One of the realities of being a pharmacist is that we’re easily accessible. There’s no appointment necessary for consultation and advice at the pharmacy counter. Questions range from “Does this look infected?” (Yes) to “What should I do about this chest pain?” to more routine questions about conditions that can easily be self-treated. Part of the pharmacist’s role is triage — advising on conditions that can be self-managed, and making medical referrals when warranted. Among the most common questions I receive are related to stress and fatigue. Energy levels are are down, and patients want advice, and solutions. Some want a “quick fix,” believing that the right combination of B-vitamins are all that stand between them and unlimited energy. Others may ask if prescription drugs or caffeine tablets could help. Evaluating vague symptoms is a challenge. Many of us have busy lifestyles, and don’t get the sleep and exercise we need. We may compromise our diets in the interest of time and convenience. With some simple questions I might make a few basic lifestyle recommendations, talk about the evidence supporting supplements, and suggest physician follow-up if symptoms persist. Fatigue and stress may be part of life, but they’re also symptoms of serious medical conditions. But they can be hard to treat because they’re non-specific and may not be easily distinguishable from the fatigue of, well, life.

This same vague collection of symptoms is called something entirely different in the alternative health world. It’s branded “adrenal fatigue,” an invented condition that’s widely embraced as real among alternative health providers. There’s no evidence that adrenal fatigue actually exists. The public education arm of the Endocrine Society, representing 14,000 endocrinologists, recently issued the following advisory:

“Adrenal fatigue” is not a real medical condition. There are no scientific facts to support the theory that long-term mental, emotional, or physical stress drains the adrenal glands and causes many common symptoms.

Unequivocal words. But facts about adrenal fatigue neatly illustrate why a science-based approach is a consumer’s best protection against being diagnosed with a fake disease.

The adrenals are a pair of glands that sit on the kidneys and produce several hormones, including the stress hormones epinephrine and norepiniephrine that are associated with the “fight or flight” response.  Can you tire these glands out? In the absence of any scientific evidence, chiropractor and naturopath James Wilson coined the term “adrenal fatigue” in his 1998 book of the same name. Take a look at the James’ own questionnaire, at adrenalfatigue.org, to see if you have have it. Do you ever experience the following?

1. Tired for no reason?
2. Having trouble getting up in the morning?
3. Need coffee, cola, salty or sweet snacks to keep going?
4. Feeling run down and stressed?
5. Crave salty or sweet snacks?
6. Struggling to keep up with life’s daily demands?
7. Can’t bounce back from stress or illness?
8. Not having fun anymore?
9. Decreased sex drive?

If you answered yes to any of these questions, you may have adrenal fatigue.

Some lifestyles are apparently more vulnerable to adrenal fatigue, including single parents, shift workers, an “unhappily married person”, and the “person who is all work, no play.” There’s no information provided to substantiate the quiz, qualify the vague terminology, or link to any relevant literature. (Of course there is the usual Quack Miranda warning which makes all of this possible: “These statements have not been evaluated by the Food & Drug Administration … etc.”)

Based on this quiz, it’s safe to assume that adrenal fatigue is the most prevalent fake disease in the world. And sure enough, that’s what its proponents think, too:

Dr. John Tinterra, a medical doctor who specialized in low adrenal function, said in 1969 that he estimated that approximately 16% of the public could be classified as severe, but that if all indications of low cortisol were included, the percentage would be more like 66%. This was before the extreme stress of 21st century living, 9/11, and the severe economic recession we are experiencing.

So let’s look into the medical literature on adrenal fatigue. There’s no entry in Dorland’s medical dictionary, nor does the ICD classify it as a medical condition. Pubmed lists only one relevant paper which is a review by two naturopaths, and published in the Alternative Medicine Review. But there’s no evidence for them to review.

Fake diseases are compilations of various symptoms into conditions without any scientific basis. Peter Lipson has examined this in detail here at SBM. As Dr. Lipson points out, it’s human nature to want answers and to understand patterns of symptoms. Defining a cluster of symptoms in general terms is the first mistake. Symptoms need to be collated in a rational way to understand the parameters of the disorder. With adrenal fatigue, there’s no objective operational description, nor is there a validated symptom score. Using a vague list of symptoms to identify patients is the second mistake. While laboratory tests are advertised for identifying adrenal fatigue, there’s no persuasive data to demonstrate that blood or saliva tests provide any meaningful information, or are correlated with any underlying pathology.

Adrenal fatigue shouldn’t be confused with adrenal insufficiency, a legitimate medical condition that can be diagnosed with laboratory tests and has a defined symptomatology. Addison’s disease causes primary adrenal insufficiency and usually has an autoimmune cause, with symptoms appearing when most of the adrenal cortex has been destroyed. Secondary adrenal insufficiency is cause by pituitary disorder that gives insufficient hormonal stimulation to the adrenals. Some liken adrenal fatigue to a milder form of adrenal insufficiency — but there’s no underlying pathology that has been associated with adrenal fatigue. That’s actually a common method of disease invention: take a real disease and claim that it exists in a subclinical form, though of course it lacks a single unambiguous sign or symptom. We are supposed to believe that it’s still a serious problem even though it is, by definition, so mild that it is undiagnosable by any physician.

While adrenal fatigue may not exist, the same can’t be said for the treatments. When you’re treating a fake disease, anything goes. Everything from homeopathy to herbal remedies to hydrotherapy, to traditional Chinese medicine and vitamin supplements are advocated for treatment. The endpoints of treatment are as nonspecific as the criteria for diagnosis. Young, conveniently, has his own supplement programs. The Adrenal Fatigue Institute (apparently unrelated to Young) sells a supplement called Cylapril via TV infomercials and online ads. Disappointingly but perhaps not suprisingly, there are a number of health professionals that offer adrenal fatigue services, from labs that will diagnose it with scientific-looking lab reports [PDF], to pharmacies that offer specialty-compounded adrenal fatigue products.

Conclusion

While adrenal fatigue may not exist, this doesn’t mean the symptoms people experience aren’t real. These same symptoms could be caused by true medical conditions such as sleep apnea, adrenal insufficiency, or depression. Accepting a fake disease diagnosis from an unqualified practitioner is arguably worse. Patients don’t receive a science-based evaluation of their symptoms, and they may be sold unnecessary treatments that are probably ineffective and potentially harmful. There’s no question that it would be frustrating to be experiencing fatigue symptoms and then to be told by a health professional that there is nothing medically wrong. But that is arguably better than the distraction of treating a fictitious condition.