GANGGUAN SOMATOFORM (F45)

Definisi :

- Kelompok gangguan yang memiliki keluhan berupa gejala fisik (sebagai contohnya, nyeri, mual, dan pusing) yang
menonjol, tidak dapat ditemukan penjelasan medis

- Gejala dan keluhan somatik menyebabkan penderitaan emosional/gangguan pada kemampuan pasien untuk berfungsi di
dalam peranan sosial atau pekerjaan.

- Gangguan somatoform tidak disebabkan oleh pura-pura yang disadari atau gangguan buatan.

Somatoform berdasarkan PPDGJ III dibagi menjadi,

F.45.0 gangguan somatisasi

F.45.1 gangguan somatoform tak terperinci
F.45.2 gangguan hipokondriasis
F.45.3 disfungsi otonomik somatoform
F.45.4 gangguan nyeri somatoform menetap
F.45.5 gangguan somatoform lainnya
F.45.6 gangguan somayoform YTT

DSM-IV, ada tujuh kelompok, lima sama dengan klasifikasi awal dari PPDGJ ditambah dengan gangguan konversi,
gangguan dismorfik tubuh.

Pada bagian psikiatri, gangguan yang sering ditemukan di klinik adalah gangguan somatisasi dan hipokondriasis.

Gambaran keluhan gejala somatoform :

Neuropsikiatri: “kedua bagian dari otak saya tidak dapat berfungsi dengan baik” ;
“ saya tidak dapat menyebutkan benda di sekitar rumah ketika ditanya”
Kardiopulmonal: “ jantung saya terasa berdebar debar…. Saya kira saya akan mati”
Gastrointestinal: “ saya pernah dirawat karena sakit maag dan kandung empedu dan belum ada dokter yang dapat
menyembuhkannya”
Genitourinaria: “ saya mengalami kesulitan dalam mengontrol BAK, sudah dilakukan pemeriksaan namun tidak di
temukan apa-apa”
Musculoskeletal “saya telah belajar untuk hidup dalam kelemahan dan kelelahan sepanjang waktu”
Sensoris: “ pandangan saya kabur seperti berkabut, tetapi dokter mengatakan kacamata tidak akan membantu”
 F. 45.0 GANGGUAN SOMATISASI

Etiologi : belum diketahui.

- Teori yang ada, teori belajar, terjadi karena individu belajar untuk mensomatisasikan dirinya untuk mengekspresikan
keinginan dan kebutuhan akan perhatian dari keluarga dan orang lain

Epidemiologi

a. wanita : pria = 10 :1
b. rasio tertinggi usia 20- 30 tahun
c. pasien dengan riwayat keluarga pernah menderita gangguan somatoform (beresiko 10-20x > besar dibanding yang
tidak ada riwayat).

Kriteria diagnostik untuk Gangguan Somatisasi

A. Keluhan fisik dimulai sebelum usia 30 tahun, terjadi selama periode beberapa tahun
B. Tiap kriteria berikut ini harus ditemukan,

 4 gejala (G) nyeri: sekurangnya empat tempat atau fungsi yang berlainan (misalnya kepala, perut, punggung, sendi,
anggota gerak, dada, rektum, selama menstruasi, selama hubungan seksual, atau selama miksi)

 2 G gastrointestinal: sekurangnya dua gejala selain nyeri (misalnya mual, kembung, muntah selain dari selama
kehamilan, diare, atau intoleransi terhadap beberapa jenis makanan)

 1 G seksual: sekurangnya satu gejala selain dari nyeri (misalnya indiferensi seksual, disfungsi erektil atau ejakulasi,
menstruasi tidak teratur, perdarahan menstruasi berlebihan, muntah sepanjang kehamilan).

 1 G pseudoneurologis: sekurangnya satu gejala atau deficit yang mengarahkan pada kondisi neurologis yang tidak
terbatas pada nyeri (gangguan koordinasi atau keseimbangan, paralisis, sulit menelan, retensi urin, halusinasi,
hilangnya sensasi atau nyeri, pandangan ganda, kebutaan, ketulian, kejang; gejala disosiatif seperti amnesia; atau
hilangnya kesadaran selain pingsan).
C. Salah satu (1)atau (2):

 Setelah penelitian yang diperlukan, tiap gejala dalam kriteria B tidak dapat dijelaskan sepenuhnya oleh sebuah
kondisi medis umum yang dikenal atau efek langsung dan suatu zat (misalnya efek cedera, medikasi, obat, atau
alkohol)

 Jika terdapat kondisi medis umum, keluhan fisik atau gangguan sosial atau pekerjaan yang ditimbulkannya adalah
melebihi apa yang diperkirakan dari riwayat penyakit, pemeriksaan fisik, atau temuan laboratorium.
D. Gejala tidak ditimbulkan secara sengaja atau dibuat-buat (seperti gangguan buatan atau pura-pura).

Dignosis multiaksial (PERKIRAAN) :

Axis I : Gangguan somatoform, somatisasi
 Axis II : tidak ada diagnosisi aksis II
Axis III : tidak ada diagnosis aksis III
Axis IV : masalah dengan keluarga (biasanya)
Axis V : 51-60 gejala sedang, disabilitas sedang

Tata laksana dan diagnosis banding (TERLAMPIR)

Prognosis : dubia et malam. Pasien susah sembuh walo sudah ngikutin pedoman pengobatan. Sering kali pada psien wanita
berakhir pada percobaan bunuh diri.

F.45.1 GANGGUAN SOMATOFORM TAK TERPERINCI

ETIOLOGI, unknown
EPIDEMIOLOGI, bervariasi, di USA 10%-12% terjadi pada usia dewasa, dan 20 % menyerang wanita.
Kriteria Diagnostik untuk Gangguan Somatoform yang Tidak Digolongkan

 Satu atau lebih keluhan fisik (misalnya kelelahan, hilangnya nafsu makan, keluhan gastrointestinal atau saluran
kemih)

 Salah satu (1)atau (2)

A. Setelah pemeriksaan yang tepat, gejala tidak dapat dijelaskan sepenuhnya oleh kondisi medis umum yang
diketahui atau oleh efek langsung dari suatu zat (misalnya efek cedera, medikasi, obat, atau alkohol)

B. Jika terdapat kondisi medis umum yang berhubungan, keluhan fisik atau gangguan sosial atau pekerjaan yang
ditimbulkannya adalah melebihi apa yang diperkirakan menurut riwayat penyakit, pemeriksaan fisik, atau
temuan laboratonium.

 Gejala menyebabkan penderitaan yang bermakna secara klinis atau gangguan dalam fungsi sosial, pekerjaan, atau
fungsi penting lainnya. Durasi gangguan sekurangnya enam bulan.

 Gangguan tidak dapat diterangkan lebih baik oleh gangguan mental lain (misalnya gangguan somatoform, disfungsi
seksual, gangguan mood, gangguan kecemasan, gangguan tidur, atau gangguan psikotik).

 Gejala tidak ditimbulkan dengan sengaja atau dibuat-buat (seperti pada gangguan buatan atau berpura-pura)

Diagnosis multiaksial
Axis I : Gangguan somatoform, somatisasi
Axis II : tidak ada diagnosisi aksis II
Axis III : tidak ada diagnosis aksis III
Axis IV : tidak ada stressor
Axis V : 61-70

Tata laksana dan diagnosis banding (TERLAMPIR)

 Prognosis : bervariasi, sulit diprediksi karena prognosisnya bergantung pada gejala yang lebih dominan.

F.45.2 GANGGUAN HIPOKONDRIASIS

Hipokondriasis adalah keterpakuan (PREOKUPASI) pada ketakutan menderita, atau keyakinan bahwa seseorang memiliki
penyakit medis yang serius, meski tidak ada dasar medis untuk keluhan yang dapat ditemukan. Berbeda dengan gangguan
somatisasi dimana pasien biasanya meminta pengobatan terhadap penyakitnya yang seringkali menyebabkan terjadinya
penyalahgunaan obat, maka pada gangguan hipokondrik pasien malah takut untuk makan obat karena dikira dapat
menambah keparahan dari sakitnya.
ETIOLOGI, masih belum jelas
EPIDEMIOLOGI
Biasanya terjadi pada usia dewasa, rasio antara wanita dan pria sama
Kriteria Diagnostik untuk Hipokondriasis

 Perokupasi (keterpakuan) dengan ketakutan menderita, ide bahwa ia menderita suatu penyakit serius didasarkan pada
interpretasi keliru orang tersebut terhadap gejala-gejala tubuh.

 Perokupasi menetap walaupun telah dilakukan pemeriksaan medis yang tepat

 Tidak disertai dengan waham dan tidak terbatas pada kekhawatiran tentang penampilan (seperti pada gangguan
dismorfik tubuh).

 Preokupasi menyebabkan penderitaan yang bermakna secara klinis atau gangguan dalam fungsi sosial, pekerjaan, atau
fungsi penting lain. Lama gangguan sekurangnya 6 bulan.

 Preokupasi tidak dapat diterangkan lebih baik oleh gangguan kecemasan umum, gangguan obsesif-kompulsif,
gangguan panik, gangguan depresif berat, cemas perpisahan, atau gangguan somatoform lain.

Diagnosis multiaksial
Axis I : Gangguan somatoform, somatisasi
Axis II : tidak ada diagnosisi aksis II
Axis III : tidak ada diagnosis aksis III (????)
Axis IV : ???
Axis V : 51-60 gejala sedang, disabilitas sedang

Tata Laksana dan diagnosis banding (TERLAMPIR)

Prognosis : 10 % pasien bisa sembuh, 65 % berlanjut manjadi kronik dengan onset yang berfluktuasi, 25 % prognosisinya
buruk.

F.45.3 GANGGUAN DISFUNGSI OTONOMIK SOMATOFORM

 Kriteria diagnostik yang diperlukan :

a. ada gejala bangkitan otonomik ex, palpitasi, berkeringat, tremor, muka panas, yang sifatnya menetap dan
mengganggu

b. gejala subjektif tambahan mengacu pada sistem atau organ tertentu (tidak khas)
c. preokupasi dengan penderitaan mengenai kemungkinan adanya gangguan yang serius yang menimpanya, yang tidak
terpengaruh oleh hasil Px maupun penjelasan dari dokter

d. tidak terbukti adanya gangguan tang cukup berarti pada struktur/fungsi dari sistem/organ yang dimaksud

kriteria ke 5, ditambahkan : F.45.30 = JANTUNG DAN SISTEM KARDIOVASKULAR

F.45.31 = SALURAN PENCERNAAN BGN ATAS
F.45.32 = SALURAN PENCERNAAN BGN BAWAH
F.45.33 = SISTEM PERNAPASAN
F.45.34 = SISTEM GENITO-URINARIA
F.45.38 = SISTEM ATAU ORGAN LAINNYA

F. 45.4 . GANGGUAN NYERI YANG MENETAP

Individu yang merasakan nyeri akibat gangguan fisik, menunjukkan lokasi rasa nyeri yang dialaminya dengan lebih
spesifik, lebih detail dalam memberikan gambaran sensoris dari rasa nyeri yang dialaminya, dan menjelaskan situasi
dimana rasa nyeri yang dirasakan menjadi lebih sakit atau lebih berkurang (Adler et al., dalam Davidson, Neale, Kring,
2004). Sedangkan pada nyeri somatoform, pasien malah bertindak sebaliknya.

ETIOLOGI, tidak diketahui

EPIDEMIOLOGI
Terjadi pada semua tingkatan usia, di USA 10-15% pasien datang dengan keluhan nyeri punggung.
Kriteria Diagnostik untuk Gangguan Nyeri

 Nyeri pada satu atau lebih tempat anatomis

 Nyeri menyebabkan penderitaan yang bermakna secara klinis atau gangguan dalam fungsi sosial, pekerjaan, atau
fungsi penting lain.

 Faktor psikologis dianggap memiliki peranan penting dalam onset, kemarahan, eksaserbasi atau bertahannnya nyeri.

 Gejala atau defisit tidak ditimbulkan secara sengaja atau dibuat-buat (seperti pada gangguan buatan atau berpura-pura).

 Nyeri tidak dapat diterangkan lebih baik oleh gangguan mood, kecemasan, atau gangguan psikotik dan tidak
memenuhi kriteria dispareunia.

Diagnosis Multiaksial
Axis I : gangguan somatoform, nyeri menetap
 Axis II : tidak ada diagnosis aksis II
Axis III : tidak ada (???)
Axis IV : ????
Axis V : 51-60 gejala sedang, disabilitas sedang

Tata laksana dan diagnosis banding (TERLAMPIR)

Prognosis : jika gejala terjadi < 6 bulan, cenderung baik
Jika gejala terjadi > 6 bulan, cenderung buruk (cenderung menjadi kronik)

F.45.8 GANGGUAN SOMATOFORM LAINNYA

Pedoman Diagnostik :

a. keluhan yanga da tidak melalui saraf otonom, terbatas secara spesifik pd bgn tubuh/sistem tertentu
b. tidak ada kaitan dengan adanya kerusakan jaringan
c. termasuk didalamnya, pruritus psikogenik, ”globus histericus”(perasaan ad benjolan di kerongkongan>>>disfagia)
dan dismenore psikogenik

( TAMBaHAN DSM IV)

a. Gangguan konversi
Adalah suatu tipe gangguan somatoform yang ditandai oleh kehilangan atau kendala dalam fungsi fisik, namun tidak ada
penyebab organis yang jelas. Gangguan ini dinamakan konversi karena adanya keyakinan psikodinamika bahwa gangguan
tersebut mencerminkan penyaluran, atau konversi, dari energi seksual atau agresif yang direpresikan ke simtom fisik.
ETIOLOGI

- Teori psikoanalisis, (1895/1982), Breuer dan freud : disebabkan ketika seseorang mengalami peristiwa yang
menimbulkan peningkatan emosi yang besar, namun afeknya tidak dapat diekspresikan dan ingatan tentang peristiwa
tersebut dihilangkan dari kesadaran

- Teori behavioral, Ullman&Krasner (dalam Davidson, Neale, Kring, 2004), terjadi karena individu mengadopsi simtom
untuk mencapai suatu tujuan. Individu berusaha untuk berperilaku sesuai dengan pandangan mereka mengenai bagaimana
seseorang dengan penyakit yang mempengaruhi kemampuan motorik atau sensorik, akan bereaksi.
EPIDEMIOLOGI
Terjadi pada 11-500 per 100.000 penduduk. Biasanya terjadi pada usia anak-anak (akhir) hingga dewasa (awal). Jarang
terjadi sebelum usia 10 tahun dan setelah 35 tahun.
Kriteria diagnostik untuk Gangguan Konversi

 Satu atau lebih gejala/defisit yang mengenai fungsi motorik volunter atau sensorik yang mengarah pada kondisi
neurologis atau kondisi medis lain, disertai dengan kejang/konvulsi.

 Faktor psikologis dipertimbangkan berhubungan dengan gejala/defisit karena awal atau eksaserbasi dari gangguan ini
biasanya didahului oleh konflik atau stresor lain.
 Tidak ditimbulkkan secara sengaja atau dibuat-buat

 Gejala atau defisis (setelah penelitian yang diperlukan) tidak dapat dijelaskan sepenuhnya oleh kondisi medis umum,
atau oleh efek langsung suatu zat, atau sebagai perilaku atau pengalaman yang diterima secara kultural.

 Gejala atau defisit menyebabkan penderitaan yang bermakna secara klinis atau gangguan dalam fungsi sosial,
pekerjaan, atau fungsi penting lain atau memerlukan pemeriksaan medis.

 Gejala atau defisit tidak terbatas pada nyeri atau disfungsi seksual, tidak terjadi semata-mata selama perjalanan
gangguan somatisasi, dan tidak dapat diterangkan dengan lebih baik oleh gangguan mental lain.

Tata Laksana dan diagnosis banding (TERLAMPIR)

Prognosis : baik jika, onset awal, ada faktor presipitasi yang jelas, intelegensia masih baik, segera dilakukan treatment.
Prognosis buruk jika terjadi hal sebaliknya.

b. gangguan dismorfik tubuh

Pada gangguan dismorfik tubuh, individu diliputi dengan bayangan mengenai kekurangan dalam penampilan fisik mereka.
Membuatnya bisa berlama-lama berkaca di depan cermin memandang bentuk tubuh yang dianggapnya kurang, sering
pasien mendatangi spesialis bedah dan kecantikan.

Etiologi, unknown
Epidemiologi
Muncul kebanyakan pada wanita, biasanya dimulai pada akhir masa remaja, dan biasanya berkaitan dengan depresi, fobia
social, gangguan kepribadian (Phillips&McElroy, 2000; Veale et al.,1996 dalam Davidson, Neale, Kring, 2004).

Kriteria Diagnostik untuk Gangguan Dismorfik Tubuh

 Preokupasi dengan bayangan cacat dalam penampilan. Jika ditemukan sedikit anomali tubuh, kekhawatiran orang
tersebut menjadi berlebihan.

 Preokupasi menyebabkan Penderitaan yang bermakna secara klinis atau gangguan dalam fungsi sosial, pekerjaan, atau
fungsi penting lainnya.

 Preokupasi tidak dapat diterangkan lebih baik oleh gangguan mental lain (misalnya, ketidakpuasan dengan bentuk dan
ukuran tubuh pada anorexia nervosa).

Tata Laksana dan diagnosis banding (TERLAMPIR)

Prognosis : beravariasi(???)
BAGAN DIAGNOSIS BANDING GANGGUAN SOMATOFORM
DEFENCE MECHANISM
http://www.simplypsychology.org/

Rationalization

Rationalization is the cognitive distortion of "the facts" to make an event

or an impulse less threatening. We do it often enough on a fairly
conscious level when we provide ourselves with excuses. But for many
people, with sensitive egos, making excuses comes so easy that they
never are truly aware of it. In other words, many of us are quite
prepared to believe our lies.

* Reaction Formation
This is where a person goes beyond denial and behaves in the opposite
way to which he or she thinks or feels. By using the reaction formation
the id is satisfied while keeping the ego in ignorance of the true
motives. Conscious feelings are the opposite of the unconscious. Love
- hate. Shame - disgust and moralizing are reaction formation against
sexuality.

Usually a reaction formation is marked by showiness and

compulsiveness. For example, Freud claimed that men who are
prejudice against homosexuals are making a defense against their own
homosexual feelings by adopting a harsh anti-homosexual attitude which
helps convince them of their heterosexuality. Other examples include:

* The dutiful daughter who loves her mother is reacting to her Oedipus
hatred of her mother.

* Anal fixation usually leads to meanness, but occasionally a person

will react against this (unconsciously) leading to over-generosity.

COPING
Coping with stress
Stress has a major impact on mental and physical health.
Now that you know how to recognize your stress and identify
its source, let’s see how you can cope with it.

This section explains how to live with stress and the different
coping strategies.

What is coping?
Coping refers to the thoughts and actions we use to deal with
a threatening situation.

A stressful situation may be considered a threat for you but

not necessarily for your neighbor. You and your neighbor may
become stressed by the same situation, but for different
reasons (e.g. the situation is new for you, but unpredictable
for your neighbor).

After all, since we all become stressed for various reasons we

will need to choose different coping strategies.
 As you will see, there are many strategies and some are
better than others.

Two different coping strategies

Problem-focused strategy
This strategy relies on using active ways to directly tackle the
situation that caused the stress: you must concentrate on
the problem. Here are some examples:

1. Analyze the situation

e.g. Pay attention, avoid taking on more responsibility than
you can manage.
2. Work harder
e.g. Stay up all night to study for an exam
3. Apply what you have already learned to your daily life.
e.g. You lose your job for the second time - you now know the
steps to apply for a new job
4. Talk to a person that has a direct impact on the situation
e.g. Talk directly to your boss to ask for an extension to the
project that is due in one week.
 Emotion-focused strategy
Emotion-focused coping strategies are used to handle
feelings of distress, rather than the actual problem situation.
You focus on your emotions:

1. Brood
e.g. you accept new tasks instead of saying “no”, but you
keep complaining and saying it is unfair.
2. Imagine/Magic thinking
e.g. You dream about a better financial situation.
3. Avoid/Deny
e.g. You avoid everything that is related to this situation or
you take drugs and/or alcohol to escape from this situation.
4. Blame
e.g. You blame yourself or others for the situation.
5. Social support
e.g. You talk to your best friend about your concerns.

In a long-term perspective, are these

strategies harmful?
 Imagine that you are having a bad day at work and that you
do not feel like seeing your boss. You can avoid him for many
hours or even a day, but if you avoid him everyday this
strategy will become unsuccessful and may even cause extra
stress. This is why it is important to develop different
strategies in order to adapt to different situations.

Efficient coping strategies

Coping strategies are different depending on the situation and
the person; here are some good coping strategies.

1. Be positive!
Look at each obstacle you encounter as a learning
experience
e.g. you may not have done well on your mid-term exam, but
that has motivated you to study harder and ace your final
exam.
2. Make the choice not to over-react to stressors and deal
with them one at a time
e.g. take a few deep breaths and carry on.
3. Take an objective view of your stressor
e.g. is preparing dinner for 12 people really that horrible?
4. Communicate!
Don’t ruminate or bottle up your emotions, as this will lead to
an explosion later on.
5. Accept yourself (and others).
No one is perfect and there is always room for mistakes.
6. Make connections with people
Social support is key!
7. Deal effectively with mistakes
i.e. Learn from your mistakes and apply them to future
decision making.
8. Deal effectively with successes also!
This will build on your competence.
9. Develop self-discipline and control
e.g. train yourself to study harder in preparation for your final
exam, or train yourself to work out four times a week to lose
those pounds you gained since last Thanksgiving dinner!
10. Maintenance!
Practice, practice, practice for a long life of resilient living!
Now that you know how to recognize your stress and you
know the different coping strategies, you just need to find the
coping strategies that work best for you and apply them to
your daily life.

What Are the Psychological Benefits

of Exercise With Depression?
Improved self-esteem is a key
psychological benefit of regular physical
activity. When you exercise, your body
releases chemicals called endorphins.
These endorphins interact with the
receptors in your brainthat reduce your
perception of pain.
Endorphins also trigger a positive feeling in
the body, similar to that ofmorphine. For
example, the feeling that follows a run or
workout is often described as "euphoric."
That feeling, known as a "runner's high,"
 can be accompanied by a positive and
energizing outlook on life.
Endorphins act as analgesics, which means
they diminish the perception of pain. They
also act as sedatives. They are
manufactured in your brain, spinal cord,
and many other parts of your body and are
released in response to brain chemicals
called neurotransmitters. The neuron
receptors endorphins bind to are the same
ones that bind some pain medicines.
However, unlike with morphine, the
activation of these receptors by the body's
endorphins does not lead to addiction or
dependence.
Regular exercise has been proven to:
 Reduce stress
 Ward off anxiety and feelings of depression
 Boost self-esteem
 Improve sleep
Exercise also has these added health
benefits:
 It strengthens your heart.
 It increases energy levels.
 It lowers blood pressure.
 It improves muscle tone and strength.
 It strengthens and builds bones.
 It helps reduce body fat.
 It makes you look fit and healthy.
Is Exercise a Treatment for Clinical
Depression?
Research has shown that exercise is an
effective but often underused treatment for
mild to moderate depression.
Cortisol, a glucocorticoid (steroid hormone), is produced from
cholesterol in the two adrenal glands located on top of each
kidney. It is normally released in response to events and
circumstances such as waking up in the morning, exercising, and
acute stress. Cortisol’s far-reaching, systemic effects play many
roles in the body’s effort to carry out its processes and maintain
homeostasis.

Of interest to the dietetics community, cortisol also plays an

important role in human nutrition. It regulates energy by selecting
the right type and amount of substrate (carbohydrate, fat, or
protein) the body needs to meet the physiological demands
placed on it. When chronically elevated, cortisol can have
deleterious effects on weight, immune function, and chronic
disease risk.
Cortisol (along with its partner epinephrine) is best known for its
involvement in the “fight-or-flight” response and temporary
increase in energy production, at the expense of processes that
are not required for immediate survival. The resulting biochemical
and hormonal imbalances (ideally) resolve due to a hormonally
driven negative feedback loop. The following is a typical example
of how the stress response operates as its intended survival
mechanism:

Whole-Body Effects of Elevated Cortisol

Blood Sugar Imbalance and Diabetes

Under stressful conditions, cortisol provides the body with glucose
by tapping into protein stores via gluconeogenesis in the liver.
This energy can help an individual fight or flee a stressor.
However, elevated cortisol over the long term consistently
produces glucose, leading to increased blood sugar levels.

Theoretically, this mechanism can increase the risk for type 2

diabetes, although a causative factor is unknown.1 Since a
principal function of cortisol is to thwart the effect of insulin—
essentially rendering the cells insulin resistant—the body remains
in a general insulin-resistant state when cortisol levels are
chronically elevated. Over time, the pancreas struggles to keep
up with the high demand for insulin, glucose levels in the blood
remain high, the cells cannot get the sugar they need, and the
cycle continues.

Weight Gain and Obesity

Repeated elevation of cortisol can lead to weight gain.2 One way
is via visceral fat storage. Cortisol can mobilize triglycerides from
storage and relocate them to visceral fat cells (those under the
muscle, deep in the abdomen). Cortisol also aids adipocytes’
development into mature fat cells. The biochemical process at the
cellular level has to do with enzyme control (11-hydroxysteroid
dehydrogenase), which converts cortisone to cortisol in adipose
tissue. More of these enzymes in the visceral fat cells may mean
greater amounts of cortisol produced at the tissue level, adding
insult to injury (since the adrenals are already pumping out
cortisol). Also, visceral fat cells have more cortisol receptors than
subcutaneous fat.

A second way in which cortisol may be involved in weight gain

goes back to the blood sugar-insulin problem. Consistently high
blood glucose levels along with insulin suppression lead to cells
that are starved of glucose. But those cells are crying out for
energy, and one way to regulate is to send hunger signals to the
brain. This can lead to overeating. And, of course, unused
glucose is eventually stored as body fat.

Another connection is cortisol’s effect on appetite and cravings for

high-calorie foods. Studies have demonstrated a direct
association between cortisol levels and calorie intake in
populations of women.3 Cortisol may directly influence appetite
and cravings by binding to hypothalamus receptors in the brain.
Cortisol also indirectly influences appetite by modulating other
hormones and stress responsive factors known to stimulate
appetite.

Immune System Suppression

Cortisol functions to reduce inflammation in the body, which is
good, but over time, these efforts to reduce inflammation also
suppress the immune system. Chronic inflammation, caused by
lifestyle factors such as poor diet and stress, helps to keep
cortisol levels soaring, wreaking havoc on the immune system. An
unchecked immune system responding to unabated inflammation
can lead to myriad problems: an increased susceptibility to colds
and other illnesses, an increased risk of cancer, the tendency to
develop food allergies, an increased risk of an assortment of
gastrointestinal issues (because a healthy intestine is dependent
on a healthy immune system), and possibly an increased risk of
autoimmune disease.4,5

Gastrointestinal Problems
Cortisol activates the sympathetic nervous system, causing all of
the physiologic responses previously described. As a rule, the
parasympathetic nervous system must then be suppressed, since
the two systems cannot operate simultaneously. The
parasympathetic nervous system is stimulated during quiet
activities such as eating, which is important because for the body
to best use food energy, enzymes and hormones controlling
digestion and absorption must be working at their peak
performance.

Imagine what goes on in a cortisol-flooded, stressed-out body

when food is consumed: Digestion and absorption are
compromised, indigestion develops, and the mucosal lining
becomes irritated and inflamed. This may sound familiar. Ulcers
are more common during stressful times, and many people with
irritable bowel syndrome and colitis report improvement in their
symptoms when they master stress management.5 And, of
course, the resulting mucosal inflammation leads to the increased
production of cortisol, and the cycle continues as the body
becomes increasingly taxed.4

Cardiovascular Disease
As we’ve seen, cortisol constricts blood vessels and increases
blood pressure to enhance the delivery of oxygenated blood. This
is advantageous for fight-or-flight situations but not perpetually.
Over time, such arterial constriction and high blood pressure can
lead to vessel damage and plaque buildup—the perfect scenario
for a heart attack. This may explain why stressed-out type A (and
the newly recognized type D) personalities are at significantly
greater risk for heart disease than the more relaxed type B
personalities.6
Fertility Problems
Elevated cortisol relating to prolonged stress can lend itself to
erectile dysfunction or the disruption of normal ovulation and
menstrual cycles. Furthermore, the androgenic sex hormones are
produced in the same glands as cortisol and epinephrine, so
excess cortisol production may hamper optimal production of
these sex hormones.5

Other Issues
Long-term stress and elevated cortisol may also be linked to
insomnia, chronic fatigue syndrome, thyroid disorders, dementia,
depression, and other conditions.4,5

Assessing Cortisol Levels

The adrenal stress index (ASI), a salivary test, is the preferred
test for adrenal function and a well-accepted, noninvasive, reliable
indication of cortisol levels.7-10 However, a trained professional
should interpret the results because factors such as age, gender,
timing with the menstrual cycle, pregnancy, lactation, smoking,
medications, medical conditions, caffeine and alcohol
consumption, caloric intake, and other test results (particularly
related hormone tests such as sex hormone levels) will
contextualize the significance and meaning of the
measurement.9,10

The ASI is available as a home kit. Four saliva samples are taken
at specific times and then shipped to a laboratory for analysis.
Conveniently, in addition to measuring the adrenal hormones
cortisol and dehydroepiandrosterone, the same test also
measures antibodies to gliadin, often used as a marker for
intestinal inflammation, Candida infections, and sensitivity to
gluten-containing grains. (Note that this test cannot diagnose
gluten sensitivity definitively.)7

A blood cortisol test is available, but it is considered inferior to the

salivary test for three reasons: It tests cortisol levels only at one
given point in time, which provides less information than levels at
four times (which reveals important imbalances); the blood test
itself (or simply going to the doctor) can stress a person enough
to cause a cortisol surge; and it is considered less sensitive
because it measures the total hormone level as opposed to
specific components.5
http://www.medscape.org/viewarticle/502825