Trump’s Brain Is Not Okay

An expert’s view of Trump’s mental slide into dementia.

As the legal walls close in around him, Donald Trump is becoming more unhinged by the day. And yet, he has not yet paid a political price for his increasingly unstable behavior.

While for many it’s obvious how serious Trump’s declining mental capacity has become, for too many Americans that reality has not yet broken through. The media continues to treat Trump like a normal candidate; many Americans have baked Trump’s bizarre behavior into their perceptions of him; and many take right-wing lies about Joe Biden’s mental fitness at face value.

Given this, we wanted to hear from John Gartner, founder of Duty To Warn, a group of mental health professionals who have been raising the alarm about Trump’s increasingly sociopathic behavior since 2017. Now in 2024, Gartner has an even more dire warning about Trump: that there are increasing signs the former president is heading fast down the road toward dementia. 

Seven months out from Election Day, it’s more important than ever to understand the signs of Trump’s steep and disturbing decline directly from a mental health professional. And then it’s on all of us to help amplify the signal. 

— Jay and The Big Picture Team

John Gartner, Founder of Duty To Warn

You have been sounding the alarm about Trump’s declining mental state for some time now. Can you give us a sense of the history of that effort, including why you believe so many folks in the media seemed to gloss over the risk?

When Duty to Warn began in 2017, our mission as mental health professionals was to warn the world that Trump was dangerously unfit and a malignant narcissist. Practically conventional wisdom today among anyone who’s not in the cult. But we had to bang that drum every day for 5 years to penetrate the public mind. 58,000 tweets. Hundreds of interviews, all while we were being pilloried as unethical for daring to warn the world about the American Hitler.

After Biden won, I took off my uniform and went home. We all did. The last thing—truly the very last thing—I wanted to do, was re-enter politics. But I couldn’t believe my eyes. Day after day the press was gaslighting the American people: Pathologizing Biden’s normal signs of aging, such as forgetting names, and normalizing Trump’s flagrant signs of dementia. That false narrative was having a real impact on the polls, and no one with the right letters after their name was stepping in to correct the record.

This wasn’t a new issue for me. I had written a series of op-eds about Trump’s signs of dementia in 2018 and 2019, and I was part of a group that publicly pressured Ronny Jackson to give Trump the dementia screening test that he can’t stop bragging about “acing.” I’d known for years Trump was showing medically unmistakable signs of dementia, but the press was hyper-focused on Biden falling off his bike, forgetting names, and being “too old.”

One day, in silence, in my garden, I felt the Universe, God, the Force, whatever you want to call it, communicate with me. It was a simple message: If someone was going to take up this struggle, it would have to be me and I said yes. I reactivated my long-dormant Twitter account, to fight the information war, one last time.

We hear a lot about Biden’s age and gaffes, to the point where most Americans cite Biden’s age but not Trump’s as a big issue for the election, even though they are only three years apart. Based on what you and other experts have observed, why are you sounding the alarm about Trump, but not about Biden?

I call it the “double lie.” Pathologizing Biden’s normal aging is the first lie. Normalizing Trump’s dementia is the second. The sorts of small lapses we’ve seen in Biden are part and parcel of normal aging. Forgetting names and dates doesn’t make us seniors less competent. What we lack in memory we more than make up for in judgment, experience, and wisdom. Other cultures revere their elders, but America in 2024 mocks and devalues theirs. The problem isn’t old people in government—the dreaded “gerontocracy.” It’s age-ism.

Joe Biden’s calling the current president of France by the old president of France’s name is like me calling my youngest daughter by my oldest daughter’s name, which I do all the time. When I get together with my fellow senior citizens, the topic of forgetting often comes up. Sure, I forget names and even appointments sometimes. But I’m a better psychologist now than I’ve ever been. I actually pity the patients who had the young Dr. Gartner. He didn’t know anything, and, honestly, I can’t even imagine why anyone paid him. I would argue that Biden, too, has objectively performed well at his job, despite, or maybe even because, of his age. Don’t judge us senior citizens by how fast we walk, or if we stumble over a name or two. Judge us by our performance.

And hello. Forgetting the name of the president of France isn’t the same as thinking Obama is president or that Nikki Haley and Nancy Pelosi are one person. Can we introduce a sense of proportion and some common sense here?

In other interviews, you have provided examples and evidence of Trump’s dementia. Can you explain what that is and how it typically manifests? And can you connect the dots and give examples of how Trump exhibits symptoms?

I don’t know if people know this, but in real life, in day-to-day clinical practice, we diagnose dementia based on behavioral observation and informant reports every day of the week. Thousands of medical charts would back me up on that. An “interview” with a demented person doesn’t usually yield a lot of information, for obvious reasons.

As a professional community, thousands of us have observed hundreds of hours of Trump’s public behavior. We also have dozens of informant reports. So all the people hyperventilating about “diagnosing from a distance” should take a breath. This is more business as usual than you might think. In real life, we’ve institutionalized tens of thousands of patients on far less data.

The evidence for Trump’s dementia is this: Trump shows an overall decline from his own cognitive baseline, with marked progressive deterioration in 4 areas: memory, ability to use language, behavior, and gross and fine motor skills.

Let’s take these one by one:

1) Decline from baseline:

Overall, he shows a shocking decline in verbal fluency from his previous baseline. Trump was once highly articulate. He spoke in polished paragraphs with a sophisticated vocabulary. Now, his vocabulary is impoverished, and he often can’t finish a sentence or even a word. Typical of dementia patients, he repeats himself and overuses superlatives and filler words.

In “Trump wasn’t always so linguistically challenged. What could explain the change?” senior science writer Sharon Begley conducted an informal study of Trump’s linguistic decline in 2017:

“We asked experts in neurolinguistics and cognitive assessment, as well as psychologists and psychiatrists, to compare Trump’s speech from decades ago to that in 2017; they all agreed there had been a deterioration, and some said it could reflect changes in the health of Trump’s brain. ..For decades, studies have found that deterioration in the fluency, complexity and level of vocabulary of spontaneous speech can indicate slipping brain function due to normal aging or neurodegenerative disease.”

“In the 1980’s,” Begley wrote, “Trump fluently peppered his answers with words and phrases such as “subsided,” “inclination,” “discredited,” “sparring session,” and “a certain innate intelligence.” He tossed off well-turned sentences such as, “It could have been a contentious route,” and, “These are the only casinos in the United States that are so rated”…Now, Trump’s vocabulary is simpler. He repeats himself over and over, and lurches from one subject to an unrelated one.”

A Boston Globe study found in 2015 that Trump was speaking at a 4th grade level, much lower than the other candidates, but more importantly much lower than his former self. An Ivy League graduate who once “tossed off well-turned phrases” had fallen to a 4th-grade level of speech. The MOCA dementia screening test that Trump brags about passing is slated to the mental age of a kindergartener (“Show me the picture of the lion?). Only a few grades to go.

But not only has Trump declined dramatically since the 1980s. More alarming is that Trump has declined far more precipitously in the last 4 years. Multiple former members of his administration report being shocked that “he’s not the same person he was.”

This is very important for people to understand. Not only will Trump continue to get worse and worse, his rate of decline is accelerating, and if he is typical, he will fall off what they call the “cognitive cliff” relatively soon. Based on his current accelerating rate of decline, it seems very unlikely that Trump could see out a second term without falling off the cliff and becoming totally incapacitated.

2) Memory:

Forgetting names and dates is normal for people who are aging, like Joe Biden, and me, and millions of others. By stark contrast, the Dementia Care Society says “confusing people and generations” is a sign of advanced dementia. And this is the type of profound memory disturbance we’re seeing in Trump.

Recently, Trump confused Nikki Haley and Nancy Pelosi. You can kind of intuit how the demented thought process works in Trump’s mind to combine people. There’s an archetype in his head of a hated powerful female politician he is fighting. Fragments of Nikki Haley and Nancy Pelosi stick to this miasma of ill-defined thought and feeling, and combine in his imagination to form a new combined person who doesn’t really exist: Bad, bad, Nikki-Pelosi woman. Me hate her.

8 times he’s said he’s running against Obama. How often does he say and think it in private? I think this suggests that Trump has also combined Obama and Biden into one imaginary hated Joe-Obama person. The Trump campaign is trying to spin it as if Trump was either joking or suggesting Biden is an Obama puppet or some such thing. Nice try. Trump said it plainly, over and over. He didn’t look like he was joking (does he ever?) and said literally nothing to suggest he was referring to some Biden-Obama cabal.

The more plausible explanation is that once again we are watching the workings of his demented mind in real time. Obama and Biden have something very important in common in Trump’s brain that can allow them to be fused in his molten mind: two Democratic presidents who bested and humiliated him have become one imaginary super-villain.

What happens to a nation when its chief executive has lost his capacity for executive functioning? Michael Wolff wrote that Trump not infrequently failed to recognize old friends. I don’t mean he forgot their names. He acted as if he’d never seen them before in his life. If you’ve ever had a relative with dementia you know how heartbreaking that stage of decline can be-- to have to remind a loved one of who you are.

Trump is almost there.

3) Language

Trump shows formal signs of disordered speech we typically see only in organically impaired dementia patients:

A) “phonemic aphasia”

Trump uses non-words in place of real words, that usually include a fragment of the actual word. For example saying “mishuz” instead of missile, or “Chrishus” instead of Christmas. You can look at supercut reels assembled by Ron Filipkowski on Twitter, The Daily Show, and now by the Democratic House Judiciary Committee, as well. Both Chairman Nadler and Rep. Swalwell showed their own supercuts of Trump’s cognitive decline at the Hur hearings, to counteract Hur’s partisan slur about Biden’s “poor memory.”

To demonstrate how pervasive these errors are, I present this long but far from exhaustive list of Trump’s phonemic aphasias:

“President U-licious S Grant” (For Ulysses S. Grant)

“space-capsicle” (for space capsule)

“combat infantroopen”(for combat infantry)

“sahhven country”(for sovereign country)

“renoversh” (For renovations)

“Anonmmiss” (for anonymous).

“transpants” (for transplants)

“lawmarkers” (for lawmakers)

“supply churn” (for supply chain)

“Rusher” (for Russia)

“raydoh” (for radio)

“Liberal-ation (for liberation”)

“benefishers” (for benificiaries)

“con-ducking” (for conducting)

“stat-tics, suh-tic-six” (for statistics)

“crimakle” (for criminal)

“armed forsiva” (for armed forces)

“internate” (for Internet)

“transjija” (for transition)

“stanktuary” (for sanctuary)

That last example took place during Trump’s State of the Union Address, just to contrast that with the SOTU we just witnessed. In recent rallies in GA, NC, and VA over the course of just a few days Trump evidenced more examples:

“We have becrumb a nation”

“All comp-ply-ments” to Joe Biden.

“I know Poten.”

“He can’t cam-pay. He can’t campaign.”

“We will expel the wald-mongers.”

But of course, this is exactly what we should expect. As he deteriorates, these deficits will make themselves apparent more and more often. Now he can’t get through a rally without an example. Cornell psychologist Harry Segal speculated Trump may be “sundowning” and hence most vulnerable to going off the rails at night-time rallies.

Some have argued that Trump’s impaired speech could be an articulation problem, rather than a brain problem. Some have argued he could be slurring from a variety of causes, from loose dentures to drug toxicity (indeed many have speculated that Trump might be abusing or even snorting Adderall or some other stimulant.)

But all those competing explanations are disproven by one fact. Trump commits these aphasic errors in his written posts, as well, proving the problem is in his brain, not his articulation.

For example, he recently posted:

“Joe Buden DISINFORMATES AND MISINFORMATES”

B) “Semantic aphasia”

Semantic aphasia is using a real word, but in a way that doesn’t correspond to its meaning. For example, when Trump referred to the “oranges of the investigation.” Another example would be “midtown and midturn elections.” Recently, when apparently trying to say “three years later,” Trump said:

“Three years, lady, lady, lady.”

More recently Trump said at a rally:

“We’re going to protect pro-God…”

In mid-sentence he goes blank and looks at the ceiling. When he reboots, the words he uses to complete the sentence don’t make sense:

“…context and content.”

C) Complete loss of all verbal language

Like an infant sometimes, Trump just makes sounds:

“Gang boong. This is me. I hear bing.”

Until finally, he is reduced to silence. 

“Saudi Arabia and Russia will re-ve-du. Ohhh…”

Trump’s face went blank, followed by a sigh, and a silent pause while he looked at the ceiling.

D) Tangential Thinking

Trump evidences “tangential thinking” where he drifts from one unrelated thought fragment to another, and sometimes tries to “confabulate” them into a story. But the narrative is literally incoherent. When the press describes Trump’s speeches as “rambling,” they are gaslighting us with a euphemistic word that normalizes the grossly abnormal. Trump regularly degenerates into incomprehensible strings of words.

Just recently outside a New York courtroom, Trump declared:

“We can’t have an election in the middle of a political season. We just had Super Tuesday. And we had a Tuesday after Tuesday already.”

Other examples would be:

“We are an institute in a powerful death penalty. We will put this on.”

“I could tell you about aircraft carriers, where they use electric catapults. They couldn’t go to the steam, which works better for about 1/100th the price, you know? The electric catapult, you know that story? I could tell you about the elevators on a tremendous carrier, the Gerald Ford, and they decided not to use hydraulic like the John Deere tractor, they decided to use magnets, ‘we’re gonna use magnets!’ to lift up the elevators with seven planes.”

In a recent string of rallies in GA, SC, and VA he said:

“They say I’m cognitively impaired. I’m not cognitively.”

“They don’t want illegal immigrants knocking on their front door and saying I’m going to use your kitchen. And I’m going to use your bedroom and there’s not a damn thing. And that’s the nice ones, okay?”

“They raided my house in Florida, Mar-a-Lago, they raided. With no raid, they had no reason to do so.”

Some of his utterances are incomprehensible for a different reason. They suggest Trump is so disoriented he’s occupying a different reality than everyone else. 

For example:

“They’re weaponizing law enforcement for high-level interference against Joe Biden’s top and only political appointment. A guy named me. A guy named me.”

At a recent rally, he said: 

“Biden beat Barack Hussein Obama. Ever heard of him?”

Biden never beat Obama. So we have to conclude that Trump is confused about basic reality, and living in a different reality that changes unpredictably. When a confused patient is evaluated in an emergency room, a standard psychiatric question to determine if a patient is disoriented is:

“Who is President of the United States?” 

If you get that wrong the most probable explanations are dementia, psychosis or drug toxicity, and most probably you’d be admitted for observation in any case.

4) Motor Performance:

Dementia expert Elisabeth Zoffmann, assistant professor of Forensic Psychiatry at the

University of British Columbia, told Salon that Trump evidences a “wide-based gait, commonly found among patients with dementia. Video online shows that he swings his right leg in a semi-circle as if it were dragging a dead weight. He has also shown deterioration in his fine motor coordination, for example having difficulty drinking a bottle or a glass of water without two hands.

Some doctors have also pointed out the peculiar way he leans forward as a typical sign of a type of dementia known as frontotemporal dementia. It could be frontotemporal, or it could be Alzheimer’s like his father had. There’s more than one cause of dementia and that’s where a brain scan would be helpful, but we’re never going to get to see that.

5) Behavior:

He is showing marked deterioration in impulse control and judgment, becoming ever more paranoid, aggressive and confused. Even the judges in his cases are throwing up their hands because they see Trump actually can’t control his outbursts at this point, it’s like a Tourette’s tic.

What are the real risks to our nation of a president who is exhibiting signs of dementia? I can imagine a list of horribles, but what are some of the ones that spring foremost to mind?

It’s an axiom that when a patient with a personality disorder becomes demented, everything about their personality-disordered behavior gets exponentially worse. Trump will become more horribly Trumpian, if you can believe it. Everything evil and destructive about him will become even more exaggerated in an unbound, and even more erratic way, until he is nothing but rageful id, with no rational control or inhibitions. It will be pure chaos. From that point, there’s simply no bad outcome that you can think of that’s inconceivable.

People need to understand dementia is a progressive illness, which means the Trump you see today is the best Trump you’re ever going to see. It’s all downhill from here. Trump’s rate of decline is accelerating, and if he’s typical, at some point, he will “fall off a cognitive cliff” and become completely disabled.

Trump could be found wandering the lawn of the White House in his pajamas confused about where he is. I’m not joking. I honestly believe that will happen if he’s reelected. At the rate that he’s deteriorating, I don’t believe it would be possible for him to get through the next 4 and a half years without becoming incapacitated while in office.

In the Middle Ages they said: “A bad king is better than no king. And no king is better than a child king.” That’s what we would have: a king (because he’ll be a dictator from “day one”) who, while always a child temperamentally, will have becomes a child mentally, as well.

Even in this scenario where his cronies try to control him, I see Trump escaping his handlers, and seizing control, even in his demented state, to wreak catastrophic havoc, destruction, and revenge.

You’re not alone in your concerns about Trump, and you’ve even begun a petition from medical professionals warning of the danger. Can you tell us about that effort and whether it is moving the needle?

I knew I couldn’t break through the false narrative about Trump and Biden’s cognitive health alone. We needed a chorus of professional voices. To summon them I reached out to colleagues and put a petition for licensed medical and mental health professionals online that states in part:

“Our diagnostic impression of Trump is probable dementia. 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.”

We have over 500 valid signatures (we have to discard 2/3 of the signatures that we can’t confirm are professionals), and that number is growing. However, to me, more persuasive than the number of signatures, are the comments left by the signers explaining their professional reasoning and describing the symptoms of dementia they see in Trump.

I put those comments together in one tweet thread and pinned it to the top of my Duty To Warn account. I’m grateful that 1.8 million people have had a chance to read it. The collective voices of these professionals are powerful.

Here are a few examples:

“I am a neuropsychiatrist and movement disorders neurologist at an academic medical center. There is more than enough reason to suspect dementia including worsening thought process, looser connections between thoughts, tangentiality, paraphasias, irritability, paranoia, persecutory ideation, impulsivity, and so on; which are clearly different than videos of him from 10 years ago.

“Without personally examining him, I cannot clarify further, but he appears to at least have a cautious gait. The most plausible disorder would be a mixture of frontal lobe dysfunction (sort of like frontotemporal Dementia or CTE) from a vascular Dementia.” -- Ankur Butala, M.D.

“As an experienced physician who was board-certified in Family Medicine, Geriatrics, and Emergency Medicine…Trump clearly demonstrates deteriorating cognitive function. His public posture, leaning forward when standing, his difficulty walking down a ramp, and his increasing speech difficulties are suggestive of frontotemporal dementia. Again, this is all based on public information and my years of experience.” ---Thomas C. Long, M.D.

“The evidence for dementia in Donald Trump has become overwhelming. Unlike normal aging, which is characterized by forgetting names or words, Trump repeatedly shows something very different: confusion about reality.” ---Lance Dodes, M.D., Department of Psychiatry, Harvard Medical School

“This is not just ‘rambling.’ Trump evidences a type of cognitive impairment seen in dementia. Symptoms like ‘word salad’ (incoherence), ‘loose associations’ (a lack of connection between ideas), impairments of memory, and language problems (mis-pronouncing words or making up words that don’t exist).” --Dr. Michael Bader, psychologist

Finally, mental health professionals are turning their attention to Trump and his cognitive deficits. Some psychologists were eloquent about Trump’s malignant narcissism in 2019, but no one is talking about Trump’s dramatic decline at the podium. It’s true that Biden has an old brain, but it’s functioning well. Trump demonstrates atypical dementia onset every week.

I have extensive experience with elderly populations, and any geriatric psychologist will tell you that dementia doesn’t come on all at once. It begins to show when someone is under stress or tired, that’s why the term “sun-downing” is so descriptive. My grave concern: we are now seeing Trump at an early, yet very troubling, stage of dementia. I’ve seen from Donald Trump in the past six months, his speech is riddled with cognitive errors, misattributions, and odd digressions indicating a significant decline in functioning. I would strongly insist on an extensive mental health/neuropsychological assessment if one of my elderly relatives was speaking the way Trump does.

In the past few months, Republicans have accused Joe Biden of being “confused” and “incoherent,” arguing that he’s aging badly. Yet his State of the Union address disproved any of these claims – he is a high-functioning elderly president. All of this focus on Biden’s age has distracted commentators and reporters from the obvious decline in Trump’s functioning. He repeatedly states he’s running against Obama, while his speeches often give way to odd digressions that leave him and the audience bewildered. During his presidency, Trump was erratic, explosive, and prone to pathological lying. Now, it’s even more dire because he’s losing his ability to think coherently.” --Harry Segal, Ph.D. Department of Psychology, Cornell University

We’ve met plenty of resistance but more and more we’re starting to be heard. The funny thing is that every time a journalist writes about us, they’re shocked by the magnitude of the public response. We’ve been covered by Salon, The Hill, and my hometown paper, the Baltimore Sun. In each case, the article sat on their respective publication’s leaderboards as the #1 most-read article for days.

Dan Rodricks who wrote the Sun column told me the last article that got that many views was “Ravens make the playoffs.” People are hungry for reality and objective truth. They want to know the medical truth about both Biden and Trump’s cognitive health and learn it from credible sources they can trust. If you can’t trust doctors, when we’re talking about a medical condition, then who can you trust?

John Gartner is a former assistant professor of psychiatry at Johns Hopkins University Medical School. As the founder of Duty to Warn (on X at @duty2warn), John has been warning us about Donald Trump’s mental state since 2017.