Nerves as a Problem

In 1996 the Wall Street Journal noted, “The nervous breakdown, the affliction that has been a staple of American life and literature for more than a century, has been wiped out by the combined forces of psychiatry, pharmacology and managed care. But people keep breaking down anyway.” Indeed they do keep breaking down. Kitty Dukakis, wife of former presidential candidate Michael Dukakis, remembered lying in bed doing nothing. “I couldn’t get up and get dressed, but I couldn’t sleep either.” What was the matter with Kitty Dukakis and millions of sufferers like her? Depressed? What does psychiatry think? In psychiatry there are a few distinct, sharply defined diseases that would be difficult to miss, such as melancholia and catatonia. These tend to be psychotic illnesses, involving loss of contact with reality in the form of delusions and hallucinations, though not always. Then there is the great mass of nonpsychotic ill-defined illnesses whose labels are constantly changing and that are very common. Today these are called depression, oft en anxiety, and panic as well. These are all behavioral diagnoses, suggesting that the main problem is in the mind rather than the brain and body. Yet there is a tradition, now almost lost, of viewing psychiatric symptoms as a result of body processes, and it has always been convenient to speak of these as “nervous” diseases, even though much more of the body than the physical nerves may be involved. Writing in 1972, English psychiatrist Richard Hunter directed attention toward the body as a whole. “Many diseases are ushered in by a lowering of vitality which patients appreciate as irritability and depression. The mind is the most sensitive indicator of the state of the body. An abnormal mental state is equivalent to a physical sign of something going wrong in the brain.” The term symptom cluster is popular today, but that is jargonish, so let us call these patients “nervous.” Their distinguishing characteristic is that they do not have the “C” word, as Eli Robins at Washington University in St. Louis used to call it, meaning that they are not “crazy.”

Context

Consider the current landscape of depression. In an ABC poll in 2002, 15% of Americans said they felt “really depressed” once a week or more. Another 17% said once a month. That means that one-third of the American population believes itself to be depressed in a given month. If you are riding on a subway train with a hundred other people, one-third of them will be currently depressed, or have just been, or are about to be. That is a lot. In fact, it is way too many. We know that only 3% of the population is chronically sad. We know that the serious disease, melancholia, is only a fraction of the ranks of the depressed. Far too many people have received the diagnosis of depression. Whose fault is this? At the beginning of our story, psychiatry spoke German. From around 1870 to 1933, German-speaking Europe was the epicenter of world psychiatry. This was so for two reasons. One, German, Swiss, and Austrian psychiatrists saw large numbers of very sick individuals because they practiced in mental hospitals, leaving outpatients to other practitioners. Of course this was true of alienists elsewhere, but there were more mental hospitals in Germany affiliated with universities because Germany had so many universities. Almost all had university psychiatric hospitals. This was not true elsewhere. So German psychiatry was oriented toward the academic study of large numbers of patients, and a genial figure such as Emil Kraepelin used these resources to make big strides. Second, German psychiatrists had a thorough familiarity with internal medicine because they were also trained as neurologists. From the viewpoint of subject matter, neurology has always been treated as a subspecialty of internal medicine, even though in Central Europe it was hived off to the nerve specialists. In learning so much neurology, German psychiatrists acquired a feeling for brain illness as involving the entire body: They were indeed attuned to looking at the body as a whole, in contrast to Anglo-Saxon psychiatrists, who usually did not also train as internists.

Fatigue

Let us try to unpack nervous disease. What does it consist of? For one thing, most of the patients are tired, even exhausted, and one of the main components of the nervous picture is fatigue. Today, psychiatrists do not think of fatigue as a terribly important symptom. After such obvious sources as iron deficiency have been eliminated— and it has been determined that the patient is not suffering from one of those quasidelusional disorders such as “chronic fatigue syndrome”—most clinicians would be inclined to ascribe fatigue to depression. For patients, however, fatigue remains a hugely important matter. A study of Stirling County in Canada’s Atlantic provinces in 1970 found that only 6% of psychiatrists considered fatigue to be serious; by contrast, people in the community reported “feeling weak all over” as one of the most serious symptoms among a list of 46. In hospital charts today it is not uncommon to see the acronym “TATT,” Tired All The Time. The complaints of the fatigued and weary echo across the ages. In 1712 Lady Mary Wortley Montagu, en route in a journey, complained to a correspondent, “This is what writing tackle the Inn affords, and my head and hand are both disorder’d with fatigue, both of mind and body.” Lest psychological fatigue be thought mainly a women’s complaint, one of the “grand asthenics” of all time was Parisian novelist Marcel Proust, who, around the turn of the century, was so droopy with fatigue—his medical father had written a book on the subject! —that he barely made it from his bedchamber. His correspondence from 1909, for example, mentions fatigue throughout. On Friday, November 26, after his guests had departed, “I set about demolishing what I had written. And over my heart, fatigued from this absence of repose, voilà the fog that rolls in again. It’s about three in the afternoon and [another nervous] crisis seems to be starting up.” Whatever period or social class is under discussion, fatigue simply tumbles from the page.

The Rise of Nervous Illness

It is much better, people think, for the nerves than the mind to be ill. The nerves are physical structures, and heal in the way that all organs of the body heal naturally. Disorders of the mind are frightening because they are so intangible, and, we think, may well lead to insanity rather than recovery. From time out of mind, people have privileged nervous illness over mental illness. From time out of mind, societies have had expressions for the varieties of frets, anxieties, and dyspepsias to which the flesh is heir. In France and England in the seventeenth and eighteenth centuries, one term was “vapours,” a reference from humoral medicine to supposed exhalations of the viscera that would rise in the body to affect the brain. A major apostle was London physician John Purcell, writing in 1702, of “those who have laboured long under this distemper, [who] are oppressed with a dreadful anguish of mind and a deep melancholy, always reflecting on what can perplex, terrify, and disorder them most, so that at last they think their recovery impossible, and are very angry with those who pretend there is any hopes of it.” He emphasized melancholia and anguish, and for him the “vapours” were something more than a mild attack of the frets. But this was not for everyone. Lady Mary Wortley Montagu, now 60 and living in exile in Italy, described to her estranged husband in 1749 Italian health care arrangements, and how physicians visited rich and poor alike. “This last article would be very hard if we had as many vapourish ladies as in England, but those imaginary ills are entirely unknown here. When I recollect the vast fortunes raised by doctors amongst us [in England], and the eager pursuit after every new piece of quackery that is introduced, I cannot help thinking there is a fund of credulity in mankind . . . and the money formerly given to monks for the health of the soul is now thrown to doctors for the health of the body, and generally with as little real prospect of success.”

The Return of the Two Depressions (and an Anxious Postscript)

Before 1980 there had been two depressions, melancholia—also called endogenous depression—and nonmelancholia, called a number of terms such as reactive depression and neurotic depression. DSM-III flattened this distinction, abolishing the clinical distinction between the two with the homogenizing term major depression. To be sure, DSM-III reinserted the term melancholia in the discussion as a subtype of major depression, but only in letter, not in spirit. In the decades after 1980 melancholia returned, but to a landscape of mood disorder that had been leveled and laid waste by the concept of “depression.” In a world where everybody is depressed, nobody is melancholic. Emil Kraepelin had sent the diagnosis of melancholia into a death spiral. The psychoanalysts had little interest in the concept, aside from venerating a single essay of Freud, and the only people interested in keeping melancholia alive as a notion after the 1930s were the British who, with their admixture of Heidelberg science and homegrown common sense, had turned into shrewd psychopathologists. The textbook that Willi Mayer-Gross, a Heidelberg refugee, published in 1954 together with Eliot Slater and Martin Roth gave pride of place to involutional melancholia as the serious melancholic illness that oft en affected people at midlife and afterward. But world psychiatry after World War II marched to an increasingly American beat, and the Americans had little use for the antique term melancholia. The glossary of Alfred Freedman’s Comprehensive Textbook of Psychiatry, the world’s leading textbook first published in 1967, had scads of psychoanalytic terms but claimed of melancholia: “Old term for depression that is rarely used at the present time.” In Europe after World War II, endogenous depression was the serious variety and melancholia was deemed as “contaminated by Freud and the 19th century novels that degraded it to grief,” as Tom Ban, who trained in Budapest in the early 1950s, put it. “For Kraepelinians, grief and depression were not the same, and they excluded each other. Anyone who had an identifiable precipitating factor could not be labeled as having a depressive state.”

Drugs

History has always known antidepressant remedies. In an era of faith, the faithful held to the Word as an augury of recovery: “cast down, but not destroyed.” But in a secular era and certainly by the middle of the twentieth century, pharmacological remedies were required. Indeed they were urgently indicated, for the diagnosis of depression itself was starting to spread. Because of Kraepelin and Freud, by 1940 depression had become a common term for serious psychiatric disease. An editorial in the Lancet called depression “perhaps the most unpleasant illness that can fall to the lot of man.” Depression was thus, while not terribly common, a considerable public health issue. What is puzzling in this story is that around 1940 depression began an inexorable, irreversible climb from awful but unusual to epidemic status. With the 1960s, depression started to become epidemic. One reason for the upswing in depression in mid-twentieth century was the cheering of the pharmaceutical industry. The drugs of the first generation of psychoactive medications were indicated for nervous disease, but there after the firms switched to depression because here were clearly the markets of the future. The early drugs represented an effective treatment for nervous disease. Their effect was sedation, and sedative drugs in medical practice go back to opium and to members of the belladonna family that have been known since Ancient times. Sedation means the process of calming, or allaying excitement. It does not necessarily involve the obtunding of consciousness, although large doses of sedatives may do that. Sedation means easing the pain of being, soothing the griefs and worries of existence, and calming the depressive and anxious agitation of the nervous syndrome. Although we all have worries and anxieties, we do not all have a pathological syndrome called nervousness. Historically, it was those with nerves who benefited from the early psychopharmacological treatments, beginning with the bromides at mid-nineteenth century. The first sedative made by chemical synthesis, chloral hydrate, was used clinically in 1869. A succession of sedatives from the organic chemical industry followed.

Paradigm Shift

Kraepelin’s influence in renaming melancholia “depression” was enormous. But that alone would not suffice to explain why, an ocean away and a hundred years later, everybody became depressed. Mediators were needed to carry the doctrine of depression to the discipline of psychiatry, and then to individual patients. Those mediators were the American psychoanalysts, many of them distinguished migrants from Europe, and they gave pride of place to neurotic depression. Other mediators extracted depression and anxiety from the pool of nerves and yoked them together, making mixed depression-anxiety the favored disorder. To gain some perspective: In the first third of the twentieth century, in a great paradigm shift that transferred behavioral disorders from neurology to psychiatry, the spotlight shift ed from nerves, a diagnosis that implicated the whole body, to mood, a diagnosis that implicated mainly the mind. Mental illness triumphed over nervous illness, and depression became the main mood diagnosis. In 1908, Oswald Bumke, a psychiatrist then at the university psychiatric hospital in Freiburg, Germany (later to become professor of psychiatry in Munich), scolded the family physicians who never suspected depression in their wealthy patients whom they sent from spa to spa and sanatorium to sanatorium for the treatment of nondisease (symptoms without organic causes). The family doctors, who doubtlessly suspected the symptoms were of psychological origin, focused on the symptoms themselves; Bumke, more interested in mental than in physical symptoms, focused on what he believed the underlying cause to be: “depression,” as manifest in symptoms such as tiredness or an anxious preoccupation with their bodily health. For clinicians of Bumke’s generation, depression was a familiar concept. In understanding the rise of depression there are two questions that have to be sorted out: Why the depression diagnosis becomes so common and why depressive symptoms become divorced from the nervous syndrome and take on a life of their own as an affective disorder. Because events on both tracks happen around the same time, the narratives interblend, but they are separate stories. To foreshadow, it was American psychoanalysis that first put depression in the spotlight.

A Different Kind of Nervous Breakdown—Melancholia

Feelings of low mood are not trivial. In 2010 the National Center for Health Statistics of the Department of Health and Human Services asked a random sample of the U.S. population about their mood. In reply to Do you feel hopeless?, 6.8%, or 1 in 15, said yes. In reply to Do you feel worthless?, 5.3% said yes. In reply to Do you feel that “everything is an effort”?, a whopping 16%, or one in seven, said yes. Low feeling is very common. Yet it is not melancholia. Historically, plenty of people have suffered from low moods. Today, few of us can stay in our beds because we have to earn a living. Yet it was once common for middle-class women, in households that had servants, to take to their beds when feeling down. In 1917, London literary figure Virginia Woolf, age 36, noted in her diary for October 25: “Owing to the usual circumstances, I had to spend the day recumbent.” She meant that she was having her period, and always had to lie down. Still, menstruation was not the only reason she went recumbent. Late in 1918 she had a tooth out and spent two weeks in bed, “and being tired enough to get a headache—a long dreary affair, that receded and advanced much like a mist on a January day.” “Here is a whole nervous breakdown in miniature,” she recorded in July 1926. “Sank into a chair, could scarcely rise; everything insipid; tasteless, colourless. Enormous desire to rest.” In November 1931 she was assailed by “a perpetual headache,” and “so took a month lying down.” On October 5, 1932, she said, “I spent yesterday in bed; headache; infinite weariness up my back: clouds forming in my neck; half asleep.” So this is the kind of nervous behavior that was congruent with people of her social class at that place and time. But there are deeper, more alarming notes.

Anxiety

In 1970 Aubrey Lewis, the past master of the Maudsley Hospital, England’s premier psychiatric facility, was 70 years old. In his long decades of experience, he was puzzled by the rise of anxiety as a popular stand-alone diagnosis. The evolution of the term, he said, had gone through two phases. The first was using anxiety “as a qualifying term for the agitated depression of melancholia.” Anxious melancholia meant melancholia out of control. In the second phase, anxiety became “a qualifying term for a neurosis in which subjective feelings of alarm are associated with visceral disturbances.” This would be Freud’s anxiety neurosis. He noted that the number of articles on anxiety in the scientific literature had increased from three in 1927 to 222 in 1960—and was still rising. As Lewis wrote in 1970, anxiety was about to undergo a third phase in its evolution: Anxiety, or panic, attacks would shortly occupy center stage. Anxiety, another part of the nervous syndrome, has a distinctive story line: For most of the history of psychiatry, it was considered part of some other disorder, or not really attended to at all. Clinicians paid no particular heed to whether their patients were worried or fearful: These emotions were part of the human condition. Augustin Jacob Landré-Beauvais, professor of clinical medicine at the Salpêtrière Hospice in Paris, in his great catalogue of signs and symptoms written in 1809, takes it for granted that anxiety will be present in infectious illnesses. “Anxiety accompanies the better part of acute illnesses and some chronic illnesses, and is produced by various causes,” he said, and considered it an advance warning of an attack among “hypochondriacs, hysterics, and epileptics.” Then throughout the nineteenth century anxiety became part of the nervous package. As the nervous syndrome disaggregated in the early twentieth century, anxiety was spun off to become a free-standing disorder, “anxiety neurosis” in psychoanalytic parlance. More recently, anxiety tout court has morphed into panic disorder, and we shall shortly watch panic stride to the center of the stage.

Nerves Redux

We might have thought that the concept of nerves ended in 1957 when the United States Post Office Department initiated a fraud proceeding against John Winters of New York City, who had been promoting a product called Orbacine containing bromide and niacin for “every-day nervousness and its symptoms.” Although Winters’ claims went a bit beyond nerves, the Post Office wanted an end to the whole business and Orbacine disappeared. But the concept of nerves had enemies other than the Post Office. Three in particular had tried to do away with it: psychoanalysis, psychopharmacology, and the DSM series. All failed to kill it completely, and the concept lingers on because of its obvious face value: Our patients clearly have a nervous illness or something resembling it. They do not have a “mood disorder.” In medicine the nervous syndrome, the condition that dare not speak its name, has taken on various allures. Once upon a time, hysteria was the equivalent of a nervous diagnosis in women. There were physicians who had little patience with calling their former hysteric patients “depressed”: They remained hysteric! Jacques Frei, a member of the department of psychiatry of the University of Lausanne in Switzerland, noted in 1984 “the importance that depressive symptomatology has taken today as a call for help among female hysterics. . . . It seems that the hysterical woman today has a better chance of a hearing if she presents with a depressive picture, even evoking suicidal ideas.” Although hysteria today is discredited as a diagnosis, it is interesting that older clinicians such as Frei saw it as a diagnosis that trumped depression; he even argued that his patients at Cery Hospital were modeling their symptoms to conform to the new diagnoses. The 1950s and 1960s saw alternative diagnoses to the nervous syndrome come and go, fragments of clinical experience that seemed to make sense to individual physicians but were not more widely taken up because their originators did not have prestigious academic appointments. Take “the housewife syndrome” that Palma Formica proposed in 1962.