Neurasthenia

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Derivation and definition[edit]

This word is derived from the Greek word meaning nerve and from asthenia which means loss of strength. It can be roughly translated as “neuron disability”. It was a diagnosis of nervous debility involving pronounced weakness. The closest modern diagnosis to neurasthenia is probably chronic fatigue syndrome. The late great William Osler defined neurasthenia as “the expression of a morbid, unhealthy reaction to stimuli acting on the nervous centers which preside over the functions of organic life”. He felt it was caused by both heredity and strain, particularly to those having “cares and anxieties” of living that lead to distress and “worry”.

Old definitions[edit]

Definitions have been sprawling and imprecise due to the very wide variety of symptoms and symptom severity, and the lack of an objective test. This left doctors in the late 1800s and early 1900s with their observations of symptoms patterns in their patients. Some tried very hard to define it, including the 1904 description of the great William Osler, but even his description rambles. His definition states that it is “A condition of weakness or exhaustion of the nervous system, giving rise to various forms of mental and bodily inefficiency. (See: https://archive.org/stream/principlespra00osle#page/1122/mode/2up) He further explained: “The term, an old one, but first popularized by Beard, covers an ill-defined, motley group of symptoms, which may be either general and the expression of derangement of the entire system, or local, limited to certain organs; hence the terms cerebral, spinal, cardiac, and gastric neurasthenia.”

Hartenberg’s description of one of his cases histories[edit]

[Italics and inserts in square brackets added for emphasis after the fact to highlight similarities between neurasthenia and the chronic fatigue syndrome—fibromyalgia continuum.]

“Suppose a man of about forty, who comes into my consulting-room and addresses me as follows: ‘Doctor, I have come to consult you because I am continually tired and unable to work. When I get up in the morning I am more weary than when I went to bed at night. [non-restorative sleep pattern] All day I feel my body tired and my limbs ache; the slightest [pain] effort exhausts me ; [easy fatiguability] I can no longer take walks nor indulge in any physical exercise. Even standing upright is an effort.[Some very severe fibromyalgia patients present with a hunched over posture, likely from severe fatigue.]

Moreover, I am tired, not only in the body but in the brain. I constantly feel as though I had a tight band around my skull. [This is likely chronic tension headache which is a fibromyalgia co-morbidity.] My head feels empty; my mind refuses to work; my ideas are confused; [fibrofog] and I can no longer fix my attention.

My memory is going; when I read I no longer know at the end of the page what I was reading about at the beginning. I forget appointments and facts connected with my business. [cognitive strain of sleep deprivation.]

Also I am depressed, bored everywhere and at all times; things that amuse others have no interest for me. I take pleasure in nothing; on the other hand, I have become morbidly impressionable to painful emotions; I worry about everything; the slightest difficulty frightens me; the least opposition exasperates me.

As to my will, my energy I have none left. I no longer know what I want, what I ought to do. I doubt, I hesitate, I dare not come to a decision. I have, in addition, lost my appetite and I sleep badly. Sexual desire is in abeyance.

Under these conditions I have a dread of the future if you cannot cure me I do not know what is to happen.

Whilst he is talking to me in this strain I am studying the man attentively. I notice that his face looks tired and drawn, the cheeks are sunken, the complexion is sallow, the eye dull, the expression sad. His voice is flat and toneless. He sits heavily on his chair, his back is bent, his head is bowed. In brief, his whole aspect reveals lassitude and depression.

If now I examine him I find no sign of any organic affection of the nervous system. The reflexes may possibly be a little active. When I listen to his heart it is nervous, beats loudly, and accelerates under emotion. Above all, I find a considerable dilatation of the stomach, with peristaltic movement and tenderness in the hypogastric region.

Observation of the man thus summed up discloses an almost stereotyped portrait of the ordinary everyday neurasthenic, the one most frequently encountered, together with most of the essential signs of neurasthenia.

If we analyse his symptoms we find that the majority of them are manifestations of a diminution in the activity of the central nervous system, indications of weakness, of inadequacy, e.g. the difficulty in physical effort and intellectual work, loss of memory, of power of concentration, of willpower, sexual coldness, etc. We thus have the immediate impression, from the first study of our patient, that he is suffering from a diminution of the functional capacity of his nervous system. He is in a state of depression, fatigue, exhaustion.

But, in addition, our patient complains of yet more symptoms which are no longer significant of depression but rather of nervous irritability (e.g. hyperaesthesiae, hyperactivity of reflexes, exaggerated manifestation of emotion, insomnia, etc.).

There is then, in reality, in the case of the neurasthenic patient a mixture of symptoms of weakness and irritability, a fact long ago recognized by the sponsor of the neurosis, the American Beard, who on this account named it "irritable weakness."

It may further be affirmed that these signs of weakness and irritability are manifested simultaneously in the various primary functions of the nervous system: motor, sensory, emotional, organic functions, etc. (Pages 3-4 Treatment of Neurasthenia, by Hartenberg, Paul, translated by Ernest Playfair. 1914, Publisher Edinburgh, H. Frowde and Hodder [and] Stoughton, available in full online at: https://archive.org/stream/treatmentofneura00hartuoft#page/4/mode/1up and in full text mode at: https://archive.org/stream/treatmentofneura00hartuoft/treatmentofneura00hartuoft_djvu.txt. https://en.wikipedia.org/wiki/Neurasthenia. For a direct link to this quotation see: Page 3, https://archive.org/stream/treatmentofneura00hartuoft#page/3/mode/1up.)

Current WHO criteria[edit]

Neurasthenia is a listed diagnosis in the WHO ICD-10, 2010 system. (http://apps.who.int/classifications/icd10/browse/2010/en#/F48.0) The entry for it in this system indicates that the cultural variation for this disorder is considerable. There is one main variant in which “the main feature is a complaint of increased fatigue after mental effort, often associated with some decrease in occupational performance or coping efficiency in daily tasks.” Generally, the “mental fatigability is typically described as an unpleasant intrusion of distracting associations or recollections, difficulty in concentrating, and generally inefficient thinking.” For the other major type the key feature is “feelings of bodily or physical weakness and exhaustion after only minimal effort, accompanied by a feeling of muscular aches and pains and inability to relax.” Both main types commonly involve “other unpleasant physical feelings…such as dizziness, tension headaches, and feelings of general instability.” Other common symptoms are: “Worry about decreasing mental and bodily well-being, irritability, anhedonia, and varying minor degrees of both depression and anxiety…” Furthermore: “Sleep is often disturbed in its initial and middle phases but hypersomnia may also be prominent.”

The WHO description is basically describing chronic fatigue syndrome and fibromyalgia. This is yet another piece of evidence that CFS and fibromyalgia are two related disorders which are on a continuum.

History of the idea of neurasthenia[edit]

The condition may have been known to early medical writers such as Marshall, Darwin, Villemain, Jaeger, and others. (Some authors have even suggested that Charles Darwin suffered from neurasthenia.) The word “neurasthenia” occurred in Dunglison's Medical Dictionary in 1833. Many books about neurasthenia were written in the late 1800s and early 1900s.


Neurasthenia.png
The entry on neurasthenia in Dunglison, 1833.
Public domain material available online at: https://archive.org/stream/62650260RX2.nlm.nih.gov/62650260RX2#page/n89/mode/1up


Robley Dunglison.jpeg
Robley Dunglison, 1798-1869


Dunglison was the author of several early medical dictionaries. (See: New Dictionary of Medical Science and Literature, Robley Dunglison MD, 1833, Volume 1 which is available in full online at: https://archive.org/details/62650260RX1.nlm.nih.gov. For the full text version see: https://archive.org/stream/62650260RX1.nlm.nih.gov/62650260RX1_djvu.txt. Volume 2 is available in full online at: https://archive.org/details/62650260RX2.nlm.nih.gov. For the full text version see: https://archive.org/stream/62650260RX2.nlm.nih.gov/62650260RX2_djvu.txt.)

Beard’s concept[edit]

Beard was the leading figure in the field of neurasthenia in his day, especially in the English-speaking world. He published a number of significant works on it. Thanks to Internet Archive and to a lesser extent Google Books, they are even more accessible today than they were when they were published in the late 1800s.


George miller beard.png
George Miller Beard.
Public domain image found in Wikimedia Commons https://commons.wikimedia.org/wiki/File:George_Miller_Beard.jpg


In 1869 he wrote: “I have for some time been in the habit of employing the term ‘neurasthenia’ to express the morbid state that is commonly indicated by the indefinite phrase nervous exhaustion…. The diagnosis of the neurasthenic condition is sometimes entirely clear, and again is quite difficult. The diagnosis is obtained partly by the positive symptoms, and partly by exclusion.” (See: Huth, Edward J. sourced from: Beard, George Miller. Neurasthenia or nervous exhaustion. Boston Med Surg J. 1869; 29:217-21 available in full online through Google Books See The Boston Medical and Surgical Journal, Volume 80. This is page 217 in Google Books. The link is at: nrs.harvard.edu/urn-3:HUL.FIG.GITEM:32044089567960.)

For Beard’s writings about neurasthenia see below in the subsection called: “Bibliography of early works on neurasthenia in chronological order”.

Van Duesen’s theories[edit]

Van Duesen/Van Dusen was the Superintendent of the Michigan Asylum for the Insane. He essential revived the term neurasthenia which he also called nervous exhaustion.

Van Deusen had his own unique description which is somewhat different than that of other writers on neurasthenia. He mentioned a number of concepts that have gone out of favour, such as his idea of cerebral hyperaemia (Page 9).

Unique is his contention that mistrust is an important precipitating factor. He wrote: He mentions the idea of “nervous prostration” (Page 9). Presumably this refers to the difficulty standing and tendency to lie down of people that are exhausted by poor sleep and psychological strain. This is seen occasionally in modern times in patients with severe fibromyalgia. Some of them use canes and walkers. Some walk hunched forwards. Many miss appointments because they are periodically home in bed with exhaustion.

He wrote: “Its leading symptoms are general malaise, impaired nutrition and assimilation, muscular atonicity, changing the expression of the countenance, uterine displacements, with consequent results, and neuralgias of debility, cerebral anemia with accompanying tendency towards hyperesthesia, irritability, mental depression, impaired intellection, melancholia and mania. In cases terminating fatally, death ensues from exhaustion, or from coma, with subarachnoid effusion.” Clearly his conception of neurasthenia is differs from the modern disorders of chronic fatigue syndrome and fibromyalgia in several respects because we do not think of them as fatal. Nor do we relate these disorders to uterine displacements. However, we do relate fibromyalgia in many patients to malaise, pains of neurological origin, hyperesthesia, irritability, and depression.

He mostly focused on psychological factors as the cause but he also drew attention to the role of poor sleep and the roll of other illnesses as contributing to it. He can therefore be considered as forunner to pyschogenic theories of neurasthenia, and chronic fatigue syndrome.

He said: “Among the causes, excessive mental labor, especially when conjoined with anxiety and deficient nourishment…It is traceable to depressing emotions, grief, domestic trouble, prolonged anxiety and pecuniary embarrassment; hemorrhage and debilitating diseases following or coincident with depressing mental influences and sleeplessness.” (Observations on a form of nervous prostration, (neurasthenia) culminating in insanity. Van Deusen, E. H. Amer. J. Insanity. 25 (4): 445–461, April 1869, visible online at Google Books in preview mode at: https://books.google.ca/books?id=Oi8xAQAAMAAJ&printsec=frontcover#v=onepage&q&f=false and partially visible online at: https://ajp.psychiatryonline.org/doi/abs/10.1176/ajp.25.4.445?journalCode=ajp.)

Just as in modern times we see cases of post-infectious fibromyalgia and post-infectious chronic fatigue syndrome, so too did van Deusen document that there were occasional cases of what could be called “post-malarial” neurasthenia. (This fits in well with the author’s theory of the fibromyalgia vortex, whereby anything that activates the vortex, be it a mental conflict, sleep disorder, trauma, or infection, can drive the patient towards fibromyalgia.)

Old Treatments of Neurasthenia with Tonics and Elixirs[edit]

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Nerve and Brain Elixir for Neurasthenia.
Label design by Normajean Hultman. Claude Moore Health Sciences Library, Historical Collections & Services. (The original link was: http://exhibits.hsl.virginia.edu/nerves/tonics/ but as of 2020 it was no longer functioning.) Public domain image found in Pinterest at: https://www.pinterest.ca/pin/529876712412211286/.
The label reads: “Nerve and Brain Elixir. For the treatment of Neurasthenia and all other disturbances of the nervous system. Dr. Galen’s powerful Nerve Restorative. Treatment for men and women. A spoonful a day to relieve Nervous Exhaustion.”


At their peak, there were dozens of tonics and elixirs for neurasthenia. The very concept of a drug involves a suggestion that it is going to help cure. The concept generally has a positive connotation unless it is debunked. Tonic appeal to the wish for a quick fix. Those which are quackery have more to do what is referred to by M. Doidge as “drugophilia” which is the irrational love and appeal of drugs.

An article appeared at a University of Virginia website which stated that some tonic were get-rich-quick tools by quacks trying to make money from guidable people. It also stated that other tonic were “concoctions by honest pharmacists and physicians”. “Many ads from the 1890s through the 1930s reflect concerns about restoring nervous energy and vigor. Long after most physicians had rejected neurasthenia as a condition, drug stores continued to sell nerve tonics. Moxie soda, a carbonated drink today, began as a nerve tonic in the 1880s.”(These quotations come from an internet article entitled “Tonics and Elixirs for Neurasthenia” it was available online at: http://exhibits.hsl.virginia.edu/nerves/tonics/ but as of 2020 the link was not longer functioning and the source could not be found.)

Acceptance of the idea of neurasthenia[edit]

Neurasthenia gained acceptance as a diagnosis the end of the 19th century largely due to writings by Bouchut (1860) and Beard. It was mentioned by Van Dusen in 1867. However, it was Beard who in 1868 brought the term “neurasthenia” to the attention of the general public attention. (For an interesting early work about nervousness which even has a section on the incubus see: Observations on the Nature, Causes, and Cure of those Disease which have been commonly called Nervous, Hypochondriac, and Hysteric; to which are prefixed some remarks on the sympathy of the nerves, Robert Whytt, Edinb. 1765, second edition, available in full online at: https://archive.org/details/observationsonna00whytuoft and also in full text at: https://archive.org/stream/observationsonna00whytuoft/observationsonna00whytuoft_djvu.txt.)

The term neurasthenia has gone out of favour, but it was used by Freud in Studies in Hysteria. See: https://archive.org/stream/studiesinhysteri002062mbp/studiesinhysteri002062mbp_djvu.txt.) It was still in some use during WWI.

Freud’s description of neurasthenic pain[edit]

Freud wrote: “The neurasthenic in describing his pain gives the impression as being occupied with some difficult mental problem, something far beyond his powers. His features are tense and distorted as though under the domination of a painful affect, his voice becomes shriller, he struggles for expression, he rejects all designations that the physician makes for his pains, even though they are undoubtedly afterwards found to be correct. He is ostensibly of the opinion that language is too poor to give expression to his feelings.

These sensations are something unique, they never existed before, so that they cannot be exhaustively described. It is for this reason that he never tires of constantly adding new details, and when he has to stop, he is distinctly controlled by the impression that he was unsuccessful in making himself understood to the physician. All this is due to the fact that his pains absorb his whole attention.”

[Author’s comment: I have seen hundreds of patients which fibromyalgia pains. Many and probably most would have been diagnosed with neurasthenic pain in the time of Freud. I have seen some who are very similar to Freud’s description here. My impression is that his description is not as universal as he lets on. Today doctor’s see the situation he describes as being an aspect of what we now call pain focused behaviour.

What is special about his description is its detail and intuitive character. He is reaching to interpret what he sees in his patients and to try to integrate it into an overall understanding of the patient’s pain. This is becoming something of a lost art.]

(Page 97, Studies in Hysteria, page 98 Sigmund Freud, available online at: Sigmund Freud and Joseph Breuer, Translated by AA Brill, Beacon Press, Beacon Hill, Boston 1937 Edition of the original 1895 book, available online at: https://archive.org/details/studiesinhysteri002062mbp or see the full text version at: https://archive.org/stream/studiesinhysteri002062mbp/studiesinhysteri002062mbp_djvu.txt.)

The multitude of names for neurasthenia[edit]

Never in the history of medicine have there been so many names for one condition. This was already an issue in 1901! (Today the problem remains. Fibromyalgia and chronic fatigue syndrome are part of the same continuum as neurasthenia. Even now there are many alternative names for them in current usage.)

This curious situation gives pause to consider why this occurred. Baldwin (1901) wrote: “Of other names for the malady [i.e. for neurasthenia] may be mentioned encephalasthenia (Althaus), the French nervosisme cachexie, and the more popular terms, nervous prostration, nervous exhaustion, failure of brain power, pathological fatigue, morbid irritability.”

Nervous prostration is a term that has dropped out of the medical lexicon. (The idea behind nervous prostration seems to be that people lose their ability to stand up if they get chronically exhausted enough. Perhaps this is part of why in modern times we see an unexplained number of severe fibromyalgia patients in wheel chairs.)

Baldwin’s 1901 description of neurasthenia[edit]

Introduction to Baldwin’s account[edit]

The following description is a paraphrased summary of the entry for “Neurasthenia” in: Dictionary of Philosophy and Psychology, James Mark Baldwin, 1901, available in part online at: http://psychclassics.yorku.ca/Baldwin/Dictionary/. For the neurasthenia entry see: http://psychclassics.yorku.ca/Baldwin/Dictionary/defs/N3defs.htm#Neurasthenia. For the full dictionary from Internet Archive see: https://archive.org/stream/philopsych02balduoft#page/168/mode/1up.

Comments by the author of Fibro Wiki have been interspersed in square brackets. Note that the author believes that fibromyalgia and chronic fatigue syndrome (CFS) are part of an overlapping continuum which he believes to have a great deal in common with neurasthenia. The main differences are that in CFS, fatigue is the main symptom, but the patients often have diffuse muscular pain; while in fibromyalgia, pain is the main symptom, but most also have fatigue and sleep disturbance.

Considered in the light of the now rather massive scholarly literature of chronic fatigue syndrome and fibromyalgia; Baldwin’s description of neurasthenia is remarkably accurate. It seems that millions of dollars have been spent in effect relearning what was already known in 1900. The accuracy of his account is a testament to the usefulness of keen observation, even in the absence of modern statistical research techniques and to uncover clinical patterns.

Classification of neurasthenia as a syndrome[edit]

Neurasthenia is a “symptom complex” (i.e. a syndrome). Neurasthenia, as he described it, is very similar to what nowadays is called “chronic fatigue syndrome”. Modern authors about fibromyalgia often refer to it as syndrome rather than as a specific disease. This is for good reason because it presents and unfolds in a wide variety of ways. At the low end it can occur as a very minor occasional condition that probably does not rise to the level that it would be labelled as a disease. At the high end, it can appear along with its many comorbidities, thus creating some of the sickest, most symptomatic and miserable of people in all modern society.

Sensory-motor character[edit]

Typical cases have a “mental as well as a sensori-motor character” which at the time of Baldwin was called “cerebro-spinal”.

[He is spot on in mentioning the sensory-motor character as many patients have a host of wide ranging sensory abnormalities and long with many problems with movement include difficulties with gait, posture and strength as well as number of sleep-related neuromuscular problems such as restless leg syndrome and bruxism. Many severe modern fibromyalgia patients are reliant on canes, walkers and other mobility aids.]

He states that “spinal neurasthenia (myelasthenia) is characterized by motor abnormalities, particularly by difficulty in walking, by a feeling of sinking of the limbs, by abnormal locomotor tendencies…”

[It is common in modern times for many of the more severe patients who are labelled as chronic fatigue syndrome or as fibromyalgia to have severe motor problems. Based on the author’s experience as a fibromyalgia consultant, severe cases often use wheel chairs and walkers due to their mobility problems. In his experience the patients in wheel chairs with fibromyalgia are in them because they have e a combination of general fatigue from poor sleep, disuse atrophy of muscles, muscle pain balance problems and dizziness with associated fears of falling.]

Mental symptom aspect[edit]

Baldwin goes on to say: “When the mental symptoms are particularly marked and the motor symptoms not prominent, the condition is by some termed cerebral neur-asthenia (cerebrasthenia, encephalasthenia)…”

Sexual subtype of neurasthenia[edit]

According to Baldwin, a specific sexual neurasthenia was described by Beard, Krafft-Ebing, and others; gastric or dyspeptic neurasthenia (nervous dyspepsia) has also received special attention (Glatz).” Beard wrote a book entitled “Sexual neurasthenia nervous exhaustion”, https://archive.org/details/sexualneurasthe00beargoog.

Modern doctors do not speak of “sexual neurasthenia” but it is well recognized that many patients with fibromyalgia have a variety of sexual problems including what has been labeled in modern times as “vulvodynia”. Often there is reluctance by patients to volunteer personal details and an associated reluctance by doctors to ask.

Sexual abuse is common in past history of many severe fibromyalgia and chronic fatigue cases. It is well known that such trauma can have complex repercussions on love and sex life. (See for example: Childhood sexual abuse and chronic fatigue syndrome. Van Den Eede F, Haccuria T, De Venter M, Moorkens G. Br J Psychiatry. 2012 Feb;200(2):164-5 available in full online at: http://bjp.rcpsych.org/content/200/2/164.2.long.]

Hysterical subtype of neurasthenia[edit]

Baldwin stated: “Hystero-neurasthenia is an approximation of neurasthenical symptoms to a hysterical type a condition emphasized by French writers.”

[Freud’s Studies in Hysteria was re-examined by the author and now in retrospect, based on a close examination of his cases histories, several of his so called “hysterics” were also fibromyalgia patients. New research has demonstrated a statistical connection between hysteria and fibromyalgia. This not only applies to women in peacetime, but also to men in war time. Some of the most dramatic cases of hysteria occurred in soldiers who were traumatized in WWI. Furthermore, the Craiglockhart hospital for British soldiers was probably (in the judgment of the author) largely comprised of post-traumatic chronic fatigue patients. For a modern paper showing the association between chronic fatigue syndrome and combat see: Migraine in gulf war illness and chronic fatigue syndrome: prevalence, potential mechanisms, and evaluation. Rayhan RU1, Ravindran MK, Baraniuk JN. Front Physiol. 2013 Jul 24;4:181 available in full online at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3721020/.) For further information on hysteria see the entry Hysteria as fibromyalgia comorbidity]

Other types neurasthenia listed by Baldwin were[edit]

Hereditary. [A family history of fibromyalgia is a risk factor for fibromyalgia. The reasons for this are not known for certain, but there could be a psychological explanation, and so it is better to simply describe the pattern as being “familial” without imposing the judgement that it is genetic.]

Traumatic. [There is a broad medical literature showing that many cases of fibromyalgia are post-traumatic.]

Adolescent. [Modern medical science has a small scholarly literature on pediatric or juvenile fibromyalgia as well.]

Neuralgic. [It is a little unclear what this means, but it likely means that there are a group of patients that have neurological type symptoms. Dysesthesias and paresthesias are common in fibromyalgia.]

Baldwin on the neurasthenia-migraine association[edit]

Neurasthenia was associated with neuralgia and migraine. [So is fibromyalgia and chronic fatigue syndrome. See for example: Migraine headaches in chronic fatigue syndrome (CFS): comparison of two prospective cross-sectional studies. Ravindran MK1, Zheng Y, Timbol C, Merck SJ, Baraniuk JN. BMC Neurol. 2011 Mar 5;11:30 available in full online at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3058027/.]

Baldwin on the time patterns, chronicity and build-up of neurasthenia[edit]

Baldwin stated that neurasthenia was almost always chronic. Onset is “slow; the symptoms ensue in irregular sequence; they appear first in lighter and then in more cumulative form, and the entire attack often covers a period of many years”. It tends to fluctuate and recur and to periodic “intense paroxysmal attacks”. Patients may suffer “chronic exhaustion which is commonly termed nervous prostration”.

[It is commonplace in the experience of the author to see the same temporal patterns in fibromyalgia clinic. For example, it is fairly common to see patients with a series of traumas, such as 3 or more car accidents over a period of years, whose fibromyalgia escalates in relation to these traumas.]

Baldwin’s ideas on predisposition to neurasthenia and causal factors[edit]

In modern times we call these “risk factors”.

He states: “Ziehen finds that a neurotic inheritance is traceable in 74 per cent. of all cases”.

As possible causal factors he lists:

  • unhygienic conditions of life,
  • abnormalities of sexual life,
  • accidents,
  • over-exertion,
  • fright,
  • ill health generally, and
  • “most frequently the accumulated strain of overwork under conditions of worry and stress”

Baldwin’s effort to define categories of symptoms of neurasthenia[edit]

Faced with the great multitude of possible symptoms and trying to break them down into broader categories he wrote: “The symptoms of neurasthenia may be considered under the head of (1) mental attitude; (2) the subjective sensory and motor disturbances; (3) the physical condition. The great variability of the symptoms and their tendency to involve more than one of these factors must not be lost sight of. (1) Prominent mental symptoms are the difficulty in holding the attention for a protracted effort, a speedy fatigue, a diminished readiness for acquisition of new impressions, momentary states of confusion and distraction, mental restlessness and unsettlement, the persistence of unbidden thoughts, irregularity of memory, a lack of pleasure in ordinary occupation, irritability, excessive anxiety about small affairs, lack of self-control, an undue occupation with one's own bodily and mental condition, unreasonable fears and aversions, marked idiosyncrasies, and the like. Along with these there are often periods of intense depression (particularly in severe cases or where the disorder reaches its worst stages), occasionally leading to suicide.”

[The long list of mental symptoms that he gives is very similar to the list seen amongst patients with severe fibromyalgia or chronic fatigue syndrome. Many of them are due to server chronic sleep deprivation. Depression is known fibromyalgia comorbidity.]

Baldwin’s comments on symptoms due to fatigue and irritability[edit]

The following statement by Baldwin could have easily appeared in a modern journal: The “great variety of mental symptoms is more or less easily traced to states of fatigue and the irritability characteristic of certain phases of fatigue.”

[Author’s comment: Based on a review of the medical literature of sleep medicine by the author of this wiki, it is now known that there are dozens of symptoms of sleep deprivation. The typical modern patient with moderate to severe fibromyalgia or chronic fatigue syndrome has multiple sleep problems and is quite sleep deprived.

In recent years much of the medical literature on these conditions has been dedicated to the study of what is currently known as “central sensitization”. This term did not exist in the time of Baldwin. However, Baldwin mentions irritability as causing many of the symptoms. Generally speaking the CNS is irritable in fibromyalgia. This is manifested as allodynia and other indicators of central sensitization. Based on the author’s clinical experience, many fibromyalgia patients are also emotionally irritable, likely due largely to effect on their nervous system of sleep deprivation.]

Baldwin’s comments on anxiety and related symptoms in neurasthenia[edit]

Anxiety is one of the main symptoms of fibromyalgia syndrome. There are exceptions but it is the rule. Baldwin stated: “The neurasthenic fears are characteristic, and often constitute the most distressing symptoms. Their unreasonableness is recognized by the patient; conduct is often carried out in opposition to them, but they always occasion anxiety, distress, and a feeling of impending calamity. Almost all the various PHOBIAS (q.v.) -- agoraphobia, claustrophobia, mysophobia, and so on -- have been noted in neurasthenia. Such hesitation in conduct may be properly viewed as a defect of will or irresolution. This is exhibited in the difficulty of maintaining the attention, the restlessness, the slow and weak attempts to throw off invalid habits, the dependence upon others, and the necessity of constant stimulation and encouragement. (2)”

Baldwin’s comments on what he called the “sensory symptoms” of neurasthenia[edit]

He wrote: “Of first importance among the sensory symptoms are the paraesthesias, or abnormal sensations, and the characteristic pains. Such paraesthesias are difficult to describe. The patient complains of a feeling of tightness in the head, a feeling of heaviness, a feeling of inward pressure (this symptom, 'Kopfdruck,' Ziehen finds in 85 per cent. of all cases), a sense of confusion in orientation, and various forms of VERTIGO (q.v.). He is subject to various dull, aching pains, or fatigue pains as the result of slight exertions, while specific throbbing or piercing local pains in the head or spine are not uncommon. The tendency of such symptoms to fluctuate and to disappear under proper mental stimulation indicates their quasi-subjective (psychogenic) character. Disturbances of the specific sense-impressions is less common. Blurring of the images, as in protracted reading; difficulty in accommodation; buzzing, pulsating, or beating in the ears; tickling or itching in the skin, and local hyperaesthesias are frequently noted. Of motor disorders may be mentioned a muscular weakness often markedly felt, and which, probably in combination with a vaso-motor disorder, at times gives rise to a feeling of faintness and impending unconsciousness. Tests with the dynamometer indicate an abnormally early appearance of fatigue symptoms. Delicate co-ordinations are often affected; the handwriting loses in definition; slips of the tongue in speaking, twitching of the muscles, tremor, hoarseness, or a hollow sound of the voice, and motor restlessness are also common…there may be a special sensitiveness to heat and cold and to changes of the weather; the respiration is often accompanied with effort, a sort of neurasthenic asthma; an explosive irritating cough may appear; a peculiar flushing of the skin when touched or stroked may be observed, while irregularities in the urine (oxaluria, phosphaturia, and excess of uric acids and urates) are particularly significant. Sexual abnormalities, both as symptoms and as aetiological factors, are often present, and when prominent form the sexual type of neurasthenia. Irregularities of sleep, mostly insomnia, are the rule; even where the amount of sleep is sufficient it is apt to be interrupted and unrefreshing in character. (Dictionary of Philosophy and Psychology, James Mark Baldwin, 1901. http://psychcentral.com/classics/Baldwin/Dictionary/defs/N3defs.htm.)

“With this intellectual exhaustibility are usually conjoined a series of other phenomena which are quite characteristic, above all the so-called "Kopfdruck" the feeling of a permanent pressure on the head which is increased by every mental exertion, also giddiness of the head, pain and tension in the occipital region and nape of the neck, heightened sensitiveness of the eyes to light, sleeplessness, psychical irritability and peevishness.” Clinical lecture on neurasthenia and its treatment, by Prof. H.V. Ziemssen, translated by Edmond J. McWeeney, 1894.)

[Author’s comment on Kopfdruck: I had not heard this word prior to 2020, but when I did, I immediately remembered that one of my most serious insomnia/migraine patients has been complaining of this bitterly for an extended period. His many doctors have been at a loss to know what to do about it.]

[Author’s general comments: There is something to be learned from this old definition of neurasthenia. It is close to chronic fatigue syndrome but with overlap with fibromyalgia as he does mention pain as a common symptom.

His description of special forms including a muscular form is of interest. This has been something of a lost observation. I am aware of a woman with fibromyalgia patients whose most noticeable symptom was the fact that she arrived with walker which she relied upon heavily having difficulty supporting herself yet she had no known orthopaedic or neurologic explanation. She might qualify as the motor type described by Baldwin.]

Baldwin’s account of a multitude of symptoms[edit]

There are so many that it is difficult to know how the modern reader can make us of them. There are some patients with central sensitization syndrome that have fibromyalgia and most of the many other items on Yunus’s list. So for example they could have IBS and interstitial cystitis on top of fibromyalgia and so they would have a number of bowel and bladders symptoms. We can safely assume that central sensitization syndrome existed a hundred years ago and a thousand years ago.

There are few if any diseases known to modern medicine which have as many symptoms as patient with sever fibromyalgia and multiple comorbidities

Baldwin’s theory of the fatigue aspect[edit]

Baldwin expresses the following theory as to the cause of the fatigue: “It is mental worry rather than overwork that induces the fatigue or neurasthenia; it is the environment, free from anxiety, that is so much more difficult to procure than mere rest from exertion.” We now know that this is probably an oversimplification because we have modern research showing that these patients also often have a wide variety of sleep disorders which contribute to the fatigue. For further clarity see the entries in this wiki for vortex, the fibromyalgia.

Baldwin’s theory of the nature and course of the disorder[edit]

Baldwin give the following description on the nature and course of neurasthenia: “The nature of the disturbance which conditions the neurasthenic state is not known. Neurasthenia is, with few doubtful exceptions, of a chronic character; its onset is slow; the symptoms ensue in irregular sequence; they appear first in lighter and then in more cumulative form, and the entire attack often covers a period of many years. A marked characteristic is the fluctuation and recurrence of the symptoms both in shorter and longer periods, while moments of intense paroxysmal attacks are not uncommon. As the disease is often of long standing before treatment and recovery begin, so there is also a considerable period of convalescence, during which many of the typical neurasthenic symptoms persist. Not unfrequently some traces, like scars, remain almost indefinitely. The disorder is rarely fatal, nor is it prejudicial to longevity.”

Borel’s theory of the oversensitivity to criticism of neurasthenics[edit]

Forth stated that “Borel explained how neurasthenics suffered from “great moral susceptibility: a trifle the smallest obstacle, the slightest reproach, the lightest emotion agitate le malade, who is ready to burst out in anger or pity.” (Cultures of Neurasthenia form Beard to the First World War, Marijke Gijswijt-Hofstra and Roy Porter(eds), Clio Medica 63, Wellcome Series in the History of Medicine, Amsterdam and New York, Rodopi, 2001, available from Google Books in preview mode at: https://books.google.ca/books?id=d3LTMUKW4GwC&printsec=frontcover#v=onepage&q&f=false. Forth gives as his reference V. Borel, Nervosisme au Neurasthenie, 1894 Laussanne, F. Payot, available in French online at: http://gallica.bnf.fr/ark:/12148/bpt6k76953x.r=.langFR.)

[Author’s comment: The oversensitivity that is referred to here is a problem of evaluative processing. Research is be needed to test the theory and to verify if it is more common or more intense in patients with fibromyalgia and chronic fatigue syndrome than in the general public.]

Further information[edit]

For informaiton about neurasthenia in China see: Sociocultural and Individual Differences, Fanny M. Cheung, in Comprehensive Clinical Psychology, 1998, 10.02.6 Transformation of Neurasthenia, https://www.sciencedirect.com/topics/medicine-and-dentistry/neurasthenia.

Bibliography of early works on neurasthenia in chronological order[edit]

There are a remarkably large number of old medical books in French about neurasthenia. Many can be found in full at Internet Archive by entering the word “neurasthenie” into the search box.

Bouchut, Eugène, Du nervosisme aigu et chronique et des maladies Nerveuses. (1859, 2nd ed. 1877) https://archive.org/details/dunervosismeaig00boucgoog.

Bouchut, Eugène, De l'état nerveux aigu et chronique : ou, Nervosisme, appelé névropathie aigue cérébro-pneumo-gastrique, diathèse nerveuse, fièvre nerveuse, cachexie nerveuse,...et confondu avec les vapeurs, la sureexcitabilité Paris: Baillière,Publication date 1860, available in full online at: https://archive.org/details/b28065487.

Beard, George, Neurasthenia, or Nervous Exhaustion, Boston Med Surg J 80:217-221 April 29, 1869 available online at:http://www.nejm.org/doi/full/10.1056/NEJM186904290801301.

Beard, George Miller, Cases of hysteria, neurasthenia, spinal irritation, and allied affections; with remarks, Publisher Chicago, Spalding 1874 available in full online at: https://archive.org/details/39002011127108.med.yale.edu.

Beard, George M. (George Miller), Certain symptoms of nervous exhaustion. New York Academy of Medicine, 1878, available in full online at: https://archive.org/details/101485081.nlm.nih.gov.

Dowse, Thomas Stretch, On brain and nerve exhaustion: "neurasthenia", its nature and curative treatment, London : Bailliere, Tindall and Cox 1880, available in full online at: https://archive.org/details/b21949980.

Beard, George M, Amer. Nervousness New York : Putnam 1881 available in full online at: https://archive.org/details/americannervousn00bearuoft.

Beard GM: A Practical Treatise on Nervous Exhaustion (Neurasthenia). New York: William Wood and Co; 1880, available in full online at: https://archive.org/details/apracticaltreat03beargoog.

Althaus, Julius, On failure of brain-power, London: Longmans, 1882 available in full online at: https://archive.org/details/b21950982 and in full text at: https://archive.org/stream/b21950982/b21950982_djvu.txt.

Beard, George Miller. Sexual neurasthenia nervous exhaustion: Its Hygiene, Causes, Symptoms, and Treatment, with a chapter on diet for the nervous. Publisher E.B. Treat, 1884 available in full online at: https://archive.org/details/sexualneurasthe00beargoog.

Levillain, Fernand La neurasthénie [electronic resource]: (maladie de Beard) méthodes de Weir-Mitchell et Playfair, traitement de Vigouroux(1891), https://archive.org/details/b20394482.

W. F. Robinson. Electro-therapeutics of Neurasthenia. GS Davis, Detroit, 1893 available in full online at: https://archive.org/details/b21724775 or at: https://archive.org/details/electrotherapeu00robigoog.

Borel, Nervosisme et Neurasth. (1894).

Corning, Brain Exhaustion (1884) available in full online at: https://archive.org/details/brainexhaustionw00corn.

Cullerre, Nervosisme et Neuroses, Publisher Paris : Baillie (1887) available in full online at: https://archive.org/details/nervosismeetnv00cull.

Beard, George Miller, A practical treatise on nervous exhaustion (neurasthenia): its symptoms, nature, sequences, treatment. (1889) available online at: https://archive.org/details/practicaltreatis1889bear.

Bouveret, Léon, La neurasthénie: épuisement nerveux, Baillière, 1891 available from Google Books online in preview mode at: https://books.google.ca/books/about/La_neurasth%C3%A9nie.html?id=yOkRAAAAYAAJ&redir_esc=y.

Gorton, David Allyn, Neurasthenia: or nervous exhaustion. (1894) available at: https://archive.org/details/39002010293117.med.yale.edu.

Schrenck-Notzing, Neurasth. (1894). Not in internet archive.

Loewenfeld, Pathol. u. Ther. d. Neurasth. u. Hysterie, Publisher J.F. Bergmann, 1894, available in full online at: https://archive.org/details/pathologieundth00loewgoog

Dornbluth, Nervöse Anlage u. Neurasth. (1896). (Not found in internet archive 2018)

Gilles de la Tourette, Les états neurasth. Publisher Paris: Baillière (1898), available in full online at: https://archive.org/details/lestatsneurast00gill.

Moll, Albert, Das nervöse Weib. (1898). 1903 version available online at: https://archive.org/details/bub_gb_IEgRAAAAYAAJ.

Loewenfeld, L[eopold] Die moderne Behandlung der Nervenschwäche (Neuras-thenie) der Hysterie und verwandter Leiden. Mit besonderer Berücksichtigung der Luftkuren, Gymnastik, der psychischen Behandlung und der Mitchell-Playfair'schen Mastkur. Wiesbaden: Verlag von J. F. Bergmann, 1899, available in full online at: https://archive.org/details/b21717680.

Ostrander, Henry Young Neurasthenia and its treatment, New York: The Charles N. Crittenton Co.1900, available in full online at: https://archive.org/details/39002011211530.med.yale.edu.

Sinclair, Helen Brown, Neurasthenia 1903, https://archive.org/details/jstor-3402264.

Dana CL. The partial passing of neurasthenia. Boston Med Surg J 1904; 339-344, partially visible online at: http://www.nejm.org/doi/full/10.1056/NEJM190403311501301.

Clarke, John Michell, Hysteria and Neurasthenia, 1905, available in full online at: https://archive.org/details/hysterianeurasth00clar.

Savill, Thomas Dixon, Clinical lectures on neurasthenia, London: Henry J. Glaisher ; New York : William Wood, 1908 available in full online at: https://archive.org/details/b2813607x.

Ballet, Gilbert, Neurasthenia, translated from the 3rd French edition by P. Campbell Smith, London : Henry Kimpton, 1911. https://archive.org/details/b21942134.

Ballet, Gilbert, Neurasthenia, published London, Henry Kimpton (1911) available in full online at: https://archive.org/details/39002052141067.med.yale.edu.

Vittoz, Roger; translated by H.B. Brooks, Treatment of neurasthenia by teaching of brain control. Longmans, Green, 1911, available in full online at: https://archive.org/details/39002010910793.med.yale.edu.

Tucker, Beverley R. (Beverley Randolph), 1874-1945, S. Weir Mitchell; a brief sketch of his life with personal recollections. 1914, Publisher Boston, R.G. Badger; [etc., etc.], available in full online at: https://archive.org/details/sweirmitchellbri00tuck.

Hurry, Jamieson B. (Jamieson Boyd), 1857-1930, The vicious circles of neurasthenia, and their treatment. Publisher London: Churchill 1915, available in full online at: https://archive.org/details/viciouscirclesof00hurruoft.

Hösslin, Rudolf von, b. 1858; Müller, Franz Carl, 1860-1913; Handbuch der Neurasthenie, Publisher Leipzig : F.C.W. Vogel, 1893 and available in full online at: https://archive.org/details/b21907419.

For even more sources search online through Internet Archive under the keyword “neurasthenia at: https://archive.org/details/neurasthenia00balliala.

Additional titles are also listed by searching for “neurasthenia” at: https://www.worldcat.org/.