Making fatigue less tiresome
Med J Aust 1996; 164: 580-581

There are no clear-cut causes, categories or cures

Fatigue, or excessive tiredness of body or mind, is a common presenting problem in general practice. In a survey of morbidity and treatment in general practice in Australia, 2.6% of all patients presented with weakness or tiredness [1]. However, fatigue is often hidden or is a secondary symptom when the patient asks his or her doctor for a "check up" or complains of sleep disturbance [2]. Shires and Hennen estimated that one in 10 patients in family practices in the United States presented with fatigue as a primary complaint [3].

Fatigue has been implicated as a major cause of occupational and motor vehicle accidents. It leads to impaired performance and limitations to daily functioning, especially in the elderly.

In this issue of the Journal, Hickie et al identified fatigue using a modified version of the Schedule of Fatigue and Anergia. This schedule was originally developed to assess chronic fatigue syndrome [4], and may help general practitioners in identifying and assessing patients with prolonged fatigue.

Associations and causes of fatigue

In clinical practice, fatigue can masquerade with many other conditions. It is one of a group of symptoms, including dizzines and headache, for which a clear diagnosis may be elusive, leaving both the patient and doctor frustrated.

Despite its frequency, there has been relatively little study of the causes of fatigue. In a United Kingdom general practice, Herrett found no physical cause of fatigue in 62% of his patients [5]; it was usually associated with sleep disturbance or stress. Many patients were suffering from psychological problems or psychiatric illness, including depression and anxiety, or bereavement. Another general practice study found that chronic fatigue was the presenting symptom in 7.5% of patients with depressive illness but, when questioned, 97% of patients admitted to fatigue [6].

Hickie et al identified psychological disorders in 70% of patients with fatigue. However, it is difficult to determine whether these disorders were causal or merely an association. It is possible that, in some cases, both fatigue and psychological disorders were secondary to other causes such as chronic disease or social problems. Fatigue was more likely in females, people of low socioeconomic status and people with fewer years of formal education. We might expect, for example, that mothers with young children may suffer fatigue and depression because of sleep deprivation and post-natal depression. Newly arrived migrants and refugees may suffer stress as a result of war or social upheaval in their countries of origin. People who have recently lost their job may suffer from psychological distress and sleep problems.

Common causes of fatigue are listed in the Box and include chronic, malignant and cardiac diseases, as well as infections such as Epstein-Barr mononucleosis and HIV. Obstructive sleep disorder is an important cause of daytime fatigue, occurring in 2% of people attending general practices and 10% of middle-aged men [5].

Management of fatigue

Although fatigue and psychological disorders are commonly associated, care is needed with drug therapy. Fatigue is a common side effect of many drugs, especially psychotropic drugs, alone or in combination with alcohol. There is no panacea for persistent fatigue (although patients will sometimes try any "tonic" in desperation!.

General practitioners should not oversimplify their approach and categorise fatigue into either psychological or physical causes as these are ofen interrelated. Furthermore, we have to be cautious about labelling patients as having chronic fatigue syndrome. Hickie et al found that only 0.3% of those with prolonged fatigue had been diagnosed with chronic fatigue syndrome by their general practitioner. A holistic approach is required, based on an understanding of the social, psychological and lifestyle influences affecting the patient.

The challenge for the general practitioner is to consider the wide range of disorders responsible for fatigue. They must be perceptive in their diagnostic approach without resorting to overinivestigation. However, it is important that the underlying factors or causes of fatigue are eventually identified.

John E. Murtagh
Professor of General Practice
Monash University, Melbourne, VIC

1. Bridges-Webb C, Britt H, Miles DA, et al. Morbidity and treatment in general practice in Australia 1990-1991 Med J Aust 1992; 157 Suppl: S1-S56.
2. Marinker M, Watter CAH. The patient complaining of tiredness. In Cormack J, Mariner D, Morel D, editors Practice: London: Kluwer Medical, 1982. Section 3 1
3. Shires DB, Hennen BK. Family Medicine, New York: McGraw Hill, 1980: 129-137.
4. Lloyd AR, Hickie I, Boughton CR, et al. Prevalence of chronic fatigue syndrome in an Australian population. Med J Aust 1990; 153: 522-526.
5. Jerrett WA. Lethargy in general practice. Practitioner 1981; 224: 731-737.
6. Lau BWK.The chronically tired patient in general practice. Asian Med J 1986: 8:2135-2144 .
7. Murtagh J. General practice, Sydney: McGraw-Hill, 1995. 613-616.

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