Patient Case Study: Stress-Related Hypercortisolism and Subclinical Hypothyroidism

Initial Presentation

Eric was a 35-year-old attorney who presented with complaints of persistent anxiety, mild depressive symptoms, and low energy. A high-achiever in a demanding legal role, he described himself as “always on edge” and “never able to really relax.” He noted that work stress had worsened over the past two years, and despite his partner encouraging him to start antidepressant medication, he was strongly averse to using pharmaceuticals unless absolutely necessary. He was hopeful that an integrative approach could help him regain balance.

Eric denied a history of panic attacks or trauma, but endorsed longstanding difficulty setting boundaries at work, poor sleep quality, and a tendency to prioritize productivity over self-care. He exercised inconsistently (usually long runs on the weekend), typically skipped meals or ate on the go, and had no mindfulness or restorative practices in his routine.

Initial Relevant Labs

Initial lab evaluation included standard bloodwork and a functional HPA axis assessment, which revealed the following:

• Morning serum cortisol: 25 mcg/dL (elevated)
• TSH: 5.5 mIU/L with normal free T3 and free T4 (suggestive of subclinical hypothyroidism)
• Vitamin D: 25 ng/mL (suboptimal)
• Comprehensive salivary and urinary cortisol panel: Cortisol elevated across all points, consistent with HPA axis dysregulation (HPA-D) and hypercortisolism

Working Diagnosis

• HPA axis dysregulation (Hypercortisolism)
• Subclinical hypothyroidism
• Vitamin D deficiency

Initial Treatment

Eric’s treatment plan addressed multiple layers of dysfunction, from lifestyle foundations to targeted nutrient repletion. The following interventions were initiated:

• Lifestyle interventions:
  • Took a 1-month leave of absence from his legal work
  • Started Acceptance and Commitment Therapy (ACT) with a licensed therapist
  • Began Mindfulness Based Stress Reduction (MBSR), a meditation program with evidence for reducing anxiety (Hoge et al., 2014)
  • Overhauled sleep hygiene (aiming for 7.5–8.5 hours per night)
  • Began hiking 2–3 times per week and incorporated resistance training to support mood and metabolic health

• Nutrition & supplementation:
  • Whole-food, protein-rich diet low in ultra-processed foods
  • Vitamin D3: 5,000 IU daily with food
  • Magnesium glycinate: 300 mg at bedtime
  • Phosphatidylserine: 100 mg three times daily
  • Activated B-complex: 1 capsule twice daily

Explanation

This multi-pronged approach was aimed at reversing the physiological impacts of chronic stress and poor self-care. Elevated morning and diurnal cortisol patterns confirmed hyperactivation of the HPA axis—a key driver of Eric’s symptoms. Phosphatidylserine was selected for its evidence-based ability to blunt cortisol and improve perceived stress (Benton et al., 2001). Magnesium and B vitamins supported the stress response and nervous system resilience (Cuciureanu & Vink, 2011).

Suboptimal vitamin D was addressed with daily repletion, given its essential role in mood regulation and HPA modulation (Cheng et al., 2020). The subclinical hypothyroidism was monitored closely but not treated pharmacologically, as it was suspected to be secondary to stress-related suppression of hypothalamic-pituitary-thyroid (HPT) signaling.

Importantly, Eric’s own motivation and readiness for change were central to the success of this intervention. His commitment to therapy, meditation, and time away from work laid the groundwork for recovery.

Follow-Up Presentation

At his 4-week follow-up, Eric reported meaningful improvements in energy, sleep, and emotional regulation. He had resumed light work duties with improved boundaries and described feeling “more grounded” and less reactive to stressors. He noticed fewer mood swings and more mental clarity throughout the day.

After 3 months, Eric continued to feel significantly better. His anxiety was markedly reduced, energy was sustained, and he described feeling more “resilient” in the face of challenges that previously would have derailed him. He continued to meditate daily, exercise regularly, and prioritize downtime.

Follow-Up Testing

• Vitamin D: 45 ng/mL → Supplementation reduced to 2,000 IU daily
• Morning serum cortisol: 12 mcg/dL → Now within optimal range
• TSH: 3.2 mIU/L → Trending toward normalization

Follow-Up Treatment

• Discontinued phosphatidylserine
• Continued magnesium, B-complex, and vitamin D (at a lower dose)
• Continued ACT therapy and meditation practice
• Ongoing emphasis on work-life balance and consistent movement

Case Summary

This case illustrates how stress-related HPA axis dysregulation can present with symptoms that mimic or overlap with anxiety and depression—and how effective non-pharmacologic approaches can be when the root cause is addressed.

Rather than treating the symptom of anxiety in isolation, the upstream drivers of Eric’s presentation were explored and addressed: chronic stress, poor boundaries, sleep deprivation, and micronutrient depletion. Through foundational lifestyle redesign, targeted nutrient repletion, and nervous system retraining, Eric experienced a meaningful and sustainable transformation.

This case highlights the value of a patient-centered, functional approach to mental health—especially in highly motivated individuals who prefer to avoid medication. It also underscores the physiological impact of chronic stress on both the HPA and thyroid axes, and the importance of giving patients the tools to shift out of chronic fight-or-flight physiology.