Fatgue Management

‘Tired all the time’ is one of the commonest reasons for consulting a doctor anywhere in the world. The feeling of being constantly tired may be interpreted as “weak” or even “fever”. It may be accompanied by a variety of vague symptoms such as abdominal pain or chest pain. It is often a diagnostic challenge and common sense may be a better diagnostic tool then extensive laboratory work.

There are a few diseases that make us tired anywhere in the world. There are some that are commoner in the tropics. However in many cases the problem is Life not disease.

Medical Problems
All sorts of medical problems can make someone tired. Aneamia, thyroid disease, other rare hormonal diseases, diabetes, chronic infection etc. Most tired people do not have such diseases and there is no need to do loads of blood test and other investigations looking for problems that are not there. A sensible history and examination should reveal most medical conditions.

Some drugs can cause fatigue. Overuse of medications is still very common, and it is easy for the vulnerable to be persuaded to take an unnecessary drug for a disease that is not there. Thankfully in Europe there is a growing awareness of the dangers of excessive use of medicines, especially antibiotics and sleeping pills.

“Common things occur commonly” and in Uganda there are 3 chronic infections notorious for making us tired.

Bilharzia
When you first get infected with Bilharzia you may get fever, rash, cough, diarrhoea or other symptoms of acute illness. Thereafter you just feel tired. Most regular sailors and fishermen realize when the Bilharzia Blues sets in and take the dawa. The response can be quite dramatic; you wake up 3 or 4 days later feeling Wow! Energy!

Children can become moody, difficult or fall behind in class. If they have ever been in the lake think Bilharzia.

Giardia
Classically giardia causes eggy burps and greasy smelly floating-in-the-pan diarrhoea. It can also just make you tired. As it is often missed in the stool because the cysts come in showers every 3 or 4 days, it makes sense if you are tired and gassy to try the treatment anyway.

Intestinal Yeast
Also causes vague watery or gassy diarrhoea, but can often just make you tired without any intestinal symptoms. A few yeast of different species are normal inhabitants of the healthy bowel. Otherwise we wouldn’t rot when we are dead! But we often find candida in the stool in enormous numbers. Does yeast make us tired or do tired people get yeast? Or both? Why do we often see yeast in short termers yet not long term residents? Is it an antigenitically different strain that we have to develop immunity to? There’s a Ph.D. there somewhere!

Whatever, the good news is that treatment is usually very easy, effective and safe and a lot of people feel dramatically better when their candida is treated.

We also sometimes find amoebic cysts in the stools of tired people. Do non-pathogenic amoebas cause tiredness or indeed any symptoms at all? Another Ph.D. for any young bored biologist out there!

Chronic fatigue syndrome
Once called ME for myalgic encephalitis, or yuppie flu, now usually referred to as the “post infection chronic fatigue syndrome” to distinguish this group from other stress related fatigue syndromes. Surf the web and you will find “executive stress syndrome” or “executive burn out” or any other combination of terms that the author uses to describe a non-specific tired-all-the-time condition that does not follow an obvious infection. All pretty irrelevant anyway, as the “treatment” is the same.

The theory is that following an infection, especially viruses, the body continues to produce antibodies and fights the infection long after the disease has disappeared. You feel tired as if you had flu, but the specific symptoms have long gone.

Often antibodies are found to such weirdoes as cytomegalovirus, Epstein Barr, or the latest flu. It can follow an ordinary cold, and I’ve seen it after bilharzia, shigella, undiagnosed viruses, and after no obvious infection. Although it can affect anybody it most often hits young professionals. Instead of resting during and after a mild infection, you keep on pushing yourself and becoming more and more tired. This makes you struggle even harder to keep up.

In its most extreme form people with CFS are so tired they sleep 16 to 20 hours a day and even going to the loo requires 2 hours rest to recover from the effort. One young woman I visited at home every week or so could just about make me a cup of coffee while she reported her progress then slept for the rest of the afternoon to recover from my visit. After one month she could just make it out to a hammock in the garden and after 3 months she was fit enough to make it to Entebbe. Back in the UK she continued very slow improvement and was off work altogether for 1 year. This could have been prevented if she had simply taken 3 days off and gone to bed during and after the original illness.

Most people are not as seriously affected as that, and can get better with only 2 or 3 weeks of strict bed rest, and 20 hours sleep a day. Probably all cases could be prevented by getting lots of sleep as soon as the problem starts. If you are tired, go to bed. Sleep 50% more than you think you need, and do 50% less than you think you can.

Be warned! Chronic fatigue syndrome is real and could put you off work for months. Next time you have a cold and feel tired, GO TO BED!

Depression
CFS, culture shock, stress, depression, chronic illness, they all overlap and feed each other. Often it is very difficult to know where a genuine disease ends and lifestyle problems begin. When does feeling low and tired become a mental disease?

We hardly ever see the real psychiatric cases with suicidal depression. We do see a lot of people where stress and problems at home or at work are causing tiredness that borders on a depressive illness. Analysis in the UK has shown that 60% of visits to a doctor are partly for psychological reasons.

It is more surprising to learn that in clinics in refugee camps and famine feeding centres, where you would think there would be more physical disease, the same number of consultations are for psychological problems. The big missionary societies and volunteer organisations all report that the commonest reason for terminating a contract and for medivac is psychological problems, and again the oft reported figure is 60%.

Mildly depressed people almost always feel tired and have trouble sleeping. They often say they would feel better if only they could get a good night’s sleep, and I am sure they are right. Classically they go to sleep ok, then wake up around 2 or 3.00am and lie awake thinking about things for an hour or two. Sometimes they fall asleep at dawn, get up to go to work, and then feel tired all day.

This disruption of the sleep/wake cycle is apparently due to low levels of the chemical responsible for mood. Low doses of one of the older antidepressants are usually very effective and non-addictive. They give a good night’s sleep and you wake up feeling alive. They do take a long time to work, but the good effect is often permanent.

Many people with tiredness due to mild depression simply need to cut their workload and go to bed early! Others drink too much, a very common cause of depression. Sometimes a patient will tell me they are depressed, yet I find none of the classic symptoms. Often the situation they are in is genuinely depressing! Feeling depressed may be the appropriate response in some circumstances. In these cases drug treatment is definitely not indicated.

Stress
Most people who are tired all the time do not have anything really wrong, and they are simply stressed. Stress is however seldom simple, seldom due to one thing and the affected person is the last to realize. He may even feel great, as adrenaline is quite euphoric.

I have said many times that here in Uganda we don’t see much tropical disease. What we do see is a lot of niggling little infections, coughs colds and flu, upset stomachs weird viruses, especially in the first 2 or 3 years while our immune system gets used to everything that’s going. Nothing very important but each one knocks us down for a few days or a week and makes us tired. Instead of resting we struggle heroically on and get more and more tired. A few slide into the full CFS picture. Most of us get better, but a month later another virus hits us and down we go again.

We could cope with all these nuisance infections if we were working 9 to 5 and going home with the Evening Standard on the commuter train. Instead we fight through the traffic at 7.15, work from 8 to 6 and then battle matatus all the way home. There we catch up with paper work, or go to an official function and drink too much. Just as all the hard work pays off and you are on top of your in-tray, your secretary takes a week off with family problems, the e-mail brakes down and there’s a 3 day power cut at home just as the baby cuts a new tooth and is up all night.

The result? Stress. It may manifest itself as fatigue, abdominal pain, headaches etc and you may be convinced you have malaria, blood pressure, or ulcers, but what you really need is a couple of days off, a week of early nights and a change in lifestyle.

This is not a popular prescription, and many patients want lots of investigations, referral to a specialist and often finish up going to Nairobi or South Africa. This enforced break often cures the complaint: – if you are lucky without spending a fortune, or picking up a non-existing diagnostic label!

Sometimes it is the children who are ill with vague symptoms, as children are the “barometer of the family”.

Culture shock
This is another cause of fatigue and again often manifests itself as physical illness. Particularly prone are single people working up country, or married men separated from their family on short term assignments. I feel particularly sympathetic with the young volunteers working up country. I am appalled at how poor the orientation and preparation is for some of these organizations! They are given some information about malaria and some other tropical diseases, and if they are lucky some figures about AIDS. But sometimes nothing at all about the difficulties of living in an environment that is totally different from their background. I remember it was hard enough for me going from Cornwall to London as a student, especially as the students from Durham and Newcastle seemed to be speaking a different language!

On first arrival, everything is wonderful, the people are friendly and the world is exiting and stimulating. You are determined to work hard, be friendly and learn about this strange new culture, and certainly immersing yourself in a different culture can be very rewarding and a real eye opener. Unfortunately after 3 months some of you think you are an expert, and it may be 2 years before reality sinks in. By then most of you have left, often disillusioned, and often ill.

Fact. You are what you are: Danish, British, American, whatever. You will never be an Acholi or a Muganda. Your immune system is totally different. It takes years before you can eat anything and everything without risking diarrhoea. Your skin takes years to acclimatize; you cannot wander around in the sun without getting problems. You sweat more and need to drink more. Physically you have no hope of matching the endurance of people who have worked in the heat all their lives. You have no immunity to malaria and if you live up country you either take prophylaxis, are very careful about nets etc, or you are going to be very ill every month.

Psychological health is no different. You are what you are: age, background, culture.

You do not speak the local language and more importantly you do not understand the body language. You will believe people whom you would never believe if they were from your town. Trust people who are not trustworthy. Make the wrong relationships. Ignore the people who really do want to help and are giving you the right advice.

We lived in Teso for 3 years and Kotido for 9. Been there done that got the T-shirt.

In other words, exactly the same as anywhere else in the world! (Except here the wrong boy or girlfriend could be fatal.)

We need the reassurance of the familiar to avoid stress. Staying alone or with only a few people from your background in a small community for weeks at a time is very stressful. You couldn’t manage it in the Hebrides and you should not try it here.

The old shipboard romance was due to the same emotional claustrophobia. (Would Jack and Rose really have been happy together?) Watch Kampala City people posted up country, and learn from them! Get out at least once a month, meet other people from a similar background, do something familiar. Those who manage best are the ones who accept they are different, and realize that it is that very difference that makes you useful. Vive La Difference! You are much more likely to be happy healthy and eventually leave with a genuine warts-and-all-love for Uganda and Ugandans if you make sure you come into town every month or so, meet other people from the same background as yourself, do what you would normally do and just be yourself.

A good prophylactic is to join some club or society that does something totally unrelated to your work. Have Fun. Golfers I am sure suffer less stress than other people. (Unfortunately I am too young to play golf). Join the Amateur dramatic society. Learn to sail. Run on the hash. Sing in a choir, there are many. Join the mountaineering club. Learn to fly. There are countless clubs and societies with a wide range of people, nationalities, ages and ideas. This gets you out of the goldfish bowl, allows you to step back and look at yourself and lets you meet others with similar stresses and worries as you.

Last of all. Remember the stressed person is the last to realize they are stressed. Listen to your friends. If they are concerned, take a holiday, a few days off, relax, have fun.

Summary
Fatigue is very common and may come with a variety of other symptoms. Most medical conditions can be suspected or ruled out by a simple examination and basic tests.

Chronic fatigue syndrome can be the end result of tiredness following any simple infection and the only treatment is lots of sleep. Prevention is better than cure: if you are tired, go to bed.

In many cases the problem is stress related. Stress can usually be prevented by a varied social life, sensible time off and getting plenty of sleep when you are ill.

If you feel you are living in a goldfish bowl, get out, take time off, have fun.

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