http://bmj.com/cgi/content/full/325/7362/480
| Home | Help | Search/Archive | Feedback | Table of Contents |
|
|||||||||
 Collections under
which this article appears: Somatoform
disorders Musculoskeletal
syndromes (including chronic fatigue and Gulf war syndromes)
|
ABC of psychological medicine
Michael Sharpe
Fatigue can refer to a subjective symptom of malaise and aversion to activity or to objectively impaired performance. It has both physical and mental aspects. The symptom of fatigue is a poorly defined feeling, and careful inquiry is needed to clarify complaints of "fatigue," "tiredness," or "exhaustion" and to distinguish lack of energy from loss of motivation or sleepiness, which may be pointers to specific diagnoses (see below).
|
Prevalence
Like
blood pressure, subjective fatigue is normally distributed in the population.
The prevalence of clinically significant fatigue depends on the
threshold chosen for severity (usually defined in terms of associated
disability) and persistence. Surveys report that 5-20% of the general
population suffer from such persistent and troublesome fatigue.
Fatigue is twice as common in women as in men but is not strongly
associated with age or occupation. It is one of the commonest
presenting symptoms in primary care, being the main complaint of
5-10% of patients and an important subsidiary symptom in a further
5-10%.
Fatigue as a symptomPatients
generally regard fatigue as important (because it is disabling), whereas doctors
do not (because it is diagnostically non-specific). This discrepancy
is a potent source of potential difficulty in the doctor-patient
relationship. Fatigue may present in association with established
medical and psychiatric conditions or be idiopathic. Irrespective of
cause, it has a major impact on day to day functioning and quality of
life. Without treatment, the prognosis of patients with idiopathic
fatigue is surprisingly poor; half those seen in general practice
with fatigue are still fatigued six months later.
|
 |
Causes of fatigue |
|---|
 Top  Causes of
fatigue  Assessment and
formulation General
management Referral for
specialist... Conclusion
|
|---|
The physiological and psychological mechanisms underlying subjective fatigue are poorly understood. Fatigue may rather be usefully regarded as a final common pathway for a variety of causal factors. These can be split into predisposing, precipitating, and perpetuating factors.
Predisposing factors include being female and a history of either fatigue or depression.
Precipitating factors include acute physical stresses such as
infection with Epstein-Barr virus, psychological stresses such as
bereavement, and social stresses such as work problems.
| Medical conditions
that may present with apparently unexplained fatigue
|
Perpetuating factors include physical inactivity, emotional disorders, ongoing psychological or social stresses, and abnormalities of sleep. These factors should be sought as part of the clinical assessment.
Other physiological factors such as immunological abnormalities and slightly low cortisol concentration are of research interest but not clinical value.
Diagnoses associated with fatigue
Among patients who present with severe chronic fatigue as their main
complaint, only a small proportion will be suffering from a
recognised medical disease. In no more than 10% of patients
presenting with fatigue in primary care is a disease cause found. The
rate is even lower in patients seen in secondary care.
Fatigue is a major symptom of many psychiatric disorders, but for a
substantial proportion of patients with fatigue the symptom remains
unexplained or idiopathic. In general, the more severe the fatigue
and the larger the number of associated somatic (and unexplained)
complaints, then the greater the disability and the greater the
likelihood of a diagnosis of depression.
| Psychiatric diagnoses
commonly associated with fatigue
|
Chronic fatigue syndromes
Chronic fatigue syndrome is a useful descriptive term for prominent
physical and mental fatigue with muscular pain and other symptoms. It
overlaps with another descriptive term, fibromyalgia, that has often
been used when muscle pain is predominant but in which fatigue is
almost universal. There is also substantial overlap of the diagnoses
with other symptom based syndromes, the so called functional somatic
syndromes.
| Diagnostic criteria
for chronic fatigue syndrome
Inclusion criteria
Exclusion criteria
|
The term myalgic encephalomyelitis (or encephalopathy) has been used in Britain and elsewhere to describe a poorly understood illness in which a prominent symptom is chronic fatigue exacerbated by activity. This is a controversial diagnosis that some regard as simply another name for chronic fatigue syndrome and that others regard as a distinct condition. This article will focus on chronic fatigue syndrome.
Prevalence and outcomeChronic
fatigue syndrome can be diagnosed in up to 2% of primary care patients.
Untreated, the prognosis is poor, with only about 10% of patients
recovering in a two to four years. A preoccupation with medical
causes seems to be a negative prognostic factor.
| |
Assessment and formulation |
|---|
|
Top Causes of
fatigue Assessment
and formulation General
management Referral for
specialist... Conclusion
|
|---|
HistoryThe
nature of the fatigue is an important clue to diagnosis, and it is therefore
important to clarify patients' complaints. Fatigue described as loss
of interest and enjoyment (anhedonia) points to depression. Prominent
sleepiness suggests a sleep disorder. The history should also cover
| Screening tests for
fatigue
|
ExaminationBoth
a physical and mental state examination must be performed in every case, to seek
medical and psychiatric diagnoses associated with fatigue.
Routine investigationsIf
there are no specific indications for special investigations, a standard set of
screening tests is adequate.
Special investigationsImmunological
and virological tests are generally unhelpful as routine investigations. Sleep
studies can be useful in excluding other diagnoses, especially
obstructive sleep apnoea and narcolepsy.
| Factors to consider in
a formulation of chronic fatigue
|
||||||||||||||||||||
Psychological assessmentIt
is important to inquire fully about patients' understanding of their illness
(questions may include "What do you think is wrong with you?" and
"What do you think the cause is?"). Patients may be worried that the
fatigue is a symptom of a severe, as yet undiagnosed, disease or that
activity will cause a long term worsening of their
condition.
FormulationA
formulation that distinguishes predisposing, precipitating, and multiple
perpetuating factors is valuable in providing an explanation to
patients and for targeting intervention.
| |
General management |
|---|
|
Top Causes of
fatigue Assessment and
formulation General
management Referral for
specialist... Conclusion
|
|---|
Persistent fatigue requires active management, preferably before it has
become chronic. When a specific disease cause of fatigue can be
identified this should be treated. If no disease diagnosis can be
made, or if medical treatment of disease fails to relieve the
fatigue, a broader biopsychosocial management strategy is required. A
discussion with the patient about fatigue and its treatment can be
supplemented with written material (see below).
| Management of chronic
fatigue
|
Patients should be told that they are suffering from a common and treatable condition that the doctor takes seriously and for which behavioural treatment can be helpful. While patients may be concerned about possible disease and the need for medical investigation and treatment, it can be explained that no disease has been found, and hence there is no disease based treatment, but that with help there is a great deal that the patients can do themselves.
Identifying unhelpful beliefsPotentially
unhelpful beliefs should be discussed. If a patient has a simple aetiological
model (such as "It is all due to a virus") an alternative approach
based on a biopsychosocial formulation can be outlined. This has the
advantage of highlighting potential perpetuating factors, as these
may be regarded as obstacles to recovery. Doctor and patient can
then work together to overcome these. It is rarely productive
to argue over the best name for the illness; instead, the emphasis
should be on agreeing a positive and open minded approach to rehabilitation.
|
Managing activity and avoidanceGradual
increases in activity can be advised unless there is a clear contraindication.
It is critical, however, to distinguish between carefully graded
increases carried out in collaboration with patients and "forced"
exercise. It is also important to explain that erratic variation
between overactivity on "good" days and subsequent collapse does
not help long term recovery and that "stabilising" activity is
a prerequisite to graded increases.
|
Depression and anxietyIf
there is evidence of depression a trial of an antidepressant drug is worth
while. Patients with fatigue are often sensitive to the side effects
of antidepressants. However, if they are given adequate information
about what to expect when treatment begins, with small doses, most
patients can tolerate them. Randomised trials have shown
psychological therapies such as cognitive behaviour therapy to be
equally effective for mild to moderate depression.
Managing occupational and social stressesPatients
who remain in work may be overstressed by it. Those who have left work
may be inactive and demoralised and may not wish to return to
the same job. These situations require a problem solving approach to
consider how to manage work demands, achieve a return to work, or to
plan an alternative career.
| |
Referral for specialist management |
|---|
|
Top Causes of
fatigue Assessment and
formulation General
management Referral for
specialist... Conclusion
|
|---|
Most patients with fatigue are managed in primary care, but certain groups may require referral to specialist care:
Referral may be to a physician or psychiatrist as is deemed most appropriate.
Psychologists may be able to offer cognitive behaviour therapy. Where
available, joint medical and psychiatric clinics are ideally suited
to the assessment of chronic fatigue and related problems. It is
essential there is close liaison between primary and specialist care
to ensure a clear, consistent, and encouraging approach by all
concerned.
| What is cognitive
behaviour therapy?
|
Rehabilitation
Rehabilitation based on behavioural principles is currently the most
effective specialist treatment approach.
| What is graded
exercise therapy?
|
Cognitive behaviour therapy is a collaborative psychological rehabilitation that incorporates graded increases in activity but also pays greater attention to patients' beliefs and concerns.
Graded exercise therapy is a structured progressive exercise programme
administered and carefully monitored by a therapist.
| Evidence based summary
Wessely S. Chronic fatigue: symptom and syndrome. Ann Intern Med 2001;134:838-43 Whiting P, Bagnall AM, Sowden AJ, Cornell JE, Mulrow CD, Ramirez
G. Interventions for the treatment and management of chronic fatigue
syndrome: a systematic review. JAMA 2001;286:1360-8 |
Both may be used in conjunction with antidepressant drugs. Both have been found to be effective in randomised trials of hospital referred cases of chronic fatigue syndrome. Some general practitioners are able to provide graded exercise or cognitive behaviour therapy in their practice or clinic. Others may wish to refer to a trained therapist.
| |
Conclusion |
|---|
|
Top Causes of
fatigue Assessment and
formulation General
management Referral for
specialist... Conclusion
|
|---|
Fatigue is a ubiquitous symptom that is important to patients and has a major
impact on their quality of life. It remains poorly understood and has
hitherto probably been not been given adequate attention by doctors.
Early and active management of fatigue in primary care may prevent
progression to chronicity. Patients who have developed a chronic
fatigue syndrome can benefit from specific treatments. Paying more
attention to the symptom of fatigue may help to avoid the distress
and poor outcome that is associated with patients feeling that their
problems are neither accepted nor understood. It may also reduce the
numbers who turn to a variety of unproved, and even harmful,
alternative approaches.
| Further reading
|
| |
Acknowledgments |
|---|
The painting Weary is held at Russell-Cotes Art Gallery and Museum, Bournemouth, and is reproduced with permission of Bridgeman Art Library. The graph of distribution of fatigue in the population is adapted from Pawlikowska T, et al BMJ 1994;308:763-6. The box of diagnostic criteria for chronic fatigue syndrome is adapted from Fukuda K, et al Ann Intern Med 1994;121:953-9. The print of "Mrs Bradbury's establishment for the recovery of ladies nervously affected" is reproduced with permission of Wellcome Library. The graph showing efficacy of cognitive behaviour therapy is adapted from Prins JB, et al Lancet 2001;357:841-7.
| |
Footnotes |
|---|
Michael Sharpe is reader in psychological medicine, University of Edinburgh. David Wilks is consultant in infectious diseases, Western General Hospital, Edinburgh.
The ABC of psychological medicine is edited by Richard Mayou, professor of psychiatry, University of Oxford; Michael Sharpe; and Alan Carson, consultant neuropsychiatrist, NHS Lothian, and honorary senior lecturer, University of Edinburgh. The series will be published as a book in winter 2002.
|
|||||||||
|
Collections under
which this article appears:Somatoform
disorders Musculoskeletal
syndromes (including chronic fatigue and Gulf war syndromes)
|
Read all Rapid Responses
| Home | Help | Search/Archive | Feedback | Table of Contents |
ALL INFORMATION, DATA, AND
MATERIAL CONTAINED, PRESENTED, OR PROVIDED HERE IS FOR GENERAL INFORMATION
PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REFLECTING THE KNOWLEDGE OR OPINIONS
OF THE PUBLISHER, AND IS NOT TO BE CONSTRUED OR INTENDED AS PROVIDING MEDICAL OR
LEGAL ADVICE. THE DECISION WHETHER OR NOT TO VACCINATE IS AN IMPORTANT AND
COMPLEX ISSUE AND SHOULD BE MADE BY YOU, AND YOU ALONE, IN CONSULTATION WITH
YOUR HEALTH CARE PROVIDER.
