Clinical and Public Health Significance of Chronic Subsyndromal
States: Mental Disorders or Normal Variations?
Judd LL, Saletu B, Filip V (eds): Basic and Clinical Science of Mental and
Addictive Disorders. Bibl Psychiatr. Basel, Karger, 1997, No 167, pp 1–5
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Diagnosis and Classification of
Neurasthenia
Norman Sartorius
Department of Psychiatry, University of Geneva, Switzerland
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Although listed in some of the medical dictionaries in the mid-19th century, it was not until Beard [1], an American neurologist, described neurasthenia that the condition assumed the nosological status of a disease entity.
Beard was convinced that neurasthenia was an entirely organic condition, that
it was caused by the environment and that it was more common in the educated
than in the ‘blue collar’ workers. He saw fatiguability as the central feature
of the disease and prescribed rest as the chief and sufficient treatment. Beard
also listed other symptoms – ranging from spasms, fears and pains to insomnia,
impotence, dyspepsia and irritability.
The neurasthenic syndrome was probably frequently seen in Europe at
the time because Beard’s neurasthenia quickly found acceptance, first in Germany and France and then in other European countries. It fitted well with
Pavlov’s concepts of mental functioning and its derangements and gained
popularity in Russia; probably, in part through Russia and in part directly,
the term and concept arrived in China where it was quickly and well accommodated in the traditional framework of disease causation and development. It
spread world wide and then began to lose popularity: it disappeared from the
Diagnostic and Statistical Manual, 3rd Revision (DSM-III) of the American
Psychiatric Association (APA) and stayed out of the APA’s DSM-IV.
In the twelve decades of its existence the syndrome of neurasthenia was
described and classified by many. A variety of now forgotten symptoms were
assigned to the syndrome including such oddities as Rosenbach’s ‘palpebral
spasm’, ‘dysnystaxis’, ‘le casque neurasthénique’, ‘Harnstottern’ and ‘neuropathic eyes’. Frequent somatic complaints led to the search for a specific
organic cause which was presumed and which found an expression in terms
such as ‘Pendelherz’ (penduling heart) or ‘colica membranacea’.
Other less exotic symptoms have also been often mentioned as part of
the neurasthenic syndrome including difficulties of concentration and memory,
increased irritability and reduced tolerance to noise, criticism, ‘normal’ stress
and changes of weather. Cardiovascular and numerous autonomic symptoms
as well as sexual symptoms ranging from a reduction of libido to premature
ejaculation were also listed among the frequent symptoms of neurasthenia,
often with a note that the symptoms were rather vaguely described. Over the
years, various names have been given to the syndrome as a whole. Among
the more widely used were ‘neurocirculatory asthenia’, ‘nervous exhaustion’,
‘psychasthenia’, ‘environmental allergy’ and ‘pseudomyasthenia’. The search
for an organic cause of the syndrome continued unabated – witnessed also by
terms such as ‘chronic Epstein-Barr’s syndrome’, ‘mylagic encephalomyelitis’
and ‘postinfectious fatigue’.
The classification of neurasthenic syndromes has also been a subject of
much attention. Beard [1] proposed that neurasthenic syndromes should be
grouped by the primary symptoms and/or their presumptive organ of origin
and spoke of cerebral, spinal, affective, gastrointestinal and hemyparetic forms;
Glavan [2] some 60 years later, divided it into cerebroasthenia, myeloasthenia,
algic forms, dyspeptic neurasthenia, vasomotor neurasthenia, sexual neurasthenia and mixed forms. Miyake [3] spoke of genuine neurasthenia, reactive
neurasthenia, pseudoneurasthenia and shinkeishitsu personality (often presenting neurasthenic complaints). The Chinese traditional concepts were used
to divide neurasthenia into seven subtypes [4] using labels such as ‘insufficiency
of yang’, ‘insufficiency of yin’, ‘overactivity of yang in the liver’. The official
Chinese Psychiatric Association’s classification (CCMD-2) maintains one concept but for its diagnosis requires more and somewhat different symptoms from
those listed in the definition given in the Tenth Revision of the International
Classification of Diseases (ICD-10) [5]. The CCMD-2 requires the presence
of at least three symptoms, one each from a group of symptoms occurring in
neurasthenia (‘weakness’, ‘sleep disturbance’, ‘nervous pain’, ‘emotional’ and
‘excitement’ symptoms). Weakness, fatigue and fatiguability which the ICD10 took as pivotal symptoms does not have the same importance in the CCMD2 where it is one of five groups of symptoms characteristic of the disease.
Component symptoms of the neurasthenia syndrome however remained
reasonably stable over the years although various authors listed other symptoms in addition to the ‘asthenic core’ of the syndrome [6] (table 1).
The ICD-10 criteria [7] were changed from those proposed in the ICD9. While the ICD-9 listed symptoms without making any one of them obligatory, ICD-10 requires that the symptoms of fatigue, fatiguability or weakness
be present in the company of at least two more symptoms from a list of
symptoms such as sleep disturbance. The ICD-10 also states that the presence
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Sartorius
Table 1. Symptoms listed by various authors
Symptom
Exhaustion, physical
Exhaustion, mental
Fatiguability
Weakness
Need to sleep
Hypersensitivity
Irritability
Pains
Fears
Insomnia
Autonomic symptoms
Sexual symptoms
Reduced stress tolerance
Symptoms listed by
Beard
Freud
X
X
X
X
X
X
X
X
X
X
X
ICD-10
X
X
X
X
X
X
X
CCMD-2
Angst
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
of a well-defined syndrome (e.g., of depressive disorder) takes precedence and
that the diagnosis of neurasthenia should not be made when neurasthenic
syndromes are ‘comorbid’ with another mental disorder.
The neurasthenic syndrome appears in the course of a variety of somatic
illnesses including malignant tumors, myasthenia, thyroid disease, chronic
infectious disease, sleep apnea and abuse of drug and medicaments. When
these conditions are present they should be listed as the principal diagnosis.
The recommendation for users of the ICD-10 however is also that they should
record as many diagnoses as can be justified on the basis of clinical and
laboratory findings; it would therefore be expected that a patient with a chronic
infectious disease and a syndrome of neurasthenia would be given two diagnoses.
The question which is central to the nosology of neurasthenia is its status:
Is it a disease? A syndrome present in a variety of diseases? A personality
type? Or an organic brain syndrome that can be caused by various traumata?
Standardized assessments of patients with the clinical diagnosis of neurasthenia consistently show that a certain proportion – varying from 30 to 70%
of all cases – could be assigned to another category, most frequently one from
the depressive disorders group; there is however a significant proportion of
cases in which no other categorical diagnosis can be made and the only
remaining diagnosis is that of neurasthenia. Neurasthenia so diagnosed is not
a mild condition. In a major international study of patients with psychological
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Diagnosis and Classification of Neurasthenia
Table 2. Percentage of patients with
neurasthenic syndrome among those contacting general health care facilities
Center
Patients, %
Athens
Bangalore
Berlin
Groningen
Ibadan
Mainz
Manchester
Nagasaki
Paris
Rio
Santiago
Seattle
Shanghai
Verona
Overall
4.6
2.8
7.3
10.4
1.1
7.7
9.7
3.4
9.3
4.5
10.5
2.1
2.0
2.1
5.4
problems seen in primary health care, 5.4% of all those contacting services
had a neurasthenic syndrome (table 2). The percentage of ‘pure’ neurasthenia
(i.e., neurasthenia in the absence of any other mental disorder) among the
neurasthenic syndromes varies greatly (from 6% in Athens to 60% in Nagasaki,
the average over all centers being in the region of 30%). The reasons for the
variations among centers could be many including differences in the populations consulting the services participating in the study, different attitudes to
mental disorder (and weakness) in the different countries and differences in
the perception of what health services can effectively treat. What, however, is
striking is that neurasthenia is the main and only reason for consultation in
general health care services in 1.7% of all contacts with such services and that
it produces significant disability when it occurs. Patients with a diagnosis of
neurasthenia had been disabled, on average, for 8.7 days in the course of the
month preceding the examination – a disability level reached only by depressive
disorders seen in the same settings [7].
Chronic fatigue occurring in the absence of any formally diagnosable
mental disorder is most probably a severe form of neurasthenia with a predominance of symptoms of weakness and fatiguability. Several excellent reviews
of the syndrome, its epidemiology, biological substrate and treatment have
been published in recent years [8]. The pathogenesis of the condition is still
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Sartorius
unclear: yet, there is a strong tendency to view the condition as being a remnant
of an affection of the brain by an infection or toxin, for example. A large
number of people with chronic fatigue syndrome contact general health care
and many of them have or have had a comorbid mental disorder [9]. There
is however a certain number of them who do not or did not have any other
psychiatric disorder.
The facts listed above also explain why neurasthenia has been retained
in the ICD-10. It seems to be a ubiquitous morbid state; it is frequent, and
it produces disability. At the same time the pathogenesis of neurasthenia is
unclear and long-term follow-up data are lacking. The availability of a category,
combined with training in the use of operational criteria, may produce data
about the frequency and other characteristics of neurasthenia in different
countries. Such data, as well as the results of research on mental disorders
usually seen in primary and general health care (which has gained strength
in recent years), may help in clarifying the nature of neurasthenia and improve
chances for its successful treatment and perhaps prevention. This would be
an important contribution to the resolution of the major public health problems which mental disorders – including neurasthenia – now present for society.
References
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7
8
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Beard GI: American Nervousness, Its Causes and Consequences. New York, GB Putnam, 1881.
Glavan B: Diagnosis of Diseases of the Nervous System (in Croatian). Tipografija d.d. Zagreb,
1937.
Miyake K: Treatise of Psychiatry, ed 6 (in Japanese). Tokyo, Nankodo, 1932.
Zhou K, Shu F, Chen JX, Xu SH, Zhou CF, Xu PJ, Shi L, Sang NJ: A controlled combination
treatment study of neurasthenia classified by traditional Chinese medical criteria (in Chinese). Chin
J Neurol Psychiatry 1986;19:306–308; cited from Lee S: The vicissitudes of neurasthenia in Chinese
societies: Where will it go from the ICD-10? Transcult Psychiatr Res Rev 1994;31:153–172.
World Health Organization: The ICD-10 Classification of Mental and Behavioural Disorders.
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Üstün TB, Sartorius N: Mental illness in general health care. An International Study. Chichester,
Wiley, 1995.
Wessely S: Chronic fatigue syndrome – the current position. I. Background, epidemiology and
aetiology. Primary Care Psychiatry 1995;1:21–30.
Wessely S, Chalder T, Hirsch S, Wallace P, Wright D: Psychological symptoms, somatic symptoms
and psychiatric disorders in chronic fatigue and chronic fatigue syndrome: A prospective study in
the primary care setting. Am J Psychiatry 1996;153:1050–1059.
Prof. N. Sartorius, Department of Psychiatry, University of Geneva,
16–18, bd de St Georges, CH–1205 Geneva (Switzerland)
Diagnosis and Classification of Neurasthenia
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