How Everyone Became Depressed (16 page)

Thus the clinical picture of melancholia remained hard to mistake. Giovanni Mingazzini, professor of psychiatry in Rome and director of the university psychiatric clinic, also headed a private sanatorium for women. He said in 1926, “A good third of the [sanatorium] patients suffer from typical melancholia.” He thought the percentage up over time, and also noted that the nature of their self-accusations had changed from having spit on the communion host, to having given the children syphilis (despite not having it themselves) or stolen money from friends.
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It is for such patients that the term melancholia retains a certain robustness even today.

Nervous breakdown has never been a medical term. It is a patients’ term, just as cerumen has always been a doctors’ term for ear wax. Yet patients once believed profoundly in nervous breakdowns as a psychiatric condition several pegs higher than nerves, until the great switch to depression. Even today, the concept of the nervous breakdown has a kind of subterranean existence in the patients’ folklore. Yet the nerve syndrome was a quite specific pattern of illness whereas the nervous breakdown was not. The nerve syndrome entailed anxiety, depression, fatigue, somatic illness, and obsessive concern. Looking back over historical records, we can see who had the nerve syndrome and who did not.

Nervous breakdown shares only the term nerves in common with the nerve syndrome. It is a synonym for serious psychiatric illness of any kind, not a specific disorder. In a short story in Collier’s magazine in 1935, George, the hero, tries unsuccessfully to contact Josephine, on whom he has cast a lustful eye. “He saw no other girls. He went home nights and walked the floor and drank too many drinks and didn’t go to sleep until all hours.”
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The title of the story was “nervous breakdown,” but clearly George did not have a psychiatric illness.

Here, on the other hand, is John F. O’Donnell, the chief of police in Denver, who shot himself to death in 1949. In a note that he left behind for his wife and son he said, “I feel like I am going to have a nervous breakdown and surely do not want to be a burden to you.” For Chief O’Donnell, a nervous breakdown was a nontrivial illness. Dr. John E. Eichenlaub, writing in Today’s Health in 1954, said, “You hear a lot of people say that a nervous breakdown ruins a person for life, that no one ever gets over one.” This is pretty serious business, not at all what George had. (Dr Eichenlaub went on to dispel readers’ fears.)

So clearly a nervous breakdown was not a specific disease but anything going wrong in one’s emotional life that was deemed serious, and in today’s terms, a nervous breakdown could have been an episode of melancholia, a brief bout of psychosis, an encounter with catatonic stupor, a panic, or a moment of psychotic anxiety. In describing nervous breakdowns we are not therefore identifying a specific disease, but understanding why the term “nerves” has had such staying power in popular culture: It is a tag for distress and inability to cope. But the drama of the story is how this tag, and its cousin the nervous syndrome, slides from nerves to depression.

Physicians generally speaking have never accepted the notion of the nervous breakdown and when their patients raised it, doctors treated the whole concept condescendingly.
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Thomas Ross, a specialist in psychoneuroses and former head of an English hospital for the treatment of “functional nervous disorders,” said in 1923 that if you asked your patient about his own view of the matter, “the commonest reply is to the effect that his nerves are run down.” Of course Ross would hear nothing of this, and suggested telling patients that the nervous system “is more of the nature of a telephone exchange into which messages come and from which they go.”
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This concept was no more scientifically exact than the views of Ross’s patients, but illustrates medicine’s great impatience in these years with the concept of tired nerves—Ross himself was sympathetic to the ideas of the Freudian school.

Doctors wrote constantly in the popular press about what really constituted a nervous breakdown, hoping to detach readers from obnoxiously unscientific notions about nerves. In 1936 Jacob Markowitz, a member of the department of physiology of the University of Toronto, commented that “There is an extraordinary amount of nervousness in big cities today,” and said that, in real medical terms, it would boil down to anxiety neurosis, compulsion neurosis, neurasthenia, melancholia, and hysteria.
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(After the outbreak of war, Markowitz became something of a hero in treating desperately ill men—he himself had also been taken prisoner—in a Japanese prisoner of war camp.
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) It is ironic that many of the supposedly scientific diagnoses that doctors in the 1930s wished to thrust upon their patients, such as hysteria, were themselves later discredited. Medical efforts to substitute truth for folly have themselves a long and embarrassing history.

But in the patients’ world, the nervous breakdown was omnipresent and medicine had to deal with it. During World War II, many draftees gave histories of “nervous breakdowns” to Army psychiatrists such as Samuel Kraines, who normally taught at the University of Illinois College of Medicine. Should they be deferred? Yes, said Kraines. The histories the patients gave of “breakdowns”—which he put in quotation marks—savored of insomnia, great fatigue, inability to concentrate, and depressive feelings. Kraines diagnosed this as manic-depression and said the men would crack under combat.
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Thus doctors often came into contact with the concept of nervous breakdowns, but always in the tales of their patients, received with an arched medical eyebrow.

Did physicians nowhere accept the notion of breakdown and crisis? Yes, in France. The French term for nervous breakdown is “crise nerveuse,” and there is a tradition in French psychiatry of diagnosing “crises,” analogizing from the fever crisis in internal medicine as the moment when the patient takes a turn for the better. Etienne Esquirol inaugurated this kind of analogy in 1816, saying, “Why wouldn’t the doctrine of crises be applicable to mental alienation [psychiatry]? Does madness not have causes, symptoms, and a course that are distinctive? Why should it not be judged as other diseases?”
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In 1860 B én édict-Augustin Morel, chief physician of the Saint-Yon asylum near Rouen (and originator of the doctrine of degeneration in psychiatry), spoke of the “crisis”—possibly an eruption of erysipelas, a bacterial infection, in a manic patient—as the first prognostic sign of a favorable outcome.
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In French psychiatry it was then neurologist Jean-Martin Charcot who abducted the crisis concept, borrowed from the study of fevers, and imported it into psychiatric pathology in the form of the “hysterical crisis,” a theatrical display of great passions as the supposed episode of hysteria found its climax.
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Because of Charcot’s great influence, this kind of crisis reached its apogee in French psychiatry late in the nineteenth century, and lingered on in official diagnostics as the “crise émotive,” something resembling a panic attack.
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But French psychiatry is very distinctive in this regard. Psychological medicine elsewhere had little use for crises and certainly not for breakdowns, regarded as unscientific metaphors.
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The term nervous breakdown itself had a relatively brief life. It surfaced only late in the nineteenth century. Ella Adelia Fletcher, a popular health writer, deplored in 1900 the reckless expenditure of “nerve-force” that led to “a form of disease which is so much more acute in the United States than anywhere else in the world, that it has received the generic name Americanitus.” And the specific form of Americanitus was “nervous collapse.” “The living death of a nervous wreck is one of the most pitiable spectacles that we ever encounter, and destroys the happiness of more homes than actual death ever does.”
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So, here is the nervous breakdown before our eyes.

In American periodical literature a slow trickle of articles on nervous breakdown begins before World War I. In 1909, for example, James Jackson Putnam, a distinguished Boston neurologist, with a large psychotherapy practice, cautioned against nervous strain and tension.
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After World War I, nerves and nervousness took increasing prominence in the national discussion—including contributions in 1918 such as “Why the Jew is Too Neurotic.”
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References to “nervous breakdown” in headlines of the New York Times, searchable in a database, do not begin until 1905. “C Oliver Iselin Ill: Suffers a Nervous Breakdown,” was the initial headline (Iselin was a noted yachtsman).
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Thereafter, most nervous breakdown stories oscillated between suicides and people who abandoned public life because they could not function anymore. The 5-year period 1925–1929 was the highpoint of such stories, with 34. References to nervous breakdowns then decline steadily across the 1930s and peter out after 1944. Subsequently, there would be only a handful; the last clinical nervous breakdown story ran in 1961: “$100,000 Bail Asked in Miami in Event Frenchman Returns to U.S.—Wife Says He Had ‘Nervous Breakdown.’”
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The nervous breakdown arc thus clearly tracks across the first four decades of the twentieth century. Previously, headline writers chose terms such as mental derangement; afterward they used the term depression.

It is of interest that the Times treated “nervous disorder” as a synonym for nervous breakdown, using it, however, far less frequently. The mother who shot her child and killed herself in 1909—the first mention in a headline— had a “nervous disorder.”
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Thereafter it was used interchangeably with nervous breakdown in describing suicides. Al Capone’s nervous disorder made it impossible, said his doctor, for him to appear in court in 1941.
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The last reference to nervous disorder was in 1947 (“Turkish Patriarch

… Said to Be Victim of Nervous Disorder”
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). So newspaper editors did not care very much for “nervous” terms, certainly not after the Great Depression.
But among people in the real world the nervous breakdown was indeed a hot topic, becoming by the 1920s the standard designation for any serious psychiatric affliction. Julian Huxley, the well-known evolutionary biologist and science writer, suffered a “nervous breakdown” in 1913 following a romantic misadventure; the symptoms sounded like melancholia and there was a history of melancholic illness in the Huxley family.
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Huxley simply reached for the popular term of the day to describe his distress. Similarly, Vienna playwright Arthur Schnitzler, who also had a lifelong history of psychiatric illness, described in his diary the “nervous collapse” that he experienced in the early 1920s, including “deepest despair” and “bitter tears.” In the grips of melancholic illness, he would lie and bed and sob.
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In 1936 novelist F. Scott Fitzgerald experienced a “crack-up” that sounds more like a kind of time-out than an extended breakdown. But it caused him plenty of misery. At age 39—he wrote of himself in the third person: “… It was his nervous reflexes that were giving way—too much anger and too many tears.” He described the symptoms as follows: “I had a strong sudden instinct that I must be alone. I didn’t want to see any people at all.” He describes anhedonia: “… For a long time I had not liked people and things, but only followed the rickety old pretense of liking. I saw that even my love for those closest to me was become only an attempt to love.” He experienced insomnia, “hating the day because it went toward night,” and loss of judgment, in a famous line: “At three o’clock in the morning a forgotten package has the same tragic importance as a death sentence . . . and in a real dark night of the soul it is always three o’clock in the morning, day after day.” He went to a rented room “in a drab little town” and tried to puzzle out “why I had developed a sad attitude toward sadness, a melancholy attitude toward melancholy and a tragic attitude toward tragedy.” This might be constructed as illustrating Jaspers’ dictum about serious illness as beginning with “the feeling of loss of feelings.” Fitzgerald likened himself to a cracked old plate that just suddenly cracks.
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Many had experienced crack-ups and breakdowns. “Have you ever had a nervous breakdown?” social researcher Katharine Bement Davis asked 1000 American women in 1929. One hundred and ninety-six had actually had a breakdown, and a further 104 had “almost” or “nearly” had one. “This together amounts to 30 per cent of the entire 1000,” Davis observed.
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Clearly, among the public the concept of nervous breakdown was ringing a massive bell.
But then the diagnosis nervous breakdown underwent a drift from meaning serious-illness-but-not-insane to becoming a circumlocution for insanity. This was a kind of bait-and-switch that befell the notion of nerves in a number of settings, as, for example, in the private nervous clinics that insisted they did not accept psychotic patients but in fact often did so, assuaging family members with the notion that their afflicted relative, who was totally psychotic, just suffered from nerves.
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This drift had started with nerves relatively early. At the turn of the century, T. Seymour Tuke, the third generation of that famous Quaker dynasty, was a staff psychiatrist at Chiswick House, a private nervous clinic in a London suburb. In 1901 he deplored “the tendency to gloss over what is in reality actual insanity and unsoundnesss of mind by calling it by euphemistic epithets.” He said he had “personal knowledge of cases that have been called and treated as ‘nerve cases’ that have been without doubt cases . . . of insanity and certified.”
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By 1940 “very nervous,” at least in the cosseted little world of Swiss private psychiatric clinics, had come to be identified with frank insanity. What kinds of patients did the La Soldanelle clinic in ritzy Chateau d’Oex admit? Patients with organic diseases, to be sure, such as anemia and rheumatism were accepted, as well as psychiatric patients with “weakened nervous systems.” But “Contagious patients and the very nervous are excluded.”
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The coded language is clear.
Might you be having a nervous breakdown? asked the Ladies Home Journal in 1941. What are some of the symptoms? “In the throes of an acute nervous attack, no matter how organically healthy the victim might be, the heart does beat abnormally fast, the hands do clench and stiffen, the breath comes with difficulty, and the brain may falter and go temporarily blank.”
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We would later recognize this as a panic attack, but in 1941, it sounded like insanity, with the brain going blank and the hands clenching uncontrollably. This would not, unlike nerves, be a diagnosis that people would seek out.
In understanding the departure of the term nervous breakdown there are, accordingly, various forces. Some were pull forces. Psychiatry pulled nerves off center stage and rushed on depression as an understudy. Patients themselves pushed nerves off stage because it had come to mean insanity, which nobody wanted.
Yet even today if you put the term in people’s mouths, they will respond positively. Several national-level random surveys of the American population, most recently by the National Opinion Research Center of the University of Chicago, asked respondents if they felt “an impending nervous breakdown.” In 1957, 18.9% of the population said yes; in 1976, 20.9% said yes and in 1996, 26.4%. These respondents might all have been diagnosed as depressed by their physicians, yet the public clung sufficiently to the breakdown concept that, when prompted, in the 1990s a quarter of the American public confessed to fearing one!
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(One survey of people’s associations with the term “nervous breakdown” concluded that the term “appears to maintain a unique linguistic value to laypersons.”
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Here again, of course, the investigators were putting words into people’s mouths.)
Yet on the whole, by the end of the 1950s the oomph had gone out of the nervous breakdown concept. Popular magazines ran articles on it only to debunk it in favor of depression. “There is no such thing as a nervous breakdown,” said Good Housekeeping in 1960. “Mrs Thompson” didn’t have nerves. “She had a depressive reaction.”
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