How Everyone Became Depressed (3 page)

Now let us put on our seven-league boots and vault ahead to the late 1970s. “Nerves” have now vanished, but the specific components of the package of nervous disease remain with us. Anxiety, for example, was still considered by many as part of a larger package. Katherine Halmi, a psychiatrist at the University of Iowa, told an advisory committee of the United States Food and Drug Administration in 1977, on the subject of using antipsychotic drugs in the treatment of anxiety, that “anxiety” could not be narrowly defined in the list of indications for a drug. “The thing that bothers me about this is that the patients that come for anxiety are not just anxiety patients . . . In some cases, they do have in fact discrete psychiatric diagnoses. In many cases, they do not.” The bottom line is that “Any patient who comes to a physician’s office does not have just anxiety.”
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So the understanding had continued that apparently specific terms such as anxiety were in fact markers for larger disorders. This is never spelled out in any official handbook of diagnostics, yet is clearly part of the profession’s operating rules. In the late 1980s, when the Eli Lilly Company in Indianapolis was developing Prozac, they constructed a “dictionary” of the exact meaning of symptoms that might be reported in the scattered trials. Charles Beasley, the Lilly scientist in charge of the Prozac program, later said, “The dictionary that was being used at the time contained distinct entities of ‘nervousness’ and ‘anxiety.’ And guess what? Getting any degree of agreement from amongst 10 psychiatrists on how you slice and dice these two terms or what the distinctions between them are . . . would be, I think, virtually impossible.”
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Thus, when many clinicians wrote “anxiety,” they thought “nervousness.”

Anxiety remained part of a larger package going into the 1980s. Authors David Goldberg and Peter Huxley, psychiatric epidemiologists, wrote in 1980, “Minor affective disorders—that is to say, anxiety states, minor depressive illnesses—account for the vast majority of [psychiatric] illnesses seen in a primary care setting.” Goldberg had done a survey of the symptoms of 88 patients “diagnosed as psychiatrically disordered” in several family practices in Philadelphia: 82% of them had “anxiety and worry”; 71% had despondency and sadness together with fatigue; 52% reported somatic symptoms; and 19% had “obsessions and compulsions.” There was indeed in Philadelphia a coherent syndrome of what we might call nervousness, although the authors preferred the label “conspicuous psychiatric morbidity of general medical practice.”
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Physicians of every epoch focus on the symptoms of nervousness that make most sense to them in terms of their larger theories. Fleury concentrated on fatigue and “nervous exhaustion.” Today, a medical community drenched in talk of “affective disorders” would see the sadness, insomnia, and phantom pain that Fleury mentions as evidence of major depression. The point is that the terms nerves and depression both tell us the same thing: The problem is not a disorder of mood; the problem is a disturbance of the entire body. But clinicians today are more conditioned to see the affective side than, let us say, the tar-ball stomachs, the early-morning vomiting and diarrhea, and the leaden fatigue of the somatic side.

By the 1970s, the term nervousness, grievously assaulted by psychoanalysis in previous decades, was almost extinct in medical diagnostics, although not in the minds of patients. We catch a last gasp in 1972 with a new set of diagnostic criteria put forward by the department of psychiatry of Washington University in St. Louis, a group of important clinicians known as the “St, Louis school.” Among the diagnostic criteria for “anxiety neurosis,” they specified “chronic nervousness with recurrent anxiety attacks . . . ”
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But the St. Louis group soon abandoned “nervousness” as they moved into the language of mood disorders centering about “depression.”

Now, in switching from nerves to mood diagnoses such as depression, the idea was that depressed people are basically sad, rather than having wholebody diagnoses. The essential concept of a mood disorder is that your mood is either euphoric, as in mania, or sad, as in depression. Yet depressed mood is often not present in depression as the term is used today (see also Chapter 11). As Philadelphia psychiatrist Aaron Beck discovered in the 1960s: Of patients with mild depression, only 50% had a dejected mood; of those with moderate depression, 75% had it.
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These are the great majority of depressions. So moving the spotlight from nerves to depression has illuminated a large number of people who are not sad at all, but are discouraged, or unhappy, or uncomfortable. All these people, however, are encouraged to think that they have a mood diagnosis called depression and that their moods are down. As Max Hamilton, the great English student of mood disorders, said in 1989 of patients with depression and anxiety, “Not all of these have a depression of mood. In a sense, we have the paradox of depression without depression.”
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The frequency of nervous illness gave its stamp to an era. Robert Musil, the great Viennese novelist who in 1930 composed The Man Without Qualities, spoke of “a nervous age” (ein nervö ses Zeitalter).
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And the ranks of the nervous were indeed numerous.

There are formal epidemiological data. One German epidemiological survey conducted in 1935–1938 found the “nervous” to number about 9% of the population of a rural area. Of the 284 nervous individuals identified in a door-to-door count, 74 also had organic illnesses; 59 had a “neurasthenia” that was “not immediately conspicuous”; and 13 had “nervous disorders of a clearly psychogenic nature.” Of the nervous, a further 50 individuals had thyroid problems (thyroid difficulties can have psychic ramifications). The nervous were thus almost one in ten.
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In rural Sweden in 1947, the lifetime incidence of the population suffering from “neurosis” was put at 7.0%.
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A survey of morbidity in general practice in England in the mid-1950s estimated the prevalence of “psychoneurotic conditions” as about 7.4 per 100 population.
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These studies are not readily comparable but they do indicate that those suffering from nerves in one form or another represented a not inconsiderable share of the population.

There was a reason that German psychiatrists were called “nerve doctors” (Nervenä rzte), and when they left the asylum for community practices, it was nerves and not insanity that they saw. In 1882, Conrad Rieger, a psychiatrist in Würzburg, tried to advise his colleague Emil Kraepelin, then in Leipzig (who was shortly to become world famous for devising the diagnoses “dementia praecox” and “manic-depressive disorder”), about how to plan Kraepelin’s future career. “As near as I know the situation in Leipzig, you would have, as an assistant at the university psychiatric outpatient clinic, a good opportunity to found a private psychiatry practice on the side. Erb [Wilhelm Erb, director of the outpatient clinic] would probably try to give you a boost rather than make things difficult, and the whole business would be just terrific for you. You’ve actually seen enough ‘mentally ill patients’ in Munich [where Kraepelin earlier worked at the Munich asylum]. And I’m finding increasingly that it’s precisely the middle classes, that one never sees in an asylum, who are very common in a private nervous practice.”
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In Britain, the ranks of the nervous were legion. In 1968, at a conference at McGill University celebrating the 25th anniversary of the founding of the Department of Psychiatry, London psychiatrist Stephen Taylor (later Lord Taylor) described community nervousness. In 1959, he and Sidney Chave had done a survey: “We found, among people who were not necessarily attending their doctors, a sub-clinical neurosis syndrome. The symptoms, which tend to cluster, are: mild depression; undue irritability; ‘nerves’ or excessive nervousness, and insomnia. This group constitutes about 30 per cent of the population.”
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Nervousness also seemed quite well represented in the United States. When Herbert Berger began practicing family medicine in the early 1930s in “a semirural community,” he said that he had “the certainty that I lived in a belt of inbred neurotics . . . It felt fairly certain that the residents of my community had intermarried (with some poor stock to begin with) and that this explained the large number of functionally incompetent individuals whom I met.” But now on Staten Island in 1956 as an internist, Berger said, “I see even more neurotic personalities.” “Gradually I have come to recognize that these individuals never wish to be told that they are just nervous. The word ‘imagination’ is anathema to them for they are certain that they are seriously ill, and they expect and demand that the physician treat their disease with considerable respect. It is often necessary to medicate these people.” The remark lets us understand why the flood of psychoactive drugs—Miltown (meprobamate) being the first blockbuster in 1955—was received with such gratitude by community physicians. In rural New York, and on Staten Island, nervousness was as common as in rural Germany. Berger had to explain to his patients time and again that “This is not insanity and that nervous individuals never become insane.”
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Today in the United States, epidemiological surveys conducted on a doorto-door basis by the federal government at the national level show that about one American in seven is “nervous,” whereby respondents were left to define nervous themselves: In 2010 19.4% of the population told interviewers they had “nervousness either all of the time or some of the time” (18.0% of the men and 20.6% of the women): one woman in five!
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For people in general, the concept of nervousness remains very much a reality.

It is much better, people think, for the nerves than the mind to be ill. The nerves are physical structures, and heal in the way that all integuments of the body heal naturally. Disorders of the mind are frightening because they are so intangible, and, we think, may well lead to insanity rather than recovery. From time out of mind, people have privileged nervous illness over mental illness.

From time out of mind, societies have had expressions for the varieties of frets, anxieties, and dyspepsias to which the flesh is heir. In France and England in the seventeenth and eighteenth centuries, one term was “vapours,” a reference from humoral medicine to supposed exhalations of the viscera that would rise in the body to affect the brain. A major apostle was London physician John Purcell, writing in 1702, of “those who have laboured long under this distemper, [who] are oppressed with a dreadful anguish of mind and a deep melancholy, always reflecting on what can perplex, terrify, and disorder them most, so that at last they think their recovery impossible, and are very angry with those who pretend there is any hopes of it.”
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He emphasized melancholia and anguish, and for him the “vapours” were something more than a mild attack of the frets.

But this was not for everyone. Lady Mary Wortley Montagu, now 60 and living in exile in Italy, described to her estranged husband in 1749 Italian health care arrangements, and how physicians visited rich and poor alike. “This last article would be very hard if we had as many vapourish ladies as in England, but those imaginary ills are entirely unknown here. When I recollect the vast fortunes raised by doctors amongst us [in England], and the eager pursuit after every new piece of quackery that is introduced, I cannot help thinking there is a fund of credulity in mankind … and the money formerly given to monks for the health of the soul is now thrown to doctors for the health of the body, and generally with as little real prospect of success.”
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In a similar tone, Louis Sé bastien Mercier, a late-eighteenth-century French litt érateur, mocked the “vapours” of the society women: “Our doctors, accustomed to taking the pulse of our pretty ladies, now see only the vapours and nervous illnesses … A pretty woman with the vapours does nothing other than drag herself from her bath to her toilette, and from her toilette to her couch.”
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Vapours released their grip only slowly. In 1821, French psychiatrist Étienne-Jean Georget deplored that medical writers were still using the term “vapeurs,” rather than the modern expressions hysteria and hypochondria that Georget favored.
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But then vapours went out of style. The great term for neurological and psychiatric illness of a nonpsychotic nature that dominated public and medical profession alike from the mid-eighteenth to early twentieth century was “nervous illness,” implicitly assuming that mental symptoms were reducible to the nerves of brain and body as explicitly neurological symptoms.

The term “nervous diseases” reaches way back in medicine, without any particular author taking priority for first describing them. In 1602 Felix Platter, the official physician of the city of Basel, described a patient who had a lip pain so intense that it felt as though a “red-hot iron” was burning him. Platter noted “that such conditions come from the nerves, and that some nervous disorders [Nervenleiden] are capable of inflicting chronic distress without there being otherwise the slightest hint of disease, is amply illustrated in my practice.”
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But it was unquestionably Oxford physician Thomas Willis who in his 1667 work Pathologiae Cerebri, translated into English in 1684 as An Essay of the Pathology of the Brain and Nervous Stock, introduced the concept of the nerves to academic medicine in a rigorous scientific way as a cause of disease: through autopsies. On the causes of epilepsy, he wrote, “As to the places affected, for the seat of the irritative matter, although this brings hurt in any part of the nervous system, yet for the most part, it is wont to become most infestous [troublesome], when it is fixed near the beginnings or the ends of the nervous system, or about the middle processes of the nerves … ” How wrong other observers had been! “I know that very many ascribe these convulsive passions … to the vapours rising from the spleen: but it seems much more reasonable to deduce them from the convulsive matters laid up within the brain, and rushing upon the beginning of the nerves.” Thus, the “passions commonly called hysterical” originated in the head, not the uterus.
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Willis’s easy use of the adjective “nervous” gave rise to the term “nervous disease.” As early as 1739 we find London society doctor George Cheyne trying to convince the novelist Samuel Richardson that his various nervous flutterings were not evidence of a grave disease. This is before Richardson lapsed into frank melancholia. Cheyne: “Your noise in your ears is a common symptom of nervous Hyp and of no possible consequence.” (“Hyp” was another term for nervous ailments.) Later that year: “All your complaints are vapourish and nervous, of no manner of danger, but extremely frightful and lowering.” Richardson’s friend Mrs. Leake had sent to Cheyne a portion of a letter by Richardson that reflected, Cheyne told Richardson later, “the pain, anxiety, and discouragement your symptoms give you.” But take heart: Such symptoms, “I must sacredly assure you, are merely nervous and hysterical.” Later in 1742 Richardson’s “dejection and lowness” had reached such a state that Cheyne cautioned him, “Nothing hurts weak nerves so much as melancholy stories and despondency.” “If you would honestly have my opinion about the cause and origin of your disorder I take it you were born originally of weak nerves.” Cheyne’s wise advice might have echoed down the ages: “You will be sometimes better and sometimes worse. You will be a constant weather machine, and this last plunge has been entirely owing to this boisterous, moist, and rainy season. Every single individual of my nervous patients have suffered, some more, some less, and I myself to a very considerable degree, but all without danger [of death].”
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The concept of nervous disease—to mean the aggregation of mild depression, anxiety, fatigue, somatic complaints (such as Richardson’s tinnitus, or the ringing in his ears), and obsessive preoccupations—was thus well established within London society by the early 1740s.

In 1765 Robert Whytt, professor of medicine in Edinburgh, then the most distinguished medical center in the world, shifted the academic discussion from vapours

to nerves. In a work that, for its comments on the “sympathy of the nerves,” continued his efforts to lay the basis for modern neurophysiology, Whytt offered observations on “those disorders which have been commonly called nervous, hypochondriac, or hysteric.” He said that the term “nervous” had previously been applied to “almost all the complaints to which the human body is liable.” Whytt had a different, much more limited conception: “ … It is only proposed to treat of those disorders, which in a peculiar sense deserve the name of nervous, in so far as they are, in a great measure, owing to an uncommon delicacy or unnatural sensibility of the nerves.”
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This was the true intellectual founding of the concept of nervous disease.

Several years later another Edinburgh professor, William Cullen, placed the concept of nervous in the context of diseases in general. In his general classification of all diseases, or nosology, entitled First Lines of the Practice of Physic, published initially in Latin in 1769, 4 years after Whyte’s work, he described “neuroses or nervous diseases,” including neurological afflictions such as apoplexy and palsy, but also “hypochondriasis, or the hypochondriac affection commonly called vapours or low spirits.” Describing a mixture of depression, anxiety, and apprehension of illness, he wrote in the English edition that appeared some years later, “In certain persons there is a state of mind distinguished by a concurrence of the following circumstances: A languour, listlessness, or want of resolution and activity with respect to all undertakings; a disposition to seriousness, sadness, and timidity; as to all future events, an apprehension of the worst or most unhappy state of them; and therefore, often upon slight grounds, an apprehension of great evil.”
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Hypochondriasis is one of those old-fashioned terms for low mood, in addition to its modern meaning of unreasonable fear of illness, and what Cullen had done here was to draw together the various skeins of what would later simply be called nervous illness.

Nerves began very much as an Edinburgh concept. In 1769 Edinburgh physician William Buchan, together with William Smellie, then a medical student and later a famous obstetrician, helped bring the diagnosis of nervous disease to the great public in one of the most successful medical advice manuals of all time, Domestic Medicine, or, a Treatise on the Prevention and Cure of Diseases. He told his breathless readers that “nervous diseases … generally begin with windy inflations or distentions of the stomach and intestine; the appetite and digestion are usually bad … Excruciating pains are often felt about the navel, attended with a rumbling or murmuring noise in the bowels.” What else? Pains all over: “flying pains in the arms and limbs; pains in the back and belly … ” Then came the mental part: “Alternate fits of crying and convulsive laughing; the sleep is unsound and seldom refreshing … As the disease increases … the mind is disturbed on the most trivial occasions, and is hurried into the most perverse commotions, inquietudes, terror, sadness, anger, diffidence, etc. The patient is apt to entertain wild imaginations, and extravagant fancies; the memory becomes weak, and the judgment fails. Nothing is more characteristic of this disease than a constant dread of death.” So nerves were a serious business, and nothing to trifle with.
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Patients in their turn embraced the diagnosis of nerves because it sounded modern and up to date, unlike those hoary old humoral terms such as hypo and spleen. Nerves seemed medical—the nerves are organic structures—and it is probably close to a general rule that patients prefer organic-sounding diagnoses to mental-sounding ones. (In the United Kingdom today, individuals who cluster together in support groups to complain of fatigue refer to their condition as “myalgic encephalomyelitis,” or “ME”—inflammation of the brain and spinal cord causing muscle pain—rather than as chronic weariness.) In 1786 Mary Wollstonecraft, then 27 and not yet embarked upon the literary career that would make her famous as an early champion of the rights of women, wrote to her sister, “A whole train of nervous disorders have taken possession of me—and they appear to arise so much from the mind—I have little hopes of being better.” A bit later that year she wrote that “My nerves are so impaired I suffer much more than I supposed I should do, I want the tender soothings of friendship.” In 1788, now in London and actively writing, she complained to a friend of “the return of some of my old nervous complaints … A nervous head-ache torments me, and I am ready to throw down my pen.” By this point, she had evidently abandoned a mental theory of her sufferings in favor of a somatic one: “Nature will sometimes prevail, ‘spite of reason, and the thick blood lagging in the veins, give melancholy power to harass the mind; or produce a listlessness which destroys every active purpose of the soul.” Again, Mary Wollstonecraft showed every evidence of a typical nervous illness: She was downcast, anxious, fatigued, and had a somatic “headache.”
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Thus did the illness attribution nerves spread among the British upper class. In 1811, George Gordon Byron, Lord Byron, then 23 years old, wrote a pal from Cambridge, “I am growing nervous (how you will laugh!)—but it is true,—really, wretchedly, ridiculously, fine-ladically nervous. Your climate kills me [writing from Newstead Abbey]; I can neither read, write, or amuse myself, or any one else. My days are listless, and my nights restless; I have very seldom any society, and when I have, I run out of it.… I don’t know that I sha’n’t end with insanity, for I find a want of method in arranging my thoughts that perplexes me strangely; but this looks more like silliness than madness.”
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Thus Byron exhibited a bit of dysphoria, some anxiety about madness despite a bluff front to a college buddy, and insomnia with his restless nights. Byron was quite correct about his nervousness: Today we would call it depression, but nerves is a better diagnosis.

Elsewhere, nerves had an equally brilliant course, though it was only the name that was new, not the symptoms. In Germany, the young Franz Baader, later to become a famous Roman Catholic philosopher, confided to his diary the morning of April 13, 1786, “On awakening I felt myself rather leaden and apathetic, but calm. I blame the increased sensitivity and weakness of my nervous system, which these days I so notably feel. [He also blamed his dietary fasting]. I read some of the [poet] Klopstock’s odes, but became totally out of sorts since my spirit was, rather unusually, not able to soar along.”
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In some of these passages we detect the romantic spirit of the day, and the moods of the young romantics were highly changeable. Yet it is interesting that, unlike earlier times, they now indicted their nerves.

The Marquis de Sade put a positive spin on nerves. In 1801 we encounter his great fictional heroine, the dominatrix Juliette, who unlike the poor martyred Justine, triumphed over all her male and female sex partners before, following her usual wont, killing all the participants in the scene. Juliette is talking with an equally fearsome female companion named Clairwil. They are discussing poisoning all the participants in an episode of group sex.

Justine: “Most assuredly I will follow your lead, Clairwil. I have always loved the idea of poisons.”
Clairwil: “Ah, my angel. It is delicious to dominate over the lives of others.”
Justine: “For sure I’m going to come all over the place when this happens [une grande jouissance], because at the very moment when you first spoke to me of this plan, I felt my nerves vibrate. An incredible fire seized their mass, and I am sure that if you touch me, you will see that I’m totally wet.”
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