Feelings of Fatigue and Psychopathology:

A Conceptual History
GE. Berrios

HE medical concept of fatigue has been defined as:

T
a condition resulting from previous stress which leads to reversible impairment of performance
and function, affects the organic interplay of the functions and finally may lead to disturbance of the
functional structure of the personality; it is generally accompanied by a reduction in readiness to
work and a heightened sensation of strain (p. 369)’

The performance aspects of fatigue are defined physiologically as “a failure to

maintain a required force or output of power during sustained or repeated muscle
contraction. . . .” (p 1014)2; and behaviorally as time-related deteriorations in the
ability to perform certain mental tasks3
Gubser’s “heightened sensation” of strain includes what historically has been
called “feeling of fatigue.” Piiron was referring to the same experience when he
wrote:
together with progressive fatigue, as reflected by a diminution of performance during work on an
ergograph, afeeling ensues, which is unpleasant, gets worse with time, and leads to abandoning the
task. This general feeling is based on vague coenesthetic sensations, and on localized muscular
sensations that can sometimes be painful in nature. . . (p. 167).4 (Italics added.)

The feeling of fatigue has received much less attention in the medical literature than
the general phenomenon of fatigue.
Feeling of fatigue features prominently in some current diagnostic systems; e.g., it
does so in relation to about 20 different clinical categories in DSM-111-R’ in which,
however, no operational definition of feeling of fatigue is included. Books on
descriptive psychopathology fare no better. 6-11This article specifically deals with the
concept and history of feeling of fatigue.

EPIDEMIOLOGY
Unexplained feeling of fatigue is a common complaint in clinical practice.12 Thus,
Sugarman and Berg13 reported fatigue as having a prevalence of 9.1 per 1,000, with
a sex and age distribution equal to that of the parent population; 50% of subjects
thus affected received a psychosocial diagnosis, 22% a medical diagnosis, and 24%
had no diagnosis. Kroenke et al.14 reported feeling of fatigue to be a major problem
in 24% of a sample of 1,159 subjects: Females were overrepresented, laboratory
investigations were of little value in determining underlying diagnosis, depression
and anxiety were common accompaniments, and feeling of fatigue subjects showed

Dr. Berrios is a Consulrant and University Lecturer in Psychiatry; Director of Medical Studies and
Fellow, Robinson College, Cambridge, England; and Librarian, Royal College of Psychiatrists of the
UK.
Address reprint requests to G.E. Berrios. M.D., Department of Psychiatry, University of Cambridge,
Addenbrooke’s Hospital (Level 4), Hills Rd., Cambridge CB2 ZQQ, England.
0 1990 by W.B. Saunders Company.
0010-440X/90/3102-0004$03.00/0

140 Comprehensive Psychiatry, Vol. 3 1, No. 2 (March/April), 1990: pp 140-15 1

FATIGUE AND PSYCHOPATHOLOGY 141

little improvement. Valdini et a1.15 compared 115 fatigued subjects with 139
controls in a l-year follow-up: Cross-over was considerable: 42% of their subjects
improved, and 20% of the controls became fatigued. Subjects complaining of feeling
of fatigue attended the surgery more often and received “psychological” diagnoses
more frequently. Cheni6 reported that feelings of depression and anxiety were
correlated with feeling of fatigue, particularly in physically inactive subjects under
stress; females were more prone to feeling of fatigue; weight showed little
correlation with the symptom. Hoehn-Saric and McLeod” reported that subjects
with an “external locus” of control complain of feeling of fatigue more often than
those with an internal locus of control.

CLINICAL ASSOCIATIONS
Feeling of fatigue can be found associated with chemotherapy for breast
carcinoma,‘* hypercortisolaemia,” hypophosphataemia,20 postviral syndromes,21*22
plasma levels of diazepam, 23 alterations in energy metabolites in muscle,24 high
carbohydrate intake in obese subjects with noncarbohydrate craving,25 multiple
sclerosis, 26 diabetes mellitus,27 brainstem lesions in children,28 and other disease
states.2g
Feeling of fatigue can also be prodromal to many conditions. Appels and
Mulder3’ reported it to herald myocardial infarction, and Harrigan et a131 reported
it to predict onset of migraine headaches. Christensen et a1.32reported feeling of
fatigue to correlate with both preoperative trait- and state-anxiety; it increased in
some subjects up to day 30 after operation, when it no longer correlated with trait-
anxiety; they concluded that postoperative feelings of fatigue depend less on
psychological makeup than on cardiovascular and neuromuscular status. None of
the above studies made use of a refined measurement of feeling of fatigue.

TERMINOLOGY AND CONCEPTUAL ASPECTS

The feeling of fatigue is common and is associated with numerous physical and
psychiatric conditions. In addition, it forms part of the experiential meaning of
many technical and vulgar terms: asthenia, anergy, tiredness, weariness, languor,
lassitude, depression, melancholia, acedia, apathy, inertia, abulia, lethargy, exhaus-
tion, vecordia, tediousness, ennui, debility, lack of vitality, lack of vigor, pusillanim-
ity, adynamia, boredom, feebleness, failing of strength, hyperesthesis, irritability,
anhedonia, “being out of sorts,” “ feeling knackered,” and “down in the dumps.” To
clarify the semantic field of the feeling of fatigue, five questions can be asked.
The first is whether the terms listed above include a common denominator in the
form, e.g., of a primary sensation or of its attending somatic experiences. They
appear to have such an experiential link. Indeed, this common sensation may confer
on the set of terms a “family resemblance.“33 The second question is whether the
sensation that constitutes the feeling of fatigue is distinctive enough to be
qualitatively separated from mild pain or discomfort. In this respect, we show that
fatigue historically, has been considered both as a primary and a composite
experience.
The third question is whether, regardless of whether fatigue is a primary
sensation, it can be recognized independently from its usual causal associations, e.g.,
when experienced in situations not preceded by any exertion. Clinical observation
142 G.E. BERRIOS

appears to show that it can; i.e., subjects respond with alarm to the presence of
feeling of fatigue when it has not been preceded by physical or intellectual work or
by disease (i.e., when is “unexplained”).
The fourth question is whether this unexplained feeling of fatigue is phenomeno-
logically identical to the feeling experienced after exercise. The answer to this
question must be sought in empirical research. The fifth question is whether-if the
feeling of fatigue is considered a primary experience-it is related to a common
neurobiological structure or mechanism, e.g., to putative “fatigue receptors” whose
activation by exogenous or endogenous agonists would trigger the experience of
feeling of fatigue.2g*34

HISTORICAL ASPECTS OF FATIGUE AND THE FEELING OF FATIGUE

The objective phenomenon of fatigue, as opposed to the feeling of fatigue, was
well studied during the nineteenth century. This knowledge was summarized by
MOSSO,~~ a professor at Turin, who had trained under Hugo Kronecker in Leipzig in
1873. Kronecker36 had then been working on the muscle of the frog, and like other
physiologists of the period (Ludwig, Schmidt, Aducco, and Maggiora), was
interested in the “laws of fatigue.” Because most of these studies involved animal
models, such laws were perforce based on interpretation of curves of muscle
performance obtained by means of dynamometers and myographs. These research-
ers rarely if ever considered the feeling of fatigue as a measurable dependent
variable.
Mosso’s originality lay in his efforts to develop a unitary view of fatigue, including
both physical and intellectual (mental) aspects. He also pondered the feeling of
fatigue:
Humboldt, when showing how the living environment can enrich language, tells us that the Arabs
have more than 20 words to refer to the desert. But we have only one term to refer to fatigue. The
reason for this is easy to understand. . . fatigue is toofeatureless nn internal sensation to distinguish
any varieties (p. 1 19).35(Italics added.)

He further emphasized this lack of definition:

What fatigue, pleasure, hunger, or thirst means can be understood and their intensity qualified by
the use of adjectives, but they cunnor compete in precision with the image that the desert can
impress on us (p. 119).

Mosso related this to the vagueness of propioception:

Fatigue, which can be considered as a sort of poisoning, can alter the composition of the blood and
biological homoeostasis; however, we just feel it as a vague sensation of tiredness. . . .35

Since the work of Mosso, and particularly that of the French SchooL3’ it has been
a common belief that intellectual fatigue reflects a decline in the energy metabolism
of neurons and that behavioral and cognitive variables must be examined to detect
its presence.38 Yet Mosso’s views on the vagueness and inaccessibility of feelings of
fatigue itself were also influential; e.g., MacDougall” suggested that “a sharp
distinction must be drawn between objective and subjective exhaustion, between
fatigue (Ermtidung) and weariness (Mtidigkeit).” He defined weariness as:
a superficial fact of attention, which may appear, disappear and reappear many times in a day . .
[it] can be induced in a fresh subject by dull work, monotony, stale familiarity. . . [it] can abate as
FATIGUE AND PSYCHOPATHOLOGY 143

fatigue increases . . . weariness is a fluctuating personal attitude which is scarcely susceptible oj

record in any form (Italics added).

Mosso also influenced the work of Ioteyko whose research on fatigue had started
with her doctoral thesis of 1896 on “fatigue and muscle respiration.” By the time her
excellent book on fatigue4’ appeared, she had already moved from Brussels to Paris
and had completed about 10 important research publications. Ioteyko considered
the feeling of fatigue as a separate although vague experience and justified its
inclusion in evolutionary terms: “In higher species, particularly in man, a third
condition is essential to define fatigue: this is a sensation of ‘malaise’ known as
feeling of fatigue.”
Other investigators took a more “composite view” of the nature of fatigue:

[FJeeling of fatigue is not a simple act, but a psychological state made out of a number of simpler
elements which include changes in affect or sentiment corresponding to obscure and sometimes
subconscious tactile and muscular sensations. Feeling of fatigue is but a form of coenesthesis4

Views such as these precluded development of an adequate phenomenology of the

feeling of fatigue and placed it beyond measurement. MacDougall himself
suggested:

[In] the study of fatigue we have to seek for the phenomena of actual reduction in capacity for
productive work; and from its effects we must discriminate the factors of interest and weariness
(p 203.39

But because weariness did not have a linear, or even monotonic correlation with
fatigue, a study of the latter could shed little light on the feeling of fatigue.3g
A second line of research into fatigue during the nineteenth century related to the
concept of intellectual fatigue among school children and to its relevance to teaching
methods. Kraepelin4* Ebbinghaus,“3 and Griesbach did much of the earlier work in
this area. By the end of the century, however, MacDougal13’ was able to celebrate
the fact that schoolmasters, such as Kensies44 and Wagner,45 had showed interest.
Most of this research was based on the “work curve” paradigm developed by
Kraepelin46 and later completed by Pauli and Arnold. This methodology of analysis
did not include the feeling of fatigue. The history of fatigue in education is beyond
the scope of this article.
Early work on the objective aspects of fatigue was marred by a conceptual
confusion that impeded comparison of research results: Fatigue was defined by some
researchers as a process, i.e., as the interaction between stress (and other covariates)
and the dependent variables, and by others as the e@ct itself.’ The analysis of
feeling of fatigue, on the other hand, was caught up in the parallel etiological debate
of whether it was a truly central and primary experience (preceding all physiological
concomitants) or whether it was the introspective reading of peripheral somatic
changes (as suggested by Williams and Lange) (pp. 93-94).40*47Other investigators
compromised and suggested that the feeling of fatigue only magnified peripheral
sensations.48
After World War II, Bartley and Chute49 suggested that the “experience of
fatigue” might be evaluated by “psychological methods.” Even then, they did not
include among these methods the measurement of feeling of fatigue. Bugard,34 in a
book that represents the culmination of the old approach, dedicated little space to
144 G.E. BERRIOS

feeling of fatigue, although he echoed Coirault’s view that “fatigue is a state of

nervous suffering, which, together with insomnia, constitutes the common denomi-
nator of the prodromal phase of many mental diseases.” Bugard34 preferred to
concentrate on visual and sensory changes as the best indicators of central nervous
system fatigue. Such concepts prevailed, although since early in the twentieth
century a definition of fatigue as “lassitude or weariness resulting from either bodily
or mental exertion”50 had already been established, and although Jasper? had
called for a distinction between objective and subjective fatigue (feeling of
weariness or fatigue).
Clinicians (particularly alienists), however, were forced to pay attention to the
feeling of fatigue because since the late nineteenth century they increasingly
evaluated a population of subjects whose only complaint was unexplained feeling of
fatigue and needed to develop techniques that might differentiate simulators from
real patients.51

FEELINGS OF FATIGUE IN THE HISTORY OF

PSYCHOPATHOLOGICAL CONCEPTS
A source of writings on feeling of fatigue can be found in the work of late
nineteenth century alienists, e.g., on the concept of “nervous prostration” or
neurasthenia.52 This clinical category, supported by a newly developed theory of
functional nervous disorder,53-56 became a fashionable diagnosis in the hands of
writers such as Beard57*58and was to engulf, toward the end of the century, most
functional disorders having feeling of fatigue as a common denominator.59-62
The concept of neurasthenia was the final stage in the evolution of an older notion,
“asthenia,” that had played a crucial role in Brunonianism during the late 18th
century. 63*64Brownj3 wrote: “Asthenic disease is a state of the living body
characterized by a weakening, occasionally disordered, of all functions.” All
asthenic diseases were not accompanied by fatigue, because some included states of
defective excitation that distorted their symptomatology; others, like emaciation or
extenuation, were. One of the important offshoots of Brunonian theory was that
bleeding was discredited as a treatment of asthenic diseases (p. 104). By the end of
the nineteenth century “asthenia” had lost its theoretical role and become a simple
description for “a lack or impairment of strength. r’38Tuke65 did not even include the
term in his dictionary.
A derivative category was adynamia66 defined as “a state of impotence, of lack of
force of the organism.” By this period, the concept had become a hypothetical
construct:
[Sltrictly speaking, adynamia accompanies all diseases . . . adynamia is little else than an
appearance, a phenomenon which can be attached to different diseases. . . pathologists conceive of it
as a direct reduction in vital force or in the functional rhythms, as a form of asthenia. .“9’
Adynamias could result from excessive or insufficient stimulation.

Another related category was irritability, still defined during the middle of the
nineteenth century as it had been by Von Haller67 a century earlier: “a property
peculiar to muscle substance by which it contracts on the application of stimuli.“68
Glisson had first used irritability during the 17th century to name a property of all
the body fibers which was independent of consciousness and of the nervous system.69
This concept (together with sensibility) was to undergo major elaboration during
FATIGUE AND PSYCHOPATHOLOGY 145

the following century, and in its British version (particularly in the hands of Cullen
and Whytt) it became related to the nervous system. In the end, both concepts were
to become properties of the cell.“*”
Irritation, a modality of irritability, played an important role in the development
of the concept of neurasthenia, through the mediating notions of nervous and spinal
irritation (pp. 64-76).53 Asthenia, now defined as “a state of spinal nervous
exhaustion caused by excessive irritation following over-stimulation,53 was to
reappear as one of the forms of presentation of the spinal irritation syndrome and be
termed “spinal neurasthenia.” Beard54 extended the concept and explanatory
mechanism from the spinal cord to the brain. Charcot legitimatized neurasthenia as
a “major neurosis” in 1887, 72 but developed a narrow view of the disorder. This
allowed him to suggest that neurasthenia and hysteria might be found in com-
bination.73
Fatigue and feeling of fatigue were central symptoms of neurasthenia. For
example, Savil16’ included “mental exhaustion and inability to think and study . . .
easily tired, easily startled, state of debility and exhaustion,” and Cobb62 supported
this view in one of the last great books to be published on the subject. Fatigue and
feeling of fatigue were, however, also present in other “psychonevroses.” Dubois61
one the most important writers on these groups of disorders, showed much interest in
“fatigabilitt” (feeling of fatigue), a term which he complained was not in the
French dictionary and which named a “gradual diminution of functional power, a
difficulty to persist on the task at hand . . . etc.” He quoted extensively from TissiC
who had performed research in cyclists and agreed that fatigue could lead to
“transient, experimental psychosis” (p. 139). More important, he also quoted the
work of F&C:on the mental symptoms of fatigue.
According to FCr&,37,74 fatigue after severe exercise could produce symptoms
similar to those exhibited by neurasthenia sufferers. These included nihilistic and
paranoid ideas, selfish attitudes, rekindling of obsessional thoughts and compul-
sions, and depression. . . . F&-t” linked proneness to fatigue with the theory of
degeneration.75-78 He also saw an association between a tendency to nervousness and
high arousal (p 185). Hecke17’ wrote at length on the complex interaction between
the feeling of fatigue and psychiatric symptoms (pp. 215-218), as did Spanish
writers:
[T]he subject presents depression and apathy, there is a weakness of the will, and sometimes
abulia, there are illusions and increased susceptibility to suggestion.4’

Fatigue and feeling of fatigue also featured prominently in the notion of

“psychasthenia,” a fragment of the old neurasthenia concept.8h82 The creation of
psychasthenia, in Cobb’s view,62 was a theoretical reaction against the “organic”
view of neurasthenia:
[I]t is small wonder that a reaction to this view should set in, and a school arise which loudly
declaimed the opposite-namely, that neurasthenia was caused by abnormal mental processes,
which produced the disorder by means of mental mechanisms the work of Janet marked the first
step towards the recognition of the psychical etiology of this disease.

Janetg3 wrote:
[Tliredness and a horrible sense of fatigue is caused in psychastenics by the least physical or
psychological effort . fatigue rapidly affects sensations and perceptions, intellect and movement.
146 G.E. BERRIOS

One of his patients once complained of “a blanket of fatigue falling over me.” Janet
created his category based on the theoretical view that psychasthenics showed a
reduction in psychological energy which, inter alia, led to a “loss of the sense of the
real” a “feeling of incompletion,” obsessions, compulsions, and phobias.*’
Ribot84 was interested in the experiential quality of the feeling of fatigue which he
classified as an internal sensation of the same type as hunger and disgust. Answers
given by respondents to his field research included various “modes” of representation:

[S]ome feel it (ideally) in the muscles; others mentally. . . muscular twitchings in the calves of the
legs . . , the eyes feel swollen . . . a feeling of relaxation . . . slowness of movement . . . general
lassitude of a diffuse kind . . . mental weariness. _ heavy feeling in the brain.

Ribot added: “[Allthough all my correspondents can revive the feeling of fatigue,
three or four can only succeed in doing so with difficulty.”
Dechamps” reported that fatigue and feeling of fatigue did not often “correlate.”
Thus, in some diseases, such as tabes or chorea, feeling of fatigue “was not
experienced even after severe work” whereas in others, such as neurasthenia, feeling
of fatigue “was intense without having done any work.” For Dechamps, fatigue
“resulted from chemical and anatomical change,” whereas the feeling of fatigue
resulted from the “synthesis of tactile sensations, both peripheral and internal
(coanesthesis).”
The notions of neurasthenia and psychasthenia were themselves disaggregated,
disappearing after the Great War. Their remains were included into the new forms
of neuroses generated by the psychodynamic and behavioral views. For example, the
feeling of fatigue found a new home with the anxiety and affective disorders,86
wherein it became entangled with anhedonia, a term coined by Ribot84 to name
situations when:

like pain, pleasure is separable from the complex of which it forms part, and under certain
conditions may totally disappear. Anhedonia (if I may coin a counterdesignation to analgesia) has
been little studied but it exists.

Anhedonia was incorporated by Kraepelin and Bleuler into the symptomatology of

depression and schizophrenia, respectively.86a
Fatigue continued to being investigated in occupational psychology and medicine;
feeling of fatigue was investigated much less. This is surprising because in
work-orientated societies unexplained feelings of fatigue are likely to be reported as
interloping and undesirable mental states in urgent need of diagnosis and treatment.
Indeed, moralistic treatment of fatigue began in the 192O~.~l
In addition to being found in isolation, feeling of fatigue remains in clinical
circulation as a hidden experiential component in other “symptoms” such as
anhedonia, lethargy, lack of drive, abulia, and amotivation, considered by some as
“negative” features of schizophrenia,87*88or as side effect of neuroleptics.89 Of late,
the feeling of fatigue has become the central symptom of the postviral
syndromes.2’*22.90

PHENOMENOLOGY OF THE FEELING OF FATIGUE

Several factors explain the dearth of studies into the phenomenology of feeling of
fatigue: first, the fact that a sort of emotional experience appears to be an important
FATIGUE AND PSYCHOPATHOLOGY 147

aspect of feeling of fatigue, and that the semiology of affectivity is notoriously

crude.” Second, feeling of fatigue constitutes by all accounts a poorly defined
experience, whose recognition, like others in the area of experiential mental states,
vary according to cultural background.92 Third, feeling of fatigue is ambiguously
poised with regard to its referent: When used in the first person (i.e., “I feel
fatigued.“), it names an experiential state; when used in the third person (i.e., “He is
fatigued.“), it ordinarily includes reference to objective signs of fatigue. Fourth,
whether feeling of fatigue refers to a primary32 or to a composite feeling-state is
unclear. Fifth, it is unclear whether the peripheral or somatic manifestations of
fatigue (e.g., breathlessness, nausea, muscular tiredness, aching) are essential parts
of the concept as, e.g., the somatic aspects of anxiety appear to be part of the
definition of anxiety. As a consequence, whether it is possible to deal with the
subjective and objective components of feeling of fatigue independently is unknown.
If feeling of fatigue names (like pain) a primary feeling-state,93 irrespective of
whether it is preceded by exertion, we can hypothesize that it should be the same for
all clinical situations: i.e., the fatigue of Addison’s disease should be the same as that
of multiple sclerosis,26 depressive illness, neoplasm, anxiety disorders, myalgic
encephalomyelitis,22*94*95or glandular fever. 21 This question must be answered by
empirical research, for which however, an evaluative instrument is required.
Development of such scale is not an easy matter, and pessimism in this regard was
expressed early.96 The semantic construct underlying feeling of fatigue (from which
scale items will have to be obtained)97,98 includes sensory, emotional, cognitive, and
even evaluative components. In practice, this means that feeling of fatigue, like
fatigue itself, is a multidimensional state.99 These dimensions require sorting out
and then translation into scale items susceptible to quantification. Furthermore, to
avoid contamination from organic symptomatology or distorted propioceptive
information, it is important that a scale for feeling of fatigue be based mostly on the
psychological attributes of the experience, particularly when there is evidence that
objective measures of fatigue correlate poorly with feeling of fatigue.“’ Current
scales of fatigue are unidimensional and do not explore the composite nature of the
concept.“’
The first stage in identification of the semantic construct of feeling of fatigue is to
tease out its meaning systems. Four are apparent:
1. Feeling of fatigue after work. In feeling of fatigue after work, the experience is
explained by its antecedent and is often associated with the cognition of not
wishing to continue performing. This constitutes the typical, anchor meaning.
2. Premature feelings of fatigue. Premature feelings of fatigue obtain when the
experience is reached too quickly or when recovery takes too long.
3. Unexplained feelings of fatigue. Unexplained feelings of fatigue cause alarm
because they have no relevant antecedent. The experience may also be
accompanied by a feeling of not wishing to begin any task. This meaning is
common in relation to physical and psychiatric disease.
4. Feeling like not embarking on any activity. Feeling as though one does not
wish to begin any activity may occur in the absence of a feeling of fatigue and
probably is an independent phenomenon. Historically and clinically, however,
the two sensations have been lumped together. Examples are anhedonia,
abulia, inertia, lack of drive, amotivation, mild irritability, lack of concentra-
tion, boredom, and the “can’t be bothered” feeling.
148 G.E. BERRIOS

These four meaning-systems should generate different questions and must be clearly
separated. They also may lead to different predictions with regard to correlations
between the experience of feeling of fatigue and objective measures of fatigue. A
preliminary version of such a scale has now been developed and is undergoing field
trials (a specimen is available on request).

SUMMARY
Since the 19th century, fatigue has received far more attention in the medical
literature than feeling of fatigue. The latter is defined as a primary, sui generis
feeling, which can be studied (and is experienced) independently of physical
phenomena such as tiredness, and cognitive concomitants such as “not wanting to
continue or initiate a task.”
The unexplained feeling of fatigue is a common medical complaint, and
accompanies various medical and psychiatric conditions. Several meaning systems
can be identified in relation to feeling of fatigue and provide material for
construction of a measuring instrument. Such a scale will allow us to answer four
questions: Is the feeling of fatigue a unitary and primary experience or sensation? Is
it the same regardless of the clinical or social context in which it occurs? Are the
somatic and cognitive accompaniments of feeling of fatigue an essential part of its
definition? Does feeling of fatigue have a neurobiological basis?

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