Chronic Fatigue & Chronic Pain

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Because of the chronic and persistent pain and fatigue, it is easy to get into habits of activity and rest that may not be the best way to deal with the pain and fatigue. CBT can help to identify those unhelpful ways of thinking and acting, and help us make healthy and positive changes, and therefore reduce the pain and fatigue.

Okay, I have this medical condition. What’s keeping the pain and fatigue going now?

Breaking this simplistic vicious cycle means stopping before the pain or (physical and mental) fatigue makes you stop - and scheduling in some rest periods. Thoughts and physiological factors also play a significant part in the cycle:

There are several factors which contribute to fatigue and pain, on top of an existing chronic pain or chronic fatigue condition. These include:

Doing too much too soon after illness

Resting too much for too long

v The longer you rest, the more symptoms you will have later

v Prolonged rest makes it harder to get active again and increases fatigue

v Prolonged rest affects the heart and lungs, nervous system, and muscles.

Boom and bust

v Doing too much when you have some energy, results in feeling more tired and experiencing more pain, and then have to rest for longer

Disturbed sleep

Thinking about Pain and Fatigue

v Worrying and focusing on fatigue and pain tends to make them more prominent in our attention, resulting in experiencing more pain and fatigue

v Worrying that the symptoms may be a sign of getting worse, or after an activity, we might worry that we’re harming ourselves by what we’re doing

Life stress & low mood

v Financial difficulties – due to not being able to work, or having to work less

v Worry about being able to do what needs to be done

v Feelings of guilt in not doing what we think we should be doing, thinking that we’re letting others down

Mental fatigue

Difficulty concentrating, easily distracted, poor understanding
Poor short term memory, difficulty retaining new information
Forgetting how to do things that used to be done automatically, without thinking

These can all lead to feeling low in mood, frustration, anxiety, helplessness, sense of loss of control, and depression. This causes us to feel even more tired and experience more pain.

A more complicated vicious cycle of pain and fatigue might therefore look like this:

All these factors interact with each other, so we could have several double-ended arrows crossing the circle.

As with other vicious cycles, we can learn to break them by doing something differently (at the points in red) or thinking differently (at the points in orange).

Helpful techniques include:

Doing things differently
- Monitoring and pacing activity
- Physical exercise
Problem solving
Goal setting

Thinking differently
- Thought challenging
- Focus of attention

Learning these techniques will not cure your pain, fatigue or the underlying medical condition, but making these changes can help you take control of your life, enabling you to live a more enjoyable, independent and fulfilling life.

Doing things differently

Monitoring and pacing activity

Complete the Activity & Rest Diary for a week or two, then look through it and notice the times when the pain or fatigue is not so bad, or feels particularly bad. Are there any patterns? Are there activities or doing activities for certain periods of time that influence your pain or fatigue? Are there activities which seem to result in feeling less pain or fatigue? Notice the times when pacing yourself might have helped.
Pace yourself. Plan to do the activity for periods of time that are okay, and mean stopping the activity before your body makes you stop (pain and fatigue). Schedule in rest periods.
Use the Activity & Rest Diary again, to schedule in more of the activities which seem to help, and less of the activities which are more unhelpful.
Be aware of times when doing less, or doing an activity for less time, or resting would have been helpful - and ensure you remember to allow for this when planning your days.

Scheduling in rest and relaxation, fun and enjoyment, achievement

Use the ACE Log
It's important to get a healthy balance of activities which give you a sense of achievement, enjoyment and being close to others. Choose activities which are important to you, have positive meanings, or are purposeful. Ensure you schedule in rest periods too.

Rewarding yourself

When you're doing well, or remembering to pace yourself, doing more of what helps, or doing less of what doesn't - give yourself a treat, a pat on the back.

Physical exercise

Check out with your GP or other appropriate health professional how you can gradually increase physical exercise. Devise a plan with them - and stick to it.

Problem solving

Use the Problem Solving worksheet when faced with a big or difficult problem

Goal setting

Set yourself some short-term goals to help guide you in your new regime
Start with small steps - break down your goals into smaller, simpler, easier steps
Follow this guide:

Decide what you want to achieve - be specific!
Make sure the goal is realistic and achievable. Set a time frame that you want to achieve this by - again, realistic and achievable. Do you have the necessary resources?
Clarify your goal - what is it you really want to achieve? What for? Is this something you need, or just want? How important is it? What difference will it make to you?
Write down you goal - add as much detail as you can about what you want to achieve. Write down the steps you need to achieve on the way to the ultimate goal. What do you need to do? When? How? What help do you need? How will you know when you've got there? What will you be doing differently? What will other people notice about you?
Do it! Start with the first step - don't try to leap ahead, just take things steadily and achieve one step at a time.
Review your goals every day, asking yourself what you've done to work towards your goal? What do you need or what are you able to do today? Stick with it, keep at it. You will much more likely to achieve your goal if you are determined and persistent.
Congratulate and reward yourself when you achieve the steps on the way, and when you achieve your goal.

Other suggestions

Mindfulness - learn Mindful Breathing

Focus your attention fully on another activity - Mindful activity

Relaxation techniques - try lots and find one that works for you

Put on some music - sing and dance along, or just listen attentively (use music that is likely to help you feel your desired emotion - avoid sad songs if you're depressed)

Meditation or Prayer

Help others

Be with others - contact a friend, visit family

Talk to someone

Grounding techniques - look around you, what do you see, hear, smell, sense? Hold a comforting object.

Engage in a hobby or other interest - if you don't have one, find one! What have you enjoyed in the past? What have you sometimes thought

about doing but not got around to?

Write down your thoughts and feelings - get them out of your head

Just take one step at a time - don't plan too far ahead

Pamper yourself - do something you really enjoy, or do something relaxing

Positive self-talk - encourage yourself, tell yourself: I can do this, I am strong and capable - find an affirmation that works for you (even if you don't believe it at first!). Write it down and memorise it for when you need it. See Affirmations

Do something creative - make a box of items that remind you to use the

techniques that help, or put photos on paper, or write and decorate a list

Use Safe Place and relaxing Imagery

Tell yourself: "I've got through this before, I can do it now". When we're going through a tunnel and become fearful of being trapped, there's no point in stopping - we just have to carry on in order to reach the end of the tunnel. That light is there, and waiting!

Avoid alcohol, drugs (other than those prescribed by your doctor) and cigarettes.

Eat a healthy diet

Drink 6-8 glasses of water each day

Find ways of helping you get more sleep at night

Thinking differently

STOPP! Pause, take a breath

Ask yourself:

What's going through my mind now? What meaning am I giving this?

What am I reacting to? What have I been thinking about here?

What meaning am I giving this?

How am I making sense of it all?

Am I getting things out of proportion?

Am I thinking negatively about the future? Am I comparing my current situation to how things used to be?

Am I expecting something from this person or situation that is unrealistic?

What's the worst (and best) that could happen? What's most likely to happen?

Am I using that negative filter? Those gloomy specs? Is there another way of looking at it?

How important is this really?

What advice would I give to someone else in this situation?

Am I spending time ruminating about the past or worrying about the future? What could I do right now that would help me feel better?

Am I putting more pressure on myself, setting up expectations of myself that are almost impossible? What would be more realistic?

What do I want or need from this?

Am I just focusing on the worst possible thing that could happen? What would be more realistic?

Is there another way of looking at this?

Am I exaggerating the good aspects of others, and putting myself down? Or am I exaggerating the negative and minimising the positives? How would someone else see it? What’s the bigger picture?

Things aren’t either totally white or totally black – there are shades of grey. Where is this on the spectrum?

This is just a reminder of the past. That was then, and this is now. Even though this memory makes me feel upset, it’s not actually happening again right now.

What would be the consequences of doing what I normally do?

Is there another way of dealing with this? What would be the most helpful and effective action to take? (for me, for the situation, for the other person)