Coping with psychological stress 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 Doctor's view, kindly provided by Dr Alessandro Prete, Consultant Endocrinologist at Queen Elizabeth Hospital Birmingham, UK. Physical and emotional stress Why take extra for emotional stress? Good stress and bad stress Top up or chill-out - reducing the stress of a long-term condition The Doctor's View: Emotional stress, bereavement and stress dosing Adrenal crisis anxiety Professional support Webinar: You & Your Emotional Wellbeing 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 stresses such as fever, illness, infection, injury or surgical interventions, known as the Sick Day Rules. However, it is a lot less clear that we also need to increase our steroid replacement dose 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. However it is important to recognise and know your symptoms. Emotional stress has been reported as the triggering factor of acute adrenal insufficiency in up to 1 in 6 patients developing an adrenal crisis. This is recognised in the NICE Guidance: Adrenal insufficiency: identification and management. The psychological stress definition now includes examples such as bereavement, exams, and getting married or divorced, to help illustrate and provide real-life examples to improve understanding. Why take extra for emotional stress? We tend to have a default position of separating body and mind, so we can forget 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. In modern situations, such as a demanding job, school exams or a stressful family situation, the lack of cortisol may make itself felt and that’s when we may need to 'top up', as explained further by Dr Alessandro Prete in the Doctor's View below. "Good" stress and "bad" stress Here is a personal example to illustrate how difficult it can be to pin down exactly when psychological stress will set in from one of our members. "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." Another example kindly shared on our Blog is Bex's experience of needing to increase her hydrocortisone dose for her wedding day. 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. But how can we manage any stress or anxiety that we experience as a result of living with a long-term medical condition? On our 'Reducing the stress of a long-term condition' page, we share resources for looking after your mental health. The Doctor's 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. This is recognised in the NICE Guidance: Adrenal insufficiency: identification and management. 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. Adrenal crisis anxiety Worrying about having low cortisol, not knowing your symptoms of adrenal crisis, or whether you'll be able to give an emergency injection if needed is completely normal. These concerns are an added stress to your everyday life and are part of your ‘invisible’ condition. But for some people, these worries become more intense, harder to control and result in anxiety. You don’t have to face this anxiety alone, and with the right support, it can become more manageable. Understanding what is going on inside your body and feeling prepared may help you. Here are some suggestions if you're worrying about having low cortisol or going into adrenal crisis. Start logging your low cortisol symptoms to help learn the signs for your body, for example in the Notes app on your phone. Are there any patterns or is there something you might be able to change in your routine? You can then discuss this with your healthcare team. Get educated! Read our Managing your Addison's or adrenal insufficiency booklet, and other publications. Knowledge is power. Make a plan of options that you could take if you do get low cortisol or adrenal crisis symptoms so you feel prepared. For example, if you’re worried about getting low cortisol in a work meeting, would you prefer to excuse yourself from the meeting to treat it (others may assume you needed to use the bathroom) or are you happy to immediately take more medication and let others know you feel unwell? Always have extra medication, your emergency injection kit and hospital folder ready should you feel unwell, and make sure those you’re close with know where this is all kept. Practise different relaxation techniques like mindful breathing, so you can use these when you're worrying about becoming unwell and to help manage your anxiety. These can also be helpful for those who experience anxiety when waiting for appointments in GPs or hospital. Talk to your healthcare team They will have come across it before and can offer you techniques to help you cope. They might also suggest you see a psychologist or a counsellor if your anxiety is bad. Apps and Mindfulness Apps such as Headspace you can try yourself at home and when you’re out and about. Other forms of mindfulness such as breathwork can help with your anxiety Talk to other people with Addison’s and adrenal insufficiency Your family, friends and healthcare professionals are all there to support you, but sometimes you need to talk to other people who have experienced the same things as you. You can chat with others on our online forum and through our local members' social meetings who are there to offer all kinds of support. Professional support Anxiety and depression are serious mental health conditions, which can affect anyone, regardless of culture, background and family history. So if you experience symptoms for two weeks or more, you should talk to your GP or another healthcare professional. They will be able to do an assessment with you, and recommend what to do next, so you can get the support that is right for you. It’s always going to be a hard thing to do, but asking for help and talking about your problems with someone can be really helpful. If you are unsure, always speak with your healthcare team to refer you for professional emotional support. More places you can get support Wren Project A UK charity providing free, 1-1, listening support for adults with an autoimmune disease diagnosis. Please note that Wren is therefore only able to support those with autoimmune Addison's disease (primary adrenal insufficiency). Rareminds Wellbeing Hub Resources for all aspects of living with a rare condition, with sections dedicated to diagnosis, uncertainty, change and loss, relationships, feelings, healthcare navigation and many other challenges. Online Forum Speak with others who just 'get it'! A welcoming space to share experiences, ask questions and discuss the practicalities of living with Addison's and adrenal insufficiency. Catch up on our online Wellbeing webinar, run in collaboration with Rareminds, recognising both the importance of emotional wellbeing and the unique challenges of living with a rare condition. Our aim was to share expert advice, remind you that you’re not alone, and offer practical strategies to help support your emotional wellbeing. Following the event, attendees let us know how they found the session, with many describing the session as “empowering” and “reassuring.” 94% of people felt less isolated and 83% felt more resilient, having attended, so although it is easy to feel that there isn’t enough time, or it can wait for another day, your emotional wellbeing is really worth putting first. Click the link below to watch back! Contact other national charities The charity 'Scope - Equality for Disabled People' offers a helpline if you would like to talk on the phone. Reach out to Mind and Rethink Contact - a charity for families of disabled children offers a 'listening ear' service. Connect with the rare diseases community. Check out Rare Disease UK, Rare Revolution and Cambridge Rare Disease Network. 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 X / Twitter, Facebook, Instagram, LinkedIn, Threads, TikTok and YouTube. Manage Cookie Preferences