How Everyone Became Depressed (8 page)
In the 1920s and after, as nerves and neurasthenia were ground to bits by the diagnoses of anxiety and depression, nervous exhaustion maintained itself, and even increased in prominence. This shows a growing need for a kind of time-out diagnosis that did not indicate madness. In a sense, it sounds much more sympathetic to say, “How could you expect the poor thing to carry on! Her nerves were exhausted,” than to say, “How could you expect the poor thing to carry on! She was psychotic.” Eduard Hirt, consulting physician for a health insurance fund in Munich, who had a good overview of diagnoses in private practice, said in 1926, “The word neurasthenia has certainly become seldom in medical outpatient practice, but ‘chronic nervous exhaustion’ has unfortunately become expanded today to mean not just the now abolished neurasthenia but a host of other psychogenic conditions and other syndromes of degeneration.”
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Exhaustion was becoming a fig-leaf, in other words, for other diagnoses that people did not readily wish to admit having and Hirt deplored the consequences for insurance reimbursement. What might some of those conditions be? In Germany in the 1920s, just after the World War I (according to Maximilian Laehr, a veteran asylum psychiatrist in Berlin-Zehlendorf ), the conditions being diagnosed as “acute and chronic exhaustion” included posttraumatic neuroses (which would include psychologically disabled veterans), chronic occupational intoxications (lead poisoning and the like), and various addictions—none of which would be gladly discussed in company. The limits of the concept, said Laehr, were psychically abnormal behavior that disturbed others, and disorders that required constant supervision.
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The Great Depression seems to have dramatically increased the number of people with nervous exhaustion. So grim were conditions that Adolf Hoppe, a sanatorium doctor in north Germany, said, in language that reminds us of the Great Recession of our own time, that we are no longer talking of the “exhausted” but the “ground down.” “Sanatorium treatment used to help the exhausted relax and rebuild. But for those who are ground down, the therapeutic goal can only be to help the convalescent solely to increase his powers of resistance, to hold out and to endure.”
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Yes indeed: the victims of economic disaster were not crazy, just exhausted, a point made at a meeting of the Clinical Society in London, in April 1931, when Philip Seymour-Price, who had run a high-end practice for almost 30 years at exclusive Sloane Gardens in London, “asked whether it was not possible for nervous exhaustion to be a pure and simple exhaustion of nerve energy, a case of a really tired-out nervous system, which with rest and treatment might get perfectly well. Was it any wonder that the business man of to-day, with things as they were on the Stock Exchange or in the City, or the woman of to-day, with things as they were in domestic service [not being able to hire domestics] became utterly exhausted? These people should be not labeled psychotic or anxiety-neurotic; they were just ordinary people very short of nervous energy.”
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Nor did the flatness and fatigue of emotional exhaustion spare Americans during the Great Depression. On May 1, 1934 Patrolman Alfred Herbstsomer in Millburn, New Jersey, answered the phone, to hear a man’s voice say “casually and unemotionally,” “This is Percy Layman. I just shot my wife, Herby, and now I’m going to shoot myself. You’d better come over right away.” Within minutes police arrived to find Layman’s body on the kitchen floor, his wife scarcely breathing beside him with a fatal wound in her right temple. The cause of such distress? Said the New York Times, he had recently been discharged from a sanatorium as cured, Yet “his business ventures since were reported to have met little success.”
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This is so sad. As I write these lines in the summer of 2012, and look about at the massive unemployment in our own society, the anxious home owners whose mortgages are underwater and dread the sheriff ’s knock, there is a good deal to be said for these sentiments about breakdown and exhaustion, even though they have nothing to do with neurotransmitters.
In any event, long though nervous exhaustion lingered as a synonym for nervous breakdown, it did cede to the advancing tide of depression diagnoses and vanished beneath the waves. By the advent of DSM-III in 1980, fatigue had gone out of psychiatry.
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Motto: At a meeting of the Psychopharmacologic Drugs Advisory Committee of the U.S. Food and Drug Administration, November 1980, on what drugs should be
prescribed for insomnia:
John Kane (Long Island Jewish Hillside Medical Center): “Prior to the prescription of sedative hypnotics other conditions which might be responsible for insomnia, for example,
anxiety, depression, psychosis, should be ruled out.” Donald M. Gallant (Tulane Medical School): “Well, by ruling out anxiety I think you would rule out the entire
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.
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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 André -Beauvais, professor of clinical medicine at the Salpê tri ère 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.”
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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.
Yet anxiety is rarely found alone. William Sargant, an influential biological psychiatrist at St. Thomas’s Hospital in London, said in 1962, “Pure anxiety states are rarely seen in clinical practice because secondary symptoms of hysteria, depression or obsessional thinking generally complicate the picture.”
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(Today, in drug trials, the rule is, as George Beaumont, a clinician with Geigy Pharmaceuticals, said in 1996, that a virgin anxiety patient is “worth his or her weight in gold.”
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) Yet there is such a thing as psychotic anxiety, a quite different disorder, and it is often found alone and not part of a larger syndrome. On the fringes of anxiety are phobias, panic reactions, and even obsessive-compulsive disorder. Trying to draw sharp boundaries among these neighboring conditions is like trying to draw lines in a bucket of water.
But our purpose here is not clinical. It is to see how common illnesses such as nerves lose their credibility and dissolve into other syndromes that are, at the end of the day, less credible. Anxiety disappears from the nervous package by taking on an independent existence.
Anxiety means various things. Anxiety can be a clinical syndrome, a combination of symptoms that anxious patients often display, such as mental worry, plus a sinking in “the pit of the stomach,” plus diarrhea. It is a ubiquitous emotion, synonymous with apprehension, and familiar in normal behavioral states. In post-World War II American psychiatry anxiety was considered a “ neurosis,” a vague term for any behavioral disorder that was not psychotic. And in the world of psychoanalysis, anxiety was deemed “the chief characteristic of the neuroses,”
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meaning that it was a supposed intrapsychic mechanism for dealing with conflict. Otto Fenichel, one of the chief interpreters of Freud’s doctrines for the American public, wrote in 1945 of “anxiety hysteria”: “A part of the dammed-up energy [in neurotic conflict] is discharged, but in such a way as to intensify the defense against the rest. The typical neurotic symptom expresses drive and defense simultaneously.”
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Thus in the United States in the middle of the twentieth century, anxiety was absolutely center stage.
Yet not all believed the psychoanalytic version. One day, in a discussion of anxiety with Robert Spitzer (the architect of “ DSM-III”), New York psychiatrist Max Fink said, “It’s complicated for me, because I don’t define anxiety very easily. Anxiety is a poorly-described term. There is the overt anxiety where a person is tremulous, sweating, tachycardia, fearful, etc. There is the precipitated anxiety by lactate, where you get an acute syndrome [lactate can precipitate a panic attack]. There is the stage fright which you call anxiety. In many depressed people, they are frightened and they’re nervous, and we say they’re anxious and depressed.”
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Clearly, for biologically oriented psychiatrists such as Fink, anxiety was not so central.
Indeed, anxiety was often linked to something else. Katherine Halmi, a psychiatrist at the University of Iowa, said in 1977, “The thing that bothers me about this is that the patients that come for anxiety are not just anxiety patients. You have to weigh all the other medications they may be on and medical illnesses. In some cases, they do have in fact discrete psychiatric diagnoses. In many cases, they do not.”
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So anxiety is in some ways like a handful of smoke; in other ways it is a very solid and overpowering disorder.
Anxiety may either be considered a disease in its own right, which is this book’s take on psychotic anxiety (see the section below on Juan Lopez-Ibor), or as one symptom among many in larger disease entities; in the psychiatric illnesses, anxiety is quite common, and we see garden-variety anxiety as part of the larger package of nervous illness that includes depressed mood, fatigue, obsessive thinking, and various somatic symptoms of a nonorganic nature.
Others too see anxiety as just one symptom among many, rather than as a separate disease. In 1985 a team from Yale University called efforts to “distinguish anxiety disorders as separate diagnostic entities” problematic, “because the subjective features of anxiety are often difficult to describe uniformly, anxiety is a ubiquitous emotion in normal behavioral states, and symptoms of anxiety are common in most psychiatric syndromes.”
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So a few clinicians still adhere to the former view that anxiety is not a distinctive disease such as mumps. Yet there are not many such observers because the pharmaceutical industry has marketed anxiety so relentlessly as a separate disease. The official view in the diagnostic manual of the American Psychiatric Association, currently in its fourth edition ( DSM-IV, 1994), is that anxiety is a stand-alone disease, quite separate from depression. (And as I write now, it looks as though this state of affairs will persist in DSM-5.)
One more thing. Anxiety may or may not include tension. There are anxious patients who are not tense, but few tense ones who are not anxious. Veteran psychopharmacologist Tom Ban remembered from his days of training in Budapest in the early 1950s, before he decamped for Canada in the Hungarian Revolution of 1956, “The Hungarians qualified anxiety by saying whether it’s tense or not. It was a subclass of anxiety.”
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Said New York family doctor Harry Friedlander in 1953, reporting on clinical trials of a new drug, mephenesin, the first of the anxiolytics, in combination with a barbiturate: Something was needed other than the plain barbiturates to “cope with the tremendous increase in recent years of what we have come to call anxiety tension.”
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And the combo did seem to release patients from the grips of tension. (Or at least it was the barbiturate that did so
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; mephenesin soon vanished, replaced by its more powerful cousin meprobamate—Miltown.)
Tension thus rings down over the years in the patients’ charts and the pharmaceutical ads. In 1953, Ciba Pharmaceutical Products (now Novartis) launched the drug reserpine (Serpasil) for “anxiety, tension, nervousness and mild to severe neuroses” as well as for hypertension.
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By 1958 Merck Sharp & Dohme was marketing the drug benactyzine (Suavitil) for “tension, mild depression, anxiety, fears.”
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Tension made sense to many patients and their physicians for decades as part of a larger group of troubles, before vanishing from the language of psychiatry. DSM-IV makes no use of tension as a diagnostic concept, save for glancing references to “muscle tension.”
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(In the draft DSM-5 “tension” appears occasionally in the disorder descriptions alongside “anxiety,” yet is not an independent diagnosis.)
So official diagnostic concepts are of little help. Worry, tension, somatic anxiety, psychic anxiety: all are jumbled together. Rather than insisting on precise definitions let us see if we can figure out what ordinary people usually had in past times, and today.
Among the nervous patients in Frederick Parkes Weber’s west end London practice was Frau X, 38 years old when he saw her in 1922; she had a long history of divorce and personal disruption behind her as, for family reasons, she navigated between Germany and England. Parkes Weber suspects hyperthyroidism to be the cause of her nervous problems, including paroxystic accelerations of her heart rate. Also, she has trouble swallowing. We pick her up again in April 1927, when “during her last (short) Easter holiday she had again her troublesome vegetative nervous system attacks—in these attacks she becomes altogether a prey to cramps of the stomach or oesophagus, cardiac palpitation, paroxysmal, angiospastic conditions [contraction of blood vessels], with pallor of the upper and lower limbs.” She is relieved by “high frequency electrical current.”
At mid-life Frau X resolves to undertake a new career in one of the professions, and the studying and examinations are hugely stressful for her. She continues to have “nervous attacks” with cardiac and circulatory symptoms “necessitating day and night nurses.” (Almost all Parkes Weber’s patients were from a social stratum that could afford such attention.) She begins taking the barbiturate Luminal (phenobarbital).
In December 1927 she was admitted to a German nervous clinic in Degerloch near Stuttgart in “a complete nervous collapse with a continuation of her obsessive and anxious states,” as her German doctor told Parkes Weber. “She is fearful of every terrible event imaginable, that she could become mentally ill or have a stroke or a heart attack and become completely incapable of working. She has continuous attacks of convulsive swallowing and she struggles for air.” Parkes Weber added in his note next to the letter of this German physician, “I think this is a kind of nervous visceral (spastic) tic.” The German doctor’s letter resumes: “She also suffers from complete insomnia and loss of appetite and the general consequential weakness. Recently, she has been unable to arise from bed, the more so because she suffers from highly copious menstrual bleeding, and she is not able to write you herself.” The German physician predicted, however, a complete recovery, which in fact took place.
By October 1928 she is back in the large German city where she lived, “depressed.” Parkes Weber reflects about her case in his notes: “She was certainly born with an excitable and easily upset vegetative [autonomic] nervous system … easily influenced by excitement and emotions of all kinds. (Even after her marriage she could hardly sleep in a room by herself without a light; she was, I believe, fearsome in other respects, and her daughter [name omitted] has an abnormal dread of dogs; abnormal fear of cows is present in the female members of the family.)” Parkes Weber has now abandoned the idea that Frau X ever had hyperthyroidism, save perhaps symptoms from taking too many thyroid tablets. She was depressed, anxious, spent long periods in bed, had a riot of somatic symptoms, and obsessed about fate and death. In Parkes Weber’s eyes, the emphasis was on her anxiety, but in fact she seems to have been a typical nervous patient. The case shows well how “mental” symptoms such as anxiety and depression in fact represent illnesses of the whole body.
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Anxiety and anguish, sturdy terms, have always been part of patients’ everyday language. Gerolamo Cardano, a Renaissance mathematician and physician with a long history of physical woes, said in his autobiography in 1575 that “I have discovered by experience, that I cannot be long without bodily pain, for if once that circumstance arises, a certain mental anguish overcomes me, so grievous that nothing could be more distressing.”
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Anxiety and anguish are among the most basic of emotions, and of course people have always had words for expressing them.
Similarly, the term anxiety has been part of the descriptive vocabulary of medicine since time out of mind. In 1602 Basle’s municipal physician, Felix Platter, whose Observations contained numerous psychiatric cases, described a melancholic patient “who complained about ever more severe mental anxiety [Seelenangst] and became so agitated that she … ran back and forth from room to room.”
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To be sure, anxious behavior has not always been called anxiety. Vincenzo Chiarugi of Florence, whose concept of the therapeutic asylum was spelled out in his three-volume textbook in 1793–1794, counts as one of the early pioneers of psychiatric diagnosis and treatment. In this work he lays out the various stages through which melancholia progresses: “We shall call true melancholia all that which is accompanied by sadness and fear [timore].”
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Strictly speaking, fear is not exactly anxiety, because the latter is often said to lack a specific object. Yet the word anxiety was not yet current in the Italian medical vocabulary, and from the case reports in Chiarugi’s study, anxiety is meant as well as concrete fears of given things. Philippe Pinel, another founding figure in psychiatry, chief of the Salpê tri ère hospice in Paris, described in his large classification of diseases in general, published in 1798, melancholic illness as figuring among the “neuroses.” He wrote of the “causes” of melancholia: “sadness, bitter disappointments, fear, office work, tiredness of life … an imagination that infinitely multiplies and exaggerates the misfortunes of life … ” As for the symptoms of melancholia, Pinel wrote, “The sleep is agitated and troubled by terrifying objects and lugubrious images; the patient is constantly tormented by singular ideas.”
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Again, this is anxiety in so many words.
