Article of interest: stress and relapses

Article of interest: stressful life events trigger MS relapses. #MSBlog #MSResearch

“I must get asked ‘does stress trigger relapses’ once a month by someone with MS. I usually say possibly and quote this meta-analysis below. If stressful life events trigger relapses what can be done about it? I am not sure. May be MSers could go a pre-emptive stress management course to give them the skills to counteract and manage stressful events? Studying this will be difficult; the power calculations for doing a randomised study to prove stress management would be staggering. Despite this there are compelling other reasons to manage stress to improve your mental well-being and health. Have any of you any experience with this? If you do can you let us know? Thanks.”

Mohr et al. Association between stressful life events and exacerbation in multiple sclerosis: a meta-analysis. BMJ. 2004 Mar 27;328(7442):731.

OBJECTIVE: To quantify the association between stressful life events and exacerbations of multiple sclerosis.

DATA SOURCES: PubMed, PsychInfo, and Psychological Abstracts searched for empirical papers from 1965 to February 2003 with terms “stress”, “trauma”, and “multiple sclerosis”.

REVIEW METHODS: Three investigators independently reviewed papers for inclusion/exclusion criteria and extracted the relevant data, including methods, sample statistics, and outcomes.

RESULTS: Of 20 studies identified, 14 were included. The meta-analysis showed a significant increase in risk of exacerbation in multiple sclerosis after stressful life events, with a weighted average effect size of d = 0.53 (95% confidence interval 0.40 to 0.65), P < 0.0001. The studies were homogenous, Q = 16.62, P = 0.22, I2 = 21.8%. Neither sampling nor study methods had any effect on study outcomes.

“None of these studies on their own are very positive; it is only when you add them together in the meta-analysis do get a relatively strong effect.”

CONCLUSIONS: There is a consistent association between stressful life events and subsequent exacerbation in multiple sclerosis. However these data do not allow the linking of specific stressors to exacerbations nor should they be used to infer that MSer are responsible for their exacerbations. Investigation of the psychological, neuroendocrine, and immune mediators of stressful life events on exacerbation may lead to new behavioural and pharmacological strategies targeting potential links between stress and exacerbation.

About the author

Prof G

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.


  • Prof G – a quick feedback on stress:

    I'm currently having a stress-related relapse and had had three this year due to stress at work (mobbing and lawsuit). The same could be said for the outbreak of my MS in 2010 – after a long (monthish) non-stop period of extreme stress and no sleep and trauma. I have no doubt whatsoever that stress triggers my relapses (I get symptoms the next day) and that it makes my MS worse, much worse. Stress management could help but only so far – going to see additional doctors can be stress in itself.

    It's better to try to sort out your life in the big areas (marriage, money, health) and cut short any sources of negative stress.

    There is an article in the 'Daily Wail' about a new stress protein which switches on and causes cancer cells to return so it seems not only MS related – more research urgently needed.

  • Interesting – I am convinced my original episode and subsequent relapses were due to stress – I could feel the numbness creeping into the soles of my feet as I was under the stressful situation which I could not escape from without resigning from my job.

  • These combined studies shows that on average a stressful event is damaging to MSers. General levels of underlying stress may have a completely different outcome, or none at all! An underlying stress level is harder to quantify, and relapses during base levels of stress would be more difficult to categorise.

    Stress events were a factor for me during my RRMS phase, and I suffered a relapse within 3 months of starting each new job. Other relapses occured during jobs, but I have never been able to correlate these. I enjoy a base level of stress, and wouldn't want to have a completely non-eventful life.

    I agree with Prof G above, sort out the major areas of your life to at least reduce stress hormone levels in your blood. Accupunture has been helpful to me, and being able to walk away from things I don't like without being embarrassed is another.

  • I am a dotor, diagnosed with MS shortly after completing stressful housejobs with accompanying long hours and on-calls. I am currently experiencing my 2nd ever episode 18 years later, at a time when GPs workloads are rising relentlessly, and my stress levels are very high. I sincerely believe that both of my episodes were triggered by stress – certainly I had no preceding infections to have acted as triggers.

  • I'm an MS nurse, and due to the findings discussed above, I use a technique called HeartMath with bags of research behind it, which is teachable using biofeedback software in 15 minutes as part of a clinic session, and I find great to help my patients become more resilient to stress. Here's the links to the website with research on it, and my own poster on the research I did on it

  • I have known for some time that stress is a trigger for my relapses. When discussing stressful situations I actually feel buzzing in my legs. My massive relapse in 2008 (which put me in hospital/rehab for 10 weeks) was 3 days before I was due to get biopsy results for cancer (which was fortunately clear). I think the adrenal glands (or endocrine system) are somehow involved

  • Yes during my first relapse the inexperienced/incompetent GP referred me as non urgent choose and book to the hospital, it was a 17 day wait. During this time I became stressed and anxious and tired. When I came home from the MRI and started steroids I had a huge severe relapse due to the accumulated stress, exhaustion and anxiety. I didn't know anything about MS at the time. GP's seem to not understand that MS is not always non-urgent. It is okish to refer the patient as non urgent if they are not suffering stress or anxiety but if they are it needs to be an urgent referal. I'm pretty sad this happned to me as it was avoidable the relapse if he referred me as urgent and I got steroids straight away. I have got so many lesions in my brain and spine from this relapse. It progressed my MS so quickly. So sad.

  • Yes stress is evil if you have MS. My MS has advanced many years due to a stressful situation I was in (before I was diganosed with MS). Other conditions such as CFS/ME patients are given stress management. It is time MS patients were offered something. Perhaps the NHS Expert Patients Programme could be adapted with stress managment ideas for MSers. It's run by volunteers I think. Also ideas for coping with life's stressful events.

    Stress increases inflammation especially when a patient is relapsing (increasing lesion load, hence causing more damage). So yes stress can trigger a relapse or make the relapse much more severe.

    • Hello. A condition specific self manangement programme for MS would be good I would of thought. (NHS Expert Patient Progamme). Either online or face to face in a group. Delivered by a trained healthcare professional and peer self management facilitaors. This is alreay seen for Rheumatoid Arthritis I think. So why not for MS?

      Cover such topis as:
      1) Stress manangment (I think quite a proportion of MSers know stress either makes everyday MS worse, makes relapses worse or triggers relapses). Stress is not good for MS whatever.
      2) Managing relapses – the importance of a UTI check, the importance to know infections trigger relapses. I am surprised how many MSers are not aware of this, heat intollernance coping ideas etc.
      3)Pain and fatigue (inc ideas for coping with cramp etc).
      4)Exercise and healthy eating.
      5) Sufficient rest and sleep. How to improve sleep quality.

      My MS nurse seems to have so many MSers to look after and is always very busy. This may take some of the pressure off MS nurses. Also this would give MSers some confidence with their condition.

  • I am an RRMSer I know from experience stress is very evil in MS. It can trigger nasty long relapses if the period of stress has been long (weeks). My stress was from the environment I was living in plus also I had moved to a new city to begin a course. I lived with people who stayed up very late every night this carried on for four weeks. I didn't know I had MS at the time this happened and ended up having a bad long relapse. I wish I had known I had MS (and how MS and stress don't mix well) before I moved away to the new city as I would have not agreed to living in that kind of environment. I would say to MSers be careful of stress, but don't wrap yourself in cotton wool.

  • I have had three attacks all after stressful events. First time after my brother had psychosis. Second time after breaking up with my girlfriend and third time after my brothers second psychosis. I kinda knew I’ll have an attack the third time but didn’t know how to manage the three month long stress.
    ProfG should MS patients preemptively go on antidepressant drugs?

By Prof G



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