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

them.





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

miserable.



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.