Managing stress and 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 with GPs or hospitals.
• 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

Talking 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. 

ADSHG members can chat with others on our online forum  or face-to-face at our Member Get-Togethers or at a local meeting in your area. 

Dr Alessandro Prete (Consultant Endocrinologist, Queen Elizabeth Hospital Birmingham) shares his advice:

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

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 work, school, or home.

Whether to increase the dose of steroids temporarily 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 a 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.

Hydrocortisone users:

If patients with adrenal insufficiency use hydrocortisone tablets for stress dosing, they can add 10- 20 mg of hydrocortisone to their total daily dose; in case of prolonged stress, additional 2.5- 10 mg doses of hydrocortisone can be taken every 5-7 hours.

Prednisolone users:

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.

Summary:

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.