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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 17 of 17. This is the beginning of the thread.
Posted by denise528 on September 4, 2004, at 12:23:17
Hi Scott,
You're a popular guy on here you should train to become a psychiatrist yourself you'd be in demand.
I'm sorry to ask you so many questions and I know that I've asked this one before but can't remember the answer.
I've asked my doctor about having a dexamethasone suppression test (he didn't know what one was) but I faxed him through some details.
I'm going to see about having one but surely if ones levels of cortisol are high, then there would be some physical signs of it, such as obesity or easily bruising and I suffer from none of these so don't want to waste there time. What are your opinions on this?
Also I mentioned in an a previous thread, I rang the professor in Newcastle who performed a study on memifitide on Psychotic depression and he said that whilst it had long term affects on the psychosis it only had short term affects on the depression so not sure what to think about this.
Do you suffer any symptoms of psychosis?
Denise
Posted by SLS on September 4, 2004, at 12:38:48
In reply to To Scott (SLS) Cortisol question, posted by denise528 on September 4, 2004, at 12:23:17
Hi Denise.
How are you?
> I've asked my doctor about having a dexamethasone suppression test (he didn't know what one was) but I faxed him through some details.
The DST was more popular 20 years ago in psychiatry than it is today. I think it is good information to have. It might help in making treatment decisions in the future.
The DST doesn't measure the amount of cortisol circulating in your blood stream. It is an indicator of how well the "thermostat" for cortisol management is operating. Of course, the function of this regulatory mechanism along the HPA (hypothalamo-pituitary-adrenal) axis helps to determine cortisol secretion. Hypercortisolemia can be subsyndromal in that it doesn't necessarily produce outward symptoms.
> Also I mentioned in an a previous thread, I rang the professor in Newcastle who performed a study on memifitide on Psychotic depression and he said that whilst it had long term affects on the psychosis it only had short term affects on the depression so not sure what to think about this.
Did you mean nemifitide or mifepristone?
> Do you suffer any symptoms of psychosis?
Only during drug-induced mania. It is not part of the natural course of my illness and not a part of my depression.
:-)
- Scott
Posted by denise528 on September 4, 2004, at 12:59:57
In reply to Re: To Scott (SLS) Cortisol question » denise528, posted by SLS on September 4, 2004, at 12:38:48
Hi Scott,
Thanks for the quick response, how's the Cymbalta trial going?
I think you try and get on one of the mifrepristone trials and then let us all know how you get on.
Yes, sorry I did mean mifepristone I realised after I'd submitted the note that I'd got it wrong. Do you have any of the physical symptoms of high cortisol levels?
Also, meant to ask you about ECT as I know you had it, what type did you have and did it not help at all?
I hate all of this I wish I was wanting to do something other than obsessively scour the internet looking for "THE ANSWER" and I'm sure you'd rather be doing something other than trying to provide them.
Denise
Posted by Racer on September 4, 2004, at 14:17:02
In reply to Re: To Scott (SLS) Cortisol question, posted by denise528 on September 4, 2004, at 12:59:57
Elevated cortisol can have a lot of different symptoms, many so subtle you probably wouldn't recognize them. Excessive thirst, excessive urination, lethargy, restlessness, increased startle response, loss of muscle tone, pot belly, etc. Most of them come on slowly, too, so you probably wouldn't be able to say that they're certainly related to your adrenal system.
The DST is one test of many for cortisol. Salivary cortisol levels are one option, for a snapshot view of where you are at any given time, but a 24 hour urine sample is probably the most accurate way to assess your cortisol production. It's also the yuckiest, of course... ;-D
There are new studies being done on the subject of the stress system and depression, by the way. Some research suggests that very short courses of low dose dexamethasone will actually put the brakes quite firmly on severe depression in a matter of days. Let's cross our fingers that something good comes out of this for us, eh?
I can empathize with your internet searching, too. It's finally become clear to me how much adrenaline has been fueling my own distress over the past year or so. While the cortisol link is pretty much old news to me (quite familiar with Cushing's Disease, up close and personal), it's only recently that I've recognized how much anxiety builds up for me and started to look for ways to control that. Still no hard and firm answer, of course, but it's still a start.
Best luck on your research, be sure to pass on what you find. (And the Psychiatric Times site has a recent article on cortisol and depression. You might find some good info there.)
Posted by 4WD on September 4, 2004, at 16:09:47
In reply to Re: To Scott (SLS) Cortisol question » denise528, posted by Racer on September 4, 2004, at 14:17:02
> Elevated cortisol can have a lot of different symptoms, many so subtle you probably wouldn't recognize them. Excessive thirst, excessive urination, lethargy, restlessness, increased startle response, loss of muscle tone, pot belly, etc. Most of them come on slowly, too, so you probably wouldn't be able to say that they're certainly related to your adrenal system.
>
> The DST is one test of many for cortisol. Salivary cortisol levels are one option, for a snapshot view of where you are at any given time, but a 24 hour urine sample is probably the most accurate way to assess your cortisol production. It's also the yuckiest, of course... ;-D
>
> There are new studies being done on the subject of the stress system and depression, by the way. Some research suggests that very short courses of low dose dexamethasone will actually put the brakes quite firmly on severe depression in a matter of days. Let's cross our fingers that something good comes out of this for us, eh?
>
> I can empathize with your internet searching, too. It's finally become clear to me how much adrenaline has been fueling my own distress over the past year or so. While the cortisol link is pretty much old news to me (quite familiar with Cushing's Disease, up close and personal), it's only recently that I've recognized how much anxiety builds up for me and started to look for ways to control that. Still no hard and firm answer, of course, but it's still a start.
>
> Best luck on your research, be sure to pass on what you find. (And the Psychiatric Times site has a recent article on cortisol and depression. You might find some good info there.)
I think this is probably relevant to a lot of us. I can actually feel adrenaline/cortisol levels rising when I have to get something done. Since I have no *real* energy because of depression, the only way to accomplish anything is to get those stress hormones circulating. That's what it feels like, anyway. I have two speeds - hyper-jittery adrenaline speed and slug on the couch speed.If one's cortisol levels are out of whack, though, what does one do about it? I mean if there is a problem with the HPA axis, is there, then, a treatment?
Posted by SLS on September 4, 2004, at 17:00:29
In reply to Re: To Scott (SLS) Cortisol question, posted by 4WD on September 4, 2004, at 16:09:47
Hi.
> If one's cortisol levels are out of whack, though, what does one do about it? I mean if there is a problem with the HPA axis, is there, then, a treatment?One way to bring about the normalization of the HPA axis is to bring depression into remission. It really doesn't matter how you go about it. Both drugs and ECT work. Abnormal DST normalizes when the depressive state improves. It is considered a state-specific rather than a trait-specific abnormality. For those people who do respond to antidepressants initially and in whom DST does not normalize, the risk of relapse is significantly greater.
http://www.psychiatrist.com/pcc/pccpdf/v03n04/v03n0401.pdf
I don't think it is fully understood which comes first, depression or HPA dysregulation. Is HPA dysregulation the result or the cause of depression? Might it represent a self-reinforcing loop between the two? It very well might. This might account for why there has been some limited success treating depression with anti-glucocorticoids (anti-cortisol agents) such as ketoconazole and mifepristone. As part of the HPA regulatory machinery, CRH (corticotropin releasing hormone) is a substance secreted by the hypothalamus to initiate the events leading to the production of cortisol. New drugs are being developed that block the receptors for CRH, and might thus interrupt the dysregulated HPA loop. In addition, CRH acts as a chemical messenger within the brain itself, where several subtypes exist. In fact, there is now some speculation that a substance other than CRH might also act as a messenger at these receptors.
- Scott
Posted by Racer on September 4, 2004, at 17:00:46
In reply to Re: To Scott (SLS) Cortisol question, posted by 4WD on September 4, 2004, at 16:09:47
Per the NIMH info on anxiety, Buspar and beta-blockers are useful for treating anxiety. The beta blockers reduce the body's ability to produce adrenaline, although they are also likely to lower blood pressure. Buspar has to reach stead state in your blood stream, but the beta blockers can work on an as needed basis.
Hope that helps.
Posted by 4WD on September 4, 2004, at 17:18:51
In reply to Re: To Scott (SLS) Cortisol question, posted by SLS on September 4, 2004, at 17:00:29
> Hi.
>
> > If one's cortisol levels are out of whack, though, what does one do about it? I mean if there is a problem with the HPA axis, is there, then, a treatment?
>
> One way to bring about the normalization of the HPA axis is to bring depression into remission. It really doesn't matter how you go about it. Both drugs and ECT work. Abnormal DST normalizes when the depressive state improves. It is considered a state-specific rather than a trait-specific abnormality. For those people who do respond to antidepressants initially and in whom DST does not normalize, the risk of relapse is significantly greater.
>
> http://www.psychiatrist.com/pcc/pccpdf/v03n04/v03n0401.pdf
>
> I don't think it is fully understood which comes first, depression or HPA dysregulation. Is HPA dysregulation the result or the cause of depression? Might it represent a self-reinforcing loop between the two? It very well might. This might account for why there has been some limited success treating depression with anti-glucocorticoids (anti-cortisol agents) such as ketoconazole and mifepristone. As part of the HPA regulatory machinery, CRH (corticotropin releasing hormone) is a substance secreted by the hypothalamus to initiate the events leading to the production of cortisol. New drugs are being developed that block the receptors for CRH, and might thus interrupt the dysregulated HPA loop. In addition, CRH acts as a chemical messenger within the brain itself, where several subtypes exist. In fact, there is now some speculation that a substance other than CRH might also act as a messenger at these receptors.
>
>
> - ScottThere's definitely a link there. My pituitary gland keeps instructing my adrenal glands to produce excess prolactin, resulting in abnormal production of small amounts of fluid from my breasts (galactorrhea). Taking bromocriptine stops this symptom but it returns when the bromocriptine is stopped. Dopamine depletion in the brain can result in galactorrhea. The galactorrhea started shortly after starting antidepressants (non-dopaminergic ones). I feel that I am producing excess cortisol. I can't quite wrap my mind around the implications of these somehow related facts but I know there is a significance there somewhere.
Marsha
Posted by greenwillow on September 5, 2004, at 1:57:06
In reply to Re: To Scott (SLS) Cortisol question, posted by 4WD on September 4, 2004, at 17:18:51
> > > If one's cortisol levels are out of whack, though, what does one do about it? I mean if there is a problem with the HPA axis, is there, then, a treatment?
What exactly is the HPA axis? I have high urinary-free cortisol, but follow-up with the dexamethasone test was apparently ok. I have one of those endo docs who doesn't communicate, and I am uncertain if the doc has adequately addressed my situation.
Posted by denise528 on September 5, 2004, at 9:51:20
In reply to Re: To Scott (SLS) Cortisol question » denise528, posted by Racer on September 4, 2004, at 14:17:02
Hi Scott and Racer,
Thanks for the information, I have started to read it but am finding it difficult to digest anything today and reading these articles feels like trying to find a needle in a haystack and I'm not entirely convinced I'm ploughing through the right haystack.
I just want to see something that says a + b = NO DEPRESSION - VOILA. I wish it was that simple.
If I find anything of interest I'll be sure to post it on here.
Scott - you say that anything that alleviates the depression then balances out the HPA Axis, does that mean that if you just work on correcting the functioning of the HPA Axis then it will stop the depression or does it not work like that?
Racer, Yes let's hope but if as you say, short courses of low dose dexamethasone will actually put the brakes quite firmly on severe depression in a matter of days then wouldn't those people who'd had a dexamethasone suppression test have felt an alleviation of depression whilst having the test?
Denise
Posted by denise528 on September 5, 2004, at 10:50:04
In reply to Re: To Scott (SLS) Cortisol question, posted by SLS on September 4, 2004, at 17:00:29
Hi,
I was wondering if excess Cortisol was the only symptom of an abnormal HPA Axis, would it be possible to have a normal HPA Axis and not release excessive amounts of Cortisol? And who is to say what a normal HPA Axis is anyway.
Have they done studies on so called normal people to see if half of them demonstrated non-suppression to dexamethasone, maybe high coritsol levels don't necessarily correlate to depression??Denise
Posted by Racer on September 5, 2004, at 13:12:22
In reply to Re: To Scott and Racer, posted by denise528 on September 5, 2004, at 9:51:20
Dunno -- I was just passing on what I'd read. The article, I think from the Psychiatric Times online, discussed the results of a small study using 4mg of dexamethasone for four days. It said that it relieved depression in the study participants, without the side effects of long term treatment. It sounded not like a cure, by any means, but as a jump start for longer term anti-depressant treatment.
At any rate, I can't answer your question regarding the DST. I'm just repeating something I read that applies, hoping it helps.
Good luck.
Posted by Racer on September 5, 2004, at 13:23:34
In reply to Re: To Scott (SLS) Cortisol question, posted by greenwillow on September 5, 2004, at 1:57:06
HPA axis: hypothalamic-pituitary-adrenal axis. If you really want to get pedantic, you can add the limbic system in, too.
This is the 'committee' responsible for getting you through stressful situations. Now, what you and I consider stressful isn't necessarily what your limbic system thinks of as stressful. Your HPA axis is responsible for things like getting you out of bed in the morning, which it considers stressful. It's also what leads to the release of cortisol, and eventually adrenaline. Simplistically: your limbic system tells your hypothalamus to look for something stressful. Your hypothalamus tells your pituitary to gear up for something stressful. Your pituitary then opens the channel to your adrenal glands, which turn on the cortisol pumps, until the pituitary recognizes enough of it that it checks with the hypothalamus to see if there's enough cortisol to turn the adrenal pumps off. Under normal circumstances, the hypothalamus would send the message to turn down production, but a number of things can cause this feedback system to lose its precision. Any member of this committee can cause it to break down, resulting in either under or over production of cortisol.
Addison's Disease leads to too little cortisol being produced, and Cushing's Disease leads to too much. Cushing's Syndrome is also related to too much cortisol cruising around, although it's not caused by the classic Cushing's Disease (benign pituitary tumor). Someone who takes steroids for an extended period will show signs of Cushing's Syndrome, for example.
(And, as an aside, mild Cushing's has some benefits: it's associated with an improvement in osteoarthritis, for example.)
Hope that helps, and it you have any other questions, ask away. With any luck, someone else will answer the next one ;-)
Posted by greenwillow on September 7, 2004, at 3:48:39
In reply to Re: To Scott (SLS) Cortisol question » greenwillow, posted by Racer on September 5, 2004, at 13:23:34
So do I have this right, that I can have high urinary free cortisol, normal dexamethosone test, ACTH blood test slightly low, blood cortisol normal and that the cause is maybe just stress? And not a disease or something? I definately do not have the physique attributed to Cushings, although I do have symptoms of soft tissue pain. I am finding that my circadian rhythm is all out of whack (I am falling asleep at 6:30 a.m.). Does that have anything to do with high urinary-free cortisol? Does that fact change the meaning of any of the test results? I hope my questions make sense and that someone can address them. thanks
Posted by Racer on September 7, 2004, at 12:32:53
In reply to Re: To Scott (SLS) Cortisol question, posted by greenwillow on September 7, 2004, at 3:48:39
My mind isn't all here right now -- new med making me miserable and incapable of thinking very well -- so I can't give you a definitive answer, but I can tell you as much as I remember, to tide you over until someone else answers.
There are two different types of receptors that shake hands with cortisol, but only one of them gets friendly with dexamethasone. I suspect that the normal DST would mean that you're experiencing more activity in the cortisol specific receptors, thus not a lot of suppression from the dexamethasone. That's only a guess.
When you got these results, did the doctor tell you how high your results were? Where within the normal range your DST results landed? What the normal ranges were? In fact, why didn't your doctor explain all this to you in the first place? (Answer: just to confirm my opinion that a lot of doctors should really be duct taped to a chair so that someone can explain the facts of life to them. It irritates me beyond belief that so many doctors don't bother to explain tests and test results to patients. Another of my soapboxes.) It may be that your high results were only marginally high, or that your DST results were borderline. That's another thought.
As far as all the rest of it goes, I'd look around for all the factors that are contributing to the difficulties with sleeping, etc. It may very well be that this is all related to your HPA axis, but it may also be caused by psychological factors, like worry, or by more mechanical factors, like sleeping from 6:30AM until 2PM and not being able to get to sleep because you haven't been up long enough. That's the problem, especially with psychiatric difficulties: too many variables to analyse. And it's usually a combination, rather than just one.
Another factor to consider is diet. I wish I could remember where I read this, but sodas -- especially diet sodas -- seem to interfere with the normal circadian hormone cycle. Since cortisol needs to rise shortly before you wake up, it could be that eating or drinking artifically sweetened products is whacking out your hormonal systems, thus keeping you up. While it won't be definitive, you could try adjusting your diet to avoid all those nasties for a while and see what happens? Can't hurt, and might help. (Especially since another study regarding the effect of aspartame on depression was halted midway because the negative effects on the study participants were so pronounced. Their depression was so much worse that the researchers halted the study entirely, because they believed it would be unethical to continue it.)
I know it's not much, and doesn't really answer your questions, but it's the best I could manage in my current state. I'm sure someone with a working brain will happen along soon.
Best luck.
Posted by 4WD on September 7, 2004, at 14:04:33
In reply to Re: To Scott (SLS) Cortisol question » greenwillow, posted by Racer on September 7, 2004, at 12:32:53
> My mind isn't all here right now -- new med making me miserable and incapable of thinking very well -- so I can't give you a definitive answer, but I can tell you as much as I remember, to tide you over until someone else answers.
>
> There are two different types of receptors that shake hands with cortisol, but only one of them gets friendly with dexamethasone. I suspect that the normal DST would mean that you're experiencing more activity in the cortisol specific receptors, thus not a lot of suppression from the dexamethasone. That's only a guess.
>
> When you got these results, did the doctor tell you how high your results were? Where within the normal range your DST results landed? What the normal ranges were? In fact, why didn't your doctor explain all this to you in the first place? (Answer: just to confirm my opinion that a lot of doctors should really be duct taped to a chair so that someone can explain the facts of life to them. It irritates me beyond belief that so many doctors don't bother to explain tests and test results to patients. Another of my soapboxes.) It may be that your high results were only marginally high, or that your DST results were borderline. That's another thought.
>
> As far as all the rest of it goes, I'd look around for all the factors that are contributing to the difficulties with sleeping, etc. It may very well be that this is all related to your HPA axis, but it may also be caused by psychological factors, like worry, or by more mechanical factors, like sleeping from 6:30AM until 2PM and not being able to get to sleep because you haven't been up long enough. That's the problem, especially with psychiatric difficulties: too many variables to analyse. And it's usually a combination, rather than just one.
>
> Another factor to consider is diet. I wish I could remember where I read this, but sodas -- especially diet sodas -- seem to interfere with the normal circadian hormone cycle. Since cortisol needs to rise shortly before you wake up, it could be that eating or drinking artifically sweetened products is whacking out your hormonal systems, thus keeping you up. While it won't be definitive, you could try adjusting your diet to avoid all those nasties for a while and see what happens? Can't hurt, and might help. (Especially since another study regarding the effect of aspartame on depression was halted midway because the negative effects on the study participants were so pronounced. Their depression was so much worse that the researchers halted the study entirely, because they believed it would be unethical to continue it.)
>
> I know it's not much, and doesn't really answer your questions, but it's the best I could manage in my current state. I'm sure someone with a working brain will happen along soon.
>
> Best luck.
I found that amazing about the study that was halted. I'd never heard about that. I drink a lot of caffeine free diet soda. Here's a link to the study.http://www.mindfully.org/Health/Aspartame-Adverse-Reactions-1993.htm
Marsha
Posted by PoohBear on September 9, 2004, at 9:24:24
In reply to Re: To Scott (SLS) Cortisol question, posted by 4WD on September 7, 2004, at 14:04:33
Good job people, great discussion, so much to learn!
Tony
This is the end of the thread.
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