Psychotherapy

CHAPTER I

NERVOUS WEAKNESS (NEURASTHENIA)

Neurasthenia, from the Greek roots, neur, meaning nerve, and sthenos, strength, joined by the negative particle a, turning strength into weakness, means nothing more than nervous weakness. To tell a patient that he or she is nervously weak, or is suffering from nervous weakness is usually not satisfactory, but it may be absolutely true and may represent the limit of our knowledge with regard to the particular case. To tell them that they are sufferers from neurasthenia is satisfying as a rule, because then they have a nice, long, and imposing word with which to talk to their friends about their ailment. To discuss with friends one's own nervous weakness is just a little absurd; to talk over neurasthenia and its symptoms, however, adds importance to those symptoms and makes them seem manifestations of some interesting underlying condition.

The discussion of symptoms always does harm, but the internal complacency with its constant auto-suggestion of the underlying nervous disease is still more harmful. Neurasthenia seems to most people to signify a new and serious disease of the nervous system which has developed as the result of our high-pressure civilization and the modern strenuous life, and, therefore, has a special interest and an exaggerated importance. All of this makes for an unfavorable attitude of mind towards the affection and encourages the intensification of symptoms by attention to them. The opposite state of mind in which symptoms would be given their proper value by the term nervous weakness would act as a constant source of favorable suggestion. I believe that if the word neurasthenia must be used, it should be translated for the patient and the absolutely functional character of the affection insisted on in order to neutralize its suggestive influence.

Probably the most serious objection to the use of the word neurasthenia comes from the number of organic affections having vague nervous symptoms, including especially tiredness, a certain incapacity to do what was readily done before with tired feelings and a general feeling of unfitness, that have come to be grouped under this head. In this it resembles the word rheumatism rather strikingly. The diagnostic general principles seem to be: tired feelings equal neurasthenia; achy feelings (especially if worse on rainy days) equal rheumatism. So whenever either word is used, patients are apt to think of cases they have known which were labeled by one of these two terms, rheumatism or neurasthenia and ended by developing some serious condition. The unfavorable suggestion consequent upon this has made many patients miserable and has prevented them from using their nervous energy to relieve their condition.

The use of the word neurasthenia has another decided disadvantage in that the facile recourse to it often keeps the physician from examining his patient sufficiently to detect an underlying pathological condition. The term can be made to cover so much that it has done great harm in this way. I feel, therefore, that in the discussion of what can be done for patients suffering from nervous weakness we should first of all describe and set aside a number of forms of disease that have sometimes masqueraded as "neurasthenia" and that have given the affection stronger unfavorable suggestiveness. Sir William Gowers, whom no one would suspect of either minimizing the significance of the word or of the affections that have come to be grouped under it, nor of wishing to attract attention by differing from others, has in one of his recent smaller medical works40 emphasized both of these unfortunate connotations of the word. Because his expressions as applied to other medical terms that are too general in their significance, will help physicians to get at the real meaning of them I venture to quote his opinion at some length:

The history of the word "neurasthenia" is noteworthy. … I have to confess to the authorship of two words. One, "myotatic," was always a puny infant, and I doubt whether it still maintains an independent existence. The other, "knee-jerk," instantly attained universal use, and indeed, I think has seemed to most persons to have sprung spontaneously from the thing itself, without suggestion—perhaps the greatest compliment a word can pay its author. But the general use at once achieved by "neurasthenia" was in spite of a strong objection to it which was felt by many. The Royal College of Physicians of London could not include it in their "Nomenclature of Disease," and yet it is now one of the most common of medical words in every language. It would be instructive in more than one way to have a careful study of the forces which have influenced its career, but that I cannot attempt. We must, I think, admit that not only is it a satisfying word to those who suffer, but it has a certain convenience which has also compelled many to employ it who at first objected. If I may be pardoned for a partial paradox, its convenience is not the less real because this rests on features that are illusory. Remember that the word is a name which should have little meaning, even to those who use it. You may employ it to collect the symptoms of the case under a general designation, but do not let it cover them as a cloak.

Neurasthenia and Melancholia.—A serious mistake of diagnosis, though it is often not a mistake of knowledge but of medical judgment, is the confusion, apparent or real, of neurasthenia with melancholia. The word melancholia has come to have a definite serious significance, as it should, in the minds of many persons and as a consequence physicians sometimes hesitate to use it, and employ instead the all-embracing term neurasthenia, or neurasthenic depression. It is popularly well known that melancholies are likely to commit suicide if their condition is serious, while neurasthenia is not at all connected with the idea of suicide. As a consequence, patients are often not guarded as they otherwise would be and so we have suicides every month of so-called neurasthenics who were really sufferers from melancholia. This sad state of affairs reflects in two ways to the detriment of medicine. First, it leaves melancholies without due protection. Second, it leads many of the neurotic patients whose ailments have been labeled neurasthenia and who read the stories of these supposed neurasthenics, to think that they, too, are tending toward suicide and so they are less capable of reacting against their neurotic condition and in general are much worse for the unfortunate dread of some such fatal termination.

Neurasthenia Simulation by Organic Disease.—Neurasthenia is especially a dangerous term since, like other words of this kind with wide connotation, many quite disconnected diseases may in early stages simulate it and give rise to the thought that there is only a functional nervous disease present, when the symptoms are really a manifestation of an underlying organic disease, heightened somewhat by a nervous organization or by worry on the patient's part. So-called neurasthenia in the old must always be looked upon with suspicion. Neurasthenia in the young may be a purely functional nervous disease, though it is probable that in most cases the nervous system is congenitally defective, or at least is unable to perform the functions which have been assumed by the patient. If a nervous organization has stood the strain of the trials of early and middle life, which are usually severe enough to try out individuals from the physical side, if they are in moderate circumstances, or from the mental side if they are wealthy, it will not, as a rule, be overborne by the burdens put upon it by age unless some organic disease has come to seriously disturb it.

Neurasthenia and Arteriosclerosis .—There are many serious conditions that masquerade as neurasthenia. Perhaps the most important is precocious arteriosclerosis. That a man is as old as his arteries is now recognized as an absolutely sure maxim of internal medicine. In many people the arteries wear out before their time and in all there is an inevitable wearing out in the course of years. With the beginning of degeneration of the arteries there are likely to be many symptoms that closely resemble neurasthenia. In the elderly these are nearly always symptoms of defective circulation because of lack of elasticity in the arteries and their failure to accommodate themselves to the variations of pressure in the circulation as the consequence of changes of position, variations in the barometer, heat and cold, and the like.

In these cases a study of the blood pressure will give the differential diagnosis when the actual thickening of the arteries cannot be felt, but it must not be forgotten that nervous excitement may greatly heighten blood pressure on occasions so that a number of observations have to be made.

Neurasthenia and Bright' s Disease .—Other general diseases almost inevitably produce nervous symptoms. It is curious how often a severe exacerbation of Bright's disease, which has been in existence for some time but has given no specific indication, is preceded by a series of neurotic symptoms thought to be due to nothing more than neurasthenia. Men of thirty-five to forty-five, the favorite time for the occurrence of the severe forms of Bright's disease, begin to complain of tiredness, especially on waking in the morning, of inordinate fatigue in the evening, of some stomach symptoms and occasionally a tendency to diarrhea. All of these are ascribed to a neurasthenic condition. Early in these cases an examination of the urine should be made as a routine practice, because if there is nothing in it the patient will be just that much more reassured, while if it contains any pathological elements he need know no more about it than his physician deems proper, yet the real nature of the case and its indications will be appreciated. Without this a physician will often find himself suddenly confronted by serious symptoms in a patient when nothing of the kind was anticipated because the condition was thought to be entirely functional.

Occasionally the symptoms of Bright's disease seem to develop suddenly, as it were a storm in the organism out of a clear sky. As a matter of fact, however, there have been for some time before more or less indefinite symptoms pointing to some serious process at work, which if valued at their proper worth might have led to a much earlier diagnosis of the impending nephritis. Such patients are labeled as neurasthenics for months and at times even years before the serious conditions develop which make the recognition of their ailment comparatively easy. One case of this kind has come under my observation that is interesting in its lessons. A medical student had during the first year of his course exhibited every now and then what seemed to be neurotic symptoms. He was inclined to complain of headache for what seemed very slight reasons, and of pains and aches whenever there was a change in the weather and especially a fall in the barometer. He often had stomach symptoms and was anxious about his heart; in general he was looked upon as one of the nervous, complaining kind. During the course of a lesson in clinical pathology in his fourth year, he was asked to furnish a sample of urine which it was supposed would be normal, for comparison with an abnormal sample that was being investigated in the laboratory. To the surprise of the professor and to his own consternation, his urine was loaded with albumin. Up to that time there had been absolutely no objective symptoms and only the vague indefinite subjective symptoms mentioned. The next day his feet swelled. Even this for a time was considered to be rather an index of the neurotic tendency in him to react to very slight causes. It was hoped that the albuminuria was functional, as the examination was made in the full tide of digestion, and that it would pass off. Subsequent examinations, however, showed not only albumin but also casts. There was a slight intermission of symptoms and then an exacerbation. Within a month after the chance examination of his urine and its unexpected result he had a convulsion. Two weeks later, altogether six weeks after the albumin was first discovered, he died in nephritic coma.

Such cases are not so rare as they are thought, though they are seldom so fulminant. There is a story told of a professor at one of our American medical schools who, some twenty years ago, took a sample of his own urine in order to demonstrate the normal characteristics of healthy urine, and to his utter surprise he found albumin and casts in it. Within six months he was dead from Bright's disease.

Nervous Diarrhea and Organic Disease .—Other internal conditions may be called neurotic when they are really due to definite pathological entities. For instance, in three cases I have seen what had been pronounced by several physicians to be chronic diarrhea of nervous origin, proved to be due to quite other and serious pathological conditions of internal organs. In one of them a chronic diarrhea of several years' standing finally culminated in death in early middle age from nephritis. After the event, there seemed to be no doubt but that the diarrhea, which no ordinary means of treatment had succeeded in benefiting more than temporarily, was really due to the effort of the intestinal mucosa to supplement the defective work of the kidneys. In this case apparently one of the strongest evidences that the affection was of nervous origin was the fact that whenever the patient was away from home, eating rather plentifully of a varied diet, his intestinal condition was better than when he was eating much more simple and unvaried food at home. The change of scene and surroundings proved a tonic to his kidneys and perhaps also to his skin, thus saving his intestines some of the extra work they had assumed.

Neurasthenia and Diabetes .—Another serious disease that may in its earlier stages be mistaken for neurasthenia is diabetes. There is no doubt that some patients have been passing sugar for a long time before any sure symptom can be noted in their general health, or, indeed, before there is anything to call attention to the possibility of glycosuria. In many of these cases, however, there is a feeling of muscular tiredness and a sense of inadequacy for occupations which were before easy, that may be attributed to neurasthenia. When this muscle tiredness changes to crampy feelings that should be enough to lead to an examination of the urine.

Undoubtedly one of the reasons why neurasthenia is sometimes called the American disease and is thought to be more frequent among us than it is in Europe is this confusion with the beginnings of serious organic disease because of failure to examine patients carefully in order to detect underlying organic conditions. In recent years this neglect has become rarer and the consequence has been a reduction in the numbers of so-called neurasthenia cases. Our morbidity statistics of twenty years ago, for instance, seemed to show that we had only half as much diabetes to the population as they had in Europe. One of the reasons for this was undoubtedly the ease with which the diagnosis of neurasthenia might be made at the beginning of diabetes, and that the terminal stages of the affection were often masked by the development of the tuberculosis so frequent in diabetic conditions or of albuminuria with symptoms pointing to Bright's disease. Even at the present time it would be quite possible to reduce the number of neurasthenia cases by more careful attention to diagnosis.

Simulated Neurasthenia Due to Over-attention.—While there is danger of confusing neurasthenia on the one hand with more serious disease there is a distinct liability on the other hand to exaggerate the significance of certain minor symptoms by employing the word when it is only over-attention of mind to certain portions of the body that constitutes the disease in its literal sense. If something has particularly attracted a patient's attention to some part of his anatomy and if his attention is concentrated on it and allowed to dwell long on it, his feelings may be so exaggerated as to tempt him to think that they are connected with some definite pathological condition and he may even translate them into serious portents of organic disease. If a patient once begins to waste nervous energy on himself because of solicitude with regard to these symptoms then it will not be long before feelings of tiredness, incapacity for work, at times insomnia and certain disturbances of memory are likely to be noted. Then the neurasthenic picture seems to be complete. This is the process so picturesquely called "short-circuiting" by which nervous energy exhausts itself upon the individual himself instead of in the accomplishment of external work. Many of the worse cases of so-called neurasthenia have their origin in this process. It is true that this set of events is much more likely to occur among people of lowered nervous vitality, but under certain conditions it may develop in those who are otherwise in good health up to the moment when the attention happened to be particularly called to certain feelings. The physician can start these patients off anew after improving their physical condition, if he can only bring them to see how much their concentration of mind upon themselves is the cause of their symptoms.

It has been well said, though to some it will doubtless seem an exaggeration, that we human beings are a regular boiler factory of sensations which, fortunately for our sanity, mental and physical, we have learned to neglect to a great extent. Wherever our clothing touches us, wherever the air touches us, wherever shoes or belts constrict us, there are definite sensations. These continue, but attract no attention unless they exceed a certain limit to which we are accustomed. Habit in this matter is very different in different individuals. After men and women have grown used to tight shoes or tight corsets these no longer produce disturbance. The chance visitor in a boiler factory or loom room of a cotton mill thinks he could not live in such din. But after a time people get so used to the din that silence and quiet may even become oppressive to them. City dwellers from the slums, especially children, find the peace of the country disturbing when they are first taken for vacations.

Over-attention to sensations, often scarcely abnormal, is indeed the real source of many of the symptoms that can so readily be exaggerated into pathological portents when attention is directed to them. Every portion of our body is connected with the central nervous system. Every square inch of surface touched either by clothing or the movement of the air producers a sensation at every moment of our waking life. Ordinarily we pay no attention at all to these sensations. We can recognize their presence by turning our attention for the moment to any portion of the body and recognizing at once that there are sensations coming from it, though the moment before we did not notice them. If we think of the point of our big toe on the right foot we find, though we were totally unaware of it a moment before, that a certain pressure is being exerted in it. If we continue to think of it queer feelings develop in it. We may get a sense of numbness that proceeds up along the tendons that lead to it. We can follow them up to the insertion of the muscles in the shin. If we dwell on the subject we have curious prickly sensations and numb feelings, all of which were there and were neglected a minute before but now are acutely felt.

This same thing is true of all the manifold sensations that come streaming into the brain. We learn almost to enjoy them though we are paying no attention to them. To be without them would mean very often a fright lest there should be something the matter. Usually we think of the outside of our body as the main source of sensation. It must not be forgotten, however, that our viscera have also certain sensitive nerves and while these are not as closely distributed as those on the surface they are there and their presence is often a source of pleasure or at least of satisfaction, but may be the source of poignant discomfort. We are constantly disregarding ordinary messages from these, too. Something may easily call our attention to these sensations, however, and then we may translate them into pathological terms though they are really only physiological. Ordinarily man may put a couple of pounds of food and drink into his stomach and not feel it at all. If anything particularly calls attention to our stomachs, however, and we dwell on it, then this weighty feeling may seem to indicate serious indigestion because of the discomfort that is produced. This is what nervously weak persons, the so-called neurasthenics, are constantly doing. It is this habit that by suggestion and training they must be taught to break.

There is a tendency to the substitution of one neurotic symptom for another whenever by psychotherapy and mental discipline one condition is overcome. Often the substitution is of something just as bad or even worse. I have known cases where people when properly persuaded gave over paying too much attention to their stomachs and then proceeded to pay too much attention to their sleep with the result that insomnia developed. On the other hand, I have known patients to get over insomnia and then develop a series of complaints of queer feelings in their head which they usually spoke of as headache, though when asked to describe them carefully they confessed that they were at most a sense of pressure or of unusual feeling in some part of the head.