A healthy human body is able to make necessary physiological changes to adapt and coexist with our space, whether environmental, home, familial, work, parental, or any situation we find ourselves in over the course of our lifetime. Every situation that we encounter—daily, monthly, and yearly—can exert stress on us subtly or dramatically, and our endocrine system, which includes the hypothalamic-pituitary-adrenal (HPA) axis, is the first line of reactivity to respond in an appropriate way. As evidenced by a growing number of chronic illnesses related to stress, human beings are the only species on the planet to intentionally act against our own innate body systems, such as working against our circadian rhythms (night-shift work), and subjecting ourselves to unnecessarily intense stressors (watching horror movies or dramatic TV, for example). We may exert a near-continuous low-grade stress on our body’s systems, even subconsciously, but every organ in our body has a limit to what it can respond to over time before it starts to break down.

When the body is in overall balance (in a state of rest and peace), it can more easily adapt to stressors and maintain internal homeostasis. When the body is in a state of chronic stress (in a “fight or flight” mode), the response becomes more of an acute reaction, and the short- and long-term effects of that stress can impact the body in dramatic ways. The long-term symptoms of chronic stress are not always obviously associated with the stressor specifically, but when we look at the pathways of the HPA axis, the immune system, the digestive system, and our overall psyche, it’s clear that over time, chronic stress plays an impactful, and sometimes debilitating, role in our overall health.

HPA AXIS 101

The hypothalamic-pituitary-adrenal axis is an intricate network of feedback loops that allows the endocrine system to respond and communicate instantly to our perception of safety. To be even more specific, this feedback loop also includes the pineal-hypothalamic-pituitary-thyroid-adrenal axis, which fully encompasses the energy-regulating adaptive response system throughout the body, and influences the entire endocrine and neuroendocrine system. Every organ is affected by the other, and when one organ responds acutely to something, such as an external stressor, the other organs respond via the HPA feedback loop to balance the response. The endocrine glands release hormones into the bloodstream (notably cortisol and epinephrine) in response to stress inputs, and the body can respond to these hormones within the bloodstream in a matter of seconds. However, the residual systemic response to these hormones may last for weeks or even months following the initial stressor. (A wonderful resource to learn more about the human body’s long-term response to chronic stress is Why Zebras Don’t Get Ulcers, by Robert Sapolsky).

Cortisol is one of the main hormones influenced by acute and chronic stress, and is one of the primary glucocorticoids produced by the adrenal cortex that largely directs our endocrine function. Through the HPA axis feedback loop, cortisol is also closely tied to the immune system and the central nervous system communication network, which also impacts our gut health, our circadian rhythm and sleep quality, and of course, our energy levels and blood sugar balance. Glucocorticoids play a direct role in affecting immune cells and have been shown to have immuno-suppressive activity, and under certain conditions, they can also act in an immune-stimulating capacity (Bellavance & Rivest, 2014). Thus, with elevated levels of cortisol in the body (i.e., elevated stress response), there is the possibility of developing suppressed immune function over time, as well as autoimmune dysregulation from long-term stimulation of the immune response. As one researcher notes, “Epinephrine is part of the body’s stress alarm system, and it directs life force away from anabolic, regenerative functions, such as eating and sleeping, and activates the HPA axis stress response network” (Chrousos, 1998, p. 312). The individualized actions of cortisol and epinephrine are classic examples of the long-term effects of elevated stress on the individual. Symptoms may present quite differently from person to person, with a presentation of immune suppression in one person and immune stimulation in another, for example.  For the herbal clinician, this makes it important to get an accurate timeline of the client’s health story including their stress history, their symptom history, and their specific symptoms over time. Can we link a stressor, or group of long-term stressors, to the presentation of developing symptoms over the course of weeks, months, or years? Working backwards can lead us to focus on the initial cause of the symptoms, rather than focusing on the symptoms alone.

The essence of our adrenal strength comes from the inputs that we routinely put into them, including healthy whole foods, fresh air, and clean water. Also of note are the emotional stressors that impact the HPA axis including emotional stress, grief, loss, excitement, and fear or generally not feeling like your environment is safe (Guilliams & Edwards, 2010). Stress triggers do not have to be physical. Because the body responds to all manner of stressors, a holistic approach to stress management can include not only herbal supports, but lifestyle adjustments and indicated nervous system tonics (such as homeopathics or appropriate supplements) as well. Focusing on the internal cascade of hormonal responses in the body and emotional and environmental inputs is essential for re-establishing homeostasis, and balancing our allostatic load over time.

THE LONG-TERM EFFECTS OF CHRONIC STRESS

Allostatic load is the expense accumulated by tissues and organ systems for sustained arousal resulting from chronic overactivity or inactivity of physiological systems that are normally involved in adaptation to environmental challenges. Several factors may impact allostatic load including our environment, our social network, foods, and exposure to toxicity. Our allostatic flexibility is a balance between the immune system, gut health, the central nervous system, and the endocrine system (McEwen, 2006). Each person may experience the same stressor differently, and our individual perception of stress, most especially our sense of control and safety regarding that stress, will determine our long-term allostatic response. What is stressful to one person may have little or no impact on another person. Traffic or driving, for example, may be debilitatingly stressful to someone with chronic anxiety or hypothyroidism, but have no impact whatsoever on a young, healthy 20-year-old. How often we subject ourselves to stressors that negatively impact us will determine the eventual presentation of long-term health issues.

Acutely, when we feel stressed, the adrenal cortex releases cortisol and epinephrine (also called adrenaline) which immediately increase glucose levels and blood flow to help us deal with the stressor. If this response is activated for weeks, months, or even years, it can easily lead to conditions such as hypertension, insulin dysregulation, and digestive issues such as irritable bowel syndrome (IBS), gastroesophageal reflux disease (GERD), and increased inflammation in the gut (Mariotti, 2015). Autoimmune issues may develop if our reaction involves increased immune stimulation, or we may present with suppressed immune function, causing us to be susceptible to every minor cold or bug that comes around. Depending on how our individual response to stress varies, the long-term presentation of stress will be different for each person.

SECONDARY SYMPTOMS OF CHRONIC STRESS

As one might expect, the immediate symptoms of stress are obvious and directly associated with the stressor. The symptoms of acute stress include rapid heartbeat, increased cortisol and adrenaline levels, constriction of blood flow and higher blood pressure, and perhaps sweating. All of these symptoms are designed to get us out of a stressful situation (the “fight or flight” response). However, there are secondary symptoms of chronic stress that are harder to directly associated with stress. These symptoms come from the body’s learned response to daily, weekly, monthly, or even yearly stress.

Secondary symptoms of chronic stress can include (and are not limited to) fatigue, lethargy, pain, emotional instability, depression, elevated systemic inflammation, poor sleep, infertility or menstrual irregularities, immune conditions (decreased or increased immune function), hypothyroidism, and poor memory. Some people may present with a sense of learned helplessness if their perception of stress is continually out of their own control.

CASE STUDY

30-year-old female with a health history of irregular menstrual cycles since age 15, eczema since age 20 (localized to legs and eyelids), borderline anemia in her twenties (resolved by age 29), and frequent constipation. She has been on several different forms of hormonal birth control since age 15 to regulate her menstrual cycle, and has recently discontinued this within the past 12 months. Current supplements include a multivitamin, 1,000 mg vitamin C, and echinacea capsules. She has a family history of diabetes and alcoholism on her maternal side, and various cancers and dementia on her paternal side.

Current health concerns: anxiety, fatigue, constipation, eczema, and irregular sleep patterns with intensely fearful dreams.

Lifestyle: She works full-time as a social media manager for a large architectural company based in New York City (she lives in Long Island and commutes into the city four times per week). She enjoys her job overall, however, she rates her stress 8 out of 10 on a daily basis due to often unclear project demands, impossibly short deadlines, and an “over-involved, narcissistic” boss. She pre
fers to work alone from home, and finds that when she is working alone, she is much more productive, peaceful, and her work is of higher quality. She notes that most of her anxiety comes from constant “nit-picking” about her work (which performs well by social media standards), checking emails, and financial strain, and she reports having some social anxiety when she goes out with people she does not know well. She exercises daily by walking about 2 miles total via her commute to work, and enjoys kickboxing about twice per month, which she considers a considerable stress relief. Her biggest source of anxiety, which she experiences multiple times per day, is her boss contacting her outside of work hours, and expecting responses within minutes. Feeling like she needs to always be connected and available is extremely draining to her, and she can never fully “shut off” from work. She reports that by the city’s work standards, “the city never sleeps, and neither can we.”

Health picture: Growing up, she was raised in a family that was aware of health and wellness, and her diet was always nutritious, and mainly vegetarian. Once she went to college in New York City, her diet became more erratic and her symptoms became more prominent, which she noticed was closely tied to her stress levels. When she experienced social or academic stress, she was unable to stay asleep at night, she would experience a racing heart (sometimes for 30 minutes or more), her eczema would get “out of control” and she would experience night terrors. For years, her periods were irregular and this was managed by hormonal birth control, but this caused weight gain, and “emotional ups and downs” over the years, and she discontinued this 9 months ago. Her periods have been somewhat erratic since that time, about once every 30 to 45 days. Dietarily, she does not have much time to cook and prepare nutritious meals, and is lacking essential nutrients including omega-3 fats, zinc, and magnesium. Her fiber intake is also extremely low, averaging about 10 grams per day. She is under consuming water by about 40 ounces per day, and frequently over consuming foods that are constitutionally drying such as chips, pastas, and popcorn. The lack of hydration combined with these drying foods and lack of vegetables and fiber is likely contributing to her symptoms of constipation. She is consuming about 4-5 cups of coffee daily with creamer and sugar, and often having 1-2 glasses of wine each night to “unwind” from the stress of the day. She did note that alcohol impacts her ability to fall asleep quickly, but has a hard time breaking this habit.

Locus of control: She feels trapped in her job and lifestyle due to financial constraints and the extreme high cost of living in this area. She has a roommate but can still barely afford the rent or the food and lifestyle she knows is best for her. She has been searching for another job for over a year, but feels continually discouraged, as the jobs she feels qualified for are few and far between, or very similar to the job she already has with the same work demands. She believes that her job and health status are “out of her control,” and is spinning her wheels trying to keep up with the schedule and availability that her current job demands, usually over 55 hours per week.

Initial Plan

During the first visit, we focused primarily on her immediate symptoms of overwhelm, racing heart, constipation, and poor sleep. We also discussed the areas where she does feel in control of her life and health, and focused on increasing these daily. We took initial steps to improve her diet, and remove foods that contribute to increased inflammation in the body. She chose one practice to incorporate daily to feel more in control of her stress, and committed to practicing this daily.

Nutrition support:

We began with a full elimination diet to remove any inflammatory foods that may have been causing systemic stress including gluten, dairy, corn, soy, wheat, processed sugar, popcorn, nuts, seeds, cocoa, alcohol, and caffeine. A comprehensive dietary plan focused on increasing vegetable and fruit intake to 7-8 servings per day, and included 3 servings of healthy fats daily (avocados, olive and coconut oils, fatty fish). The leafy green and fruit intake will also contribute to increasing her fiber intake daily. The plan included 8 ounces of bone broth daily, as well as apple cider vinegar before meals to support hydrochloric acid production. For proteins, we focused on wild-caught game meats such as duck, turkey, buffalo, and high-quality fish, as well as lentils, kidney beans, and organic eggs. We increased her water intake to about 60 ounces per day (including herbal tea). We replaced the nightly wine consumption with a mineral water spritzer with citrus herbal bitters.

Herbal stress support:

Initially, the focus was on central nervous system stress support for acute stressors with botanical suggestions, as well as lifestyle recommendations to improve her locus of control.

The acute herbal formula was selected to address heart support and palpitations with motherwort, a general nervine with an affinity to ease into night time with linden, and calming the central nervous system and digestive system with chamomile.

Acute herbal tincture formula
1 part motherwort (Leonurus cardiaca) aerial parts tincture

1 part linden (Tilia spp.) flower and bract tincture

1 part chamomile (Matricaria chamomilla) flower tincture

Dose 60 drops (2mL) three times per day in a little water. Dose 20 drops in acute situations when needed.

The tonic herbal formula was selected to enhance her overall nutrient intake with nettle. Milky oats was selected as a gentle nervine and central nervous system tonic, as well as a neurotrophorestorative, and astragalus was included to support immune modulation (not immune stimulation). It was suggested to remove her current echinacea supplement due to its immune-stimulating effect.

Tonic herbal tea formula

1 part nettle (Urtica dioica) leaf

2 parts milky oat (Avena sativa) tops

1 part astragalus (Astragalus membranaceus) root

Steep ¼ cup in 1 quart of water overnight, and strain in the morning. Drink throughout the day.

Emotional support:

She has been interested in seeing a therapist for several months, and her health insurance provided by her current job accommodates for this. Thus, it was suggested that she seek support with a therapist for her anxiety and chronic stress support. Exercise, outdoors when possible, was also suggested including long walks, swimming, and increasing kickboxing to 4 times per month when time allows. She agreed to do deep breathing practices for 4-5 minutes prior to sleep and when needed throughout the day when she feels out of control in a situation. She also began journaling in the evenings before bed to write down anything on her mind, including getting the stress “out of her system” before trying to fall asleep. She will continue her job hunt, including other locations where she is interested in moving to (out of state is an option for her). In the meantime, she agreed to “take more control” and have a conversation with her boss about not being available outside of work hours.

Follow Up Plan (3+ months):

Upon subsequent visits, we built upon this initial plan to gradually add in one food at a time that was originally eliminated. She documented this reintroduction, and any resulting symptoms in a food journal. It was discovered that caffeine makes her anxiety significantly worse, and when she consumes corn or corn products, she tends towards constipation. Without corn products and an increased daily water intake, she was having daily bowel movements. She agreed to continue eliminating all caffeine and corn-based products while continuing the acute tincture and tonic herbal tea. She noticed that her eczema flares when she over consumes sugars, and she began limiting this, and instead used honey and maple syrup for sweetening foods. She reported that the journal practice was very helpful to support her sleep, and within 4-5 weeks she found a therapist that she began seeing twice per month. She began networking within her social and professional community for jobs slightly outside of her skill set, and this community involvement allowed her to feel more in control of her job search, rather than sending resumes “out into the ether to strangers.” She continued to face resistance about the extended work hours and availability requirements of her current job, but used the acute herbal tincture as a tool when she felt anxiety come up in the moment, at a dose of 20 drops at a time. She completed a yearly comprehensive metabolic panel (CMP) and vitamin D testing with her primary care doctor, and she came back slightly deficient in vitamin D (32). It was suggested that she begin supplementing with 5,000 IU daily for 3 months to support this, and then have her levels re-checked at that time.

Overall, the short- and long-term plan strongly emphasizes supporting the central nervous system, the HPA adrenal stress response via lifestyle practices, communication, and therapy, and gently supporting her immune system with both botanical suggestions and removing pro-inflammatory foods from her diet. Over time, her herbal and lifestyle suggestions will change depending on her situation and ability to respond rather than react to stressors.

CONCLUSION

With any holistic approach to chronic stress, asking deep questions and listening to the clients primary cause of stress is essential to get to the bottom of where and why the HPA system is upregulated. Working on the cause, which usually involves supporting the adrenal glands and inflammation pathways first, and trying to remove the stressor (be it a person, situation, or changing the environment) can be a huge benefit to lessing the allostatic load of a chronically stressed person. Botanically, utilizing nervines, adaptogens, nutritives and nootropics and/or neurotrophorestoratives are an excellent place to start.

REFERENCES

Bellavance, M., & Rivest, S. (2014). The HPA immune axis and the immunomodulatory actions of glucocorticoids in the brain. Frontiers in Immunology, 5, 136.

Chrousos, G.P. (1998). Stressors, stress, and neuroendocrine integration of the adaptive response: The 1997 Hans Selye Memorial Lecture. Annals of the New York Academy of Sciences, 851, 311-335.

Guilliams, T.G., & Edwards, L. (2010). Chronic stress and the HPA axis: clinical assessment and therapeutic considerations. The Standard, 9(2), 1-12.

Mariotti, A. (2015). The effects of chronic stress on health: new insights into the molecular mechanisms of brain-body communication. Future Science OA, 1(3), FSO23.

McEwen, B.S. (2006). Stress, adaptation, and disease: allostasis and allostatic load. Annals of the New York Academy of Sciences, 840(1), 33-44.