When ‘stress’ is in the differential: Preventing diagnostic overshadowing in complex chronic illness
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Stress can impact the immune system, but physicians should also test thoroughly to ensure nothing else is going on.
—Kanika Monga, MD
The relationship is multifactorial, and stress is certainly not the sole cause of autoimmunity.
—Kristin Galetta, MD
Daniel Arkfeld, MD, DDS, wasn’t convinced that stress or trauma could play a role in autoimmune disease.
Then he met a new patient.
“I didn't believe stress or trauma could cause autoimmune disease, and then I had a patient whose wife died, and the next morning he woke up with new-onset rheumatoid arthritis,” Dr. Arkfeld, a rheumatologist with Keck Medicine of USC, told MDLinx.
“Wow. The stress of his wife dying…probably, he had some factors there beforehand, but [they] tipped him over to flaring 12 hours later. Recently, we had this Eaton fire in L.A., which burned down 10,000 homes. A couple of my patients have been affected. One, she had a combination of lupus and Sjogren's syndrome, and 12 hours after the fire, her ears autoimmune inflamed into a chondritis flare…, and I think the stress of the fire had a big factor in that.”
The experiences of his patients was enough to sway his opinion.
“I've changed my mind that, yes, trauma and stress can definitely trigger autoimmune disease, and I do think that does happen.”
Related: Could 'being too nice' raise autoimmune disease risk in women?Stress in the differential diagnosis
For many patients with chronic, complex illness, stress may find its way into the differential diagnosis.
But experts say physicians must strike a delicate balance in considering stress, while also exploring other possibilities.
“[Stress] should always be considered, but you must run labs and complete a thorough evaluation while also obtaining a history involving recent stressors. Stress can coexist with organic disease. So if there is a way to help treat stress, that is ideal. Stress can impact the immune system, but physicians should also test thoroughly to ensure nothing else is going on,” Kanika Monga, MD, FACR, a clinical rheumatologist in Houston told MDLinx.
“I believe that chronic stress keeps the body in a state of low-grade inflammation that can eventually tip the immune system in the wrong direction,” Dr. Monga said.
One of many factors
For patients with autoimmune disease, stress is believed to be one of many possible contributing factors to the development of disease. It can also play a role in flare-ups of disease.
“Many studies looking back at patients’ histories have found that a large share of people with autoimmune disease report significant stress before their disease developed. Stressful events are also linked to worse disease flares in the weeks to months that follow. Chronic stress appears to weaken the body's anti-inflammatory defenses, and increase inflammatory reactions,” Kristin Galetta, MD, a board-certified neurologist at Stanford, told MDLinx.
“However, the relationship is multifactorial, and stress is certainly not the sole cause of autoimmunity. It is probably better to think of stress as one factor that can influence immune activity in someone who may already have a combination of genetic, hormonal, environmental, and other risk factors.”
The relationship is still evolving
The exact relationship between trauma, stress, and disease is the subject of an evolving body of research.
Experts say stress needs to be a consideration for physicians, but cannot be used as a sole explanation for a patient’s symptoms until all other possibilities have been ruled out.
“Stress can potentially contribute to disease activity, but it is unlikely to be the sole driver of an autoimmune disease. At the same time, stress can produce very real physical and neurologic symptoms that can sometimes resemble autoimmune disease," Dr. Galetta said.
“So stress should be considered as one possible contributor, but it shouldn't be used as an explanation for unexplained symptoms until other important causes have been appropriately evaluated,” Dr. Galetta said.
Related: 7 health dangers aggravated by stress