In Praise of the Nervous Breakdown

Perhaps not beyond repair.

Even the most level-headed individual can be rendered insufferable by taking an introductory psychology class. Suddenly the neophyte student will become an arrogant expert, deriding the ignorance of friends, family, and dinner companions.

The use of the term “nervous breakdown” is a case in point. Uttering the words is a bit like blowing a dog whistle: Intro Psychology graduates will converge from miles around to clarify that there is no such thing.

In this case, however, the phenomenon is not restricted to sophomores. Mental health professionals of every stripe will nod in agreement. Nerves don’t spontaneously break or, if they do, they don’t cause the most common forms of mental distress. The term does not appear in the DSM-5 nor, for that matter, in DSMs I through IV. Doesn’t exist; never did.

Pay attention to the people so corrected, however. They respond with bemused tolerance or finger-tapping impatience, but seldom with gratitude or thanks at being better informed. In discussing their (or their family member’s) nervous breakdown, they were not asserting an etiology of distress, nor providing a psychiatric diagnosis.

Instead, they were describing a period of time during which the sufferer became less capable of managing the vicissitudes of life and instead withdrew inward while experiencing some form of psychological pain. The emotional tone may have been characterized more by anxiety, or depression, or embitterment. They may or may not have exhibited transient psychotic symptoms. Perhaps they were hospitalized; perhaps not.

From Nervous Breakdown to the 21st Century

“Nervous breakdown” became an informal way of describing transient psychological difficulty early in the 20th century (Barke, Fribush, & Stearns, 2000), and persisted (with peaks and valleys) to its end. It was the preferred term in familial gossip about others, and it was often the way that people would describe their own mental blips – when they weren’t calling them “crack-ups” (as F. Scott Fitzgerald did in his 1936 essay about his own experience).

Today there have been enough students of psychology (and public education by experts) that the term has faded somewhat, though we continue to hear of celebrities being hospitalized for mysterious “nervous exhaustion” (or the abbreviated “exhaustion”) – likewise a term never to be found in any diagnostic manual. Try going up to triage nurses in a busy emergency ward and saying "I'm exhausted." Watch their expression.

Instead, we hear about depression – often, about how it is a chronic and relapsing illness caused by mysterious and never-named (or, umm, found) biochemical imbalances. We understand that mental distress is “an illness like any other illness,” though the people who say this would be hard pressed to define the essential characteristics of an “illness,” so this becomes a bit meaningless. We subdivide anxiety into half a dozen primary “anxiety disorders” to be distinguished from depression, anger, disillusionment, grief, and other difficult emotions by ... by ... well, by a belief system that is impolite to describe as more theological than scientific.

In the process we have created a bogus corpus of common knowledge that exceeds that known by those who have actually read the literature or examined the data. We have also learned to characterize someone who has had episodes of difficulty as being forever defined by their least functional period. Thus, a person who has once experienced a major depressive episode qualifies, from that moment until death, as having Major Depressive Disorder. People are defined by their pathologies more than by their recoveries.

Recent controversies over the development of the DSM-5, as well as the failure of some etiologic theories of disorder (like the monoamine hypothesis for depression), have tarnished the image of formal diagnosis somewhat. Many of us in the field wonder if our diagnostic attempts have been more pathologizing than enlightening or helpful.

In this atmosphere, maybe it’s time we dusted some older ideas off the shelf for a second look. We could do worse than to start with “nervous breakdown.”

What’s so good about nervous breakdowns?

Consider the similarities between nervous breakdown and skin breakdown.

When I was younger I spent some time working in a rehabilitation hospital for people who had suffered spinal injuries. The nerve damage would often prevent clients from perceiving the normal discomfort that might formerly have prompted them to shift positions. As a result, unless they were mindful they would sit in the same position for hours and develop pressure sores – essentially the breakdown of skin and subcutaneous tissue. These would have to be carefully managed but would eventually heal.

So the characteristics of skin breakdown are:

1. A reduction of functioning in a certain system (in this case, skin), 
2. Caused by external stimuli (like a poorly padded wheelchair), plus 
3. Inattention to self-care (like timed posture adjustments whether one feels uncomfortable or not), which is
4. Expectable in normal individuals (they do not reveal that one was born with defective skin), and are
5. Manageable or treatable, and 
6. Once resolved is no longer called a skin breakdown (because the skin has healed), and 
7. Serves as a reminder that one may be at risk of this problem (having had it before) and may need to engage in closer self-care in future.

All of these are useful ideas in the case of most psychological conditions. If we transfer the concepts to, let’s say, depressive episodes, we have:

1. A reduction in behavioral or emotional coping or functioning,
2. Typically brought on in part by external events (losses, work stresses, role conflicts, relationship issues), plus
3. A disruption or deficit in self-care (exercise, diet, sleep factors, the role of social contact, making personally meaningful activity a priority). These are
4. Expectable in normal individuals (meaning that they do not require evidence of a biological defect in advance of the development of the disorder and do not provide evidence that one is a defective human being), and are
5. Manageable and treatable (most depressive episodes are self-resolving and most can be resolved more quickly with coaching to enhance self-care and life balance using behavioral activation – and sometimes medication), and
6. Once resolved should no longer be called depression (any more that a person recovered from a bout with flu should be defined as a “flu sufferer”), and
7. Can serve as a reminder that one may be at risk of a recurrence (having once had the problem may indicate or produce a higher susceptibility of the problem in future, therefore mandating closer attention to self-care in the future).

Although one could easily quibble with a few points, this perspective is considerably more useful and in accord with the data (at least for most people in depression) than the disease model that the mental health system attempts to impose instead.

The Key Distinctions

For me, the most important differences between the current model of disorder and the “nervous breakdown" idea are (at the risk of some repetition of the above):

Episodic nature. One says “I had a nervous breakdown” rather than “I am a nervous breakdown” or “I have nervous breakdown disorder, even though right now I feel fine.” It was an event, not a characteristic of the person. It does not define them.

Symptomatic Vagueness. The term allows the user to disclose a period of psychological distress without necessarily revealing all of the intimate details. Critics may complain that this lacks the specificity of formal diagnosis, but formal diagnosis is often useful only insofar as it guides treatment selection – which current diagnostic methods do remarkably poorly. In any case, no one is suggesting that the entire diagnostic system be replaced by a pamphlet with the words “nervous breakdown” on it.

Trigger-Based. When people talk about nervous breakdowns they tend to focus on the factors that brought them about. “I was under enormous pressures at work, I had a health scare, and my spouse left me.” This is in accord with the data on most psychiatric conditions – they tend not to appear out of the blue. By contrast, the dominant model most clients are presented with is defect-based and noncontextual. “It’s just a biochemical imbalance, it could have happened at any time and had little to do with your life.”

Nonsensical. The strained smiles of those who are informed that “nerves don’t break” tells the tale. Most people understand that the words in the term “nervous breakdown” are the product of heritage, not science, and are not intended to be taken literally, any more than the terms “radical conservative” or “viral meme.” At best, all of these are metaphorical or allusive in nature. The disorder-based terms we currently use, on the other hand, bring with them unhelpful and often inaccurate baggage.

Recoverable. Once diagnosed with depression, people are defined as suffering from Major Depressive Disorder and are frequently informed that they must be in some form of treatment henceforward, even if they appear to be symptom-free. The evidence for the benefit of ongoing post-episode treatment is poor. Nervous breakdowns are typically viewed, by their episodic nature, as events that are resolvable – perhaps with rest, a reduction in stress, or a systematic reworking of one’s life circumstances.

Recurrence-Aware. The nervous breakdown idea acknowledges that most episodes of mental distress can be expected to resolve quite well with good inter-episode recovery. (The evidence appears to be accumulating that depression became a more-frequently chronic disorder with the onset of chronic treatment.) But it also allows that a person may be more vulnerable to such episodes than others, therefore meriting greater vigilance for stress, lifestyle imbalance, and early warning signs of destabilization.

The Capacity/Stress Model

Perhaps best of all, the nervous breakdown idea hints at the notion of a “breaking point” and at the interaction between the person and the environment in a way that seems to fit with evolving conceptions of distress episodes.

Put simply, people appear to have a capacity for processing demands, stresses, and losses imposed on them by their environment. If they challenge themselves gently and allocate sufficient resources to self-management (getting adequate sleep, leisure, exercise, a proper diet, and so on – the need for which may vary based on individual factors), then they are generally able to cope with these demands. Further, their capacity may gradually increase over time – just as exercising with increasing weights may result in greater muscle capacity, within limits.

When circumstances overload a person or crowd out self-care, the processing capacity appears to shrink. What once was a manageable level of demand now exceeds the person’s ability to cope, driving coping abilities lower still. Thoughts and behavior may become disorganized and chaotic as the person thrashes away at their circumstances or retreats inward from a sense of defeat.

The “breaking of nerve” is not a literal event, but a decline in the person’s ability to manage things at their former level. Recovery typically involves rest, a rethinking of the circumstances that led to the collapse, and the gradual reintroduction of elements of the person’s life (perhaps with pharmacological assistance along the way).

Exceptions

I am not arguing for the wholesale abandonment of diagnostic specificity, nor the blending of all distress episodes into a single term. Clearly there is some usefulness (at least to the care team) in knowing whether a person’s contact with reality has been lost, or whether anxiety or despair predominate, or whether suicidality is present. But these important aspects are typically found in the case description rather than in the diagnostic label in any case.

Certainly there are people in whom a biological predisposition to episodes of distress or decompensation is a major factor. Certainly there are people for whom a purely medical approach is necessary or more helpful than a nonmedical one. And certainly there are individuals whose illnesses will prove chronic rather than episodic.

But to suggest that the idea of nervous (or “mental”) breakdown is necessarily a more primitive concept than the inaccurate or faux-precise diagnostic categories with which we currently diagnose people seems false. If we look at the utility to the sufferer, I suspect that the older and less formalized perspective may be superior.

If only we could get psychology students to agree.

References

Barke, M, Fribush, R, & Stearns, PN (2000). Nervous breakdown in 20th-century American culture. Journal of Social History, 33, 565-584.

Carey, B (2010). On the verge of “vital exhaustion”? New York Times, June 1. http://www.nytimes.com/2010/06/01/health/01mind.html?ref=health?8dpc&_r=0

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