Find out about the evidence behind stress management and MS.
Stress has been recently dubbed ‘the health epidemic of the 21st century’*. Up to 19% of total health expenditure is thought to be attributable to stress-related illness (Cigna 2019). Alongside this, a wealth of evidence is mounting around the impact of stress on the physical, emotional and cognitive functions of the body (O’Connor 2021). There can be no dispute that supporting people’s ability to manage stress effectively is an essential part of preventative healthcare and supported self-management.
For people with MS, there are multiple factors making stress management both more challenging, and more necessary than for others – both for management of symptoms and in slowing progression of MS itself. Learning the importance of balancing their nervous system and managing stress effectively is an essential part of living with MS.
*This term has been consistently attributed to the World Health Organisation, although its original reference is not forthcoming.
A stressed nervous system is an imbalanced nervous system, spending more time in a sympathetic (fight and flight) than parasympathetic (rest and digest) state. The sympathetic response is needed to activate the body in times of stress, increasing heart rate, diverting energy to the muscles and releasing glucose for energy. The parasympathetic nervous system supports homeostasis – maintaining effective digestive, reproductive, endocrine and immune systems (Waxenbaum 2023).
MS is known to affect the autonomic nervous system, with detailed research into dysregulation of the sympathetic and parasympathetic systems as relates to biological functions (Pinter 2015). A number of common MS symptoms, including disordered sleep, mood, pain and fatigue, can all also be caused by a dysregulated or maladapted nervous system (sleep: NASEM 2023; mood: Furuyashiki 2019; pain (Abdallah 2017), suggesting that some symptoms may be alleviated or improved through deliberately balancing the nervous system.
Stress also affects mitochondrial function (Eisner 2018) which in turn has been found to cause or increase fatigue (Wood 2021) and reduce our stress resilience (Morató 2020) creating a potentially damaging cycle, whilst the latest research into mitochondrial function demonstrates the complex impact of stress on the mitochondrial role in illness and healing (Naviaux 2019).
Finally, there is compelling evidence around stress’ impact on pain, mood and sleep, which, in a complex interplay, can all impact each other either positively, or negatively (Peel 2023) whilst the link between stress and fatigue is well researched (see the section on ‘psychological trauma and biological illness’).
In addition to the evidence around nervous system imbalance and its potential to impact symptom expression, there is also clear evidence that stress can directly impact disease activity itself.
Patterns have been found between increased stress and relapse (Polick 2023; Jiang 2022). A significant epidemiological study examining the impact of stress across the lifespan, and specifically examining stress experience pre-18 years old and post-18, found that stress correlates with a higher level of disability across the lifespan, whether in children or adults. Researchers also noticed that in adults, stress was associated with more severe relapse, although interestingly, this was not the case in children and young adults (Polick 2023).
Negative stressful life events have been found to increase risk of new brain lesions (Burns, 2014), whilst another study found that stress induced grey matter atrophy. Findings also included stress-induced cerebral function in people with MS regardless of the cognitive load of the stressor, and researchers concluded that ‘stress-induced brain activity reflects clinical disability in MS’. However, they also noted some similar stress-induced activity and grey matter atrophy in controls suggesting that MS is not the sole cause of these outcomes (Weygandt 2016).
Studies in psychoneuroimmunology studying the links between the brain, the nervous system, and the immune response have demonstrated the complex but significant interplay between stressors and immune function (Salleh 2008). Whilst the biological impact of psychological trauma has been well documented in work by eminent practitioners such as Drs Bessel van der Kolk (2015) and Gabor Maté (2019).
There is no assumption that all people with MS will have experienced trauma (though Maté’s work suggests that trauma is more common than not), however a 2021 study reviewing the severity of MS fatigue through a psychodynamic lens concluded that there is clearly an ‘asymbolic trauma-related perspective on MS-fatigue’ (Pust 2021). Additionally, there is some suggestion that the diagnosis of MS itself can cause trauma in and of itself, with a preliminary study finding that diagnosis had triggered post-traumatic stress disorder in some people with MS (Giovannoni 2022).
Symptoms such as fatigue, pain, low mood and disordered sleep are found in other conditions where a maladaptive stress response is thought to be at play such as ME, CFS and fibromyalgia (Arrol 2013) and several studies have found significant reduction, or even complete recession of, these symptoms by addressing that stress response and through an integrative approach to psycho-biological healing (Howard 2011; Arroll 2012).
This may suggest that, for some people with MS who also have a maladaptive stress response, symptom burden might be lessened through psychotherapeutic work and active management of stress triggers and responses.
Managing and relieving stress is very specific to the individual, and there are many proven examples including exercise (Puterman, 2010; Sharon-David, 2017), journaling (Baike, 2005), meditation and mindfulness (APA, 2019) and creativity (Kaimal, 2016).
Overcoming MS specifically advocates for use of mindfulness-based stress reduction techniques as a way to reduce stress, given the negative impact of stress on MS symptoms and disease progression (see ‘Stress and MS’) The use of breathing, and grounding oneself in the present to alleviate stress are all actively advocated for by the World Health Organization in their global practical guide (WHO 2020).
Meditation may help to reduce stress and balance the nervous system by deliberately activating the parasympathetic ‘rest and digest’ system through calming the mind and steadying and slowing the breathing. A systematic review and meta-analysis of over 17,000 citations found that mindfulness meditation programmes had a moderate improvement effect on anxiety, depression and pain levels after just 8 weeks and a small but significant reduction in psychological stress (Goyal 2014). The researchers noted that as meditation is designed to be a long-term practice, these effects may increase over time. Meditation has also been found to reduce the inflammation caused by the stress response (Rosenkranz 2013).
A large part of meditation is slowing and steadying the breath, and a wealth of studies have also looked at the effect of deliberately slow breathing on physical and emotional health. One systematic review concluded that breath techniques can ‘enhance autonomic, cerebral and psychological flexibility’ which ‘related to emotional control and psychological well-being’ (Zaccaro 2018).
In people with MS specifically, a study found meditation increased quality of life and reduced depression, anxiety, and sleep problems after an 8 week period although the results were not maintained after six months highlighting the importance of multiple management techniques (Cavalera 2019).
Mindfulness, also advocated for by Overcoming MS, is the practice of being present in both the body and mind, or ‘the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment’ (Kabat-Zinn 2003). Mindfulness has been found to reduce patient-reported symptoms, improve coping and increase perceived quality of life in people with physical health conditions (Greeson 2019). It has been associated with lower perceived stress after six weeks (Bartlett 2021), and reduced levels of anxiety, depression and pain over the course of a year in people who experience chronic pain (Rod 2015). Indeed, a systematic review of a particular set style of mindfulness developed by Jon Kabat-Zinn called Mindfulness-Based Stress Reduction, used for an eight week period, resulted in demonstrable functional and structural changes in parts of the brain including the prefrontal cortex (responsible for regulating thoughts and emotions) and hippocampus (used for memory, learning and emotion), as well as changes in the amygdala associated with better emotional regulation (Gotink 2016).
Other forms of cognitive training and practices involving mindfulness have also been found to be beneficial, particularly a branch of cognitive behavioural therapy known as ACT, or acceptance commitment therapy. In a large systematic review and meta-analysis of its use in people with chronic illness, and found ACT to improve quality of life and reduce some symptoms such as anxiety and depression (Konstantinou 2023). Specifically looking at people with MS, one study found decreased symptoms of depression, insomnia, fatigue and paresthesia at 8 weeks, and improved emotional understanding (Sadeghi-Bahmani 2022).
Clearly there is sufficient evidence for meditation and mindfulness techniques as supportive tools to manage stress itself, as well as to reduce symptoms which may contribute to stress or change the stress response, and encouraging people with MS to try various techniques to find something that suits them is a positive way to support self-management.
