Saturday, February 18, 2017

Using Discourse Analysis to Assess Cognitive Decline

Figure from Gauthier et al. (2005).

Alzheimer's Disease (AD) and other dementias are progressive neurodegenerative conditions that unfold over time. Subtle symptoms such as forgetfulness and word finding problems may progress to mild cognitive impairment (MCI), and then escalate to full-blown dementia. Recent efforts to classify prodromal states have included automated analysis of spontaneous speech, which loses complexity as the disease progresses.

In one study, Frazier Fraser et al. (2015) applied machine learning methods to speech transcripts and audio files from the DementiaBank database. The participants were 167 patients with probable AD and 97 controls. The authors considered a total of 370 linguistic features, and found that a subset of 35 was able to classify patients vs. controls with 82% accuracy.1 While an advance over previous studies, this is not yet useful for diagnostic purposes. Another limitation was the relatively short length of the speech samples.2

Using factor analysis, the researchers found that four dimensions of speech3 were most indicative of dementia:
  • Semantic impairmentusing overly simple words
  • Acoustic impairment e.g., speaking more slowly
  • Syntactic impairment  using less complex grammar
  • Information impairment not clearly identifying the main aspects of a picture they were told to describe

Public figures who give repeated interviews leave a searchable record of spontaneous speech that can be analyzed for changes over time. Presidential press conferences provide another rich source of data for linguistic analysis.

Berisha et al. (2015) examined transcripts from the press conferences given by Ronald Reagan (1981-1989) and George H.W. Bush (1989-1993). We know that President Reagan received a formal diagnosis of Alzheimer's disease in 1994, five years after leaving office. And as far as we know, the elder Bush is still cognitively intact for his age (he's 92 now).

The quantified linguistic features included:
  • Number of unique words
  • Non-specific nouns – e.g., thing, something, anything
  • Filler words – well, so, basically, actually, literally, um, ah
  • Low-imageability, high frequency verbs – e.g., get, give, go, have, do

Reagan showed a significant decline in the number of unique words over the course of his presidency, but Bush did not.

Likewise, Reagan showed a significant increase in the use of non-specific nouns and fillers, but Bush did not.

There are several caveats here. Reagan was 69 when he was elected, while Bush was 64. Reagan was president for eight years and Bush for only four years; yet Bush held over twice as many press conferences as Reagan. Nonetheless, the results are consistent with a decline in cognitive function (which is not uncommon when aging from 69 to 77). Can we can classify Reagan as having MCI on the basis of these results? I don't think so. We'd really need comparable data from a population of demographically matched elderly participants.

President Donald Trump

After his Feb. 16 press conference, the public debate over whether President Trump is mentally unbalanced has intensified. Much of the current and past discussion has centered on the possibility of Narcissistic Personality Disorder (NPD), as speculated in The Atlantic and Vanity Fair and The Guardian. Sure, Trump has many of these qualities (that predate his actual grandiose status as POTUS):
  1. Grandiosity with expectations of superior treatment from others
  2. Fixated on fantasies of power, success, intelligence, attractiveness, etc.
  3. Self-perception of being unique, superior and associated with high-status people and institutions
  4. Needing constant admiration from others
  5. Sense of entitlement to special treatment and to obedience from others
  6. Exploitative of others to achieve personal gain
  7. Unwilling to empathize with others' feelings, wishes, or needs
  8. Intensely envious of others and the belief that others are equally envious of them
  9. Pompous and arrogant demeanor
And we can call him narcissistic in the generic sense of the word. But do we need to diagnose him with a quasi-psychiatric disorder, as in this NY Times letter signed by 35 mental health professionals?4
Mr. Trump’s speech and actions demonstrate an inability to tolerate views different from his own, leading to rage reactions. His words and behavior suggest a profound inability to empathize. Individuals with these traits distort reality to suit their psychological state, attacking facts and those who convey them (journalists, scientists).

In a powerful leader, these attacks are likely to increase, as his personal myth of greatness appears to be confirmed. We believe that the grave emotional instability indicated by Mr. Trump’s speech and actions makes him incapable of serving safely as president.

Dr. Allen Frances, chair of the DSM-IV task force, has forcefully argued that Trump does not meet criteria for NPD, because he is not distressed by his behavior:
Mr. Trump causes severe distress rather than experiencing it and has been richly rewarded, rather than punished, for his grandiosity, self-absorption and lack of empathy. It is a stigmatizing insult to the mentally ill (who are mostly well behaved and well meaning) to be lumped with Mr. Trump (who is neither).

Discourse Analysis

Here I'll suggest a different approach: can we quantify age-related neurological change using spontaneous speech?

“You know what uranium is, right?  It's this thing called nuclear weapons and other things.  Like, lots of things are done with uranium, including some bad things.  Nobody talks about that.  I didn't do anything for Russia.  I've done nothing for Russia.”

This is the most egregious example in the one hour, 17 minute train wreck. But there are other signs. He used the construction “very, very” 20 times. The word “thing” (and its variants) was uttered 102 times.

Am I going to diagnose him with anything? Of course not. That's unethical! But I will say that since Mr. Trump has been a public figure for nearly 40 years, we can objectively analyze his spontaneous speech and quantify any changes over time. I must emphasize that there is no magical scale to use for classification or comparison purposes (at least not yet). We don't know what's normal age-related decline and what's pathological.

I suggest that the best corpus of spontaneous speech data is the collection of Trump interviews/conversations with David Letterman. I believe they're unscripted, and there are many of them on YouTube (I've linked to eight below). Letterman has aged too, so you might as well analyze his speech as well.


1 The authors performed...
...a 10-fold cross-validation procedure in which a unique 10% of the data (i.e., the ‘test set’) are used in each iteration for evaluation, and the remaining 90% (i.e., the ‘training set’) are used to select the most useful features (of the 370 available as described in “Features” above) and construct our models. The reported accuracy is an average across the 10 folds. In a given fold, data from any individual speaker can occur in the test set or the training set, but not both.
2 A show-stopping limitation is that the two groups were not matched for age or education. The mean age was 71.8 for AD vs. 65.2 for controls, and years of education 12.5 vs. 14.1 yrs.

3 See also Alzheimer’s Disease Markers Found in Speech Patterns (link via @aholdenj).

4 BTW, they're not supposed to diagnose non-patients, that's unethical.


Berisha V, Wang S, LaCross A, & Liss J (2015). Tracking discourse complexity preceding Alzheimer's disease diagnosis: a case study comparing the press conferences of Presidents Ronald Reagan and George Herbert Walker Bush. Journal of Alzheimer's Disease, 45 (3), 959-63 PMID: 25633673

Fraser, K., Meltzer, J., & Rudzicz, F. (2015). Linguistic Features Identify Alzheimer’s Disease in Narrative Speech. Journal of Alzheimer's Disease, 49 (2), 407-422 DOI: 10.3233/JAD-150520

Gauthier S, Reisberg B, Zaudig M, Petersen RC, Ritchie K, Broich K, Belleville S, Brodaty H, Bennett D, Chertkow H, Cummings JL. (2006). Mild cognitive impairment. The Lancet  367:1262-70.

Thomas, C., Keselj, V., Cercone, N., Rockwood, K., & Asp, E. (2005). Automatic detection and rating of dementia of Alzheimer type through lexical analysis of spontaneous speech. IEEE International Conference, 3, 1569-1574. doi: 10.1109/ICMA.2005.1626789

Donald Trump on the David Letterman Show

11-10-1988 Letterman Donald Trump

Donald Trump Interview on Letterman Show (1997)

Donald Trump Interview on David Letterman Show (1998)

Donald Trump on David Letterman Show (2008-08-08)

Donald Trump talks business and banks on David Letterman Show (2009-02-18)

Donald Trump on David Letterman Show (2010)

Donald Trump on David Letterman 17 October, 2013 Full Interview

Donald Trump on David Letterman January 8th 2015 Full Interview

You can find them all here.

other Trump

The Trump Archive - over 900 televised speeches, interviews, debates, and other news broadcasts related to President Donald Trump. See post at Internet Archive.

Donald Trump 1980 Interview (Brokaw)

Ronald Reagan videos

The President's News Conference - 1/29/81

The President's News Conference - 8/12/86

Iran/Contra Excerpt from 11/19/86

The President's News Conference - late Oct 1987

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At February 19, 2017 9:44 AM, Anonymous Bill McCown said...

You might also want to check out Gottschalk, L., Uliana, R., & Gilbert, R. "Presidential candidates and cognitive impairment: Measured behavior in campaign debates". Public Administration Review, 48 (1988) 613-619. The research uses the well- validate Gottschalk Gleser content scales to claim that Reagan was cognitively impaired as early as 1980.

The popular press reaction is available here

At February 19, 2017 9:45 AM, Anonymous Bill McCown said...

By the way, keep up your brilliant blog. It is the highlight of my day when I receive it.

At February 19, 2017 9:22 PM, Blogger The Neurocritic said...

Bill - Thanks so much for the kind words. I also appreciate the links to the Gottschalk et al. study. I listened to brief clips of Reagan's later press conferences, and he sounded downright erudite and well-informed compared to Trump's Feb. 16 performance.

At February 22, 2017 1:59 PM, Blogger Simfish InquilineKea said...

I'm curious if people with ADHD also tend to use more non-specific and filler words too. Even those who are extremely curious (or have the ADHD+high curiosity combo).

At February 22, 2017 7:02 PM, Blogger jamzo said...

you might check the work of jonathan fine (deceased), professor of linguistics at Bar-Ilan University, Israel

from his obituary

Jonathan’s research focussed on text analysis and in particular on the analysis of transcripts of doctor/patient interactions as an entry to the interface of language and psychiatry, publishing extensively and showing a keen awareness of the fuzzy boundaries between psychiatry and neurology. He gradually developed a theoretical model for the analysis of psychatrist/patient interaction, culminating in his book, Language in Psychiatry: A Handbook for Clinical Practice (Fine, J. 2006. London: Equinox).

At March 08, 2017 5:14 AM, Blogger Elka said...

Very interesting. And a great collection of useful links!

The idea of cognitive decline would be plausible if not for the fact that his symptoms were always there. They are indicative of narcissistic psychopathy and a few learning problems, likely related to NP. He's slower and less careful with respect of image management, but that -- growing carelessness -- is the progression of narcissistic psychopathy (or malignant narcissism).

Great blog, BTW.

At March 08, 2017 9:52 AM, Blogger The Neurocritic said...

Elka - You seem rather certain. "Malignant narcissism" is not a formal psychiatric disorder. Have you done a quantitative analysis of the language in his past public appearances to rule out the possibility of cognitive decline?

"Malignant narcissism is a hypothetical, experimental diagnostic category. Narcissistic personality disorder is found in the DSM, while malignant narcissism is not."

At April 01, 2017 3:19 PM, Anonymous Anonymous said...

The 82% accuracy ... was the 18% false positives or false negatives.

At April 02, 2017 11:33 AM, Anonymous Anonymous said...

"Frazier et al" -> "Fraser et al".

At April 02, 2017 5:13 PM, Blogger The Neurocritic said...

Anonymous of April 1 - they didn't say, but I could have missed it.

Anonymous of April 2 - Thanks for pointing out the typo, it's fixed now.

At April 03, 2017 7:05 AM, Blogger Mr. Holznagel said...

Great piece, thanks. But I'm a little confused: I thought at the end there you were going to "analyze his spontaneous speech and quantify any changes over time." Did I miss something? Or were you just inviting others to do it?

Not asking for diagnosis, of course, but the analysis would certainly be interesting.

At April 03, 2017 11:12 AM, Blogger The Neurocritic said...

Mr. Holznagel - Thanks for your comment. I was indeed inviting others to do it, since computational linguistics is not my area of expertise.

I suppose I could jump-start the enterprise by finding the best speech transcription software. Suggestions, anyone?

At April 03, 2017 8:16 PM, Blogger dustproduction said...

This blog post was given the Y\The David Pakman Show by the blogger and was recently discussed there:

At April 04, 2017 2:34 AM, Blogger The Neurocritic said...

Thanks, dustproduction. I became aware of the video on Sunday (April 2) after seeing a tweet from @HSchoenbacher. I hadn't heard of David Pakman before that. Overall, I appreciate the coverage and think he does a good job. But he overstates the case in his posts at Daily Kos and HuffPo. He begins,

"A blogger has written a post claiming to show evidence that President Trump has a cognitive decline, possibly early stage dementia or Alzheimer’s. It may sound like the unhinged rants of a conspiracy theorist, but the blog post is actually quite sane."

But I never actually claimed that Trump has dementia... Here's what did I say:

"Am I going to diagnose him with anything? Of course not. That's unethical!"

At April 19, 2017 2:12 AM, Anonymous Anonymous said...

Hi Nurocrotic
I think you could look into Mosaic Down's syndrome which gives simular results. I am not an expert it and it is a long shot but maybe worth talking to someone who is an expert.

From a phycologis point of view he shows extreme lack of self awareness which is why he can lie and tell a Jewish reporter that he is the most antisemitic person he knows without batting a eyelid, most people could not do this. Down's kids desperately what to fit in and will pick up underlying issues in there peer group and magnify back to them, when changing peer groups they can do 180 flips to fit in. Lots of Down's kids end up in secure mental homes because they are easy to manipulate and set up by gangs to do crimes.

DT was taught positive thinking, army trained and inherited 20 million and told he could run a business which may have help counter balance the typical defects of Down's syndrome.

Typical mental

Short attention span
Poor judgmentImpulsive behavior
Slow learning
Delayed language and speech development
Problems sleeping
Loveing attention seeking

Typical physical
Flat nasal Bridge
Small chin
Flaps to eyes
Upwards slanting eyes
Short neck
Pore mussel tone
Small hands
Flat hair
Small mouth

Donald Trump, Trump's Ali G and view from inside the white house?

Positive Down's

Early influence

If I am right DT has fooled everyone and is quite impressive.
PS this could be irresponsible to publish this to the press without more fact based research.



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