Dr. Sharon Orrange
Primary Care Physician
Dr Orrange received her BA in Biology at the University of California San Diego and a Masters Degree in Health Sciences at the Johns Hopkins University School of Public Health She received her MD from the USC Keck School of…
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LOCATION: Santa Monica, CA, USA
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  • Assistant Professor of Clinical Medicine, Division of Geriatric, Hospital and General Internal Medicine, Keck School of Medicine, University of Southern California
YEARS IN PRACTICE: 11
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Fatigue Part I: Why am I so Tired?
22
Posted in Addison's Disea... by Dr. Sharon Orrange on Mar 14, 2009

If I had a dollar for every time I hear this from a patient I could save our economy. This is a serious and disabling complaint we hear from 22-33% of patients in our primary care offices.  In this blog I want to address the potential causes of fatigue, and what workup your doctor should pursue. In a follow-up blog we will talk about approaches to the treatment of fatigue.


First, make the distinction in your mind of fatigue from somnolence, feeling winded, and muscle weakness, although these symptoms may also be associated with fatigue. People with fatigue report a lack of energy, mental exhaustion, poor muscle endurance, delayed recovery after physical exertion, and nonrestorative sleep.


There are many potential causes of fatigue including lifestyle issues, physical conditions, mental disorders, and medication side effects. Here are your initial steps toward figuring out the cause:


1) Ask yourself about the quality and quantity of your sleep. If your sleep is disrupted by getting up to use the restroom, a partners snoring, or allergic rhinitis (stuffy nose) that wakes you up chances are you are NOT getting a good restorative sleep. Solutions for this are addressed in my blog on 10 steps to better sleep http://dailystrength.org/blog/90-10-easy-steps-better


2) Get a good physical exam. Physical examination findings that could suggest a worrisome cause of fatigue include enlarged lymph nodes, a heart murmur, an enlarged thyroid, lower extremity swelling (heart failure, liver disease), poor muscle tone and other neurologic abnormalities.


3) If the physical exam is unrevealing consider talking to your doctor about some basic blood tests. Laboratory studies should be considered although their results affect management in only 5 percent of cases. Many physicians will order a complete blood count, erythrocyte sedimentation rate, chemistry panel, thyroid-stimulating hormone, and urinalysis. Women of childbearing age should receive a pregnancy test.


What is chronic fatigue? Chronic Fatigue is defined as fatigue that lasts longer than six months. Chronic fatigue is not the same thing as Chronic Fatigue Syndrome which includes fatigue as well as 4-5 other associated symptoms and won't be specifically discussed in this blog. Medical or psychiatric diagnoses can explain fatigue in at least two-thirds of patients with complaints of chronic fatigue. In one study, for example, a psychiatric diagnosis was found in 74 percent of over 400 patients who presented to a chronic fatigue clinic with at least one month of fatigue. The three major psychiatric illnesses were major depression (58 percent), panic disorder (14 percent), and somatization disorder (10 percent). There is debate, however, whether depression in individual patients is the cause or consequence of symptoms of chronic fatigue.


Medical causes for chronic fatigue that deserve to be investigated if no psychiatric cause is found include:



  • Heart causes: heart failure, chronic obstructive lung disease

  • Disturbed sleep: sleep apnea, GERD, allergic rhinitis

  • Endocrine causes: diabetes, hypothyroidism, adrenal insufficiency

  • Infectious: mono, hepatitis, HIV

  • Inflammatory: Rheumatoid arthritis, lupus

  • Medications: antihypertensives (beta blockers, etc), muscle relaxants, sedatives, pain medicines


Fatigue is frustrating and often there are no easy answers.  In the next blog I will talk about steps you can take toward the treatment of fatigue.


 


"Fatigue is the best pillow"


 Benjamin Franklin


 


Dr O.


 


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Displaying comments 22-3 of 22
22
I am a newly 60 year old female. I have gone through menopause. I have been told I have Rheumatoid arthritis. It seems that I have been tired for so long. After menopause I had trouble sleeping. I tried the PM meds for night sleeping and have found Ambein to work but I don;t like taking them. With them or without I still wake up so tired. My knees espically the right one hurts all the time. I have pain in my upper shoulders upper arms neck. You can poke them and they hurt. I have been having excessive sweating of the head. I just have the water drip off the hair down the sides of the face. The back of my neck is soaked from sweat running off the hair. I am so hot and I don't sweat, but by the time I get home I have to change my shirt. Now I also noticing my face. It seems to have puffed up I am overweight. Anyway I am a wreck.
By maryil  Apr 29, 2009
21
For those who are up to date with medical research there is NO debate, however, whether depression in individual patients is the cause of symptoms of chronic fatigue. Depression is a consequence of severe CFS. If it were a cause then SSRI, MAOI's or TriCyclics would work. They have all proved to be unbeneficial just read Prosac Backlash or talk to Cheney, Myhill, Nicholson or any number of the major 35 researchers into CFS. This is a very poor article Dr Orrange. Its the sort of trash that CFS sufferers can do with out. Its not helpfull. Its time you got up to speed with Mitacondrial Dysfunction. When you do I have every confidance that you will write an amendment, and contact all those who responded to your post. Now is not the time for you to crawl into a protective defensive shell, now is the time to learn and get the facts right for the sake of those who suffer.
Al
By Ali5tair  Apr 21, 2009
20
I think SAT scores can also cause fatigue
By SamuelX  Apr 13, 2009
19
I have been experiencing some unexplained symptoms--not the least of which is fatigue. To be frank, I am fed up with doctors who suggest psychiatric problems when they have not found a medical cause. To think that you would start with psychiatric causes for chronic fatigue and then consider medical diagnoses is quite troubling to me.
By bethnich  Apr 07, 2009
18
I was so damned fatigued for no reason that the doctor could find at first. In addition, I had muscle and joint pain and fatigue and night sweats. After almost giving it up, my doc did one last long shot test for hepatitis, thinking it was unlikely. Guess what? I had Hepatitis C. Please consider that HEP C, which is a silent disease in many people, can be the cause of fatigue and rule it out as a possible cause!
By HEPCinRVA  Apr 04, 2009
17
Well, crap. I have a heart cause, disturbed sleep, an endocrine cause, an inflammatory cause, and a medication cause (or three). No wonder I'm fatigued. I'm going to have to take a nap now.
By kaydi8  Apr 01, 2009
16
Yikes! No wonder I'm tired!! I have major depression, panic disorder, somatization disorder, GERD, allergic rhinitis, hypothyroidism (Hashimoto's Thyroiditis - which is an autoimmune disorder), and have to take Seroquel (atypical antipsychotic) and Vistiril (antihistimine for anxiety) and Remeron for the depression. Yet when my doctor prescribed Provigil (stimulant) to help me function to care for my children, Medicare sent me a letter saying it wasn't medically necessary!!

How frustrating! What would make Provigil medically necessary? Catatonia?!?

Of course I could pay for it myself, but since I'm on Social Security and get no child support for my twins who were conceived by rape that is financially impossible. The price tag ($252/month) is 25% of my monthly income. But, because of my fatigue, Children's Services is threatening to take my children!

Any ideas for help? Could I be eligible for respite care with my diagnoses?

Thank you so much for this article. At least I now know WHY I'm constantly fatigued!!
By katiescarlett  Mar 31, 2009
15
the less you do the more tierd you get , i find exersise helps me get my energy levels up , takes a month or two before youll feel the benifits as your body will feel worse for the first 6 to 8 weeks , but it helps for sure
try buying a walk counter and try an do 10,000 steps a day walking , the step counter helps keep your goal
By mark0102  Mar 24, 2009
14
My severe pain has lead to increased fatigue; pain wears you out like nothing else.
By mianutzy  Mar 24, 2009
13
Foung the information about Vitamin D, B12 and Stored Iron informative. I will be going to an Endocronologist shortly. I have Fibromyalgia, Epstein Barr, Psorasis, and Chronic Fatigue. I also am going through menopause. Which blood tests would be helpful to check for my Fibromyalgia as I feel very achy lately, especially around the neck and shoulders? I lost my livlihood since I also have chronic tennis elbow, treated with extracorpeal shock wave. Anything repetive makes my life miserable, and I have not had much quality of life since all my ailments hit at once. Any advice would be helpful. Tried the popular meds for FMS, to many side affects. I have not yet tried acupunture so that is my next treatment. I am concerned there is some type of deficiency not yet picked up by my Rheumatologist.
By NJGirl07  Mar 17, 2009
12
1) Holidayddd: Yes menopause causes sleep disturbance and fatigue no question about it. There are studies using hormone replacement, antidepressants and short term sleep aides (ambien, etc) in perimenopausal women with good results.

2) Jessdavisva: Mono (Epstein-Barr Virus) is mentioned above as a cause of fatigue..that would be ACUTE mono (where EBV IgM or the acute antibodies) can be found on blood tests.

3) ginnyh70: unfortunately fatigue is a well described side effect of all beta blockers...
By DrOrrange  Mar 17, 2009
11
Hi! I have been dignosised with fibromyalgia, restless leg syndrome, IBS, depression, etc... i still have trouble sleeping but now it seems i can't get enough sleep. I could sleep all nite plus sleep in to 12-1pm during the morning and day and still wake up tired. Would you happen to know of some test that maybe my dr can do to find out about this or it is due to one of my dignosis. Thanks
By msattitude36  Mar 16, 2009
10
How about Peri-menopause. Oprah did a show on menopause and they were saying that could be a cause of fatigue?
By hollidayddd  Mar 16, 2009
9
Couldn't the Epstein-Barr Virus be the hiding culprit at times?
By jessdavisva  Mar 15, 2009
8
Hi Thanks for the post. My dr prescribed proprnanolol for bp and anxiety but it makes me tired and depressed is there a beta blocker that will not make one tired?
Regards
Ginny
By ginnyh70  Mar 15, 2009
7
Hi Thanks for the post. My dr prescribed proprnanolol for bp and anxiety but it makes me tired and depressed is there a beta blocker that will not make one tired?
Regards
Ginny
By ginnyh70  Mar 15, 2009
6
Thanks for another great post Dr O -

I seem to get a lot of sleep and have no trouble sleeping and believe I get ample uninterrupted sleep, but I always wake up tired - will keep reading and discuss with my Respiratory Doc too.
By Breathes  Mar 15, 2009
5
Maybe its because you havent been getting much sleep lately. But im just 12 years old, so you might reccommend a doctor not me.
By sydneyu  Mar 15, 2009
4
I am very, very tired and sleep little. I feel slightly depressed by this and lack motivation. I dread tasks. I am also Bipolar 2. I take medication (mild) to help, but it works for two hour only. I think the animals, nightmares and children are keeping me from sleeping. I hate it.
By Lain2  Mar 15, 2009
3
Vitamin D deficiency is especially prevalent in countries with long winter seasons, as the angle of the sun during winter prevents the usual *Sunshine Vitamin D* accumulation, as does the use of sunscreen 100% of the time a person is outside. I am told 15 minutes a day in summer sunshine without sunscreen will keep your Vitamin D level up to par and will not cause you to get cancer and die.

My fatigue is caused by stress and heart failure so there is nothing to be done about it.
By Appleby  Mar 15, 2009
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