In Praise of the Nervous Breakdown

Randy Paterson, PhD, RPsych
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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. On the Verge of “Vital Exhaustion”? New York Times, June 1, 2010

25 COMMENTS

  1. “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.”

    The key to this sentence is found between the parentheses. Listen closely. Pay attention. The psychiatric obsession with diagnosing people with imaginary diseases HARMS people. It does not help them, nor is it in any way “useful” (unless you are referring to the kind of utility that a former German regime subscribed to in their “treatment” of Jews).

    “If we look at the utility to the sufferer, I suspect that the older and less formalized perspective may be superior.”

    No one takes the so-called “utility” of the “sufferer” seriously. What can “utility” for a “sufferer” possibly mean? Suffering people don’t need utility. They need relief. Psychiatry is the cause of suffering, not the cure.

    What students of psychiatry and psychology need to understand is that their fields are based almost entirely upon lies and fraud which have lead to excruciating pain and suffering in untold millions of people.

    “I am not arguing for the wholesale abandonment of diagnostic specificity”

    The reason why no one can argue for the wholesale abandonment of diagnostic specificity is that there is no such thing. The diagnoses are completely subjective, fictitious inventions of the psychiatric overlords that created the DSM-V. Throw out the DSM-V, eliminate psychiatry and all of its evil branches, and watch people grow and flourish.

    • The reason that pressure to abandon to DSM creates such ugly scenes of opposition from psychiatry, I think, is because that’s how psychiatrists get paid by people who have to use insurance to pay for their visits. At this juncture, I think it would be wise if Congress were to pass a bill defining psychological and emotional distress as a health issue worthy of treatment of subsidy– our bodies and minds are not separate, never were, never will be. And stress takes a toll on a lot of systems in our bodies, it’s not just some ethereal state in the brain or mind. It’s highly unlikely that a whole lot of people would see psychiatrists for no good reason, especially now.

      Before psychiatry became mindless, I benefited greatly from it, and read an article, near the end of my need for counseling and the limits of what it could provide, saying that most people were satisfied after seeing a psychiatrist ONCE. That’s not a steady income, but there are certainly a lot of people who could benefit from long-term or repeated as-needed confidential counseling, with perhaps some drug intervention (with fully informed consent and with vigilance).

  2. Just Google the term “nervous breakdown”, and you will find somebody write that it isn’t a medical term. I have to laugh at that reluctance. I always preferred the term nervous breakdown, chiefly because in no way did it denote “disease” as in the sense of some kind of life sentence. I was given pretty severe diagnoses at first. I was called “schizophrenic”. I’ve talked to people about people with “schizophrenia” and, believe me, that’s not the kind of thing to tell people you have. Did I have “schizophrenia”, and was that diagnosis later upgraded to “schizo-affective disorder”? (“Schizo-affective”, by the way, is a lump all category for people who are doing better than your standard lost cause prognosis. I attribute my success, on the other hand, to total non-compliance with drugging plans.) I brush the lint off my shoulders. If anybody asks, I neither have “schizophrenia” nor “schizo-affective disorder”, but I did have a nervous breakdown once, way back when, a lifetime ago.

  3. In current times, even though the term isn’t used very much, isn’t there the same amount of stigma attached to having a nervous breakdown as in calling something else?

    In the working world it is looked upon as weak and fragile. I know in workplaces I’ve been in if someone was known to have a history of a “nervous breakdown”, it would not be looked upon favorably for hire, promotion or treatment as an employee.

    • There is not so much. Nervous breakdown is a totally understandable thing that anyone can go through at any time when things become hard. It evokes empathy in all the good people who are able to feel it. It also calls for help for this person to overcome the difficulties. What the DSM labels do s the opposite – they locate the problem in the person, not the circumstances and they make the biology (which you can’t do much about) responsible as opposed to the social context. Sure, they will be people who will demean you and laugh at you either way but for most people there’s a huge difference.
      The other thing I’ve noticed: people ar very fast to accept the concept that somebody they don’t really know is being mentally ill but they are less keen on doing so when it’s them (obviously) or someone who they know and understand his/her circumstances. Even if they use disorder-related terms like depressed they use it in a much more thoughtful way than your standard “psychology student” (or any student or qualified psych professional). People use common sense in these assessments more often than not but sadly only when the thing is personal on some level – on a general level they believe the hype.

  4. A nervous breakdown is a term that best describes my personal experience. DSM is ridiculous and as someone rightly called it “a book of insults”. Just as useful as the discussions about the number of devils at the point of a needle or whatever they used to discuss in the dark ages.

  5. What’s wrong with the ‘nervous breakdown’? It could mean anything; but this could be okay.

    Supposing a person has a ‘nervous breakdown’: they can find out what’s wrong, and put things right. Then they should be less likely than average to break down in the future because the problems have been sorted out.

    There would be no point in making a big deal out of the symptoms because when people ‘breakdown’ lots of rubbish comes to the surface anyway.

    I think the ‘nervous breakdown’
    is not a bad approach.

  6. Yes, I’d like to see the concept revived as my very significant overwork (>80 hrs/wk in a very high stress job) and stress were treated as depression and the medication made me even less able to function and sleep, leading to a full blown breakdown. Had it been recognised for what it was (I had no history of “mental illness”) I may have recovered with a bit of R & R. As it was, I ended up psychiatrized, diagnosed, locked up, forcibly medicated with anti-psychotics and antidepresants, and traumatised beyond belief.
    What should have been a single abhorrent but fully comprehensible event after 30 years of working and contributing to society at a high level became a chronic and deeply stigmatising “unmasked” condition that ended my career and apparently my value to society.

    All I can say is, “BRING BACK THE BREAKDOWN” as a single event that isn’t a sign of some underlying defect of character and/or chemistry, so people are allowed to do what they need to do to recover and re-enter a fully productive, drug-free, stigma-free, psychiatry-free life.

  7. I agree, I have no objection to that phrase to describe how I felt at one point in my life. To me, ‘nervous breakdown’ and ‘personal growth’ go hand in hand, in that one leads to another. At least, it should, if not tampered with in an invalidating way, as pathology or something like that.

    I find it to be a neutral term that well describes the spirit of that particular event, when things collide and life seems to crash down on you, leaving one temporarily disoriented. I tend to believe that everyone has a nervous breakdown at one time or another. To me, it’s a right of passage. Surrender and trust during chaos are important lessons. You learn and create a lot from ‘breaking down’ and building back up again.

    • I’d even say that having a nervous breakdown and “going crazy” is actually a very enlightening experience. It allows you to see things you’ve never bothered to look at, re-evaluate your life, re-think your values and see things from a different perspective. You finally see the lines that hold you down and the social concepts that were so engrained in your mind that you never thought twice about them:

      “It is no measure of health to be well adjusted to a profoundly sick society.” – Jiddu Krishnamurti

      “Too much sanity may be madness. And maddest of all, to see life as it is and not as it should be.” ― Miguel de Cervantes Saavedra, Don Quixote

      Madness can be liberating.

    • Hi Fiachra, yes, that’s how I see it. For me, it was an awakening–at first, to something I was not noticing that was affecting me adversely, and then, to the truth of my heart. It’s like a soul-retrieval, when we heal, learn and grow from these events. That’s a creative process.

      These are opportunities to heal core issues and get in synch with our natural self, what I call our ‘spirit nature.’ All the mixed messages from our toxic environments can send us in a direction which is not good for us, so when these ‘breakdowns’ occur, I interpret this as my spirit trying to get me to re-direct in a way that will be appropriate and desirable to me, to align me with my truth. Part of the fun in life is discovering our truth, and who we are. That’s an extremely creative and rich process. Breakdown of the old is necessary for shifting into the new–just like what is going on in the world now. I believe the planet is currently having a nervous breakdown, and we’re here to shift into something better than what it’s been.

      Our task, of course, is to make this easier and more understandable for others when this passage occurs. It may be uncomfortable, the way core transitions tend to be, but in no way does it need to be, either terrifying or excruciating. In fact, it can be a beautiful unfolding of our awareness, leading to exciting new things. From the mud, springs the lotus.

  8. Hi Alex,

    This reminded me of Goffmans Stigma;notes on the management of spoiled identity. The use of the term ‘nervous breakdown’ whilst still carrying some social stigma, is nothing like the process of having an ‘official’ label attached by a psychiatrist. The first may cause a little discomfort for those around the person, the second is absolutely poisonous to every aspect of the person and will ‘stick’ for a long time. The authority is removed by the use of the term (ie It couldn’t have come from a psychiatrist, because even a first year psych student knows ….). In that sense it’s a great idea for the management of identity.

    There are also situations where the other direction may be taken. One example being the shoplifter who becomes a kleptomaniac when presented to court. The ‘official’ label may be sought to reduce the consequences of ones actions.

    I really must reread Goffman.

    Good article. Thanks.

    • I think what’s coming to light, here, is that a ‘nervous breakdown’ is, in reality, an awakening to change occurring. Change happens, whether we welcome it or not, that’s the nature of life, ever-evolving.

      I think when we resist change for too long, some kind of ‘nervous breakdown’ will occur, somewhere–either in individuals, or in a society, or both. Change HAS to occur, and resistance is like putting up a damn to the natural flow of things, of energy. I think we, as a society, are in the habit of this, to resist nature. When enough pressure has built, the damn bursts. To me, this is a good analogy to having a ‘nervous breakdown.’

      Once the damn burst (busting through resistance), it will be a very powerful rush of energy of which we really have no control, but if we surrender our control, now that the resistance has been beaten down, then eventually, nature’s inherent tendency to restore balance will run its course, and we’ll see what that looks like, in the end. Something–perhaps a lot–will have changed, and we can only witness it, with trust, and then assimilate it, somehow.

      However, I think what we’re arguing about here is that the mental health system/field/community, etc., by philosophy and practice, try to control the rush after the damn has burst, which is really self-defeating and more effort than anyone can really bare.

      So to me, what is missing in current mental health practices and beliefs is that nature does have a desire to restore balance on its own, if we know how to trust a process. By labeling it and medicating it, we screw it all up, and simply create bigger and bigger damns, which keep energy building and exploding, never smoothing out to its natural flow.

      By these terms, a ‘nervous breakdown’ would be nothing to stigmatize or shun, but actually an event to welcome and celebrate, as it is a sign that change is inevitable and occurring, which I believe to be a good thing.

      If we were to once and for all stop turning it into a chronic illness–which to me is a complete fabrication of ‘the system,’ and its greed along with some weird need for control–then perhaps nature could finally take its course and healing could occur on a grand scale. That rings true to me, in any event. I certainly don’t have any studies to back it up, but it seems logical.

  9. Concerning to me is that Psychology 101 students would deign to have any authority over anything. We live in a world where it seems that going to school or studying “medicine” charges people intellectually to feel that the know something and therefore can make plenty of assumptions about other people. All the “transpersonal” values such as intuition, the value of psychological breaks to re-orient the person towards authenticity, the need sometimes for radical changes in order for a person to improve, the lack of understanding about how much real and sustained PTSD will manifest like bipolar but actually IS a nervous breakdown, where vital functioning ceases to work because a person gets trapped in fight or flight by default, and it literally erodes the cells and the body, piece by piece. A world where Trump is president is a world where a sensitive person is rightly tearing out their hair. Never mind the chemicals that we all live with, and that stress makes it nearly impossible to digest. I was going to get a psychology degree but realized I was learning more from the study of music and other somatic, mind-body methods. The courses in psychology are all mind-based, such that you have people who are not in touch with themselves and therefore do not know, fundamentally, how to listen to others, doling out psychological cures and diagnosis. It’s crazy that we still have to argue diagnosis. In so many ways, a diagnosis doesn’t matter. Al symptoms point to imbalance, and each human is suffering both uniquely and collectively. There will always be some things in common (breathing helps a person to reset), and always some different things. On person in a nervous breakdown might truly just be overworked. I think an important percentage of America is living a nervous breakdown. Other people might truly be operating out of fight or flight and then cease to function. Others still might be having a metabolic disorder. Although all 3 situations will affect metabolism. Anyway, you’re one of the good ones. Thanks for the article. I’m just fed up to the ears and beyond with academia and what it’s doing to the world.