What is fatigue?
It’s puzzling, isn’t it? With so much energy throughout nature, how can anyone possibly feel fatigued? Why is fatigue a daily experience for millions of people? Why for many of them is it the dominant experience of their lives?
Deepak Chopra, Boundless Energy.
What is fatigue?
All around us we see nature and our physical environment abounding with energy. Einstein tells us that energy is simply equal to mass multiplied by the speed of light squared – so in theory at least, the larger we are, the more energy we should have. So why is it that fatigue (or exhaustion or extreme tiredness or lack of energy) is something most of us have experienced at one time or another? - probably about 25% of the population experience fatigue at any one time. Most children take their energy for granted, so why do we expect to have less energy as we get older?
Fatigue is a common health complaint and also one of the hardest to define – it is usually taken to mean a lack of energy and motivation and feeling weak. It is a symptom (rather than a specific disease or disorder) that can result from many different medical conditions. It can be either mental or physical (or both) in origin and is often poorly understood and treated by conventional approaches to heath.
Sometimes it is hard to know exactly whether you are tired, weak, fatigued, or have other symptoms. Nevertheless, any type of fatigue can indicate a serious medical condition and needs prompt medical investigation. Fatigue or exhaustion, the feeling of extreme tiredness or weakness, can make it difficult for you to perform ordinary tasks. It affects everyone differently; you may feel very tired and all you want to do is sleep; it may feel like you are wading through treacle and as if your brain is packed in cotton wool soaked in anesthetic (this is how I remember it); it may also be accompanied by pain and sometimes can make you feel that you have little control over your life. In many cases, exercise and repeated activity will build up strength and stamina and the fatigue will disappear. This is not the case with ME*.
Typically when you have persistent fatigue, your doctor will review your symptoms and ask about your daily routine, work habits, and environmental conditions. He or she will give you a physical examination and may want you to have basic blood tests done to rule out diseases that may cause fatigue. If you are under a lot of emotional stress or experience recurrent anxiety or depression, your doctor may diagnose fatigue caused by psychological disturbances.
In the case of ME the standard blood tests come back ‘negative’ and ‘diagnosis’ is the result of having excluded other serious illnesses.
Fatigue may be physical or mental in its origin and has a huge number of possible underlying causes. You may have physical fatigue as the result of a long day of hard work or a hectic schedule. In contrast, emotional fatigue is usually more striking in the morning and less draining as the day progresses.
Fatigue is a symptom of many medical conditions including:
Ö MS (Multiple Sclerosis)
Ö Cancer
Ö Anemia
Ö Hepatitis
Ö Rheumatoid Arthritis
Ö Hypothyroidism (under-active thyroid)
Ö ME/CFS (Chronic Fatigue Symptom)
Some other causes of physical fatigue are:
Ö Infections such as ‘flu and glandular fever
Ö Not getting enough sleep
Ö Poor physical condition, lack of exercise
Ö Obesity
Ö Pregnancy
Ö Environmental causes such as exposure chemicals, e.g. pesticides and formaldehyde,
Ö Side effects of certain prescription and over-the-counter medications e.g. antihistamines and blood pressure medications.
Ö Medical treatments such as surgery, chemotherapy and radiotherapy.
Ö Chronic pain
Some causes of emotional fatigue include:
Ö Depression or anxiety
Ö Overextending yourself or trying to hide your emotions from others
Ö A major life change
Ö Workplace stress
CFS/ME: what is it and how it may be different from other fatigues?
Chronic fatigue syndrome (ME*) is a long-term unexplained fatigue that has not always been present, and may occur with other symptoms such as recurrent sore throats, muscle pain, multi-joint pain, tender lymph nodes, new patterns of headaches and complaints such as impaired memory or concentration. It is generally the result of some sort of stress such as an infection or major life-changing event. ME stands for Myalgic Encephalomyelitis. Myalgia means 'painful muscles', common in many with ME; encephalitis is 'inflammation of the brain and nerves' - not actually detected in the strict sense in those with ME.
Two of the most characteristic and debilitating signs of ME/CFS are very poor stamina and delayed post-exertion fatigue. It therefore differs from ordinary fatigue in that there is not an exact correlation between the effort and the fatigue and there can be anything from hours to days between any effort and exhaustion. Repeated activity doesn’t lead to adaptation and improvement in strength and stamina (as happens in other cases) – in fact the reverse generally happens. Sometimes the fatigue is mainly mental, and sometimes mainly physical.
* N.B. ME is used here as a generic term to cover all the names given to this syndrome including CFS/ME, CFS and Fibromyalgia for the reason given at the end of this piece.
How is it diagnosed?
In the case of ME, the standard blood tests come back ‘negative’ and ‘diagnosis’ is the result of having excluded other serious illnesses. The physical symptoms may come under the care of endocrinologist (hormones), immunologists (infections and the immune system), neurologists (the nervous system) or gastroenterologists (the gut). None provide the complete cause - or treatment.
There are a number of different criterion, for example the Oxford and Canadian, which are applied to decide which type of ME, if any, you have. Typically, the fatigue and symptoms have to have lasted for at least 6 months, be new in origin, and often need to be accompanied by 4 – 6 other symptoms from their list. These criteria are probably more useful for research selection purposes than for medical diagnosis. The severity of an individual’s ME can be measured on the CFS Ability scale, dividing the spectrum ranging from 0 to 100 bands (or from 0 – 10 on the Bell scale) into 10 bands. 0 is defined as ‘Severe symptoms on a continuous basis. Bed ridden constantly, unable to care for self.’ 100 (or 10) describes someone unaffected by ME - ‘No symptoms with exercise. Normal activity overall. Able to do house/home work full time with no difficulty.’ To qualify for disability living allowance, for example, a person needs to be 80% disabled – i.e. score 20 or less on the ability scale.
Who is likely to develop ME and why?
There may be several types of people who are pre-disposed to ME (2). People with weak immune systems, either genetically deficient or due to exposure to factors which have damaged their immune systems. People who have problems detoxifying chemicals and so become sensitive to them at levels harmless to others. Those whose diets or lifestyles, e.g. shift-work, smoking etc.
High achievers and perfectionists who push themselves hard and judge themselves by their results; those who constantly place the needs of others above their own and only value themselves when doing so; anxious and fearful people; and those who have experienced an unresolved trauma of some sort. All these produce an on-going stress on the mind and body.
If these are the pre-dispositions to developing ME – the time bomb ticking away as it were - then it needs a trigger to light the fuse to precipitate ME (and some with the pre-disposition may never develop ME). ). A trigger such as a severe emotional, mental or environmental stress or a severe infection or exposure to a chemical can prove to be ‘the last straw’. Others are unaware of any such trigger and symptoms may gradually emerge.
What mechanisms are present in ME?
Two mechanisms which are thought to be present in virtually all those with ME / CFS and FM are maladaptive stress response and mitochondrial malfunction. The long term effect of these two mechanisms may explain the array of symptoms observed. (1, 2, 3)
Initially when we are under stress, our limbic (primitive) brain, particularly the amygdala (3), reacts (via the hypothalamus – pituitary- adrenal (H-P-A) corridor), by getting our adrenal gland to produce more adrenaline. This works fine for short-term stress, and produces the ‘cave-man reaction to their saber toothed tiger’ danger response known as flight, fight or freeze. After taking the appropriate action, adrenaline production drops and we return to normal. With our modern stresses such as described above, these 3 responses don’t solve the problem and so we remain in the stressful situation; our adrenal glands keep firing and start producing the stress hormones which include cortisol. Cortisol levels build up slowly and steadily producing additional fear and stress, altering recovery time to adrenaline bursts etc. until we ‘burn out’ and go into a state of high alert. Unable to sleep, unable to produce enough cortisol to keep our mitochondria (see below) functioning, our adrenal glands stop producing their hormones. This has a negative impact on our immune system, digestive system, nervous system – in fact on every aspect of the working of our body.
The characteristics of ME, delayed fatigue and poor stamina, as well as the muscle pain of Fybromyalgia and the affects on various organs in the body can be explained by a malfunction in the mitochondria. The level of mitochondrial activity is directly proportional to the level of cortisol (controlled by nitric oxide levels) and so will be decreased during adrenal stress.
Mitochondria can be thought of as tiny re-chargeable power packs found in nearly every cell - effectively they are the engines of our cells, supplying the energy necessary for all cellular processes to take place. (4)
Under normal working conditions, mitochondria are the sites of energy production and house the perfect, complex cycle of chemical reactions which converts glucose (sugar) into the energy which powers the workings of our body. Given a constant supply of glucose and oxygen, the chemicals normally keep re-cycling providing us with the energy we need for our muscles, organs, body heat etc. as we need it. In the final part of energy production, ATP (adenosine tri-phosphate) is converted into ADP (-di-phosphate) + P (phosphate) and in the process releases energy for use in the body. Normally the ADP + P (+ energy from glucose) then re-combine to form ATP again, ready to release the next batch of energy. With ME there is a problem and the cycle goes so slowly that ATP can’t form in time to release the required energy, so leading to fatigue. In ME, if you carry on needing energy, your body can then break down ADP into AMP (-mono-phosphate) + P to release extra energy. AMP doesn’t recycle back to ADP and so is lost to the system and is then lost to your body; this means that recyclable ATP and ADP are lost too. It takes days or weeks for the body to make ATP again from scratch which explains why ‘crashes’ can take so long to recover from. This shows why such approaches as Cognitive Behaviour Therapy (CBT) and graded exercise can be so dangerous with ME.
Alternatively, energy production can get stuck in its far less efficient stage, glocolysis which doesn’t use oxygen; this produces pain-causing build-ups of lactic acid in the muscles (this is what happens to athletes at the end of a race but they can recover in a few minutes). Again, in ME this recovery is a slow process – and may partly explain the pain of fibromyalgia. All in all, it appears that energy is limited in ME due to errors in this system. This is especially noticeable in the muscles of the heart with the result that the heart can no longer pump enough energy-supplying blood around the body when a person is standing up, and can just about cope when they are lying down. ME can, then, be thought of as a life-saver. The effect of poor blood circulation results in the shutting down of the organs in the body in a certain sequence depending on their level of priority – skin, muscles, liver and gut, brain and finally the heart, lungs and kidneys, explaining other ME symptoms.
It is interesting to look at ME as a protective mechanism. Initially it gets the person out of the situation which produced the stress – so that they can no longer go on giving, or working in a stressful environment for example. It would also allow the body full rest to fight an infection. By causing a person to lie down rather than stand, it allows their heart to pump enough blood to keep their body functioning.
Generally, the correct treatment will depend on the cause of someone’s fatigue. For example, short-term fatigue, resulting from exercise, dehydration or sleeping badly can be quickly addressed by resting, drinking water or getting a good night’s sleep. In many cases, exercise and repeated activity will build up strength and stamina and the fatigue will disappear.
The cause and alleviation of long–term fatigue is far more complex. Since it can be the symptom of many different medical conditions and most infections and can also result from depression, un-healthy lifestyle choices, workplace issues and emotional concerns, as well as a variety of other physical, environmental and emotional stresses, it is most important to get a correct diagnosis and understanding of the cause of your fatigue before starting most treatments.
Although fatigue is a common health complaint, it is generally very badly handled. Conventional approaches seek to diagnose a condition and then divide treatments into medical (treating physical symptoms) or psychological (dealing with the mind) to get rid of the symptoms. The medical approach helps to eliminate the symptoms use drugs, hormones or surgery to address this through modifying the functioning of specific parts of the body; the psychological approach helps patients to recognise de-energising conscious patterns of thoughts and behaviours and then to change them (e.g. using Cognative Behaviour Therapy (CBT)). In the case of fatigue one individual often needs both approaches at the same time.
At the moment, the NHS is carrying out the PACE trials to test the efficacy of their psychological approach to the treatment of ME and others with fatigue, as selected under the Oxford criteria. PACE stands for: Pacing, Activity (graded exercise) and Cognative behaviour therapy: a randomised Evaluation. Current conventional treatments are producing the following results, according to the ME Association:
- Those who manage to return to completely normal health, even though this may take a considerable period of time. The percentage falling into this category is fairly small.
The majority, who tend to follow a fluctuating pattern with both good and bad periods of health. Relapses or exacerbations are often precipitated by infections, operations, temperature extremes or stressful events.
A significant minority, who remain severely affected and may require a great deal of practical and social support.
A few, who show continued deterioration, which is unusual in ME/CFS. When this occurs, a detailed medical assessment is advisable to rule out other possible diagnoses.
Most complementary therapies are holistic in their approach, treating the person as a whole. Many such as acupuncture, reiki, reflexology and massage use approaches to restore the correct ‘flow of energy’ through the body. Much of this is about treating symptoms rather than finding and correcting the underlying cause of the lack of energy. The ‘mind’ approaches such as Neuro-linguistic Programming (NLP) and hypnotherapy are excellent for eliminating the cause of the problem but are not experienced at restoring the ‘flow of energy’. Hypnotherapy is used clinically to address aspects of ME including stress management, sleep problems, pain control and anxiety. Working as it does with the sub-conscious mind, it can be used to enhance the workings of the para-sympathetic nervous system and calm the over-activated sympathetic nervous system. Using visualisations, people can ‘instruct’ their body about how to start the healing process.
The links between the mind and body are starting to be discovered and more widely accepted. Psychoneuroimmunology (PNI), the study of the interaction between psychological processes and the nervous and immune systems of the human body, has produced many replicated studies that find such a link. Although researchers have yet to found a biological mechanism linking the two systems that does not mean it is not a real phenomenon; there are many psychological and medical phenomena for which the precise mechanisms has not yet been defined.
The most effective ME treatments to date have used a variety of approaches. The use of ‘mind’ therapies to re-educate the individual and the working of their body; nutrients and optimum diet to reduce environmental stresses and help the body recover; hormonal treatments to restore the correct balance and functioning of the body.
Recovering Your Energy
Specifically, the remedy for chronic fatigue … [and in fact, all fatigue] … lies in the ability to tap into the unlimited natural field of energy that surrounds us at every moment.
Deepak Chopra, Boundless Energy.
The most important consequence for any individual experiencing fatigue from whatever cause is that they LACK ENERGY and this has a major impact on their lives.
Until now, little has been done to address the problems of lack of energy directly. This is where the approach described in the book, based on Energetic NLP (which takes the best of both the energy and mind – based complementary approaches), is so powerful – addressing the emotions and the beliefs behind the fatigue and providing simple methods that anyone can use for recovering and managing their own energy and tapping into natural sources of energy.
These methods fit perfectly with one of the principal precepts of medicine ‘first do no harm’. They can be used by an individual working on themselves and listening to their bodies; or with the guidance of a trained and skilled practitioner working with their client to help them to remove the causes for the fatigue, come up with new life strategies and promote optimum health and energy. The solutions come from the client rather than the therapist and so are tailor made for the individual.
For those with all forms of fatigue, including ME, there will be times when these practices and interventions alone will be all that is required to restore energy and health permanently. Others may not yet be at the stage to make a recovery; others still will need nutritional support, hormonal treatment or an exercise programme. Whatever an individual’s situation, an awareness of what has happened to their energy in the past and how they can manage it now and in the future is invaluable to the individual and practitioner.
It is important that individuals make changes to their way of thinking and to their lifestyle in order to promote recovery, otherwise regaining their energy will simply take an individual back to the original source of the stress and will result in a relapse. Changes should be made at a pace to suit the individual, devised by the individual as a result of them listening to their body and unconscious mind.
The term ME has been used because it appears to be an excellent name for the syndrome – each person’s ME is individual to them, and the solution really is about learning about yourself, listening to yourself, and looking after yourself. It is about putting your own oxygen mask on first, attending to your own needs first and only then attending to others. Otherwise (continuing the analogy), you will collapse and, rather than helping, cause even more problems! This will probably involve a whole shift in the way you think, your beliefs and the way you regard yourselves; remember it is, in fact, quite the opposite of being selfish. Look after yourself and then you are free to look after others if you choose or to use your skills in whatever way is most appropriate for you.
By reading this book and following the exercises you can complement and enhance your existing treatments, remove your blocks to recovering your energy and learn techniques which will change your life for ever for the better.
Diana Kingham 2009. www.optimiseyourlife.com.
For further detail about the discussion in this Appendix, please see:
1. Dr Sarah Myhill: a doctor (25 years NHS and private practice) with considerable experience of ME/CFS and other forms of fatigue. She uses a broad approach including nutritional, environmental & hormonal treatments, and offers a wide range of specialist tests. Her web-site contains a number of excellent articles and observations.
2. The Optimum Health Clinic with Alex Howard and colleagues. Their very successful integrated approach includes nutrition, NLP, hypnotherapy and courses.
www.freedomfromme.co.uk
3. Ashak Gupta’s successful approach involves retraining the amygda (part of the primitive brain) to work correctly using NLP, meditation, yoga and coaching.
www.cfsrecovery.com
4. Myhill, S., Booth, N.E., McLaren-Howard, J. Chronic fatigue syndrome and mitochondrial dysfunction. Int J Clin Exp Med 2009; 2: 1-16 (available to download from Dr Myhill’s site: Energy; Mitochondrial failure article),
Conclusion. ‘We have demonstrated the power and usefulness of the “ATP profile” test in confirming and pin-pointing biochemical dysfunctions in people with CFS. Our observations strongly implicate mitochondrial dysfunction as the immediate cause of CFS symptoms. However, we cannot tell whether the damage to mitochondrial function is a primary effect, or a secondary effect to one or more of a number of primary conditions, for example cellular hypoxia, or oxidative stress including excessive peroxynitrite. Mitochondrial dysfunction is also associated with several other diseases and this is not surprising in view of the important role of mitochondria in almost every cell of the body, but this fact appears to have been recognised only in recent years. The observations presented here should be confirmed in a properly planned and funded study. The biochemical tests should be done on CFS patients after, as well as before, appropriate interventions and possibly on patients with other disabling fatigue conditions. It would also be good to confirm the biochemical test results in a second (perhaps government-supported) laboratory.’
5. Chopra, Deepak. Boundless Energy: The complete mind-body programme for overcoming chronic fatigue. Rider, Ebury Publishing, 1995. Excellently presented medical examples; he applies the aurverdic approaches to health including diet, exercise and listening to your body.
UK Support groups and NHS treatment:
Action for ME www.afme.org.uk
Association for Young People with ME www.ayme.org.uk
The ME Association www.themeassociation.org.uk
ME Support www.mesupport.co.uk
Barts Hospital NHS CFS/ME treatment www.bartscfsme.org
PACE: Pacing, activity (graded exercise) and cognative behaviour therapy: a randomised evaluation. The current NHS trials for the treatment of ME and fatigue. www.thepacetrial.org
Most people with ME/CFS fall into one of four groups: