Adrenal Fatigue, Adrenal Insufficiency, or Something Else?

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How stress impacts us all

“I’m so exhausted all the time, I think I have adrenal failure.” “My friend told me her naturopath said her that her adrenals crashed and I think mine have too.” “I took a test and my cortisol was low and my chiropractor told me I have adrenal fatigue.”

If you are interested in integrative and holistic medicine, you’ve inevitably read something online, taken some sort of quiz, or been offered a program or product regarding adrenal fatigue. Or is it adrenal exhaustion? Adrenal insufficiency? Adrenal failure? What’s the difference between all these terms anyway? As it turns out, quite a lot.

The term “adrenal fatigue” was first coined in 1998 by a chiropractor, Dr. James Wilson and written about in his publication Adrenal Fatigue, the 21^st Century Stress Syndrome.[1] Somehow, this 21^st century in which we are now fully immersed was felt to be more demanding on our health and function than the stressors of World and Civil Wars, migrating to different continents, and the Great Depression that our grandparents and great grandparents experienced before this. So, what do we really mean to say when we discuss the impact of chronic stressors on our health, vitality, and zest for living?

The medical condition of adrenal insufficiency

Primary adrenal insufficiency, or Addison’s disease, is a medical condition that has been shown in various population studies to affect between 39 to 140 individuals per million people.[2] In this day and age, the most common cause of primary adrenal insufficiency is autoimmune destruction of the adrenal cortex, whereas in Thomas Addison’s day, the physician for whom it was named, it was destruction due to tuberculosis.[3] As with other autoimmune conditions, the majority of those living with autoimmune adrenal destruction and related insufficiency are female. The majority (84 – 95%) of patients experience fatigue, but symptoms of weight loss, darkening of the skin, low blood pressure, salt cravings, nausea, vomiting, abdominal pain, and muscle and joint pain also commonly are present.[4] Diagnosis involves blood tests to check cortisol and corticotropin (ACTH) levels, and tests to screen for a tumor that might be causing the problem.

Although there are clear diagnostic criteria for diagnosing Addison’s disease, there is a broad range between normal cortisol levels and those seen in frank adrenal insufficiency. Which begs the question: what’s happening in that big, grey zone?

The gray is wide, and what do we call it?

What is the appropriate terminology to describe the state of sub-optimal function, fatigue, and exhaustion that we associate with chronic stress taxing the adrenals? Is burnout an appropriate medical term? Of course, we would need to dress this up for the use of diagnosis codes, but perhaps “Fatigue, attributed to excessive physical, mental, or emotional exertion” would do the job. There actually are a good many studies in which burnout is the terminology used to describe the presentation of this state, but again, no standardized clinical marker exists.[5]

What do we really mean to say when we discuss the impact of chronic stressors on our health, vitality, and zest for living?

A description such as “Stress-associated fatigue syndrome” may capture what we are attempting to define. Much like irritable bowel syndrome, this would be a diagnosis of exclusion, with other possible causes of fatigue ruled out. And then, similarly to other syndrome-type diagnosis, a list of inclusion criteria would be applied. For example, the patient must present with 3 of the 5 following criteria:

• Fatigue, defined by a low level of energy which limits the ability to perform the typical activities of daily living more than 50% of the time.
• Sleeping excessively or being unable to sleep.
• Frequent infections or difficulty in recovering from illness.
• Mood changes including mild to moderate depression, anxiety, panic attacks, or general apathy.
• Any one of the following symptoms: weight loss, skin hyperpigmentation, postural hypotension, salt cravings, nausea, vomiting, abdominal pain, muscle or joint pain.

The verbiage surrounding the diagnosis also should include the clause “Symptoms must be preceded by a state of chronic stress due to illness, work, emotional trauma, challenges of physical or mental endurance, and/or disrupted sleep.”

Cortisol does not act alone!

The levels of every hormone, neurotransmitter, protein, and metabolic intermediary in the body are dependent on many, many factors. Cortisol of course is no different. The function of each of the glands along hypothalamic-pituitary-adrenal (HPA) axis impact our levels of cortisol, while factors such as thyroid function, insulin levels, obesity, and inflammation also have an effect.

For review, the hypothalamus secretes corticotropin releasing hormone (CRH), which stimulates the anterior pituitary to release adrenocorticotropic hormone (ACTH), which subsequently stimulates the adrenal cortex to produce and release cortisol. There is a negative feedback loop by the secretion of cortisol on the both the pituitary and hypothalamus secretion of ACTH and CRH respectfully. The release of CRH is stress-dependent and the HPA axis also has a diurnal rhythm.[6]

In the chronic stress state, the HPA axis function and responsiveness to stress changes. The adrenal glands often increase in size and become more sensitive to stimulation, thereby increasing their production of the stress hormone cortisol.

The HPA axis response is different with acute and chronic stress, even with different pathways in the brain serving to mediate it.[7],[8] In the chronic stress state, the HPA axis function and responsiveness to stress changes. The adrenal glands often increase in size and become more sensitive to stimulation, thereby increasing their production of the stress hormone cortisol.[9],[10] Under normal circumstances, high levels of cortisol in the blood usually send a negative feedback signal to the brain, telling it to stop stimulating the adrenal glands. But this negative feedback becomes dysfunctional in high stress states, contributing to further nervous system imbalances and sleep trouble.

Although the way the HPA axis adapts to chronic stressors seemingly only worsens the situation for us, it is important to remember the stressors in life in more primitive settings were things like the threat of attack by animals or other enemies, settings in which survival would improve if the body became more vigilant and had a more rapid response. Unfortunately, our bodies can’t tell the difference between a grizzly bear and a tight deadline at work: the physiological response in both situations is the same.

So, what do we do for this dysregulated state of adrenal function and presentation of fatigue?

The standard, conventional treatment for individuals with suspected adrenal fatigue is corticosteroid drugs like hydrocortisone and prednisone. But is this the correct treatment course?

Anyone who has ever been on a corticosteroid will probably report they had a significant boost in energy levels despite what the treatment was for. But the reason that mindful practitioners don’t dote out steroids like holiday candy is that there is a significant potential for harm, particularly when they are used on a long-term basis. Osteoporosis (low bone density), stomach problems, weight gain, diabetes, insomnia, the reactivation of viral infections, and even psychosis are just a few of the risks of using steroid medications. Excess cortisol can also adversely impact thyroid function,[11] further messing up our body’s regulation of the endocrine system.

Thankfully, there are other approaches to managing adrenal fatigue states: substances such as botanicals, nutritional supplements, homeopathics and glandulars help many people with stress-associated fatigue syndrome. Holistic providers are also well aware symptoms cannot be treated without addressing the cause. Much of our time spent helping depleted people heal therefore involves improving diet, aiding patients to recognize and remove contributing stressors, and supporting nutritional deficiencies. Each of these things has a much greater impact on overall health than a corticosteroid treatment.

One thing that is important to remember is the tremendous array of conditions that have fatigue as a symptom. This includes common diagnoses of hypothyroidism, anemia, autoimmune disease, and even more scary diagnoses such as cancer. After ruling out other possible common causes of fatigue, we can then move forth with holistic approaches such botanicals and nutritional support.

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