Cognitive-behavioural therapy (CBT) teaches people the relationship between their thoughts, their feelings, and how they behave. 

Thinking in a way that is negative or unhelpful is often associated with uncomfortable feelings, like sadness, anxiety, or irritability. These feelings can drive unhelpful behaviours. These behaviours might reduce discomfort in the short-term, but they do not support healthy long-term coping.

For example, someone who thinks that others will judge them for using a cane may feel anxious and avoid seeing people socially. In this example:

• the thought is that others will judge me
• the feeling is anxiety
• the behaviour is not socializing with others

This behaviour may reduce the discomfort that the person feels around others, but it does not give the person the chance to prove their unhelpful thinking wrong, or to learn that they can cope. Also, the reduction in discomfort is not long-term. Continuing to manage anxiety by avoiding others can lead to worsening anxiety over time.

CBT teaches skills to help you notice your thoughts and to adjust your thinking and behaviours to be more helpful. These skills to adjust your thinking and behaviours can reduce emotional distress and help you cope with challenges now and in the future.

CBT can also help you change your expectations of yourself to better match what you can do. This can help you to use fatigue management strategies more effectively. For example, CBT can teach you to think differently about taking more time to finish a task, asking for help, setting boundaries, and being OK with saying “no."

Learn more about CBT and talk to your healthcare provider if you'd like to work with a therapist.​

Mindfulness

Mindfulness teaches people to live in the present moment, without judging things as “good" or “bad." Mindfulness can be helpful in:

• lowering stress before it leads to exhaustion
• recovering from mental fatigue
• improving both physical and mental health

For example, people who practice mindfulness release less cortisol from their brain. Cortisol is the hormone that is released when there is stress and it negatively impacts the immune response in your body. 

Learn how to practice mindfulness.

Relaxation

There are many types of relaxation skills that can help manage stress and improve your mental health, and thus reduce secondary fatigue due to mental health.

• Progressive muscle relaxation is a deep muscle relaxation technique that is helpful for depression, anxiety, insomnia, and muscle pain. It can even improve fatigue levels. You may need to adapt this technique if you have spasticity and pain.
• Deep breathing or belly breathing are techniques that can reduce stress and lower anxiety. Both stress and anxiety cause us to hold our breath or to breathe in a shallow way. Learning to take deep, relaxing breaths is easy and effective and lowers your stress response.
• Imagery is another tool used to help reduce stress and anxiety, which in turn can help manage fatigue. One form of imagery involves using all 5 senses to imagine a peaceful scene. You can use a video to guide you through the imagery.
  

Acceptance-based therapies

Learning to accept MS can help you adjust and adapt to the changes brought on by MS, including fatigue, in a healthy way. Acceptance-based therapies can be helpful in several ways. They can help you identify what really matters to you and find ways to help you work toward doing those things. Acceptance-based therapies can also help you tolerate difficult emotions that arise in response to having fatigue.

Acceptance takes time. Be patient with yourself. Some research studies have found that it can take 2 years or longer to reach a point of acceptance, and acceptance typically accompanies each new MS symptom or change.

Mental health concerns

Many mental health concerns have fatigue as a symptom, and so can worsen MS fatigue. 

For example, one of the symptoms of depression is low energy and fatigue. The fatigue from depression adds to the fatigue from MS, resulting in very high levels of fatigue. This is also true of other mental health concerns, like bipolar disorder, panic disorder, and generalized anxiety disorder.

Medicine can be helpful for many mental health concerns. If you have questions about medicines for mental health concerns, talk with your doctor.

If you or someone you know needs emotional or mental health support, visit Help in Tough Times for a list of resources or call Health Link at 811 anytime, day or night. You can also call 211 to find programs and services in your community. Support from 211 Alberta is also available via text and online chat.

If this is an emergency, call 911 or go to your nearest emergency department.

Sleep habits

Here are some suggestions to improve your sleep.

• If you have food or drinks with caffeine, have them earlier in the day to avoid being alert at bedtime. Caffeine is a long-acting stimulant and its effects on your alertness can last up to 12 hours. Caffeine can be found in food and drinks like coffee, tea, pop, and chocolate. It is also found in some medicines.
• Avoid smoking close to bedtime, because nicotine is a stimulant. If you need help cutting back or quitting smoking, talk to your healthcare provider or visit AlbertaQuits.ca.
• Avoid alcohol before bed. It might cause you to feel drowsy at first, but it results in a lighter and less restorative sleep.
• Don't have a heavy meal before bed. Your digestive system slows down at night, which makes larger meals hard to digest. This can cause an upset stomach, gas, bloating, or heartburn. It's OK to have a light snack before bed. Choose a snack that is high in complex carbohydrates, like bread or crackers. Avoid snacks that are high in sugar, fatty, or spicy as they can cause gas and heartburn.
• Limit how much fluid you drink starting about 2 to 3 hours before bedtime. This will prevent your bladder from filling up and needing to use the bathroom while you sleep.
• Have a bedtime routine so that your body and brain become trained to expect sleep. Go to bed and get up around the same time every day. Do quieter activities, like watching TV or reading, during the evening. Try a relaxing activity like deep breathing or imagery before bed. Your bedtime routine might also involve taking a bath, wearing pyjamas, or closing your blinds. These all act as signals to your brain that sleep is coming.
• Exercise 3 to 6 hours before bedtime. Exercising too close to bedtime can activate your body and interrupt sleep.
• Minimize stress in the evening by avoiding emails, arguments, or difficult conversations before bed.
• Make sure where you sleep is quiet, dark, and comfortable. Use your bed for sleep and sex only. It is important to connect your bed with sleep instead of activities that happen when you are awake, like eating, watching TV, or working.
• If you are lying awake in bed for longer than 30 minutes, get up and do something quiet like reading or watching TV and then go back to bed when yo​u are feeling drowsy.
  

Positive sleep thoughts

Many people have ideas about how a poor night's sleep will impact them the next day. Having negative thoughts like these while trying to get to sleep usually causes stress, which then disturbs your sleep. They can also lead to a bad mood and poor function the next day.

Try to focus on positive sleep thoughts, like:

• “How I function during the day might need to change, but I can get through the day."
• “It is important for me to prioritize what's important."
• “My body will work to recover core sleep and will likely be better tonight."

Sleep disturbances

Poor sleep or sleeping less can make your MS fatigue worse. But sometimes MS itself can be the reason you can't sleep well.

Many people with MS have sleep disturbances. This includes having trouble falling asleep, waking up in the middle of the night and not being able to get back to sleep, or waking up earlier than planned.

There can be many reasons that you have sleep disturbances, including:

• your MS symptoms, like bladder and bowel symptoms, pain and spasticity, difficulty turning over, or the changes to your brain
• other medical issues like epilepsy, heartburn, psychiatric disorders, breathing problems, and restless leg syndrome
• medicines you take, which can have side effects like alertness and restlessness
• stress and day-to-day worries
• where you sleep, with things like temperature, light, comfort, and noise level all impacting the quality of your sleep

There are ways to improve your sleep, called sleep hygiene. This includes ideas to manage your stress, change what you eat and drink, and adjust where you sleep.

Talk to your healthcare provider if you need help managing your MS symptoms, other medical issues, or medicines that may be impacting sleep.

Insomnia

Some of these sleep disturbances might be insomnia, but others are not. Insomnia is more than just “not sleeping well" and a doctor, psychologist, or sleep specialist need to make the diagnosis.

It is important to see a healthcare provider if you think you have insomnia because deciding for yourself that you have insomnia can lead to more problems with sleep. Some people who believe they have insomnia will engage in thoughts and behaviours that can actually cause true insomnia. Cognitive behavioural therapy is often the first treatment for insomnia.

Napping

If you didn't have a good night sleep, and feel like you need more sleep during the day, it's OK to nap (have a short sleep during the day). Napping can restore your energy and increase the energy you have for the evening.

Limit the time you spend napping to less than 1 hour. Napping for longer than 1 hour increases the chance that you will fall into a deep sleep, which can make it hard to wake up.

Try not to nap after 4:00 p.m. Napping too long or too close to bedtime can affect your restorative nighttime sleep.

Napping does not mean that you are being lazy or avoiding things. MS has a big effect on your body. It is tiring to think, to process, and to move. Take time to nap, if you need to.  

Rest

Rest is an important part of managing your fatigue levels. Rest does not mean you are “giving in" to fatigue. Rest lets you do more of the things that you find meaningful.

Rest does not always mean sleeping or napping. There are many different kinds of rest and ways to rest:

• Physical rest: deep breathing, relaxation
  
• Mental rest: silence, music, meditation
• Emotional rest: talk, therapy, reducing emotional baggage
• Social rest: taking a break from socializing or visiting with friends
• Creative rest: reading, walking in nature
• Spiritual rest: doing activities that bring a sense of purpose or meaning
• Sensory rest: turning off devices, going into a quiet space without visual or sound distractions

Learn more about pacing (a strategy that involves expecting fatigue and planning to rest) and follow these guidelines to manage fatigue and restore your energy levels through rest.

• Rest before fatigue sets in (rest before you get tired).
• Make rest a priority and a habit.
• Plan rest breaks into your day, then schedule other activities around your rest periods. This is part of planning and pacing.
• Short, frequent breaks are helpful. Consider resting for 10 minutes after 45 minutes of activity.
  

Healthy eating

If you are living with MS, there is no specific diet that you need to follow. There is no evidence to support that eliminating foods or eating special foods will either slow or stop the progression of MS. Be aware of diets that say you should stop eating whole groups of food. Limiting what you eat may result in eating fewer nutrients and can make eating less enjoyable. Restricting certain foods may also contribute to fatigue.

A well-balanced diet includes:

• a variety of whole foods that are less processed
• lots of fruits, vegetables, and whole grains
• lean meat and plant-based proteins
• healthy fats

A Mediterranean style of eating can be a great way to include these foods. Learn more by registering for the free online class “Mediterranean style eating for health" offered by the Alberta Health Services South Health Campus Wellness Centre. Find upcoming dates, registration details, and more information in the Wellness Centre Program Guide (PDF) (scroll down to the “Food, Nutrition, and Cooking" section of the guide).

Focus on overall healthy eating strategies:

• Drink enough fluid. How much you need to drink can change from person to person. Keep fluids easily available, like having a water bottle within reach.
• Eat regularly throughout the day to prevent blood sugar highs and lows, which can affect fatigue. How much to eat and when to eat can change from person to person. Some people find eating smaller meals more often helps with fatigue. Others prefer 3 meals per day. Try eating a meal or snack at least every 4 to 6 hours. You may want to set an alarm to remember to eat and drink.
• Include protein and fibre at meals and snacks to help control your blood sugar levels and maintain consistent energy levels. Examples of protein sources include meat, chicken, fish, eggs, dairy, tofu, beans, lentils, nuts, and seeds. Examples of fibre include whole grains, fruits, vegetables, beans, lentils, nuts, and seeds.
• Limit foods that are high in added sugars such as granola bars, sweetened yogurt and cereals, and sugar-sweetened drinks.
• Talk to your healthcare provider before starting any vitamins or mineral supplements. The safety of many supplements has not been studied for people living with MS. Some have been shown to be unhelpful or may impact your medicines.

If you would like support for healthy eating, talk to your healthcare provider about a referral to a registered dietitian.​