Neurasthenia

Overview

Fatigue is one of the most common symptoms encountered by doctors in primary care; about a quarter of patients express recent fatigue as a cause of concern.¹ But at what point does feeling tired become a medical condition? What conditions or syndromes can cause this type of fatigue? What diagnosis do patients often receive? These questions, and more, will be answered below. 

Cases of unexplained exhaustion have been studied for centuries, and many different illnesses have been named depending on their specific characteristics. This article will outline what neurasthenia is and why and how the term originated. Its causes, risk factors, symptoms and methods of diagnosis will also be explored. The main conclusion is that the concept of neurasthenia is now being replaced by the more modern diagnosis of psychological disorders and chronic fatigue syndrome (CFS).

What is neurasthenia?

Neurasthenia is a condition that involves physical and mental exhaustion without any identified specific cause, similar to CFS.

The illness was first described in North America in the 19^th century.²  It was characterised as a disease independently by both the neurologist George Beard and Dr. Edvin Van Deusen, but it was the former who went on to become the main source of knowledge about neurasthenia. Beard attributed the disease to the increasingly busy lifestyle of white-collar workers (mostly white and male) during a period of modernisation.³  Later psychologists such as Sigmund Freud also linked exhaustion to modernity.⁴  Indeed, late 19^th century American society witnessed the introduction of cars, planes and telephones, a rise in immigration and more women moving into the professional world.

Neurasthenia, often called “American nervousness” was a common diagnosis in the 19^th century in America and Europe. However, it decreased in popularity at the beginning of the 20th century due to many doctors describing it as simply a group of symptoms that could be attributed to many different diseases, such as mood disorders.³

Is neurasthenia a neurotic condition?

Neurotic disorders is an older term for psychological conditions that are characterised by an impaired psychological function, excluding any hallucination or delusion symptoms. Neurotic conditions include anxiety, depression, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), antisocial personality disorder, social anxiety and other types of phobias.

Neurasthenia is described as a neurotic condition by some physicians. Back in the 19^th century, some called it the female equivalent of hysteria – a disease associated with women who suffered from any kind of mood disorder, unhappiness or anxiety.⁵ In many cases, neurasthenic symptoms such as fatigue are accompanied by mental health disorders; however, this is not always the case. While some argue that neurasthenia is a form of psychological condition, other experts maintain that there are enough cases of fatigue without mental illness to consider neurasthenia a separate disorder.¹

Is neurasthenia real?

Doctors and neurologists are still debating whether neurasthenia can be made as a separate diagnosis or is simply a combination of symptoms that can be applied to other syndromes.

Two of the main medical diagnosis tools for health practitioners are the International Classification of Disease (ICD), written by the World Health Organisation, and the Diagnostic and Statistical Manual of Mental Disorders (DSM), by the American Psychiatric Association. One of the latest editions of the ICD, the ICD-10 (2016), recognises neurasthenia as a separate diagnosis, under a group of neurotic conditions. However, the most recent versions of the DSM, the DSM-4 and the later DSM-5 (2013, revised in 2022), categorise neurasthenic symptoms under a different type of diseases: somatic syndrome disorders (also called somatoform disorders). 

So, whether neurasthenia is a separate condition with its own causes and diagnosis, or whether it’s a combination of symptoms that could be attributed to other identified medical or psychological conditions is still up for debate. However, it is clear that there are individuals suffering from neurasthenia and other fatigue symptoms, and a form of treatment should be provided for them.

Causes and risk factors of neurasthenia

The specific cause for neurasthenia is not clear. George Beard and other neurologists back in the 19th century attributed the disease to a busy lifestyle and a constant modernisation of society, which could also be applicable to current times.³ Nowadays, it is thought that the symptoms of neurasthenia may arise from a variety of social, biological and psychological factors, and that there is not a specific, identifiable cause.⁶ There is some evidence that genetic factors, emotional disorders and viral infections may contribute to the onset of neurasthenia.

Genetic factors: there is some evidence that some individuals may be genetically predisposed to a higher risk of neurasthenia.⁶ 

Emotional disorders: adverse life events impacting mental health and previous mental disorders can also significantly increase the chance to develop neurasthenic symptoms. However, it is not clear whether mental illness can trigger neurasthenia, or whether the symptoms of neurasthenia (debilitating fatigue, difficulty concentrating) are what causes the low levels of emotional wellbeing observed in many patients.⁷

Viral infection: neurasthenia, like chronic fatigue syndrome, can develop after suffering from Epstein-Barr virus, commonly called glandular fever.⁶

There are certain risk factors that can increase the chance of suffering from neurasthenia. They include:

• Excessive energy in childhood
• Obesity
• Emotional disorders
• Negative life events
• Prolonged medical conditions in childhood
• Viral infection
• Being AFAB (assigned female at birth)

Symptoms of neurasthenia

Observed symptoms of neurasthenia are varied. The main symptom is unexplained fatigue that significantly impacts the patient’s daily life.

Other symptoms include, but are not limited to, the following:

• Fatigue after minimal physical or mental effort
• Headaches, especially tension headaches
• Dizziness
• Difficulty concentrating
• Muscle pain
• Irritability
• Trouble sleeping
• Depression 
• Anxiety
• Feelings of hopelessness
• Decrease in appetite

Diagnosis

A diagnosis of neurasthenia is not common nowadays. Since the early 20^th century, the number of people diagnosed with neurasthenia, as well as the number of doctors considering it a valid diagnosis, has decreased significantly.³ In the Western world, neurasthenia as a diagnosis has become less popular; similar diagnoses such as CFS have replaced it.

As neurasthenia covers a wide range of symptoms, there is not a clear consensus in the medical field about how it should be diagnosed.⁸  As mentioned before, some diagnostic manuals such as the ICD still include neurasthenia as an illness, while others like the DSM barely mention it.

Patients may come to their primary healthcare provider, usually their GP. Although most individuals contact a medical doctor first more often than a psychologist or psychiatrist, they may be referred to psychological care if they’re experiencing mood symptoms.⁶ 

Common misdiagnoses

Patients presenting with symptoms of neurasthenia are often diagnosed with other disorders, mainly fatigue syndromes and mental health disorders. Different experts have different opinions on whether there is a worthwhile distinction between neurasthenia and these diagnoses; most argue that further clarification on how they differ is needed.⁷

Some of these diagnoses, and what they mean, are listed below:

Chronic fatigue syndrome: (CFS), also called myalgic encephalomyelitis (ME). The main symptom of this disorder is extreme fatigue that has lasted for at least 6 months. Other symptoms are headaches, difficulty sleeping and problems concentrating. It is a very similar condition to neurasthenia, and some argue it is just another name for the same illness.

Post-viral fatigue: this is prolonged fatigue after a viral infection. The difference with other fatigue syndromes is that the symptoms do not last as long and eventually go away.

Depression: depression is a mental illness characterised by prolonged sadness, hopelessness, and loss of interest in what used to make one happy or excited. It can be treated with antidepressant medication and psychological therapy. The World Health Organisation (WHO) estimates that depression affects about 5% of adults worldwide.

Anxiety: anxiety is another psychological illness characterised by regular feelings of stress, worry or fear. Symptoms can range from mild to severe. Anxiety disorders can be classified into generalised anxiety disorder (GAD), social anxiety, post-traumatic stress disorder (PTSD) or phobias (agoraphobia, claustrophobia, etc). Treatment involves psychological therapy and sometimes antidepressant medication.

Dementia: dementia may be caused by neurodegenerative disorders such as Alzheimer’s, Parkinson’s and Huntington’s disease. It involves memory loss, impaired cognitive abilities and often fatigue. Therefore, it shares some common symptoms with neurasthenia. Some patients presenting with neurasthenic symptoms may in fact be suffering from dementia.

Summary

Neurasthenia is a condition characterised by physical and mental fatigue, among other symptoms such as headaches or dizziness. The term started being used in the late 19th century in America to describe the exhaustion and low mood that busy middle class workers were experiencing. Back then the cause was thought to be modernisation, specifically the fast-paced life it demanded. Currently, it is thought that neurasthenic symptoms may be brought about by a variety of social, psychological and biological factors. 

There is a debate as to whether neurasthenia should exist as a separate diagnosis, or whether it is simply a combination of symptoms that can be attributed to a psychological disorder. Neurasthenia is not a common diagnosis nowadays, and individuals with these symptoms are usually diagnosed with CFS or, as mentioned, mental health disorders such as depression.