What will happen if a person with Addison's disease is exposed to high stress?
There are a few ‘types’ of Addison’s disease and the symptoms of Addison’s can vary between these types and between individuals - and strictly speaking, only one ‘type’ is actually Addison’s disease……see below!
What Happens In Addison’s Disease
Whatever the cause, the format for developing the disease is similar; three bits of the body start giving one another confusing information and these three are: The adrenals (sitting on the kidneys like little coif hats), the pituitary gland (a teeny little bit of the brain, snuggled behind the top of the nose) and the hypothalamus, (down in the base of the brain). It is usually down there, busy connecting messages from the nervous system and endocrine system (it regulates important functions like: temperature, sleep and stress and detects changes in the body. It then decides what to send to fix it and gives permo to release whichever hormones, as required). This three way exchange is known as the HPA Axis (Hypothalamic-Pituitary-Adrenal) and it’s very important not to confuse it.
The Addison’s disease Dr Thomas Addison described, is when the adrenal glands have eroded right down to the medulla. It is usually diagnosed only after the three layers of the adrenal cortex (90% of the whole gland) have already gone and you just have the medulla left. This is referred to as autoimmune Addison’s.
Autoimmune Addison’s symptoms as they appear - The 3 stages:
Being autoimmune, the body seems to wake up one day and decide that the adrenals are actually the enemy (we’re not sure why..). So it destroys them, outer bit first. The progression isn’t always linear or identical between people, but typically, the first symptoms to get going are: thirst, salt-cravings, muscles cramps and tiring quickly after exercise. This is due to the first layer (zona glomerulosa) being the place minerals and salts are regulated. The primary cause of this type was from TB, again, the body gets confused and when killing off TB (Mycobacterium tuberculosis) it accidentally mistakes the adrenals for it, so zaps them too. Fewer people now have TB, so the incidents of Addison’s is slightly reducing.
Then, most patients will notice feelings of anxiety, poor tolerance to stressful situations and a myriad of broadly psychological changes: mood, sleep, intrusive thoughts, even paranoia. With this there may also be an inability to fight off viruses, bacterial and fungal infection, and a darkening of skin, usually in patches, eventually, all over. Feeling faint, fainting and episodes of tachycardia can happen too, and blood pressure tends to be low*. This is the middle layer (zona fasciculata) waving the white flag and no longer doing its job - which is to produce cortisol (cortisol manages immune response and stress management). When the hypothalamus spots incoming stress, it asks the pituitary to get on to the adrenals (by sending CRS) and order some nice, calming cortisol. The pituitary duly gets on to the adrenals (by releasing ACTH) and when it gets no reply, it sends more. This also happens to stimulate MSH (melanin stimulating hormone) so in Addison’s, we tan as we stress. It is often the ‘golden/orange glow’ with dark brown splodges on skin, gums, nails, palms etc that ring the “Addison’s?’ bell in a physicians head.
The final bundle of symptoms tend to be changes in periods, erectile function, loss of body hair, decreased muscle mass and strength, mood swings, bone density, extreme fatigue especially after bursts of exercise, weight loss and skin disorders. This is because the final of the three layers (zona reticularis)is where androgens are produced.
But not all Adrenal Failure Is Autoimmune.
Ischemic Addison’s
The same symptoms are usually suffered by this category of “Not Exactly Addison’s But There Aren’t Enough People With It To Warrant a Whole New Name” (only 1 in 5 million people will have this one, so they’re simply referred to as having ‘Ischemic Addison’s’. (As in - the blood supply to tissue stopped (ischemia) - so no more adrenals and no more cortisol).
This group will notice similar symptoms to the autoimmune group as they no longer have any adrenal function either. But crucially, not in the same order (symptoms from the three stages can happen all at once or the other way around and often come on faster). This type is usually caused by losing the adrenals or damaging them past redemption, during emergency surgery, a serious car accident, septicaemia or cancer of the adrenals.
The Third Type - simply referred to as ‘Adrenal Insufficiency’
A better name would help here too, as this tends to make people think that the insufficiency is a ‘one slice or two - I’d prefer a bit more cortisol’ type of situation. When it’s very much a ‘not enough cortisol’ condition. It doesn’t seem to be autoimmune and the adrenals are still there, just not doing their thing, so the cause is a conundrum. This type of Addison’s is sometimes confused with a condition referred to as ‘insufficient cortisol’ - after reporting symptoms of tiredness and feeling sluggish, a relatively low blood cortisol level is found and blamed for causing the symptoms. But these are not the same; someone with Adrenal Insufficiency definitely needs daily, life-long steroid therapy and will become seriously ill without them. They can’t shrug it off with more sleep and a diet high in green vegetables.
And Finally, not Addison’s, but can look like it - with a few symptoms missing - AKA:
Secondary Adrenal Insufficiency.
This is when the adrenals are actually ok, but the pituitary gland is very confused. It can be because a micro-adenoma is growing on it, or it’s been hit, hard.
You won’t see people in this category turning any shade of Addison’s orange as the ACTH is normal. But it doesn’t appear to be asking for cortisol, so the hypothalamus is wasting it’s time, the cortisone in-box is empty. This also needs treatment - and probably a brain scan, to see if a little adenoma has settled in an inconvenient place and quite possibly needs to be zapped.
So - the answer to your question!
If you have Addison’s disease or one of the above variations, you are probably on either hydrocortisone or prednisone, these are steroids that mimic cortisone, the precursor to cortisol, made by functioning adrenals. And when the right dose is taken and the symptoms are all nicely suppressed, being exposed to ‘high stress’ shouldn’t have a very unusual response. The only problem is that more than half the people with rubbish adrenal function, who take all the right medication at the right time, still have symptoms of Addison’s - especially concerning the pesky sympathetic nervous system. So the reaction to ‘high stress’ is likely to be variable to very poor. It would depend on a few more details, as to whether it could trigger an Addisonian Crisis, but it’s certainly possible.
A crisis isn’t a subjective description, much like low cortisol, the patient isn’t deciding it’s a crisis, it’s a medical term, to describe things needing immediate attention, preferably in a hospital. The symptoms I often see listed are: vomiting, severe pain in abdomen and or back, tachycardia, dizziness, high fever, low blood pressure, confusion, clammy skin and hypoglycaemia. There are other symptoms and some people may present with very few of those. Because the disease is rarely seen, even by hospital doctors, that list tends to become quite rigid and rigid lists can make a bad situation worse. Most people having an Addisonian crisis, if left, will go into shock (again, not a subjective description - it’s not shock like finding a free parking space in central London) - it’s another medical term that we now use casually. Hypovolemic shock is what happens when the body has insufficient blood/fluid to function. This results in inadequate oxygen delivery to the body's tissues and organs (including brain!) and if left, one, some or all will fail. It can vary in severity, but it will deliver some of the symptoms listed, and possibly a few others like crushing pain in the chest, left arm and shoulder. But not necessarily a fever, or low blood pressure. The blood pressure will get very low, BUT in most of my many episodes of AC, my (everyday low) blood pressure will first go up…later it will plunge down. I have often heard a reassuring voice tell me ‘your blood pressure is excellent at least - 150/90″. And if I could speak, I would repy - ‘in this situation, that is not excellent - hang around another half an hour”….et voila, bp now 65/40. Important, to the patient at least, is to understand that when in crisis, it is very, very difficult to speak words to people in an order that makes any sense. I really would like the list to include that - please, list-compilers.
But if we’re talking an ordinary, but under-par day, still able to do admin, when, suddenly ‘high stress’ happens. My brain immediately hands over the controls, entirely, to my sympathetic nervous system. The startle reflex becomes pantomime ridiculous and so does my mirroring reflex. Example: I witnessed someone hit their head - shouldn’t really be a high stress situation - but I dropped everything I was holding, my knees buckled, hands over head (my head, not the poor head-hurtee) heart-rate doubled and the room filled with white noise.
If the day is a bit rough already and someone drops a glass (or anything remotely similar-sounding) you’d think I’d been machine-gunned. Example: AC symptoms had started, I was sitting, using a straw to drink a litre of Dioralyte (a mix of sugar and water -getting it in fast can save a drip in A&E). The straw helps prevent spills from the shakes and ataxia. Someone kind had patiently helped get the straw to my mouth, when behind me the dog excitedly fell over his metal supper bowl. This caused me to flail a large mug of hot, salty water all over myself and the kind person. He duly refilled it, helped me back into position, in so doing his phone fell out of his pocket into the same bowl (resulting in another soaking and this time I got the dog too.) But that’s just me, other people will do other things. So, if you know the person next to you has any type of Addison’s,my advice would be don’t test their stress-receptors by bringing on any high stress!