Cortisol's Impact on Health and Mood: PACER Integrative Behavioral Health

Hey there, everybody, and welcome to this presentation on cortisol. This is part of the PACER Integrative Behavioral Health Series and I'm your host, Dr. Donnellice Snipes. In this sort of brief presentation on cortisol, you're going to learn about its functions, signs of too much and too little cortisol, causes of disruption, and interventions that we can use to help people balance their cortisol levels. Let's start with the basics. Cortisol is your main stress response hormone. When we think of stress, we think of cortisol. Cortisol operates somewhat in sync with your circadian rhythms, which is one of the reasons it's important to keep your circadian rhythms in sync. But correct. Cortisol rises to its highest level in the morning and is supposed to decrease gradually throughout the day when the HPA axis is not functioning effectively. Sometimes this doesn't happen. Cortisol is a steroid that acts to reduce inflammation and suppress the immune system under conditions of stress. Now, that is what happens when the HPA axis is working well and cortisol is secreted and then eliminated and the the system's functioning, functioning normally. When cortisol is in the system persistently or at too high of levels, the tissues start to become resistant to the effects of cortisol and it actually starts losing its effect. So instead of reducing inflammation, inflammation will actually increase and the immune system will become less functional or in some cases, hyperactive. Cortisol, when it's functioning like it's supposed to, also helps increase blood sugar levels to prepare you for that fight or flee, to regulate your metabolism so you have the energy necessary to fight or flee. And interestingly enough, it assists with memory formation. A little side note is that some of the initial signs of depression are often accompanied by an increase in cortisol that is caused by a disregulation of the HPA axis triggered by by recurrent or chronic stress. So what happens when that HPA axis becomes dysfunctional? Then cortisol is released and it's supposed to cause adrenaline to be released and blood sugar to be released so we can fight or flee, but the tissues just aren't responsive to it, so the person feels flat, apathetic, has low energy. What causes the HPA axis to become wonky and an imbalance of cortisol? Well, acute and chronic physical, affective, cognitive, environmental, or even relational stressors. Physically, when we don't get enough quality sleep or our circadian rhythms are disrupted, that throws the cortisol balance out of whack. When we don't have enough adequate nutrition. When our body doesn't have the building blocks to make the progesterone that is used to make cortisol, we may not have enough cortisol. Likewise, when we are malnourished, the body perceives that as a threat and will ramp up that HPA axis. Even if you're eating plenty of calories, if you're not eating a healthy diet, it the gut will send a signal through the vagus nerve to the brain that says, hey, we're not getting all the supplies we need to make the hormones and neurochemicals so that HPA axis will register that as a threat and ramp up. Stimulant and alcohol abuse or even use are associated with increased inflammation and increased cortisol release. Pain and illness also trigger that HPA axis to activate and the release of cortisol affectively. Most of the time, cortisol spikes in response to excessive stress in an acute situation or even chronic stress. Chronic low grade stress. Emotionally, if somebody is grieving, if they're depressed, if they're anxious, if they're angry, if they're resentful. When we know people who on any given day have a low grade level of one of those dysphoric emotions, cognitions or our thoughts also cause stress. The way we perceive things, the way we interpret things will lead our brain to decide whether it is something happy, something neutral, or if it's a threat. So if we are seeing everything as dangerous, threatening, glass half empty sort of thing, then our perceptions, our cognitions are going to contribute to affective distress, which is going to increase cortisol levels. And remember, when the system is working well, it increases cortisol levels. But if that keeps going on over time, if it's chronic, then our cortisol levels and the cortisol system will start to break down. Even though cortisol's released the tissues and the, the breast of the body may not respond to it in the same way. Symptoms of too much cortisol Rapid weight gain, mainly in the face and torso with slender arms and legs, which is kind of an interesting thing. You would think with too much cortisol you would actually see weight loss, but that's not the case. A flushed and round face. And if you've seen people who've been on high levels of corticosteroids for some sort of ill, you've probably seen this in them. You've seen them gain weight in their trunk area and their face fills out and becomes much rounder. That is the effect of the cortisol, the cortisone on their, on their body. High blood pressure, osteoporosis, skin changes, increased in increases in bruising and these really dark purple stretch marks. Muscle weakness, mood swings, increased thirst and frequency of urination, Reduced libido and impaired sleep. When we have too much cortisol in our system, it is more difficult to relax. Adrenaline is higher. Our body is having more difficulty maintaining homeostasis because it's focused on fight or fleet when you're stressed for too long. When cortisol levels stay high for too long, you may develop glucocorticoid resistance. When that happens, you may have enough cortisol in your bloodstream, but it's not able to activate the tissues and the neurons like it's supposed to. Other times, you may not have enough cortisol just because you don't have enough for some reason. Maybe your progesterone levels are low or you don't have the nutrients needed to help the body break down progesterone and turn it into cortisol. Either way, when cortisol can't do its job, people experience extreme fatigue, weight loss and decreased appetite, darkening of their skin, low blood pressure, salt craving, low blood sugar. Because remember, cortisol causes your body to release blood sugar. So if you don't have enough of it, or if it's not able to trigger those tissues to release blood sugar, then you'll have low blood sugar, gastrointestinal symptoms, nausea, diarrhea, vomiting, abdominal pain, muscle or joint pains. Remember, cortisol is a steroid and as a steroid it helps to reduce inflammation. If you don't have enough of it in your body, then you're going to have an increase in in inflammation, irritability, depression and even body hair loss or sexual dysfunction. The important takeaway here is to recognize that cortisol is intimately involved in every aspect of our being. So if that system is breaking down, people are going to experience a multitude of symptoms. Symptoms. So let's talk about briefly how it interacts with other neurotransmitters. And remember, our mnemonic device here is snagged E. I had that extra E there. Had to throw it in serotonin, your calming serotonin or your 5ht1 is suppressed by cortisol. Cortisol is a stimulating neurotransmitter. 5ht1 is a calming neurotransmitter. Norepinephrine is increased when the HPA axis is functioning normally. But in the long term, under situations of chronic Stress, just like the body, becomes less responsive to cortisol, less norepinephrine is actually reduced. In people who are experiencing chronic stress, acetylcholine triggers cortisol secretion. So if people don't have enough acetylcholine, then they may not experience that cortisol secretion. A lot of this is going to sound similar to what we were talking about in the last video that talked about adrenaline. So cortisol and adrenaline, really, they're not the same thing, but they do go hand in hand. Glutamate is increased with cortisol when the HPA axis is activated. So when we do the video on glutamate, a lot of this is going to sound very, very familiar. GABA is reduced as cortisol increases. Remember, GABA is our natural anti anxiety, calming, muscle, relaxing neurochemical. So as cortisol increases, the one that tells you to fight, flee, get ready, tense up, you know, GABA is naturally going to go down in the short term when the HPA axis is functioning properly. When cortisol is released and adrenaline and norepinephrine are released because that HPA axis is set off, endorphins are also going to be released in order to help people not feel the pain while they're trying to fight or flee. Like everything else, if that stressor goes on for too long and those endorphins just float around for too long, the body develops a tolerance to them, becomes resistant to them, so they don't have the same effect. Dopamine is reduced in some areas of the brain and increased in others when cortisol is released. They have found, though, that chronic stress does result in reduced functioning of the dopaminergic system. Dopamine is our let's do it again neurochemical, our motivation neurochemical. Well, at a certain point, if we keep trying to do it again and trying to make that stress go away, and it doesn't go away, the dopamine is also going to not be released as much or the tissues aren't going to be as receptive to it because they're just like, no, we've been down this road and it doesn't work. So it's important to remember that continuous or excessive exposure to any neurochemical will likely over time cause a level of tolerance or resistance to that neurochemical. And finally, your endocannabinoids again increase in the short term to help with pain management, but they are down regulated in response to chronic stress. Now let's think about why people engage in addictive behaviors to increase endorphins and dopamine. So when people are under chronic stress and endorphin, endorphins and dopamine are being reduced, guess what? It makes sense that they are at risk for the development of addictive behaviors. They want to feel better, you know, serotonin is suppressed, they want to increase their serotonin, they want to increase their endorphins and their dopamine. So our interventions a lot of times are going to be centered around both reducing stress but also doing things to help the person naturally increase or let their body increase. Do dopamine, endorphins, serotonin and GABA and endocannabinoids. How do does cortisol interact with other hormones? And your mnemonic here is cat T dope and I don't know who he is, but that's was the only way I could make it make sense and get everything in here. So cat T Dope. Well, obviously cortisol doesn't affect itself, but adrenaline is another hormone and it increases when the HPA axis is activated and cortisol and nora noradrenaline are secreted. Thyroid hormones in the functioning HPA axis increase when cortisol is increased. But cortisol from chronic stress actually starts to interfere with the conversion of T4 to T3 and lowers the levels of thyroid stimulating hormone in the blood. So ongoing chronic stress reduces thyroid hormone levels. That's the takeaway that I want you to get from this. Testosterone is also decreased in response to chronic stress, especially induced by the HPA axis activation. Interestingly though, if the stress is due to competition, like before a sports match, then testosterone levels actually go up. But when the stress is due to a threat, not competition, they found that testosterone levels often go down. Dhea. Interestingly, if you have too much DHEA in your body, a lot of people will feel anxiety symptoms. If people, people who take over the counter, DHEA often take it in much higher doses than the body needs or should be exposed to. So they may feel feelings of agitation, irritability and anxiety. But interestingly enough it actually has been found to oppose cortisol. So they balance each other out and they work in proportion. And that is one of our key words for this entire series is proportion. As one thing goes up, another thing may go down. But we want to make sure they get in the right proportion. We don't want to just randomly start mega increasing serotonin or mega increasing dopamine because it's going to affect the availability of everything else. And probably not to the same degree. So you're going to have things that still stay out of balance. The body and the brain. Aim for homeostasis. If it is given a healthy body that is relatively stress free, you know, a body that has the ability to relax and rejuvenate and everything, the body itself will naturally move towards homeostasis. Most people don't have genetic dysfunction that causes problems with homeostasis. There is a percentage of people who do benefit from assistance in increasing certain neurotransmitters or hormones because of genetic alterations. But most of the time, if we can help them resolve their lifestyle factors, the body can regain homeostasis on its own. The caveat to that is aging. As people age, a lot of their hormones actually go down. Neurotransmitters don't change in their amount, but hormones like dhea, testosterone, estrogen, a lot of your gonadal hormones especially reduce as we age. So sometimes people do need to talk with their physician about balancing those hormones and figuring out what to do to balance them. But I've gone off on a tangent here. Oxytocin may actually increase. Remember, oxytocin is your bonding hormone. It may actually increase in response to stress in order to prompt caretaking and help seeking behavior. People who were depressed, who had high levels of cortisol and high levels of oxytocin were found to be much more likely to seek help than people who had high levels of cortisol and low levels of oxytocin. Progesterone, remember I said, is the precursor to cortisol and is released in response to stress. Low progesterone can cause low cortisol. Progesterone has anti anxiety properties thought to modulate the stress response. Now in some people, progesterone may make them feel a little bit more anxious if they're taking progesterone. Based birth control, for example. And it may not be the progesterone, it may be the body's reaction to that progesterone, trying to keep it in balance with the estrogen. Estrogen causes anxiety. So. So you may have a reaction in people the take home from that. Obviously we're not gynecologists or prescribing physicians, but the take home from that is if somebody starts taking hormone therapy and starts experiencing significant mood symptoms or even not significant mood symptoms, but ones that are bothersome, it's important for them to discuss that with their doctor. Because progesterone can, as well as estrogen can alter the balance of not only gonadal hormones, but also stress hormones and as a result, neurotransmitters. Finally, estrogen is suppressed in response to cortisol in a healthy HPA HPG axis. Under chronic stress, when those cortisol levels are reduced or the cortisol system, the HPA axis starts becoming dysfunctional, progesterone may be reduced and estrogen becomes dominant. So what do we do about it? You know, that's really where we want to go from here. The prior slides were to provide you some information so you can see, and we're going to keep going over it so you can see the interrelationship and the interconnectedness of all of these hormones, neurotransmitters, behaviors, thoughts, environment, you know, they're all interconnected. If you pull on one, you're going to affect everything. If people aren't getting adequate sleep, it's going to affect their HPA axis, it's going to affect their immune system, it's going to affect their mood, it's going to affect potentially how they spend their time and what their environment is like. And it's going when they're sleepy and not having great feelings and impatient and their HPA axis is all over the place, it probably is going to cause negative impacts on their supportive relationships, which are the one of the biggest buffers against stress. So it's important that we recognize everything is interrelated. Think of that butterfly theory. So physically, we need to make sure that people are regulating their circadian rhythms and getting adequate quality sleep. That includes being screened for sleep apnea, if that is potentially a problem, because sleep apnea increases cortisol levels, quality sleep. And I know people don't like hearing this, but as adults, we still are supposed to be getting seven and a half to nine hours of quality sleep per night. And that is one of the biggest contributors to HPA axis dysfunction in American culture, is that we don't get enough quality sleep, nutrition improvement, and for some people, they may eat a pretty good diet. For others, they may eat like crap. For, and I tell all my clients, eat like crap, feel like crap, eat good, feel good, or at least a little bit better. We need to make sure our body factory has all of the raw materials it needs to make the hormones and neurotransmitters and repair the tissues to address pain, mood, all that sort of thing. Staying hydrated is super important because hydration helps flush out the toxins so people don't feel as sluggish. When we have toxic buildup in our body, that's a Threat going to trigger that HPA axis and potentially cause persistent levels of high cortisol, stimulant reduction, nicotine, caffeine, any kind of stimulant that you're taking. And that also includes over the counter diet, supplements, workout supplements, anything that's a stimulant, we want to try to reduce that. Because stimulants by their very nature trigger the HPA axis and trigger the release of cortisol. Some stimulants like caffeine, have a really long half life. So it's important that people recognize that when they drink caffeine at noon, it is still impacting them. It is still keeping their system aroused up until 10, 11 o', clock, maybe even midnight that very same day. If they are trying to get good quality sleep and they go to sleep at 9, they should probably try to eliminate caffeine. I know that's a, that's a big ask for. Most people eliminate caffeine after 9 o', clock, so 12 hours before they go to bed, at least 8 hours before they go to bed, and eliminate other stimulants like nicotine, four hours before bed. And that's another big ask for a lot of people. Having stimulants in your body impairs your sleep. So even if you're in the bed for 12 hours, you're, if you're not getting quality sleep, it's not going to be restorative and it's not going to help regulate that HPA axis. Pain needs to be addressed, not necessarily pharmacologically, but if they need medicine, they need medicine. But it's also important to help them explore non pharmacological interventions for pain. And I have a lot of videos on that on the YouTube channel. But it is important to recognize that pain prevents quality sleep, it often causes irritable mood, it keeps that HPA axis activated. So if we are in consistent pain, then we're under consistent stress. And you know, consistent stress leads to an increase in inflammation which guess what, leads to an increase in pain. So pain management is going to be really important. Not all pain can be controlled all the time. Some people will have a low level of pain some days that they just can't get rid of. So helping them with cognitions about pain is also important, helping them to recognize that, yes, you know, if I can get my pain from an 8 down to a 2 today, it's not completely gone, but I can do pretty much anything that I wanted. Even with a pain that's a two hormone balance and that is Your thyroid and go nadal hormones. It's important for people to go get a physical when they present for mental health treatment if they've got mood issues. Well, pretty much anything that they present for in mental health treatment could have a relationship to an imbalance of thyroid or gonadal hormones. It is not hard for them. Or low vitamin D. It's not hard for them to go to the doctor, get a physical, have their cardiorespiratory system checked out because poor functioning of the cardiorespiratory system leads to low oxygenation, leads to increased symptoms of depression, anxiety, panic. You know that HPA axis gets all wonky. So cardiorespiratory and then also have a blood test for their thyroid and gornadal hormones and their vitamin D levels. Super easy. But I have found that many times people, when they get that their information back, they may find that some of their hormones and cortisol levels can be tested too. Some of their hormones are either at the lower end of the normal range or below the normal range. Promote feelings of physical relaxation and study after study after study have shown that yoga, tai chi, and for people who don't like doing that, just even concentrated focused stretching can not only help with pain reduction, but it can promote feelings of physical relaxation and reduce cortisol levels. They've actually shown that it reduces cortisol levels effectively help people reduce their dysphoric emotions. Anger, anxiety, resentment, grief, Any of those feelings that are unpleasant, that make the person feel like there's a threat to them or to their happiness is going to trigger that HPA axis, thereby increasing cortisol. So we need to help them address those things. We also, not only are we taking away the dysphoria, but we want to promote feelings of physical and emotional relaxation through mindfulness and meditation. It doesn't have to be the old fashioned. Most people, when I say meditation, they think sitting, crisscross applesauce and chanting or something. And it's not always that. There are dozens of different types of meditation. One of my favorite is the focused meditation where you just sit in a safe space quietly and calmly focus your attention on an object. I like a candle flame, but you can also use the lava lamps that we used to have back in the 70s. Whatever it is that you want to focus on for two to five minutes, it doesn't have to be a long time. But focusing exclusively on that can help clear your mind and help train your, train you to be able to clear your mind and give your brain a rest. So it Is not bombarded with input and monkey mind and thoughts going here and there's. Mindfulness is also helpful at reducing distress and reducing cortisol levels. Laughter, again, this has been shown in clinical studies. Laughter reduces cortisol. Who doesn't want to laugh? That is one of those ones that people are usually not averse to at least trying. And it can be encouraging and, you know, stimulating to try to find things that make you laugh and bring them back. If you're doing this as a group or even as individual counseling, give people the assignment of finding three comedians they like, three videos on YouTube that make them laugh, and three other things. I like the number three. I don't know why, but having them actually diligently find something that makes them laugh and get that good old belly laugh can be super helpful. Cognitively helping them develop distress tolerance skills can go a long way to reducing distress and reducing cortisol. Increase awareness of cognitive distortions and biases. Thinking styles that increase their stress level, increase their sense of unsafeness and disempowerment so they can address those and figure out what they need to do to feel safe and figure out what they have control over so they don't feel completely disempowered. We want to increase a positive attitude and positive appraisals of events. It's raining outside. If you see that as the worst thing ever, then that is a negative appraisal. If it's raining outside and you think, okay, a positive appraisal would be, hey, I don't have to water my lawn or wash my car today. You know, those could. That's a positive appraisal of a situation. And we can help people improve problem solving skills which will help them feel more equipped and empowered to deal with unpleasant things when they occur environmentally. Sights, sounds and smells. We really want to consider the S's here. What do they see in their environment that is stressful? Try to figure out how to get rid of that. What. What can they put in their environment that helps them feel calm? For example, my dogs and my cats, plural on both of them. They help me most of the time, help me feel calm. When I'm sitting upstairs and and my cat jumps on my lap and he starts making biscuits on my chest, that's always calming to me. So finding things in their environment that can help them feel safe and content. Sounds that can help them feel safe and content, Whether that's just pure silence because they don't want the input or they want to, like we talked about in the adrenaline video, they want to listen to nature sounds. Nature sounds have been shown to reduce HPA axis activation, Adrenaline, cortisol, and norepinephrine different. So nature sounds can be great, but also do what they can to eliminate noxious sounds. If, you know, back to the dogs. When my dogs see somebody having the audacity to walk down our street, they go ballistic. And it'll be like dead quiet. And then all of a sudden it's this cacophony of dogs barking. And every time, you know, I've had dogs for 30 years and still every time they do it, I jump out of my skin. That's a stress response. We want to try to avoid that. So what can I do? Well, I can either put them downstairs, or more likely, I go to my room when I want to have time to relax and make sure that I'm not disturbed by them going bananas over something. Noise canceling headphones can be helpful, and this is especially true for people who are neuro atypical who are especially sensitive to sounds. Noise canceling headphones can really help reduce their stress levels so they don't feel as bombarded. And smells. Smells are the strongest trigger of memory. We want to introduce smells that bring up positive memories and remove smells that trigger bad memories or smells that people just find noxious. My daughter really has a strong reaction to the smell of bleach. All I have to do is be downstairs and open the bottle of bleach and she's like, mother, are you cleaning again? I don't even have to be spraying it everywhere. She's super sensitive to it and she feels like it gives her a headache. So smells. The smell of bleach for her is extremely stressful and causes her distress. For me, I love the smell of bleach. That reminds me of clean and I love clean. So when I want to clean with bleach, I have to wait until she's planning on spending the afternoon out with her boyfriend or something and open all the windows so the smell dissipates quickly. But knowing what smells are pleasurable and relaxing for you versus ones that are not is really important. If your neighbor is, you know, retarding their roof, that's a noxious smell. What do you do to overcome that? And, and how can you adjust it? Aromatherapy, like we talked about in the adrenaline video, bergamot, lavender, rose, and rose geranium have all been shown to decrease cortisol and adrenaline levels. Remember that rose and rose geranium may increase estrogen levels. And lavender in some studies has also been shown to increase estrogen levels. So if you think that part of your issue is related to gonadal hormones, you may want to err on the side of bergamot, chamomile, valerian or catnip to start out with. Interestingly, weighted blankets or weighted vests have been shown to because of the pressure have been shown to be increased with reductions in cortisol and increases in serotonin and oxytocin. I thought that was a really cool thing that they found out. So people who have stress may sleep better when they have a weighted blanket. If they are going through something stressful, Having a weighted blanket on them may help them feel calmer because of that sensory pressure. And for people who are neuro atypical or, you know, we've seen it with dogs during thunderstorms, they have weighted vests or pressure vests that you can put on them. And the same thing is kind of going on there with that pressure. It can help people feel more relaxed. So people who are neuro atypical may do well if they get overwhelmed out in public when they're going about their day. If they have a weighted vest that they can put on, or just even starting out the day, you know, wearing one constantly can help them have that feeling of deep tissue pressure. Relationally, basically what we want to do is increase the support that can help buffer against stress, Increase the relationships and the interpersonal activities that bring happiness and decrease the conflict, improve supportive relationships, enhance interpersonal skills and develop self esteem. Self esteem is so important for because when people have low self esteem, they are afraid of abandonment. They are stressed out when people disagree with them, or sometimes they get frustrated and they don't want anything to do with other people. So developing self esteem helps people feel good about themselves and not be reliant on other people for validation, which can reduce a lot of stress and anxiety. Recognizing that in most relationships you're not going to agree on everything all the time. So this can go a long way to helping stabilize natural relationships. Cortisol is released in response to any stress, even eustress. But it tends to be more pathological and, and more problematic in response to chronic distress. Cortisol increases in the morning and gradually decreases throughout the day. Low cortisol in the evening is one of the signals the body uses for the brain to begin making melatonin. If your cortisol levels never drop, the brain doesn't get that signal that, you know, it's about time to go to sleep. The body and brain need downtime to relax and recharge every day. Not just, you know, once a week, but every day. And it's important that we emphasize this to people. When cortisol levels remain high due to HPA axis activation, it keeps the person on alert, maybe on low grade alert, but they're on alert, which prevents relaxation, quality sleep, effective gut functioning, and a whole host of other problems. If cortisol levels get too high for too long, it causes neuronal death, brain shrinkage and glucocorticoid dysfunction, which is what we talked about with the tissues just not even responding to the cortisol. One of the most necessary interventions for nearly every patient experiencing immune pain or mood issues is down regulation of the HPA axis to help them react, reverse glucocorticoid resistance and HPA axis hyperactivation in response to what they've been experiencing as chronic stress. I hope this video was helpful, and I'm not sure what hormone we're talking about in the next video, but we will continue to talk about all of the different hormones that are involved in stress, as well as relaxation and the main neurotransmitters that are involved in mood and stress and bodily functioning.