TSUNG-YI LIN

NEURASTHENIA REVISITED:
ITS PLACE IN MODERN PSYCHIATRY

INTRODUCTION

Diseases, or at least mankind's perception and conception of diseases, have a

life cycle of their own. Having an existence grounded partly in biological or
behavioral reality, they are equally products of mankind's thoughts and feelings.
Thus, just as any other fundamental human idea, they may spread, grow,
transmute, take hold and prosper, or decline and fade away.
A case in point is neurasthenia, the subject of the special collection of articles
in this volume. How has this diagnostic term, and all it connotes, taken root in
most of East Asia while in the United States, the country of its origin, it has
fallen into disuse, perhaps even disparagement, all within a span of roughly one
hundred years? No answer is, of course, possible without reference to time and
place, to history and to culture. How do these factors influence the acceptance
and transformation of a disease entity such as neurasthenia?
It was George M. Beard who, in 1869, defined and then popularized the term
neurasthenia as '% chronic, functional disease of the nervous system," with the
characteristic symptoms of profound physical and mental exhaustion, combined
with a host of other signs of functional nervous dysfunctions such as headaches,
insomnia, vague pains, dyspepsia, palpitations, and flushing (Beard 1881). He
interpreted these diverse symptoms as the common consequence of an excessive
expenditure of nervous energy and called the condition "Nervousness." In
essence, neurasthenia was conceived by Beard as resulting from a draining of
the nervous energy in the face of excessive demands made upon the nervous
system.
Beard claimed that this nervousness was a peculiarly American phenomenon
since, in the most rapidly advancing modern society, too many psychological
demands were placed on the population. In his view, neurasthenia is an illness
arising out of the sociopsychological stresses which accompany a modern world
uprooted from its past, adrift from traditional values, galloping forward on the
twin steeds of commerciali~a and materialism.
It is the purpose of this paper, an introduction to the specialized articles which
follow, to trace the process of neurasthenia's transplantation and transformation
in four East Asian cultures: China, Japan, Taiwan and Houg Kong. My profes-
sional experience over the past more than forty years has taken me many times
across the boundaries of each of these cultures, as wen as those of North
America and Europe. In each culture, at various times, I have encountered a

Culture, Medicine and Psychiatry 13: 105-129, 1989.

9 1989 Kluwer Academic Publishers. Printed in the Netherlands.
106 TSUNG-YI

different, in many cases changing role played by neurasthenia. In this paper, I

will set forth my observations, based largely on personal experience, on the role
of neurasthenia in these four Asian cultures. These observations will then be
placed in broader perspective, ftrst with respect to the American psychiatric
scene and the evolution since 1950 of the four editions of the American
Psychiatric Association's Diagnostic and Statistical Manuals (DSM II, HI and
III R), and next, with respect to the world psychiatric scene and the recent
revisions of the World Health Organization's International Classification of
Diseases (ICD--8, -9 and -10).
Questions of history and culture loom large in this paper. The reader will, I
believe, be struck, as I have been, by the divergent roles neurasthenia plays in
each of the cultures treated herein. Yet, as to the four East Asian cultures, each
imported the concept and the term at approximately the same time in the early
part of the 20th century.

Transplantation and Transformation of Neurasthenia

The concept neurasthenia appears to have received a most sympathetic reception

in other industrializing nations, such as Britain, France, and Germany, in the late
19th century. The fact that Beard singled out intellectuals, or brain-workers, as
the segment of the population most vulnerable to neurasthenia apparently added
a great deal of enthusiasm to the application of this concept in Europe, for brain-
workers are the movers of modernity. As Max Weber pointed out, the basic
ethical foundation of capitalism, consisting of such virtues as hard work,
individual responsibility, sobriety, single-minded striving for material rewards,
and rationality, was well accepted by the middle class (Weber 1904). The
psychological demands such an ethic made upon an intellectual class of workers
largely cut off from traditional patterns of living should be apparent.
Neurasthenia quickly became an illness of the upper middle class, especially
the prestigious intelligentsia, and "Amercian Nervousness" was on its way to
being transformed into a Western European bourgeois illness. Many clinics,
hospitals, hostels, and spas all over Europe began to specialize in treatment of
these patients, whose numbers grew large enough to support commercial
medicine. Many panaceas for treatment of nervous breakdowns were developed
and advocated by George Beard and many other physicians whose reputations
were built on the disorder and the treatment of an elite clientele. These were
adopted, further expanded and elaborated on European soil. Rest cures, diets and
mineral waters, massage and other physiotherapies, and hot or cold baths all
made their way into such European rest spas as Baden-Baden, Karlsbad,
Marienbad, Bath, Vichy, and Tepliz.
With an increase in clinical experiences, practically every great neurologist in
 NEURASTHENIAREVISITED 107

the 1890's wrote a major piece on neurasthenia (Drinka 1984). As a conse-

quence, a large variety of hypotheses emerged regarding the etiology of
neurasthenia, emphasizing somatic (physical), neurological or psychological
causative factors. At the same time, different treatment methods were advocated
and put to clinical application in various centres. The following few examples
may suffice to illuswate the extent of theoretical and clinical activities aimed at
ref'ming the diagnosis and treatment of neurasthenia in Europe. 1
Jean-Martin Charcot (1889) made a fairly extensive use of the diagnosis of
neurasthenia. Approximately one third of his clinical cases were given this
diagnostic label. As in hysteria, he emphasized the traumatic neurotic element in
its causation and employed hypnosis fairly extensively for its treatment.
Richard yon Kraft-Ebing (1900) was another famous neurologist who used
the diagnosis of neurasthenia frequently. He singled out the anomalies in sex life
as factors mainly responsible for causing neurasthenia. For example, masturba-
tion by the adolescent was regarded as a main cause, because it sapped his (her)
nervous energy in nervous exhaustion and thus led to neurasthenia. In Kraft-
Ebing's view, homosemmlity and other sexual disturbances come from the same
origin of excessive masturbation with neurasthenia as its forerunner.
Sigmund Freud (1895) regarded neurasthenia as physical exhaustion secon-
dary to psychosexual problems which he attempted to treat with psychoanalysis.
It should be noted as well that constitutional or hereditary factors were
emphasized by many German authors, including Kraft-Ebing, as being mainly
responsible for the causation of neurasthenia.

(1) Neurasthenia (Shinkeisuijaku in Japanese) and related disease

conditions in Japan

The transplantation of neurasthenia to Asian soil appears to have followed a

similar pattern as occurred in Europe at the turn of the 20th century. It started
with a phase of enthusiastic, largely uncritical reception, was followed by a
second phase of critical assessment, and ended with transformation into various
subcategories based on new theories (Drinka 1984; Sicherman 1977).
The years I studied medicine and psychiatry from 1940 to 1946 in Tokyo
coincided with the transitional period between the enthusiastic application and
the critical assessment of the concept neurasthenia. The simple fact that a major
chapter of the then standard textbook of psychiatry by Professor Koichi Miyake
was devoted to this disease condition can be seen as an indication, though
indirect, of the significant position neurasthenia ($hinkeisuijaku) occupied in
psychiatry in the nineteen thirties and forties (Miyake 1932).
Certain clinical experience I had as a medical student and a trainee in
psychiatry may serve to illuminate the important role this concept of neuras-
108 TSUNG-YILIN

thenia played in the minds of Japanese physicians and psychiatrists at the time. I
vividly remember a case of a man in his late forties whom I diagnosed as
suffering from general paresis based on the presenting symptoms of advanced
dementia characterized by cognitive and memory impairment, pupillary
anomaly, dysarthria, and the history of syphilis in youth. Our instructor,
although agreeing with the clinical diagnosis which was confirmed later by
cerebrospinal fluid (CSF) findings, raised the question of why this patient had
not been diagnosed earlier, and quickly pointed out that the patient had a period
of "neurasthenic condition" about two years previously. He stressed, "If the
patient had been seen by someone who had the knowledge that neurasthenia
syndrome often appears as a prodromal or early sign of general paresis, this
patient could have been treated early with a much better prognosis for
recovery."
Under the tutorship of such supervisors we, students and trainees in
psychiatry in Tokyo University, all looked hard for such cardinal signs of
neurasthenia as fatiguability, irritability or sensitivity in diagnosing any and all
patients. It may be mentioned that a very large portion of the patients seeking
psychiatric treatment at the Tokyo University Hospital - whether the patient
suffered major functional psychoses, or organic brain syndrome, minor mental
disorders or substance abuse - had expressed or shown "neurasthenic syndrome"
at one point in their illness, and thus the attention given to this disease condition
by the staff was understandably widespread and intense.
The emergence of the concept shinkeishitsu and a specific treatment modality
called Morita therapy advocated by Shoma Morita, introduced a new perspective
on neurasthenia (Shinkeisuijaku) in Japan (Morita 1921, 1928). In Morita's
view, a large number of neurasthenia patients should be called shinkeishitsu,
meaning nervousness or nervous disposition, because their "'neurasthenic
condition" is basically a psychological reaction developed in a certain type of
personality characterized by hypersensitivity, introversion, self-consciousness,
perfectionism and hypoehondriacal disposition. Patients with such character
features tend to show anxiety about even slightly abnormal changes in their
daily physical and mental functioning, e.g. slight changes in heart beat, heavy
headedness, or any loss of memory or power of concentration. The anxiety over
such perceived changes of function leads to elevated sensitivity which, in turn,
causes more anxiety. This vicious circle between sensitivity and anxiety, which
Morita termed psychic interaction, escalates to form a condition of morbid fear
with which the patient is "caught" or preoccupied.
Morita therapy is a specific treatment aimed at breaking up this vicious circle
of sensitivity and anxiety, by helping the patient to accept the anxiety as it is
and, thus, avoid being caught or preoccupied with the morbid conditions (Morita
1974, Suzuki and Suzuki 1976, Reynolds 1976). It consists of two major phases
in a hospital setting.2
 NEURASTHENIAREVISITED 109

In the fast phase, the patient is instructed to lie in bed without engaging in
any activities or contact with the outside world, such as talking, reading,
watching television or listening to radio. Devoid of all possible distractions the
patient is advised not to fight against feelings that come into his/her mind but to
face them. The patient usually becomes very anxious on the third or fourth day,
but on the fifth usually comes to terms with the anxiety and begins to have a
clue about accepting it as it is.
The second phase is the work therapy, in which patients are instructed to do
what they have to do despite feeling anxious. Neurotic patients tend to avoid
doing necessary things and indulge in their preoccupations. Such patients are
encouraged to find something to do which is appropriate and relevant to a
particular situation, e.g. cleaning the house, tending the garden, working as a
receptionist or kitchen helper, etc. Through this experience of being fully
attentive to what they are doing in the present, they learn that they can do what
they have to do, despite the fact that they still feel anxious and have symptoms.
In this phase of therapy, contacts and communication between the therapist
and the patient take place through the therapist's reading of and commenting
upon the patient's daily diary and the actual daily life situations the patient faces
while engaged in work therapy activities. The length of stay in hospital usually
lasts from forty days to ninety days, with the majority of patients showing most
favourable results even after three years according to a follow-up study by
Suzuki and Suzuki (1981).
Transformation of neurasthenia in Japanese psychiatry has continued
following Morita. There appeared to have developed a general consensus about
the concept of neurasthenia and its place in Japanese psychiatry in the early
40's. The treatise on this concept contained in Miyake's Textbook of Psychiatry
(1932) is representative of that consensus. A general summary of Miyake's
views on the various types of neurasthenia follows:

1. Neurasthenia, or genuine neurasthenia, was conceived in the original

Beardian sense in terms of def'mition, etiology, symptomatology,
diagnosis and treatment method.
2. Reactive neurasthenia, or neurasthenic reaction was def'med as a tem-
porary neurasthenic syndrome characterized by exhaustion, sleep distur-
bance, irritability in reaction to (a) physical illness such as tuberculosis,
kidney diseases, infectious diseases, gastrointestinal diseases, anaemia, or
Co) psychological causative factors, e.g. anxiety, fear, worries, etc.
Reactive neurasthenia is a temporary condition which will remit with the
removal of the underlying physical of psychological stresses.
3. Pseudo-neurasthenia: A typical neurasthenic condition manifests in a
variety of psychiatric conditions as prodromal or early signs, or as a
residual condition, e.g. general paresis, schizophrenia, manic depressive
110 TSUNG-YI LIN

illness, cerebral arteriosclerosis, senile dementia, organic brain damage,

hydrocephalus, psychogenic psychosis, poisoning, alcoholism, etc. The
presence of a neurasthenic condition should, therefore, be accompanied by
an intensive diagnostic effort to rule out these above psychiatric diseases.
The identification of the presence of neurasthenia was regarded helpful or
even essential in determining the onset of the related or underlying illness,
as illustrated previously on page 108.
. Shinkeishitsu (or Nervositat, Nervosity): This is a neurasthenic condition
basically due to constitutional factors. People with such personality traits
as introversion, sensitivity, hypochondriac disposition, obsessive-compul-
siveness, or sense of insecurity or inferiority, often suffer from
Shinkeishitsu without precipitation of environmental factors. Though these
personality traits may be present early in the life of Shinkeishitsu patients,
onset of illness usually occurs in adolescence or early adulthood, and the
clinical course is chronic or semi-chronic as a rule. The traditional
treatment modality of rest-cure is usually ineffectual, and Morita therapy
is advocated by the followers of Dr. Shoma Morita as the sole remedy of
choice.

War experiences in Japan in the late i930's and 1940's exerted extreme
stresses on both military and civilian populations in all aspects of their lives. The
enormous increase of war neuroses among soldiers, including "shell shock" in
the battle fields far away from home country, and neuroses and neurasthenia
among civilians, especially among drafted factory workers, came as a shock to
the Japanese in all walks of life.
In one of the major studies of psychoneuroses among the Japanese armed
forces in South East Asia, all types of acute or chronic war neuroses as reported
in the Western literature were recognized, and the frequency (or prevalence) was
estimated to be high, although no exact figure or prevalence rates were given
(Uchimura and Akimoto 1944). The rest cure, a traditional treatment of
neurasthenia, did not bring about its expected results, and the importance of
genuine neurasthenia compared to other forms of psychoneurosis began to
diminish. These and other observations on psychoneurosis among military
personnel aroused the interest of civilian psychiatrists and administrators in the
morale of factory workers, the key segment of war-supporting civilian man-
power, as measured by the presence of neurasthenia and psychoneuroses among
them.
Thus began a surge of interest among Japanese psychiatrists in the hitherto
neglected field of psyehoneuroscs. This represented a new era in Japanese
psychiatry in which major attention was paid to psychogenic factors in mental
disorders. Attention was also increasingly paid to American and British
 NEURASTHENIA REVISITED 111

psychiatric literature: this represented, for Japanese psychiatry, a break from the
tradition of biological or neurological psychiatry of the German school. The
American domination of the post-war era in all spheres of Japanese day-to-day
life surely contributed to the Anglo-American influence in Iapanese psychiatry
as well.
In 1979 1 returned to Japan after an absence of a little more than 30 years and
spent one year as visiting professor of psychiatry at Tokyo University. ! made
three major observations on neurasthenia:

1. Neurasthenia was no longer a major diagnostic label in use in medical or

psychiatric clinical settings: only a few psychiatrists were still employing
it in Beard's original meaning. Most psychiatrists I spoke to questioned
the validity of such a diagnostic term in the classification of mental
disorders.
2. The concept of Shinkeishitsu appeared to be well established and found a
place in the psychiatric lexicon. Morita therapy is applied by a relatively
small number of disciples of Dr. Shoma Morita to this disease condition,
especially in those cases marked by taijin kyofu (anthropophobia), sekimen
kyofu (erythrophobia), or claustrophobia. These phobic conditions can be
regarded as culture-bound syndromes treated by Morita therapy, a culture-
specific modality having Zen Buddhism as its basic philosophy (Suzuki
this issue).
3. Some reported a peculiar widespread use of neurasthenia as a diagnostic
label by both professionals and laymen as a camouflage for such serious
mental disorders as schizophrenia or affective disorders. The frequent use
of this term as a camouflage diagnosis in official medical certificates
(Shindansho) was most puzzling: it was especially so, as these medical
certificates carrying the camouflage labels were treated like all other
medical certificates as legal documents and used as the basis for official
statistics for health, welfare, employment, and school. They are also used
as medical grounds for taking leave of absence from work or transfer of
jobs (Munakata this issue).

Explaining how such an irregular practice in the use of neurasthenia as a

diagnostic label has become a permissible medical modus operandi in Japan
should pose a serious challenge to medical anthropology. In my view, it may
have a few major roots in Japanese medical culture.

(a) The physician represents an almighty father figure who is entrusted with
the power and responsibility to cure and help his patient. He controls the
112 TSUNG-YI LIN

medical information regarding a patient, and only gives to the patient,

family, or government agency, a limited amount when he sees fit. In the
case of stigmatized mental disorder like schizophrenia, the majority of
physicians and psychiatrists in Japan today consider it unwise or even
harmful to inform the patient or his/her family about the diagnosis, "for
fear of causing a shock" or to "protect the patient and the family from
becoming a target of discrimination or social disgrace. "3 Often it is the
family, more than the patient, which is the object of the physician-
psychiatrist's concern because of the fear of family stigma.
(b) Why then does the Japanese physician-psychiatrist choose neurasthenia
and not other diagnostic label for the cover-up? A number of factors may
be identified as contributing to this practice. First, in Japanese medicine-
psychiatry, neurasthenia was a condition which appeared in a large variety
of disease conditions including a broad spectrum of psychiatric and non-
psychiatric mental disorders, as seen in the previous section. It is,
therefore, easily accepted when used as a diagnosis. Second, neurasthenia
is classified as a neurological disease, a diagnostic label with a biological
connotation which has the blessing of a socially acceptable sick role in
Japan where biological psychiatry predominates. Third, the fact that hard
working middle-class or upper-middle class brain-workers are more
vulnerable to neurasthenia gives this "diagnostic label an added flavor of
having social status or even "prestige" along with its sick role. In fact,
many young intellectuals in the early years of this century were regarded
and publicized as neurasthenics. Fourth, neurasthenia is known to be a
reversible disease condition which can be cured with rest, good environ-
ment and time, in contrast to such severe mental illnesses as
schizophrenia. Thus, the label finds ready acceptance among the Japanese.

(2) Transplantation of neurasthenia in China

The inlroduction of the concept neurasthenia to China in the 1920's and 30's,
coincided with a period of tremendous social upheaval:

a. continuous political convulsions, the collapse of the Qing dynasty

followed by the establishment of a new Republic, incessant power
struggles and hostilities among warlords;
b. social unrest, dislocation and internal migration of populations, coupled
with poverty, starvation, and increased crimes;
c. quest for modernization and industrialization in order to catch up with
Western nations, including promotion of modernization and education of
the masses as expressed in the May 4th (1919) Movement, New Life
 NEURASTHENIA REVISITED 113

Movement etc.;
d. the Iapanese invasion of Manchuria and the ensuing military conquest of
other regions of China with overt political and economic ambition to
subjugate the whole of China and Southeast Asia;
e. the Civil War between the Kuomintang (the Nationalists) and Chinese
Communist Party for many years which ended in 1949 with the Chinese
Communist Party forming the one-party Revolutionary Government of the
People's Republic of China on the mainland while the Kuomintang fled to
Taiwan.

Consolidation of the Chinese Communist Party brought about a number of

fundamental changes in medicine and public health as an integral part of a new
political philosophy and social order. A most outstanding feature of the revolu-
tion lies in the unprecedented emphasis on health as a priority national interest
(Lin & Wegrnan 1973). The targeting of health as a policy priority came about
not only because the reconstruction of China heavily relied on a healthy work
force, but the political ideology of the Communist Party spoke of the need to
transform the once uneducated and neglected mass of people into liberated,
dignified citizens of a modern socialist state who are both consumers of, and
participants in, the health services (Chin 1973). The fact that attention, albeit
minimal, was given to the problem of mental illness at the First All-China
Conference of Health Workers in 1950, immediately after the establishment of
the People's Republic of China, deserves special notice, a fact pointing to the
role of the political philosophy of the revolutionary government which con-
sidered "health of the people" as a priority target of political commitment (Lin
1985: 8).
Introduction of Soviet ideology and developmental models as the sole
dominant force in modernizing Chinese political, social, and scientific
reconstruction, encouraged, or rather demanded, Chinese psychiatry to adopt
Pavlovian theory as the sole fundamental theory on which to build theories and
clinical skills. In the course of the adoption of the Soviet model, concepts and
techniques from Western countries such as the U.S., Britain, and France had to
be relegated to a secondary position or given no place at all in the hierarchy of
science. For instance, sociology and psychology were banned in 1952, depriving
psychiatry of the contribution of the behavioral sciences (Lin 1985).
The strong and lasting influence of Soviet psychiatry can still be seen in three
major aspects of Chinese psychiatry today: the theoretical orientation of
psychiatrists; clinical practices; and administrative psychiatry. It appears that
Pavlovian theory has affected every aspect of psychiatric thought m" llae last
twenty-five years, as seen in most Chinese textbooks. As Young (1984) notes, it
is "like the situation in the United States up until recent years where "the
Freudian psychoanalysis or psychodynamic approach has knowingly, or
114 TSUNG-YI LIN

unknowingly, permeated into every comer of American psychiatry."

Soviet psychiatry prevailed in almost every aspect of Chinese clinical
practice, ranging from the banning of psychodynamic psychotherapy and
psychosurgery to the promotion of such preferred treatment modalities as
prolonged sleep treatment and artificial hibernation treatment. In addition,
psychiatrists were bestowed with all-inclusive rights to treat the patient,
including decisions on admission and discharge, choice of treatment modality,
and the structuring and operation of hospital routines and administrative
procedures. Furthermore, the Soviet model of the primary health care system has
had a profound and far-reaching effect on the health care delivery system in
post-liberation China. Primary care has become the virtual backbone of the
public health system intermeshed with different levels of community, social and
political organizations and their activities.
Psychiatry in China in the early 50's not only weathered the political storm,
but also managed to develop into an increasingly respectable medical discipline
with a position roughly equal, at least in theory, to other medical sciences and
health professions. The First National Conference of Psychiatric Specialists was
convened in 1958 to summarize the accomplishments of the first 10 years after
Liberation and to assess the nation's future mental health needs as contained in
the First Five Year Plan in Mental Health (1958--62) (Wu 1962).
Neurasthenia or Shenjingshuairou ("weakness of nerves") assumed an
extraordinary significance in this First Five Year Plan: a grand scale national
campaign against neurasthenia was initiated (Editorial, Chinese Journal of
Neurology and Psychiatry 1966). This campaign was aimed at controlling the
rapidly increasing problem of neurasthenia, believed to be rampant all over
China, especially among "mind or brain (intellectual) workers," a category
including bureaucrats, office workers, teachers, and students. It was also found
to a lesser extent among laborers and in the armed forces. Starting in the 1950's,
many schools complained of absenteeism among teachers and students, and
factories suffered from reduced productivity, all of which were attributed to
neurasthenia. Thus neurasthenia became one of the three priority targets of the
First Five-Year Plan in Mental Health (1958-62).
Lin (1985) hypothesized that the marked increase in neurasthenia and the
extraordinary national attention it provoked suggest the presence of a deep-
seated tension in the revolutionary development of the People's Republic of
China in the 1950's. "It appears that during the Great Leap Forward the vitality,
productivity, and optimism which marked post-Liberation reconstruction
between 1950 and 1958 encountered a sudden reversal. Yet workers and the
masses generally were still laboring under the same polidcM, exhortation and
suffering from extreme material, physical, and psychological hardships without
any means of venting their frustation or political views" (Lin 1985: 13-14).
Starting in the 1950's, medical or neurology clinics were reporting the great
 NEURASTHENIAREVISITED 115

majority of their outpatients, sometimes 80 to 90 percent, as suffering from

neurasthenia. The predominance of intellectuals among the neurasthenic patient
population suggests the difficult adjustment they were experiencing under such
adverse political and social conditions.
An ingenious therapeutic model called the Intensive Comprehensive Group
Treatment or Speedy Synthetic Method (Chert 1955, Kuan 1960, Sichuan
Medical College Dept. of Psychiatry 1960) was developed; it proved effective
and soon became the treatment of choice nationally. It involved group therapy
lasting for four to eight weeks, emphasizing re-education of the patient to
develop "correct ideas and attitudes to work and socialist fife, especially in
fostering the proper relationship of the self to the society, the Communist Party,
and the nation." It was obviously a highly politicized treatment modality.
Medication, usually including sedatives or Chinese herbal medicines, was
generally used as an adjunct to the group therapy. The role of psychiatrists in
these sessions appears to have been more along the fine of authoritarian teachers
than therapists or psychotherapists in the Western sense. The results of the
Intensive Comprehensive Group Treatment for neurasthenia were reported as
good in general, with successful outcomes ranging from 60 to 85 percent
(Peking Medical College, Department of Psychiatry 1960).
The fact that among the Chinese population neurasthenia became the vehicle
to express extreme political, social and physical stresses in the late 1950's
deserves special attention. It can be interpreted as due to the Chinese preference
for using somatic symptoms to express their stresses (somatization), which also
is consonant with the sick role of traditional Chinese culture (Kleinman and
Kleinman 1985). One cannot, however, overlook the influence of Soviet
psychiatry in this context. Pavlovian psychophysiological theories dominated
the medical thought of the time, and thus many of the neurotic symptoms
manifested by the Chinese were given a Pavlovian explanation (Li et al 1960).
The combined use of group method characterized by political indoctrination
with the conventional "rest cure" for neurasthenics also reflected the politico-
social reality of the time in China. Thus these three factors - somatization,
Pavlovian theory and political persuasion - are not only responsible for the
prevalence, modes of manifestation and choice of treatment modalities, they also
helped to popularize and perpetuate neurasthenia up until the time of my visits
to China in the 1980's, long after the conclusion of Great Leap Forward.
Regrettably no reliable objective epidemiological or clinical research data
have been made available regarding the situation of neurasthenia during the
Cultural Revolution. Although perceived as less prevalent than during the near-
epidemic situation in the late 50's and early 60's, neurasthenia persisted as a
major mental health concern of psychiatrists and public health officials
throughout the politicial and social turmoil, and still constitutes an important
mental health problem today, as the reader will see from the ensuing articles in
116 TSUNG-YI LIN

this volume.

(3) Neurasthenia in Taiwan and Hong Kong

Taiwan inherited the Japanese tradition as the foundation for developing its
psychiatry during the Japanese occupation, and continuing after World War II
through my return to my homeland as the only Taiwanese psychiatrist trained in
Japan (Lin 1953, 1961). As far as neurasthenia is concerned, it was still regarded
as a clinical entity applicable to a fair number of patients who exhibit the typical
symptom complexes identified by Beard. In addition, neurasthenia was also
considered a syndrome, called either a reactive neurasthenia or pseudoneuras-
thenia, which manifests in a number of functional or organic psychiatric
conditions at different states of various diseases. Shinkeishitsu came up sporadi-
cally from 1946 to 1950 as a diagnosis given to certain patients of
"constitutional neurasthenia" with the triad of obsessive and introverted
personality traits and socio-phobic symptoms, taijin Kyofu [anthropophobia] or
sekimen Kyofu [erythrophobia]. It must be added that the number of such
patients was extremely small compared to Japan, probably not more than five
cases a year among the more than two thousand psychiatric patients seen at the
National Taiwan University Hospital. It gradually became clear that most of
these patients could be classified as phobic or anxiety neuroses or even as
paranoid personality disorders in a few cases, in contrast to Japan where large
numbers of shinkeishitsu patients manifest a consistent clinical picture. It is
quite possible that shinkeishitsu should be recognized as a culture bound
syndrome (Kasahara 1970, Uchinuma 1983).
My own increasing contact with Western psychiatry and my two years of
clinical experience in Boston (1950--52) with attendant extensive exposure to
American psychiatry and behavioral sciences, gave substantial stimuli to new
directions in both theoretical and clinical work in Taiwan. The result was a
broadening of the foundation and scope of perspectives in Taiwanese psychiatry.
Prominent among the changes in the nomenclature and taxonomy was the
decline of the usage of neurasthenia, a result of American influence, discussed
below.
The decline of interest in neurasthenia on the part of Western-trained doctors
in Taiwan contrasted sharply with a rapid rise of its popnl~rity among the
traditional Chinese doctors and the lay public. Newspaper advertisements with
stories of miraculous cures of neurasthenia by a certain traditional remedy, a
specific herb or a combination of herbs were quite common. Further, ads for
neurasthenic remedies or herbs began to clutter the billboards of many busy
streets in the old section of Taipei city. Many Western-trained doctoa's shook
their heads in disbelief at the sight of such a neurasthenia boom. The popularity
 NEURASTHENIAREVISITED 117

and attendant commercial benefits of neurasthenia in Chinese traditional

medicine continued to grow in spite of the fact that modernization and Wester-
nization started to pick up its momentum only from the 1960's in Taiwan.
A number of reasons explain this development. Foremost among them was
the resurgence of Chinese traditional medicine in Taiwan. It can perhaps be
called a rebound phenomenon, a reaction of the Taiwanese general public to the
long suppression of the Chinese traditional and folldoric medicine by the
Japanese colonial government, which had ruled Taiwan from 1895 to 1945. It
may also be seen as a reaction against an even deeper level of Japanese suppres-
sion, the Japanese antipathy to or overt prohibition of anything Chinese,
esIxx:ially toward the end of the colonial control of the island of Taiwan in the
30's and 40's. The revival of Chinese waditional medicine hand-in-hand with
that of indigenous religious activities clearly attested to this rebound
phenomenon. The public championed popularized traditional Chinese medicine,
including the remedies it advocated for neurasthenia.
It must be added that a few practical situational problems related to medical
care did contribute to the revival of Chinese traditional medicine and folk
healing in Taiwan. The breakdown of the medical care system during and after
the War, especially due to the changeover of the government after the Japanese
defeat, made quality medical care unavailable or too cosily to the majority of the
populace, especially the poor and farmers. Traditional Chinese medicine and
folk healing [filed this gap and thus became popular. Furthermore, the Chinese
Nationalist government supported and encouraged the proliferation of traditional
Chinese medicine as it had on the mainland, promoting it as a symbol of
Chinese cultural heritage. It was in this kind of social and medical climate that
neurasthenia established itself as a major disease in the minds of the Taiwan
public in the late 1940's and early 1950's.
Neurasthenia fared similarly in Hong Kong as in Taiwan, except that the
Western-trained doctors there had received British training which paid less
attention to neurasthenia than in Japan or Taiwan. On the other hand, Chinese
traditional medicine had been widely accepted b y all segments of the population
for years, which legitimized the use of the term "neta'asthenia" as a diagnostic
label among traditional Chinese doctors and the lay public.
As noted above, the popularity of the concept neurasthenia among the
practitioners of traditional Chinese medicine and the general population is
widespread and deep-rooted in all three Chinese cultures - on the mainland and
in Hong Kong and Talwan. In a sense, neurasthenia, which originated in the
United States as "American Nervousness," has been transformed into a Chinese
concept and "indigenized" in Chinese culture, especially in the subculture where
traditional Chinese medicine dominates both theory and practice. A detailed
discussion of this specific aspect of indigenization is presented by Fanny
Cheung in this Special Issue (Cheung 1989).
118 TSUNG-YI LIN

Transformation of Neurasthenia in the U.S. and its Place

in International Psychiatry

The study of the transplantation and transformation of neurasthenia in the soil of

four Asian countries requires looking at the process of transformation in its
birthplace, the United States, and also at the broader international scene as
viewed through the lens of the World Health Organization.
In the U.S. the beginning of the decline of Beard's concept of neurasthenia
was noted as early as the turn of the century (Dana 1904, Blumer 1906). It was
widely used in World War I, but showed a rapid decline in popularity in post-
war years and largely diminished by the 1930's (Chatel and Peele 1970). In the
1940"s and 1950's neurasthenia experienced a dramatic fall in popularity as a
respectable and scientifically legitimate disease entity.
Since my contacts with American psychiatry have occurred in distinct phases,
my views on the vicissitudes of neurasthenia in American psychiatry will be
presented according to the following phases of my own experience:

a. My initial contact with American psychiatry in 1950-52 coinciding with

the publication of DSM-I.
b. Work in WHO, Geneva, 1965-1969, as a medical officer responsible for
epidemiological and social psychiatric research, coinciding with the
lrmalization of ICD-8 and tangentially related to the work on DSM-II.
c. Work in the U.S. and Canada from 1969 up to the present as a clinician
and researcher, and also involved in international mental health, coincid-
ing with the publication of DSM-m and ICD-9 and ICD-10 (Draft).

(a) In 1950 when I made my first visit to the U.S., I was perplexed at the
infrequent use of the term neurasthenia either as a syndrome or a diagnostic
entity. Soon it became increasingly clear to me that the prevailing school of
psychiatric thought of the time, dynamic psychiatry, played an important role in
causing this change (Ellenberger 1970). As early as 1894, Freud advocated the
separation from neurasthenia of a particular syndrome called the anxiety
neurosis. He considered "morbid anxiety" with "anxious expectation" or free
floating anxiety and anxiety attacks as its nuclear symptoms. Freud went further
to speculate that the psychosexual process of anxiety neurosis was distinguish-
able from neurasthenia (1895). It was presumed that anxiety neurosis had
gradually usurped a greater role in the family of neurotic disorders, relative to
neurasthenia, especially because anxiety is common or ubiquitous in most
psychiatric syndromes. Many cases which would have been diagnosed as
neurasthenia by me or my Asian colleagues then, were labelled as anxiety states
or anxiety neuroses by our American colleagues. I found myself often perplexed
and overwhelmed by the arguments of my articulate American colleagues,
 NEURASTHENIA REVISITED 119

particularly so, when seemingly convincing dynamic formulations of the disease

process, including psychosexual interpretations, were presented time and time
again. Such experiences were powerful enough to convince me, a novice in
American psychiatry, of the need to abandon the "fallacy of neurasthenia as a
diagnostic entity." This "conversion" in 1950-52 in Boston had important short-
and long-term effects on the theoretical and practical clinical work of this writer
and his colleagues in Taiwan. And doubtless similar exposure occurred to many
other Asian psychiatrists throughout the U.S.

The Diagnostic and Statistical Manual of Mental Disorders, First Edition (DSM-
I), published in 1952 (APA 1952), gives no formal recognition to neurasthenia.
In its place, under the title of "psychophysiologic nervous system reaction," a
footnote is attached to indicate what is to be done to place those cases diagnosed
as neurasthenia: "009-580 Psychophysiologic nervous system reaction." This
category includes psychophysiologic asthenic reaction, in which general fatigue
is the predominating complaint. There may be associated visceral complaints.
The term includes many cases formerly called "neurasthenia." In some in-
stances, an asthenic reaction may represent a conversion: if so, it will be so
classified, with asthenia as a manifestation. In other instances, it may be a
manifestation of anxiety reaction and should be recorded as such.
Being strongly influenced by American psychiatry, I did not then fred this
handling of neurasthenia unreasonable. The only observation I made was that
the language or diagnostic terms used in DSM-I were largely Meyerian, i.e. of
the psychobiological school. The question raised then is why both dynamic
psychiatry and psychobiology in the U.S. in the first half of the 20th century
paid attention to anxiety as a dominant factor in psychopathology, especially in
neurotic disorders? I, for one, am without a clear answer.

(b) The DSM-II, published in 1968 by the American Psychiatric Association,

accorded neurasthenia a formal diagnostic entity as a subtype of neuroses (APA
1968). The text of the section on 300.5, Neurasthenic Neuroses (neurasthenia),
reads as follows: "This condition is characterized by complaints of chronic
weakness, easy fatigability, and sometimes exhaustion. Unlike hysterical
neurosis, the patient's complaints are genuinely distressing to him and there is
no evidence of secondary gain. It differs from anxiety neurosis and from the
psychophysiologic disorder in the nature of the predominant complaint. It differs
from depressive neurosis in the moderateness of the depression and the
chronicity of its course. (In DSM-I this condition was called 'Psychophysiologic
nervous system reaction'.)" The inclusion of neurasthenia in DSM-II in 1968,
however, should not be taken as an indication of the renewed interest of
American psychiatry in this disease condition or disease criteria, as no signs of
increased clinical or popular usage of the term were observed.
120 TSUNG-YI

In my view, the listing of neurasthenia in the American classification of

DSM-II came about primarily due to the effort of the APA Committee on
Nomenclature and Statistics which took the stance of making the DSM-II
compatible with the International Classification of Disease 8th Edition (ICD-8).
As Ernest Gruenberg wrote in The Introduction of DSM-II (APA 1968):
This second edition of The Diagnostic and Statistical Manual of Mental Disorder (DSM-
II) reflects the growth of the concept that the people of all nations live in one world. With
the increasing success of the World Health Organization in promoting the uniform
International Classification of Diseases, already used in many countries, the time came
for psychiatrists of the United States to collaborate in preparing and using the new Eighth
Revision of that classification (ICD-8) as approved by the WHO in 1966, to become
effective in 1968. The rapid integration of psychiatry with the rest of medicine also
helped create a need to have psychiatry nomenclature and classification closely integrated
with those of other medical practitioners. In the United States, such classification has for
some years followed closely the International Classification of Disease.
In this connection, I recall the interesting discussions and conversations in and
out of the meetings in 1965 and 1966 in WHO, Geneva, before finalization of
the ICD-8 Section V (Mental Disorders), in which international cooperation on
mental health statistics and mental health research constituted an important
focus. The emphasis on internationalism among mental health leaders around
the world since the end of World War II seemed to have gained momentum and
direction in the early 60's, as manifest in the effort to standardize taxonomy
bilaterally (e.g., the U.S. - U.K. diagnostic study [Cooper et al 1972]) and
internationally (e.g., WHO's social psychiatry program [-Lin 1967], which
included ICD revision and development of the International Pilot Study of
Schizophrenia [WHO 1973]). My involvement in the WHO as the responsible
medical officer for the social psychiatry program gave me an opportunity to be
involved, albeit tangentially, in bringing about the compatibility of DSM-II with
ICD-8 through E. Gruenberg and M. Kramer of the U.S., among others. In short,
it was primarily the "Zeitgeist" of internationalism in mental health in the 60's
that brought neurasthenia into DSM-II in line with ICD-8.

(c) The impact of DSM-III (APA 1979) and later DSM-III-R (APA 1987) on
clinicians and researchers in American psychiatry has been positive and far
reaching, even extending beyond the borders of the U.S. The ripples DSM-III
caused in China with respect to the diagnosis of neurasthenia are worth atten-
tion.

The fact that neurasthenia is given no place in the DSM-III and DSM-HI-R
has created considerable response, mostly negative, from among Chinese
psychiatrists. For example, Young Derson of the Hunan Medical College, called
it a "flip-flop" of American psychiatry and said, "One cannot help feeling that
changes of symptoms of diagnosis does not always mean progress of mental
 NEURASTHENIA REVISITED 121

science; it sometimes only means going around and around" (Young 1989).
Indeed, neurasthenia was only listed in the subject index at the end of the DSM-
III-R "Neurasthenia p.230 and 232" to refer the reader to Dysthymic Disorders
on those two pages as suggested: one finds that the definition or description of
dysthymic disorder in DSM-III-R has little resemblance to what is known as
neurasthenia to the Chinese psychiatrists. "It is nothing but a subtype of chronic
depressive state, having little to do with neurasthenia," one Chinese colleague
recently ventured his view to me (Hu 1988).
Another important study in this area deserves special mention: Arthur
Kleinman's 1980 study in Hunan of 100 patients diagnosed as suffering
neurasthenia (Kleinman 1982). Using the Schedule of Affective Disorders and
Schizophrenia (SADS) and the diagnostic criteria of DSM-III, both adapted for
use with Chinese patients, he reported 87 percent as suffering from various
forms of clinical depression. This finding, understandably, created a great deal
of interest - and some controversy - among psychiatrists in and out of China.
The Chinese responses can be divided into three categories, based on my
personal discussions with Chinese psychiatrists during successive visits to China
since 1982.
First, outright fury has been expressed by a few diehard conservatives who
dismissed the study as of no scientific value, as "it was done by an American
who doesn't know Chinese medical thoughts and Chinese culture well enough to
make such a study." This kind of response may be regarded as similar to the
common initial reaction frequently encountered in other areas of cross-cultural
psychiatry when a new finding or theory is presented, contrary to a traditional
view or practice. Such reaction usually gives way to more rational, deliberate
reasoning later, as a rule, when full facts or detailed theoretical viewpoints are
revealed.
In Kleinman's case the above criticism hardly applies, as he has spent almost
a qmFter of a century working in Chinese language and culture, and further-
more, his research assistants for the study were all young Chinese psychiatrists.
The strong response of the Chinese psychiatrists may reflect their misreading
of Kleinman's work as implying that Chinese psychiatrists could not diagnose
depression. The resistance of the Chinese psychiatrists may be in part based on
their fear that the prevalent and pernicious stigma attached to depression as a
form of mental illness might interfere with the treatment of those "neurasthenic"
patients if rediagnosed according to DSM-III (Chang Ming-yuan 1989).
A second form of response has been an increased interest in solidifying the
theoretical foundation of and/or consolidating clinical observations on neuras-
thenia while taking a close critical view of the American approach, of DSM-III
in particular, to neurasthenia (Young 1989, Yan 1989).
Third, there has been an increased perception of need for experimental
scientific enquiry into the possible reasons for a discrepancy in diagnostic
122 TSUNG-YI LIN

practices between the U.S. and China (Zang Ming-yuan 1989).

The application of DSM-RI depression criteria to cases of neurasthenia in
Hunan carried out by Kleinman did rekindle the interest of many Chinese
psychiatrists in re-establishing neurasthenia as a disease entity in Chinese
nomenclature of mental disorders both from the viewpoints of theory and
clinical practice. For myself, I wish that Kleinman had gone one step further to
include ICD-9, along with DSM-III, in his experimental or theoretical examina-
tion of the place of neurasthenia in psychiatric classification. Kleinman himself
clearly has taken away an important lesson from his research, and has consulted
WHO on maintaining neurasthenia in ICD-10 (Kleinman 1988).
Kleinman's study (1982) raised major theoretical issues concerning somatiza-
tion and depression among the Chinese. Of the 100 Chinese neurasthenia
patients, the great majority presented predominantly somatic, or autonomic
nervous system and neuroendocrine, symptoms. For example, of the chief
complaints, headaches were present in 90%, insomnia in 78%, dizziness in 73%,
and various pains in 48.5% of the cases, in contrast to only 9% of patients giving
depression as one of their chief complaints. These and other observations,
together with research findings of other investigators (Marsella 1979), have
focused on the psychobiological significance of somatization and depression as
playing "a fundamental relationship between an individual and society"
(Kleinman and Kleinman 1985).
My involvement in the finalization of ICD-8 and in the initiation and
execution of the plan for ICD-9 gave me a great deal of insight into the complica-
tions of developing a cross-cultural scheme of diagnosis and classification of
mental disorders at the highest level of deliberation and negotiation in WHO.
The intensity of national pride, the preoccupation of each delegate with his or
her own school of psychiatry, the weight of tradition in medicine and psychiatry,
the delicate cultural barriers and language difficulties despite the help from the
best possible simultaneous interpreters, were hard to overcome within a given
limited time of the expert committee meetings.
This experience with ICD-8 led me to propose a ten year plan to develop a
universally more acceptable and practicable ICD-9 with a glossary (Lin 1967).
The seven annual seminars of the ten year plan starting from 1965 did much to
raise and resolve many important issues for clarification before arriving at a text
for ICD-9 (1978) which further developed into ICD-10 (Draft) (W.H.O. 1988).
Although it met with some opposition from certain quarters, neurasthenia was
adopted to stay as a subtype of neurosis in ICD-8, mainly supported by
European and Soviet participants. The U.S. went along with it conceivably for
the sake of developing a compatible worldwide schema.
Neurasthenia is listed in ICD-10 (Draft) as F48.0 Neurasthenia (fatigue
syndrome), which has three main features: (a) persistent complaints of increased
fatigability after mental effort, (b) persistent complaints of bodily weakness and
 NEURASTHENIAREVISITED 123

exhaustion after minimal effort accompanied by unpleasant physical sensations

and inability to relax, and (c) the absence of anxiety or depression. It is notewor-
thy that ICD-10 (Draft) emphasizes the exclusion of depressive disorder or
anxiety disorder as a condition for making the diagnosis of neurasthenia, which
in essence supports the original concept of neurasthenia.

Searching for the Place of Neurasthenia in Modern Psychiatry

The subtitleof this paper, "its (neurasthenia's)place in m o d e m psychiatry"

begs a more fundamental question: Does neurastheniahave a place in modern
psychiatry? This question has been frequently raised to me by many North
American psychiatric colleagues who know m y neurasthenia project. Many
suggest that neurasthenia is an obsolete term or that it is a misnomer for anxiety
states or depression, and not a subject for serious study.
The simplest and most direct response is that the term neurasthenia is in use
by perhaps half of the population riving on this globe in a variety of medical and
psychosocial contexts. The formal listing of neurasthenia diagnostic entity in
ICD-10 (Draft) (1988) bespeaks recognition of that fact. It also demands that all
national classifications consider according neurasthenia a legitimate place to
insure compatibility of classification and statistics of all medical disorders from
all member nations. The importance of maintaining compatible taxonomy and
statistics cannot be too strongly emphasized; it is an essential prerequisite for all
international cooperative ventures both in theory and practical health measures.
Futm'e investigation of the nature and clinical practice of neurasthenia clearly
requires international cooperative effort.
In reviewing the state of affairs concerning neurasthenia, I am impressed by
the wealth of research opportunities and topics it raises for students of cross-
cultural psychiatry. I would suggest the following questions as merely a few
examples.

I. Are there patients in the U.S. or Canada who fit the criteria of neuras-
thenia as specified in ICD-10? If so, how are they being diagnosed and
classified, and on what grounds? How are they being treated? It would
seem most desirable to have a joint diagnostic exercise like the U.S. -
U.K. Diagnostic Exercise (Cooper et al 1972) or a reverse of the IGeinman
study of neurasthenia patients in Hunan by having Chinese psychiatrists
rediagnose American depressives or neurotics. The WHO Diagnostic
Exercise which involved psychiatrists of multiple nations or schools of
psychiatry viewing videotaped interviews of patients or case vignettes to
provide diagnostic labels, and offering responses to a systematic question-
nah-e could also be considered for this purpose (Shepherd et al 1968).
124 TSUNG-YI LIN

Such studies would also help to clarify some of the questions regarding the
boundaries of various forms of neurotic disorders, and would foster
development of internationally compatible criteria for the classification of
neurasthenia and other neurotic and depressive disorders, the so-called
minor mental disorders, with well defined research methodologies. With
the results of such research and the research instruments developed,
epidemiological studies of various populations should be attempted across
the Pacific, U.S. or Canada vs China and Japan.
2. Much has been said about the role played by Pavlovian theory on the
etiological views of neurasthenia in Chinese psychiatry (Li et al 1960,
Young 1989). To my knowledge, however, there has not been convincing
demonstration of this thesis using systematic clinical or experimental
research data. There is an urgent need for our Chinese or Soviet colleagues
to enlighten psychiatrists in other cultures on this very important theoreti-
cal issue.
3. The problem of using neurasthenia as a camouflage diagnosis for
schizophrenia and other psychotic conditions appears to be widespread
and widely known in Asian culture, especially in Japan. Nevertheless,
there exists an extreme paucity of data or reports available for studying its
clinical, sociological or administrative significance. Perhaps the absence
of objective information on this uniquely Japanese phenomenon is in itself
part of the problem. My view, which appears to be in line with
Mun_zkata's (1989), is that this practice is deeply rooted in the Japanese
cultural tradition relative to the concept of mental illness and the family
attitude and social stigma attached to the mentally ill. It is this very
cultmal tradition that appears to constitute the major obstacle to changing
the long-established pattern of hospital-centered mental health service to
one of community centered care. Thus, research into the practice of
camouflage diagnosis - its extent, nature and physosocial effects on the
family and the patient - would greatly facilitate the study of patterns of
mental health service in Japan, and other Asian cultures as well.
4. Indigenization of neurasthenia in Hong Kong and Taiwan offers not only a
splendid case for investigating the concepts of, and approaches to, mental
health among Chinese, but also illustrates the integration of traditional and
Western medicine (Cheung 1989). One should not lose sight of the
important fact that a similar process is taking place on a much larger scale
on the Chinese mainland. To my observations, albeit casual and limited, a
large majority of neurasthenics seek help from traditional medicine
doctors or barefoot (farm or factory) doctors who constitute the backbone
of the primary health care system. Here appea~ to lie a hidden treasure for
research into primary mental health care in China aimed at learning about
the magnitude and kinds of mental health problems, the social-environmen-
 NEURASTHENIA REVISITED 125

tal strains, and the modalities of treamaent. I still vividly remember my

own shock when told during my earlier visit in 1982 by a barefoot doctor
(farm doctor), that "about 35% of our patients suffered from neurasthenia
at the time of the Cultural Revolution, but it is about 10% now." The gold
mine of information buried in the enormous primary care systems of
China should be dug out for scientific study, and most important of all,
used at the basis for future mental health planning (Lin & Eisenberg
1985).

Finally, I would like to remind readers that the views expressed in the nine
papers of this Special Issue only represent those of each author, and not of any
school of psychiatry, although each of these authors is a nationally recognized
expert on the topic of neurasthenia and (related) psychiatric disorders. It is
hoped that this Special Issue will contribute to further discussions of this area, a
crucial focal point in international psychiatry involving, as the reader will see, a
variety of themes and issues which we, as scholars and students, will have to
elaborate and resolve in the years to come.

Suite1503,805WestBroadway
Vancouver, B.C.
Canada V5ZIKI

NOTES

t For a detailed account which is beyond the scope of this paper the reader is referred to
Drinka (1984) and Sicherman (1977).
2 The following brief outline of Morita therapy is largely based on the paper "The
Concept of Neurasthenia and its Treatment in Japan" by Dr. Tomonori Suzuki (this
issue).
3 There exist numerous and significant legal impediments to the rehabilitation of the
mentally fll in Japan. Those diagnosed as suffering from any form of mental disorder,
especially those hospitalized, face the threat of losing their jobs and disqualification from
eligibility for innumerable jobs as specified by relevant laws (Tahara 1988). These
mental illnesses include schizophrenia, affective disorders, and all forms of psychotic
disorders. The number of jobs deemed ineligible for the mentally ill has been increasing
and now covers a wide range of occupations amounting to over several hundred including
hair dresser, taxi driver, physician and all categories of health profession, p/lot, any
business dealing with chemicals or f'zrearms, police, government employees of all levels,
accountant, lawyer, etc. It appears that only a few non-skilled jobs are available for the
mentally ill. Furthermore, the mentally ill are deprived of certain rights which are
essential for a citizen in modem society, e.g. voting rights, rights to seeking elective
office, to hold a driving licence, etc.
126 TSUNG-YI LIN

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