A Deferential Diagnosis of Fatigue

by Rouzbeh Shadpey

Dear Reader, the irony is not lost on me. That four years of medical studies, one year of psychiatry residency, four and a half years, and counting, of unabated weariness—garbed, for the most part, in that ungrateful diagnosis Chronic Fatigue Syndrome (do not insult me with your clinical tautologies!)—would fail to impart on me, the writer of this text and the arbiter of its diagnosis, the nature of this thing I now claim to teach you. What I am trying to say is, I do not know what fatigue is. Not even an inkling. This is not an explanation; this is a disclaimer: I am writing this syllabus to you from the epistemological and ontological abyss called weariness that separates positivist medical theory and the lived experience of disavowed suffering. In the self-flagellating manner of a repenting doctor, and in full accord with the rule of reason, I address this paradox paradoxically. I write its deferential diagnosis.

Whether lifesaving or ominous, the diagnosis stages an initiation into medicalized subjectivity rife with symbolic and material violence. Upon receiving a diagnosis, one becomes a case; upon becoming a case, one is rendered exemplary—the textbook manifestation of a normative framework of legibility. It is the rightful purview of the sick to be wary of the diagnoses grafted upon them; how they reveal through erasure is a blacklight that recodes pain, rewrites suffering, and distorts. Nevertheless in today’s clinic, where the patient’s speech is not poetry but evidence, her splayed wounds not flesh but signs, the diagnostic is hegemon. The hope for remedy is strictly to be negotiated in its currency.  

So it is: this syllabus attempts to square the violent rationale of diagnosis with its language-giving—which is to say, life-affirming—properties for those besieged by fatigue. What I am calling a deferential diagnosis is a methodological experiment that seeks to reclaim techniques of medical taxonomizing in order to develop an ode to fatigue: a transdisciplinary poetics of weariness that blurs the registers between the clinical and the critical, the organic and the psychosocial. My concept draws from its homonymic namesake, the differential diagnosis: a clinical methodology whereby doctors draw up the list of possible etiologies that may account for a patient’s symptoms. Here, clinical acumen and biomedical tests meet to parse the unruly noise of bodily symptomatology into signal. In most cases, this exercise expedites the clinical process by narrowing its list of suspected pathogens—but not always. A symptom of everything, fatigue defies the differential diagnosis and exhausts its logic. To draw the map of its possible etiologies is a task befitting the Borgesian cartographer, not the medical clinician.

The following deferential diagnosis is thus the humble syllabus of a most devastatingly modest misfortune. Its necessarily incomplete list of fatigue’s etiologies borrows from various disciplines and is arranged in no particular order. Its objective, insofar as it can be said to have one, is to offer a window into a poetics of fatigue that treats its subject—and those who suffer it—with dignity, complexity, and grace. To paraphrase Blanchot, that great writer of weariness, it is difficult to know what one speaks of when one is speaking of weariness. Let us try anyway. 

1.  Infinite conversations

“Forgive me for having asked you to come to see me. I had something to say to you, but at present I feel so weary that I’m afraid I will be unable to express myself.” 

In the enigmatic preface to Maurice Blanchot’s The Infinite Conversation (published as a standalone piece in La Nouvelle Revue Française of March 1966, three years prior to the eponymous book that would be grafted upon it), two anonymous interlocutors are gathered in a nondescript room beyond the pale of history. They are weary—this is their sole trait—and weariness conditions their conversation: “You mustn’t pay too much attention to what I might say. It is weariness that makes me speak; it is, at the very most, the truth of weariness… A weary truth.” Weariness keeps the confidants alive, speaking, while wearing away their ability to confide in one another, their speech fatigued. This is Blanchot’s conceit. In the circular tide of his infinite conversation, weariness emerges as the insensible, impersonal, indifferent outside of speech—that “most modest of misfortunes, the most neutral of neutrals.”

Hence its inclusion among Roland Barthes’ case studies on the Neutral, the lectures that would be the writer’s penultimate at the Collège de France before the event of his death. For Barthes, like Blanchot, the neutrality of weariness baffles the paradigm of meaning-making. “Is weariness an illness or not? Is it a nosological reality?” the professor queries his disciples, only to gracefully capitulate a week later, a week wearier, to the futility of his ask: “Wea­riness is thus creative, from the moment, perhaps, when one agrees to submit to its orders.” Exit weariness.

Suggested Readings:

  • Maurice Blanchot, The Infinite Conversation (1993; repr., Minneapolis: University of Minnesota Press, 2019), xiii–xxiii.
  • Roland Barthes, The Neutral: Lecture Course at the Collège de France (1977-1978) (New York: Columbia University Press, 2005), 16-20.

2.  The fine print in the Levinasian Contract 

“A philosopher has to put himself in the instant of fatigue and discover the way it comes about. Not its significance with respect to some system of references.” This is the task of Emmanuel Levinas in Existence and Existents (1947), the writing of which he began whilst detained in a forced labor camp in Nazi Germany. In what is often cited as its first philosophical investigation, Levinas raises fatigue to the status of an ontology: along with indolence, insomnia, and other such limit-experiences, fatigue offers a privileged window into the otherwise invisible—because perfectly synchronized—relationship between a self and its existence. Notably, for Levinas, the studied weariness of physiologists and psychologists which always takes an object—the weariness of doing (something)—is already subtended by the more primordial, fundamental weariness of being: “What wearies then is not a particular form of our life… the weariness concerns existence itself… in weariness existence is something like the reminder of a commitment to exist […and] the impossible refusal of this ultimate obligation.” To this irremissible duty, Levinas assigned the metaphor of an irrevocable contract. We, the weary, would do well to read its fine print. 

Suggested Readings:

  • Emmanuel Levinas, Existence et Existents (The Hague: Martinus Nijhoff, 1978), 21–36.
  • Joan Copjec, “Battle Fatigue: Kiarostami and Capitalism,” in Lacan Contra Foucault, ed. Nadia Bou Ali and Rohit Goel (Bloomsbury Publishing, 2018).

3.  Metacognitive mistrust 

In Stephan et al.’s paper “Allostatic Self-efficacy: A Metacognitive Theory of Dyshomeostasis-Induced Fatigue and Depression” (2016), published in the multidisciplinary journal Frontiers in Neuroscience, the authors propose that, given its ubiquity as a symptom in the near entirety of the body’s pathological processes, fatigue mightbetter be understood as a metacognitive phenomenon. Under this model, fatigue results from the nervous system’s held belief of failing at one of its most fundamental tasks: homeostatic/allostatic regulation. This belief, in turn, is engendered by the enhanced interoceptive surprise provoked by inhabiting a state of constant dyshomeostasis. In other words, because of enduring deviations between expected and sensed bodily states, the nervous system perceives itself as lacking control over its corporeal dominion: what we call fatigue is simply the phenomenological experience of this synaptic spiraling. Or, in the words of Clarice Lispector’s nervous system, “Did something happen to me that because I didn’t know how to live it, lived as something else?”

Suggested Readings:

  • Stephan KE, Manjaly ZM, Mathys CD, Weber LAE, Paliwal S, Gard T, Tittgemeyer M, Fleming SM, Haker H, Seth AK and Petzschner FH (2016) Allostatic Self-efficacy: A Metacognitive Theory of Dyshomeostasis-Induced Fatigue and Depression. Front. Hum. Neurosci. 10:550. doi: 10.3389/fnhum.2016.00550
  • Clarice Lispector, The Passion According to G.H. (New Directions Publishing, 2012).

4. A lack of so-called “Energy” (ie. the naturalization of white Labor Power as the measure of Universal Force)

Fatigue is time and again defined as a lack of energy. But what is energy—and how has fatigue come to signify the measure of its absence? In his seminal study The Human Motor (1992), the historian Anson Rabinbach traces the conceptual rise of energy in the late 19th century, from  thermodynamics to a transcendental materialism ripe for modern industrialist productivism: “The body, the steam engine, and the cosmos were thus connected by a single unbroken chain… an indestructible energy, omnipresent in the universe and capable of infinite mutation, yet immutable and invariant.” Under its capacious aegis, energy collapsed the difference between body, nature, and technology by positing work as a universal property of Nature; an invisible force that can only be perceived through its effects, which is to say, its labor power. In so doing, energy substituted moral drivers of labor—work ethic and its poison, idleness—with a purely quantitative energetic economy to be scientifically mined in the able body of the white worker. In this equation, fatigue came to occupy the role of the vilified Other: a chimera of the worker’s productive limit, industrialization’s final frontier, and the universe’s entropic drive (what Rabinbach calls “the permanent nemesis of an industrializing Europe.”). If energy was the great civilizational abstraction, fatigue was—and still remains—its artificially receding horizon: an apophatic signifier made to sponge modernity’s individual and social anxieties, conscious or otherwise.  

Suggested Readings: 

  • Anson Rabinbach, The Human Motor : Energy, Fatigue, and the Rise of Modernity (New York: Basic Books, 1990).
  • Mark Paterson, How We Became Sensorimotor (University of Minnesota Press, 2021), 203–38.
  • Rouzbeh Shadpey, “At the Mercy of Limitless Loss: Physiological Aneconomies of Chronic Fatigue,” Weird Economies, n.d. (forthcoming)

5. Being all out of spoons 

To draw a phenomenology of fatigue, let alone a political one, is no easy task. Fatigue undoes the very subjectivity required of us to experience it; it renders us unreliable narrators to both ourselves and others. Hence the importance of accessible frameworks for disabled people to elucidate and communicate their wavering day-to-day capacities to able-bodied others. Spoon theory is one such language, first introduced by Christine Miserandino in a 2002 blog post. In what is now considered a cornerstone of disability politics for peoplewith chronic illness, Miserandino, who has lupus, recounts detailing her fluctuating energy to her friend by equating its contingent stores with a fixed but variable amount of daily spoons. All labor—whether waged or reproductive—costs a certain amount of spoons; when the spoons run out, activity must stop until they are replenished. The cycle thus repeats. Notwithstanding its many merits, as a political framework of disability spoon theory is not immune to criticism (including our own aforedescribed critique of the energetic framework of fatigue). Its metaphor deconstructs itself to reveal an effaced specter: that other, racialized quanta of energy which having been harvested by slaves, was poured and dissolved into Empire’s tea by the master’s literal spoons, to fuel his figurative ones.

Suggested Readings: 

6. The absent Black subject of fatigue

Margo Jefferson’s latest triumph of memoir-cum-criticism ends, befittingly, with the author projecting upon her deceased grandmother a fabulated self-criticism: “If she were alive, here now with me, what would she say? I think she’d say quietly and not without tenderness: You haven’t earned your right to be tired yet, have you…?” Jefferson dedicates the ultimate chapter of Constructing a Nervous System (2022) to the memory of her grandmother, Lillian McClendon Armstrong Saunders Thompson, hypostatized at the crossroads of “the generically tired Black Grandmother” and the embodiment of endurance—where “‘endurance’ always means the forced shouldering of heavy loads; a life spent paying American society a debt you never owed.” It is a deeply touching rendition of the pernicious imbrications of anti-blackness and fatigue, whose manifold implications are gravely undertheorized in fatigue scholarship (this syllabus including). Whether it is the legacy of neurasthenia as a pathological foil for American racecraft, the echoes of which can be traced to the present day underdiagnosis of Myalgic Encephalomyelitis / Chronic Fatigue Syndrome (ME/CFS) among Black and racialized populations; the erasure of the enslaved as inorganic subjects and organic objects of extractive energetic economies, far predating the 19th century white factory worker’s embodiment of the thermodynamic human motor; the blaring absence of the Black subject from the archive of contested illness memoirs, Black somatization being a near tautology in colonial Western medicine; the polarization of Black fatigue as the slow death of weathering or the acute one of exhaustion, with mytho-scientific concepts like John Henryism bridging their gap—the concept of fatigue is steeped in the historical materiality of whiteness. The following suggestions are but a narrow window into an archive that requires serious deepening.

Suggested Readings: 

  • Margo Jefferson, Constructing a Nervous System (New York: Vintage Books, 2023), 179–85.
  • Nicholas Fiori, “Plantation Energy: From Slave Labor to Machine Discipline,” American Quarterly 72, no. 3 (2020): 559–79, https://doi.org/10.1353/aq.2020.0035.
  • Brad Campbell, “The Making of ‘American’: Race and Nation in Neurasthenic Discourse,” History of Psychiatry 18, no. 2 (2007): 157–78.
  • Alia Al-Saji, “Weariness: Dismembered Time, Colonialism, Pandemics,” Philosophy Today 64, no. 4 (2020): 821–26, https://doi.org/10.5840/philtoday20201227379.

Françoise Vergès, “On the Politics of Extraction, Exhaustion and Suffocation,” L’internationale, November 7, 2021, https://www.internationaleonline.org/research/politics_of_life_and_death/195_on_the_politics_of_extraction_exhaustion_and_suffocation/.