A Theory of Tiredness
Is Being Tired a Sign of Our Times?
My previous blog entry was a question.
Why am I tired?
On the surface, this question is simple. “I’m tired because I’ve been working hard.” Or “I’m tired because I haven’t gotten enough sleep.” Or “I’m tired because I’m out of shape.”
There are any number of responses to this question, but I raise it again in this blog because it speaks to a feeling that most, if not all people, have.
In a New Yorker article, May 17, 2021, entitled, Burnout: Modern Affliction or Human Condition? As a diagnosis, it’s too vague to be helpful—but its rise tells us a lot about the way we work, Jill Lepore wrote:
“To be burned out [tired] is to be used up, like a battery so depleted that it can’t be recharged. In people, unlike batteries, it is said to produce the defining symptoms of “burnout syndrome”: exhaustion, cynicism, and loss of efficacy.”
I would suggest that “being tired” could be added to burnout syndrome because it is how we feel when we live our lives in a frenzy. For the past year (or more) we’ve been living under the umbrella of COVID where people have altered lifestyles, and how they go about their day. Clients tell me, “Doc, I’m tired, physically exhausted, all because of COVID.”
Being tired or the feelings exhaustion, can be much more than overdoing it.
The Underpinnings of Tiredness
How should “tiredness” be defined. A dictionary definition is:
To be tired is to be: “drained of strength and energy : fatigued often to the point of exhaustion,”
More elaborated definitions include: A feeling of a lessened capacity for work and reduced efficiency of accomplishment, usually accompanied by a sense of weariness and fatigue. Tiredness is not a singular symptom that defines any one particular…[state, condition, or disease]. Rather, tiredness can be a symptom [or a feeling or consequence] of a wide range of states, conditions or diseases…
Unlimited energy is a misnomer. Theorists have suggested that our energy comes from two sources:
The Energy we actually have.
The Energy we perceive we have.
These I will distinguish as:
Biological or Physical Energy
Psychological or Emotional Energy
Biological Energy
Biological Energy is in our physiology. Our body’s ability to mobilize action. This is the energy to drive metabolic function. At a molecular level, it is embedded in ATP molecules. The acronym stands for Adenosine TriPhosphate. A specific chemical, embedded in molecules within our cells that converts matter from food and then releases it through the breakdown of the chemical bonds between the second and third phosphate groups. This action produces pure biological energy. Although it varies, the human body runs on about 100 to 150 moles of ATP per day.
An individual doesn’t have direct access to this process, but it can be screwed up or slowed down or even speeded up based on the kind of food we eat, the rate of eating food, and the amount of action we engage in. ATP is an “on-demand” energy. As the body needs and demands it, then ATP breakdown speeds up or slows down. Physiology is the source of biological energy. This makes sense as many diseases are caused by cellular shortages of chemicals (things) and DNA (information), that there should also be diseases caused by a shortage of cellular ATP (energy), say Fibromyalgia.
It goes without saying, that if you have certain metabolic diseases, take Diabetes, metabolism (breakdown of ATP Energy) goes awry because the kidney, liver, muscles and so forth are damaged, you will feel tired as a consequence. This kind of tiredness is not due to perception (although you perceive it when it happens), rather, it is due to the reality that you are not generating enough ATP to function as you would normally would.
Psychological Energy Defined
Psychological Energy is wholly different, although there might be some overlap if, say, you are depressed because you have Diabetes. In addition, one way that psychological energy is similar is that it is a source of “power” emanating from the individual, and in this case, it is difficult to discern whether it is biological energy or psychic energy or both. But, for the purpose of this blog entry, I will assume that this second form of energy is separate from the previous form.
I like the Article by Nick Paumgarten, November 1, 2021 in the New Yorker: Energy, and How to Get it: All of us know people who have more energy than we do, but the science of the phenomenon is just coming into view.
“Energy,” though, is a misnomer, or at least an elision. What we commonly call energy is actually our perception of the body metabolizing carbohydrates or fat as energy. Energy isn’t energy. It’s our experience of burning energy, converting it to work. It’s a metabolic mood. As Richard Maurer, a doctor in Maine who specializes in metabolic recovery, and who encountered me one day last summer as I mumbled about a shortage of it, told me, “ ‘Energy’ is a useless term. It is not the perception of stimulation. It is just the capacity to generate work. I think of it as only relating to potential. If a patient says, ‘I want more energy,’ maybe the doctor should just write a scrip for methamphetamine. But that’s false chi.”…
Psychological Energy Level
Believe it or not, all people are born with a sense of their own personal level of psychic energy. Just like temperament and emotional lability, Energy Level, varies widely between human beings. A marathon runner may actually be a very low energy individual, for example. As I have described in earlier blog entries, it is easy to size up a person by attending to three things: 1. Energy Level (Psychological), 2. Temperament, and 3. Emotional Lability.
Some of the measures of psychic energy that psychologists have discovered are: activity level, vigilance, reaction time, persistence, resilience and the list goes on and on. For some of these, vigilance, measurement is easy (vigilance tasks). For others, resilience, it is difficult. “What is resilience anyway?”
Some theorists of the human psyche have suggested that emotions are a kind of energy. People who tend to experience a lot of stress, feelings of worry, fear, or anger, even happiness and peace of mind, are experiencing a type of psychic “energy” emanating from within them.
Unfortunately, we use words a lot like tiredness, fatigue, drug out, burnout, lethargy to describe psychological energy, but these states are consequences of energy depletion or rushes of energy and these terms at a functional level do not distinguish between biological and psychological energy.
Psychological Energy is at the basis of executive power in the brain, decision making, thought processes, memories, and to experience present situations. A person’s ability to understand and deal with the world, which is a kind of energy, is vital to states of happiness and contentment.
Tiredness or fatigue is a hallmark symptom of depression. This is because depression blocks the expression of psychological energy. Low energy symptoms in depression are similar to profound sadness and loneliness that people with depression experience. Below are several questions that one would find on most tests of chronic depression. Note below, the focus on the feature of tiredness.
Beck Depression Inventory: Question #17 - 0=I don’t get more tired than usual, 1=I get tired more easily than I used to, 2=I get tired from doing almost anything, 3=I am too tired to do anything.
Zung Depression Scale: Question #10 - I get tired for no reason. 0=A little of the time, 1=Some of the time, 2=Good part of the time, 3=Most of the time.
Patient Health Questionnaire-9: Question #4 - Feeling tired or having little energy? 0=Not at all, 1=Several days, 2=More than half the days, 3=Nearly every day.
Take any depression measure that exists, at least one question will focus on tiredness.
Why am I tired when I’m depressed?
When you are chronically depressed, you might still have a lot of biological energy. Your body may be working and creating energy OK, but it doesn’t feel like it is. The energy you feel that you have to expend seems to be gone. Like, it just withered away or disappeared. If someone asks you to help pick up the house, it would seem as if you have been asked to do something insurmountable. You would appraise the task as too difficult. You would tell yourself, “I simply can’t do this task.”
It’s not that your energy isn’t there. You feel unable to access your existing energy. There is some truth to this feeling because when it comes to psychological energy, there are two places it resides. 1. Active Energy, and 2. Energy in reserve (or Reserve Capacity).
Yes, your energy is there, but it is sitting in reserve and you can’t get to it!
Some people theorize that we have two places for energy to reside. One of those is a nebulous, but finite repository of reserve capacity.
Reserve capacity exists from the point of birth, and people generally start with a lot of it. However, over time, as we live our lives, we use it up. A main way people have understood this is through aging. As we grow older, we use up energy. When we are young, we seem to be able to take on the stressors of life (such as is found in work and play), and we bounce back to normal levels of functioning. But, as time goes on, we keep using up our reserves and it gets harder and harder to get back to normal functioning. In later life, in advanced aging, we start to consciously notice depletions in this reserve, soon, it becomes nearly impossible to bounce back because we have depleted reserves in very advanced age, such is the decade of our 80’s and 90’s (if we live that long). The figure below highlights this point for physical function.
Another way that makes it hard to bounce back is when the pipeline (or access point) to this reserve is blocked for some unknown reason. Psychiatric conditions such as trauma, depression, anxiety, phobias, discouragement, all block the pipeline to accessing reserves. That’s why, when you are depressed, even small setbacks or hassles can exert a profound impact on resilience. You can’t bounce back, there’s no energy available to do it. Then, based on adverse events or states, you start feeling vulnerable, fearful, uncertain. When you feel vulnerable, you actually feel a lack of psychological energy.
Can Tiredness be Treated?
Yes, Tiredness can be treated. It is easier to treat biological tiredness than psychic tiredness mostly because we can create a better definition of biological tiredness. In general, anything that can be clearly defined and described can be treated with greater ease and effectiveness.
To treat “biological tiredness” it is essential that you activate your body. Even in disease, activating your body is key to treating tiredness. Even mental tiredness conforms to this heuristic or rule. If you activate your mind, then you can treat mental fatigue. The only issue with this latter point is the question: What does it mean to activate your mind? Is watching television activating your mind? Most people would say no. I would say yes, because to watch television requires a whole bunch of mental processes not the least of which is visual perception and integration. That’s why in nursing homes, elderly persons watch TV. They are doing what they can to keep their mind active.
Joe
I saw Joe for almost four years. I should note, at the writing of this entry, Joe, passed away approximately one year ago. My first contact with Joe was when he was 83 years old. He contacted me, himself, by telephone. This is what he said:
“I’m 83 years old and I live alone, I am out of energy, I’m afraid that I’m almost out of time. I still want to live, but not like this. I need help. I can’t drive. I can’t make meals anymore because of arthritis, I can barely put on my clothes. I’m losing control of my bowels, I have accidents, and then I’m left to clean up after myself and it takes me hours to do it. The smell is awful, even to me. I’m living in my own shit. I live here in this home. I’ve owned it for over 60 years. It’s big, three stories, but I live on the main floor and sleep in a recliner. I do have a person who comes in once a week to vacuum and such, sometimes more often if I have trouble. I’m not married anymore, I’m a widow. But, my last marriage wasn’t that good, we disliked each other, but towards the end she was alright. Died in the bed, it was hard to see her go. It was hard to watch them wheel her out under that dark green cloth. My kids have stopped coming by to see me, all except one. Most of my kids never really cared for me anyway. Now, they've forgotten, I guess, that I even exist. Well, they still want the house and my money, and they can have it when I’m gone, but not before. I can’t work, I can barely see to watch TV, so I just listen to the radio. Thank God I can still hear. I’ve been having dreams that I’m dead. I don’t want to die, but I guess there’s no way to avoid it. I don’t give a shit anymore, can’t even cry about my situation. I’m really lonely, I need help. I don’t want to go to a nursing home because then I’m sure I will die.
Joe needed help. Probably at that time, more help than he was willing to accept and likely more help than I could give him. When he called, my therapy schedule was jam-packed. I just didn’t have room to work him in. So, I put him on a wait list. I also gave him three names of social workers in the area that he could call. It was clear he wasn’t suicidal. From our phone conversation, remarkably, he seemed mentally intact. I guess for Joe, this was a blessing and a curse, because he was exquisitely aware that he was falling apart due to advanced aging and there seemed like nothing he could do.
Joe was persistent. He didn’t use or even understand the internet, and, of course any form of texting or social media was out of the question. He did have my phone number, and he started calling me, weekly, to check on his wait list status.
At first, this annoyed me, but his situation kept niggling at me until finally I got an opening and I worked him in. He couldn’t drive, so the first task I gave him, which I thought would disqualify him, was that he had to start by seeing me at least once in-person. Impressively, he worked to mobilize his resources and got one of his children to drive him to my office so that we could visit in person. This was an ordeal. My Office is ADA compliant, and Joe arrived in a walker. He was very, very old looking and he was in marginal pain the whole time we visited, which was only half an hour.
Come to find out that Joe was substantially wealthy. He didn’t need or use insurance, so there was not need to deal with this stumbling block in arranging future sessions. From that point on, and weekly, Joe started to see me (or connect with me) for 50 minutes per week by telephone.
Our sessions started with Joe reviewing for me his life. Which was actually a fascinating story. He was a “railroad” man and for a large part of his life he worked on the railroad, was a train engineer for many years, worked up into the executive ranks of the railroad, but he was a tough blue-collar guy who did not take any guff from anyone. His life was one of fierce independence, so it was even more remarkable that he decided he needed to connect with me for help. But, Joe was lonely, and he was also physically alone. He really had no one to talk to or to listen to him. He enjoyed talking, telling tales. I could have written a book about the people he met and the experiences he had.
Aging came on slowly for him. He worked until he couldn’t; that is, he eventually got to the point that he just couldn’t get to and from work any longer, so he retired at the age of 77. After he retired, things went downhill faster. He had invested so much of his life into work and into getting out into the routine of work, so when that was gone, he was left as he described it, “to sit on my hands and wither away.”
Joe had gone through periods of harsh treatment to his body. He smoked for many, many years. Her served in the military, the Marines. For a time, he drank alcohol heavily. He lost and gained weight, mostly losing weight when he had significant illnesses. Joe’s story was a story of persistent survival. Surviving difficult wives (at least in his view), difficult children, difficult family members, always working hard to distract himself. In his earlier life he enjoyed traveling, seeing things.
One interesting aspect to Joe is that it seemed that aging had softened him, somehow. I think about in his 70’s he started to realize that he needed people. But, then, he didn’t have the skills or the attitude to bring people to him. He did have quite a few male friends that were roughly his age and he kept in touch with them through the phone. I think this is why phone sessions worked so well for him.
Over time - I’m not entirely sure why - but I started to develop a liking for Joe. Sure, he was irascible, but he had a kind of life wisdom I haven’t encountered in many people, even in older people I’ve seen. He knew how to get along in life, and he knew how to live in such a way that you could keep going even when really bad things happen to you.
But, Joe was tired. He was tired of living especially under the constraints that he was under with advanced aging. He knew he was near the end of life, but he still seemed to possess emotional energy. I don’t think Joe had ever really been depressed or discouraged, he knew how to tap his energy. One of the hallmarks of survival for him was that Joe walked. He walked every day he could. He wasn’t walking when I saw him and I think this outlet or source of activity, once that was gone, due to his arthritis which was very advanced, it sort of sapped his will. There was something that getting out and moving, escaping the house for a while, using a walk to reset his day, that was intriguing. He didn’t view walking as exercise, he viewed it as a sort of personal meditation on life. He was now having a hard time to re-instate that coping mechanism without the act of walking. But he did finally develop a way.
I’ll save this feature of the story for later, but I present the case of Joe because he demonstrates of life-long approach to the utilization of physical and psychological energy. I’d be interested to learn about your thoughts on this topic.