Clinicians Guide to the Biology of Chronic Stress

I'd like to welcome everybody. Today's presentation on when stress becomes biological understanding HPA axis dysregulation. I'm your host, Dr. Donnelly Snipes. Do your clients report fatigue, blood sugar instability, increased pain, digestive issues, sleep problems, chronic anxiety, irritability, or even hypersensitivity to the environment, Noises, smell, smells. Everything just feels so much more stronger and more oppressive. If so, it could be due to an overly active sympathetic nervous system and a dysregulated HPA axis. Your hypothalamic pituitary adrenal axis. Now, in the last two weeks, we talked about the hypothalamic pituitary gonadal and the hypothalamic pituitary thyroid axis. And we're wrapping it up today with the adrenal axis. Today we're going to examine the function of your sympathetic nervous system and the HPA axis. How it impacts all other major neurotransmitters and hormones throughout the body, causes and symptoms of imbalance in these systems, and strategies to heal. So the HPA axis is part of a complex stressness network, also known as the hypothalamic pituitary network. And. And again, just to go over it again, hypothalamic pituitary, adrenal, hypothalamic pituitary, gonadal, and hypothalamic pituitary thyroid. They all work together to keep the body factory running. The hypothalamus is the body's main control hub for survival and balance. So it makes sense that it's involved in this stress process. The pituitary gland is the body's main hormone messenger, and your HP axes regulate what's going on in the body via hormones. The HPA axis is primarily responsible for fight ORF flight and integrates physical and psychosocial influences to allow the organism or the person to adapt effectively. The HPA axis helps regulate. It doesn't do it all by itself, but it helps regulate many systems in the body, including the cardiovascular system, the metabolic system, the immune system, the reproductive system, and the nervous system. Let's think about that real quick. Under stress, cardiovascularly, we start breathing more rapidly, often more shallowly. Our heart rate increases. Okay, so the HPA axis is hitting the gas metabolically. In order to do this, we need energy, so it triggers the release of blood glucose. Okay. Immune system. It also triggers the release of cortisol, which is a steroid, which actually suppresses inflammation and immunity in order to allow the body to focus on fighting or fleeing, not repairing and recalibrating the reproductive system when we're under stress, guess what? Probably not the best time to reproduce. And the nervous system, and that involves how our signaling is happening and everything. So the HPA axis helps regulate our survival through coordinating all of these systems. The HPA axis prioritizes survival by mobilizing energy. In the immediate terms, we're talking glucose. In the long term, we're going to be talking about fatty acids. But in any event, its job is to make sure there's a steady flow of energy going out to those tissues and everything in order to fight or flee, controlling inflammation. So we're not using a lot of energy trying to repair something that's broke until we get into a state safe place. And you can see where this can go wrong if people don't ever feel like they're safe. Suppressing reproductive signaling and adjusting thyroid signaling. Now we talked about that some under the HPT axis video. When stress is chronic, the body recognizes, hey, there's a threat out there, we can't seem to escape. So we need to conserve energy. And it will actually start developing something called RT3, which breaks down the thyroid hormone and can lead to something called non thyroidal illness syndrome. Sex, high sex and thyroid hormones. Your gonadal and thyroid hormones also shape how reactive the HPA axis is. So they can help turn it down or they can help ramp it up. And again, they work in concert. Think about during adolescence, if sex hormones help shape how reactive your adrenal axis is. Think about what's going on for these poor adolescents who have these hormone surges like nobody's business. Oh my gosh, how stressful is that? Now it's, you know, a normal part of physiological development that we can't get through or that we can't avoid. But we can help people recognize that some of your emotional reactivity or dysregulation may be due in part to hormone changes. Hormone surges, ebbs and flows. People who, who are going through menopause or andropause have significantly less of their main gonadal hormone, whether that's estrogen or testosterone. So they have less feedback going into the HPA axis to help modulate it. And chronic stress and unresolved trauma. Because the HPA axis starts suppressing reproductive signaling and alters the balance of gonadal hormones, then people under chronic stress are often demonstrating different, a different balance of gonadal hormones. Now, the sympathetic nervous system and the HPA axis are related, but not the same. And in common conversations, we often use them interchangeably. But they're not exactly the same. They work together. Your autonomic nervous system, your big, you know, nervous system main branch is divided into two branches. Your sympathetic nervous system, which has sympathy for you when you feel stressed. So it triggers the stress response. That's how I remember it. And then the parasympathetic nervous system, which is responsible for rest and digest, repair, recalibrate lots of Rs. But what's important to recognize is the sympathetic nervous system is part of the nervous system. The HPA axis is part of hormone signaling. The sympathetic nervous system starts the stress response. It gets information in from somewhere, whether it's the vagus nerve or the eyes or wherever. It gets information in and it says crap, there's a problem and it hits the gas or pulls the fire alarm, whichever metaphor you want to use. This releases the first burst of glucose and adrenaline through the activation of nerves in a part of the brain called the adrenal medulla, the, I'm sorry, the kidneys. Adrenals are not up in the brain anyway. The HP axes then kick in in a couple of minutes and their job is to fuel, stabilize and regulate the fight or fight process through the use of hormone signaling. So until this threat is passed, it's going to help future fuel what's going on. Stress causes the secretion of cortisol, adrenaline, norepinephrine and glutamate. Cortisol. And we're going to go through these later, but just big overview. Cortisol is one of your main stress hormones. It's a steroid that is involved in suppressing inflammation. It's a lot of things. It does adrenaline, we all know what that is. Norepinephrine is also called noradrenaline and is useful for helping people focus. Norepinephrine is good for, you know, keeping people, well, focused. And glutamate is your main stress neurochemical. It is the one that's released that is the main excitatory neurochemical. Too much glutamate sitting in your brain for too long is one of the things, one of the main things that starts leading to neurotoxicity and neurodegeneration or brain shrinkage because you can't run that hot for that long. Cortisol causes the release of glucose for energy and is a steroid. It's an anti inflammatory that suppresses the immune system. Now a lot of us know that, that if we go through a period like finals or something and we're stressed for a while, we tend to get sick. Our immune system was suppressed. The upside is that means that cortisol was still able to do its job and suppress the immune system and suppress inflammation. So people who get sick actually have a pretty functional nervous system a lot of times. Over time, if the person is chronically stressed, cortisol loses its ability to suppress the immune system. So we actually see people get sick a little bit less. Sometimes during sickness or injury, pro inflammatory cytokines are released and pass through the blood brain barrier where they activate the HPA axis. So recognizing sickness or injury is one way that the HPA axis is activated. When our gut microbiome becomes inhospitable for some reason, either it's not healthy because of what we're eating, or we just become stressed and the PH of our gut changes. The vagus nerve sends information to the brain, to the hypothalamus, and it says, hey, there's a threat down here. Things ain't going so well. Which triggers the stress response. Stress occurs or can occur in any and all pieces of life. Physical stress triggers the stress response. Interpersonal, emotional, cognitive, environmental, and even spiritual stress can trigger that stress response. So you don't need to have the same stressor repeatedly to start developing sympathetic dominance. It's the culmination of all of them. So if you've got 17 different mild stressors going on in four different area, four different pieces of your life, that's going to be as impactful as one super ginormous major stressor. Therefore, we don't want to minimize all of the sources of unnecessary or avoidable stress and how that adds stress to our stress bucket. And in other courses we've talked about how if you think about our stress tolerance like a bucket, every time you get stressed, you're adding fluid water to the bucket. And if you stay constantly stressed, then that bucket is constantly filled with 2/3 of the way, maybe so you don't have nearly as much room before you start feeling overwhelmed and dysregulated. Like alcohol leads to the development of tolerance. Overexposure of our receptors to any substance, including hormones and neurotransmitters, will lead to changes in the system, including tolerance and resistance. Our system has its, our body has its own. You want to think of it this way, thermostat. And we're only supposed to have so much dopamine at any one time, or so much norepinephrine or so much whatever. And if we start consistently having too much, then the body's going to say, eh, yeah, you know, we, I just can't get that excited or that stressed out every time that happens. So then we'll start developing resistance. Now, dopamine and endorphins are generally what we see, for example, in addiction. When people use it triggers a whole bunch of stuff, but it also triggers the release of dopamine and endorphins. And over time, flooding the dopamine and endorphin circuits with so much of that chemical, so much more than is normally available. Supra, normal doses, the body says, no, no, that's too much. We can't do that. So it starts becoming less reactive. The dopamine's in there, but the receptors aren't receptive. They're not answering the door anymore. Insulin. We talk about insulin resistance a lot. This is true in people who are chronically stressed, in people who are pre diabetic, etc, when we have stress, our body releases blood sugar. In order for the muscles to be able to use the blood sugar, our body releases insulin. Well, over time, if the cells and the tissues are getting bombarded with insulin too much too often, again, those receptors start becoming unreceptive. So we start seeing more blood sugar just circulating around in the blood and not able to do its job. We. Which is what we start to see in insulin resistance. Pre diabetes and diabetes. And cortisol's the same way. As I mentioned earlier, too much cortisol for too long, the body is going to say, yeah, nope, you're overwhelming me. We got to back off on that a little bit. So the receptors become less sensitive, and it takes a whole lot more cortisol to get the receptors to wake up and do their job. As I mentioned earlier, a lot of times we throw around the term sympathetic dominance and HPA axis dysregulation. Kind of like they're the same thing. We also talk about hypervigilance almost like the same thing. And they're not. They're similar, but they're not the same thing. So let's look at how chronic stress can lead to a state of mind, chronic hypervigilance and sympathetic dominance. Each time something stressful happens, your brain sends out alarm chemicals, senses sharpen, and the body prepares for action. Okay, great system. When there's a problem, I want to jump into action. When the threat is passed, when the system's working normally, when the threat has passed, the parasympathetic nervous system kicks in and basically hits the brakes. You let off the gas and you press on the brakes. That's the way it's supposed to happen. But if the alarm keeps Going off. The brain assumes the threat must still be there and it just keeps its foot on the gas. You may be trying to push the brake, but it ain't doing any good because you're still pedal to the metal floor in the gas. The amygdala's job now the amygdala is in the brain, is to look for danger and act fast. When it's repeatedly activated, it fires faster and it responds to smaller and smaller cues. So what used to be, you know, used to take a big thing that's very obviously a threat. Eventually it may not be much of anything at all to trigger that threat response. Because somebody is so tense, so hyper vigilant, they're so stressed all the time, and their stress bucket is completely full. The amygdala may start reacting before conscious thought. It becomes part of our default mode network or our autopilot. I smell this, I see this, I go this place. It stresses me out. I don't even think about it. It's just as soon as I get there, experience it, or even think about going to that place or seeing that thing, my stress response kicks off. How many of our clients have that experience where thinking about a spider omg, or thinking about going to visit their parents over the holidays just triggers that stress response? They don't even have to be there. It's like, oh, I know what's going to happen. This isn't a flaw, a survival mechanism. And we want people to recognize that the fact that their nervous system is hair trigger and the fact that they may react before conscious thought, that's their body saying, there's just so much stimulation coming in, there's not time to think about it. If I want to defend you, I've just got to protect you, okay? It's a survival mechanism. It can be altered, it can be unlearned, if you will. But this is what we start seeing with a lot of people who come into our office who are depressed, who have trauma histories, who have anxiety, They've experienced this situation. So they are either constantly on edge and feeling anxious and irritable all the time and, or they're depressed because they're just so freaking exhausted and they're receptors have become so tolerant, so unresponsive to everything because they've been bombarded so long for so many years that the person just feels flat and apathetic and with repeated stress excitatory signals. So our threat signals get louder, if you will. It's like they're yelling, hey, pay attention, there's a problem. And the inhibitory signals weaken the person in the background going, you know what? There's not really a problem. It's okay, that, that's some. That's something that happened 10 years ago. It's not happening now. So all of those inhibitory signals, they're whispering while the stress signals are screaming, the sympathetic nervous system becomes more easily triggered. So it's sitting there and it's already primed. And as soon as one of those, the amygdala senses a threat, the sympathetic nervous system kicks into action. The brain becomes noisier. More signals get interpreted as important, and fewer signals get filtered out, which leads people to start feeling overwhelmed. Because if there's. If you're somewhere, maybe at a dog park, you know, and you've got all these dogs running around, and there's all kinds of noise, and there's somebody saying, that's a dangerous dog, that's a dangerous dog. That's a dangerous dog. And then there's somebody else saying, oh, these dogs over here, they're fine. You're not hearing that. So when you see those dogs, they trigger the threat response too, because you're not hearing, this part is safe and this part is dangerous, or this is safe right now. Back then, when this happened before, you weren't safe, you were different. The situation was different. Neutral inputs for a lot of our clients start to feel threatening. It's like, if I can't assign, yes, it's definitely safe, or it's definitely a threat. If I don't know, then it's going to go in the threat bucket. And so the person starts feeling anxious, feeling unsafe, and feeling more disempowered the more this goes on. And you say, well, why don't you just rationalize what's going on? You know, use that thinking brain of yours. It's not that easy. The prefrontal cortex, or the thinking brain needs time to act, which, if the amygdala isn't even thinking anymore, it's just jumping into action. The prefrontal cortex doesn't have time to say, hey, hey, wait, wait, wait. Before you do something, let's think about this. Okay, so that's not happening. The brain needs glucose. Well, under chronic stress, the body is diverting blood flow away from the brain to larger muscles to support fight or flee. The body is diverting glucose away from the brain to. To the muscles to fuel the system for fight or flee. The person is breathing more, more rapidly, but more shallowly, so they're not getting as much oxygen. And the nervous system is in Full on. And we've talked before about how when the sympathetic nervous system is activated, when the HPA axis is activated, the, our brain basically disconnects from the prefrontal cortex. It says, I need to get safe and, and then I can think about it, but until I feel safe, I can't think about it. The brain defaults to don't think, react. And we've all been in those situations. Even if you don't have a trauma history, we've all been in those situations when our stress response gets kicked off and you don't even think about what's going on. You just get up and do. I remember when I lived in the dorms, the we would have occasionally, unfortunately, false alarms called in. So in the middle of the night, the fire alarm would start going off. Really loud, really annoying. But I got, I would get up, I'd grab my stuff and I'd get the heck out of there. I wouldn't think, is this real? You know, whatever. Do I really need to hurry this much? No. I would get up, get out, and then it would hit me when I got out there. This is probably just another stupid false alarm. And I'd get a little irritated. But it helps us understand that for people with a normally functioning or regularly functioning nervous system under conditions of acute stress, again, we disconnect. We don't maintain that thinking right right away either. For people who have chronic stress, they never feel safe. So that stress response, that HPA axis never turns off and they're never able to fully reconnect with the prefrontal cortex. Under chronic stress, memory becomes fragmented and context gets fuzzy. So the brain stores and reacts to sensations more than fit. Cat the facts in this context at this time, trauma survivors thinking about when they get triggered, they may be in the middle of the grocery store and somebody walks by them that has the same cologne on as somebody from their past that harmed them, their stress response kicks right up. That's the body reacting to, to the sensation. A sound, a look, a tone of voice, body sensation, smell, even a place or a time can trigger stress responses in people. Because the brain says, been here, done that, it happened before. Therefore it's either happening or it's going to happen again. So batting down the hatches, and this is where fitcat can be very helpful. But before people can evaluate what's going on, they have to down regulate, which is why we've talked about before, an emotional intelligence. Identify the feeling and the purpose. You know, what triggered the feeling. I'm feeling stressed right now, or I'm running right now because there's a fire alarm. Okie dokie, you know, knowing what is going on in the moment, then down regulate because you ain't going to think until you can get oxygen and sugar to the prefrontal cortex. So downregulate and then explore what's going on, what actually is happening right now, and options to address it. The body stays activated and starts feeding the fear loop under chronic stress. People who have chronic stress, people who have trauma histories often have higher heart rates. Their muscles stay tight, their breathing stays shallow, their gut activity changes, the PH actually changes in their gut and their intestines become leaky, which increases inflammation and vagal afference. The vagal's nerve in the gut sends threat messages to the brain. It says, ph is off here. That means something bad's happening. You know, we've got to prepare for that fight or fleet. The brain reads all of these physiological sensations and concludes, hey, there must be danger. This person's got muscle tension and everything else must be danger. Physical sensations then become to the body and the brain proof that there's a threat. And then the body starts acting as if there were a threat. Whether there's a threat or not, the body perceives that there is a threat. Cues in the environment associated with the physical sensations now become associated with the threat, even if they're benign. So maybe somebody is at an, the aquarium or at, at a. Well, we'll stick with an aquarium. And they're just be bopping along, looking at the exhibits, loving the fish. And then that person with that cologne walks by and it's like, oh, crap, is this happening again? And the body says, this is happening again, not is it happening again? And the person's sympathetic nervous system triggers. Glucose is activated, the HPA axis is activated. Now, when they think about going back to the aquarium, that might cause them stress. They may feel like, oh my gosh, the last time I was there, I had this really bad flashback. And yeah, the aquarium's not a safe place because I can't control, I can't prevent being triggered. So now the aquarium is seemingly a benign place, but it's become associated with threat. People with trauma histories often start having a lot more. Their threats become much more generalized. And so more and more places feel unsafe, which means more and more of the time they feel unsafe and powerless, which means more and more of the time their HPA X axis stays activated. Their sympathetic nervous system may not even need to spark it off anymore because it's just a constant. People who have chronic stress, vigilance becomes the new baseline. It's like, okay, I'm at the aquarium now, I've got a scan and make sure that I'm safe, that somebody's not going to come up behind me, that, you know, whatever. So vigilance becomes the new baseline wherever they go. That's exhausting, that even if all other things were fine, being vigilant is exhausting. And when that, when that's your baseline, when you're constantly feeling like you've got to scan for threats because, because you're unsafe, calm feels unfamiliar, quiet feels unsafe, and stillness feels like waiting for something bad to happen. The person feels vulnerable and the sympathetic nervous system stays primed for action. Even if they've downregulated the HPA axis, which rarely happens. But even if they have that sympathetic nervous system, it doesn't take hardly anything to get it to snap into action. So that helps you understand a little bit more about what's going on neurologically and neurochemically to people who have chronic stress. Now let's take this a step further and look at what's going on under the hood besides just the HPA axis. We mentioned cortisol earlier and cortisol is your main stress hormone in terms of, you know, that we have cortisol that spikes in the morning, gets us, gives us energy to get out of bed and things like that. And it's supposed to decline throughout the day. Glutamate is our main excitatory hormone. It's our main energy producing hormone, neurotransmitter, if you will. But cortisol is your main stress hormone. It peaks in the morning and gradually declines during the day. It helps regulate circadian rhythms. When cortisol's high, melatonin is going to be low. When cortisol is low, melatonin can start to come up. It helps control blood sugar, it regulates metabolism, helps reduce inflammation when the body is responding to helps with memory formation when we're less inflamed, when we've got less neuroinflammation. Everything up here is working better and we actually can form memories more easily. It helps control salt and fluid balance and control blood pressure. So those are all just the cortisol part, adrenaline. And, and I do want to highlight again that when cortisol is high, certain neurotransmitters like serotonin and melatonin hormone may be lower. High cortisol also impacts our gonadal hormones. We remember from the past two classes that when our thyroid hormones, our godadal hormones. When any of this, these chemicals are out of balance. It also affects the availability of neurotransmitters and mood and, and impacts mood. Adrenaline. We all are familiar with it. It's a stimulant. It triggers the fight or flight reaction and increases blood pressure, respiration and blood sugar. It says, give me the energy, give me the power, let me go. Thyroxin, which is your thyroid hormone, helps regulate metabolism and increases during normal activation of the HPA axis. That's what we want when there's a normal reaction. We want to increase our increase our energy output to help us get safe. It is inversely related to cortisol under conditions of chronic or extreme stress because automatic breaking is applied through the creation of RT3. So if cortisol stays high for long enough, then instead of promoting the production release of T4 and creation of T3, the body starts releasing T4 and creating RT3 which is reverse T3, which is a breaking mechanism for metabolism. It says no, we're in conservation mode right now. There's just no point in spending energy on this anymore. Melatonin, it's our sleep hormone created from serotonin and is inversely related to cortisol stress. Cortisol stays high, serotonin, melatonin gonna be lower. It is anti inflammatory and antioxidant. We know that inflammation, whether it's, you know, we broke our arm and we've got acute inflammation right here or systemic inflammation from chronic stress or autoimmune issues or whatever. Inflammation is a stressor. And when people have inflammation, that stress response is going to stay on at least a little bit. Melatonin also assists with sleep promotion and again inversely related to cortisol, estrogen and progesterone. Remember I said under stress the body quits signaling for reproduction because hey, it's not safe to bring a little child or infant into into the world if you will. Chronic stress reduces estrogen and progesterone resulting in loss of periods or am menorrhea in women and possibly postpartum depression and autoimmune issues. Now it's interesting to note that progesterone tends to have some anti anxiety properties and tends to activate GABA neurons. So when cortisol is reducing progesterone, we got a problem. Estrogen is anti inflammatory and neuroprotein neuroprotective. If cortisol is reducing estrogen enough, then we're going to have more inflammation and more neuroinflammation. Estradiol, which is one type of estrogen can trigger the stress response when it is not in balance. We need too little, people tend to feel depressed, too much, people tend to feel anxious. But there's a lot more that's overly simplified. Estradiol and estrogen receptors are throughout the body. And just simplify it by saying if it's out of balance for that person, we may start seeing mood and vasomotor symptoms, hot flashes and such. Testosterone increases in response to normal cortisol and HPA axis activation makes sense. You know, you go out for a, a track meet, testosterone may go up some, we're going to compete. Testosterone decreases under conditions of chronic stress. Hypocortisol, hypocortisolism or glucocorticoid resistance, which all happen under chronic stress. When people are chronically stressed, cortisol loses its ability to do what it needs to do. And so you're going to start to see more systemic inflammation and you're going to start to see a decrease in functional testosterone. There's a positive correlation between oxytocin and cortisol under stress, suggesting a social support seeking response. Remember at the beginning of class or before class we were talking about tend and defend. And that's a much better representation of what cortisol does than bonding. Oxytocin can go up in response to stress because it's trying to defend what's important to that person. Under conditions of safety and bonding. Oxytocin is negatively correlated with cortisol. So we can't say that cortisol necessarily increases or decreases oxytocin. The effects are very different. Dopamine increases in response to everything it seems, but definitely in response to stress and excitement and it helps approve improve attention, vigilance and survival oriented learning. Dopamine is our motivation, our perseveration neurochemical. Chronic stress can lead to dopaminergic dysfunction or apathy. Again, chronic stress keeps dopamine levels too high for too long. The receptors become less receptive, they become less sensitive to being stimulated by dopamine, so the person has a harder time getting motivated. Acetylcholine is positively correlated with HPA axis activation, depression and pain. As acetylcholine goes up, serotonin generally goes down down. When serotonin goes down, our pain threshold goes, our pain threshold also goes down. It, we feel more pain, we actually feel it. It's not just in our head, we actually are, our nerves are more sensitive. Recognizing again how the HPA axis is impacting all of these. Now what do we talk about in terms of Mood. We talk about dopamine in terms of motivation, moving norepinephrine in terms of depression and anxiety and attention. We talk about serotonin a lot in terms of depression and to a certain extent anxiety. When stress is high, these neurotransmitters are going to be impacted. And depending on how long the stress lasts and, and how intense it is, how much it's altering the, the levels of those neurochemicals, we may see significant mood symptoms. Norepinephrine is needed to synthesize and release melatonin by the pineal gland. When cortisol levels are high, this process doesn't take place. So yes, melatonin is made from, if you will, serotonin. But what it needs, norepinephrine in the process to help break it down, glutamate and gaba. Glutamate is broken down to make gaba. So you. It's kind of interesting how some of these hormones and neurotransmitters are serve multiple functions. But I digress. HPA axis activation increases glutamate, our stress hormone, our excitatory hormone, and reduces gaba. GABA is our natural calming hormone. That's really not generally what we want to see. Persistent levels of glutamate, as I mentioned earlier, are neurotoxic. If you're constantly flooding your brain circuits, your, your prefrontal cortex and your hypothalamus with glutamate, you're going to start to see shrinkage, literal shrinkage in the density of that tissue and the size of the brain. Serotonin balance is also altered in response to the HPA axis. We've, in other courses a couple years ago, we, we've talked about how serotonin has multiple different types of receptors under chronic stress. 5ht1a goes down and 5ht2a goes, goes up, which contributes to altered mood under conditions of chronic stress. As I mentioned earlier, serotonin is necessary in order to make melatonin when it's time for bed. And high levels of cortisol will prevent the release and construction maybe of melatonin. When we don't get enough sleep, the body receives that, perceives that as, guess what? A stressor. So when people are sleep deprived, their HPA axis is going to be more active. Their sympathetic nervous system will trigger that HPA axis and say, oh, it's going to be a bad day today because we didn't get enough sleep last night. And recognizing that is really important in terms of healing. The system targeting the sympathetic nervous system and parasympathetic nervous system. Balance often calms the entire stress system because chronic stress and subsequent inflammation are often an autonomic nervous system problem. So the brake is not working, or not working very well. And the accelerator, oh boy, you just press on it a little bit and you go zero to 250. Well, maybe zero to 60, but whatever. So in a lot of the people that we're working with, through repetition and exposure to chronic stress, the sympathetic nervous system has gotten to the point where it takes virtually nothing to turn it on. The, if you want to think about it, that that accelerator is just really, really loose. You just press on it just a little bit and you're taken off. The parasympathetic nervous system is under recruited or underpowered. So think about that as the break. When you try to press the brake, it doesn't do anything or it does very little so that the vehicle, if we're think using this metaphor, continues to move. And what we're trying to do is slow it down and get it to stop. The other important thing here is to recognize again, the HPA axis is not dysfunctional, so to speak, it's dysregulated. It is reacting appropriately to upstream danger signals. The sympathetic nervous system has become too sensitive and it's constantly triggering that fight or flight reaction. It's constantly pulling the alarm, constantly hitting the gas. And everybody, every time that happens, instead of questioning and going well, sympathetic nervous system, are you sure that this is a threat this time? The HPA axis just says, all right, you say there's a threat, let's go. So the HPA axis is really doing its job. But so what we need to do is back up and help people quiet the sympathetic nervous system. Those instead. So it's not yelling anymore. Make that accelerator a little bit more, a little stiffer. So you, you have to push on it a little bit to go and improve the effectiveness of the parasympathetic nervous system or the brakes. Chronic stress related issues. You're going to see sympathetic nervous system dominance, cardiovascular disease, hypertension, pain and inflammation. And as the body becomes disregulated, we start having leaky gut that contributes to inflammation. That makes the stress response even stronger, which contributes to more inflammation. When we have more inflammation, we start seeing serotonin go down and our pain threshold go down. So we have more pain. It's a really ugly cycle. We may see autoimmune issues, insomnia, fatigue, reduced libido, polycystic ovarian syndrome, because those gonadal hormones are all out of whack and the circadian rhythms are disrupted and cortisol directly acts on the ovaries to say, you know what? Nope, no, we're not doing this right now. We see cancer related to chronic inflammation and chronic stress, diabetes, problems in the gut, microbiome, leaky gut, thyroid dysfunction, post traumatic symptoms. And I say that because if you're going to have post traumatic stress symptoms, you have to have a trauma somewhere. But the key here is the person experienced a trauma and never regained a sense of safety and empowerment. So they stayed in this state of stress or hyper vigilance, which starts causing a lot of irritability and depression and hopelessness and helplessness. Cognitively, we see executive functioning impairment. As I mentioned, when we're under chronic stress, that blood, that oxygen and that blood sugar is getting transported to the parts of the body that can help fight or flee, not to the thinking mind. So attention, planning, organization, learning, all those things. Impaired high levels of glutamate are actually associated with altered formation of memories, which, you know, you could argue is adaptive in some ways, because when you're under, when you're experiencing an extreme trauma, some of that stuff you just, you don't want to remember. And that's what the brain's doing in a lot of ways that those high levels of glutamate keep those memories from solidifying, if you will. People experience brain fog. Neuroinflammation is directly correlated to brain fog, as is sleep disruption. If you are not feeling safe, if your HPA axis is activated, then your body says, you know what, it's not really safe to drift into deep sleep. I need to stay ready to jump up and respond. And that can be exhausting. I remember when my son came home from the hospital, he was a micro preemie, and first few weeks I didn't sleep well at all. Every time he would grunt, every time he would move a little bit in his bassinet, every time something would happen, I'd be up checking to make sure he was still breathing. And you know, that was my sympathetic nervous system just jumping into action and saying, hey, it's not safe to go into deep sleep because you need to tend and defend this little peanut next to you. And dementia is strongly associated with chronic stress and neuroinflammation. We also see dementia like symptoms, cognitive slowing associated with brain fog as a result of all this other stuff. So we don't want to jump to the dementia diagnosis right away because some people may just have basically stress induced neuroinflammation and cognitive fog. Sources of the stress, as I mentioned before, can come from any of the pieces of life. Nutrition. If it's inadequate or inflammatory, it's going to add stress. Sleep. Inadequate. Or if somebody's got sleep apnea, not only will it be inadequate, but it's also every time they quit breathing, it triggers the stress response. Health. If their health is crap, the body recognizes, hey, this factory ain't working so good. That's a stressor. If they're in pain, yeah, that's stressful. Addiction and alcohol use, you're flooding the body with toxins. Yeah. Is perceived as a stressor. If your circadian rhythms get out of alignment. Remember every single cell in your body has a circadian clock. And if your circadian rhythms get out of whack, then none of the workers know when to show up to work and everything starts to go haywire. And hormone imbalances because we need to have a certain amount of estrogen and testosterone and T4 and T3. When those get out of balance, then if you think about it like a factory, the manager on the floor says this is stressful. We can't do our job effectively because we don't have enough of every single component. Interpersonally, things like insecure attachment, low self esteem, lack of support, interpersonal trauma, poor relationship skills and poor communication skills can all increase stress. These can all be targets of stress mitigation and people's recovery plan. Some things they're more willing to work on than others. I've had a lot of people when you start talking about improving their self esteem, they're like, that's hokum. You know, I'm not, I'm not doing that. Okay, you're not interested in starting on that right now, that's fine. Let's look at some of these other things like sleep and nutrition and improving any relationships that you do have or at least understanding your attachment style and maybe starting to heal that, developing secure self attachment. Emotionally, all of our dysphoric emotions are going to be associated with stress. Anxiety, anger, resentment, guilt, jealousy. Which by the way, anger, resentment, guilt and jealousy are all different forms of anger. But grief, denial, anger, depression, acceptance. So grief hits both anger and depression. And then of course, depression is a stressor. When we feel hopeless and helpless, even though we may not be rived, we feel vulnerable, we feel defeated, we feel powerless. And that's a stressor. Cognitively cognitive distortions like mind reading, all or nothing thinking, personalization, yada yada yada. Well, they identified those in CBT for a reason because they add stress, threat perception. When we feel unsafe, we are more likely to scan and notice threats and not notice the safety things. And I've used the analogy before of walking through the woods and all of a sudden a, a cottonmouth slithers in front of you and you jump back and you're like oh crap, that's not good. It takes a minute before you calm back down, before you get rebalanced or down regulate. And during that time you are much more sensitive to sounds of rustling in the leaves off to either side of the path wondering if another snake is going to come out. It's the same thing for people with trauma histories. They're almost always scanning and listening for that rustling in the leaves, so to speak. Environmentally, people with neurological differences, if they're on the autism spectrum, if they've got schizophrenia, ADHD or even people who are older may react differently to smells, sounds, sights, even light levels. It may be hypostimulating or hyper stimulating. Where to start? And I have these in different colors because if I'm working with people this is kind of how I break it down week by week. The brown is the first week, purple is the second, etc. So the first week we do our assessment, blah, they come back, I educate them about the mind body connection and how a nervous system that is hypersensitive or hyper reactive can be contributing to what's going on and how it got that way. Not saying that they are being, that they're overreacting, saying that their nervous system because it is felt like it needed to be on guard for so long in order to keep them safe. It is just, you know, very, very high strung if you will. And that one of the things we need to do is start helping the nervous system learn how to down regulate and recognize when they are safe in the present context. So I do a very brief and common term overview of the stress response and help them understand how in general stress alters all of their hormones and is going to impact their thinking, it's going to impact their patients, it's all of that stuff. So what they've got going on is something physiological will help them divine their define their rich and meaningful life. That's usually an at home assignment what people things and experiences are important to them and this gives them a baseline so every morning they can get up and they can say okay, how am I going to use my energy to nurture the things that are people and experiences that are important in my rich and meaningful life? And throughout the day when they start getting revved, when they, once they downregulate, they can ask themselves, is this, whatever's going on worth using my energy to address? Or am I just take stealing energy from the things that are important in my rich and meaningful life? And then I have them also identify two to three symptoms, not all other symptoms. It can get overwhelming. Two to three bothersome symptoms and for that week get a baseline. How often does this occur? Like fragmented sleep, how often does it occur? How often do you're crying episodes occur? Whatever they identify as their two or three most bothersome symptoms tell me how often and how intensely they occur for a week. That gives us somewhere to start the next week. They're going to integrate mindfulness practices two to three times a day. And I give them worksheets so they don't have to remember what to do. They just fill in the blank. The morning again. How am I going to use my energy today to nurture what's important in my rich and meaningful life? What stressful things do I see coming up today and how am I going to manage those? How do I feel right now and what do I need to have my very best day? You know, very concrete stuff. At lunchtime I encourage them to look back over that morning worksheet and say, you know, how you doing on maintaining what you hope to do? And then in the evening they reflect mindfully on what did I hope to accomplish today, how well did I focus my energy on the things that were important to me versus things that just weren't and is there anything I can do better tomorrow? So I encourage them to start doing those every day for the next week and I give them a list. We also practice them in, in session of different grounding and down regulation skills and, and, and I encourage them to figure out which ones work for them. Not everybody wants to do. 5, 4, 3, 2, 1. So let's figure out what works for this person to help them downregulate. Week three we start talking about diet, increasing colorful fiber rich foods and probiotics, fruits and vegetables and yogurts and fermented foods. Obviously checking with their doctor before making any major dietary changes. Increasing their hydration if they're not getting enough. Some people are. Some people drink plenty of water. But if they're not increasing their hydration to help flush out the toxins and reducing caffeine gradually so eventually they are not consuming any caffeine within eight hours of bedtime. Colorful fiber rich foods and probiotics balance the gut microbiome, help reduce leaky gut help reduce inflammation and help get rid of free radicals in the body. So nutrition is especially helpful. The next week we focus on sleep and stabilizing circadian rhythms because again, these are areas where we don't often pay much attention, but they add extreme amounts of stress to the body, which puts the person already primed to react. It keeps their stress bucket pretty full. And the final week I talk about increasing movement, not necessarily exercise. They may not have the energy or desire to do exercise right now. Increased movement, getting up and going on a gentle walk for 10 minutes after each meal, stretching Tai chi, if they're open to it. It doesn't have to be anything intense, but starting to get some more range of motion and kind of get the blood flowing a little bit more eventually, hopefully working up to exercise, but small steps. The HPA axis is crucial for survival in the face of distress. Dysfunction of the HPA axis is involved in a variety of physical, emotional and cognitive issues. A breakdown in the system will likely continue to get worse even if the person finds ways to temporarily mask what's going on. So they need to be able to figure out how to strengthen that parasympathetic nervous system. Weaken if you will, or make less less sensitive that sympathetic nervous system and learn how to downregulate.