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Stress and Allergy

Rosalind J. Wright, M.D., M.P.H., and Sheldon Cohen, Ph.D

Dr. Wright is Assistant Professor of Medicine, Channing Laboratory, Harvard Medical School, Boston, and Dr. Cohen is Robert E. Doherty Professor of Psychology, Carnegie Mellon University, Pittsburgh.

Drs. Wright and Cohen report no commercial conflicts of interest.

Have you ever noticed that sometimes when you're having a really tough day, you sneeze a lot and your skin feels itchier? It's not a coincidence, your emotions may have been the trigger. Researchers are now finding that certain allergic disorders like hay fever, eczema and asthma are regulated, in part, by hormones and brain chemicals released into the bloodstream in response to stress. When it rains, it really does pour.1,2,3,4

The nervous system is the interpreter of which events are "stressful" and determines how the body responds to the stress. Negative emotional responses disturb the carefully constructed equilibrium of the brain systems, putting some parts into overdrive and others into underdrive. The body produces a number of factors including hormones (e.g., cortisol) and neurotransmitters (e.g., adrenalin) which, in turn, can influence other systems in the body such as the immune system. If this imbalance goes on unchecked and becomes persistent, long-term damage and disease can result. In other words, it is the wear-and-tear from chronic overactivity or underactivity that is potentially damaging.5

Acute Stress v. Chronic Stress
It is important to distinguish between acute stress and chronic stress. The body's response to a dangerous situation ("acute stress"), the so-called "fight or flight" response, helps us protect ourselves against an immediate threat. In these acute stress situations, getting your adrenalin going is a good way of protecting yourself. But if your reaction goes on too long because the stress continues day in and day out, the body's defenses may be altered and become less able to respond in helpful ways.6 It is in situations of chronic stress that disruption of this ideal balance in stress hormones and neurotransmitters may happen.

Researchers have found that allergies often involve a complicated relationship between mobilized white blood cells, T lymphocytes, and chemicals ("cytokines") produced as a result of the activation.7,8,9,10,11,12 The cytokines cause other immune cells or white blood cells, e.g., mast cells and basophils, to release additional inflammatory substances that bring on an allergic response in sensitive tissues, for example, nasal and sinus passages ("rhinitis"), skin ("eczema") and airways ("asthma").13,14,15

Psychological Stress and Oxidative Stress
Another possible mechanism linking stress to allergy is through so-called oxidative stress pathways. It has been speculated that people who suffer from allergies are unable to detoxify certain oxygen molecules that arise from normal metabolism or from outside toxins such as tobacco smoke or air pollution. Psychological stress may be an additional environmental factor that worsens this oxidative toxicity and increases airway inflammation.4,23

Stress and Good Bacteria
Scientists are increasingly focusing on the bacteria of the gastrointestinal tract in early life and their relationship to allergic disorders. Lactobacillus, a non-harmful bacteria that's found in milk and in the gut, seems to play a role in the maturation of the immune system usually pushing it toward a nonallergic pattern.24 Studies have shown that psychological and physical stress may disrupt the normal balance of intestinal bacteria and this imbalance may contribute to later disease. A recent experiment showed that separation of infant monkeys from their mothers, a psychological stressor, was associated with a significant decrease in protective bacteria, particularly lactobacilli.25 These same researchers also demonstrated that this influence may begin even before birth when their mothers were deliberately exposed by the scientists to the stress of loud noises.26

Stress May Affect You and Those Around You
The psychological stress that you experience may affect you directly but also may impact those around you or close to you. Recent animal data suggest that increased maternal stress prenatally is associated with an elevated cortisol response to stress in the newborn, which is normal,16 but then can lead to a too-low response later in life.17 Researchers have found that adolescents with positive skin test reactivity and a history of hay fever, eczema or asthma have similar flattened cortisol response, and that this may change their ability to turn off the allergic reaction as quickly.18,19

There is evidence that parental reports of life stress are associated with subsequent onset of wheezing in children between birth and one year.3 This relationship led to speculation that stress may trigger hormones in the early months of life which may in turn influence allergic response. Asthma treatment guidelines have focused on the use of anti-inflammatory therapy, particularly oral and inhaled glucocorticoids or steroids. Yet, asthmatics, often have a variable response to glucocorticoid therapy.21 Although the majority of patients readily respond, it is difficult to control asthma in some patients even when treated with high doses of oral steroids.22 It has been proposed that chronic psychological stress may, by putting the stress response system into overdrive, have caused this lack of response.20

What Can Be Done to Reduce Stress?
Evidence from overlapping research supports the idea that psychological interventions aimed to reduce stress and modify mood states influence asthma expression.27 Studies have demonstrated that psychological interventions and the relaxation response may influence the expression of allergic disorders through effects on circulating cortisol levels or the immune response.28,29 A recent analysis of several studies showed that a range of psychological interventions, especially hypnotic suggestion and conditioning, can modulate the human immune response.16 Hopefully, they'll even help you stop sneezing.

Combining stress reduction techniques with more standard medical regimens typically prescribed for allergic disorders may be a good idea. Standard therapy for moderate-to-severe allergic disorders including asthma involves the more long-term use of anti-inflammatory agents (i.e., steroids), which have potential adverse effects, particularly at higher doses. Complimentary treatment strategies that may enhance pharmacologically active asthma treatment regimens, allowing for the use of lower doses with fewer negative side effects may, therefore, be a reasonable approach to therapy.

Research on psychological interventions suggest that psychological interventions including stress reduction interventions have the potential to affect a substantial number of individuals with allergic disorders given that as many as 30% to 40% of such patients demonstrate sensitivity to short-term stress and other emotional states that may worsen their disease. Of course the addition of these types of interventions should be discussed with your healthcare provider and importantly are not likely to completely eliminate the need for the medicines prescribed for the control of your allergic symptoms.

May 19, 2005

References
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21. Lee TH, Brattsand R, Leung DYM. Corticosteroid action and resistance in asthma. American Journal of Respiratory Cellular and Molecular Biology. 1996;154:S1-S79. return

22. Leung DYM. Update on glucocorticoid action and resistance. Journal of Allergy & Clinical Immunology. 2003;111:3-22. return

23. Spiteri MA, Bianco A, Strange RC, Freyer AA. Polymorphisms at the glutathione S-transferase, GSTP1 locus: a novel mechanism for susceptibility and development of atopic airway inflammation. Allergy. 2000;55:15-20. return

24. Kalliomaki M, Isolauri E. Pandemic of atopic diseases -- a lack of microbial exposure in early infancy? Curr Drug Targets Infect Disord. 2002;2:193-9. return

25. Bailey MT, Coe CL. Maternal separation disrupts the integrity of the intestinal microflora in infant rhesus monkeys. Dev Psychobiol. 1999;35:146-55. return

26. Bailey MT, Lubach GR, Coe CL. Prenatal stress alters bacterial colonization of the gut in infant monkeys. J Pediatr Gastroenterol Nutr. 2004;38:414-21. return

27. Wright RJ. Altenative modalities for asthma that reduce stress and modify mood states: evidence for underlying psychobiological mechanisms. Ann Allergy Asthma Immunol. 2003;92:1-6. return

28. McGrady A, Conran P, Dickey D, Garman D, Farris E, Schumann-Brzezinski C. The effects of biofeedback-assisted relaxation on cell-mediated immunity, cortisol, and white blood cell count in healthy adult subjects. Journal of Behavioral Medicine. 1993;15. return

29. Lehrer PM, Isenberg S, Hochron SM. Asthma and emotion: a review. Journal of Asthma. 1993;30:5-21. return

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