Psychasthenia

PSYCHASTHENIA, psychasthenia (from Greek psyche-soul and asthenia-weakness), a term introduced by Pierre Janet for a "distinct psychoneurosis" placed by him alongside hysteria. The symptoms of P. are divided into neuro-somatic (common with neurasthenia) and psychopathological, among which the central place is occupied by the characteristic experience of inadequacy, the general uncertainty of the patient about the correctness of his thoughts, feelings, and actions, due to which there is continuously maintained an obsessive need for constant checking and repetition of all mental acts and the smallest actions. The name P. is especially common in French and Russian psychiatric literature, while in Germany the term "obsessive states" (Zwangszustände) is used almost exclusively (see Obsessive States). Some authors use both terms as synonyms, which however is incorrect, since P. is a broader concept encompassing the entire psychic structure of the patient with its characteristic weakness of the psyche (hence the name P.), whereas obsessive states represent only a symptom, although extremely important, which however can develop on the basis of other heterogeneous nervous-psychic anomalies (psychoses and psychopathies). According to Janet's classic description, the disease in the intellectual sphere is expressed by "possession by tormenting doubts," in the emotional sphere by fears (phobias), and in the volitional sphere by indecisiveness. These disorders manifest in two forms: first, "restlessness of function," its exaggeration, and second, delay (insufficiency) of function. Both elements-exaggeration and insufficiency-are closely intertwined. The main feature of P. (in Janet's understanding) is the inability of the psychic apparatus to adapt to the immediate demands of the given life moment, "the inability to experience an exact feeling in accordance with the present situation," with concrete reality. On the "hierarchical ladder" (Janet) of nervous-psychic acts, the most difficult and complex is precisely this ability to coordinate around a given perception the entire sum of necessary attention and all the activity of the personality in the exact qualitative and quantitative relationship with the real demands. Janet calls this ability the "function of reality"; in his opinion it requires the greatest psychic tension. "Contrary to general opinion," says Janet, "acts that are attributed to ideas or images" stand on a much lower level" (i.e., reasoning, fantasizing, memories of the past and dreams of the future). All this in psychasthenics usually stands at a sufficient height and they often reason quite well (high intellect) and most readily indulge in memories, dreams, and theories, since this is easier for them in contrast to their inability to practically orient themselves even in the most elementary demands of daily life. The degree of psychic tension necessary for the unhindered implementation of the "function of reality" depends on some still unknown physiological processes (blood circulation and nutrition) in the brain (Janet). With fatigue, intoxications, febrile states, excitement in a completely normal person, psychic tension can lead to a sharp drop (psychlepsia), and then uncertainty, a feeling of incompleteness (sentiment d'incompletude), of unfinishedness appears. In psychasthenics, these states appear whenever they have to perform any function in a more complex environment (eating at a common table, playing an instrument in the presence of others, etc.). At such moments, psychic tension is directed along the lower paths of the "hierarchical ladder" of nervous-psychic functions, manifesting in the form of various muscle contractions, tics, vasomotor phenomena, visceral reactions, etc. After Janet, P. became the subject of a series of studies. The most complete exposition of the doctrine of P. is contained in Raymond and Dornbluth, and among Russian authors in V. P. Osipov's "Course of General Teaching about Mental Illnesses" and "Guide to Psychiatry." Most authors consider P. not as a separate neurosis of Janet, but as a psychopathological constitution or psychopathy, for which many different names have been proposed (Gartenberg-les timide, Ribot-les humbles, Sukhanov-anxious-doubting character, K. Schneider-self-doubting psychopaths, anankasts, etc.). The existence of such an innate disposition with the indicated features of extreme impressionability, fearfulness, self-doubt, general anxiety, lack of energy and decisiveness can be considered firmly established. In its origin, external psychotraumatic moments do not play a significant role-they only intensify and emphasize the constitutional traits, causing temporary exacerbations of psychasthenic symptoms. (On the significance of sexual factors and Freudian mechanisms-see Obsessive States.) The deep biological determination of such a personality disposition is confirmed by the frequently encountered somatic inferiority of these patients, expressed in asthenic or dysplastic body build, infantilism, morphological underdevelopment of individual organs. Motor inferiority, speech defects, etc., are often encountered. The question of the biological independence of the psychasthenic constitution is controversial. Some authors consider psychasthenic manifestations as if a variant of manic-depressive symptomatology, assessing outbreaks of obsessive states as equivalents of depressive or mixed cyclothymic phases (Heilbronner, Aschafienburg, Bonhoeffer, Stöcker, Kannabikh). Stöcker presents a series of genetic data from which it follows that obsessive phenomena (or P.) occur mainly in families with manic-depressive heredity. In contrast to this, Bleuler refers obsessive phenomena to the schizophrenic circle (hidden forms of schizophrenia). Given that psychasthenics undoubtedly occur in both cyclothymic (resp. cycloid) and schizothymic (resp. schizoid) families, and that the psychasthenic syndrome often first appears in a previously healthy person when he develops schizophrenia, Hoffman believes that the neurosis of obsession (or P.) is formed as a result of a mixture of two predispositions-cyclothymic and schizophrenic. Kraepelin admitted a completely special constitution in which features of psychic infantilism and primitiveness of the psyche predominate, in favor of which the frequent appearance of psychasthenic symptoms in so-called normal children speaks. K. Schneider refers psychasthenics to the group of "self-doubting psychopaths" (Selbst-unsichere Psychopathen), to which also belong Kretschmer's "sensitive" temperaments, although related to schizoids, but deserving to be singled out into a separate group. Pilcz, Meggendorfer (Meggendorfer, Pilcz) and others describe a special psychasthenic structure of the psyche, transmitted by inheritance in several generations. This gives some authors (Yudin) grounds to insist on a special psychasthenic constitution. The school of I. P. Pavlov makes an attempt at a physiological explanation of psychasthenic mechanisms: the brain of these patients is in a state of parabiosis, when weak irritations ("unreal things"-reasoning, memories, reveries) cause sufficient excitation, while strong irritations ("real"-immediate demands of the moment) cause inhibition. The research of Ivanov-Smolensky indicates general asthenia of higher cortical functions: slowing of the time of simple reaction, decrease in trainability, exhaustibility of concentration, rapid increase in fatigue. It is very probable that some organic (in the broad sense) defects in brain development underlie P. In favor of this speaks the appearance of psychasthenic symptoms after epidemic encephalitis (D. S. Ozereckovsky and M. A. Dzagharov, Mayer-Gross u. Steiner). In such cases, obsessive phenomena appear in patients who did not previously show any signs of psychasthenic constitution. Thus encephalitis recreated the necessary (apparently subcortical) mechanisms for this. Therefore, it can be assumed that in congenital P. there are abnormalities in the structure of the subcortical ganglia with the simultaneous completeness of the cerebral cortex (which is indicated by the often encountered intellectual giftedness of such persons).-As a constitutional peculiarity P. extends throughout the life of the patient, and about the course of P. one can speak only conditionally, having in mind mainly the intensifications and alleviations of the psychic peculiarities of the subject, depending on both endogenous and exogenous (psychogenic) factors.-The prognosis quo ad valetudinem is generally unfavorable. However, the matter never reaches imbecility (in the direct sense), although with the passage of time some narrowing of the personality may form, easily explainable by the fact that huge masses of psychic work are spent on the struggle with obsessive phenomena.-Recognition is based on the careful exclusion of those pathological states which can cause the psychasthenic syndrome (epidemic encephalitis, manic-depressive psychosis, schizophrenia). For constitutional P. speaks the appearance of symptoms already from childhood and youth, their presence in other family members, further-the accessibility of the patient, the preservation of the personality and the critical attitude toward the illness.

However, when P. appears during the pubertal period, it is always necessary to keep in mind the possibility of the so-called 'preschizophrenic' P. Treatment consists of invigorating work, therapy, and psychotherapy, as well as a set of physical measures aimed at strengthening the entire body and developing motor skills. Prevention has particularly great importance in child psychoneurology (fighting against indecisiveness, shyness, timidity, and feelings of inadequacy). Psychasthenic seizures, which have nothing in common with P., are classified by Oppenheim as epilepsy.