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The text I’m about to paste below doesn’t come from me. It’s written by a man I’ve known for over years. He used to work as a researcher in endocrinology. He’s not my treating physician in any way, but knows more about me than any medical doctor I’ve seen over the last few years. He’s a very busy man, but has been kind enough to take of his time to help me out. I thought I’d post this here in order to help others. There’s a first second and third part.
This letter below that you wrote points out the problems for me in trying to communicate these complicated issues with you in the Internet. You did not understand my point and it would be very difficult to try to explain the issues.One reccuring issue for you is this term ‘adrenal fatigue’ – actually most of the problem is semantic – this term is used in many ways to mean very different things – with this being further complicated by the fact that there is no consensus on any of the basic terms and references.
I use Jefferie’s basic definition which was a simple reference to an inadequate Adrenal response – which most often refers to Cortisol insuffenciency but of course can also refer to excesses (excess catecholomines).
But simply stating that the Adrenal glands are not functioning optimally does not solve the problem becuase we need to know what in the HPA axis has malfunctioned first (which came first the chicken or the egg). Knowing a simple fact like the Cortisol level is low or fluctuates (which it would be logical to call Adrenal fatigue) – does not answer anything.
To state my model in a simplistic manner is that what is frequently called Adrenal fatigue is in fact a shut down of cortisol functions (notice I did not say exhaustion or depletion of Cortisol) – this shutdown is directly caused by the Pituitary as it recieves information to do this through the Amygdala and Hippocampus – which is recieving the ‘flight or fright’ signals from the over stimulated Sympathetic system. This is a circular self perpetuating mechanism which can be seen as a partial solution to long term overwhelming stress.
So in my model so called Adrenal fatigue is in reality a natural protective mechanism that attempts to protect us from excessive circulating catecholomines and the potential eventual total collapse of the stress mechanisms.
In most cases this is not an adrenal disease at all. It is a natural reponse of the secondary stress pathways that have kicked in because the primary pathways are no longer controling the stress.
In your case you have fluctuations in adrenal function – it is not consistant – having infinite cortisol tests will not solve the problems because the common theraputic approach to so called adrenal fatigue does not even begin to address the real problems – such as Pituitary and Amygdala malfunction resulting in imbalances in the HPA axis and Sympathetic dominance.
As I said – in your case – I believe that your issues do not start in the Adrenals and that you do not have actual Aderenal insuffeciency – rather your Cortisol functions become depressed becuase the Pituitary is instructing the Adrenals not to produce Cortisol – that is the explanation for many of your Adrenal anomalies – remember your tests have shown many different adrenal abnormalities over time – including radically fluctuating Testosterone and DHEA.
The mechanism I am refering to is similar to what happens when the Insulin receptor sites shut down in the presence of excess Insulin and sugar – this is called Insulin Resistance – a simliar thing happens in a radically inactive individual who has normal Thyroid function but the receptor sites shut down becuase there is no need for energy production – I call this Thyroid Resistance – this happens in all cases of under utilized musculature and muscle wasting. These are secondary functions that kick in as we lose our primary balancing functions – they are not diseases they are adaptive mechanisms.
To explain these issues is much to complicated.
Let me give a quick overview of my analysis of your case – because of certain genetic and inherited factors you have a tendency toward exagerated and inadequate stress responses = and as you have faced ongoing stress challenges (most of which are self generated) you have overstimulated your Amygdala and SNS leaving your Parasympathetic system depressed and unable to regain balance and homeostasis throughout the HPA axis – leaving you in a constant over reved state – you have lost the ability to calm yourself and this even further perpetuates the problem – so you become like a dog chasing it’s tail – going around in a non productive, exhaustive circle – it is like being on a thrill ride that you can not get off of.
The big problem is that this process keeps on perpetuating itself and the Amygdala keeps on sending alarm signals.
A short hand way of saying this is that this is not an adrenal problem – it is a brain problem with the biggest factor being the Amygdala – it is stuck on overdrive because of the excess catecholomines – which are being released because the Amygdala itself is captured by the excess circulating catecholomines and sends signals for a stress response – and so it goes round and round.
Selye and many others have been pointing out for many years how the stress response when over activated can cause a breakdown in the stress system and create chronic exhaustion of the entire organism.
This is one of the most common disease patterns seen in modern times and manifests in many ways – but there are common factors in all the cases which boil down to the fact that some people are overwhelmed by stress and have great difficiculty recovering from major stresses or from a series of small stresses.
Once the breakdown occurs even ordinary day to day stressors can further deplete the individual. So the tendancy toward inadequate stress response is there and is easily further challenged by the most ordinary events.
As you can see this is much too complicated an issue to be discussed in this limited forum. I will get someone to help me search for a description of this process in more depth than I can give it – and send it along to you.
==========================================================There are no easy answers to the questions about what to do about your health problems – as far as the basic question of – are there any workable methods to lessen or cure symptoms like yours – the short answer is yes – but with a BIG caveat – that caveat being cure is possible but not very common – only a small percentage of individuals actually recover – a larger percentage get reduction of symptoms to greater or lesser extents – a certain percentage spontaneously remit – the problem is that even in those who do recover a large percentage often have a set back the first time one faces a major stress challange.
There are many techniques that have been devised in the past and in the present for resolving the Amygdala overfunctioning – all of those methods are complicated and take a lot of focus and committment.
All of the methods that I know of can not be done by people with severe cases becuase these methods take energy, committment, and focus – all of these are qualaties that most people with stress disorder do not have.
I can not go into the multi-demensional aspects of this problem and it’s solutions because of time problems – below is a link to a web site of a Dr. Gupta who has devised a sysem for retraining the Amygdala – he describes the mechinism of the malfunctioning of the HPA axis and the over stimulation of the Anygdala.
He is refering to CFS but the mechanism is the same in all stress induced diseases.
There is a very direct link between your diseases and CFS – the possible difference is the state of the disease and the reasonns for why one may have contracted stress inadequacy – it is generally belived (which by the way I do not agree with these ideas) that CFS is triggered by a Viral infection – but viral infections are only one component in the potential breakdown of the stress mechanisms – in your case it is not clear if a viral infection triggered or contributed to your disease pathology – you did mention that you have EBV antibodies didn’t you?
There are many infectious states that can set one up for a breakdown of the stress responses – but whether this is a factor in your case is not clear but neither is it essential to know this to understand what has happened to you.
The triggers can be many but the results are similar in all cases and all have the characteristic of the stress response being over expressed – with the result being that the Amygdala is stuck at the on postion and keeps sending signals of alarm which keeps on releasing catecholomines and we never calm or relax suffeciently to heal – rest, calm and composure are the natural ways in which the stress system recovers. But when the Amygdala is steuck on alarm mode there is no recovery.
Read Dr Guptas essay repalcing the term CFS with stress disorder and tthen the mechanism of how this theory applys to you will be clear.
Try to understand the charts he has made as those charts are a short hand manner for understanding the pathways of the stress response.
I know this article is long and has a lot of new ideas for you to digest but if you can understand what he is saying you will understand your own case.
I doubt that dr Guptas retraing program would be helpful for you – it is very rigirous and few can do it – but the important thing is not that but that he has eazily and simply explained the basic problems in the breakdown of the stress response system.
http://www.cfsrecovery.com/html/medicalPaper.asp
==========================================================
Try to understand these articles along with Dr Gupta’s essay and you will have a clearer picture of your problems – what has gone wrong.
The adrenal issue you often refer to is not a cause (although it causes symptoms) it is itself an effect of the underlying brain and nervous system malfunctions.
These types of malfunctions of the stress response are related to the adrenals and interact with the adrenals but the underlying pathology is not caused by and can not be corrected by trying to correct adrenal anomalies (especially by HRT) – but the adrenal issue like the brain issue can be indirectly approached through the conscious mind – and it’s choices – the hypothalamus. amygdala, adrenal glands, etc. function outside of consciouness BUT they are effected by consciouness – in fact as Dr Gupta says this syndrome is a complicated conditioning process that reflects a continual dance between the unconscious processes and the conscious mind.
What should be a beautiful, graceful, elegant, dance has become a kind of wild floundering around that is not only causing symptoms, it is effecting the quality of life which keeps us from achieving our goals.
If you will remember these are all the same issues I have been discussing with you since the earliest days of our correspondence – I have sent you this article on the HPA axis several times before.
In the past I always emphasized the ANS and the overexpression of the ANS and the suppression of the PNS – perhaps by emphasizing the brain structures responsible for these malfunctions of the ANS you can come closer to understanding your condition.
SNS dominance and PNS suppression is a complicated conditioned response which has been created by several closely related brain structures that are responsible for activating and controlling the stress response.
Much of this is simply an unconscious habit that keeps perpetuating itself and will continue to do so until the brain learns a new more effective and effecient way of dealing with stress.
http://en.wikipedia.org/wiki/Hypothalamus
Thank you, Chip, for this letter.
I do not disagree with much of what he said. It is one side (out of many) of my own point of view.
I also have a more optimistic point of view than the writer has.
I end up treating chronic fatigue syndrome as part of the problems many of my patients have. I love it when the pain stops. I’m pretty happy with the results I get.
The immune system has a large role, as do the endocrine and nervous systems. But then, I consider them one system.
What the writer does not state, and what Dr. Gupta does not state, is that this state called “adrenal fatigue” or “chronic fatigue syndrome” could be considered a mental illness. Of course, that is the elephant in the room. And of course, the term “mental illness” has a huge stigma that is not acceptable for many people to consider.
The problem of not considering the “mental” component of an illness is that one never gets to address one of the biggest problems – the impact that psychological factors have on an illness – be it mental or physical or both.
The term “adrenal fatigue” is a subset of what I believe is a better term: “hypothalamic-pituitary-adrenal axis dysregulation”. This helps clarify the possible factors involved. It also helps free the practitioner from looking only at the adrenal glands as part of the problem. The rest of the body’s systems are in play.
From my point of view, the mind includes the nervous system, endocrine system, immune system, and cellular metabolism. They also form one system with the primary goal being survival.
The writer’s view of sympathetic dominance versus the parasympathetic nervous system is an oversimplification. These two systems work together as a team – not as opposing systems – in many processes. For example, the process of eating and digesting food involves the two systems working in concert. Digestion is NOT only a parasympathetic nervous system activity. Without the input of the sympathetic nervous system, digestion has problems.
It is the whole system, not just the sympathetic nervous system, that in working together has problems. Each system is a part of a whole.
There are appropriate reasons the sympathetic nervous system is overactive that are not due to a stress response. For example, in iron deficiency, the sympathetic nervous system has to become overactive as a compensatory mechanism to generate energy when cellular metabolism breaks down. Similarly, in thyroid dysfunction, again the sympathetic nervous system is activated by the brain to compensate for impaired energy production. The side effects occur from this compensation.
One can’t also blame the Amygdala for all of one’s problems. The Amygdala is a processing unit of the brain that specializes in analyzing threats. It certainly is doing its job. The problem may be that the data it has may be faulty. For example, if one grows up being abused or traumatized, then the treat level of other people is raised. This information becomes part of one’s belief system (my term for the internal model of reality we all build from the time we are born, which filters our sensory input, to determine what we think of as reality). Such faulty data, then is taken into account when the Amygdala receives sensory input. Of course, the Amygdala may determine the threat level is high, thus starting processes which raise sympathetic nervous system activity.
Of course, this doesn’t rule out actual structural problems in the Amygdala itself, as may occur in Autism.
I agree with the writer that the problem is a complex one. But, then, assessing and treating complex problems are what I do every day.
Many illnesses are “psychosomatic”. They have both mental health and physical health components. They involve every influence – psychological, psychiatric, nervous system, endocrine system, immune system, metabolism and nutrition, social, etc. It is important, when faced with such a condition, to be open to and to look for every factor involved to come up with a solution.
I disagree with the writer in regard to the treatment of “adrenal fatigue” with adrenal hormone replacement. Hormone replacement has its place. And in many people, it helps improve their condition. Rather than dismissing hormone replacement therapy’s place, I would say that it is only part of the equation.
Psychiatric medications, for example, do not often work well or only partily because people don’t realize that they are only part of the equation. Psychiatric medications treat the nervous system part of a condition, but not the immune system, endocrine system parts. And they definitely do not treat the psychological or metaboic-nutritional parts of an illness, be it mental or physical illness or both. But they do have their place.
The most difficult to treat patients are those with the largest psychological issues in their condition. This includes those with personality disorders. The biggest problem is in having the patient and often their physicians acknowledge that there are psychological issues to begin with. Psychotherapy also has a role in treatment.
Any component cannot be the only treatment in many circumstances. No amount of psychotherapy can treat hypothyroidism or iron deficiency or B12 deficiency, for example. And no amount of thyroid hormone can treat a strongly psychological problem such as trauma or abuse or nutritional deficiencies – or poverty for that matter. A multimodal point of view in treatment may be necessary.
Mental illnesses, for example, are highly complex conditions. For a mental illness to occur, usually multiple system problems have to occur, involving the nervous system, endocrine system, metabolism, nutrition – aside from psychological issues. A person with a mental illness is more likely to have multiple serious physical illnesses. One of my rules of thumb when doing consultation-liaison work in hospitals was that a person, whose medical record is over 1-inch thick, has a diagnosable mental illness. Generally, the underlying problems which cause the physical illness underly the mental illness. Chronic fatigue syndrome and fibromyalgia are frequent examples. Diabetes, hypertension, heart disease and cancer are other examples.
It is important that an integrated assessment and treatment that can look at a person as a whole – looking at the whole of the psychological, psychiatric, neurologic, endocrine, immune system, metabolism, nutrition, and any other aspect of a condition – be done as much as we can with the technology we have, to assure as good an outcome as possible.
Some problems may not have a solution. We don’t have all the answers. We don’t have a lot of solutions for genetic problems or many infectious problems, for example. We don’t know enough about the mind, the brain, the body yet to know every problem, nor do we have the technology yet for many problems. What I am doing is in its infancy, for example, despite how far it is advanced compared to current conventional practice of psychiatry.
The one teaching point of all this is that if we strive to see the whole person, to see all the parts of a person working together as an integrated whole, I think we can get as close as we can to find a solution. When we see only parts of a person, then usually we do not have an adequate solution.
Thanks Dr. Mariano.
I’m one to enjoy hearing both sides of the coin, or in this instance, a different perspective. I certainly highly value your input, because you have first-hand clinical experience.
Cheers
@chipdouglas 396 wrote:
Thanks Dr. Mariano.
I’m one to enjoy hearing both sides of the coin, or in this instance, a different perspective. I certainly highly value your input, because you have first-hand clinical experience.
Cheers
The writer is correct in stating that the term “adrenal fatigue” is an oversimplification and that other systems, such as the nervous system, are in play.
This is why I believe the correct term instead to use is “hypothalamic-pituitary-adrenal axis dysregulation”.
The increase in immune system pro-inflammatory cytokine production (such as IL-1, Tumor Necrosis Factor), may have a large role in producing this condition. But this area needs further study to clarify what is occurring.
My Dr and I have started to gravitate away from the term “adrenal fatigue” as well. The term is kind of becoming looked at something a quack would say as it describes as an umbrella term for many symptoms that are lumped together. The terms we are using now is adrenal insufficiency or cortisol imbalances because it sounds more professional and is better excepted with in the medical community. In reality “adrenal fatigue” does not medically exist since there are no icd-9 codes for it. When giving lab test one can use 255.5 for adrenal insufficiency as the reason for proper code so it is medically necessary.
The increase in immune system pro-inflammatory cytokine production (such as IL-1, Tumor Necrosis Factor), may have a large role in producing this condition. But this area needs further study to clarify what is occurring.
Now, what would bring on elevated IL-1 and/or TNF alpha levels ?
I bet unremitting stress is a very likely culprit.
@hardasnails1973 445 wrote:
My Dr and I have started to gravitate away from the term “adrenal fatigue” as well. The term is kind of becoming looked at something a quack would say as it describes as an umbrella term for many symptoms that are lumped together. The terms we are using now is adrenal insufficiency or cortisol imbalances because it sounds more professional and is better excepted with in the medical community. In reality “adrenal fatigue” does not medically exist since there are no icd-9 codes for it. When giving lab test one can use 255.5 for adrenal insufficiency as the reason for proper code so it is medically necessary.
Whenever I used the term adenal fatigue in company of physiology teachers in college or other health professionals, I’d also go : this is NOT a term I like and it’s not properly descriptive of the overall picture, and yes, it does sound like a term a quack would use. Sometimes however, MDs will use this term to oversimplify this complex issue, so their patients better understand.
@chipdouglas 503 wrote:
Now, what would bring on elevated IL-1 and/or TNF alpha levels ?
I bet unremitting stress is a very likely culprit.
Chip, traditionally it has been assumed that stress directly causes pro-inflammatory cytokines. However more likely is that the two often have an underlying cause. Namely chronic infections. Chronic unresolved infections (e.g. viral, intracellular bacteria etc) will result in the body pumping out pro-inflammatory cytokines as an immune response. Chronic infections are also a cause of unremitting stress on the body, and they can radically disturb the body’s natural cortisol rhythm. Basically people with chronic infections tend to have a flatter 24-hour cortisol curve, with the area under the curve being higher. Paradoxically the body is suffering from “high” and “low” cortisol at the same time (e.g. too high at night, too low in the mornings). Most forms of stress wax and wane, but chronic infections are a stress on the body 24 hours a day, 7 days a week. There is no more unremitting form of stress than a chronic infection.
Stress was once thought to be the cause of stomach ulcers. Turns out the “stress” was caused by a chronic unresolved infection, namely Helicobacter Pylori.
Most of these infections are carried for life, so the number and extent of these infections will increase as a person gets older. This is one reason why older people have higher levels of pro-inflammatory cytokines.
@garcia 512 wrote:
Chip, traditionally it has been assumed that stress directly causes pro-inflammatory cytokines. However more likely is that the two often have an underlying cause. Namely chronic infections. Chronic unresolved infections (e.g. viral, intracellular bacteria etc) will result in the body pumping out pro-inflammatory cytokines as an immune response. Chronic infections are also a cause of unremitting stress on the body, and they can radically disturb the body’s natural cortisol rhythm. Basically people with chronic infections tend to have a flatter 24-hour cortisol curve, with the area under the curve being higher. Paradoxically the body is suffering from “high” and “low” cortisol at the same time (e.g. too high at night, too low in the mornings). Most forms of stress wax and wane, but chronic infections are a stress on the body 24 hours a day, 7 days a week. There is no more unremitting form of stress than a chronic infection.
Stress was once thought to be the cause of stomach ulcers. Turns out the “stress” was caused by a chronic unresolved infection, namely Helicobacter Pylori.
Most of these infections are carried for life, so the number and extent of these infections will increase as a person gets older. This is one reason why older people have higher levels of pro-inflammatory cytokines.
Stress CAN cause an increase in pro-inflammatory cytokines.
A chronic infection is only one type of stress.
There are many other types of stresses.
For example, a social stress that threatens one’s social status is a commonly cited and known stress that will cause an increase in pro-inflammatory cytokines. Social threats are one of the ways to easily increase pro-inflammatory cytokines in psychoneuroimmunology studies.
Realize that the source of pro-inflammatory cytokines is not only the cells of the immune system, but also the brain itself. When the brain recognizes a threat, the locus ceruleus increases norepinephrine production to signal the presence of stress. The brain’s microglia sense the stress signal and produce pro-inflammatory cytokines.
The immune system itself can signal the stress of an infection to the brain by releasing pro-inflammatory cytokines. The brain itself can signal the stress and activate the immune system. The systems have bidirectional communication. I consider them as a single system, actually.
Is the reversal of the cortisol curve “paradoxical” or is it a normal response under stress? The normal cortisol curve is with the assumption of minimal stress and a person at rest. This “paradoxical” curve is under the presence of an illness. The system may be responding instinctively to stress. For example, a common early human history stress is safety from predators. Perhaps the immune system is triggering an automatic defensive program in the brain to be more awake at night – when one is less safe from predators. This would then increase norepinephrine at night to keep awake. Cortisol would then follow norepinephrine. Injecting pro-inflammatory signals to experimental animals often results in the triggering of automatic defensive behaviors or postures. These behaviors resemble depression.
On the other side, the high cortisol in the evening may mean the other controls on norepinephrine production are off at night, resulting in a corresponding increase in adrenal cortisol production. Without this cortisol production, norepinephrine would be even more out of control and a person would be in worse trouble. The capacity to increase cortisol production to a “high” level is actually a good sign that the adrenals are capable of producing cortisol in the first place. However, the brain’s timing circuits may be off or another signaling problem is present.
@DrMariano 532 wrote:
Stress CAN cause an increase in pro-inflammatory cytokines.
A chronic infection is only one type of stress.
There are many other types of stresses.
For example, a social stress that threatens one’s social status is a commonly cited and known stress that will cause an increase in pro-inflammatory cytokines. Social threats are one of the ways to easily increase pro-inflammatory cytokines in psychoneuroimmunology studies.
Realize that the source of pro-inflammatory cytokines is not only the cells of the immune system, but also the brain itself. When the brain recognizes a threat, the locus ceruleus increases norepinephrine production to signal the presence of stress. The brain’s microglia sense the stress signal and produce pro-inflammatory cytokines.
The immune system itself can signal the stress of an infection to the brain by releasing pro-inflammatory cytokines. The brain itself can signal the stress and activate the immune system. The systems have bidirectional communication. I consider them as a single system, actually.
Is the reversal of the cortisol curve “paradoxical” or is it a normal response under stress? The normal cortisol curve is with the assumption of minimal stress and a person at rest. This “paradoxical” curve is under the presence of an illness. The system may be responding instinctively to stress. For example, a common early human history stress is safety from predators. Perhaps the immune system is triggering an automatic defensive program in the brain to be more awake at night – when one is less safe from predators. This would then increase norepinephrine at night to keep awake. Cortisol would then follow norepinephrine. Injecting pro-inflammatory signals to experimental animals often results in the triggering of automatic defensive behaviors or postures. These behaviors resemble depression.
On the other side, the high cortisol in the evening may mean the other controls on norepinephrine production are off at night, resulting in a corresponding increase in adrenal cortisol production. Without this cortisol production, norepinephrine would be even more out of control and a person would be in worse trouble. The capacity to increase cortisol production to a “high” level is actually a good sign that the adrenals are capable of producing cortisol in the first place. However, the brain’s timing circuits may be off or another signaling problem is present.
Very informative post–thanks
Likewise to the other poster above.
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