We explain why more hydrocortisone may be required to cope with emotional or psychological stress and outlines some general techniques to reduce stress and improve well-being. Read on to hear both the patient experience, as well as the Doctors view, kindly provided by Dr Alessandro Prete, Consultant Endocrinologist at Queen Elizabeth Hospital Birmingham, UK.

Physical and emotional stress

Our daily hydrocortisone gives our bodies the cortisol which our adrenals don’t make and we have clear medical guidelines for topping up the medication to respond to physical stress: fever, illness, infection, injury or surgical interventions. However, it is a lot less clear that we also need to increase our hydrocortisone dosage when we’re feeling emotionally or psychologically challenged. This could be because significant stress for one person may be completely manageable to someone else.

Apart from some key crises such as the death of a loved one, it’s difficult to outline which situations require top-ups and which don’t for certain individuals.

Why take extra for emotional stress?

Let’s back up a moment here. We tend to have a default position of separating body and mind, so we fail to take into account the multiple ways in which the two are connected. Psychological stress calls up a physical response – when we’re anxious, we get ‘butterflies’ or ‘a knot’ in our stomach; if we panic, we may have sweaty palms, a fast-beating heart; with ongoing stress, some people develop digestive problems, headaches or lowered resistance to infection. All these emotional responses let us know that our bodies and minds are intimately linked and can trigger a need for extra hydrocortisone. 

When we’re psychologically stressed, a slow, low-level burn from the fight-or-flight reflex is activated. Stone-Age parts of our minds react to this - either wanting to physically fight the problem (the anger part of stress response) or to literally run away. Both require strength in our muscles in order to be able to attack or flee, so our still-primitive bodies oblige by releasing adrenaline to power us and cortisol to shore up the body during the physical demands. This was great when the likely source of stress was a bear ambling towards the tribal campfire – you killed the bear or you ran away to safety - job done. This is less appropriate in modern situations, such as a demanding job or a stressful family situation. Over time, the lack of cortisol will make itself felt and that’s when we need 
to top up. 

A personal example to illustrate how difficult it can be to pin down exactly when psychological stress will set in. A couple of years ago, I had a wonderful two-week holiday in France, staying with three different sets of friends. We talked all day, went sightseeing, had long, late evening meals and went on enjoyable walks. It was lovely, except that after about a week I woke up one morning with that old floppy, hopeless, can’t-eat feeling and it was only after 20mg extra hydrocortisone that I was able to get out of bed at all and it took 36 hours to be able to eat much. I hadn’t realised that this complete change in the rhythm of my days, together with being in ‘switched-on sociable mode’ would be such a drain on my resources. For others, this pace might be normal, or they might cope with the change of gear without a hiccup. 

We’re all different in how we experience things. So it’s up to each of us to learn to recognise when we’re stressed and what our personal triggers are so that we can think of popping extra hydrocortisone. And it’s worth remembering that good stress is still stress and so it brings physical demands.

Top up or chill-out?

Finally and importantly, our other option is to manage our psychological state so that low level fight-or-flight doesn’t need to kick in. Here are some general techniques for this that are really good for day-to-day self-care as well as stress reduction:

• Make time to relax, every day
• Practise slow, deep breathing - making sure the out breath is longer than the in breath
• Find a different perspective - let yourself know the situation won't last & that everything will be okay
• Carefully choose the words we use - we are managing our Addison's, not suffering from it
• Focus on the positives

This article was contributed by an Addison's Disease Self-Help Group member with primary Addison's Disease.

The Doctors View: Emotional stress, bereavement and stress dosing

Patients' experiences bring into focus the potential effects of emotional stress on people living with adrenal insufficiency.

As said, clear guidelines exist on how to manage cortisol replacement in times of physical stress such as fever, infections, trauma, surgery, or severe pain. However, it is more difficult to define how emotional and psychological challenges affect the stress response, mostly because each challenge is unique and individuals may respond in different ways.

Emotional stress has been reported as the triggering factor of acute adrenal insufficiency in up to 1 in 6 patients developing an adrenal crisis. Examples of stressful events include bereavement, a life-altering diagnosis in a family member, and other acute stress at works, school, or home.

Whether to increase temporarily the dose of steroids in case of emotional and psychological stress should be considered on a case-by-case basis and patients are best suited to do this. While it is not advisable to routinely take stress dose of glucocorticoids for minor stressful life events, a top-up should be considered when coping with grief and loss, a job interview, or a final-year exam for example.

If patients with adrenal insufficiency use hydrocortisone tablets for stress dosing, they can add 10-20mg of hydrocortisone to their total daily dose; in case of prolonged stress, additional 2.5-10mg doses of hydrocortisone can be taken every 5-7 hours. Patients treated with prednisolone, prednisone, or modified-release hydrocortisone who do not have access to hydrocortisone tablets can take extra doses of their routine medication every 6-10 hours (2 to 3 times a day) until the stress has resolved.

In conclusion, emotional stress can precipitate symptoms of cortisol deficiency and stress dosing may be required in case of major stressful life events. Every individual is different in the way they experience challenging situations and should be vigilant about symptoms of cortisol deficiency. If unsure about stress dosing or if there are any concerns about the impact of emotional wellbeing on the adrenal insufficiency treatment, patients should contact their endocrinologist for advice.

Author: Dr Alessandro Prete - Consultant Endocrinologist, Queen Elizabeth Hospital Birmingham, UK.

	Some people find it helpful to speak to someone who understands what it is like to live with Addison’s and adrenal insufficiency. Our online community is a welcoming place for everyone affected by Addison’s and adrenal insufficiency to ask questions, read about people’s experiences and support each other. Visit our online forum to speak with others.
	Addison's disease or other forms of adrenal insufficiency can affect your emotional wellbeing just as much as your physical health. Read our article for tips to reduce the stress of managing a long term condition and more support for your  mental health.
	The Wren’s Project Listening Programme provides listening support, allowing you to talk about the emotional and social impact of diagnosis. Learn more.
	Looking for more articles? We've put together an A-Z of the really useful information and resources available on our website. Have a browse!

Whether you're newly diagnosed or have lived with the condition for years - please join our community and support our cause! You'll receive the latest expert advice, guidance and ADSHG news, whilst being part of our inspiring and supportive community. 

Join the ADSHG 

Connect on social media! Follow us on Twitter, Facebook, Instagram, LinkedIn and YouTube.