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Adrenal Crash and Recovery Cycle
By: Michael Lam, MD, MPH and Dorine Lam, RD, MS, MPH

Nutrient Challenges

Generally, challenges involve the use of nutritional supplements, as their results are easily evident in most cases if done right. Challenges are generally divided into four broad categories:

  • Bolus Challenges involve significant introduction of single or host of nutrients designed to elicit specific positive or negative responses.

  • Step Up challenges involving gradual increase of a single or host of nutrients designed to elicit specific positive or negative response.

  • Step Down challenges involve gradual decrease of a single or host of nutrients designed to see how the body reacts with reduced nutrients concerned.

  • Elimination challenges involve purposeful elimination of previously beneficial or neutral nutrients to see how the body reacts without such nutrient for a short period of time.

It is very important not to equate a positive outcome of a challenge as the only way to a successful challenge. In certain cases, one might be looking for a negative response. In other words, not all challenges need to be positive in order to be a successful challenge. A successful challenge is one that elicits a certain response from the body that leads us to draw certain conclusions and thus a better formulation of the overall recovery plan. For example, a neutral response and absence of diarrhea when large doses of magnesium are administered would mean that body has yet to reach bowel tolerance level (BTL). If we wish to know the BTL, we want to elicit a negative response. In this case, we increase the magnesium load until diarrhea is experienced. Positive and negative results are closely monitored with respect to each specific nutrient relative to the challenge taken. The onset of anxiety and fatigue when DHEA is administered may indicate a low clearance state. A sense of a morning hangover after a melatonin challenge the night before may indicate circadian dysfunction or overload.

Almost any nutrient can be used as a challenge substrate. Prior to commencing any nutrient challenge, one should have an idea of the body's previous nutrient reaction history. For example, let us say a person has taken ascorbic acid before at 1000 mg without adverse effect. This neutral history serves to qualify ascorbic acid as a potential nutrient that can be used if it is selected to be part of the challenge toolbox. Those who cannot tolerate ascorbic acid because of gastric irritation, for example, will preclude the use of this nutrient as a challenge substrate. Challenges should not be started with a compound that was not previously exposed to the body due to the risk of possible negative reactions. A scaled approach is best if the body is constitutionally weak or low in clearance. For example, most people develop diarrhea when BTL is reached with high dose oral ascorbic acid. Because the BTL varies from person to person, one should start off with low doses and scale up accordingly. To use this nutrient at a dose above the BTL in the beginning would not yield any results other than diarrhea.

The many different forms of nutrients can also have its unique challenge characteristics. In the example above, ascorbic acid tends to be fast acting and "spiky". Its use as a challenge substrate is best when it is desirous to know how the adrenals react to clear compounds that are stimulatory. Fat-soluble vitamin C, due to its more gentle and slower absorption characteristics, for example, would not be a good substrate to use for this purpose. It is, however, an excellent challenge if one wants to study the effect of vitamin C in a body that is highly sensitive to regular ascorbic acid.

The identification of the possible pool of qualified nutrients therefore, depends on the history as well as from actual use of the nutrient in the clinical setting scaled to match the body's tolerance. A careful and detailed nutrient reaction history can serve as a good guide to start. Many with Adrenal Fatigue are already on a battery of natural compounds. Careful evaluation of these compounds on an individual basis can help to contribute to the entire selection process.

The list of challenge substrates is vast and varied. Every natural compound has its unique characteristics and use. Having a detail physiological understanding of each of these compounds is a key prerequisite prior to starting any nutrient challenge. An astute and experienced clinician is the key to this process due to the subtle differences among natural compounds that are not easy to detect.

Here are some nutrients and their possible uses as challenge substrates:

  • Vitamin C can be used to evaluate clearance state and adrenal function.
  • Evening primrose oil can be used to evaluate estrogenic function.
  • Glutathione can be used to evaluate nutrient recycling capability.
  • DHEA can be used to evaluate androgen hormone function.
  • Progesterone can be used to evaluate internal biosis.
  • Taurine can be used to evaluate thyroid function.
  • Tyrosine can be used to evaluate neurotransmitter function.
  • Pregnenolone can be used to evaluate the cortisol synthesis pathway in the adrenal glands.

The dose necessary for a successful challenge varies greatly from nutrient to nutrient as well as from person to person. In the case of vitamin C, some can experience significant responses with as little as 10 mg, while others will need well over 10,000 mg. In addition to dosage, the delivery system has to be considered. Different forms of the same substrate also have different properties. Liquid form may be more desirable in certain situations as they tend to be absorbed faster into the blood stream. Topical forms of delivery system are particularly important when it comes to those who are highly sensitive.

It is also important to note that previously intolerable substrates may be reintroduced later again as a challenged nutrient and used as a yardstick of the recovery process. This tolerance challenge is clinically very useful.

It is very important to remember that while nutrients designed to be used during the challenge process may have positive therapeutic value, many nutrients are not suitable for long-term therapeutic use for a wide variety of reasons. For example, DHEA used during a challenge may help increase energy and reduce fatigue. Some will continue to use DHEA for a long period of time in order to have this energizing effect. However, long-term use may lead to excessive hair loss and acne as well due to the possible androgenic effect. Extrapolating a positive therapeutic outcome from the use of a challenge substrate into long-term use can be a major mistake.

System Specific Challenges

Challenges can also be designed to assess and target specific systems. Each protocol is designed to assess the functional level of a body system. They involve the use of nutrients, dietary input, and lifestyle adjustments in combinations. Here are some examples:

Metabolic system may be assessed by way of carbohydrate or protein challenge. For example, taking more protein before bedtime can point to the body's metabolic state in the middle of the night when blood sugar level may be low. The response will point to the body's ability to process glucose. This can also be very useful in assessing those with metabolic syndrome, insulin resistance, hypoglycemia, or sleep maintenance insomnia.

Sympathetic nervous system function may be assessed by a forced deep breathing challenge or nutrients such as tyrosine and selected herbs. The response will point to the body's response to sympathetic overtone and its adrenaline state.

Ingesting hard-to-digest-proteins and its assimilation may assess the gastro-intestinal system. DHEA, glutamine, and magnesium are also valuable in assessing issues of irritable bowel and leaky gut. Due to the complicity and potential of negative and sometimes unpredictable responses, all challenges should be done only under experienced professional guidance in a controlled environment. Improper challenges can trigger adrenal crash and make Adrenal Fatigue worse.

With proper qualitative challenges, the clinician can gain valuable insights far beyond any laboratory test. This facilitates the formulation of a good recovery management program customized to the body's needs.

Duration of Adrenal Recovery Phase and Recovery Factor (RF)

One key question remains - how long does the recovery take?

The duration of the Recovery Phase varies as it is dependent of the Adrenal Fatigue stage. The more advanced the Adrenal Fatigue stage, the longer will be the Recovery Phase.

Recovery factor (RF) is a quantitative measurement of the Recovery Phase duration relative to crash phase duration. This helps us to appreciate the time it takes for recovery vs. the time of the crash. RF is a numerical number derived by dividing the recovery time by the crash time. If the crash duration is 1 day and the subsequent recovery duration to return to immediate pre-crash baseline is 4 days, then RF = 4/1 = 4. In other words, it takes the body four times longer to recover relative to crash. The higher the RF number, the more depleted the adrenal reserve and the weaker the adrenal glands. RF ranges from 1-20, with the lowest number in stage 1 and the highest number in stage 4. RF gives us a rough measurement of one's adrenal function.

The RF number can vary due to tremendous individual variation. Note that as Adrenal Fatigue stage progresses, the average RF increases. The average RF for stage 2 is 2, while the average RF for stage 3C is 7. The RF range also increases. The RF range for stage two varies from 1 to 3, or a 3 fold range. The RF range for someone in stage 3D can range from 6 to 30, a 5 fold increase. Those at stage 3D can expect a recovery time of 30 times or longer compared to stage 1 Adrenal Fatigue. The weaker the adrenals, the wider the range with a bias towards slower and less than optimal recovery. It is rare to see anyone with RF of 3 in stage 3D Adrenal Fatigue unless under professional guidance. It is common for most in stage 3D to have RF from 6 to 30.

Another way to look at this: those in stage 1 Adrenal Fatigue can expect to spend 50% of the total cycle in crash and Recovery Phase each. As Adrenal Fatigue worsens, one can expect to spend a proportionally longer period of time in Recovery Phase relative to crash phase. A typical stage 3C sufferer can expect to spend about 13% of the total cycle time in the crash phase and 87% of the time in Recovery Phase. The following table depicts a summary of clinical observations. Each number represents a unit in time, usually day(s).

Adrenal Fatigue Stage
Average Days of Adrenal Crash
Average Days it Takes to Recover
Ave. Total Cycle Time
Average Recovery Factor
Crash Time as % of Total Cycle
Recovery Time as % of Total Cycle
Recovery Factor Range
1 to 2
1 to 3
2 to 6
3 to 7
4 to 10
6 to 30

In absolute terms, the RF increases greatly in Stage 3C as this is where the greatest functional decline occurs. The RF increases by 43% from Stage 3B to 3C vs. an increase of 33% from Stage 3A to 3B. This bias continues to be carried onward as one enters Stage 3D from 3C. It comes as no surprise that those in Stage 3D spend 92% of their time in recovery and only 8% in crash on average. It is therefore imperative that those with advance Adrenal Fatigue avoid crashes as much as possible.

Successful and Failed Crash and Recovery Cycle

The following graphs depict what a successful and a failed recovery program should look like.

Line A shows a normal crash of average intensity followed by a typical prolonged recovery time common in Adrenal Fatigue stage 3C. There are frequent setbacks during a slow and steady recovery.

Line B shows the same crash but under optimal recovery conditions. Such a recovery program does not guarantee a total absence of a crash. Intermittent crashes are unavoidable. A successful program, usually under experienced professional guidance, allows the sufferer a learning experience on how to recognize a crash before it comes, make available ahead of time customized tools so that if a crash does occur due to circumstances beyond control, there is immediate deployment of such tools to effect a slower and lower intensity crash. The goal is a less symptomatic crash, a "soft-landing". Some unpleasantness may be unavoidable, but the symptoms will be under control and manageable with no panic. The risk of rolling into another crash is minimized. It is not unusual to have a drastic reduction in crash frequency and symptoms if properly managed professionally. A successful program will also allow the sufferer to effect a much faster Recovery Phase and thus an overall shorter total cycle time. The shorter the cycle, the less unpleasantness and fatigue.

Line C this represents a failed program. Unfortunately most self-navigation programs fall into this category, especially for those with advanced Adrenal Fatigue or weak constitution. After the adrenal crash, recovery may appear to progress well. This is often due to administration of stimulatory compounds that include medications, herbs and glandular to sustain unrealistic adrenal function at a time when the adrenals needs to be nurtured with a carefully customized program specific for the body's need. Programs using stimulatory compounds (natural or prescription) may lead to outcome that appears to improve for a short time. The unsuspected sufferer is mislead into thinking that the right recovery path has been chosen. This false sense of improvement eventually fades as symptoms not only return but also become worse, resulting in a more severe second crash as the body cannot handle prolonged stimulation. This second crash often leads to a lower state of adrenal function below that of previous crash, setting a new low. This downward cascade is repeated far too often, and with each failure, the body becomes weaker. These crashes propel the body into advanced stages of Adrenal Fatigue that could have been avoided if a good recovery program has been followed early on.

Adrenal Exhaustion Recovery Patterns

While recovery phases of stage 1 and 2 Adrenal Fatigue are relatively uneventful, those in Stage 3 Adrenal Fatigue (Adrenal Exhaustion) usually find recovery very challenging. The body's intrinsic constitution plays a big role in determining the Recovery Phase outcome. The more advance the Adrenal Fatigue, the more varied is the recovery pattern. This is especially true of those in stage 3C or 4 Adrenal Fatigue. Those who have strong adrenal constitution do recover faster and the recovery is sustained when compared to those who have weak adrenals. Those with very weak constitution and severe stress may suffer crashes and never fully recover but continue going downward in a path of decompensation. There is no laboratory test to forecast the body's constitution. Knowing whether you have a strong, normal or weak body constitution plays an important role in Adrenal Fatigue recovery planning because the pattern of recovery and the kind of nutrients required differ depending on the type of body constitution. The more advanced the Adrenal Fatigue, the more important the body constitution plays a role in determining the ultimate natural progression of the condition.

The following depicts how the body's intrinsic adrenal constitution affects the recovery pattern in people suffering from stage 3C Adrenal Fatigue:

Nowhere is it more important to study the recovery pattern than in Adrenal Fatigue Stage 3, especially Phase C because of the variety of possible recovery outcome. The natural progression for those with normal constitution is one of slow deterioration over a period of time (Pattern 5). However, the time can be lengthened if the intrinsic body constitution is strong (Pattern 6). The goal is to extend the time as long as possible and the deterioration pattern to be slowed as much as possible. This is best achieved by a personalized recovery program (Pattern 7). Those with very weak constitution tend to fair worse (Pattern 1).

Unfortunately, excessive and inappropriate use of natural stimulatory compounds commonly employed by those who are in self-navigating mode (Pattern 3), as well as the aggressive use of prescription medications (Pattern 4), often worsen the final outcome of many Adrenal Exhaustion recovery cases. Eventually, this will push the sufferer into adrenal failure far earlier than if nothing is being done and let nature takes its course (Pattern 5). In other words, matters are often made even worse.

Fortunately, regardless of which recovery pattern is being followed, the body is generally forgiving. The key is to mimic the recovery curve as close as possible to Pattern 7. With the right professional help, the body's damage can often be reversed and nurtured back to health.

The following table summarizes the above discussion:

Importance of Understanding the Adrenal Crash and Recovery Cycle

It is easy to identify a major adrenal crash by the various symptoms. There is no mistake when a crash occurs unless it very minor. The majority of pre-crash symptoms are exacerbated and magnified greatly. Recovery, however, is much less obvious and can be confusing. It comes on insidiously, slowly and often time marred with setbacks. This is made more complicated if the body's constitution is weak. The signs are sometimes hard to detect, and often only become evident with time. Paradoxical symptoms are common, especially for those with weak constitution. Only with long clinical experience, attention to detail, and retrospect does one see a Recovery Phase with clarity.

While most Adrenal Fatigue sufferers are familiar with adrenal crash from personal experiences, most are unfamiliar with the importance of the Recovery Phase of the cycle. A recovery may be real, or maybe a prelude of a forthcoming crash in disguise. In other words, the worse may be over, but it may be yet to come. The ability to recognize whether the body is following an accelerated, normal or delayed recovery curve as well as whether the body's constitution strong or weak all play important roles to a properly formulated recovery plan.

The management of adrenal crash and adrenal recovery are very different. Administration of nutrients and adjustment of dosages designed to help recovery, if dispensed improperly during the crash phase, may in fact worsen the crash. On the converse, proper application of nutrients during the crash phase can lead to a softer landing and faster recovery. Under expert management, adrenal crash may also present as an opportunity to help the body propel directly into the honeymoon period, bypassing the stabilization and preparation period.

Similarly, nutrients required during recovery can be very different from those during the adrenal crash. The focuses are different not only as it relates to crash vs. recovery, but also as it related to each person's unique constitution. During adrenal crash, the focus is to avoid further damage and soften the crash intensity. During the Recovery Phase, the focus is to deploy nutrients to fortify the adrenals to the degree that they can tolerate and clear from the body without triggering another crash due to the often-associated low clearance state. Sometimes the nutrient dosage needs to be reduced during the adrenal crash phase and increased during the Recovery Phase. Other times, it is the reverse. Administering the wrong nutrient and dosage at the wrong time will only worsen the overall Adrenal Fatigue and delay recovery. Understanding the recovery cycle and using properly designed challenges during the right time of the recovery greatly facilitate the overall healing process.

In addition, a careful study of the Recovery Phase of the cycle is critical because the speed and character of the Recovery Phase as shown by the recovery curve is a direct reflection of the amount of adrenal reserve remaining after a crash. Some people recover relatively quickly compared to others. Younger sufferers and those who are constitutionally strong tend to recover faster and can tolerate a stronger support of nutrients, while too strong a nutritional support during Recovery Phase can trigger adrenal crash among others, especially those who are constitutionally weak. The common mistake seen in many self-guided recovery programs is the administration of excessive nutrients under the mistaken belief that more may be better. The many recovery characteristics shown by the body is the only way the body knows how to express the overall adrenal capacity and the degree of decompensation as a result of a crash. A detailed study of the recovery and its various components allows us to understand the many paradoxical reactions that are common during crashes and the ways to avoid them in the future in relation to the specific body. Generally speaking, the stronger the adrenal function remains after the crash, the shorter the Recovery Phase and the closer the post-crash energy level is to the immediate pre-crash baseline. It is the careful attention to the recovery cycle that gives us the markers and thus the ability to design a proper recovery program with accuracy and confidence in order to facilitate maximum healing. The current Recovery Phase curve helps us to formulate preventive measures so that the next crash, should it happen, is shorter, gentler, and the ensuing recovery faster.

Those who do not pay attention to the lessons learned from the Recovery Phase invariably will miss important clinical perils and thus lack a plan to handle future crashes. The result is invariably a body that is subjected to repeated crashes over time.


One of the most difficult and perplexing challenges for clinicians and Adrenal Fatigue sufferers is the management of adrenal crash and recovery cycles. Crashes are triggers that bring sufferers to their physicians in the first place, and they will continue to haunt the sufferer throughout the duration of this condition until their adrenal functions become normalized.

Unfortunately, most inexperienced clinicians and self-navigation efforts fail because of the failure to fully understand the significance of the crash and its subsequent Recovery Phase in detail. The body is communicating to us constantly. With each crash and recovery, signals are sent by the body in the form of signs and symptoms. Clinical excellence requires a detailed investigation and examination into the cause of each crash. Combining this with a careful clinical study of the pre-crash status of adrenal function will give an experienced clinician a better understanding of remaining adrenal reserve and capacity. A clearer picture will generally begin to emerge and one will no longer be dumb-founded at why a crash happens in the first place. The body is logical after all, if only we look deeper.

Understanding the crash and recovery cycle in detail and their characteristics will help the clinician and sufferer better manage the crash as it happens, prepare a soft landing, set a realistic recovery time, and select the proper tools to effect maximum adrenal healing in the shortest time with minimum risk of triggering a subsequent crash. It also helps the sufferer to understand the natural progression of Adrenal Fatigue and to have realistic expectations of the road ahead.

Message from Dr. Lam

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About The Authors

Michael Lam, M.D., M.P.H., A.B.A.A.M., is a western trained physician specializing in nutritional and anti-aging medicine. Dr. Lam received his Bachelor of Science degree from Oregon State University, and his Doctor of Medicine degree from the Loma Linda University School of Medicine in California. He also holds a Master’s degree in Public Health. He is board certified by the American Board of Anti-Aging Medicine where he has also served as a board examiner. Dr. Lam is a pioneer in using nontoxic, natural compounds to promote the healing of many age-related degenerative conditions. He utilizes optimum blends of nutritional supplementation that manipulate food, vitamins, natural hormones, herbs, enzymes, and minerals into specific protocols to rejuvenate cellular function.

Dr. Lam was first to coin the term, ovarian-adrenal-thyroid (OAT) hormone axis, and to describe its imbalances. He was first to scientifically tie in Adrenal Fatigue Syndrome (AFS) as part of the overall neuroendocrine stress response continuum of the body. He systematized the clinical significance and coined the various phases of Adrenal Exhaustion. He has written five books: Adrenal Fatigue Syndrome - Reclaim Your Energy and Vitality with Clinically Proven Natural Programs, The Five Proven Secrets to Longevity, Beating Cancer with Natural Medicine (Free PDF version), How to Stay Young and Live Longer, and Estrogen Dominance. In 2001, Dr. Lam established as a free, educational website on evidence-based alternative medicine for the public and for health professionals. It featured the world’s most comprehensive library on AFS. Provided free as a public service, he has answered countless questions through the website on alternative health and AFS. His personal, telephone-based nutritional coaching services have enabled many around the world to regain control of their health using natural therapies.

Dorine Lam, R.D., M.S., M.P.H., is a registered dietitian and holistic clinical nutritionist specializing in Adrenal Fatigue Syndrome and natural hormonal balancing. She received her Bachelor of Science degree in Dietetics, holds a Master’s Degree in Public Health in Nutrition, and a Master of Science degree in Nutrition from Loma Linda University, in Loma Linda, California. She is also a board-certified, Anti-Aging Health Practitioner by the American Academy of Anti-Aging Medicine. She coauthored with Michael Lam, M.D., the books Adrenal Fatigue Syndrome - Reclaim Your Energy and Vitality with Clinically Proven Natural Programs and Estrogen Dominance and numerous articles on Adrenal Fatigue Syndrome. Her personal research and writing focuses on the metabolic aspect of Adrenal Fatigue Syndrome. She is married to Michael Lam and is an integral part of the telephone-based nutritional coaching team helping people overcome Adrenal Fatigue Syndrome.

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