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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