Overcoming Chronic Fatigue 2nd Edition: A self-help guide using cognitive behavioural techniques (Overcoming Books)

by Mary Burgess

There is evidence that exercise in the late afternoon can deepen your sleep at night. However, avoid strenuous exercise within three hours of bedtime, as this may wake you up.

Caffeine stimulates the central nervous system; it is associated with delaying sleep onset and can cause wakefulness. Substances containing caffeine – e.g. coffee, tea, chocolate and cola – should be avoided for four to six hours before bedtime and during the night if you wake up. Coffee generally contains about twice as much caffeine as other caffeinated drinks.

Develop a regular order of doing things e.g. locking up the house, turning out the lights, brushing your teeth. This will act as a signal to your body that it is preparing for sleep and may increase feelings of sleepiness.

Lying in bed at night worrying about problems can make us all feel tense and make it harder to fall asleep. It can really help if you address worries during the day to allow your mind to relax and ‘switch off’ in bed. The strategy described below may help you to get to sleep more quickly. • Set aside fifteen to twenty minutes in the early evening. • Use this time to write down problems or loose ends that you have not had time to deal with during the day.

If you become frustrated about not being able to fall asleep, and worry about the possible ‘negative’ consequences the next day, it is likely that you will inhibit sleep further by trying harder to fall asleep. So: • Do not try too hard to fall asleep. • Tell yourself that ‘sleep will come when it is ready’, and that ‘relaxing in bed is almost as good as being asleep’. • Try to keep your eyes open in the darkened room, and as they (naturally) try to close, tell yourself to resist closing them for another few seconds. This procedure ‘tempts’ sleep to take over.

A very common factor that contributes to the maintenance of chronic fatigue is reduced activity and increased rest.

The key to becoming more active is to aim for consistency and regularity in both activity and rest, in the first instance. It is important that you plan small chunks of activity at regular intervals, rather than long periods of occasional activity. As you increase your everyday activities you will gradually become stronger and be able to cut down on rest.

Remember though that these goals are only suggestions and you may not feel they are appropriate for you. They are meant to be examples of specific SMART goals, by which we mean that they should be specific, measurable, achievable, realistic and timed.

As we mentioned in Chapter 3, your symptoms may increase slightly when you start your activity programme. However, this is usually temporary and occurs as a result of developing a new routine. Even though you may feel like resting more, try to persevere with your programme. In time, your body will get used to your new routine and gradually any temporary increased symptoms should subside.

Once you have established a more consistent pattern of activity and rest, you will be ready to increase – gradually – the amount of activity you do each day. This will probably be about two to four weeks after you start your initial activity programme.

For activities that you feel that you have achieved fairly easily and consistently, you may want to slightly increase the time you spend on the activity. Think about increasing the time by about 10 to 20 per cent.

It is not necessary for your fatigue to have decreased for you to increase or start a new activity.

Do not be tempted to carry out long periods of activities without breaks, even if you feel that you have a lot of energy. You are likely to pay for it later and feel that you need to rest, leading you to miss out on other things you want to do.

If you notice a slight increase in your symptoms, do try to maintain your activity programme as far as possible. Your symptoms should gradually decrease after a few weeks.

When experiencing unpleasant symptoms, it can be difficult not to focus on them. You may find that your attention is constantly brought back to them and that you notice when they get better or worse. You may find that you focus more on your body than you would like. This attentional process is difficult to control. However, focusing your attention on symptoms, however natural and automatic it seems, can have negative consequences. Not only can it intensify them, but it can also increase your awareness of normal bodily sensations such as your heart rate, breathing, temperature, etc. Any concerns or worries about your health that you have may intensify.

Learning to focus on the task in hand provides a great opportunity for you to practise training your attention towards whatever you are doing, therefore leading to less focus on your thoughts and bodily sensations.

Our lives are influenced by five interconnected areas: • thoughts (beliefs, images, memories); • feelings (moods or emotions); • behaviours (what we do: e.g. activity, sleep, rest); • physical reactions (fatigue, pain, sensitivity to light and noise, dizziness, changes in energy levels, sleep, appetite, etc.); • environment (what happens in our life, both past and present).

We have noticed that many people with CFS have unhelpful thoughts that can be divided into two main areas: • Fears or worries about their illness. • High personal standards and self-expectations.

Many people with CFS say that before they developed their illness they were very busy, energetic people: driven, conscientious with high expectations of themselves and sometimes others. They would sometimes describe themselves as perfectionists.

You may find that your fatigue has made it very difficult to maintain previous high standards or to do as much as you used to, and this can lead to: • being overly self-critical; • worrying about starting new things, fearing not being able to complete them or do them well enough; • doubting your judgement; making it harder to complete tasks; • focusing on the things that you haven’t done; • feeling guilty about relaxing if you haven’t completed a task to your satisfaction; • feeling frustrated about doing so much less than you used to be able to do.

Characteristics of unhelpful thoughts Unhelpful thoughts are: • automatic: as with all thoughts, unhelpful ones tend to pop into our head rapidly and unexpectedly, without any deliberate or conscious effort; • distorted: they are usually not entirely accurate; • plausible: we accept them as facts, and do not question them; • persistent: they can be difficult to switch off; • durable: it can be useful to view unhelpful thoughts as prejudices, as they can be hard to change.

Conditional assumptions are less obvious than our automatic thoughts and are often outside of our awareness. They operate as rules that guide our daily actions and expectations. They help us to ‘get by’ and to cover up perceived flaws, e.g., ‘to do everything perfectly’ to prevent us being criticised. They often have the force of commands such as ‘I must’ or ‘I should’, or may be posed as ‘if . . . then . . .’ sentences.

The experiences that we have while growing up lead us to form conclusions (beliefs and assumptions) to help us to try to make sense of ourselves, other people and the world. If we encounter traumatic experiences – for example, bullying, abuse of any kind, or excessive criticism – we may develop negative or unhelpful core beliefs and assumptions to help us cope with our situation.

Our personality is also a factor that is likely to influence the beliefs and assumptions that we develop.

Because our core beliefs help us to make sense of the world at a young age, it rarely occurs to us to assess whether they are the most useful ways of understanding our adult experiences. Instead, we tend to go on acting, thinking and feeling as if these beliefs were true. Also, although many core beliefs stem from childhood, we can acquire new negative core beliefs at any age, through powerful negative experiences such as witnessing or experiencing trauma; living in chaotic, unpredictable circumstances; or experiencing persistent unhappiness for whatever reason.

As the strength of your core belief lessens, you will be on a path to be able to identify a more helpful core belief. You may also set less harsh rules for yourself, which will help you to adopt new ways of behaving (strategies) that are more consistent with your new, ‘helpful’ core beliefs. For example, you may be willing to accept small mistakes, be pleased about things that you achieve, and be more inclined to take risks and to try new things.

Generally speaking, the stronger the belief, the more work you will have to do to challenge it. However, with persistence you can get there.

If you have a core belief that ‘I am never good enough’, which leads you to put 100 per cent effort into everything that you do, try to put slightly less effort in and see what happens. For example, if you spend on average one hour cleaning the kitchen, try spending three-quarters of an hour; again, you could predict what you think will happen. Then see what actually does happen. Has anyone noticed? Is the kitchen really that much different? Did you have more time for relaxation?

How do I strengthen my new core belief? 1. Find evidence to support your alternative belief. 2. Carry out behavioural experiments to evaluate your new assumptions.

However, about halfway through her sessions, she felt she had reached a plateau. When this was explored further, it transpired that the targets she had been working on thus far had felt ‘comfortable’, but the next step involved her thinking about doing a course, which caused her a variety of worries. Her worries were discussed at some length and she was reassured that it was completely normal to feel anxious about doing something that she had not done for a long time. It turned out that Alison had always felt a little anxious with new people and remembered being shy as a child and having some difficulties with mixing with other children. A variety of ways to help her to overcome this ‘block’ were discussed. First, the effects of anxiety were discussed, in terms of thoughts, behaviour and physical feelings (symptoms). It seemed that attending a college course was a more difficult target to achieve than she had originally thought. Therefore, steps were agreed to help her work towards going to college later that year. Exposure therapy was discussed as a helpful way to reduce anxiety. A list of ‘easy’ to ‘difficult’ things that she would need to be able to do in order to go to college were agreed. She was encouraged to include a few of these things in her activity programme over the next few weeks. Examples included phoning two friends every week and organising quotes for two rooms to be decorated. When she achieved these things, she was encouraged to continue working through ...

Asking oneself these questions is perfectly normal, because when we haven’t done things for a while or don’t practise something regularly, we tend to lose confidence in our own ability, and often when we try new things we are naturally apprehensive.

If you have had CFS or another health problem causing fatigue for a long time, it is likely that you will have stopped some activities or got out of practice at doing certain things.

We have all been in situations where we have felt anxious initially: for example, meeting new people, our first day at school, college or work, getting married, attending interviews, etc. However, after a few minutes of being in an ‘anxiety-provoking’ situation such as the examples above, we usually start to feel better and are able to concentrate on the matter at hand; this is because anxiety naturally reduces over time. ‘Exposure therapy’ makes use of this fact and can be a very effective way of overcoming anxiety. It involves repeatedly confronting situations that make you feel anxious and staying in the situation until the anxiety subsides.

When confronting situations that you have not encountered for some time, it is likely that you will feel anxious for a while; as we mentioned earlier, this is perfectly normal. Remember that these feelings are nothing more than an exaggeration of quite normal bodily reactions to stress.

Stay in the situation until your anxiety subsides. • Although feeling anxious is uncomfortable, it is not harmful. Wait and give the anxiety time to pass without fighting it or running away from it. • Speak calmly to yourself. Remind yourself that you can do this. • Tell yourself that any bodily sensations you experience are nothing more than a normal reaction to stress.

Diaphragmatic breathing using the lower part of your lungs is one of the best ways to lower stress in the body. This is because when you breathe deeply, it sends a message to your brain to calm down and relax. The brain then sends this message to your body. The diaphragm is the most efficient muscle of breathing. It is a large, dome-shaped muscle located at the base of the lungs. Your abdominal muscles help move the diaphragm and give you more power to empty your lungs.

Worry about doing more can prevent you from taking the steps that help you to overcome fatigue. • Temporary increases in pain or fatigue that may occur as a direct result of doing more can be misinterpreted as doing yourself harm, and this can then lead you to reduce the amount that you do rather than continue to attempt a gradual increase.

Having extremely high personal standards and expectations of yourself, and feeling distressed if you are unable to meet them, may also form a block to recovery, which may lead to problems like the ones listed below: • trying to complete an activity in one go (e.g. writing an essay or painting a room) – this is likely to increase your feelings of exhaustion, which may then lead to you taking excessive rest); • not being able to relax properly, as you feel you ‘should’ be doing something ‘useful’; • avoiding new activities or not resuming previous activities for fear of not doing them well enough;

having an overly active ‘inner critic’, tending to focus on the things that you have not done and ignoring all that you have done.

Write down three things that you have done each day, however small they might seem: e.g. did the washing-up, phoned a friend, did five minutes’ reading, got out of bed on time. • Praise yourself for things that you have done, rather than criticise yourself for things that you haven’t done. • Include pleasurable and fun activities in your day, rather than focus on things you feel you ‘should’ be doing.

For more ideas, read Overcoming Perfectionism by Roz Shafran, Sarah Egan and Tracey Wade in this series; ‘Dare To Be Average’, a chapter in Feeling Good by David Burns; and, ‘Self-Bullying and How to Challenge It’, a chapter in Overcoming Depression by Paul Gilbert, in this series. (For details see Chapter 14, ‘Useful resources’.) There is also a useful website about self-compassion that can be very helpful for the ‘self-critic’: www.compassionatemind.co.uk

Stress of any sort can make it more difficult for you to make consistent progress, however hard you try. Stress can increase your levels of fatigue and other symptoms, and can also make it more difficult for you to ‘switch off’ at bedtime or when you are supposed to be resting or relaxing.

If you have had fatigue for a long time, you may have stopped doing a lot of things that you used to do. Some may be big parts of your life, such as working, socialising or studying. Others may be quite small things, such as paying bills or phoning people. Whenever any of us stop doing things for some time, we lose confidence in our ability to do them. It may be that a lack of confidence in your ability to do things, or worry about things not going according to plan, is stopping you from resuming your former activities.

Remember to balance your days as much as possible in terms of a variety of activities and relaxation. • Lower your expectations of what you can manage and praise yourself for your achievements. • Discuss your concerns with a family member or a friend and maybe ask them for some help or support.

There were various points he raised that he was happy for me to share with you: Acceptance – that it would take time to get better. Also, in order to get better, he needed to reduce his exercise and stop work for a while. Diet – having a healthy balanced diet and eating at regular times. Having a regular getting-up and going-to-bed time. Planned activities and breaks throughout the day. Gradually increasing activity. Taking a step back when things were more difficult and rationalising his unhelpful thoughts. Being mindful of what he had been through in terms of being unwell, and not allowing himself to get too carried away when feeling better. He also felt that his illness had allowed him to look at his life differently and to think about what his priorities were, including things that made him happy. He concluded that money wasn’t everything and therefore decided to focus more on his love of sport than having a well-paid job.

There may be so many things that you have done to get to this point in the book and that have contributed to your improvement. Some may be fairly straightforward, such as having a good routine in the day with a regular getting-up time, planned breaks or rests and a variety of planned activities. However, you may have made other changes that have helped you, such as connecting with friends again, asking for help, delegating tasks to others, reducing your high standards to reduce the pressure you put on yourself.

If you have been fatigued for a long time, not only may you have given up doing many things, such as working and socialising, but other people may have taken over some of your previous responsibilities, for example, shopping, cooking, paying bills, household repairs. If this is the case, you may decide that resuming some of these activities would be a positive step. Remember to take things gradually and, if necessary, to break them down into manageable steps and, of course, ask for help.

Worries about symptoms may lead people to stop or reduce certain activities. This restriction of lifestyle in turn can cause them to feel frustrated and demoralised, which in turn can adversely affect symptoms. • Receiving advice from a variety of sources can lead to confusion and uncertainty about what to do for the best.