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Mental Incapacity Psychasthenia

In recent years we have come to realize that many of the so-called
nervous diseases, or if they do not deserve the serious name of
disease, nervous symptom-complexes, are really due to a deficiency of
vital energy. Some people have a store of energy that enables them to
accomplish many different things successfully. Some become exhausted
from a few trivial occupations. What is noteworthy in the cases to be
discussed in this chapter is that they show always certain symptoms of
mental tiredness or, at least, of lack of capacity for affairs.
Patients complain, for instance, that they cannot make up their minds
so as to reach decisions because they doubt so much whether the
decision they come to will be right or wrong. Others dread the outcome
of any and every act and feel that something is hanging over them.
Slight sources of irritation become so exaggerated by thinking about
them and dwelling on their possibilities that they may even disturb
sleep and appetite and, as a consequence, the general health. Fears
come over patients lest various things should happen and they dread
microbes, or infections, or dirt in general, or the approach of
insanity, and all to such a degree as to incapacitate them for their
ordinary occupations.

Many of these patients become quite incapable of willing effectively.
They not only lose initiative, the power to undertake new enterprises,
but they find it difficult to make up their minds as to details of the
ordinary affairs of life. As we have stated elsewhere in Professor
Grasset's expressive formula, these patients say that they cannot do
things, their friends say "they will not," and the physician, taking
the middle course, which, as usual in human affairs, has much more of
truth than either of the extremes, says "they cannot will."

For these states Janet of Paris suggested the word psychasthenia. It
is formed on the model of the word neurasthenia and unless it is used
with discretion will have all the objections that attach to that other
term. Above all, it shares the tendency pointed out by Sir William
Gowers with regard to neurasthenia of being "too satisfying. Men are
apt to rest on it as they would not on its English equivalent.
Physicians, if they do not actually think that they have found the
malady from which the patient is suffering, have an influence exerted
on them of which they are often unconscious, which lessens the
tendency to go farther in the search for the whole mental state." Much
more can be said in defence of psychasthenia, however, than of
neurasthenia, for the substitution for it of the translation of the
Greek words of which it is composed--"mind weakness" would be
alarming. While it is important, then, to realize that the term may
easily be made too general and prove, as such words as rheumatism has
done in our time and malaria did in the past, a cloak for ignorance
and an excuse for incomplete investigation for diagnostic purposes, it
represents a satisfactory answer to the patient's question as to what
is the matter without committing the physician to such definitely
detailed opinions as to the patient's condition as would surely prove
unfavorably suggestive.

Psychasthenia, Natural and Acquired.--There are two forms of the
mental incapacity that underlies many of the curious symptom-complexes
that have been studied under the term psychasthenia. One is natural,
that is, inherent in the special character of the individual, and the
other acquired through disease or exhausting labor, worry, or anxiety.
Some people are born without sufficient mental energy to do the work
they attempt to accomplish. This is true, also, in the physical order.
It is often pitiable to see young men who have not the physical
strength necessary for athletic exercises, or the dexterity required
for them, faithfully trying to accomplish by effort what others do
with ease. When there is some natural defect in the way they will
usually fail, no matter how much they strive. Just in the same way
some persons are not able to accomplish certain more serious purposes
requiring special mental ability or power which they attempt. Their
brothers, their friends, their schoolmates, may have the ability, and
they cannot understand why they should not have it, but the fact
remains that they are not possessed of it and if they try to make up
for this defect by overwork they simply break down.

Differential Diagnosis.--Each of the two forms of mental incapacity,
congenital and acquired, must be carefully differentiated and treated
from a special standpoint. With regard to congenital lack of mental
control, all that the doctor can do is to counsel against the
assumption of duties and responsibilities that are too heavy for the
patient. Some people have not enough nervous energy to run a business
with many details, and some even find it difficult to try to do things
involving much less responsibility. There is no use for a man five
feet in height, weighing one hundred pounds, to try to be a stevedore.
There is no use for men of delicate muscular build to try to make
their living at heavy manual labor; they simply wear themselves out in
a very short time. This inadaptability is recognized at once. Just the
same thing is true with regard to many nervous systems, but the
recognition is not so easy or immediate. Some cannot stand the strain
of intricate business details or the burden of responsibility in
important transactions. They must be taught to be satisfied, then,
with quiet simple lives without what is for them, excessive
responsibility and without strenuous business worries. A country life
with regular hours, plenty of open air and as little responsibility as
possible, is the ideal for them.

The most difficult problem in this matter is the question of
diagnosis. As a rule, the history is the most helpful for this. The
patient tells of having found difficulty all his life whenever
anything of special significance was placed on his shoulders. He is
one of those who were born tired and remain so all their lives. It has
been the custom to blame these people; they are rather to be pitied.
If they are born in circumstances that allow of their living
quietly in the country, they accomplish a certain amount of work quite
successfully and live happy, contented lives. If they are born in the
city where the hurry and bustle around them and the insistence of
friends that they must take up responsibilities becomes poignant, they
get discouraged and even despondent. It is from this class of patients
that the "ne'er-do-wells" of modern life are recruited. They form the
under-stratum of trampdom, the scions of good families with the
wanderlust, the willing but incapable. Certain of them become vicious
and criminal, either because they do not want to work or because their
mentality is perverted in some way. Such patients cannot be treated
with any hope of their becoming successful exemplars of the strenuous
life, but they may be directed into the less exacting occupations of
country life and so live quiet, useful and happy lives. For the
congenital class we can do little except to prevent them from trying
to do things that are beyond their mental capacity and helping them to
see just what their limitations are.

Mental Exhaustion.--Many disturbances of mental energy are acquired.
These may be either functional or organic. For the organic variety we
cannot do much, since it is dependent on changes in organs that are
permanent. We can, however, usually predispose the patient's mind to
the recognition of the fact that he should no longer try to devote
himself to occupations that constitute a special drain on his nervous
energy. The man, for instance, who is already suffering from
arterio-sclerosis must be warned that worry and work will surely
hasten the process and that his nervous symptoms cannot be cured, but
must be palliated. He must be advised to lessen his mental strain and
to take up something which, while occupying his mind, does not make
insistent calls on his vitality. In this matter it must be remembered
that when a man over fifty develops nervous symptoms, as a rule there
is no question of functional trouble but of organic change and usually
heart or arteries or kidneys are at fault.

In recent years we have come to realize that typhoid fever often makes
serious inroads upon a patient's vitality which can only be retrieved
by care, not alone for some months but, if possible, even for some
years, not to put an overstrain on the vital energy. Certain other
diseases produce an even more lasting effect. A sufferer from
well-developed tuberculosis will probably never be able to go back to
the strenuous city life. If he attempts to do so, not only is there
danger of a recurrence of his tuberculosis, but there may even be a
development of neurotic symptoms. Syphilis is another disease that
leaves patients in a condition in which it is dangerous for them to
assume the serious responsibilities of an exacting occupation and
especially anything that involves excitement and worry. Syphilitic
patients should be warned of the danger of pursuing vocations that
make such demands upon them. It is the actor, the broker, the
speculator, and the strenuous business man generally, who is likely to
suffer from parasyphilitic conditions, tabes, paresis and the like,
much more than those who follow occupations that make less demands on

Functional Mental Incapacity.--In a large number of cases the
incapacity to do things because of lack of mental energy is due to
functional disturbances of the nervous system. These are the most
important for the psycho-therapeutist because much can be accomplished
for them. Nearly always the patient can be benefited by advice and
suggestion, and very often some unfavorable factor at work,
using up his mental energy to no purpose, will be discovered. In order
to do good, however, careful study of the individual patient is the
most important element. The most frequent functional disturbance of
the nervous system, leading to exhaustion of mental energy, is
over-attention to one's self and to one's occupations. Men can do many
complicated things quite naturally and easily, but when they carefully
watch themselves doing them, accomplishment is not so ready and the
task is double. They tire much easier, for, as a rule, what they are
doing could be accomplished automatically and they are using up energy
attending to it. This is probably one of the commonest causes for the
rather frequent development of that state called nervous exhaustion in
our time. People watch themselves too closely and by so doing they not
only use up energy unnecessarily in the surveillance, but also they
hamper their powers to do things and so consume additional energy in
overcoming this inhibition.

Morbidly introspective people watch almost ceaselessly everything they
do. They not only watch themselves work and worry about it, but they
watch themselves play and grow solicitous that it will do them good;
they watch themselves divert themselves to see if it is giving them
real recreation and so spoil the diversion; they watch themselves eat
and disturb their appetite, and watch themselves digest and hamper
digestion; they even try at least to watch themselves sleep and so
interfere with sleep. Many of the cases of insomnia are really due to
this over-attention. They fear they will not sleep, they worry about
it, they keep themselves awake hoping that they will sleep, and in the
more serious cases even during sleep itself they are so solicitous
that their dreams become very vivid and a form of unconscious
cerebration goes on with surveillance of themselves. They do not rest
even in sleep. They wake feeling not rested, they get up with a
consciousness that they are beginning a long day without being
properly refreshed and they exhaust enough energy to complete a good
part of the day's work in wondering whether they will be able to go on
with their occupation for the day, whatever it may be.

Inhibitory Surveillance.--People become afraid that they cannot or
that they may not do things well and set a guard over themselves. This
is illustrated very well in the doubts about accomplishment because of
which they keep going back to see what they have done and how it was
done, though usually it was accomplished quite well without any
conscious attention. Dreads form another phase of this attitude of
mind. For those who are affected with them they make a thing hard to
do before it is begun, and harder to accomplish after it has been
entered upon because of the suggestion that it may lead to some
serious results, or they even inhibit their activities to a marked
extent by their solicitude with regard to them. They worry about
things before the event and thus consume energy uselessly. Worry has
been defined as anxious solicitude about what we have to do next week
at the same time that we occupy ourselves with what we are doing now
and have to do in the next hour or two. The solicitude about next week
is quite useless, as a rule, until the time comes, and it merely
disturbs what we are doing now, making it harder to do and making
errors in it almost inevitable, and so preparing ourselves for
discouragement because of mistakes that have been made and still
further adding to the difficulty of accomplishment.

Inhibition of Automatism.--These introspective people disturb
themselves by over-attention to things that need no attention, that
are accomplished automatically, and that are not done nearly so well
if they are attended to. Not only is it true that it is harder to do
work that ought to be accomplished automatically if much attention is
given to it, but also nature resents the surveillance. Not only the
brain does not work so well if watched to see whether perhaps it is
working too much, or whether there are too many feelings in our head
while we are doing things, but even the stomach resents being watched
and does not do its work as well. The same thing is probably true for
every one of our organic functions. In the chapters on the heart we
call attention to the fact that surveillance makes a perfectly healthy
though nervous heart miss beats. There is a dual waste of nervous
energy then. We are employing our attention watching things done that
need not be watched, and by that fact we are inhibiting natural
processes and requiring that more energy shall be put into them for
their accomplishment, and even then accomplishing them with
discouraging imperfection.

Mental Short-Circuit.--The reflex mental process that particularly
affects many individuals in our time and makes it hard for them to do
their work, has been well described under the figure of a
short-circuit in an electrical dynamo. The short-circuit diverts the
current so that instead of acting outside the dynamo and performing
useful work, it is discharged within the machine, brings about
deterioration of its elements and soon leads to a reduction in the
amount of electrical energy that that particular dynamo can develop.

Association Fibers Diversion.--Prof. Michael Foster in the Wilde
Lecture for 1898, "The Physical Basis of Psychical Events," [Footnote
44] has many valuable suggestions with regard to the mechanism of
mental operations on the neuron theory. He has particularly dwelt on
the function of the association fibers in connection with mental
operations, or with the raising of sensation to the plane of
mentality. A portion of the brain that is originating impulses,
instead of sending them down to the periphery, through the projection
fibers, to lead to the accomplishment of external work, may have its
messages diverted through the association fibers to other portions of
the brain and thus do harm rather than good.

[Footnote 44: Proceedings of Manchester Literary and Philosophical
Association, 1898.]

Occurrence of Psychasthenia.--It must not be thought that these
curiously interesting conditions occur only among people of low
intellectual caliber, or in those of narrow intellectual interests,
mere specialists who may have acquired a reputation for doing one
thing well. They are frequent among the most intellectual classes.
Brain workers of all kinds, unless they are careful to vary the
interests of life, unless, as suggested in the chapters on Occupation
of Mind and Diversion of Mind, they have a hobby besides their usual
occupations, are likely to suffer in this way. As a matter of fact,
many intellectual people have had what are called nervous breakdowns
of this kind. A biographical dictionary shows any number of them. Dr.
Gould's Biographic Clinics furnish many documents for the study of
these conditions. A typical instance, told by the sufferer himself,
the distinguished Sir Francis Galton, is of special significance for
the psychotherapeutist. I quote because it illustrates the fact
that such breakdowns do not portend a short or subsequently listless
life, for Sir Francis, a most successful scientific investigator,
lived well beyond fourscore years in the full possession of health of
mind and body.

It was during my third year at Cambridge that I broke down entirely
in health and had to lose a term and go home. I suffered from
intermittent pulse and a variety of brain symptoms of an alarming
kind. A mill seemed to be working inside my head; I could not banish
obsessing ideas; at times I could hardly read a book, and found it
painful to look at even a printed page. Fortunately I did not suffer
from sleeplessness, and my digestion failed but little. Even a brief
interval of mental rest did me good, and it seemed as if a long dose
of it might wholly restore me. It would have been madness to
continue the kind of studious life that I had been leading. I had
been much too zealous, had worked too irregularly and in too many
directions, and had done myself serious harm. It was as though I had
tried to make a steam-engine perform more work than it was
constructed for, by tampering with its safety-valve and thereby
straining its mechanism. Happily the human body may sometimes repair
itself, which the steam-engine cannot.

The physician with experience in such cases would be much more apt to
say, "Happily we can learn to control our mental energy and not let it
go to waste by foolish persistence at one set of ideas constantly, nor
be dissipated in surveillance of functions that work automatically if
left to themselves."

Etiological Factors.--This form of mental incapacity develops
particularly in people after they have gone through a prolonged period
of hard work and then have come to a time when they are much freer
than they were before. They are prone to think that they exhausted
their nerve force during the preceding period of labor and that now
they are paying for it. Almost invariably what is really happening is
that they now have much more time to occupy themselves with themselves
and about themselves and to worry over their ills, real and imaginary.
This is the typical nervous breakdown, as it used to be called, of
elderly retired merchants or bankers. They have looked forward all
their lives to a time when they could enjoy themselves doing nothing.
They retire from business and then their troubles begin. It is no
wonder that the old proverb, "A machine rusts out much sooner than it
wears out" should have been so often quoted with regard to this
condition. A man who has been working busily at something all his life
cannot stop all at once and do nothing. He cannot learn to occupy
himself with trivial things. Commonly, he has few, if any, interests
apart from his business and he very soon wears the novelty off these
and then introspection comes to make him exaggerate the significance
of every feeling that he has, every stiffness that occurs, every
muscle twinge due to change in the weather, until he becomes supremely

As a rule, these patients are simple, practical, common-sense,
business men, and it is hard for the physician to think that there is
nothing more than a functional neurosis present. It is even more
difficult for the patient to be made to appreciate that his ills are
mainly due to his own over-attention to himself in this idleness that
he has looked forward to with so much pleasure. Ordinary medicines
fail to relieve and the regular professional man seldom succeeds in
doing these patients much good. They constitute the richest material
for the quack and the charlatan. Much occupied with their ills they
tell their friends all about them. Whenever a strong impression is
produced on their mind by a promise to cure them with some new
wonderful remedy they are favorably influenced, often get better and
then are walking advertisements for the particular quack who has
happened to benefit them. It is this class of people that has given
more trouble to legislative committees of medical societies than any
other. Some of them appeal to legislators whenever a bill for the
admission of some new form of practitioners of medicine comes up with
the story of how much benefit they derived from the treatment. Since
they have been successful business men their word carries weight. It
is curious how little the making of money, though often presumed to be
so, is a test of real intelligence. It is often the man of one idea
with no intellectual breadth who is the best money-getter.

These conditions develop almost entirely in predisposed individuals
who, for some reason, are trying to overdo the energy they possess,
and who, as a consequence, have lost a certain control over
themselves. At times, of course, they occur in persons who have so
little occupation of mind that thoughts of various kinds along these
lines become insistently suggestive and cannot be thrown off because
the patients' interests are not sufficiently deep or sufficiently
varied to occupy their attention. The rational treatment of them,
then, must be founded on a careful study of individual cases, the
recognition of the special cause, and also the occasions at work in
each case, a neutralization of unfavorable suggestion and a provision
of such favorable suggestions and occupation of mind as will enable
the patient to rid himself of the annoyance occasioned by these and
the physical symptoms that so often develop as a consequence. In a
certain number of cases a history of corresponding or equivalent
affections in preceding generations will be found. In many patients,
however, there is no such history, though there is usually the story
of symptomatic mental conditions of one or other of the types
mentioned, earlier in life. When in good health physically the patient
has very little bother from them. When run down in weight or when
worried or anxious about business or from the stress of important
responsibilities these symptoms may become bothersome mentally and
physically. Often it will be impossible to obliterate them entirely,
but always they can be greatly improved and the patient can be made to
realize that they are not seriously significant, that in mild form
they are rather common and that, above all, they are not so peculiar
to the individual as he is likely to think, with consequent increase
of the unfavorable suggestion.

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