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    Dr. Boggess (Medical Director)

    Dr. Tony Boggess is a Physical Medicine and Rehabilitation (PM&R) physician, speaker, and writer who specializes in Nutritional and... read more

Adrenal (HPA) Stress & Recovery

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What follows is a description of subclinical HPA (Hypothalamus, Pituitary, Adrenal) axis dysfunction, adrenal fatigue, adrenal exhaustion, etc. based on my work with children and adults in clinical practice. My primary intent is to disseminate useful information and to encourage people suffering from this type of imbalance to understand their symptoms and to be hopeful.

Prolonged Stress Response

Imagine a deer grazing in the grass. Now imagine what happens when a tiger comes into the picture? In an instant, the deer becomes vigilant, tense, agitated. Its hyper-aware senses pick up every noise or movement. Its heart begins to race, muscles tense, and with amazing strength and speed the deer runs for its life!

The main difference between the deer and us is that in a few moments the deer’s fate will be determined. The animal will either escape and find another field to relax in or will end up tiger food. Either way, the physiological changes designed to protect the deer will not remain on for days, months, or years like it does with us! There is a great book, titled’ “Zebras Don’t Get Ulcers.” Why don’t they? Because zebras either run or fight when their stress systems are activated. Humans, on the other hand, think (racing mind), become defensive (verbally fight and argue), or suppress action (leads to physical tension). What’s more, in today’s society, and with individuals facing prolonged hardship, our “tigers” continually circle us and our stress systems become stuck in the “on” position. (i.e. chronic “fight or flight.”)

The symptoms one experiences might be explained by observing the deer’s response to the tiger. It’s a bit of an oversimplification, but by asking a few pointed questions we can guess what symptomatic stress might look like.

1) Would it be to the deer’s advantage to remain calm? Of course not! So stress hormones (adrenalin/cortisol) override the calming chemistry in the brain. Chronically, this might create symptoms of anxiety, tension, reactivity, et cetera.

2) Would it be to the deer’s advantage to enter deep and restorative sleep? This can manifest as insomnia, poor dream recall, not feeling well-rested in the morning, et cetera. Incidentally, what would be the safest time for the deer to sleep? Day or night? (i.e. night-time productivity and day-time fatigue). Sound familiar?

3) Would the deer be content or optimistic? Of course not! The deer has to believe dire events are pending or else it would just continue grazing. This might equate to depressed mood, negativity, becoming “a cup-half-empty” person, et cetera (even if you had always been “a cup-half-full” person).

4) Does a deer in “fight or flight” have normal digestion? The shift to “fight or flight” happens at the expense of “rest and digest.” Chronically this might lead to irritable bowel type symptoms, reduction in digestive enzymes and stomach acid, acid reflux, and ultimately gastrointestinal tract dysbiosis, overgrowth, or loss of protective chemistry, et cetera).

5) What happens to the muscles that activate the arms and legs? In “fight or flight” postural muscles are recruited to action and blood vessels and nerves can become impinged due to this chronic muscle tension. Cold hands, cold feet, excess metabolic waste, contribute to muscle pain.  Shoulder, neck and back tension, restless legs, clinching the steering wheel while driving, hiking the shoulders while typing, et cetera.

6) What happens to the deer’s neurological senses? Does the ticking clock sound too loud? Does “white noise” such as a fan help you relax? Are you or your child sensory adverse or sensitive in unusual ways?

Simply stated, during times of biological stress (inflammation, illness, infections, etc.) or real, even perceived danger (psycho-emotional stress, loss, overworking, etc.), or a combination of both, the stress response turns down or “blocks” chemicals in the brain and body that under normal circumstances promote physical and mental relaxation, positive mood, sleep, et cetera. It’s a beautifully coordinated effort between key aspects of the brain, body, and emotional axis to save your life. Activated for minutes to hours, this response is very helpful. Left on for weeks, months, or even years, it can become horribly uncomfortable and ultimately lead to chronic health and mood problems.

 

HPA (Hypothalamus, Pituitary, Adrenal) axis

Your adrenal glands are two walnut sized organs that sit on top of the kidneys and regulate 4 key things: SUGAR, SALT, SEX hormones, and STRESS (the 4 S’s). Under stressful circumstances they release Adrenaline and Cortisol, commonly referred to as the “fight or flight” hormones. Adrenaline is designed to ramp you up to take action during times of threat. Cortisol is designed to, among other things, protect against the short-term consequences of “fight or flight” (i.e. buffer the effects of Adrenaline). Together these stress hormones and the principal organs they influence are designed to protect you. However, when these signals from the brain and body stay on continuously due to chronic, unrelenting, piling up stress, the system moves into stepwise and predictable stages of malfunction and exhaustion.

Think of the adrenal glands as manufacturing and regulating these critical hormones. Under normal circumstances the manufacturing machine is humming along, responsive to the gas pedal, slowing down, speeding up, and stopping as needed. All is functioning well until a wave of critical physical and/or emotional stressors hit and BAM! The adrenals start stalling, stuttering, and releasing fuel in fits (Adrenaline) without provocation. Initially symptoms are excitatory unless masked by medications. You feel nervous, stressed out, foggy minded, can’t relax, etc. The engine is still running, but not well regulated. This is Stage 1 adrenal fatigue. Then when the engine begins to alternate between coughing, sputtering and blowing smoke and turning off altogether, true-blue, knock you down fatigue sets in. It can sometimes take years to progress to this stage, but once adrenaline rushing alternates predictably with episodes of severe fatigue, you and your stress systems have moved into Late Stage 2 or Early Stage 3. At this point, you may intensely crave salt and/or sugar, because your body can’t regulate these correctly. Your natural thirst mechanisms malfunction. You’re either always thirsty, or not thirsty at all. Water seems to go right through you. Chronic muscle tension may lead to body and nerve pain. You want to relax, but can’t, even when opportunity arises. Certain times of the day you are so fatigued you can hardly function. You may be clinically depressed or anxious. Hormones get completely out of whack and related cycles become volatile (i.e. worsening PMS, decline or extreme increase in sex drive). Your digestive system may be chaotic, alternating between indigestion, diarrhea, hunger like an ox, and no appetite at all. Hypoglycemic episodes following lunch and second winds (feeling too awake) in the evening, especially around bedtime, are your norm. You’re either completely dependent on caffeine or exquisitely sensitive to it… In either case, combining it with sugar and tons of carbs might be what your “activated” body craves to keep going. But it’s not sustainable, and it’s certainly not healthy.

You’re thinking, “if only I could turn back the clock to before all this hit, I could feel normal again.” And you’re absolutely right. Something did go awry due to the biological or emotional stress you endure, but it’s not irreversible. Your stress systems went into a chronic state of “being on,” but this same system knows how to correct itself such that if we remove the offending signals and nourish the system in a specific way, it will turn “off” and “on” as needed again and you’ll feel well again.

A Doctor’s Dilemma

Quite distinct from Addison or Cushing disease(s), which are life threatening if untreated, the subclinical adrenal (HPA) syndromes are not yet widely appreciated by most conventional doctors. However, there are several tests available to aid in confirmation such as serum and salivary cortisol, DHEA, and pregnenolone, cortisol to DHEA ratios, urine neurotransmitters, and other test that many functional medicine experts, such as myself, use. However, the diagnosis is made primarily based on history and I consider such testing confirmatory and summarizing rather than diagnostic.

It’s also somewhat unfortunate that by medical convention symptoms like chronic fatigue, anxiety, restless legs, irritable bowel, et cetera, themselves constitute a diagnosis by conventional standards. Many patients come to me with such diagnoses firmly planted in their mind. And it is confusing, when I tell patients that all these symptoms are predictable, expected, and related; and as the stress systems bounces back, their symptoms will resolve as well.

Though I technically practice both complimentary and conventional approaches, it’s sometimes comes as a shock to patients and other doctors that my treatment recommendations for adrenal problems will often be opposite of conventional instructions, and that many of the medications normally used to control symptoms may need to be safely tapered before we can proceed with more HPA axis specific treatments. Take anti-acids, like Zantac, and proton pump inhibitors, like Pepcid, for example. Well-meaning physicians who consider reflux as an overproduction of stomach acid often prescribe these medications. Yet, most, if not all, chronically stressed, HPA/Adrenal imbalances patients find their symptoms worsen eventually on such medication. Why?

Adrenaline prompts the “Fight-or-Flight” response, which operates in opposition to the “Rest-and-Digest” part of your nervous system. So by design, in such cases, digestive enzymes and acid production are turned down (not up). Therefore, adrenal patients have too little acid (hypochloria) and weak digestive factors at the start of each meal. (Remember, you don’t need to expend energy digesting food well if you’re running from a tiger!) So foodstuff sits in the stomach too long and when acid producing cells finally do kick in, they over compensate because they’re getting mixed messages: On one hand food in the stomach which says release acid and enzymes. On the other, too much sympathetic tone—too much Adrenaline, which says don’t release these. So it’s actually the rebound overproduction of acid resulting from not having enough acid and enzymes (digestive fire) to begin with, combined with undigested food held in the stomach too long that leads to reflux and esophageal burn.  So, yes, stress does cause reflux and stomach ulcers, but chronically stressed/HPA imbalanced patients will not usually make any headway other than short-term relief by taking medications that further reduce stomach acid. The more appropriate treatment, for example while we address the underlying issue might be for example to take digestive enzymes and hydrochloric acid tablets with meals to prevent rebound acid production and facilitate movement of contents out of stomach on schedule as nature intended. Of course medical evaluation is required to rule out stomach ulcers, et cetera prior to such a decision.

Another example is abnormally low or high cholesterol: Adrenal patients often have abnormal serum cholesterol. This is both predictable and expected because the conversion of cholesterol and LDLs into Pregnenolone is the rate limiting step for all adrenal steroid pathways. So it should intuitively follow that when the manufacturing capabilities of the adrenal glands are impaired or needed, low or elevated cholesterol levels might result. In either case, cholesterol and natural fats, including saturated fats, are essential for health and wellbeing (even more so, when your adrenals are in trouble!) The issue of blood vessel and heart disease begins first with having too much inflammation in the circulatory system and among the strongest inflammatory mediators are un-buffered sugars and the insulin surges and cortisol volatility that follows. Ever wonder why diabetes and heart disease come hand in hand?  Anyhow, you’ll do more than you can imagine preventing blood vessel inflammation and heart disease, and healing your HPA axis if you limit your intake of high glycemic indexed foods, like refined cane or corn sugars, potatoes, root vegetables, and anything made with refined white flour.

These are just a couple of examples, but similar rationale can be given for hormones prescribed for PMS symptoms, psychotropic medications prescribed for anxiety, depression, sleep, headaches, et cetera.

Also, depending on your stage of disrepair, new or worsening pain is not uncommon.  Excess sympathetic tone prompting Adrenaline action can make even minor things hurt, such as your rear end sitting in a chair, or the bottom of your feet wearing shoes. Pre-existing pains can become worse, and seemingly resolved pains can resurface. Bottom line: Adrenaline sensitizes nerve endings and lowers signal threshold so otherwise unexplainable pain is common but tends to reduce or resolve with HPA axis correction.

Headaches are also common. In fact, a new type of headache linked to faulty digestion has been postulated, wherein protein deficiency, i.e. lack of absorption and assimilation of amino acids, leading to neurotransmitter depletion (especially Dopamine and Serotonin) in the brain. Because this type of headache seems to only worsen with medications and shotgun analgesics, it’s wiser to address the underlying cause—in this case—the adrenal disrepair or gut problems. Also the chronic muscle tension activated in “Fight or Flight” in the upper shoulders and neck can produce so-called “cervicogenic headaches.” Headaches related to hormone abnormalities are common as well. There are many well-excepted mechanisms that link stress to headaches.

Regarding anxiety: You might think, for example, that you awaken in the early morning hours anxious because you have so much going on. But it’s more likely because of hypoglycemia or Adrenaline/Cortisol surges causing you to wake up suddenly with your mind spinning in “fight or flight” from whatever your particular tigers happen to be at the time! If we address the precipitous fall of blood sugar or unprovoked stress hormone surges, you’ll likely be able to sleep in and the things bothering you will not seem so urgent. Then when you do wake, you’ll find yourself calmer, cooler, and more collected to face the challenges of your day

Remember, if you have subclinical adrenal disrepair, the main reason you feel the way you do, is not because of your current stressors or the descriptive “diagnoses” you’ve been given. But rather your entire HPA system isn’t working well, and that makes you feel horrible in general. It also gives you very limited tolerance for more physical or emotional stress (even minor instances). So it’s important to stay moderately active, eat well, and keep emotional stressors in check.

Finally, it’s important to understand that a patient with an HPA imbalance can more easily develop allergies, sensitivities, and so-called “triggered” health problems.  Your immune system along with everything else is significantly ramped up. So seemingly harmless interventions like the yearly flu shot, or illnesses such as the common cold, can be more problematic for the “adrenal weak.” You’ve probably noticed either one of three scenarios: First, when illness hits, it hits you harder on average and last longer than it used to. Or that cuts, scrapes or bruises take longer to heal. Or you may be in an earlier stage where you hardly ever get sick at all! Or you may have unfortunately developed something autoimmune due to significant ramp up of immune reactivity combined with a genetic predisposition. Plainly stated if you are in HPA imbalance, your immune system is either over- or under-reactive and will eventually prove inefficient. And doesn’t this make perfect sense? Your two primary defense mechanisms are the fight or flight systems and the immune systems. They ramp up and down together. The suffer imbalances together. In sum, HPA axis imbalance makes one less resilient against common insults and more prone to developing allergies, autoimmune problems, et cetera. Therefore adrenal patients and any other autonomically dysregulated patient, with sympathetic excess, or stuck in “fight or flight” (i.e. children with Autism, ADHD, sensory integration problems, et cetera) should proceed cautiously with any proceedures that can illicit a strong immune response.

“So what’s next: How do we treat this?”

If this resonates with you or sounds like what you’ve been experiencing, then you may have some work ahead. The sum total of a carefully outlined biomedical rehab program combined with lifestyle strategies is how we’ll address all angles of this condition. In my experience, HPA axis imbalance is reversible in the majority of patients I work with, using the 10-step Natural Balance Program outlined below:

The 10-step Natural Balance Program

  1. First rule out other causes and confirm the problem. (Not all fatigue is adrenal or hormonal)
  2. Provide education regarding lifestyle corrections and reduction of emotional, physical, environmental-toxic and dietary stressors
  3. Begin the “intro protocol” including going to bed before the second wind, limiting simple sugars after 3 pm, and eating an adrenal healthy diet
  4. Correct salt/water balance (i.e. reduce urinary frequency, altered thirst mechanisms, electrolyte/magnesium imbalance and improve dehydration)
  5. Normalize blood sugar, reactive hypoglycemia, and nutritional tissue resistance (an essential step prior to starting supplements)
  6. Support or suppress Cortisol/Adrenaline (stress hormones) depending on what stage the body is in (I, II, or III) NOTE: trying to adjust Cortisol/Adrenaline when blood sugar is volatile is like trying to get into a car traveling 60 miles per hour – it’s just not possible
  7. Choose adrenal specific supplements and adaptogens according to individual needs and specific presentation of Adrenal (or HPA) imbalance
  8. Support hormone balance using low dose DHEA and Pregnenolone (avoiding direct hormone replacement)
  9. If needed continue with healing the digestive system and replenishing inhibitory neurotransmitters to correct sleep and mood problems such as anxiety, depression, substance cravings, insomnia, etc.
  10. Discharge instructions including long-term, lifestyle and wellness strategies to prevent future problems. (There are many genetic predisposition associated with fatigue conditions, such as MTHFR, MTRR, MTR, etc. single nucleotide polymorphisms–so education and awareness is essential to living a full and happy life.)