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Hypothalamic-pituitary-adrenal Axis in Patients Presenting to Psychosomatic Medicine with Fatigue, 2025, Matsubayashi et al

Discussion in ''Conditions related to ME/CFS' news and research' started by forestglip, May 30, 2025 at 3:37 PM.

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  1. forestglip

    forestglip Senior Member (Voting Rights)

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    Hypothalamic-pituitary-adrenal Axis in Patients Presenting to Psychosomatic Medicine with Fatigue

    Sunao Matsubayashi, Makoto Yamashita, Takeshi Hara, Makito Tanabe, Shuichi Matsumoto

    Abstract
    Many patients with fatigue are referred to psychosomatic medicine, but few studies have examined the hypothalamic- pituitary-adrenal (HPA) axis in these patients. We conducted a corticotropin-releasing hormone (CRH) test on 86 patients with fatigue, no history of oral steroid use, and no pre-existing hypothalamic or pituitary disease. We confirmed non-oral steroid use and performed pituitary magnetic resonance imaging (MRI) in patients with peak cortisol levels <18 μg/dL.

    The baseline cortisol level was 7.6±3.4 μg/dL, and the peak cortisol level in the CRH test was 15.4±3.6 μg/dL. Nineteen had a history of non-oral steroid use, and their peak cortisol levels were significantly lower at 13.7±4.3 μg/dL (vs. 15.9±3.4 μg/dL in non-users; F=5.825, p=0.0179). Sixty-seven patients had peak cortisol levels <18 μg/dL, and 43 patients had levels <15.67 μg/dL.

    Fourteen patients were newly diagnosed with pituitary MRI abnormalities, and their peak cortisol level was significantly lower than that of those without pituitary abnormalities (12.4±4.1 μg/dL vs. 14.7±2.7 μg/dL; F=6.5130, p=0.0129).

    In conclusion, some patients with fatigue in psychosomatic medicine have a decreased HPA axis associated with non-oral steroid use or undetected pituitary abnormalities. However, a significant number also exhibit a decreased HPA axis, despite having no history of non-oral steroid use or pituitary abnormalities.

    Link | PDF (Journal of Hospital General Medicine) [Open Access]
     
    forestglip, May 30, 2025 at 3:37 PM
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  2. Hutan

    Hutan Moderator Staff Member

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    If that first department is accurately named, it's a really weird department. But, maybe it's good. Because, the tools they applied aren't just psychotherapy and gaslighting - they actually do hormone testing. And so they seem to be approaching patients referred to their department a little more holistically, a bit more open minded. The possibilities still are probably constrained by the clinicians' mindset, but the possibilities are wider.

    "A normal baseline cortisol level in the morning (around 8 a.m.) is generally considered to be between 5 to 25 micrograms per deciliter (mcg/dL). Cortisol levels naturally fluctuate throughout the day, peaking in the morning and decreasing as the day progresses. In the evening, levels are typically lower, ranging from 3 to 13 μg/dL"

    The baseline cortisol level taken at 9 am was 7.6±3.4 μg/dL. So, the mean baseline cortisol levels of the 86 patients was in the normal range. But some of these patients clearly have abnormal cortisol levels and responses.

    All 86 patients underwent an ACTH test and 67 patients had an ACTH response that was less than the 18 μg/dL that is considered a normal response.

    The 67 patients with an abnormal ACTH response underwent an MRI, and 14 were diagnosed with pituitary abnormalities visible on an MRI. That seems pretty significant. Of the 86 people, all of whom the authors described as 'no pre-existing pituitary disease' and who were given a psychosomatic explanation for their fatigue, 14 did in fact have pituitary abnormalities. That's at least 16% of the people being told that they are psychosomatic when they in fact have a fairly easily identified structural cause for their symptoms.
     
    Hutan, May 31, 2025 at 9:10 PM
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  3. Utsikt

    Utsikt Senior Member (Voting Rights)

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    Yet the FND crowd think it’s fine to use positive rule in signs..
     
    Utsikt, May 31, 2025 at 9:16 PM
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  4. Hutan

    Hutan Moderator Staff Member

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    The authors give this example:
    Case 3. 36-year-old, female
    "If a RCC grows large enough, it can press on nearby structures like the pituitary gland or optic nerves, potentially causing:
    • Vision changes (like blurry vision or visual field defects)
    • Headaches
    • Hormone imbalances
    • Fatigue or drowsiness
    • Nausea "
    "Yes, a Rathke's cleft cyst can cause a lack of appetite according to multiple sources. This is because the cyst can affect the pituitary gland, which produces hormones that regulate appetite and other bodily functions. If the cyst is large enough, it can compress the pituitary gland, leading to a deficiency in these hormones, which can result in symptoms like loss of appetite, weight loss, fatigue, and other hormonal imbalances."

    So, very possibly, this woman has spent 16 years going through the trauma and harm to her body of not eating enough and being dreadfully fatigued, and the trauma of being told that she isn't thinking right and going over her childhood issues. From what I can see of the literature, hydrocortisone therapy can be enough to correct things and re-establish appetite. I'm not sure though why the cyst would not have been removed to allow the pituitary to function - it seems like a fairly safe operation.

    Table 1 reports that 8 of the patients had diagnoses of eating disorders.
     
    Hutan, May 31, 2025 at 9:25 PM
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  5. Hutan

    Hutan Moderator Staff Member

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    Another issue worthy of comment is the impact of steroids on cortisol levels. The researchers had excluded anyone who had been using oral steroids. But, they found that the people who had been using other sorts of steroids had lower peak cortisol levels. These steroids were
    • inhaled steroids for bronchial asthma
    • nasal steroids for allergic rhinitis
    • steroid ointments for allergic dermatitis
     
    Last edited: May 31, 2025 at 9:57 PM
    Hutan, May 31, 2025 at 9:40 PM
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  6. Hutan

    Hutan Moderator Staff Member

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    The Discussion and Conclusion sections are interesting. It's a weird combination of practical thinking (e.g.people with chronic fatigue should be properly assessed for pituitary problems, and treated appropriately), just possibly plausible BPS speculation and just straight out wrong psychosomatic twaddle.

    Here's a paragraph on ME/CFS (oddly included, because the study did not appear to be on people with ME/CFS):
    18. Castro-Marrero J, Sáez-Francàs N, Santillo D, et al. Treatment and management of chronic fatigue syndrome/myalgic encephalomyelitis: all roads lead to Rome. Br J Pharmacol. 2017;174(5):345-369.

    19. Vink M, Vink-Niese A. Cognitive behavioural therapy for myalgic encephalomyelitis/chronic fatigue syndrome is not effective. Reanalysis of a Cochrane review. Health Psychol Open. 2019;6(1):2055102919840614.

    I don't recall that Vink paper promoting mindfulness therapy...
     
    Hutan, May 31, 2025 at 9:57 PM
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  7. forestglip

    forestglip Senior Member (Voting Rights)

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    That's interesting. Hydrocortisone cured her fear of gaining weight? I feel like anorexia is one of the best examples of a condition your doctor would send you to a therapist to fix, yet a cheap medication did the job.
     
    forestglip, May 31, 2025 at 10:10 PM
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  8. Hutan

    Hutan Moderator Staff Member

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    And six years of care in this psychosomatic clinic, prior to the discovery and treatment of her pituitary issue, did not.

    Of course, it's a case study, and it is reported by researchers wanting to make the case for their recommended approach, with all the biases that go along with that. Rathe's cleft cysts can also be asymptomatic. I guess BPS proponents might say that the MRI finding was irrelevant, and the treatment gave the woman a face-saving way to think differently, and begin to eat better, which fixed her fatigue.
     
    Hutan, Jun 1, 2025 at 12:13 AM
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  9. Sean

    Sean Moderator Staff Member

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    Some years back the wife of a friend of mine was having all sorts of health troubles, and was bundled off to the psychs.

    Long story short, eventually somebody did some appropriate (and standard, widely available) testing and it came back positive for a specific and well known gland problem (can't remember the details).

    Was put on appropriate medication and all the symptoms resolved within a day or two.

    There's a pattern here.
     
    Sean, Jun 1, 2025 at 12:20 AM
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  10. Peter Trewhitt

    Peter Trewhitt Senior Member (Voting Rights)

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    There desperately needs to be good data on the percentage of people given a psychogenic diagnosis of some sort that resulted the missing of or delay in diagnosing a treatable biomedical condition.

    I have given here before the example of a friend referred to counselling services because of unexplained persistent chest pain following heart surgery. It took over eighteen months for her to find a doctor willing to refer her for the simple chest X-ray that revealed the eleven inch stainless steel surgical instrument left in her chest cavity. Fortunately she had ignored previous repeated medical advice to push through the pain.

    Unless a patient is made aware of the risks of missed treatable conditions, including conditions potentially fatal if untreated, surely they can not be considered as able to give informed consent for psycho behavioural interventions for presumed psychogenic conditions.

    Also the assumption that psycho behavioural interventions don’t have associated risks needs addressing, as I would have thought there are potential risks of such interventions inappropriately given in presumed ‘eating disorders’, just as we have seen their risks in ME/CFS.
     
    Last edited: Jun 1, 2025 at 7:11 AM
    Peter Trewhitt, Jun 1, 2025 at 7:04 AM
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  11. bobbler

    bobbler Senior Member (Voting Rights)

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    I think that is sadly very unusual that anyone looks further (and then of course there are many hoops more to someone actually signing off treatment even if it seems logical because it hits the bar and the treatment would work) - depending on the person and their support system/status/connections, what they are deemed to have and how strong the attitude is in those they come across in the journey there. I think that once at mental health it is a sausage machine with no access to or interest in alternatives and a particular assumption that where things don't fit it is due to the patient lacking insight/not having learned that if they want to get out of the situation ever they will be required to 'play along' (like getting parole requires pleading guilty, protesting you never had or thought x is either ignored or held as some sort of additional mental problem) and things become really closed down as people's testimony gets more likely to be even more ignored/questioned.

    I have known someone who thought they had CFS for many years, a male and not thin, who turned out to have a pituitary tumour which had to be treated as it was near to affecting vision if it were to be left.

    Just going by the small numbers of people I know who I'd know that level of info about then I assume this theme is actually common. A step beyond patterns, although there are many patterns behind them that are obvious to most it is just hard to work out what benefit there must be in it being left like that level obvious.

    I get a horrible feeling that there are some quarters where it is almost being pushed to treat illnesses that were/are known to have biomedical causes and straightforward treatments (and pernicious anemia/B12 and similar things in those who have had bowel operations or significant bowel conditions is another one, thyroid perhaps another one if you count getting the treatment right etc) as if those can be treated as if they are psychosomatic or just not treated or are seen as just 'wellness' level of things or bundled in with 'other generic buckets for x symptoms'.

    Sadly I don't think that a condition meeting the bar of being objectively testable and measured and have a relatively cost-effective treatment, particularly those where for example there should be some sort of 'care' in the sense of a clinic+GP system wanting to get that level correct, is actually an even automatic slam-dunk with regards the medical system these days. And I'd be intrigued to see whether literature and beliefs, or the decision chart type system (plus bucketing on symptoms but then 'only one assumption/place to refer' once bucketed) plays any part in that.

    And does the vicious cycle of labelling those with certain symptoms from not getting the correct treatment these days lead to some automatic lowered status given to their testimony when perceiving what is 'good enough' for them to manage on etc. ?
     
    bobbler, Jun 1, 2025 at 8:15 AM
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  12. Sean

    Sean Moderator Staff Member

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    Absolutely this.
     
    Sean, Jun 2, 2025 at 6:54 AM
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