(a.k.a. Why You Feel Like Crap)
My Crisis Saga
When I was younger, my life’s fuel was more stress than joy, but I was too busy to notice. I started college as a nursing major, switched to a joint major in biology and chemistry after two years, and graduated three years later with honors and an extraneous fifty to sixty credits. While earning top grades, I was cajoled (read: forced) into working as a lab assistant, a supplemental instructor for biology and chemistry courses, a research associate for professors in the departments of chemistry and microbiology, and a tutor and a grader—jobs that paid under minimum wage and took a considerable amount of time, but were done in pursuit of the much-coveted glowing letters of recommendation required for medical school. As you might guess, I slept about four hours a night. During my third year of college, my mom was diagnosed with what was supposed to be a terminal cancer. Her oncology team at Stanford Hospital described her recovery as “miraculous,” but for an only child with a single parent, the weight of almost losing the sole person who had ever supported and loved me unconditionally weighed heavily on my heart.
By the time medical school began, I was running hard on perfectionism and adrenaline. I was thrilled and intimidated by the opportunities ahead, sinking under the weight of anatomy and pathology textbooks, trying to squeeze in intramural basketball games and dates, and occasionally vacuuming my seriously crappy apartment.
Despite my exhaustion, I could never sleep well and never once woke feeling rested. I was constantly hungry. I lived on coffee and diet soda. I had a breast lump scare, mononucleosis, and severe joint and muscle pain, developed an autoimmune thyroid disorder, and endured five or six sinus infections every winter. I started “taking call,” which meant once or twice a week I had a thirty-six-hour shift in addition to my regular clinical duties. It was not unusual to work nearly a hundred hours a week in the hospital and clinic, without counting the hours of study required to pass rigorous examinations.
My specialty and subspecialty training took another five years. I continued to work between eighty and a hundred hours weekly, and the stakes became much higher: a mistake could harm or even kill someone, and the appropriate hypervigilance combined with my underlying perfectionist tendencies only exacerbated my stress.
I was elected president of the department’s resident organization, which meant I led weekly meetings of resident gripe sessions and was tasked with putting out the fires of personality clashes while serving as an intermediary between disgruntled residents and mostly disinterested faculty. I was asked to serve as one of the chief residents during my fourth year, which meant I had to write lectures and teach in addition to my other duties. I worked overnight shifts in the emergency department, served on a citywide suicide prevention task force, spoke at conferences, helped a colleague open a clinic for pregnant drug users, and when the state legislation held back our funding, participated in a letter-writing campaign to get the funds released. I had so little time off, the idea of wearing pajamas became a luxury, as was being at home, and I morphed into a person whose only hobbies involved things that can be done at home in one’s pajamas (mostly baking and watching Top Chef or Ice Road Truckers, if you’re wondering).
One day, I folded my arms and felt rolls where my ribs were supposed to be. I knew I had been gradually gaining weight over the years; hospital food is hardly healthy, and at two in the morning the only place in the hospital to get food is the coffee cart, and the only food at the coffee cart is brownies, so I kind of knew it was in the cards. I refused to step on the scale, but I knew my clothes weren’t fitting, I was always tired, and this former athlete could barely get through a thirty-minute workout.
What happened to me—to my body—during all of those stressful circumstances spanning about fifteen years? My brain’s crisis system went completely bonkers. I slept poorly, craved sugar, and suffered from irritability, fatigue, and burnout. Does this sound familiar? I bet you’ve struggled with similar symptoms. You’re stressed, stretched, internally preoccupied, and have lost your grasp, your edge, and your mojo. You might be in such an enormous crisis you think you’d rather trade your life crisis saga for mine! So now that we’re all bonded in misery, let me explain why this happens to us, so we can move on and do something about it already.
The Body’s Stress-Response System
There are two types of people in the world: those who love science and those who don’t feel the need to discuss whether the USS Enterprise could actually travel to another galaxy through a black hole in order to enjoy a film series. While the latter somewhat perplex me, my college science professors discovered I was gifted with the ability to communicate with this majority group, the disinterested-in-science students, and I was coaxed into being a sort of translator, breaking down science into easy-to-understand concepts for my classmates.
As we examine the science of stress, I’m going to use two languages: first, a simplified version of the basic science, and then, a translation of sorts using analogies. It doesn’t matter which you follow: there’s no exam here. Just bear with me, and within a few pages you’ll have a basic understanding of the physical origin of your life crisis symptoms.
As humans, we are hardwired to manage stress via an intricate feedback loop between the brain and the adrenal glands. Three anatomical structures are the key players composing what is referred to as the HPA axis: the hypothalamus (in the brain), the pituitary gland (also in the brain), and the adrenal glands (we have two, one on top of each kidney). Together, these areas maintain homeostasis, which is just a fancy scientific term for metabolic balance within the body. In other words, the job of the HPA axis is to create and maintain a relatively stable internal environment, even when we experience physiologic changes. The hypothalamus senses the environment, then sends a chemical message to the pituitary gland, which then sends its own chemical message to the adrenal glands, which respond by releasing several chemicals, with cortisol as the final step in the feedback loop. Once the hypothalamus senses the cortisol, it stops sending its message and the system can stop and rest until the next stress comes along.
Think of it this way: The brain is Command Central, like 9-1-1. When distress is sensed, the hypothalamus assesses the level of danger and calls 9-1-1 right away; the 9-1-1 operator (the pituitary gland) dispatches a message to alert the first responders. The adrenal glands contain the first responders. Once the first responders address the crisis, dispatch is notified, stops coordinating the response to the call, and goes back to waiting for the next call.
The adrenal glands pack a pretty big punch considering their diminutive size. It’s wild to realize something the size of an olive has so much power over how we feel. You might think it should be at least the size of a Cadbury Creme Egg to serve any purpose, but I don’t recommend saying so in medical circles, not that I speak from experience. Each adrenal gland is divided into zones (like a Cadbury Creme Egg, hello . . .), which have different functions. The center (called the medulla) releases epinephrine (a.k.a. adrenaline), which is the main chemical responsible for the fight-or-flight response. So if you’re walking along and suddenly encounter a bear, within a second your hypothalamus has sensed the danger and ordered the release of adrenaline, which prepares you to fight or run by redirecting blood away from certain areas (like your bowels) to essential survival areas (like your muscles and brain); it dilates the airways in your lungs to maximize oxygenation, and increases your heart rate and the strength of the heart’s contractions. All of this combined gives you the best chance for survival in that moment as you face the bear.
Think of the adrenal medulla as the military response to Command Central’s dispatch. It equips your body to fight or evacuate the area—whichever is the best strategy for the given situation.
Surrounding the adrenal medulla is the adrenal cortex, which is divided into three main zones, strangely referred to as “zonas” because half of what we learn in med school is Latin:
• The zona glomerulosa
• The zona fasciculata
• The zona reticularis.
You don’t have to remember their names, but think of these three zones as other first-line responders: firefighters, police, and paramedics. Here’s what the three zones do:
• The zona glomerulosa secretes a hormone called aldosterone, which regulates sodium and potassium levels (electrolytes) and fluid balance.
• The zona fasciculata secretes cortisol, which helps maintain optimal blood sugar levels for the body’s current needs.
• The zona reticularis produces sex hormones, like progesterone, DHEA, estrogen, and testosterone.
Before you get all confused and think your high school biology teacher failed you, estrogen and testosterone do primarily come from our ovaries or testes. However, in order to keep balance (there’s that word again), the zona reticularis produces small amounts of both sex hormones, which is why both men and women have both estrogen and testosterone, although in vastly different quantities.
So what happens when this system is repetitively stimulated? Or when the system is stimulated in non-life-or-death situations that are emotionally toxic nonetheless? Like getting laid off at work and having to look for a new job or finding out your spouse is in love with someone else? The adrenal glands respond to stress the same way, regardless of the source of the stress. In other words, your adrenals don’t understand the difference between a bear attack and a spousal betrayal: stress is stress, and whether it is physical, emotional, psychological, existential, infectious, or environmental, these hormones will be released by your adrenals.
Each component of the HPA axis’s feedback loop requires time for recuperation before the next stress comes along, and when the rest doesn’t occur, symptoms of adrenal stress can appear. The concept of adrenal stress is somewhat confusing because it isn’t technically a recognized medical disorder. We have diagnoses for the state of hypoadrenalism (also known as Addison’s disease, which is a rare condition in which the adrenals do not produce adequate amounts of the hormone) and hyperadrenalism (overactive adrenal function, also known as Cushing syndrome), with “normal adrenal function” somewhere in the middle. However, there is no clearly defined diagnosis for someone with adrenal functioning that lies between normal and nonexistent. It is possible to develop symptoms from what is best described as a sluggish hormonal response from the adrenal glands. This is what is often referred to as “adrenal stress” or “adrenal fatigue.” Whether or not adrenal stress is an official diagnosis, the physical symptoms of chronic stress make sense when we look closely at adrenal functioning. Keep in mind there is a lot of individual variation in this (which is part of the diagnostic conundrum). Let’s look at the process hormone by hormone.
Epinephrine (Adrenaline)
The release of adrenaline causes muscle tension, which prepares us for physical action (running from the bear, for example). What happens when we are stressed by a traffic jam or sitting in a conference room during a meeting with a micromanaging supervisor? Under these conditions, a rush of adrenaline can produce feelings of jitteriness, physical tension, and frustration, especially when getting up and moving around isn’t possible. Over time, chronic stress leads to tense and sore muscles, jaw clenching, tight hamstrings, neck and back pain, even headaches. Think about it: if adrenaline is telling our muscles to fight or flee the scene, we are wired to do just that, and just like the HPA axis, our muscles then need to recover before resuming normal functioning. If instead, after being primed for action, our muscles are held in a state of inactivity (sitting behind the wheel of the car or in the conference room), the muscles become tense. With chronic stress comes chronic muscle tension. Let’s finally get to Eddie:
On the insistence of his therapist, Eddie begrudgingly came in for a consultation. He gingerly lowered himself onto the couch, wincing, grabbing his back. He assured me he was fine and could handle it. “I can handle everything, actually; it’s my therapist who says I should talk to you.” He was in therapy to address his alcohol use, and for the past few months, he had experienced fatigue, low mood, sleep disruption, and low sex drive. Our discussion revealed his stress over his mother’s cancer, the strain he faced working at the family restaurant, and his inability to start his own business. In addition, he was recently engaged and looking for a house to buy with his fiancée. He had injured his back years ago playing sports, but for some reason it started acting up again, slowing his every move, turning his restaurant shifts into torturous experiences. This self-proclaimed tough guy who could handle anything on his own could barely lower himself onto a couch.
Eddie was in his predicament for a number of reasons. In addition to muscle tension from chronic stress, Eddie was going to great lengths to hide from me and everyone else his high anxiety, and parts of his brain called the basal ganglia (we have two, a left and right) were overactive. The two basal ganglia aren’t part of the HPA axis, but they are neighbors of the hypothalamus in the brain. They are associated with multiple brain pathways, notably movement, as well as emotion (feelings of calmness vs. stress or worry). I frequently point out to patients like Eddie the basal ganglia’s link between emotional stress and stiff, sore muscles. If you can calm your brain, you can calm your muscles; if you can calm your muscles, you can calm your brain. We’ll revisit this in the chapter “From Pain to Sane,” when we discuss how to reclaim your brain and body. For now, just remember there are very real brain and body connections resulting in stress-induced body pain.
Aldosterone
If you’re a salt craver during a brain crisis, aldosterone (or an imbalance thereof) may be your culprit. During acute stress, the release of aldosterone by the adrenal glands causes a quick electrolyte shift, resulting in sodium retention. Sodium retention in this case is actually a good thing because it causes water retention (water follows salt: the more salt you have in your body, the more fluid you retain), which increases blood pressure and blood volume, so our muscles and brains have access to oxygen and nutrients for optimal functioning while we’re trying to outrun (and outsmart) a bear. Over time with chronic stress, as the adrenals can’t keep up and start to fatigue, the opposite can manifest: the sodium balance shifts and sodium is excreted through the kidneys and water follows, which can lead to salt cravings and lowered blood pressure. Lowered blood pressure commonly leads to dizziness or light-headedness upon standing.
I don’t remember having salt cravings during my brain crisis saga (I was a total carbohydrate/sugar addict), but for years, I experienced light-headedness upon standing, despite my best efforts at staying hydrated. Conventional medicine told me to drink more fluids. If the adrenal stress theory is true, drinking tons of water wouldn’t have helped my symptoms of low blood pressure unless I had enough salt intake to enable me to retain the water I was drinking. You can understand why the traditional medical approach doesn’t define adrenal stress or fatigue when you realize how symptoms can differ between people. But recognizing your symptoms and understanding their origins will help you decide which of the stress interventions outlined later in the book you’ll want to follow.
Cortisol
This is where anyone worried about a muffin top or a fat belly needs to perk up and pay attention, as cortisol seems to be the key player in what I refer to as the “panda bear syndrome” (also not a recognized medical diagnosis, but very, very real). One of cortisol’s jobs is making sure the necessary organs have enough fuel to meet their increased energy demands during a crisis. Energy is used by cells in the form of glucose, which produces fast energy. Insulin, released by the pancreas, is what helps glucose get into the cells. When cortisol levels spike during acute stress, the fats, proteins, and carbohydrates we’ve eaten are converted into glucose and delivered into the cells by insulin. We then burn all these calories running from, or fighting with, the bear. With chronic stress, the adrenal glands can’t keep up with the body’s demand for cortisol (they need rest, remember), so cortisol levels start to decrease while the demand for energy in the body remains elevated. (When stress is ongoing, your tissues and cells think you’re still running from a bear, so they demand fuel in the form of glucose.) As cortisol levels decrease, however, the conversion of fats, proteins, and carbohydrates to glucose falls, and the body mistakenly thinks it needs glucose, which leads to sugar cravings. This begins a harmful cycle: sugar cravings entice us to drink soda or eat cookies, we get a spike in energy for an hour or so, but our glucose level then plunges, which places further stress on the body and adrenal glands, and this plummeting glucose level (called hypoglycemia, or low blood sugar) drives us to eat sugar again. We gain weight because insulin is increased, the glucose we ingest goes straight into the cells, and the excess is stored as fat. The most common areas for weight gain under these circumstances are around the belly and around the face (what I lovingly refer to as growing jowls).
In addition to controlling glucose balance, cortisol also has anti-inflammatory effects and protects us against the autoimmune process. Perhaps in the past you may have had a serious illness or injury and been prescribed oral or injected steroids to calm inflammation. Such steroids (like prednisone) are related to cortisol. With chronic stress, suboptimal cortisol levels can contribute to an increased inflammatory response, so you can develop allergic reactions (to environmental allergens or foods) or may be more likely to experience autoimmune issues. This may be why I developed an autoimmune thyroid problem when no such issue runs in my family, chronic sinus infections, and most devastating of all, the onset of respiratory allergy symptoms (unrelenting cough, mucus) after eating cheese (which was always my favorite thing on the planet). As if the crisis isn’t enough, now I can’t have my go-to comfort food? The universe can be cruel indeed.
In an agonizing double whammy, cortisol can impair sleep both when it is too high (why would you sleep when running from a bear, right?) as well as when it is lowered by chronic stress. Under normal circumstances, cortisol is released in regular patterns to maintain homeostasis, which contributes to a healthy sleep-wake cycle, or circadian rhythm. When cortisol levels are abnormal, sleep onset can be impaired and sleep maintenance can be disrupted by nighttime hypoglycemia. This leads to difficulty getting up in the morning, daytime fatigue, mood changes, irritability, and brain fog (caused by both poor sleep and hypoglycemia, in another of cortisol’s double whammies).
Sex Hormones
Ovaries are the primary source of estrogen in women and testes the primary source of testosterone in men, but the adrenal glands make both estrogen and testosterone in smaller quantities in both sexes. The decrease in libido seen during stress may be caused by decreased testosterone production by the adrenal glands. This actually makes sense. If you need energy to run from a bear, the body should hardly be distracted by activities geared toward reproduction, right? But over time with chronic stress, lowered libido can be devastating. Sex is awesome, and losing the desire (or ability) to participate causes discouragement and frustration and lowers our quality of life. Because of the sex hormone changes in the adrenal glands, some women may also experience worsening premenstrual syndrome (PMS) or exaggerated symptoms of menopause and perimenopause. These changes in our sex hormones affect not only our own bodies during a crisis, they also affect our partners and/or our families (via irritability and hormone-based mood swings).
To summarize, during times of acute stress, our bodies are intricately wired to improve the chance of survival. Why our bodies aren’t better at managing chronic stress is a total mystery. While it is certainly an interesting topic for medical debate, we have more pressing needs to address, such as, How on Earth am I going to manage my current life crisis? Later in the book, we’ll circle back to discuss how to address sugar and salt cravings, weight gain, muscle pain, and fatigue. But first, let’s look at our five-point model of crisis management, and then we can practice applying the steps to real-life situations.