Problems in Family Practice

The Tired Patient

Don A. Rockwell, MD Bill D. Burr, MD Davis, California

One of the most challenging diagnostic problems that comes into scess, mononucleosis, and most vi­ the physician’s office is the patient who complains of “being tired.” ral infection. It can prove to be a frustrating experience for the physician 2. Metabolic disturbance. Any fluid or (especially if the physician is also tired) and to the patient. electrolyte imbalance, especially This article will propose and describe a two-pronged systematic with extracellular fluid deficiency, whether naturally occurring or approach to the patient that can increase the probability of a iatrogenic, is associated with fati­ satisfying outcome for both physician and patient. This approach gue. Hyponatremia and hypo and assumes the “complaint” of every patient has both informational hypermagnesiumemia are most no­ value (“I think there’s something wrong.”) and transactional mean­ table although hypokalemia is most ing (“Please take care of me.”). Tiredness, fatigue, “exhaustion” common. 3. Circulatory failure and/or digitalis need to be seen simultaneously as information and need. Both toxicity. aspects require simultaneous work-up. 4. Hemolytic anemia and acute leu­ kemia. Differential Diagnosis of Fatigue REM sleep, such as many of the The vagueness of the nonspecific hypnotics and some tranquilizers. complaint of tiredness covers a host of Drugs which have little effect on possibilities from brain tumor through REM sleep are flurazepam (Dal- III. Chronic Fatigue incipient diabetes to being up all night mane) and doxepin (Sinequan). with a sick child. However, most tired 3. Acute severe dieting or chroriic Longer, more insidious causes are patients fall into one of three major moderate dieting. Ketosis, negative foiind here and the differential diag­ subgroups of fatigue. nitrogen balance. nosis includes: 4. Sedentary life style. 1. Chronic infection. These possibili­ I. Physiologic Fatigue Poor cardiopulmonary reserve. ties include subacute bacterial en­ Patients and physicians are prone to 5. Pregnancy. docarditis, tuberculosis, brucellosis, ignore the fact that fatigue is reason- Prenatal and postpartum. parasitic infestations, and chronic able to expect in the following circum­ 6. Prolonged mental stress. pyelonephritis or osteomyelitis. stances: 7. Advancing age. 2. Anemias. Megaloblastic and iron !■ Prolonged physical exertion with­ Decreased physiologic reserve. deficiency anemias are most com­ out adequate rest. mon but consider also poly­ - Inadequate amount or restless cythemia and hemoglobinopathies. sleep. Drugs may interfere with 3. Nutritional dysfunction. Any defi­ ciency in diet, such as calories, II. Acute Fatigue ('em the Department of Psychiatry and protein, or vitamins, may inducb ™ !y Practice, School of Medicine, Uni- Lassitude or tiredness of recent or fatigue. A careful nutritional his­ ve[sity of California, Davis, California. Re- !i?ted with updating from THE JO U R­ sudden onset should direct the physi­ tory is important since a “rlormal” NAL OF FAMILY PRACTICE, Volume cian’s attention towards: diet may mean that the patient is a L Number 2, 1974. Requests for reprints Houlci be addressed to Dr. Don A. Rock- 1. Prodrome or sequelae o f acute in­ vegetarian or macrobiotic “freak.” '■ ^epartrnent of Psychiatry, School of fection. Among the worst offenders edicine, University of California, Davis, Pellagra and cerebral beri-beri have « 95616 are the meningitides, cerebral ab­ not disappeared. Exogenous obesity

j o u r n a l THE OF FAM ILY PRACTICE VOL. 5, NO. 5, 1977 853 is exhausting in itself. ed sleep, important life changes such vity (toddler in the house). For many 4. Chronic exogenous intoxication. as job and new family member; dura­ patients such a reality orientation is Careful attention should be direct­ tion; periodicity; intensity; and associ­ both reassuring (ie, there’s nothing ed to common chronic intoxicants ated symptoms. seriously wrong) and educational (ie such as alcohol, barbiturates, and 2. Careful family history of dia­ maybe I can alter one aspect of the minor tranquilizers as well as less betes, anemia, endocrine disturbances, pattern and feel better). common ones, such as heavy metal, depression, alcoholism. Through this approach it is often gasoline, carbon monoxide, and in- 3. Full review of systems — per­ possible to avoid a fruitless search for secticide/pesticide poisoning. haps using a self report or automated esoteric explanations. At the same 5. Chronic endogenous intoxication. history taking. time, it is important to be particularly Most commonly uremia and hepatic 4. Oral intake history - anything wary of snap “psychiatric” or “or­ insufficiency. the patient puts into his/her mouth ganic” explanations of fatigue. Invari­ 6. Endocrine disorders. The following both in terms of nutrition and in terms ably the “organically” caused fatigue are associated with fatigue: diabetes of drugs. Careful inquiry concerning has an emotional reaction associated mellitus, hyper and hypopitui­ daily use of some over-the-counter or with it that requires attention. The tarism, hyper and hypoadrenal prescribed medication, as well as al­ patient who becomes depressed as a function, hyper and hypothyroid cohol and caffeine intake, may be result of being on reserpine is no lessa function, and hyperparathyroidism. especially rewarding. suicide risk! Thus while running down 7. Malignancies. Fatigue may be an Having elicited the above history, the “organic” causes (ie, the informa­ early sign and is a common accom­ consider which subgroup of fatigue the tional aspect of the complaint) the paniment of middle and end-stage patient falls into — physiologic, acute, transactional or need side of the com­ malignancy. or chronic fatigue. Taking cognizance plaint should also be attended to. A 8. Iatrogenic fatigue. The following of the differential diagnosis suggested psychiatric “explanation” of fatigue is drugs are frequently associated with by the particular subgroup of fatigue, never a diagnosis of exclusion. If no fatigue as a significant side effect: next move to a complete physical positive evidence of psychiatric disease All sedatives and hypnotics examination and related appropriate is found using conservative diagnosis All tranquilizers laboratory and x-ray examinations. then it may be concluded that the All antihistamines Special exams are done when indicated etiology is still unknown and that it is Most anticonvulsants by history or by age of the patient. In necessary to continue to explore with Most analgesics and salicylates the physical examination, special at­ the patient sources of fatigue. Justasa Nicotine tention is focused on evidence of diagnosis of anemia requires significant Tetracyclines muscle wasting, organomegaly, change in red cell indices, so a diag­ Colchicine lymphoadenopathy, and skin changes. nosis of depression or hysterical char­ Cycloserine Laboratory examination routinely in­ acter requires significant positive evi­ AdrenocOrticosteroids cludes a CBC with differential, urin­ dence. The skilled clinician never diag­ Progesterones (ie, many birth con­ alysis, and a chemistry panel with noses purely by exclusion. trol pills) blood sugar and liver function studies. Ergot alkaloids Other studies are done as indicated by Insulin clinical status and age. Mild digitalis toxicity In spite of its lack of scientific Mild Vitamin A toxicity status the clinician may rely heavily on Mild Vitamin D toxicity the intuitive sense that “something’s Common Patterns of Tired Patients 9. Neuropsychiatric dysfunction. In­ up” and that this should be pursued. cluding intracranial neoplasia, sub­ Trust in intuitive skills is important in In everyday practice, there are sev­ dural and extradural hematomas, the work-up of the “tired patient” eral major patterns for the tired pa­ amyotrophic lateral sclerosis, narco­ since chronic fatigue may precede pos­ tient which merit further discussion, lepsy, myasthenia gravis, Syden- itive physical and laboratory findings. hams chorea, depression, hysterical In the authors’ experience a careful 1. Depression characters, hyperventilation, and history and physical examination will The first major group of tired pa­ chronic anxiety. uncover 80-85 percent of causes, the tients are the depressive patients and screening laboratory studies an addi­ patients with depressive equivalents, A tional five percent, and the remainder developmental appreciation of depres­ will require more time and repeated sion is important since depression is evaluation. manifested in different ways according A threshold model is often useful to age, sex, and socioeconomic status. Making the Diagnosis to explain chronic fatigue since in Infants and children rarely manifest Crucial to the differential diagnosis many cases the causes are multiple and depression by the typical “lowered of fatigue is a careful history. Detailed additive. For example, chronic fatigue mood.” Infants and children may he information on the following items may be precipitated by a minimal manifesting depression when they are should be obtained: anemia in a patient already at thres­ hyperactive; running away; withdraw­ 1. Onset of symptom; relationship hold as a result of chronic minimal ing; having school, eating, or sleeping to known factors such as starting sleep loss (baby in the house) and problems; and when having vague medication, increased activity, decreas­ minimal increase in usual physical acti­ physical complaints. Adolescents life-

854 THE JOURNAL OF FAMILY PRACTICE, VOL. 5, NO. 5, 197J and Hollister. 1 A brief summary of Table 1. Discriminators of Depression by Socioeconomic Class* their work is shown in Table 2. On the treatment side of the equa­ tion one can rely heavily on both the Low Middle High relationship with the patient (frequent brief visits) and an aggressive psycho- pharmacological approach. Having se­ Affective lected an appropriate psychoactive Hopelessness L o n elin ess Decreased social life agent, one should persist with that Self-accusation Helplessness Pessim ism agent for from three to six weeks and

Crying G u ilt Dissatisfaction push the total daily dosage to near

Dissatisfaction C ry in g Anxiety-Tension “toxic” levels. If the patient is not having side effects the “treatment” is G uilt Anxiety-Tension not likely to be effective. The attempt Depressed Mood Depressed Mood to involve the family in the treatment program is often rewarding; the au­ Somatic thors concur with Cammer’s finding Palpitation Decreased Sex Drive Fa tig u e that the family can greatly facilitate Headache Urinary complaints Inso m nia progress.2 Once entertained, the possi­ A norexia Trouble falling asleep bility of the patient having a depres­ Waking Early H ead ach e sion has been whether as a primary

A n o re x ia source of tiredness or secondary to

Waking early other “organic” illness, the authors believe a direct inquiry into the pa­ tient’s potential for suicide is manda­ *Adapted from Schwab 7 tory. Continued attention to this risk is necessary throughout the treatment course of the depressed patient.

wise may frequently “act out” depres­ that other functional or organic sive conflicts with the result that syndromes, such as peptic ulcer and 2. Hysteria depression manifests in boys as anti­ ulcerative colitis, can be “symptoms” A second group of tired patients are social behavior or poor school per­ of depression and are commonly ac­ the so-called hysterics. Woodruff and formance, in girls in sexual misconduct companied by depression. While any Guze3 have developed a diagnostic or running away, and in both by organ system may be involved, skin pattern characteristic of the hysteric. “doing drugs,” drinking, and through disorders and pain syndromes (head­ This includes: psychosomatic problems. Young ache, backache, residual pain) lead the a. a complicated or dramatic medical adults more frequently somatize or act list after the GI tract. history out depression then evidence a classic Tiredness is a very common b. a minimum of 25 symptoms in nine picture. By middle age the more typi­ symptom of depression. It is impor­ of ten systems in the review of cal “textbook” depressive pictures are tant to recognize that the signs and symptoms (“a positive review of seen, but the physician should also be symptoms of depression vary not only systems”) aware that depression continues to by age but also by sex and socio­ c. a minimum of 25 symptoms with­ manifest often via acting out behaviors economic status. Males more common­ out a medical explanation of eti­ - particularly sexual and drug — and ly manifest depression by lowered ology in somatic problems. At all stages mood, pessimism, guilt, and a sense of If a patient meets Guze’s criteria, there accidents” may be depressive, uncon­ helplessness. Comparable early signs in is a 90 percent chance that the clinical scious, self-destructive equivalents. A women are insomnia, headache, and condition will remain stable and that close look at the antecedents of “acci­ social withdrawal. Table 1 points out other serious medical and psychiatric dents” is worthwhile. the variation in the presentation of illnesses will not develop. This can be Somatization is a theme that also depression by the patient’s socio­ explained to the patient and also has pervades the life cycle of depressive economic background. an effect on the management of these equivalents. Gastrointestinal symp­ Once depression has been recogniz­ patients. toms lead the way as an arena for the ed, then the attempt must be made to These patients represent a very expression of depression. The irritable decide whether it is normal (as in small proportion of medical practice. colon syndrome is the most common grief), typical, or atypical. Depression It is crucial that the diagnosis be equivalent, but it is well to remember may be classified following Grinker limited to those patients meeting

THE JOURNAL OF FAM ILY PRACTICE, VOL. 5 NO. 5, 1977 855 Table 2. Classification and Treatment of Depression

Retarded Depression Anxious Depression Hostile Depression Hypochondriacal

Deeply depressed Much "unworthiness" and Paranoid and projective Little guilt g u ilt Psychomotor retardation Agitated Hostile belligerency Moderate depression Lacks environmental Reactive to environment A g ita te d re a c tiv ity Loss of interest in life Hopelessness Feels "abandoned and u n lo v e d " Visceral symptoms Reports anxiety A n g ry Multiple somatic complaints No self-pity S e lf- p ity No sense of humor May have sense of humor — Sense of humor is often teasing in character sadomasochistic in ch a ra cte r No precipitating stress Precipitating stress ("it came over me like a b la c k c lo u d " ) Tends to be older Prior history of neurotic Prior history of neurotic Lifelong history of Weight loss common or behavioral problems or behavior problems disturbances co m m o n co m m o n Early morning or middle Trouble falling asleep of the night awakening S u icid a l Tends to cling to MD Provocative Demanding Best psychopharmacologic Best psychopharmacologic No best psychopharmacologic Psychopharmacologic agents agents agents agent likely to associate with — imipramine (Tofranil) — phenothiazines like — often need a many "troublesome side — amitriptyline (Elavil) perphenazine (Trilafon) combination of a tricyclic e ffe c ts " plus supportive plus psychotherapy may and a p h e n o th ia z in e psychotherapy — if no use doxepin (Sinequan) as response after adequate alternative agent dosage over three weeks consider electro­ convulsive treatment

856 THE JOURNAL OF FAMILY PRACTICE, VOL. 5, NO . 5, 1977 QUZe’s criteria since otherwise it is The physician’s role in treatment may or without panic attacks, is best treat­ possible to get into a sophisticated be to involve the patient’s family, and ed by using some form of relaxation of name calling. No one denies together with the patient and family therapy (biofeedback, meditation, re­ the existence of these patients, but the realign health priorities and responsi­ laxation techniques) in combination, etiology has often been hotly debated. bility. in certain cases, with anxiety-reducing It seems important that the presence medications. of this life-style not be denied but rather that the possibility of a positive outcome be maximized. This includes: a not putting the patient through the pain and expense of a nonproduc­ tive work-up h, recognizing the transactional nature 4. Stress and Exhaustion of the complaint A fourth group of tired patients c, recommending appropriate “treat­ exhibit stress and exhaustion. Be at­ ment” which for a female patient tentive to chronic stress or a recent Conclusion can include suggesting that she re­ increase in stress on a patient. It is The tired patient presents the examine her current role in view of known that life changes are additive physician with an informational prob­ changing women’s roles and can lead to increased illness and lem (“Tell me what is wrong with d. allowing the physician to recognize accidents.5 There is evidence to indi­ me.”) and a transactional problem the common counter-transference cate that chronic overwork plus a (“I’m scared about . . . and need you problems of frustration, anger, un­ sudden recent work increase is a car­ to take care of me.”). Careful atten­ due interest, and therapeutic im­ diac “drain” and often antecedes an tion to both issues is crucial. Elucida­ potence in dealing with these pa­ acute myocardial infarct.6 An “enforc­ tion of the specific cause or causes of tients ed” vacation may be in order for these fatigue is sometimes difficult, but ef­ patients and certainly a “prescribed” fective management requires an active change of pace is in order. The ex­ diagnosis rather than a passive diag­ amples of this are innumerable but nosis by exclusion. If the causation is keep in mind several practice-related unclear the search must be continued situations: until a positive explanation is evident. a. Familes with chronically ill or dy­ At the same time, attention to the 3, Situational Exhaustion ing members (especially if the pa­ “need” side of the equation is effec­ tient is a child). tive treatment for some patients in and A third important group of tired b. Families in considerable emotional of itself. Utilization of the basic skills patients are those exhibiting “situa­ conflict often manifested by sexual of the physician and his or her team tional exhaustion.” This is a form of problems. will result in effective intervention in physiologic tiredness but is common c. Upwardly mobile young men and most cases. enough to merit special comment. women. These are situations where being tired is an appropriate response and symp­ tomatic purely of lack of rest, relaxa­ tion, and sleep. This commonsense diagnosis needs only two caveats. Be aware that in spite of all labor-saving devices many people continue to have too much to do. And also be aware that many “workaholics” are appro­ 5. Chronic Anxiety and Hyperventila­ priately tired as a result of their being tion driven internally. A final group of patients who ex­ References 1. Hollister L, Overall J, Shelton J, et al: The “workaholic” needs to be ad- perience chronic fatigue are the chron­ Drug therapy of depression. Arch Gen rised of the diagnosis and sometimes ically anxious with or without hyper­ Psychiatry 17:486, 1967 2. Cammer L: Family feedback in de­ 8ven prognosis of the condition. ventilation syndrome. Included here is pressive illness. Psychosomatics 12:127, “Hard work” or “overwork” often is a the cardiac neurotic who manifests 1971 3. Woodruff RA, Clayton P, Guze S: symptom of underlying personal or fatigue and chest pain. True anginal Hysteria: Studies of diagnosis, outcome, and prevalence. JA M A 215:425, 1971 family problems. The person must be chest pain is rarely associated with 4. Glasser W: Reality Therapy. New educated to appreciate that chronic hyperventilation syndrome while most York, Harper and Row, 1965 5. Liljefors I, Rahne R: An identical overwork: cardiac neurotics do have signs and twin study of psychosocial factors of cor­ a. is a symptom symptoms of hyperventilation. Dis­ onary heart disease. Psychosom Med 32:523, 1970 5 may well be detrimental to long- tinguishing features include deep sighs, 6. Bruhn JG , McCrady KE, du Plessis A: range physical and emotional health perioral and peripheral tingling, blurr­ Evidence of “ emotional drain" preceding death from myocardial infarction. Psych Dig and happiness ed vision, and lightheadedness — com­ 29:34, 1968 7. Schwab J, Bialow M, Brown J, et al: c' 's treatable using “reality”4 and mon in hyperventilation, rare in true Diagnosing depression in medical inpatients. family therapy techniques. cardiac disease. Chronic anxiety, with Ann Intern Med 67:695, 1967

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