Even though neurological testing would help to exclude from presidency those with cognitive impairment, such as from early Alzheimer’s disease, Parkinson’s disease, and other causes, it does not offer much help in diagnosing a patient who refuses to recognize his / her current condition. (And I think most of us would agree there are all kind of issues if we were to try to expand this testing to predict future diseases and the impact it will have on an individual.)
President Biden's situation, unfortunately is quite common, in that the vast majority of persons with cognitive decline or serious personality disorder are unaware that they even have a problem. This is usually not due to active denial of pathology, but rather due to a phenomenon called "lack of insight" or what neurologists call "anosognosia".
In this common phenomenon, the patient's brain fails to recognize that it is malfunctioning and the sufferer will insist that all is well. When cornered regarding any malfunction, they will insist that their prior accomplishments are an education of current brain function. What it boils down to is that the person is unaware of their condition and therefore is unable to accept it.
It is important to realize that someone with anosognosia isn't simply in denial or being stubborn. Their brain can't process the fact that their thoughts and moods don’t reflect reality. This is why in the situation with President Biden, his leadership that works with him each day is required by the constitution to evaluate and then act on this information. This is why the 25th Amendment of the Constitution was passed in 1967.
It is interesting to examine the four sections of that amendment, the first three basically cover the situations regarding the death of a president and the succession that will follow, Section two addresses the need to fill the Vice-Presidency in case that position is found vacant, and Section three talks about what happens when the President voluntarily steps down due to not being able to discharge his duties of that office. Section four however involve the steps needed in case the Vice-President and a majority of the Executive leadership submit to Congress their finding that the President is not fit for duty. The remainder of that amendment walks through the steps if the President disputes these charges and what would be needed to forcibly remove the President from his position.
The issue is that everyone, regardless of their health status, is constantly updating their mental image of themselves. Whenever you gain new information about yourself – say, after you get a haircut or ace a presentation – it factors into how you think about yourself. It's an ongoing, complex process. In order for it to go smoothly, your brain’s frontal lobe has to take in the new info, organize it, use it to edit your self-image, and remember that latest version.
However, when your brain’s frontal lobe is damaged, which happens often with illnesses like schizophrenia, strokes, and bipolar disorder, you can no longer properly update your self-image.
Anosognosia isn't always all-or-nothing. Some people partially lose the ability to see themselves clearly, or it can come and go. That can confuse friends and loved ones. It’s hard to understand why someone seems to fully understand their condition in one moment, then claim they're perfectly healthy the next, even though objective evidence shows they aren’t.
That is why, just like in the case of President Biden, it is important that the patient undergo a professional examination and tests to help the health care provider learn more about the patient's brain and medical history.
Some health care providers test for the condition by interviewing people showing symptoms of anosognosia and then noting their responses on a spectrum called the Scale to Assess Unawareness of Mental Disorder (SUMD). This scale can help a doctor know how severe someone's anosognosia is. It was designed for people with schizophrenia, but this scale is used for people with other conditions as well.
If you are asking the question why does it matter if the patient is functioning in most areas of their life, here's just one reason why it is so important to get the patient help. When someone with a serious mental illness insists they aren't sick (or aren’t as sick as others say they are), a dangerous situation could result. Someone with anosognosia is unlikely or unable to make logical, well-defined decisions because their brain is falling back on old memories and not their current reality.
Anosognosia isn't easy to treat. Some therapists have been having success with an approach called motivational enhancement therapy (MET). This type of talk therapy is designed to help someone understand the benefits of changing their behavior. The fact remains that the most important thing is for that person to be examined by a professional in the mental health field.
If a loved one has anosognosia, sometimes it’s best not to try to convince them that they're ill. Instead, talk about their goals, such as keeping a job or living on their own. This might encourage them to meet with a mental health professional, even if they don't think they need it for their health and well-being.
However, when we are talking about the President of the United States, this duty is more clearly defined. The constitution of the United States demands action when the reality of the President not being able to properly perform the duties of his office occurs. Once again, we are not talking about what is best for President Biden at this point, the higher calling is to determine what is best for the United States of America.
We have seen evidence that President Biden's aides have been forced to make cheat sheets for simple tasks such as walking on a stage for a public appearance. Questions in media interviews have been clearly restricted to avoid the President having to address a question he has not been prepped to handle. And finally, the American people saw with their own eyes the deterioration of his mental and physical capabilities during the first debate between President Biden and President Trump. From when he first walked slowly and unevenly on the stage, to the absolute mishandling of his answers to basic policy questions, followed by the slack jaw response when Trump was talking and Biden was unable to engage. The uproar has not ceased since the debate, in fact it has grown louder. Powerful donors, leaders in Congress, influential members of the media have all called for President Biden to withdraw from his quest for a second term as President of the United States.
And if it can happen to the President, with all his access to the best resources in the medical field, it can happen to any of us. Pray that you have people in your life who would love you enough to confront you if this situation were to occur to any of us, and that wouldn't cease their efforts until we got the help we needed.
May the same be true for President Biden.
