A Vicious Cycle: Adrenal Fatigue, Mental Illness and Gastrointestinal Imbalances

Chronic Stress

In my previous blog post, I wrote about managing stress and gave some tips for gaining control and a greater sense of calm when facing short-term stress, but what about stress that is unrelenting or chronic? How does one maintain health with persistent exposure to stress? The short answer is that one typically cannot maintain health under such circumstances. But the longer answer is one that is needed in stressful times such as these and, arguably is especially needed, for those suffering from mental illness (which imposes considerable psychological and physiological stress on an individual).

Adrenal Fatigue (aka Adrenal Insufficiency)

Adrenal Gland Function and Dysfunction

In naturopathic/integrative/functional medicine, we speak of chronic stress as leading to ‘Adrenal Fatigue’ or ‘Adrenal Insufficiency’. The adrenal gland is responsible for secreting hormones (cortisol, epinephrine, norepinephrine and dopamine, mineralocorticoids and sex hormones) that help one to adapt to stress (among other roles). If one is under unrelenting stress, the adrenal glands do not have time to recover and cannot maintain the excess secretion of cortisol and other hormones needed to deal with a stressor(s). (Increased cortisol secretion is the body’s attempt to liberate fuel and to rally the metabolic response needed to face and overcome a stressor (the ‘fight or flight’ response)). Chronic stress leads to depletion of the adrenal hormones and a variety of symptoms, commonly classified into Stage I, II and III Adrenal Insufficiency (depending on the severity and duration of the stressors).

Cortisol has a wide array of functions (which explains the broad range of symptoms that occur with adrenal insufficiency). Cortisol promotes fat burning, maintains mood and emotional stability (abnormal levels can lead to depression), counters inflammation and allergies, directs ovarian and testicular hormone levels and maintains resistance to stress. When cortisol is in excess (i.e. the adrenal glands have been over-stimulated by unrelenting stress), the body is in a catabolic state (it breaks down body tissues for fuel). This catabolic state leads to bone loss and muscle wasting. I speak often of the relationship between gastrointestinal or gut health and the health of the brain/mind and thus it is of particular note that chronic stress, in inducing the break down of bodily tissues, leads to the break down of the gut lining for fuel. This has significant adverse health effects as the gut lining maintains the integrity of the immune system, allows us to properly digest and absorb nutrients needed for neurotransmitter production and overall health and is a part of keeping inflammation and infection at bay and the bacterial flora balanced. For more on the effects of increased gut permeability (or ‘leaky gut’), click here to read a past blog post discussing this topic as it relates to food allergies.

Excess cortisol is also pro-inflammatory and leads to decreased immune function. Metabolic changes resulting from elevated cortisol levels include: increased fat accumulation in the abdomen and increased blood glucose (which can lead to metabolic syndrome and early diabetes). Impaired wound healing, tissue repair and recovery and immune system suppression also result. Symptoms of adrenal dysfunction can include excessive fatigue (particularly in later stage (Stage III) adrenal insufficiency), irritability, insomnia, depression, anxiety, poor concentration and memory, menstrual irregularities in women, impaired erectile function in men and decreased sex drive in both men and women. Chronic muscle and joint pain, food cravings, indigestion, food allergies, dry skin and lightheadedness can also occur with adrenal insufficiency.

Adrenal Fatigue Word Cloud

Causes of Adrenal Insufficiency

There are a number of causes of adrenal insufficiency, the three main ones are:

  1. Emotional stress or trauma
  2. Dietary stress (high intake of refined sugar and carbohydrates, ingestion of foods to which one is allergic, insufficient nutrients (especially B vitamins and vitamin C), overeating) and
  3. Physical pain and inflammation (resulting from exposure to toxins, infection, injury and other causes)

Many practitioners contend that emotional stress is the most significant factor (which means that untreated (or insufficiently treated) mental illness is a significant risk factor for adrenal insufficiency!). Of note, those suffering from Bipolar disorder (particularly bipolar I (characterized by increased hypomania or mania) are at significant risk of adrenal insufficiency owing to the physiologic demands and stress that result from the sleep deprivation and the elevated cortisol levels associated with this mood state.

How is Your Adrenal Health?

To find out how your adrenal glands are functioning, take the quiz below (note that this is a rough estimate and diagnosis by a clinician, often with the aid of laboratory testing, is a more accurate and preferred method for proper evaluation and treatment):

Adrenal Stress Profile Questionnaire

(Click here for pdf file of questionnaire)

Assign a number between 0 and 5 {0= Not true, 3= Somewhat true, 5= Very true} to each of the questions below and then tally the score to interpret your findings.

  1. I experience problems falling asleep.
  2. I experience problems staying asleep.
  3. I frequently experience a second wind (high energy) late at night.
  4. I have energy highs and lows throughout the day
  5. I feel tired all the time
  6. I need caffeine (coffee, tea, cola, etc.) to get going in the morning.
  7. I usually go to bed after 10 p.m.
  8. I frequently get fewer than 8 hours of sleep per night.
  9. I am easily fatigued.
  10. Things I used to enjoy seem like a chore lately.
  11. My sex drive is lower than it used to be.
  12. I suffer from depression, or have recently been experiencing depression such as sadness or loss of motivation.
  13. If I skip meals I feel low energy or foggy and disoriented.
  14. My ability to handle stress has decreased.
  15. I find that I am easily irritated or upset.
  16. I have had one or more major stressful events (i.e. divorce, death of a loved one, job loss, new baby, new job).
  17. I tend to overwork with little time for play or relaxation for extended periods of time
  18. I crave sweets.
  19. I frequently skip meals or eat sporadically.
  20. I am experiencing increased physical complaints such as muscle aches, headaches or more frequent illnesses.

Scoring and Interpretation:

0-29: Your adrenals are likely in good health

30-39: You are under some stress

40-49: You are a candidate for adrenal burnout

{If you have a score greater than or equal to 40, you may experience fatigue, weight gain, insomnia, irritability or mood swings currently or in the future if the adrenal insufficiency is not addressed.}

50-59: You likely have adrenal burnout

60+: You are likely suffering from severe adrenal burnout and need help urgently to prevent progression of adrenal exhaustion and the adverse health effects that result

If you scored 30 or higher in the above Profile, below are some Adrenal Support Guidelines that may be helpful in improving your adrenal health:

Adrenal Support Guidelines


  • Eat 3 balanced meals a day (which should consist of a combination of protein with vegetable and unrefined carbohydrates and healthy fat(s))
  • Include a couple of snacks (especially if you have more advanced adrenal insufficiency)
  • Eliminate foods that are pro-inflammatory or common food allergens: dairy, gluten, (soy), hydrogenated oils, alcohol, coffee* and soda
  • Eat within an hour of waking
  • Limit fruit consumption in the morning
  • Eat slowly and in a relaxed environment
  • Drink sufficient water (mainly away from meals)

* To eliminate coffee and minimize caffeine withdrawal symptoms, dilute your coffee with hot water in the following ratio for one week: 90% coffee, 10% hot water. The following week dilute down further to 75% coffee and then 15% hot water. Thereafter, consider drinking a coffee substitute from dandelion/chicory or green tea, in moderation. Or, alternatively, some find replacing coffee with green tea to be in reducing withdrawal symptoms that can be associated with eliminating coffee.


  • Regular daily exercise
  • Stress relief (meditation, yoga or other practices)
  • Practice good sleep hygiene (to sleep by 10:30 p.m. to work with your body’s natural circadian rhythm) and get plenty of sleep
  • Foster healthy relationships and a positive outlook
  • Minimize commitments and look for ways to decrease mental, emotional and physical stress (Dr. James L. Wilson suggests creating a ‘Good for Me, Bad for Me’ chart in which you list, in one column, all of the things that make you feel good, alive, healthy and happy (i.e. ‘Good for Me’) and in the other column, list out all the things that make you feel bad, drained or unhealthy (i.e. ‘Bad for Me’) in order of most to least significant. Then one is to write out a plan to increase the top item on the ‘Good for Me’ list and to decrease or eliminate the top item on the ‘Bad for Me’ list. This is to be revisited every few weeks or so to address the next item(s) on the list in a similar manner.)

Supplements such as anti-inflammatory agents (fish oil, curcumin and bioflavonoids), amino acids, nutrients that support blood glucose regulation and minimize oxidative stress, glandulars and herbs (adaptogens and nervines) are used, on an individualized basis, in my practice to support adrenal recovery and to aid patients in making the dietary and lifestyle changes that will support healing and balanced adrenal function.

Finally, to recap and integrate what we have covered, it is important to note that a functional medicine perspective, to be holistic/integrative, is complex and interrelated and thus when it is said that stress is pro-inflammatory, there is a bi/multi-directionality as well whereby inflammation in the body is a drain the adrenal glands, similarly, poor gastrointestinal health can lead to adrenal fatigue just as adrenal fatigue can lead to poor GI health and a final example, anxiety can increase perceived stress and increase the risk of adrenal fatigue just as adrenal fatigue can lead to increased anxiety (in part as one recognizes that they do not have the reserves to face or endure a stressor and so anxiety and irritability can set in as one tries to arrange their life to try to avoid or minimize stress).

If you are suffering from adrenal fatigue, I hope that 2018 is a year in which you can minimize stressors, improve your resilience and health and realize your potential as a result! If you have yet to read my related posts on stress, click on the links below:

Stress Management or Mastery? Tips to Improve your Stress Response
Improving Your Resilience to Stress

If you are interested in restorative yoga for stress relief, a trusted colleague is offering a class in Portland this month. Click here for more information.


Kalish Institute of Functional Medicine. (n.d.). Understanding Adrenal Fatigue Master Class. Retrieved from https://courses.kalishinstitute.com/p/adrenal-fatigue-masterclass

Schuler, C. (2015). Damage Control for Anxiety and Panic Attacks. The Second Opinion Series. Volume 3: The Depression Sessions. Retrieved from http://thedepressionsessions.com

Wilson, J. L. (2014). Clinical Perspectives on stress, cortisol and adrenal fatigue. Advances in Integrative Medicine, 1, 93-96.

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