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Is there more to fatigue?

Date: 14 November 2004

MIND MATTERS BY DR LEE AIK HOE FATIGUE, donít we suffer from it some time or other? In our hectic lifestyles, we are prone to physically running ourselves out of energy. We are often committed to too many activities and responsibilities. This is understandable fatigue and we just need to correct our pace of life. But there are others who suffer from fatigue for no apparent reason, and for long periods too. Tina (not her real name) is a 43-year-old married lady. She works as an executive for a private corporation. She had presented to her doctors with unexplained tiredness for the past four months. She needed to rest a good part of the day. She found it tiring to go out for meals or shopping and would avoid them. She had given up ferrying her children for their activities. She also complained of headaches and pains in her legs. She had insomnia and needed medicine to help her sleep. She took frequent medical and annual leave from her work to rest at home. She consulted physicians, and later a neurologist, but extensive tests came up normal. Fatigue is commonly defined as a subjective experience of tiredness and lack of energy. Chronic fatigue is characterised as fatigue lasting more than six months, although it is an empirical time period and shorter periods should also be considered. There are many medical causes of chronic fatigue and these should be excluded. A visit to the physician would warrant looking for causes such as anaemia, infections, metabolic and endocrine causes, malignancies, heart ailments and others. These are usually not difficult to diagnose with the help of blood tests and other basic investigations. If any of these are detected and treated adequately, the fatigue reverses and the person regains the energy that had been lacking. Occasionally, despite a known medical illness being diagnosed and treated, fatigue may still complicate the problem. Again investigations may not reveal the cause of the persistent fatigue. This has occasionally been seen following the treatment of some infections and cancers. Fatigue is also a common psychiatric symptom. Psychiatric illnesses, apart from their psychological symptoms, are known to cause physical symptoms too. Anxiety presents with mainly physical distress such as palpitation, breathlessness, cold and clammy hands and feet, tremors, frequency in passing urine or motions and many other symptoms. It may lead to a feeling of exhaustion. Depression leads to physical complaints as well. The sufferer has poor appetite, weight loss, occasional body aches and pains and fatigue. Alex (not his real name) was a college student who slept a lot. His parents were quite exasperated that when he came back from college he would lie in bed and appeared to sleep through the day and night. He seemed tired all the time and his studies began to suffer. After a few months, his father decided to bring him to a psychiatrist. Alexís father had suffered depression some years ago and considered the possibility that Alex could be going through an emotional problem. Alex could not identify any psychological stresses but admitted that he had lost concentration and also lost interest in his studies and his friends. Alex was put on antidepressants and gradually over a period of two months he felt more energy and began to show interest in his studies again. He passed his exams and went on to do his twinning studies overseas while still taking the antidepressant. His parents were quite relieved and proud when Alex finally graduated. Fatigue has long been recognised as an important symptom of depression. It occurs together with feelings of weakness, poor concentration and inability to cope with oneís daily routine. The sufferer is often puzzled by the extra effort needed to perform any activity. Fatigue and sleep disturbance are the two strongest indicator of depression among medical patients. A condition called chronic fatigue syndrome has been considered an entity for a long time. In this condition, the sufferer has persistent fatigue associated with various other symptoms such as headache, muscle pain, poor concentration, insomnia, hair loss and sometimes enlarged lymph nodes. The cause of this condition is unknown and a diagnosis is made by excluding all physical and psychiatric disorders. In the past, certain viruses have been implicated, but unproven. It has been reported that the incidence of chronic fatigue syndrome in the West is one per 1,000 and occurs more commonly in younger women. No specific treatment is available. However psychiatric evaluation is useful and treatment with antidepressant and psychotherapy may produce marked improvement. Tina was referred to a psychiatrist while hospitalised. She accepted the consultation with the psychiatrist but dropped out of treatment after discharge from hospital. She still clung on to the belief that it could not be due to a psychological problem. Six weeks had passed before she consulted the psychiatrist again, mostly out of desperation as she had not recovered and her job was at stake. She accepted treatment this time with the insistence of her family. Tina was put on antidepressant medications and received counselling. Over a period of another six weeks, she gradually recovered. Her mood was brighter and more positive, and she did not feel as tired anymore. She could go out shopping with her children again and started taking responsibility for them. She restarted work with half-day attendance for a month before resuming normal full-day duties. Chronic fatigue in patients requires a multidisciplinary medical approach. In the absence of any medical cause, a psychiatric assessment will be useful. Coexisting depression is often present in the sufferer and a course of treatment for depression using medication and counselling helps. Referral to a psychiatrist is often resisted by the patient as the patient feels that her symptoms are being trivialised. This is a wrong perception as the physical suffering can best be treated with a combined approach. This article is contributed by members of MPA & Early Intervention Unit (EIU). The information provided is for educational purposes only and should not be considered as medical advice.

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