Neurasthenia

The rise, evolution and ambiguous decline of the nervous breakdown in the United States open an interesting window on pervasive anxieties. The concept raises several intriguing historical questions: Why did it originate in the first place, quite early in the century, when other concepts, notably neurasthenia, were already available? (It will become clear that this is one of the hardest issues to resolve.) Why did it decline after the 1960s--the last major popular treatment of the phenomenon, Frank Caprio's How to Avoid a Nervous Breakdown, appeared in 1969? And in fact, how much did it decline, as opposed to losing favor with experts and popularizers? Timing and causation, then, two of the pillars of historical analysis, enter in strongly, along with an effort to trace the evolution of the concept and to determine its meanings during its several-decade heyday.

There is little question that the concept was significant. At various points a great many Americans thought they were suffering a breakdown, or feared one, or knew someone who was involved. A steady stream of articles and books addressed the topic. Popular music paid heed, as in a 1937 recording of "Rehearsin' for a nervous breakdown" by John Kirby's band or a later Rolling Stones number about the "19th nervous breakdown". The term became, and to some degree remains, a standard part of American vocabulary, warning, sometimes humorously, sometimes in testimony of great psychological pain, of an impending clash between external forces and internal capacities. And of course the phenomenon has received historical attention, as part of various studies of American nerves and mental health categories and professions. But few treatments have focused on the phenomenon itself; analysis lags behind that devoted to neurasthenia, which came first but was shorter-lived, though having the advantage of a firmer professional literature. [1] For reasons that will become obvious, nervous breakdown tends to slip through the cracks of medically-oriented social and cultural histories.

This article seeks briefly to explore the historical issues in this rich American artifact. It begins by focusing on the range of functions the nervous breakdown concept served, from its apparent origins around 1901 through its amplifications from the 1930s to the 1960s. Only with the various functions in mind can the problems surrounding origins, popularization and decline be explored--for the concept's sweeping implications help explain why some of the answers to key questions are a bit fuzzy, though suggestive about important concerns in American life. And the concept was, disproportionately, American, particularly before World War II: the term, and related advice literature, spread elsewhere, but even then the points of reference, even the case studies, were drawn from the United States. [2]

The most interesting feature of the nervous breakdown concept, if not at its origins at least quite soon, involves its decidedly ambivalent relationship to professional medicine and psychology. Supported by some professionals, nervous breakdown never broke through to clearly official standing--it did worse, in this regard, than the almost-equally slippery neurasthenia category. But, in an age of medicalization, this ambiguity was clearly part of nervous breakdown's popular appeal. People liked the idea of a disease entity that described symptoms and anxieties they felt, rather than an entity clearly delimited by the burgeoning apparatus of the mental health professionals. They accepted the notion of nervous breakdown often because it was construed as a category that could be handled without professional help, despite the pain it conveyed. Nervous breakdown is not the only disease entity that has been "demedicalized" in the 20th century, [3] but it is an important case, revealing a longstanding need to keep s ome distance from purely professional diagnoses and treatments. Its apparent decline owed something to the greater triumph of medical models, but its persistence shows ongoing ambivalence. Not, usually, anti-medical, [4] nervous breakdown has been characteristically unmedical. This feature shines through in the various definitions of the disease, some of them surprisingly contradictory at least on the surface, from the l920s to the l960s. Correspondingly, the nervous breakdown concept, as it moved from medical origins to more popular usage, more often challenged power alignments than furthered them--again a contrast to more purely medical constructs in modern social history.

Professional ambivalence about breakdown has had one further effect: a dearth of estimates concerning incidence. A sense that the rate of nervous breakdowns was high and rising operated from the 1920s to the 1960s--a key component of wider beliefs about the heavy mental toll of modern life. But how many people actually experienced the phenomenon, or even entered the presumably substantial ranks of those who felt "on the verge," is one of several unknown features about this pervasive but mildly mysterious disease-like entity.

Background: American Nerves

A framework for concern about what the 20th century would call stress developed by the middle of the 19th century. Growing adherence to the idea of body as machine helped pave the way, as it replaced more fluid (humoral) traditional imagery. When knowledge of the results of strain on machines was added in--a contribution from engineering by the 1850s--a clear model was at hand. British and American authors could write of physical or mental collapse when a man could not stand "the stress of his will and the strain of his perseverance." Attention to cardiac problems helped focus these concerns, with strain initially the preferred word, but stress coming to replace it soon after 1900. But strain could be applied to the nerves as well, when overwork or excessive worry permanently depleted resources and damaged the body--writings in this vein began in the 1850s (though English work on debilitation, first directed against luxury and wealth, dated back to the early 18th century). [5] Descriptions of bankrupt men fr om the 1820s onward often described them as "broken," even referring to their "broken springs," while references to nervous prostration continued the application of mechanical strain to the nerves. Nervous breakdown would revive, expand, and more widely popularize these 19th century concepts.

Identification of nervous maladies gained growing medical and popular attention in the United States after the Civil War (the association of knowledge of wartime traumas and wider definitions of nervous problems would recur in World Wars I and II, with more direct bearing on ideas about breakdowns). [6] Attention to neurasthenia became an important part of late-19th-century American middle-class culture. A doctor, writing in 1920, characterized the history and the persisting impact:

[Neurasthenia] was first described in 1869 by the eminent neurologist Beard, who thought it was entirely caused by the stress and strain of American life. That not only America, but every part of the whole civilized world has its neurasthenia is now an accepted fact. Knowing what we do of its causes we infer that it is probably as old as mankind; but there exists no reasonable doubt that modern life, with its hurry, its tensions, its widespread and ever present excitement, has increased the proportion of people involved.

Particularly the increase in the size and number of the cities, as compared with the country, is a great factor in the spread of neurasthenia. Then, too, the introduction of so-called time-saving, i.e. distance-annihilating instruments, such as the telephone, telegraph, railroad, etc., have acted not so much to save time as to increase the number of things done, seen, and heard. The busy man with his telephone close at hand may be saving time on each transaction, but by enormously increasing the number of his transactions he is not saving himself. [7]

Fatigue was neurasthenia's chief symptom, bringing a loss of concentration and efficiency. Problems were magnified into calamities; the neurasthenic was "the victim of an abnormal state that is neither health nor disease." Pains, eating disorders and other physical symptoms might accompany the condition, along with anxiety. It is vital to note that outright collapse was not usually posited, one of the distinctions from the later nervous breakdown idea that in so many respects is hard to separate from its neurasthenic progenitor; but worry about collapse could be part of the condition, blurring this boundary.

As with nervous breakdown subsequently, neurasthenia was widely publicized, from the 1880s onward. Over 300 articles on the subject appeared in American medical journals alone between 1870 and 1900, while books and articles by authorities such as S. Weir Mitchell gained extensive readership. Like its effective successor as well, the concept became very malleable. Though consistently identified with modern work pressures and stress, it could also result from undue idleness. A distinction opened between neurasthenic businessmen, heroes of their race but suffering personal costs because of America's unprecedented devotion to hard work, and middle-class women, who became neurasthenic because they had too little to do. Another distinction highlighted working-class women, whose neurasthenia resulted from the fact that they were characteristically overworked and often abused by their husbands to boot, and neurasthenic working-class men whose problems resulted from vicious habits such as excessive drink and unbridle d sexuality. Whatever seemed wrong with a group, in other words, might be captured by neurasthenia. Women, the weaker gender, might additionally held to be predisposed by nature, a motif that nervous breakdown would often maintain: male problems resulted from exterior conditions, such as the zeal of professionals, whereas women were inherently vulnerable. It was also true that concern about sexual misbehavior, particularly male masturbation, could override group bounds; Beard placed considerable stress on "sexual neurasthenia", resulting from the "nervous excitement" of self-abuse but also the worry prompted by shame. This theme would largely drop out of the nervous breakdown discussions. [8]

A more important contrast involved treatment. Unlike nervous breakdown, neurasthenia generated hosts of suggested, professionally-sponsored remedies, including rest cures under the guidance of doctors and the burgeoning group of mental health professionals. Edward Shorter has indeed suggested the vital role of neurasthenia in giving these new professionals potential roles beyond service in asylums, where jobs were limited and, often, unpleasant. Professional advantage does not erase the potential validity of the neurasthenic category, but it surely entered into its dissemination and into common reactions to it. Professional considerations also provided a framework for an evolution in recommended treatments, from largely somatic approaches to increasing emphasis on psychological therapy by 1900. Mitchell's cures, however, continued to combine rest and special diets with psychological therapy sessions. [9]

The term nervous breakdown was introduced into this context in 1901, in a technical medical treatise, addressed to physicians, that in some ways harked back to earlier ideas of strain. Albert Adams replicated much of Beard's thinking about neurasthenia, using his new breakdown term essentially interchangeably. It was not entirely clear why he introduced the neologism. Experienced in writing short, slickly produced manuals for physicians, he may have wanted a catchier title. More important was his mechanistic emphasis. Adams was eager to posit literal physical damage to the nerves when subjected to outside pressures such as overwork or excess. Hence the more dramatic vocabulary. Everyone, in Adams' view, has a "set amount" of nerve capital; with stress, plump and healthy nerve cells shrink and fray, leading to the common symptoms of somatic aches, fatigue, anxiety, and memory loss. Standard therapies for neurasthenia could restore the cells--Adams was particularly fond of Mitchell's Rest Cure, though he added that "the most important element of treatment is moral control." Adams also argued that men were far more susceptible than women, if only because of their propensity to overwork, "burning the candle at both ends" "Brain workers" who abused alcohol, tobacco or caffeine were prime targets, though hereditary factors could play a role as well. [10]

Adams' specific physical arguments had little impact, but his term quickly added to the lexicon available to discuss nervous ailments. Attention to "shell shock" in World War I provided an additional ingredient, and by the 1920s, along with continued use of neurasthenia and stress or strain, nervous breakdown had clearly become part of a standard American vocabulary. In the United States, promotion of the term by Abraham Myerson, in the 1920s, added vital support, for he was a nationally prominent research psychiatrist in Boston, instrumental in trying to move psychiatry out of the confinement of asylums and into a broader range of urban problems, including issues of daily life and adjustment. A few scientists, on both sides of the Atlantic, continued to use breakdown to heighten their defense of psychology as science, testing nervous stresses in terms of cellular damage in a machine-like human animal. But this support quickly turned ironic, as popularized use became more diffuse and experts' scorn for the t erm intensified accordingly. What, as it began to flourish, did nervous breakdown come to mean? [11]

Early development of the nervous breakdown idea depended on a mixture of individual contributions and supporting events. Adams' desire to emphasize mechanical strain, within the rubric of neurasthenia, provided a somewhat random spark. There may also have been some need to heighten the drama of neurasthenia, amid gibes about the condition from widely-read commentators like O. Henry, early in the century: "There is nothing more alarming to a neurasthenic than to feel himself growing well and cheerful." The impact of World War I, despite disputes about shell shock, provided support for the breakdown idea, as opposed to a more gradual process of psychological deterioration. Growing emphasis on efficiency heightened attention to the body as machine and to the economic costs of disruption--a theme in some early British as well as American work on the subject. Here, breakdown and neurasthenia continued to be used as equivalents, but with preference for the new, more mechanical term. More novel intellectual compone nts included the attention to unconscious impulses and the distorting power of repression, even though the only commentators on nervous breakdown that mentioned Freud almost always rejected his theories (Myerson, for example, found them "bizarrely sexual"). Caprio saw breakdown resulting from problems in early emotional development: "something went wrong and kept us from learning how to handle ourselves on the battlefield [of life]". Emotional tension, not overwork, thus became the real culprit, an insight clearly derived from changes in more formal psychological theories. [12]

Nervous breakdown thus originated as a somewhat eccentric medical idea, though one which picked up earlier mechanistic thinking. It offered more vivid vocabulary than neurasthenia and soon a less fully medical-professional context as well--both aspects advantaging the new concept over existing formulations. By the 1920s, the term gained wide usage as a means of describing to oneself and others some kind of collapse and of seeking space and tolerance for dealing with the collapse.

Establishing Meanings

Nervous breakdown quickly embraced an array of meanings. Its scope harbored potential contradictions, for example about severity and relationship to insanity. It allowed attacks on work and idleness in a common context of concerns about the modern pace. It covered outside pressures and personal responsibility in a complex amalgam, and as with ambiguities about work, this amalgam carried over into recommended therapies. It also informed a pronounced tendency to see breakdown in terms of a gap between external reality and personal assumptions.

Even more than neurasthenia, though with great overlap, nervous breakdown began to cover a wide range of definitions, some of them in principle hard to reconcile. The term inevitably embraced a multiplicity of symptoms. Myerson, in 1920, described the symptoms as "almost everything imaginable." Caprio, in 1969, attempted to establish a gradation of incidences, from mild to moderate to severe. In mild cases patients expressed fatigue, worry and moodiness, but could still function; moderates began to complain that any effort was excessive, while in severe cases people were completely disabled, unable even to shop or tend to personal chores, and potentially suicidal. Yet many descriptions of nervous breakdown belied this rational progression, insisting that the phenomenon always involved terrible pain: as F. Scott Fitzgerald wrote in "The Crack-up", "Every act of life from the morning tooth-brush to the friend at dinner had become an effort", while Charlotte Oilman, calling the condition a "gray fog" across her mind, claimed "I could not read nor paint nor sew nor talk nor listen to talking, not anything; I lay on that lounge and wept all day." [13]

Vagueness and disagreements about symptoms and severity carried over into disputes over the mental status of the victim of a breakdown. Myerson argued that nervous breakdown (in contrast to neurasthenia; writing in 1920, the distinction remained important) was insanity itself, its "stark face". But another doctor, discussing shell shock in 1918, was explicit in the sharp boundary between nervous breakdown and insanity, arguing that victims had no need for institutionalization and could indeed continue to work. And other popularizers, only a bit later, were at pains to distinguish from insanity, using the phenomenon as a layer of troubles that could be defined and managed quite differently. Disputes about what nervous breakdown meant helped account for widespread professional disdain for the term: in a period when mental health experts worked to established clear status, refinements and distinctions in terminology, not catchalls, made most sense. But for many popularizers and lay users, the very amorphousness of the term was surely part of its attraction. Even for professionals, the term helped call attention to the reality of purely mental, not physical collapse. For despite the strong physical referents of Adams' introduction of the nervous breakdown concept, most writers from the 1920s onward were at pains to note that nerves did not literally snap; the breakdown, though real, was not physiological. Here was a component that long kept some professionals mildly interested, blurring the otherwise pronounced tendency for nervous breakdown to separate doctors, scorning the term, from a wider public that clearly found it useful. [14]

Nervous breakdown, whether in professional or lay use, also embraced a fascinating tension about the impact of work, here extending elements already present in the discussions of neurasthenia. On the one hand, it was perennially tempting to see overwork as a key cause of nervous breakdown. From this, a popularizer could move to an indictment of modern civilization, for its inhuman pace. Adams' initial use of the term embraced this focus, which surely won widespread popular response. "One of the commonest observations about contemporary society is that the pace, pressure and uncertainty of existence today quicken the rate at which people crack up mentally." "What is our spectacular civilization if, in the end, our nervous systems cannot stand up under its pressures?" The oft-asserted increase in the rate of nervous breakdown here became part of a widely-accepted causation pattern: modern life verged on becoming too demanding. But breakdown gurus also attacked underwork, a pattern of living that allowed people to spend too much time on silly worries because they did not have enough to do. Nervous breakdown here became part of what Tom Lutz has described as a resurrection of the work ethic in the 1920s, with disease the punishment of those who were insufficiently engaged. Ellen Glasgow's novel Barren Ground, in 1925, traced the career of Dorrinda Oakley, who suffers a series of genuine personal problems but is cured by a regimen of work, lest she wallow in unnecessary anxieties about her emotional state. Breakdowns, according to this view, concentrated in the idle loafers at the top and bottom of society: "The great mass of humanity is sound and sweet because it works," as one doctor put it in l92O. [15]

Tensions over this aspect of the definition had obvious gender implications. Adams, stressing work pressures, had argued that men most commonly broke down. But the idleness scenario, often supplemented by gender assumptions about vulnerability to frivolous worries, highlighted women. Myerson's nervous housewife suffered from "bad training, liability to worry, wounded pride, failure, desire for sympathy, boredom, unhappiness, pessimism of outlook, over-aesthetic tastes, unfulfilled or thwarted desires, secret jealousy, passions and longings, fear of death, sex problems and difficulties and doubt"--a long list, to be sure, but not one involving excessive pressure from the world of work, but rather its absence. In a later volume, Myerson added the encroachments of industrial production on the family, feminism, and women's petty discontent resulting from their own conflicts between demands for equality and demands for pampering. All this was compounded by increasing inactivity within the home. Zest for work, ind eed, was a sign that nervous breakdown did not impend, for energy and activity kept a person going. "The feeling that comes with successful effort, with rewarded effort, is a new birth of purpose and will." The housewife too often suffered from "deenergizing emotions." Another blast against idle women saw them languishing as a result of their avoidance of "the strain of anything and everything which makes the game of life worth living." [16] The later Meyerson formula, in emphasizing new stresses, further, neatly placed the dilemma as a contemporary one, helping to explain the need for a novel term.

Yet simple dichotomies were not really the main point. The same author who condemned idleness also, inconsistently, pinned the real blame for modern nervous disorders on "over-study": "It is this wasting ambition which exhausts the spring of childhood and the vitality of youth." [17] And the housewife verging on breakdown was in fact a victim of modern pace herself: "A woman whose every action is hurried, whose every hour is open to disturbance, whose every breath is drawn with superfluous emphasis, will talk about the nervous strain under which she is living, as though dining out and paying the cook's wages were the things which are break her down." Frivolity in a sense, yes, for the stress was artificial; but sheer idleness was not the culprit. Modem life, in this view, remains a villain, but now as it imposes both too many tasks and too many temptations away from really healthy focus for energy. [18]

Unresolved tensions about the nature of breakdown-inducing pressures carried over, of course, into proposed remedies. Rest and distraction remained popular. Travel might be recommended. But the reengagement with the work ethic might lead to attacks on these very recourses: recommendations of rest were, "of all errors, the most irretrievable." "The modern treatment for nervous disorders is not rest. Fatigue ... does not break us down--on the contrary, we have in us a sort of electric battery that charges by running.... People have an unusual font of energy because they work hard." Again, no clear trend emerged. Many breakdown victims in the 1940s and 1950s assumed that rest and a change of pace were essential, while others saw their problem in terms of boredom and lack of adequate challenge. The concept could embrace both diagnoses, both implied remedies--often in the same person. [19]

Just as nervous breakdown accommodated various views about over- and under-work, and about gender, the concept inevitably maintained vital tensions about personal blame. A strong thread, from the 1920s onward, was the breakdown victim as responsible for his, or more commonly her, own fate. "Self-pity is a bubble that needs to be pricked ... It is a bubble of self-complacency that makes a person say, 'Oh, I am just working on my nerves!' Collapse invariably follows in its wake. If we did but know it, the collapse has no more reality to it than the earlier sense of working on one's nerve. Each is a hollow fancy; neither is a physiological fact. The suggestion to one's self that something may snap, passes over into the suggestion that something has snapped, and then the game is up." Similar comments issued from the 1950s, as experts lamented how men, once insulted by claims their nerves were shot, now used being "on the verge of a nervous breakdown" as an acceptable basis for fear. Their only legitimate excuse might be the general increase in health anxieties, not always adequately handled by regular doctors. [20]

Closely linked to the issue of blame was an unresolved distinction among outside pressure, inherent flaw and irresponsibility in causing nervous collapse. Every person, so one argument went, had a breaking point; to that extent, some outside stress was always responsible. But: "How he breaks will in large part be determined by his underlying psychological weaknesses." The issue loomed large in discussions, during and after both world wars, about the breakdowns of soldiers. Many authorities, particularly in World War I, argued that only the deficient faced real problems; after all, many men survived the shocks of war without trauma. Many army programs, in both world conflicts, assumed that psychiatric screening of the "mentally unfit" would eliminate collapse: "If a soldier was a man he would not permit his self-respect to admit an anxiety neurosis or to show fear." Many therapists urged the contrary, yet they too might betray ambivalence. One contended, in 1943, that "bravery or cowardice has little to do wi th it" -- the same symptoms cropped up no matter how men were selected. But the same authority quoted with approval a military doctor who argued that as the "less strong personalities" were weeded out, the crises diminished. [21]

The assessments were often repeated in civilian contexts. "Hysteria is probably the one [form of nervousness] having its source mainly in the character of the patient. That is to say, outward happenings play a part which is secondary to the personality defect." Were nervously-prostrate housewives "shamming", or were they victims of forces beyond their control? A manual in 1960 urged people to understand that breakdowns were no more manageable than shell shock or battle fatigue. But--again the ambiguity--two pages later: "Hysteria has no cure but control. Many a wise, well-poised woman, who is a fine influence all around, has sternly disciplined what hysterical tendencies she had, into subjection to her good judgment." Here, perhaps, was a backhanded resolution to the mix of components in the nervous breakdown concept: victims were rarely frauds, yet there were underlying weaknesses, and at the same these were subject to rational mastery. Those who yielded, therefore, were indeed partly at fault. [22]

Cure, in consequence, depended heavily on strength of will, learning broader interests and "the art of getting on with yourself." Outside help might be needed--again, the concept admitted various, even contradictory approaches-- but there was a strong impulse toward personal responsibility. "You will have to restrain yourself, by an effort of will ... But you will find that these inclinations ... will pass, if you do not yield to them." "1 should like people to take as much pride in their mental health, in keeping their heads under trying circumstances, as they do in their appearance." Many accounts of nervous breakdown, including personal testimonies, featured a sense that people could or should work problems out on their own, that this ailment was not primarily open to outside intervention. Though shame and stigma about visits to mental health professionals figured into this reaction, components of the concept itself, as it evolved over several decades, contributed strongly. "For the great majority of peop le, extensive psychiatric treatment is neither available nor necessary." Or, from Great Britain: "competent and sympathetic psychiatrists unfortunately are not always available." [23]

And this tension, between uncontrollable cause, whether external stress or internal defect, and individual responsibility, informed not only approaches to treatment, but efforts by afflicted individuals to explain what went wrong in the first place. Again, there was no single statement, but a widespread impulse to see breakdown as a disjuncture between external reality and internal mental framework. Exterior problems, sometimes at work, more often in personal life, played a role, but emphasis most commonly centered on a breakdown of a personal framework of understanding, such that what was happening no longer made sense--hence, after a struggle to hold the line, a crisis and sudden collapse (the breakdown idea surfacing here vividly). Prior psychological vulnerability played a role--the victims knew that other people might have survived their objective problems readily enough--but it was the sudden gulf between personal expectations and apparent reality that set the seal. By the same token, collapse could ge nerate a personal reassessment, often without significant expert intervention, that would not only end the crisis, but leave the victim far stronger, at greater peace because of greater acceptance of limits, than ever before. Commentary in this vein might be partly implicit, like the woman who admitted that despite splendid personal circumstances she "wore herself out" with "petty worries" until she broke down, only gradually gaining a firmer set of expectations and self-understanding. Or as another put it, referring to the final, salutary phase: "In the end, you rescued yourself, that was the whole point, my credo at the time, and perhaps still." In some commentary, vaguely Freudian notions of subconscious repression were invoked to explain the framework crisis, but this was rarely pushed too far because of the concomitant strand of self-control: Victims must be "capable of improving themselves," depending on their "own inner resources." [24]

At extremes, the nervous breakdown concept was riddled with contradictions. Victims were ridiculous neurotics, who required professional help to see the folly of their petty worries. Or they were tormented souls, buffeted by external dilemmas and prior vulnerabilities. Or they were truly heroic figures, tortured but capable of lifting themselves from crisis. They might be idle or overworked, disproportionately male or disproportionately female, needing rest or needing energizing. Clearly the range of the concept, its applicability to such a wide variety of dilemmas, provided solid bases for its appeal. Yet, particularly as the concept was sorted out in popularizations from the late 1930s to the 1960s, some central themes could emerge, combining several of the disparate themes.

The highlighting of personal resources, often independent of, even antagonistic to professional help, and the downplaying of purely external stress in favor of the issues of mental frameworks, were crucial in this composite, which increasingly moved nervous breakdown away from many other available diagnostic categories, including neurasthenia.

Basic Causation

Nervous breakdown provided major service for at least half a century in reaching an unprecedented audience, which accepted the term, and in combining complex symptoms with several key explanations. In its varied formulations, but also in its predominant themes, nervous breakdown unquestionably met needs stemming from the context of the 20th century, and that help explain the concept's emergence (along with the 19th-century precedent) despite overlapping existing categories. Causation is no simple matter, and several factors go beyond the concept's explicit content. Despite the silence of most early formulators on why they found this new category useful--or even about why they thought a new term was needed at all; and despite a lack of direct evidence on why the concept so quickly and clearly won public fancy, it is possible to tease out plausible explanations. Flexibility--the concept's applicability to such a variety of tensions--was a vital component. Caprio, as late as 1969, had the phenomenon cover depre ssion, anxiety, compulsion, hypochondria, trauma and several other states. But various Americans, expert and lay alike, were trying to express some primary concerns through their references to breakdown, and these concerns explain why the term caught on and why its content evolved as it did.

Clearly, from the 1920s onward the concept picked up where neurasthenia left off in capturing specific but varied anxieties identified in modern life. Some of the connections were made directly. The idea of excessive pressure on children from extensions of schooling, for example, took root around 1900, finding expression in childrearing manuals and a longstanding campaign against homework, as well as entering into popularizations of nervous breakdown. New family pressures resulted from the rapid decline of domestic servants, which in turn underlay some of the perception--and possibly the reality--of more nervous housewives. Newly-articulated gaps between romantic expectations of marriage, and actual reality for women, defined another new set of worries that could be translated into nervous breakdown, accounting for frequent references to familial tensions and unhappiness in the concept's popularization. Even ambivalence about the growing tendency for elderly parents to live alone, rather than sharing an adul t child's household (a trend from the 1920s onward) could be picked up in the list of anxieties that might generate breakdown. [25]

More broadly, the frequent reference to breakdown in terms of a framework of expectations that had stopped seeming applicable--"an individual's experience of the collapse of his or her framework of self-understanding"--while rich in psychological implications, also touched base with broader cultural shifts in the early decades of the century. The 1920s ushered in a number of new emotional and physical standards, and it might be hard to keep up. New rules against traditionally-approved expressions of anger (for men) or grief could lead to unanticipated frustrations, when a person found assumptions confounded by novel emotional intolerance. New standards for women also included new criteria for appearance and stylishness (including control of weight), and for managing a new array of social activites and club life. Here too, expectations could outpace reality--glamour goals for example might inspire frenzied effort which nevertheless fell short, in terms of improving one's love life or social success. Or a more traditional outlook could be frustrated by the new standards--pressure to be modern and casual about grief could belay the intense emotional that personal loss still engendered. Either way, a gap could open between the norms and aspirations intended to define behavior, and what was actually possible. The nervous breakdown definitions neatly coincided with the advent of major innovations in the standards for emotion, appearance and personal function. Nervous breakdown captured some of the pressures and confusions involved, which is why the issue of framework adjustment and the frequent references to disjunctures with personal understanding, along with personal responsibility for coping, came through so strongly. [26]

Nervous breakdown also arose at a time when drug use was changing rapidly, especially for middle-class women. Medical attacks and legal prohibitions on opiate use, from the 1890s onward, surely reduced some of the chemical supports that had previously conditioned stress. Never mentioned in the nervous breakdown literature, the coincidence in timing was nevertheless uncannily precise, while the new emphasis on breakdown (contrasted with neurasthenia) may have captured key experiential results. Along with the impact of war, in fact, this facet particularly explains this innovation in the evaluation of nervous distress. [27]

Finally, the early stages of the nervous breakdown concept surely captured a new ambivalence about professional help. Therapists were touting their wares. The idea of mental illness became more accessible, and nervous breakdown was one manifestation of this. Yet professionals tended to reject the concept as too vague and generalized; nervous breakdown never won a place in medical literature. And, absent drugs and amid disputes about treatment, professionals did not necessarily have much to offer in any event. To be sure, by the 1940s, numerous young women were hospitalized for breakdown, winning at the least some rest amid the otherwise unredeemed burdens of the baby boom. But professional scorn for the concept hardly encouraged a massive patient stream (precise numbers are unavailable in any event). Believers in nervous breakdown could be confirmed in their tendency to include a large dose of self-help in their definition, while those suspicious of therapists, or moved by the stigma still attached to consul tation, might attach themselves to the concept precisely because of its non-psychiatric slant. The dominant acceptance of the breakdown idea reflected a complex stage in the relationship between deeply-felt psychological unease and available expertise. One woman who did use a therapist triumphantly selected a bad one, so that most of her recovery would be up to herself. The key service of nervous breakdown did not involve justifications for medical treatment so much as a validation of a need for some sympathy and space for personal recuperation and an inability to carry out normal functions. [28]

Nervous breakdown became a widely-used notion by which Americans explained certain symptoms or anticipatory fears to themselves and through which they sought support from family and acquaintances. It worked, in these functional terms of legitimizing key definitions of distress. Flexible vagueness made it a valid catchall. It described new worries and larger reactions to changing behavioral standards. The focus on collapse and on personal rather than professional responsibility made sense in the medical context that prevailed for several decades after 1900. In this complex setting, the concept authorized and guided widespread self-diagnosis as well as reactions to the woes of others.

Transitions

Conventional wisdom argues that the validity of nervous breakdown began to decline by the late 1960s, and indeed there were signs of major change. Further, many of the causes that had sustained the concept began to shift, so explanation is not obscure. Indeed, the factors prompting a reduced reliance on nervous breakdown confirm some of the reasons for its popularity in the first place.

There were two major symptoms of change, suggesting a reduction in the salience of nervous breakdown in the popular American lexicon. First, the rate of articles and books declined; it became hard, in browsing a bookstore or thumbing through magazines, to come upon descriptions of nervous breakdown or advice on how to avoid or overcome it. As we will see, references did persist, mainly in recurrent first-person accounts of the experience. But popularizers themselves clearly concluded that a once-vibrant market had dwindled. Frank Caprio's book was the last of the genre.

At the same time, popular disease preferences clearly shifted as well, in two directions. First, the concept of stress gained ground. The term had persisted independently in the 1920s and 1930s, as well as being incorporated into common versions of nervous breakdown. But from the 1950s onward it stood more triumphantly on its own. Widely-publicized theories of stress by Hans Selye (whose book, The Stress of Life, emerged in 1956 but who inspired popularized articles from the late 1 940s onward) set the process in motion. The stress emphasis, popularized also in studies of type A personalities and through other terms such as burn-out, related to the growing attention paid to high blood pressure and cardiac disorders. Here, clearly, was a new twist on the old interest in noting the psychic and somatic costs of the pace of modern life. ("High blood pressure is primarily a disease of stepped-up living and urbanization," one Time magazine account trumpeted, claiming among other things, with complete inaccuracy, t hat southern Blacks were exempt from the problem.) [29]

Along with stress came growing attention to depression, here from the 1970s onward. Just as stress took over nervous breakdown's role in reflecting the pressures of modem living, so depression picked up other features, such as a predominant emphasis on women and a sense of inability to function. Taken together, stress and depression reduced breakdown's utility as a catchall category, for problems that the concept had once, however uncomfortably, united were now broken into two more clearly separate categories. Stress took over the idea of outside factors, depression the focus on internal states. Here in turn was both cause and concomitant of the declining place of nervous breakdown in the psychological self-help literature. [30]

Popular beliefs about psychic functioning were becoming somewhat more precise. Further, a prefereence for models of organic deterioration, in the case of depression, increasingly rivaled the implications, in nervous breakdown, that an individual could regain control after some kind of pause.

Several factors combined in this transition, from the 1960s onward, while also accounting for the new focus on stress and (a bit later) depression. The impact of World War II, and then the Cold War and Vietnam, was crucial. Experts increasingly urged that the psychological effects of wartime trauma on men could not be talked away as cowardice or even the outcropping of some previous psychological deficiency. Stress happened, with often horrendous results. While disputes lingered in World War II, the widely-publicized pressures on troops in Korea and then Vietnam capped a process of growing understanding. Correspondingly, it became appropriate for soldiers to express their own recognition of the problem (like the Gulf War pilots who openly discussed their fear) and for commanders, as well as military doctors, to recommend appropriate mental preparation. Expert terminology might still vary, but stress captured growing public recognition of the issue, designating psychologically demanding situations that did no t require elaborate definition. Expert studies spilled over into the families of servicemen, also subject to stress. And the climate of the postwar decades, filled with job opportunities but also increasingly recognized pressures of corporate and commuter life, further bolstered the utility of the stress concept. The work ethic did not erode (a feminist- and male liberationist-inspired 1970s attempt to attack "workaholics" did not ultimately succeed), but the kind of ready endorsement of effort that had characterized the 1920s began to yield to greater ambivalence. [31]

Nervous breakdown could of course have handled the idea of pressure from war and work, but we have seen that on the whole the focus in the breakdown concept had shifted toward internal factors rather than external provocation. So the context was ripe for newly-emphasized terms like stress and depression, that would better capture the problems experts and the public both recognized as dominant.

By the 1950s also, a new series of drugs began to attack some of the crucial symptoms often attached to the breakdown idea. (Nervous breakdown performed its greatest service in the decades between two different drug regimes.) Widely-prescribed tranquilizers began to give doctors new weapons and new appeal; Miltown (Meprobamate) was the first "minor" tranquilizer available for anxiety. Antidepressant drugs soon followed. With housewives the principal patient population, the potential impact of psychotropic medications on nervous breakdown would be obvious. First, the need for a disease that would emphasize self-help and adjustment of personal framework, as opposed to consultation of medical professionals, was diminished. Second, the utility of a concept that stressed sudden collapse, after previous mental health, was also altered. People who judged themselves "on the verge" could now delay or attenuate symptoms by prescription drugs. They might still suffer--drugs indeed might mask problems that would later t urn into fullblown depression--but the notion of crisis was reduced. Whether this helped spur the public acceptance of depression, which was based more on an understanding of gradual process, of erosion rather than breakdown, must remain speculative at this point. But prior reliance on the idea of a collapse of functioning was clearly affected. [32]

Combined with new drugs was the twin effect of growing psychological precision and increasing willingness to consult mental health professionals. During the 1920s-1950s period some doctors had written about nervous breakdown for a popular audience, either because they found the concept cropping up in their practice or because they sought public attention and used the term both to boost sales and to tap into an understanding that would help them convey useful messages about mental health. But there had been no expert incorporation. Then, the advent of specific drugs joined with a more research-based, reductionist brand of medical diagnosis.

The production of official diagnostic manuals by the American Psychiatric Association, which began in 1952, made the gulf between psychiatric and popular terminology obvious. Nervous breakdown was never listed. Even neurasthenia was downplayed, though it might cover a particular category. The first Diagnostic and Statistical Manual (DSM I) offered a cluster called psychoneurotic disorders. "Longitudinal (lifelong) studies of individuals with such disorders usually present evidence of periodic or constant maladjustment of varying degree from early life. Special stress may bring about acute symptomatic expression of such disorders." The Manual went on, then, to list a host of specific disease categories: Anxiety reaction, Dissociative reaction; Conversion reaction; Phobic reaction; Obsessive compulsive reaction; Depressive reaction, and so on. The point is clear: experts had never liked a catchall, and now they were generating increasingly standardized categories to substitute for it. Subsequent editions of th e DSM amplified this process. DSM II kept the basic categorical list, though it now offered "Neurasthenic neurosis" replace what had been "Psychophysiologic nervous system reaction." DSM III interestingly retreated a bit, with a new offering, "Generalized Anxiety Disorder", though there was no bow to anything as plebeian as nervous breakdown and a note urged the common association with more precise disease entities, most notably depression. DSM IV maintained this category, but returned to the emphasis on a wide variety of specific, separately labeled diseases, thus differentiating Panic Disorder from Anxiety Disorder, and this in turn from Obsessive Compulsive Neurosis and from Post-traumatic Stress Disorder. Expertise continued to require maximum possible precision of what another reference study called "Symptom Groups," and this argued against any move toward popularized terminology. In the same vein, growing emphasis on and precision about menopause provided another instance of expert blessing on a seeming ly more precise alternative to the breakdown catchall. [33]

One obvious result of these developments was the increasing unwillingness of doctors to write articles or manuals that referred to nervous breakdown. This shift could have effects of its own. But it was greatly heightened by a measurable change in public acceptance of the idea of mental illness and the legitimacy of professional consultation and treatment. In 1947 14% of the population admitted seeking professional help at some point, but by 1976 the proportion has nearly doubled, to 26%-headed by college graduates (at 32%). The need to deny mental problems or to assume they could be handled privately diminished, and the stigma attached to consultation steadily decreased. Growing use of experts directly attacked that vital component of nervous breakdown that had proudly stressed self-help in diagnosis and cute. Ironically, its was perceived breakdown itself that impelled many people toward the growing turn to therapy, to relieve the pain: "Respondents who actually experienced serious crises ... or symptoms o f distress (particularly anxiety and apprehension about a nervous breakdown) more often used professional help and were less likely to assert that they would never face a problem they could not handle on their own." Yet the same new recourse, which often provided alleviation in part through prescription drugs, could diminish the viability of the concept that had promoted it in the first place. Further, use of experts facilitated incorporation of more of their terminology and diagnostic distinctions (though by no means did all the categories win public favor); depression and to a lesser degree stress were key beneficiaries. To the extent that terminology guides disease recognition--and historians have documented how important available categories are--nervous breakdown suffered. [34]

Growing professionalization could also both cause and reflect decreasing tolerance for assisting victims of anything as vaguely-defined as nervous breakdown, unless they were willing to seek professional help. To the extent that breakdown had been a term designed to legitimate a set of very real problems but also to elicit support from family and friends, this aspect of the move toward therapists could also have significant implications.

The final major factor in the decline of nervous breakdown--along with growing exposure to war, new drugs and mental health professionalization-- involved changes in gender roles, though here we explore an area that might in fact have given nervous breakdown a boost. The basic shift is familiar: married women began to enter the labor force in growing numbers in the 1950s and 1960s. At the same time, more articulate feminism began to attack previous disease categories that had singled women out, and nervous breakdown was certainly vulnerable to a new assertion of equality. [35] Women at work or women who used feminist categories of discontent might lose the feelings of domestic futility that had so obviously encouraged acceptance of the breakdown idea a half-century earlier. To the extent they had problems, they were novel, or differently explained, or both, and the shifts involved less sense of a personal framework suddenly made irrelevant. Many of the problems, further, were most easily captured by the grow ing emphasis on the burdens of stress. Disjuncture with personal frameworks persisted of course, precisely because of the rebalancing of work and domestic roles--and men were now involved as fully as women. But the specific issues were new, and nervous breakdown may have come to seem irrelevantly dated. Here, not only stress but also depression were more serviceable.

The factors undermining nervous breakdown must be seen in combination. The mini-revolution of gender might well have provided new support for the breakdown idea, except for the nearly-simultaneous impact of drugs and professional scrutiny. But the combination was powerful, and accounts for the apparent end of an era. The demise of a once-fertile health belief is as interesting as its origin, and the factors involved in both clearly overlapped. Anxiety did not diminish as nervous breakdown faded, but the ways to define it, and to an extent the ways to experience it, did alter.

Conclusion: Lingering Impacts

Yet nervous breakdown did not in fact fade away, and may have maintained a more vigorous life, beneath the surface of expertise, than many observers realized. Evidence is twofold. First, the concept retained surprising currency in certain kinds of literature; the genres were more limited than before, but still lively. Articles on the experience of breakdown maintained respectable frequency through the 1990s. Breakdown was also used in law: the evangelist Jim Bakker used a breakdown claim in an attempt to escape conviction on fraud charges, and lawyers apparently debated only whether this was yet another fraud-not whether nervous breakdown might happen. Suits against employers might cite work-based conditions that caused breakdown. In the popular magazine literature, a few articles of the old mental-health-advice type recurred. Breakdown also won attention in entertainment; an episode of the "King of the Hill" television show, in 1998, revolved around an uncle suffering breakdown (which in this case provided comic material, but this use too was not new). [36] Finally, breakdowns, or the feeling of being on the verge, might combine with stress to describe reactions t o newer kinds of pressure, such as an increasingly consumer-driven Christmas season. In the second place, as the articles on personal experience themselves attested, many individuals continued to find nervous breakdown the best way to understand what had happened to them or what they feared was about to happen. A 1980 survey showed a large percentage of Americans, particularly of small town or suburban (rather than big-city) background, giving credit to the concept while distinguishing it from mental illness. A majority said they knew someone who had suffered a breakdown, and a noticeable minority said they had experienced one themselves (with durations, intriguingly, ranging from five minutes to eight months-the concept retained flexibility). One study suggested that the Americans who credited the concept were a bit older than average and definitely of white, majority-ethnic background. But college students frequently cited fears of breakdown in using counseling services, at least into the 1970s.

Contemporary beliefs about breakdown had adapted to the times to some extent, particularly in emphasizing outside pressure more frequently than was true in the concept's heyday. Yet discussions of personal frameworks collapsing, and the greater self-understanding needed to emerge from breakdown, maintained strong connection with core features in the past, helping also to explain why, even amid fashionable emphasis on stress and depression, the concept might still serve. Most revealingly, contemporaries continued to dissociate the idea of breakdown from mainstream professional help. Rather, sources for support were primarily sought from family and friends. This continuity followed from professional scorn for the notion, but it also suggested a legitimacy beyond the needs of victims themselves. Breakdown still authorized a search for support, and it had to be self-defined. [37]

Even the populist use of the concept to tweak authority and modernity survived. A popular desk motto in the 1980s, for clerks and secretaries, proclaimed, with various specific phrasings: "As soon as the rush is over, I'm going to have a nervous breakdown. I deserve it."

Nervous breakdown's history and its continued currency suggest a fascinating undercurrent to American worries about worry in the 20th century. Purely professional definitions and remedies, even as they gained currency, have not sufficed. Amid growing acceptance of therapy, a pure medicalization model does not capture all the concerns involved, in an anxious society. Other needs require expression, and for the past 80 years nervous breakdown has performed vital service for these needs. A concept that would convey distress, a complex internal collapse of assumptions, and a recovery process that would emphasize self-help and local assistance was born of conditions in the early decades of the century and survives, somewhat below the surface, because many of these conditions have persisted. Along with medical diagnoses like stress and chronic fatigue syndrome, the category continues to designate concerns about the pace of modern life, in a society that needs an array of ideas both to protest this pace and to prov ide excuses for at least temporary withdrawals. Nervous breakdown must be worked into the historical perspective on contemporary American culture.

Abstract: Megan Barke, Rebecca Fribush, Peter N. Stearns, "Nervous Breakdown in 20th Century American Culture"

This article traces the rise of the term and concept, nervous breakdown. It emphasizes the reasons the concept gained ground, particularly between the 1920s and l950s, as an explanation for various new or newly-pronounced professional diagnoses and as a plea for some time and space for individual recovery. While nervous breakdown had medical overtones, it emphasized a collapse of personal understanding but also the possibility for personal reconstitution. The causes for the popularity of nervous breakdown, ranging from shifts in standards in the 1920s, altered gender roles, and changing pharmacology, also help explain the concept's decline after the 1960s; but surprising persistence is discussed as well.

ENDNOTES

Our thanks to Caroline Acker and an anonymous reviewer for advice and suggestions. Comments by various members of the Carnegie Mellon Center for Cultural Analysis were invaluable.

(1.) Edward Shorter, A History of Psychiatry: From the Era of the Asylum to the Age of Prozac (New York, 1997), esp. ch. 4; F. G. Gosling, Before Freud: Neurasthenia and the American Medical Community 1870-1910 (Urbana, 1987); Tom Lutz, American Nervousness, 1903: An Anecdotal History (Ithaca, 1991).

(2.) W. B. Wolfe, Nervous Breakdown, Its Cause and Cure (London, 1934; 3rd ed., 1949). The concept spread to Germany amid the tensions of post-World War II occupation, particularly among lay authorities. It also found uses in Australia, still more recently.

(3.) Janet Golden," 'An Argument that Goes Back to the Womb': The Demedicalization of Fetal Alcohol Syndrome, 1973-1992," Journal of Social History 33 #2 (1999): 269-298.

(4.) Thus nervous breakdown does not move away from a basically medical vocabulary, in contrast to ideas like spirit posession, which in other societies describe similar symptoms.

(5.) Robert Kugelman, Stress: The Nature and History of Applied Grief (Westport, CT, 1992); George Cheyne, The English Malady (London, 1733).

(6.) George M. Beard, American Nervousness: its Causes and Consequences (New York, 1881), pp. 96-133; Gosling, Before Freud.

(7.) Abraham Myerson, American Women: Images and Realities (Boston, 1920), pp.19-20; see also Myerson, The Nervous Housewife (Boston, 1927).

(8.) Gosling, Before Freud; George M. Beard, Sexual Neurasthenia (New York, 1906); for a comparable, though unusual, discussion of sexual causes of nervous breakdown, Wolfe, Nervous Breakdown, ch. 4--the treatment is very similar to Beard's for neurasthenia, though with updated emphasis on homosexuality as potential cause.

(9.) Shorter, History of Psychiatry, ch. 4; John R. Lord, "The Evolution of the 'Nerve' Hospital as a Factor in the Progress of Psychiatry," Journal of Mental Science 75 (1929): 307-15; S. Weir Mitchell, "Rest in Nervous Disease," in Edouard C. Seguin, A Series of American Clinical Lecture I (New York, 1876), pp. 83-102.

(10.) Albert Adams, Nervous Breakdown (New York, 1901). See also Adams: Diseases of the Heart (Chicago, 1900) and Consumption (San Fransisco, n.d.).

(11.) Charles Myers, Present-Day Applications of Psychology with Special Reference to Industry, Education and Nervous Breakdown (London, 1918).

(12.) Adams, Nervous Breakdown; Frank Caprio, How to Avoid a Nervous Breakdown (New York, 1969), pp. 26-31; 0. Henry, Let Me Feel Your Pulse (New York, 1910), p. 30; Edwin Lancelot, The Problem of Nervous Breakdown (New York, 1920) (a British study).

(13.) William Loosmore, Nerves and the Man: a Popular Psychological and Constructive Study of Nervous Breakdown (London, 1930); Myerson, American Woman, p. 21; Caprio, How to Avoid; F. Scott Fitzgerald, The Crack-Up, with other uncollected pieces.... ed. Edmund Wilson (New York, 1945).

(14.) Myerson, American Women, p. 18; Myers, Present-Day Applications; Walter Alvarez, How to Live with Your Nerves (Chicago, 1950) (condensed in Reader's Digest, Apr., 1951, pp. 103-5).

(15.) Tom Lutz, "'Sweat or Die': The Hedonization of the Work Ethic in the 1920s," American Literary History 8 (1996): 259-82; Ellen Glasgow, Barren Ground (1925; reissued Charlottesville, VA, 1938); Farnsworth Crowder, "But Is the World Going Mad?" Reader's Digest 30 (May, 1937): 53.

(16.) Myerson, American Women, pp. 25, 26, 44 and Nervous Housewife. p. 13 Note that this later work also included insistence on a dramatic restructuring of marriage and of household chores, as remedies. But this radical approach might resonate less than the diagnosis. See also Robert O'Brien, "What is a Nervous Breakdown?" Reader's Digest 76-7 (Aug., 1960): 73-6; Agnes Repplier, "The Nervous Strain," Atlantic Monthly 106 (1910): 198-201.

(17.) Repplier, "Nervous Strain," p. 200.

(18.) Josephine Jackson, "That Tired Feeling," Reader's Digest (Sept., 1922): 427-8; Myerson, American Women, pp. 44-5.

(19.) Eleanor Kelly, "The Fashionable Subconscious," Reader's Digest (Aug., 1923): 340; Lutz, "'Sweat or Die'."

(20.) Jackson ,"Tired Feeling," p. 428; "It's My Nerves," Time, Apr. 14, 1952.

(21.) O'Brien, "What is a Nervous Breakdown," p. 75; Frederick Painton, "There is No Such Thing as Shell Shock," Reader's Digest 43 (Oct., 1943): 59-63; "Give Us a Break," Reader's Digest 45 (Nov., 1944): 8-11; Roger Spiller, "Shell Shock," American Heritage 41 (1990): 75-87.

(22.) Joseph Jastrow, Sanity First! (New York, 1935); Edmund Bergler, Tensions Can Be Reduced to Nuisances (New York, 1960), pp. 26-7.

(23.) Keene Sumner, "The Secret of Sound Sleep," Reader's Digest (Jan., 1923): 764. Jastrow, Sanity, pp. 176-7; Bergler, Tensions, pp. 206-10; Wolfe, Nervous Breakdown.

(24.) Vanessa Ochs, "Taking the Cure," Tikkun 10 (1995): 47; George Stevenson, "How to Deal with Your Tensions," Reader's Digest (Mar., 1969): 89-92; Gladys Rush Alexander, I'm Glad I Had a Nervous Breakdown (New York, 1966), pp. 4-5.

(25.) John Spurlock, "The Problem of Modern Married Love for Middle-Class Women," in Jan Lewis and Peter N. Stearns, eds., Emotional History of the United States (New York, 1998), pp. 319-32; Peter N. Stearns, American Cool: Constructing a 20th-Century Emotional Style (New York, 1994).

(26.) Keith Purdie and Jim McLennan, "'After My Breakdown': Implications for Counselors of Accounts of Change in Self-Understanding," Counseling Psychology Quarterly 6 (1993): 17-27; Peter N. Stearns, Battleground of Desire: The Struggle for Self-Control in Modern America (New York, 1999).

(27.) David Courtwright, Dark Paradise: Opiate Addiction in America Before 1940 (Cambridge, 1942); David Musto, The American Disease: Origins of Narcotic Control (New Haven, 1973); W. Wayne Morgan, Drugs in America: A Social History, 1800-1980 (Syracuse, 1981); Jeffrey Foster, "The Rocky Road to a 'Drug Free Tennessee': A History of the Early Regulation of Cocaine and the Opiates, 1897-1913," Journal of Social History 29 (1996): 547-64.

(28.) Cynthia Crossen, "Losing It: Nervous Breakdowns, By Any Name, Aren't What They Used To Be," The Wallstreet Journal, Dec. 3, 1996, p. 1; Shorter, History of Psychiatry.

(29.) Hans Selye, The Stress of Life (New York, 1956); "How Worry Hurts the Heart," Science Digest (Sept., 1947); "Civilized Diseases," Life, Dec. 23, 1946 (an early article on Selye's work); R.C. Beardman, "Modern World Viewed as Too Much for Man," New York Herald Tribune, Oct. 7, 1947; stress in disease was listed for the first time as a Reader's Guide category in 1951; J.D. Ratcliff, "Stress, the cause of all disease?", Reader's Digest (Jan., 1955); "Stress Disease," Newsweek (June 26, 1950): 40; "Life of Stress," Time (Oct. 9, 1950): 93. For samples of ongoing coverage, "'Stress,' How It Can Hurt," Newsweek (Apr. 21, 1980): 106; J.D. Ratcliff, "How to Avoid Harmful Stress," Today's Health (July 1970); Benedict Carey, "Don't Face Stress Alone," Health (Apr., 1997).

(30.) Shorter, History of Psychiatry; but a fuller historical perspective on the rise of depression and its public resonance in the United States remains vital.

(31.) Spiller, "Shell Shock"; Reuben Hill, Families Under Stress (New York, 1949); Ron R. Grinker and John Spiegel, Men Under Stress (New York, 1945).

(32.) Shorter, History of Psychiatry; Crossen, "Losing It."

(33.) Thomas Langrer and Stanley Michael, Life Stress and Mental Health: The Midtown Manhatten Study (New York, 1963); American Psychiatric Association, Diagnostic and Statistical Manual I (New York, 1952), II (New York, 1968), III (revised) (New York, 1987), and IV (New York, 1996). Ian Hickie, D. Hadzi-Pavloovic and C. Ricci, "Reviving the Diagnosis of Neurasthenia," Psychological Medicine 27(1997): 989-94 argues that the expert prejudice has been overdone, that other categories, like depression, equally overlap flexible popular concepts. Thomas H. Hohenshil, "DSM-IV: What's New," Journal of Counseling and Development 73 (Sept/Oct, 1994):106

(34.) Joseph Veroff and others, Mental Health in America: Patterns of Help-Seeking Prom 1957 to 1976 (New York, 1981), pp. 266-72.

(35.) "Women and Their Physicians," in special issue "Women and Mental Health," Women and Therapy 3 (1984): 63-9; Ruth B. Hoppe, "The Case for or against, Diagnostic and Therapeutic Sexism," in special issue "Women and Mental Health," Women and Therapy 3 (1984): 129-36; Vivienne Walters, "Stress, Anxiety and Depression: Women's Accounts of Their Health Problems," Social Science and Medicine 36 (1993): 393-402.

(36.) Christina Burnett, "What Is This Thing Called a Nervous Breakdown?" Cosmopolitan 216 (May, 1994): 164; "Wounded by Rare Media Criticism, Japan's Empress Michiko Loses Her Voice in What Some Fear May be a Nervous Breakdown," People Weekly 40 (Nov. 8,1993): 132; "Men on the Verge of a Nervous Breakdown," People Weekly 36 (Dec. 30, 1991 and Dec. 6,1992): 100-105; Bill Nichols and Jack Kelley "Bakker's Condition Debated" USA Today (Sep. 1, 1989):A,3:2; Autumn Polansky "Are Your on the Verge?" Cosmopolitan 223 (Oct. 1997): 274; John Reinhold, "Users and Nonusers of College Counseling and Psychiatric Services," Journal of the American College Health Association 21 (1973):201-8; Laura Ziv, "1 Had a Nervous Breakdown and Nearly Lost My Mind," Cosmopolitan 223 (Oct., 1997):272; Caroline Mansur, "Telltale Signs of a Stressful Life," New Scientist 134 (1992): 34-6; "Walker v Northumberland CC" The New Law Journal 6674 (1994):1659 (on a negligence case where an employee suffered nervous breakdown); see also Robert Howe, "Self-Help Course Allegedly Shattered a Life," Washington Post, July 7, 1992; Teresa Hunter, "Bank Faces Law Suit After Customer Has a Breakown," Guardian, Oct. 3,1992. Nixon official John Mitchell's wife Martha was discounted as a witness in the Watergate scandal because of rumors she suffered a breakdown: Jonas Robitsches, "Stigmatization and Stonewalling," Journal of Psychohistory 6 (1979): 353-408. There is also some evidence that more expert credence concerning nervous breakdown continues in the English-speaking world outside the United States. M. Epstein and S. Hosking, Falling Apart (South Melbourne, 1989); E.W. McCormick, Nervous Breakdown (London, 1988); S. Sutherland, Breakdown (London, 1987). Here too, further explanatory investigation would be intriguing.

(37.) Richard Omark, "Nervous Breakdown as a Folk Illness," Psychological Reports 47 (1980); Purdie and McLennon, "'After My Breakdown'."

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