TDF (trendy diagnosis fatigue)

Has everyone heard about the two fad endocrine diagnoses making the rounds—Wilson’s syndrome and adrenal fatigue? In the past few months I seem to have been bombarded by patients requesting treatment for this supposedly underdiagnosed thyroid condition, or testing for adrenal fatigue.

Wilson’s syndrome was coined in the 1990s by E. Dennis Wilson, and I thought it had dropped out of sight, but it appears to have made a comeback—particularly from the naturopathic/homeopathic circles and from patients reading some of the popular health books. Adrenal fatigue is a newer term and I wasn’t aware of it until recently (and I now wish I still wasn’t!). It was coined by yet another Dr Wilson, Dr James Wilson (no relation to our editor), who wrote the book Adrenal Fatigue: The 21st Century Stress Syndrome.[1] Neither of these are accepted medical diagnoses, but the number of articles on the Internet and health books on these topics is astounding and are testament to the fact that interest in them probably won’t stop any time soon. Now I cringe when I see a referral to discuss adrenal fatigue or low body temperature.

So, what are these so-called disorders? Wilson’s syndrome encompasses about 60 common and nonspecific symptoms (insomnia, irritability, fatigue, hair loss, unhealthy nails, weight gain, poor memory, depression, a relatively low body temperature, and normal thyroid levels in blood). Dr Wilson claims to have discovered a new type of abnormally low thyroid function that is treated with a special type of thyroid hormone, triiodothyronine-T3. It is often precipitated by excessive stress. If it is treated and the body temperature returns to normal, treatment can often be stopped once the thyroid has reset its thermostat. The diagnosis is made based on an oral temperature below 98.6°F (an average of readings at three different times of day over several days) and symptoms, both of which are imprecise. A study of 143 normal individuals[2] showed body temperature at 8 a.m. averaged 97.6°F, with 50% below 98.6°F and many below 98°F, so what is a normal body temperature? Treatment with T3 can be harmful if not monitored very carefully. There is no good evidence that T3 is any better than placebo in treating these nonspecific symptoms in individuals with normal thyroid function. Treating someone for this syndrome could mask or miss other significant underlying medical problems. I tried to find clear information on the web site for the treatment doses, and found very little concrete information other than that sustained-release T3 is the only way to go (has to be compounded) and incremental increases in the dosage are recommended until the body temperature hits 98.6°F.

I have had a few patients who tried this treatment and never reached the target temperature despite being on doses of T3 that made them biochemically hyperthyroid. In addition to the T3 one could also purchase a lengthy list of vitamin supplements, all of which have fancy names but in essence are just like any other vitamins and can add up to high costs.

What about adrenal fatigue? This is thought to be a mild form of adrenal insufficiency that occurs in individuals who experience severe, persistent emotional or physical stress. The theory purported is that under conditions of chronic stress the adrenals eventually cannot keep up with the production of cortisone required to cope with the stress. This leads to a number of symptoms including fatigue, weakness, body aches, and depression. Again, the standard blood tests aren’t sensitive enough to pick up this deficiency, but the body is; hence the symptoms.

Blood cortisol levels are usually in the normal range, but Dr Wilson explains that they are clearly too low for a patient with adrenal fatigue. What does this mean? I have done formal ACTH stimulation tests on a number of these people (to put the issue to rest) and all of them had robust cortisol responses. Some even reached levels above the upper limit of normal range—probably because they were stressed! The recommended treatment for this condition mainly involves commonsense things to cope with stress—healthy nutritional habits, regular exercise, and of course the expensive vitamin regimen. But the really concerning thing to me is that “in some cases,” supplemental cortisone may be recommended. The doses suggested vary but can be equivalent to 10 to 20 mg hydrocortisone daily. This is completely inappropriate advice for individuals with normal adrenal function and can potentially lead to far more serious consequences.

What do I do in my practice? I spend as much time as I can explaining the science and physiology, but I often end up as frustrated as my patients. I feel as if my explanations are falling on deaf ears, no matter how much time I spend. So I do what I can: present the facts and hope that science will prevail in the end.

—SEH

References

1.  Wilson J. Adrenal Fatigue: The 21st Century Stress Syndrome. Petaluma, CA: Smart Publications; 2001. 361 pp.
2.  Mackowiak PA, Wasserman SS, Levine MM. A critical appraisal of 98.6 degrees F, the upper limit of the normal body temperature, and other legacies of Carl Reinhold August Wunderlich. JAMA. 1992;268:1578-1580.