HEALTH / Stop the world, I want to get off: More and more people are TATT - tired all the time. Are they bringing it on themselves? Or do they face intolerable pressures? Anne Woodham on ways of tackling the problem

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The Independent Culture
'I ALWAYS felt tired and yet there was so much to do,' says Hannah. 'Exhaustion was just part of the deal.'

Hannah is a public relations consultant specialising in crisis PR, a job involving strict deadlines, last-minute travelling and sudden bursts of frenetic activity. But she is also the mother of two sons under five, and, because she is married to a publishing executive, conscious that wining and dining business contacts is an extra-curricular obligation.

One day recently she found herself in her GP's surgery. 'I suppose I had quite a lot on my plate. We had house guests and there were extra meals to cook, and my son's birthday party to organise because his nanny was on holiday. The younger boy woke us up at five as usual, but I'd gone into work eager to get my teeth into a new project, and then been distracted by people with footling queries, wanting me to do other things. I couldn't concentrate, and felt awful, so I said I'd go home to work. I drove back feeling very jumpy and tingly, then lay down and fell asleep for an hour.

'The doctor said 'You're overdoing it,' whereupon I burst into tears and hit the wall. So she told me to take four weeks off, no excuses, and do nothing but rest and report once a week to the practice nurse for a massage.'

Hannah had fallen victim, rather spectacularly, to what could be described as fatigue fall- out. Because she pushed herself to the limits of her endurance - emptying her energy account, as one doctor puts it - she succumbed to a panic attack, and it was weeks before she could drive more than a few miles from the house without hyperventilating, her breath coming in shallow dizzying gasps from the top of her lungs.

In any one morning, says west London GP Sheila Hunt, tiredness alone can bring two or three people to her surgery, and this, she suspects, is only the tip of the iceberg. Complaints of fatigue, or feeling tired all the time (known as TATT), are increasingly widespread. Nor are GPs themselves exempt. Many are in a similar condition, staggering under mountains of paperwork generated by the Department of Health's GP Contract in 1990.

In one British study, 20 per cent of men and 30 per cent of women admitted to 'always feeling tired' during the previous week. In another, nearly a quarter of women (23 per cent) and 13 per cent of men said yes when asked 'Do you often get spells of complete exhaustion or fatigue?' One in 10 patients attending a south London general practice claimed they felt tired all or most of the time.

Class and gender make little difference, according to psychiatrist Anthony David, who led the south London study. The only group who scored higher than the rest were pregnant women and mothers with young children, a finding so obvious, Dr David says, that it 'won't go down as a great medical discovery'.

Is fatigue the same as stress? Yes and no. Fatigue is certainly an indication of too much stress, but the term is confusing. Stress in itself is no villain. A certain amount is necessary to motivate us and bring a buzz of achievement. And while there is 'good' fatigue - bodily exhaustion at the end of hard, physical work that packs one off for a good night's sleep - 'bad' fatigue can be a sign of ill health or mental and nervous overload, so should be taken seriously; a red light on the dashboard. If ignored, as in Hannah's case, it can trigger a stress-related illness or clinical depression.

What causes fatigue? Physical ailments account for as many as one third of instances, which is an argument for checking out persistent and inexplicable fatigue with a doctor. Allergies, diabetes, urinary tract infections, peptic ulcers, thyroid disorders and drugs such as antihistamines and beta-blockers can all induce numbing fatigue.

Nearly half the women of childbearing age in Britain - 49 per cent - suffer from mild anaemia. Iron is essential for cell function,

and low levels in the blood mean less energy, resulting in persistent tiredness, irritability, shortness of breath and dizziness. Women with heavy periods are particularly vulnerable, but more women and even men are now at risk because of the trend towards eating less red meat and offal. Not only are these foods stuffed with iron, but, says Good Housekeeping Institute nutritionist Fiona Hunter, 'it is in a form better absorbed than that in vegetable products'. It takes mounds of cabbage and cereal to equal a sirloin steak.

'Liver once a week,' she says firmly, 'even a liver pate, can make someone with low iron levels feel more energetic quite quickly.' Like most nutrition experts, she recommends a balanced diet rather than resorting to vitamin and mineral supplements. 'The body is like any piece of machinery. If you don't give it the right fuel, it won't work efficiently.' In her opinion, people who go through the day on cups of coffee and sugary doughnuts probably deserve to feel sluggish.

Marianne, a 40-year-old teacher with three children, was unaware that she was anaemic. 'It creeps up on you insidiously. I noticed I had no energy, fell asleep at dinner tables, and took to my bed after lunch at weekends. If I climbed a flight of stairs I felt dizzy. I put it down to having a job and kids and a basket of ironing.

'I went to the doctor to complain about my heavy periods. She took a look at my fingernails and said, 'These are too pale, I'm giving you a blood test for anaemia.' My iron count was way down and she prescribed iron supplements, which, although they tend to make you constipated, have been brilliant. I've discovered there's life after supper.'

Once medical causes of fatigue have been discounted, then one must look for psychological, social and environmental reasons: 'lifestyle' factors - disrupted sleep, long working hours, inadequate ventilation, lack of exercise, financial worries, family responsibilities. Three-quarters of patients consulting GPs with fatigue were also suffering with anxiety and depression, according to a recent study in the British Medical Journal.

But where does ME, the ultimate fatigue complaint, come into the equation? What usually begins as a cold or flu turns into a debilitating condition; overwhelming lethargy, mental exhaustion and associated aches and pains. And yet, despite a flurry of research and a high media profile, tests stubbornly refuse to show a common physiological pattern.

Some abnormalities in the immune system and muscle cells have been found; certain viruses, especially elusive retroviruses, are suspected. But is ME (or chronic fatigue syndrome, as international specialists prefer to call it) a single complaint, or different ailments that happen to share fatigue as a symptom?

An unpalatable fact for many sufferers is that antidepressants can often make a difference, indicating a psychological factor. Could ME, then, be a 'lifestyle' disease? A case of the unconscious mind manipulating the immune system, causing it to drop its guard? Harvard anthropologist Norma Ware, who interviewed patients about their lives before they became ill, was struck by how busy they were. They were 'involved in a million things at once, piling part-time on top of full-time employment, or combining jobs with child-rearing, volunteer work, vigorous exercise programmes, caring for ageing parents, active social lives'. For nearly half her interviewees, chronic fatigue syndrome proved to be the catalyst enabling them gratefully to adopt a new way of life, one in which they were in control.

It is control, or lack of it, that surfaces again and again in discussions of fatigue. 'What we're hearing more and more is that people no longer have as much control and autonomy in their jobs as they had before,' says Valerie Sutherland, director of the Centre for Business Psychology in the Manchester School of Management. 'You can cope with quite a lot if you feel you're in control, as opposed to 'strain' jobs, characterised by high demand, high volume of work, and a lack of autonomy.'

When people feel unable to cope, she says, they become depressed and tired and consequently even less capable of dealing with the situation, plunging into 'a vicious downward spiral'. Poor sleep patterns, whether due to insomnia or deprivation, impair daytime performance because the body misses the long delta brain waves of deep sleep, necessary to repair tissues and restore the immune system.

The middle-of-the-night wails of his newborn son destroyed Charles's sleep quota. Though he sympathised with his wife, his own fatigue began to worry him. 'I was used to gauging how many hours' sleep I needed to function efficiently and I wasn't getting it.'

Normally, he says, he can cope with fatigue. 'If I go for a 35-minute run first thing in the morning I feel zippier for the whole day. Mental stress is more tiring than physical stress, and when you run your brain relaxes and chemicals whizz round your body so you feel elated.

'I also feel more vibrant since starting my own marketing consultancy and taking control of my own destiny. I can concentrate on my own goals rather than fretting because some bastard higher up the organisation is frustrating everything one does. That's why I don't

like missing sleep; when I'm tired I feel less in control of life.'

Far from saving time and effort, modern technology pre-empts any escape from work pressures, and raises expectations of even greater output. Not only do executives totter grey-faced from airport to meeting, but mobile telephones ensure they are never out of reach; fax machines and computers quicken the pace.

'It used to take five days for a document to reach the US,' says Dr Sutherland. 'Now you work all day on a report and send it to New York or Houston; if you're not careful it's back on your desk expecting an answer before you've left the office.'

Add the spectres of recession and unemployment, coupled with obligatory 12-hour working days (and, for working mothers, a second shift at home) and most people's energy reserves will be running into the red. Yet some treat fatigue as a badge of honour, and others take it so much for granted that they are unaware of the extent of their exhaustion.

'There's a case for making people listen to their own bodies,' says GP Martin Scurr. 'We don't mind saying we're hungry, so why do we feel embarrassed about saying 'I'm tired, I must have a day off'?'

At his Jesuit prep school, he recalls, rest days were built into the schedule. 'But if you work for a big corporation, and your doctor says you need a week off, it's seen as swinging the lead, and you worry that someone else will be in your seat when you get back.'

With 'refreshable' fatigue, a holiday or short break, even several nights' good sleep, can restore energy levels. But often there are intractable underlying causes that an astute

GP could tease out. 'If you're always tired,

the issue should be what triggers it?' insists David Peters, chair of the British Holistic Medical Association and a lecturer in general practice at St Mary's Hospital Medical School.

Dr Peters draws an analogy with a car. 'Some people are running on empty, and then how are they going to refuel? And why do they want to stay in the fast lane?'

Even if they had the time and energy, few GPs are qualified to offer the kind of advice that is often most beneficial: psychotherapy, stress and time management, career counselling and complementary therapies such as massage, relaxation and acupuncture. Yoga, according to a study by psychologists at Oxford University, is one of the most efficient methods of boosting mental and physical energy.

Despite the NHS's new provision for referrals to complementary therapists, in reality few practices can spare the money. Yet Dr Peters believes complementary medicine can offer ways not only to relax but to step off whatever treadmill is causing one's fatigue. 'Some people don't respond well on a language basis; but there are other ways of interacting with a practitioner - touch, imagination, breathing, acupuncture, homeopathy - that aren't just about sitting in a surgery, talking and listening.'

Where complementary therapies have been incorporated into general practice, they are

remarkably effective in treating fatigue. GP Sheila Hunt refers tired patients to the practice counsellor; or to the nurse, who is trained in therapeutic massage; or, privately, to an acupuncturist. 'Massage helps people sleep better and to relax more and, in a strange way, gives them energy,' Dr Hunt says. 'Being touched helps people unwind, so that patients often open up with our nurse in a way they don't with me, and it becomes a counselling session.'

Her own response to an extra workload is in line with the stress management techniques she recommends to overburdened patients. She and her partner reorganised surgery hours and restructured their working methods to ensure that time off was guaranteed. 'It's not entirely conventional, but we offer a good service and, as we're feeling better on it, it works well for the patients too.'

And for those occasions when, as she puts it, she's 'up the wall'? A taste of her own medicine: exercise, acupuncture, massage.-

Is your fatigue taking you into the red?

Do you suffer from insomnia?

Do you have difficulty making decisions?

Are you making more mistakes than


Are you irritable and tense?

Take action if you answer yes to any of these. You could be pushing yourself into burnout.

The British Holistic Medical Association produces audio tapes and booklets to help people sleep, relax and cope with stress. Available by mail order ( pounds 9.95 incl p&p) from BHMA, 179 Gloucester Place, London NW1 6DX. Tel 071-262 5299.