Stress, Insomnia and the Adrenal Glands (Cortisol and DHEA)
Tired all the time?
Now we can really find out just how much stress is the cause.
A new test which measures cortisol and DHEA called the ASI or Adrenal Stress Index may be of great importance for people with CFS/ME, or for anyone suffering from undue fatigue or who feels that they have a problem with stress.
Most of us already know what causes stress but what we don’t know is why some people can handle it and others can’t. Nor, until now, could we determine scientifically if stress really is affecting our health.
The new test enables people to do just that. Previously, adrenal hormones such as cortisol and DHEA, so important for our energy levels, had always been measured by a blood test taken once and once only at a random time of day, taking no account of the fact that the level of cortisol varies very considerably throughout the day. This is still the way it is done by the NHS and it accounts for the fact that CFS/ME patients get little or no help from endocrinologists – even if they get to see one in the first place, which is unlikely.
This new test involves taking saliva samples four times a day – before breakfast, at noon, at tea time and just before bedtime. The early morning cortisol level should be the highest of the day giving us a strong start and enabling us to meet the demands of the day. A healthy person’s output of cortisol always follows the same curve, which can be plotted on a graph. It drops throughout the day until it falls to its lowest level by 11 p.m. or midnight, thus enabling us to be ready for bed and to sleep restfully throughout the night. Whenever the patient’s curve departs from the normal there is a problem. High night time cortisol means that the patient is finding it difficult to relax from the stress of the day and will have trouble going to sleep. This results in reduced REM sleep, a kind of sleep that is neither restful nor restorative, and which can produce depression and reduced energy levels the next day.
Another kind of patient will have normal cortisol output in the afternoon and evening, but will have too high and too sudden a release of cortisol in the early morning. This will result in early morning wakening at around 5 or 6 a.m, or even 4 a.m. and an inability to go back to sleep. This, in my experience, is a major cause of insomnia in patients with ME.
A third kind of patient will have high cortisol throughout the day. Initially, DHEA levels may also be high in order to provide some compensation for this, but if stress becomes chronic the adrenals can no longer maintain the production of extra DHEA with the result that there will be an elevated Cortisol-to-DHEA ratio.
This divergence, as it is called, has been seen in many patients’ tests since the ASI test was first introduced, and it signifies an initial stage of adrenal exhaustion. It can have potentially very harmful effects on health including diminished immune function, reduced REM sleep, diminished skin regeneration and a catabolic state where tissue breakdown exceeds tissue repair and building, leading to muscle wasting, weight loss and bone loss (osteoporosis).
It is not hard to see that this state is not far away from the start of even more significant adrenal fatigue, which I and other practitioners are seeing in CFS/ME patients.
Patients with this more significant adrenal fatigue will often have both a very low DHEA and low cortisol output throughout the day. Instead of having an 8 a.m. cortisol level of between 13 and 23, which is what gives a normal person get up and go to start the day, their morning level can be as low as 4, or even 2, and stays almost as low throughout the 24-hour period.
Someone with this low cortisol output will be in real trouble. If they still have a job they will be hanging on by their fingernails, needing to push themselves all day long and having no energy whatsoever left for looking after children or cooking meals or enjoying themselves socially. Many, like those with M.E., will have had to stop working and will be in a state of very severe chronic fatigue.
The ASI test is already seen by the small number of practitioners who use it as exceptionally helpful in assessing all patients with high stress or with chronic fatigue. Where practitioners using the test can be particularly helpful to their patients is in spotting when things are beginning to go wrong and thereby prevent any further deterioration. Its advantages over the standard blood cortisol test ordered by a GP are obvious and it should enable people, at last, to discover scientifically whether stress really is getting them down, and whether it is, or is not, a major reason for some of their health problems.
Michael Franklin is a clinical nutritionist who runs the Allergy and Nutrition Centre in Oxford and London and also offers an ASI interpretation service for those unable to travel. He is the author of ME: What is it? How do you get it? How to get better (Random Century), one of the very first books to have been published on ME. He can be contacted on 01865 459553 or 0845 456 0944 (low cost call).
This article first appeared in InterAction, the journal of Action for ME.
It should be noted that the ASI test can also be extremely helpful for the following conditions:
Our practice was runner-up in the 2009 CAM Awards for Outstanding Practice.
The Allergy and Nutrition Centre
Harley Street London, Sussex and Oxford
0845 456 0944