Diagnosis of Chronic Fatigue Syndrome
at Our Healing Research Centers

When a patient first presents himself at our Center, we take an extensive history. Nine times out of ten, a tentative diagnosis of hypoadrenalism can be made from this alone. The patient usually tells us about symptoms similar to those already described. We hear tales of the various physicians they have been to, and of the multitudes of medications that have been prescribed. I will never forget one patient who told me she had fifteen different types of tranquilizers in her purse. I asked her how she knew which one to take. She replied that she really didn't know. She would just keep taking first one and then the other until she felt better.

After the history of a suspected hypoadrenal patient is taken, we begin the physical examination and laboratory work. Although it is possible to measure such adrenal secretions as the 17-ketosteroids, we rarely find this test sensitive enough to detect functional hypoadrenalism. This test is used to detect the organic adrenal diseases such as Addison's disease, but these factors are usually within normal levels in functional hypoadrenalism.

One laboratory test we do suggest in suspected hypoadrenalism is the five to six hour glucose tolerance test. Because there is a frequent relationship between hyperinsulinism (low blood sugar) and functional hypoadrenalism, we always check to make sure that both conditions do not exist in the patient. It has been my experience that where a physician knowledgeable in these metabolic disorders has discovered one and treated it unsuccessfully, it usually was because the other had also been present but not treated.

We do extensive blood and urinary testing of these patients. Usually, however, except for the glucose tolerance test, we generally don't discover abnormal findings, unless the patient also has a concomitant disorder. It is possible of course that a chronic systemic ailment may be aggravating the functional hypoadrenalism. If this is true, this condition must be treated concurrently with the adrenal problem.

In recent years a new test, the Adrenal Stress Index (ASI) test by DiagnosTech Labs of Seattle, Washington, has been developed that allows us not only to determine whether or not functional hypoadrenalism exists, but more importantly, exactly where the patient is in the Selye progression of stress adaptation (See Selye stress chart on history of condition).

We now consider this test so essential to the care of all our patients, that we no longer accept CFS patients who will not take this test. It is fully explained in the book Chronic Fatigue Unmasked 2000. If you need more information on this essential test, please ask your Center physician.

 The Postural Blood Pressure Test

One of the most important diagnostic features of the physical examination is what is known as the postural (orthostatic) blood pressure test. In this test, which is routine in our office, the patient is placed in a reclining position four or five minutes; the blood pressure is then taken and recorded. The patient is brought to a standing position with the blood pressure cuff still in place on his arm. The blood pressure is immediately taken and recorded. The pressure is again taken in a minute with the patient still standing.

In the patient with full adrenal integrity, the blood pressure will be five to ten points higher in the standing position than in the reclining position when they first rise because of the increased tone of the abdominal blood vessels, which are under control of the adrenal glands. When you lie down, the heart relaxes, and all the large vessels tend to relax, because every vessel is at approximately the same height as the heart, and gravity has little effect on the blood flow. When you suddenly stand up, however, there is a tremendous downward pull of gravity on all the blood in the upper body, the tendency being for the blood to flow down into the large abdominal vessels and pool there. If there was not some compensatory mechanism to correct this, most of us would go into a state of oxygen deprivation (anoxia) whenever we stood up, immediately becoming dizzy or faint. However, there is a mechanism, mainly under the control of the adrenal glands, that increases tonicity (constriction) in the large abdominal vessels whenever we stand up. This abdominal constriction produces a slight rise in blood pressure that occurs normally upon standing. In adrenal insufficiency, however, this mechanism functions weakly. In fact, it reacts in inverse ratio to the integrity of the adrenal glands. Thus, the more the adrenal glands are depressed or unable to function, the less this mechanism is able to work. When a patient with hypofunctioning adrenal glands stands up from a reclining position, the blood pressure tends either to stay the same or drop slightly in mild cases. In the more severe cases, the drop may be considerable. I have seen patients in whom the blood pressure dropped forty points upon standing. These patients usually become quite dizzy upon standing--of all the symptoms of hypoadrenalism, this dizziness upon arising from a reclining state is one of the most consistent.

Because the degree of blood pressure drop is usually a dependable indication of the adrenal state, it is used at our Centers to measure patient improvement. As a patient is treated and makes subjective improvement, we also find objective improvement in the orthostatic blood pressure readings. Although not the most important adrenal function, it is the easiest to measure, and such improvement generally parallels improvement in the other particulars of adrenal function.

The difference in nature between the first and the second standing reading is also important. In my experience I find the first standing reading indicative of the short- term stress on the adrenal gland while the second reading is more inclined to give us information on the nature of the regeneration of the adrenal gland itself. For instance if a patient would read 110/70 lying down, 100/65 when first standing but 120/75 on the second standing reading, I would surmise that hr has had some recent short term stress but that the adrenal gland on a long-term basis is regenerating. On the other hand if the respective readings were: 110/70, 100/65 and 95/60, I would deduce that this patient is not regenerating and needs more stress reduction and increased treatment. If the first standing reading is lower than the reclining reading it means that the patient has been under some recent stress and would do well to back off his lifestyle until the adrenal gland is able to catch up to his needs. If the third reading is lower than the reclining reading it shows that the stress on the adrenal gland is such that it is deteriorating--not regenerating--and measures must be instituted immediately to correct this situation or it could become difficult to correct.

Although this test was developed many years ago, we find it used little by most physicians.* However, I find it an unerring indication of this rather enigmatic condition. One can even predict a patient's feelings for several days following the test once one becomes in tune with the patient and the test. The postural blood pressure varies from day to day and even from hour to hour in some cases, as does adrenal function. If I have a patient who has been doing well under treatment, whose orthostatic pressure suddenly drops considerably more than usual, I know that he is under some new or sustained type of stress that even he may not be aware of. We can then search for the new problem and correct it, even before it can produce viable symptoms. Physicians who do not regularly use this test deprive themselves not only of an effective diagnostic tool but also of a therapeutic guide par excellence.

To us, a combination of the history, the lab tests, and a positive postural blood pressure test is considered sufficient to make a diagnosis of functional hypoadrenalism, however, it is only with the ASI test that we are able to determine exactly the state of the patient in this condition. Of course, the programmed intuitive nature of the physician also enters into the diagnosis. When one has handled many hypoadrenal cases, they tend to stick out like sore thumbs. Their whole nature and being help make the diagnosis. The physician must only look and listen. The only real way to miss functional hypoadrenalism is to not be aware of its existence, or as the Bible says: "There are none so blind as those who will not see."

*Since this was written, work has been done at Johns Hopkins hospital by way of a tilt table to demonstrate this change in blood pressure in Chronic Fatigue patients. Of course we have been doing this test for over forty years now. With this in mind, however, perhaps in another forty years we may well find that the rest of our work with this condition will be "discovered."

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