A group of 36 health professionals wrote an open letter to Congress in May warning that President Donald Trump is in a state of cognitive decline. Although the medical and political communities were willing to call out President Joe Biden's apparent decline during the 2024 election, critics argue that Trump has received an inexplicable and inexcusable pass for his own infirmities. Individual clinicians have been willing to sound the alarm, but nothing has occurred on a systematic level to alert the American people to concerns that their president is psychologically unwell.

What follows is AlterNet's exclusive interview with psychiatrist Dr. Henry Abraham, formerly of Tufts University. Abraham said Trump is literally a "maniac" because he displays manic traits such as posting on social media into the night. He also broke down Trump's tendency to ramble, his grandiosity and his obsession with his predecessor, President Barack Obama. The interview has been lightly edited for clarity, context and length.

Baseline versus decline

Asked to describe, as a clinician, the symptoms he has observed of Trump's seeming decline, Abraham began with a methodological caution: "The real question here is, what is baseline and what is decline? Those kinds of questions, of course, are very difficult to pin down."

Having observed Trump for a long time, and having spoken with people who have also observed him professionally in the same room, Abraham said he can identify "10 or 11" psychiatric symptoms that are, for him, red flags. "And you don't have to be a rocket scientist to recognize a red flag," he said.

He illustrated the point with a metaphor: "I like to use the metaphor here of a man in a supermarket. He's getting in line in a supermarket, and he has a basket full of food, and he smashes it into the woman in front of him, because she has more food than he does and it's going to take a long time and he's in a rush — and what's she doing buying so much food, and get out of the way, and she's a terrible person, and I'm really in a rush and I'm far more important than she is. And he pushes it, and he really shoves her with the shopping cart. Now, if you saw that, you would say — well, you'd probably call the police, because it's really a bizarre kind of thing. But that's the whole point. It's a bizarre kind of thing. It's crazy. It's a red flag."

To a clinician, such behavior invites consideration of "various psychiatric disorders which might explain that behavior." The challenge, Abraham explained, is that "we really can't make a diagnosis without looking at all the facts and, of course, having the patient in some form cooperate with the examination. So we can't come away with a diagnosis, but we can come away with, 'Geez, this is a symptom which is a red flag to us, and we should pursue it and we should note it and we should not forget about it.'"

He said that is the situation of "nearly all of us in the medical profession" with respect to Trump: "We see red flags, we know what causes those red flags, but we don't know the specific proximate cause of the red flag."

Daytime sleep and nocturnal mania

The first red flag that "really jumps out" at Abraham is that Trump "falls asleep at really inopportune times," seemingly "virtually every day," while remaining "up all night in a very disordered frame of mind."

"No one stays up half the night tweeting 50 or 75 or 150 times and has a normal mental status examination," Abraham said. "If a patient comes in to me and says, 'Oh, I've been up all night and I've tweeted a hundred times,' I would say, 'Oh, okay, that's a red flag. That's manic behavior.'"

He noted that there are many causes of manic behavior, nearly all of them treatable with proper treatment, but that manic behavior is "invariably self-defeating and in many situations absolutely dangerous."

As for explanations, he offered several possibilities: Trump "could be hyped up on stimulant drugs at night," or "might have a sleep disorder which prevents him from sleeping when he's pacing the halls with his laptop and says, 'Oh, I can't stop thinking about Letitia James.'" Other possibilities include stimulant drugs, coffee or "too much Diet Coke."

"But actually that merges into another red flag," Abraham said. "He's pathologically hyped up and manic. In fact, the noun for this is maniac. He's a maniac at night, but he's not a maniac during the day, generally. So it's a nocturnal form of mania which remains to be explained."

Rage and the nuclear arsenal

Another red flag, he said, is Trump's "inability to control his rage. And this is pretty dangerous stuff. If he's alone at night and he's in one of these rageful states — well, he has sole access to nuclear weapons. He could, on his own, launch a nuclear attack against whatever enemy he chooses, and he has a few, but Iran comes to mind, since he's started a war with Iran. That's a very dangerous thing. In fact, that's probably the most dangerous. That probably goes at the top of my list of abnormalities of mental function which threaten literally hundreds of millions of people."

Asked to confirm that this ranked first on his list, Abraham replied: "That's number one. So mania, plus rage, plus access to nuclear weapons is not a healthy combination."

Disorientation and repeated cognitive testing

Abraham said Trump "periodically seems to be disoriented. He doesn't know where to walk. He needs to be literally led by the arm by world leaders, who have to treat him like the demented grandfather that he probably is."

He noted that dementia per se has many different causes and cautioned against a specific label: "You can say, 'Oh, he has Alzheimer's disease' — probably not; at least he doesn't have a flagrant, advanced and undeniable Alzheimer's disease. If we saw his MRI, we'd say, 'Oh, well, he has cortical atrophy,' or he has various other radiologic evidence that he has developing dementia with organic features that actually are visible. That would be confirmatory. But we don't have that."

Nor, he said, are the results of Trump's mental state screens available — the so-called MoCA examinations, the Montreal Cognitive Assessment test. He described the MoCA as a 10-minute test that anyone can be trained to administer and that does not require great expertise to give or to add up the score, though it takes some skill to understand the results. Ordinarily, he said, the MoCA is given just once; serial testing signals that a clinician is tracking something. He compared it to taking a patient's temperature: doctors do not keep taking a temperature every day after finding a fever — they investigate what is causing it.

"The same thing is true with the MoCA," he said.If we're repeating the MoCA frequently — which we've done, I think, now four times since he's been in public office — we're obviously tracking a number. And that number could be mild cognitive impairment. It could be a significant cognitive impairment in someone who has a dementia, which is my greatest worry here."

Tangential speech

Abraham said Trump can put together a proposal for a press conference or read a teleprompter and deliver a speech, but "in the middle or at the end of his reading of the teleprompter, he has an aside or a discursive kind of discussion, and he's talking about things that just literally don't track with what he's supposed to be talking about." He pointed to episodes in which Trump moved from Tesla and electric vehicles to electric boats, falling into the water, being attacked by sharks, or dying from electrocution — "which would he prefer? And what was the topic again?"

"This is another red flag, and this is called tangentiality," Abraham said. "He's tangential. He's not always tangential, but he's tangential enough to say he's tangential. He has a symptom. It's a red flag. Someone is tangential and comes into the office and exhibits that, you write it down. You don't ignore it."

Disinhibition: 'Quiet, piggy'

Abraham cited Trump's remark to a reporter at a press conference — "Quiet, piggy" — as clinically notable. "Besides being offensive — we all know it's offensive — to a clinician, it's interesting, because this is someone who is in the middle of a professional kind of exchange... But he can't stop himself from the thought that pops into his head. He can't control it. In fact, he can't inhibit — the inhibitory circuits that we all walk around with, so we don't walk around telling fat people 'Quiet, piggy,' they're broken down."

He added: "He can't hold himself back from what he thinks is either mirthful or hurtful, or in some way it expresses a deep-seated emotion which he doesn't understand is not a socially acceptable way to engage people." This is not about failing to meet a standard of diplomatic reserve, he said, but about "ordinary conversation, where he loses control of an emotion that he's having."

He recounted a recent event in the Oval Office in which Trump received the astronauts from the Artemis expedition, with the head of NASA present. Trump was not, as far as Abraham could tell, using a teleprompter, and was cordial and in a good mood; the astronauts had just come back from the moon, and "it was a feather in everyone's cap." Trump "was being Mr. President, and he was being congratulatory," though Abraham described him as "a little patronizing" toward a member of the press when he claimed not to have read a document concerning "a terribly important decision by the Supreme Court which had come down."

"Then all of a sudden, he starts talking about the ears of the head of NASA," Abraham said. "He says, 'Oh yes, look at those ears, they're really big ears, you know?' He does have big ears, that's true. But who says such a thing? He can't keep himself from that loss of control. He can't do what other people do in ordinary circumstances. And so that's a red flag. That's disinhibition. He can't control his impulses."

"Pretty soon we can put it together: He's tangential, he has rage attacks, he can't control his emotions, and he has his finger on the button. These things begin to snowball in a way that's quite worrisome," Abraham said.

Grandiosity that 'has definitely gotten worse'

Another red flag, Abraham said, is that Trump "is grandiose. Now, he's always been grandiose." To assess whether his symptoms are changing, Abraham said he asked a friend — a journalist in the White House press corps who has followed Trump for some time and who will remain anonymous — to review "a dozen or so symptoms" and say whether each was the same, better or worse over the last year.

"The report that I got from the person who sees him every day is that half of them have definitely gotten worse, and they're the ones that I am most interested in tracking," Abraham said. One that has "gotten particularly worse" is grandiosity. Trump "always had a grandiose side to him," exaggerating his sexual prowess or his intelligence and presenting himself as "always the smartest person in the room."

Setting aside speculation about the psychological roots of such behavior, Abraham pointed to what he called the record: "the guy who dresses himself up like the Pope." To the possible rejoinder — "Well, I'm just joking" — Abraham replied: "I don't think so, because in another image of himself that he put on Truth Social, he was healing the sick, like Christ. And a third, which is my favorite of this whole bunch that he's put out, is Donald Trump shaking hands with God... He photographed himself shaking hands with God, and he posted it to his millions of followers."

He recalled that a Catholic colleague who saw the image of Trump as Pope was incensed by it and called it blasphemous — a man who, Abraham noted, is not a psychiatrist. "I said to myself: blasphemy, yes, but psychopathology, yes, squared. This is more than blasphemy. This is a meaningful clinical presentation of a symptom, a red flag that we need to pay attention to."

His press corps contact, Abraham said, told him: "The grandiosity has definitely gotten worse in the last year." In his view, that "ticks the box" of progressive mental illness and becomes another piece of the puzzle alongside disinhibition, rage and periodic disorientation.

Incoherence and the 2020 election

Abraham said Trump sometimes "just doesn't make sense" — not following a tangent, but "just speaking incoherently," trying to make a point while the points "come in fragments." "That's a red flag," he said, adding that Trump's illogicality "has been increasing as well."

The 2020 election, he argued, presents another concern. "If someone comes in and complains of a belief that they have, that they've had for a while, that't change — it's fixed — and, most importantly, it's false, it's disproven by overwhelming and contradictory evidence, you have to say, at the very least, this is a fixed idea, as we say in the trade. But more likely than not, it's a delusion."

"If he truly believes that he won the 2020 election, despite overwhelming contradictory evidence, he's deluded," Abraham said. "This may be dementia, but it can also be consistent with psychosis. So this is a big, big red flag."

He acknowledged the alternative reading — that the claim is an enduring political lie of the kind told by "most of the world's dictators and despots" to build a base of power. "But there's no evidence that he comes off the podium and says, on a hot mic, or to one of his staffers and someone else overhears, 'Well, I really put one over there. I know I lost the 2020 vote.' No, he doesn't say that at all. If we take him at his word and he believes he won the election, he's deluded, and that's not a good sign."

Other statements — that COVID would be gone in a week, or that sunlight would be the best treatment — appear to be things Trump believes, Abraham said, but they "don't necessarily rise to the occasion of anything that has the delusional power that the belief about that 2020 election does."

"So his grip on reality either is stock in trade, or he's putting one over on everyone, or he's putting one over on himself, and that's the scariest possible explanation," he said.

Declining language and unanswered medical questions

Abraham also flagged memory problems. "He doesn't hang on to words and language the way he used to," he said, noting that researchers have studied Trump's language going back 40 years and found his command of it "less competent over time." In speech clips from several decades ago, Trump could "insert a dependent clause in the middle of a paragraph that he was speaking and then come back to the independent clause in a really expeditious way. He doesn't do that anymore. If he comes up with a dependent clause, he's lost. And this is not a good sign. It also is a benchmark of a deterioration in cognitive function."

He emphasized that there are "any number of medical explanations" for the signs and symptoms he described. "They could be as benign as simple aging, or they could be as serious as untreated neurosyphilis," he said. "We don't know the answer to those questions because of a lack of transparency by his caregivers. And I think that is a huge problem for the governance of the country."

The Obama fixation

When AlterNet interviewed Governor Chris Christie in 2019, he said of Trump: "Every negotiation can't be a test of manhood. Every negotiation can't be a beat-down." Asked whether Abraham had a sense of why Trump treats every negotiation that way, he offered a different reading: much of what Trump has been doing as president, in his view, amounts to tearing down the legacy of Barack Obama.

"I think the heart of that is because Trump is many things, but one of the things is he's a racist," Abraham said. "And I think he has such a terrible problem with low self-esteem. He's always been the dumbest kid in the class. He's been told he's been dumb his whole life. And he's been told he's been a jerk his whole life. So what do you do when you're confronted with that kind of self-concept? Well, one very primitive way is to turn it upside down and say, 'I'm not the dumbest person, because I'm the smartest. I know more about COVID than anyone. I know more about nuclear weapons than anyone. I'm a perfectly stable genius.' What he's really saying is he feels the complete opposite."

"But the thing with Obama — I really believe that that's the case," he continued. "I think in his heart of hearts, he says, 'I can't let a Black man actually do better in his job than I'm doing. And so anything that he's accomplished, I'm going to destroy one way or another.' And he has been doing that, literally."

This article is adapted from AlterNet's exclusive interview, originally published at Alternet.