Week 1: Understanding chronic fatigue

Week 4: Healthy thinking, healthy self

Week 5: Balancing your activity patterns

Week 6: Maintaining your gains and staying well

A CBT model of chronic fatigue

CBT offers a way of understanding your chronic fatigue experience, symptoms and situation. It is a way of looking at what is going on for you and how your thoughts, feelings and behaviour interact with each other, and your fatigue. It also helps to highlight the areas that are important for you to work on throughout this course and beyond. Below, we present a model of chronic fatigue with relevant examples. The examples include things that are common to many people with chronic fatigue, however, they may not fit your experience perfectly. Even if you don’t completely agree with the model, see if you can identify with some parts. 

Example: Max’s chronic fatigue cycle

Max has suffered from chronic fatigue for just over a year. His main symptoms are fatigue, muscle weakness and pain. He also experiences frequent headaches and sensitivity to light. Over time, Max has become hyper-aware and focussed on his chronic fatigue symptoms, particularly his fatigue. We will discuss the reasons for this ‘hypervigilance’ later in the course, but it is not uncommon for people with chronic health conditions to experience this. When Max feels fatigued, he becomes fearful and reduces his activity levels to avoid feeling worse.

As a result of his reduced activity, Max has lost fitness and muscle strength. He also has difficulties with sleep and has lost confidence in his own abilities. This causes Max to withdraw even more from his usual activities. When he does re-engage in activities, Max’s performance is lower than it used to be, which causes him to be self-critical. Sometimes, in an attempt to meet his own high standards, Max will push himself to ‘do better’. In doing this, he overexerts himself, which leads to even longer periods of inactive recovery. 

All of this results in feelings of frustration, sadness, loss of control, helplessness, anxiety and low mood. These emotional states worsen Max’s fatigue and other symptoms, including his physical pain. Increased periods of rest also mean little distraction from symptoms, unhelpful thoughts and worries about not doing well enough in life. Max compares himself to his friends and colleagues, and feels inferior. Max wants to be more active, yet he believes that increasing his activity will worsen his fatigue. What he doesn’t realise is that he is caught in a self-fulfilling prophecy, whereby his expectations are coming true because he believes and acts like they will.  

When you understand how your symptoms are being maintained by your thoughts, feelings and behaviours, you can take steps to intervene. For example, by reducing his activity and worrying about his performance, Max actually worsened his symptoms. These behaviours led Max to lose muscle strength, feel stressed and tense in his body, and lose confidence in himself. If Max changed this behaviour, perhaps he would experience some symptom relief. This would have flow on effects to the way he thinks and feels. 

Similarly, by practicing relaxation techniques, Max could reduce his anxiety and physical tension. Instead of thinking negatively, Max could be more balanced in the way he talks to himself. He could tell himself encouraging things like, “I’m doing my best, that’s good enough” and “activity isn’t the enemy, I just need to find the right balance”. This may help Max approach rather than avoid activity. It may also directly improve his symptoms by reducing his body’s stress response (we cover this more next week).

Before moving on, have a think about your own chronic fatigue cycle. You may not have all the pieces of information yet, but see if you can identify some parts of the puzzle. For example, when you’re experiencing a symptom flare up, how do you feel and what thoughts commonly go through your mind? What do you tend to do in response? See if you can draw your own chronic fatigue cycle on a piece of paper. You can add to this diagram as you gain more insight and progress through the course.