Fatigue, Chronic fatigue, or Adrenal Fatigue?
Fatigue is a common, nonspecific symptom with a broad range of causes, including acute and chronic medical disorders, psychological conditions, medication toxicity, and substance use. Fatigue can be used to describe difficulty or inability to initiate activity, subjective sense of weakness, or difficulty with concentration, memory, and emotional stability (mental fatigue). Fatigue could be described as acute, lasting one month or less, subacute fatigue, lasting between 1 to 6 months, and chronic fatigue, which is lasting over six months. According to medical literature, about 30% of patients who seek attention in primary care offices are complaining of fatigue. Fatigue is reported more commonly in women than in men. Causes of fatigue could be multiple. Acute fatigue is usually attributable to an acute medical condition. For example, a person with flu, a patient who is stressed or drinking a lot of alcohol, or a person suffering from anemia.
Some acute and chronic fatigue can be more complicated, and it could be caused by many other identifiable medical and psychological conditions. Some of them are chronic conditions such as congestive heart failure, emphysema, or sleep apnea. Some endocrinological conditions, such as hypothyroidism (low thyroid), hypogonadism (low testosterone), adrenal insufficiency (such as Addison’s disease) can cause severe fatigue. Chronic liver and kidney disease, rheumatoid arthritis, lupus, Hashimoto’s thyroiditis can also produce chronic fatigue. Fibromyalgia and psychological conditions, such as anxiety and depression, neurological conditions and medications’ toxicities are also on the list of causes. Usually, about 2/3 of patients can be diagnosed with an identifiable source of chronic fatigue. A minority of patients for whom the root cause of chronic fatigue cannot be found, fall under the umbrella of Chronic Fatigue Syndrome, which is poorly understood and treated.
Evaluation of chronic fatigue includes initial assessment, comprehensive history, physical examination, and laboratory studies to rule out an underlying hormonal imbalance such as thyroid or adrenal, severe nutritional deficiency, such as iron, B12, folate or thiamine, and updated cancer screening interventions to identify potential underlying malignancy as a cause of presenting fatigue.
Once the correct diagnosis is established, a patient is treated according to his diagnosis. For example, if a patient is diagnosed with Lyme disease then the treatment for Lyme disease with antibiotics is initiated. If the patient is diagnosed with an autoimmune condition such as Hashimoto’s thyroiditis, Rheumatoid Arthritis, or Psoriasis, then specific treatments should be started, and once the respective condition is treated or controlled, symptoms of fatigue should improve. If the patient is diagnosed with major depressive disorder or anxiety which could present as fatigue, the treatment for depression or anxiety could be started with medications and psychotherapy.
If a patient, on the other hand, presents with chronic fatigue for which no definitive cause can be established, the diagnosis of Chronic Fatigue Syndrome is established. The definition of Chronic Fatigue Syndrome is restricted and is reserved to diagnose patients for whom no other causes of chronic fatigue could be identified. There is some overlap there with the diagnosis of fibromyalgia, which presents with musculoskeletal pain often accompanied by fatigue and for which no cause has been established.
In patients with residual fatigue or Chronic Fatigue syndrome, traditionally a trial of antidepressant therapy is recommended even if the patient does not meet the criteria for major depression. If there is no improvement, the patient is recommended a trial of psychological therapy, such as cognitive-behavioral therapy and exercise therapy.
In my experience, many patients who are diagnosed with Chronic Fatigue Syndrome experience severe debilitating symptoms. Some of my patients complain of such severe fatigue that it interferes with activities of daily living such as working, walking, or even standing and taking a shower! Some of the patients I see look normal and do not appear sick and some have been already put on an antidepressant without clear improvement.
Might these patients fall under the umbrella of this mysterious condition which is often called Adrenal Fatigue? Adrenal Fatigue is not a medical diagnosis recognized by mainstream medicine. There was no mention of adrenal fatigue in my textbooks in medical school or internal medicine residency training. When I first read about Adrenal Fatigue on the internet, I believed it was mass hysteria propagated by alternative medicine doctors and patients who opposed standard medical treatments. However, through years of experience, my personal journey, and further research on the subject, I now realize that there are many patients who suffer with a form of fatigue, for which traditional medicine has no classification. I believe that Chronic Fatigue Syndrome is loosely related to what is called Adrenal Fatigue, and involves many symptoms, such as various degrees of fatigue, weakness, severe insomnia, inability to lose weight, anxiety, allergies, brain fog, and various forms of stress, just to name a few.
Mayo Clinic writes on its website that “ adrenal fatigue is a term applied to a collection of nonspecific symptoms, such as body aches, fatigue, nervousness, sleep disturbances in digestive problems. The term often shows up in popular health books, …and isn’t accepted medical disease.”
In my experience of treating many fatigued patients and years of reading available non-mainstream literature, I can now say that a constellation of named symptoms do not have an equivalent diagnosis in medical textbooks, but render many patients with debilitating and confusing symptoms which are difficult to diagnose and treat following standard of care practice guidelines. Many patients self-diagnose themselves with Adrenal Fatigue and seek alternative treatments to help restore their health. Often I hear symptoms, such as exhaustion, weight gain, decreased libido, feeling “wired and tired” at the same time and not being able to fall asleep, feeling that the system is in “overdrive” from persistent release of adrenaline, cravings of salt or sweets and relying on caffeine beverages just to stay awake and get through the day. Many report difficulty in getting up in the morning, brain fog and having multiple allergies. Some patients who continue to ignore their symptoms feel progressively more lethargic, weak, develop hyperglycemia (low blood sugar), hypotension (low blood pressure), and inability to participate in activities of daily living. Some patients and practitioners report that at later stages a person may develop POTS, Postural Orthostastic Tachycardia syndrome, — an obscure condition where upon standing up one’s heart rate is elevated but blood pressure remains normal. Usually diagnosed by a tilt-table test and treated by Cardiologists, POTS is also related to prior exposure and reactivation of EBV, Epstein Barr Virus, which attacks the autonomic nervous system and is implicated in exacerbation of some immune conditions.
There are no uniform guidelines or standard of care to better approach and treat Adrenal Fatigue or the type of fatigue which does not fall under Chronic Fatigue Syndrome. In my experience, every patient is unique and finding underlying causes (which are usually multiple) and proper treatment is challenging. However, with a systematic approach in addressing each individual’s metabolic predisposition, evaluation of stress, hormonal and nutritional status, it is possible to significantly improve or resolve many cases of fatigue. Special attention needs to be paid to restoration of sleep, which is fundamental to restoration of body’s energy, brain function, and hormonal balance. Any source of underlying infection or inflammation needs to be found and treated, as it continues to weaken the person’s defenses. Gut microbiome needs to be restored through proper diet and supplementation. Food allergies and sensitivities have to be checked and an appropriate diet plan established. There is no “one fits all diet” and customization is key here, specifically tailored to a person's medical history and lifestyle. Special attention needs to be paid to the group of B vitamins which are essential for metabolism, energy, restful sleep, and which become especially depleted when a person is under continuous stress. Most importantly, it is imperative to maintain hope, a positive outlook, and adopt healthy techniques such as visualization, meditation, and yoga breathing to embark on the course to a successful recovery and restoration of good health. From positive thoughts to necessary testing and step-by-step implementation of dietary, supplementations, sleep and other lifestyle improvements, it is possible to regain life’s energy and balance.
Please reach out with any questions and for help.
Dr. Natasha Fuksina, Integrative Internal Medicine physician and a former chronic fatigue sufferer.
