Staff Perspective: Fatigue vs. Sleepiness – Untangling the Tiredness Conundrum
Culturally, we use the word “tired” to describe so much – being mentally and/or emotionally drained, overly frustrated, sleep deprived, physically spent, and lots of stuff in between. These states are not caused or cured by the same thing. But they can basically be divided into two categories – tiredness/sleepiness and fatigue. This difference isn’t something I had ever considered before being diagnosed with Multiple Sclerosis. But, given one of my most prevalent symptoms of MS is fatigue, I soon realized just how much people don’t understand the difference.
What is the difference? Google’s AI overview actually does a good job describing this: “Tiredness makes you feel sleepy; fatigue makes you feel worn out but not necessarily sleepy.” Tiredness/sleepiness is a temporary state fixed by sleep. Fatigue is a more long-lasting feeling of being drained that persists despite adequate sleep/rest. I explain fatigue as that feeling you get after a cross-country airplane trip, or better yet, transatlantic. You get to your final destination and collapse on the hotel bed, absolutely drained. But you aren’t tired, so you aren’t going to sleep. You simply have absolutely no energy left. Regardless of how much the kids want to go to the Disneyland park immediately upon arrival, they are out of luck!
To make matters more interesting in my particular case, insomnia is also widely prevalent with MS. A recent meta-analysis looking at sleep disorders and MS showed that 1 in 2 adults with MS endorsed poor sleep quality and 1 in 5 were diagnosed with insomnia. Many other neurological disorders, from MS to long covid, have higher rates of insomnia along with fatigue. I am one of the unlucky ones who now has both – random bouts of insomnia and chronic, debilitating fatigue. How do I stay functional through the fatigue? A steady dose of stimulants – something that can rapidly mess with my sleep and trigger insomnia. It is an interesting balance that I manage. And a common conundrum faced by many who have both.
As a clinical psychologist, and one of the CDP instructors who teaches CBT for Insomnia, I find it interesting how little we talk about what to do for patients who experience fatigue but not insomnia, or for patients who have both. Many of our patients have underlying medical conditions, from MS to long Covid, and their fatigue and/or tiredness is enmeshed with their other behavioral health symptoms, like depression and anxiety.
I think a starting place for all of us is making sure our assessment is correct in that we are assessing for both tiredness/sleepiness and fatigue and recognizing that these can be caused by different things. The usual tools can be confusing for this. For example, the Insomnia Severity Index (ISI) is widely used to screen for sleep problems and it does a good job for this in general. But it depends on the patient understanding the difference between sleepiness and fatigue, and I’ve found many do not. If I feel drained of energy all day, I might assume that is because my sleep is not good. That would lead me to answer questions on the ISI, or other measures, expressing my dissatisfaction with my sleep and how much that is impairing my life. This, in turn, could lead to a treatment plan including treatment for insomnia, which isn’t going to help general fatigue at all if it is linked to a medical condition.
It becomes even more convoluted when a patient experiences both insomnia and fatigue. Although they aren’t the same thing, the feelings they produce in the body are incredibly similar, if not the same in some cases. So how do we identify which symptom descriptions are linked more to which problem? For example, if I am physically fatigued I feel similar to when I haven’t slept much – weaker and slower in general. If my insomnia is treated and I sleep well, I am still not going to feel rested upon awakening due to my underlying chronic fatigue, so how do I know if I’m “doing better” with better sleep? I’ve noticed that interview forms often mix fatigue and tiredness questions together which is not helpful. True, fatigue can be a symptom of tiredness, but it can also be something completely separate.
The initial challenge for providers is to educate patients on the difference between tiredness and fatigue while they are in the assessment stage and ensure our assessment tools help us distinguish between the two. We must also ask about any medical conditions that may lead to either or both. It is a challenge. Even as a provider with both fatigue and periodic insomnia, I sometimes find it hard to distinguish with patients. But I think the key is to remember this basic truth – if you are tired/sleepy, you can actually lie down and go to sleep. Your sleep drive is high. If you are only fatigued, you won’t sleep because it isn’t linked to your sleep drive.
Treatment planning for tiredness, fatigue, or both is beyond the space I have for this particular blog. But basically, we know that the plan for tiredness will depend on the specific sleep disorder identified (happily, we have good treatments for many of these). The same is true for fatigue – the treatment is going to depend on the underlying medical condition. That is where it gets tricky because there are so many different conditions involved. Medication is a common answer. Behavioral treatments aimed at maximizing and strategically using available energy are also generally used. Unfortunately, behavioral treatments for fatigue are not widely taught or even known about by general providers. They are more utilized within health specialty clinics.
Our starting point is assessment. You have no idea how much rapport and credibility a provider instantly gets from me when, on their own, they acknowledge that tiredness and fatigue are two different things. I instantly think “yes, they get it!” More often than not, however, I am educating my providers on the difference. So please, be sure you are acknowledging the difference. If your patients don’t seem to understand, educate them. That way both of you can explore how to best approach treatment and how to have realistic expectations on treatment outcomes.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Debra Nofziger, Psy.D., is a Senior Military Behavioral Health Psychologist and certified Cognitive Processing Therapy Trainer with the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
CITATION:
Zeng, X., Dorstyn, D. S., Edwards, G., & Kneebone, I. (2023). The prevalence of insomnia in multiple sclerosis: A meta-analysis. Sleep Medicine Reviews, 72, Article 101842.
https://doi.org/10.1016/j.smrv.2023.101842
Culturally, we use the word “tired” to describe so much – being mentally and/or emotionally drained, overly frustrated, sleep deprived, physically spent, and lots of stuff in between. These states are not caused or cured by the same thing. But they can basically be divided into two categories – tiredness/sleepiness and fatigue. This difference isn’t something I had ever considered before being diagnosed with Multiple Sclerosis. But, given one of my most prevalent symptoms of MS is fatigue, I soon realized just how much people don’t understand the difference.
What is the difference? Google’s AI overview actually does a good job describing this: “Tiredness makes you feel sleepy; fatigue makes you feel worn out but not necessarily sleepy.” Tiredness/sleepiness is a temporary state fixed by sleep. Fatigue is a more long-lasting feeling of being drained that persists despite adequate sleep/rest. I explain fatigue as that feeling you get after a cross-country airplane trip, or better yet, transatlantic. You get to your final destination and collapse on the hotel bed, absolutely drained. But you aren’t tired, so you aren’t going to sleep. You simply have absolutely no energy left. Regardless of how much the kids want to go to the Disneyland park immediately upon arrival, they are out of luck!
To make matters more interesting in my particular case, insomnia is also widely prevalent with MS. A recent meta-analysis looking at sleep disorders and MS showed that 1 in 2 adults with MS endorsed poor sleep quality and 1 in 5 were diagnosed with insomnia. Many other neurological disorders, from MS to long covid, have higher rates of insomnia along with fatigue. I am one of the unlucky ones who now has both – random bouts of insomnia and chronic, debilitating fatigue. How do I stay functional through the fatigue? A steady dose of stimulants – something that can rapidly mess with my sleep and trigger insomnia. It is an interesting balance that I manage. And a common conundrum faced by many who have both.
As a clinical psychologist, and one of the CDP instructors who teaches CBT for Insomnia, I find it interesting how little we talk about what to do for patients who experience fatigue but not insomnia, or for patients who have both. Many of our patients have underlying medical conditions, from MS to long Covid, and their fatigue and/or tiredness is enmeshed with their other behavioral health symptoms, like depression and anxiety.
I think a starting place for all of us is making sure our assessment is correct in that we are assessing for both tiredness/sleepiness and fatigue and recognizing that these can be caused by different things. The usual tools can be confusing for this. For example, the Insomnia Severity Index (ISI) is widely used to screen for sleep problems and it does a good job for this in general. But it depends on the patient understanding the difference between sleepiness and fatigue, and I’ve found many do not. If I feel drained of energy all day, I might assume that is because my sleep is not good. That would lead me to answer questions on the ISI, or other measures, expressing my dissatisfaction with my sleep and how much that is impairing my life. This, in turn, could lead to a treatment plan including treatment for insomnia, which isn’t going to help general fatigue at all if it is linked to a medical condition.
It becomes even more convoluted when a patient experiences both insomnia and fatigue. Although they aren’t the same thing, the feelings they produce in the body are incredibly similar, if not the same in some cases. So how do we identify which symptom descriptions are linked more to which problem? For example, if I am physically fatigued I feel similar to when I haven’t slept much – weaker and slower in general. If my insomnia is treated and I sleep well, I am still not going to feel rested upon awakening due to my underlying chronic fatigue, so how do I know if I’m “doing better” with better sleep? I’ve noticed that interview forms often mix fatigue and tiredness questions together which is not helpful. True, fatigue can be a symptom of tiredness, but it can also be something completely separate.
The initial challenge for providers is to educate patients on the difference between tiredness and fatigue while they are in the assessment stage and ensure our assessment tools help us distinguish between the two. We must also ask about any medical conditions that may lead to either or both. It is a challenge. Even as a provider with both fatigue and periodic insomnia, I sometimes find it hard to distinguish with patients. But I think the key is to remember this basic truth – if you are tired/sleepy, you can actually lie down and go to sleep. Your sleep drive is high. If you are only fatigued, you won’t sleep because it isn’t linked to your sleep drive.
Treatment planning for tiredness, fatigue, or both is beyond the space I have for this particular blog. But basically, we know that the plan for tiredness will depend on the specific sleep disorder identified (happily, we have good treatments for many of these). The same is true for fatigue – the treatment is going to depend on the underlying medical condition. That is where it gets tricky because there are so many different conditions involved. Medication is a common answer. Behavioral treatments aimed at maximizing and strategically using available energy are also generally used. Unfortunately, behavioral treatments for fatigue are not widely taught or even known about by general providers. They are more utilized within health specialty clinics.
Our starting point is assessment. You have no idea how much rapport and credibility a provider instantly gets from me when, on their own, they acknowledge that tiredness and fatigue are two different things. I instantly think “yes, they get it!” More often than not, however, I am educating my providers on the difference. So please, be sure you are acknowledging the difference. If your patients don’t seem to understand, educate them. That way both of you can explore how to best approach treatment and how to have realistic expectations on treatment outcomes.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Debra Nofziger, Psy.D., is a Senior Military Behavioral Health Psychologist and certified Cognitive Processing Therapy Trainer with the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
CITATION:
Zeng, X., Dorstyn, D. S., Edwards, G., & Kneebone, I. (2023). The prevalence of insomnia in multiple sclerosis: A meta-analysis. Sleep Medicine Reviews, 72, Article 101842.
https://doi.org/10.1016/j.smrv.2023.101842