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I AM coming more and more to feel that the term neurasthenia, which is so generally used to designate all sorts of nervousness, should be limited to those conditions of nervous exhaustion, brain fag, and fatigue, which are more or less the result of actual physical conditions, such as overwork and other forms of long-continued stress and strain.
We must not overlook the fact that we can actually form a fatigue complex; that, as the result of overwork, long-continued muscular tension, and perhaps certain deficiencies in the ductless-gland secretions, we can bring about conditions of chronic fatigue which will make such an impression upon consciousness that in time the sympathetic nervous system will be able to bring on all the symptoms of fatigue as the result of habitual reaction. In this sense fatigue really comes to be an obsession, and perhaps it is all right to designate such patients as belonging to the neurasthenic type or group.
I have in mind now the case of a woman in her late forties, the wife of a professional man, who has developed this sort of fatigue. Unquestionably she has a fatigue complex. She is organically sound, physically in perfect condition.
It is not a case of psychasthenia - fatigue from childhood or adolescence - as this woman was all right until almost thirty years of age, when she had her first so-called nervous breakdown. There was some basis for this breakdown; there was overwork as well as over-worry - long-continued stress and strain. She recovered in normal fashion from the breakdown, but she never recovered from the fatigue. She has had it from that day to this. Subsequent to this attack she had three or four spells of what was diagnosed as nervous exhaustion, but so far as I can see they were only exacerbations of this legacy of chronic fatigue which has continued to curse her for almost two decades.
During seven years of semi-invalidism she never walked across the room without assistance. Before any attempt was made to have her walk, she was put on the rest cure and fed up until she gained in weight from about ninety pounds to one hundred and forty pounds. Explanations were made to her which she apparently accepted. The whole experience was analyzed and reanalyzed, traced out and retraced for her. We started her out with a trained nurse to walk. By a persistent regime and with the encouragement of the nurse we were able to get her to walk four blocks, but the nurse had to get right after her or she would sit down on the curbstone or walk into the first house to rest on the porch. She has driven an automobile for a hundred miles, but she will do absolutely none of these things if left alone. As her nurse says, "If she is left to herself she immediately squats".
I have not given up hope that this woman will be cured of her fatigue complex, but I must confess that none of the methods thus far employed have delivered her. If we had maintained supervision of her for longer periods, I presume she would have been cured; but it costs money to keep doctors and trained nurses on the job, so when she is a bit improved, both she and her husband feel that she ought to be well enough to go on about her business, and she goes home; then in six months she drifts right back to an easy chair or a soft mattress. All you can get from her when you urge her to make physical effort to do things and go to places is: "But, Doctor, you don't understand how tired I am. I am utterly worn out. I want to do these things, but I am simply exhausted. I just can't do it".
Not only would this patient be permanently cured if she could remain under supervision longer, but she would also probably be cured if she were forced into action to earn a living. She was well taken care of by her well-to-do parents before she was married, and her husband has supplied her every need all these years; so she is not compelled to lift a finger in order to satisfy her physical wants. Under supervision she will put forth the necessary effort to prove, even to herself, that she can do the work, that she can safely ignore fatigue and ridicule exhaustion; but when left alone without the necessity of making these efforts, she gravitates back to a life of ease. She takes the path of least resistance, and I don't believe she is ever going to get well unless force of circumstance compels her to make an effort that will last until new habits can be formed - until the fatigue complex can be displaced by one of self-confidence and stamina sufficiently strong to overcome it permanently.
An architect, forty-three years old, who is in perfect physical condition, but who has quit work three different times in his life for periods ranging from three months to a year, comes in to discuss his fears. He has been well instructed about the nature of his trouble. He understands the ancestral role of fear. He knows well enough that there is absolutely no foundation for his symptoms, but when he quit work a few weeks ago he gave as an excuse to his wife and associates that he was overcome with an inexplicable fatigue, that he was just tired out.
This patient is in good flesh, in good health, but, having failed to overcome and uproot his fear complex, he is developing now, as a defense reaction, a real fatigue complex. He has not been willing to make those adjustments which would enable him to drive out his fears and occupy his mind with faith activities. He has been too negligent in the past management of his case. He has not sincerely carried out his doctors' instructions. He is a moral coward. I have explained to him that if he would get rid of his "fear-mosquitos" he must not only clean up his own back yard and dig out the under-brush, but must also get around and clean up the neighborhood and the vacant lots adjoining. In the case of the little foxes that spoil the vines, I have told him, it is not enough to stop up one hole in the fence; every hole must be stopped up.
But what I am especially presenting this case for is to call attention to the fatigue complex as a defense reaction. No longer could he go to his wife and confess his fears; no longer could he tell his associates that he had these old-time dreads - but he had them. He wanted a new story to tell. He wanted to flee from reality, to retire from the fight, but he wanted to save his face, and so he has for several years been developing this fatigue complex. He has subconsciously worked it out in every detail. He has perfected it so that he has a tired feeling and everything that goes with it, including palpitation, tremors, and that pathetic facial expression, that martyr attitude of "Well, I suppose I could go on until I dropped in my tracks. I am willing if you think best, but I certainly am all in".
And this man comes to me to get medical support and endorsement for his fatigue complex! Of course, I don't give it to him. He is going right back to work. It is his only salvation, and I expect him to go back this time with determination to make an end of his fear complex and also of the associated fatigue complex.
Just as the fear complex can be formed so that you can have all the physical exhibitions of terror without having a fraction of a drop of the adrenal secretion poured into the blood stream, so we can develop a fatigue complex to the point where we can have all the nervous and physical accompaniments of profound exhaustion in the presence of robust physical health and in the absence of any real physical fatigue.
Undoubtedly fatigue can become habitual. Unquestionably thousands of people suffer from purely nervous fatigue, a tired feeling which bears no relation to preceding muscular work, and which has no real foundation in the physical organism. Now, how do these "sons and daughters of rest" acquire this sort of a fatigue complex? It comes about, as a rule, after the following fashion: The fatigue complex is nearly always preceded by a fear complex. There is brought about that chronic reaction to fear on the part of both mind and body which is so characteristic of the fear or stage-fright complex. The mind is more or less apprehensive, there may be even a mild state of anxiety. The psychic background is one of chronic fear or worry.
I have called attention in a previous chapter to the fact that fear is the psychic state of alarm which acts upon the sympathetic nervous system so as to cause it to pull the adrenal trigger, throwing the powerful secretion of these ductless glands into the blood stream, as a result of which all the physical accompaniments of fear and anger are forthwith manifested. The purpose of all this is to prepare for increased efficiency in flight, or for more determined resistance in combat. The natural end-result of such exertions would be more or less of a feeling of exhaustion, of fatigue. And so it seems natural that the nervous system should prepare to send out fatigue warnings and to bring on that tired feeling, to be followed by rest and relaxation, as the result of every episode of the excitation of this fear-anger mechanism.
When the sympathetic nervous system has learned to short-circuit this affair, and, as the result of chronic worry, to produce - on its own initiative and quite independent of any participation of the adrenal secretion - these psychic and physical manifestations of fear, it is little wonder that it acquires the trick of bringing on this spontaneous, ever-present, and distressful fatigue. It seems to say to itself: "Since the end-product of all this business is fatigue and rest, since all this false alarm I am turning in has no other objective than to wear the patient out and bring on fatigue, I will cut the whole process short and give him an ever-present tired-out feeling. Rest is what he wants. The purpose of this whole performance is to escape from reality, to get out of doing things. Then why should I produce these frequent upheavals involving rapid breathing, thumping heart, increased blood pressure, dizziness, nausea?" And so the chronic state of fear comes to be associated with the chronic state of fatigue. Biologically, the end-result of all fear phenomena would be physical fatigue; therefore, in the modern nervous counter-part of primitive forest experience, we indulge in psychic fear and immediately experience nervous fatigue, a fatigue which is so wonderfully perpetrated as to possess all the earmarks of genuine physical tiredness.
In the earlier stages of our various nervous troubles, sometimes before the stage of chronic fatigue is reached, the sympathetic nervous system in its reactions pauses for a while in the domain of muscular tension. As a part of the fear-anger reaction, the muscles are made very tense, and it is only after the flight or fight that the fatigue naturally ensues, Now, in our mild types of nervousness, in the early stages of most psychoneuroses - particularly the anxiety states - the patient may indefinitely remain in a state of constant muscular tension. There is almost complete inability to let go, to relax. These patients are more or less tense even in sleep. They are particularly tense on retiring.
Nervous tension - in reality, of course, muscular tension - is so characteristic of some of these cases, and intrudes itself so obviously, that it is almost entitled to a place in the diagnosis. We even have the anomaly of a physical condition of nervous muscular tension along with brain fatigue, a comparative psychic exhaustion, indecision, deficient memory, etc.
And thus nervous or physical tension comes to be - in connection with the arousal of the fear-anger mechanism - a half-way station on the road to the final culmination of this process as nervous fatigue. These chronic fatigue states have been, in the past, diagnosed as neurasthenia, nervous exhaustion, nervous prostration, brain fag, etc., but no matter what name we may assign to the condition, the fatigue is essentially of nervous origin. It is habitual tiredness that has become conditioned as a reaction to the psychic states of chronic fear and anxiety, and it represents an effort on the part of the sympathetic nervous system to accommodate its neurotic owner in the matter of acquiring a good and sufficient alibi for dodging responsibility, avoiding work, escaping reality; with some saving of one's dignity, to have a good and sufficient reason for seeking prolonged rest. In other words, chronic fatigue is the camouflage to cover one's retreat from the world of reality back to the nursery.
While this is the real purpose of the subconscious in the early establishment of these complexes of fear and fatigue, we must recognize the fact that when they have been long functioning, when they have become chronic, we are likely to suffer from fatigue at the very time when we are about to engage in some pleasurable activity. The fatigue habit becomes a secondary experience which serves to prevent our enjoying many things in which we delight. The same thing is illustrated in the case of alcoholism. The individual drinks alcohol at first in an effort to get away from an unpleasant situation, to forget, to flee from reality, and it serves this purpose temporarily; but as time passes he becomes the victim of a drug habit, and so continues repeatedly to drink alcohol as the result of this chemical craving; thus the alcohol which enables him to escape certain unpleasant duties at first, later on serves to incapacitate him for engaging in many pleasurable and desirable activities. The biology of fear was destined to assist us in fleeing from danger, but in the case of the psychoneuroses it is perverted into the role of a conspirator whose only objective is to assist us in fleeing from reality.
The symptoms of neurasthenia do not differ from those found in the other neuroses, except that, in the view of present-day science, they are more complex. If we take a typical case of the inadequacy feeling, a case of chronic fear, perhaps complicated by some other complex, and roll these all into one, as we sometimes do find them in life, adding, perhaps, some physical cause that has contributed to the breakdown, then, I think, we are justified in continuing to use the old-fashioned term of neurasthenia.
It should be remembered that probably no one patient has all the symptoms that are herewith presented as being those of a typical neurasthenia. Let me make it clear that, in general, neurasthenics present these five cardinal symptoms:
Neurasthenics are always more or less depressed; they have general fears and definite dreads, even bordering on the anxiety states. They apprehend some impending doom. They have characteristic fits of neurasthenic despair, but are more alarmed by their psychic inadequacy. Not only are they unable to make decisions, not only is memory affected, but they have a peculiar and alarming tendency to what they call "brain wandering". It is really a partial loss of conscious control over the mind. This, of course, they regard as a forerunner of insanity, and in that way it contributes greatly to the augmentation of their anxiety states.
Other patients develop a dreamy state of mind, accompanied by lack of all interest in life; a pitiful sort of generalized feeling of inferiority, so that they come to regard themselves as the helpless victims of some subtle disorder; and it becomes an established policy never to do anything to-day that can be put off until to-morrow.
This feeling inevitably leads the patient to dread the future. His fears are multiplied, his obsessions augmented, his premonitions intensified, his apprehensions enormously magnified. The neurasthenia reflects on everything he does. He has to reason about every thought, and yet can reach no definite decisions. He feels his feelings, and fears his fears. A vicious circle is established. He lives very little in the present; he lives, rather, in feelings of regret for the past and of apprehension for the future. He constantly spies on himself and is destined to become more or less hypochondriac.
Self-contemplation results in the production not only of a diseased imagination, but of an unhealthy and unwarranted egotism, culminating in irritability, sleeplessness, and characteristic fits of neurasthenic anger. Neurasthenias soon come to believe that they have not had a square deal in life; that everyone is down on them , and that even their dearest friends and loved ones are unsympathetic and hard-hearted as regards their sufferings.
While their capacity for mental work is greatly abridged, there occurs from time to time a sort of psychic explosion that sets the mental machinery running at a rapid pace for a short season. Such an attack may even come on at night and is sure to produce insomnia. These patients sometimes have a tendency to lose their natural affection, and this abnormal state is accompanied by that ever-present peevishness which makes it so hard for the neurasthenic's family either to please him or to live with him. Nervous sufferers of this kind become very sensitive about their own personal dignity. Every little thing is construed into a personal slight; they want to occupy the limelight, and are hurt when their friends are not disposed to listen to their long recitals of misery. They are highly suspicious of the motives of their friends and families; they develop quickly into chronic ailers and become a burden to themselves and a nuisance to their associates.
Of course, all this time there are the usual symptoms of headache, neuralgical feelings, darting pains, full feelings in the head, buzzing sensations, trembling, and even nausea and vomiting.
On top of all this, sooner or later will come the three marked fears of neurasthenia - the fear of insanity, the fear of death, and the fear of suicide. The fact that doctors repeatedly examine these patients and tell them they are all right only convinces them that the doctors have fallen down on the job, and they prepare for an immediate journey to the insane asylum. If they have succeeded in overcoming the fear of impending dissolution, the mind often becomes tainted with the fear of suicide, which thought they are doomed intermittently to entertain as a possible escape from their suffering.
All sorts of sensations are experienced around the spinal column, but the one characteristic and ever-present symptom is fatigue - that terrible feeling of exhaustion, that utter tiredness which is always present, but usually more exaggerated in the morning. It is a characteristic symptom of neurasthenia or nervous exhaustion that the more these patients sleep, the worse they feel when they wake up in the morning. They simply feel "rotten" when they first get out of bed. During the forenoon they begin to pick up a little; by noon they feel fairly decent; in the afternoon many of them have a complete collapse and have to lie down; but, however this fatigue behaves during the day, after dinner and during the evening the neurasthenic nervous system strikes its stride, gets into its swing; they feel fairly well, sometimes are able to participate in the party and stay up until a late hour without experiencing anything like the exhaustion which gripped them earlier in the day.
Neurasthenic symptoms are especially prone to attack the digestive system: there is stomach trouble and gas in the bowels, which sometimes serves to make pressure on the heart and to set it jumping and thumping in a fashion that is highly disconcerting. These nervous sufferers are always complaining of some sort of stomach trouble. If it isn't nervous dyspepsia, it is constipation. They become dietetic faddists in an effort to cure their digestive troubles, including those profound flutterings in the abdomen, and other real or imaginary gastrointestinal disorders. They always fear cancer of the stomach, and the classic explanation for their trouble is the old-fashioned auto-intoxication; instead of being willing to recognize that it is their nerves which are plaguing them, they settle upon auto-intoxication as the cause of their affliction.
Neurasthenics are always suffering from circulatory disturbance in some part of the body. They are too hot, or too cold. They usually have a rapid pulse. They have frequent attacks of so-called palpitation. Their skin is usually pale, but not always; many of them complain of insomnia, tho the majority of nervous sufferers, except those in the acute throes of a nervous breakdown, sleep fairly well, and all of them usually sleep more than they think they do.
The reader should be assured that I am by no means reciting the complete list of neurasthenic symptoms. There are literally hundreds that have not even been mentioned here, and yet this whole galaxy of symptoms and feelings can be present in a single neurotic sufferer, while at the same time the most exhaustive research examination will show him to be organically sound and in every way normal as a physical specimen of humanity; all of which only goes to prove what a rumpus, what a bunch of nervous capers, can be started up by an uncontrolled mind and a highly irritable nervous system without in the least being able to produce a real or organic disease.
Janet uses the term psychasthenia to include almost everything of a neurotic order that doesn't fall under the head of hysteria, but in this country I think there is a tendency to limit the term more to a sort of hereditary neurasthenia, an inborn fatigue, a constitutional inadequacy, or, as we sometimes diagnose it, constitutional inferiority.
It should be made clear at the outset that this inferiority does not necessarily have to do with the quality of the patient's mental work; some of the best of minds, qualitatively speaking, belong to this group. It has more to do with the efficiency - the quantitative output of the mind and the ability of the nervous system to stand up under ordinary function and usage. Many unfortunate individuals are condemned to go through life with a functionally crippled nervous system. They are foredoomed to suffer more or less from mental fatigue - brain fag - all due to their heredity.
The psychasthenia is able often to comfort himself with the flattering knowledge that he travels in exceedingly good company, for it is a fact that a very large number of the world's geniuses in science, art, and letters, have been more or less psychasthenic. Many individuals who manifest exceptional control of the mind along some particular line are found to be greatly lacking in brain control as regards the common experiences of their every-day life.
I do not for one moment admit that psychasthenia is the gigantic disorder which its discoverer, Janet, claims it to be. This French authority would lead us to believe that psychasthenia embraces almost every sort of nervous disturbance, ranging from simple neurasthenia up to melancholia and arrant madness. I look upon psychasthenia as an hereditary affair - as an hereditary or inborn weakness3 in the matter of brain control and emotional reaction. Of course, I also recognize that overwork, emotional stress, and intoxication, together with all the so-called neurasthenic factors, may serve to develop and accentuate this hereditary psychasthenic predisposition. Many a psychasthenia does not appear in the individual's experience until the nervous system is subjected to some extraordinary strain.
Right along we meet with victims of psychasthenia and other forms of nervous trouble who insist that they have always enjoyed good health, and that they experienced no trace of their nervous troubles until a certain time when they were afflicted with the "flu", or when they experienced some form of nervous stress and strain; but if we take the pains to make inquiry into the family history and to scrutinize the past mental and nervous life of these patients, we seldom find any difficulty in settling the fact that they have long been subject to abnormal mental and nervous states. They have been all along the victims of a latent psychasthenia that was smoldering in the mind as fear and anxiety, or as the tendency to escape from reality, and it only awaited a suitable occasion on which to burst forth as a bona fide psychoneurosis, as a real nervous break-down or neurotic upheaval. In fact, the event or experience which these patients so often settle upon as the starting-point of their trouble was simply the straw that broke the camel's back, the drop of water that caused the vessel to overflow.
Psychasthenia is in reality a lowering of the emotional threshold. It differs from ordinary neurasthenia not only in the fact of its more uniform hereditary origin, but also in that it is more largely concerned with purely psychic and emotional influences as regards the exciting causes. In the case of so-called neurasthenia, the exciting causes are more often in the nature of some extraordinary grief, some new fear or some unusual anger. These shocks or strains are, of course, no more than those which the normal individual is meeting constantly, but in the case of unusually sensitive minds these stresses serve to precipitate a nervous attack of some sort. In the case of psychasthenia, the exciting cause is more often a purely mental or emotional reaction which is not founded on any actual experience or real event, but merely represents a psychic upheaval which originated largely in the patient's mind. These things which fan the smoldering psychasthenia into flame are usually of such a nature as to be more or less upsetting to a normal mind if they really existed; but in the case of the psychasthenia they usually do not exist.
I have in mind the case of a psychasthenic girl - she is now about thirty years of age - who every year or so gets into a terrible jam with herself over the fear that she might commit some crime. At a large church gathering in Chicago, a few years ago, several prominent prelates were severely poisoned - someone having to do with the cooking of the food had deliberately arranged to poison the whole group. Of course, this came out on the first pages of the newspapers the following morning, and before the day was over this woman was in my office in a serious state of mind over the fear that she might get it into her head to poison the family she was working for; or if she should go home on a visit, as she contemplated doing soon, what was to hinder her poisoning her whole family? I have seen this patient go through a dozen such attacks. It requires months and months for her to get over one of them. She is a typical psychasthenia with certain hysterical tendencies. She has always been in this condition, and, generally speaking, always will be. She suffers from inordinate fatigue; has been tired ever since she was fourteen years of age; never gets rested. She can never carry through the majority of the things which she has the ambition and creative imagination to initiate. The quality of her mental output is good, but quantitatively she just can't hold out. She collapses in the midst of practically everything she undertakes. When I explain to her how unreasonable are all her fears she is almost persuaded to laugh at them; but she soon grows sober and drifts back into her old dread.
We are all more or less subject to our emotions. Transiently we take on the color of our environment. When at the theater or when reading a novel, and even when indulging in a day-dream, we may be brought to the place where we tremble with emotion, shed real tears, and violently contract our muscles in righteous indignation; but the moment this episode has passed we quickly right our emotions, pull ourselves together, and restore our nervous equilibrium. The psychasthenia, however, is the victim of an ever-present emotional upset of this sort; it becomes, not a transient episode in his psychic life, but a permanent state of mind and body. It is altogether easy for him, under these conditions of emotional stress, to imagine himself committing some revolting crime, or to persuade himself that he has become suddenly insane, or to envision himself as a victim of some tragic accident. These things are all very real and intense to him. He is not just day-dreaming; he is the victim of something which has become so fixed upon his memory as to be a part of his life. And so these harmful emotions become habitual in the case of psychasthenias, causing a drain upon the nervous system.
The important fact in psychasthenia is not that such ideas or emotions come to find their existence in the mind or rise up into the consciousness; the thing to bear in mind is not only that there is some habitual psychic tendency at work, but that there seems to be an actual physical condition of the cortex of the brain which permits and favors this uncontrolled and injurious form of extraordinary emotional and physical reaction to passing states of fear and fancy. In many respects psychasthenias behave and reason like a child. They are affected by external influences and react to internal impulses in a manner which indicates that their viewpoint is that of the easily upset and quickly alarmed mentality of childhood. They are victims of retardation of development as regards their emotional control.
Still further to make clear the difference between neurasthenia and psychasthenia, I may say that those influences of irritation, stress, and strain, which would, in a fairly normal individual, result in producing neurasthenia, will, in the case of these susceptible and hereditary predisposed individuals, produce a genuine case of psychasthenia. The perplexing feature of so-called acquired psychasthenia (in reality, hereditary) is that in the earlier stages it exhibits nearly all the commonly observed symptoms which belong to neurasthenia. On the other hand, psychasthenias are far more likely than neurasthenias to manifest symptoms which are suggestive of more serious mental disorders; as a clinical disorder, therefore, psychasthenia comes to occupy a place between the less serious neurasthenias, on the one hand, and the more serious hysterias, phobias, melancholias, and manias, on the other.
The so-called congenital psychasthenia usually makes its appearance at or around puberty. The child is spoken of as delicate, nervous, and timid; while the acquired form (I prefer the term latent) may not appear until the patient is well past middle life, and then only after some prolonged and unusual period of hard work and over-worry. Many a business or professional man experiences his first real attack of neurasthenia or psychasthenia when between forty and fifty years of age. Others are able to postpone this catastrophe until after retiring from business, and then, with nothing to think about but themselves, they quickly succumb to their latent, hereditary nervous tendencies, and with amazing rapidity develop into full-fledged neurasthenias or psychasthenias.
At the present time I have a patient fifty-five years of age who has until recently been at the head of a large business enterprise. He has retired, and although for twenty-five years he was threatened, off and on, with nervous breakdown, he always successfully avoided it. Now, however, he is the victim of a most distressing psychasthenia. His mental fatigue annoys him terribly, his appetite is gone, his sleep disturbed, his initiative is slipping, and it is little wonder that he complains that his mental powers are "breaking up", and that he gravely fears insanity. And yet his ailment is nothing more than this acquired (latent) form of psychasthenia.
The thought must not for one moment be entertained that our psychasthenias are recruited from the ranks of hysterics and other people of mediocre mental caliber. As previously remarked, they are frequently found among the most intellectual classes; and many of these great minds have been so successful in the mastery of their mental and nervous weaknesses that they have been able entirely to surmount their hereditary tendencies. Sir Francis Galton, the eminent British scientist - the father of our infant science of eugenics - who lived well beyond four score years in the full possession of his mental and physical powers, meanwhile turning out a vast volume of work, was evidently predisposed to psychasthenia, for, concerning one of his attacks or breakdowns, he says:
"I suffered from intermittent pulse and a variety of brain symptoms of an alarming kind. A mill seemed to be working inside my head; I could not banish obsessing ideas; at times I could hardly read a book, and found it painful to look at even a printed page. Fortunately I did not suffer from sleeplessness, and my digestion failed but little. Even a brief interval of rest did me good, and it seemed as if a dose of it might wholly restore me. It would have been madness to continue the kind of studious life that I had been leading. I had been much too zealous, had worked too irregularly and in too many directions, and had done myself serious harm."
Psychasthenes are like poets - born, not made. Nevertheless, it must not be supposed that every one who is afflicted with worry, fears, and obsessions, is a victim of psychasthenia. On the other hand, when not one but all of these imperative moods of thought, coupled with enfeebled will power and more or less brain fag, manifest themselves comparatively early in life without adequate cause, and are sufficiently developed to interfere with one's usefulness, I think it is safe to diagnose such a condition as psychasthenia.
As psychasthenia is usually some sort of defect in hereditary evolution, it overtakes us without our will or leave. Our personal responsibility has to do only with avoiding everything that will tend to make the situation worse, and doing whatever we can to overcome nature's handicap, thus enabling us to make a creditable showing with an otherwise abnormal nervous mechanism and a crippled nervous control.
The psychasthenia is the individual who was "born tired", and who has remained more or less tired throughout life. A careful medical examination will differentiate between the "weariness" of psychic fatigue and that of physical and parasitic maladies, such as hookworm disease, and the like.
Many psychasthenias who are born and reared in the country get along fairly well. Those who are so unfortunate as to grow up in a great city find it much more difficult to live happy, useful, and self-supporting lives. It is largely from this class of neurologically disinherited individuals that the common "ne'er-do-wells" of modern society are recruited. The majority of our inveterate and incurable tramps are affected with this psychasthenic taint; as are also those scions of certain aristocratic and wealthy families who are now and then so strikingly attacked by the wanderlust. It would thus appear that the term "psychasthenia" might be pressed into service for the purpose of describing certain strata of modern society which are otherwise commonly called "lazy".
It is the handicapped individual suffering from an extreme case of congenital psychasthenia, who, when he finds himself unable to compete for a livelihood with his fellows, does not hesitate to turn criminal and begin to pillage and plunder society. These represent the brightest and shrewdest of our criminal classes, and are in marked contrast to the feeble-minded criminals who compose by far the larger part of the inmates of our penal institutions.
In addition to the characteristic mental fatigue of psychasthenia, the patient suffers from a variety of mental disturbances, many of which are identical with, and common to, the sufferings of the various neuroses. Practically, the chief complaint is an incapacity for doing things, coupled with an ever-present over attention to everything connected with one's thinking, living, and working.
The psychasthenia spends the larger part of his mental effort and nervous energy in watching himself and trying to help carry on those varied mental and physical processes which nature designed to be automatically executed. In this way his energies are almost wholly consumed in useless channels - in efforts which are not only unnecessary, but which are highly harmful to the normal workings of both the psychological and physiological processes and mechanisms of the human organism.
All introspective patients are not necessarily psychasthenic, but all psychasthenias are introspective. They watch all the workings of the mental machinery and the physical processes with the eagle eye of a trained detective. They are incessantly spying upon themselves. They watch the minutest details of their daily work, only to criticise their best efforts and worry over the results. When they engage in play or recreation, they watch so closely for the expected relief, that they effectually destroy all the good that might have come from their otherwise beneficial diversions. They watch their stomachs so closely as to lose their appetites and spoil their digestions. It is a physiological fact that no self-respecting stomach will continue to do a good grade of work if its owner insists on watching its operations with a suspicious eye.
These patients even try to watch themselves sleep, and, of course, there can be but one result - insomnia. Even when the attention is relaxed sufficiently to permit sleep to overtake them, their slumbers are more or less disturbed by nightmares and other vivid dreams, all largely born of the apprehensive watchfulness of their waking hours. And so it is little wonder that they awaken in the morning unrested and unrefreshed.
The psychasthenia is especially prone to worry about his work. He is always going back to see if things are done right; trying the door again to see if it is locked; getting up out of bed and going downstairs to see if the cat was put out or the dog was let in. A generalized dread seems to possess the mind - a chronic over attention to things that need no attention - a short-circuiting of the nervous forces to the performance of useless work, as in the case of the dynamo, when a short circuit so diverts the current that instead of passing outside for the performance of useful work, it is dissipated within the generator, thus deranging the functions of the machine and interfering with both the quantity and quality of its work.
Psychasthenics frequently appear to be well nourished - in good flesh. Such cases are often diagnosed as neurasthenia, and the patients are started out on long walks, horseback riding, golf playing, etc. Such mistaken treatment only leads to early and utter collapse - to the complete discouragement of the patient and the utter bewilderment of friends. These patients are not like the mild neurasthenias who are fatigued all day but can dance all night.
The psychasthenia is usually highly impressionable, more or less timid, hesitating, lacking in initiative, an odd genius, usually a dreamer, often over-scrupulous, unfailingly exaggerating the importance of his personal shortcomings, all the while extremely irritable, very changeable in humor and more or less despondent - in rare cases even mildly melancholic at times.
About fifteen years ago I was called to see a woman, then about thirty-five years of age, who had been in bed for three years, suffering from what had been called a profound nervous exhaustion. She was the mother of three children, and had a husband who adored her and was abundantly able to provide her with all the necessities and luxuries of life, even to trained nurses.
This woman was an only child, had been raised in a sheltered environment, had always had her own way, and was utterly spoiled; both before and after marriage she had been petted and pampered, but the one outstanding thing about her was that ever since she was fifteen she had been afflicted with a tired feeling. She had always been short of breath; she never could do all the things that other young people did, because she couldn't stand the pace. She said she had never known a full month in her life in which she felt rested; and so the responsibilities of married life, the bearing of three children, and a few years of effort to help in their raising, had "done her up". She spent more and more time in bed following the birth of the children, and finally after a case of the "flu" she just decided to stay in bed - made up her mind she wouldn't get up. She had not stepped her foot on the floor for over three years when I saw her.
Every examination that could be made in her home was gone through with and she was found to be sound. Interesting to say, she was in good flesh - always had been. She always had a fairly good appetite, not withstanding her repeated attacks of indigestion. When I asked her what was the matter, she replied: "Everything on top of the earth. I have everything but brain tumor, and I am not sure but that I am getting that".
She had had gall-stones, cancer of the stomach, numerous tumors, heart disease, kidney disorders, liver trouble, and tuberculosis, earlier in life. That is, she thought she had these diseases. Every time she read a health book or the medical column of a newspaper, or an almanac thrown on the front porch, she had some new disease. She had tried about every form of medicine, medical practitioner, and healing cult in existence - except Christian Science. She was a firm believer in the Methodist religion and could never bring herself to give up the faith she had been raised in.
What was to be done? For a number of sessions I sat down and explained to her exactly what the trouble was, told her that the diagnosis was psychasthenia, perhaps complicated by hysterical flare-ups now and then. I told her frankly that she was going to be fatigued in this way all her life. I explained to her that she was about a 50-per-cent. woman, speaking in terms of quantitative work-product; that she was a low-pressure boiler, a slow-speed motor; but that she could get right up out of bed any day she wanted to and go about her business, and that she would probably live long and have a fairly good time if she would but master the art of properly relating herself to herself and to the world at large. I explained that she could do what any other woman could if she would give herself twice the time in which to do it.
And be it said to the everlasting credit of this woman that after the third session of this kind of talk, she sat right up in bed, saying: "I am going to try it. I am disgusted with this sort of life. If I had all the diseases I thought I had I would have been dead a long time ago, and if there was anything really wrong with my mind I would have been insane before this. It looks to me as if I weren't going to die or go crazy, and my religion won't let me commit suicide. I am going to get right up and I am going to do it now". And she did. In general, she has been out of bed ever since. Throughout all these years she has returned to fairly normal life, raising her family and doing her part in the world. Two of the children are married. She became a useful club-woman and grew to be an expert in getting along with her constitutional fatigue. She has come to possess more self-control, so that she starts but a few projects and finishes most of them. She has learned how to get along with the feeling of inadequacy that must always be more or less present because of her inability to compete with her fellows on an even basis; but, on the whole, she is leading a normal, healthy life. She is now happy, and, of course, her home is a far different place from what it used to be when she led a life of semi-invalidism.
I think it is best to limit the term psychasthenia to this sort of hereditary or constitutional fatigue. It resembles neurasthenia, but as far as the fatigue is concerned it is incurable. There is a definite limit to the capacity for achievement, and this handicap must be accepted. The treatment consists in the successful adjustment to conditions as determined by the hereditary endowment or congenital handicap.
Not long ago I met a middle-aged society woman who had been all over this country and Europe seeking treatment for nervousness. She had never had a nervous breakdown, but she had grown, since adolescence, to be less and less efficient. She suffered more and more from fatigue. There was a progressive disorder of some kind, she feared, at the bottom of her trouble, and she never ceased to seek medical help. Finally, she was persuaded to stop flitting around from doctor to doctor and from sanatorium to sanatorium, to be examined, studied, and critically analyzed; I found her in a very favorable state of mind to begin work on. She had about given up the idea that she had any organic disease, as she had once feared, and was quite willing to accept the diagnosis of psychasthenia.
We began to work out a program. She learned that she could do fairly good work if she would attempt but a limited amount, and so the past two years have been very different. Her entire plan of living and working has been reorganized. She gets up with the family in the morning, and does between two and three hours' work about the home, and then she rests an hour before lunch. After lunch there are two hours of activity, followed by two hours of rest, relaxation; sometimes she sleeps and sometimes she does not. Then there is a walk or outdoor exercise of some sort before dinner, and she is quite a normal woman throughout the evening, provided she doesn't stay up late more than one or two nights each week.
During the past year she has been all but free from headaches; she has had only one digestive upset, tho she has had palpitation attacks; she has gone on about her business, and, as she says, has had the first happy year of her life since she was sixteen years of age. But has she been delivered from her fatigue? Not at all. She said to me the other day when I asked her about the fatigue: "You have taught me not to think about that. I have learned from you to keep my mind on what I am doing and not on how I feel. When I stop to think how I feel, I am just as tired out as when I first came to you". And so, while I apply the term neurasthenia to an acquired fatigue complex, I would like to reserve the term psychasthenia for this form of inherent fatigue, this constitutional inferiority, coupled with mental insufficiency, which will not permit its victims to lead a normal, average life as it is lived in this competitive world. They must learn how to modify their lives and to live happily even in the presence of this ever-present tired-out feeling. They must simply learn to forget their fatigue.
While, for the purposes of advice and treatment, we recognize many forms of fear, worry, feelings of inadequacy, and many other complexes, together with hysteria, neurasthenia, etc., neurologists more recently have endeavored to put all these psychoneuroses into the following three classes:
1. The anxiety neuroses or neurasthenia - Under this group are found those cases in which the patients are thoroughly preoccupied with themselves - the restless, emotional, introverted, and inhibited type of individual - and the symptoms which are characteristic of this group have to do with disturbance of functioning in some vital organ or system due to emotional depression or as the result of suggestion, together with an inordinate degree of introspection and consciousness of normal physiological functions. These cases are always characterized by fatigue and numerous other sensory disturbances.
2. Hysteria - The hysteric patient seeks to meet the difficulties of life by a sort of negative emotionalism. There is a trumping up of symptoms which constitute sufficient excuse for the disinclination to continue the life-struggle.
3. The compulsion or obsessional neuroses - Recently some neurologists have proposed that this entire group be called psychasthenia. Within this group are placed those neuroses which are characterized by the effort to ignore many of the ordinary difficulties of life, or to pretend that they are absent; and in association with this attitude toward life there are present certain compelling or obsessing symptoms of thinking, feeling, and acting.
And we must not overlook the fact that a patient can be afflicted with more than one kind of neurosis. He may suffer from an anxiety neurosis, hysteria, and some form of a compulsion neurosis, all at the same time.