THE MYTH OF "NERVOUS FATIGUE" Evelyn had been irritable, restless and tense for the past ten years. Sleep was poor. Appetite had declined to the point of making a meal an ordeal. There was a constant tightness of the throat, pressure in the head, palpitations and gastric discomfort. Overshadowing all complaints in importance and intensity was "an awful fatigue, an exhaustion that starts right when I get up in the morning and continues without letup till late afternoon. Then it eases up and in the evening I feel almost well." In spite of this sustained suffering, "without letup/' Evelyn managed to keep her job for years, supplementing her husband's income. It was only in the past two years that the fatigue and exhaustion became "unbearable." She resigned her position and tended to her household and her young son. "But in taking care of my home I have to drag myself all morning and the greater part of the afternoon. I am exhausted most of the day.** E Examiner P Patient E: You have attended classes for several months. Has your condition improved during these months? P: It has. I sleep well, and my appetite is much better. The pressure in the head has hardly bothered me lately, and the pain in the abdomen is getting less and less. But I am still fatigued. In the morning I have to drag myself and can hardly keep on my feet. Then I take lunch, and right after I have finished eating I am all exhausted, my eyes droop and I have to lie down for an hour or so. E: You say that you are "all exhausted/' May I ask you what precisely you mean when you use the word "exhaustion?" 318 MENTAL HEALTH THROUGH WILL-TRAINING P: Why, I am all in. I have no pep and must force myself to do the simplest thing. E: Look here, Evelyn, an exhaustion that has lasted for years, day after day, even hour after hour, ought to have finally reduced you to a physical wreck. Your muscles should have shrunk, your face should by now look gaunt and haggard. Instead, you maintained your weight, your complexion is blooming, and your capacity for working is equal to the task of taking care of house, family and social activities. Several months ago when sleep was poor and appetite scant your claim to be exhausted might have been logical. But with a good appetite and sound sleep it is difficult to think that you are suffering from a state of exhaustion. P: I don't understand it myself, but it is a fact that I feel tired and weary all the time, except in late afternoon and evening. E: You say you "feel tired and weary all the time." I do not deny that. You alone are competent to state how you feel. What interests rne is whether your so-called fatigue is a mere subjective feeling or an actual and objective condition, whether you merely feel tired or actually are tired. You seem to be puzzled by the sharp distinction and I shall try to be more specific. You understand that if somebody says he feels guilty that does not necessarily mean he is guilty. And if somebody feels feverish that does by no means establish the objective fact that he has fever. These examples will prove to you that a subjective feeling does not necessarily point to an objective condition. And if you say you "feel tired and weary all the time," I shall ask you whether you consider your tiredness a subjective feeling or an objective condition? P: All I know is I am miserable all day. I wake up in the morning, and the fatigue is there the moment I open my eyes. E: You told me, Evelyn, that for the past few months your sleep has been good. Suppose you awoke this morning after a good night's rest. Would you nevertheless have felt fatigued immediately after awakening? MENTAL HEALTH THROUGH WILL-TRAINING 319 P: I feel fatigued immediately after I wake up in the morning regardless of whether sleep was good or poor. E: If this is true then it is established that you suffer from the subjective feeling of tiredness and weariness, and not from the objective condition of fatigue. I shall tell you why I can afford to be so positive about my statement. You see, Evelyn, soldiers after a long march, athletes after an exhausting race, laborers after a strenuous effort, may sometimes be too tired to fall asleep. But once they lapse into a sound sleep they invariably and inevitably feel refreshed after awakening. These are examples of extreme fatigue. Even in these utmost exertions sleep eliminates fatigue with unquestioned certainty. In minor exertions, mere rest without sleep will have the same effect. The only exception to this rule is physical ailment, like an anemia or tuberculosis. In these conditions, even a sound sleep may not do away with fatigue. But with physically healthy persons, sleep never fails to remove fatigue. If it is true that for several months past you have enjoyed good sleep you have no reason for being tired in the morning. To sleep means to rest the muscles. How can your muscles be fatigued if they are rested? P: I don't know what to say. The fact is that I am all in no matter how well I slept. If you call that a subjective feeling you must think it is mental. But I didn't even have time to think about it. It is there the moment I wake up. E: I do not know what precisely you mean when you use the word "mental." Presumably you refer to the possibility that you may have the thought of fatigue in your mind and instantly feel the fatigue in your muscles* This instantaneous response of the muscles to a thought seems to puzzle you. I do not see why it should. You have certainly gone through similar experiences hundreds of times. Remember the occasion, for instance, when you were at a meeting and were called upon to make a speech. Instantly, your heart began to palpitate, your face reddened, your abdomen trembled and the knees shook. To use your own words, you "didn't even have time to think" of the speech; you merely heard your name called, and the muscles of 320 MENTAL HEALTH THROUGH WILL-TRAINING your heart, abdomen and legs were thrown into violent tremors "in no time." In the instance which I quoted the thought in your mind which caused your muscles to shake was the fear of not being able to deliver a well constructed address. It was a fear, or you may call it a fear idea, or the idea of danger. Do you understand now that if an idea strikes or occupies your mind the muscles may respond with a violent reaction in a fraction of a second? P: I understand that. But when I get up in the morning there is no idea of danger in my head. E: The question is what you mean by danger. If you wish to indicate that, in the morning, you are not trembling with the fear of being killed or trapped or burned I shall fully agree with you that no such idea may occupy your brain immediately after awakening. But there are subtler forms of fears and dangers. These subtle anxieties and apprehensions go by the name of preoccupations. I happen to know from your own account how readily you fall victim to such preoccupations. Let me remind you, for instance, of the anguish you experience whenever you expect visitors for the afternoon or the evening. You fret and worry days in advance, anticipating some bungling or clumsiness while performing the part of the hostess. You know that when finally the much dreaded day arrives you feel troubled and helpless "the very minute" you awaken. The day stares you in the face as a threat, as an event fraught with heavy responsibilities. You are without pep or zest. Your vitality is at a low ebb. A heaviness seems to descend on your limbs. Everything is done with effort. You have to drag yourself, feel "all in," exhausted, lifeless, fatigued. Do you understand that all of this is caused by your preoccupation, and that the preoccupation is based on the idea of danger ? P: It is true I am worrying my head off when I expect guests. People are critical, and it is not easy to please them and make them feel at home. But we don't have visitors every day, and there is not a day when I feel relaxed. I am always tired. E: I mentioned your preoccupation with your guests as an example only. The example will demonstrate to you that a pre MENTAL HEALTH THROUGH WILL-TRAINING 321 occupation of this kind is apt to produce, in a split second, a condition in which you feel "all in," dragging, exhausted and listless. Being a nervous patient you are always preoccupied with your disability. This preoccupation is a kind of worry which hardly ever leaves you. You are always on guard against something untoward happening in some part of your body. Looking back on your unhappy experiences of the past ten years you can recall numerous instances in which you planned a social engagement, a card game, a show, a trip and were stricken with a severe head pressure or palpitations or abdominal pain or numbness. The card game had to be interrupted, or you managed painfully to go through with it in wretched agony. You remember the frequent occasions when dinner parties had to be cancelled because your throat suddenly "locked," and you were afraid you might not be able to swallow or speak; or the dances that had to be called off because a heaviness settled on your legs so that you could hardly walk. It was observations of this character that in time suggested to you that it was no use planning. The unpredictable suddenness with which your symptoms could make their appearance gave you no guarantee that if you made a plan you could go through with it. Gradually the inability to plan spread to the trivial chores of everyday life. You set out to prepare a meal, and your eyes blurred. Or you decided to darn your husband's socks, and the hands trembled. The symptoms came without warning. They shot through your body without cause, without provocation. To use your own words, you "didn't even have time to think about them." I may tell you that symptoms which shoot up so unexpectedly, in a mere fraction of a second, are called "trigger symptoms." They shoot forth with the rapidity of a bullet after the trigger has been pulled. Their trigger character makes them appear weird, mysterious, threatening. In essence, they suggest to you that you have utterly lost control of your primitive bodily functions. Having noticed time and again that your organs may go on a rampage without warning you feel you cannot trust your body. You must always be on the alert for some sudden disturbance. You cannot plan with any assurance of carrying out 322 MENTAL HEALTH THROUGH WILL-TRAINING your decisions. But if you are deprived of the power to plan, your day is carried on without accomplishment. Moreover, without planning, you miss that singular joy of looking ahead to accomplishments. The joyous trembling of watchful anticipation is taken from your daily routine. Life becomes a never-ending drabness and drudgery. It is this type of life that you look forward to when you awaken in the morning. In a flash, before you had "time to think about it," the dismal dreariness of your existence stares at you. Again one of those empty days with no plans, no decisions, no accomplishments. You become discouraged, disgusted with the dead monotony that is in store for you, and it is the self-disgust that robs your tissues of their vitality. There is no vigor, zest or incentive with which to start out on the daily routine. Your body is devoid of stimulation; it feels uninspired, flabby, limp. This feeling of limpness you call "fatigue." You will now understand why towards evening your vitality returns and why, after supper, you "feel almost well." There is nothing left for planning after supper, no drabness to be anticipated, no drudgery to be performed in self-disgust. The dreadful day is gone or going. Nothing is expected of you any more. You breathe freely now, and your vitality returns. Do you realize now that what you call "fatigue" is nothing but a psychological reaction to the anticipated and dreaded boredom of daily existence? Do you understand that the tiredness of which you complain is not in your muscles but in your mind? P: You are right, doctor. I realize now that everything you say is exactly as I feel it. My mornings are dreadful. I have nothing to look forward to. I can't plan; I am afraid to plan. You are right, doctor, but why was I never told what is wrong with me? I have seen all kinds of physicians, and the one told me I was suffering from nervous exhaustion, another said my energy was running down, and I should take it easy. One blamed it on my thyroid gland; another told me I had a poor constitution and he couldn't do anything about it. I was warned not to overwork, was told to take long periods of rest, to go on trips and vacations. If you say that my trouble is nothing but MENTAL HEALTH THROUGH WILL-TRAINING 323 boredom and disgust why did nobody tell me that before? It would have spared me ten years suffering, and I could have saved thousands of dollars spent on cures, sanitariums and trips. E: It is painful for me to answer this question. I do not like to be critical of what other men think or believe. Unfortunately, there are superstitions that refuse to die. One of them, very preposterous and pernicious, is the myth of nervous fatigue or nervous exhaustion. All I can tell you is that, in 1880, a New York physician formulated the absurd theory that a group of patients whom he called "neurasthenics" suffered from a state of nervous exhaustion.* How uncritical this man was is evident from the fact that he did not hesitate to make unwarranted and extravagant claims, for instance, that the "disease runs in families," that it is due to inheritance, that it has its origin in the spine, that it is typically American and, hence, proposed to call it "American Nervousness." Somehow this fanciful idea spread all over the globe and is still widely accepted today as a message of scientific truth. I cannot tell why a theory of this kind has been permitted to figure in textbooks and to be practiced on hapless sufferers. All I can state is that superstitions are born easily but die with difficulty. I do not blame you for feeling resentful of the unnecessary hardship that was imposed on you during ten long years of anguish. But resentment will not help you. It will only serve to whip up your emotions and throw an additional load on your nervous system. What you need is re-education. You must learn to reject as untrue all the silly notions that were crammed into your head and to accept the explanation which I gave you. Up to now, with the thought of exhaustion in your brain, you were afraid to move, to work, to tax your "weak" muscles. I take it for granted that henceforth you will throw to the winds all this drivel about nerve exhaustion and will not hesitate to tax your muscles to your heart's delight. P: You told me that before, and I made every effort to accept your view. On many mornings I jumped out of bed with- *George M. Beard, A Practical Treatise on Nervous Exhaustion (Neurasthenia), New York, 1880, William Wood. 324 MENTAL HEALTH THROUGH WILL-TRAINING out paying attention to my fears. I ignored the heaviness in my muscles and did my work, but it was certainly difficult. Your assurance that the fatigue is in the brain and not in the muscles helps me at times. But after I continue with my work for awhile the thought strikes me that maybe the other doctors were right when they warned me not to strain my muscles. After ten years it seems not easy to shake off the fears. E: You said you made every effort to accept my views about fatigue. This is, of course, an exaggerated claim. I do not expect anybody to make "every" effort in any endeavor. What you mean is that you tried hard but did not succeed. But remember, Evelyn, I never asked you to "accept my views." I asked you to practice them. My view with regard to "nervous fatigue" is that you can safely ignore it, that it is a bugaboo and not a real danger. This view cannot be "accepted" and, as it were, placed in your brain there to preside over your actions. In order to make a view direct your action it must be acquired, digested and absorbed through patient practice. This is true of every sphere of life in which you wish to plant views into the thoughts and brains of a person. In bringing up your children you did not merely present them with lovely notions and lofty principles, asking them to accept them. These views had to be practiced, again and again, till finally they were incorporated and lived and experienced and acted out spontaneously. When you intended to make your boy adopt the view of group responsibility you did not tell him to accept your principle of group behavior. Instead, you told him not to make noise in the presence of people. You urged him to say "thank you" and "please." This you did for months and years until finally the new habits took root. After ceaseless practice your boy finally incorporated the view in his system, made it part of his organism. The practice made the view "sink in" and take its firm place in the brain from where it then directed action. In this process of child training you influenced your boy's muscles and through them established a firm structure of habits. It was these good habits that represented your view. You understand now that I asked you to MENTAL HEALTH THROUGH WILL-TRAINING 325 practice my view, not merely to accept it. The continued practice would have brought acceptance in its train. You will perhaps remember what precisely I asked you to do. I told you to jump out of bed and to go about your work, fatigue or no fatigue. But I also warned you to avoid all actions that embody the view of danger, I specifically instructed you not to look in the mirror to watch your so-called fatigue in your anxious features. I asked you to avoid the practice of touching the muscles of your arms and legs to investigate the degree of their flabbiness. I cautioned you not to sit down after a few steps or a few manipulations. Most important, I enjoined you not to complain about your fatigue, not to moan or sob, not to ask for help or sympathy. If you had complied with these instructions you would have established a new set of habits of how to deal with this legendary thought of nervous fatigue. The old habits of fear would have been crowded out of your mind, and a new set of constructive trends would have settled down or sunk into your brain. My view would then have occupied and taken possession of your brain without any effort on your part to accept or adopt it. If you say that "after ten years it is not easy to shake off the fears" I shall advise you that you had no business assuming that it might be easy. Mere acceptance of a view is easy, but practicing it means sustained application with endless trials and endless failures till finally you score the ultimate success. You thought of merely accepting a view. That would have been easy but ineffectual. What I wanted you to do was to practice, i.e., to direct your muscles to carry out my view. I presume that after tonight's interview you will no longer entertain the unrealistic notion that mere lip-service to a principle -will reestablish a new set of habits. Practice alone will do that.