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SOMATIC PRESENTATIONS: CULTURE |
From the Department of Psychiatry (S.L.), The Chinese University of Hong Kong, Shatin, HKSAR; and the Department of Anthropology (A.K.), Harvard University, MA, USA.
Address correspondence to Sing Lee, Professor, Department of Psychiatry, The Chinese University of Hong Kong, Shatin, HKSAR. E-mail: singlee{at}cuhk.edu.hk
ABSTRACT
Objective: To examine how sociocultural factors shape the professional classification and transformation of neurasthenia (shenjing shuairuo in the Chinese language) in China.
Methods: We review the relevant literature as well as cite our own research experience on the topic.
Results: We identify three main periods of transformation, namely, the prereform period (before 1980) in which neurasthenia encompassed a wide range of anxiety and mood disorders; the reform period (1980s–1995) when the Diagnostic and Statistical Manual of Mental Disorders—III (DSM-III) and Kleinman’s study in Hunan steadily shaped the Chinese conceptualization of nonpsychotic mental disorders; and the postreform period (after 1995) when neurasthenia has become a rarely used category of subsyndromal depression among Chinese psychiatrists.
Conclusions: The dramatic transformation of neurasthenia in China speaks to the global power of the DSM system of classification, on the one hand, and the latter’s failure to engage cultures in the local system of psychiatric practice, on the other. The Chinese story of neurasthenia and the social context in which the disease category is contested, marginalized, and reconstituted as the popular Western disease of depression among Chinese psychiatrists attest to the socially constructed nature of psychiatric classification. The public health implications of this transformation remain unclear.
Key Words: neurasthenia • somatoform disorder • transformation • China
Abbreviations: DSM = Diagnostic and Statistical Manual of Mental Disorders; CCMD = Chinese Classification of Mental Disorders; ICD-10 = International Classification of Diseases—10th Revision.
INTRODUCTION
"Categories are the outcomes of historical development, cultural influence, and political negotiation. Psychiatric categories—though mental illness will not allow us to make of it whatever we like—are no exception."Arthur Kleinman, Rethinking Psychiatry (1988, p.12)
Although it is not widely recognized, the professional classification of mental illness is subject to no less sociocultural influence than the symptoms or experience of the illness itself (1–3). This is partly because mental disorders are complex in etiology and dimensional in nature (e.g., normal sadness versus depression, and existential angst versus generalized anxiety disorder). The lack of biological markers that precludes an etiological diagnosis is another recognized reason. These facts about diagnostic categories in psychiatry produce tensions with practical needs in clinical practice and professional training that focus on "making the correct diagnosis."
Nonetheless, it is sobering to remember that physical diseases that are complex in manifestations and etiology (e.g., autoimmune diseases) or dimensional in nature (e.g., hypertension) do not run into the same amount of nosological and diagnostic controversies as mental disorders do. Like mental disorders, many well-recognized physical diseases do not have clear-cut biological markers (e.g., epilepsy, trigeminal neuralgia, and irritable bowel syndrome). This suggests that the classification and definition of mental disorders may be especially susceptible to nonscientific influences and may serve diverse purposes for different parties. Yet, we should not forget that scientific categories (and with them measurement devices and the findings they produce) also change and can be influenced by economics, politics, and culture (4). From this perspective, the professional transformation of neurasthenia in China illustrates such a connection between psychiatric diagnosis and social change (1).
Origin of Somatoform Disorder in the DSM-III
Despite the frequent reference to "somatization" among Chinese people in the Western psychiatric literature, traditional Chinese medicine does not contain an equivalent conceptual category to describe the loosely understood phenomenon in which patients preferentially present their distress as somatic rather than psychic symptoms (5). Specifically, the ontological view of disease that certain symptoms are more real than others, or "core" rather than "peripheral" (as is used in the Diagnostic and Statistical Manual of Mental Disorders (DSM) configuration of symptom hierarchy, viz., operationally defining one to two mandatory symptoms as pathognomonic and treating the other symptoms as less specific and optional), is nonexistent in traditional Chinese medicine. Because traditional Chinese medicine was the source of knowledge about health and medicine for Chinese people over the millennia, its nondualistic approach to symptoms was also the way that Chinese culture has addressed this issue. As a result, the conventional Western cultural approach embodied in the DSM was foreign to Chinese society (as it was to pre-DSM-III Western psychiatric nosology, such as the DSM-II). It was also alien to the clinical cognitive schema of Chinese psychiatrists. Instead, the latter treated varying clusters of somatic and psychic symptoms as occurring simultaneously in the conceptualization of diseases including neurasthenia (shenjing shuairuo, a culture-syntonic term that means "weakness of nerves") (Figure 1).
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Somatoform disorder, which was first created in the DSM-III, marginalized somatic distress and gave primacy to psychological symptoms in the configuration of mood and anxiety disorders. There it was a residual category that should only be diagnosed when all shades of other Axis-I disorders (usually with core psychic symptoms) were excluded. Unlike the Chinese conceptualization of neurasthenia, somatoform disorder should have a dominant somatic symptom. Even if mood and other nonsomatic symptoms are present, they should not be severe enough to reach the diagnostic threshold of the anxiety and depressive disorders (Figure 2). Thus defined, the category of somatoform disorder was new to the Chinese epistemological theory of disease (5).
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Origin of Neurasthenia in China
The term "neurasthenia" was revived by the New York neurologist, George Beard, in 1869 to denote a variable syndrome of lassitude, poor concentration, headache, sleep disturbance, and >50 other symptoms. The term steadily acquired popularity with both physicians and the general public in North America up to the early years of the 20th century. The term was probably introduced to China from Japan in the early 1900s, and is rendered semantically into the Chinese language as shen jing shuai ruo. In Japan, the term "neurasthenia" is translated as shinkeisuijaku and gained currency after the Meiji period (1868–1912). Although this is pronounced differently from shenjingshuairuo, the two terms are ideographically identical. In all likelihood, the written Chinese term was adopted from Japanese sources (1).
Shen may be translated as spirit and is emblematic of vitality, the capacity of the mind to form ideas, and the desire of the person to live life. Jing originally refers to the meridians or channels which carry qi ("vital energy") and xue ("blood") through the body. Conceptually, shenjing is treated by both Chinese physicians and lay people as one term that may mean nerve, neurological, or nervous. Shenjing can decline (shuai) and weaken (ruo) after nervous excitement, resulting in various symptom complexes.
This connotation of nervous weakness in shenjingshuairuo resonates with a number of ancient conceptual categories that signify weakness (xu) or the deficiency of a vital essentialism in traditional Chinese medicine, such as the depletion of qi which follows overstraining, or the stagnation of qi when one overly worries. The term is readily distinguishable from the folk expression of jingshen bing, which refers to insanity and promises severe social stigma. Subjects with shenjingshuairuo are, ipso facto, not deranged in mind and not dangerous to others (4).
As a euphemistic term, shenjingshuairuo is easily graspable by Chinese people, including doctors, to connote "excessive stress in a susceptible person" and/or "nervous disposition," in addition to "neurological weakness." The fact that it is also nonstigmatizing allows it to infiltrate social relations and to encourage private distress to be elaborated into a public form. Regarding its professional definition, shenjingshuairuo included a variety of symptoms much like those described by Beard (2).
Three Periods of Transformation
Under the joint influence of the DSM-III and other sociocultural forces, the Chinese concept of neurasthenia has transformed in remarkable ways that have brought it into conformity with DSM-III-based epistemology. The process of transformation can be divided into three main periods during which the disease acquired a different identity.
1. Prereform Period (Before 1980)—"Neurasthenia As It Is"
In a review of psychiatric epidemiological surveys in the early 1980s, Cheung (6) found that neurasthenia was by far the most common neurotic disorder in China. In the clinical setting, as many as 80% to 90% of Chinese psychiatric outpatients received the diagnosis of neurasthenia from the 1950s to 1980 (7)—indicating that the disease was a broad category for nearly all nonpsychotic disorders and resembled the old Western concept of neurosis or "general neurotic syndrome" (8). Clinically, psychiatrists made no attempt to differentiate the condition into specific types of anxiety and depressive disorders as we understand them today. In contemporary nosological terms, neurasthenia therefore encompassed most, if not all, of the (syndromal and subsyndromal) depressive and anxiety disorders. This was possible because its definition at the time was not based on any symptom hierarchy. Its symptom configuration attached equal diagnostic weight to the constituent symptoms that could be somatic, cognitive, or emotional in nature (Figure 1). As such, it was not the same thing as the DSM-III somatoform disorder (Figure 2). When applied to the Chinese context, the DSM-III criteria may constitute a category fallacy, which is the imposition of a conceptual category from one culture to another without proper regard for its contextual validity in the latter (4). Nonetheless, neurasthenia is frequently equated to a somatoform disorder and at times chronic fatigue syndrome in the Western psychiatric literature (3,9).
The end of the above period witnessed the development of the DSM-III and Chinese psychiatrists’ increased opportunity for international engagement.
2. Reform Period (1980s–1995)—Impact of the DSM-III and Kleinman’s Study
During the earlier part of this period, neurasthenia was still defined as a variable somato-affective syndrome (10). At least two events alerted and later obliged Chinese psychiatrists to reconsider how they should reconceptualize the disease. First, the rejection of neurasthenia by the DSM-III and DSM-III-R (where the term was cursorily mentioned as a somatoform disorder in an appendix of the respective manual) and the DSM hierarchical approach to configuring symptoms for diagnosis rendered neurasthenia an unreal disease. Second, the concern over the nosological legitimacy of neurasthenia was fueled by the publication of Kleinman’s widely cited study in Hunan (7), which indicated that 87% of Chinese patients with the illness could be rediagnosed as having DSM-III depression and responded favorably to tricyclic pharmacotherapy. Inasmuch as neurasthenia was the most common psychiatric diagnosis made by Chinese psychiatrists at the time of the study, this high rate of rediagnosis suggested that they had flagrantly missed patients with "major" depression. This was a grave matter because depression, unlike neurasthenia, was proven to respond favorably to tricyclic antidepressant therapy (1).
Although few Chinese psychiatrists read Kleinman’s scholarly work in its entirety, the study created several years of heated debate and at times mistrust among Chinese psychiatrists. Nonetheless, a subsequent series of Chinese studies "confirmed" that a substantial proportion (30% to 70%) of patients with neurasthenia did suffer from depression (11). This failure of neurasthenia to fulfill contemporary tests of reliability and validity set the stage for the next period of transformation when Chinese psychiatrists began to rediagnose patients with familiar neurasthenic symptoms as having depression. Under the additive impact of pharmaceutical marketing, neurasthenia was marginalized as a crude or even "wrong" clinical diagnosis (1).
3. Postreform Period (After 1995)—The Burial of Neurasthenia
During this period of rapid social change in China, there has been an active exchange of Chinese psychiatrists with Western psychiatry on multiple fronts as well as a powerful influence of the pharmaceutical industry. The latter has marketed depression as a common mental disorder and repackaged neurasthenia as a pharmaco-responsive form of depression (1). The result is a rapid assimilation of the latest DSM system. A deep transformation in clinical diagnostic style followed.
There has been a national system of psychiatric classification known as the Chinese Classification of Mental Disorders (CCMD) in China. The first edition dated back to 1981, whereas the second (CCMD-2), second-revised (CCMD-2R), and third (CCMD-3) editions were published in 1989, 1995, and 2001, respectively (12). Notably, the CCMD-2 includes a cautionary statement that neurasthenia "has aroused international disputes, and there was a previous tendency for overdiagnosis to occur in China. Therefore, other forms of neurotic and psychophysiological disorders should be prudently excluded before the diagnosis is made" (13). CCMD-3 is the longest of all editions and the first to have used a symptom hierarchy, like that of the DSM, in establishing psychiatric diagnosis.
Although Chinese psychiatrists are unfamiliar with the concept of somatoform disorder, pressure to unify the CCMD with globally accepted systems such as the DSM-IV and International Classification of Diseases—10th Revision (ICD-10) has resulted, for the first time in China, in the inclusion of the category of somatoform disorder in CCMD-3 (1). At the same time, the application of hierarchical rules requires that neurasthenia can only be diagnosed after all anxiety and depressive disorders are excluded. Neurasthenia received a code of 43.5 in the CCMD-3 and even ranks after the various somatoform disorders and somatization disorder (43.4x) in the new Chinese diagnostic hierarchy. An anticipated consequence is that neurasthenia is rarely diagnosed (or diagnosable) by Chinese psychiatrists nowadays, at least in urban China where professional awareness of international practice is greater and the CCMD-3 is followed more rigorously. Those who do diagnose neurasthenia may be considered outdated if not deficient in clinical skills. It should be noted, however, that the pace of change in diagnostic practice is uneven in China. The diagnostic category of neurasthenia is still widely used by general physicians and psychiatric practitioners outside of urban areas. It is also widely understood in both urban and rural China, although the term for depression is gaining usage among better educated, middle-class Chinese and younger people generally. Some are now suggesting that stigma associated with depression may be lessening among this growing group, leading to greater willingness to reveal dysphoria and thus more accurate estimates of the prevalence of depression among younger cohorts of people in urban China (14).
Has the DSMization of Neurasthenia Made a Difference to Treatment?
As Chinese psychiatrists abandon the diagnosis of neurasthenia, the clinical diagnosis of depression has increased. However, whether this merging of diagnostic practice with international practice leads to better access to treatment or better treatment outcome is another matter.
A recent community epidemiological survey conducted in Beijing and Shanghai indicated that 96.6% of Chinese people with any 12-month DSM-IV disorder and 80.2% of those with moderate and severe disorders in Beijing and Shanghai received no treatment in the previous 1 year (15). This enormous treatment gap exists despite the fact that these two major cities in China already have a higher than average concentration of health care resources, including better trained psychiatrists. Moreover, of those individuals who sought help, they did so primarily from nonpsychiatrists who pay little attention to complex diagnostic systems, such as the DSM-IV or CCMD-3. Because of the greatly limited access to health care, it can be argued that the reconceptualization of neurasthenia in China has resulted in limited impact on the rate of treatment of depression among Chinese people.
Regarding psychiatric practice, a critical question that matters to patients’ welfare is whether the demonstrable change in diagnostic practice has led to better outcome of psychiatric treatment. This is hard to answer because modern psychopharmacological agents, such as the selective serotonin reuptake inhibitors (widely adopted by psychiatrists in urban China, provided patients are covered by insurance or can pay for the medications) have been effectively used across the entire spectrum of anxiety, depressive and impulse control disorders. Moreover, because of the demise of professional interest in neurasthenia, no systematic research has been done to examine the efficacy of these medications in neurasthenia. A diagnosis of neurasthenia (especially in a general medical setting), nonetheless, confers far less stigma than one of depression.
Implications for DSM-V as a Global Diagnostic System
From a cross-cultural perspective, it could be considered that the category of somatoform disorders was created to accommodate the somatic presentations of mental disorders in non-Western communities where depression was reportedly rare. Ironically, the diagnosis remains rarely used in the clinical practice of non-Western psychiatrists, who have increasingly used depression as a clinical label. To Chinese general physicians who see patients with somatoform disorders (e.g., chronic pain), somatoform disorder remains a bewildering term compared with familiar categories, such as irritable bowel syndrome, tension headache, fibromyalgia, and the like. It is thus paradoxical that a disease category that marginalizes somatic distress in the DSM-III system and is believed to be common in non-Western communities has been marginalized by non-Western psychiatrists themselves. Additionally, such marginalization is shared by psychiatrists in the West. For example, recent community psychiatric epidemiological surveys using the Composite International Diagnostic Interview in many countries, including the US and China, do not include somatoform disorders (15,16).
The story of neurasthenia in China and the social context in which neurasthenia is contested, marginalized, and reconstituted as the popular Western disease of depression among Chinese psychiatrists is at once unique and shared. It may, to some extent, guide our attempt to understand the social (disappearing) course of culture-bound syndromes in diverse communities (e.g., dhat syndrome in India, Hwabyung in Korea, and Taijin-kyofusho in Japan) where psychiatry is also undergoing transformation under global forces, such as the DSM system, and pharmaceutical marketing is making the previously Western culture-bound syndrome of "depression" a master narrative among clinicians (17). At this stage, the usefulness of the diagnosis of somatoform disorder remains to be evaluated from public health, clinical, and biological perspectives. Apart from the need to solve certain conceptual problems of the category (e.g., the validity of completely dichotomizing bodily and psychic symptoms associated with human suffering in addition to the stated feature of a refusal to acknowledge psychological causes among affected people), we believe that socioeconomic forces (definitely) and empirical evidence (hopefully) will mold its future course.
NOTES
Received for publication January 31, 2007; revision received April 12, 2007.
This article is being co-published by Psychosomatic Medicine and the American Psychiatric Association.
DOI:10.1097/PSY.0b013e31815b0092
REFERENCES
This article has been cited by other articles:
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  J. E. Dimsdale, V. Patel, Y. Xin, and A. Kleinman Somatic Presentations A Challenge for DSM-V Psychosom Med, November 1, 2007; 69(9): 829 - 829. [Full Text] [PDF]
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