Patients experiencing lassitude and fatigue have a more or less characteristic way of expressing their symptoms. They say that they are “wiped out, or burned out,” “tired all the time,” “weary,” “exhausted,” or that they have “no energy,” “no ambition,” or “no interest.” They may manifest their condition by showing an indifference to the tasks at hand, by emphasizing how hard they are working, or how stressed they are by circumstances; they may be inclined to lie down or to occupy themselves with trivial tasks. On closer analysis, one observes and hears that many such patients have difficulty initiating activity but also in sustaining it; that is, their endurance is diminished. This condition, of course, is the familiar aftermath of sleeplessness or prolonged mental or physical effort, and, under such circumstances, it is accepted as a normal reaction. When, however, similar symptoms appear without relation to such antecedents, they should be suspected of being the manifestations of disease.
The physician’s task is to determine whether the patient is merely suffering from the common physical and mental effects of overwork or from personal life stresses. Overworked, overwrought people are observable everywhere in our society. In addition to fatigue, such persons frequently show irritability, restlessness, sleeplessness, and anxiety, sometimes to the point of panic attacks and a variety of somatic symptoms, particularly abdominal, thoracic, and cranial discomforts. Formerly, society accepted this state in responsible individuals and prescribed the obvious cure, a vacation. Even Charcot made time for regular “cures” during the year, in which he retired to a spa without family, colleagues, or the drain of work. Nowadays, the need to contain this type of stress, to which some individuals are more prone than others, has spawned an industry of meditation, yoga, and similar activities. Individuals with hobbies, nonwork interests, and athletic pursuits seem to be less subject to this problem. A common problem in diagnosis, however, is to ascribe fatigue to overwork when actually it is a manifestation of anxiety or depression, as described just below.
Among chronically fatigued individuals without medical disease, not all deviate enough from normal to justify the diagnosis of anxiety or depression. Many persons, because of circumstances beyond their control, have little motivation and much idle time. They are bored with the monotony of their routine. Such circumstances are conducive to fatigue, just as the opposite, a strong emotion or a new enterprise that excites optimism and enthusiasm will dispel fatigue. Some persons are born with low impulse and energy and become more so at times of stress; they have a lifelong inability to exercise vigorously, to compete successfully, to work hard without exhaustion, to withstand illness or recover quickly from it, or to assume a dominant role in a social group—a “constitutional asthenia” (Kahn’s term). Most of these traits are evident from childhood. These difficulties are not currently framed in these terms because they sound judgmental, but disorders of this type have been known since antiquity and only vary in name and social context in each era.
Fatigue as a Symptom of Psychiatric Illness
The majority of patients who seek medical help for unexplained chronic fatigue and lassitude are found to have anxiety, depression, or both. Formerly this state was called “neurasthenia,” a term introduced by Beard, but because lassitude and fatigue rarely exist as isolated phenomena, the current practice is to label such cases according to the total clinical picture. The usual associated symptoms are anxiety, irritability, depression, insomnia, headaches, dizziness, difficulty in concentrating, reduced sexual drive, and loss (or sometimes increase) of appetite. In one series, 85 percent of persons admitted to a general hospital and seen in consultation by a psychiatrist for the chief complaint of chronic fatigue were diagnosed, finally, as having anxious depression or a chronic anxiety state. In a subsequent study, Wessely and Powell found similarly that 72 percent of patients who presented to a neurologic center with unexplained chronic fatigue proved to have a psychiatric disorder, most often a depressive illness.