The Madness of Mary Lincoln

Appendix 3: The Psychiatric Illness of Mary Lincoln

appendix 3 The Psychiatric Illness of Mary Lincoln James S. Brust, M.D. To establish a psychiatric diagnosis of a historical figure long dead is a difficult task for anyone, psychiatrist or historian. Jason Emerson does a fine job in this book, The Madness of Mary Lincoln, and perhaps gets closer than any previous historian to revealing the true extent of Mary Lincoln’s mental illness, and it was a pleasure to both learn from and advise him on his work. As a professional psychiatrist, I would like to elaborate on Emerson’s conclusions from a medical perspective.1 The first question for the psychiatrist is, should we even attempt to diagnose someone out of the past? In those instances where an individual’s psychiatric condition was a key factor in historical events, some understanding of his or her mental state would be important. We can cautiously try to gain such knowledge from contemporary accounts by the patient, as well as eyewitnesses. Fortunately, in the case of Mary Lincoln, the historical record may be richer than it is for most nineteenth-century American figures, especially with the addition of the newly discovered primary source material presented in this book. We must be aware of the limitations of such a backward-look diagnosis, but we do have some information on which to base it. What, then, can we say of Mary Lincoln’s psychiatric condition? One must proceed with caution: The mysteries of mind and brain are enormously complex, and scientific understanding is still in its relatively early stages. Diagnostic terminology and classification are continually changing , and the inherent limitations of relying solely on the historical record rather than live interviews greatly increase the difficulty. In recognition of the complexity of attempting to understand how people think, act, and feel, the American Psychiatric Association changed to a multiaxial diagnostic system in 1980.2 A full psychiatric diagnostic formulation now consists not only of the primary diagnosis (or diagnoses) on what is called Axis I, but also personality factors on Axis II, medical illness on Axis III, psychosocial and environmental problems or stressors on Axis IV, with Axis V being an assessment of the individual’s overall level of functioning. 185 186 . Appendix 3 When applied to Mary Lincoln, this widened diagnostic system further illuminates her case. Psychosocial and environmental stressors (Axis IV) were marked, of course, with the early death of three of her four sons and her husband’s brutal murder as she sat beside him. Medical illnesses (Axis III) seem to have been prominent as well, with issues such as migraine headaches, various pain syndromes, infections, likely diabetes with various complications, perhaps tabes dorsalis, and even the possibility of syphilis. Personality factors are considered on Axis II. These are lifelong, enduring patterns of behavior and ways of perceiving, thinking about, and relating to others and oneself. If they deviate markedly from cultural norms and lead to long-standing distress and impairment, they can be classed as Personality Disorders. Personality traits that might be maladaptive can be considered as part of the diagnostic formulation even if they are not pervasive enough to constitute a full-blown Personality Disorder. A number of such traits, described throughout this book, might be attributed to Mrs. Lincoln, including paranoid traits (distrustful and suspicious of others, seeing malevolence in their motives), histrionic traits (attention seeking, using self-dramatization and exaggerated expression of emotions), narcissistic traits (a grandiose sense of self-importance and need for admiration), and borderline traits (exaggerated fears of abandonment , inappropriate and intense anger, and unstable relationships that alternate between idealization and devaluation).3 Before looking at the question of what, if any, psychiatric diagnosis Mary Lincoln might have had on Axis I, a word is in order on general trends in American psychiatry over the past fifty years. In the nineteenth century and before, those who cared for the mentally ill were essentially asylum keepers, struggling to deal with the bewildering and poorly understood array of serious disorders that beset their patients. As answers were sought and new theories tested, American psychiatry over the first half of the twentieth century took a turn toward the psychological and away from the biological—influenced first by Sigmund Freud’s psychoanalytic theory, and then by Adolf Meyer, whose influential psychobiological model saw psychiatric illness as a “reaction” to life events.4 But over the past fifty years, psychiatry in this country has turned to a much more biological and...