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The Royal College of Psychiatrists Improving the lives of people with mental illness

 

Tiredness

 

Introduction

We all feel tired from time to time. Usually, it's obvious why we are tired. We take the time to rest and get over it quickly.

But tiredness can be a serious problem if:
  • there is no obvious reason for it
  • it goes on for a long time
  • it is so bad that you can't do anything at all.

This sort of tiredness can stop us from enjoying and getting on with our lives.

How common is tiredness?

At any given time, 1 in every 5 people feel unusually tired and 1 in 10 have prolonged fatigue. Women tend to feel tired more than men. It can be a problem at any age, but is less common in the very young and old.
 
If you want to work out how you became tired in the first place, it can be helpful to think about:
  • parts of your life that might be particularly tiring
  • any events that might have triggered your tiredness
  • other things in your life that might be keeping you tired.

Reasons for being tired

These can be physical or psychological, or both.

Physical

  • Being overweight: Your body has to work harder just to do everyday things.
  • Being too thin: Your muscles may not be strong enough to do everyday things without becoming tired.

Physical illness

Any serious illness can make you tired, especially painful ones. Even less serious illnesses, like glandular fever, can leave you feeling worn out.

General: 
  • Anaemia
  • Autoimmune disorders
  • Chronic infections
  • Cancer
  • Liver, heart or long-term chest problems

Glandular:

  • Diabetes
  • Hypothyroidism

Sleep:

  • Narcolepsy
  • Sleep apnoea

Muscular:

  • Myositis
  • Multiple sclerosis

Even if you have got over cancer or heart problems, you can still have a problem with tiredness.  There is also evidence that some women with tiredness may have too little iron, in spite of apparently normal red blood cells.

Treatments

The following treatments can exhaust you:
  • serious operations on your abdomen or chest
  • medications like beta-blockers and strong painkillers
  • treatments for cancer, such as radiotherapy and chemotherapy.

Doing too little - and getting unfit: if you don't get any exercise, you may find it hard to sleep through the night.

Doing too much and tiring yourself out: if you carry on doing things - whether physical or mental - even when you feel tired, you may find it harder to recover, and get even more tired.
 
Pregnancy and having a young baby: both of these can sap your energy.
 
Poor sleep: disturbed sleep can leave tired and you will find it hard to concentrate.
 

Psychological

Worries and stress: worry makes you feel tired - especially when you cannot see a way out of your problems.
 
Insomnia: if you don't sleep well for a long time, you can start to feel tired, irritable and fed up.
 
Depression: depression tends to make you feel tired all the time. It can make you wake early which can make you feel even more tired.
 
Everyday difficulties: everybody gets stressed and exhausted when bad things happen to them. It's worth remembering that even positive events, like moving home or getting married, can also be exhausting. Being faced with a difficult decision, especially 'no win' situations, can exhaust you.
 
Emotional shock: bad news, bereavement or the break up of a relationship can all make you feel drained.
 
Expecting too much of yourself: everyone has standards - in work and in their personal life.  They are usually helpful - they give you a sense of direction.  But, if you expect too much of yourself, you can find yourself repeatedly failing, making you feel frustrated and tired.
 

Habits

Sleep: If you are feeling tired, you may get into the habit of sleeping in the day. This can make it more difficult to 'switch off' at night and get a good night's sleep.
 
Sleeping too much: it sounds odd, but this too can make you tired - perhaps because it reduces your fitness.
 
Activity: a 'roller-coaster' of too much activity followed by too much rest; if you do too much on a good day, you may overdo things and feel even more tired the next day.
 

Work and family

Continuing difficulties: there are some things in life that you find hard, or impossible to change. If you don't feel in control of your life, it is easy to get frustrated and tired.

Looking after small children: no surprises here. If your child doesn't sleep through the night, neither do you. It can be really hard work just to keep going with your daily routine.

Night work: night workers often find that they get tired easily. This is more likely if the timing of their shift is constantly being changed.

Work stress

  • Too much work
  • Not enough control over your work
  • Not being recognised for the work you do

will all tend to make you feel tired.

Unemployment: not working when you want to can tire you out through frustration.

What we drink

Coffee and tea: coffee, tea and some soft drinks contain caffeine. This is a chemical which makes us feel more awake. Six cups of coffee a day or ten cups of tea (or six mugs) are enough to upset sleep and make you wound-up and tired.
 
Alcohol: if you drink alcohol in the evening, it tends to wake you up in the middle of the night. If you drink quite a lot regularly, it can make you depressed and affect your sleep.
 
'The last straw'

tired leaflet


It will often takes several things together to make you feel tired. For example, if you feel stressed for a long time, you will probably sleep badly and feel 'below par'. You might then catch a cold. This can be the 'last straw' which finally exhausts you. You feel that you have to rest to get over this, but then quickly become unfit. You will now find that just doing everyday things can make you even more tired. If you can't get back to your normal routine, you will probably feel worried and frustrated. This gives you more sleepless nights and makes you more tired ....... and so a vicious circle is set up.
 

Beating tiredness

1. Improve your sleep
  • Go to bed and get up in the morning at the same time every day, no matter how you feel.
  • Make sure your bedroom is comfortable: not too hot, not too cold, and not too noisy.
  • Don't eat or drink a lot late at night. Try to have your evening meal early rather than late.
  • Try to gradually reduce the time you spend 'napping' during the day.
  • If you can't sleep, don't lie there worrying about it: get up, leave the bedroom and do something you find relaxing. When you feel tired enough, go back to bed.
  • Pick a way to relax before going to bed - such as reading, listening to music or using a relaxation technique.
  • Have a hot bath before bed. This should be as hot as you can bear, without scalding you, and last a good twenty minutes.
  • If something is troubling you, and there is nothing you can do about it there and then, try writing it down. Tell yourself you will deal with it in the morning, and then go to bed.
  • If none of this works, go and see your doctor.
2. Take some exercise
Many people feel too exhausted to start any exercise. However, in the long run, regular exercise will make you feel less tired and more energetic. So what can you do about this?
 
Try starting with a small amount of exercise: it doesn't matter how little as long as it's easy and you can do it regularly - every day, if possible. You then slowly increase the amount you do over a period of weeks and months, adjusting it so you don't get more tired. It can be as little as walking from one room to another.  Over time, you can increase the amount of time you exercise (or distance you walk), aiming to eventually do half an hour a day (you may need to divide this half hour into several short periods of time).
 
Walking is the easiest exercise to try, but anything that you enjoy will do. Many people like to swim or cycle regularly. What you are trying to do is to gradually improve your fitness and strength. You may be able to get advice from someone who knows how to help unfit or ill people to get fit.
 
If you find that you are doing too much, and feeling worse, don't give up! Carry on with some less demanding regular exercise, perhaps for a shorter time each day. Don't do anything more energetic until you have got used to the amount of exercise you are doing at the moment.
 
Once you are managing half an hour a day, you should gradually increase the intensity of your exercise so that you start to get a bit out of breath.
 
3. Cut out caffeine
Gradually stop having all caffeine drinks over about a three week period. Everyone knows that coffee and tea contain caffeine, but watch out! There are many other drinks and products that have caffeine in them, such as energy and cola drinks, some painkillers, and energy-boosting pills. Some herbal remedies also contain a lot of caffeine. If you are in any doubt, read the ingredients list on the packaging.
 
Try to stay off caffeine completely for a month to see if you feel better without it. You may find that stopping caffeine gives you headaches. If this happens, just cut down more slowly the amount of caffeine you are drinking.
 
Chocolate can also be a problem if you eat it every day because it contains chemicals that make you feel more awake.
 
4. Weight
If you are overweight, you will feel a lot better if you lose some weight gradually. A crash diet is not helpful and can make you more tired. Apart from eating healthily, the best way to lose weight is to gradually do more active and do more exercise.
 
If you are too thin, you will not recover your full energy unless you start to get back to your normal weight. By doing this you can start to re-build your muscles and your strength.
 
5. Plan your day/week
Try to plan your day and your week. Try to make sure that you don't have any really hectic, tiring days. Organise it so that you do a little every day. If you cram everything into one day, you may be too exhausted to do anything for the rest of the week. Try to do your chores when you think you will have the most energy.
 
6. Have realistic expectations
Be kind to yourself. If you have been tired for a long time, don't expect to be back to your normal self overnight. Set realistic goals for yourself and your recovery. Don't expect too much too soon. All progress is good, however small or unimportant it may seem at the time.
 
Learn from your tiredness:
  • were you demanding too much of yourself before you got tired?
  • did you have a good balance between work, rest and enjoying yourself?
  • should you reconsider what you want from life?

What doesn't help

We'd all like a magic cure to take away our tiredness. There isn't one. There are many products on the market that claim to do this. There is no good evidence that any of them help for very long. This goes for vitamins, minerals, stimulants, total rest and sleeping, and exclusion diets that cut out particular foods.
 

Not getting better

There is always a reason and sometimes more than one. You may be suffering from an undiagnosed illness. Ask your doctor to check out whether you have any of these problems. Common treatable problems include thyroid disease, anaemia, sleep apnoea (temporarily stopping breathing when asleep), restless legs (an uncomfortable restless feeling in the legs that happens when you are trying to rest), anxiety and depression.
 

M.E. and Chronic Fatigue Syndrome

A small number of people suffer from severe and disabling tiredness that goes on for a long time and for which there is no clear cause. This is  called Myalgic Encephalomyelitis (ME) or Chronic Fatigue Syndrome (CFS).

For a diagnosis of CFS, you have to have:

1. 6 months or more of medically unexplained tiredness that is:

  • new - you haven't always felt like this
  • not associated with continuing effort
  • reduces the amount you can do
  • not relieved by rest.

2. 4 or more of the following symptoms:

  • sore throat
  • tender lymph nodes
  • muscle pain
  • joint pain
  • headache
  • unrefreshing sleep
  • tiredness after exercise that last more than 24 hours.

3. No active physical disease or mental disorder that could be responsible for these symptoms. So, before a diagnosis of CFS is made, physical and psychological examinations (and physical investigations) are requited. You will also need an assessment of your mental state.

People with CFS/ME have often felt that doctors believed that their problem was 'all in the mind' - even though they had physical symptoms. Doctors now recognise that this is an illness, although it is poorly-understood. Like many other 'physical' illnesses, such as asthma and irritable bowel syndrome. some psychological treatments seem to help. This does not necessarily mean that CFS is a mainly physical disorder. So - what do we know?

Viral infection
Certain viral infections can trigger CFS/ME. We also know that people with CFS/ME have no continuing infection with the virus. So, there may be factors other than the virus which keep CFS/ME going and delay your recovery. These are called 'maintaining factors' and  often the same ones as those that cause general tiredness, as described earlier in the leaflet.
 
Maintaining factors
These include difficulty in sleeping, depression and anxiety. If you can identify the factors that are keeping the CFS/ME tiredness going (they are usually more than one), you have a chance of improving.  They are often that same factors that cause the general tiredness as described above.
 
Trying too hard
Even trying to get better can sometimes make things worse. For instance, if you rest too much, you will get weaker and more unfit.  So when you do try to do something, you feel even more tired. It can also be easy to get into a 'boom and bust' pattern, where you do too much one day and then 'collapse' the day after.
 
What we believe about health
Most of us think that if we have a viral illness, we should go to bed or rest at home for a few days.  This works very well for short illnesses. However, if you do carry on resting for longer than a week or two, it tends to make you more tired.
 

Treatments for CFS

We now have treatments that we know can help CFS/ME. They won't work for everybody and it is important to make sure that any treatment suits the individual. They include:
 
  • Supervised graded exercise therapy (GET). This is a way of gradually increasing your amount of physical activity and stamina without over-tiring yourself. It doesn't suit everybody, but does seem to help about 2/3 of those who try it.
  • Cognitive behaviour therapy (CBT). This is a talking treatment which helps you to change any unhelpful ways of thinking about your illness and to improve your coping skills.
  • Pacing. This is a common sense approach to adjusting one's daily activity so that you avoid over-tiredness and a possible relapse.

What if I don't do anything about it?

If you are tired for a few weeks after a viral infection, you are likely to get over it without any trouble.
BUT
If you have had CFS for six months or more, you will probably need help - only about 1 in 10 people with established CFS/ME gets better without any treatment.
 

How well do the treatments work?

  • About 6 out of 10 people feel better with either CBT or GET, although quite a few people with CFS have reported that GET tends to make them more tired, not less.
  • About a quarter of treated patients rate themselves as completely recovered from their CFS/ME after CBT - and the same number still consider themselves recovered five years after the treatment finished.

Which treatment to choose?

Both CBT and GET (see above) are helpful for many people - but they clearly do not help everybody. Pacing makes good common sense, but does not yet have much evidence to support it, although it is currently being investigated.
 
If you need help of this sort, you may need to see a specialist or therapist trained in rehabilitation.
 

Further reading

Coping with chronic fatigue by Trudie Chalder. Sheldon Press, London, 1995.
 
Chronic Fatigue Syndrome: The facts by Michael Sharpe and Frankie Campling. Oxford University Press, Oxford, 2000.
 
Self-help for Chronic Fatigue Syndrome: A Guide for Young People. Trudie Chalder, Kanees Hussain. Blue Stallion Publications, Witney, Oxon, 2002.
 
Overcoming Chronic Fatigue: A self-help guide using Cognitive Behavioural Techniques. Mary Burgess with Trudie Chalder. Robinson, London, 2005.
 

References

  • NHS Centre for Reviews and Dissemination. Interventions for the management of CFS/ME. Effective Health Care 2002;7: 1-12.
  • CFS/ME Working Group. Report of the CFS/ME working group: Report to the Chief Medical Officer of an Independent Working Group. 2002.
  • Royal College of Physicians. Chronic Fatigue Syndrome. London: RCP, 1996. (Report of a joint working group of the Royal Colleges of Physicians, Psychiatrists and General Practitioners).
  • McGregor RS. Chronic complaints in adolescence: chest pain, chronic fatigue, headaches, abdominal pain. Adolescent Medicine State of the Art Reviews 1997;8: 15-31.
  • Calverton MD  (2002) Health behaviour in school-aged children, 1997-1998. World Health Organisation. Macro International.
  • The association of obesity, cytokine levels, and depressive symptoms with diverse measures of fatigue in healthy subjects (2005) Weonjeong Lim, et al Arch Intern Med. 2005;165:910-915.
  • Iron supplementation for unexplained fatigue in non-anaemic women: double blind randomised placebo controlled trial (2003) Verdon F et al.  BMJ, 326: 1124-1128.
  • Watt T  et al (2000) Fatiguein the Danish general population. Influence of sociodemographic factors and disease. J. Epidemiol. Community Health, 54(11): 827 - 833.
  • Janssen N  et al (2003) Fatigue as a predictor of sickness absence: results from the Maastricht cohort study on fatigue at work. Occup. Environ. Med., 60(90001): 71 - 76.
  • Andrea H et al (2003) Associations between fatigue attributions and fatigue, health, and psychosocial work characteristics: a study among employees visiting a physician with fatigue. Occup. Environ. Med., 60(90001): 99 - 104.
  • Sharpe M & Wilks D (2002) Fatigue. BMJ, 325, 480-483.
  • Viner R. & Christie D. (2005) Fatigue and somatic symptoms. BMJ 330, 1012-1015.

This leaflet was produced by the Royal College of Psychiatrists' Public Education Editorial Board.
 
Series Editor: Dr Philip Timms.

With grateful thanks to Professor Peter White and Professor Matthew Hotopf.

RCPsych logo© May 2012. Due for review: May 2014.  Royal College of Psychiatrists. This leaflet may be downloaded, printed out, photocopied and distributed free of charge as long as the Royal College of Psychiatrists is properly credited and no profit is gained from its use. Permission to reproduce it in any other way must be obtained from permissions@rcpsych.ac.uk. The College does not allow reposting of its leaflets on other sites, but allows them to be linked to directly.
 
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