Does stress affect multiple sclerosis?
Part 1 of 2
It’s commonly believed that stress makes multiple sclerosis (MS) worse – that you’re more likely to have a relapse during those high-tension periods in your life. As far back as 1868, Jean-Martin Charcot, who was the first to describe modern-day MS, suggested that MS might be related to “long-continued grief and vexation” (Charcot JM. Gazette des hopitaux 1868;41:54-555). A nineteenth century case seemed to confirm the report when it suggested that MS was caused by a woman learning that her sister had just died in childbirth (Moxon W. Lancet 1873;236).
But what do we mean when we talk about “stress”? Is it a physical thing (difficulty getting around), an emotional thing (difficulties in your marriage), either or both? Is problem stress one big crisis (being diagnosed)? Is it the drip-drip of daily mini-crises that wear you down? Or is it just the fact of living with MS?
Does it matter if a stress is negative or positive? Is a fight with your spouse more “damaging” than running a marathon? What about a person’s individual response to stress? A divorce is highly stressful. But one person may perceive it to be the end of the world, while the other sees it as the end of stress and the start of a new life.
So “stress” is a slippery concept that’s difficult to grab. Is stress something we need to avoid at all costs? Hans Selye, a pioneer in the field (he wrote 30 books on stress), said that all life events cause some stress. The only complete freedom from stress is death – so stress cannot be avoided. It’s part of the fabric of life.
Can stress cause MS?
In the 1930s, Selye was struck by the idea that physical and mental stressors (a term he coined) have profound effects on the body. The general concept that emerged was that acute stressors mobilize the body to action and increase the immune response, whereas chronic stressors tend to have the opposite effect. If stressors influence how the immune system works, it’s fair to ask if a person living a stressful life has a greater risk of developing MS.
There’s no evidence that stress in itself is a cause of MS. An analysis of over a quarter-million women in the Nurses’ Health studies found that people with high levels of stress at home were not more likely to develop MS (Riise and colleagues. Neurology 2011;76:1866-1871). Even people suffering the extreme stress of physical or sexual abuse weren’t at higher risk of MS. One study isn’t definitive, but it does suggest that stress – whatever its effects on the immune system – doesn’t play a major role in the development of MS.
Can stress make my MS worse?
Numerous studies over the years have looked at whether stress can trigger an MS relapse. A decade ago, a meta-analysis of 14 studies found that there was an increased risk of having a relapse following a stressful life event (Mohr and colleagues. Br Med J 2004;328: 731). The effect was small, but the authors noted that the harmful impact of stress on relapses was actually greater than the beneficial effect of interferon-beta on relapses. A subsequent meta-analysis agreed that stress can worsen MS, but found it was a little difficult to be definitive because of the way the studies were done (Artemiadis and colleagues. Neuroepidemiology 2011;36:109-120).
Different studies may measure different kinds of stress so it isn’t clear if certain types of stressors cause more problems than others. At the extreme end is the stress of war. During the war between Israel and Lebanon in 2006, Israelis with MS experienced an increase in relapses (Golan and colleagues. Ann Neurol 2008;64:143-148). The people who were worse off were those who reported the highest level of stress. That is, the perceived threat (and how you cope) appears to be as important as the physical threat itself. Another observation was that people felt the stress more acutely when they were having a relapse compared to when they were in remission, presumably because they felt more physically vulnerable.
So the stress-relapse relationship works both ways. Stress worsens MS, but MS also worsens your feelings of stress.
Meanwhile, things were equally as bad in Lebanon. A University of Beirut study found that during the July war, about 1 in 10 Lebanese people with MS had a relapse in that month (Yamout and colleagues. J Neurol Sci 2010;288:42-44.). One-third of the people having an MRI during the war had a flare-up of new brain lesions, indicating that their symptoms were true relapses.
Fearing for your life in a war zone is admittedly an extreme example but it serves to show that high levels of stress can trigger a relapse. A Canadian study also found that severe life events, such as having an affair, marital friction or a loved one moving away (mentioned in almost half the examples), were common in the six months before a worsening of symptoms (Grant and colleagues. J Neurol Neurosurg Psychiatry 1989;52:8-13.).
However, a single, severe stress may not pose the biggest problem. A study in the Netherlands asked people to keep a diary of their stressful events and relapses (Buljevac and colleagues. Br Med J 2003;327:646). The stressors were what you might expect: an illness, problems in the family, job hassles, a death in the family, money troubles, a close friend’s illness or death, problems with their spouse or partner, and so on. Even a vacation was seen by some as a source of stress. Overall, the risk of having a relapse was doubled in the week after a stressful event.
This list combines acute and chronic stressors – some may resolve in a day, whereas some may grind on for years. But opinion is divided between which is the more “toxic”. A further source of confusion is which is the greater stressor: MS or non-MS life events.
An Australian study tried to tease apart some of these complexities by categorizing stressors as a personal emotional threat (likely to worsen feelings of anxiety or depression) or as a goal frustration (likely to block personal goals, thereby causing anger and frustration) (Brown and colleagues. Mult Scler 2006;12:453-464). Each of these was then classified as acute (lasting fewer than six months) or chronic (longer than six months). Also considered was whether the stressor was related to MS (e.g. remodelling your home to accommodate a wheelchair) or unrelated to MS (e.g. death of a family member).
So what did they find when all of this slicing and dicing was done?
First of all, life events unrelated to MS were far more common than MS-related stressors. And emotional stressors were more important than frustrations. Overall, relapses were more common in people experiencing a high cumulative number of emotional stressors. Most of these life events weren’t terribly stressful in themselves. What was important was the number of stressors. People could shrug off one or two problems. But as these problems accumulated, there was an increasing likelihood of having a relapse within the next three months.
One other observation is also important to consider. When asked about positive and negative stressors, people reported twice as many negative events. Other studies have found this as well – that people with MS report having fewer positive experiences in their lives, and fewer uplifting moments. Seeing the glass half-empty has its consequences. But it also raises the possibility that just as negative life events seem to worsen MS, positive life events may actually have a protective effect.
In Part 2 we’ll look at what can be done about stress. Click to read Part 2
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