Managing Stress

Stress can exacerbate arthritis pain, as well as other conditions harmful to your health. Chill out, and feel better now by managing stress intelligently.

Chuck Currie, 35, knows plenty about managing stress. From serving sandwiches at Baloney Joe's soup kitchen to running operations for the Goose Hollow Family Shelter in Portland, Ore., Currie worked with the homeless, one of the nation's most stressed populations, for 17 years. He witnessed people suffering from disabling health conditions and teenagers dying from AIDS.

Two years ago when Currie moved to St. Louis, changed his career path and started a Master of Divinity program, he experienced a surge in his own stress. Help didn't come easily. "Moving, changing careers and entering seminary were all stressful things that happened in quick succession," he says. At the same time, Currie began experiencing swollen and painful joints in his hands and feet. At times his symptoms were so severe he couldn't get out of bed; twice the flares sent him to the emergency room. Currie, who has psoriasis, had developed psoriatic arthritis, an inflammatory joint condition occurring in roughly 23 percent of people with psoriasis.

As Currie experienced, stress packs a powerful wallop for people with autoimmune diseases, because some of the biological pathways that ignite the stress response are the same pathways involved in immune-system malfunctions. For people with arthritis and other inflammatory diseases, stress prompts the release of chemicals in the brain and body that can trigger flares, inflammation and pain. To make matters worse, some of those chemicals, like cortisol, increase the risk of developing other chronic health conditions, such as heart disease, obesity, anxiety and depression, which can often create more stress. Managing your health after this cycle takes hold can seem like jumping for a helium-filled balloon that's floating out of reach. Luckily, what goes up can come down, and managing stress through reduction techniques can help restore your system's balance and protect your overall health.

Chemical messengers

What exactly is stress? Hans Selye, MD, known as the "Father of Stress," defined stress as our response to any demand or stressor. Traffic jams. Tiffs with family members. Long waits at the post office. Many people experience stressors like these every day. If you're living with arthritis, you know a chronic condition can heap additional stressors on the pile. Stiff joints can slow you down in the early morning, making you late for work. A favorite pastime like needlepoint can go from relaxing to aggravating. Joint pain can keep you up at night, making you feel sluggish and cranky the next day. The potential result? Stress overload.

When we're sailing through life without any hurdles, our body's organs and the chemicals they produce are balanced. When we experience a stressor – for example, when our car fishtails on a slick highway – our bodies respond by activating chemical messengers, says George P. Chrousos, MD, chief of the National Institute of Child Health and Human Development, Pediatric and Reproductive Endocrinology Branch, National Institutes of Health, in Bethesda, Md. The chemical message starts in the hypothalamus, the master gland in the brain, which spits out a hormone that zings over to the pituitary gland, which shoots out another hormone that signals the adrenal glands to release stress hormones, including epinephrine (adrenaline), norepinephrine (noradenaline) and cortisol.

These releases occur in seconds and help fuel our natural fight-or-flight response – the jolt that enables us to focus and react, and right our fishtailing cars. When these chemical messengers work well, they help us navigate around life's punches: a fever breaks, a bad mood lifts, pain subsides. But, when one or more of these chemical messengers doesn't do its job just right, the balance can go down with the punch. Stress hormones also control other chemical messengers that influence biological processes such as body temperature, heart rate, blood pressure, appetite, metabolism, mood, sleep, fertility, pain perception and immune system responses.

In Currie's case, his psoriasis was significantly linked to stress. In fact, a Finnish study found that men, in particular, were more likely to experience psoriasis and joint pain when stressed. "It's cyclical," says Currie, "because the stress level will impact my arthritis, and the arthritis will impact my stress level."

Shared pathways

Because people with arthritis are already experiencing inner body stressors that affect cortisol production due to their disease, researchers are now examining how cortisol levels are affected by external daily stressors in people who have arthritis, as well as in those who don't.

Researchers at Pennsylvania State University's Milton S. Hershey Medical Center in Hershey, recently studied how a stressor such as sleep loss (six hours of sleep instead of the recommended eight) affected 25 young, healthy college students. After one week with less sleep, the students' blood tests showed decreases in cortisol and increases in cytokines, chemicals that spark inflammation – changes also found in people with RA even when they get a full night's sleep.

With chronic stressors like consistent sleep loss, would the healthy college students be more susceptible to developing RA? While experts agree that many factors, including heredity, likely contribute to a person's chances of developing conditions like RA, stress is one of the suspected culprits. The reason? The stress response and the immune response share some of the same pathways.

"The processes that fire up the immune system and lead to the proliferation of inflammation-inducing chemicals are the same processes that are stimulated by stress," says Alex Zautra, PhD, an Arthritis Foundation-funded researcher and professor of psychology at Arizona State University in Tempe.

Some experts believe there's a chicken-and-egg predicament involved: Immune system hiccups can cause stress, and stress can cause immune system hiccups in susceptible people. Who's susceptible? Experts say it depends on how we are "wired."

Wired for stress

Researchers have a number of theories about how people become wired, or rather miswired, for stress. For instance, exposure to chronic, ongoing stressors such as living with arthritis or caring for an aging parent, can impact chemical messengers. Ohio State University, Columbus, researchers measured an inflammatory chemical in older adults and found those who were taking care of a chronically ill spouse had four times the amount of it in their blood compared to non-caregivers. The increased inflammation marker persisted in the caregivers years after the sick spouse died, indicating that changes to stress circuitry can have long-lasting effects.

Fetal exposure

Some people can be predisposed to stress at birth. Malnutrition in pregnant women, for example, can lead to low birth weight and stress in the fetus, which can set the child up for a lifelong hyperactive stress response, says Dr. Chrousos. Every time these small children are stressed, they have a big response. By the time they are 35 or 40 years old, they have metabolic syndrome, which includes high blood pressure, high blood lipid levels, obesity, glucose intolerance and excessive cytokines in the blood. Having that constellation of risk factors, says Dr. Chrousos, predisposes people to higher rates of atherosclerosis, heart attacks, strokes, diabetes and early death. 

Trauma

Physical or psychological trauma – sexual abuse or losing a loved one, for example – can also change stress circuitry in some people. Some researchers think post-traumatic stress disorder (PTSD) occurs when, during the initial trauma, the norepinephrine that is released to help imprint memories acts too strongly or too intensely on the brain. People with PTSD have recurring, unbidden memories or flashbacks of their trauma, as well as nightmares and insomnia, which can keep their stress and norepinephrine levels high long after the trauma occurred. People with fibromylagia who have symptoms of PTSD – 56 percent in one study – have higher levels of pain and stress than those with no PTSD symptoms. 

Hormones

Women appear more susceptible to stress than men. The culprit? Estrogen. While intense stress suppresses estrogen production in the body – which is partly why female athletes who train intensely can stop menstruating – estrogen itself seems to make the brain more responsive to stress. Interestingly, men with RA tend to have elevated levels of pro-inflammatory estrogens and decreased levels of testosterone, an anti-inflammatory hormone, compared to men without RA.

Socioeconomic status

People with low education levels have more acute or severe daily stressors, according to a recent study from Wake Forest University School of Medicine in Winston-Salem, N.C. For instance, rain is an inconvenience to an office worker, but it means lost wages to an outdoor laborer. Your socioeconomic status also determines the type of resources you have to deal with stress, says study leader Joseph G. Grzywacz, PhD. Massages, mental health counseling or health-club memberships don't come easily to those struggling to meet basic life needs.

"Stress is really a component of every disease," says James Rosenbaum, MD, chair of the Division of Arthritis and Rheumatic Diseases and the Edward E. Rosenbaum professor of inflammation research at Oregon Health & Science University in Portland. Take a look at the adverse health effects: 

Increased abdominal fat, obesity. Researchers now know that excess cortisol ushers fat toward a person's middle, where the fat deposits and builds up around the abdomen. Even relatively thin, healthy women under chronic stress can exhibit some fat buildup around the middle. Excess abdominal fat and obesity are risk factors for heart disease and diabetes, and this type of fat secretes copious proinflammatory chemicals, worsening inflammation. 

Diabetes. Obesity is a leading cause of diabetes, but the chemical imbalances caused by stress, regardless of obesity, can also trigger type 2 diabetes development. Researchers at the University of Washington, Seattle, found that increased levels of fear, lack of control and depression raise levels of glucose and insulin, each of which are danger signs for diabetes.

Cardiovascular illnesses. Acute stress increases blood pressure and constricts blood vessels, both cardiovascular concerns, and stress can also pump up levels of cholesterol, triglycerides and homocysteine – all heart disease indicators. 

Sleep disturbances. In a 2003 nationwide sleep poll, 72 percent of people with arthritis reported sleep problems. Loss of deep, restorative sleep can be attributed to stress and can lead to insomnia. People not sleeping can then stress about losing sleep, and another cycle begins. Sleep deprivation, in turn, can prevent the brain from modulating pain.

Mental health challenges. Stress alters neurotransmitters that regulate mood and emotion, leaving a person more susceptible to depression and anxiety. Depression can also worsen inflammatory conditions. For example, a study out of Stanford University Medical Center, Calif., discovered that people who are depressed experience two times more chronic pain than those who are not depressed. "Depression itself has been associated with elevations in proinflammatory cytokines," says Zautra. "That's independent of whether the person has arthritis. So when you combine these factors, they become a more potent brew."

Premature aging. Connections among stress, premature aging and decreased lifespan were recently identified in a University of California, San Francisco (UCSF) review of women, aged 20 to 50, who were caregivers to children living with a chronic illness, such as autism. Compared to women of the same age who were caring for healthy children, chronic stress levels speeded up the aging process in the women caring for sick children. Researchers found that stress accelerated the division of telomeres on the end of chromosomes. As the chromosomes divide, telomeres get shorter, causing weakened muscles, deterioration of vision and hearing, increased aging of the skin, mental decline and failing organs. 

Managing stress

Although stress can take quite a toll on the body, as Dr. Selye first examined, stress is our response to a stressor. By practicing methods of stress reduction, you can decrease the damaging effects of stress. The trick to stress reduction is finding strategies that work best for you, says Dr. Rosenbaum. One person might find taking a drive in the country relaxing, while another might find the time behind the wheel stressful. Knowing you have the resources to deal with your disease and feeling empowered to control your health as much as possible can reduce the stress-load of having a chronic condition, says Dr. Rosenbaum. Bolster your stress management techniques by adding new ones to your repertoire, such as:

Release self-defeating thoughts. Becoming aware of judgments about your health and body, such as "I'm too young to have pain" or "I should be stronger than this," can ignite the stress response. Mindfulness-Based Stress Reduction (MBSR) may help people let go. It involves recognizing stressors, and letting them drift away like clouds, says Trish Magyari, the MBSR program director at the Center for Integrative Medicine at the University of Maryland Medical Center in Baltimore. "People learn that self-defeating thoughts are doorways to the pit of their own personal despair. If they can learn to see the doorway, they can learn they don't have to go through it," says Magyari.

Breathe and focus. One MBSR technique for managing stress is diaphragmatic breathing, which is done by consciously taking deep breaths in through the nose, out through the mouth and expanding the diaphragm. Progressive skeletal muscle relaxation -- a series of tightening, holding, then releasing muscle groups in procession from toes to face – and imagery or focused attention – centering on a word, phrase or image to relax -- also are used.

Vent. Releasing anger, hurt or other negative emotions can diminish stress. A study of the effects of keeping a journal by researchers at Southern Methodist University, Dallas, found that those who logged 20 minutes a week for four weeks lowered their blood pressure, easing physical reaction to stress. Help can be found by writing in a daily journal, calling a friend or joining a support group, providing a daily or weekly vent needed to keep stress from building.

Cap your sweet tooth. A body under stress craves carbs and sweets when the extra cortisol produced in response to stress triggers the cravings. While carbs and sweets release feel-good endorphins, the effects are short-lived and the body begins to crave more, again putting a person in a hard-to-break cycle. UCSF researchers studied women with high levels of cortisol and found the participants turned to sweets and ate more after stressful events. Studies indicate that a diet rich in fruits, vegetables and proteins lowers cortisol levels.

Turn off the TV and get moving. Sedentary behavior, like chronic television watching, is associated with weight gain and increased health risks – hence, more stress. A recent Harvard University, Cambridge, Mass., study concluded that men who watched TV more than 40 hours per week had almost three times the risk of developing diabetes, compared to men who watched TV for less than an hour per week. Get a break in routine by taking short, brisk walks when stress starts to build. Yoga and tai chi are more meditative forms of exercise that can also be easy on the joints, providing flexibility and strength training as well as stress relief. A study from Reed College in Portland, Ore., suggests 90 minutes of yoga reduces perceived stress as well as salivary levels of cortisol; other studies have shown two to three hours of tai chi a week improves sleep quality and mental health.

Medication. As inflammatory chemicals ignite or perpetuate swelling and pain, pharmaceutical companies design drugs that target or block those specific chemicals to reduce inflammation. For example, the biologic response modifiers (BRMs) adalimumab (Humira), etanercept (Enbrel) and infliximab (Remicade) target and block the proinflammatory chemical TNF-a, which accumulates in the joints of people with certain types of arthritis, like RA, contributing to flares and tissue damage. Researchers are now reviewing if stress reduction itself can work like a BRM and block the build-up of proinflammatory cytokines in people with autoimmune diseases. If stress relievers like practicing breathing techniques or following a more nutritious diet don't work, a doctor can provide short-term relief for acute stress or severe anxiety through medication.

To keep his stress in check, Currie practices meditative prayer and exercises to his ability, which is especially important now that he's taken on a new stressor in his life – parenthood. He and his wife are experiencing twice the stress – and twice the joy – after welcoming twin daughters last July. While not all stress is avoidable, and some can even spur you on to try new experiences and grow, you can find strategies that help you overcome detrimental stress or stress overload so you're less susceptible to flares.