Several years ago, I wrote a post on the subject of adrenal fatigue. I don’t recall exactly what prompted the rant, but I’m sure it had something to do with a personal trainer or MD-turned-author trying to make a quick buck by pushing supplements. It really annoyed me (still does, really) that people who should know better would jump on bandwagons built on almost insultingly simplistic science. Capitalize on the general mistrust of mainstream medicine and you’ve got a set of passive income streams in the making.
I think that this is a topic worth revisiting. It appears that my original article, now almost five years old, garnered some attention in the last day or two, so I thought it’d be worth addressing some of the “interesting” replies. More importantly, my understanding of stress and fatigue has progressed since those days, so this post can serve not only to debunk “adrenal fatigue” claims, but to explain how stress actually works and what might be happening in lieu.
Insultingly Simple Science
The idea behind “adrenal fatigue” is that — somehow — your adrenal glands become exhausted and unable to keep up with the demands of every day life. People reporting these symptoms claim to suffer from chronic exhaustion, with no energy to complete even the most basic activities that most of us take for granted.
That in itself is not without precedent. There is Addison’s disease, also known as adrenal insufficiency — the glands simply don’t produce enough stress hormones. The stress hormones include the catecholamines, epinephrine and norepinephrine, and glucocorticoids (the infamous cortisol). Both are necessary to mount a response to any environmental challenge; for all the bad rap cortisol gets in the bodybuilding and mainstream fitness communities, your life would not be pleasant without it. Just ask anyone with Addison’s disease.
But Addison’s is a quick diagnosis, and the disease involves a physical dysfunction of the adrenals, sometimes congenital, sometimes due to later infection or trauma. There’s no mistaking the symptoms once Addison’s kicks in.
The idea that your stress hormones are depleted during chronic stress, leaving you unable to cope, was a cornerstone of Hans Seyle’s General Adaptation Syndrome. Living organisms can only take so much before they collapse from exhaustion.
Except that it doesn’t quite work that way.
Most of us will be familiar with the term homeostasis, the stability-seeking behavior of living organisms. Homeostasis says that biological systems will seek out their set-point, an ideal value (or range of values) that are supposedly ideal for health and survival. Even this notion has been challenged in recent years.
Living organisms are complicated. So complicated that we’ve got a fancy term to describe them: complex adaptive systems. Think of how the weather, with every last molecule of air and water on the planet acting under broadly-understood thermodynamic laws to generate everything from a wind gust to the hurricanes that can knock down cities. We understand how it works, but the thing is so intricate, with trillions and quadrillions and zillions of parts interacting in nonlinear fashion, that we can’t hope to make any fine-grained predictions about its behavior.
That’s a complex system. We understand it, but predicting its behavior is Very Hard, if not impossible. Now take that concept and apply it to a living organism every bit as complex as the weather, an organized storm of molecules — except that it’s actively working to stay in certain stable configurations.
That’s your body. Your brain works to coordinate this nightmare through a bewildering array of feedback loops and regulatory pathways. There are no independent set-points and no single adjustments — the process of life is governed across your entire body, with an interplay of all your tissues and organ systems loosely managed by the brain.
This is allostasis: the brain’s attempt to keep you in a state of dynamic equilibrium by managing all of the organ systems and regulatory loops that compose your body.
Sound complicated? Good.
There’s dysfunction, and there’s dysfunction
In Why Zebras Don’t Get Ulcers, Robert Sapolsky gives an entertaining account of how stress dysfunctions and stress-related diseases happen. The premise of the book is that the allostatic processes meant to keep us alive in life threatening situations — as in the ulcer-free zebra sprinting for its life from the hungry lion — were never meant to remain active. The “fight or fight” reflex is supposed to get the zebra away from the lion, or maybe help it kick the lion’s teeth in, and then switch off. When that doesn’t happen, the same processes which save us begin to damage us, causing wear and tear that eventually leads to physical illness.
In the modern world, it’s too easy to stay “switched on” and stressed out. We find threats everywhere, and thanks to the uniquely human ability to imagine, our threats don’t even have to exist. Have to speak in public tomorrow? Pointy-haired boss looking over your shoulder? Kids sick again?
Due to intricacies of brain function, the same neurological pathways that assess a real threat and send you into overdrive are the same pathways involved in planning, forethought, and memory. Imagined events can evoke an emotional response every bit as real as that car that almost T-boned you. That emotional response sets off the cascade of stress symptoms with no regard to what got you so worked up in the first place.
In the allostatic view, there is no depletion of stress hormones, and really there is no exhaustion of adrenals or anything else. What we’re seeing is the accumulation of damage caused by the very mechanisms meant to protect us.
There’s quite a bit of literature on how cognitive appraisal — your psychological awareness of a potential threat — not only influences the stress-response pattern, but even becomes dysfunctional in patients with stress disorders. Your personality and coping approach, called your affective style, determine how stressed you become and how likely that stress is to aggravate later symptoms (both physical and psychological).
You can never rule out physical causes entirely, but a great deal of the symptoms can be explained by exaggerated stress-responses. Sapolsky mentions that there are “high reactors” — the so-called Type A personality — who treat life as an endless series of challenges to be overcome with pure hostility, or else with anxiety and neurosis. Even if there is an initial infection — as suggested in cases of chronic fatigue syndrome — or psychological trauma, it’s likely that poor coping styles perpetuate the physical symptoms.
Not only do these people shift into stress-mode over the slightest problem, but once there they demonstrate an extreme over-reaction — cortisol levels increase well above normal, and stay that way for entirely too long. The “high reactor” isn’t going to handle stress well.
Connect this back to the cognitive appraisal theory, and to Sapolsky’s thoughts on psychological stress. Combined with the absence of any clear physical cause, it’s likely that this cluster of symptoms has more to do with anxious, neurotic, or just plain hostile personalities who literally stress themselves sick.
The Adrenal Fatigue Doesn’t Exist?
I was prompted to write this piece because of a handful of troll comments that popped up on my old article, which all linked to a blog posted on another site. I’m not going to add to that fire, but I want to address a few final points about the “adrenal fatigue” concept.
My dislike of “adrenal fatigue” has always been a response to the peddling of pseudoscience that surrounds the term. With no scientific support whatsoever, a range of experts from MDs with books to personal trainers and Paleo Diet gurus have all appeared with miraculous, divinely-inspired knowledge of how to cure your malady — and of course a brand of supplements that will fix you right up.
That’s not helping. You don’t fix gaps in scientific knowledge by making things up.
Medical doctors are absolutely correct when they say that there’s no evidence for “adrenal fatigue”. Back when I wrote the original article, a search on Pubmed turned up one result for that search string, and it was a review paper describing how “adrenal insufficiency” had a history of not existing.
I’m sympathetic to people who experience these symptoms. “Adrenal fatigue”, such as it is, may exist entirely in your head, but that doesn’t make it any less real. We don’t ignore pain or treat it as unimportant because it’s a subjective sensation. As all the stress research shows, the subjective sensation translates into physical symptoms. I don’t doubt for a minute that people claiming these symptoms really have them, and I don’t doubt that their hormone levels are out of whack.
The quality of life experience is just as important as any materialist biological function. You don’t ignore that, but it doesn’t make any sense to treat the disorder as if your adrenal glands are actually “burned out”. Sleep and exercise won’t “fix it”, for the simple reason that you can’t overcome 16 hours of intense stress with token efforts — and exercise might even make it worse. Treating the hormones and glands with various shades of quack pseudoscience is putting a Band-Aid on an amputated leg; you might control some of the symptoms but you haven’t addressed the real cause of the problem.
And that’s what irks me most of all. For all the advocates of this disorder want to ignore measurable evidence of a dysfunction (“I know I have it!”), these same people are hung up on reductionist thinking — the idea that there must be something wrong with the gland, or else with the regulatory loop between the gland and the hypothalamus. There must be a physical cause, and it must be treatable with chemicals.
No acknowledgement of psychological or behavioral causes. But your mind can and does affect your body. Your thoughts, your tendency to get needlessly worked up, and your actions can all contribute to physical illness. What you think and how you behave does affect you. If your doctor doesn’t find a physical cause, maybe there isn’t one.
Maybe it’s you.
If it were me, the first thing I’d do is look at my coping style. Do I freak the holy hell out over a (proverbial or literal) drop of spilled milk? Do I spend most of my day as an anxious, neurotic mess, worrying about bills and work and kids and who knows what else? Do I get angry at the slightest provocation?
I’d look at my behaviors. Am I eating 800 calories of lettuce each day while doing three hours of cardio? Am I a CrossFitter? (I’m only half-kidding here — you know that some of you get freaky with the exhaust-yourself-everyday training, and that’s not helping) Do I rely on stimulants to have a good workout? Do I get enough sleep?
Medical doctors are right to discount the idea — there’s nothing physically wrong for them to treat. What you need is a good psychiatrist.