Layout 1 [Qualitative Research in Medicine & Healthcare 2017; 1:6698] [page 73] Introduction Fatigue has been defined as a subjective, unpleasant symptom, which incorporates feelings that range from tiredness to total body exhaustion.1 Although fatigue is a common with nearly 10% of population, at any one time, experiencing fatigue that lasts more than six months, it is often not assessed in clinical settings.2 This lack of assess- ment is probably due to a variety of reasons, including: the lack of consensus definition of fatigue, current assess- ments of fatigue are insensitive, non-specific, and uni-di- mensional that may miss important dimensions of fatigue, and fatigue is an invisible symptom. Hepatitis C Virus (HCV) is one of the diseases where fatigue is particularly prevalent and has an impact on in- dividuals’ lives. HCV is a blood-born viral infection that causes both hepatic and extrahepatic manifestations. Acute infection with HCV often fails to clear in roughly 75% of carriers, leading to chronic HCV infection.3,4 The chronic condition may lead to liver cirrhosis, hepatocel- lular carcinoma or liver failure, all accompanied by extra- hepatic manifestations such as debilitating physical and mental symptoms.5,6 Fatigue, cognitive impairments and depression are the most common symptoms in HCV. 3,7-11 Fatigue specifi- cally, has been shown to negatively impact the health-re- lated quality of life of those with HCV.12,13 Up to 97% of HCV infected patients have reported experiencing fatigue during the course of their disease,14 and 88% of infected Fatigue and Hepatitis C: a focus group study Christina Spataro,1,2 Sophie Afdhal,1 Ali A. Weinstein,1,2 Carey Escheik,1 Patrick Austin,1 Kathryn Brodie,2 Lynn Gerber,1-3 Zobair M. Younossi1,3 1Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA; 2Center for the Study of Chronic Illness and Disability, George Mason University, Fairfax, VA; 3Center for Liver Diseases, Department of Medicine, Inova Fairfax Hospital, Falls Church, VA, USA ABSTRACT Fatigue is often undiagnosed by health professionals as it is still seen as a nonspecific symptom without standard evaluations and effective treatments. Fatigue is present across many different diseases and has a profound effect on the quality of life of patients. However, it is still difficult to measure because of the lack of specificity of currently used self-report instruments. Patients with chronic hepatitis C infection, (HCV), experience fatigue as one of the most debilitating symptoms. The purpose of this study was to explore the types and dimensions of fatigue experienced by patients with HCV, identify specific terms they use to describe fatigue and assess how it influences everyday activities. Sixteen individuals with HCV (56% female, aged 58.1 ± 3.7 years) participated in three focus group sessions. The focus group sessions lasted between 60 and 90 minutes and were digitally recorded via audiotapes. Recorded focus groups’ audiotapes were analyzed through thematic analyses. The analysis suggested two primary categories of fatigue experiences. These were: capacity and engagement in activity. Capacity refers specifically to an individual’s sense of how much energy they have to do life ac- tivities or their maximum ability to produce energy. The word energy is the ability to perform work and includes one’s ability to access or utilize, expend, and restore it. The phrase engagement in activity, comprised two domains: initiation (getting started or being moti- vated) and personal satisfaction (value of the activity). This investigation helped to identify important domains of fatigue experienced by those with HCV. The findings augment our current understanding of fatigue for this group because the domains of fatigue and the terms used to describe it are not commonly represented in the most frequently used fatigue assessments. Correspondence: Ali A. Weinstein, George Mason University, 4400 University Drive, MSN 5B7, Fairfax, VA 22030, USA. Tel: +1.703993-9632. Email: aweinst2@gmu.edu Key words: Qualitative research; Fatigue; Capacity; Motivation; HCV. Contributions: AAW, CE, PA, LG, and ZMY contributed to the conceptualization and design of the study. CS, SA, CE, PA, AAW, and LG analyzed the data and created the qualitative thematic scheme. AAW facilitated the focus groups. All authors participated in the writing and editing of the manuscript with KB providing ad- ditional literature searches and analysis of the contextual and his- torical context of fatigue. All authors read and approved the final manuscript. Conflict of interest: the authors declare no potential conflict of in- terest. Funding: this work was supported by the Betty and Guy Beatty Center for Integrated Research. Received for publication: 9 March 2017. Revision received: 5 July 2017. Accepted for publication: 7 July 2017. This work is licensed under a Creative Commons Attribution Non- Commercial 4.0 License (CC BY-NC 4.0). ©Copyright C. Spataro et al., 2017 Licensee PAGEPress, Italy Qualitative Research in Medicine & Healthcare 2017; 1:73-79 doi:10.4081/qrmh.2017.6698 Qualitative Research in Medicine & Healthcare 2017; volume 1:73-79 No n- co mm er cia l u se on ly patients report experiencing some form of fatigue every day.15 Not only is fatigue one of the most common symp- toms reported by patients, it is regularly described as the worst and most debilitating symptom.7,9,10,16 Treatments for HCV often worsen fatigue symptoms in patients, fur- ther impacting a patient’s quality of life.17 Fatigue is often undiagnosed by health professionals as it is still seen as a nonspecific symptom without stan- dard evaluations and effective treatments.7,10,11,14 Since its features can vary widely from individual to individual, fa- tigue is often overlooked and undertreated by physicians. Many patients report feeling like their doctor does not take their fatigue seriously.18 Patients also often attribute their fatigue to the increasing demands of modern-life, re- sorting to self-treatment. The gap between the experience of patients and their physicians’ understanding of their ac- counts may be explained by the both the lack of physician resources and awareness, as well as the lack of a consis- tent way to measure and define fatigue. As a result, fatigue has many consequences on patient quality of life, their families, and costs to the healthcare system.19 This em- phasizes that we need to more thoroughly define the fea- tures and domains of fatigue so that it can be identified and treated more efficiently. Though fatigue is considered by healthcare profes- sionals as a symptom, it is nonetheless classified as non- specific and therefore marked by the complexity of psychological, social, and medical factors that character- ize patients with nonspecific complaints since the era of modern medicine.20 Inasmuch as clinicians are trying to optimize the well-being of their patients, however, that goal relies on sound tools to evaluate both real and per- ceived deficits in a way that can be used for the particular patient over time.21 Although there are a wide array of tools that assess fatigue, there is no instrument that can provide both specificity and sensitivity for measuring fa- tigue.21 The lack of a specific and sensitive tool along with the lack of a consensus definition of fatigue is the perfect storm that leads to under diagnosis and under recognition of this important symptom. It is time to allow patients to express their experiences with fatigue so that the medical field can more properly assess and then treat this life changing complaint. We need to more fully understand the specific aspects of fatigue that patients are experiencing and its impact on their lives. Obtaining a more detailed account of fatigue may lead us to improved treatment approaches that could alleviate this multi-faceted and complex experience. Ask- ing patients to discuss their symptoms and their impact on their lives may help expand the vocabulary we can use to describe and measure fatigue. The aim of this study was to explore the different dimensions of fatigue by adopting a qualitative approach that would ensure that we would understand how respondents understood and were able to express their experiences with fatigue. It was essential to investigate this aim with qualitative methodology, so we chose to approach it by means of focus groups. The main purpose of focus group research is to gain insight from respondents that would not be feasible using other methods (i.e., surveys).22 We were interested in how the patients themselves describe fatigue and therefore we wanted them to use their own words and not just survey re- sponses. Focus groups are often used as tools to develop concepts for questionnaires.23 Fatigue needs to be investi- gated more broadly since a definitive definition of this symptom does not exist. If we are to be successful in treat- ing fatigue within the context of HCV, first it is necessary to understand the full extent of experiences of patients with HCV. This will allow appropriate assessment tools to be designed and provide targets for potential intervention. Materials and Methods Participants Sixteen subjects were invited to participate in one of three focus group sessions. These participants were iden- tified from a current list of patients seen at an outpatient liver clinic. Potential participants were contacted via phone to gauge interest and determine availability. Inclu- sion criteria included diagnosis of chronic hepatitis C (confirmed in medical records) and ability and willingness to provide informed consent. Any condition, which in the opinion of the investigators would make the subject un- suitable for enrollment, such as documented history of mental illness was grounds for exclusion. All participants presented with HCV, seven of whom were currently on treatment with combinations of medication-based thera- pies. Additional participant characteristics are provided in Table 1. [page 74] [Qualitative Research in Medicine & Healthcare 2017; 1:6698] Article Table 1. Participants’ characteristics. N (%) Number of participants 16 Gender Male 7 (44) Female 9 (56) Age (Mean±SD) 58.1±3.7 Marital status Married 7 (44) Single 5 (31) Divorced/widowed 2 (12) Genotype 1A 9 (56) 1B 5 (31) Unknown 2 (12) Past treatment non-responder 8 (50) Achieved sustained virologic response 5 (31) Diagnosed cirrhosis 5 (31) SD, standard deviation. No n- co mm er cia l u se on ly Procedure Participants provided written informed consent prior to participating in the focus group session and the Insti- tutional Review Board at Inova Fairfax Hospital approved this investigation. Focus group discussion was led by a moderator (author AAW) and facilitated via prepared dis- cussion prompts (Table 2). The focus group sessions lasted between 60 and 90 minutes and were digitally recorded via audiotapes. The purpose of focus groups in this study was to encourage participants to explore the di- mensions of fatigue by using terms that uniquely repre- sented their feelings of fatigue, how they thought it would be best communicated and how it impacted their lives. The use of focus groups for providing information to help design assessments and surveys has long been established.24 In addition, the focus group methodology was chosen since it allows flexibility. Because we did not want to impose our own preconceived dimensions of fa- tigue into the discussion, we made sure that the prompts were quite general. The focus group strategy allows the moderator to probe issues in depth, address new issues as they arise, and ask participants to elaborate on their re- sponses.24 In addition, participants can be more comfort- able talking in a group rather than an individual interview and these interactions between participants can generate more discussion. Analysis To understand, explore, and explain fatigue, qualita- tive content analysis was used. Recorded focus groups’ audiotapes were analyzed to code words, sentences, or paragraphs. Categories were then generated based on codes with shared content by multiple researchers (au- thors CS and SA). The category development involved the sorting of the codes into key ideas. These key ideas were created by examining the participants’ choice of words, considering the group context, and looking for consistency among groups and group members. Then these categories were linked together into themes, trying to remain as close to the language used by the participants as possible. The development of themes was a collabora- tive effort by all of the authors. Results After three focus groups were conducted, saturation had been reached with no new areas of fatigue being en- dorsed in the third focus group. One of our goals was to elaborate the terms used, refine what was meant, and use them as a basis for our thematic description. The follow- ing are the terms that are noteworthy: i) capacity refers to the amount of energy available for use, like gas tank ca- pacity; ii) access refers to the ability to get gas to engine, like the fuel pump or fuel injector; iii) depletion refers to energy being lost, such as running out of gas; and d. restoration refers to the ability to refill energy, such as fill- ing the gas tank. Example quotes were selected and high- lighted in the results section to help document this thematic structure. Dimensions of fatigue Given the diversity of patient history and the wide va- riety of symptoms that can occur in patients with HCV, initial analysis focused on identifying how fatigue was de- scribed, and then to determine if there was consensus among the participants on these descriptions. We created a word cloud to represent the most commonly used words in describing fatigue (Figure 1). Fatigue seemed to be present continuously in many of the individuals. One par- ticipant stated That 2 or 3 p.m. [tiredness] thing that most people have, that lasts all day for us. As participants discussed fatigue, it was clear that two different dimensions of fatigue were endorsed: physical dimensions of fatigue and mental (non-physical) dimen- sions of fatigue. Reported physical health concerns in- cluded muscle weakness, shortness of breath, inability to move or eat, sleeping problems, and detrimental weight loss. The physical side of fatigue also included reports of constant tiredness despite adequate hours of sleep, feeling so burnt out that it was difficult to get out of bed, the need for immediate rest once energy runs out, and many reports of constant and difficult recovery from bouts of fatigue. [Qualitative Research in Medicine & Healthcare 2017; 1:6698] [page 75] Article Table 2. Focus group discussion prompts. Prompt 1 Can you describe the feeling of fatigue that you associate with CLD? What does fatigue feel like specifically to you Is that different than how others use the word fatigue Does the amount of fatigue you experience change over time? Prompt 2 How does it affect your daily living? Is there anything that you avoid doing? Is there anything that you miss, for example that you can’t do? Prompt 3 How do you manage in daily life when you have this feeling of fatigue? Do you have any trick or strategies? Prompt 4 Has the fatigue caused you any distress? Can you describe the distress? Prompt 5 Has anyone offered you advice about dealing with fatigue? What was it? Did it help? Prompt 6 If there was one thing that someone could have done/said to help you with your fatigue what would it be? CLD, chronic liver disease. No n- co mm er cia l u se on ly The fatigue is like being tired all the time. It’s like sleep deprivation. Even though you’ve slept a full night it’s like deprivation. Sleep deprivation without the actual deprivation. Mental fatigue was described by the patients as debil- itating in its own way. I fatigue myself because my mind is always going. Some participants felt that mental fatigue could be overcome, but motivation became a barrier within the dimension of mental fatigue. Some were frus- trated by the belief that they have the physical capabilities, while others were resigned to their depleted activity and productivity levels. Either way they were faced with the same concern that can be summarized by one patient’s statement: It messes with your mind. Your focus is off, you’re more concerned with your physical well-being, you need to get past I’m feeling bad and I need to get up but it’s not happening and it messes with your mind. The mental side of fatigue takes a clear toll on patient well-being, largely due to not knowing how to handle their fatigue or its cause. I sit there at night and just can’t shut my brain down, just start thinking about everything and give myself panic attacks because I’m overanalyzing. Capacity As one of the overarching themes identified during analysis, capacity is used to refer to the participant’s phys- ical and mental capabilities. We empirically defined ca- pacity as one’s actual or potential ability to perform and withstand both physical and mental challenges. The definition encapsulates individual ease and difficulty with which tasks can be performed. Patients reported varying degrees of limitation in function, with some experiencing minimal difficulties and others who were unable to get out of bed or complete basic tasks. Capacity is closely in- tertwined with functional ability and is further defined by these subsections: access, depletion, and restoration. Access Participants expressed that energy was not readily available to them and their capacity to manage fatigue was influenced by being able to access energy. Thus access refers to patients’ ability to moderate their energy level when needed. In this theme, there was consensus that the act of initiating activity and avoiding resignation to the current diminished energy levels tended to help with ac- cessing energy. Participants were divided over whether their actual energy levels were diminished. Despite this, difficulty accessing energy was a problem for a vast ma- jority of the participants. The participant responses on ac- cessing energy displayed multiple views to a similar issue. Some participants felt that a sense of distraction and re- fusal to give in to fatigue is what allowed them to keep accessing energy. For me, energy breeds energy. If I keep doing stuff, it might feel a little painful but unless I get in a low blood sugar situation, I can keep going. So the more I do things, I won’t say the better I feel but I stay at that level and if I don’t dip down, I don’t feel horrible and fatigued. Sometimes you just have to force yourself to get going and once you’re going you can. If I start doing something I’ll keep going until I’m ready to drop over dead, I’m just going to keep going, getting started is the hardest part, and it’s the getting going. [page 76] [Qualitative Research in Medicine & Healthcare 2017; 1:6698] Article Figure 1. Word cloud depicting frequently utilized descriptors of fatigue during the focus group sessions. No n- co mm er cia l u se on ly Another felt that forcing themselves to access energy allowed them to accomplish more than they otherwise might. Sometimes it’s not as bad but it’s like you said, you’ve got to force yourself to get out and once you’re going you can. On a Saturday, for me to get out of the house before 3 p.m. is huge. If I don’t have to do some- thing, I won’t. Metaphors of motion and cars were frequently utilized by patients to describe the fatigue and energy relationship. Sometimes this referred to a gas tank being quickly emp- tied, not being able to fill it up or even get to a gas station. One participant expressed that the energy is present, but she cannot access it. I don’t have a lack of energy, it’s an inability to access that energy. It’s like a car that won’t start. There’s gas in the tank but the car won’t start. The fatigue part of it is like sitting there all day, turning the key over and over, but it won’t start. Depletion Participants indicated that the rate of depletion of en- ergy also influences their sense of capacity. Depletion was conceptualized as how quickly a patient’s capacity or level of energy diminished and negatively affected their functional abilities. This is a major physical problem af- fecting the participant’s ability to function as well as a psychological stressor. Participants expressed great frus- tration by the change in their previous level of energy and it proved to be an emotional topic for some. This category also helps to illustrate the differences in the way in which different participants coped with the depletion. One participant noted that they preferred to expend their energy until completely depleted. I just make it to my bed and I’m lying there. So even if I want to go I just can’t do it. It’s like mind over matter and I’m just going to burn until I can’t burn anymore and burn out. Some firmly expressed that their depletion did not allow them to exceed their limited activity. If I got up today and worked a whole 8 hour day, I wouldn’t make it until tomorrow. Restoration Restoration also emerged as a theme that was consis- tently mentioned in all three focus groups. Restoration refers to the process in which fatigue levels can be miti- gated and then how quickly and effectively they are able to recover that loss of energy. When speaking about their fa- tigue, many expressed that their capacity for restoration does not exist in the way one would hope, returning energy to baseline naturally, but instead is seen as how one must behave in order to ensure that proper recovery occurs. Restoration proved to be a difficult process for many and responses demonstrated a wide variety of experiences. Sleep was acknowledged as a major strategy for restoration but it did not seem to be effective based on feedback: Naps can help recharge but doesn’t completely get rid of fatigue. Naps don’t help at all. Even when I sleep well at night, I’m still tired dur- ing the day. To sleep and still wake up feeling run down is a bad feeling. Exercise was a frequently endorsed strategy for restora- tion but some observed serious issues with recovery: When I was doing yoga, when I did go to the gym, it did make me feel better but it would take me days to recover from. I normally go to the gym every day and then by 3 o’clock I’m fatigued. But if I miss doing any kind of workout, the fatigue is worse. The frequently utilized car metaphor was applied to restoration with the comment that without proper consid- eration for rest, it can be detrimental: Now that I’m not going to the gym, it’s kinda like a car slowly running out of gas. Sooner or later you’d better stop and get the fill up or you’ll just be dead on the side of the road. Just stalled out. So I gotta get back to doing some of the stuff you don’t feel like doing but you know if you do, everything else will get better. Things as well as your outlook will get better. Engagement in activity Another overarching theme that developed was repre- sentative of patients’ personal initiation and desire to com- plete activities. While the capacity theme focused on the physicality of activities, this grouping was utilized to clas- sify individuals’ attitudes when facing fatigue and the abil- ity to successfully mobilize. Thus this term was used to denote willingness and frequency with which participants took part in activities and was further defined by these sub- sections: initiation issues and personal satisfaction. Initiation issues One of the primary barriers to activity was initiating activity due to motivation, not energy level. Patients re- ported lack of motivation, which resulted in an inability to engage in activities without external stimuli. Lack of initiation seemed to cause distress and impacted their abil- ity to engage in activity. Participant feedback regarding initiation issues focused on how difficult it was for them to overcome internal lack of motivation to engage. Their statements included: [Qualitative Research in Medicine & Healthcare 2017; 1:6698] [page 77] Article No n- co mm er cia l u se on ly I only sleep sometimes 5 hours, 8 hours at the most a night and that’s all I need but I still have no energy during the day. It’s not like I’m tired in that way where I want to sleep all day long, lying around. My problem is that I’m awake and I have no energy, no motivation, no drive, no wanting to get out and get things done. It’s like, what’s wrong with me? I’m just watching the hours go by and the days got to go by until next thing you know its time for me to go to bed. Next thing you know it’s the same thing again but I’m not getting stuff done during the day, getting things accomplished. If I have to put things off I do until I can’t put them off no more. My mental self can see myself getting up but my physical self can’t do it. Frustrating because I want to. Almost every day I wake up right at 9 o’clock. I only sleep 5-8 hours a night, but I still don’t have en- ergy during the day. I’m awake and I don’t have any motivation. Just sitting and watching the hours go by until it’s time to go to bed, and I’m not getting any- thing done during the day. I’d keep putting it off until I didn’t have to put it off anymore. I will put off going to the grocery store until there is nothing else in my refrigerator because I know I will have to get up and walk around the store. But once I get out and get going, then I get things done and I’m really happy I accomplished. But getting that first step, getting going is the hardest part. Personal satisfaction While the manifestations and consequences of fatigue varied, a common theme was participants expressing varying degrees of dissatisfaction and distress with their current situation. This subcategory of personal satisfaction referred to both patients’ general disposition and their spe- cific concerns regarding getting things accomplished. Some were frustrated by an inability to get things done while others expressed dissatisfaction with what they are currently able to get done. One of the major concerns expressed in this theme was that those participants who can get things done were not sat- isfied with the results. Participants who reported this as their main concern felt a fair degree of frustration at the loss of former abilities. Many felt that they could complete activities that were essential (i.e., attending work and coordinating per- sonal and family care) but were unable to do additional things they deemed important (i.e., produce higher caliber work, support family and friends as much as they would like) or had to at least scale back on the intensity of activities. I’m busy a lot and I make sure I don’t over-sched- ule myself but it makes me kinda sad because I’m al- ways a go, go, go type of person. A lot of times I burn myself out by going so fast. Affects activity schedule because I have to balance activity and can’t do all the things I want to do. Discussion People who use the word fatigue may experience a va- riety of bodily sensations that are interpretable as symp- toms to the medical community. Indeed, this study showed that fatigue is a term that has different meanings to individuals and is used in a variety of ways to describe this multifaceted symptom. The participants used the term fatigue to describe both physical and mental components. Our research group has frequently questioned whether people experiencing fatigue can effectively communicate fatigue experiences through standardized fatigue tests. Our goal for this research was to gain an understanding of the nature and breadth of experiences of fatigue for those with HCV in their own words. The use of focus groups (qualitative methodology) was essential to accom- plish this goal. It was apparent that commonly used standardized fa- tigue questionnaires do not include many of the fatigue domains that were discussed by those with HCV. The re- sults of this investigation expand the spectrum of fatigue symptomatology and may provide a first step in the de- velopment of new evaluation tools. The multiple terms used to describe fatigue along with the overall findings of this study strongly suggest that a uni-dimensional conceptualization may not adequately as- sess fatigue. Currently the symptom of fatigue is not widely understood, and most research fails to specify the multiple meanings and variations behind the fatigue symptom.7,8,10,11,25 Our findings highlight these widely var- ied meanings of fatigue. The severity and impact of fatigue on patients empha- sizes the need for more accurate assessment of fatigue in patients with HCV. Understanding the multifaceted nature of fatigue and focusing on the specific symptoms of fa- tigue being experienced (i.e., physical or mental or both) is important as these different aspects of fatigue may re- quire different treatment methods. A limitation of our study is that it did not address causes for fatigue. Many of the focus group participants reported suffering from chronic disease and comorbidities such as obesity, diabetes, depression and hypertension all of which may contribute to fatigue or its impact. About half of our patients were also currently undergoing treat- ment for HCV. Medications and other treatments could also have contributed to feelings of fatigue. It is interest- ing to note that regardless of the presence of absence of comorbidities, the participants seemed to describe a com- mon language to express their symptoms. The focus group sessions did not have participants share their lived expe- riences and how their different experiences affected their fatigue. Therefore, our data do not include the contextual experiences of the participants and the relationship be- [page 78] [Qualitative Research in Medicine & Healthcare 2017; 1:6698] Article No n- co mm er cia l u se on ly tween the context and their experiences of fatigue. Another limitation is the small sample size of our in- vestigation. However, we stopped recruitment because we felt strongly that saturation was reached among the three focus groups, with explanations and experiences being very similar between all groups. A limitation of the uti- lization of focus groups is that the group setting can in- fluence the responses of individuals, which can be especially problematic when a dominant member of the group monopolizes discussion. We did not specifically no- tice this issue in our analysis, but it is an inherent limita- tion to focus groups. In addition, many of the authors are experienced fatigue researchers and these experiences with fatigue could have biased the content and categoriza- tion of the participants’ experiences. These findings strongly suggest the need for further research on this topic. An overall goal of further research into fatigue should be the development of a detailed as- sessment that incorporates the domains of fatigue en- dorsed by patients in this study: physical vs. mental, capacity (including access, depletion, and restoration) and engagement in activity (including initiation issues and personal satisfaction). Participation of patients will be es- sential in the creation of this assessment tool. It is clear from the current study that patient input is critical in fully understanding the experience of fatigue. Conclusions In conclusion, this study found that within the focus group setting, the word fatigue for patients with HCV has meanings and dimensions not frequently included in stan- dardized fatigue metrics. These focus group participants confirmed what has been reported by many investigators, that fatigue has a disruptive effect on their lives. The di- versity of fatigue experiences highlights the importance of developing assessments that address the observed do- mains of fatigue. References 1. Whitehead L. The measurement of fatigue in chronic illness: a systematic review of unidimensional and multidimensional fatigue measures. J Pain Symptom Manage 2009;37:107– 28. 2. Skapinakis P, Lewis G, Meltzer H. Clarifying the relation- ship between unexplained chronic fatigue and psychiatric morbidity: results from a community survey in Great Britain. Am J Psychiatry 2000;157:1492–8. 3. Forton DM, Thomas HC, Taylor-Robinson SD. 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