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West J Med. Sep 2002; 176(4): 257–258.
PMCID: PMC1071745

Why is neurasthenia important in Asian cultures?

DEFINITION OF NEURASTHENIA

Although neurasthenia was dropped from the Diagnostic and StatisticalManual (DSM) in 1980, it is included in the appendix section of thefourth edition of the manual, under “Glossary of Cultural-BoundSyndromes.” It is listed as shenjing shuairuo, a condition“characterized by physical and mental fatigue, dizziness, headaches,other pains, concentration difficulties, sleep disturbance, and memoryloss.”1p48

The Tenth Revision of the World Health Organization's InternationalClassification of Diseases (ICD-10) presents a set of well-definedinclusion and exclusion criteria for thediagnosis.2 The coresymptoms are identified as mental and/or physical fatigue, accompanied by atleast two of seven symptoms (dizziness, dyspepsia, muscular aches or pains,tension headaches, inability to relax, irritability, and sleep disturbance).To make the diagnosis, it must be a persistent illness. Exclusion criteriainclude the presence of mood, panic, or generalized anxiety disorders.

A major reason that neurasthenia has survived as a common diagnosis inAsian cultures is that it is considered an acceptable medical diagnosis thatconveys distress without the stigma of a psychiatric diagnosis. Health careprofessionals working with Asian American patients find that many patientsfrom Asian countries describe their symptoms as neurasthenia, although theymay meet DSM diagnostic criteria for other disorders.

Many clinicians in the United States see the symptom complex ofneurasthenia as similar to that of chronic fatigue syndrome (CFS).Characterized by pervasive fatigue with a diffuse constellation of somatic,cognitive, and emotionalsymptoms,3 CFS isthought by some experts to be a contemporary revival ofneurasthenia.4Others have noted that although the two conditions overlap in their focus onphysical symptoms, neurasthenia has a broader scope of symptoms and hasimportant culturalconnotations.5,6In particular, patients and physicians in Asian countries considerneurasthenia a “core diagnosis,” even though the patient may havemore severe disorders, including psychosis. The symptoms cited in the 1994Centers for Disease Control criteria forCFS7 do overlap withthose of neurasthenia. Fatigue is the essential symptom for both diagnoses;others that overlap include muscle pain, headaches, inability to concentrate,irritability, and sleep disturbance. Chronic fatigue syndrome differs fromneurasthenia, however, in that the diagnosis requires that more symptoms arepresent and is associated with specific physical signs and impairment ofsocialfunctioning.8

NEURASTHENIA IN ASIAN CULTURES

Japan

In Japan, neurasthenia is known as shinkeisuijaku, meaning“nervousness or nervousdisposition.”9Initially, it was seen as “a psychological reaction developed in acertain type of personality characterized by hypersensitivity, introversion,self-consciousness, perfectionism and hypochondriacaldisposition.”9Morita therapy, which involves a period of mandatory rest and isolation and aperiod of progressively harder work, leading to resumption of a social role,was initially the treatment of choice. This treatment, which has its basis inZen Buddhism, is aimed at breaking the cycle of sensitivity and anxiety (seewww.morita-therapy.org).

More recently, professionals and lay people in Japan have used neurastheniaas a “camouflage” to cover serious mental disorders, such asschizophrenia and affectiveillnesses.9 This usemakes the patient's role more socially acceptable and allows biologicallyfocused Japanese psychiatric professionals to apply their treatments.

Neurasthenia in Japan is currently considered a curable physical conditionwithout the stigma of a psychiatricdiagnosis.10 Thetreatments of choice include plentiful rest, a peaceful environment, and timefor a relatively gradual and prolonged recovery. Unfortunately, nowell-designed studies have been conducted to assess the effectiveness of suchsupportive approaches compared to psychological or pharmacologicapproaches.

China

In the 1983 version of Chinese-English Terminology of TraditionalChinese Medicine, the etiology of neurasthenia is described as a decreasein vital energy (qi). Harmful factors to the patient's body, bothexogenous and endogenous, reduce the functioning of the five internal organsystems (“wuzang”: heart, liver, spleen, lungs, kidneys),which leads to deficiency of vital energy (qi) and lower bodilyresistance.

In 1983, Xu and Zhon established an elaborate set of diagnostic criteriafor neurasthenia, known as shenjingshuairou (“weakness ofnerves” in Chinese). Currently these are found in the ChineseClassification of Mental Disorders(CCMD-2).11 Unlikethe ICD-10 definition of neurasthenia with its core symptom of fatigue, thatincluded in the CCDM-2 cites no dominant symptom in the diagnosis. Three ofthe following five symptoms are required: “weakness” symptoms,“emotional” symptoms, “excitement” symptoms,tension-induced pain, and sleep disturbance. The duration of illness must beat least 3 months, and one of the following is required: disruption of work,study, daily life, or social functioning; significant distress caused by theillness; or pursuit of treatment. Other clinical conditions that may producesimilar symptoms must be absent.

Asian Americans

After his research experiences in China, Kleinman concluded thatneurasthenia was best understood clinically when it was regarded as a“biculturally patterned illness experience (a special form ofsomatization), related to depression or other diseases or to culturallysanctioned idioms of distress and psychosocialcoping.”12,p115

Findings from a study of Southeast Asian refugees in California support theimportance of retaining neurasthenia as a diagnosis, showing that it cannoteasily be subsumed under the Western criteria ofdepression.13 Inother words, although neurasthenia and depression overlap, neurasthenia seemsto be distinct and causes distress in its own right.

Findings of several studies have led to interest in resurrecting theneurasthenia diagnosis included in the DSM for assessing Chinese Americans.These findings suggest a high prevalence of neurasthenia in Chinese Americans,that this diagnosis may be missed or misdiagnosed, and that patients withneurasthenia are not receiving treatment.

  • Hong and colleagues examined 76 native Chinese university students in theUnited States. They found that those students in whom neurasthenia wasdiagnosed had experienced symptoms of depression, as measured by the Centerfor Epidemiological Studies-DepressionScale.14
  • Zheng and colleagues studied data from the Chinese American PsychiatricEpidemiological Study, a 5-year study involving 1747 completed households inLos AngelesCounty.15 Theyfound that 6.4% of the participants met ICD-10 diagnostic criteria forneurasthenia, compared to 3.6% who suffered from major depression. Of thosewith neurasthenia, 56.3% did not experience any other current or lifetimepsychiatric diagnoses, ie, they were “pure” sufferers fromneurasthenia.
  • Using the same data set, Takeuchi and colleagues found that lessacculturated Chinese immigrants tended to express their distress throughsomatic and neurasthenic symptoms. Depression was expressed similarly for bothpoorly and highly acculturatedimmigrants.16

EVALUATION AND TREATMENT

Cheung has suggested that when asked directly, Chinese immigrant patientsacknowledge both affective and somatic symptoms in their experience ofdepression anddistress.17Inquiring about neurasthenic experiences may avert the stigma-riddenresistance that the term “depression” tends to invoke. This effortcan help to build rapport and a therapeutic alliance.

Traditional therapy for neurasthenia has included eating healthier, regularlight exercise, improved hygiene, massage, psychotropic medication, theappropriate use of rest, and adjustment of work or lifestyle to decreasestress.12Currently, antidepressant medication and psychological counseling are standardtreatments of choice.

Figure 1
Maggie Wong/CBWCHC

Notes

Competing interests: None declared

References

1. American Psychiatric Association. Diagnostic andStatistic Manual of Mental Disorders, 4th ed (DSM-IV).Washington, DC: American Psychiatric Association;1994.
2. International Classification of Diseases, Tenth Revision(ICD-10). Geneva: World Health Organization;1992.
3. Ware N, Kleinman A. Depression in neurasthenia and chronic fatiguesyndrome. Psychiatr Ann 1992;22:202-208.
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9. Tsung YL. Neurasthenia revisited: its place in modern psychiatry.Cult Med Psychiatry 1989;13:105-129. [PubMed]
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11. Chinese Medical Association and Nanjing Medical University.Chinese Classification of Mental Disorders, Second Edition, Revised(CCMD-2-R). Nanjing: Dong Nan University Press;1995.
12. Kleinman A. Social Origins of Distress and Disease:Depression, Neurasthenia and Pain in Modern China. New Haven:Yale University Press; 1986.
13. Chung RC, Singer MK. Interpretation of symptom presentation anddistress: a Southeast Asian refugee example. J Nerv MentDis 1995;183:639-648. [PubMed]
14. Hong W, Chan L, Zheng DC, Wang C. Neurasthenia in Chinese studentsat UCLA. Psychiatr Ann1992;22:199-201.
15. Zheng YP, Lin KM, Takeuchi D, Kurasaki KS, Wang Y, Cheung F. Anepidemiological study of neurasthenia in Chinese-Americans in Los Angeles.Compr Psychiatry 1997;38:249-259. [PubMed]
16. Takeuchi D, Wang YX, Chun CA. Stress healthrelationships in Chinese Americans: testing acculturativedifferences. Poster session presented at the Eighth AnnualConvention of the American Psychological Society; Toronto, Ontario; August,1996.
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