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A practical guide to overcoming chronic fatigue, adrenaline fatigue syndrome and chronic low energy, by a renowned and experienced health expert.
Are you overwhelmed by fatigue? Feeling tired but wired? Struggle with concentration or sleep? You're not alone. Discover the cause of your fatigue and overcome it with 12 practical steps.
Approximately 30 million people suffer from chronic fatigue syndrome, and 43% of people admit to feeling too tired to function at work. With post-viral fatigue and chronic fatigue syndrome expected to rise significantly as a result of the Covid-19 pandemic, looking after our health is more vital than ever. Diagnosing and treating fatigue remains a mysterious and confusing process, with traditional medical approaches focusing on managing symptoms rather than understanding and addressing underlying causes.
In Decode Your Fatigue, Alex Howard, leading expert on chronic fatigue, guides you through a clinically proven...


Year:
2021
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Hay House
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english
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PRAISE FOR

DECODE YOUR FATIGUE



‘A hopeful, practical book to help people move from debilitating fatigue to a purposeful, joyful life once again.’

MIRANDA HART, COMEDIAN, ACTOR, AND WRITER


‘Are you ready to be empowered instead of blown off? Enlightened, instead of fumbling in the dark? Here is a map to help you get there. From somebody healthy, who has been where you are!’

JACOB TEITELBAUM, M.D., AUTHOR OF THE BEST-SELLING FROM FATIGUED TO FANTASTIC!


‘Alex Howard, and his colleagues, have been doing exceptional work with patients and clients with various types of persistent fatigue for many years. Fatigue is an immensely complex issue to investigate and properly address clinically, and this book does a masterful job of tackling these complexities and discussing them in a format and style that it easily understood and relatable for the layperson and medical professional alike. Bravo!’

PROFESSOR DR. DAVID BRADY, AUTHOR OF THE FIBRO-FIX


‘In writing this book Alex shows how Western medicine is failing patients with CFS/ME. Doctors do not look for disease causation nor try to identify the mechanisms by which that person has become ill. In Decode Your Fatigue, Alex gives the reader a roadmap and explains how symptoms can be used as important direction finders to guide recovery. With the rules of recovery and the tools to fix, all is possible. The tools are within everyone’s grasp and the book is logical so difficult concepts are easily understood. Yes, this is not an easy journey, it takes determination and courage. But with Decode Your Fatigue you can do it.’

DR. SARAH MYHILL, AUTHOR OF DIAGNOSIS AND TREATMENT OF CHRONIC FATIGUE SYNDROME AND MYALGIC ENCEPHALITIS: IT’S MITOCHONDRIA, NOT HYPOCHONDRIA


“Finally, a practical guide to recovery from fatigue that is not only inspiring but also very doable. Each of the different systems that are involved in fatigue are covered. Decode Your Fatigue teaches you how to personalize your healing journey, which is so very important because each of us is quite u; nique. Thank you, Alex, for this comprehensive roadmap to recovery! Highly recommended!”

DONNA GATES, M. ED., ABAAHP, INTERNATIONAL BESTSELLING AUTHOR OF THE BODY ECOLOGY DIET


‘I am deeply appreciative of Alex and his team’s work at OHC. There are a lot of books about fatigue. So many that you may want to skip this one – but I implore you: DON’T! Let this be the book you pick up and read. Alex’s approach to deep, lasting, multifactorial, complex fatigue is different. Yes, it started with his own experience, but it evolved to him establishing a clinic with a committed research department and a team of brilliant, like-minded individuals all drilling down into different aspects of the fatigue puzzle. Not only have they treated thousands of patients successfully over the decades, but they’ve published many research studies on their approach. Regardless of the underlying cause of your fatigue, if you give this book the time – and your precious energy – it will likely be the last stop you’ll need to make on the long, often deeply discouraging journey of healing from chronic fatigue.’

DR KARA FITZGERALD, CLINIC DIRECTOR AND HOST OF THE ‘NEW FRONTIERS IN FUNCTIONAL MEDICINE’ PODCAST


‘Decode Your Fatigue provides an extraordinary opportunity for the reader to finally feel understood, validating what we might be experiencing with our health challenges and symptoms related to the lack of energy. Alex provides an easy 12-step process that cultivates hope for achieving recovery. This is a must read for anyone suffering from chronic fatigue or other similar ailments, and will become a staple in our clinic and in our practitioner education’

ANDREA NAKAYAMA, MSN, FNLP, CNE, CNC, FUNCTIONAL MEDICINE NUTRITIONIST, FOUNDER AND CLINICAL DIRECTOR, FUNCTIONAL NUTRITION ALLIANCE





Published in the United Kingdom by:

Hay House UK Ltd, The Sixth Floor, Watson House,

54 Baker Street, London W1U 7BU

Tel: +44 (0)20 3927 7290; Fax: +44 (0)20 3927 7291; www.hayhouse.co.uk

Published in the United States of America by:

Hay House Inc., PO Box 5100, Carlsbad, CA 92018-5100

Tel: (1) 760 431 7695 or (800) 654 5126

Fax: (1) 760 431 6948 or (800) 650 5115; www.hayhouse.com

Published in Australia by:

Hay House Australia Pty Ltd, 18/36 Ralph St, Alexandria NSW 2015

Tel: (61) 2 9669 4299; Fax: (61) 2 9669 4144; www.hayhouse.com.au

Published in India by:

Hay House Publishers India, Muskaan Complex,

Plot No.3, B-2, Vasant Kunj, New Delhi 110 070

Tel: (91) 11 4176 1620; Fax: (91) 11 4176 1630; www.hayhouse.co.in

Text © Alex Howard, 2021

The moral rights of the author have been asserted.

All rights reserved. No part of this book may be reproduced by any mechanical, photographic or electronic process, or in the form of a phonographic recording; nor may it be stored in a retrieval system, transmitted or otherwise be copied for public or private use, other than for ‘fair use’ as brief quotations embodied in articles and reviews, without prior written permission of the publisher.

The information given in this book should not be treated as a substitute for professional medical advice; always consult a medical practitioner. Any use of information in this book is at the reader’s discretion and risk. Neither the author nor the publisher can be held responsible for any loss, claim or damage arising out of the use, or misuse, of the suggestions made, the failure to take medical advice or for any material on third-party websites.

A catalogue record for this book is available from the British Library.

Tradepaper ISBN: 978-1-78817-459-6

E-book ISBN: 978-1-78817-461-9

Audiobook ISBN: 978-1-78817-603-3

Interior illustrations: iii, v, 1, 59, 139: Antigone Konstantinidou; all other images: Sam Smith





CONTENTS



PART I: WHAT IS FATIGUE?

Chapter 1. Radical Responsibility

Chapter 2. Why Conventional Medicine Is Baffled by Fatigue

Chapter 3. How Your Body Creates Energy

Chapter 4. How Your Mind and Emotions Affect Fatigue

Chapter 5. A New Model for Understanding Fatigue


PART II: DECODE YOUR FATIGUE

Chapter 6. The Personality of Fatigue

Chapter 7. Understanding the Loads on Your Body

Chapter 8. Are You in a Healing State?

Chapter 9. Your Digestive System – Breaking Down Your Energy Source

Chapter 10. Your Hormones and Your Body’s Energy Reserve System

Chapter 11. Your Immune System – Reducing Your Body’s Load


PART III: RECOVERING FROM FATIGUE

Chapter 12. Coaching Yourself for Recovery

Chapter 13. Learning to Listen to Your Body

Chapter 14. The Three Stages of Recovery

Chapter 15. Cultivating a Healing State

Chapter 16. Nutrition Fundamentals

Chapter 17. Working with Practitioners

Chapter 18. Create Your Recovery Plan


References

Acknowledgments

Index

About the Author

Hay House Unlimited Audio

Continue Your Journey with Hay House





Chapter 1



RADICAL RESPONSIBILITY


Like most people, I grew up believing that if you fall ill, you take a pill and you feel better. At least that was until just before my 16th birthday, when I found myself in a physical hell that no pill could cure.

I woke up one morning and something felt very wrong. It was as though someone had pulled the plug on the energy in my body, and I had none left. The short walk from my bedroom to the bathroom felt like a marathon, my muscles ached, and I became light-headed while doing even the most basic tasks.

Following several visits to the doctor and various blood tests, it was concluded that I had a virus. I just needed to rest, I was told, and all would be back to normal in a month or two. That felt like a lifetime for a teenage boy who just wanted to play sports and make music with his friends.

For a while ignorance wasn’t exactly bliss, but it never crossed my mind that what I was experiencing was anything more sinister than a virus that would pass in its own time. Except, it didn’t…

Three months later, I was heading to the doctor once more in search of answers. This time, my grandmother was leading the charge – if anyone could get answers, it was her. My health hadn’t improved since my last appointment; in fact, it’d declined significantly. An attempt to restart school a few weeks earlier had gone horribly wrong: after 10 days of pushing through and pretending there was nothing wrong with me, I’d crashed, and was now feeling worse than ever.

The doctor’s surgery (office) was only a five-minute drive from our home but it might as well have been a million miles away. By the time we arrived I was so dizzy I could hardly stand and the exhaustion was so crippling it took everything I had not to just lie on the floor and curl up in a ball.

As we sat in the waiting room, I tried to distract myself by scanning the other patients. With a strange kind of envy, I found myself wishing I could swap my illness for a more tangible condition. I’d willingly have taken a broken limb or some kind of unpleasant infectious disease because they at least have a clear recovery path. The lack of clarity on my own way forward was almost as bad as my crippling symptoms.

When I was called in to see the doctor, my grandmother accompanied me. As I completed my description of the latest developments, or lack thereof, she interrupted: ‘Do you think it could be chronic fatigue syndrome, or ME?’ she asked the doctor, in the slightly overassertive voice someone uses when they realize they might be speaking out of turn.

A long pause followed, during which the doctor’s face assumed a somewhat pensive expression. My slower than normal brain used this interval to try and make sense of what my grandmother had just suggested. I didn’t know much about chronic fatigue syndrome, but I understood it was bad news and that it was a diagnosis I didn’t want.

Eventually, the doctor responded: ‘Yes, I think that’s the most likely explanation.’

After another pause, I stepped in. ‘Well, what does that mean?’ I asked. ‘Is there a pill I can take or something?’

‘No, I’m afraid there is nothing I can give you,’ he replied. ‘The best I can offer is counseling.’

As I struggled to process the enormity of what the doctor was telling me – that I had a serious condition for which nothing could be done – his suggestion that I have counseling stung deeply. I wanted to shout and scream about how ridiculous it was, but I didn’t have the energy. How could he be so insulting? My illness was in my body, not my mind.





The Downside of Hope


It would take several years before the horror of that autumn morning fully sank in. As the months passed, my grandmother, unwilling to accept that conventional medicine couldn’t provide a solution to my condition, dragged me around the weird and wonderful local alternative healthcare scene: nutritionists, energy healers, Chinese and Indian medicine practitioners… I saw them all.

I remember feeling genuinely hopeful and excited on the first few occasions; however, a clear and predictable pattern soon emerged. The virtues of the latest offering would be described to me, and I’d read a leaflet that included testimonials from people with symptoms like my own. I’d suspend my disbelief and become optimistic that the treatment would work, only to be disappointed once more when a few weeks or months later it became clear that it wasn’t making a blind bit of difference.

In time, I stopped getting my hopes up. Not because I didn’t want to get better – I did, I wanted it more than anything – but because I could no longer handle the emotional roller coaster of disappointment. I wasn’t cynical by nature but I became cynical because it was the only way I could protect myself from the downside of hope.

Over the next two years I saw numerous supposed medical experts; I radically transformed my diet; I had more blood tests than I was aware existed; and I consulted everyone from faith healers to people I’m not sure were medically sane – all to no avail. If anything, my symptoms got worse, and after a prolonged period in this living hell, my mindset certainly did.





The Turning Point


My health reached its lowest ebb when I was 18. And while it wouldn’t be true to say I was suicidal – because I didn’t want to die – at the same time, I just couldn’t see a way to keep living in the nightmare my life had become. I was in pain every day, and sometimes taking the few steps from my bedroom to the bathroom felt like climbing Mount Everest. It was in this state of desperation that I picked up the phone one day and called my uncle, and had the conversation that would change the course of my life.

My uncle was a bit like Gandalf in Lord of the Rings – he wasn’t around very often but he did have a sneaky habit of turning up at just the right time with just the right words of advice, before disappearing again over the horizon. I’d learnt to deeply admire and respect him from a distance, and the fact that he ran an indie record label also made him very cool to an aspiring punk-rock guitarist like myself.

When you have a severe chronic illness it’s not so easy to rely on the usual pleasantries when beginning a conversation. The seemingly innocuous question ‘How are you?’ has multifaceted answers and ‘I’m fine, thank you,’ as polite and normal as it sounds, is a blatant lie. ‘Fine’ falls into the same category as ‘pleasant’ or ‘amiable.’ It can refer more to the absence of something than to its presence.

However, by that stage in my illness I was past the point of caring what other people thought of me. Without the energy left to hold back, I told my uncle exactly how I felt: I hated my life and everything in it; I didn’t want to face another day of the hell my life had become; I was at the end of my tether and I couldn’t take much more.

Now, one would typically expect a response of compassion and gentleness in such a situation, and it wasn’t that my uncle didn’t know that I deserved both – he did. But he also realized that tea-and-biscuits sympathy wasn’t going to change anything. He knew that, as hard as it might seem, if I wanted the circumstances of my life to change, I was going to have to change them myself.

He started off by asking me a simple question: ‘On a scale of 0 to 10, how badly do you want to get better’? I didn’t have to think about it for long. I believed I’d do virtually anything – short of murder or amputating one of my limbs – to get better. I decided I was a 9½ out of 10. My next task was to make a list of all the things I thought I could do to get better, followed by a list of all the things that made me worse. My uncle suggested I put down the phone and come up with these two lists before calling him back in 10 minutes.

As I compiled my list of the things I could do to get better, I uncovered all kinds of excuses: I’d already tried everything and nothing had worked, and how was I supposed to find answers when no one else had? However, I respected my uncle and I was also desperate, so I listed things like meditation and yoga and learning more about food and nutrition; I even wrote ‘exploring more about psychology’ – I was that desperate.

I then worked on my list of things that made me worse. I had just one word: life. It felt as if trying to get through the day was its own unique source of torture.

I called my uncle, feeling proud that I’d at least bothered to do the exercise. I walked him through my lists, and he pointed out that part of what I needed to do was dig deeper to find answers. However, it was his next two questions that changed everything for me. ‘How many hours a day do you spend doing the things that you believe could make a difference?’ he asked.

My answer was as pathetic as it sounded. It was, basically, none. I knew of things I could be doing – they were on my list, after all – but the truth was, I wasn’t doing them.

He then asked, without a hint of judgment: ‘How many hours a day do you spend watching television?’ I took a moment to calculate the number of soap operas I sat through, along with various other mindless TV shows, and rather sheepishly, gave him my answer: I was watching TV for around seven hours a day. I had my excuses of course: I didn’t have the energy to do anything else and it helped numb my mind while my body was so ill.

My uncle then revealed the carefully poised point he wanted to make: ‘So, you want to get better on a scale of 9½ out of 10, and you’d do almost anything to achieve it. You have a list of things that could possibly help you, although you don’t spend any time doing them. However, you do have seven hours a day that you spend watching television.’

‘Something doesn’t quite add up there, does it?’ he concluded, with just enough softness and heart that, rather than becoming defensive, I found myself thinking long and hard.

Over the next hour, my uncle helped me draw up a plan that would change everything for me. From that moment on, with a depth of determination that surprises me to this day, I committed myself to finding a path to recovery. I gave it everything. My healing journey consumed my entire life; I was so desperate, I felt I had no other choice.





Decoding My Fatigue


Over the next five years, I saw more than 30 different practitioners, I read more than 500 books, and I practiced meditation and yoga for thousands of hours. Along the way it struck me that recovering from fatigue is like decoding a cryptic puzzle – you need to apply the right interventions, in the right sequence, at the right time.

My recovery path involved seemingly endless trial and error, and at times trying to make sense of things was beyond frustrating. In time, it became clear to me that putting things together in the right way can be as important as having the right ingredients: I found that treatments that are helpful at one stage of recovery can make things worse at another stage. Long before the concept of biohacking gained currency in popular culture, in a sense that was what I was doing – running endless experiments on my body to slowly decode the puzzle of my fatigue.

Five years after that fateful conversation with my uncle, I finally knew that I’d fully recovered. I believe that everyone who goes through an experience like mine has a measure for this, where they think, If I could do that without payback, then I’d know I’m fully recovered.

For me, that was going for a full-on run and holding nothing back. If you’d seen me that day, I’m sure you’d have agreed it really wasn’t far off that iconic scene in Rocky. I ascended one of the steepest hills in London, giving it my all, and I was in tears by the time I reached the top. However, the run itself wasn’t the real test of my recovery – that came in the days that followed when, instead of the physical payback that’s so typical of chronic fatigue, I felt nothing but ready to go again.





Founding The Optimum Health Clinic


In the later years of my recovery, I studied for a degree in psychology in Wales, and as part of my final-year research, I interviewed 10 people who, like me, had personal experience of severe fatigue, to understand how it’d impacted their sense of self. The three who’d recovered reported that in spite of the immense difficulty and suffering they’d endured, their lives had been enriched by the experience. This is something that’s referred to academically as post-traumatic growth.1

And although I’d have found it very hard to accept it when I was at my most desperate, I knew the same was true for me. Having been to hell and back, I’d learned things about myself and the world that gave me a powerful sense of my own capacity, along with a deep sense of my responsibility to help people in a similar situation.

So, after a year of working as an apprentice to one of my psychology trainers, I decided to set up the kind of clinic that I’d wished had existed in the years I’d been ill. Fueled by little more than a passion to help and the belief that I’d found some of the answers along the way, I launched The Optimum Health Clinic (OHC) from my bedsit in North London, at a time when making the rent each month was a serious struggle.

Within a few months, I’d received thousands of inquiries from people all over the UK who were suffering from myalgic encephalomyelitis (ME), chronic fatigue syndrome (CFS), and fibromyalgia. In time, I invited a nutritional therapist, Niki Gratrix, to join me – although I had a good basic knowledge of nutrition, I knew that my specialty was psychology.

And, as things grew beyond what Niki and I could handle on our own, we were joined by Anna Duschinsky, who became our Director of Psychology, allowing me to focus on the overall vision and leadership of the clinic. Anna had a very similar healing story to my own, and our personal experiences became a critical part of our patient-centered approach.

It was an immensely exciting time, but it came with a great burden of responsibility. From day one, we were determined not to fall into the trap of claiming that we had all the answers, or that ours was the only approach to fatigue that mattered, as many other practitioners had done. With a maturity that was in many ways beyond our years, we carefully crafted a game-changing approach to treating fatigue-related conditions that places the individual differences of each patient at the heart of everything.

In the early years of the OHC, finding, training, and supporting the best practitioner team possible presented so many challenges. Aside from an A level in business studies, I had no experience of business, and indeed, had never even held a ‘proper’ job. We were continually learning as we worked, and looking back now I think it’s something of a miracle that we managed to survive the rocket-ship growth we experienced at times.

Thankfully, we seemed to attract the right people at just the right time to help guide and support us, a blessing that has sustained us to this very day. And, as it happens, you’ll meet some of them while reading this book.

In time it became super clear to us that if we wanted our approach to fatigue-related conditions to ultimately be accepted by and integrated into mainstream medicine, we needed to talk the language of medicine, otherwise known as the language of research. And so in 2011 we founded our own research department.

A year later we published a prospective preliminary study in the British Medical Journal Open that demonstrated statistically significant improvement with our approach.2 We followed this up with publications in Psychology and Health, Medical Hypotheses, and the Journal of Integral Theory and Practice, to name but a few.3

In the years since, the OHC teams have worked with over 10,000 patients in more than 50 countries. We have 20 full-time practitioners and are considered one of the world’s leading integrative medicine clinics. Along the way we’ve learnt a lot, and today we know infinitely more about fatigue-related conditions than I did back in the years when I was ill. Yet there is still so much more to be discovered; and, unfortunately for them, the greatest source of that learning is inevitably the patients who don’t respond as we expect.





Our Journey Together


My aim in this book is to bring together the key principles of the approach I’ve developed alongside the OHC teams, to produce a practical guide that’ll help you to help yourself. Although for many of you this won’t necessarily replace the value of an online coaching program, or the need to work with a practitioner, there is a great deal you can do for yourself at home. Indeed, I’m deeply touched by the many comments I receive via email and social media from people who’ve been able to impact their healing journey dramatically by putting into action the tools you’re about to learn, simply by following them online.

In setting the tone of this book, I intend to tread a number of delicate lines:

I want to give you hope, without having you fall victim to the endless disappointment that I experienced.

I aim to stay true to the scientific complexity of this group of conditions, while also making practical tools accessible to you.

As my uncle did for me, I want to offer you compassion and empathy, while also being bold enough to give you a kick in the ass if and when you need it.



I’m sure that at times I’ll fail in all of these intentions; however, I hope that by sharing them with you here, you’ll at least know they’re good! Furthermore, although this book is aimed at readers who are on a healing path from fatigue, I’m also aware that there are a number of medical experts who follow my work, and so, where appropriate, I’ve provided details of primary sources to assist those who wish to go deeper into the research that underpins our approach.

You may be reading this book as neither a sufferer nor a medical expert but as a caregiver or a relative of someone who’s going through this immensely difficult experience, and so I’ve also included additional resources to support you.

I’m sad to say that my first-hand knowledge of fatigue isn’t limited to my own experience and that of our patients – my sister-in-law suffered from chronic Lyme disease and at her most severe, she came to live with me and my wife for 2½ years; you’ll read her story in the final chapter. Caring for her was its own unique challenge and as a result I can truly say that I’ve seen this group of conditions from every angle.

At this point I should also clarify that I loosely group the conditions chronic fatigue syndrome, myalgic encephalomyelitis, post-viral fatigue syndrome (including ‘long COVID’), Lyme disease, fibromyalgia, and various others under the label ‘fatigue-related conditions.’ (I’ll explain this further in the next few chapters.) I appreciate that this simplification is very far from perfect; however, as we’ll discuss, while there are some unique defining features to some of these diagnoses, there are also unifying factors that make it helpful to talk about them together.

Lastly, you may be reading this as someone who’s suffering from mild fatigue, and at times you might find my language a touch alarming, or even feel that it doesn’t relate to your own experience – particularly when I describe instances in which people’s entire lives are devastated by their symptoms. A helpful way to approach this is to consider that if these tools are effective even in those severe cases, they’re highly likely to be helpful in much milder circumstances. Indeed, that’s very much my experience.





The 12-Step Plan


At the heart of this book are 12 steps, or lessons, that’ll not only help you to decode your fatigue but also to start to create your path to recovery and learn how best to navigate it. These are the same 12 steps that I look at with all of my patients at the OHC – and they form the core of our approach.

And guess what? We’re already at the first of the 12 steps! Here’s the thing: I know you didn’t choose to have fatigue. What’s more, you don’t deserve it (no one does!) and you don’t want it. And yet, whether you like it or not, right now it’s happening and together we need to deal with it.

As my uncle helped me to realize, if you want the circumstances of your life to change, you have to be the one to change them. Indeed, that’s our first step:





Step 1: Take responsibility


What I call radical responsibility means taking charge of our own life, on every level we can. Now, there is a very important distinction between blame and responsibility. You’re not to blame for the situation in which you find yourself – you didn’t do this deliberately – but if you don’t take responsibility for changing it, the chances are that no one else will. So, before we go any further, I want to invite you to do the same exercise that my uncle set for me:



* * *





How Badly Do You Want Your Energy Back?


Take a few minutes to answer these questions and compile a list:


On a scale of 0–10, how badly do you want to get better?

Now make a list of all the things you know you could do to get better (you’re going to learn a lot more in this book!)

How many hours a day do you spend doing the things that you’ve just identified as being helpful?





* * *





How to Use the Book


Right now, I challenge you to make a commitment to yourself: whatever it takes, at least finish this book. If you’re struggling with motivation right now, I think you’ll find that’ll change if you stay with me in the coming pages. If you have the motivation but don’t know where to start, that’ll also, I hope, start to change.

In Part I, we’re going to take the time to really understand what fatigue is, what causes it, and why conventional medicine has failed to truly understand it. In Part II, we’re going to take the time to decode your fatigue together, and then in Part III we’ll create a plan for your recovery.

You might feel tempted to jump straight to Parts II or III; however, because this book’s content has been very carefully structured and it follows a particular sequence, I’d ask you to please read it in the order I’ve presented it. Also, just so you know, there are a few instances when I get a little technical; however, as this information isn’t essential to your journey I’ve put it in boxes and you can skip it if you wish.

Finally, I’ve created a free online Decode Your Fatigue companion course to be used alongside this book. It includes video interviews with many of the people whose case studies you’ll read in the coming chapters, along with quizzes and questionnaires to help bring further clarity, and even some recipe plans to help with my recommended dietary changes. You can access the course at www.alexhoward.com/fatigue.

Before we go any further, I think it’s important to define what we actually mean when we refer to fatigue and fatigue-related conditions, and to explore why conventional medicine has likely failed you. So buckle up, and let’s get stuck into the rather painful history of this complex but fascinating group of conditions.





Chapter 2



WHY CONVENTIONAL MEDICINE IS BAFFLED BY FATIGUE


It was a freezing cold February morning and the first time I’d managed to get to school in over a month. Along with my fellow pupils, I’d returned after the Christmas holidays ready for another busy term, but just a week later, I’d experienced another severe crash of chronic fatigue. Even during one of my better periods, I could attend school for only a few hours a day, but one afternoon I’d done fractionally too much activity by trying to join an extra lesson and had then needed a month of recovery to get back to my pathetic baseline.

As I sat in the classroom waiting for the Economics lesson to begin, the usual feeling of loneliness kicked in. I’d never understood before how people can feel lonely when they’re around others, but I found I no longer had anything in common with my classmates. I couldn’t take part in sports, I rarely stayed for mealtimes, and I certainly couldn’t attend any social events. I put on a brave face but often it was a struggle to even find anything to talk about.

It didn’t help that I’d only been at this particular school for six months and hardly knew anyone because I’d missed so many lessons due to illness. One day a guy in my class asked me where I’d been. I explained by telling him I had chronic fatigue syndrome, and that I’d had a crash and had been resting in bed at home.

I can hear his response today as clearly as I did back then: ‘You lucky git! Sounds like heaven to me! I wish I could spend a few weeks lying in bed and chilling out.’

I don’t think my classmate intended to be unkind; at worst, his comment was a barbed joke, but it had a devastating effect on me. It was another nail in the coffin of my attempt to be understood by others, and I retreated a further step deeper into my own inner world.





Royal Free Disease


Almost two decades of working with others with fatigue in its varied and complex forms has taught me that I was far from alone in having experiences like this. In fact, I think one of the most difficult things about suffering from fatigue is the judgment and blame that seem to go along with it.

Fatigue and fatigue-related conditions such as myalgic encephalomyelitis (ME), chronic fatigue syndrome (CFS), and fibromyalgia are categorized as ‘medically unexplained illnesses.’ To be clear, this doesn’t mean there are no explanations for them, only that conventional medicine is unable to explain them.4, 5 Perhaps a more accurate label would be ‘medically unexplained illnesses from a conventional medicine perspective.’

But why has conventional medicine failed so spectacularly to offer answers to those who are affected by fatigue? Given that understanding this question is the foundation of our entire adventure in decoding your fatigue, let’s take some time to answer it. To do that, we need to take a step back in time, to 1950s Britain.

Between July and November 1955, 292 members of staff at London’s Royal Free Hospital came down with a condition whose symptoms ranged from low-grade fever and swollen lymph nodes to severe headache and fatigue. Two hundred and fifty-five of those affected were admitted to the hospital, and by October it was forced to close temporarily to contain the outbreak. For many of these patients, symptoms went up and down over a long period, and in some cases their effects were devastating. And yet, despite considerable medical investigation and research, there was no identifiable cause of the outbreak.6

After the incident, Dr. Melvin Ramsay (of the Royal Free Hospital’s infectious diseases department) coined the name myalgic encephalomyelitis for this condition, which means myalgic (muscle pain), encephalo (brain), myel (spinal cord), itis (inflammation),7–9 to reflect the spinal cord inflammation in some of those affected, alongside the pain and headaches experienced.

With no medical explanation for myalgic encephalomyelitis, or Royal Free Disease, the hypothesis of mass hysteria was put forward, and to this day some pockets of medicine still refer to it as an example of collective medical hysteria with no physical origin.





The Legacy of Germ Theory


To understand why conventional medicine was so lost for answers in explaining the Royal Free outbreak, we need to take a further step back in the history books, to the formulation of a central belief of conventional medicine: germ theory.

Louis Pasteur was a 19th-century French chemist and microbiologist whose contribution to medical microbiology is almost without equal – among his discoveries were the principles of vaccination and microbial fermentation, and the food preparation process that bears his name, pasteurization. At the heart of Pasteur’s impact was his evolution and popularization of germ theory, which is still accepted today.

The core tenet of germ theory is that the spread of microorganisms known as pathogens or ‘germs’ in the body can cause disease.10, 11 Put in the simplest terms, from the common cold to the life-threatening sepsis, disease is the result of an external agent infecting the body and making us ill.

However, although Pasteur’s germ theory wasn’t fundamentally wrong, his work was incomplete. The problem with germ theory is that it perpetuates an over-simplified model of medicine that searches for a single cause, a test to measure it, and then a single drug to neutralize it or a vaccination to attempt to prevent it. That’s fine when you’re dealing with many acute illnesses, but it’s a total disaster when you’re seeking to understand multifaceted chronic illnesses.

As we’ll soon discuss, fatigue is a complicated condition that has different subgroups, stages, and systems affected, each of which has its own unique signature in an individual sufferer. The application of germ theory to fatigue has failed at every juncture. After decades of searching, no one has managed to isolate a single pathogen, so there is no biomarker test and no uniform treatment in the form of a pharmaceutical drug.12–15

And, even when it comes to something seemingly clearly defined, such as ‘long COVID’ (i.e. fatigue symptoms that continue for 3–6 months after infection with coronavirus), the question still remains as to why some people recover within a few weeks, and others don’t.

Aside from the devastating impact of the ineffectual application of germ theory to fatigue, and the resulting paralysis of research and treatment paths, I’d argue that there has also been an almost more severe consequence – the lack of a biomarker has resulted in the conclusion that fatigue must be ‘all in the mind.’16–18





Arrogance on Steroids


Historically, the medical perspective on fatigue has been, ‘We can’t find anything wrong with you, so there isn’t anything wrong with you.’

When you think about that statement from the fatigue patient’s point of view, it’s staggeringly arrogant. The inherent assumption is that conventional medicine knows everything there is to know about the human body, and because it can’t find anything wrong with you, there is nothing wrong with you.

Indeed, in the decades following the Royal Free outbreak, the very limited research funding for fatigue went to the psychiatric community, to enable it to better understand the ‘disordered thinking’ of those with fatigue. The stories of personal tragedy that resulted from this approach lie beyond the focus of this book, but they’re heartbreaking and enraging in equal measure.

If it hadn’t been for the persistence and determination of an already vulnerable and depleted patient community, we’d probably still be stuck in the medical dark ages in our understanding of the nature of fatigue. We owe a lot to the brave, and at times truly heroic, actions of fatigue sufferers who have stood up for their rights and a deeper understanding of their experience.

In the last few decades endless lobbying and campaigning has resulted in full recognition of the validity of this group of chronic illnesses by the medical establishment. The USA’s Centers for Disease Control (CDC) guidelines now say that ‘myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a serious, long-term illness that affects many body systems.’19

Progress has undoubtedly been made, but unfortunately, it’s done little to cure the arrogance of conventional medicine. Common medical understanding has moved from ‘We can’t find anything wrong with you, so there is nothing wrong with you’ to ‘Clearly there is something wrong with you, but we don’t have any answers. So there are no answers.’

Think about that for a moment. Once again, the inherent assumption is that conventional medicine has all the answers: ‘We don’t understand what’s happening, and therefore it’s either not real or it’s not possible to understand it.’ This isn’t just arrogance – it’s arrogance on steroids.

Now at this point you’d be forgiven for thinking that I harbor ill will toward the medical establishment for what is at best incompetence, and at worst abuse, toward fatigue sufferers. But in fact, you’d be wrong. Conventional medicine saves countless lives every day – we only have to look at the incredible work done by our healthcare systems in response to COVID-19 to see this. And if I get knocked down by a bus, you won’t hear me screaming for a nutritionist and a psychotherapist – no, I want the painkillers, the surgeon, and whatever else modern medicine can offer to save my life.

So I’m not opposed to conventional medicine – I’m just against arrogance and closed minds. And, unfortunately, there is quite a bit of that around in both conventional and non-conventional medical circles. Of course, when we’re dealing with life, death, and intense human suffering on a daily basis, it’s understandable that we need to have a certain confidence in our approach. Imagine being the pilot of an airliner with hundreds of trusting passengers, and each step of the journey questioning whether the plane will stay in the air, whether you have what it takes to fly it, whether the engines are going to work, and so on. You’d go crazy before the first day was over.

Certainty is a reasonable human need, and maintaining a curious, open, and discerning mind is no easy feat when working as a medical practitioner. Yes, it’s a very big thing to ask of our physicians; and yet, it’s also critical when faced with complex and deeply misunderstood conditions such as fatigue.

Indeed, during my conversations with GP friends over the years, many have told me that they feel something similar. The truth is that most doctors dread seeing patients with chronic illnesses they don’t understand.20, 21 At the end of the day, your typical doctor chooses a career in medicine because they want to help people, and after years of physically, emotionally, and mentally grueling training, the last thing they want is to sit across from patients who are suffering and feel powerless to help them.

The coldness and harshness that patient communities feel from their GPs isn’t a reflection of their lack of caring – instead, it’s a defensive strategy that doctors use to avoid feeling their sense of inadequacy and failure.22





A New Paradigm for Medicine


So, given the fundamental problems with a conventional medical approach to working with fatigue, you can begin to see why sufferers face such an uphill battle to find answers and to decode their fatigue.

But, as always, where there is a problem, there is an opportunity, and over the years there have been a number of trailblazers looking for answers. Some have been seen as rebels, some as outcasts, and others have managed to cruise below the radar while doing outstanding and important work.

The terms ‘alternative’ and ‘complementary’ medicine have become popular in recent years, but personally I don’t like either of them; I think they imply that non-conventional methods are somehow lesser than those of conventional medicine and need to be kept on the side. I prefer the term integrative medicine 23, 24 because I believe a truly holistic approach will integrate anything that has relevance to supporting the healing journey.

In more recent years, the concept of functional medicine has been gathering recognition,25 and indeed, I feel it best captures the essence of the approach we use at The Optimum Health Clinic. Functional medicine ‘employs a systems-oriented medical approach that works to identify and understand the underlying or root causes of a disease.’ Put another way, rather than treating symptoms, in functional medicine we’re really looking to dive deeper into the root causes of your fatigue.





Defining Fatigue


In that spirit, before we go any further, we need to define exactly what we’re talking about when we speak of fatigue. In the dictionary, fatigue is defined as ‘extreme tiredness resulting from mental or physical exertion or illness.’ However, I’m not sure how helpful this is.

If your levels of mental or physical exertion are excessive, then your fatigue doesn’t require decoding and your remedy is simple: live a more balanced life. What’s more likely is that your levels of exertion are normal and yet you still experience fatigue. This leaves us with the real question – why does a normal level of activity leave you fatigued?

Perhaps you’ve just recently started to find that the day is longer than the energy you have to meet it, and that your afternoon energy dip is no longer defeated by a strong espresso. Perhaps you’ve suffered with severe fatigue for many years, or maybe you’ve oscillated between phases of normal functioning and phases of fatigue but have never felt that your energy is reliable in the way it should be.

Regardless, the reason you’re reading this book is that something remains unexplained. You aren’t just a mystery to modern medicine – you’re a mystery to yourself. And it’s my hope that by the time you reach the end of this book, that mystery will be solved, at least in part.





Diagnosing Fatigue


This brings us to the second step in our 12-step plan:





Step 2: Get an accurate diagnosis


You see, a diagnosis of fatigue is no diagnosis at all: fatigue is a symptom, not a condition in itself. The reason we need to decode your fatigue is that fatigue, whether it’s self-diagnosed or medically diagnosed, is ultimately a false diagnosis. To really understand this point, we need to explore the diagnostic process for fatigue-related conditions.

A diagnosis of fatigue isn’t a diagnosis of the presence of a particular physical injury, a particular pathogen, or even a specific marker or set of markers that are out of balance. A diagnosis of fatigue, be it chronic or otherwise, is a diagnosis of exclusion. That means it’s a diagnosis in the absence of any known cause.





The Diagnostic Process


The diagnostic process for fatigue should go something like this.


You go to your doctor because you feel exhausted, and perhaps have some other symptoms such as muscle pain, dizziness, or sleep issues.

Your doctor considers your symptoms and history and orders a standard set of blood tests that look at basic markers such as full blood cell count; iron and ferritin levels; the inflammation markers ESR or CRP; liver, kidney, and thyroid function; tests for diabetes, and a celiac screen. Ideally, this will also include Vitamin D and what’s called a bone profile, and a test to rule out glandular fever.26, 27

The doctor will also investigate any other abnormalities that could explain the fatigue you’re experiencing. The purpose of this is to rule out various other explanations, such as autoimmune disease, thyroid, and more rarely, cardiac or pituitary disease, sleep disorders, neurodegenerative disease, diabetes, or some cancers.28

If those investigations come back abnormal in any way your doctor will do further investigations and potentially refer you to a specialist consultant, resulting in a different diagnosis.

If the markers all come back normal, or, following the referral there is no known cause and no other obvious reason for your fatigue, you’ll get a diagnosis of a ‘fatigue-related condition’ such as chronic fatigue syndrome, fibromyalgia, or post-viral fatigue syndrome.29, 30



Now, there is a very important point being made in the above process. If you’re suffering with fatigue, chronic or otherwise, it’s of critical importance that you engage with a suitably qualified medical professional to thoroughly investigate the conventional medical approach. There are multiple causes of fatigue that are identifiable by orthodox medicine,28, 31, 32 and if any of these is the culprit, acting sooner rather than later could literally be the difference between life and death.

So please, before you go any further in this book, make sure you’ve been fully assessed by a suitably qualified medical doctor and that you’ve gone through the steps above; or at the very least, do it in parallel (unless your doctor is willing to follow a number of lines of investigation at the same time, this process can take many months.) Don’t take this warning lightly, and don’t delay or put off seeing a doctor.

That said, going forward, I’m assuming that you’ve engaged with a suitable medical professional and the problem is that they couldn’t decode your fatigue, despite having followed medical due process. If this has happened, the good news is that there is unlikely to be anything life-threatening underlying your symptoms, which means we can get to work on decoding your fatigue together and creating your path toward healing.

At this point, you’d be excused for thinking, Well Alex, I’ve already had a diagnosis of chronic fatigue syndrome, so all of the above doesn’t apply to me. Actually, I disagree. A diagnosis of chronic fatigue syndrome really just means that your fatigue is ‘chronic,’ otherwise known as ongoing. Adding the word syndrome might make it sound more official, but it tells us nothing further about what’s actually going on.

There is also so much disparity in the definition, diagnosis, and treatment of chronic fatigue33 that although it can be a relief to have a name for what’s happening, it may not get you very much further with your healing. In fact, as controversial as it might sound, I have a similar attitude to diagnoses such as post-viral fatigue syndrome, myalgic encephalomyelitis, and fibromyalgia – none of these is actually a helpful diagnosis.

A useful medical diagnosis would be something like, ‘You’ve torn your ACL ligament’ or ‘You have appendicitis.’ Of course, my point isn’t that you’d want either of these diagnoses, but they would at least be accurate and give you a clear path toward treatment.

How about fibromyalgia, you might ask. Well, fibromyalgia is another condition with its own history of controversy,33, 34 but in essence we’re still talking about a fatigue condition, except with the additional symptom of pain.

And what about Lyme disease and coinfections? As we’ll get into in Chapter 11, we’re at least closer here to a helpful diagnosis; however, as many people with chronic Lyme disease have experienced, using a typical germ theory approach of nuking the Lyme disease is rarely as effective as one might hope.35–39 We still need to look at a multisystem approach and take into account more than just the immune system and its inability to fight the Lyme.

Although it can be unsettling to step free of the certainty of a medical diagnosis, I believe it’s also deeply empowering. By diving deeper into understanding what’s truly going on for you, you’re a step closer to decoding your fatigue and plotting your path to recovery. And, although this will be an intricate and challenging path, when you start to find real answers, it’ll also become an exciting one.

Before we move on, we need to get super clear on something: the exact biochemical process behind fatigue. What’s actually going on at a cellular level? What would you say if I told you that we can answer this question with great specificity? You see, in fact, your fatigue is likely very far from being medically unexplained – a very well understood biochemical process is causing it.





Chapter 3



HOW YOUR BODY CREATES ENERGY


It was an early evening in the autumn of 2005 and I was about to head home from work. However experienced you become as a practitioner, seeing patients one after the other throughout the day is mentally and emotionally demanding, and the last thing I felt like right then was a long conversation about complex cellular biology.

In those days, The Optimum Health Clinic was located in a basement on London’s Harley Street; it wasn’t quite as glamorous as it sounds, but it was a huge step up from the bedsit in which we’d started. As I closed my laptop and began to pack up my things, I felt that sense of satisfaction you get after a hard day’s work done well. I was ready to leave when Niki Gratrix, my cofounder, burst into my clinic room. She had a look of frantic excitement in her eyes, which I knew meant I wasn’t going home anytime soon.

‘Alex, you’re not going to believe what I’ve been reading about today,’ she began. One of the things that I most loved about working with Niki was her intense passion and excitement for learning, and at times like this it was infectious.

‘Alex, seriously – this is the most important breakthrough in fatigue research I’ve come across. I’m telling you, this is going to change everything,’ she continued.

I took a deep breath, waved goodbye to my lazy evening on the sofa, and replied: ‘OK, that’s some big talk. What is it?’

‘So, what’s the biggest outstanding mystery of fatigue?’ Niki asked with an expectant look on her face.

I was tempted to say something facetious, like: ‘I don’t know – why is being tired so tiring?’ But making fun of Niki in that moment would have been a bit like shooting an excited puppy, so instead, I played along: ‘I don’t know, you tell me,’ I said.

‘Post-exertional malaise,’ Niki continued. ‘Why is it that someone with fatigue can have the energy to do something and then their energy crashes afterward?’

Niki had sparked my curiosity there – she certainly had a point. It was bad enough that people with fatigue had low energy in the first place, but it never seemed to make sense that they could do something at the time, and then afterward, crash for no obvious reason. Post-exertional malaise (PEM), as this is known, is not only one of the most mysterious symptoms of chronic fatigue but also one of the most deeply frustrating and painful for sufferers.

‘OK, you’ve got my attention,’ I said. ‘If you can explain why that happens, and more importantly, tell me that you have some kind of solution and you aren’t exaggerating, then this is a big deal.’

Over the next hour or so, Niki patiently outlined to me the groundbreaking research she’d seen on ATP and mitochondrial function.40 For the first time, someone was able to explain to me not only the actual mechanism of low energy but also why people with fatigue will crash, seemingly out of nowhere.





What Is Energy?


Before we can fully explore what Niki explained to me, there is a fundamental question we need to answer – if fatigue is the absence of energy, what actually is energy? What is this mysterious currency that’s in such short supply when someone feels fatigue?

Let’s think about currency for a moment. It’s a means of exchange that allows something to move around – as in the way we use money to exchange goods in trade. The energy currency of your body is an energy-rich molecule called adenosine triphosphate, or ATP for short. ATP provides the fuel for pretty much every function in your body that requires energy – from nerve cell impulses to muscle cell contraction to fueling your brain, your heart and all the other organs of the body. Ultimately, the energy source keeping your body alive is ATP.

So, if ATP is the currency of energy in the body, it seems reasonable to assume that endurance-trained athletes have higher levels of ATP at rest, and are better at making it when demanded by exercise. And this is very much the case. A study published in 2018 found that when compared to controls, trained athletes demonstrate 10 percent more ATP at rest and possess significantly increased levels of ATP during exercise activity.41

Furthermore, trained athletes have the ability to increase available ATP by 100 percent more than controls during exercise. Put simply, the factor that allows endurance athletes to perform at the levels they do is that they’re literally making more energy currency.





Where Does Energy Come From?


If ATP is the currency of energy in our body, we now have another, equally important, question to answer – where does our energy come from? What’s the process by which the body makes energy? And why is it that an endurance athlete appears to have energy in abundance and yet someone with fatigue has to ration their energy, as though supplies might run out at any moment?

Well, ATP is manufactured by specialized structures inside our cells called mitochondria. If ATP is the currency of energy, the mitochondria are the energy factories that make the currency – they are effectively the ‘powerhouses’ of the cell. Almost all living cells have mitochondria; some cells produce more than others, but every single cell in your body, apart from red blood cells, has its own powerhouse. Indeed, fat cells have many mitochondria because they store energy, and equally, muscle cells have a lot because they need to respond quickly to energy demand.

At this point, you’re likely thinking, Well, to decode my fatigue, I just need to get my mitochondria working properly. And in a sense you’re right. This is the next step in our 12-step plan:





Step 3: Understand the role of your mitochondria


Essentially, our mitochondria help turn the energy we take from food into energy that the cell can use. The actual chemical process of how they do this is pretty long-winded, and you don’t need a full understanding of it in order for us to continue our journey together; however, for those of you who remember some of your high-school biochemistry, the following technical box may serve as a helpful summary. (As I explained in Chapter 1, these boxes are optional rather than critical.)





How Our Mitochondria Make Energy


Energy production in the mitochondria begins with the food we eat. Plants use photosynthesis to capture energy from light in the form of carbohydrates, and humans obtain that stored energy by digesting and absorbing it – either directly from plants or from the animals that consume them (we’ll get into your digestion in Chapter 9).

Your mitochondria combine these molecules from food with oxygen and convert them to water and carbon dioxide, releasing energy. This process is called aerobic respiration.

The energy produced through aerobic respiration is stored within the energy-carrying molecule ATP (adenosine triphosphate). ATP has three (tri’) phosphate groups, linked to each other by bonds (see top of diagram). The energy is trapped in the bonds to each phosphate group and in that way it can be transported to where it’s needed.

Energy is released when the bond between the second and third phosphate group is broken. The remaining molecule (having released one phosphate group) becomes adenosine diphosphate, or ADP.

ADP can then be transported back into the mitochondria and recharged into ATP through chemical reactions that add the third phosphate molecule back (see center of diagram). This is known as ADP/ATP ‘recycling’ and is the most efficient way to generate new energy. When any aspect of this process isn’t working effectively, we’ll experience post-exertional malaise.



The ATP/ADP cycle





Post-Exertional Malaise Explained


So, now that we’ve discussed the basic principles behind what energy is and how it’s created, let’s return to my crucial conversation with Niki. As I mentioned earlier, one of the most frustrating symptoms of fatigue is post-exertional malaise (PEM), and also what we call the ‘delayed fatigue response,’ which is when the fatigue takes several days to appear; more on this in a moment.

After a lie-down or a good night’s sleep, a healthy individual can expect to feel the same as they did before a modest level of exertion, but this isn’t the case with ongoing fatigue. Let’s say you’re struggling with low energy but are just about managing to function at a low level. It’s Saturday afternoon, you have friends visiting, and everyone decides to go for a walk. Now, this walk is a stretch on what you’d do on an average day but you don’t want to let people down – and actually, you feel like getting some fresh air.

Over the next couple of hours, you maintain a steady pace and walk around three or four miles. It’s been a while since you blew away the cobwebs like this, and you find you’re having a better time than you expected. That evening your muscles are a bit stiff, but you go to bed feeling relieved that you got through it – and a little surprised that you’re not paying more of a price.

On Sunday morning your body still feels a little stiff, but you seem fine. You notice that your nervous system is perhaps a little overstimulated and that you’re finding it difficult to take it easy. Maybe yesterday’s walk has given you some more energy.

When you wake up for work on Monday morning you feel as if you’ve been hit by a train. You’re utterly exhausted. You feel faint simply standing up, all your muscles hurt, and with little choice, you call in sick. Your symptoms don’t improve for a few days – you continue to feel totally wiped out – before gradually getting better.

You find yourself wondering, What the heck just happened? It must have been the walk – but why did it take several days before you felt the impact, and why did it then take several days for you to recover?

This is the delayed fatigue response, and it’s a key feature of many people’s fatigue. They do something and they seem OK, and it’s only several days later that they feel the impact of it; for others, there isn’t even a delay – whenever they go beyond their energy capacity, there is a resulting exhaustion. This is what’s technically known as post-exertional malaise (PEM).

PEM is a well-documented factor in chronic fatigue syndrome.42, 43 A 2010 study of 48 women with CFS found that 60 percent of them took five days to feel better after exertion.44 And it’s not only exercise that causes PEM45 – it can also have physical and physiological,46, 47 emotional,48 cognitive,49, 50 or sensory and environmental causes.45, 51

So, what’s the relationship between mitochondrial function, ATP, and PEM? Well, it’s all down to how ATP is generated within your mitochondria. Here’s another technical explanation for those of you who are interested.





ATP Recycling and Post-Exertional Malaise


Each of our mitochondria has the capacity to produce 36–48 ATP (units of energy) from scratch. This is a lengthy biochemical process that can take up to two days. The majority of our energy (ATP) production is needed ‘on demand’ when we use it for cellular activities such as exercise, so instead of making it all from scratch, we take a shortcut by recycling the ADP we produced earlier. This process, which takes about 10 seconds, is called oxidative phosphorylation, and it’s responsible for meeting about 60 percent of our energy demand.

Oxidative phosphorylation is responsive to the needs of our body, and with normal mitochondrial functioning, we can train our body to become more efficient and produce more energy. As long as we don’t over-train the body, the more demand it gets used to, the better this process of oxidative phosphorylation is able to work, including making more mitochondria. Remember what we discussed earlier about endurance athletes?

However, in certain situations when this recycling isn’t taking place quickly enough to meet demand, two ADPs can be combined to form one ATP and one adenosine monophosphate (AMP), releasing only a small amount of energy. In muscle, AMP may be further broken down to inosine monophosphate (IMP), which may then be lost altogether through the urine.

Making ATP from AMP is a very slow and energy-consuming process, and it takes some days for the body to recharge, particularly if AMP has been depleted. This is why we can end up experiencing post-exertional malaise.

Put simply, the cause of fatigue is suboptimal, or inefficient, ATP recycling. If we push ourselves beyond our capacity, ADP is converted to AMP, which can only be recycled much more slowly. It then takes several days to make fresh ATP from new raw ingredients. Ultimately, fatigue is the result of not having enough ATP or ADP from which adequate levels of energy can be made.



Here’s the thing – you’re not crazy: your fatigue is real. There is a very clear and specific process in your body that’s likely not working properly. And guess what? We can even test it.





Testing Mitochondrial Function


In the days following Niki’s initial discoveries we were even more excited to discover that a UK-based laboratory was pioneering mitochondrial function testing in fatigue patients. Dr. John McLaren Howard was collaborating with Dr. Sarah Myhill, one of the British pioneers of functional medicine for fatigue patients, and they’d developed a truly groundbreaking blood test.52, 53

In addition to rating how efficiently a patient’s mitochondria produced energy, this test could also look for possible issues with toxicity and blockages of the mitochondria. Niki and I quickly realized the test could be a big advantage when working with our patients. There was, however, a rather major hurdle – the laboratory would only work directly with medics, and at this point there were no doctors working in the OHC practitioner team.

Undeterred, I got straight on the phone to a medic friend and asked them if they’d be willing to sponsor all of our mitochondrial testing with the laboratory, which they were more than happy to do. And, over time, due to the sheer volume of testing we were doing, we forged our own relationship with a further lab internationally offering such tests. In the years since then, we’ve performed thousands of mitochondrial function tests, and we’ve found it to be an enormously useful clinical tool.

The beauty of testing mitochondrial function is that we have the ability to break down the complicated business of making energy into a series of logical steps and physiological questions. And, having conducted so many tests over the years, the learning is enormously important in making sense of a patient’s clinical picture, even when we don’t test. For the patient, this information is invariably the first time that anyone has been able to explain the physiology behind their fatigue, and as such it’s often met with great excitement and at times, huge emotion.





Fueling the Mitochondria


Now, you can probably guess what happened next. Inspired by the outstanding work of others in the field, we’d discovered how energy is created, and we also knew which raw ingredients the body uses to make energy. What was the obvious conclusion to come to? You’ve guessed it – we decided to start supplementing those patients with poor mitochondrial function with these raw ingredients!

Using carefully designed protocols of supplements such as co-enyzme Q-10, D-ribose, magnesium, and L-carnitine,54, 55 we dosed people up to see what would happen. The results? In some cases, they were astounding. For some patients it was almost like a miracle. People who’d struggled with severe fatigue for years literally felt as if someone had plugged their body back into the mains circuit again. Patients who felt as if they’d tried everything to combat their fatigue suddenly had an explanation for the symptoms and a test demonstrating what was wrong; and they also had an effective strategy to correct it. It was almost like germ theory at its finest.

Unfortunately, although those miracle cases can still happen, and using appropriate raw ingredients to support mitochondrial function is still part of our wider approach for some patients, experience has shown us that it’s often not that simple.

Fueling the mitochondria with raw ingredients can be a bit like pouring more fuel into a faulty engine. We noticed that some people ended up with a lot more energy with which to return to their former life, but they eventually crashed again, this time more severely and further, therefore compounding the issue. Others found they were more wired with energy but were unable to sleep, and their other symptoms ended up worse rather than better.

Part of mitigating these issues was about dosing and going slowly with supplements. However, we also came to realize a much more important truth – in many cases, fatigue isn’t healed by treating the mitochondria directly. Mitochondrial malfunction may often be the culmination of the perfect storm of functional deficiencies and burdens further upstream. So, ultimately, to decode the puzzle of your fatigue, we need to trace a pathway backward from the mitochondria.

Indeed, as I reflect on that conversation with Niki in those early years of our work, I realize it was just as critical as I thought at the time, but for a different reason: by understanding the mechanisms of fatigue, we can better target everything else we’re doing at the clinic, and we understand on an even deeper level why our interventions work.

In fact, as you’ll discover in Chapter 5, there are a number of factors that affect mitochondrial function, and it’s by addressing and balancing these that your body is able to heal. And, as you’re about to discover, one of the most powerful ways of changing our mitochondria is shifting what’s happening in our nervous system.

You see, rather sneakily, in this chapter I haven’t mentioned another vital role of your mitochondria, which may well be the key to unlocking your healing. We’re going to explore how the mind–body connection has a direct impact on your energy production.





Chapter 4



HOW YOUR MIND AND EMOTIONS AFFECT FATIGUE


Nick was in his mid-thirties and had been a police officer since leaving school. It was a career he loved and his ambition had taken him a long way. In his most recent assignment, he’d undertaken the highest level of undercover work the police do, and he’d felt privileged and proud to be chosen.

Within a few months of Nick starting this two-year assignment, his sergeant had a stroke, a colleague was killed in the line of duty, and his closest police partner was diagnosed with a mental illness stemming from the problems and pressures of the job. However, Nick’s attitude to stress at the time was that ‘it was just being busy.’ He described the police force as an environment in which ‘you kick on, you kick through, and you maintain professionalism in your image.’

‘I wanted to maintain my part in it,’ he explained to me. ‘Selfish or not, there is this image that we cops want to keep, and mine was of this burly copper who ain’t going down, who isn’t going to show any emotion, and has to get on with it.’

For the duration of Nick’s undercover assignment there was no support for him and the difficult emotions he was experiencing – not only due to the loss of his colleagues but also the dangerous and intense work he was doing. Throughout the assignment, Nick had seemed fine, but within a month of completing it he started to develop symptoms of fatigue and muscle pains. Things went from bad to worse, and in time he was forced to stop working completely and was diagnosed with ME/CFS.

Nick then came across my first book, Why Me? My Journey From ME to Health and Happiness, and, inspired by my belief that it’s possible to recover, he came to see us at the OHC; he worked with me on the psychology side and with one of our nutritional therapists on the physical side. Nick had no lack of commitment and determination to get well but he was also honest about the fact he was deeply skeptical that talking about his thoughts and feelings would have any impact on his physical body.

As he sat on the train home from his first consultation with me, Nick decided the trip had been a waste of time. ‘At the time I wasn’t open enough,’ he later told me. ‘I wasn’t open to what I was being told and I probably wasn’t ready to receive and embrace it. I believed that if you got sick, you took a pill and you got better. I wanted the pill; I wanted the GP to say, “There is your ME pill. Swallow it and you’ll be all right on Monday.”’

However, Nick did follow to the letter the nutritional advice he was given, and he couldn’t deny that it had a fairly immediate and significant impact on his energy levels. Realizing that he needed more persuading about the role of psychology, I put him in touch with a former patient called Colin (whose story you’ll read in Chapter 8), who shared his experience of the direct and immediate impact of working with his psychology.

Nick returned to the clinic for further psychology sessions with a more curious attitude, and together we did some good work, following an early version of the approach you’re about to learn. Nick would later say, ‘I would never have spoken a few years ago about the connection between mind and body. This has been a massive transformation for me in many ways. The change has been internal rather than external. You have to get yourself in the environment internally and externally where you’re going to heal.’

Nick went on to make a full recovery and returned to his career with the police force, where he remains to this day. If Nick, a ‘burly copper who ain’t going down,’ can learn to understand his thoughts and feelings and work with them to support his healing, then I think it’s possible for anyone to do so.





The Role of Psychology


As I’d explained to Nick, there is an awkward truth with many chronic illnesses. Whether we like it or not, psychology plays a critical role in healing. I know this may not be what you want to hear, and I know that when the same was said to me it felt deeply offensive – the inference was that there was nothing wrong me and I was making up the hell I was living in. But if you can just hang in there with me, I want to make a few important points.

When we speak of the role of psychology, we’re not talking about fatigue being ‘in the mind.’ In fact, it’s quite the opposite – as we’ll get into – fatigue is very much in the body. When people think of something as being ‘in the mind,’ the inherent assumption is that it’s not real. An example of this is phantom limb pain – someone’s tragically lost a limb and yet they continue to experience pain in that limb, as if it still exists. As real as their pain might be, it’s in their mind (albeit unconsciously) not their body. As we saw in the previous section, the same cannot be said of fatigue.

Another perception of something being ‘in the mind’ is that it’s just a lack of motivation, a form of depression. The conclusion therefore is that if one can just ‘get motivated’ or ‘have something exciting to look forward to,’ then somehow the symptoms will abate. If only it were that simple.

Although depression is a real and difficult experience in itself, its fundamental biochemistry is very different from that of fatigue, as is the pathway to recovery.56–58 The felt experience of depression is that all we want to do is climb into bed and hide away from the world. With fatigue it’s the opposite – all we want to do is climb out of bed and come back into the world, but we simply don’t have the energy to do it.

Misdiagnosing fatigue as depression is a serious error. Whereas the research on depression clearly demonstrates that exercise and a certain level of social interaction are beneficial,59–62 the findings on fatigue are the direct opposite.63–66 I should also state that depression can sometimes be an inevitable consequence of suffering from fatigue; however, in that instance it’s a symptom of fatigue,67 not the cause of it.





The Origins of Mind–body Medicine


The fact that our mind affects our body isn’t a controversial one. Indeed, anyone who’s salivated in anticipation of a favorite meal (i.e. their body responds to the food before they’ve eaten it) will struggle to deny that what we think can make things happen in our body. However, the science of just how powerfully and deeply our mind and body are connected is only just getting started.

In 1986, a landmark study published by Dr. Janice Kiecolt-Glaser and her colleagues demonstrated the impact of stress on the immune system.68 The researcher team took blood samples from 34 medical students one month before their examinations and a second on the day of the exams. On exam day, there were significant declines in a number of measures, including the activity of natural killer (NK) cells, whose job it is to contain and help kill infections. Ultimately, stress led to a reduced ability to fight infections and a greater likelihood of becoming ill.

Another important paper, published in 2011, collated data from a number of studies over the years demonstrating the impact of psychological stress on wound healing.69 To quote the authors, ‘Psychological stress can have a substantial and clinically relevant effect on wound repair.’

The paper gives multiple examples of a number of different ways of assessing the impact of stress on wound healing, but I think one of the most interesting is the first study, conducted in 1995, which involved family caregivers to those suffering from dementia.70 The daily stress of living with loved ones’ loss of memory, inappropriate emotions, and wandering and restless behavior is considerable. Indeed, caregiving stress has been associated with heightened anxiety and depression, immune dysregulation, an increased risk for cardiovascular disorders, and even death.

A 3.5 mm punch biopsy wound was created on the nondominant forearm of 13 women who were caring for relatives with dementia and 13 non-caregiving controls who were similar in demographics and makeup. The researchers found that the wound took 24 percent longer to heal in the caregivers than in the controls. Put simply, stress slows down the body’s healing capacity.





How Stress Affects Energy Production


As I outlined at the start of this chapter, it’s very common to feel both cynical about and resistant to the idea that psychology plays an important role in fatigue. And yet, as we’ve been exploring, there is undeniable evidence that our mind has an impact on our body. But the relationship between stress and energy isn’t only an indirect one; in fact, stress directly impacts our energy production.

Back in 2008, we had a patient called Louise who lived in Singapore and was suffering from quite severe ME/CFS. Keen to make progress as quickly as possible, she was working with our nutrition and psychology teams in tandem.

To help us get as deep an understanding as possible of what was going on for Louise, we decided to do mitochondrial testing to explore how well her body was producing and recycling energy on a cellular level. However, the only lab offering this at the time was based in London, so there were some logistical challenges, to say the least, in getting samples halfway across the world before they degraded.

At one point it appeared that Louise’s samples had been lost in the mail, and so she focused on working with our psychology team to calm her nervous system and cultivate a healing state in her body. As a result of various delays, including Louise’s family holidays, it was three months before we could arrange for a replacement test kit to be sent to Singapore, the samples returned, and the results analyzed.

We then discovered that Louise’s original test kit had been analyzed and it was the results that had been misplaced. So we found ourselves with two test results, with the only intervention between them being a strong focus on our psychology approach.

The results were pretty astounding. There’d been a dramatic improvement in Louise’s mitochondrial function, and, given that she’d been ill for several years without improvement, this was unlikely to be a coincidence. Calming her nervous system had directly impacted her mitochondrial function.





Cell Danger Response


At the clinic we’d become used to seeing a patient’s energy transformed as a result of calming their nervous system; however, it would be another decade before I came across the science that truly explained cases such as Louise’s. Put another way – we knew what we did worked but this finding could finally explain the actual biology.

Dr. Robert Naviaux is a professor in residence at the University of California in San Diego, and at the heart of his work is the idea that the human body is a highly intelligent system that’s evolved through millennia to protect its own survival under stress. His theory is called cell danger response (CDR), and it explains how our cells act differently when we’re under extreme and prolonged stress.71, 72

Dr. Naviaux says that: ‘The cell danger response (CDR) is the evolutionarily conserved metabolic response that protects cells and hosts from harm. It’s triggered by encounters with chemical, physical, or biological threats that exceed the cellular capacity for homeostasis [the process by which biological systems maintain an internal stability that persists despite conditions in the world outside]’.71

Later, we’ll get much more into the concept of stress, and how suffering from fatigue is in itself a trigger for stress, as well as a consequence of it, but first, I want to explore further the impact of stress on our actual cellular energy production.

When we talked about mitochondria in the last chapter, I didn’t tell you the whole story. While our mitochondria are the powerhouses of our cellular energy production, they also have a second, equally important, job – danger signaling. They are the body’s equivalent of the canary in the coalmine.

Coal miners face many dangers, one of which is the risk of death from gases such as methane and carbon dioxide. In the old days, miners would take a canary in a cage down with them to provide an early warning mechanism. If there were dangerous levels of these colorless, odorless gases in the mine, the canary would fall unconscious, signaling to the miners that they needed to get out of the mine immediately. Indeed, my paternal grandfather was a coal miner, so I may well owe my very existence to the effectiveness of those canaries and their early warning system.

Our mitochondria have the same function in our body. Because their metabolism is so fast, they are the first to sense danger or toxicity; in fact, although inside the cell the focus of the mitochondria is their work as an energy carrier metabolism, outside the cell they have a completely different role as a signaling molecule that warns neighboring cells if there is stress in the environment.

But here’s the really important thing: when the cell danger response (CDR) is activated, the mitochondria switch their priorities. They de-prioritize energy production in order to free up resources to prioritize danger signaling.73 Put simply, when your body’s under stress, you make less energy so your body can protect itself.

For the first time, thanks to Dr. Naviaux’s emerging paradigm-shifting work, we can explain a great many cases like Louise’s. When we calm the nervous system, the body enters a healing state and can re-prioritize energy production. In other words, when your body is calmer, you get more energy.

In Parts II and III of the book, we’re going to get much further into what causes stress in the nervous system, and how to cultivate a healing state. But for now, it’s critical you understand that the mind–body connection isn’t just some theory – it’s a very real factor in decoding and healing your fatigue.

So, now that we’ve explored how your body creates energy and the critical role of mind–body medicine, we have enough of the foundations to get into the model of fatigue I’ve spent the last quarter of a century creating.





Chapter 5



A NEW MODEL FOR UNDERSTANDING FATIGUE


I remember the feeling as if it happened yesterday… I was eight years old and standing at the counter of a hiking shop, about to buy a compass. It felt just like Christmas morning, and I was full of anticipation and excitement.

My mother had recently remarried, and my stepfather loved walking. I’d not had a father figure for the previous seven years, so that meant I too loved walking and everything that went with it. I’d been saving up my pocket money for months to buy this compass: a seemingly magical device that would reliably show the way.

This was the late 1980s – long before a compass became just one of thousands of apps we have at our disposal, let alone Google maps, making such a tool seem utterly primitive. When I got home, the first thing I did was pull out the map of our local area from my stepfather’s cherished map collection. With a little bit of guidance, I could now direct myself around the neighborhood with confidence. In fact, as long as I had my compass and the correct map, I could navigate anywhere.

A decade or so later – soon after that fateful conversation with my uncle – I found myself thinking about that compass and those maps. Here I was on the most challenging voyage of my life, and I had no map and no compass. Motivation and discipline alone were not enough – if I was going to have any chance of escaping my illness, I needed a map.





Mapping Your Fatigue


Much of the next seven years of my life was about creating my own map of fatigue, through a painful and frustrating process of trial and error. Each twist and turn had its own story, and its own painful experience, that helped me navigate it better next time around.

Sitting here writing this book, several more decades later, I’m immensely proud of the map that’s been created through my own experiences of fatigue and those of the tens of thousands of people we’ve supported at the OHC.

But it’s been far from an easy process. We’re enormously indebted to all the patients we’ve worked with over the years at the OHC, each of whom, in their own way, has helped us to confirm elements of the map – or indeed to discover its limitations – and day by day, patient by patient, it has evolved and improved.

As we explore the fatigue map together, I guarantee that you’ll find limitations and places where it doesn’t match your own experience. This is partly because the map is imperfect and partly because for the sake of brevity, I’ve had to shorten it drastically in places. Indeed, the value of a map lies in its ability to simplify something complicated to help us navigate more efficiently – by definition, nuances and details are left out, and there are always exceptions to every rule.

That said, I’ve yet to meet a patient for whom at least some elements of this map were not immensely useful in decoding their fatigue, and for many people it’s like going from seeing the world in black and white to seeing it in color for the first time.

In this chapter, my aim is to introduce you to the fatigue map – which we use every day in the clinic and with every client. It has two parts: map 1, which helps us understand how you got ill in the first place, and map 2, which helps us understand the key stages of your path to recovery.





Fatigue Map 1: Understanding How You’ve Become Fatigued


Let’s start by briefly exploring map 1. As we’ve discussed, your fatigue is multifaceted and is impacted by a number of factors. You have your underlying genetics, which create certain vulnerabilities; you then have your personality and the way you approach your life; and on top of this, you have the various loads, or traumas, that have impacted you in your lifetime.

These factors, together, result in various impacts on certain systems in your body; here’s what this looks like:


Genetics + Personality Patterns × Loads

= Impact on bodily systems

To understand this further, let’s explore each of the factors in a little more detail.





Genetics


There is a question I’m asked regularly: ‘Is fatigue genetic?’ In essence, this means, was my fatigue predetermined by my genes? Was it always going to happen? Well, the level of genetic causation of fatigue in its various forms hasn’t been widely studied – just one frustrating example of how fatigue-related conditions have been a casualty of a major lack of funding.

The data we do have suggests that there may well be a modest genetic component. For example, one study found that the estimated genetic impact was more than doubled for identical twins (with identical genetics) than with non-identical twins (who are no more related than other siblings). Put another way, if your identical twin has ME/CFS your chance of developing it is twice as high.74

Another study, looking at genes in ME/CFS, found 10 relatively common genes, or gene variants, that were significantly more common in people diagnosed with ME/CFS.75 We could, therefore, easily just assume that fatigue is genetic, and that there is nothing we can do about it. However, if that were the case, there wouldn’t be much point in you reading this book, and the OHC approach wouldn’t have helped so many people over the years.

So we need to ask ourselves a more fundamentally important question: can our genes be turned ‘on’ and ‘off’? You see, having a genetic predisposition to a disease or a condition only becomes a problem if those genes are activated. As an attempt to answer this question, I think an ongoing study by my friend Dr. Kara Fitzgerald is of particular interest.

Kara and her team were looking at DNA methylation. Without getting too scientific, DNA methylation is a process by which we can change the activity of a DNA segment without changing the sequence.76 Put another way: they were looking at turning genes on and off!

In the study, participants implemented a series of basic lifestyle changes – including meditation, exercise, and dietary interventions – alongside using specific nutrients known to affect methylation. The finding? After eight weeks, participants who made these changes were measured as being biologically over three years younger. Yes, you read that correctly – eight weeks of lifestyle changes had added over three years to their lives.76

The implications of this finding for our health, and specifically our fatigue, is pretty exciting; however, although I think there is some interesting research on its way in the coming years that’ll identify the genes that are particularly relevant in fatigue, this will never be the full picture. The way that we live and what happens to us in our lifetimes has a far bigger role to play.





Personality Patterns


Remember our friend Louis Pasteur, the creator of germ theory? Pasteur’s entire career was built on the idea that external agents invade our system and make us sick. Well, on his deathbed he purportedly confessed: ‘The microbe is nothing, the terrain is everything.’

What Pasteur meant by this is that the presence of the microbe (pathogen) itself is not the defining factor in someone becoming sick – it’s more the health of the environment in which the microbe exists. This is why you can expose 10 people to the common cold and perhaps only one individual will catch it. Indeed, every one of us is exposed to countless germs every day but we all know that it’s when we’re already run-down that we tend to get sick.

What determines the health of the terrain of our body? Well, there are many factors, and we’re going to explore them together. But, as we discussed in the last chapter, the state of your nervous system has a direct impact on your mitochondrial function and energy production. And although I’d pretty much fight to the death to defend the argument that fatigue isn’t psychological in origin, the way that we live our life has an enormous impact on the health of the terrain of our body.

Indeed, over the years at the OHC we’ve discovered five key personality patterns that we believe significantly increase the likelihood of developing fatigue. These patterns, which we call ‘energy depleting psychologies,’ are ways of living our life that are inherently draining and will affect the very terrain in which our cells live. In the next chapter, we’re going to explore each of these patterns in detail.





Loads


So, we have our genetic predisposition and we have our personality patterns, but how about the things that happen to us during our lives? Loads represent the many external burdens and events that overload an individual in the years leading up to their becoming fatigued.

As we’ve touched on, fatigue is almost never caused by one single factor. If a single and acute stress is placed on our system, the chances are that within a relatively short period of time we’ll bounce back and recover. If we suffer from ongoing fatigue, it’s almost certainly because a series of burdens has been placed on our body over a sustained period of time.

The analogy we use for this is loads on a boat. No one single load on the boat causes it to sink but too many loads, including too many small loads, have a cumulative effect. As the saying goes, ‘It’s the final straw that breaks the camel’s back.’

These loads are any kind of external burden that’s placed on us in our lives. Some may stem from childhood, while others may be more recent. Some may have been a one-off, but others may have been ongoing for many years. Furthermore, loads can be psycho-emotional in origin, such as a divorce or financial stress, or physiological, such as exposure to toxic mold or being bitten by a tick and exposed to Lyme disease.

To decode your fatigue, we need to figure out each of those loads and remove them where possible. Ultimately, for healing to happen, we need to create an environment where these burdens on your body are removed. And that’s exactly what we’ll be exploring in Chapter 7.





Bodily Systems


Your body consists of a number of interlinked systems, each of which has a purpose in its functioning and survival. When these systems aren’t working optimally, your health and vitality are immediately affected; examples of bodily systems are your respiratory system, reproductive system, and skeletal system.

Although any of these systems can be impacted by fatigue, our experience is that the nervous system, digestive system, endocrine system, and immune system in particular are affected. Indeed, in Part II, once we’ve explored your personality patterns and loads, we’ll be looking at how each of these bodily systems is related to your fatigue.

It’s also worth noting that multiple bodily systems are usually affected, and they’re also impacting each other. For example, if your digestive system isn’t working correctly, this may result in hormonal imbalances in your endocrine system, and so perhaps your nervous system will also end up out of balance. Furthermore, they’re not discrete systems and they interrelate closely with each other as part of a whole.

Here’s a reminder of the formula for map 1, which I hope now makes a little more sense:


Genetics + Personality Patterns × Loads

= Impact on Bodily Systems

Put another way, your genetics and your personality patterns load the gun and the final loads pull the trigger, resulting in the impact on your bodily systems.

Now, this is likely a lot to take in at this point, and please be assured that we’ll get into it in a lot more detail in the coming chapters. To bring it alive a little right now, let’s revisit the story of Nick the police officer from the last chapter.

Nick may well have had some sort of genetic impact; indeed, this is why he developed chronic fatigue syndrome instead of heart disease, like his colleague. We can then add to this his personality patterns: he was intensely driven by nature; he felt the need to control himself and everything around him; and he was an absolute perfectionist.

On a physiological level, there’d also been a load in the form of a virus, and the series of stressful events at work resulted in a number of significant loads. This all impacted several of Nick’s bodily systems, including his digestive, immune, and endocrine systems, and as result, he ultimately developed CFS. In the coming chapters, as we decode your fatigue together, we’ll explore how these factors might have come together for you.





Fatigue Map 2: Your Path to Recovery


Now that we’ve briefly explored map 1, which helps us decode how you became ill, I now want to introduce map 2, the purpose of which is to support your recovery journey. The formula for this map is as follows:


State + Stages × Sequence

= Healing Impact on Bodily Systems

As before, let’s go through each of these factors briefly; we’ll look at them in a lot more detail in Part III, as we work together to craft your recovery plan.





State


In order for your body to heal, it has to be in a healing state. Even if you weren’t in a state of heightened stress and anxiety before you became fatigued, when you’re constantly struggling with your energy, your body tends to go into the exact opposite state it needs to be in to heal. And, as we explored in the previous chapter, this has a direct impact on your energy production.

Furthermore, when your energy resources are depleted, the things that were previously not stressful start to become much more so. And you start to live with an ongoing anxiety about how you feel each day – should you rest, should you push through, will you ever feel normal again?

I think an important point to bear in mind is that the body has a powerful and innate capacity for healing. If we cut ourselves, as long as we keep the wound clean and the skin is held together, it will heal. If we break a bone, as long as the bone is set correctly, it won’t just mend, the stronger part of the bone will be the location of the break.

In neither of these cases is the source of the injury important – the body has an innate drive and capacity toward healing. When healing doesn’t happen, there is a more important question to ask ourselves – what’s stopping us from healing? Well, there are a number of factors, and we’re exploring them in this book, but before anything else can be effective, the body has to be in a healing state.





Stages


Have you ever wondered why you can try an intervention at one point in your recovery process and it seems to make your symptoms worse but that same intervention tried at a later stage seems to help significantly? Or vice versa – something that made you feel better earlier now makes you feel worse. This was a phenomenon that caused us significant confusion for many years, until one day I had an epiphany and realized that there are three different stages to the recovery process.

Understanding which of these stages we’re at is critical for knowing how much activity we should or shouldn’t be doing, as well as knowing which interventions are likely to help and which are likely to make things worse. In Chapter 14 we’ll get into these three stages of recovery in detail, and we’ll use them to help you listen to your body and figure out your activity levels.





Sequence


Understanding the stages of recovery doesn’t only help us navigate how much activity we should be doing, it does something equally important: it helps us sequence the order in which we use various interventions. You see, different factors are important at different stages. Treatments that might be highly effective at one stage can be seriously harmful at another stage.

As true as the phrase ‘One person’s medicine is another person’s poison’ might be, when we start to understand the stages of recovery we also realize that ‘One person’s medicine at stage 3 of recovery might be the same person’s poison at stage 1.’

Sequencing can happen on multiple levels, from the macro of our activity levels and in which order to focus on different therapeutic approaches, to the micro of introducing supplements and dosing.

At this point, the key thing to realize is this: knowing something’s good for you isn’t enough to tell you when it’s good for you. Being aware of that alone will be helpful, and we’ll come back to this point a number of times within this book.





Bringing it All Together


When it comes to recovering from fatigue, it’s critical that we bring each of these ingredients together. Until your body is in a healing state, the risk is that nothing else you do is going to be truly effective. We also have to identify which stage of recovery you’re at, so we know how much activity you should or shouldn’t be doing, and we have to work with your body rather than against it for this to be effective.

Once we’ve established which recovery stage you’re at, we need to sequence the right interventions in the right order. If we get this wrong, you could be doing exactly the right things at the wrong time and the effect will be negative.

I know this might all sound rather complex, but the purpose of Parts II and III of this book is to help you understand it in more detail and also to map it to your lived experience, so we can work together to decode your fatigue and create your path to recovery.

So, now you’ve been introduced to the core principles behind the two maps we’re going to use to decode your fatigue, it’s time to get into them in more detail. Let’s start with your personality patterns.





Chapter 6



THE PERSONALITY OF FATIGUE


Claire Jones has loved music since she was a little girl. She started out playing the piano and violin but at the age of 10 she heard a musician play the harp and was spellbound. She begged her parents for lessons and, keen to harness such intense passion in one so young, they found her a teacher; three weeks later, she started to learn the harp.

Throughout her teenage years, Claire practiced the harp for hours every day. She gained a place at the Royal College of Music in London, and she performed for anyone and everyone at any opportunity. Playing the harp wasn’t just a hobby for Claire – it was her great love.

However, it wasn’t until she was 15 that Claire realized what her real dream was. In 2000, Prince Charles, heir apparent to the British throne, restored a position that hadn’t been held since 1871 – there would once again be an ‘Official Harpist to HRH The Prince of Wales.’ The holder of this position would perform on a £150,000 gold-leaf harp made by the famous Italian harp maker Victor Salvi.

In the harp world, there was no greater prize for an aspiring harpist than to play for British royalty. With her heart and mind set on achieving her goal, for the next seven years Claire continued to give everything to the harp. And at the age of 22, she achieved her childhood dream and became Prince Charles’s Official Harpist.

For the four years that Claire held the position, she performed for the Royal Family more than 180 times, including at the wedding of Prince William and Kate Middleton. She also released several very successful albums, including The Girl with the Golden Harp. Alongside her hectic performing and recording schedule, Claire also took her role as an ambassador for the harp very seriously: she regularly visited schools, helped and guided aspiring harpists, and did all she could to support the next generation of harpists.

To the outside world, Claire had a perfect life. However, the lived reality wasn’t quite as it seemed, and her relentless schedule took its toll on her body. Due to being so busy she’d skip meals, she lived in a constant state of stress and anxiety between performances, and there were never enough hours in any given day.

Soon after playing at the Royal Wedding, Claire started to develop debilitating flu-like symptoms and would sometimes need days in bed to recover after performing. In the wake of a particularly demanding tour of the USA, her symptoms became so severe, and she was in so much pain, she could barely climb stairs. And it wasn’t just any pain – it was so crippling that no painkiller could touch it.

Claire’s symptoms became so concerning that her husband took her to a hospital emergency department, where she promptly collapsed and had a seizure in the corridor. Eventually, she was diagnosed with ME/CFS