How Everyone Became Depressed (7 page)

But fate took a different turn. There was news from Parkes Weber’s father, Sir Hermann: In January 1908, while stopping at the Grand Hotel in the French spa of Grasse, Reverend X had a “nervous breakdown” and in a private clinic on the French Mediterranean coast was administered the Weir Mitchell “cure”; in his notes, a skeptical Parkes Weber put “cure” in quotation marks.

Su fficiently restored to travel to America, Reverend X returned from his travels in October 1908 and came to see Parkes Weber. Apparently America had not gone well, and the Reverend “spent part of the time in bed.” He was now gripped with somatic complaints. Noted Parkes Weber in the Reverend’s chart: “Mr X is an example of the ‘neurasthenic’ or ‘asthenic’ constitution (probably with a certain amount of gastroptosis etc [a supposed sinking of the stomach in the abdomen] and some ‘American neurasthenia’ superadded.”

Reverend X drifted from spa to spa, taking a “quack remedy” called “Antineurasthin,” and experiencing at the German watering-place Bad Nauheim a “nerve storm.” Things went decidedly better after Reverend X tried what Parkes Weber referred to as “some new sedative,” but that was, in fact, one of the powerful new barbiturates, Medinal (barbital), that had recently been introduced in England. Yet sedation is not a cure, and the Revered X, over an illness trajectory that lasted yet a decade, continued to suffer “feelings of nervous exhaustion” and other flutterings.
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Parkes Weber, a kind man and generous with his patients, did not see medicine as a business but as a science, and several eponyms are associated with his name (for example, Rendu Weber Osler disease, or hereditary hemorrhagic telangiectasia). He certainly did not regard himself as a psychiatrist, nor did he use psychiatric lingo in his chart notes.

Yet contributing to the ultimate decline of the diagnosis of neurasthenia was its increasing association with psychiatry. As London psychiatrist and medical historian Simon Wessely points out in his overview of the history of neurasthenia, the disorder went out of style as a diagnosis because it lost its organicity, and became transferred from “central nervous” models to psychological models.
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Neurasthenia occupied an increasingly prominent place in psychiatry textbooks. This was a literature written by psychiatrists, not neurologists or electrotherapists. Maurice Dide and Paul Guiraud were both clinicians at the Braqueville mental hospital in Toulouse. Their guide to psychiatry for the family doctor, published in 1922, makes neurasthenia sound very close to depression, with its psychomotor slowing and its sensations of “ennui.” “This volitional distaste for acting and reacting is well translated by the English word spleen,” they noted. “Although the neurasthenic is often dismissed as a ‘malade imaginaire,’ it would not be accurate to reduce this syndrome to the exaggeration of a thousand small psychological miseries which, normally, pass unperceived. His suffering is real and involves a state of nosophobic preoccupation [fear of disease] that is continually reactivated.”
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This does not sound like “exhausted nervous centers.”

Simultaneously with its englobement by psychiatry, neurasthenia began to leech out of family medicine. In 1921, Tom Williams, a District of Columbia neurologist, writing for an audience of family doctors, found neurasthenia a useless term; the patient’s symptoms could almost always be attributed to some physiological or psychic cause.
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The typical family doctor who is dealing with nonorganic illnesses, said German psychiatrist Kurt Schneider in 1933, “calls the male cases neurasthenics, the female cases hysterics; or the doctor calls the patients whom he finds unsympathetic on a human level hysterics, and the people he finds sympathetic and wants to treat as ill, neurasthenics.”
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The term had become effectively deorganicized.

Neurasthenia came to divorce itself from the notion of nervous disease as something encompassing the entire body and started to refer solely to a disturbance of affect, hovering in a disembodied manner in the space of the mind without physical attachment to the rest of the body. Among academic English neurologists at the National Hospital for the Relief and Cure of the Paralysed and Epileptic at Queen Square in London, neurasthenia was assimilated to the “psychoneuroses” by 1932; the term disappeared after 1941.
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Outside of psychiatry, progressive figures such as English neurologist Farquhar Buzzard had started to decompose neurasthenia into depression and anxiety. In 1930 Buzzard, who had just become Regius professor of medicine at Oxford (and who as all neurologists in those days saw many psychiatric patients in his private practice), said that “ … out of any 100 patients sent or brought to me suffering from depression, insomnia, loss of concentration, and fatigability, 99 are labeled neurasthenia or neurosis, and perhaps one a possible manic-depressive psychosis. After investigation the proportion is probably fifty-fifty.” (The other fifty being not neurasthenia but anxiety neurosis.) He proposed the term “autonomous depression” to describe those patients “in the dump of neurasthenia.” The two alternative diagnoses to weigh, said Buzzard, were anxiety neurosis and autonomous depression.
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Yet despite the doubting neurologists, in psychiatry, neurasthenia soldiered on, possibly because of the sanctity Freud had lent the term in 1898 by calling it one of the “actual neuroses,” unlike the “psychoneuroses,” actual meaning caused by current events rather than anomalies in early childhood development; Freud considered neurasthenia the result of masturbation and coitus interruptus.
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(Yet Freud himself took little interest in the diagnosis and many of his followers pooh-poohed it entirely.
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) Neurasthenia survives even today in the international classification of diseases (ICD) of the World Health Organization, where it is ranked among the “neurotic, stress-related and somatoform disorders” (the WHO distinguishes among a variety caused by mental effort and another associated with physical weakness, and insists that it be differentiated from asthenia, burn-out, malaise, and psychasthenia, among other diagnoses.
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None of these possibly quite valid diagnoses exists in American psychiatry! It will be interesting to see if these diagnoses escape alignment with the DSM in future editions of the ICD series.). Neurasthenia appeared in the second edition of the Diagnostic and Statistical Manual of Mental Disorders (“DSM”) of the American Psychiatric Association, published in 1968, as “neurasthenic neurosis (neurasthenia)”; this DSM edition also featured an “asthenic personality”; neurasthenia vanished from American psychiatry thereafter.
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Neurasthenia ebbed in the public discussion as well. It never amounted to much in the press. The first reference to it in the headlines of the New York Times occurred only in 1898: “Boy Ate a ‘Whisky Biscuit’: Young Samuel Guttman Suffers from Neurasthenia for His Experience.”
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The decade before World War I saw a few more mentions, likewise a few after the war, the last being in 1935 (“Sir John Collie Dead; Neurasthenia Expert”).
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The Timesgot much more excited about nervous breakdowns (see Chapter 7).

In international psychiatry, however, neurasthenia has led a robust existence almost to the present as a synonym for minor affective disorder, or minor depression, in contrast to melancholia, which is very serious depression. We in the United States do not have the concept of minor depression, because all acute depressions are “major depression.” Nor do we have the termminor depression— because the insurance companies will not pay for anything minor. So American nervous disorders have always tended to be Texas-sized, bigger than what they are. But at an international level, as stated, neurasthenia cuts still quite a figure.

The most severe form of neurasthenia was nervous exhaustion, a synonym for nervous breakdown; it was several orders of magnitude more severe than garden-variety neurasthenia, or nervous illness. To qualify for admission to the Homewood Retreat, a private psychiatric hospital in Guelph, Ontario, led by psychiatrists, someone would have to be fairly ill. Cheryl Warsh has tabulated the symptoms of the patients admitted with neurasthenia between 1883 and 1920; of their 687 symptoms, 12.6% of the total were melancholic in nature, the most frequent kind of symptom. Almost 7% displayed delusions. Many others hallucinated. Only 2.9% of the symptoms were “fatigue or weakness.”
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Although the Retreat apparently did not use the term nervous exhaustion, these are the patients who would qualify for it: psychotic, melancholic, and incapable of dealing with the stresses of normal life, in other words, the kind of nervous breakdown called nervous exhaustion.

In understanding the relationship between simple nervous disease and nervous exhaustion, there are two traditions. One was established by Beard himself, who considered nervous exhaustion to be synonymous with neurasthenia. This tradition viewed exhaustion as a familiar physiological state arising from stress and overwork, really the equivalent of neurasthenia. Weir Mitchell deplored the “sexual excess” of the young and saw it as a cause of “nervousness.” “I presume that the term nervous exhaustion is as good a label as any,” he sniffed in 1877.
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Investigators such as Angelo Mosso, professor of medical physiology at the University of Turin and author of an influential book on fatigue, fed into this tradition by regarding the subjective sensation of exhaustion (“épuisement,” which he also called “la fatigue intellectuelle”) as characteristic of any chronic nervous disease: It was omnipresent.
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For Emil Kraepelin, the German psychiatrist who initiated the modern system of classifying psychiatric disorders, “nervous exhaustion” (nervö se Ersch ö pfung) was just a synonym for Beard’s neurasthenia. Kraepelin put it among the “psychogenic illnesses,” while he assigned manic-depressive illness and dementia praecox—the major diseases—to weightier categories entirely. “The prognosis of simple nervous exhaustion is seen as thoroughly favorable,” he wrote in 1915, “in so far as the causative agent is removed,” which he mainly considered to be overwork.
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(By this final edition of his textbook in 1915, Kraepelin viewed nervous exhaustion more benignly than he had earlier, when he classed “chronic nervous exhaustion” among the “exhaustion conditions,” alongside “acute dementia” and other nontrivial disorders.
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Why his own thinking evolved along these lines is unclear, possibly because so many private nervous clinics had sprung up, with good treatment results, that exhaustion symptoms no longer seemed so alarming, or maybe it was that Germany was now in a terrible war, where gravely damaged men were continuously invalided back from the trenches and the problems of the “weary” appeared comparable to those of patients with unruly stomachs.)

But another tradition believed there was really no such thing as simple neurasthenia and that nervous exhaustion was a serious disease of its own, entailing melancholy and psychotic symptoms together with admission to a hospital. These were true nervous breakdowns, although the term was not yet in use. “Clinically,” said German psychiatrist Heinrich Averbeck in 1886, the chief physician at a private nervous clinic in Bad Laubbach on the Rhine River, “acute neurasthenia is the collapse of nervous energy, the bankruptcy of the nervous system.” This sudden exhaustion might affect the brain, or the spinal cord, the sympathetic nervous system, or the entire central nervous system, but it could be abrupt in onset and overwhelming in impact. He described high officers who felt their minds had become deadened. The stuffing seemed to come out of them: “Acute neurasthenia is seldom fatal, but it imprints upon the patient the stamp of being ‘finished,’ used up; the patient has become ‘old before his time’; not just physically but also morally; these patients become ‘broken existences,’ ‘ruins’ of earlier greatness.”
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This picture of ruin and collapse in acute neurasthenia is quite different from the tense businessmen Beard described. Averbeck’s account captures perfectly the image of people’s lives coming apart without their being formally “crazy”: For this is the essence of the nervous breakdown: Your life, as you knew it, has come to an end because you can no longer cope. Yet you are not “nuts,” which is what psychosis means. And today we have only the concept of psychosis to convey this sense of breakdown.

American observers saw in “exhaustion” this sense of things coming apart. Charles Dana, who at 50 years old had just become professor of neurology at Cornell Medical College in New York, thought the essential form of neurasthenia, if one were even to retain the term, was psychotic, not benign. He preferred the term “exhaustion neuroses” for the lesser forms of neurasthenia and did not believe in any form of neurasthenia not caused by the psyche. Then there were “neurasthenic psychoses,” such as “the melancholic neurasthenia of later life.” If all these major illnesses are cut out, “one has cut out about 50% of neurasthenia. What is left is usually not a general neurasthenic state, but a local disorder. So … we may yet end in finding that there is no such thing as neurasthenia at all.” In this talk to the Boston Society of Psychiatry and Neurology, which in January 1904 he had come up from New York to give, he told his audience that if neurasthenia turns out not to exist, “America has been deleted of one of its most distinctive and precious pathological possessions. If no longer able to claim any disease as specially our own [neurasthenia was often described as “the American disease”], or point with pride to a national and neurasthenical syndrome, there is removed … an important stimulus to patriotism and racial solidarity!” But he was kidding (or at least I hope he was). The point is that if neurasthenia existed at all, then it was as a psychosis. (He proposed the term “phrenasthenia,” that didn’t catch on.)
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The most influential advocate of neurasthenia as a form of madness, not of nerves, was the Austrian psychiatrist Richard von Krafft-Ebing, who would win international notoriety with his Psychopathia Sexualis, published in 1886, an explicit catalogue of every sexual practice that diverged from the missionary position. Yet it was in his psychiatry textbook that Krafft-Ebing influenced the field of psychiatry. The first edition, written in 1872 when Krafft-Ebing was 32 years old, did not even mention neurasthenia. But in the third edition in 1888, he embraced neurasthenia as mainly a form of madness. He conceded the existence of a benign neurasthenic neurosis that usually ended favorably in those blessed with healthy constitutions. But in those born predisposed to illness, neurasthenic “psychoneurosis” was a terrible disorder, leading often to terminal decline and madness. “On August 14, 1882, Herr H, railway station employee, 41, was brought to the Graz University Psychiatric Clinic because on August 12 he had suddenly become insane, considering himself the stationmaster and behaving accordingly.” Krafft-Ebing had not yet assumed the professorship of psychiatry in Vienna and was still professor in the provincial city of Graz. “The patient behaves in a confused and irritated manner, and demands to be taken to his office, because he is the chief of the station. He does not belong here. He doesn’t know that he is in a hospital, feels perfectly well, and is justifiedly irritated only because the previous station master is unwilling to submit to his authority.” We will not follow the further progress of the case, which ends well for the railway employee, except that he loses his post, becomes destitute, alcoholic, and is readmitted. Krafft-Ebing does not use the diagnosis “nervous exhaustion,” because for him the term “psychoneurosis,” or what was later called simply “psychosis,” tells the whole story.
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Krafft-Ebing’s psychiatry textbook had a large international impact, and the last edition, published in 1903 a year after his death, was even more adamant about neurasthenia as a form of madness. So, with Krafft-Ebing the nervous exhaustion approach—or its functional equivalent—was gathering steam.