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Ann. N.Y. Acad. Sci. 1057: 466–478 (2005). doi: 10.1196/annals.1356.036
Copyright © 2005 by the New York Academy of Sciences

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Stress-Induced Hypocortisolemia Diagnosed as Psychiatric Disorders Responsive to Hydrocortisone Replacement

Hoag Memorial Hospital Presbyterian, Department of Neurology-Psychiatry, Newport Beach, California 92660 USA

Address for correspondence: Suzie E. Schuder, M.D., 901 Dover Drive, Suite 204, Newport Beach, CA, 92660 USA. Voice: 949-722-9884; fax: 949-722-9885. sschuder{at}yahoo.com

In patients of all ages, many disorders labeled as psychiatric may actually be due to hormonal insufficiencies. For example, cortisol deficiency is rarely taken into account in a medical or psychiatric work-up, so persons with mild to moderate cortisol insufficiency are for the most part relegated to receiving a psychiatric diagnosis when, in fact, the same disorder is represented. However, the symptoms of cortisol insufficiency appear to closely parallel such psychiatric disorders as post traumatic stress disorder (PTSD) and addictions. There has been some question of whether substance abuse causes a hypocortisolemic state. In reviewing the literature and obtaining detailed histories of addicted patients, it appears that childhood trauma, also known as "early life stress" (ELS), instead may elicit a hypocortisolemic state. This leads some to self-medicate with an addictive substance to quell the pain of a cortisol insufficiency, both physical and emotional. In fact, the literature supports the concept that addictive substances increase cortisol in predisposed patients. Patients with a variety of psychiatric disorders including addictions were found to have signs and symptoms of mild or moderate hypocortisolemia. Generally, an appropriate comprehensive examination supported a diagnosis of cortisol insuffiency. For the most part, these patients were succesfully treated with physiologic doses of bio-equivalent hydrocortisone, along with replacement of any other deficient hormone. By correcting underlying hormonal insufficiencies, many patients improved, with some patients having a total reversal of psychiatric symptoms. It is therefore reasonable to evaluate and treat hormonal insufficiencies with hormones prior to using psychotropic medication.

Key Words: stress • trauma • cortisol • PTSD • hormones • substance abuse • aging • paranoia • irritability • hostility • startle • alcoholism • psychotropic • DSM