The causes
The problem of fatigue
When the normal tiredness we all get after a hard day is not relieved by a good night’s sleep or a break from the routine (like a weekend off), then we call it fatigue, or maybe just “tired all the time”.
Fatigue is often accompanied by being run down in other ways. Low mood can move into depression, we may perform badly and so get anxieties. We get headaches and brain fog. If the fatigue is prolonged our immune defences may be compromised, digestion can be affected, with poor appetite and upset bowels, increased sensitivities to foods and chemicals, and a general malaise can set in, with widespread aches and pains.
Many of us have experienced this. It might come after an intense period of hard work, or after an illness or emotional upset. Usually it passes as things settle down, and the body and mind recover themselves and find balance again.
However sometimes it doesn’t go away, and things then start getting really difficult. We find that modern medicine and modern society quickly run out of useful ideas. We are no longer seen as playing our part, told to “take a break and recharge”, that there is nothing seriously wrong that can’t be put right with a stronger resolve: even “pull yourself together”! Doctors often can find no clear medical causes and may write it up as the catch-all ‘chronic fatigue syndrome’ (CFS) or, even now, consider it “all in the mind”, diagnose clinical depression and reach for the antidepressants.
Sometimes fatigue is linked to another diagnosis, although each of these is also controversial: myalgic encephalomyelitis (ME), Lyme disease, post-traumatic stress disorder (PTSD), or Gulf War syndrome. More helpful for sufferers looking for an explanation, it can be classified as ‘post-viral syndrome’, notably after ‘glandular fever’ (Epstein-Barr or mononucleosis) and most recently ‘long covid’. It may be a feature of other conditions such as fibromyalgia, which is itself contentious, unless one is suffering from it.
There are some amazing supports out there, some inspiring doctors, and among health professionals, occupational therapists and physiotherapists can be notably helpful, but too often long-term fatigue is accompanied by neglect.
The answer from many years of experience and centuries of traditional insights is “yes”!
In the coming posts in this Issue of the Gazette we will look at different angles on managing fatigue that have really stood the test of time. There are no quick fixes here. Fatigue is not like that. However there is the real prospect of finding ways to rebuild strength by methodically addressing the underlying disruptions that lead to fatigue, correcting those that are correctable, and building better resilience to those that are not.
In this article we introduce the main disruptors before addressing each in future posts
What are the possible causes?
There are several possible mechanisms that can account for the feeling of fatigue.
Stress and our coping hormones. Undoubtedly persistent stress and work and life pressures are the most common causes of fatigue. Initially we usually respond to a stress as a challenge, with some energy and even enthusiasm. If the stress persists then we may settle into some sort of equilibrium with it, moreorless coping. If the stress goes on too far however we can reach a state of exhaustion that can be hard to remedy, at least while the stress remains.
The term ‘adrenal fatigue’ has sometimes been used for this state. However this is not a clever description of what is actually happening. Better to be seen as a much more extensive hormonal disruption, involving the ‘HPA axis’: a circuit that includes the hypothalamus and pituitary gland in the brain, and the adrenal cortex that produces steroid hormones, each gland regulating and affecting the other. HPA axis disruption simultaneously reduces adrenal responses to stress, lowers mood and upsets sleep, and thus the best option for recovery.
The HPA axis is a large part of our coping mechanism
CRH: Corticotrophin Releasing factor
ACTH: AdrenoCorticoTrophic Hormone
We will look at ways we might help retrain the HPA axis in the next post.
Inflammation. Some of the chemical messengers (cytokines) produced by white blood cells involved in inflammatory responses generate malaise and fatigue. This is a good idea if it means that the injury leads to a “retreat into a cave” so as to rest and recover. However as we have seen in an earlier post, when inflammation becomes long term (‘chronic’) it begins to defeat these benefits. It is noteworthy that some of the most potent fatigue-causing cytokines are produced by immune cells fighting viral infections.
Autoimmunity. Viral infections are also particularly likely to disturb long term immune responses, including to generate increased levels of autoantibodies (antibodies to one’s own tissues). Some investigators now consider that CFS may be a form of autoimmune disease.
Neuroinflammation. Chronic fatigue has been linked to abnormal MRI brain scans, linked to cytokine intrusion through the blood-brain barrier and the toxic excitation of brain support cells (microglia). Chronic fatigue might therefore become a form of encephalitis.
We will look at these inflammatory and immunological factors together in the third post, and will also refer back to posts in our Immunity series.
Gut health. Chronic fatigue has been linked to depletion and other changes in the microbiome or gut flora. As we saw again in our last series, the digestive system is where immune disruptions often start, and we will see further evidence of the link in this series.
Circulatory problems. CFS sufferers have been found to have significant disruption in ECG readings of heart function as well as other markers of circulatory challenges, including to the brain. We will look at evidence-based approaches we can bring to improving this factor.
System breakdown? Given the bewildering diversity of factors listed above, and the stubbornness of some cases of chronic fatigue, one can see something much larger going on here: a breakdown of multiple, normally integrated, control systems: hormonal, neurological, immunological-inflammatory, digestive-microbiome, circulatory and more. We can see a complex cascade of disruptions leading to a sort of system failure.
So rather than focus on one aspect of the situation it may be better to assume that the condition has exposed a wider collision between the sufferer and their world. If so, the work is to create the opportunity for self-corrective ‘critical transition’, or in simpler terms, a system ‘reboot’. In a future post we will peek into the inspiring insights into ‘complex living systems’ and how these ecosystems are essentially self-organising. Rather than seeing our living beings liable to be broken like mechanical machines we may see the prospects for a reformation.
There is a very well-established approach to this – it used to be called convalescence, though is hardly ever used now! We will address how we do this to systematically build resilience and strength in the final part of this Fatigue issue.
A traditional convalescent home at Msené-lázne in the Czech Republic. Not all societes have abandoned the age-old health care principle that effort and time is needed for recuperation, so as to prevent relapse and long term debility.
And we need to remember: while there is breath there is life,
and life has miraculous powers!
When to see the doctor
If you have other symptoms as well as problems with tiredness, or a medical condition that seems to be worsening, it is important that you see your doctor before using the information in these posts on your own. Although sometimes fatigue is considered a diagnostic challenge by doctors, do pursue blood tests and other investigations to rule out clearly identifiable causes, including from other serious disease. If you have recently started taking new medication, it would be worth speaking to your pharmacist about whether this might be the cause of your problems.
For a deep dive please check out further resources: