A brief history of the nervous breakdown
"Nervous breakdown is a term for a mental disorder with no agreed-upon medical definition." - Wikipedia
There are a few popularly recognized events left in psychology and they tend to have either a short shelf life, temporally speaking (the panic attack1), or a longer one (the psychotic break2). Somewhere along the way – actually, I can tell you exactly when – we lost not only the language to describe the space in between – the nervous breakdown – but also the will to put this psychological event into the language of the physical.
The change began as a series of small cuts and ended with a permanent severing. Yes, graphic, but when your aim is to restore the language of the physical to mental health in order to accurately render the experience for people experiencing it, I’m telling myself I gotta go graphic or go home.
It’s worth a brief history of how this happened — how we once had a familiar phrase to describe the phenomenon of dropping out of society to attend to one’s nerves. How we lost it. What took its place. What we might get back if the phrase — and acknowledgement of the event’s existence — is restored.
The naming of troubled mental states goes back a long way. Historians have found written references to “nervous diseases” in texts dating back as early as the 17th century.3 These were often wrapped in anatomical descriptions about the gallbladder and spleen.4 In other words, back then anxiety and depression weren’t manifestations of the head, so much as body disorders. We like to titter about such organ-based thinking now, but what the early shrinks got right was the physicality of it all. And, though it sounds archaic to us now, the attempt to connect anatomy with mental disorders made sense for the ones struggling to treat the patients: physical symptoms are clear and easy to gauge. My stomach hurts before I give lectures: stomach disorder. I faint on the trolley: heart disorder. Etc.
A physical diagnosis — e.g. my skin itches everywhere — also kept a person out of the asylum who might otherwise belong there. Sir Peter Maxwell Davies, author of historical plays, gave his King George III the line “I’m not ill, I’m nervous”5 in his celebrated one-man show, reflecting the thinking at the time that a physical disease of nerves, especially in the upper-classes, was more a sign of refined sensibilities than mental illness.6 The distinction was crucial. It kept George out of straight-jackets.
By the 18th century, descriptive trends had evolved a bit. People described themselves as living in stressful environments that aggravated symptoms of the body. Doctors, too, believed that stress was on the rise.7 But the term was never quantified. Instead, 18th-century physicians began to diagnose people with “nerves,” a disorder of the body akin to anxiety, with dashes of depression and fatigue; there was no focus on self-reported moods.8 By this time, most anatomical pairings were dropped, but the physical was still important to the diagnosis. People with nerve syndrome were not described as sadder than the population at large; instead they were uncomfortable – uncomfortable in their bodies and in their minds. In addition to physical symptoms, these people were preoccupied with what was happening inside. They couldn’t stop thinking about their internal states, their thoughts, and how their minds worked. But mental discomfort was a symptom, not the root of the disease.
The 19th century is when “melancholia,” a concept dating back to the Middle Ages,9 stepped onto center stage. This is when classification of mental health disorders begins in earnest.10 As physicians grappled with the relationship of physiology and psychology, melancholia emerged as a diagnosis that spanned both physical symptoms (insomnia, loss of appetite, physical slowdown) and mental ones (lack of social responsiveness, mental slowdown). A person in breakdown would be described as suffering from a long bout of melancholia. The term was used all the way up to and through the 1930s.
The word hysteria, another disease rooted in a primitive understanding of the body, returned to the fray in the late 19th century, then came in handy in the early 20th century when physicians needed to find a descriptor for the shell-shocked soldiers returning from World War I.11 The boys didn’t much like it. To that point, the word had been ascribed mostly to women, connected for thousands of years to the roving and havoc-wreaking female uterus. Though misogynist in origins and misguided in nature, by that point hysteria had evolved into an umbrella term used to describe, in part, the physical and mental symptoms we would now call PTSD.12
Then came the 20th century and the era of Freud, the Austrian neurologist who introduced psychoanalysis to the world. His was an approach to psychiatric medicine that blended investigation of the conscious and unconscious; it dug up repressed fears, mined dreams. It believed the material, physical world was influenced by the mental, subjective one, especially in the sexual realm, which was Freud's favorite area of focus.13
But Freud’s acolytes became more interested in neuroses of the mind than biology,14 as time went on, and by the mid-20th century, influential psychoanalysts had wholly abandoned the physical body as the locus of mental disease. The entire story was in the head, they argued. If Woodward and Bernstein had a follow the money motto; the psychoanalysts of the 1950s preferred follow the head. And they codified that thinking in 1952, thirteen years after Freud’s death, when the DSM was published. It was the first official manual of mental disorders, meant to serve therapists and the like. And from the moment of its inception it was controversial. Critics accused it of everything, from lacking scientific basis to pathologizing normal human experience.15
The Freudians head-based theories were everywhere in the book: the words “nervousness” and “nerves” began to disappear, replaced with words like “neuroses” and “anxiety.” The replacement had been happening outside the book during the previous twenty years, so slowly that most physicians hadn’t noticed. Now it was oak.
But it was the revised edition in 1980 that severed the old, physical limb right off. The new edition forever changed what we talk about when we talk about mental health.16 Diseases were split and split again, like atoms in a fission reactor. Depression was decoupled from anxiety. Anxiety was subdivided into types (social anxiety disorder, panic disorder, agoraphobia, etc.). Both anxiety and depression were decoupled from nerves, and nerves were decoupled from the physical body. Fatigue fell out of the book entirely. No descriptor for a disease of the entire body was left standing in the DSM III, unless you counted “major depression,” which left so much out. “The shattering of the nervous syndrome was complete,” according to Dr. Edward Shorter, author of How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown. He goes on to call the DSM III “a jumble of non-disease entries created by political infighting within psychiatry.” (I reference Shorter regularly, and there’s a reason for that: he’s a medical historian. There aren't a ton of those, and even fewer who have written on the history of the nervous breakdown. Shorter’s book was a touchstone for me in this research.)
The psychoanalysts weren’t wholly to blame by 1980. There were so many arguing parties by then, and, most important, so much money. Pharmaceuticals to the rescue. The more distinct each disease, the more drugs had to be created for each one. Or vice versa, really. GAD, Generalized Anxiety Disorder, was basically invented as a disease in the 1980s so that doctors could write in on a pad of paper, send you off to the pharmacy, and qualify you for a bottle of benzodiazepines.17 First there were benzos, then there was GAD. That meant the pharmaceutical offering dictated the diagnosis, not the other way around.18 This approach had costs and benefits. Benefit: more nuanced diagnoses for a wide variety of reported experiences. Cost: confusion, obfuscation, a science with a missing (physical) limb. Most noticeably, the nervous breakdown – which had previously been a catastrophic event attended to by many hands – was now a nonentity, best described as a bump in the continuum that is depression. Like a car driving over a rodent on a long road-trip (“What was that, honey?”). Those of us who’ve seen it up close know that it’s more akin to a car driving over another car that closely resembles your own body. But, not so in the DSM III.
By the early 1990s, the DSM was so controversial that the impending release of a new edition was closely tracked by the media. But the DSM IV didn’t differ much from its predecessor, unless you count a sprinkling of the word “impairment” throughout — as in, sometimes this or that disease leads to significant impairment. What kind, when, for whom, for how long, ending in what way — the manual doesn’t say.19 Ditto for the DSM V released in 2013.
And now you are fully caught up. And despite all this mixed-signaling from the professionals — among regular folk, you and me — the word breakdown and the phrase nervous breakdown live on, capturing the physical and mental aspects of a unique dropping-out. The phrase lingers for a reason. The shoe fits.
Many, like author and medical historian Dr. Edward Shorter, are proposing a holistic change to the diagnostic system. Rather than insisting on precise definitions for every little feeling and symptom, he suggests we figure out what ordinary people are experiencing and treat those things. I’ve got thoughts on that (and agree with it wholeheartedly), but, for the purposes of this essay, my aim is for you to understand how we got here. Where we go from here is a topic for another day.
For my money, I’d like the clarity of the full-body diagnoses back officially; like the 19th century doctors mentioned above, modern-day Japanese people use this nuanced style of naming.20 I’d also like some acknowledgement that the event has a time-frame. It’s not a continuum. It’s an event with a beginning and an end. I had my break in my early mid twenties. If the psychiatrist I saw in Toledo, Ohio, could have named what I was going through when I was in the middle of it, might I have avoided some of the struggles that followed? If I knew that I was experiencing a nervous breakdown, a clinically recognized physical and emotional rift, would it have helped me avoid future pitfalls? I believe the answer is yes.
Thank you to Danielle Svetcov for her editorial contributions to this piece.
Panic Disorder, NHS
Understanding Psychosis, National Institute of Mental Health
The History of ‘Nervous Disorders' from 1600 to 1840, and a Comparison with Modern Views, Cambridge University Press
Shakespeare and the Four Humors, National Library of Medicine
Ruud Welton,”I’m Not Ill, I’m Nervous”, Cambridge University Press
”From Nerves to Neuroses”, Science Museum UK
How Everyone Became Depressed, Edward Shorter, Oxford University Press
The History of Melancholia, National Library of Medicine
The Evolution of the Classification of Psychiatric Disorders, National Library of Medicine
“Shell Shock Revisited: An Examination of the Case Records of the National Hospital in London, National Library of Medicine
“From Hysteria and Shell Shock to Posttraumatic Stress Disorder: Comments on Psychoanalytic and Neuropsychological Approaches, National Library of Medicine
Freud on Mind and Body, William Paterson University
Psychoanalysis and the Brain – Why Did Freud Abandon Neuroscience? National Library of Medicine
The History of the DSM, American Psychiatric Association
The History of Generalized Anxiety as a Diagnostic Category, National Library of Health
The Evolution of the Classification of Psychiatric Disorders, National Library of Medicine
“From Neurasthenia to Morita Therapy: the development of psychiatric knowledge in modern Japan,” Cipango, The French Journal of Japanese Studies
As a counsellor it always takes a while to get past the names professionals have given to a client’s issues and begin working with the whole person. Thanks for the history lesson. I will go back to using my mum’s language of mental health. - bad on his nerves - you are getting on my nerves - nervous breakdown - I’m a bit nervy
Fascinating.