When the Doctor Says Your Disease is Just Stress

Amina AlTai had always prided herself on her drive and resilience. When she began experiencing brain fog and fatigue, Ms. AlTai, 39, simply thought it was from working long hours in her marketing job. So she started writing down reminders to keep herself on track. But then her hair started falling out, she gained and lost a lot of weight and she started having gastrointestinal issues.

Ms. AlTai was certain that something was wrong. But the first six doctors she saw didn’t take her seriously, she said. Some told her she had so much hair that losing a little bit shouldn’t be a problem. Several said she seemed healthy, and dismissed her symptoms as simply stress. It was only when another physician ordered blood tests that Ms. AlTai was diagnosed with Hashimoto’s disease and celiac disease, two autoimmune conditions that can damage the thyroid and the small intestine.

“They called me and told me, ‘Don’t go into work. Go to the hospital instead, because you’re days away from multiple organ failure,’” Ms. AlTai remembered. The two chronic diseases had upended her ability to regulate hormones and absorb critical vitamins and nutrients.

Scientists now know that stress is intimately linked with many chronic diseases: It can drive immune changes and inflammation in the body that can worsen symptoms of conditions like asthma, heart disease, arthritis, lupus and inflammatory bowel disease. Meanwhile, many issues caused by stress — headaches, heartburn, blood pressure problems, mood changes — can also be symptoms of chronic illnesses.

For doctors and patients, this overlap can be confusing: Is stress the sole cause of someone’s symptoms, or is something more serious at play?

“It’s really hard to disentangle,” said Scott Russo, director of the Brain-Body Research Center at the Icahn School of Medicine at Mount Sinai.

How stress may trigger chronic disease

Stress naturally kick-starts what’s called the fight-or-flight response. When we encounter a threat, our blood pressure and heart rate climb, muscles tense and our body concentrates blood sugar to make it easier to quickly react, said Dr. Charles Hattemer, a specialist in cardiovascular health at the University of Cincinnati.

If people are stressed for weeks or months, their bodies may be unable to keep up as well with other functions, leading to problems like forgetfulness, fatigue and trouble sleeping. Stress hormones like adrenaline and cortisol can chronically elevate blood pressure or increase plaque deposits, which can damage the heart over time, Dr. Hattemer said.

There are also hints that stress can contribute to the over-activation of the immune system and lead to inflammation. In a study of 186 patients, researchers in Italy found that 67 percent of adults with celiac disease had experienced a stressful life event before their diagnosis.

More recently, Dr. Russo and his colleagues showed in two studies that distressed mice had higher levels of neutrophils, which cause inflammation, and fewer T cells and B cells in the bloodstream that could produce antibodies or kill cells infected with viruses.

He and his colleagues also found patients with major depressive disorder had similar imbalances in immune cells compared to healthy controls. Researchers believe that the body changes the makeup of immune cells circulating in the blood as a way of reducing damage from an infection or acute stress, Dr. Russo said.

When faced with chronic stress, though, the body sometimes “just can’t shut the immune system down,” Dr. Russo said.

For people who may already be at risk of chronic diseases, whether because of their genetic predisposition, exposure to chemicals, air pollution, or viral infections, a prolonged period of stress may tip them over the edge toward becoming sick.

Lynne Degitz, 56, spent several years battling what seemed like extreme infections on and off. Once, she thought she had mono. Another time she was sure it was bronchitis. Neither she nor her doctors thought it might be a chronic illness.

Then she started a new, higher-stress job and began experiencing fevers, joint swelling and fatigue nearly every day. “I had interesting, demanding work, so I just kept going,” Ms. Degitz said. “I would just use short term disability to recover or use vacation time to recover when I needed it.”

After more than two years of going back and forth to medical appointments, and trying treatments that ultimately didn’t help, Ms. Degitz was diagnosed with a type of arthritis known as Still’s disease. Doctors don’t know exactly what causes it, but research is beginning to suggest that it is likely a combination of factors, including abnormal reactions to infections and stress.

“We all have physical ailments and weaknesses,” Dr. Russo said. “Stress just exploits those and makes them worse.”

For patients with chronic illnesses, the same stressors that might have triggered their symptoms can make it hard to get a handle on their condition.

And some said they don’t always feel that doctors appreciate how hard it can be to manage stress, especially when they are feeling sick. When Teresa Rhodes was first diagnosed with rheumatoid arthritis several decades ago, a doctor suggested she exercise more to reduce her stress and strengthen her joints, which were being damaged by the disease.

But “the symptoms of the disease themselves were stressors,” said Ms. Rhodes, who is now 66. “It’s very hard to exercise when you’re so fatigued.” It was only after other stressors in life lifted — her children grew up and she left a difficult marriage — that she was able to get enough rest and eventually begin working out again.

Many doctors are not trained to ask about sources of stress, or counsel patients about the impact of stress, said Alyse Bedell, a clinician-researcher who specializes in the how stress affects digestive health at UChicago Medicine. A 2015 survey of more than 30,000 patient visits to doctors offices found that primary care doctors only counseled patients about stress management during 3 percent of visits.

When Stephanie Torres’s 12-year-old son Nico was diagnosed with Crohn’s disease, she was surprised to hear that the gastroenterologist thought managing the stress that clearly triggered his symptoms was the family’s responsibility. “Her response to me was basically, ‘This is your problem. You go solve it.’”

Patients said that instead of simply suggesting they cut out sources of stress, doctors could work with them on small ways they can manage stress every day. Once Ms. AlTai was diagnosed and started taking medication for both her conditions, she felt well enough to make dietary changes needed to address the nutrient deficiencies caused by her diseases. She started going for regular walks and meditating in the morning.

Ms. AlTai eventually left her marketing job and became an executive coach, allowing her to set her own schedule, she said. Being hospitalized and diagnosed with two chronic diseases made her realize those changes were necessary.

“I call it my stop moment, because literally it stopped me in my tracks,” she said. “I had to really re-evaluate my relationship with work and success and stress.”