Grant agrees. She knows the “Oh dear, here we go again” look from doctors when she brings up her fatigue. “Doctors don’t want to hear how tired patients feel – I think it makes them feel uncomfortable because they can’t fix it,” she says.

Untangling Causes

Finding the cause of fatigue means ruling out the many possible culprits. Dr. Pischel explains that fatigue has many contributing factors. “Not only is joint inflammation a major factor but also chronic pain, hormonal changes, anemia, poor sleep, depression and stress.” But one in five people with RA also has fibromyalgia, and the majority of those with fibromyalgia also experience chronic fatigue. 

Some people with inflammatory diseases also have celiac disease, cardiovascular problems or lung problems associated with inflammation, and all of those conditions make the body’s systems work harder and may lead to fatigue. Figuring out the trigger is like unraveling dozens of tangled strings of lights to find the few burned-out bulbs.

Sleep problems are usually the first line of investigation. But even if insomnia or restless sleep is an issue, the search is not over. Maybe multiple factors are at work.

Sleep and pain

For many people with arthritis, fatigue often is triggered by insomnia and unrefreshing sleep due to unrelieved pain. Getting into a position comfortable enough to allow solid slumber is a challenge when joints are swollen and sore. And quality of sleep tends to be more important than quantity. Getting six or seven hours of deep, restorative sleep makes you feel better than spending eight or nine hours in bed tossing, turning and waking up repeatedly.

People with obstructive sleep apnea may wake briefly hundreds of times per night as they gasp for air. Weakened muscles or excess tissue in the throat can block the airway and lower the amount of oxygen in the blood. Sensing the low oxygen level, the body arouses itself. Waking up briefly to allow the airway to open interrupts normal, restorative sleep. Studies show that disrupted sleep or too little sleep may heighten pain.


Chronic pain can cause fatigue directly, or it can lead to depression, which can increase fatigue. Depression is the most common cause of fatigue among all patients who visit doctors. While fatigue occurs most often with depression, it also accompanies other mood disorders, including anxiety, bipolar disorder and seasonal affective disorder. 

Grant has struggled with depression despite having a generally positive attitude about life. She attributes some of her depression to medication side effects. The prednisone she took for 12 years created mood swings, and she required two years to stabilize after stopping it. In addition to mood-swings, other corticosteroids like prednisone also contribute to depression and insomnia.