General practitioners often see a syndrome they call “tired all the time.” How often doctors see it depends on how tiredness is defined and where it is measured. Morrell recorded fatigue as the most important reason for consultation in 24 per 2000 registered patients in one year 1; Jerrett recorded fatigue as a presenting or supporting symptom in 150 per 2000 registered patients.2 Yet patients may not necessarily mention fatigue when they consult. A survey of patients waiting in one surgery found that a tenth reported “substantial fatigue” for a month or more 3; 18-34% of respondents in a community survey reported always feeling tired in the past month 4; and when young women patients were asked to record symptoms in diaries 400 episodes of fatigue were recorded for every one reported to the doctor.5 Clinicians may regard this iceberg as a puzzle, and a blessing. But how should they manage the cases that do present?
Little has been published on tiredness in primary care, with only one prospective study from Britain2 and two retrospective ones from American family practice.67 The results suggest that psychosocial causes are paramount in 40-51% of cases and physical causes in 21-39%.267 The remaining cases are of mixed or undetermined cause. Fatigue presents three times more often in women of childbearing age,2 who often have a working day that is long and difficult to organise, with no boundary between home and work.8 The wise doctor steers between the extremes of trivialising and medicalising such “social” fatigue. If the cause is existential rather than medical counselling may help the patient consider various alternatives and make new choices.
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Source: Ridsdale L. Tired all the time. BMJ. 1991 Dec 14;303(6816):1490-1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1671843/