The Fatigue Spectrum in Chronic Stress and Trauma

Chronic stress, posttraumatic stress disorder (PTSD), and burnout don't just stay in the head. At some point, the overloaded body systems stop working, and that manifests as fatigue. Eventually, you end up in a state of chronic fatigue.

At the low end of the scale, it's easy to ignore; you wake up tired after a full night's sleep. A bit further down the scale is burnout, or what Sweden calls exhaustion disorder (Eskilsson et al., 2017). Then, at the far end of the scale, you have a medical diagnosis of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS).

Stress and the Body

People with PTSD have significantly raised levels of inflammatory mediators (Passos et al., 2015), and inflammation in itself is linked to fatigue (Cho et al., 2013). Both childhood trauma and PTSD are associated with a greatly increased risk of CFS (Dansie et al., 2012; Heim et al., 2009). ME/CFS is a biological illness rather than a psychological one (Centers for Disease Control and Prevention, n.d.). The systems aren't separate, of course, and a body that's been under chronic stress for years may have very few reserves left to recover.

People with ME/CFS and long COVID will refer to what happens when you do too much as a "crash." The medical term is post-exertional malaise (PEM), and it can occur days later. In one survey of people with ME/CFS, 90 percent reported experiencing PEM following both mental and emotional exertion (Chu et al., 2018). Burnout isn't ME/CFS in another guise, but anyone who's been running on depleted reserves for years will have felt that delayed bill. That's the approach I'm taking, not the diagnosis.

Three Tiers of Sustainability

An Individualized Sustainability Plan (ISP) in the ETI approach is built on three levels of activity:

1. Enjoyment is the "right now" stuff—what just feels good.
2. Self-care is also enjoyable and provides consistency (sleep, food, movement, people, time in nature).
3. Sustainability is the level of contemplation; it's about observing what works, what doesn't, and why.

The tiers aren't a hierarchy; all of them are absolutely essential. The issue is that people keep lumping them together, and that confusion often causes pacing to fall apart. Pacing is present in all of the tiers, as we don't just use our energy in one way.

Pacing the Whole Person

Chronic stress will always take away enjoyment first, viewing it as the "optional" one. It isn't. A nervous system that has never known pleasure doesn't know what safety is. What was once restorative can quietly become depleting—like a long phone call with a loved one, where you absorb their pain alongside your own. Emotional pacing in this scenario doesn't mean less joy; it means your joy comes in measured doses the system can cope with.

Self-care is where the push-and-crash cycle does the most damage. You decide to walk every day, cook properly, and get to bed at a reasonable time. Then you have a bad week, and the whole thing comes crashing down because you've built it for your best days. Physical pacing is very much in the long COVID camp. You work out what you can do on a fairly normal, slightly tough day, then build up slowly from there without fixed increases. A five-minute-a-day routine can survive a crash week. An hour-a-day routine often cannot.

Cognitive load is also part of self-care. Chronic stress constricts your attention and depletes your working memory, so every decision costs you. Writing things down so your memory doesn't have to carry them is self-care. So is making a decision once, rather than every morning, and reserving your clearest hours for the most demanding thinking.

Social pacing is easy to ignore. NICE gives it a name for a reason (National Institute for Health and Care Excellence, 2021). Being around people drains energy, even if you want to be there. The parents of a child with a chronic illness spend hours explaining the illness to people who are genuinely well-meaning and who still end up asking the completely wrong questions. Pacing in this context might mean leaving the party while you still have enough energy to get home, without having to explain yourself to anyone.

And then there's spiritual pacing. By spiritual, I mean whatever gives your life meaning. There's a massive pressure to find the meaning in what's happened, to grow from it and make it into something. That pressure in itself is a massive drain on your energy. Spiritual pacing focuses on mapping what feels right and feels wrong by observing what it is, noticing how it feels, and responding accordingly.

Where Pacing Supports Sustainability

Sustainability is the tier people don't focus on. It doesn't feel good in the moment, and it also contains the other two. Because of the delay, we can't really pace ourselves based on how we feel at any one point in time. It's all down to observation over time.

For trauma survivors, this very act of noticing can be in itself an act of repair. We were taught very early on to override the body's signals because they weren't safe or useful to attend to. Learning to read them again, without judgment, is a very slow process.

Reflection also changes what you do on a good day. A good day is information, not a license to go out and sort through every single debt in one go. You spend some of the extra, you keep some in the bank. A crash is not evidence of failure. It just tells you where the edge is. The shame that follows is just another withdrawal from an account which was already very low.

Reflection is the bridge to contemplation; while reflection involves actively listening to your thoughts and experiences, contemplation is a state of deep inner looking in which you understand and absorb what you have reflected on.

Contemplation

In chronic burnout, we're in a state of pain of some kind. It can be hidden, and we can be numb, or completely overwhelmed. Contemplation is not about finding a way out of that state. It's about noticing how we're feeling right now without judgment. Judgment takes us straight out of the present moment and into withdrawal. There's nothing wrong with that. We're absolutely allowed to withdraw, to regress, to shut down. The point is to increase our capacity to notice without judgment, even without judging the judgment. The more we can do that, the more we can contemplate. The more we can contemplate, the more we can expand sustainability.

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