Marjorie Diehl’s hoarding was, for her lawyers in the Bob Thomas case, irrefutable evidence of her psychosis. The Erie County District Attorney’s Office was not nearly as sure. While the prosecution did nothing to dispute that Diehl was a hoarder, it would disagree with the underlying idea that she was mentally ill. The challenge was broad. The District Attorney’s Office questioned the efficacy of psychiatry in general—its ability to really figure out what is going on in the human mind. The defense’s ambassador for psychiatry was Robert L. Sadoff, who had diagnosed Diehl so many times. He explained at her trial that her hoarding was symptomatic of her manic-depressive illness and that it signaled a serious impairment of her judgment. Sadoff said psychiatric analysis had helped prove that Diehl was mentally unstable.
The prosecutor was not as convinced. An exchange between him and Sadoff captured their differences—and encapsulated the basic differing views about the effectiveness of psychiatry.
“There’s an awful lot we don’t know about human behavior; would that be a fair statement?” the prosecutor said to Sadoff at trial, in May 1988.
“That’s a fair statement,” Sadoff said.1
The prosecutor, John A. Bozza, an assistant district attorney, asked whether Diehl’s mental illness had a physiological component. He was questioning, in front of the jury, whether Sadoff’s diagnosis that Diehl suffered from manic-depression had any validity or was flawed because it was based more on observation than on pure science.
“When we talk about certain personality disorders, we are really talking about descriptions of behavior, are we not, at least to some degree?” Bozza said.
“To some degree, we are, yes,” Sadoff said.
“I mean, when we say that someone is manic depressive,” Bozza said, “we are really describing how they behave on occasion, is that not correct?”
“It is part of what we are doing, yes,” Sadoff said. “Not the whole thing.”
“Well,” Bozza said, “when you talked about Marjorie Diehl, you indicated that she had been diagnosed for a long period of time as manic depressive.”
“Yes.”
“I believe you indicated that she had conveyed in some way the symptoms of this illness?”
“Yes, she did,” Sadoff said.
“Now, those symptoms were behavioral in nature, were they not?” Bozza said.
“Yes, they were.”
“They were things that people could see?”
“Yes.”
“Things actually that people could hear, correct?”
“Yes.”
“Because they are verbal—verbalization behaviors, also, are they not?”
“Yes,” Sadoff said. “That’s correct. I would accept that.”
“Now,” Bozza said, “we don’t know in Marjorie’s case whether or not there is something physically wrong with her, do we?”
“You mean apart from the fact that she has manic-depressive illness?” Sadoff said.
“We don’t know what the physical features of manic-depressive illnesses are?” Bozza said.
“We have not uncovered all of the physiological components,” Sadoff said. “We have not.”
“You haven’t done any physiological tests on Marjorie, have you?”
“No, I have not,” Sadoff said.
“This wouldn’t be like uncovering a virus or a bacteria, would it?” Bozza said.
“It would not,” Sadoff said.
“Really,” Bozza said. “The impressions of this particular disorder are very subjective, are they not?”
“On whose part?” Sadoff said.
“On any psychiatrist’s part.”
“Well, if you have an agreement among a number of psychiatrists about the symptoms that we have observed over the years in patients who fit a certain category,” Sadoff said, “I think it becomes more objective than it does subjective.”2
Bozza asked Sadoff about Robert Callahan’s diagnosis, in 1976, twelve years earlier, that Diehl suffers from manic-depressive illness.
“Was that not a subjective interpretation?” Bozza said.
“On his part?” Sadoff said.
“Yes,” Bozza said.
“At that time,” Sadoff said, “that would be subjective for him with respect to her based on the agreed symptoms of thousands of other psychiatrists who have seen patients in the same way and subjectively arrived at the same conclusions.”
“I understand that,” Bozza said. “But there was no objective—a test available to him to determine that she had manic-depressive illness?”
“There’s no manic-depressive virus or bacteria,” Sadoff said.
“No depressive virus,” Bozza said.
“No.”
“Nothing to be tested?” Bozza said. “Physiologically to be tested to see if anyone has the disease?”
“At this stage of the game?” Sadoff said.
“At this stage of the game or in 1975,” Bozza said. (He misspoke here, meaning to say 1976, the year of Robert Callahan’s diagnosis.)
“Right,” Sadoff said.
“So in a sense, really, psychiatry,” Bozza said, “is it fair to say, is somewhat less scientific than some of the other branches of medicine?”
“If you put it in those terms,” Sadoff said, “yes, I would agree with you.”3
Bozza continued to discuss what he suggested were psychiatry’s deficiencies and advances. During the examination, Sadoff had a book with him on the witness stand. It was the most important volume in modern psychiatry: the third and latest edition of the Diagnostic and Statistical Manual of Mental Disorders, the bible that mental health professionals use as they diagnose those with mental illness.
Bozza said to Sadoff: “Psychiatry, Doctor, in all deference to you and all of the fine work that others like you I am sure do, has certain limitations, does it not, with regard to human behavior?”
“I would be the first to admit that,” Sadoff said.
“For example,’ Bozza said, “do we know, generally, why people behave the way we do?”
“In some cases, generally, we do,” Sadoff said.
“OK.”
“In some cases, specifically, we may not,” Sadoff said.
“So we are not at that point in psychiatry of being what you might say is an absolute scientific,” Bozza said.
“I would never claim that,” Sadoff said. “I don’t think psychiatry would be absolutely scientific. As long as we can be certain within a reasonable medical certainty, that would be enough for me.”
“We have improved,” Bozza said. “I think psychiatry has improved in the last twenty years.”
“I think we are coming to improve, a dynamic flow towards improvement,” Sadoff said.
“But there are lots of mysteries about human behavior?” Bozza said.
“That’s what makes life so interesting,” Sadoff said.4
The prosecution’s contention—that psychiatry is more subjective than objective, more a compiling of behaviors than a scientific enterprise—extended well before and beyond the trial of Marjorie Diehl, a troubled woman on trial for murder in a Rust Belt city in northwestern Pennsylvania in the 1980s. The tension between psychiatry and science has existed for thousands of years. But each generation has continued to find that the observation of behavior still remains, in many ways, the key pathway to trying to understand the psyche and the mental illness that can undermine it. As Sadoff said, those observations, made of countless patients over so many years, have created a catalog of dysfunction that has become a foundation for psychiatry and its quest for more scientific certitude. Central to that process, to that compilation of unusual human behavior, is the tome that was at Sadoff’s side on the witness stand: the Diagnostic and Statistical Manual of Mental Disorders, or the DSM. It is a book built on thousands of years of experience, observation, and theorizing over what constitutes mental illness.
Madness, for the ancient Greeks, was a matter of imbalance. The physician Hippocrates traced physical and mental ailments to the four humors: blood, yellow bile, black bile, and phlegm. The humors roughly corresponded with the four natural elements: air, fire, earth, and water. As each of the natural elements comprised the world’s physical surroundings, the four humors stood alone or combined to form human temperaments; the humors represented not just phlegm, blood, and bile, “but vital forces.”5 Phlegmatic, from phlegm, was related to water and connoted tolerance and reasonableness; melancholic, from black bile, was related to the earth and connoted depression and moodiness; choleric, from yellow bile, was related to fire and connoted passion or, in the extreme, aggression or mania; and sanguine, from blood, was related to the air and connoted liveliness and sociability. A proper balance of the humors produced a person who was of sound mind and body, whose mental and physical health thrived.
Hippocrates (460–377 BC E) linked mental illness to an imbalance of the humors, such as black bile, or melania chole, an overabundance of which he said created melancholy or depression. Though black bile is absent from nature—the gall bladder, in contrast, really does produce yellow bile—Hippocrates and his predecessors, such as Empedocles (495–430 BCE), insisted black bile was indeed genuine—a belief that recognized that depression and other forms of mental illness were seen as real in ancient society. As Andrew Solomon has noted in The Noonday Demon, his extensive history of depression, Hippocrates was innovative in connecting mental illness to the brain, even as he also linked mental illness to imbalances of the humors. “It is the brain which makes us mad or delirious, inspires us with dread and fear, whether by night or by day, brings sleeplessness, inopportune mistakes, aimless anxieties, absentmindedness, and acts that are contrary to habit,” Hippocrates wrote. “These things that we suffer all come from the brain when it is not healthy, but becomes abnormally hot, cold, moist, or dry.”6
Thousands of years of hindsight reveal humoral theory’s obvious flaws, such as a reliance on a bodily fluid—black bile—that does not exist. Yet the theory was remarkably prescient. Hippocrates and his contemporaries were correct in surmising that an imbalance of sorts leads to mental illness. In another example of his foresight, Hippocrates believed depression—and the excess of black bile—resulted from a mixture of “internal and external factors,” and that some mental trauma could be traced even to prenatal development.7 Homer, in the Iliad and the Odyssey (circa mid-eighth century BCE), has madness and depression doom even the strongest warriors, such as the Greek hero Ajax—another recognition of mental illness as intrinsic human trait. Socrates (circa 470–399 BCE) and Plato (circa 428–347 BCE) largely downplayed what Solomon calls Hippocrates’s “organic” approach to madness and depression; the two great thinkers considered mental illness more a psychic than a physical ailment, a type of woe that philosophers rather than physicians could better understand.8 Plato traced the origins of madness to childhood, among other sources, but, like Hippocrates, he grounded his overall understanding of mental illness to imbalances, whether due to internal or external turmoil.
Seventy years after the death of Hippocrates, Aristotle (384–322 BCE) shared this view, as he too accepted the idea that a proper mixture of the four humors produced equanimity in spirit and body. While he never discounted the ill effects of depression, melancholy, and madness, Aristotle helped originate a concept that persists to this day: that depression is often a characteristic—some might argue a requisite characteristic—of great artists. When Marjorie Diehl-Armstrong asserted that her bipolar disorder—a dysfunction rooted in depression—placed her among such eminences as Hemingway and Lincoln, she was espousing a belief that Aristotle had articulated three hundred years before the dawn of the Common Era: “All those who have attained excellence in philosophy, in poetry, in art, and in politics, even Socrates and Plato, had a melancholic habitus; indeed some suffered even from melancholic disease.”9 Aristotle, even more bluntly, also said, in a well-known maxim attributed to him, “No great mind has ever existed without a touch of madness.”
The Roman physician Galen, perhaps the greatest doctor after Hippocrates, expanded on humoral theory to explain depression. Galen (129–199 BCE) developed nine temperaments, including melancholy, which he believed to be an intrinsic part of the human psyche. Melancholy was a trait Galen said originated in the self, though he also attributed it to an excess of black bile. He prescribed opium, mandrake, and herbal remedies to relieve depression.10 Galen’s emphasis on the four humors, combined with his discoveries regarding the circulatory system, also contributed to the popularity of bloodletting, the highly invasive procedure meant to relieve physical and mental problems. Bloodletting and the use of purgatives and laxatives, common among the ancient Greeks and Romans, were thought to adjust the levels of blood and the other three humors, including the mysterious black bile, to recalibrate the body to a healthier and more balanced state. “Both mental and physical disorders were considered by Galen to be caused by an excess (plethora) of one of the four humors.”11 The famous quotation from the Roman poet Horace (65–8 BCE), “Est modus in rebus,” or “There is a mean in all things,” captured the Roman and Greek axiom that an even-tempered life is a productive life.
Humoral theory and bloodletting persisted well into the 1800s, as physicians and then psychiatrists continued to struggle to find the causes of physical diseases and mental infirmities. The conception of mental illness nonetheless had changed long before then. In the Middle Ages, believers considered mental illness the consequence of Lucifer’s constant struggle with God and Christ. By the Renaissance, as superstition ceded to science, physicians looked to direct observation to help explain mental illness, including depression, the saturnine disorder attributed, in astrological terms, to those born under the sign of Saturn. By the 1700s and the Enlightenment, “mad-doctors,” and “lunatic-doctors” concentrated on treating the mentally ill in private and public asylums in England. The most famous of these institutions, “Bedlam,” or the Bethlem Royal Hospital, operated as a hospital starting in 1329, and “bedlam” eventually became synonymous with mental disorders. Also during the 1700s in Britain, doctors who worked in insane asylums started classifying mental illness, creating a rudimentary system that psychiatrists expanded over the centuries. As autopsies became more common, physicians and others studied the bodies of the dead for empirical evidence of mental illness.
What became psychiatry originated in the 1800s, as physicians in France and Britain studied mental illness in medical schools. Those who treated the mentally ill became known as “alienists,” after the French physician Philippe Pinel published his treatise on l’alienation mental, or “mental alienation,”12 in 1801; it was translated into English five years later as A Treatise on Insanity. “Of all the afflictions to which most humans are subject,” Pinel wrote, “the loss of reason is at once the most calamitous and interesting.”13 Physicians who specialized in mental illness became known as psychiatrists by the 1840s, “the pivotal decade in the history of the profession.”14 Later, in the 1880s, psychiatry further took hold in Europe, as Robert Koch, in Germany, and Louis Pasteur, in France, discovered germ theory as the cause of physical diseases. The breakthroughs in medicine gave alienists reason to hope: “If scientific understanding and cure were possible for the suffering of the body, then why not for the suffering of the mind?”15
The recognition of psychiatry as a separate branch of medicine spread to the United States, whose major contribution to the field had been the publication, in 1812, of Medical Inquiries and Observations upon the Diseases of the Mind, by Benjamin Rush, a Philadelphia physician who studied insanity at the Pennsylvania Hospital. Rush served as surgeon general of the Continental Army and signed the Declaration of Independence as a founding father of the United States. He is also known as the founder of American psychiatry. He was an insightful physician who, like his peers, still practiced bloodletting, just as Hippocrates and Galen had done. He also advocated purging the body through the use of mercurous chloride, or calomel, popularly known as mercury.
Many of Rush’s entries in Medical Inquiries and Observations upon the Diseases of the Mind are speculation; Rush observed that “Single persons are more predisposed to madness than married people,”16 and that masturbation, or onanism, can cause madness, particularly in young men.17 But Rush also observed, with more of a foundation, the relationship between madness and genius. Echoing Aristotle, he wrote:
Persons of strong and active minds are said to be more predisposed to madness than persons of an opposite character. [The poet John] Dryden has given a currency to this opinion, by asserting “great wit and madness to be nearly allied.” Where this is the case, it is the effect of an active imagination and strong passions predominating over the understanding. But the cases are few, in which a vigorous intellect, elevated above the dominion of the subordinate faculties of the mind, has been perverted by madness from mental causes. Where the disease has been induced by intense study, I think I have observed it most frequently to occur in persons of weak understandings, who were incapable of comprehending the subjects of their studies. Certain occupations predispose to madness more than others. Pinel says, poets, painters, sculptors and musicians, are most subject to it, and that he never knew an instance of it in a chemist, a naturalist, a mathematician, or a natural philosopher.18
Rush died in 1813 in Philadelphia. Thirty-one years later, also in Philadelphia, thirteen superintendents of mental asylums met to form the Association of Medical Superintendents of American Institutions for the Insane, the first organization of its kind in the United States. In 1892, it became the American Medico-Psychological Association, and it was renamed the American Psychiatric Association (APA) in 1921. The APA (whose seal features a profile of Rush) soon would lead the push to classify mental illness, as Rush had attempted to do. The association’s work manifested itself in the most important psychiatric textbook ever produced in the United States—the DSM, whose publisher is the APA. The DSM, by detailing categories and subcategories of hundreds of mental abnormalities, provided psychiatrists, at last, with their own catalog, their own dictionary of disorder.19
The DSM affected Marjorie Diehl-Armstrong’s life more than perhaps any other book. The psychologists and psychiatrists who examined her used it to put a name to her mental troubles in her many criminal cases. And, relying on scientific advances, particularly those in the late twentieth century, the professionals who examined Diehl-Armstrong were able to look to a growing body of biological and genetic studies to try to determine the origins of her mental illness. Bipolar disorder and schizophrenia, for example, are now believed to have genetic, biological, and environmental causes, though the interplay between the three, as well as the details of the genetic damage, remains elusive. Despite the encouraging scientific work, “the madness that haunts us still evades our grasp,” the psychologist Leonard George has written. “Millions around the world succumb, and few recover fully.”20
Defining a disorder differs from being able to fully explain it. Debate continues over whether the DSM, for all its heft (the current edition, the DSM-5, published in 2013, is 947 pages and lists 157 disorders), has truly delivered psychiatry from “the approach that was at once its salvation and its scourge: a classification of diseases based on description and observation but with no account of what caused them.”21 The DSM greatly helps professionals identify and label mental illness, and it represents the authoritative text for insurance coverage. Yet the DSM offers no unifying explanation for why mental illness occurs—a reflection of the persistent and perhaps eternal difficulty of unlocking the mysteries of the human mind. Marjorie Diehl-Armstrong’s multiple psychiatric diagnoses illustrate the puzzle: though professionals, to varying degrees, have been able to specify what mental diseases afflicted her, and to prescribe powerful drugs to address those diseases, they have never been able to pinpoint the sources of her instability—biological, genetic, or otherwise. Many clues and possibilities exist for her behavior. But in her case, as in so many others, the what comes with solid answers. The why does not.
Today’s scientific research has made a breakthrough increasingly possible. Psychoanalysis, which Sigmund Freud pioneered in the 1890s, has fallen short—its effectiveness is now highly disputed—and that failure helped to turn psychiatry even more toward an empiricism that focuses both on the mental and the biological. In this regard, the humoral theory of Hippocrates and Galen has survived, in a more sophisticated fashion, as psychiatrists seek a “holistic” approach to examining mental illness: “We suffer not just as ill bodies or as ill minds but as ill persons.”22
The naming process—the province of the DSM, with its pages and pages of defining the what in pursuit of the why—remains critical nonetheless. “Give a name to suffering, perhaps the most immediate reminder of our insignificance and powerlessness, and suddenly it bears the trace of the human,” psychotherapist Gary Greenberg has written in his history of the development of the DSM. “It becomes part of our story. It is redeemed.”23 For better or for worse, the DSM continues to stand as psychiatry’s bible, its definitions meant to illuminate cases such as Marjorie Diehl-Armstrong’s.
The first edition of the Diagnostic and Statistical Manual of Mental Disorders, which the APA published in 1952, was rooted in science. Its forerunner was a textbook by German psychiatrist Emil Kraepelin, often considered the father of modern psychiatry because of his emphasis on scientific analysis; his belief that mental illness had biological and genetic origins; and his insistence on rigorous classification of mental illness. Kraepelin, who spent some of his formative professional years examining patients in an Estonian asylum, advocated for psychiatry as a branch of medicine, and his major works sought to classify mental illness as a medical doctor would classify physical diseases. In 1883, he published his Compendium der Psychiatrie: Zum Gebrauche für Studirende und Aertze (Compendium of Psychiatry: For the Use of Students and Physicians), which became Ein Lehrbuch der Psychiatrie (A Textbook: Foundations of Psychiatry and Neuroscience).
The sixth edition of the Psychiatrie, published in 1899, was among Kraepelin’s most influential contributions. It “reordered the psychiatric cosmos for the next century by grouping most of the insanities into two large categories, dementia praecox (or premature dementia) and manic-depressive illness.”24 Dementia praecox, later to become known as schizophrenia (from the Greek “to split” and “the mind”), led to severe mental deterioration, including delusions and hallucinations, that Kraepelin found to be all but permanently debilitating. Manic-depressive illness, which would come to encompass bipolar disorder, was “the non-deteriorating and sometimes remitting form of serious psychotic disturbance,”25 whose major symptoms included swings between severe depression and mania. Kraepelin diagnosed both dementia praecox and manic-depressive illness as brain disorders. Before his analysis, those with mental illness had, for the previous four hundred years, been grouped under one category: insane, from the Latin insanus, meaning unsound mind.26
Kraepelin’s clear-eyed taxonomy of mental illness is now considered a bedrock of psychiatry. It initially waned in popularity for a time, as Freud’s psychoanalysis captivated the profession. But the American Psychiatric Association and its predecessors looked to Kraepelin, rather than Freud, as they formulated their own classification system for mental illness. As Gary Greenberg has written, one of the first challenges for such a classification system, known as a psychiatric nosology, came in 1917, in an address that Thomas W. Salmon, a prominent psychiatrist with the United States Public Health Service, delivered to the American Medico-Psychological Association in Buffalo, New York. “The present classification of mental disease is chaotic,” Salmon said. “This condition of affairs discredits the science of psychiatry and reflects unfavorably on our association.”27 He called for “a classification of twenty different mental diseases ‘that would meet the scientific demands of the day.’”28
The impetus for Salmon’s classification system came, in part, from the United States Census Bureau, which in 1840 started to count individuals who were “insane.” The bureau, however, lacked any categories for mental illness. Taking the lead from Salmon, who took his lead from Kraepelin, the American Medico-Psychological Association in 1918 published the Statistical Manual for the Use of Institutions for the Insane. The association collaborated on the forty-one page Statistical Manual with the Bureau of Statistics of the National Committee for Mental Hygiene, in New York City; Salmon, who helped write the Statistical Manual, was the committee’s medical director.
The Statistical Manual was a success, in that the Census Bureau adopted its system to help classify the mentally ill. The Statistical Manual took an unvarnished approach—it was designed, the authors wrote, as a handbook for mental institutions as they used forms to compile their annual statistics. The handbook’s definitions were meant to help professionals catalog mental illnesses rather than diagnose patients. “The manual and duplicate forms will be furnished free to all cooperating institutions,” the authors wrote, “and it is earnestly hoped that they will generally be adopted, so that a national system of statistics of mental disease may become an actuality.”29
Though it was a survey rather than a diagnostic tool, the Statistical Manual offered insight into the understanding of mental illness at that time. It listed twenty-two disorders, each with its own set of definitions and explanatory notes. One disorder, psychosis with Huntington’s chorea, or a neurological disease, was described as having symptoms that include “mental inertia and an emotional change, either apathy or silliness or a depressive irritable reaction with a tendency to passionate outbursts.”30 Its cause: “hereditary in nature.”31 Descriptions of other disorders featured no causes; the disorders seemed more like manifestations of other problems. The disorder known as involution melancholia, for example, included “the slowly developing depressions of middle life and later years which come on with worry, insomnia, uneasiness, anxiety and agitation, showing usually the unreality and sensory complex, but little or no difficulty in thinking. The tendency is for the course to be a prolonged one.”32
Among the longest descriptions were those for the two disorders that Kraepelin had studied so intensely: dementia praecox (“the term ‘schizophrenia’ is now used by many writers,” the Statistical Manual said33), and manic-depressive psychosis. Of the two, the definition for dementia praecox was less precise, though the authors said it could include a number of characteristics, such as “a seclusive type of personality,” and “a gradual blunting of the emotions, indifference or silliness with serious defects of judgment and often hypochondriacal complaints, suspicions or ideas of reference.”34 In describing manic-depressive psychosis, the Statistical Manual was more detailed. It set forth an analysis that would generally fit those to come:
This group comprises the essentially affective benign psychoses, mental disorders which fundamentally are marked by emotional oscillations and a tendency to recurrence. Various psychotic trends, delusions, illusions and hallucinations, clouded states, stupor, etc., may be added. To be distinguished are:
The manic reaction with its feeling of well-being (or irascibility), flight of ideas or over- activity.
The depressive reaction with its feeling of mental and physical insufficiency, a despondent, sad or hopeless mood and in severe depressions, retardation and inhibition; in some cases the mood is one of uneasiness and anxiety, accompanied by restlessness.
The mixed reaction, a combination of manic and depressive symptoms.35
World War II increased the need for psychiatric tools that were more sophisticated and comprehensive than the Statistical Manual. Thousands of soldiers returned home with mental and physical trauma; treating them required more categories for disorders and even more uniformity of classification. The New York Academy of Medicine had called for such standardization as early as 1927, and six years later, the American Medical Association, with the help of the APA, published A Standard Classified Nomenclature of Disease. It listed twenty-four disorders, and like the Statistical Manual, was indebted to Kraepelin and his scientific approach to mental illness.36
During World War II, however, standardization for the evaluation and classification of mental disorders still was largely absent. The U.S. Army and Navy had their guides, and the United States Veterans Administration had its own, in addition to A Standard Classified Nomenclature of Disease as well as the Statistical Manual. Psychiatrists found the Statistical Manual particularly lacking as they tried to understand the mental problems of so many returning soldiers and their other patients: “Its basic terms didn’t even come close to describing what psychiatrists were seeing in the clinic.”37 Led by George Raines, chairman of its committee on nomenclature, the APA set aside plans for revamping the Statistical Manual and instead created an entirely new publication: the first edition of the Diagnostic and Statistical Manual of Mental Disorders, which came out in 1952 and ran to 132 pages.
The federal government by then had fully taken control of compiling statistics for mental illness; such work was a task of the National Institute of Mental Health, founded in 1949. The APA and its psychiatrists were able to focus more on diagnoses; the APA tailored the first Diagnostic and Statistical Manual for that endeavor. It listed and defined 106 disorders; psychiatrists diagnosed patients to determine which definition fit. According to the APA: The DSM-I “was the first official manual of mental disorders to focus on clinical utility for classification. Definitions were relatively simple and consisted of brief prototypical descriptions.”38 The DSM-I became the universally accepted textbook of psychiatry, a book that set forth taxonomy of mental disorders and their treatment.
The DSM-I and its successors would include the broad categories of mental disorders that would apply, in varying degrees, to the case of Marjorie Diehl-Armstrong. The DSM listed psychoses, or severe mental disorders in which the patient is often out of touch with reality and suffers from delusions and hallucinations; neuroses, or less severe disorders in which anxiety is a prevalent symptom; and personality disorders, in which the patient acts in socially unacceptable and destructive ways. The specific disorders in the broad categories came under steady review, as the APA revised the DSM to reflect changes in society and advances in the understanding of mental illness. The DSM-II, published in 1968, listed 182 disorders.
It differed prominently from the DSM-I in that it eliminated the possibility that mental disorders could be a reaction to something, rather than illnesses that simply existed. As one critic has written, this one change was momentous, and made diagnosing mental illness less grounded in science than under the DSM-I by “severing cause from effect” and abandoning “the rigorous proofs of the scientific method.”39 From now on, according to this analysis, “in the absence of cause and effect, a mental illness would be anything the psychiatric profession chose to call a mental illness.”40 Among the other more important developments in the DSM-II was that it “encouraged users to record multiple psychiatric diagnoses (listed in order of importance) and associated physical conditions.”41 Twelve years later, such an emphasis on multiple layers of diagnoses would become a hallmark of the DSM-III, published in 1980.
The third edition was, at the time, the longest DSM (494 pages) and the most comprehensive (265 disorders). The definitions were more detailed. The DSM-III, according to the APA, “was the first effort by a medical specialty to provide a comprehensive and detailed diagnostic manual in which all disorders were defined by specific criteria so that the methods for making a psychiatric diagnosis were relatively clear.”42 What also stood out was the DSM-III’s expansion of the multilayered approach of the DSM-II. The DSM-III introduced “a multiaxial classification system” with five axes, one or more of which could be part of the diagnosis of a mental illness.43 The five, according to the APA, are: “I. Clinical syndromes and ‘conditions not attributable to a mental disorder that are the focus of attention and treatment’; II. Personality disorders and specific developmental disorders; III. Physical disorders; IV. Severity of psychosocial stressors; and V. Highest levels of adaptive functioning in the last year.”44 The multiaxial system, though later phased out for a single axis system, would help in the evaluations of Marjorie Diehl-Armstrong.
Each edition of the DSM reflected changes in society. Each edition added or deleted disorders. One change that brought the most attention was the APA’s elimination of homosexuality as a psychiatric disorder in 1973; the DSM-III, published three years later, no longer included it, though other types of disorders related to homosexuality had entries.45 “Sexual orientation disturbance” first replaced “homosexuality”; the APA revised the entry to “ego-dystonic homosexuality” before dropping references to homosexuality in 1987.46 The change, though slow, showed how the DSM, at its best, could be a fluid and progressive document.
At its worst, the DSM could still be subjective, a textbook filled with speculation rather than empirical evidence. The imprecision exists because of a problem that goes back to the ancients: the mind, particularly a troubled mind, is a mystery. “This is not cardiology or nephrology, where the basic diseases are well known,” one critic of the DSM, psychiatric historian Edward Shorter, has said. “In psychiatry no one knows the causes of anything, so classification can be driven by all sorts of factors—political, social and financial. What you have in the end is this process of sorting the deck of symptoms into syndromes, and the outcome all depends on how the cards fall.”47
Similar criticism greeted the development of the DSM-IV, published in 1994 with 297 disorders and 886 pages. One satirist captured the trepidation that had come to accompany each new edition of the DSM.
The DSM-IV is on its way! The Diagnostic and Statistic Manual of Mental Disorders, a comprehensive index of mental illnesses published by the American Psychiatric Association, will creep into the hearts and offices of mental health professionals next month when its fourth edition rolls off the presses.
What is found therein? The special 27-member task force responsible for researching and writing the DSM-IV has retained many of the listings from the index’s revised third edition, including notoriously tragic mental illnesses like Caffeine Intoxication (“more than two to three cups of brewed coffee” leading to symptoms like “restlessness,” “nervousness,” “excitement,” “insomnia” and the like) and Nicotine Withdrawal (“Abrupt cessation of nicotine use” followed by “dysphoric or depressed mood,” “insomnia,” “anxiety,” “restlessness” and the like). Among the new mental illnesses that the index suggests are rampaging the country is Inhalant-Induced Anxiety Disorder.48
Another writer characterized the DSM-IV as psychiatrists’ latest futile but lucrative attempt to pigeonhole human behavior to such a degree that everyone could be considered to suffer from some type of mental illness. “Here, on a staggering scale,” argued this commentator, “are gathered together all the known disturbances of humankind, the illnesses of the mind and spirit that cry out for the therapeutic touch of—are you ready for this?—the very people who wrote the book.”49
The APA’s own sober analysis characterized the DSM-IV as fulfilling a need “that has been clear throughout the history of medicine”: a need to classify and categorize mental disorders.50 “The utility and credibility of DSM-IV require that it focus on clinical, research, and educational purposes and be supported by an extensive empirical foundation,” its editors wrote. “Our highest priority has been to provide a helpful guide to clinical practice.”51 The editors of the DSM-5, published nineteen years later, addressed their critics more directly: “Why be concerned with DSM?” they wrote. “Why indeed. Simply put, DSM provides a common language to those among us who conduct research on and/or treat individuals with psychiatric disorders. Perhaps one of its most important missions is to help insure consistency in the definition of mental disorders for clinicians in the United States and elsewhere.”52
More than a decade before the release of the DSM-5, the APA in 2000 published a text revision of the DSM-IV, called the DSM-IV-TR. The revision corrected errors and added new information, but left intact the diagnostic criteria of the DSM-IV. The findings in the DSM-IV are what professionals would use to diagnose Marjorie Diehl-Armstrong following her indictment in the Pizza Bomber case in 2007. With all its faults and all its advantages, the DSM-IV would be the one guidebook that the psychiatrists, and the courts, would have to rely on to examine Diehl-Armstrong’s mental instability. The DSM-IV would help classify her imbalance—even if, as Robert Sadoff intimated on the witness stand, it would never be able to fully explain why that imbalance had come to plague her as she was brought to court, again and again, for the deaths of men, starting with the killing of Bob Thomas.