Adrenal insufficiency

Page most recently updated 7 September 2026

This page focuses on the reported psychiatric associations, which may be the initial presenting manifestation, and on other clinical features that may assist the psychiatrist or primary care physician in identifying the underlying diagnosis, considered through the lenses of the diagnostic lenses framework.

Adrenal insufficiency is an endocrine disorder characterized by inadequate production or action of adrenal hormones, resulting in multisystemic effects.

It can present with psychiatric features such as depression, anxiety, irritability, apathy, fatigue, cognitive impairment, behavioural change, and, less commonly, psychosis, particularly in severe or prolonged adrenal insufficiency.

Other characteristic features include neurological manifestations such as weakness, lethargy, dizziness, headache, and, in adrenal crisis, confusion or altered consciousness. Severe glucocorticoid deficiency may produce profound neuropsychiatric symptoms that can resemble a primary psychiatric disorder.

From a multisystemic lens perspective, clinical features in other body systems include (but are not limited to):

  • Cardiovascular: hypotension, orthostatic hypotension, reduced vascular tone, and, in adrenal crisis, cardiovascular collapse.

  • Renal/electrolytes: hyponatraemia, hyperkalaemia (particularly in primary adrenal insufficiency), hypoglycaemia, and volume depletion are characteristic metabolic abnormalities.

  • Gastrointestinal: anorexia, nausea, vomiting, abdominal pain, diarrhoea, and weight loss are common.

  • Endocrine: primary adrenal insufficiency may cause hyperpigmentation due to increased ACTH, while secondary adrenal insufficiency generally lacks hyperpigmentation and may be associated with other pituitary hormone deficiencies.

  • Musculoskeletal: muscle weakness, fatigue, and generalized aches may occur.

  • Dermatologic: hyperpigmentation of the skin and mucous membranes is characteristic of primary adrenal insufficiency.

Early diagnosis is important to enable prompt glucocorticoid replacement, prevent potentially fatal adrenal crisis, correct associated metabolic abnormalities, identify and treat the underlying cause, and reduce potentially reversible neuropsychiatric and systemic complications.

Selected references and further reading — Multisystemic lens

Cardinal RN, Bullmore ET. The diagnosis of psychosis. Cambridge: Cambridge University Press; 2011.

Sachdev PS, Keshavan MS, editors. Secondary schizophrenia. Cambridge: Cambridge University Press; 2010.

Levenson JL, editor. The American Psychiatric Association Publishing textbook of psychosomatic medicine and consultation-liaison psychiatry. 3rd ed. Washington (DC): American Psychiatric Association Publishing; 2019.

Stern TA, Beach SR, Smith FA, Freudenreich O, Vranceau AM, Fava M, editors. Massachusetts General Hospital handbook of general hospital psychiatry. 8th ed. Philadelphia: Elsevier; 2025.

Arciniegas DB, Yudofsky SC, Hales RE, editors. The American Psychiatric Association Publishing textbook of neuropsychiatry and clinical neurosciences. 6th ed. Washington (DC): American Psychiatric Association Publishing; 2018.

Agrawal N, Faruqui R, Bodani M, editors. Oxford textbook of neuropsychiatry. Oxford: Oxford University Press; 2020.

Boland R, Verduin M, editors. Kaplan and Sadock's comprehensive textbook of psychiatry. 11th ed. Philadelphia: Wolters Kluwer; 2024.

Loscalzo J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL, editors. Harrison's principles of internal medicine. 22nd ed. New York: McGraw Hill; 2025.