They were linked from the beginning, from Hippocrates on: black bile and yellow bile, depression and mania. An overabundance of black bile led to melancholy or depression—the mental imbalance that, starting in antiquity, dominated all others. But too much yellow bile created a mental imbalance that Hippocrates, Galen, and their contemporaries considered serious and debilitating in its own right—mania, another form of madness. The two humors, though separate, often seemed to combine. Astute observers noted how depression often followed mania—derived from the Greek menos, for spirit—and how mania often followed depression, in varying degrees of intensity. “Medical conceptions of mania and depression are as old as secular medicine itself,” according to one comprehensive history of the condition. “From ancient times to the present, an extraordinary consistency characterizes descriptions of these conditions. Few maladies in medical history have been represented with such unvarying language.”1 The two complex maladies—depression and mania—could remain separate but also become fused in a distinct disease: manic-depressive illness, now commonly known as bipolar disorder, which, along with schizophrenia, represents one of the earliest known mental illnesses.
About 1.9 million Americans are known to suffer a form of manic-depressive illness, or about 2.6 percent of the adult population in the United States; the average age of onset is twenty-five years old.2 The prevalence is higher among those in prison, or those who have engaged in criminal behavior—such as Marjorie Diehl-Armstrong.3 Though she often displayed behavior that trended much more toward the manic than the depressive, the cyclical nature of her illness was apparent, especially to her. She diagnosed herself as manic depressive.
“I am a functioning bipolar,” Diehl-Armstrong once said. “If you can get along in a state prison with the type of deviates they have here—if you can get along, you are maintaining your mood pretty well.”4 Several months later, also from prison, she said: “I am also a unique bipolar person. I am a rapid cycler with mixed states. They wanted to put me in a textbook. You can be manic and depressive at the same time. I don’t like any of these labels. I am a unique person.”5
Diehl-Armstrong, as frequently is the case, is correct in her analysis. She was a unique person, in the sense that manic-depressive illness affects each person differently. It is a disease that melds with each person’s personality traits and magnifies them. Manic-depressive illness exhibits general symptoms that are consistent from person to person. But, on an individual level:
Manic-depression is an equal opportunity disease: It may affect those whose underlying personality is shy or outgoing, altruistic or narcissistic, responsible or spoiled, kind or cruel. The symptoms of mania and depression interdigitate with the person’s underlying personality to create a unique medley that differs not only from person to person but even from day to day within a single person as the disease process evolves. It is this interaction of disease symptoms with underlying personality that makes manic-depressive illness so difficult to comprehend for most people.6
Hippocrates and Aristotle made the connection between depression and mania, and so did the Greek physician Soranus of Ephesus, who practiced around 100 CE. His works included a biography of Hippocrates as well as treatises that were ahead of their time on childbirth and mental disorders. Soranus did not consider depression and mania the extreme poles of the same disease—a concept that would take more than a thousand years to develop—though he related how “melancholia and mania were two distinct diseases but with similar . . . symptoms and requiring similar treatments.”7 Soranus found that those with melancholy, though often depressed, also often displayed mania, particularly as the depression waned. Among the symptoms he observed were: “mental anguish and distress, dejection, silence and animosity towards members of the household, sometimes a desire to live and at other times a longing for death, suspicion when a plot is being hatched against them, weeping without reason, meaningless muttering and again occasional joviality.”8 The use of again suggests that mania frequently alternated with depression.
Aretaeus of Cappadocia, who practiced in the second century CE, is another ancient Greek physician who recognized the relationship between depression and mania. He traced the origin of mania to the heart, and considered mania and depression as corresponding ailments, with the one the inversion of the other. In yet another example of the farsightedness of the ancient physicians, Aretaeus, writing around 150 CE, explained the connection between mania and depression:
In my opinion melancholia is without any doubt the beginning and even part of the disorder called mania. The melancholic cases tend towards depression and anxiety only . . . if, however, respite from this condition of anxiety occurs, gaiety and hilarity in the majority of cases follows, and this finally ends in mania. Summer and fall are the periods of the year most favorable for the production of this disorder, but it may occur in spring.9
The history of manic-depressive illness and bipolar disorder follows the pattern of the history of mental illness in general. Their insightful commentaries aside, ancient physicians like Aretaeus subscribed to humoral theory to explain manic-depression, and such thinking persisted through the Middle Ages until the Renaissance. As mental illness then became the province of asylums rather than medical hospitals, understanding of manic-depressive illness and other disorders deepened. The French psychiatrist Philippe Pinel, in his groundbreaking Treatise on Insanity, translated into English in 1806, described a person who suffers from manic-depressive illness as one who “gives himself up to all the extravagances of maniacal fury, or sinks inexpressibly miserable into the lowest depths of despondence and melancholy.”10
Other French psychiatrists contributed heavily to the understanding of the disease that featured depression and mania. In 1854, Jean-Pierre Falret described manic-depressive illness as a circular disorder, or la folie circulaire; that same year, Jules Baillarger called the disorder la folie á double forme, which echoed Falret’s findings and emphasized how two mental states made up a singular disease.11 A German psychiatrist, Emanuel Ernst Mendel, in 1881 found that mania had varying levels, including hypomania, or a milder stage of mania. And another German psychiatrist, Karl Kahlbaum, described, in 1882, cyclothemia, or a cycling of “episodes of both depression and excitement.”12 The observations and descriptions gradually brought psychiatrists to a fuller understanding of a disorder that, though not yet named manic-depressive illness, was by now very much a hyphenated mental illness, a disease with two main elements.
The father of modern psychiatry, Emil Kraepelin, finally joined the two—depression and mania—and named the newly diagnosed disease manic-depressive insanity in the 1896 edition, the fifth, of his Compendium der Psychiatrie, first published in 1883. Kraepelin defined the disorder as encompassing a wide range of behavior, but with mania on one pole and depression on the other, with mixtures of each in between, which gave manic-depressive disease its cyclical nature. “Manic-depressive insanity,” Kraepelin wrote, “includes on the one hand the whole domain of the so-called periodic and circular insanity, on the other hand simple mania, [and] the greater part of the morbid states called melancholia.”13
Kraepelin’s diagnosis of manic-depressive illness, a disease of doubles, is intertwined with his other major achievement: his diagnosis of dementia praecox, or schizophrenia. In one analysis, Kraepelin—as described in the 1899 edition of his textbook—defined manic-depressive illness, which he did not believe to be permanently debilitating, as a counter to schizophrenia, which he believed was permanently debilitating. The one could not exist without the other, just as manic-depressive illness could not exist without episodes of mania and depression: “Manic-depressive insanity had its place in the 1899 edition of the textbook as a foil to dementia praecox rather than a condition developed in its own right.”14 Whatever his reason for deciding upon manic-depressive insanity as a separate and distinct illness, Kraepelin’s description of the disease still largely holds true today.
The characteristics of manic-depressive illness have remained consistent as well: emotional highs coupled with emotional lows, with so many variants, or mixed states, bridging the two. Mania is best described as an extreme sense of euphoria; as Kraepelin wrote, “mood is mostly exalted in mania, and in lively excitement it has the peculiar coloring of unrestrained merriment.”15 Such a feeling—a sense of heightened merriment—best fits the category of hypomania, while full-blown mania is more severe in conveying a sense of extreme awareness. In most cases of mania, no matter what the degree, the symptoms are an overly happy mood; distracted thoughts; grandiosity and an overblown sense of self-esteem; and increased activity, including increased sexual activity, excessive writing, excessive talking—the phenomenon known as “pressured speech”—and risky and bizarre behavior.16 All these symptoms point to a mind that is all but out of control in its exuberance, a mind in which all thoughts are accelerated, no matter their importance.
As his or her mind races at full tilt, a person who suffers from manic-depressive illness or bipolar disorder often displays one of its signature traits: a flight of ideas, a rapid-fire recitation of all sorts of thoughts and beliefs, often delivered in a tone and manner that convey the speaker’s belief that he or she is more brilliant than anyone. As Kraepelin wrote of a manic-depressive person caught in a flight of ideas: “In states of excitement they are not able to follow systematically a definite train of thought, but they continually jump from one series of ideas to a wholly different one and then let this one drop again immediately.”17 When a manic-depressive relates his or her flight of ideas through pressured speech, the effect on the listener can be punishing, as if caught in a barrage of words and phrases, especially when delivered in a menacing tone. The excessive writings of a manic-depressive person can produce a similar effect on the recipient: words after handwritten words fill both sides of the page, crowd into the margins, and more often than not, spread onto the envelope. No open space is left free of the writer’s ideas, just as no molecule of air is left free of a manic-depressive person’s pressured speech. As two psychiatrists have written in a contemporary guide to understanding manic-depressive disorder, “listening to the speech of a person in extreme mania is an unforgettable experience.”18 In terms of excessive writing, the psychiatrists have found, referring to the trademark designs and scripts on a manic-depressive person’s envelopes, “Mania is the only psychiatric diagnosis that can be determined with 99 percent certainty without even opening one’s correspondence.”19
The depressive states in bipolar disorder or manic-depressive illness mirror the manic states, in reverse. The person’s thoughts and activities slow; mood plummets; and self-esteem decays into self-hating behavior. “The bipolar depressive states, in sharp contrast to the manias, are usually characterized by a slowing or decrease in almost all aspects of emotion and behavior: rate of thought and speech, energy, sexuality, and the ability to experience pleasure.”20 The characteristics of bipolar depressive states emulate the characteristics of clinical depression. In either case, the person is virtually inconsolable, though the depression of the person suffering from manic-depressive disease can seem even more severe because it is coupled with mania: The depression can seem deeper because extreme highs so often precede it. Wrote Kraepelin of depression: “Mood is sometimes dominated by a profound inward dejection and gloomy hopelessness, sometimes more by indefinite anxiety and restlessness. The patient’s heart is heavy, nothing can permanently rouse his interest, nothing gives him pleasure.”21 In the darkest cases, a manic-depressive person caught in a depressive state descends into a kind of emotional stupor.
A person who suffers from bipolar disorder can reside in another troubled emotional zone, one between mania and depression: the zone of mixed states, in which a person exhibits traits consistent with mania and depression at once. Some studies have suggested some 13 percent of those with bipolar disorder suffer from mixed states, while others believe mixed states are present in virtually all cases of bipolar disorder.22 Kraepelin, again, captured the essence of two components of mixed states, describing them as “excited depression” and “anxious mania,” which correspond, respectively, with states of agitated depression and dysphoric mania.23 In mixed states, a person is neither happy nor sad, neither euphoric nor gloomy, but a combination of both. The presence of mixed states can also signal severe bipolar disorder, and, “as a rule, individuals with mixed states take longer to recover, relapse more quickly, are more resistant to medications, and are more likely to commit suicide.”24
Marjorie Diehl-Armstrong understood all the gradations of bipolar disorder, including its mood swings and it cyclical nature. She experienced the illness time and time again, and described how she felt to numerous psychiatrists and psychologists. David B. Paul, who met with her sixty-four times, related how she described her experience with bipolar disorder to him. Paul wrote in a report in August 1985:
She claims her pattern is one of rapidly alternating moods and claims that she does have manic episodes also. Mania is a state which she described as being like Christmas, a wonderful feeling in which she was euphoric and feared nothing. She felt like she had been given a special chemistry, which is as good a way to characterize the illness as any. However, it was accompanied at times by anxiety and, when she is manic, she neither sleeps nor eats.
Sometimes, she will engage in high level productivity. Sometimes, she is too disorganized for this, with thoughts coming at her from all directions, to which she responds by crying continuously. However, she indicated that, most of the time, she has severe depressions in which she was totally dysfunctional, had a variable appetite and had a hypersomnic sleep pattern in which she could sleep all day and night.
She indicated knowledge that her judgment was impaired when manic and related this to delusions of omnipotence and impulsivity. When she is depressed, she is totally occupied with her internal feelings.
Depression pulls her in one direction, and mania in another, and she has times in which she yearns for a sort of a middle road of emotional stability.25
The Diagnostic and Statistical Manual of Mental Disorders—the American Psychiatric Association’s handbook for psychiatrists and psychologists—changed the name of manic-depressive order to bipolar disorder in 1980, with the publication of the DSM III. Though less descriptive than manic-depressive disorder, the term bipolar disorder still conveys the sense of a disease of extremes, and the DSM-5 continues to recognize that bipolar disorder is far from a singular disease. The DSM-5 breaks down the malady into sections and subsections, each describing symptoms that swing between mania and depression and mix the two. Critical to the DSM-5’s analysis is the frequency and intensity of the mania as well as the prevalence of the periods of depression. Also critical for the writers of the DSM-5 is where bipolar disorder is covered in the book: “between the chapters on schizophrenia spectrum and other psychotic disorders and depressive disorders.”26 Bipolar disorder, according to the DSM-5, represents a bridge between schizophrenia on the one end and other psychotic disorders on the other. It is a pivotal disease.
The DSM-5 offers a number of diagnoses for what had been known as manic-depressive illness: bipolar I disorder, bipolar II disorder, cyclothymic disorder, bipolar disorder related to substance abuse and medications, and unspecified bipolar and related disorder. Bipolar I disorder, according to the DSM-5, most resembles the “classic” description of manic-depressive disorder from the nineteenth century, though a diagnosis of bipolar I requires neither psychosis nor a lifetime experience of a “major depressive episode.”27 But the DSM-5 acknowledges that major depression is a symptom in most cases of bipolar I disorder. Bipolar II disorder, according to the DSM-5, requires “the lifetime experience of at least one episode of major depression and at least one hypomanic episode”; the DSM-5 emphasizes that bipolar II disorder is not necessarily a milder form of bipolar I disorder, particularly because those who suffer from bipolar II disorder also typically experience “serious impairment in work and social functioning.”28 The National Institute of Mental Health defines bipolar I disorder as featuring “manic episodes” that last at least a week, with subsequent depressive episodes of at least two weeks. Bipolar II disorder is less severe, “defined by a pattern of depressive episodes and hypomanic episodes, but not the full-blown manic episodes” as with bipolar I disorder.29
Cyclothymic disorder, the third specific form of bipolar disorder, is a broad category, meant for those who experience mania and depression, but to a lesser degree than those who suffer from bipolar I disorder or bipolar II disorder. According to the DSM-5, “The diagnosis of cyclothymic disorder is given to adults who experience at least 2 years . . . of both hypomanic and depressive periods without ever fulfilling the criteria for an episode of mania, hypomania, or major depression.”30 Also broad is the final, and least specific, category for bipolar disorder, according to the DSM-5: other specified and unspecified bipolar and related disorders, which feature symptoms of bipolar disorder that differ from those of bipolar I and bipolar II disorders and cyclothymic disorder.31
Cyclothymic disorder and the other classifications for bipolar disorder, including bipolar I and bipolar II, allow for a broad and inclusive definition for the disease—an inclusion that the DSM has fostered in another way. The APA criteria for a mixed-states diagnosis broadened from the DSM IV, published in 1994, to the DSM-5, published in 2013. The DSM-IV required “that the individual simultaneously meet full criteria for both mania and major depressive episode.”32 The DSM-5 redefined “mixed episodes” as “mixed features.”33 While the full-blown episodes of both mania and depression are rare, “mixed states with varying degrees of mania and depression are comparatively common.”34
For someone like Marjorie Diehl-Armstrong, the expanded definition of mixed states—a critical component of bipolar disorder—pointed to more of her behaviors as proof that she suffered from some form of bipolar disorder or manic-depression. One particularly astute definition of manic-depression accounts for the disease’s reach and evolving nature:
Manic-depression describes a mood disorder that includes at least one episode of mania or at least one period of severe depression plus one period of mild mania (hypomania, or bipolar II) or severe mania (bipolar I). The periods of severe depression or mania may or may not be accompanied by symptoms of psychosis, such as delusions and hallucinations, in addition to the mood symptoms. Cyclothymic disorder is characterized by periods of mild mania (hypomania) and mild depression.35
The number of symptoms for bipolar disorder and manic-depressive illness might seem limitless. So do the number of possible causes. Brain injuries and neural deformations, genetic problems, neurochemical irregularities, immune dysfunction, and endocrine dysfunction represent only several theories of causation.36 Those searching for a definite cause for bipolar disorder will be disappointed, just as the DSM-5 and its predecessors will disappoint those who look to those volumes for cures for all kinds of mental illness. The causes of bipolar disorder and manic-depressive illness remain as mysterious today as they were for the Greek and Roman acolytes of humoral theory. Bipolar disorder—in the case of Marjorie Diehl-Armstrong and so many others—remains a disease that psychiatrists can seek to manage and treat through medication and therapy, but a disease still without a cure. Bipolar disorder and mania and depression are in many respects lifetime illnesses, as familiar to so many Americans as the names of the medications developed to address them: mood stabilizers such as lithium and Tegretol; antipsychotic drugs such as Risperdal and Abilify; antianxiety medications such as Xanax, Klonopin, and Valium.
Also familiar is the cultural belief that links bipolar disorder to artistic creativity and intellectual brilliance. Diehl-Armstrong is one of so many people to cite the popular theory, which holds out as examples a parade of artists and writers diagnosed with “mania, severe depression, or both”: Van Gogh, Michelangelo, Robert Lowell, Virginia Woolf, Walt Whitman.37 Many creative minds, however, have thrived absent mania and depression; just as many people who suffer from bipolar disorder and manic-depressive illness lack creativity or the keen insight that artists possess. The link between creativity and bipolar disorder rests somewhere between myth and reality; the relationship acts, perhaps, as a comfort to those who suffer from what can be such a socially paralyzing disorder. Wrote one medical author in response to the question of how to gauge whether a great leader or artist was bipolar: “Try looking through history for charismatic, magnetic leaders with boundless energy, little need for sleep, wordiness, and an unquenchable sexual desire, who deteriorated as they aged. Were they bipolar? You can make up your own mind.”38
For Marjorie Diehl-Armstrong the answer was always clear. She had most definitely made up her mind about her diagnosis: She was bipolar, and she was in good company—with Churchill and Lincoln and Van Gogh and the other famous manic-depressives—and she was blessed.
“It’s the only mental illness that can also be considered a gift,” Diehl-Armstrong, in one of her lengthiest reflections on her mental illness, testified at the Pizza Bomber trial. “In fact, I’ve had some psychiatrists that said they wished they had it. Because it’s all in a continuum, the depression and the mania. My mania is hypomania. It’s not a raving maniac type mania. There’s some people—if you are the type of person that has that kind of hypomania, the doctors tell you that you are not going to be the raving psycho person that jumps out of the window that thinks they’re a bird that can fly.”39
Diehl-Armstrong said her mental illness helped keep her focused. She defined “hypomania” as having “a lot of energy, not requiring too much sleep. Like a photographic memory, it helps you a lot in school. It helps you be a good student. It gives you a lot of energy. And it also gives you resilience. . . . Hypomania gives you hope.”40
“I have bipolar disorder,” Diehl-Armstrong continued, talking at a rapid pace. “I get depressed and manic at the same time. And I’m rapid cycler, which means it can change really from one minute to the next. Now, the only problem it gives me with this, is sometimes perceiving situations and people, it makes me more vulnerable and easily victimized by people. It does not make me sociopathic, which I’ve never been.”41
During a pause in Diehl-Armstrong’s reverie about her mental illness, Sean J. McLaughlin, the judge in the Pizza Bomber case, asked her to speak more slowly. He said the stenographer, a courtroom veteran named Ron Bench, had to be able to get all her words down. Diehl-Armstrong responded with an explanation that, with a sense of humor, again centered on her mental illness.
“Ms. Armstrong,” McLaughlin said, “we want to get the whole story in, but we’re going to be here a long time if you don’t listen to and respond to questions, OK?”
“OK,” Diehl-Armstrong said.
“Ron, are you doing all right?” McLaughlin said to the stenographer.
“Yes,” he said.
“He’s very good. I used to do that job for a doctor,” Diehl-Armstrong said. “He’s very good.”
“Ms. Armstrong, you’re right: he’s very good, he’s doing a good job,” McLaughlin said.
“I’m sorry for giving you such a hard time,” Diehl-Armstrong said.
Her defense lawyer, perhaps remembering Diehl-Armstrong’s sense of grandiosity, asked her about the time she said she worked as a medical stenographer.
“Were you the best at it or the worst at it?” he said.
“At what, my job?” Diehl-Armstrong said. “I typed over a 100 words a minute. Being a little manic helps for that.”42