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Empowering Sufferers Worldwide Since 2001

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Adrenal Fatigue Symptoms
By: Michael Lam, MD, MPH

Phase C: Disequilibrium (Impaired Homeostasis)

Phase B dysfunction of Adrenal Exhaustion involves disruption of the major adrenal related hormonal axis. The body as a whole, however, is still functioning relatively well. Despite sub-clinical hypothyroidism, low energy, estrogen dominance, irregular periods (in females) and low libido, critical body functions remain relatively intact.

As the adrenals decompensate and enter into Phase C of Adrenal Exhaustion, the body weakens further, triggering its various reserve systems to spring into action as the body loses its homeostasis and equilibrium.

Let us now examine this more deeply. Homeostasis is derived from Greek, meaning to stand equally and is used to describe a theory of physiology expounded by Claude Bernard. The theory was that, in order for a closed system to maintain equilibrium with its surrounding environment, the system requires many minute exchanges and dynamic adjustments internally to maintain the status quo. Our body is comprised of more than 70 trillion cells. To be in optimum health, a cell and by extension the body must maintain its equilibrium or homeostasis with its surrounding environment. At the cellular level, basic chemical and electrical transactions occur. For homeostasis to occur, the cells must be able to excrete waste and take in new materials in equal measure. Regulatory systems such as the negative feedback loop and the autonomic nervous system are needed to maintain this equilibrium. Cellular equilibrium homeostasis can therefore, be defined as the stability of physiological systems that maintain life. Without this equilibrium, the body will not be able to perform such mundane function as standing up, maintaining stable body temperature and heart rate, for example. As the needs of cells will change depending on the stress placed upon them, such regulatory systems are normally activated automatically and this is an unconscious event. Without our knowledge, these regulatory systems keep our body in perfect harmony internally. These systems are jeopardized in Phase C of Adrenal Exhaustion.

The key regulatory systems for internal equilibrium are the nervous system and the endocrine system. While the functions of both of these systems may be compromised in earlier phases, they enter into a steep slope of declining function during this phase, with dire consequences, as we shall see. In layman's terms, the internal thermostat of the body is broken. In order to maintain normal function, the compensatory systems of the body comprising the neurological and endocrine systems are activated. Unfortunately, these reserve and compensatory systems are crude at best and they lack the fine-tune capabilities of the regular systems. The key functions of the body are saved but there is a price to be paid as a variety of side effects surface. In a way, these side effects are the body's way of alerting us that it is in trouble. Often, instead of taking advantage of these hints to help us gauge the level of dysfunction and use them as markers during the recovery process, the tendency is to turn to the quick fix approach of suppressing these symptoms. Over time, this only weakens the adrenals as well as the other systems involved.

In addition to Phase A symptoms such as salt craving, insomnia, and low blood pressure at rest, and Phase B symptoms such as feeling cold, sluggish, irregular periods, PMS, low libido, acne and hypoglycemia, the typical Phase C Adrenal Exhaustion patient will also complain of one or more of the following: sudden onset of anxiety attacks, impending doom at rest, sudden onset of heart palpitations despite a normal cardiac function, sudden onset of dizziness and lightheadedness at rest, waking up in the middle of the night for no reasons and the inability to go back to sleep, sudden onset of fragile emotional states such as crying for no apparent reason, fragile reactive fluid state with edema and sodium imbalance, a sudden onset of fluctuating blood pressure, orthostatic hypotension, POTS, cardiac arrhythmia and orthostatic intolerance.

Dysfunction of the Autonomic Nervous System (ANS) is responsible for many of the above Phase C symptoms. Let us examine this more closely.

Autonomic Nervous System (ANS)

The nervous system of the body is divided into the central (brain and spinal cord) and the Peripheral Nervous System. The Peripheral Nervous System of the body is in turn divided into two parts: the Somatic Nervous System that regulates skeletal muscle functions that help us deal with the outside world and the Autonomic Nervous System (ANS) that regulates functions of the smooth muscles and glands within the body for proper inner world workings. The ANS is further divided into the Parasympathetic Nervous System (PNS), the Sympathetic Nervous System (SNS) and the Adrenomedullary Hormonal System (AHS). The PNS regulates the vegetative processes such as urination and digestive function. Dysfunction of the PNS leads to a wide variety of illnesses including abnormal gastric acid secretion, reduced gut motion, erectile dysfunction, and loss of urinary control and bowel movement irregularities. The SNS regulates the unconscious housekeeping functions of the body, including blood pressure, body temperature, force of the heart-beat, and heart rate. The AHS (also called the sympathetic adrenergic system) regulates the emergency and distress functions such as those responsible for the body's "fight or flight" response and it has properties similar to SNS, plus more. It is also activated in fainting, shock, extreme fear, hypoglycemia, and low body temperature. The other parts of the ANS include the Enteric Nervous System (ENS), which regulates enteric functions and the Sympathetic Cholinergic System (SCS) that regulates sweating.

The combination of AHS and SNS constitutes the sympathoadrenal system (SAS). Maintaining a normal balance of the SAS within the ANS is vital to optimal body function and homeostasis. This is of particular importance in the case of Adrenal Exhaustion because it is the dysregulation of the messengers of these two systems, namely adrenaline (also called epinephrine) in the case of AHS and norepinephrine (also called noradrenaline) in the case of SNS, that is the hallmark of Phase C Adrenal Exhaustion symptoms.

Sympathoadrenal System (SAS)

The sympathoadrenal system is one of the major pathways mediating physiological responses in the body and plays an important role in the regulation of heart rate, blood pressure, glucose, sodium and other key physiological and metabolic processes such as the fight or flight response. The SAS is affected by many disease states and is able to preserve homeostasis by corrective physiological responses. Many therapeutic agents are either adrenergic activators or inhibitors.

The two components of the SAS are the SNS and the AHS. Norepinephrine is a neurotransmitter secreted under the control of the SNS. Adrenaline is a hormone secreted from the adrenal medulla, which is under the control of the Adrenomedullary Hormone System (AHS) and deals with emergency functions of the body. Norepinephrine is the key neurotransmitter responsible for regulating blood pressure and heart rate at rest. Adrenaline is also present, though in a much reduced amount.

Chemically, adrenaline is the chemical son of norepinephrine, and in turn, norepinephrine is the chemical son of dopamine. These three chemicals fall within a family called catecholamines and they represent three different ways the body is regulated internally. Adrenaline is a hormone that has wide ranging effect throughout the body as it is transported by the blood stream once it is released from the adrenal glands. Norepinephrine is a neurotransmitter released from the nerves of the SNS and acts mainly locally on nearby target cells such as the heart. For example, norepinephrine released by the SNS into the heart regulates heart rate and its presence in the blood stream has to be in high concentration before it can exert its effects as a hormone. Finally, dopamine appears to have dual properties. Peripherally, in the gut, adrenal and kidneys where it is produced in and released from, dopamine acts on the same type of cells in the immediate vicinity. In the central nervous system, dopamine behaves like a neurotransmitter.

Low levels of norepinephrine are associated with loss of alertness, poor memory and depression. Norepinephrine appears to be the neurotransmitter of "arousal" and it is for this reason that medications for depression and ADHD often target both dopamine and norepinephrine in an attempt to restore them to normal levels. Mild elevations in our norepinephrine level produce heightened arousal, something known to be produced by stimulants. This arousal is considered pleasurable and several "street drugs" such as cocaine and amphetamines work by increasing the brain level of norepinephrine. Moderately high levels of norepinephrine create a sense of arousal that makes us uncomfortable, such as anxiety, increased startle reflex, jumpiness, fear of crowds and tight places, impaired concentration, restless sleep, and physical changes. The physical symptoms may include rapid fatigue, muscle tension/cramps, irritability and a sense of being on edge. Almost all anxiety disorders involve elevation in norepinephrine levels. Severe and sudden increases in norepinephrine levels are also associated with panic attacks.

Adrenaline (epinephrine) is one of the most powerful vasopressor (causing a rise in blood pressure) drugs known. It increases the strength of heart muscle contractions as well as the heart rate. It constricts blood vessels and veins, and is also a powerful bronchodilator and inhibits the release of histamines, which are triggered by allergic reaction. Finally, adrenaline is responsible for the body's "fight or flight" response.

At rest, plasma concentrations of adrenaline and norepinephrine are low (less than 1 microgram per liter), but they can rise under certain physiological (adaptation) or pathological conditions. For example, when one goes from the supine to the standing position, norepinephrine concentration increases two fold. In patients with pheochromocytoma plasma, catecholamines can rise transiently and reach high levels.

The actions of adrenaline and norepinephrine are generally similar, although they differ from the other in certain of their effects. Norepinephrine constricts most blood vessels, while adrenaline causes constriction in many networks of minute blood vessels but dilates the blood vessels in the skeletal muscles and liver. Both hormones increase the rate and force of contraction of the heart, thus increasing the output of blood from the heart and increasing the blood pressure under normal conditions. These two hormones also have important metabolic actions. Adrenaline stimulates the breakdown of glycogen into glucose in the liver resulting in the rise of blood sugar level. Both hormones increase the level of circulating free fatty acids. The extra amounts of glucose and fatty acids can then be used by the body as fuel in times of stress or danger, when increased alertness or exertion is required.

Because adrenaline is much more powerful than norepinephrine, its deployment is more tightly controlled and it is released in great amount during times of extreme distress. It is sometimes called the emergency hormone because it is released during stress and its stimulatory effects will fortify and prepare an animal for either flight or fight response. Chronic or acute stress leading to Adrenal Exhaustion increases AHS activation. A rise in the absolute level of adrenaline in the body will cause the following: increase in heart rate, increase in blood sugar, increase in respiration, reduction in serum potassium, relaxation of skeletal muscle blood vessels, increase in energy, increase in emotional sweating, constriction of skin blood vessels (pallor), relaxation of the gut and trembling. This adrenaline overload, along with norepinephrine, will worsen the existing ANS imbalance that is already happening in earlier phases of Adrenal Exhaustion and will trigger an additional host of dysfunctions, above and beyond those already experienced in the earlier stages of Adrenal Fatigue.

In healthy people, excess adrenaline released from the adrenal glands during stress is quickly swept up by efficient adrenaline transporters that carry away these undesirable hormones before it can wreak havoc inside the body. For example, standing requires blood vessels to contract to keep gravity from allowing all your blood from pooling in your legs. This is accomplished through the release of small amounts of adrenaline. The body releases just the right amount of this hormone throughout the day as we move around and change positions. However, excessive amounts of adrenaline are cleared out of the body. The body's blood pressure is thus maintained in a normal state. In Phase C of Adrenal Exhaustion, activation of the SAS will lead to the release of a larger amount of adrenaline and norepinephrine, which will remain in circulation for longer than usual duration before they are inactivated.

Blood pressure in the Adrenal Exhausted state is usually below normal level but it can abruptly increase and stay high if a large amount of adrenaline is released quickly into the bloodstream. At the same time, the heart rate may be elevated as well. Consistent high levels of norepinephrine and epinephrine will also lower the threshold of normal cardiac rhythm, triggering abnormal cardiac arrhythmias such as atrial fibrillation. Adrenaline released during an emergency response, is usually self-limiting in fit people. However, in Phase C of Adrenal Exhaustion, this release can become exaggerated in certain people. The physiological mechanisms of the pathway is not fully known but research studies are pointing to the loss of the more stable negative feedback loop of regulatory function in favor of the less stable and ultimately destructive positive feedback loop response as a possible etiology.

As mentioned earlier, adrenaline is a hormone that is stimulatory in nature. Symptoms of excessive adrenaline include heart palpitation, irritability and anxiety. Less common symptoms are dizziness, cold sweats, brain fog and orthostatic hypotension.

In addition to possible adrenaline overload, those with weak adrenals may have a reduced capacity to clear excessive unwanted adrenaline and its metabolites from the body, leading to the toxic build-up of metabolites and manifestation of symptoms such as fatigue, jitteriness, and nervousness, brain fog, anxiety, insomnia and fatigue. This low-clearance state is especially prevalent in people with weak adrenal glands. We shall discuss these phenomena in more detail in Phase D.

Defective epinephrine and norepinephrine transporter systems can also worsen the condition and contribute to higher levels of excessive adrenaline because norepinephrine is the chemical father of epinephrine and its level is tied to epinephrine.

Reactive Sympathoadrenal Response (RSR)

Over stimulation of the SAS with resulting adrenaline and norepinephrine overload in the context of Adrenal Fatigue are usually a compensatory reaction of the ANS that is triggered by stress and causes the SAS to be activated and put into overdrive. The resulting cascade of automated responses is called Reactive Sympathoadrenal Response (RSR). Because activation of SAS is a secondary function of Adrenal Exhaustion, it is called reactive. The systems activated are the sympathetic nervous system and the adrenomedullary hormonal system, thus the name sympathoadrenal. The responses generated are usually due to over-stimulation and sometimes because of imbalance as well. The term Reactive Sympathoadrenal Overtone (RSO) is used when the response is due to over-stimulation. In short, the body is bathed in a sea of adrenaline and norepinephrine.

RSR comprises of a myriad of symptoms such as clinical or sub-clinical orthostatic intolerance, fragile blood pressure, inability to stand for a long time, lightheadedness, "spaciness," tachycardia, CVD, irregular heart rate, temperature intolerance, body fluid and electrolyte imbalance, sweating, fainting, POTS, loss of bowel and urination control, sense of impending doom, and dizziness. Some of these symptoms are due to excessive amounts of adrenaline and norepinephrine while others are due to imbalances between adrenaline and norepinephrine (also called sympathoadrenal imbalance). Some are of unknown etiology. Fainting is a classic example of sympathoadrenal imbalance, while tacycardia is a classic example of sympathoadrenal overtone.

Sympathoadrenal overtone contributes to the development of Cerebral Vascular Diseases (CVD) such as stroke through the effects of catecholamines on the heart, blood vessels, and platelets. Sympathoadrenal activation also modifies the function of circulating platelets through catecholamine-induced changes in hemodynamic factors (increased shear stress), circulating lipids, and inhibition of vascular eicosanoid synthesis.

In Phase C of Adrenal Exhaustion, the body can become extraordinarily sensitive to stressors. Mundane activities may act as triggers in this phase while they normally do not behave as triggers in early stages of Adrenal Fatigue. It appears that the threshold for stressors to act as triggers is lowered for reasons not well understood. For example, activities such as eating a big meal high in refined carbohydrates, watching an action movie, being exposed to fluorescent lighting, taking a cold drink, prolonged sitting in front of a computer monitor, taking a long car drive, being startled by the phone ringing in a quiet room, performing a short but intense dance or exercise, being exposed to cold or hot temperature that the body is not used to (even though the temperature is within normal comfort zone for the general population), taking an uphill or long walk, being exposed to indirect sunlight, drinking soda pop, tea, or coffee, eating chocolate, and eating food that is hard to digest such as corn, etc. may act as triggers.

While the activation of the SAS ensures the body's survival by bringing more blood supply to the brain, the fine control of the rest of the body is compromised, including the metabolic, endocrine and central nervous systems. The body, as a result, will experience exaggerated and wild metabolic and hormonal roller-coaster rides with fluctuations in blood sugar level, body temperature, blood pressure, heart rate, sleep, and emotional states. The state of acute adrenal weakness is also known as an adrenal crash. Symptoms of Adrenal Fatigue will become drastically exaggerated during an adrenal crash. Once the SAS is activated, it may take hours or even weeks before the body is able to return to baseline.

Standard medical workups remain unremarkable, as the symptoms tend to remain sub-clinical. The weaker the adrenal function, the longer the recovery time is.

There may be a genetic involvement in this convoluted picture. More research is needed but it is clinically clear that those with weak adrenals have higher tendencies to be more sensitive to excessive adrenaline / norepinephrine and more prone to suffer symptoms resembling sub-clinical dysfunction of the ANS (also called dysautonomia). The weaker the adrenals, the stronger this association will be. Interestingly, dysautonomia is also much more prevalent in those people who suffer from mitral valve prolapse, a very common and benign condition of the heart. Those who suffer from Adrenal Fatigue and mitral valve prolapse should therefore be on special alert for dysautonomia.

Unless an experienced clinician is on alert, this reactive state can easily be missed and the symptoms will often be dismissed as insignificant. Patients are often started on the failed approach of drugs such as anti-depressants to control the symptoms rather than healing the adrenals. This is a common mistake. Each symptom is there for a reason; it is the body's way of alerting us of trouble within. Close attention should therefore be paid to every symptom, as each is a piece in an extensive jigsaw puzzle. Treating the symptom will often mask the underlying pathology and thus miss the big picture.

Those who are in Phase C are often concurrently burdened by worsening symptoms of Phases A and B (severe single organ system dysfunction and hormonal axis imbalance). There is tremendous overlapping of symptomatology among the three phases because they are closely related. Disruption of the ANS (characteristic of Phase C pathology) affects the Hypothalamic-Pituitary-Adrenocortical axis (HPA) that controls adrenal cortex function. As adrenal cortex hormone depletion progresses (Phase A pathology), overall adrenal function is compromised as the cortisol, estrogen, and thyroid functions have become dysregulated, leading to OAT axis imbalance (Phase B pathology).

The HPA axis and the SNS are also interrelated. Stimulating one system tends to inhibit the activity in the other. As the SNS outflow is increased, glucocorticoid released from the adrenal cortex is reduced. In other words, the reactive sympathoadrenal response (RSR) seen in Phase C with increased secretion of epinephrine and norepinephrine will blunt cortisol and aldosterone output. As a result, salt craving will increase and low blood pressure will become more pronounced, exacerbating Phase A and B symptoms. Administration of glucocorticoids (such as hydrocortisone) decreases SNS outflow, whereas studies have shown that surgical removal of adrenal glands increases SNS outflow. Paradoxically, glucocorticoids also promote adrenaline output from the adrenal medulla by promoting the activity of the enzyme responsible for converting norepinephrine to epinephrine. Studies have shown that pathological states involving the failure of adrenal cortex often are associated with decreased adrenaline production. The exact mechanism is not known but it is clear that our understanding of how the various hormones affect one another within the adrenal and nervous systems remains in its infancy and that the three phases of Adrenal Exhaustion are intimately related to one another in terms of how one affects the other.

As Phase C progresses, cortisol and aldosterone levels, already low, will generally go lower. Salt cravings and low blood pressure will become more pronounced and usually get worse. Without sufficient cortisol to blunt the compensatory adrenaline response, the body then becomes susceptible to the ever larger gyrating level of adrenaline and norepinephrine output that can be abrupt as the SAS is activated in the body. As more adrenaline is being released without the dampening effect of cortisol, blood pressure can suddenly rise and spike on a reactive basis, leading to an abrupt onset of intermittent higher than normal blood pressure, anxiety, and heart palpitations. When the rush is over, the body drops back down to a lower than normal level of function, resulting in lower than normal blood pressure, and the patient becomes exhausted. Blood sugar can similarly be affected, with resulting sub-clinical hyperglycemia first leading to a hypoglycemic state characteristic of an unstable blood glucose curve, while blood sugar remains within normal limits by conventional medical standards. It comes as no surprise that the body is constantly drained of energy just having to deal with this never-ending parade of disequilibrium. Because sleep is invariably disrupted, a state of persistent tiredness or chronic fatigue is common as the body is essentially in a "slow down" mode in order to conserve energy.

In some people, the reactive sympathoadrenal response (RSR) can be exaggerated with levels of epinephrine and norepinephrine output becoming higher and well beyond normal activation. As a result, many feel "wired and tired" at the same time throughout the day. The body is tired and wishes to rest but is at the same time on full alert 24/7. When it is time to sleep, the body is unable to relax and severe sleep insomnia is the norm. Many are nocturnal, unable to sleep at night and only able to catch cat-naps during the day, as the body is in this constant state of high alert. Others may be able to fall asleep after a long time, when the "tired" factor outweighs the "wired" factor. However, this is usually short lived and the tendency is to be awakened after a short rest as the "wired" factor resurges into dominance.

As the condition deteriorates and the sufferer moves closer to Phase D, extreme fatigue sets in as the patient becomes bedridden for a large part of the day. Sleep patterns are often disrupted with sudden onsets of cold sweat from adrenaline rushes along with unstable blood glucose and blood pressure levels. This leads to shortness of breath, anxiety attacks, edema, headache and heart palpations accompanied by a slowing GI system with constipation and inability to assimilate food etc. There will be frequent visits to the Emergency Room (only to be told that all is well and then sent home with anti-depressants). During the day, frequent small meals and severe carbohydrate restriction may be needed to avoid frequent reactive hypoglycemia episodes and their many unpleasant side effects. If not reversed soon, even normal nutritional supplements that have helped earlier will start to fail and in fact, make the condition worse off. The failure may even extend to steroidal medications as severe paradoxical reactions may surface. Those who are in Phase C truly live in a state of the "living dead," abandoned by their physicians and left to self navigate through deep unchartered waters.

Phase D: Near Failure

All hormones in the body are interrelated to one another in some form. Many important hormones are dependent on other hormones to work. For example, estrogen is needed for progesterone to work. A minimum level of each hormone is required to be present in the body before basic body functions can begin. As the levels of cortisol and aldosterone hormones fall below the minimum required for normal body function and their output fails, the body may either slow down its normal function or down-regulate the amount needed in order to preserve what is on hand for only the most essential of body functions. The body's strategy of returning to a simple state of physiologic function is in full force. This down-regulation further reduces vital hormonal output, exaggerating a downward vicious cascade. In this phase, rapid weight loss, gastric disturbance, and severe loss of muscle tone are common; as the body enters into "shut down" mode to further conserve energy.

When the levels of these critical hormones fall below the minimum levels required for basic body function, the organs become severely compromised. Pump failure starts to occur and attempts to prime the pump to regain the footing become very difficult. The threshold level of each hormone varies from person to person. No laboratory test is currently available to help determine this with accuracy. The key to help prevent or reverse this state lies in understanding the patient's history and observing the clinical presentations with careful attention to minute detail. The patient is often incapacitated and bedridden, requiring assistance to conduct daily activities such as driving, shopping and preparation of meals. The low energy state renders the patient bed-ridden most of the time.

No organ is spared as the body down-regulates throughout all phases of Stage 3. The symptoms may not be new as the phases progresses, but they reach their peak intensity at Phase D.

Let us look at what the high intensity of the symptoms of this phase are telling us about our body internally. The first symptoms to show up usually represent the organ system to be turned off first as it is not required for basic survival. Reproduction is considered a luxury and not a vital function when survival is at stake. Libido as a result is lowered. Sex drive becomes non-existence. The thyroid also goes into a slow down mode as the body attempts to reduce the basal metabolic rate (idle speed) to conserve energy. This naturally leads to sluggishness, constipation, and worsening fatigue. Clinical hypothyroidism is common. The gastrointestinal tract as a whole tends to slow down in its assimilation of food. Complex and processed foods become hard to digest and less is absorbed. Digestive enzymes and acid release are reduced. Gastric motility slows. As a result, foods do not churn as much compared to that of a normal healthy person. Poor digestion is common, accompanied by reduced absorption; increased gas, bloating, and constipation. As this happens, the liver and kidney functions are also affected. Both are the clearing houses of the body's toxins. As liver function slows (though laboratory tests are usually normal), complete breakdown of metabolites becomes compromised. Overall, body clearance of such by-products tends to slow concurrently as toxic metabolite build up occurs as a result. Fat-based metabolites tend to find their way into areas of the body high in fat as they attract each other. Lipophilic organs (organs that like fat) such as the brain have a tendency to attract such fat based metabolites easily. Instead of a normal complete clearance out of the body on a timely basis, such metabolites tend to accumulate instead. Metabolites that accumulate in the brain can lead to and contribute to memory loss, confusion, anxiety, and brain fog. Normal brain function may be impaired if severe. Some accumulate in joints and muscles, leading to muscle pain of unknown origin and joint inflammation. This is just part of the picture.

The down-regulation or return to simplicity will continue as long as the body sees it as a positive step to conserve energy for survival. As the body further slows down, muscle breaks down to generate energy, leading to an overall net loss of protein and muscle mass. When this happens, the body enters a catabolic state, with overall weight loss and muscle wasting. Fibromyalgia and Chronic Fatigue Syndrome may be triggered. Appetite reduces as the gastrointestinal tract motility slows and gastric capacity reduces.Those with sugar imbalances and insulin resistances are particularly vulnerable to a worsening state. Electrolyte imbalance, especially as it relates to sodium and potassium, becomes common. The myriad of physical symptoms mentioned above is convoluted and appear confusing. Most of them surface concurrently. However, the progression is quite logical and clear if you see them as the body's way of slowing down, reaching its peak at Phase D. Indeed, like a domino effect, the shutting down process happens in steps. At Phase D, the body is reduced to bed rest. Ambulatory help for daily chores are required. Fatigue is extreme with the gastric system paralyzed, heart rate irregular, mental function clearly compromised, while the feeling of wired and tired abounds, as adrenaline is high when energy is low.

This continuum of down-regulation will not stop until the body finds its equilibrium. This is the point where energy demands slow to a point that matches the input. This is the point when the body finally feels it can survive and not threatened. Sad to say many are often bedridden at this state.

As you can see, low hormonal and low-clearance states, which has began in earlier phases, gets worse quickly. These important clinical hallmarks are frequently overlooked.In this phase, the adrenals have lost most of their ability to serve as the body's stress control center. They become hypersensitive. Attempts to jump start them quickly usually fail. Traditional medications, nutritional supplementation and the classical macro nutritional programs seldom are successful and may in fact backfire.

Crashes occur frequently, with delayed recovery. The underlying physiological pathways are not well understood. Conventional scientific logic is unable to solve the puzzle. Looking at the big picture, it is evident that the body's symptoms are part of an overall process of severe systematic slowing down if not an outright shutting down of internal operations save and except the most essential ones for survival. Conventional medical workup continues to be negative. Functional medicine workup is usually inconclusive. In addition to previously mentioned characteristics of Stage 3C, the following additional unpleasant symptoms commonly surface in this Phase:

  • Bloating with gastric and jaw tightness after eating, and only small amounts of food or liquid can be tolerated at one time
  • Extreme sensitivity to minute dose of iodine, Chinese's herbs, glandular, Vitamin C, Vitamin B
  • Extreme intolerance to most vegetables, especially those high in potassium
  • Extreme nervousness and sense of impending doom
  • Uncomfortable chest and head contractions when arising from a supine position
  • Extreme sensitivity to gluten, wheat, and dairy products
  • Extreme sensitivity to massage, acupuncture, sauna, detoxification, or stretching
  • Extreme fluid and electrolyte imbalances such as dilutional hyponatremia and fragile blood pressure
  • Extreme reliance on prescription medications for sleep
  • Extreme temperature intolerance to heat such as sunlight, hot bath and cold such as passing by an open refrigerator, cool room, and cold water
  • Shortness of breath when not lying down or if not concentrated on breathing
  • Breathing ceases to become an automatic subconscious function but requires conscious energy
  • Extreme high frequency of racing thoughts with the mind unable to stop and feeling continuously “wired”
  • Extreme sensitivity to TV, computer monitor, telephone, cell phone, fluorescent lights, electric blanket, Wi-Fi signals
  • Extreme overall weakness that impedes normal talking or eating
  • Extreme and persistent constipation requiring enema to empty bowls
  • Extreme cold hands and feet in a room where others feel normal
  • Extreme sensitivity to chemicals in common household items such as perfume, shampoo, and other oil based products
  • Extreme dry skin and hair
  • Fatigue worsens with small dosage of steroidal medications such as Cortef or Florinef
  • Extreme weight loss
  • PMS type symptoms from day 4-14 of the menstrual cycle
  • Extreme sensitivity to vibration (traveling in a car on a bumpy road)

It is not uncommon to see a reversal of the 24-hour saliva cortisol curve pattern, with low cortisol in the morning and high in the late afternoon and evening. The cortisol to DHEA ratio is generally high. Sufferer is bedridden, unable to do daily chores or walk from room to room without feeling fatigued and drained. Constant ambulatory assistance is required.

Current concepts point to the likelihood of pump failure, receptor site dysfunction, transport system dysregulation, low clearance due to incomplete detoxification, metabolite buildup, Autonomic Nervous System reactive responses, and electron driven retoxifications as possible etiology for the wide variety of paradoxical and exaggerated reactions commonly seen in this phase. A key mechanism of this breakdown is by development of positive feedback loops. The internal self-regulatory loop system of the body is generally based primarily on negative feedback and not on positive feedback circuits. Positive feedback loops are inherently unstable and are usually the cause for the final breakdown in many chronic diseases. For example, failure of the Sympathetic Nervous System (SNS) mentioned earlier causes lightheadedness. There may be a need for prolonged bed rest, which in turn worsens the orthostatic hypotension as the patient tries to get up. Over stimulation of the SNS may lead to rapid heart rate, cardiac arrhythmia, reduced cardiac output, and heart failure. Heart failure will in turn trigger more SNS stimulation, and thus propel the viscous cycle downward.

The timing and rapidity of system failure from the positive feedback loops depend on the dynamic interactions among the various systems in the body, with primary emphasis on the neurological, endocrine, and cardiac systems in an Adrenal Fatigue setting. Breaking the positive feedback loop and allowing the system to reset itself offers the best overall clinical strategy. This can be accomplished with a micro nutritional approach, foundational and rudimentary diet protocols and medications as needed. Downward titration of micro nutrients to match the body's clearance capacity is the key and if this is done properly, the body's nutritional needs are attended to without over-burdening the body's clearance system. The body will slowly become properly nurtured and be given the opportunity to rebuild its own reserve of hormones back to the minimum threshold required for the various organs to function normally.

One common clinical recovery mistake in Phase D is the use of high dose nutrients. Practitioners not well trained in this phase are misled to increase nutritional dosages, thinking that what works before in earlier phases should work better in higher dosages in this phase and as a result, higher doses of Vitamin C, Vitamin B, glandulars, herbs, thyroid support, and glutathione are administered to the patient. Some clinicians may even attempt aggressive toxic metal elimination whilst other practitioners will resort to intravenous delivery systems. Little do they know that high doses may not lead to better results. There may well be a transient period of well-being but these strategies will often fail over time. The body will go through phases of a roller-coaster ride with plateaus, highs, and lows as it tries to restore equilibrium if there is sufficient reserve left to meet the minimum required threshold. Over time, however, the body continues to decompensate as it fails to restore equilibrium with each attempt. While such aggressive nutritional strategy may have worked well in earlier phases and stages of Adrenal Fatigue, the response of high dose nutritional therapy will often become blunted and the overall condition may actually get worse in this phase. Worsening of the patient's condition upon administration of nutritional supplements or medications is a major hallmark in Phase D, as evidenced by severe paradoxical reactions associated with a low-clearance state.

To avoid further decompensation, it may be necessary to stop using the high dose nutritional approach temporarily, both at the macro and at the micro levels. Instead, the blueprint of a successful recovery program usually involves a meticulously designed program of micro nutritionals with dosages timed and titrated downwards to a level acceptable by the patient's body without creating a toxic retoxification response under a low clearance state. With this approach, the body, over time, will likely assimilate the nutrients properly at a rate it can process comfortably. This will start the stabilization period followed by the rebuilding process. No matter how good the nutrients are forcing nutrients into the body when it is not ready to accept them will only worsen the condition. Using natural unprocessed forms of macro nutrients and small doses of micro nutrients that are gentle enough to be delivered and effect cellular bioavailability without significant toxic response is a far more effective approach. This may take a few weeks or a few months, depending on the body's state of function. With the right dosage and proper nutrients, the body will have a chance to stabilize on its own and rebuild, once it is able to "reset" itself. Once significant reserves have been restored to the adrenals, the physician can then revert back to the more aggressive micro nutritional approach slowly. A macro nutritional approach may gradually be restarted as well. Clinical outcome can be very positive and dramatic. In this phase, the key is not to force nutrients into the body when it is weak, but to nurture the adrenals with proper nutrients at a dose the body can process and allow the adrenals to slowly heal themselves.

Therefore, even basic nutrients that are usually helpful to the adrenal function, such as Vitamin C, B, and others, have to be given very carefully. This is where most self-navigated programs fail. Nutrients, adaptive herbs, or glandulars often behave in a stimulatory fashion in this phase due to the body's low clearance state. Even steroids or intravenous nutritional delivery may become ineffective and trigger worsening responses. The proper dosage and selection of the right delivery system are critical because cellular bio availablity and metabolic clearance are often severely compromised. Administration of Vitamin C, cortisol, DHEA, and pregnenolone, all of which are normally welcomed by the weak adrenals, cease to bring about any improvement in symptoms but may become ineffective and possibly toxic in this phase. In other words, nutrients may back fire and this cannot be overemphasized. The more the adrenals are exhausted, the less they can tolerate medication, nutrients, herbs, or glandulars. It may appear that nothing appears to work and that the brutal downward decompensatory cycle seems to be well entrenched. Sufferers will become desperate and try to overcome their physical and mental exhaustion on their own to no avail. Depression will often set in and suicidal tendencies surface. Physicians are often helpless.

Progression to this Phase D from earlier phases can be gradual or abrupt. It is not uncommon to see that a stressful event (e.g. death of a loved one, over-exercise, overwork, medication intolerance, excessive exogenous steroid overload from medications, infectious processes such as snake/spider bites or pneumonia) can overwhelm the already decompensated and constitutionally weak adrenals, leading to a rapid descent into Phase D (bypassing earlier phases) within days or weeks.

Phase D is not a state to be self-navigating. Routine laboratory tests are normally not helpful and may even be confusing at this point. Expert professional guidance is absolutely necessary and if left unattended, the natural progression of Phase D condition will cause further decompensation and ultimate collapse. Unfortunately, qualified physicians in this area are extremely rare. However, recovery is possible and often can be quite speedy and dramatic, but getting the right professional help is the key. A comprehensive recovery program is essential, allowing for some trial and error due to the poorly understood underlying physiology of Adrenal Fatigue.

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About The Author

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.

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