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Authors: Edward Shorter

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Nerves as a Problem

Motto: “Once upon a time I was falling in love Now I’m only falling apart.”
Bonnie Tyler, “Total Eclipse of the Heart”

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, often 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.”
2

The Nervous

The term symptom cluster is popular today,
3
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.” This distinction between insane and noninsane illness has existed for many years. Parisian psychiatrist Jules Falret said of the diagnosis hysteria—meaning excessive emotional lability—in 1866, “It’s a nervous disorder not a form of insanity.”
4
Nerves and psychosis are separate concepts. Historically, the label nerves has not always been used, although it has a sturdy pedigree reaching back into the eighteenth century. Symptoms of nerves include tiredness, anxiety, mild depression, compulsive thoughts and actions, and a rash of physical complaints without an obvious organic cause. Some of these are frankly psychiatric, such as mild anxiety and depression (the severe forms of both seem to be different illnesses entirely). Some relate to the physicality of the body, such as somatic symptoms of fatigue, pain, ill-functioning bowels, and the like. Not all patients will have all five domains, given the enormous variability from person to person that exists in subjectivity. Indeed, it is quite possible to feel just uncomfortable in nervous illness, without being anxious or depressed. Yet the presence of this five-pack of symptoms across the ages is quite constant, although the attention of physicians and patients at any point in time may be focused on one or the other.

It was thus a bit like assembling an Easter basket. A nervous patient would have a symptom from each of several domains. Here is Maurice de Fleury, a 44-year-old Parisian psychiatrist, describing in 1904 the “neuropaths” in his extensive private practice:

They come through the door and announce themselves: “Docteur, je suis neurasth énique.” Doctor, I’m neurasthenic. The patient might take from his pocket the papers on which he has written down all his symptoms. This was the kind of patient that Jean-Martin Charcot, the great Parisian neurologist, had called “l’homme aux petits papiers,” or “the patient with the little slips of paper.”

What’s the matter with the patient?
The first symptom, said Fleury, is “profound lassitude.” “His legs scarcely hold him up.” Fleury said there was a kind of “chronic sadness of those with nervous exhaustion, which is only the vague and confused awareness of their state of physiological misery and functional lassitude.”
Then the neuropath suffers sleeplessness: “The nights are deplorable.” He has trouble falling asleep, is “torpid” with the digestion of the evening meal, and then awakens toward midnight.
On the somatic side, “The pains that plague the neurasthenic are infinitely variable,” said Fleury. And the digestive tube: “Frequently those with nervous exhaustion are subject to stubborn constipation and, following, to muco-membranous enteritis,” a popular diagnosis in which patients believed they could identify “membranes” from the gut in their stools.
In terms of frank psychiatric symptoms, said Fleury, “things are in disarray. Their memories have lost in precision. Some patients have lost almost completely their memory of numbers, and proper names, and are subject to obsessive thoughts. I know some who go back up their five sets of stairs two or three times to reassure themselves that they have locked their door.”
Fleury likened neurasthenia to what he called “baby sister” melancholia. Melancholia, like neurasthenia, had depressive and anxious forms. He described a borderland between the two diagnoses as “serious anxious neurasthenia, with progressive wasting, obsessive thoughts, self-accusations, and quite close to melancholia” (for which Fleury used the older French term “lypemania”). “Melancholia can supervene, and push the patient to suicide.”
5
Thus we are not just dealing with self-centered middle-class people who eat too much and are tired all the time despite spending their days sitting down. These are serious though nonpsychotic disorders and it is important to bear in mind that these patients have real illnesses and are not just victims of “medicalization,” or the conversion of normal sensations into medical diagnoses. Fleury was typical of many writers on neurasthenia: It was an illness that drew upon the entire body in different domains, not at all just a mental illness.
What did the concept of nerves mean to Marion D, 49, a patient of Frederick Parkes Weber, a fashionable consultant on Harley Street in London’s West End? On July 27, 1906, she saw Parkes Weber because of headaches “for the last five years.” As well, “A great trouble is ‘nervousness,’ worst between 4 and 5 pm . . . Very often she has feelings of depression, but commonest— she gets neurasthenic ‘irritable weakness’—Sometimes she goes 3 days without these feelings—such attacks last hours.” “Patient used to have nervous feelings at night—for instance, that if she went to sleep she would never wake up again. (This was owing to feeling so weak and wretched—no real delusion.)” Parkes Weber’s diagnosis at this point was “climacteric neurasthenia, with vascular excitability.” (Climacteric means menopause.)
Six months later, in January 1907, he saw Marion D again. “She feels giddy and muddled in her head and dreadfully ‘tired.’ . . . She says the urine has been rather thick. Bowels regular.” Parkes Weber changed her medications from bromides and valerian to Ichthyol pills (ammonium bituminosulfonate, now used as a skin cream).
Alas, the change in medication was for the worse. When she returned again in April 1907 Parkes Weber noted that “[She] mentally feels wretchedly, depressed and weak and has no energy.” Later that year, she moved on to a private sanatorium in Buxton, and Parkes Weber lost her from view.
6
Marion D was a splendidly ordinary example of the nervous patient. She experienced crushing fatigue, was mildly depressed, terribly anxious about waking up in the morning and in her late-afternoon episodes of “nervousness,” and reported somatic symptoms of various kinds such as headaches. Parkes Weber does not mention obsessive thoughts but the entire story has an element of obsessiveness as she fretted about her nervousness and her medications. She was neither psychotically depressed nor anxious, and suffered, as far as she herself was concerned, from “neurasthenia.” Almost all his patients also obsessed about which continental watering places they should visit, and Parkes Weber, a specialist in balneology, seconded these ruminations with claims about the supposed virtues of Plombi ères versus Bad Homburg.
By the 1920s, terms such as “neurasthenia” had gone out of style (“tired nerves,” oh dear); rocketed by psychoanalysis, “neurosis” was coming into style. Yet plenty of nonanalysts found the term neurosis useful for patients who were troubled but did not have a major mental illness. Angelo Hesnard, professor of nervous diseases at the French naval medical college, distinguished between—the French here is so delicious that I’m going to use it“les petits n évropathes” and “les grands n évropathes.” “Les petits,” the patients with lesser neurotic illnesses, would never consult a psychiatrist but were treated in family medicine, or self-treated, and had a variety of nonorganic complaints. Hesnard furnished a list of all the illnesses they thought they had but did not: heart, gut, kidney, liver, and so forth. “Les grands n évropathes,” by contrast, had serious obsessional ideas about health and would likely be treated in private nervous clinics—which then abounded in Europe. But they were not “insane” in the classical sense, and would not be found in psychiatry textbooks.
7
What did these neuropaths, or neurotics, really have? Hesnard said they could be broken down into several main groups, and it is these groups that guide us in much of our analysis: First came the fatigued, formerly known as the neurasthenic, a term that by the 1920s by going out of style but was a mixture of tiredness and dysphoria; then there were the anxious, with their “neuropathic anguish” (a term for somatic anxiety); Hesnard included the obsessives and the phobics; finally, those with “hysteria,” a term that I do not find useful but that in the 1920s meant more or less physical symptoms caused not by lesions but by the action of the mind. This schema could be simplified even more for the general practitioner; as Joseph Collins, a neurologist at the New York Post-Graduate Medical School, put it in 1909: “Finding the patient lachrymose and emotional, he calls the disorder hysteria; if depressed and inert, he calls it neurasthenia.”
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These are the five domains that add up to the concept of nerves and nervousness: (1) pathological fatigue, not just tiredness at the end of the day but nervous exhaustion; (2) mild depression, by which is meant nonmelancholic depression; melancholia is another kind of depressive illness entirely and is considered in Chapter 6; (3) mild anxiety, by which is meant, nonpsychotic anxiety; the latter, again, is a different illness; (4) somatic symptoms, such as chronic pain, insomnia, and disordered bowel function; and (5) some variation of obsessive thinking, the mind dwelling on certain themes even with the realization that this behavior is irrational. In 1913, the great German psychopathologist Karl Jaspers said that obsessive thoughts (Zwang) were present in all pathological psychic processes,
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and indeed this domain of obsessiveness is part of the larger package of nervousness. These five domains represented an illness entity that exists in Nature and cuts Nature more closely at the joints than do notions such as major depression and general anxiety disorder today, which are considered to be independent illnesses. It is important to mention that these five domains cannot be boiled down to the concept of a mood disorder.
It is in the context of these domains that we are better able to situate depression, which is on the face of it a mood disorder not a disorder of the whole body. Depression means low mood, and the term has been in use for at least two centuries. Here is Clara Bloodgood, an actress who in 1908, playing the leading role at the Academy Theater in New York in Clyde Fitch’s comedy “The Truth,” committed suicide in her hotel room. “She was always extremely nervous,” said her manager. The newspaper account ascribed her death to a “nervous breakdown.” But it was William Courtenay, her leading man, who invoked the “d” word: “Of course, I know that Mrs. Bloodgood was subject to spells of nervous depression,” he said. Today, the headline would read depression (although newspapers have stopped putting supposed mental states in the headlines of suicide stories). But Mrs. Bloodgood was laughing and gay hours before her suicide, and was not clinically depressed in any meaningful sense.
10
She was nervous.
None of these various domains of the nerve syndrome include psychosis, meaning loss of contact with reality in the form of delusions and hallucinations. The presence of psychosis automatically changes the frame and we are no longer dealing with nerves. One English psychiatrist in 1854 was describing a female patient, formerly very ill with “insanity,” who now had recovered and was working usefully around the asylum but from time to time experienced the odd auditory hallucination. “The patient knows that she has a nervous disease and consequently is no longer insane.”
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Among experienced clinicians, the view predominated that the neuroses (when used in a nonpsychoanalytic sense meaning nervous illnesses) were a completely different breed of animal from the psychoses. Lothar Kalinowsky, trained in the German tradition, with years of experience in the university psychiatric clinic in Rome behind him (as a Jew, he had fled Germany to Italy), ended up by 1944 as a staff psychiatrist at the New York State Psychiatric Institute. With this vast wealth of experience, his view of the complete difference between neuroses and psychoses is interesting. In a discussion in 1944 he noted that patients with “anxiety neurosis” responded poorly to electroshock treatment, but those with “agitated depression,” meaning melancholia, responded splendidly. “[This] is another argument in support of the opinion that the neuroses and the psychoses have a different basis. I do not think a typical anxiety neurosis ever passes over into the psychotic picture of an agitated depression.”
12
The distinction between nerves and insanity is therefore an important one.
Nervous illness was like a bucket of water: It is pointless to draw lines in it or make sharp demarcations. All the domains flooded together. Hesnard was leery of too much classifying because deep down there was a kind of “unity of the neuroses,” rooted in our “affective,” or emotional, life.
13
Many asylum psychiatrists had a similar unitarian perspective. They discussed “the unity of the psychoses,” the idea that there was really only one underlying form of psychotic illness, but that it went through different stages. This was known in German as “Einheitspsychose,” or unitary psychosis. Hesnard did not coin the term “Einheitsneurose,” but he might well have. (Of course, it was the last thing he would have done because in these years French and German physicians were at daggers drawn.)
For some writers, the concept of nervousness implied a kind of psychic precursor, or stem cell, from which specific diagnoses arose. Oswald Bumke, professor of psychiatry in Munich, said in 1924 that neurasthenia, or constitutional nervosity, an inborn state of nervousness, “represents the primeval muck from which all functional psychoses [severe illnesses] are differentiated.”
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According to this concept, nervous illness was not a specific diagnosis but rather a constitutional substrate from which specific symptom patterns evolved. The idea is appealing and over the years has had great resonance among those who believe in genetically determined constitutions.
Yet nervousness is not just a predisposition, as Bumke believed, but a specific syndrome. Historically, it seems clear that fatigue, anxiety, mild depression, somatic symptoms, and obsessive thoughts held together in a continually recurring pattern, and that the term nerves or nervousness refers to this package, or syndrome. I just want to introduce this concept here; it will be elaborated on later. A big point now is that we cannot be overly precise in this domain because the different symptoms and syndromes blend together, now one, now the other catching the light. As Columbia psychologist Joseph Zubin once said, “Only in mathematics can definitions be foolproof and rigid. In biology rigidity of definition falls by the wayside, and the power of the defined concept to integrate observations becomes the criterion of a good definition.”
15
So in nerves we are integrating observations about various behavioral domains into a larger concept, however uncrisp at the edges the image may be.

BOOK: How Everyone Became Depressed
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