1. How to deal with fatigue
Saul Berkovitz MRCP, MCPP, MFHom
Consultant Physician, Chronic Fatigue Service
Royal London Hospital for Integrated Medicine
University College London Hospital NHS Trust

2. “Everyday” fatigue A normal sensation experienced by everyone
Exhaustion or tiredness (physical or mental)
Temporary and relieved by rest
Different from:
Weakness
Shortness of breath
Effort intolerance
Sleepiness
loss of motivation and pleasure

3. Fatigue in the population
Main complaint in 5-10% of GP consultations
an important factor in another 5-10%
‘TATT’
Half of patients are still fatigued 6 months later

4. Medically significant fatigue
Persistent or relapsing fatigue
Lasting several months
Not the result of over-exertion
Not relieved by rest or sleep
Causing substantial impact / disability

5. Associated symptoms sore throat tender lymph glands muscle pains
joint pains
new headaches
unrefreshing sleep
post-exertional malaise
poor memory or concentration

6. Maintaining factors Older age Mood disorders Illness beliefs
Inactivity
Sleep problems
Search for legitimacy, benefits, diagnostic label

7. Cancer-related fatigue
Variety of cancers
Before diagnosis (40%)
During treatment (80-90%)
Beyond treatment completion (33% at one year)
High impact (more than pain, depression, nausea)

9. Possible mechanisms of fatigue
Alteration in serotonin (“happy hormone”)
Alterations in cortisol (“stress hormone”)
Alterations in circadian rhythm (“biological clock”)
Alterations in muscle metabolism

11. Approach to management
“Biopsychosocial” rather than “biomedical”
A definite diagnosis
Over-investigation vs. under-investigation
Empathy
Non-judgemental style
Commitment to continued care if required
Associated anxiety & depression

12. Management – drug treatment
Anaemia (epoetin alpha)
Antidepressants
Night time sedation (amitriptyline)
Corticosteroids
Psychostimulant (methylphenidate (Ritalin))
Wakefulness enhancer (modafinil)
Metabolic enhancer (L-Carnitine)

13. Management – non-drug treatment
Self-management
Professional management
Multidisciplinary; integrated; group or individual
Activity management therapy
Graded exercise therapy (GET)
Cognitive behavioural therapy (CBT)

14. Activity Management Therapy

15. Activity management therapy
Pacing advice
Activity diaries and scheduling
Energy conservation
Stress management + relaxation training
Management of sleep problems
Longer term target setting
Coping with setbacks

17. Graded exercise therapy

18. Graded exercise therapy
Appropriate exercise is safe and beneficial in fatigue
Gradually progressed exercise programme starting from an individualised baseline
Assessment
Aerobic exercise, strength training, core stability training and stretching
Gym / home
Short- and long-term goal setting

19. Cognitive Behavioural Therapy

20. Cognitive behavioural therapy
How thoughts and feelings influence behaviour (and affect health and well-being)
Aims to promote self-management
Short-term
Collaborative
Problem-solving
Goal-focused
Individual or group

21. Cognitive behavioural therapy
Unhelpful beliefs / thoughts about illness
“Activity makes me feel worse, so it will damage me”
“I can’t do X as well / often as I used to so I won’t do it any more”
“I can’t do X any more so I’m a failure”
Guilt / denial / embarrassment
Overestimating threats (catastrophising)
“I might collapse in the street so I won’t risk going out”
Over-vigilance of symptoms
Shift away from the pursuit of cause
Functioning the best we can within our constraints

22. Self-management Pacing Graded exercise Stress and mood management
Fatigue services:
Books: “Fighting Fatigue: Managing the Symptoms of
CFS/ME” by Sue Pemberton
Computerised CBT:

23. Acknowledgements
Chronic Fatigue Team, Royal London Hospital for Integrated Medicine
Chris Perrin (Nurse Specialist)
Mary Queally (Occupational Therapist)
Margaret Hooper / Raj Sharma (Psychologists)
Esther Odetunde (Physiotherapist)
Sue Thurgood (Dietician)