How Everyone Became Depressed (10 page)

Here is Frau M, 23 years old, in a Viennese private nervous clinic around 1890: At age 16, just married, she had a spontaneous abortion, with significant blood loss. As her clinician Hanns Kaan, tells her history, “From then on she became insomniac and anxious; for example she had to arise at night and check whether she had truly extinguished a match she had lit earlier. When she fought against this impulse, she was overcome by a nervous crisis, with heart palpitations [Herzbeklemmung], shortness of breath, and anxious sweating (precordial anxiety).”
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Frau M, young and nervous, was clearly having panic attacks.

Using the term “mood-depression” (Gemüths-Depression), in 1859 Flemming described somatic anxiety as a traveling companion of melancholia. As the illness advances, “The feeling of oppression and anxiousness, which had accompanied the entire symptom train, now mounts to a powerful, nameless anxiety, the seat of which the patient localizes in the cardiac area, the upper abdomen, the lower chest, or under the sternum.” The patient describes the feeling “as though he had a stone lying upon his heart, an iron wheel compressing his chest, a rope that is squeezing his body together.” Patients consistently used these images, said Flemming.
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A key development in the story is removing anxiety from the nervous syndrome and seeing it, as least in its spasmodic forms, as a free-standing illness. Severe forms of anxiety were regarded as part of the nervous breakdown by the laity. It is therefore interesting to watch anxiety emerge from the soup of melancholia, at an epoch when melancholia meant severe illness of various kinds.

The first big step in liberating anxiety from melancholia was taken in 1866 by Jules Falret, son of Jean-Pierre Falret (who in 1851 had been the first to offer a careful description of bipolar disorder). Jules Falret said there was a form of rational insanity that he, with a clunky touch, proposed to call “partial insanity with predominance of the fear of contacting external objects.” Noting that his father had proposed the term “fearfulness disorder” (maladie du doute) for it, Falret junior offered a careful clinical description: “The true core of this disorder consists above all in a general disposition of the mind to ceaselessly return to the same ideas or the same acts, feeling the continuous need to repeat the same words to accomplish the same actions, without ever succeeding in satisfying the need or being convinced, even by evidence.” This was a partial insanity: “These patients are perfectly aware of their state [of illness]; they recognized the absurdity of their fears and seek to extract themselves, but they don’t succeed in this and are, despite themselves, obliged to return to the same ideas and to accomplish the same acts.” “It takes them quite a while to put on their makeup, to decide to come to the table, and they even fear bringing the food to their mouths. They are afraid to take walks, in the fear of sullying their feet with the ground; they shun the company of other people to avoid shaking hands … ” Although previous authors, such as Falret senior, had alluded to the existence of obsessive thinking and compulsive actions, Falret junior assembled the entire package (and has received from historians almost no credit for this because he chose such an opaque designation). Falret junior said that the disorder erupted in paroxysms: “It is remarkable, in fact, that this mental state, which may extend itself for one’s entire life with the irregular alternation of paroxysms and sometimes very pronounced remissions, never ends in true dementia.”
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Another classical account stems in 1866 from the pen of B én édict-Augustin Morel, chief of the mental hospital at Saint-Yon near Rouen. He described what he called “emotional psychosis” (d é lire émotif ), a picture of excess emotivity in combination with chronic somatic symptoms of anxiety, and obsessive-compulsive symptoms such as fear of touching things; Morel, who introduced with great certitude the concept of “degeneration” into psychiatry in 1857, was just as confident about the causes of this new “d é lire”: it emerged from the autonomic nervous plexuses of the abdomen; the diagnosis did not catch on.
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Wilhelm Griesinger, professor of psychiatry in Berlin, read Falret’s piece and reflected about some of his own patients. In March 1868 Griesinger described to the local Society for Medical Psychology in Berlin a remarkable syndrome that he had never previously encountered, certainly not in the asylum patients that were the meat and drink of Berlin psychiatry, but not often in outpatients either: They were unable to keep themselves from asking silly questions in an obsessive and uncontrollable manner, even though they knew the questions—such as “why are there not two suns and two moons”?—were ridiculous. The behavior was definitely not part, he said, of “the customary depressive sensations of anxiety.” Two of the patients Griesinger had seen only briefly; a third, a young man of 21, he had gotten to know better. Griesinger also mentioned the latter patient’s susceptibility to paroxystic symptoms of somatic anxiety: “His sleep is troubled; the patient often has a ‘headache in his nerves,’ as he puts it, ‘from the continuous thinking and rumination.’ Now and then he feels his heart pounding.… Frequently a slight tremor of his facial muscles is apparent, more evident in his hands; not infrequently he has the sensation that his entire body is vibrating.” Griesinger believed the patient was making his symptoms worse with continuous masturbation, and adopted the patient’s own term, “Grü beln,” or obsessive rumination, as a name for the new syndrome.
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After Falret, this constitutes one of the earliest mentions of paroxystic anxiety as a symptom independent of melancholia or depression with somatic as well as mental symptoms.

There now emerged a series of reports on what was probably somatic anxiety. In 1871 Jacob DaCosta, a Philadelphia internist who had served as an army doctor during the Civil War, described “irritable heart,” a condition he had seen in many soldiers accompanied by “dizziness and palpitation, with pain in the chest.” The symptoms oppress the sufferers, who perceived cardiac “palpitations,” and fear they are about to die. The troops develop other symptoms as well, such as aphonia, “inordinate sweating,” and “dimness of vision and giddiness.” “Pain was an almost constant symptom, I cannot recall a single well-marked instance of the complaint in which it was wholly absent … It was generally described as occurring in paroxysms, and as sharp and lancinating.” The pulse was accelerated and the patients were short of breath. DaCosta believed that the action of the heart in these otherwise healthy young men was actually disordered, the organ enlarged. (He had no x-rays to verify his physical examination, and could only percuss the heart to determine its size.) DaCosta, bent upon demonstrating organicity and not hysteria in the troops, does not comment upon their mental states, but some sound anxious: Some had “smothering sensations.”
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(English cardiologist Thomas Lewis, who served as an army doctor in World War I, revisited in 1918 the subject of what he was now calling “soldier’s heart” and “the effort syndrome”; he implicated “neurasthenia,” and said, “A large proportion of the men are of highly-strung nervous temperament, an unusual number are sensitive or querulous, others are apathetic or depressed.”
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Therewith, irritable heart was on its way out.)

As we saw above, it was actually Brü ck who was among the first to describe a panicky fear of open spaces. But he did not name it, and he who names a phenomenon owns it. In 1872 Carl Westphal, 39 years old, associate professor of psychiatry in Berlin, described panicky responses to open spaces under the term “agoraphobia,” linking anxiety specifically to the sudden onset of physical symptoms. Westphal’s first patient, a traveling salesman of 32, was incapable of “traversing public squares. A feeling of anxiety overcomes him immediately as he tries it.” Westphal said the seat of the anxiety was more “in the head than in the cardiac region.” It was easier for him to navigate open spaces in company with someone else, so in the evening, to find his way home, he might chat up a prostitute for part of the way, then strike up a conversation with another to continue on, “gradually reaching his home.” He also reported a strong tremor in his hands during these “anxiety attacks” (Angstzufälle).

Westphal’s next patient, a young man of 24, also had “powerful feelings of anxiety” when attempting to cross public squares that caused “an ascending feeling of warmth beginning in his lower abdomen accompanied by cardiac palpitations.” The patient also reported “generalized tremor.” Neither patient had a mood disorder. Westphal discounted earlier reports that fear of open spaces was linked to dizziness, and called it a phenomenon of anxiety. He concluded that “In the preceding observations, I have called attention to a psychic symptom that is, in essence, a previously unknown general neurosis.”
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Westphal’s patients were otherwise not nervous. This was a big milestone in detaching anxiety—or at least the episodic form—from nervous illness and assigning it to the nervous breakdown.

Five years later, in 1877, Westphal, by now a professor of psychiatry in Berlin, made it clear that he was separating the new disease of “fear of public places” from traditional “nervous illness.”
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Animated by the criticisms of nationalistic colleagues that “agoraphobia” was too Latinate and that a solid teutonic expression was preferred, he now called the disorder Platzfurcht, fear of public squares; there was some back and forth between defenders of Brü ck, who thought fear of fainting in open places and other settings the essential, and Westphal, who found fear of open spaces themselves the essential.
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In 1877 Westphal also established as a general disease category, “obsessive-compulsive disorder,” in which he no longer considered anxiety the primary disturbance but a consequence of the illness. Westphal’s change of heart led to later views that “obsessive-compulsive disorder” (OCD) was not really an anxiety disorder at all, a view quite incompatible with the historical record.
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(In a rare reversion to tradition among the disease-designers, in DSM-IV, OCD ranks among the anxiety disorders.)

There is such a thing as anxiety without panic, and it, too, can occur in a paroxysmal rather than a continuous chronic form. English psychiatrist Henry Maudsley at the West London Hospital, who would shortly introduce the term “panic” into psychiatry (see below), in 1867 called this “paroxysmal anguish,” and associated it with melancholia.
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Yet it was the French who undertook systematically the parsing of anxiety into subtypes divorced from melancholia. This began a process that has reached its ultimate form today in dividing anxiety into microfragments that themselves have little credibility as independent entities but have turned out to be highly profitable for the pharmaceutical industry.

In 1875 Henri Legrand du Saulle, 45 years old and at the time an assistant physician at the famous training ground, the psychiatric clinic of the Paris Prefecture of Police, took the first step in this literature of exact description of anxiety by carving out obsessive thoughts together with a compulsive fear of touching things (La folie du doute avec d é lire du toucher). Legrand was quite immersed in the growing culture of interest in obsessive-compulsive symptoms in France in these years: He was a former student of Morel’s and a close friend of Jules Falret’s. Given the great tension that prevailed between France and Germany in these years—France had just lost a war to Prussia in 1871—he acknowledged a number of French forbears in the study of such disorders but did not mention Westphal. Legrand portrayed a malady that by stages went relentlessly downhill, ending in the social isolation of the victim who became afraid of contact with everything imaginable. At the Prefecture of Police he saw a lot of psychopathology, and some of that experience made its way into the pages of his 1875 book. But the relentless progression of the illness by clearly demarcated stages that he described came more from an obsession of the late nineteenth century with finding the iron laws of everything, whether economics (Marx) or evolution (Darwin). Legrand called it a “neurosis” (une n évrose), but otherwise it had little in common with the nervous syndrome. Legrand’s patients were plagued with anxiety, and he refers a number of times to their “anguish.” Of interest, however, is Legrand’s account of what sound very much like panic attacks in the second phase of the illness: the sudden onset of headaches, sweating, spasms, feelings of fainting, “and the turbulent excitation that ends in constituting a real morbid picture … that lasts from two to twenty-four hours, but more commonly five or six hours.” Legrand used the adjective “paroxystic” to describe the temporal course of the disorder.

Typically, Legrand’s patients realized that their obsessive thoughts and compulsive refusals were irrational: the girl of twelve, who believed that “all the objects at home were more or less impregnated and covered with cancerous matter [a person with a facial cancer had visited the home] recognized perfectly that her terrors had no basis, but she could not banish them from her mind.” (She recovered, in turn married and became a mother, and then was again visited by the same kinds of fears, this time of a “rabies powder” that supposedly enveloped her home.
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What separates anxiety definitively from the nervous syndrome is not really obsessive-compulsive thinking and actions, because nervous patients were subject to plenty of obsessing about their condition. It is rather the condition of panic, which occurs in discrete bursts and is overwhelmingly somatic, with pounding heart, sweating, and so forth. In 1890 É douard Brissaud, trained more as a neurologist than a psychiatrist (and at the time, at age 37, occupying the history of medicine chair of the Faculty), gave a formal description of panic attacks, which he termed “paroxystic anxiety.” (Anxiety for him was “intellectual anguish,” which is the modern distinction between somatic anguish and mental anxiety.) He reported a patient suffering from “l’anxi é t é paroxystique” who would arise in the night fearful that “he is going to die suddenly.” He has no chest pain or shortness of breath, “but he cannot stave off the presentiment of immediate death.” He also has daytime crises “of the same apprehension of dying.” His legs almost give way. “The thought that this crisis might occur at the moment when he is crossing a big street has caused him to adopt the practice of taking narrow streets.” But it is not agoraphobia because these crises recur in the middle of crossing even the little streets and passers-by have to assist him. For the past 5 years he has had “very violent cardiac palpitations with sharp intercostal [at the ribs] neuralgia accompanied by anguish and a tendency to faint.” “Since then, his palpitations have occurred in the paroxystic form and always accompanied by great anguish.”
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This is sometimes seen as the first formal description of panic attacks, but as we have seen, numerous observers preceded him avant la lettre. It is important that the transition from phobias such as agoraphobia to panic was seamless; at the beginning these shrewd observers discerned little difference between agoraphobia and panic. Later, these were to be sundered as separate conditions.