How Everyone Became Depressed (9 page)

During the nineteenth century psychiatrists made great progress in describing individual symptoms, which is the science of psychopatholog y, and in sorting symptoms into various diseases, which is the science of nosology. Both of these sciences of exact description focus ever more on anxiety as a symptom, not as a disease of its own. John Haslam, the apothecary of Bethlem Hospital, a famous asylum in London, was not a great innovator in describing symptoms, but in an account of his cases in 1809, he does attribute “anxiety” to several of them, such as the 36-year-old woman who in a postpartum depression killed her baby, then “became more thoughtful and frequently spoke about the child; great anxiety and restlessness succeeded.”
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By contrast, a major innovator in the exact description of disease was the Leipzig asylum psychiatrist Christian August Heinroth, who in his 1818 textbook uses the term anxiety (die Angst) as a symptom, not just a state of mind. In an account of “mixed forms of mood disorders,” he said of the march of symptoms, “Anxiety and melancholy [Angst und Schwermuth] increase from hour to hour; no consolation, no kindly words help; the patient is mute and deaf to all intervention, to all urging … ”
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This is, to my knowledge, the first time that anxiety was used in a clinical sense in psychiatry.

By mid-nineteenth century, anxiety had become well-established as a symptom of psychiatric diseases of various kinds. One footnote: In retrospect it is tempting to see the 1844 book of Danish philosopher Soeren Kirkegaard, The Concept of Anxiety, as an important milestone in this forward progression. It is not. Kirkegaard was writing of the existential anxiety that many Christians felt when confronted with the prospect of choosing their own eternal salvation. His book was entitled in Danish Begrebet Angest, translated in the German edition as Der Begriff Angst, or The Concept of Anxiety. Yet Kirkegaard’s book appeared in German only in 1923, in French in 1935, and in English in 1944 as The Concept of Dread. Only the Princeton translation in 1981 used the term anxiety in the title.
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Although of great importance to subsequent philosophical discussion, Kirkegaard’s book had almost no impact on medicine during the nineteenth century.

In the second half of the nineteenth century, as psychiatric historian German Berrios points out, French writers began a distinguished tradition of refined symptom description.
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Joseph Guislain, professor of psychiatry in Ghent, Belgium, and 55 years old at the time of publication of his important psychiatry textbook in 1852, for which he chose the unfortunately idiosyncratic title Phrenopathies, linked anxiety firmly to depression. “There is a whole series of melancholias in which the patient is dominated by vague worries. He feels ominous premonitions. He doesn’t feel well in any sense; terrible misfortune seems to threaten him; he’s fearful of everything, afraid of everything.” This clearly detached anxiety from specific worries and gave it an unanchored, inchoately menacing sense.

Guislain also distinguished between anxiety and anguish. “In the melancholia that is characterized by fears, the patients experience feelings of anguish. They are either profoundly dejected or else unable to remain still for a minute.” So that was anguish: fearfulness in the context of what is called psychomotor change, speeding up or slowing down. By contrast, “anxiety” for Guislain meant strange somatic feelings: “It is the melancholy that I call anxious, or pneumomelancholy, with respect to trouble that reigns in the organs of the chest … Anxious melancholy is sometimes preceded by a painful feeling that the patient experiences in the region of the heart.”
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(Later, these meanings would be reversed, anguish meaning somatic sensations and anxiety being the mental perception.)

But it is the Germans who, in the second half of the century, come to dominate the understanding of anxiety, and this German supremacy begins with Wilhelm Griesinger, professor of psychiatry in Berlin when in 1861 he published the influential revised edition of his textbook, Die Pathologie und Therapie der psychischen Krankheiten ( The Pathology and Treatment of the Psychiatric Diseases).
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He described the “unsettling” feelings (Be ä ngstigung) “which often emanate from the epigastrium and region of the heart, and appear to rise upwards. ‘Here,’ say many of these patients, and point to the pit of the stomach, ‘Here something is sitting like a stone. If I could only get rid of it!’ These feelings of anxiety increase then to an intolerable condition, a desperation that often passes over into mania.”
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There were not a lot of new concepts in Griesinger’s text, but it did become the leading German language reference book, and therewith the premier psychiatric textbook of the world.

Emil Kraepelin, the great German clinician and nosologist, wrote the final chapter in the German anxiety story just before World War I. For Kraepelin, there was no question of anxiety being an independent disease, or even an important symptom that required its own extensive description. He said it was omnipresent in psychiatric illness, especially in “the depressive conditions of circular insanity.” (By circular insanity he meant manic-depressive illness.) Anxiety, he said, often lacked a specific object, and represented a “union of dysphoria with inner tension.” This was quite an authoritative statement. Yet in Germany, Freud’s psychoanalysis was already shaking the ground under Kraepelin, and after World War I these thoughts about anxiety as one symptom among many, “the commonest of the pathological changes of mood,” would be forgotten.
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The English in these years rather limped along behind the German heavyweights. To be sure, the concept of anxiety as part of some larger nervous disease gained ground in England, as elsewhere, and in 1866 William Murray, who lectured on physiology at the College of Medicine in Newcastle-on-Tyne, offered one of the speculative theories about neurophysiology that abounded in the late nineteenth century: The seat of “emotional diseases” must lie in the “defective nutrition of the nervous centres, irregular distribution of the blood inducing paresis through the capillaries of the brain,” and so forth, all highly reminiscent of Beard’s theory of neurasthenia. Yet Murray focused not on fatigue but anxiety: “Foolish fears are no longer dismissed by sober sense, the risings of morbid feelings are no longer controlled by the will … and thus the way is open for the rushing in of vain imaginations, groundless fears, or absurd suspicions … The man is not insane … but he is the victim of emotional disease, which, while not causing him to be haunted by positive delusions [madness], leads him irresistibly to view the dark side of everything, to entertain the most distressing fears where none ought to exist, till life is made gloomy, morbid, miserable.”
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Murray and his ratiocinations about “the cerebrospinal system” passed unheralded from the scene. Yet neither his nor anyone else’s writings about anxiety made any difference in clinical practice in England. Even though anxiety was accepted as part of some larger package—call it “emotional disease” if one will—these academic musings made little difference in the actual practice of psychiatry. And this is known because the patient records of a semicharitable private psychiatric hospital, the Holloway Sanatorium in Virginia Water, just to the west of London, have survived for the late 1880s and early 1890s. We can see what the clinicians are thinking in their daily practice. At the Holloway Sanatorium, the physicians were astute clinical observers, but on the open service at least (for voluntary boarders), they were often reluctant to make diagnoses. They simply described what they saw. In August 1895 Arthur W, a middle-aged man, was admitted. He “has a restless, anxious, careworn expression.” Mentally, the patient “cannot settle down to anything, is inclined to worry in an undue way over trifles and is in a vague state of dissatisfaction with himself. Does not know what to do, keeps asking for advice, and then wandering away in the course of conversation from the subject matter in hand. Sleeps badly.” Clearly, there was some larger problem with Arthur W. His physicians noted his anxiety together with other symptoms that sounded like a larger nervous syndrome. And indeed there was some larger problem: 8 months after admission he was certified and sent to the closed service for patients with major illnesses.
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On the women’s service on the closed side, Rosetta X, 19 years old, came in on April 16, 1889. The admission medical certificates—two were required— claimed that she was psychotic and heard God telling her to do various things, but at admission this “healthy looking, well-developed girl, with freckled face, moist skin, auburn hair and blue eyes … appears to be of an extremely nervous disposition. She will not look in your face when shaking hands or answering questions. She is incessantly moving her hands, fingers or head … Mentally she appears to be suffering from the ‘impulsive insanity of adolescence,’ intermingled with ‘hysteria.’” On the unit she kept to herself, “answers only in monosyllables when questioned without raising her head, and silently does the needlework put into her hands.” She was discharged “recovered” almost a year after admission.
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Here again, her anxiety leaps to the eyes. Yet for her clinicians it had no particular significance. She had a “nervous” disposition.

This was the picture of the nerve syndrome on the ground: anxiety blended in with the other components of depression, fatigue, compulsive thoughts (Rosetta, as she told her mother in letters, obsessed about the food on the unit), and somatic symptoms to form a pattern that was easily recognizable without any particular component standing out. Once we encounter the rise of the affective disorders, this will change.

Panic would rank high in a list of disorders composing the nervous breakdown. Panic patients may be immobilized with fright, and may become withdrawn recluses in their efforts to avoid further panics. It is a true breakdown.

The concept of panic disorder is not new. Eighteenth-century English novelist Fanny Burney (Frances D’Arblay) had panic attacks, and she uses that term . In August 1778, at 25 years old, she was a guest at the Thrales, a noted literary couple, and heard one of the company, not knowing she was the author, make an unflattering remark about the novel Evelina that she had just published anonymously. “My heart beat so quick against my stays, that I almost panted with extreme agitation at the dread either of hearing some cruel criticism or of being betrayed, and I munched my biscuit as if I had not eaten for a fortnight.” Indeed, her mouth was so dry that she was unable to swallow, and had to ask Mrs. Thrale for water, imploring her in private not to identify her, Fanny, as the author. That night at the Thrales passed in disquiet. “When Mrs Thrale came to me the next morning, she was quite concerned to find I had really suffered from my panics. ‘O Miss Burney, cried she, what shall we do with you? This must be conquered … ’”
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Fanny Burney was a nervous creature, and in May 1792 she confided to her diary about her unease in the company of strangers: “ … The panics I have felt upon entering to any strange company, or large party even of intimates, has, at times, been a suffering unspeakably, almost incredibly severe to me.”
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For this Englishwoman panic was a real entity.

Psychiatry was somewhat slower to discover panic. We are about to watch anxiety states sailing off on their own in the form of panic disorder, phobias, and even obsessive thoughts and compulsive actions. It is a bit of a perilous voyage, and where one cuts Nature at the joints not always clear.

A core symptom of the nervous breakdown, as people generally conceived it, was becoming panicky in public. Panic in open places has long been recognized in medicine. The old spa doctors realized that many of their patients were highly anxious and that the warm spa waters could calm them. In 1844 Anton Theobald Brü ck, the spa doctor in tiny Bad Driburg, in a memoire praising the waters, said there were all kinds of dizziness (Schwindel), and that dizziness in open spaces represented an ideal indication for the waters of Bad Driburg: One of their patients, a priest, “perceived the most profound anxious dizziness (Schwindelangst), just as soon as he was no longer safe at home. He needed a solid floor underneath him, just as others require this kind of solidity, in order to avoid dizziness. If he had to cross a field, where the wide heavens stood open above his head, he would be gripped by unspeakable anxiety, and creep about on detours, under hedges and trees, and even, if all else failed, open up his umbrella.” This would later be seen as a panic attack, but Brü ck did not assign the syndrome, associated with pounding hearts and other forms of somatic anxiety, a particular name.
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A very preliminary step toward panic as an independent diagnosis was the concept of “precordial anxiety,” proposed in 1848 by Carl Friedrich Flemming, director of the Sachsenberg asylum in North Germany. “Often when we examine a person with insanity,” said Flemming, “he complains of a feeling of anxiety that has its seat in the breast and upper abdomen, and is connected with the sensation of internal heat and the feeling that a rock is pressing in on him or an iron band is tightening about his body.” The anxiety struck paroxystically. “In more severe cases, the patient feels the need for frequent deep breaths, so that it seems like a real gasping for air.” There were spasmodic changes in the pulse and slowing of the heart rate alternating with acceleration. The feelings of anxiety often followed the somatic sensations. An obsessive-compulsive element was strong: “The patients say they are anxious because they cannot fend off terrible thoughts, and because sad things, ugly words and immoral acts occur to them of which they cannot free themselves and they feel compelled to tell others.” Flemming described a woman plagued by anxiety who believed herself guilty of the death of her child from measles. She recovered, then 4 years later “had to endure bravely the unexpected death of her husband and the deterioration of her material circumstances … Two years after the death of her husband she was obliged by her employer [she was working as a live-in servant] to sell the clothes, previously kept under lock and key, of her late husband. She got to work cleaning them. The sight of these clothes made such a strong impression on her, that a nameless anxiety befell her, which in the course of several hours had so intensified that people were obliged to protect her from herself.”
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This is nervous-breakdown-level panic, on the basis of chronic anxiety and melancholia.