The history of treating what is now called anxiety involves shifting explanations, moving from spiritual affliction to humoral imbalance, then to a physical problem of the nervous system, and finally to a psychological condition. The modern diagnostic term “anxiety” is a relatively recent concept; historically, similar states of distress were described under categories like “melancholia,” “nerves,” or the 19th-century diagnosis of “neurasthenia.” Treatments for these conditions have varied, reflecting the prevailing scientific, philosophical, and cultural understanding of the human body and mind.
Ancient and Classical Approaches
In ancient Greece, Hippocrates established the theory of the four humors. He believed that an excess of black bile caused “melancholia,” a condition encompassing sadness, fear, and despondency that aligns with historical descriptions of anxiety. Treatments focused on restoring humoral balance through diet, exercise, and lifestyle changes.
To purge the excess black bile, physicians prescribed emetics or laxatives, such as the herb hellebore, and used practices like bloodletting or therapeutic baths. The Roman physician Galen continued this tradition, suggesting that diet and physical therapies, including massage and gymnastics, could help lift spirits. Philosophical schools also offered remediation, with Stoic and Epicurean thinkers developing cognitive approaches to manage emotions.
During the medieval period, the humoral theory blended with spiritual explanations, suggesting that idleness could lead to melancholy. Treatments included prayer, exorcisms, and encouraging physical labor. Herbal remedies, music, and physical activities were consistently used, demonstrating an early, holistic understanding that physical and emotional engagement supported mental well-being.
The 19th Century: The Age of Nervous Disorders and Rest Cures
The 19th century saw anxiety-like symptoms categorized as “neurasthenia,” or nervous exhaustion, believed to be a physical depletion of the body’s “nerve force.” This diagnosis, often associated with the stresses of modern life, became highly prevalent, particularly among the middle and upper classes. Since the condition was viewed as physical, treatments centered on intensive environmental and physical management.
The neurologist Silas Weir Mitchell created the highly influential “Rest Cure,” a regimen designed to treat neurasthenia and hysteria, especially in women. This treatment involved six to eight weeks of strictly enforced bed rest and isolation, prohibiting all intellectual or creative activity, including reading and writing. The rationale was to rebuild the depleted nervous system by minimizing stimulation and exertion.
The Rest Cure also involved systematic overfeeding, often including large quantities of milk and meat, combined with daily massage and electrical stimulation of the muscles. Mitchell believed this intensive approach would rapidly increase fat and blood levels in nervous women. For men, Mitchell often prescribed the “West Cure,” involving rugged physical activity like hunting and cattle roping, suggesting a gendered difference in treatment.
Early Pharmacological Interventions
Long before modern psychotropic drugs, various chemical agents were used to sedate symptoms of anxiety. Opium, derived from the poppy plant, was one of the earliest and most widely used substances, with medicinal use documented as far back as 1500 BCE. Opium and its derivative, laudanum—an alcoholic tincture—were readily available and frequently prescribed throughout the 19th century to induce sleep and quell agitation.
A major development occurred in 1857 with the introduction of bromide salts, such as potassium bromide, which became the first widely used chemical sedatives for nervous conditions. Bromides were extensively used in the late 19th century due to their strong sedating effects. However, bromides had a narrow therapeutic window and often led to toxicity and severe side effects.
The early 20th century saw the arrival of barbiturates, beginning with barbital in 1904, which quickly replaced bromides as the dominant class of sedatives. Barbiturates were highly effective at depressing the central nervous system and became the primary pharmacological tool for managing severe anxiety. These drugs introduced significant risks, including high potential for dependence and a severe risk of fatal overdose due to respiratory depression.
The Emergence of Psychological Treatment
As the 19th century closed, a new perspective challenged the purely physical and sedative models of treatment. This shift focused on the mind and consciousness, giving rise to the first systematic psychological treatments. Early work involved hypnosis, which was used to access and address repressed memories and traumatic experiences believed to be at the root of symptoms like hysteria and anxiety.
Sigmund Freud, initially an advocate of hypnosis, pioneered “psychoanalysis,” often referred to as the “talking cure.” The core technique was free association, where patients spoke freely without censorship, allowing the therapist to trace pathways back to unconscious conflicts and repressed desires. Freud theorized that anxiety often stemmed from internal conflicts between the instinctual drives of the unconscious mind and the demands of the external world.
Psychoanalysis provided the first comprehensive theory that mental illness could be treated through systematic verbal engagement, fundamentally changing the approach to anxiety. Other methods involving suggestion and early forms of behavioral management also emerged. These psychological models offered an alternative to the physical confinement of asylums or the chemical sedation of pharmacological agents, making the patient’s internal experience the focus of treatment.