Fatigue, the Brain and Therapists

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Fatigue is a common symptom of many health conditions and is even the primary symptom of some conditions (eg: Chronic Fatigue Syndome.) But it is not widely known that it is also commonly associated with brain disorders. In my years as a clinical psychologist and neuropsychologist I came across many patients and clients who, when carefully assessed, said that debilitating fatigue was their biggest concern. My students were trained to assess this along with other psychosocial problems even if the presenting problem was a brain disorder that seemed unlikely to be associated with fatigue.

It is now well established that following a mild head injury that results in a post-concussional syndrome, excessive fatigue will indeed be one of the main problems. The only treatment for this is to rest, and return to work, school and leisure activities gradually. The likely cause of fatigue as part of the post-concussional syndrome is the tearing and shearing of the white matter connecting the frontal cortex to the rest of the brain. Those frontal regions have a lot to do with our general level of alertness, so this makes sense. (See my PsychToday blog post: The Unseen Injury: Post-concussional Syndrome). A large study I and my colleagues published on the outcome of subarachnoid haemorrhage (this occurs when blood is expelled at high pressure around the outside of the brain when a weak point on an aneurysm bursts), showed that while in many cases survivors have a good recovery in terms of their general cognitive functions over the next few months to a year, a staggering 86% to 90% still continue to suffer from debilitating fatigue 12 months later. 35% still suffer from fatigue and report it as problematic when assessed after 4 and 7 years. This is probably due to mild diffuse cortical damage caused by the toxic effects of the blood around the brain.

Indeed people who suffer almost any sort of trauma to the brain, from surgery to remove a brain tumor to dementia will likely suffer from fatigue. If you have ever been in a situation where you have been deprived of sleep for 30 or more hours you will have a sense of what this does to you; it makes you feel fuzzy, unfocused, irritable, and irrational. It reduces your reaction and response times and makes you less tolerant of noise and alcohol. It affects your attention span and therefore your ability to take in new information—that is, you will feel as if your memory has been compromised (which, of course, it has).

More recently it has been shown that pituitary disorders, even small benign pituitary adenomas (swellings of the pituitary gland) which are common (one study puts the prevalence rate at 16.7%) and are found more often in women than men, are often undiagnosed or underdiagnosed by medical practitioners. The pituitary gland is a pea-sized gland which sits in a bony hollow just behind the bridge of the nose. It is attached to the base of the brain by a stalk. It secretes hormones and also controls several other hormone glands in the body, and disorders of it can thus result in a wide range of symptoms. A recent small qualitative survey published in the Pituitary World News reported a wide range of mental health problems (eg: anxiety/panic, mood fluctuations) in people with pituitary disorders, but of interest when ‘physical symptoms’ were self-reported, the most common was fatigue, followed by headache (often a co-symptom with fatigue).

This “mental” or “psychological” type of fatigue that is so common after damage or disorders of the brain is different in quality from good healthy fatigue after lots of exercise. With that sort of fatigue, when you get into that lovely bed you fall asleep in a healthy way, likely stay sweetly asleep all night, and awake refreshed in the morning. With “mental” fatigue sleep may be of poor quality and on awakening the individual feels as tired as before. Of course this is not really “mental” or “psychological” fatigue, as its cause is physical; a brain that is not working as efficiently because of physical damage.

The take-home message here is this: if you are a therapist or medical doctor, take reports of debilitating fatigue seriously for two reasons; your client may have some sort of brain disorder, or if you know this is already the case (for example if you are counselling someone with a post-concussional syndrome, or you know they have a pituitary disorder) take their fatigue seriously and give them coping strategies to help them through this stage (rest, relaxation exercises, establishing a relaxing routine before they go to bed). And of course, and always important, acknowledge their fatigue as a real symptom, rather than brushing it aside as “something we all have to cope with some time. Now let’s work on your poor memory.” Once the fatigue resolves, that poor memory (and the irritability, and mood swings, and headaches, and even depression) may well improve as well.