The term neurasthenia has had a variegated history, and although retained as a diagnostic entity in the ICD-10 it does not appear in the DSM-IV. In cultures where neurasthenia still enjoys popular professional and lay acceptance it has a variety of usages:

Therefore, in diagnosing, understanding, and managing neurasthenia the clinician has to be aware of the context in which the term is used.

The concepts of nervous weakness and asthenia (debility, lack of strength) have existed throughout the history of medicine. Hippocrates described the illness of the Scythians as a general asthenia linked to damage to the genitalia caused by horseback riding. In France, Bouchut (1764) described a syndrome similar to the latter-day neurasthenia, which he called ‘neuropathie’. Cullen (1772) conceived muscles and nerves as a unitary nervous force and all diseases as movements against the nature of that nervous force. He coined the word neuroses for this process and postulated that diseases were due to the various alternations of excitement and atony in the nervous system. A few years later, his pupil Brown (1780) elaborated on the hypothesis by dividing diseases into sthenic diseases, which were due to excessive excitement, and asthenic diseases, which were due to deficient excitement. These views on the polarity of the nervous system as a cause of mental illness set the scene for neurasthenia to become a disease entity.

By the beginning of nineteenth century the term neurasthenia was already in use. In 1869, Van Deusen in Holland published a monograph on neurasthenia. This was quickly followed by the publication of a paper, which Beard⁽¹⁾ had presented to the New York Medical Journal Association. Beard based his description of the disorder on a series of 30 cases. In reorganizing the subjective nature of the complaints and the unique clustering of symptoms in each patient, Beard had difficulties in attempting to limit the number of symptoms that constituted the syndrome; he started with 50 symptoms and expanded it to 75 in later publications.

Eventually it became clear that the expanding kaleidoscope of symptoms should be managed in a way that made some sense. Beard approached this problem by organizing the symptoms into subtypes of neurasthenia: cerebrasthenia (cerebral exhaustion) characterized by symptoms that were directly or indirectly connected with the head; myelasthenia (spinal exhaustion) was defined by symptoms related to the involvement of the spinal cord; digestive asthenia was characterized by dyspepsia, constipation, and flatulence. As time went on more subtypes were added by other investigators and specific treatment approaches were developed.

Despite the over inclusiveness of the term, Beard maintained that neurasthenia belonged to one family with a common pathology, prognosis, history, and treatment. As more cases were reported, he felt able to claim that neurasthenia was predominantly an American illness.⁽²⁾ He attributed the increase in prevalence to the pressures of modern civilization.

Notwithstanding its vagueness, or perhaps because of its vagueness, neurasthenia gained popular acceptance not only by the medical profession but also by the general public. Although by the turn of the century it had become practically a household word, its popularity did not preclude dissent. Most of the criticisms focused on the disorder’s over inclusiveness and lack of precision; for instance, Brill called it ‘the newest garbage can’ in medicine.

The first two decades of the twentieth century witnessed an increasing number of discoveries of more specific causes of disease. This period also saw greater attention being paid to the taxonomy of neuroses. These forces combined to bring about the decline of neurasthenia as a diagnostic entity.

In 1895, Freud published two seminal papers in which he drew up the blueprint for reconfiguring the various neurotic disturbances that were grouped together under the term neurasthenia. In the paper entitled ‘On the grounds for detaching a particular syndrome from neurasthenia under the description of ‘anxiety neurosis’⁽³⁾ he questioned the validity of continuing to allow neurasthenia to cover all the symptoms described by Beard. He saw the need to classify different categories of neuroses based on the following:

In the paper ‘Obsessions and phobias: their psychical mechanism and their aetiology’,⁽⁴⁾ Freud removed obsessions and phobias from neurasthenia. As a result of these two papers, neurasthenia ceased to be an amorphous concept and was differentiated into the following categories:

Intermittent and periodic types of neurasthenia were to be included under melancholia.

The first list of symptoms Freud proposed for neurasthenia proper included headache, spinal irritation, dyspepsia with flatulence, and constipation. Later, he added sexual weakness and fatigue.

The possibility of including some neurasthenic symptoms under melancholia was mentioned but not expanded on by Freud. This task was taken up by Kraepelin.⁽⁵⁾ He distinguished three major types of depression: manic-depressive disorder, involutional melancholia, and a milder form of neurasthenic depression. He asserted that all these types of depression were due to an underlying disordered brain function.

Having been so denuded, the use of the term neurasthenia as a diagnostic entity by the medical professions had declined in the United States by the time of the First World War. The first edition of the DSM-I published in 1952 gave no formal recognition to neurasthenia. Instead, it was replaced by the category of ‘Psychophysiological nervous system reaction’, the predominant symptom of which was general fatigue. In an effort to make DSMII congruent with ICD-8, neurasthenia reappeared in American psychiatry as neurasthenic neurosis.

In DSM-III neurasthenia disappeared as an entity and appeared only in the index where readers were asked to refer to ‘Dysthymic disorder’. However, unlike the DSM classification, neurasthenia consistently remained a subtype of neurosis throughout the many versions of the ICD. ICD-9 defined neurasthenia as follows.

The following categories were included:

One of the most fascinating aspects of the history of neurasthenia is its ready acceptance by countries other than the United States where it was originally conceived as a peculiarly American phenomenon. The diagnostic entity took firmer root in some countries than in others. In many countries the concept was indigenized and took on local cultural colour.

The reasons for its spread can be summarized as follows: