Concept and diagnostic entity

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The concepts of nervous weakness and asthenia (debility, lack of strength) have existed throughout the history of medicine. Hippocrates described the illness of the Scythians as a general asthenia linked to damage tothe genitalia caused by horseback riding. (2) In France, Bouchut (1764) described a syndrome similar to the latter-day neurasthenia, which he called 'neuropathie'. Cullen (1772) conceived muscles and nerves as a unitary nervous force and all diseases as movements against the nature of that nervous force. He coined the word neuroses for this process and postulated that diseases were due to the various alternations of excitement and atony in the nervous system. A few years later, his pupil Brown (1780) elaborated on the hypothesis by dividing diseases into sthenic diseases, which were due to excessive excitement, and asthenic diseases, which were due to deficient excitement. These views onthe polarity of the nervous system as a cause of mental illness set the scene for neurasthenia to become a disease entity.

By the beginning of nineteenth century the term neurasthenia was already in use. In 1869 Van Deusen in Holland published a monograph on neurasthenia. This was quickly followed by the publication of a paper which Beard had presented to the New York Medical Journal Association. (3) Beard based his description of the disorder on a series of 30 cases. In reorganizing the subjective nature of the complaints and theunique clustering of symptoms in each patient, Beard had difficulties in attempting to limit the number of symptoms that constituted the syndrome; he started with 50 symptoms and expanded it to 75 in later publications. Nemiah(4) went through the list and grouped the symptoms into seven major categories:

1. a variety of muscular spasms, bodily aches and pains (headache being the most prominent);

2. manifestations of autonomic nervous system discharge, indistinguishable from somatic symptoms of anxiety;

3. general exhaustion and heaviness of the limbs;

4. morbid fears;

5. a sense of hopelessness;

6. insomnia;

7. a miscellaneous collection of seemingly unrelated phenomena such as impotence, dental caries, and dyspepsia.

Eventually it became clear that the expanding kaleidoscope of symptoms should be managed in a way that made some sense. Beard approached this problem by organizing the symptoms into subtypes of neurasthenia: cerebrasthenia (cerebral exhaustion) characterized by symptoms that were directly or indirectly connected with the head; myelasthenia (spinal exhaustion) was defined by symptoms related to the involvement of the spinal cord; digestive asthenia was characterized by dyspepsia, constipation, and flatulence. As time went on more subtypes were added by other investigators and specific treatment approaches were developed.

At about the same time, Charcot used another approach where the symptoms were divided into primary or core symptoms and secondary symptoms.

Despite the overinclusiveness of the term, Beard(5) maintained that neurasthenia belonged to one family with a common pathology, prognosis, history, and treatment. As more cases were reported, he felt able to claim that neurasthenia was predominantly an American illness. (6) He attributed the increase in prevalence to the pressures of modern civilization.

Notwithstanding its vagueness, or perhaps because of its vagueness, neurasthenia gained popular acceptance not only by the medical profession but also by the general public. Although by the turn of the century it had become practically a household word, its popularity did not preclude dissent. Most of the criticisms focused on the disorder's overinclusiveness and lack of precision; for instance, Brill called it 'the newest garbage can' in medicine.

The first two decades of the twentieth century witnessed an increasingnumber of discoveries of more specific causes of disease. This period also saw greater attention being paid to the taxonomy of neuroses. These forces combined to bring about the decline of neurasthenia as a diagnostic entity. Janet divided neurotic syndromes into two main classes: hysteria, which included dissociated states of consciousness and a variety of sensorimotor phenomena, and psychasthenia, which encompassed symptoms including phobias, obsessions, anxiety, and neurotic depression. He viewed neurasthenia as either a subdivision of or a prelude to psychasthenia.

In 1895, Freud published two seminal papers in which he drew up the blueprint for reconfiguring the various neurotic disturbances that were grouped together under the term neurasthenia. In the paper entitled 'On the grounds for detaching a particular syndrome from neurasthenia under the description of "anxiety neurosis"', (7) he questioned the validity of continuing to allow neurasthenia to cover all the symptoms described by Beard. He saw the need to classify different categories of neuroses based on the following:

• collection of symptoms that were more closely related to one another

• common aetiology

• common psychical mechanism.

In the paper 'Obsessions and phobias: their psychical mechanism and their aetiology', (8) Freud removed obsessions and phobias from neurasthenia. As a result of these two papers, neurasthenia ceased to be an amorphous concept and was differentiated into the following categories:

• neurasthenia proper

• anxiety neuroses

• obsessions

• pseudoneurasthenias due to cachexia, arteriosclerosis, early stages of the general paralysis of the insane, and psychoses. Intermittent and periodic types of neurasthenia were to be included under melancholia.

The first list of symptoms Freud proposed for neurasthenia proper included headache, spinal irritation, dyspepsia with flatulence, and constipation. Later, he added sexual weakness and fatigue.

The possibility of including some neurasthenic symptoms under melancholia was mentioned but not expanded on by Freud. This task was taken up byKraepelin. (9) He distinguished three major types of depression: manic-depressive disorder, involutional melancholia, and a milder form of neurasthenic depression. He asserted that all these types of depression were due to an underlying disordered brain function. Kraepelin also recognized a fourth type of depression, caused by environmental stresses, for which there were no neuropathological correlates.

Having been so denuded, the use of the term neurasthenia as a diagnostic entity by the medical professions had declined in the United States by the time of the First World War. The first edition of the DSM-I published in 1952 gave no formal recognition to neurasthenia. Instead, it was replaced by the category of 'Psychophysiological nervous system reaction', the predominant symptom of which was general fatigue. In an effort to make DSM-II congruent with ICD-8, neurasthenia reappeared in American psychiatry. It was described as follows. (19

Neurasthenic neurosis (Neurasthenia)

This condition is characterised by complaints of chronic weakness, easy fatigability, and sometimes exhaustion. Unlike hysterical neurosis the patient's complaints are genuinely distressing to him and there is no evidence of secondary gain. It differs from Anxiety neurosis and from psychophysiology disorders in the nature of the predominant complaint. It differs from Depressive neurosis in the moderateness of the depression and in the chronicity of the course...

In DSM-III neurasthenia disappeared as an entity and appeared only in the index where readers were asked to refer to 'Dysthymic disorder'. However, unlike the DSM classification, neurasthenia consistently remained a subtype of neurosis throughout the many versions of the ICD. ICD-9 defined neurasthenia as follows.

A neurotic disorder characterized by fatigue, irritability, headache, depression, insomnia, difficulty in concentration, and lack of capacity for enjoyment (anhedonia). It may follow or accompany an infection or exhaustion or arise form continued emotional stress.

The following categories were included:

• fatigue neurosis

• nervous disability

• psychogenic asthenia

• general fatigue.

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