Your Book Review: Exhaustion
Finalist #13 in the Book Review Contest
[This is one of the finalists in the 2022 book review contest. It’s not by me - it’s by an ACX reader who will remain anonymous until after voting is done, to prevent their identity from influencing your decisions. I’ll be posting about one of these a week for several months. When you’ve read them all, I’ll ask you to vote for a favorite, so remember which ones you liked - SA]
Imagine you find yourself, over the course of a few weeks or months, becoming steadily more tired. You’re not doing any more work or other activities than you usually do, but nonetheless you find that you are able to do less and less before running out of energy. You start to pick and choose your battles – do I really feel up to this gym session? Do I really need to go to this work function? – and little by little your world begins to shrink. The sense of exhaustion becomes more pervasive, and occurs from when you wake up until you go to sleep. Any exertion leads to you paying for it in a general worsening of exhaustion and malaise that makes you question whether the activity was worth it. Eventually, you learn your lesson and withdraw from even the most basic activities – sometimes you don’t get out of bed, have trouble feeding yourself, and find your thinking has become clouded and sluggish ( a phenomenon sometimes called ‘brain fog’). Sleep becomes difficult, activities become less enjoyable, and you find that you are restless and anxious despite spending almost all your time attempting to rest.
As Anna Schaffner explains it in Exhaustion: A History, you will find yourself in good company. The book has testimony from Charles Darwin, Henry James, Oscar Wilde, Virginia Woolf, and Thomas Mann, amongst others, giving accounts of their chronic pathological exhaustion.
While exhaustion and tiredness are universal after we’ve exerted ourselves, and resolves with rest, Schaffner is concerned here with chronic, pathological fatigue and weariness. This type of exhaustion isn’t just tiredness; aside from the ‘brain fog’ already mentioned, people describe hypersensitivity to light and noise, mood changes, diffuse or changing aches and pains, or fluctuating neurological or bowel symptoms. When the exhaustion is prominent and other easily-diagnosed conditions are excluded, individuals today will receive a diagnosis of something that is variously called Chronic Fatigue Syndrome (CFS), Myalgic Encephalomyelitis, Systemic Exertion Intolerance Disorder (SEID); or whatever unsatisfactory name is currently in fashion. As Schaffner does, I will use Chronic Fatigue Syndrome/CFS in this review, more because of its ubiquity and that it is agnostic to potential causes of the condition (SEID is the more recent term, but it’s too early to say whether it is going to catch on).
I read this book to try to make sense of CFS and its related conditions, and the book in my opinion begins to come together as it moves into the modern conceptions of exhaustion, but it is important to first follow Schaffner as she traces the explanatory models used in science and culture throughout Western history – there are only passing mentions in the book about Eastern conceptions of this condition, although it seems as though it is almost as common in Asian countries as in the West, where versions of neurasthenia are still diagnosed in China (shenjing shuairou; 神经衰弱) and Japan (shinkeisuijaku; 神経衰弱) and elsewhere.
Schaffner’s book opens with an account of Pope Benedict XVI’s renunciation of his office in 2013. She dwells on his broken and hunched figure, his self-description of his weariness and moral injury (the Church, then and now, plagued by financial and sexual abuse scandals), and his stated desire to retire and play the piano:
It costs the old man all his energy to perform the next task. He clears his throat and, slowly, like an ancient turtle, raises his head. He spreads his arms and blesses the crowd. Then, in a grating, broken voice, he begins to say his farewells… He spoke of the burden of an office too heavy for him; he said the world was changing and doing so at a pace with which he could not keep up.
While this pronouncement was shocking, it was not completely unprecedented. His words and demeanour reflected a previous papal renunciation, that of Celestine V in 1294; this Pope had left the job after only around five months, citing physical and mental exhaustion, and much of the language the two pontiffs used was remarkably similar (although in Celestine’s case, there is some concern that his successor Boniface VIII was nudging him towards the door).
And it becomes apparent through Schaffner’s selection of religious works, medical texts, novels and poetry, that throughout history the way people describe their malaise has been remarkably consistent (inasmuch as such a wide range of phenomena lumped into the same basket can be consistent). The things that have changed over the course of history, she argues, are the explanations we give for the phenomenon – who or what is to blame and how we construct a narrative both for the development of exhaustion, but also hopefully how recovery might occur.
She opens her account with Galen’s humoral theory, where exhaustion was linked closely with melancholia, that famous over-production of black bile. I won’t detail Galen’s theories here; instead, I’ll point you towards last year’s ACX review contest entry of On the Natural Faculties. But it is worth noting here that many of the symptoms Galen describes are familiar to us – I described some of them earlier, but there are prominent features of not only what we would now call CFS but also what we have now carved off into the related concept of depression. The link between CFS and psychological distress is fraught with controversy, and we’ll deal with it more later on.
After dispensing with the humours, Schaffner moves on to the moralistic/religious development of acedia, the forerunner of sloth, one of the seven deadly sins. It was first described by early Christian writers in monasteries such as John Cassian (circa 425CE), who described monks becoming agitated, unable to relax, but also anergic and unable to attend to their usual devotions or tasks until:
...worn out by the spirit of accidie, as by some strong battering ram, [the victim] either learns to sink into slumber, or, driven out from the confinement of its cell, accustoms itself to seek for consolation under these attacks in visiting some brother, only to be afterwards weakened the more by this remedy which it seeks for the present.
So here we see one of the first accounts of one of the hallmark symptoms of CFS, what we now call post-exertional malaise. You do something to break the monotony of rest, but after exerting yourself you feel significantly worse.
Occurring as it did in monastic orders, the explanation for acedia was moral in nature – it was due to weak willpower or a moral defect. Schaffner, quoting Thomas Aquinas:
Apathy [acedia] is a sort of depression which stops us doing anything, a weariness with work, a torpor of spirit which delays getting down to anything good. Spiritual goods are real goods, and taking no joy in them is bad in itself; and it is bad in its effects if it so depresses a man as to keep him back from good works. Acedia then is doubly wrong. Sadness as such merits neither praise nor blame; what we praise is a controlled sadness at evil, what we blame is sadness that is either uncontrolled or is sad about good.
…which is something that might reasonably be referred to today as victim-blaming.
As for the cures, increased focus on work and preventing idle time was felt to be the remedy, something that was felt to be both practically and spiritually a good path to follow out of the malaise.
Schaffner then takes the short intellectual journey from sin to sexuality via a slightly weird but interesting digression into vampires. Those retiring women who are pale and lack energy aren’t simply tired: their life force is being sucked out of them! While interesting, and giving her a chance to shoehorn in some examples of what I presume was part of her previous book on sexology and perversion in the 19th century (which I haven’t read, but now kind of want to), it doesn’t really add much to the overall picture we are concerned with here.
Besides, around this period however the major concern was more earthly; sins such as masturbation (Aquinas famously ranked this quite highly amongst the sexual sins) had now become terrifying causes of mental and physical turmoil in tracts such as Onania: or, the heinous sin of self-pollution and all its frightful consequences (in both sexes) considered with spiritual and physical advice to those who have already injured themselves by this abominable practice (1756). People began to attribute a number of symptoms of exhaustion to the practice, which was felt to be exploding in popularity (sorry) due to the excess of leisure time and the availability of printed smut. Tissot, the author of a later screed on masturbation, enumerates a number of frightening outcomes:
… loss of life energy, weakness and exhaustion, but also convulsions, sleeplessness, paleness, pimples, consumption, diarrhoea, the weakening of intellectual powers, bad digestion, vomiting, anguish, paralysis, spasms, melancholy, catalepsy, epilepsy, imbecility, loss of sensation, disorders of the urinary system and even death.
This is particularly pronounced in men, for whom the loss of seminal fluid is allegedly forty times more damaging to vital energy than losing an equivalent amount of blood. Semen-accounting practices aside, the main point is that here we begin to find the tying together of Galen’s humoral imbalances with the idea of a loss of vital energy that cannot be easily replaced. In Schaffner’s account, as technology moved on into the industrial era, we start to see new ideas from science being put into service to explain exhaustion, and many of these theories concerned the expenditure or transfer of finite amounts of energy and a subsequent rest state or energy deficit: that is, we begin to use things up and can’t replenish them. These ideas included the thermodynamic idea of entropy, discoveries in the electrical nature of nerve conduction, and the ideas of genetic and mental degeneration.
This led to the development in the 19th century of a new, vaguely defined illness known as neurasthenia. It was, in the conception of the time, an illness of overworked and played out nerves due to their overstimulation at the hands of industrialisation and modern society. A neat rhetorical trick was employed by physicians at the time, who claimed that sensitive and creative people doing brain work were more susceptible than those in the working classes. This is an important change, as it begins the move away from the moralistic conception of exhaustion and produces a blame-free, stigma-free conception of an illness which has a tendency to strike the special and the smart. It is no coincidence that many of the writers and thinkers I mentioned earlier that suffered from exhaustion (James, Woolf, Mann, Wilde et al) are all concentrated in this era – they all were diagnosed with neurasthenia. As Darwin announces and elaborates on the theory of evolution, more attention is paid to the idea of inherited weaknesses in nerves, culminating in cultural accounts like Huysmans’s Á rebours (Against Nature), which described the final, exhausted, idle throes of generations of inbreeding in the person of a decadent, hypersensitive and exhausted noble recluse.
If you’re a doctor in this period, the other benefit of the reformulation of exhaustion into neurasthenia is that it manifests in those who are rich enough to pay your fee, and simultaneously makes the physician indispensable. So, we begin to see in the writings of physicians, psychiatrists and novelists the two opposing views of how this condition is to be best treated. On one side, we have rest; the other, activity.
Improvised rest cures were followed by Darwin (who could only intermittently attend to work on the Beagle and had regular daily periods of repose at home throughout his life, interspersed with hydrotherapy at various spas), with more prescriptive programmes followed by Virginia Woolf, who followed a ‘rest cure’ for women designed by an American physician named Silas Mitchell. The rest cure was premised on unambiguous misogyny: the idea that women were overstimulated by moving outside the home and doing things that they were unsuited for, like thinking and writing, were wearing out their nerves and depleting their blood of nutrients. Thus, the home (and bed)-bound, low-stimulus, rest cure, that also focused on rapid weight gain (“to gain in fat is nearly always to gain in blood”).
On the other hand, we have the exhortation to activity, which as we’ve seen has been a suggestion from at least the days of monks with acedia, but is now in the West explicitly linked with the co-called Protestant work ethic, with work and its resultant energy and meaning being thought of as a necessary good (Max Weber, the sociologist who coined the term, was also diagnosed with neurasthenia – it seems a wonder anything intellectual got done during this period). There’s a gender bias here; while women had the rest cure, men diagnosed in the late 19th Century might be prescribed a “West Cure” where they might, in Mitchell’s words, “engage in a sturdy contest with Nature” by spending time with cowboys and sleeping rough – something Billy Crystal also found helpful.
The twentieth century was an era of rapid advances in Western medicine, particularly in virology and immunology. New vaccinations for illnesses were developed, antibiotics and antivirals became available, surgical techniques and safety advanced, the fatal childhood illness of diabetes was turned into a chronic adult illness by insulin, cancers were cured, and medicine discovered the randomised control trial and began lambasting all other health disciplines for not upholding the fine traditions of evidence-based medicine that they had only just invented.
At the same time, there was an increasing recognition of, and alarm about, the environmental effects of industrialisation – toxic chemicals, greenhouse gases, nuclear and other electromagnetic radiation, noise, antibiotics and hormones in our food, genetic modification of crops, and many others.
So it is not surprising that, just as contemporary theology, culture or science has been harnessed into previous explanations of exhaustion and its related symptoms, new explanations have been developed that lean on the anxieties of our times. The major differences in the more modern conception of exhaustion is the way affected individuals seek out biomedical explanations, but do so in the face of a medical establishment that looks at these explanations as incomplete or wrong.
Schaffner gives a reasonable accounting of the way CFS was characterised – post-polio fatigue being noticed in the 1950s, the discovery of Epstein-Barr Virus (EBV) in the 1960s and the initial thoughts that EBV was a robust cause of CFS, the subsequent discovery that about 95% of the population has had EBV so this explanation couldn’t be complete, followed by classification of the syndrome settling into a cause-agnostic set of symptoms. This, however, didn’t stop the fighting.
Essentially the conflict lines up between three rough groups. The first is the patient advocacy groups, who are made up of a group of sufferers of the condition and (some of) of their carers and family, who firmly believe that there is an undiscovered viral or autoimmune condition that not only caused their condition but continued to exert its effects in their ongoing symptoms. It’s not simply that they had an infection and are now deconditioned or slow to recover; it’s that the condition was never properly diagnosed, is continuing to account for their ongoing exhaustion, and could people please stop referring them to psychiatrists. This group is heterogeneous but on the whole prefers names for the condition that imply an ongoing disease process, such as myalgic encephalomyelitis.
Opposite them are a mix of (some of) the sufferer’s frustrated partners, carers and family members who have difficulty with living with someone who has chronic disability. This can include the individual’s doctor, who sometimes deals with chronicity poorly. The fringes of this group start muttering darkly about mass psychogenic illnesses and fads, access to insurance and compensation, and prefer to use the term chronic fatigue syndrome but with audible air quotes. You may think this is strawmanning the anti-CFS group, but Schaffner has the medical/psychiatric historian Edward Shorter to set us straight:
The Saga of Chronic Fatigue Syndrome represents a kind of cautionary tale for those doctors who lose sight of the scientific underpinning of medicine, and for those patients who lose their good sense in the media-spawned ‘disease of the month’ clamor that poisons the doctor-patient relationship… A whole subculture of chronic fatigue has arisen in which those patients too tired to walk give each other hints about how to handle a wheelchair and exchange notes about how to secure disability payments from the Government or from their insurance companies.
The medical consensus about CFS is different from both of these extremes, with the current conception being that there are a number of different pathways into the condition. Some of them are likely triggered by the immunological response to viral infections, with COVID being the most recent example of one of these (hence ‘Long COVID’). But, because not everyone who gets COVID/EBV/whatever develops this syndrome, something else needs to be going on. That something, in the case of COVID, could be a particular immunological profile leading to some ongoing inflammatory response, but this hasn’t been established for other viruses. Not to mention that when people actually try to characterise whatever this immunological response might be, the state of the evidence appears to be ‘cytokines, natural killer cells, T-calls something something’.
And those who get CFS also often have many of the same risk factors we find predisposing to mental illness – childhood trauma, or pre-existing anxiety or depression. This might make people vulnerable to developing some maladaptive thoughts about their convalescence that can in turn lead to longer-lasting deficits. CFS researcher Simon Wesseley:
We suggest that agents such as EBV or viral meningitis can lead to the experience of abnormal symptoms, such as fatigue, malaise and myalgia. However, the transition from symptoms to disability may be more closely linked to cognitive and behavioural factors. Hence interventions such as CBT designed to reduce disability and counteract maladaptive coping strategies ought to be more effective in reducing disability than symptoms. The evidence so far supports this model – many patients do show considerable improvements in disability and everyday functioning, but are not rendered symptom-free by cognitive or behavioural interventions.
Wesseley is right about the evidence: there is some evidence for CBT and graded exercise, with Wesseley himself providing one study into the latter – a study that led to him getting death threats from patient groups.
Why the death threats? The sense of intense anger and distress at the mere whiff of a non-biological component of the explanation, or a non-biological treatment, is due in part to the long process people go through to get to a diagnosis. CFS is a condition that assumes the trappings of biomedical Western medicine, but suffers from the inconvenient lack of concrete blood and X-ray results that would convince biomedically-minded doctors to take it seriously. Sufferers describe going from doctor to doctor, receiving greater or lesser doses of Shorter-style hostility or incomprehension, sometimes only coming across the diagnosis online. Having been told, explicitly or implicitly, that “it’s all in your head”, the natural response is to kick as hard as possible in the other direction.
Psychiatrists are adept at answering the question “Is it real, or is it all in my head?” with “Yes”. Unfortunately, much of our folk psychology is more Cartesian than this, and the idea that only biomedical symptoms are real is well entrenched with a large chunk of the population, including many doctors. And, as Schaffner points out, if you’re not fighting your attitudes towards disease and your depression, you’re fighting modernity and an unchangeable immune system, and in that fight you’re always going to feel overmatched.
One of Schaffer’s main points is that, despite the shift in narratives about how we explain exhaustion to ourselves, each age has the tendency to link it both to sociocultural critiques of current society (as compared to a mythologised more natural, simpler age) and to utilise the latest explanatory models current in culture or science at the time. Thus, in medieval times we get acedia, the sign of a more sinful and corrupt decline in Christian practice; from the late Baroque period and on into the Victorian era there are a lot of discussions about sexual practices being the culprit in this new age of licentiousness; in the late 19th century we find neurasthenia due to the idea of nervous energy being prematurely used up by a combination of the demands of an industrialised world and the degeneration of dissolute bloodlines; or more recently a mystery virus, modern toxin or immunological disorder that relies on the edifice of scientific medicine to diagnose, an edifice that is populated by a group of clinicians and researchers who are largely sceptical of (or even hostile to) this explanation.
But what is chronic fatigue syndrome really? Schaffner’s view is that it’s the newest explanation for an age-old set of linked experiences that people have suffered and written about for thousands of years. I agree with this as far as it goes, but this doesn’t mean that current conceptions of the condition are equivalent to those seen in the past – our advancing knowledge of the immunology, virology and the links between mind and body should count for something, otherwise we are just telling new stories about illness that are objectively worse because they don’t even have any sexy vampires.
But it is clear that people make different meanings of their suffering, and focus on different things when they report it. Classical melancholic depression, for instance, also features lack of energy, appetite and sensory changes alongside the low mood and feelings of guilt and suicidality. Are we simply seeing an artificial divide between people with prominent fatigue who receive or cling to a biological explanation (CFS sufferers) vs people who receive or cling to a psychological explanation (depression sufferers)? Shorter would have us think so, and has thrown in some accusations of malingering in the CFS group for good measure. But most psychiatrists would still class melancholia and CFS as two different conditions. And to complicate things further there is likely to be overlap, as chronic disability makes you depressed, and severe depression leads to you becoming physically deconditioned.
There is some hint, though, that CFS is something that is a subset of a wider group of other contested disorders, separated only by the explanation that sufferers prefer. When people have similar sets of non-specific symptoms, and they attribute them to electromagnetic sensitivity, Chronic Lyme Disease occurring in countries with and without Borrelia-carrying ticks (but also, sexism), household chemicals, or Communist death rays, then you have to conclude that there is a lot we don’t know about human energy and its lack.
Would I recommend this book? Yes - it covers a lot of ground, including several aspects I’ve barely touched on here as I raced towards a discussion of modern CFS. Schaffner riffs on some other culprits including Saturn and other astrological bodies, exhaustion as a critique of capitalism in literary works, and includes a discussion of modern workplace burnout (which is what the ‘special and smart person’ humblebrag elements of neurasthenia appear to have evolved into). The book isn’t perfect – some of her literary examples seem a bit stretched (there’s an extended discussion of Jason and the Argonauts which conflates despair and exhaustion, as well as an off-base interpretation of Lars Von Trier’s film Melancholia), there’s a chapter-long engagement with Freud’s idea of the death drive that seems to only tangentially touch on exhaustion, and she relies on some oversimplified psychiatric models of depression (not as simple as serotonin deficiency).
Her conclusion manages to weave in Pope Francis, because apparently when you start a book with a Pope you need to finish with one, but also touches on the idea of exhaustion of natural resources, climate change and the vagaries of capitalism to create an idea that maybe, after a succession of periods in which everyone thought their age was the most draining, perhaps we are indeed the ones with the best reasons to be exhausted.