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Tired Beyond Relief

Exhausting the Alternatives

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When evaluating a patient complaining of fatigue, Ferentz, who practices family medicine in Baltimore, starts by taking a patient's history, administering a physical exam and, if appropriate, following up with blood tests or screenings to rule out physical causes. "[Fatigue is] almost always due to something else, not medical," he says. More often than not, he says, it is tied to depression, stress or lifestyle. Depression can be treated with antidepressant medications, he says; lifestyle-related causes of fatigue can be addressed through maintaining a balanced diet, a healthy sleep schedule and an exercise routine, Ferentz advises.

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Andrew Heyman, a clinical lecturer in integrative family medicine at the University of Michigan Health System, follows a similar course, first ruling out medical causes of fatigue and then addressing other issues. "We go back to basics," he explains, "how you sleep, eat, breathe, think. What's my diet like? Am I exercising? Getting enough sleep? What's my general mental state? Do I have sense of purpose and meaning in life?"

Heyman's training in alternative and complementary medicine often draws him toward theories and treatments that fall outside conventional medical wisdom, but only after he has exhausted traditional answers. Heyman says he has seen remarkable improvements in patients' fatigue resulting from use of acupuncture, meditation, and certain herbs and supplements.

"In my experience, the cumulative effects of stress begin to present themselves in the 40-to-50-year age range. The body cannot sustain its capacity to deal with that level of stress," Heyman says. He often suggests his fatigued patients take such herbs as ginseng and ashwagandha, which he describes as "adaptogenic," meaning they "help one to adapt to stress and change." Heyman cautions that "herbs work like drugs and can have side effects," so folks should take them only under professional guidance.

Beyond treating underlying depression and correcting suspected lifestyle imbalances, the medical community has little to offer those complaining of fatigue. There's evidence that exercise can have a positive effect. Studies also support the effectiveness of cognitive behavior therapy, in which patients work to view their fatigue differently and learn to cope with it better while they change contributing behaviors, such as poor sleep habits. DeLuca notes that medications used to combat fatigue, such as phenylephrine and amphetamine, often have side effects -- including addiction -- and are generally prescribed only in severe cases or when behavioral treatments haven't helped.

Your Brain Working Overtime?

When the words "fatigue" first appeared in the medical literature in the late 1800s, it was described as a fact of life, not a problem. "You just accepted it," says DeLuca. "Then, with the Industrial Revolution, came the notion of 'man the machine,' which can only go so far without fatigue."

People apparently were okay with being diagnosed with fatigue when it was considered a purely physical phenomenon. But with rising interest in psychology in the early 1900s, fatigue came to be seen as a symptom of psychological disorders, which carried a stigma.

That stigma lingers today, as some fatigue sufferers -- particularly those diagnosed with CFS -- bristle at the implied notion that their illness is "all in their heads." But British psychiatrist Simon Wessely, a leading fatigue researcher, maintains that looking at fatigue through the lens of psychiatry increases our understanding of the condition and could help us learn to treat it better.

DeLuca notes that relatively new imaging technologies are making important contributions to our understanding of fatigue's potential physiological roots. Functional MRI, for instance, allows us to monitor brain activity while a patient is completing a task that requires mental exertion, he says. A healthy person's fMRI might show activity in a "circumscribed area isolated to the left hemisphere while working on the task. But the diseased person is using huge areas of both hemispheres," DeLuca says. "Perhaps the objective measure is not the behavior but the brain activity. This is new.

"My hypothesis is that medical fatigue may be the extra cerebral effort that it takes to perform at the same level [as a healthy person]. Maybe the brain [of the fatigued person] is working harder, needs more resources."

For now, though, DeLuca says, "there are no [objective] criteria, so there can be no medical treatment. There is no way to distinguish between fatigue resulting from a cardiac condition and that associated with a psychological condition. We call it fatigue, but maybe there need to be separate categories. Some suggest we need to eliminate the term and start over." ¿

Jennifer Huget is a frequent contributor to Health. Comments:health@washpost.com.


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