Understanding HPA Axis Dysregulation

The tower of fear...

Also commonly known as Adrenal Fatigue, HPA Axis Dysregulation affects nearly every organ and system within the body. 
Learn how to support and balance the HPA Axis and how to restore its function.



Looking at the Tower of Fear, as I like to call it, and imagining the Hypothalamus is the antenna, the Pituitary Gland the black box, and the pillar the hormonal path, with at the bottom the Adrenals.
You have right there the HPA Axis. 
Under stress, will circulate to the Adrenals, generating the stress response and stop it once it is over, by sending signal to the brain (in a negative feedback loop) ​

​According to one of the central themes of evolutionary medicine there is a profound mismatch between our genes and our modern environment and that this mismatch is driving the current epidemic of chronic, inflammatory disease.
 
Many clinicians still deny a link between the food we eat and the genesis of disease; in the same way as many experts reject the occurrence of global warming. Yet, our diet is one of the most frequently mentioned examples of this mismatch. But there is another example that I believe is every bit as important (but far less commonly recognised): our stress-response system.
 
As explained in previous articles, the stress response is primarily governed by the HPA axis (refer to Stress and Fatigue article, in the Summer Edition 2016 – Part 2). Stress activates the HPA axis and sets off a cascade of (Neuroendocrine) signals that ultimately lead to the release of hormones and neurotransmitters, including Epinephrine (Adrenaline), Norepinephrine (Noradrenaline) and Cortisol. However complex this system, the key thing to understand is that the mechanism in which the body engages in response to stress is somewhat protective in the short term but is very damaging in the long term, as previously demonstrated.
 
Putting our human physiology into its original context, back to the time of our ancestors. Let’s imagine a hunter-gatherer looking for food and must now run for his life. In this case, it is a good thing that his heart rate, blood pressure and blood sugar all increase – along with many other changes deigned to help us (humans) survive. These changes however are adaptive; they mean life or death by either fleeing or fighting for survival.
In the context of our modern lives, when this same stress response is continually activated, let it be by stressors such as getting stuck in traffic, working two jobs, not sleeping enough, using electronic devices at night, and eating an inflammatory diet, or abusing stimulants (caffeine, sugar, etc.). Even though they are far from the same as being chased by a sabre-tooth, or a time of famine, our stress response reacts to them as if they were: we experience the same increase in blood sugar, blood pressure, and heart rate, but in this case, these changes are maladaptive. Rather than help us to survive, they contribute to a whole array of chronic diseases as previously explained, including the Metabolic Syndrome, Type-II Diabetes, and unfortunately a shorter lifespan.
 
​Let’s get into more details, and from all the research used in previous articles, let’s add them altogether. And it all starts with the dysregulation of the HPA Axis, due to chronic activation of our stress response, which leads to changes in Cortisol production by the Adrenals (either too much or too little), disruption in the diurnal Cortisol rhythm (when it should be high in the morning and low in the evening to allow us to get up in the morning and go about our day and let us fall asleep at night, too little Cortisol is produce in the morning and too much in the evening), affecting other hormones and neurotransmitters such as Melatonin and epinephrine.

Dysregulation of the HPA Axis associated with:
 

• Not feeling refreshed in the morning, even after a good night sleep
• Dependence on stimulants to prevent or counteract energy crash after lunch or late in the afternoon
• “Second wind” later in the day, typically after 6:00 or 10:00 PM.
• Loss in productivity, or difficulty in increasing athletic performance
• Poor memory and concentration
• Difficulty recovering from exercise
• Lowered (suppressed) immunity (poor wound healing and susceptibility to viruses infections
• Extra abdominal fat
• Lower body temperature, cold extremities, and in worse cases Hypothyroidism
• Tendency to feel better just after eating
• Salt cravings
• Decreased stress tolerance
• And an overall indicator of HPA Axis imbalance: unexplained fatigue

 
Still today many practitioners refuse to acknowledge Adrenal Fatigue, usually used to explain the symptoms of fatigue, sleep disturbance, and chronically low Cortisol levels and HPA dysfunction. A concept based on Selye’s “General Adaptation Syndrome” (or GAS).

In Selye’s General Adaptation Syndrome, the occurrence of a stressor occurs leads to three stages: 1) Alarm: the body initially responds to a stressor with changes that lowers resistance, 2) Resistance: if the stressor continue, the body mobilises to withstand the stress and return to normal, and 3) Exhaustion: ongoing, extreme stressors eventually deplete the body’s resources so we function at less than normal (hence, the unexplained fatigue). Either there is a return to homeostasis (to a balanced state, or of normal performance in the absence of stressor), or the body’s resources are not replenished and/or additional stressors occur, the body suffers and breakdown, opening the door to illness and possible death.
This is also applicable to athletes, or people over-exercising, pushing their body to the limit every single day. Inflicting stress to the body, tissues and organs, as often high intensity exercising is accompanied by large supplemental doses, protein powders and carbohydrates to sustain energy levels. ​

According to this theory, in a healthy stress response, Cortisol, DHEA, and Pregnelonone are within the normal range. In Stage I, Cortisol increases while DHEA decreases. In stages II and III, Pregnelonone, and DHEA, the same as Cortisol, progressively diminish (as the Adrenals become ‘fatigued’ and unable to continue to produce it), until they are totally depleted in the final stage. Failure.
 
Today’s understanding of the HPA Axis dysregulation have lead to identify four primary triggers that affects the HPA Axis, which in turn affect nearly every organ and system of the body (including the gut, thyroid, metabolism, male/female reproductive system):
 

1. Perceived stress (including, emotional, psychological and anticipatory stress).
2. Blood sugar imbalances (Glycaemic dysregulation).
3. Circadian disruption (including sleep depravation, shift work, not enough exposure to natural light during the day or too much exposure to blue light at night, frequent travel across time zones)
4. (Systemic) Inflammation (due to poor diet, sedentary lifestyle, binging, gut dysfunction (Dysbiosis, opportunistic pathogenic infections, etc.), food intolerances and autoimmune conditions.

 
For this reason, Adrenal Fatigue is a term not commonly used in Western medicine, for practitioners it is not only a problem of Cortisol production due to weak adrenal glands, but a syndrome characterised by a mismatch between our modern diet and lifestyle, and our innate stress response system. Yet, most are still failing to make the link between diet, lifestyle and disease, and, still today, the entire syllabus of a doctor in training will dedicate no more than 20 hours to nutrition.
 
Because stress is so prevalent in our society, and because of the wide-ranging effects of HPA Axis dysregulation, protocols to restore HPA Axis function must dictate life-changing improvements.
Compiling all the solutions given in my previous newsletters, my personal recommendations include diet and lifestyle changes (In the context of this newsletter, however, I am not discussing therapeutic herbs or supplementation, as I believe this should be done under the supervision of a health practitioner):
 
Dietary recommendations
 

• Avoid stimulants, including caffeine and sugary snacks, as they place additional stress on the body
• Avoid alcohol (stresses the liver, which may already be working sub-optimally)
• Ensure adequate Sodium-Potassium balance
• Eat smaller meals throughout the day to prevent dips in energy, focussing on a moderate carbohydrate diet and adequate protein intake, especially at breakfast to reduce cravings later in the morning, which is also beneficial to keep blood sugar levels stable

 
Most people with HPA Axis dysregulation also have blood sugar management issues. Avoiding foods that impact directly on raising blood sugar and keeping a diet moderately low carbohydrate diet can only be beneficial; however, cutting carbs out of the diet completely may worsen insomnia, fatigue, brain fog, as the body is fighting to find sources for energy.
When blood sugar is low, the Adrenals produce Cortisol in order to bring it back up. When this happens repeatedly, it will place stress on the Adrenals and exacerbate HPA Axis dysregulation.
When Adrenal Fatigue sets, the balance between Sodium and Potassium is broken. To keep blood pressure low the body excretes Sodium, hence why you may crave salty foods. Eating much Potassium-rich food may therefore worsen HPA Axis dysregulation.
 
Lifestyle recommendations
 
Dietary changes alone are not enough to recover from HPA Axis dysregulation, as it is often caused by lifestyle-related factors such as stress, inadequate sleep, lack of social connection, and not enough connection with nature. Even the perfect diet is ineffective if lifestyle changes are not made.
 

• Bedroom hygiene: no use of (blue light) electronic devices two hours before bed time, including TV, Smartphone, and make the bedroom only a place to sleep. If you do not have any shutter make sure to have light-blocking curtains, as light impacts on Melatonin production, including the light emanating from an alarm-clock. If you need an alarm-clock to wake up in the morning, make sure the digits are not facing you and preferably cover them up or place it on the floor. Furthermore, if you have difficulties sleeping, keeping an eye on the clock may actually keep you from falling asleep. 
• Find a way to relax that works for you, let it be meditation, reading a book, breathing techniques, listening to relaxing music, or relaxing podcasts, regular massages, walks in nature, etc.
• Exercise in a way that it works for you, and avoid overtraining. Exercise is vital in stress management; however, it can become a source of stress for the body when overdoing it. It does not need to be intense and has to be progressive. For example, as you start to engage in physical activities after a long sedentary period, walking, cycling, yoga, or other lower-intensity activities are ideal. You can move towards moderate-intensity strength training once you feel it is right for you.
• Socialise with people that make you feel good about yourself; have a pet; cultivate pleasure and connection; learn to enjoy life again; and make time for play, and physical contact.
• Get closer to nature.

 
Sleep is the most important for those with HPA Axis dysregulation, and even napping may be necessary in the worse of cases. Learning to stop, take breaks, go on holiday may be vital to re-establish a circadian rhythm, and it will not reflect on how productive you are. Again, be very mindful about your inner-conversation and the way you talk to yourself. Slowing down or taking a rest does not make you lazy or unworthy. These are often the reason behind your state of stress in the first place. Identifying your museum of beliefs may help you to be kinder to yourself and let go of what is preventing you being yourself, and to relax. NLP may be a great tool to consider.
Along with poor sleep, psychological, emotional, and anticipatory stress are primary contributors to HPA Axis dysregulation, and managing stress is a crucial part of the recovery process. Stress management is a necessity for people with Adrenal Fatigue (usually the ones who are least likely to let go) as it forces them to face core patterns of beliefs and behaviours that are anchored in their subconscious and are difficult to change. But it also forced them to slow down; to take a moment and assess where they are, how they got there, and where they want to be; to step back, to disengage if even for a brief time; to prioritise self-care; to reconnect with oneself.
Stress-management practices must be incorporated in daily routine to mitigate the harmful effects of stress when it cannot be avoided. 
 
Fatigue is usually misunderstood or dismissed by the mainstream medical model, and the root causes never really addressed. Adrenal Fatigue, or HPA Axis dysregulation describes the physiological changes that occur as a result of chronic, unrelenting stress, and can be at the root of the fatigue – since, it affect nearly every organ and system in the body.
People who do not get enough rest and relaxation to enjoy life, who drives themselves constantly, who are never satisfied or perfectionists, who are under constant pressure (especially with few outlets for emotional release), who feel trapped or helpless, who feel overwhelmed by repeated or continuous difficulties, or who have experienced severe or chronic emotional or physical trauma or illness are probably already suffering from some degree of adrenal fatigue.
 
Treatments to support and balance the HPA Axis, and restoring its function, must include dietary interventions and nutrition, and lifestyle changes (in the form of sleep, rest, stress management, and pleasure).

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References:
 
Lam, M. Lam, D. (2012). Adrenal Fatigue Syndrome: Reclaim Your Energy and Vitality with Clinically Proven Natural Programs. In Maling, J, McCullough, V. Loma Linda. Adrenal Press Institute. 
Lewis, G. Wessely, S. (1992). The epidemiology of fatigue: more questions than answers. Journal of Epidemiology and Community Health. 46(2), pp. 92–97