Why Am I Always Exhausted?

You're exhausted, and it's the kind of exhausted that a whole night of sleep doesn't touch. You push through back-to-back meetings at the Comcast Center, or you sit in your home office in Fairmount staring at a screen that won't come into focus. Then 11 PM comes around, your head hits the pillow, and your mind takes off running.

You've already given up coffee. You've tried melatonin. You went to your PCP, who checked a TSH, which is the basic thyroid test, and a CBC, which is a complete blood count, and then sent you home with "You're fine. Maybe you're just stressed?" You walked out no less tired than you walked in.

"When you tell me you're stressed, I treat that as a mechanism rather than a diagnosis. Years of it change your biochemistry. The morning cortisol rise that's supposed to hand you your momentum gets blunted, your evening cortisol climbs instead, and that's a good part of why you lie there awake at night. All of it can be measured, so we measure it."

Why Is "Adrenal Fatigue" a Myth When I Feel This Exhausted?

"Adrenal fatigue" is a phrase that sounds right and doesn't match the biology. It suggests that your adrenal glands, the small glands above each kidney that make cortisol, have worn themselves out and can't produce hormones anymore. Your adrenals are almost always doing their job. What's broken is the signal coming from your brain.

So we work from HPA axis dysregulation instead, which is a measurable problem in the communication loop running from your brain down to your adrenals:

1. The brain-body disconnect. Years of high-intensity performance teach your brain, and specifically the hypothalamus, which is your control center for stress, to turn the volume down on your stress response so that it can protect you.
2. The result. You feel flatlined, because your central thermostat is stuck in low-power mode.

Medicine 3.0 vs. Standard Care for Chronic Fatigue

What Does the Fishtown Framework for Chronic Fatigue Look At?

Our framework for chronic fatigue looks at your energy through 3 lenses: the signal, meaning your hormones; the fuel, meaning your metabolism; and the engine, meaning your mitochondria. Most of the people we work up have something going wrong in 2 of the 3. Here's how we map each layer.

1. The Cortisol Awakening Response (CAR)

A standard cortisol test takes a single blood draw in the morning, which tells you about as much as one frame tells you about a movie. We want the whole curve, so we measure your cortisol the moment you wake, again at 30 minutes, and then once more later in the day.

• Healthy pattern: your cortisol climbs about 50% in the first 30 minutes after you open your eyes. That rise is your built-in ignition switch.
• Dysregulated pattern: the line stays flat, which is the morning inertia that has you hitting snooze 5 times, or it overshoots hard, which you feel as morning anxiety and panic.

2. Mitochondrial Stalling and the Organic Acids Test (OAT)

Mitochondria are the power plants inside your cells, and their job is to turn food and oxygen into ATP, the energy currency the rest of your body spends. To find out whether that furnace is clogged, we run the Organic Acids Test (OAT), a urine test that reads the byproducts your metabolism leaves behind.

• Succinic and fumaric acid. When these run high in your urine, your Krebs cycle, the central energy-making loop inside your cells, has stalled.
• Nutrient gaps. We often turn up a shortage of CoQ10, riboflavin (vitamin B2), or carnitine working as the bottleneck.

3. The Philadelphia Environment Audit

Living through a Northeast winter does things to your physiology that rarely come up in a standard visit.

• Light deficiency. From November through March there isn't enough daylight here to hold your circadian clock in place, and it drifts. We rebuild your mornings with a 10,000 lux lamp, which is a bright light box that imitates sunrise, so your cortisol gets the trigger the sky isn't giving it.
• The glucose rollercoaster. A quick-carb lunch, whether it's from Paesano's, Liberty Kitchen, or a Wawa hoagie, pushes your insulin up and then drops your blood sugar out from under you, and the crash that follows feels like fatigue. We put protein and fiber first at meals and pair that with a Continuous Glucose Monitor (CGM), a small sensor on your arm that reads your blood sugar minute by minute, so we can smooth those swings out.

When Should I See a Doctor for Chronic Fatigue?

See a doctor for chronic fatigue when the low energy has run longer than 3 months, or sooner than that if it has started taking things you love off the table. Plenty of people are tired, and that doesn't make it normal for you. Get yourself evaluated if any of this sounds like your week:

• You need more than 2 cups of coffee before you feel like your baseline self.
• You've stopped going to the gym, stopped seeing friends, or stopped going out to dinner because there's nothing left in the tank.
• Light exercise puts you on the couch for hours afterward, which we call post-exertional malaise.
• Your mood, your focus, or your work is slipping.

Scientific References

1. Cleare AJ. "The HPA axis and the genesis of chronic fatigue syndrome." Trends in Endocrinology & Metabolism. 2004.
2. Booth NE, et al. "Mitochondrial dysfunction and the pathophysiology of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome." International Journal of Clinical and Experimental Medicine. 2012.
3. Stussman B, et al. "Characterization of Post-exertional Malaise in Patients With Myalgic Encephalomyelitis/Chronic Fatigue Syndrome." Frontiers in Neurology. 2020.
4. Holick MF. "Vitamin D deficiency." New England Journal of Medicine. 2007.
5. Hannibal KE, Bishop MD. "Chronic stress, cortisol dysfunction, and pain." Physical Therapy. 2014.

Related at Fishtown Medicine

• Tired for Months, Labs "Normal": The Workup That Found It - a patient case walking through the full fatigue workup
• Fatigue (not depression) - the medical causes of fatigue that get mislabeled as mood
• Reactive Hypoglycemia - the metabolic pattern behind afternoon crashes
• Unintended Weight Gain - the hormonal and metabolic causes worth ruling out
• Metabolic Stagnation - when weight loss stalls despite doing everything right

Related Articles:

• Thyroid Optimization
• The Importance of Sleep
• Metabolic Health 101
• A Positive ANA: What It Means - a common finding in a fatigue workup, and how to read it

Ashvin Vijayakumar MD (Dr. Ash) is a board-certified internal medicine specialist at Fishtown Medicine in Philadelphia. We help patients reclaim their energy by treating the root cause rather than chasing the symptom.