Stress is one of those fuzzy psychological constructs. It is usually defined as a state of mental or emotional strain, and a chronically ill friend of mine used to call it the “dirty little secret of chronic illness.” Why? Because stress makes every autoimmune disease worse, but patients don’t like to admit that to their physicians since, she would explain, their doctors then blame everything on it.
When I was young and broke and doing ill-paid grunt work that came with minimal or no health insurance, I found out that stress was also the disease of the underinsured.
Apparently, being poor is extremely stressful, because every ailment — even, in the case of my partner, jaundice and peritonitis — was the result of “stress.” What was even more surprising was that, as our incomes and health insurance improved, even though we were then working longer hours at more demanding jobs, our physicians felt that our stress decreased, only to be offset by an increase in our ill-health.
I think that’s why I tend to develop a facial tic whenever I hear something blamed on “stress.” Like that study of people with chronic urticaria in which the researchers found that the patients were depressed and assumed that the chronic urticaria was the result of depression, rather than the other way round.
Think about it. By definition, chronic urticaria means having hives pretty much all day, every day, for over six weeks. Can you imagine what it’s like to itch like crazy and want to tear your skin off for over six weeks — and have your doctors fail to help you? Would it really surprise you if you were depressed after a month-and-a-half of this torture?
When I see a study like that one, I feel as though it is simply a monument to the failure of empathy on the part of some clinicians.
While it may annoy me to see researchers blame “stress,” I can never object to rigorously designed research studies, and while reading the January/February issue of Arthritis Today, I read a squib on a very interesting study. Intrigued, I dug it out.
Here’s what Slavich, Way, Eisenberger, and Taylor did: They took 124 “healthy young participants.” So they were not working with people who had chronic illnesses. These were healthy kids. What they had them do was the Trier Social Stress Test, “…which involves preparing and delivering an impromptu speech and performing difficult mental arithmetic in front of a nonresponsive, socially rejecting panel of raters.”
The researchers intentionally put the participants through a socially stressful experience that involved an element of rejection.
Then, they collected “oral fluids” (is that a euphemism for spit?) during the test and determined the levels of “two key markers of inflammatory activity — namely, a soluble receptor for tumor necrosis factor-α (sTNFαRII) and interleukin-6 (IL-6).” The latter half of that sentence may look like gobbledygook to you, but the key point is that they looked for biochemicals that promote inflammation. And guess what? The stressed participants had significantly elevated levels of those substances. The authors note, “These effects did not differ as a function of gender, ethnicity, or body mass index (BMI)….”
Next, they took a subset of the participants and had them play a computer game, “…In which participants were ultimately excluded by two other supposed players, leading to an experience of social rejection.” While they were doing this, the researchers examined how well the increases in inflammatory cytokines correlated with neural activity. They found that areas of the brain that are “involved in processing rejection-related distress” were more active the higher the levels of the inflammatory substances.
So what does this mean? It means that “talk to the hand” has more far-reaching consequences than we would have guessed.
The authors comment:
Although we did not assess health outcomes in the present study, it is possible that individual differences in magnitude of inflammatory responses to social stress may have implications for health. Specifically, they may help to explain the considerable variability that has been observed in susceptibility to disorders with an inflammatory component, including asthma, arthritis, cardiovascular disease, certain types of cancer, and depression. Risk for depression, for example, increases substantially following rejection-related life events, but not all people who experience rejection become depressed. Greater neural responses to rejection may be associated with greater inflammatory activity, which is subsequently reflected in the pathogenesis of inflammatory-related disorders such as depression.
Unlike the authors of the earlier study I mentioned, Slavich, et al., are aware that their study is correlational and that causality cannot be proven.
Still they wonder “why neural sensitivity to social rejection would relate to inflammatory responding,” and they hypothesize that “to the extent that physical threats are more likely to occur in situations that involve social threat or rejection, social rejection may trigger inflammatory activity to manage the possibility of injury.” They also note that inflammation can lead to what they call “sickness behaviors,” which may reduce the potential for further conflict.
Recently, there’s been a lot of discussion about the issue of kids being bullied in school. This research provides a very sound reason why parents, teachers, and administrators should do everything they can to minimize children being ostracized or picked on. Not all children may be genetically inclined to respond to rejection with an increase in inflammation, but for those who are, that bullying could have long-term negative effects on the children’s health.
The study also suggests that the way that doctors may respond to patients can have an influence on how they feel. Something that I have seen over and over again in moderating online groups is the following scenario: A young woman in her 20s or early 30s starts feeling unwell. She aches and activities that used to be fun are now painful. She goes to see her GP, only to be told, after a workup for various rheumatic conditions, that there’s nothing really wrong with her. What I see, again and again, is that the woman responds with anger and confusion. She perceives the doctor’s response as a rejection of her, personally, and an attempt to invalidate her experience. She may give up on exercising and comfort herself with food that helps to pack on the pounds, which only makes the problem worse. Ultimately, she is diagnosed with one or more disabling autoimmune diseases.
I just wonder if this story could turn out differently if the medical community was more supportive and encouraging early on. Having a negative RF test does not mean that one is “fine.” I have never tested positive for RA, and yet my inflammatory arthritis is now disabling.
There’s much more work that needs to be done if we are to really understand the neurocognitive pathways through which experience and immunology interact, but this study provides some food for thought.
- Özkan M, Oflaz SB, Kocaman N, Ozseker F, Gelincik A, Buyukozturk S, et al. Psychiatric morbidity and quality of life in patients with chronic idiopathic urticaria. Ann Allergy Asthma Immunol. 2007; 99:29–33.
- Slavich GM, Way BM, Eisenberger NI, Taylor SE. Neural sensitivity to social rejection is associated with inflammatory responses to social stress. Proceedings of the National Academy of Sciences of the United States of America. 2010; 107:14817–22.
- Stress Reduction Kit, photo by programwitch/K Latham: “This This photo was taken on October 4, 2007.”
- Talk to the hand, photo by catfordCelt/martin allen: “This photo was taken on October 26, 2008 using a Canon EOS 40D.”
Copyright © 2011 by Candace L. Van Auken. All rights reserved.