Donald Trump's unpredictable actions fuel concern for his mental and cognitive health

Ever since Donald Trump first ran for president, questions have been raised by his detractors about his state of mind.

Critics of his behaviour have pointed to multiple things they describe as red flags: an erratic and disorganised speaking style, apparently compulsive lying, a consistent stream of excessively grandiose claims and statements, and visible difficulty regulating his temper — as made clear by his behaviour on social media, where he frequently lashes out at opponents in late-night and early-morning rants.

Responding to these concerns and criticisms over the years, Trump has several times described himself as a "very stable genius." In the last year of his presidency, he began boasting about "acing" a basic cognitive test designed to detect signs of early-onset dementia, though he has not engaged with questions about why he took the test in the first place.

But however strong Trump's denials have been, the issue is only growing more pressing as he campaigns for the presidency once again.

In recent weeks, Trump has been behaving particularly oddly, rambling and slurring his words in increasingly long-winded speeches and at one point remaining on the stage after an event to spend half an hour silently dancing to a mournful playlist.

One particularly strange appearance lately saw him deliver a five-minute-plus monologue about the late golfer Arnold Palmer, in the course of which he alluded to other linksmen's astonishment at the size of Palmer's genitalia.

Trump appears aware that people are discussing the strangeness of his free-associative monologues, which he has taken to describing as "the weave".

Trump's campaign has also declined to release his medical records and pulled him out of numerous public events and interviews, fuelling speculation that he is "exhausted" and that they are trying to limit opportunities for him to give a particularly poor performance.

Meanwhile, Kamala Harris's campaign is leaning hard into the idea that Trump is unfit to be president not just because of his previous conduct but because he is not psychologically up to the task.

"It is clear: Donald Trump is increasingly unstable and unhinged," Harris said at a recent campaign stop. "And he is seeking unchecked power."

She said the same in an interview with Trump-friendly network Fox News, linking the former president's alleged mental decline to his increasingly dark rhetoric, which includes proposals to shut down critical media outlets, deport millions of people, and unleash the American military on his critics.

Also piling on lately is Trump's predecessor, Barack Obama, who has been on the campaign trail for Harris.

"Along with his intentions, there is also a question of his competence," Obama told a crowd in Arizona. "Have you seen him lately? He is out there, he's giving two, two-and-a-half hour speeches, just word salads."

"You would be worried if your grandpa was acting like this. I'm not joking, you would right? You'd call up your cousins and say, 'Have you noticed?' So imagine it coming from a guy who wants to be given unchecked power," he added.

"We do not need to see what an older, loonier Donald Trump looks like with no guardrails."

But while Harris and her allies are making sure to use the word "increasingly" along with "unstable", adding some urgency to their argument, concerns about Trump's mental fitness for the job extend far back to the early days of his presidency — and even before.

The first time around

While Hillary Clinton was running against Trump in 2016, she directly attacked his character as a danger to the US.

"It's not hard to imagine Donald Trump leading us into a war just because somebody got under his very thin skin," she said in a speech, calling him "temperamentally unfit" for the role of commander-in-chief.

"Donald Trump's ideas aren't just different. They are dangerously incoherent. They're not even really ideas — just a series of bizarre rants, personal feuds and outright lies."

"I will leave it for psychiatrists to explain his affection for tyrants."

Once Trump entered the Oval Office, the discussion of his state of mind only grew louder. The incendiary 2018 book Fire and Fury, an expose of goings-on in the Trump White House during his first year in power, featured deeply sourced reporting on the president's unstable moods, his extreme difficulty in concentrating and taking in information, and his obsessive repetition of often false stories.

According to the book's author, Michael Wolff, many who worked in the White House at the time told him that they frequently discussed whether Trump's behaviour warranted removing him from office by invoking the 25th Amendment, under which a president's cabinet can remove him if he is "unable to discharge the powers and duties of his office".

Outside the White House, Trump's psychological makeup was described in dire terms by his niece, clinical psychiatrist Mary Trump. In her 2020 book Too Much and Never Enough, she detailed how her uncle's personality problems had their roots in his family upbringing and argued that they should be taken extremely seriously.

"The fact is, Donald’s pathologies are so complex and his behaviors so often inexplicable that coming up with an accurate and comprehensive diagnosis would require a full battery of psychological and neurophysical tests that he’ll never sit for," she wrote.

There was also great debate in the American psychiatric and psychological establishment over whether or not it was ethical for clinicians to diagnose Trump with a personality disorder from afar without examining him in person.

This is an argument that dates back to the 1964 election when more than 1,000 psychiatrists told a survey that, in their professional opinion, then-Republican presidential candidate Barry Goldwater was unfit for office.

After Goldwater won a defamation suit against the magazine that published the survey, the American Psychiatric Association adopted what is now known as the Goldwater Rule, under which members must not present their arm's-length opinions about candidates as informed clinical opinion or diagnosis.

"While it is perfectly fine for a psychiatrist to share their expertise about psychiatric issues in general, it is unethical to offer a professional opinion about an individual without conducting an examination," the association's president wrote in 2017.

'Healthiest individual ever elected'

Since he was first running for president, Trump has pushed back hard against claims that he is not a model of health.

During his first campaign in 2015, he had a doctor release a report on his health that described his test results as "astonishingly excellent", claimed that "his physical strength and stamina are extraordinary", and declared that "If elected, Mr Trump, I can state unequivocally, will be the healthiest individual ever elected to the presidency".

However, the doctor who wrote this letter later revealed that Trump had dictated it to him.

In 2020, as he prepared for a campaign against Joe Biden, who is four years older than him, Trump repeatedly bragged that he had performed perfectly on a test designed to detect early onset dementia. He did not address why he had taken the test in the first place.

Among the questions on the standard test is one that asks the subject to remember five words and another that asks them to identify pictures of different animals.

Having lost the presidency to the man he derided as "Sleepy Joe", Trump prosecuted his campaign against Biden this year by repeatedly attacking his rival's mental acuity and advancing age, claiming that the Democrats were ignoring a sharp deterioration in Biden's abilities.

When Biden struggled badly in a TV debate with Trump in the summer, struggling to finish sentences and at times staring blankly into space, it briefly seemed that it was the president's cognitive issues rather than Trump's that would become the story of the election.

However, when Biden dropped out and was replaced on the ticket by Harris, Trump suddenly found himself running against a far younger and more vigorous opponent — leaving him the oldest presidential nominee in history.

He and his running mate, JD Vance, frequently deride Harris as intellectually subnormal, with Trump going so far as to deride her as "crazy" and "nuts". While this may play well with their voters, there is so far no sign of any serious discussion about the state of Harris's mental health.

The vice president has also released her medical records, which show her to be in excellent physical health besides minor myopia and seasonal allergies — and despite all the speculation about his physical and mental exhaustion, there is so far no indication that Trump will be releasing his.