Aug 24 2010

Fake Diagnosis Fatigue

There is yet another dubious diagnosis coming into vogue – adrenal fatigue. This is an entirely made up syndrome invented by naturopath and chiropractor James Wilson. His website begins with the classic solicitation:

Are You Experiencing Adrenal Fatigue?*

* Tired for no reason?
* Having trouble getting up in the morning?
* Need coffee, colas, salty or sweet snacks to keep going?
* Feeling run down and stressed?

If you answered “yes” to one or more of these questions, you may be experiencing adrenal fatigue.*

That’s right – even if you answered “yes” to just one of those questions, which means that you are an average adult, then you may have this fake syndrome. This is beyond satire.

Wilson, of course, has a book to sell and is happy to sell you supplements to treat your “adrenal fatigue.” All of this makes adrenal fatigue seem more like a business model than a genuine medical diagnosis.

There isn’t really a controversy over adrenal fatigue – there is no scientific reason to think it exists. There is a fake controversy over the fake disease, with a number of dubious practitioners who want to sell supplements and products to treat this common “syndrome” – Wilson claims that 80% of people have adrenal fatigue at one point in their life. That’s great for the bottom line.

The adrenal glands are small glands that sit atop the kidneys (hence the name – ad renals). They produce cortisol, adrenaline, and other hormones that regulate body metabolism. Adrenal insufficiency is a real disease that can be diagnosed and treated.

Wilson now claims that adrenal fatigue is not as severe as adrenal insufficiency, but can result from chronic stress, and the chronic slightly low levels of adrenal function lead to the symptoms. This is a common strategy for making up fake diseases, and is very clever because sometimes knowing where to draw the line between healthy and unhealthy is a legitimate medical controversy. So it’s easy to take a real problem and then claim that a milder chronic version of it is also a real disease.

For examples, doctors debate over where exactly to draw the line between normal blood pressure and hypertension. Osteoporosis (lack of calcium in the bones causes them to become brittle) is a real and concerning medical problem mostly affecting the elderly and women more than men. But now there is the notion that osteopenia – a decrease in calcium in the bones but not enough to be osteopororis – is a milder or even preliminary version of osteoporosis and should be treated to prevent progression to the more serious form. This idea is legitimately controversial.

Probably the best way to resolve these questions is to perform clinical studies to see who benefits from treatment. That is a concrete question you can resolve with specific research – at what point do the benefits of treatment outweigh the risks and expense?

There are also, of course, other syndromes which are not legitimately controversial and seem, in my opinion, to have been made up just to carve out a marketing niche. Just as with adrenal fatigue, there is a claim by another Wilson (Dr. E. Denis Wilson) for low functioning thyroid (which he humbly named Wilson’s Syndrome). The symptoms?

Wilson said that the syndrome’s manifestations included fatigue, headaches, PMS, hair loss, irritability, fluid retention, depression, decreased memory, low sex drive, unhealthy nails, easy weight gain, and about 60 other symptoms.

So if you have fatigue, irritability, depression, and poor concentration do you have Wilson’s syndrome or adrenal fatigue? Or are you just a busy 40-something with kids, too little sleep, and too little exercise?

How do we know if a proposed syndrome is real? Well, first we need to have a discrete clinical entity. There has to be something specific about one or more symptoms or the combination of symptoms. There is no reason to suspect that a list of very common non-specific symptoms is a discrete clinical entity (and there is every reason to think that it isn’t). Or we can have a specific biomarker – some lab test or study that shows an abnormal result and also demonstrates validity – that is predicts something (such as response to a specific treatment). Fake syndromes like adrenal fatigue do not have any such biomarkers, but they do have dubious ones.

Lab tests are often abused to give false legitimacy to dubious diagnoses. Such dubious tests are designed to generate false positives, while more legitimate tests are dismissed with hand waving explanations about how they are not the right kind of test. If you want to diagnosis mercury toxicity, then do a bogus provoked mercury test and compare the results to normal values developed for non-provoked tests. That way you are almost certain to get a false positive. Or you can use standard tests developed for Lyme disease (like the Western blot) and just ignore the CDC diagnostic criteria, lower the bar all the way so that if any antigens are positive you call the test positive (sensitivity and specificity be damned).

Or, as in the case of adrenal fatigue, you can use a highly variable test, like a saliva test for cortisol, and keep testing until you get the result you like. More specific tests, like a blood test, or a stimulated cortisol, are dismissed because they measure cortisol in the blood and not the tissue (OK, what does that mean in terms of actual specificity and sensitivity?). Also, cortisol levels rise and fall, so you really need to do a timed test (8AM is typical) or multiple tests. Bottom line – the saliva test for cortisol is perfect for generating false positives and so is the favorite of adrenal fatigue advocates.

I would review the literature on adrenal fatigue, but there is nothing to review. Wilson and others have only anecdotes to offer as evidence. These anecdotes typically take the form of – “I was tired and depressed, but my doctor could not find anything wrong with me. Then after getting diagnosed with adrenal fatigue I began exercising, improved my diet, worked on stress relief, and took Dr. Quack’s magic elixir, and after a year the magic elixir made me feel better.”

This is what I call the “part of this nutritious breakfast” fallacy – make some positive healthy lifestyle changes, and/or get a real treatment, along with a fake treatment, then credit the fake treatment in the end when you feel better.

Real diseases and syndromes and real treatments have a body of scientific literature that they are built upon. Fake diagnoses that a dubious practitioner pulled out of their nether regions do not. What they do have are conspiracy theories about Big Pharma, stories about how doctors are all greedy, stupid, or just cannot see past their own noses, and anecdotes about how wonderful their treatments are. The pattern is clear, but unfortunately it is also timeless. There never seems to be a shortage of people willing to buy it.

Of course, mainstream medicine has its failings and foibles, but that is not a reason to accept any particular dubious claims. That’s just another logical fallacy used to distract people from the scientific facts.

Adrenal fatigue has all the markings of a fake diagnosis used to exploit those dealing with common symptoms of life. Some of these people may have a real underlying disease, and can get distracted from pursuing a proper diagnosis by the offer of a simple fake one. Many people need lifestyle adjustments, and that is where they should focus their efforts – not on magic supplements to treat nonexistent syndromes.

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14 responses so far

14 Responses to “Fake Diagnosis Fatigue”

  1. Bronze Dogon 24 Aug 2010 at 1:02 pm

    “This is what I call the “part of this nutritious breakfast” fallacy”

    I may have to use that. Perfectly covers a lot of woo: They’re the equivalent of Chocolate Coated Sugar Bombs that happen to be surrounded by wholesome stuff in the commercial.

    I believe George Carlin once joked that it was more like “adjacent to a complete breakfast.”

  2. rhacodactyluson 24 Aug 2010 at 1:32 pm

    Do you bleed when cut?
    Have to sleep regularly?
    Not enjoy odd numbered Star Trek films?
    Have trouble sensing ultraviolet electromagnetic radiation?
    Consistently fall for BS health claims?

    You may be experiencing adrenal fatigue.

  3. SARAon 24 Aug 2010 at 1:32 pm

    What strikes me about theses lists of symptoms is they are very similar to the non specific symptoms of real illnesses.

    And lots of people find themselves staring at medical websites self diagnosing themselves into hypochondria. I know I have found myself doing it and I’m supposed to be skeptical.

    This behavior is where these medical miracle sites get so much leverage. You do a nice google search on my symptom and voila – I find Dr. Wilson who is nice enough to diagnose me and provide me with easy to follow and drink remedies.

    I’m afraid the internet has taken our human foible of wanting easy answers and turned it into a monster.

  4. HHCon 24 Aug 2010 at 1:52 pm

    Perhaps Chiropractor Wilson asks these questions to assist him with routinely scheduling his office appointments. Clients won’t come in to their morning appointments for the reasons that they are too stressed or can’t wake up in time. He probably gets tired of working with agitated, caffeinated clients or hyperactive ones. Which leads him to sell these magic supplements so he can schedule and “treat” his customers regularly.

  5. BKseaon 24 Aug 2010 at 4:27 pm

    I think this guy is onto something here. Every morning I crave a cup of coffee. It is resolved with 100% effectiveness by a naturopathic tonic derived from ground coffee beans.

  6. bachfiendon 24 Aug 2010 at 5:32 pm

    Several years ago, I thought that I might have adrenal insufficiency, to go along with my treated and well-controlled hypothyroidism (there is a syndrome which has both), because I had many of the same non-specific symptoms listed, together with very easy skin tanning with minimal Sun exposure, even in Winter (adrenal insufficiency leads to elevated ACTH, which acts like melanotropin on melanocytes).

    So eventually I had an ACTH stimulation test, which was completely normal. The conclusion was that I had non-specific symptoms and very easy skin tanning, not adrenal insufficiency.

    I knew that I didn’t have adrenal insufficiency during the test because I got an almost immediate feeling of well-being after the injection of the ACTH.

    Cortisol does lead to subjective feeling of well-being in normal people, so I think any efficacy of treatment would be due to a real effect. JFK with Addison’s disease (adrenal failure) developed Cushing’s syndrome (the reverse; too much cortisol) because he overdosed on the cortisol (the correct dose made him feel good, too much made him feel even better)

  7. Plittleon 24 Aug 2010 at 6:27 pm

    So if you have fatigue, irritability, depression, and poor concentration do you have Wilson’s syndrome or adrenal fatigue?

    …or Wi-Fi sensitivity? I think we should round up all these quacks whose syndromes have the exact same symptoms, put them in a cage and let them duke it out.

  8. elmer mccurdyon 24 Aug 2010 at 11:52 pm

    See, this is why I like Quackwatch. You have a question about a treatment, you look it up, and much of the time you get the scoop, with no need to slap on any generalizations.

  9. Colldenon 25 Aug 2010 at 4:31 am

    Steven

    “Or are you just a busy 40-something with kids, too little sleep, and too little exercise?”

    So the reason that such a lifestyle might cause fatigue, depression, irritability, etc, has nothing to do with its long term impact on adrenal function?

    What is your opinion on psychological burnout? Does that exist? what are the physiological mechanisms behind the extreme fatigue and depression that burnouts claim to experience after the crash?

  10. Pinkyon 25 Aug 2010 at 6:35 am

    It’s a business model, yes, but not a good one.

    A good business model would allow for both ‘adrenal fatigue’ and ‘adrenal hyperactivity’ thereby hedging one’s bets ;-)

    Steve, please keep writing your TL;DR conclusions for those of us with ADHD! Cheers.

  11. ebohlmanon 25 Aug 2010 at 8:39 pm

    What strikes me about theses lists of symptoms is they are very similar to the non specific symptoms of real illnesses.

    One of the saddest posts I ever read was from a “Morgellon’s” sufferer over on White Coat Underground some months ago. Every time she was challenged, she’d name another “Morgellon’s” symptom she was experiencing and come up with a tortured explanation of how it came about, and every time that symptom would be a classic one of undiagnosed diabetes (e.g. she’d feel tired after eating a carb-heavy meal “because” the sugar was feeding the parasites). By the end of the exchange, I was near-certain that this was someone who had a real, serious, but treatable disease which she had mentally reframed into a fake disease.

  12. SimonWon 26 Aug 2010 at 1:16 am

    “Probably the best way to resolve these questions is to perform clinical studies to see who benefits from treatment.”

    As someone involved in Thyroid Support groups, I’d like skeptics to look further at the topic of “normal” in endocrinology.

    A lot of patients with thyroid disease are tired, depressed, and irritable (beyond what one might expect of 40 something parents – being a 40 something parent with a thyroid disorder a situation close to my heart), since these are common symptoms of many complaints including both under and over treated thyroid disorders. So we see a lot of this adrenal fatigue syndrome pushed to thyroid patients, of course adrenal disorders often being autoimmune in nature, they genuinely do occur more commonly (although still rarely) in people with thyroid disorders. So the doctors doing this will have some notable successes, even if they are generally misguided.

    The medical establishment (short of naming names) in the UK is busy convincing itself that one dose a day of levothyroxine is the perfect treatment for everyone, despite fairly clear experimental evidence it is unlikely to be optimal, although it may be as good as treatment is likely to get. We know however these people (those receiving levothyroxine) are much more likely to be obese, and more likely to die of Ischaemic heart disease, and there is little evidence to suggest this is due to aspects other than thyroid hormone levels (there is some evidence it might not be simply thyroid hormone levels, nice clean answers don’t often turn up in this topic).

    But the bigger problem with simply treating people and seeing who benefits is that one has to do the research. TSH is still the common screening test in the UK, even within the normal range this correlates inversely with cholesterol. It appears treating people who have thyroid antibodies and high “normal” TSH is probably justified, but with current testing strategies in the UK this group is unlikely to be identified unless or until they develop overt hypothyroidism. There is a load more research on the borderline area, but it doesn’t make the question of “normal” any clearer.

    Worst still many GPs struggle with what is normal for thyroid function, because the conventional approach of taking say the lower 97.5% of TSH results and drawing a mythical line in the sand is too simplistic. Various different countries draw their mythical lines in different places depending how they exclude people with thyroid dysfunction. So the average time to diagnosis for what is a well understood, common and (usually) easily treated disorder remains stubbornly around the 5 years after symptoms develop mark.

    The US AACE make what I think is pretty good recommendations:
    http://www.aace.com/pub/positionstatements/subclinical.php

    Probably the truth is that there is no universal normal here. That “subclinical” autoimmune thyroid disease is common enough to be classified as “normal” in the conventional sense of the meaning of normal. It is probable that some of the lifestyle advice given by governments and supported by epidemiological evidence is distorted by including a significant subgroup with thyroid dysfunction.

    My hope is GPs will read:
    http://www.medicine.ox.ac.uk/bandolier/band46/b46-5.html

    … and develop a healthy skepticism towards blood test reference ranges for common disorders.

  13. HHCon 26 Aug 2010 at 11:11 am

    Simon W, One tablet dosage of levothyroxine is essentially a placebo or homeopathic administration in the UK. Gastroabsorption of the medication is poor unless fasting has occurred prior to consumption. Daily dosages for specific U.S. medical diagnostic classifications are recommended. This establishes a therapeutic level. By the way, its not recommended as a treatment for obesity.

  14. Eon 04 Sep 2010 at 2:47 pm

    Not long ago I contributed a comment to a newspaper blog by a so-called respected health goddess. One requirement to do so was that you had to give your email address. The subject was her interview with a successful chiropractor (not mentioned above) and his thoughts on adrenal fatigue. I pointed out how there is no such thing as adrenal fatigue and how it’s merely a medical myth.

    Well, that comment set off a chain of nonsense that I can only describe as ‘unsettling.’ The blogger turned around and gave the chiropractor my personal email and he contacted me with a defense. It gave me the slight creeps she did that without my permission so I wrote another comment in the newspaper expressing this. The blogger wouldn’t publish that comment but did email me saying she didn’t see the problem. I assume she also told the chiropractor how I felt and assume he wasn’t happy because he commenced to send me a silly rewritten spam message. Spam, as in, ”Hi, I’m stuck an airport in…can you send money,” spam. Obviously, chiropractors aren’t too smart because this dummy actually signed his name. I emailed the newspaper’s editor and we even talked over the phone regarding the matter. He advised me to email the chiropractor and directly ask him never to contact me again. That seemed to work – thank goodness!

    Even though I’m glad this guy is out of the picture, one thing that bothers me is how the whole thing played out behind the scenes. The public was never given the opportunity to see the true colors of either the chiropractor or the health blogger.

    More recently, I saw an acquaintance who told me she had paid this particular chiropractor hundreds of cash dollars for a grouping of diagnostic testing (perhaps including adrenal fatigue). I told her of my experience and was even willing to show her the emails. I don’t think she believed me because she now ignores me, and that makes me very sad.

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