Episode 5 – Tired all the time.

A very common symptom I encounter in my day to day practice is feeling tired all the time. It is so common we have an acronym for it; TATT.

To explore this with my patients I ask them to tell me all about their lives. One of the great privileges I have as a GP is that I get to hear people’s stories. People are living frantic, stressful, crazy lives. Nearly all of us are. People are juggling multiple commitments at home and at work. They are looking after children, parents, friends and colleagues, caring for everyone else, but failing to look out for themselves. Often people are spending very little time on rest, relaxation and recreation. They have stopped doing the things that they really enjoy doing. Frequently they are not getting enough sleep, or are getting poor quality sleep, due to lack of time, anxiety or because of the use of caffeine or alcohol to control stress.

Sometimes it can feel like we are battling life, rather than living it. It’s very easy to get swept up by life, or driven along in a rut, and lose sight of what it’s really all about. It’s easy to forget why we are doing it. To forget to live life with purpose, with a clear understanding of why we have chosen the life we are leading. With clear goals; knowing where we are now, where we want to be, and how we are going to get there. When we are not living life on purpose, when life is something that is happening to us, and we firefight and battle our way through from day to day, this will always lead to exhaustion. It leads to anxiety, fatigue, and physical symptoms. It is our bodies way of telling us that we have got the balance wrong. That we are lacking wellbeing and are becoming unhealthy. Our bodies are telling us that it’s time to reset and reboot.

I tell people, “no wonder you feel tired, look at what you are doing, look at how you are living.” And they stop, and they think about this a little bit, I see a flicker of recognition, some concession, that “well, yes, I have been a bit busy recently, and maybe I haven’t been sleeping that well for a while”. But there is always a but. Even though they are living a crazy, stressful life, and even though they know they are living a crazy life, they are still not convinced that this could be the reason they feel tired all the time. Often, they say, “yes, I’m busy, but I’m more tired than I should be for the amount of busyness” or, “I’ve always been busy, why should it be a problem now?”

There is a difference between knowing and believing. They Know they are busy, and they know that theoretically being busy can lead to fatigue; but they don’t believe that being busy is the reason they feel tired all the time.

Patients frequently tell me that they just don’t feel right. They feel like something is wrong. They feel so bad that that something must be abnormal or has malfunctioned. Well they are right, it has. But the reason it has malfunctioned is not due to an underlying disease, it is down to exhaustion. It is because they are not doing the things their body and mind needs to function properly, and the symptoms they are experiencing is the bodies way of telling them they need to take stock and change things up.

The degree or severity of our symptoms, how bad we feel, is not always a reliable indicator of the presence or absence of an underlying “western medical” disease. Lack of balance and exhaustion can make us feel truly awful, whilst people can have incredibly serious diseases and have no symptoms at all.

When I first have this discussion people rarely believe me. They are still convinced that there is “something wrong”, that there is more to it, that there is some underlying body malfunction that needs to be identified and fixed, not through changing the things that are making them tired. Not fixed by them, by their actions and lifestyle, but fixed by the doctor, to be fixed by western medicine. They want a test, to identify a disease, and a pill to fix it.

It almost feels like people want to have a disease. They seem disappointed when I tell them that I think their bodies haven’t had a major malfunction, that they are tired because they have been working hard, sleeping poorly, have little rest or recreation, and are not looking after themselves. That it is them, and not me, that has the power to make them feel better. That with some hard work, by making some gradual, gentle changes to their lifestyles, the body and mind can heal, and flourish, if only given the right environment to do so.

I have sometimes thought that this is a bit strange, and hard to understand. Why would you want a disease?

But I know that I am guilty of exactly the same thoughts. I know what it feels like to “want to have a disease.” Last winter I hurt my foot running in Barcelona. It was pretty painful, and I hobbled all the way through the airport to get home. The next day it was even worse, and I could barely walk. I was meant to be working but I was worried I might have sustained a stress fracture. After hours of internal debate I went to A&E to get an X-ray. I felt the disappointment when it wasn’t broken. I think there are several reasons for this.

I felt like I was weak. That I had wasted everyone’s time, gone to A&E unnecessarily when I should have known better. I felt that had my foot been broken it would have legitimized my time off work and all the whinging and whining I had been doing over the past 24 hours. I felt like I would be entitled to some sympathy.  I wanted to know what was wrong, why it hurt, and get a better idea of how long it would take to heal. I felt like had it been broken these questions would have been answered, but instead I was left with uncertainty. Finally, I felt that had it been broken the responsibility I had for my own recovery would be diminished; it would be out of my own hands.

But all of these sentiments are incorrect, and more importantly, completely unhelpful. Having a diagnosis does not make the condition any more or less painful. It doesn’t mean we are any more or less deserving of sympathy, love, care and medical attention. We don’t need to legitimize having a symptom or seeing a doctor by having a disease. It is enough that we have a symptom or a worry. A big part of a doctor’s job is to exclude disease and allay fears.

I think that our tendency to want a diagnosis is related to our excessive faith in western medicine. We believe that if a disease is identified it can be easily treated. That as soon as we know what is wrong, we can be cured and will then feel better. I wish this were true. If it were, my job would be much easier. In episode two I suggested that doctors are especially good at understanding very serious conditions. A disease, a diagnosis, is by definition something doctors understand, we named it after all. This means that most diseases are pretty bad news.

People worry about having an undiagnosed, occult condition that is making them unwell. They believe that if the condition was identified it can be addressed and treated, but if it remains hidden it will continue to cause them harm, and moreover, the earlier it is detected the less harm will result. This is sometimes true, but mostly it isn’t, and in general terms this attitude probably does more harm than good to our population. I think it is the major source of health anxiety. Health anxiety is becoming an epidemic. I see it every day. I’m going to do an episode on it later. It’s such a problem I will probably do several episodes.

The reason the concept of early detection is mostly not true is, firstly, because the majority of symptoms people experience are not related to a disease that western medicine understands. Secondly, even if the symptom is due to a disease western medicine understands, even if that disease is identified, there are often limitations to what western medicine can do about it. If you are unlucky enough to get a serious disease a large part of the treatment is going to involve learning to come to terms with the disease and dealing with it. Most diseases, even with treatment, are going to have a detrimental impact on day to day life. The treatments to rehabilitate and to heal, to cope with a condition, are still all about lifestyle. You are still the one that will have to do all the hard work, it remains your responsibility; apart from the fact that it will be considerably harder to restore health than if you didn’t have the disease. This doesn’t mean that a diagnosis means you can never be healthy, but it does make it more difficult.

I think the media is partly responsible for this tendency to want a diagnosis. On TV western medicine is often portrayed as the miracle we all want it to be. As soon as House MD makes his diagnosis the patient is immediately cured.  I recently watched House Of Cards – I’m behind the curve – Kevin Spacy has a liver transplant after being shot and is running for election the next day. A liver transplant is not a quick fix. It is an incredibly serious life-threatening procedure, resulting in prolonged hospital admissions, lifelong medication, and lifelong risks of complications. It is also a lifesaving procedure. But if you can choose a reason for feeling tired all the time; if you can pick between a hectic lifestyle, or autoimmune hepatitis resulting in liver failure, pick the lifestyle. Don’t feel fobbed off and cheated, feel relieved and exulted.

The other sentiment I felt when I hurt my foot is the idea that, if it was broken, at least I would know what was wrong. I can understand this perspective. It is linked with health anxiety. “The devil you know”. Our capacity to worry about what might be wrong probably outstrips the reality of what is wrong. If only we could come to a diagnosis for the symptoms, our mind could be put at rest. But sadly this is also unhelpful logic. The thing is, even if you get a diagnosis of a disease, you still won’t really know what’s wrong. You won’t know for sure if the symptoms you are experiencing are actually related to the diagnosis you have been given. Just because you have one disease doesn’t mean you haven’t also got another one. Just because you have a diagnosis does not necessarily mean you are any closer to feeling better, and it probably means you are further away. Had my foot been broken, it would have still been broken. The treatment would have been the same – to stay off it until it was better.

The message here is that you do not want a disease. You do not want me to find something “wrong”, by which I mean, to find a condition that western medicine is good at. It will not result in a quick fix that will enable you to run around like a spring chicken. You will still be feeling just as tired, just as washed out. You will still be the one that will have to make significant changes to your thoughts and your lifestyle, in order to overcome the disease and feel better. Feeling better will be easier without a diagnosis than with one.

There are, of course, some medical conditions that can give rise to feeling tired all the time, and I think it would be helpful to explore this and consider how they relate to progressive medicine. However, it should be noted that this is general information, it is not a substitute for seeking medical attention, and if you are worried about your health you should see you GP, that is what we are here for.

Progressive medicine is not a substitute for western medicine, it encompasses it. I am still a medical doctor, and I do believe in western medicine. Progressive medicine does not claim that these conditions don’t exist. People get sick, and if they do western medicine can often help to treat the condition and control symptoms.

There are some common, and many rare conditions that can present with feeling tired and washed out. For example, if you have an underactive thyroid you will lack energy and may have multiple other symptoms, such as feeling intolerant of cold, gaining weight, hair loss and muscle cramps. Low thyroid levels are fairly common, and although it requires lifelong medication and frequent blood tests, it is entirely treatable.

Sometimes if you are not absorbing food properly this can lead to vitamin deficiencies or anemia (a low red blood level) which could lead to feeling tired and washed out. There are some very common food absorption problems such as coeliac disease, which is an allergy to wheat. This is treated by completely excluding wheat from the diet, which can be a very difficult thing to do, and has a major impact on day to day life.

If you have hypothyroidism or coeliac disease you may lack energy, and having a hectic, stressful lifestyle will exacerbate this. But managing your lifestyle, reducing your stress, will still make you feel better. Even if you have a disease it is only one part of the issue; you are still just as susceptible, if not more so, to the life stresses that all of us are exposed to on a daily basis. If the condition is not treated it is less likely that you will be able to restore full health through lifestyle alone, but even with treatment, lifestyle is still going to play an essential role in recovery and maintaining balance. People are not just a set of diseases and conditions that need treating, and a disease never exists in isolation of the person. If we want to be well we need to take an holistic approach. Identifying and treating disease is not the end of the story, it is only the first step.

At the extreme end of the spectrum people can have very serious conditions leading to feeling tired and washed out, such as liver failure, renal failure or cancer. In truth, pretty much any disease can lead to feeling tired all the time, and there are literally thousands of diseases. But it is really important that we don’t get hung up on this. The fact that having cancer can cause someone to feel tired and washed out does not mean that everyone who is feeling tired and washed out has cancer. Feeling tired all the time is incredibly common, in fact it is almost universal, whilst serious conditions such as cancer and liver failure are very rare.

If you are feeling tired all the time you should see your GP. They will likely do a serious of tests to screen for common and uncommon conditions. Western medicine is pretty good at detecting serious conditions such as liver failure and kidney failure, and common conditions such as coeliac disease and hypothyroidism. We can screen for hundreds of different conditions by considering the pattern of your symptoms, by examining you, and taking blood tests. If your pattern of symptoms and physical examination are not concerning, and your screening bloods are all normal, it is fairly unlikely that you have a serious underlying disease that is causing your symptoms. It means you can put your health anxiety to bed and your mind at rest.

The good news is that most of the time the blood tests will be normal, because exhaustion is pretty much universal in our society, but diseases are relatively rare. And if the tests come back normal don’t loose faith. Be delighted. It is a gift. It does not mean that you are further away from feeling well because “no one knows what’s wrong”, it means you are one step closer to good health and wellbeing. It means that your journey to good health is off to a great start. There are no major issues that are going to complicate your body’s ability to heal and recover, once you start providing the right environment for it to do so.

And if you are unlucky enough to be diagnosed with a disease, don’t despair. Having a disease does not mean that you can never be healthy, and it doesn’t mean good health is outside your control, although it might mean that you will have to work a little bit harder for it.

Either way I hope you will join me for episode 6 where we are going to explore further how it is possible to retain health irrespective of the test results. Why good health is in our hands, and how it is possible to choose health.