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Notes -
Obviously, most are highly interested in the president’s mental status right now so I figured I’d outline some related medical content.
Caveat- I’m not a geriatrician because fuck that (sorry if you are), so if anyone wants to throw out more specific domain knowledge feel free.
As is usual for medicine, terms are both highly specific and something that specialties don’t necessarily agree on, I’ll skip most of this to avoid blathering about the difference between a mild vs. major neurocognitive disorder vs. dementia as much as possible, but is it worth noting that the word dementia in a colloquial sense can end up being used to refer to normal or above normal age related cognitive decline and changes (which is likely what is happening to the president), or it can be used to refer to one of several highly specific disease process that may result in things like fast or slow progression, or extremely worrying symptoms like hallucinations.
A lot of people have commented “well my grandpa had looked like that” type comments and that’s not necessarily bad data but specific diagnosis of this stuff is surprisingly complicated and unsatisfying since a lot of it requires looking at the overall “clinical” picture and going “yeah probably” (including waiting years to see if progressive decline is happening) with confirmation being only available post-mortem if at all. One of the reasons for this is that the wheels falling off your brain results in some weird shit, some people get behavioral changes years before they get memory problems which leads to them getting diagnosed with something completely different, or something that is not even a “dementia” at all. It’s a huge pain in the ass.
As an aside, I think we may good evidence that the Biden administration is aware of and lying about his neurologic health, which I think many suspect but something that we can point to as evidence is helpful.
Readers may be aware that for a number of years Biden has been publishing his health assessments due to questions about his medical health and fitness. I have used these as a teaching tool because they are exceptionally well written notes and learners can get quite a bit from them. They can be found via google, however: https://www.whitehouse.gov/wp-content/uploads/2024/02/Health-Summary-2.28.pdf. Caveat – I don’t have specific knowledge on presidential notes, it may be standard of care to neglect to mention the specific stuff I’m going to talk about. But I question that.
If you read his note, you’ll observe he had a very extensive neurologic exam (as every president probably does and everyone probably should but doesn’t), but he actually has notable neurologic findings. These are ultimately unexciting and not related to the problem at hand, but it means his neurologic exam was performed and reported. Problem: a neuro exam includes assessment of cognition, sensorium, etc. It’s not all reflex hammers and muscle tone (for shits and giggles here’s a citation PMID: 32491521). Sidebar: this note does seem to rule out most pathology with notable physical component like Parkinson’s or cerebellar problems. Since specific deficits are present and commented on, I actually believe that.
However, I do believe his mental status exam is not being reported on, or was declined. Every patient who sees a doctor is having their mental status assessed. Most of this is invisible and often it’s not commented on in documentation. For a primary care provider role, you don’t need to comment on thought process and affect, but you will eyeball the person and if something looks off chase it.
Your doctor is paying attention to what you are saying and how you are saying, but mostly this is on autopilot. Standard of care is to assess orientation “who are you” “where are you right now” “what’s the date and time.” You might not get these questions every time because if you are having a complicated conversation with the doctor, they’ll assume you are oriented (rightly so) and then spare you the stupid questions. Asking them is however the standard of care, and you bet Biden is getting asked those questions and other basic mental status exam questions, which typically include things like some basic math and read back of three objects at five minutes.
Example MSE: https://meded.ucsd.edu/clinicalmed/mental.html
Now with someone in Biden’s age range, gaffes, stress levels, and observed behavior I’d want to do a more exhaustive test. Again, my feeling of what represents standard of care is that he needs a higher level of screening tool, which I do not see reported. Likely declined or deliberately skipped by his physician.
So, what are these? Two standard ones you can look are the Mini Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA). You can google these yourself and these are what inspired me to write this. For the most part there isn’t fancy brain imaging or lab tests, we ask you to name a lion on a sheet of paper and you can’t and you get a “dementia” diagnosis.
The fact that nobody gave him an MMSE, reported that he got full points (which he should if he’s the fucking president) and has pointed to that as positive evidence….that’s concerning.
These instruments can be performed by anyone, I want to see Trump chase Biden around with a MoCA sheet, shouting “do you have a moment to talk about your mental status???” The tougher part is ruling out medical causes of illness, which they did as normal.
TLDR: Typically, if you come in for a neuro-cognitive assessment you’ll get labs and imaging, but the doctor will know the level of impairment from history taking (including with family) and from the physical exam. The history taking requires some art, but the exam portion comes on a sheet of paper and can be performed by basically anybody in under 20 minutes. It’s not asking the president to sit in an MRI for a couple hours. This has concerning implications.
Would you re-examine Parkinsons being ruled out if it came to light that a neurologist specializing in Parkinsons had met with Dr. O’Connor eight times since August 2023?
I'm obviously a medical layman, but this, combined with just the weird shit we've seen from televised events involving Biden, not blinking enough, slurred, breathy, and hoarse speech, and a lack of facial expression, makes me think that there may be something here.
Interesting.
Admittedly I haven't given the guy a physical exam and I haven't watched any footage of him walking around (gait is huge for this).
It's worth noting that if you are movement disorder specialist, you are still a Neurologist. Biden's PCP probably doesn't need outside help to diagnosis PD (although they would absolutely bring in expertise for management) so it's very possible they had some concern for general Parkinsonism, especially since more "normal" age related cognitive decline or dementia may have somewhat similar presentations and they wanted to rule something out with neurology help. Again scrambled old brain does weird shit that can complicate diagnosis.
That said, my bias against it being PD is that because if it is PD or Dementia with Lewy bodies then we have big problems, Biden should be impeached and people should probably go to jail. Both of those have neuropsychiatric manifestations that are unacceptable in a sitting president.
I'd expect them to decline to publish his health assessment instead of essentially fabricating it but maybe I'm expecting too much professionalism.
For comparison (although not quite on this level), what do you think should happen if they find out he's become schizophrenic and hid it?
Best steelman I got is that he's got regular dementia or cognitive decline with quite a bit of movement disorder type symptoms so they wanted an outside effort for suggesting management etc.
(Got here from the monthly AAQC roundup)
Would you be willing to do a post on schizophrenia in general? I'm not angling for some sort of tin-foil hat "Biden is schizo!" angle. It's just an interesting disorder to me and you seem to know More Than The Average Bear about this kind of thing.
Failing that, got any dank links?
What specifically would you like to know?
Initial specialty education and cross specialty education often results in some pretty solid plain English resources, not sure how this will parse to someone without a medical background but here's an example website that gets tossed around by Psych to teach other specialties about Psych considerations: https://www.bulletpsych.com/topics
The first topic is psychotic spectrum disorders! Speaking of which that's probably the highest yield concept here. In medicine we tend to be obnoxiously specific about our terms (for good reason).
Psychosis refers to a person losing the ability to discern what's real and what it isn't (Sidebar: borderline refers to the borderline between psychosis and neurosis, which tells you a little bit about the behavior of people with borderline personality disorder). It doesn't mean that a person is evil or engaged in criminal behavior.
A number of things can cause psychosis - chronic or acute medical illness, the effects of recreational drugs, another mental disorder (like Bipolar disorder).
People who are psychotic may or may not be aware that the voices and experiences are not real, often this very neatly matches up with severity and someone may have "insight" when on medication and well treated however this is not a hard rule.
The big ticket manifestations of psychosis are delusions and auditory hallucinations (typically: "voices"). The latter is pretty self-explanatory but it's worth noting other hallucinations exist but are less common - if someone has tactile hallucinations or visual hallucinations the issue is more likely to be non-psychiatric in nature. Delusions are a bit more complicated. Someone believes something that isn't true. This can be benign ("my neighbors are from Mars but that doesn't bother me in any way") or very scary ("all the doctors work for the CIA and are going to sterilize me so I better kill them").
Additionally you'll see things like disorganized speech, disorganized behavior, and "negative symptoms" like passivity and reduced emotional range.
Something to note specifically about schizophrenia is that it's a somewhat progressive, chronic disease that usually manifests in early adulthood that requires medication management. Even with mild symptoms the risk of progression is high and therapy and willpower alone are not adequate to treat it. You'll see horrible things like a young lawyer from a rich family slowly decompensate over the years, get disbarred, run out of money, and run out of family patience, leaving them homeless and destitute. It blows.
On a funny but dark note, these patients can often be hilarious through just saying something funny, or behavior in a grossly irrational or inconsistent way that can't help but make you laugh.
They are also often dangerous.
We also have a psych trainee here self made human I'm too much of a boomer to tag him but I'm sure he'd have a lot to add.
Thank you for this, very insightful.
To add specificity, I'm interested in that demarcation point related to neurosis and delusion. Where does perception end and earnest (and non-reality based) belief begin?
To illustrate, image there's someone who has a unshakeable belief that they're going to get fired from their job. They believe it's just a matter of time. Maybe they can point to a causal chain that gets them there ("My last project didn't go well with a customer" / "I know that this other team similar to mine got downsized" etc.). What matters it that their belief in the inevitability of being fired is as strong as "the sky is blue." It's essentially self-evident to them. They catastrophize over it, definitely are neurotic in the fixation on it, perhaps rising to the level of obsession in the OCD context. They begin to see adverse impacts on all areas of their life; diet and exercise suffer, they stop attending social engagements, become withdrawn, and, as a perverse self-fulfilling prophecy, their work performance suffers.
It's my understanding that that would NOT be characterized as schizophrenia regardless of the intensity of the beliefs or their adverse impacts. They aren't erroneous and any objective factual issue (like the "neighbors from Mars" illustration you provided) they simply have an extreme perceptional bias they can't be worked out of. But, at that level of extreme, are we talking about something that qualifies as delusion?
Or, is this more in the territory of mood disorders a la MDD or Bipolar? Maybe this is somewhere in those weird border-borderline diagnoses like schizoaffective?
As you stated, schizophrenia is a progressive illness. People don't go from waking up one day without symptoms to tearing out their walls looking for the listening devices the next. It starts and grows with a little more subtlty. In my (admittedly amateur) epistemology reading, this seems to mirror the perception-to-belief continuum I see debated so often.
None of this is easy.
Some thoughts.
-One offered definition of delusion is: "a delusion is a fixed false belief based on an inaccurate interpretation of an external reality despite evidence to the contrary." Not mentioned here is the importance of cultural context. One of the reasons why it's not appropriate to label a Democrat or Republican, or a woke activist, or a ghost believer, or a religious person delusional is because their is some element of shared cultural support for the beliefs. This is important to keep in mind.
-Level of fixation and ignoring evidence to the contrary is variable. Delusions are some of the hardest symptoms to treat with medication but they can be treated, at times very successfully. Patient when less sick (and sickness can be caused by stress, sleep deprivation, medical sickness) may find that they still believe the thing but have the insight to lie about it to someone else (which they may not when fully decompensated), may be willing to say something like "I guess it's possible that this isn't true" or many have it resolve in totality.
-With schizophrenia it is more common to have a prodrome and/or progression of symptoms but it's not universal, especially with complicated factors like medical illness, severe stress, drugs, and other psychotic disorders like bipolar with psychotic features. Schizophrenia specifically involves a combination of factors and you'll generally see the negative symptoms, gross disorganization and other things that give you the whole "this guy is crazy" vibes. Disease like "delusional disorder" exist (patient believes one thing or a category of things without the other symptoms like hallucination and functional decline. Example: husband absolutely convinced his wife is cheating on him and seemingly nothing else is wrong. These patients can be very "safe" but are extremely terrifying to me on an existential level lol.
-As above mental illness is often defined as deviation from cultural norms and functional impairment. This gets hairy. Homosexuality was at one point a mental illness, does not appear appropriate now....but by this definition is that only because it's now culturally acceptable? Woke people with woke anxiety appear to be deviating from cultural norms and often have severe functional impairment, but they are social support for the beliefs. Shit's complicated.
-In the case of the more traditional disease like schizophrenia we can look at brain imaging, see things improve with antipsychotics but our understanding of what's going on is incomplete and the philosophical questions have tension with the medical ones.
-Often we are just saved by the fact that most people who are sick and present themselves for psychiatric care are obvious. Their are other types of mental illness that are more often seen by non-psychiatric doctors for general medical care because they stay out of trouble and function well (ex: schizoid personality disorder). This complicates matters.
-Other types of psychiatric disease like OCD, Autism, and Anxiety can appear psychotic and push into psychosis territory (maybe even become psychosis?).
-Leaning on formal diagnostic criteria helps greatly for reducing ambiguity but again most cases are obvious. It is possible that not obvious cases exist in large numbers and healthcare just doesn't see them because they don't need it.
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Thank you for your insights!
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Interesting, in the UK we usually ask them to name random things lying around in the consultation room.
"Phone, pencil, underpaid idiot diagnosing me" and so on. I wager it's due to NHS budget cuts.
Object naming IS a component of a standard mental status exam over here (not that most are doing a full one), but for detailed analysis you'll want to use one of the validated screening tools.
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The winning move for Trump is to do nothing right now. He's clearly smart enough to know that at least for now, Biden's shooting himself in the face while aiming for the foot, and doing so far more effectively than anyone else can, and that it's currently catching lots of other Democrats in the crossfire. "Let's watch you and him fight" is the winning move for Trump right now.
But if Biden gets formally nominated, Trump should totally challenge him to both do the montreal cognitive assessment on live TV. Literally every news channel will eagerly air that. Hell you can probably get a popular and not generally perceived as partisan doctor- a weightloss guru or something- to show up to do it.
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what does that mean? is there a picture of a lion and you can call it simba? i feel like i'm going to fail the dementia test.
There’s a picture of a lion, and you have to say, “That’s a lion.”
It's not dementia it's avant garde.
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One of the tests asks you to identify three distinctive animals from a drawn picture - a lion, camel, and rhino.
People do get this wrong, sometimes people that you wouldn't guess because they stay sharp in some areas but not others.
Do you know why use specifically those animals?
I can totally see someone forgetting the word for rhinoceros under the pressure of the test. The animal is quite unique, and unless you live in Africa, I doubt that you think about rhinos a whole lot.
Or is that the point? Because I'm really afraid of failing a simple test like this.
I don't know why the names of charismatic megafauna are learnt so early, but both my kids knew lion, camel, rhino, elephant, dinosaur etc. well before their second birthdays.
This was reinforced by available media - picture books, toys, Youtube Kids etc.
I agree that its weird, but I would be very surprised if a cognitively normal three-year old in WEIRD culture struggled to name those animals.
And similarly, people learn the names of women. But when suddenly approached on the street, they struggle to name one! While a cognitive test setting is different from a guy asking you questions while waving a dollar in your face, I would be afraid of forgetting "rhino" under pressure.
https://youtube.com/watch?v=LlCEmPF4-V0
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I always thought there must be some instinct at work, telling the child that they need to know what kind of big, scary things are around. Same thing that makes young children - especially boys? - obsessed with diggers and other large machinery.
sigh Scott did it
Thanks!
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I think they were picked because the silhouettes are known to nearly everybody in the western world (charismatic megafauna!).
Top 10 all time prog rock band name, for sure.
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I’m pretty sure that’s the point. Animals everyone knows (even my three year old niece could point them out) but not something you run into every day.
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Trump did take the MoCA twice and he aced it. So rubbing it in Joe's face at the debate ks pretty much this.
Wasn't the response at the time something like "Why does he care so much about this test. It's so easy anyone not obviously having dementia could pass it."?
I bet the folks saying that at the time aren't saying that today.
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