Motivation and emotion/Book/2022/Fatigue and emotion

Overview
So, how can the draining effects of a hard day of work be erased after a productive session of physical exercise or a good night’s sleep, when a normal day of work during a stressful period can leave us completely drained, and doing physical exercise only seems to worsen this feeling? Fatigue can be the underlying process that, despite our best attempts to combat, prevents us from feeling refreshed. So what can be done to counteract these effects if not sleep alone? This book chapter discusses what fatigue and emotion are, how fatigue affects our emotions, and what can be done about the negative effects.

Focus questions:
 * What is fatigue?
 * How does fatigue effect our emotions?
 * How can we reduce fatigue's negative effects?

Fatigue
Fatigue is a multidimensional concept that presents in various forms effecting motivation, cognition, emotion, and your physical and mental state (Billones et al., 2021). It is something everyone will experience through different times in their life and can present as a low mood, unfocused mental state, or an undesirable bodily state despite efforts to prevent these with sleep or physical exercise (Hockey, 2013). A low mood can feel like extreme tiredness or lethargy (Hockey, 2013). An unfocused mental state includes being constantly distracted, irritable and generally uncomfortable (Hockey, 2013). An unpleasant bodily state entails headaches, and tight and painful muscles and joints (Hockey, 2013). Whilst fatigue does not have its own in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013), it generally features as a symptom of most disorders. In addition, it is a symptom that can increase the severity of illnesses like depression as well as sleep impairments, and cognitive dysfunction (Kinsinger et al., 2010).

The work-fatigue hypothesis
Besides fatigue being a general symptom or side effect of illnesses, there is a dominant hypothesis that predicts the development of fatigue using motivation as the basic determinant called the work-fatigue hypothesis. The work-fatigue hypothesis states that fatigue is the direct consequence of work, which in turn decreases job performance (Hockey, 2013). There are several key concepts that affect this hypothesis which include the intensity, meaning, and variety of the work (Hockey, 2013).

Table 1

The three concepts relating to the work-fatigue hypothesis

Putting this theory together, it makes sense that when there is low variety to the work undertaken, little to no meaning in it, and the intensity can become greater than what can be handled, the motivation of a worker would greatly reduce leading to fatigue.

Motivational control theory of fatigue
Robert Hockey (2013) developed a theory that explains why we develop fatigue and what it means for us through a motivational control framework. The theory explains that fatigue is not necessarily a negative function as it is the body’s way of telling us that the tasks we are completing do not provide enough utility, and that we need to refocus our priorities to goals or tasks that provide us with better extrinsic or intrinsic rewards which may also be completed with lower costs to effort (Hockey, 2013). This is consistent with the work-fatigue hypothesis as to prevent fatigue it states that work needs to be of appropriate intensity, meaning, and variety, and that if we cannot change these things or work priorities when they are not being satisfied, fatigue will occur. Figure 1 shows the framework developed by Robert Hockey to explain that when we develop a primary goal and work on it, fatigue can be a product of excessive effort, and potentially low variety to tasks undertaken.

Types of fatigue


According to the DSM-5 there are two types of fatigue which include physical and mental fatigue. Physical fatigue impacts daily function, not allowing an individual to function how they normally would which becomes more obvious during exercise where they become more tired instead of energised (American Psychiatric Association, 2013). Mental fatigue is defined to often present as somnolence which is a state of extreme tiredness where an individual has a strong need to sleep, or will sleep for abnormally long periods (American Psychiatric Association, 2013).

Emotion
Emotion is not a term that has been universally defined in the realm of psychology and tends to be viewed as a list containing emotions such as anger, sadness, and disgust (Cabanac, 2002). However, a general encompassing definition is that emotion is a mental state that causes physiological arousal, and cognition that reflects this arousal (Cabanac, 2002).

Case study: Ryan is a 34-year-old male working in an office job that processes incoming shipments to a port on the west coast of Australia. Everyday Ryan feels he is processing the same boring shipments, and feels there is no challenge to the work he does, he is essentially bored, however the shipments do not stop, and he must work tirelessly. He does not feel much attachment to his job, and he does not feel like there is much meaning, anyone could do his job. He does not see the effects it has on the real world; he does not see the important pieces of technology or food containers that will influence someone’s life. After months of these feelings, his job production begins to decrease, and he feels more neurotic each day at work and stops having enjoyable conversations with his colleagues. Throughout the day he feels tired, and believes that no amount of sleep will make him feel energised or excited to start his day. Ryan is currently experiencing fatigue, and on this trajectory he will experience emotional exhaustion. This case study highlights how fatigue and emotional exhaustion can begin to develop and effect someone. The case study is applicable to various workplaces where the roles people have are repetitive, of high workload, but offer little challenge and no sense of purpose, showing how common it is for fatigue to creep into peoples lives.

What are the effects of fatigue on people and emotion?
Fatigue has many effects on emotions, which include emotional exhaustion, issues with how we process emotional information, how empathetic we are, and how we regulate our emotions.

Emotional exhaustion
Emotional exhaustion describes an individual who has had their emotional resources completely depleted or drained (Zapf, 2002), resulting in feeling that they have lost all their energy which can be manifested by fatigue (Zoharm 1997). Emotional exhaustion is a term that is generally applied to a worker, and they will exhibit several symptoms with fatigue being the greatest, other symptoms include feeling like they have no energy, feeling frustrated with their work, and feeling that they are working too hard which is similar to the intensity aspect of the work-fatigue hypothesis (Brady et al., 2020).

Emotional exhaustion can be thought of as a concept very similar to fatigue, but there is a big emphasis also placed on the negative emotions associated which typically include feeling frustrated towards their work or co-workers (West et al., 2012). Furthermore, when someone is heavily tired which represents the fatigue aspect of emotional exhaustion, people are more likely to feel less optimistic, and experience amplified pain and negative moods such as anger, depression, and fear (Haack & Mullington, 2005).

What further supports the integral role that fatigue has on emotional exhaustion is a study by Michielsen et al. (2003) which found after a study using 325 Dutch working class people, that general fatigue and emotional exhaustion were highly correlated when workload stressors began to amount for participants.

Maslach Burnout Inventory Manual
The Maslach Burnout Inventory (MBI) Manual developed in 1997 contains a measure for burnout which is constructed by 22 items spread across three core concepts of emotional exhaustion, depersonalisation, and personal accomplishment (Maslach et al., 1997). There are nine items which can be used to assess emotional exhaustion and they relate to feelings of being exhausted by one’s work, and being emotionally overextended (West et al., 2012). This then suggests that we can become emotionally exhausted when these two feelings being to appear. This relates to the work-fatigue hypothesis as the intensity aspect is similar which further suggests that these issues of fatigue and emotional exhaustion begin to occur when our work becomes overpowering, with too many things to complete.

Sleep deprivation studies
Another way to study the effect that fatigue has on emotion is to look at sleep deprivation studies as they investigate how fatigue and extreme tiredness effect our emotions and cognitions. And whilst it should be noted that sleep deprivation does not necessarily lead to fatigue, it does share symptoms of fatigue such as having a strong urge to sleep, as well as being a cause of fatigue (Hanson & Huecker, 2019), so it is reasonable to assume that the effects sleep deprivation has on emotion can be applied to those who are fatigued.

A study by Van Der Helm et al. (2010) used an emotional face recognition test to investigate how sleep deprived participants recognised the intensity of the emotions of sad, happy, and angry, in 37 participants. They found that sleep deprivation impairs the participants ability to recognise facial emotions, particularly angry and happy emotions which shows fatigues effect on disrupting the recognition of other people’s emotions from face value (Van Der Helm, 2010). This phenomenon has been recorded through other studies, one study even demonstrated through a group of 37 participants, that when they were sleep deprived, they were much less emotionally empathetic towards people compared to those who were not sleep deprived (Killgore, 2010). This further highlights that fatigue plays a role in disrupting emotional information, as well as alluding that it also effects how empathetic we are to others (Guadagni et al., 2014).

Other effects fatigue has on our emotions is that not only does it interrupt with processing emotional information, but it can also lead to impairments in emotional regulation (Grillon et al., 2015). Grillon et al. (2015) found that mental fatigue impaired emotional regulation following a cognitive task. It should be noted that this is the first time a study has attempted to make the connection between mental fatigue and emotional regulation, and there has been very little subsequent research to confirm this link so the reliability is hindered until further studies can build upon this research (Grillon et al., 2015).

Consolidation of information quiz
{Michielsen et al. (2003) found fatigue and emotional exhaustion are highly correlated : + True - False
 * type="(+)"}

{The MBI Manual has how many items? - 19 + 22 - 24
 * type="(+)"}

{Does emotional regulation improve with fatigue? + No - Yes - Maybe
 * type="(+)"}

How can we reduce fatigue's effects on emotion?
To prevent or deal with the effects that fatigue has on emotion, the cause of fatigue first needs to be investigated so it can be treated to prevent fatigue or reduce it from occurring. Several causes of fatigue have already been explored including the work-fatigue hypothesis, and as a symptom of a disorder. This section examines how to reduce general fatigue as this will prevent the effects that it can have on emotion. Much of the research that will be discussed will be targeted at reducing chronic fatigue, and whilst this is not the exact same as fatigue in general, it is reasonable to assume that due to the similarity, the research can be generalised to fatigue in general. For chronic fatigue, two different approaches have been identified as potential viable treatments to reduce the effects, these include, cognitive behavioural therapy (CBT), and traditional Chinese medicines (TCM), and for fatigue that occurs as a side effect of illness, methylphenidate will be discussed.

Cognitive behavioural therapy


CBT is a type of therapy that is beginning to find efficacious results in supporting those with chronic fatigue (Price et al., 2008). CBT generally involves various things such as cognitive restructuring and psychoeducation which aim to change thought patterns that may be maladaptive or faulty into more adaptive and useful patterns, to positively influence behaviour (Otte, 2011). A meta-analysis by Price et al. (2008) investigated multiple therapies through 15 different studies with a total of 1043 people with chronic fatigue. They found that CBT, compared to other psychological therapies which included counselling, education, and relaxation, was more favourable in reducing fatigue, this also extended to follow-ups, although the studies used included different follow-up times which ranged from one to seven months (Price et al., 2008).

A study by Stulemeijer et al. (2004) looked at using CBT to reduce fatigue symptoms of 62 adolescents, 29 of which were in the therapy group, and the remaining 33 were in the waiting list. The results indicated a significant reduction in fatigue severity, with a further significant increase in school attendance (Stulemeijer et al., 2004). Whilst the sample size was very small, weakening the generalisability, it does suggest that productivity increases when fatigue decreases which is supported by the work-fatigue hypothesis.

A further study that supports the idea that CBT reduces fatigue is a study by Deale et al. (1997) which through a randomised controlled trial with 60 patients with chronic fatigue, found that fatigue was reduced. The trial contained a follow-up, and 37 of the 53 participants who received treatment had achieved good outcomes which meant a substantial improvement in physical functioning (Deale et al., 1997). Whilst again, the sample size was small, the results are supported by other studies showing a strong reliability that CBT reduces fatigue.

Traditional Chinese medicine


Another treatment for fatigue that may appeal to individuals who do not prefer mainstream western medicine, is TCM which could come in the form of herbal medicine, acupuncture, acupoint application, moxibustion (burning mugwort), and qigong (martial arts).

A study by Wang et al. (2014) investigated the effects of TCM on fatigue through 23 randomised control trials containing 1776 participants. The types of TCM used were the ones previously listed, and it was found that several studies and meta-analyses stated that TCM had statistically significant effects on reducing fatigue severity (Wang et al., 2014). However, the researchers noted that there was a high likelihood of bias for a lot of the studies used, so the results do not have a high generalisability (Wang et al., 2014).

Another study by Zhang et al. (2019) investigated specifically acupuncture and Chinese herbal medicine through 16 studies equating to 1346 participants. They found that acupuncture had the largest effect on reducing fatigue, however, the studies used had low quality, limited data, and it was suggested that for some studies the effect size was exaggerated (Zhang et al., 2019). Whilst TCM presents as a new application to treat fatigue, further rigorous data needs to be conducted before it can be confidently assumed that TCM significantly reduces fatigue.

Methylphenidate
Exploring all illnesses that cause fatigue as a symptom is impractical, as such, this section will investigate the use of methylphenidate for reducing fatigue in people with cancer and depression. Fatigue is the most common symptom for cancer patients (Yennurajalingam & Bruera, 2014), and is regarded as a common symptom of depression (Fuhrer & Wessely, 1995). Methylphenidate is typically a psychostimulant used to effectively treat attention-deficit/hyperactive disorder (Faraone, 2018), but its effects on fatigue are starting to be studied as a potential treatment option for those with either cancer or depression.

A meta-analysis conducted by Minton et al. (2008) investigated the effects of methylphenidate on cancer related fatigue using over 27 trials, with a total of 6746 participants. They found that methylphenidate had a statistically significant effect in reducing fatigue for cancer patients, strengthening the reliability of the overall findings that methylphenidate reduces cancer induced fatigue (Minton et al., 2008).

A further study that supports these findings is a meta-analysis by Gong et al. (2014) who found through investigating five randomised controlled trials on 498 patients with cancer where methylphenidate was administered to treat fatigue and depressive symptoms, prolonged use of methylphenidate had a statistically significant result on reducing fatigue and depressive symptoms. However, side effects were present for the methylphenidate group which included vertigo, appetite loss, anxiety, and nausea, which depending on the severity, may not outweigh the benefits (Gong et al., 2014).

Another study by Susan Hardy (2009) conducted 19 controlled trials administering methylphenidate to medically ill older adults, and found that methylphenidate reduced depressive symptoms, fatigue, and apathy. However, the study does explain that due to the small sample size, and poor methodological quality, strong inferences cannot be appropriately drawn (Hardy, 2009). This study optimises the majority of research on methods to reduce fatigue as there is much more research that needs to be conducted using rigorous scientific methods, however, the results of these mentioned studies still show a positive outlook on the use of methylphenidate, CBT, and TCM.

Quiz
{Price et al. (2008) found counselling to be as effective as CBT in reducing fatigue: - True + False
 * type="(+)"}

{Fatigue has one primary cause: - True + False
 * type="(+)"}

{Which treatments might work for you? + CBT + TCM + Psychostimulants
 * type="[+]"}

Conclusion
This chapter has explored what fatigue and emotion means, and from the case study, how relatable it can be to experience fatigue in workplaces. Emotional exhaustion has been investigated as the main effect that fatigue has on emotion, with other effects relating to emotional processing. Finally, this chapter explored various ways to reduce fatigue as a way of stopping its effects on emotion. These treatments include methylphenidate for those where fatigue is a symptom of either cancer or depression, and CBT and TCM for general fatigue. The important thing to take from this is that fatigue can cause some detrimental effects to our emotion and wellbeing, particularly in workplaces (Michielsen, 2003), and whilst the research to reduce fatigue is reasonably new and underdeveloped, there is a positive outlook for the development of particularly CBT and methylphenidate to reduce fatigue. Future research should look to strengthen the reliability of using CBT, TCM, and methylphenidate in treating fatigue.