Nowadays, a number of different treatment options are available for people living with anxiety disorders. These include therapies such as CBT and hypnotherapy, various types of medication, and even self-help techniques. In the past, however, the medical profession had a more limited understanding of mental health. This, in turn, meant that the care patients received could prove ineffective or even harmful.

The twentieth century saw many major breakthroughs in the treatment of anxiety disorders. For example, psychotherapy, still in its infancy at the beginning of the era, had become firmly established as effective by the turn of the new millennium. Nonetheless, the ways in which anxiety was treated in the 1900s can prove shocking to read about today. We'll take a look at some of them in this article.

Defining anxiety

Nowadays, it's common knowledge that ‘anxiety’ can describe both a symptom and a category of mental health conditions. However, it wasn't until 1980 that diagnoses such as generalised anxiety disorder (GAD) and panic disorder came into being.

To some extent, this is because anxiety was not always thought of as being a negative. In High Anxieties, Ian Dowbiggin wrote that “the view was that most social anxiety was normal and even an asset”. Things changed towards the turn of the twentieth century, at “a time when many of the old dangers that had threatened humanity for centuries […] began to abate in severity, leaving people to fret about less immediate worries”. We explore this angle more in our article on the positive side to anxiety.

It took some time for the medical community to even arrive at the name ‘anxiety’. It was common in the late nineteenth century to use the term pantophobia, derived from the Greek for a ‘fear of everything’.

Another typical diagnosis, meanwhile, was neurasthenia. Literally referring to ‘nerve weakness’, this hypothesised condition was used as a way of attempting to explain the variety of symptoms that appeared to be caused by the stress of urban life. Though still in use today in some parts of Asia, it is no longer commonly diagnosed elsewhere.

The term ‘anxiety neurosis’ was first used by Sigmund Freud in 1895, though in typical Freudian fashion he believed that it arose due to a buildup of ‘sexual excitation’. Later authors moved away from Freud's suspected cause while keeping the name, and anxiety neurosis remained the official diagnosis until the release of DSM-III, which split this into GAD and panic disorder.

Asylums

A defining feature of mental health treatment at the turn of the twentieth century was the use of asylums. At the time, those in the UK were governed by the Lunacy Act 1890.

The Lunacy Act formed the bedrock for British mental health law until 1959. It represented an improvement on the situation seen throughout much of the nineteenth century, in which there was serious public concern that patients were being committed against their will. However, it required most people needing treatment to be classified as ‘pauper lunatics’, a label that carried significant social stigma and likely dissuaded many from seeking help.

Voluntary admission only became possible following the passage of the Mental Treatment Act of 1930, which saw the replacement of the term ‘asylum’ with ‘mental hospital’. It was not until the 1959 Mental Health Act that psychiatric treatment became part of the broader health care system, by which point mental hospitals housed 0.4% of England's population.

Conditions

The term ‘asylum’ likely brings to mind a certain set of mental imagery: a grim, austere place where patients were effectively prisoners kept in padded cells. It can be surprising to learn that, in the Victorian era, they were seen as a more humane approach to the treatment of mental illness: a sanctuary from workhouses and prisons. However, according to the Science Museum, by the end of the nineteenth century, “the optimism around county asylums had virtually disappeared”, and “the asylum became simply a place of confinement”.

The reasons for this were twofold. Firstly, in the Victorian era, it was hoped that, with the reforms made to asylums, “they were about to conquer mental illness”. However, as Edward Shorter wrote in A History of Psychiatry, the “pressure of numbers” meant these expectations went unmet. Secondly, as a result of their failure to ‘cure’ mental illness entirely, asylums had become places where people could spent the rest of their lives. As a result, they were “overcrowded and underfunded”.

Given these pressures, conditions within asylums could be harsh. In the US at the end of the nineteenth century, journalist Nellie Bly went undercover in an asylum, reporting that patients were often treated cruelly by doctors and nurses, being given spoiled food and being ‘bathed’ by having buckets of cold water poured over their heads.

Nevertheless, not all of the era's mental hospitals appear to have been so bleak. In Swansea's Cefn Coed Hospital, the aim was “both care and cure”, with amenities including a farm, gardens and entertainment spaces. In stark contrast to the view of asylums as a place of incarceration, the focus here was “recovery and rehabilitation”.

Forms of treatment

The early 1900s saw the introduction of a range of new treatments for patients with mental illnesses. These were sometimes branded ‘heroic therapies’ at the time, and were often highly experimental.

Some treatments pioneered in the early twentieth century went on, with refinement, to form the basis of modern psychiatry. Others, however, proved harmful to patients, and were abandoned over time.

Shock therapies

One popular treatment in psychiatric hospitals in the first half of the twentieth century was shock therapy. Nowadays, we're likely to associate this term with electroconvulsive therapy, which is still in use today for certain depressive disorders. However, before its invention in 1938, shock therapies could be considerably more dangerous.

Some patients at the time received shock therapy via high doses of metrazol. This treatment was proposed by Ladislas Meduna, who believed it was impossible for someone to experience both epilepsy and schizophrenia at the same time. Theorising that seizures could prevent mental illness, he administered metrazol, causing the patient to convulse within minutes. However, these seizures were so severe that patients could end up with broken bones: one study found that 43% experienced fractured vertebrae.

Other forms of shock therapy included deep sleep therapy, in which unconsciousness was induced in patients for days or weeks. In some areas, this was still in use until the 1970s, with 25 patients dying at Chelmsford Private Hospital in Australia in the mid-twentieth century. A similar treatment was insulin shock therapy, which saw patients put into artificial comas via the use of large doses of insulin.

Psychosurgery

Another treatment used for conditions including anxiety was psychosurgery. This attempted to cure mental illness by removing a part of the brain tissue. Amongst the most common was lobotomy, a procedure that saw the severing of most connections between the prefrontal cortex and the rest of the brain.

Tens of thousands of lobotomies were performed worldwide, including 40,000 in the United States alone. However, the procedure was “crude and inexact” and could leave patients permanently incapacitated, with some even being killed. Even one of the pioneers of lobotomy, Walter Freeman, noted that “every patient probably loses something by this operation… some spontaneity, some sparkle, some flavour of their personality”. Most countries went on to abandon lobotomy for psychiatric purposes in the second half of the twentieth century.

‘Rest cures’ and ‘work cures’

Patients diagnosed with neurasthenia were sometimes prescribed with the ‘rest cure’: a regime consisting of weeks of bed rest. During this time, they may also have faced dietary restrictions, with the treatment being complemented with massage and muscle stimulation. It was commonly used in female patients, even becoming the subject of the well-known short story The Yellow Wallpaper.

Later on, views of human psychology shifted, with the focus moving from giving people time to recuperate to encouraging them to regain their energy in a more active way. Doctors thus began to prescribe ‘work cures’. This involved keeping people's minds busy by providing them with activities such as pottery, carpentry or college courses to complete.

Early psychotherapy

While many of the treatments given in the early 1900s are unrecognisable to modern audiences, one aspect that will be at least somewhat familiar is the growing use of psychotherapy.

Early forms of psychotherapy took inspiration from the work of Sigmund Freud, who encouraged patients to speak freely about any topic that came to mind. It was thought that these conversations could then be analysed to discern what was affecting the person's mental health. This was known as psychoanalysis. Though this form of psychotherapy has since fallen out of favour, the Science Museum notes that it is “still at the heart of many rehabilitation therapies”.

A competing theory was that of behaviourism, which drew on the work of Ivan Pavlov in its belief that conditioning was the cause of many of our actions. Early forms of behavioural psychotherapy eventually formed the basis for modern techniques such as CBT.

Medications

Today, the most common classes of drug given for anxiety disorders are SSRIs and SNRIs, which work by blocking the reuptake of serotonin and, in the latter case, norepinephrine. However, these medications only became available from the late 1980s onwards. Before that, a variety of different medicines had been used for the treatment of mental illness.

One of the most commonly prescribed classes was barbiturates. In Listening to the Past: History, Psychiatry and Anxiety, Andrea Tone writes that “by the early 20th century, barbiturates available in dozens of formulae and brands on European and American markets had been added to the arsenals of the anxious”. This included use amongst soldiers due to its ability to provide “quick relief from severe anxiety and hysteria”. However, they came with a host of dangerous side effects that meant that their use was gradually discontinued.

Anxiety disorders in soldiers

Close to 70 million people from nations across the globe fought in the First World War. With such a large percentage of the population directly involved in the war effort, public awareness of soldiers' welfare was high. This included the thousands of cases of a condition known as shell shock. Today, we would categorise this as a form of post-traumatic stress disorder, one of the main forms of anxiety disorder.

The prevalence of shell shock began to precipitate. In Shellshock and the psychiatrists, Martin Stone noted that, prior to the war, the most common explanation for mental health conditions was that they arose a result of “hereditary degeneration”. Seeing “young men of respectable and proven character […] reduced to mental wrecks after a few months in the trenches” discredited this theory.

Before the war, doctors not working in asylums were likely to have had little experience in treating mental illness. Many of them gained this through treating shell shock in army hospitals during the war. As a result, there were ever-louder calls for reform, with Stone writing that “the existing medical and institutional structure of psychiatry was under threat during the years after the First World War”.

This did not mean that there was instantaneous change. There was resistance from existing asylum doctors, for whom “the return to peacetime was a question of ‘business as usual’”. Nonetheless, important lessons were learned, such as the benefit of early treatment. Psychotherapy, too, grew in prevalence. Meanwhile, the 1930 Mental Treatment Act saw the face of care for anxiety disorders changing, with out-patient options and the ability for voluntary treatment.

Anxiety treatments in the 1900s: conclusion

The first half of the twentieth century was a time of great change in the treatment of anxiety disorders and other mental illnesses. The Victorian asylum was still present, but in the process of being reformed. New therapies were emerging: some dangerous, others promising. Perhaps most importantly, the medical profession was moving closer to an understanding of the causes of anxiety, paving the way for modern psychotherapy and medicine as we know it.