Excerpt from Chronic Fatigue Unmasked 2000, Chapter One, by Gerald Poesnecker (Originally Adrenal Syndrome) by #73810 Blog entry

MY more than forty years' experience has led me to believe Chronic Fatigue Syndrome (CFS) is a condition of the neurohormonal and immune mechanisms of the body that produces a weakening of the body's ability to respond to stress of all kinds. The most common symptoms produced by this condition are unexplained exhaustion sometimes alternating with spells of anxiety or panic, a tendency to be oversensitive and/or allergic to certain substances or environments, a lessening of the ability to reason rationally and to make decisions readily, a tendency toward low blood pressure, sensitivity to cold, poor circulation (cold hands and/or feet), and brain fog or other mental aberrations which can mimic a large variety of mental diseases. Individuals in the Countershock or Resistance stage of CFS may not suffer the fatigue, but will experience mostly the anxiety and/or panic symptoms until they enter the Exhaustion stage. Most patients with CFS have at least one of these symptoms, and some have all and many others besides.This condition, to a lesser or greater degree, affects 20 to 25 percent of the American population. Fortunately, most of these are not severely afflicted, but today vast numbers of our people function at less than half their true potential because of CFS. Since it is the nature of the CFS patient to be a responsible, creative and productive citizen, the loss to America caused by this condition is significant.

As common as this condition is, only in the last few years has it been recognized, and it still is rarely treated effectively by most practitioners of the orthodox medical persuasion. In my early editions of this work, I called this condition, "The most ignored disease in the country today." Unfortunately, while the condition is not as ignored now as it once was, it does seem that the patients still are. A patient of mine, who is a vice president of a most prestigious university in Philadelphia, went to three of the best-known medical centers in Philadelphia with the symptoms of CFS. They all agreed that he had CFS, but they were equally unanimous in assuring him that they didn't know anything he, or they, could do to help his condition. Both he and his wife later came to us as patients and in a few weeks both were much improved.

Personally, I think that much of this medical apathy has been produced by the general vagueness of this disease's character, by the neurotic-like symptoms of its victims and by the slow and tortuous path of its correction even with the best and most advanced therapies. In our Clinic, I always meet the newly diagnosed CFS patient with mixed feelings. I am on one hand pleased to know that the patient has started on the road to becoming useful and productive again instead of languishing in a low-functioning state; on the other hand, I always groan a bit inside when I think of the amount of care, time and constant loving support that will be necessary to carry this patient through the seemingly unproductive early stages of treatment. With perseverance, however, all patients respond, and in the end they prove to be among our most appreciative patients. This thought-at times, this thought alone-gives us the ability and the strength to carry on with the CFS patient.

There seems to be a quirk in many doctors which, perhaps more than anything else, may explain their seemingly conspiratorial refusal to recognize CFS. Most physicians, in order to function as stable human beings, require a certain amount of personal ego satisfaction when they treat a patient. Even though there are vast fields of disease which are complete mysteries to modern medicine, the average day-to-day working physician often feels he must, at least in some manner, examine all the symptoms and problems that confront him. If he cannot rationally explain them, he must make up explanations, and if he cannot cure his patients, he must find some way to place the blame for his lack of understanding, knowledge and ability on the patient or on the circumstances. In the early days of medicine, physicians had ready explanations for causes of symptoms and ailments which were presented to them. The fact that today we realize that most of these early explanations were ridiculous has not prevented the medical profession from continuing this practice. To witch doctors, all diseases are caused by demons that inhabit their patients. Their job, of course, is to exorcise these demons. The "scientific" physician, when confronted with a patient who displays the symptoms of CFS, has a ready answer: "The patient is depressed, neurotic, mildly psychotic, unmotivated or just bored with life." With that self-satisfied stance that can be a "badge of our tribe," the patient is given a tranquilizer, antidepressant or both, and with the fatherly advice to stop worrying and to go to work he is sent home. It is just as impractical to tell a tubercular patient to go and play football as it is to tell a CFS patient to stop worrying.

Am I exaggerating? Am I a little too hard on my medical contemporaries? One has only to remember that a short time ago patients were literally bled to death in an effort to satisfy this medical ego-our first president being among those to be so helped into the next world.

There is, however, a specific cause that produces these wrecks of human society, and there are ways of returning these people to active, productive lives. This book defines this disease, lists the various symptoms produced by this condition, assesses the various stresses that trigger and aggravate this ailment and outlines a comprehensive plan of treatment to overcome this insidious disorder. This last paragraph was written in 1983 and I see no reason to alter it for this new 1999 edition. That is still what this book does and we trust that it does it better today than ever before.

Before proceeding with our discussion of Chronic Fatigue Syndrome, its causes and its treatment, let us consider the nature of the adrenal gland-the gland that our research has determined is the major culprit (or victim) of CFS. The adrenal sits like a bishop's cap on the top of each kidney; each weighs about as much as a nickel coin. The adrenal gland is recognized as one of the body's most important endocrine or ductless glands, that is, glands that produce hormonal or hormone-like substances and discharge them directly into the bloodstream. Each of the endocrine glands is subject to a chain of command. The pituitary gland, so-called master gland of the body, sends out stimulatory or trophic hormones which regulate each of the target endocrine glands, such as the adrenals, the thyroid or the reproductive glands. The pituitary in turn is regulated or controlled by the hypothalamus, which produces specific releasing factors for each of the pituitary trophic hormones. (Later in our text you will read more about this Hypothalamic–Pituitary Axis and its effect on CFS.)

The adrenal glands are composed of two parts-the medulla (inner portion) and the cortex (outer surrounding portion). The medulla fits inside the cortex like a walnut inside its shell. The medulla and cortex produce many substances, the most important of which are epinephrine (formerly called adrenaline), which is produced by the medulla, and various sterols, such as cortisone and aldosterone, produced by the cortex.

When the body is called upon to respond to stress, the adrenal gland is its primary agent and target. Stress on the body stimulates (probably by way of the sympathetic nervous system) the adrenal medulla to increase epinephrine production. This hormone increases the secretion of adrenocorticotrophin (ACTH) by the pituitary gland, which in turn activates the adrenal cortex to greater production of corticoids such as cortisone.

Of primary concern in the discussion of CFS is its differentiation from Addison's disease (organic adrenal insufficiency) and from adrenal insufficiency secondary to hypopituitarism. The term Chronic Fatigue Syndrome as we use it here refers to a state of depletion of the adrenal glands in the absence of atrophy or destruction. In other words, it is a state of functional depletion, or exhaustion. This is in contrast to Addison's disease, in which there is physical atrophy or destruction of the adrenal glands, or to hypopituitarism, in which there is some form or degree of destruction of the pituitary gland. Both Addison's disease and hypopituitarism are relatively rare, whereas CFS as herein described is nowadays becoming more and more common.

Until recently the standard diagnosis of Chronic Fatigue Syndrome was a matter of exclusion; that is, such diagnosis was justified only after other causes of chronic fatigue, exhaustion, weakness and lassitude had been ruled out. Fortunately, the biological and biochemical changes that underlie this syndrome are now much better understood than in our early editions of this work. Definitive tests are now available in the form of the Adrenal Stress Index™ (ASI), a series of tests that chart the adrenal gland output throughout an entire day in comparison with the DHEA (the substance from which the hormones are produced) and immune system levels. With this test it is possible to determine not only if the patient has CFS or not, but also just what stage of the condition he is in and what is the best treatment for a complete recovery.

Unlike CFS, most patients with pathological adrenal function may be fully assessed by standard laboratory tests which include serum cortisol levels and urinary corticosteroids. In Addison's disease, even in advanced adrenal destruction or atrophy, the resting or basal levels of these tests may be within the lower levels of normal. For this reason, a diagnosis of Addison's disease may depend on results of a pituitary stimulation test in which corticotropin (ACTH) is injected into the patient. In normal persons a significant rise in serum cortisols follows ACTH injection, but in Addison's disease there is minimal or no response. In cases in which pituitary insufficiency is suspected, the metyrapone stimulation test is utilized. These tests are described in detail in standard medical texts.

Standard medical texts state that clinical adrenal insufficiency (Addison's disease) usually does not occur unless at least 90 percent of the adrenal cortex has been destroyed by idiopathic atrophy, granulomatous destruction, or some other form of destructive process. By the same token, currently available tests, including the ACTH stimulation test, may not show abnormal results except in the case of advanced disease or depletion. On the basis of present information, it would appear that these tests lack the sensitivity to detect or diagnose lesser degrees of adrenocortical depletion, as in CFS. Therefore, the condition of CFS is largely undetected by these orthodox measures. The ASI is still at this time not well known except in the alternative medical community.

What causes this system breakdown? Why are some people affected and others not? There are two common causes of this condition. They are often mixed in the sufferer to the point that it is difficult to say which actually caused the disorder in any specific case. The two causes are hereditary weakness and overwhelming, unremitting stress. After more than forty years of working with this condition, I feel that inherent hereditary weakness of the system is probably the most consistent cause of the difficulty. The glandular weakness seems to be passed down from one generation to another, the most common relationship being from mother to daughter, although any genetic combination is possible. Without adequate treatment, each succeeding generation often becomes weaker than the previous generation. Therefore, in most CFS cases, the sufferer has inherited a lessened ability to adapt to the stresses of life. To make this more readily understandable to the patient, I usually refer to this situation as the inheritance of a weakened or poorly vascularized adrenal gland. While this is not entirely scientifically correct, there being other factors in a deficient general adaptive system, this is easy for the patient to comprehend and is not that far from the truth.

Some persons' adaptive mechanisms are so weak that no matter how they govern their lives, they are destined to have a problem with this system. Such a problem usually begins shortly after puberty from the stresses of the glandular changes which occur at this time. These patients come to us and say, "I've been tired as long as I can remember, Doctor. I never have had the energy or the ability to do what other people do with ease." The majority of hereditary adrenal cases, however, have sufficient adrenal functioning to live a relatively stable, normal life until a truly overwhelming, unremitting stress presents itself-a stress that exhausts the adaptive mechanism and finally throws these patients into full-blown CFS. These persons show the interplay of the two basic causes of CFS: first, a hereditary weakness of the basic adrenal system itself, and, second, unremitting stresses that are able to inhibit the normal functioning of the mechanism.

The combination of these factors, however, varies tremendously in any specific individual. For instance, as previously mentioned, it is possible for an individual to be born with such a weakened adaptive system that almost any of the normal adaptive needs of life can throw that person deeply into CFS at some point in his life. Patients with this weakness are to be greatly pitied, for until they receive proper treatment, they are never able to experience the real pleasures and satisfactions of life.
A larger number of individuals have some weakness of the adrenal system, but can live fairly normally until the stresses in their lives pile up to such a degree that they, too, will begin to manifest the symptoms of CFS. The majority of our patients fall into this category. With wise and dedicated treatment they can be returned to normal functioning, but will need to live within their adrenal ability if they desire to keep from returning to the CFS state.

Next, there are individuals who are blessed with a fairly normal adrenal mechanism, but who are unfortunate enough in life, as Shakespeare put it, "To suffer the slings and arrows of outrageous fortune," and to have stresses and pressures so enormous and so unresolved that the normally functioning adrenal system with which they are blessed is no longer capable of sustaining their needs. It eventually weakens and plunges them into some variety of CFS. These individuals should be the easiest to return to productive life, but this is not always the case. The main problem is that since they were healthy for so long, it is difficult to get them to make the needed changes in their life-style that are essential for their recovery.

Last, there are the fortunate persons whose adrenal or general adaptive mechanism is so strong that almost nothing in life can affect it. They are capable of going through all possible stresses, and therefore, at least in the past, have not succumbed to CFS, no matter what occurs. We say "in the past" because as the stresses of life continue to increase, it is possible that even the strongest adrenal may give way to CFS in time.
Most of us fall somewhere in between the extremes of the last category of individuals who possess a strong general adaptive mechanism and the first-mentioned case of the unfortunate patients with serious hereditary inadequacy.

Almost all of us feel the effects of temporarily lowered adrenal functioning at some time in our lives, usually following a bacterial or viral infection or after some particularly grueling mental or emotional stress. At such a time, we often experience a short-term weakness and inability to do our regular tasks as efficiently and as accurately as we would like. This is the result of acute adrenal exhaustion. If we are wise, at this time we will rest and not attempt to force ourselves to do more than our weakened ability readily allows. If we obtain sufficient sleep, stay on a healthful diet and do not force ourselves to work until our strength returns, our adrenal system will shortly regenerate. Now, imagine yourself constantly in this state of weakness and exhaustion and you will know what the CFS patient feels every day. In Chapter III of this book, "The Nature of the Patient," this state is discussed at great length.
As can be seen from the above discussion, CFS is due to a malfunctioning of the neurohormonal system of the body. It is caused by a breakdown of a physical component of the human system. Unfortunately, the vagueness of most of the symptoms produced by CFS leads the patient to feel that the main difficulty is one of a mental or emotional nature. Indeed, the symptoms of CFS are almost identical to those caused by anxiety, depression or various other mental conditions. When we are fearful or in a state of depression, these emotional states cause various glandular mechanisms of the general adaptive system to produce secretions which cause symptoms similar to mental disorders. Cold sweating, dry throat, rapid and irregular heartbeat, dizziness, cloudiness of the mind, nausea, flushing of various parts of the body, and so on can all be caused by various emotional effects on the general adaptive system. These symptoms are the body's attempt to prepare us for a possible threat which does not exist except in our fears. For instance, if we were out in the woods hunting, the cry of a wildcat behind us would create a certain sense of fear. This fear would cause the body to prepare for what is known as the "fight or flight" mechanism-either to fight this danger or to run away from it as rapidly as possible. When in our modern life we develop an emotional fear or apprehension, the body mechanism is not capable of distinguishing it from a true danger; therefore, through the glandular system, it prepares us in the same manner as if we needed to face a real danger. Since there is no real danger and subsequent action, we do not readily utilize the hormones which were pumped into our systems, and thus a variety of symptoms are produced as these hormones first register, intensify and then slowly dissipate.
Many modern psychologists and psychiatrists recommend physical activity such as running or jogging to help allay the symptoms of anxiety and similar difficulties. What is occurring, of course, is that the various anxiety-produced substances are being utilized by the physical activity and are not left lying around, as it were, to create more physical symptoms to aggravate the original anxieties further. This therapy has some merit, although it is not an answer to the original anxiety. In CFS, this same admixture which is produced by the anxious patient is produced by the weakened glandular system itself in an effort to bring its body hormone levels up to the normal level. Thus we have a situation in which a person is not necessarily anxious or emotionally distraught, and yet the physical weakness (CFS) produces symptom patterns which are almost identical to those produced in the nervous, neurotic individual.

Just imagine what can happen to the patient suffering from this condition who goes to the average physician! Since there are no specific laboratory tests that identify CFS in its earlier stages, the doctor finds no known disease process; and since the patient's symptoms mimic those of an emotional or mental difficulty, it is little wonder that the physician usually diagnoses the condition as mental anxiety. The patient is advised to stop worrying, told to go home and relax, given either a tranquilizer or an antidepressant or both, and summarily dismissed. This is not meant as criticism of the doctor, who followed recommended medical therapy; in fact, almost any competent medical authority not conscious of or skilled in the diagnosis and treatment of CFS would come to the same conclusion.

In our early years, by the time we saw most CFS patients they were convinced that they really were mental cases. They have been assured by their physicians, their friends and even their loved ones that there was nothing wrong with them that a change of mind, a change of the way that they look at their lives or a few tranquilizers would not help. This was not true then, nor is it true today. CFS patients are individuals with a true physical disorder as specific as if they had pneumonia or tuberculosis. You might as well tell the tubercular individual to stop coughing as to tell the CFS patient to stop worrying or to stop feeling so tired and do an honest day's work like any normal human being. Persons afflicted with CFS simply are not normal human beings; they are individuals with a real problem who need real treatment and real understanding.

Thus CFS may be viewed as a triad, all three parts of which must be considered in every case: First, the heredity factor on which all prognosis or outcome is based. Second, the stress component which is composed of stresses that may cause the CFS or be caused by it. Third, the group of symptoms which due to the nature of the condition are not only caused by the condition, but can become stresses which further aggravate the condition.

The whole condition sounds ominous and almost hopeless of resolution, and so it must seem to the afflicted patient. For it is a condition that not only can be triggered in sensitive people by ordinary stresses of life, but which actually produces its own stresses via its symptomatology. We might say it is a beast that flourishes on its own excrement. As we come to understand more about the character of this disease, we see why it is so neglected and also so prevalent.

To understand it more fully and to become knowledgeable in its treatment, we must comprehend the interplay and ramifications of its three sides: heredity, stresses, and symptoms.

Little can be done about the inherited factor except to attempt to determine its extent, since all treatment and prognosis (length of treatment and chance of complete recovery) depend on this fact. If inherited weakness is great, treatment must be extensive and great efforts must be made to reduce all patient stresses to a minimum. Conversely, if the heredity factor seems slight, treatment and stress reduction can be much less stringent and a quick recovery can be assured.

There is unfortunately no simple, exact way to determine the degree of hereditary weakness in any specific case. However, a clinician with much experience can usually make a fair estimate from the case history. Three matters are of prime importance: the age at which the symptoms began, the severity of the symptoms and the amount of stress that was required to produce the symptoms. If the symptoms began early, were severe and seemed to set in with little or no appreciable external stress, the heredity factor is strong, and such a case will require the best and most extensive therapy we have.

As a general guide, we can say that the degree of inherited neurohormonal weakness is in direct proportion to the severity of the patient's symptoms and inversely proportional to the stresses involved and the age at which they began.

Much has been written here concerning stress, but little has been written to define stress. To understand the stresses that affect CFS-not only those that cause it but also those that exacerbate it-is to understand the syndrome itself.

A stress in this context can be defined as any factor that stimulates the general adaptive system. These stresses may be divided into several types:

A full understanding of the stresses involved in CFS is vital to recovery because all treatment is based on two simple principles on which the physician and the patient must work together. One, do everything possible to build strength into the adaptive mechanism, and two, remove as many stresses from this mechanism as possible. Unless the nature of the stresses are understood, they cannot be removed from a person's life. Some stress admittedly is useful, but long experience has taught me that no matter how hard a physician and a patient work, there will always be some stresses left. It was Benjamin Franklin who said, "Those who have nothing to worry about will worry about nothing."

Symptoms of CFS are unique-not so much because of their basic character, for these are symptoms common to other conditions, but because they themselves can have a profound effect on the course and progress of the disease. To understand this facet of CFS, let us examine a typical patient. Let's take a working mother who is developing the condition and who of late has been experiencing unusual and unexplainable symptoms, such as strange tinglings, dizziness, mild nausea, the inability to concentrate, difficulty in remembering and in making decisions, being constantly and usually tired, digestive disturbances, apprehensions and anxieties that do not seem to have a basis in fact but that come sweeping over her for no apparent reason. Every little thing seems like a mountain to her, every cry of one of her children sounds like a screaming siren in her ear, every request of her husband seems like an unwarranted demand. Why would she not be anxious? Why would she not wonder if she is losing her sanity? Why would she not manifest all forms of worries and fears which by their very nature create further stresses that in turn worsen the CFS, which creates more symptoms, and so on, ad infinitum?

As we have described, the symptoms of CFS produce a snowballing effect, and unless this effect is controlled, there is little hope of helping the patient. Once the worse CFS symptoms begin, they are often sufficient in themselves to perpetuate the condition regardless of outside stresses.

In order to truly treat this condition successfully, all the above factors must be taken into consideration. An entire new paradigm of doctorpatient relationship needs to be established. No doctor can do more than about half the work needed to overcome this condition-the rest is up to the patient. He must come to understand the condition and work in harmony with his physician. The doctor needs to take the reins of the case but must hold them loosely so that the patient can learn to overcome that which is in his province.