What is Adrenal Crisis?
By Dr. N. Karen Thames
Licensed Clinical Psychologist
Founder and Executive Director of The EPIC Foundation
In simple terms, Adrenal Insufficiency occurs when the body does not have enough cortisol in it. You see, cortisol is life sustaining and we actually do need cortisol to survive. You have probably seen the commercials about “getting rid of extra belly fat” by lowering your cortisol. These advertisements make it hard for people to actually understand the importance of the function of cortisol. This condition is also known as Addison’s Disease in primary Adrenal Insufficiency cases. Cortisol is directly produced by the Adrenal Glands which are two small organs that sit on top of the kidneys.
Some patients have organic problems or other illnesses that lead to a dysfunction in the adrenal glands. However, there are some patients who develop Adrenal Insufficiency as a result of getting treated for Cushing’s Syndrome/Disease. People with Adrenal Insufficiency (AI) actually do not have adequate adrenal functioning due to inadequate or complete lack of the life sustaining stress hormone, cortisol. We NEED cortisol to survive.
After a Cushing’s patient has surgery to treat Cushing’s, he/she goes from having very high levels of cortisol to no cortisol at all. For pituitary patients, the pituitary, in theory, should start working eventually again and cause the adrenal glands to produce enough cortisol. However, in many cases; the pituitary gland does not resume normal functioning and leaves a person with a lack of significant hormone functioning (Nicholas-Patterson, 2016). The first year after pit surgery is spent trying to get that hormone to regulate on its own normally again. During that period, the patient is at risk for Secondary Adrenal Insufficiency symptoms. Going from very high levels of Cortisol to drastically lower levels of Cortisol is what the patient wants, but the flip side is that it confuses the body. Therefore, the patient must be vigilant about watching for signs of dangerously low Cortisol levels.
For a Cushing’s patient who has had pituitary/brain surgery, we call the insufficiency, “Secondary Adrenal Insufficiency”. For a patient who has had a Bilateral Adrenalectomy (BLA), where both adrenal glands are removed as a last resort to “cure” Cushing’s; his/her body will not produce cortisol at all for his/her life. This causes Primary Adrenal Insufficiency or Addison’s Disease. According to the National Adrenal Disease Foundation and its medical director, Paul Margulies, MD, FACP, FACE, “Primary adrenal insufficiency, also known as Addison’s Disease, is caused by the total or near total destruction of the adrenal glands and results in the severe deficiency of both cortisol and aldosterone. Secondary adrenal insufficiency, in contrast, is due to the absence of the normal stimulation to the adrenal cortex from a lack of ACTH. This results in a partial or total deficiency of cortisol, but often a normal or near normal production of aldosterone (Margulies, 2013).
Cortisol is the stress hormone and also known as the Fight or Flight hormone. Its function is to help a person respond effectively to stress and cortisol helps the body compensate for both physical and emotional stress. So, when faced with a stressor, the body will produce up to10X the baseline levels in order to compensate. When a person cannot produce adequate amounts of cortisol to compensate, we call that Adrenal Insufficiency. If it gets to the point of an “Adrenal Crisis”, this means that the body can no longer deal and will go into shock unless introduced to extremely high levels of cortisol, usually administered through an emergency shot of steroid.
There are ways to help prevent a crisis, by taking more steroid than the maintenance dose during times of stress. This can be anything from going to a family function (good stress counts too) to fighting an infection or illness. Acute stressors such as getting into a car accident or sometimes even having a really bad fight require more cortisol as well.
It was once believed that everyone responded to every stressor in the exact same way. So, there are general guidelines about how much more cortisol to introduce to the body during certain stressors. For instance, during infection, a patient should take 2-3X the maintenance dose of steroid (cortisol). Also, even the maintenance dose was considered the same for everyone. Now days, most doctors will say that 20 mg of Hydrocortisone (Steroid/Cortisol) is the appropriate maintenance dose for EVERYONE. Now, we know that neither is necessarily true. Although the required maintenance dose is about the same for everyone; some patients require less and some require more. I have friends who will go into an adrenal crisis if they take LESS than 30 mg of daily steroid. On the other hand, 30 mg may be way too much for some and those folks may even require LESS daily steroid, like 15 mg. Also, I want to stress (no pun intended) that different stressors affect different people differently. For some, for instance, an acute scare may not affect them. However, for others, receiving bad news or being in shock WILL put their bodies into crisis. That person must then figure out how much additional steroid is needed.
Signs and symptoms of Adrenal Crisis can include:
- Lower back pain
- Stomach/leg pain
- Pale skin/shivering
- Loss of appetite
- Neurological deficits
- Low blood sugar
- Low Blood Pressure
(Some people experience high Blood Pressure during crisis)
- Cardiovascular collapse
- Suicidal Ideation
- May present with Shock-like symptoms
- Possible loss of consciousness
(Adrenal Insufficiency United; www.AIUnited.org)
Interestingly, many patients actually experience high blood pressure during an Adrenal Crisis. This is referred to as a “Paradoxical Response”. Many doctors don’t realize that and will often dismiss patients who come to the ER with AI, especially those who have had pituitary surgery.
Cushing’s patients, for various reasons, are prone to Secondary or Primary Adrenal Insufficiency. If you experience the aforementioned symptoms, it is not “just the flu”. I have actually had deferred treatment in the ER because they said that my “case could wait because it was just the flu” and actually lost consciousness and almost lost my life right there in the middle of the ER. It is important to seek immediate help and insist upon getting help ASAP. Many patients have the emergency steroid shot at home to get them over until they present to the ER.
If you have a loved one, please inform them of your case, what your symptoms look like, and how to get help. There may be times when you cannot advocate for yourself. For instance, when I am deep in crisis, I become so confused that I cannot even add 1 plus 1, literally. My husband has had to be my voice and advocate for me in the hospital when the staff has no clue how to treat me.
This video explains Adrenal Crisis in simple terms: https://www.youtube.com/watch?v=ZXVMqcG06Es&feature=youtu.be
To those we have lost in our community to Adrenal Insufficiency, Rest in Peace my friends! Your legacies live on forever! Please visit our Legacy page to honor our friends.
- Margulies, P. (2013). Secondary adrenal insufficiency: The
facts you need to know. Great Neck, NY: NADF.