The Neurasthenia-Depression Controversy

A Window on Chinese Culture and Psychiatric Nosology

Donald McLawhorn

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000372038
• Edition: 1
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

This book is about the largest debate that has occurred in the field of cultural psychiatry and its impact on diagnosing, theorizing, and clinical practice. It is also about the role of culture in psychopathology specifically in relation to China. This book is the first comprehensive and critical assessment of the anthropological psychiatry that has provided Western physicians with their ideas about somatization and culture. It is argued that psychiatric nosology and the broader cultural milieu interact in a fascinating way and co-facilitate individual conformity to culturally salient categories, consciously or unconsciously, through a process of belief, expectation, and learning. The result is that codified experiences can be translated from the mind to the body and back again. Through a critical evaluation of the Neurasthenia-Depression controversy, we can gain a view of the contested and shifting nature of psychiatric nosology, and thereby attempt to introduce the beginnings of a model that elucidates how psychiatric distress varies across cultures.

This timely book challenges conventional wisdom about neurasthenia and depression in Chinese societies. Its findings will be of value to anyone who works with Chinese people with these mental illnesses across the global diaspora.

1Introduction

Our golden arches do not represent our most troubling impact on other cultures; rather, it is how we are flattening the landscape of the human psyche itself. We are engaged in the grand project of Americanizing the world’s understanding of the human mind.¹

In 1980, the American Psychiatric Association (APA) published the third edition of its clinical manual, the Diagnostic and Statistical Manual of Mental Disorders (DSM-III).² One of the many changes that made up the new version of the manual was the removal of the clinical category neurasthenia (nerve debility/nervous exhaustion), which had been a globally recognized disease category for over one hundred years. Both China and Japan had traditionally employed the category in their respective neuropsychiatric nosologies, but after 1980, Japan followed the United States and also abandoned shinkei suijyaku (神経衰弱) for lacking validity as a disease concept.³ While, in both the USA and Japan, the category has been subsumed under other clinical “entities,” the Chinese-language equivalent, shenjing shuairuo (神経衰弱/神经衰弱: hereafter abbreviated SJSR) is still a debated category that can be found on China’s public health websites, in its professional neurology and psychiatric literature, and in its diagnostic manual, CCMD-3 (Chinese Classification of Mental Disorders Version 3).⁴ Physicians in China (and the Indian subcontinent) have continued to make use of the category, though drastically less so, and it has wide popularity as a health concern among laypeople within mainland China, Taiwan, Hong Kong, and other parts of the Sino-sphere. Because of its clinical utility outside the USA, neurasthenia had also been retained in the World Health Organization’s publications of the International Classification of Diseases (ICD) in the decades after 1980. It was only recently removed from the most current edition, ICD-11, which was presented to the World Health Assembly on May 25, 2019.⁵ Until 2019, the ICD-10 was the lone internationally recognized diagnostic reference that served to illustrate that the retention of neurasthenia in the Chinese manual was not a cultural idiosyncrasy.

In only the previous decade, a 2002 consensus statement on neurasthenia by the World Psychiatric Association stated:

Contrary to some current beliefs and recent reports, Neurasthenia syndrome is a common problem occurring in all parts of the world. The syndrome has significant negative consequences for individuals and to society and is therefore a public health problem of major importance requiring improved recognition, understanding, research and education.⁶

Nevertheless, those engaged in the inner workings of global psychiatric nosology dealt another blow to neurasthenia by removing it from ICD-11. Neurasthenia has gone from being among the most broadly employed diagnostic categories across Asia to being sequentially removed from diagnostic manuals. How can we understand this?

This can partly be attributed to the global influence of the DSM, which moved beyond its previous abandonment of neurasthenia, reintroducing it as a cultural syndrome in 1994. A cultural index only appeared in the DSM in the 1990s, after nearly three decades of collaboration between anthropologists, psychiatrists, and other mental health researchers. In 1994, the APA published DSM-IV, which included a section titled “Outline for Cultural Formulation and Glossary of Culture-Bound Syndromes” (p. 843). Listed among these “culture-bound syndromes” is the following:

Shenjing shuairuo (neurasthenia): In China, a condition characterized by physical and mental fatigue, dizziness, headaches, other pains, concentration difficulties, sleep disturbance, and memory loss. Other symptoms include gastrointestinal problems, sexual dysfunction, irritability, excitability, and various signs suggesting disturbances of the autonomic nervous system. In many cases, the symptoms would meet the criteria for a DSM-IV mood or anxiety disorder. This diagnosis is included in the Chinese classification of mental disorders, second edition (CCMD-2).⁷

By situating it as a “locality-specific pattern of aberrant behavior and troubling experience,”⁸ the APA defines neurasthenia as a culture-bound syndrome that belongs to the Chinese experience, which continues with both the DSM-IV Text Revision and the 2013 publication of DSM-5. This has raised questions about whether the “real” underlying problem that patients experience is better described as a form of mood disorder, anxiety disorder, somatization (躯体化), or if there are instances of SJSR that simply cannot be explained by any other category of experience. Whatever the case, the last two versions of the DSM have relegated the category to the periphery as a “local” issue. Nevertheless, SJSR has historically been very “real” to Chinese people and has entered into the lexicon of all native Chinese speakers. References to the illness in literature and magazines, webpages, and online shopping websites are numerous, and a simple web-search of the Chinese term yields a seemingly infinite array of information from countless perspectives.

Professionally, in the decades approaching the turn of the twenty-first century, SJSR is claimed to account for up to half of all psychiatric diagnoses in China, and some Chinese neurologists and psychiatrists continue to insist that it is not merely a disorder of somatization, but a valid clinical category that may or may not have a clear correlate in mainstream Euro-American experience. It can be given as an account for undesirable behaviors, failure at work or school, difficulties in the home, and other functional impairments of daily life. Self-help instruction continues to be published on the topic as it has since the final decade of the nineteenth century; in fact, such material is more plenteous today. Medicines of all kinds are still on offer for those who might have developed the disorder. Furthermore, Chinese researchers continue to publish scientific papers based on neuroimaging, nerve conduction, and other methodologies in order to argue for the validity of this clinical category or for the purpose of finding effective treatment. A search for the term 神經衰弱 in the Chinese academic database, CNKI, from 1990 to the present, yields over 6,000 articles across a variety of journals, ranging from Western biomedicine to traditional Chinese medicine approaches.⁹ In 2017 alone, there were over 1,500 such articles. For example, in March of 2017 The Journal of Clinical Medical Literature published an article titled “Study on the changes of serum cortisol and high sensitivity C-reactive protein in elderly patients with neurasthenia.”¹⁰ In July of 2017, Cardiovascular Disease Journal of Integrated Traditional Chinese and Western Medicine published a rather different approach in the article “Anshen-bunao ye combined with oryzanol for the treatment of neurasthenia patients.”¹¹ These two recent articles serve to show the disparate approaches to SJSR today. Serum cortisol and C-reactive protein are two very common clinical variables that a contemporary psychiatrist might find valuable when assessing a patient in an American hospital. Anshen-bunao ye,¹² on the other hand, is a tonic remedy in China that contains deer antler, licorice root, ginger, and other ingredients. It can be readily bought in China or online, and it is packaged professionally, which is demonstrated wherever it is available online. It is taken orally, as is oryzanol, which can be derived from rice oil and other plant sterols.¹³

Modern approaches of clinical chemistry are being employed alongside other eclectic methodologies in attempts further to delineate the meaning and management of SJSR as a clinical category. The subject of SJSR continues to be vast and carries implications for psychiatry in a global arena as well as for China’s continued engagement with the world in fields like medicine.

I have been thinking and reading about SJSR and neurasthenia for only fifteen years, which began when I was first living in Taiwan in the early 2000s.¹⁴ Since that time, I have realized that one can spend an entire lifetime examining the topic as it pertains even to just one location during a single year in history. It may be for that reason that I have begun to abstract how I think about the category by alternately expanding and contracting the focus of my inquiry. As a physician and Asian studies researcher, I have a particular interest in cultural psychiatry, and so, I approach SJSR from a multidisciplinary perspective that includes anthropology, psychiatry, history, sociology, and philosophy, as indicated in the next sections. I am reminded of a 2011 book edited by Arthur Kleinman et al. titled, Deep China: The Moral Life of the Person: What Anthropology and Psychiatry Tell Us about China Today.¹⁵ My own book might well be titled, What China and SJSR Can Tell Us about Anthropology and Psychiatry Today. An examination of SJSR raises serious questions about the impact of Western psychiatry on the rest of the world, which has been a matter of concern for critical literature since Foucault. Additionally, SJSR can push us to reconsider the ontology of mental illnesses as well as the mind–body problem in both philosophy and neuroscience.¹⁶ I will return to these issues throughout this book. Presently, by way of further introduction, let me attempt to frame the questions I hope to address over the course of this book.

Questions and their contexts

Not only is the Chinese-language literature since the 1990s plenteous, English-language writing about SJSR could now amass copious volumes. These range from poorly written and unrigorous regurgitations of other authors’ claims, to well-thought-out and diligent efforts. One example of the more rigorous attempts to understand the category is a paper of Hugh Shapiro’s for the “Symposium on the History of Disease” at the Academia Sinica. In “Neurasthenia and the Assimilation of Nerves into China,” Shapiro rightly claims that “psychiatry and medical anthropology have produced the most serious analyses of Shenjing Shuairuo.”¹⁷ From among those literatures, Shapiro organizes seven categories of explanation raised to account for the very “ordinariness”¹⁸ and taken-for-granted nature of SJSR as a once-imported category in China. His “dominant explanations” are listed here with the addition of my own brief explanations of each category:¹⁹

1.Somatization: “the expression of personal and social distress in an idiom of bodily complaints and medical help seeking.”²⁰ This view has dominated cultural psychiatry and will be the subject of much of the latter half of this book.

2.Euphemistic function: Diagnoses such as schizophrenia can be burdensome and stigmatizing, whereas SJSR is less stigmatizing and less socially threatening. This view is intimately related to somatization and will reappear frequently.

3.Desirable sick role: SJSR is conceptually related to overwork, which frames the diagnosis in a possibly favorable light and entitles the sufferer to certain privileges.

4.Physician–patient rapport: SJSR is a familiar and non-threatening concept. Other diagnostic labels might lead to patient non-cooperation or loss to follow-up.

5.Self-help: Patients are more likely to seek treatment when the illness considered is neurasthenia, as opposed to some other more stigmatizing category.

6.Status: The SJSR label has been fashionable in certain times and places.

7.Nosological soundness: SJSR describes a form of experience not captured with other categories. This is the most controversial of views regarding SJSR, and it has at times constituted a position of re...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of Figures
• List of Tables
• 1 Introduction
• 2 Western origins of neurasthenia
• 3 Weak nerves in China
• 4 Western psychiatry engages shenjing shuairuo
• 5 Shenjing shuairuo survives into the twenty-first century
• 6 Ongoing struggles with nosology
• 7 Conclusion
• Index