From nerves to neuroses

Mental illness can affect the mind, body and behaviour, and the symptoms can be difficult to pin down. Sometimes there are no obvious physical signs of a condition and sometimes physical signs are very apparent.

No wonder that people have looked to the stars, the supernatural, heredity and social and environmental factors for ways to explain and treat mental illness.

In the 1600s, a growing interest in anatomy and dissection led to new discoveries about the nervous system and  the pathways between the nerves, spinal cortex and the brain.

Among mental health doctors a new debate emerged about whether the causes of some mental illness might lie in the physical malfunction of the nerves rather than something less tangible.

Neurology is a branch of medicine dealing with disorders of the nervous system. Neurological practice relies heavily on the field of neuroscience, the scientific study of the nervous system.

A neurologist is a doctor specializing in neurology. Since neurologists entered the field of mental illness, psychiatry and neurology have tended to overlap. Early pioneers of neurology included Guillaume Duchenne de Boulogne (1806–1875) and Jean-Martin Charcot (1825–1893).

Wellcome Collection CC-BY

Neurology was readily accepted as a mental health discipline, because a physical basis for their condition gave people hopes of treatment and even cure, whereas disorders of the mind raised the prospect of indefinite incarceration in an asylum.

Neurological treatments for mental illness included hypnosis, electrotherapy and the 'rest cure'. These could be carried out in doctors’ offices, health spas or patients’ homes. But expensive neurological therapies were only available to the wealthy. For ordinary people with nervous illnesses, there were nerve tonics.

In the 1700s, the term ‘nervous breakdown’ referred to a specific medical disorder that was emphatically a disease of the nerves, not a disease of the mind. The difference was subtle but crucial, as it kept patients out of asylums.

The nervous breakdown was also known as ‘nervous exhaustion’ and ‘nervous collapse’. It was characterised by pain, weakness, migraine headaches and fatigue. The condition also included symptoms that we now associate with depression, such as despair, feelings of inadequacy and a lack of joy in any aspect of life.

Popular and medical opinion linked nervous sensitivity to delicacy and refined sensibilities. It allowed people with nervous symptoms to avoid the stigma and prejudice associated with mental illness. The diagnosis of nerves became fashionable among the upper classes: ‘I’m not ill, but I’m nervous,’ King George III assured his court.

Hysteria was a condition long associated with women. Symptoms differed from patient to patient and from one historical period to another, but they always involved both the body and the mind. Some characteristic symptoms were: shortness of breath, heaviness in the abdomen, muscular spasms and fainting. Anxiety, irritability and embarrassing or unusual behaviours were also noted.

The Ancient Greek philosopher Plato gave an explanation for hysteria in which the uterus was an animal. He said it roamed inside women’s bodies, causing symptoms as it moved. As anatomical knowledge improved, the idea of the roaming uterus was rejected, but medical explanations for hysterical symptoms remained vague for centuries.

In the 1800s, hysteria was recast as a nervous disease. Nearly all Victorian physicians considered women more sensitive and mentally and emotionally fragile than men. They believed women were more susceptible to nervous breakdowns and ‘weak nerves’, so hysteria, as the classic ‘female malady’ had to be a nervous disease.

However, in the late 1800s the French neurologist Jean-Martin Charcot proposed that hysteria was a more general inherited nerve disease, similar to multiple sclerosis, and not a ‘sexual problem’ unique to women.

Sigmund Freud, who had studied under Charcot in 1885, later developed the theory that hysteria was rooted in unconscious emotional conflict rather than weak nerves. But the characteristics of the condition remained elusive.

Neurasthenia emerged as a new nervous disease in the late 1800s. The term was coined by American asylum doctor Edwin Holmes Van Deusen, who noted a particular condition among rural, isolated communities of farmers and especially farmer’s wives. People with neurasthenia were lonely, bored, depressed and often over-burdened with childcare and housework. Typical symptoms were irritability, insomnia, indigestion and a general malaise, which could develop into mental breakdown if ignored.

In New York, neurologist George Beard popularised the term neurasthenia, but reframed the ‘rising epidemic’ of neurasthenia to the hectic pace of urban life. Neurasthenia became something of a catch-all diagnosis that could be the result of rural isolation and boredom, or urban over-stimulation and crowding.

Treatment was similar to nervous breakdowns: a range of therapies if you could afford them and tonics if you could not. Another popular and relatively safe treatment, especially for neurasthenic men was vigorous outdoor exercise.

The diagnosis of neurasthenia never caught on in Britain, where doctors saw it as an American attempt to lend false scientific legitimacy to the old condition of nerves.

A new condition like neurasthenia required a new treatment. The rest cure was a strictly enforced regime of six to eight weeks of bed rest and isolation, without any creative or intellectual activity or stimulation. It was often accompanied by massage and electrotherapy, as well as a fatty diet, rich in milk and meat.

The cure was devised by neurologist Silas Weir Mitchell as a treatment for neurasthenia. He attributed neurasthenia to a depletion of the nerve force. This depletion irritated the brain, digestive organs and reproductive system. It was also used to treat hysteria and anorexia nervosa and prescribed more for women than men.

Wellcome Collection (CC BY) Image source for A convalescent young woman reading. Gouache painting by David Bles.

Weir saw the rest cure as particularly suited to treating women, partly because he thought women tolerated a lack of stimulation and inactivity better than men. He also saw it as a corrective for women who were overly active, socially and physically. According to Mitchell, the high fat diet boosted weight and blood supply, making a woman “as a mother more capable, as a wife more helpful”.

The rest cure was really only suitable for educated, skilled and wealthy patients who had the time and help to undergo the treatment in their own homes or in a fashionable sanatorium. It may have kept some patients alive and others out of asylums, but some patients and doctors found the cure worse than the disease. Charlotte Perkins Gilman’s chilling short story ‘The Yellow Wallpaper’ describes how a woman isolated by her rest cure begins obsessing on the yellow wallpaper in her room and eventually goes mad.

In the early 1900s, German neurologists distinguished neurological diseases from neuroses. Neurological disorders such as epilepsy, dementia, multiple sclerosis and Parkinson's disease had a proven anatomical basis in the nervous system or brain, whereas the basis of neuroses could not be definitively determined as either physical or mental.

Neurasthenia gradually became part of the broader diagnostic category of neurosis and the term disappeared from medical usage. But the ‘nervous breakdown’ remained popular as a less stigmatised way to describe a debilitating but temporary episode of mental illness.

The distinction between neuroses and neurological disease put conditions like ‘nerves’ and nervous breakdown firmly in the domain of the mind and not the body, and by the 1930s, treating neuroses was clearly the domain of psychoanalysis and psychiatry, rather than neurology.

Max Halberstadt [Public domain] Image source for Sigmund Freud

In the first half of the 1900s psychoanalysis was extensively used for treating neuroses. The therapy was developed by Sigmund Freud in Vienna at the very end of the 1800s. Freud was convinced that neuroses, strange dreams and other difficult-to-explain aspects of mental life were rooted in conflicting and usually unconscious desires rather than neurological malfunction.

Freud’s psychoanalytic practice was based on listening carefully to the patient. He recorded whatever they talked about, looking for clues to the origins of their condition. One of Freud’s patients, Bertha Pappenheim, summed it up as the ‘talking cure’.

After Freud, psychoanalysis went on to develop in many directions and became one of the most influential therapies of the 1900s.

Psychoanalysis became very influential in American mental health when many European practitioners fled Nazi Germany in the 1930s and made their homes in the United States. Their efforts helped to establish psychoanalysis during and after the Second World War. Psychoanalytic theory became popular among American psychiatrists as well as psychologists as a way to acknowledge the role of both mind and body in mental illness.

The use of psychoanalysis within psychiatry began to decline from the 1960s, largely because of the development of new psychiatric drugs, which offered a cheaper and less labour-intensive treatment. But psychoanalysis in its various forms is still at the heart of many rehabilitation therapies.