful economy, he also controls its most devastating nuclear arsenal.
The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President, The Psychology of Trump Contagion: The Science of Understanding and Resisting Trump’s Rule, and The More Dangerous Case of Donald Trump: 37 Psychiatrists and Mental Health Experts Assess a President.
Narcissism is divided into «grandiose» (when a person’s self-esteem is extremely high) and «vulnerable» (when self-esteem is low or unstable).
The American Psychiatric Association developed a nine-item checklist for identifying narcissistic personality disorder. Five items are considered sufficient for diagnosis. A person with this disorder:
1. has a grandiose sense of self-importance, often exaggerates achievements and talents;
2. is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love;
3. believes that they are special and unique and should associate only with other special (for example, high-status) people;
4. requires excessive admiration;
5. has a sense of entitlement, expecting especially favorable treatment;
6. exploits other people;
7. lacks empathy, is unwilling to recognize or identify with the feelings and needs of others;
8. is often envious of others or believes others are envious of them;
9. shows arrogant, haughty behaviors or attitudes toward others.
Bandy Lee left the APA back in 2007, meaning the Goldwater Rule does not act as a formal constraint on her public statements. Still, due to the persistence of that directive, the first collective book published by psychiatrists about Donald Trump deliberately refrained from assigning a specific diagnosis.
“What we were expressing was a medical consensus of ‘dangerousness’ — which thousands of mental health experts shared at the time,” Lee told The Insider. “However, since everyone was asking about diagnosis, and there was still little awareness about unfitness or dangerousness, we decided to educate the public about different possible diagnoses in general — in keeping with the Goldwater Rule, which instructs not to diagnose a public figure definitively without a personal examination as a patient. Therefore, we decided to [list] all the different diagnoses that were possible, with each author choosing a different topic.”
There is, however, one book on Donald Trump’s mental health that stands apart. That’s because it was written by someone who spent significant time with him: his niece, clinical psychologist Mary Trump.
She has openly admitted she didn’t spend long in the profession, never taught at a university, and wasn’t a prominent scholar. But her 2020 book, Too Much and Never Enough, a psychological biography of her uncle, became a runaway bestseller.
The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President, The Psychology of Trump Contagion: The Science of Understanding and Resisting Trump’s Rule, and The More Dangerous Case of Donald Trump: 37 Psychiatrists and Mental Health Experts Assess a President.
Narcissism is divided into «grandiose» (when a person’s self-esteem is extremely high) and «vulnerable» (when self-esteem is low or unstable).
The American Psychiatric Association developed a nine-item checklist for identifying narcissistic personality disorder. Five items are considered sufficient for diagnosis. A person with this disorder:
1. has a grandiose sense of self-importance, often exaggerates achievements and talents;
2. is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love;
3. believes that they are special and unique and should associate only with other special (for example, high-status) people;
4. requires excessive admiration;
5. has a sense of entitlement, expecting especially favorable treatment;
6. exploits other people;
7. lacks empathy, is unwilling to recognize or identify with the feelings and needs of others;
8. is often envious of others or believes others are envious of them;
9. shows arrogant, haughty behaviors or attitudes toward others.
Mary believes the future president’s personality was shaped by his father — her grandfather Fred Trump, whom she describes as a high-functioning sociopath. Donald’s mother, also named Mary, is portrayed as physically and mentally unwell and entirely submissive to her husband’s will.
The author traces how Donald Trump’s character was molded under the influence of his authoritarian and manipulative father, how Fred Trump tormented his eldest son — Mary’s father, Fred Jr. — and how this upbringing left the future president cruel and lacking in empathy.
Still, Mary Trump can hardly be seen as an impartial researcher. She herself has acknowledged being deeply hurt by the family and struggling for years with the resulting psychological trauma.
In any case, the Goldwater Rule does not apply to analyses of public speech like those carried out by The New York Times and STAT. There are other studies, too — for instance, those examining how Trump’s speech reflects his narcissism, particularly his much higher than normal rate of first-person references, a trait typical of “grandiose narcissism.” Even during his first presidential campaign, Trump outpaced all other Republican candidates in this regard. However, similar speech patterns have been noted in many other American presidents as well.
Emergency intervention
In 2017, psychologist John Gartner founded a public organization called Duty to Warn. He collected signatures from more than 41,000 professionals who asserted that Donald Trump suffers from a serious mental disorder.
By 2018, Congress was already discussing the possibility of removing Trump from power for medical reasons. Formally, this could be done using the 25th Amendment to the U.S. Constitution, which was adopted after the assassination of John F. Kennedy in order to outline the procedure for transferring power in the event that a president becomes seriously ill or is deemed incapacitated.
The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President, The Psychology of Trump Contagion: The Science of Understanding and Resisting Trump’s Rule, and The More Dangerous Case of Donald Trump: 37 Psychiatrists and Mental Health Experts Assess a President.
Narcissism is divided into «grandiose» (when a person’s self-esteem is extremely high) and «vulnerable» (when self-esteem is low or unstable).
The American Psychiatric Association developed a nine-item checklist for identifying narcissistic personality disorder. Five items are considered sufficient for diagnosis. A person with this disorder:
1. has a grandiose sense of self-importance, often exaggerates achievements and talents;
2. is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love;
3. believes that they are special and unique and should associate only with other special (for example, high-status) people;
4. requires excessive admiration;
5. has a sense of entitlement, expecting especially favorable treatment;
6. exploits other people;
7. lacks empathy, is unwilling to recognize or identify with the feelings and needs of others;
8. is often envious of others or believes others are envious of them;
9. shows arrogant, haughty behaviors or attitudes toward others.
In 2018, Congress was already discussing the possibility of removing Trump from office for medical reasons
Since the end of Trump’s previous term, however, American society has become more polarized — and so has the psychiatric community. According to Bandy Lee, her conclusions were initially in line with the medical consensus among experts, including Republican supporters. That reality has changed:
“We had a medical consensus — including among Republican psychiatrists (they simply declined to contribute to our book, even though they agreed on the analysis). Now, with politics influencing or pressuring just about every field, we see a number of mental health professionals deviating from the former consensus. The APA provided a convenient exit ramp by falsely calling evasion of our societal ethical responsibility (to protect society) ‘ethical,’ through its distortion of the ‘Goldwater rule’ with the first Trump presidency — this is what it means to be politically biased.”
Originality or illness?
Boris Zlotin, an American inventor, entrepreneur, and instructor in creative thinking, sees Trump primarily as an innovator. He even wrote a book titled Inventor Trump that cites various examples of the divisive president’s creativity.
For instance, in 1976, when the Trump the real estate mogul began renovating the old Commodore Hotel, he immediately changed its address. The building was listed on the less prestigious 42nd Street, but the developer took advantage of the fact that part of the structure also faced Lexington Avenue. That trick allowed him to raise the property’s future value.
Another example is Executive Order 13837, issued in 2018, which allowed the administration to exert pressure on labor unions. Trump limited the amount of time employees could spend on union activities not connected with their direct job duties.
“And what about his recent claim that import tariffs would allow the elimination of the income tax? It’s the most hated tax in America. His approval rating jumped 2% right away, while the Democrats’ dropped by the same amount,” Zlotin continues.
“What he and Vance did with Zelensky in the Oval Office — I gave them a standing ovation. And when Trump imposed tariffs, all the countries lined up to talk to him. If he had arranged those meetings through normal diplomatic channels, it would’ve taken months.”
Zlotin owns an extensive collection of MAGA caps. But like many intellectual Trump supporters, he distances himself from the broader base of the president’s electorate:
“That Trump lies — well, who besides us even notices? Don’t take anything he says seriously. Look at what he does. He behaves boldly, he plays to win. He doesn’t care about anyone except American voters. And he understands and knows the American middle class perfectly. What he says doesn’t seem dumb or unhinged to these people.”
Of course, the fact that Trump has won two out of the past three U.S. presidential elections may seem like a point in favor of Zlotin’s argument that the president is doing just fine cognitively speaking — at least in his supporters’ eyes. But to Bandy Lee, it is a sign that Trump’s derangement is spreading. She outlines the process in her 2024 book, The Psychology of Trump Contagion:
“Now, we are imperiled not just by an unstable individual having sole command over thousands of thermonuclear arsenals that could destroy the planet many times over, but by a contagion of symptoms all over the nation and the world, such that much of the population has lost the ability to see that anything is wrong.”
That conclusion, however, is open to debate. In 2020, a team of researchers in Colorado conducted a study examining how Trump’s supporters and opponents perceive his personality. They hypothesized that “participants who voted for Trump would rate his personality as less dysfunctional than those who did not.” The results were surprising.
The 265 participants were given SCATI questionnaires — a tool used to screen for 14 major personality disorders. The test includes 70 statements such as “I find the suffering of people or animals amusing,” with responses ranging from “strongly disagree” to “strongly agree.” Participants watched Trump campaign ads and were then asked to complete the survey as if answering on his behalf.
Unexpectedly, both Republicans and Democrats rated Trump high in traits associated with sadistic, narcissistic, antisocial, and passive-aggressive personality disorders. The difference was in how they interpreted the results — some saw it as a warning sign, while others still saw no reason not to support him.
The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President, The Psychology of Trump Contagion: The Science of Understanding and Resisting Trump’s Rule, and The More Dangerous Case of Donald Trump: 37 Psychiatrists and Mental Health Experts Assess a President.
Narcissism is divided into «grandiose» (when a person’s self-esteem is extremely high) and «vulnerable» (when self-esteem is low or unstable).
The American Psychiatric Association developed a nine-item checklist for identifying narcissistic personality disorder. Five items are considered sufficient for diagnosis. A person with this disorder:
1. has a grandiose sense of self-importance, often exaggerates achievements and talents;
2. is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love;
3. believes that they are special and unique and should associate only with other special (for example, high-status) people;
4. requires excessive admiration;
5. has a sense of entitlement, expecting especially favorable treatment;
6. exploits other people;
7. lacks empathy, is unwilling to recognize or identify with the feelings and needs of others;
8. is often envious of others or believes others are envious of them;
9. shows arrogant, haughty behaviors or attitudes toward others.
