Apr 30

“Nervous Breakdown”: Re-Welcoming the Terminology

In the annals of modern science, I am unaware of any comparable wholesale demolition of a field of scientific knowledge and its replacement with a fairy castle of fantasies…the spotlight shifted from nerves, a diagnosis that implicated the whole body, to mood, a diagnosis that implicated mainly the mind. Edward Shorter, author of How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown 

The term “nervous breakdown” is commonly considered an outdated one and not an actual clinical diagnosis—more of a lay expression that denotes “falling apart” or feeling unable to function.

Other nearly synonymous terms for “nervous breakdown” from the olden days have included “crackup” and “neurasthenia.” Back to the present, on the other hand, European psychiatrists of late have been using “burnout syndrome” to denote this type of condition. And in this country we tend toward using mood and anxiety disorder diagnoses from the latest versions of the DSM. Although this manual is widely accepted as the clinical “bible” by many, it’s also widely criticized by many others.

A recent post by psychiatry historian Edward Shorter, PhD, in Psychology Today argues, in fact, that at some point our field and the DSM veered in the wrong direction—that is, we should still be thinking in terms of “nerves” and “nervous breakdowns” because these provide a better description of what many people experience.

He states that a “nervous breakdown” is really “melancholic depression,” a diagnosis that isn’t even found in today’s DSM, but, rather, is lumped into “major depression.” Another possible diagnosis, “mixed anxiety/depression,” that could also translate as “nervous breakdown,” was dumped from the DSM decades ago.

From the book description of Shorter’s How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown (2013):

About one American in five receives a diagnosis of major depression over the course of a lifetime. That’s despite the fact that many such patients have no mood disorder; they’re not sad, but suffer from anxiety, fatigue, insomnia, or a tendency to obsess about the whole business. ‘There is a term for what they have,’ writes Edward Shorter, ‘and it’s a good old-fashioned term that has gone out of use. They have nerves.’

David Healy, MD, author of Pharmageddon, apparently agrees with Shorter:

Why are you being told you have depression or anxiety and why are you being given antidepressants or anxiolytics, when in fact you’ve had a nervous breakdown? The answer lies in the fact that managing nervous breakdowns is a more complex clinical task than just simply giving a pill. There is more than just a simple change of words here, these are words that matter. In eliminating the nervous breakdown, psychiatry has come close to having its own nervous breakdown.

The book review by Tom G. Bolwig, psychiatrist: “Shorter strongly emphasizes the role of bodily malfunction in the melancholic vs. the non-melancholic depression debate…Shorter’s criticism of contemporary views on ‘nerves’ and ‘depression’ are sharp, but well-founded. This fine book deserves a wide readership — it should be mandatory reading for all professions working in mental health care.”

Why, in summary, need we have such concern over labels and words? Because the more exacting the understanding of the problem, the better the treatment. And Shorter and others believe that too often our current treatment strategies, including prescribed medications, are matched to inadequate diagnoses.