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Op-Ed: COVID and the 25th Amendment

President Trump’s increasingly unhinged behavior, culminating in spurring his followers to become a violent mob in the halls of Congress, has led many to call for his ouster whether by impeachment or the 25th Amendment. As a neurologist, I’m wondering if his increasing dysfunction dates back to his COVID infection.

Practicing on our border with Mexico, I’ve seen the spectrum of COVID-19-related neurologic impairment, from mild worsening of chronic headaches or anxiety all the way to persistent coma, with all white matter gone above the brain stem level. When neurologic complications occur in hospitalized COVID-19 patients, I typically see devastating results.

Milder COVID infections in my office patients still can leave longer term, sometimes subtle impairments.

Delirium has been increasingly identified as a presenting symptom of COVID-19, and deficits of memory or other cognitive symptoms can last far beyond the acute illness. We increasingly recognize that SARS-CoV-2 virus has a predilection for the nervous system, with a multi-center prospective study of its neuropsychiatric effects recently announced.

When President Trump was admitted to Walter Reed National Military Medical Center with acute COVID-19 infection, his notable excesses included the SUV drive-by for his followers, imperiling the Secret Service agents who drove him. According to the New York Times, he had wanted to be shown on TV leaving the hospital looking frail, then pulling open his shirt to reveal a Superman costume underneath, but was reportedly restrained by his staffers. His tweets and other utterances seemed more disinhibited following his acute illness, which I dismissed at first as likely only the transient effects of steroids given for his COVID-19.

Since his apparent recovery, he’s consistently been less coherent through the election. But following his loss, his behavior is even more confused and restricted. His presidential activity consists only of wildly disputing the election results, punctuated by golf.

Early in his White House tenure, experts already noted loss of verbal agility, reduced vocabulary, and sentences less complete or coherent. They considered early dementia, but ultimately, they couldn’t know then and can’t know now. His niece Mary Trump, in her bestseller Too Much and Not Enough, employed family observations and her own psychological training to diagnose narcissistic personality.

However, without similar insider details on his post COVID-19 behavior, and especially without examining the president, we can’t distinguish the psychological effects of narcissistic injury (losing the election) versus neurologic impairment from COVID-19, all perhaps worsened by early stages of dementia. For good reason, the American Psychiatric Association stands by its “Goldwater Rule” that accurate psychiatric diagnosis is impossible without direct examination of the individual involved, and trying to diagnose public figures from public behavior is unethical. This is even more imperative organic versus psychological factors must be weighed.

In the end, invoking the 25th Amendment or impeachment remain political acts that rest on behavior, regardless of medical causation. The decision rests with political figures such as Vice President Pence, who may or may not rely on medical expertise to understand the behavior or its progression. Sadly, the recent behavior speaks for itself.

James Santiago GrisolĂ­a, MD, is chief of staff-elect at Scripps Mercy Hospital in San Diego and a clinical neurologist. He also is the editor of the San Diego County Medical Society’s San Diego Physician magazine.