Month: April 2018

Stress: If you don’t have it, you’ve apparently found the pot of gold at the end of the unicorns’ rainbow. If you do—like most Americans—the phrase “cortisol levels” might have come up during one of your visits to your doctor’s office.
Cortisol is best known as “the stress hormone,” a chemical messenger the body produces when we’re feeling like we’re at the end of our rapidly fraying rope. It’s produced and secreted by a part of the body known by doctors as the HPA axis—a combination of the hypothalamus, pituitary gland, and adrenal gland that sends varying amounts of cortisol out to other parts of the body.
Linking cortisol to stress gives it a negative connotation, but in truth this hormone is not all bad, says David Cutler, MD, a family medicine physician at Providence Saint John’s Health Center in Santa Monica, California. In fact, Culter says cortisol is “essential in controlling our growth, organ development, immune functions, inflammatory response, and many other cellular activities.”
And while our cortisol levels do tend to spike when we’re stressed, cortisol production is part of the body’s functioning even when we’re having nice, normal, calm days (hey, they do exist!). Unfortunately, when your cortisol levels get out of whack, so can your body. Cortisol levels that are too high or too low can cause everything from extreme fatigue to blood pressure issues.
So how do you know if your cortisol levels are too high, too low, or just right? And is there really anything you can do about all that stress?
Sit down, chill out, and let’s do this.

What is cortisol, anyway?

Despite its colloquial name as the body’s stress hormone, cortisol is more aptly described by doctors as a steroid hormone, Cutler says—a complex molecule that has a variety of metabolic functions throughout the body.
“Its structure of carbon-containing rings is typical of steroid molecules,” Cutler explains, “And its functions can be mimicked by the synthetic cortisol hydrocortisone or other steroids.”
Yes, hydrocortisone, the tube of cream you grab at the drugstore when you’ve got an itchy rash, is related to cortisol. In the case of an allergic rash, smearing on a few dabs of hydrocortisone can tell the body to chill out and stop reacting to the allergen so you can get a little relief from all that itching. In the body, on the other hand, naturally produced cortisol helps to keep our systems in check, whether it’s maintaining the right levels of blood glucose or maintaining a healthy blood pressure. Basically, cortisol gives the body a little relief…from itching, and a whole lot more.
Much of what doctors know now about stress and the role cortisol levels play in the body’s response goes back to the 1930s and 1940s, when Hungarian endocrinologist Hans Selye explained the role the HPA axis plays in our fight-or-flight response to a problem. Selye found that corticoid hormones like cortisol were “indispensable for the maintenance of life and especially for the acquisition of adaptation to changes in the external or internal environment of the body.”

Cortisol Levels and Your Body

For the body to keep adapting to changes in its external and internal environment, cortisol levels have to change, Cutler says, and that’s usually normal. For example, cortisol may kick in as a response to any sort of stressor on the body,
Of course, this doesn’t just refer to “stress” as we’ve come to know it. Stress isn’t just your boss yelling at you or your child darting into traffic.
Stress can be getting extra busy in between the sheets, sending a message to your heart that it needs to increase the amount of blood it’s pumping to your heart, STAT! Stress can also come from that snacking on a pile of what you thought were gluten-free pretzels, only to find out you just “got glutened,” and knowing your celiac allergies are going to kick in, triggering an immune response.
“The transient rise or lowering of cortisol level is normal and in fact happens on a daily basis as cortisol levels peak upon awakening and bottom out shortly after bedtime,” Cutler explains. “They can also be affected by physical illness, fever, sleep deprivation, inflammation, pregnancy and emotional factors. In addition to internal factors, external factors such as diet, alcohol, caffeine, prescription medication, and nutritional supplements can also affect cortisol levels.”
You’ll notice some of these issues, including emotional factors, lack of sleep, and alcohol and caffeine usage can all be linked to what we traditionally think of as stress, while other factors are stressing the body in a more medical sense.
Semantics aside, when your body encounters stressors, cortisol comes out to play, helping the body keep its systems in check, and keeping your body healthy even in the face of an attack on the immune system. When everything seems okay, cortisol levels are then supposed to drop, increasing again only when they’re needed.
Unfortunately, cortisol levels don’t always work the way they should, says Carol Lourie, a naturopath and functional medicine expert who specializes in women’s health.
“Chronic stress is a contributing factor in elevated cortisol,” Lourie says. Other medical conditions that can increase cortisol levels are pregnancy, Cushing’s syndrome, Addison’s disease, pituitary or adrenal tumors, high blood pressure, obesity, and metabolic syndrome. Prolonged use of certain medical steroids such as prednisone or cortisone can also affect a person’s cortisol levels.

Addison’s Disease

If you have Addison’s disease, for example, your body may not produce enough cortisol and aldosterone (another steroid hormone), says Joseph Geskey, DO, an internal medicine specialist and vice president of medical affairs at OhioHealth Doctors Hospital in Columbus, Ohio. That lack of cortisol can result in a variety of gastrointestinal issues including nausea, vomiting, abdominal pain, diarrhea, muscle weakness, and weight loss.
When managed well, Addison’s sufferers can live a fairly normal life—in fact the most famous Addison’s patient might be President John F. Kennedy, whose disease was kept relatively secret until after his assassination, when an autopsy revealed his adrenal glands were almost nonexistent.

Cushing’s Syndrome

Patients who have Cushing’s syndrome are also affected by cortisol levels that are different from their peers’, but in their case, the cortisol levels are too high instead of too low.
“Cushing’s disease is caused by a tumor in the pituitary gland (located in the brain) that produces a chemical called ACTH (adrenocorticotropic hormone) that stimulates the adrenal gland to produce too much cortisol,” Geskey explains.
Cushing’s sufferers typically have round faces, extra fat on the back of the neck, stretch marks on the abdomen, easy bruising, and extra hair growth on face, neck, chest, and abdomen. If the tumor grows large in the pituitary gland, it can also cause vision loss, Geskey warns. Other complications of too much cortisol can be cataracts, [linkbuilder id=”336″ text=”diabetes”], hypertension, depression, and osteoporosis.

Signs Your Cortisol Levels Are Out of Whack

Despite the rather long list of conditions that might affect the body’s cortisol levels, there is some good news: Cortisol abnormalities are unusual according to Cutler. On the other hand, that also means doctors rarely test cortisol levels as part of an average physical or doctor’s visit.
“Because there is a very wide range of ‘normal’ levels of cortisol, as well as a certain degree of variability in these results, cortisol levels are generally not checked as part of a routine exam, but rather only if there is a high degree of suspicion of there being a cortisol abnormality,” Cutler explains.
So what sort of symptoms might prompt legitimate suspicion in you or your doctor? Lourie says it’s good to mention your concerns to your doctor if you have any of the following symptoms:

• Feeling you are overreacting to certain situations, have a very short fuse, or are easily angered
• Feeling anxious frequently for no apparent reason
• Feeling tired all the time no matter how much sleep you get
• Inability to relax and calm down, even during a restful moment
• Inability to sleep or waking up feeling unrefreshed
• Unexplained weight gain (without changing diet or exercise routine)
• Inability to lose weight (despite exercise and dedicated diet change)
• Unexplained acne
• High blood pressure
• Hormonal problems such as irregular menses or extreme cramping during menses

Many symptoms that would seem to indicate cortisol level abnormalities can be explained by other issues and will go away with treatment of said issues, but there are blood tests that can be done for cortisol levels to get to the bottom of the issue if other treatments don’t address the problem.
“Levels may seem abnormal when, in fact, there is no disease. And subtle symptoms may be found to be the result of cortisol abnormalities after more common causes have been excluded,” Cutler notes.

Managing Cortisol Levels

If a cortisol level abnormality is suspected, a primary care doctor will typically refer a patient to an endocrinologist, says Muneer Imam, MD, lead physician at the CIIT Medical Center, Long Island. The endocrinologist will call for blood tests, typically performed early in the morning and later again in the day to address the fact that cortisol levels fluctuate through the day.
Imam says a normal cortisol level is 6.2 to 19.4 micrograms per deciliter. “Anything below or above is out of normal range.”
If the numbers aren’t in range, the next step is determining why levels are too high or too low.
In cases of Addison’s disease, medicine is typically required. Doctors will turn to a class of pharmaceuticals known as glucocorticoids to replace the cortisol and mineralocorticoids to replace aldosterone, Geskey says. If an Addison’s patient gets sick, they can suffer an adrenal crisis, in which case doctors may administer cortisol via an injection.
For Cushing’s syndrome patients, on the other hand, treatment can involve surgery, medication, and radiation therapy. Surgical removal of the tumor that causes the condition offers the only long-term cure, Geskey says.
Diet changes may also be recommended by your healthcare provider, as food can have an effect on cortisol levels for some people.
Addison’s patients are often directed to increase their calcium and vitamin D levels, as well as salt intake, Geskey says, while Cushing’s patients may be told to eat a diet with foods rich in calcium and protein, which can possibly prevent muscle and bone loss associated with having too much cortisol.
Even those who are otherwise healthy and whose levels are not severely off track may benefit from dietary changes. For example, Lourie says, “Fast food choices and chronic stress add up to elevated cortisol levels.”
She starts patients off with an anti-inflammatory diet, eliminating sugars, processed foods, alcohol, and coffee. “The focus is on lots of fresh vegetables, healthy fats, gluten-free whole grains, small amounts of organic chicken, meat, and fish, as well as fruits.”
If upending your entire diet isn’t in the cards, it’s still a good idea to simply increase the amount of healthy foods in your diet, Lourie says, as that can put your entire body on a track to better health.
For other people with cortisol level issues that aren’t directly related to a medical condition that needs to be treated, diet, exercise, and other lifestyle changes are all on the table. Stress in life, after all, is part of what can make your cortisol skyrocket, and with it the side effects of cortisol levels that are too high.
Stress reduction techniques such as meditation, yoga, and acupuncture have all been found to help reduce cortisol levels.
“Although they are different, one of the common denominators is they all lower the body’s sympathetic nervous system, the fight or flight response, and activate the parasympathetic nervous system,” Lourie explains. “This is the part of the body’s nervous system which is calming and encourages relaxation and joy.”
Even focusing on something calming such as an art class to take your mind off your day-to-day could have benefits. In one small study performed by researchers at Philadelphia’s Drexel University, cortisol levels were tested on a group of 39 healthy adults before and after a 45-minute art class. The results? Three quarters of the group saw a drop in cortisol after letting their creative juices flow.
Of course, any treatment approach should be discussed with your medical practitioner, but if lifestyle changes can reduce your stress, you may just kill two birds with one stone.
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Many of us get nervous when it comes to public speaking. We might feel slightly frazzled or shy in social situations. We might even avoid large gatherings or unfamiliar social spaces.
But what does it mean if you have a constant fear of social situations? What if you worry about events for days or weeks before they take place? What if your avoidance of social situations affects your career, schooling, or relationships? What if your anxiety is affecting you on a physical level, causing you to become sweaty or nauseated around others?
If you have experienced these symptoms, you’re not alone. According to the National Institute of Mental Health, recent statistics suggest about 12.1 percent of U.S. adults experience social anxiety disorder at some point in their lives. There are a few risk factors that increase your chances of having social anxiety disorder, including being divorced or widowed and experiencing stressful life events. Women and girls are more likely to experience social anxiety disorder.
“Having negative social experiences and growing up in stressful environments are two environmental factors that can contribute to the development of social anxiety disorder,” says Amy Serin, PhD, a neuropsychologist and founder of The Serin Center. “As with most diagnoses, there is a dynamic interplay between genetics and environment that can determine the eventual development of a disorder.”
Fortunately, Serin notes, social anxiety disorder can be effectively treated. Here’s what you need to know.

What exactly is social anxiety disorder?

Social anxiety disorder isn’t simply about being shy or introverted, although a socially anxious person may appear that way to others. Social anxiety disorder typically leads people to avoid social situations entirely, or to have great difficulty in those situations. In some cases, the anxiety stems from being afraid of how people perceive them.
“Introverts simply recharge their energy during solitude but can have no anxiety when dealing with others. There is a preference for being alone versus being with others,” Serin says. “Shyness may be a less severe form of social anxiety and occurs when a person may clam up or prefer to avoid social interaction in general.”
Social anxiety disorder, on the other hand, includes severe stress responses to social situations. “Social anxiety disorder typically presents as marked fear in social situations, above and beyond what one would typically expect given the situation,” says Jana Scrivani, PsyD, a licensed psychologist with expertise in the diagnosis and treatment of social anxiety.
Before a psychologist diagnoses someone with the disorder, certain criteria must be met. Psychologists use the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria to inform their diagnosis. “In order for a fear of social situations to be considered a disorder, it must interfere in someone’s life,” says Scrivani. In other words, the social anxiety must make it difficult for someone to function to be considered a disorder. “Additionally, the distress needs to persist for at least six months, and not be attributable to something else,” she says. For example, if someone avoids school because of a long-term illness or an unpleasant encounter with a particular teacher or classmate, that’s not attributable to social anxiety.
Anxiety disorders can also be accompanied by a number of physical symptoms including heart palpitations, excessive sweating, shaking, hot and cold flashes, shortness of breath, dizziness and lightheadedness, and trouble swallowing. These might seem like symptoms of the flu, but are often linked to anxiety. Anxiety results in these physical experiences by producing a flight-or-fight stress response in our bodies, which in turn affects our hormonal system and ultimately impacts our physical health.

Can social anxiety disorder be treated?

Social anxiety disorder is difficult to live with, but it can be treated successfully, says Scrivani. “I’ve worked with many people throughout the years who have made significant strides in overcoming social anxiety!” she says. “The first step would be to look for a provider who is experienced with social anxiety disorder.”
Seeing a therapist is often the first step in managing social anxiety. One of the most effective treatments for social anxiety disorder is cognitive behavioral therapy (CBT), says Lara Fielding, PsyD, EdM, an Los Angeles-based clinical psychologist and author. CBT is commonly used because numerous studies have shown that it’s an effective treatment for social anxiety disorder. CBT teaches people different ways of thinking, understanding, and reacting to situations.
Another effective form of therapy for social anxiety disorder is acceptance and commitment therapy, or ACT. This involves linking the client’s values with the necessity to persist through the anxiety. Their values are used to motivate them to work through their anxiety.
Exposure therapy is usually used in combination with CBT to treat social anxiety disorder. Fielding explains that during CBT, a therapist might encourage their client to create a hierarchy of feared social situations. These situations range from mildly anxiety inducing to unbearably anxiety inducing. The therapist might then guide them to gradually expose themself to those situations, starting with the least worrisome situation. “The client must stay present to the anxiety until the peak has passed, without engaging in any reassurance-seeking or other safety behaviors, until the anxiety begins to extinguish on its own,” Fielding says. After repeated exposures, the anxiety begins to subside and the client starts to feel more in control.
Fielding also notes that mindfulness-based CBT is incredibly effective for the treatment of social anxiety disorder. With anxiety disorders, you experience primary reactions and secondary reactions. The secondary reactions involve you fearing your anxiety and wanting to avoid that discomfort. “In mindfulness the aim is to practice letting go of the reactivity in such a way that the primary pain is accepted, so the secondary reactivity does not take hold.” Fielding says.
You’ll take note of your heart pounding, your instinct to run away, and so on. You’ll accept this discomfort and learn that it doesn’t have to dictate your actions. “Mindful awareness of the relationship between the thinking, feelings, and action impulses begins to paradoxically reduce the secondary reactivity,” she says.
There are other forms of therapy for social anxiety, such as psychodynamic therapy. However, Fielding says these forms haven’t been studied thoroughly enough. “This type of therapy has little or no evidence for being effective with serious anxiety disorders,” she explains. “CBT and ACT have multiple randomized controlled trials—the gold standard of science—showing them to be effective.”
Serin reiterates that social anxiety disorder can be treated. “At Serin Center, we have treated hundreds of individuals with social anxiety disorder with a combination of neurofeedback, therapy, and bilateral alternating stimulation,” she says. Neurofeedback involves mapping brain activity and then using that to inform therapy, while TouchPoints are wearables that vibrate on alternating sides of the body, altering the body’s flight-or-fight response. This soothes the wearer when they’re feeling anxious.
Anxious about seeing a therapist? Do some research first to put your mind at ease. Ask for referrals from friends. Consider online therapy options like Talkspace or BetterHelp if the idea of a face-to-face conversation is too intimidating. Remind yourself that it’s an investment in your life: You are worth your own effort.

Other Ways to Manage Social Anxiety Disorder

While therapy should be your first port-of-call when it comes to addressing social anxiety disorder, it’s great to have other stress management techniques, too. These coping skills can help you in between sessions or while you’re still looking for a therapist, but they can’t replace a professional healthcare provider altogether.
Here are some techniques to consider.

• Practice deep-breathing exercises to help you manage your anxiety. This skill can help you soothe yourself in seconds, whether you’re at home, in the bathroom at the office, or in a quiet room at a party.
• While alcohol or drugs can seem like great social lubricants, relying on them should be avoided. “Resist the urge to use alcohol or other non-doctor-prescribed drugs to manage social anxiety,” Scrivani suggests. “Those coping mechanisms only serve to mask the anxiety, and instead of realizing that you can face a particular situation, you’ll attribute your ability to cope to the alcohol or drug.”
• While your intuition might tell you to avoid social situations, this avoidance makes it worse. “Avoid the avoidance trap!” Scrivani says. “The longer you avoid an anxiety-provoking situation, the more fear and anxiety that situation will elicit the next time you’re faced with it.”
• Remember that, in most social situations, people aren’t scrutinizing you. Gently remind yourself that people are usually self-conscious—they’re thinking about themselves, not you, Scrivani says.
• Consider joining support groups for social anxiety. These groups could be online or in-person. Yes, it seems ironic to suggest a meetup to people with social anxiety, but it can sometimes be comforting and healing to speak to those who have the same fear as you while dealing with that fear. Try meetup.com to find a local support group.
• If you’d like to talk to someone, consider calling an anxiety hotline. A trained responder can listen to your concerns and help you manage your anxiety. Here’s a helpful list of international hotlines, including some that are anxiety specific.
• In some cases, medication might be prescribed as a treatment for social anxiety disorder.

While having social anxiety might make you feel hopeless, it can be effectively managed. “It’s important to understand the diagnosis is not a life sentence of anxiety, avoidance, and narrowing down of potential to avoid social interaction,” Serin says. “It’s important to understand that there is hope for people with social anxiety disorder and there are many professionals who can help.”

How to Support a Child Who Has Social Anxiety

Social anxiety can manifest at a young age. Some statistics show that about 9.1 percent of U.S. teenagers ages 13 and 18 have social anxiety disorder.
It’s important that parents are aware of the signs so that they can support their children who might have the disorder. Young children can experience significant struggles to reach out for help, as they might not have the vocabulary to explain how they feel.
The most notable sign of social anxiety disorder is if your child tends to avoid social situations. Another is if they seem particularly uncomfortable or noticeably quiet in social situations. Fielding says that the child might even become angry when they have to engage socially, especially in environments outside their comfort zones.
“The most important and effective thing anyone can do to help a loved one struggling with social anxiety (or any mental health struggle) is start from a position of understanding and validating the difficulty the other person is having,” says Fielding. “Loved ones can often invalidate the person struggling by telling them to just relax or trying to reassure them too often.” In other words, you might want to remind your child that there’s nothing to be worried about—but if you do this too often, it might come off as dismissive and invalidating.
Another thing you shouldn’t do is contribute to your child’s avoidance of social situations, Fielding says. The more someone avoids an anxiety-inducing situation, the scarier the situation can become. While avoiding anxiety-inducing situations seems like a quick fix, it can wind up reinforcing the anxiety.
Instead, Fielding suggests responding compassionately to your child and helping them habituate to social situations—that is, helping them get used to interaction by gradually increasing their exposure. If you’re going to a family event, for example, don’t expect them to socialize for hours right away. Go for only an hour or two. Afterward, point out how they were able to handle it. Use this achievement to praise them rather than to invalidate their initial fears.
If their anxiety seems severe, consider taking them to see a counselor or a psychologist who works specifically with children and adolescents. The counselor can treat your child while giving you helpful pointers for supporting them.
The most important thing to remember about social anxiety disorder is that it’s treatable. It is totally possible to manage the symptoms of social anxiety disorder so that you can live a full life without anxiety interfering. And, while therapy can be a difficult experience, it’s worth it—after all, your mental health is worth the investment.