Hello.
Thank you for your query at DoctorSpring.com.
I have gone through your history in detail and I understand what you are going through.
Adrenal insufficiency and Cushing's are unlikely. However, I need some additional information in order to provide my best opinion.
1. Please mention your age and sex.
2. Please mention your weight and height. Do you have any centripetal obesity (fat around the abdomen and trunk) ?
3. Do you have any loss of appetite?
4. Any weight loss?
5. Do you have any difficulty climbing stairs or holding slippers like flip-flops? Do you have a feeling of “heaviness” or “stiffness” in your limbs?
6. Please mention the duration of each of your symptoms.
Please reply to the above as a follow-up.
Feel free to voice your concerns.
Thank you.
Patient replied :
To answer your questions: 33, male, 194 lbs., 6'0; yes, I have fat around the abdomen, no loss of appetite, no weight loss, yes to heaviness and stiffness in legs and arms. Symptoms have been gradual over 5 year period and more or less "started" about 8-10 years ago and slowly progressed since then. I believe everything worsened after my 5 year period with Zoloft. After I got off of the medicine, I hit rock bottom and have had to climb out since then. Episodes of uncontrollable stress and anxiety were intense to where I felt like I would have a melt down at any moment. Don't get me wrong, I am not crazy or bipolar, but I have had more stress and anxiety than a 33 year old should have had in his lifetime. Additionally, I exercise and lift weights regularly, which does seem to help until I begin to "use" my muscles again and everything begins to get stiff. While driving, I have basically movements of the legs that are uncontrollable, therefore making it hard to drive. And, just to be clear, I have had a lot of grieving and guilt over watching pornographic images over the last 10 years, of which I have "heard" that it can "mess" with acetylcholine levels. So, there you have it. Can you at least point me or my physician in the "right" direction. I am going to visit another neurologist next week, and if nothing, it's on to Mayo Clinic. Just need some extra help and another opinion!
Hello. Thank you for writing to us again.
Your 5 year stint with Zoloft ( Sertraline ), could be responsible for the symptoms you have been experiencing. But since it has been there for a long long time, it does not seem that likely. Zoloft withdrawal can lead to dizziness, light headedness, repeated muscular spasms, muscle aches, paresthesia ( feeling of abnormal sensation ), insomnia ( e.t.c ). If there was an abrupt stoppage of using the drug, it is possible that you manifested Zoloft withdrawal. That is one of the possibilities.
Since you had a very tough life, it is quite understandable that you were forced to use Zoloft. The symptoms you mentioned can also be attributed to Generalized Anxiety Disorder. Even people with GAD, manifest a plethora of symptoms such as difficulty in breathing, choking sensation, difficulty in concentration, muscle spasms, constant trembling, e.t.c So it is possible once you stopped Zoloft your symptoms got back, and you have been experiencing Generalized Anxiety Disorder ever since. It is quite common, and the best part is it can be treated without medication mostly. We normally recommend CBT ( Cognitive Behavioral Therapy ) with a Psychologist, and some sessions will be invaluable. Every people functions differently, and in CBT the psychologist will study your behavior, understand how you function and guide you in the right track.
To rule out other causes, an MRI of the brain will be essential. You should also get your serum B12 levels checked. Once you have the reports you can upload them and we will assist you further. I will recommend you get in touch with a psychologist, i feel it will be really helpful for you. You have fought back each time, life has thrown challenges at you. You can overcome this physical condition too.
Hope this is helpful,
Regards
Patient replied :
I do understand the anxiety issue, which runs in my family, but what puzzles me is the stiffness in my lower back pelvic region that NEVER goes away. For instance, when I am doing something like changing a car battery or putting something together that takes the more "fine" muscle movements, my legs, back (and most of my body) stiffen up even more under what might not be pressure to the normal person. My legs get stiff and weak at the same time to where I feel as if I can't move or finish the task. I just have to walk off and stretch and then return to the task. That can't be just anxiety, but you are the doc. Anything that involves the "fine" muscle movements, my body reacts a different way by trying to do it in another position. I have been at this for 10+ years, and I feel like I am not digging far enough to find out what it is. I can't stress enough how hard it is for me to do the "normal" tasks of just pouring a glass of water. My body stiffens up to where I can't hardly move and my right arm shakes when I try to use it. Any more ideas that might be helpful? Please advise.
Hello.
Your lower back stiffness seems to be anxiety related as well. I know it becomes hard to accept that anxiety can lead to such 'difficult to cope with' physical symptoms, but you should understand that our brain is the seat of control of both our physical as well as mental/emotional functions. For this reason, by the complex interplay of neurotransmission, functional conditions such as depression, anxiety etc present with various physical symptoms and vice versa.
As for difficulty in fine muscle functions, this seems to be a separate entity. Difficulty in performing fine movements with shaking could indicate the presence of an intentional tremor. It is caused due to cerebellar(an area of brain concerned with posture, balance and controlling complex motor tasks) dysfunction. This could again be a manifestation of anxiety, where severe anxiety interferes with cerebellar functioning. This can be worsened by intake of caffeine, cigarettes or alcohol. Other causes of an intentional tremor are alcoholism, alcohol withdrawal, neurological conditions such as: peripheral neuropathy, stroke, MS etc.
In your case, the neurological and other causes can be ruled since you have already been examined by 3 neurologists and many GPs who would have definitely evaluated you for the same. It is impossible that so many doctors can miss any neurological or other physical cause.
So everything seems to fit into a diagnosis of an anxiety disorder. Since you have only visited one psychiatrist, I would suggest that you consult another one and go ahead with Cognitive Behavioral Therapy with or without medications, as advised earlier. This should take care of all your symptoms and improve your quality of life.
I hope this was helpful.
Feel free to discuss further.
Thank you.
Patient replied :
I believe you are on target with the anxiety, depression. But, I still feel as if I may have something causing or might be the effect of these. My fatigue and muscular weakness and low blood pressure upon standing are all signs of adrenal insufficiency or the other way around. I feel as if my brain is constantly telling my body to stress out over nothing. But, this has progressed over time, not just overnight. I feel deep down that I have the symptoms of some type of hormone dysfunction, but I don't know how to tell the doctor without him looking at me like I'm "crazy" and that I don't know what the heck I'm talking about. The neurologist just took blood and everything came back normal. Was looking for something that might point to stiff person's syndrome. I will find out more tomorrow. A lot of times (as I have read), adrenal problems are overlooked as something else until something drastic happens. I may be wrong, but I need your help in looking into how to ask the doctor to check for this and if possibly this could be the cause of my problems. Here are the symptoms again: muscular weakness which involves trembling mostly around the thigh area, abdominal area, back area (which also has stiffness and slight pain sometimes); fat around the midsection and seems if I might be losing muscle mass in my legs and arms; I do have the problem of blood pressure dropping when standing too quickly; as a side note, I have used medicines to help with asthma over the last 15 years; fatigued majorly; still have the tremor when using the right arm (probably due to anxiety); but I can "feel" my adrenals being taxed just now, and it feels like my body is constantly being told from my brain "stress, stress, when there is no stress". Do you know what I mean? I just don't want to overlook something that could be the main problem and it be attributed to a misdiagnosis. Please advise since this is my last question. Thanks so much for your help!
Hello.
I do understand your concern about something like an adrenal insufficiency being missed.
It is true that sometimes adrenal insufficiency (decreased adrenal hormone production) is not detected until the person presents with adrenal crisis.
Fatigue, muscle weakness, generally low blood pressure and also on standing can be present in chronic adrenal insufficiency but these are not specific to it. However, trembling, fat around the mid-section are not seen in adrenal insufficiency. In fact, fat around the mid-section is seen in excess of adrenal hormones, not in insufficiency.
In addition, adrenal insufficiency presents with symptoms such as hyperpigmentation of skin, especially around sun-exposed (such as the face, neck, and backs of hands) and areas exposed to chronic friction or pressure (such as the elbows, knees, spine, knuckles, waist [belt], midriff [girdle]). Hyperpigmentation, is evident in nearly all patients with primary adrenal insufficiency, is the most characteristic physical finding. Do you have this hyperpigmentation?
Gut symptoms, usually nausea, occasionally vomiting, abdominal pain, or diarrhea that may alternate with constipation, are quite common too.
If you have these symptoms, then adrenal sufficiency is likely.
What you can do is consult an Endocrinologist and ask for a thorough work-up for the fatigue, weakness and the blood pressure dropping on assuming a standing posture. You can discuss the same with him/her voicing your concerns. Please tell them that you are worried about a hormonal cause being overlooked as a cause of your symptoms, just like how you have told here. This will definitely be taken seriously and your concerns will be looked into. Normal work-up will be conclusive and will be reassuring to you.
You can continue evaluation of the stiffness with the neurologist.
As for the tremor in your right hand, it could be due to the asthma medications. Beta agonists like Albuterol etc are known to cause tremor as a side effect.
If this is hampering your routine, it is best to discuss with your treating doctor for further management.
And lastly, I would again advise you to see a good psychiatrist for the anxiety and depression and start off with suitable and effective treatment.
I hope this was helpful.
Thank you.