Have you ever wondered if stress can trigger the onset of chronic disease? Or if trauma, infection, or something challenging can put you over the edge and stimulate the onset of serious symptoms? If so you are not alone. Many of us with chronic illness had an onset after trauma or following a stressful period in our lives.

This is a common phenomenon in chronic illness and I draw on the science of adverse childhood experiences (ACEs) to refer to this category of trauma as Adverse Pre-Onset Experiences (APOEs).

If an adverse event or an “APOE” triggered your disease, you are not making it up or grasping at straws in hopes of finding a cause for your illness. It does not mean that your disease is “all in your head.”

Environmental stressors such as infections, stress in home and work life, accidents and surgeries, and more can all strengthen and convert the effects of conscious and unconscious perceptions of threat in our nervous systems. This acts like the last straw that unmasks and fully activates a latent defense response. It is the activation of this nervous system pattern of self-protection that leads to symptoms.

Dr. Robert Naviaux is a professor of Medicine, Pediatrics, and Pathology at the University of California, San Diego (UCSD) and refers to this survival response as the “cell danger response” or CDR ⁽¹⁾Naviaux, R. K. (2014). “Metabolic features of the cell danger response.” Mitochondrion 16: 7-17.

The CDR underlies the changes in cell function and physiology in all kinds of autoimmune and other chronic illnesses and is regulated by the nervous system. Environmental stressors shift the nervous system into states of fight, flight and freeze and this drives the CDR.

Stress can Trigger Chronic Disease

Predisposition for chronic illness begins years or decades before onset. Environmental stressors that trigger onset are merely the last in a series of events that build and then convert an underground process into something that becomes overt.

Research studies show that stressful events are common before the onset of many different chronic illnesses including:

• type 1 diabetes ⁽²⁾Nygren, M., et al. (2015). “Experience of a serious life event increases the risk for childhood type 1 diabetes: the ABIS population-based prospective cohort study.” Diabetologia 58(6): 1188-1197, ⁽³⁾Dahlquist, G., et al. (1991). “The Swedish Childhood Diabetes Study: a multivariate analysis of risk determinants for diabetes in different age groups.” Diabetologia 34(10): 757-762. Full Text, ⁽⁴⁾Robinson, N. and J. H. Fuller (1985). “Role of life events and difficulties in the onset of diabetes mellitus.” J Psychosom Res 29: 583-591. Abstract, ⁽⁵⁾Mead, V. P. (2004). “A new model for understanding the role of environmental factors in the origins of chronic illness: a case study of type 1 diabetes mellitus.” Med Hypotheses 63(6): 1035-1046. Full Text, ⁽⁶⁾Mead, V. P. (2007). Timing, Bonding, and Trauma: Applications from experience-dependent maturation and traumatic stress provide insights for understanding environmental origins of disease. Advances in Psychology Research. A. M. Columbus, Nova Science Publishers. 49: 1-80. Page 37 in Full Text;
• rheumatoid arthritis ⁽⁷⁾Al-Allaf, A. W., et al. (2001). “A case-control study examining the role of physical trauma in the onset of rheumatoid arthritis.” Rheumatology (Oxford) 40(3): 262-266. Full Text;
• fibromyalgia, chronic fatigue, multiple chemical sensitivities and related illnesses ⁽⁸⁾Clauw, D. J. (2001). “Potential mechanisms in chemical intolerance and related conditions.” Ann N Y Acad Sci 933: 235-253. Abstract. ** the unfortunate use of terms such as “somatoform” and “psychological” is common in this group of diseases but when viewing the findings from a trauma perspective it is possible to see it from a different angle that validates patterns seen in ME/CFS, FMS and MCS;
• inflammatory bowel disease such as Crohn’s and Ulcerative Colitis ⁽⁹⁾Mead, V. P. (2007). Timing, Bonding, and Trauma: Applications from experience-dependent maturation and traumatic stress provide insights for understanding environmental origins of disease. Advances in Psychology Research. A. M. Columbus, Nova Science Publishers. 49: 1-80. Page 50-51 in Full Text, ⁽¹⁰⁾Hollander, D. (2003). “Inflammatory bowel diseases and brain-gut axis.” J Physiol Pharmacol 54 Suppl 4: 183-190. Abstract, ⁽¹¹⁾Qiu, B. S., et al. (1999). “The role of CD4+ lymphocytes in the susceptibility of mice to stress-induced reactivation of experimental colitis.” Nat Med 5(10): 1178-1182. Abstract;
• multiple sclerosis ⁽¹²⁾Warren, S. A., et al. (1982). “How multiple sclerosis is related to animal illness, stress and diabetes.” Can Med Assoc J 126(4): 377-382, 385. Full Text, ⁽¹³⁾Warren, S., et al. (1982). “Emotional stress and the development of multiple sclerosis: case-control evidence of a relationship.” J Chronic Dis 35(11): 821-831;
• Parkinson’s disease ⁽¹⁴⁾Vlajinac, H., et al. (2013). “The stressful life events and Parkinson’s disease: a case-control study.” Stress Health 29(1): 50-55. Abstract links to full text, ⁽¹⁵⁾Smith, A. D., et al. (2002). “Stress-induced Parkinson’s disease: a working hypothesis.” Physiol Behav 77(4-5): 527-531. Abstract,
• and others.

What constitutes a stressful event is different for everyone and can look or even feel like remarkably ordinary events that happen in everyone’s lives. You may have wondered if stress can trigger chronic disease if your own symptoms began after a routine surgery. Or cared for a loved one for a year. Perhaps you dismissed the idea as in your imagination, or worried that it meant your illness was psychological.

While the psychological effects of trauma such as PTSD (post-traumatic stress disorder) are well known, trauma also influences the nervous system and physical health. This helps explain how stress can trigger chronic disease without meaning that your disease is psychological.

Understanding the links between trauma and chronic disease explains how chronic illness is not something you created. It shows that your illness may have been influenced by things that happened to you and not because of something you did or did not do.

What is Trauma?

Trauma occurs when too much happens too fast. When you have too little support or time or resources at the time of a very difficult or intolerable event. Trauma does not only happen to people who live through war or natural disasters but results from experiences that feel overwhelming or life-threatening – whether your life is actually in danger or not.

Trauma is associated with experiences that feel like too much, that seem inescapable, or that are outside of your control. Think about being caught in a challenging, stressful job that you hate but that pays your bills so you can support your family and keep a great insurance plan. It’s the kind of experience that can have an impact on your health even as it can look normal to others or be discounted by your health care professionals, family, colleagues and others.

Trauma is more about how an experience FEELS rather than about the event itself ⁽¹⁶⁾Levine, P. (1997). Waking the tiger. Berkeley, North Atlantic Books, ⁽¹⁷⁾Levine, P. A. (2010). In an Unspoken Voice: How the body releases trauma and restores goodness. Berkeley, North Atlantic, ⁽¹⁸⁾Scaer, R. (2005). The Trauma Spectrum: Hidden wounds and human resiliency. New York, W.W. Norton, ⁽¹⁹⁾van der Kolk, B. (2014). The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma, Viking.

The very good news is that there are many effective and compassionate approaches for healing the long term physical, biological and emotional effects of trauma. These methods can be powerful tools when working with trauma AND chronic disease.

Stress and Trauma are Triggers (APOEs)

Research in trauma explains how stress that occurs before the onset of symptoms is a trigger or precipitator of chronic disease rather than the cause ⁽²⁰⁾Mead, V. P. (2007). Timing, Bonding, and Trauma: Applications from experience-dependent maturation and traumatic stress provide insights for understanding environmental origins of disease. Advances in Psychology Research. A. M. Columbus, Nova Science Publishers. 49: 1-80. Full Text of this Book Chapter. Stressful events are generally the last in a series of difficult life experiences rather than the first ⁽²¹⁾Clauw, D. J. (2001). “Potential mechanisms in chemical intolerance and related conditions.” Ann N Y Acad Sci 933: 235-253. Abstract. ** the unfortunate use of terms such as “somatoform” and “psychological” is common in this group of diseases but when viewing the findings from a trauma perspective it is possible to see it from a different angle that validates patterns seen in ME/CFS, FMS and MCS.

Trauma and chronic disease are linked by common patterns that evolve over years. These patterns can even develop decades before onset and happen outside of your awareness.

You – and your body – are designed to heal and recover from trauma. The treatment of trauma is an important, unrecognized and underutilized tool for addressing and working with symptoms of chronic illness.

My Experience of Stressful Events Before the Onset of Chronic Fatigue

When I first began to wonder whether stress might be a trigger for the onset of chronic disease I explored whether it had affected the development of my chronic fatigue (ME/CFS). I didn’t come up with much at first.

It was only in the process of learning more about patterns commonly seen in trauma that I discovered how my medical training had been stressful and traumatic for me. It hadn’t felt life-threatening per se, but over the course of many years I had regularly felt overwhelmed and hopeless in the course of 100 hour work weeks, 36 hour shifts or when I inadvertently caused harm to my patients because medicine is often limited in what it has to offer.

As I worked with my own trauma I slowly began to recognize how stressful events had accumulated during my medical career and had been a trigger for the onset of my ME/CFS. Stress can trigger chronic disease and my experience was no different from so many others.

Naviaux’ group has found that metabolic function in ME/CFS reflects a state of hibernation and freeze with a CDR consistent with low or hypometabolism. This survival state is what drives symptoms ⁽²²⁾Naviaux, R. K., et al. (2016). “Metabolic features of chronic fatigue syndrome.” Proceedings of the National Academy of Sciences of the United States of America. The other end of the CDR spectrum is the more hypermetabolic state of fight and flight. Naviaux explains it is the underlying pattern of cell function in other chronic diseases, such as autoimmune conditions like type 1 diabetes and lupus, metabolic syndrome which is comprised of a cluster of symptoms including high blood pressure, high cholesterol, truncal obesity and insulin resistance, high blood sugar levels and increases risk for stroke, diabetes and heart disease.

Trauma Doesn’t Always Lead to Chronic Disease

The idea that stress is an important link between trauma and chronic disease can seem laughable given the severity and intensity of very real, debilitating physical symptoms. You may have doubts given that not everyone who has lived through even the most intense experiences of trauma, such as childhood abuse or living in a war zone, develops a chronic illness. Similarly, most doctors do not develop a chronic illness following their training as I did. These facts, however, do not negate the evidence that stress can trigger chronic disease. This is because it is not the final stressor itself that causes chronic disease but the gradual accumulation of effects from stress and traumatic events over time that affect risk.

If you experienced stress or trauma before the onset of your chronic illness it means that there is hope.

Learning about trauma can give you a huge context for understanding and relating to your symptoms with greater compassion, flexibility and equanimity. Working with trauma also offers you tools for dealing more effectively with your symptoms.

When You Have No Stress or Trauma Before Onset

Different types of events can precipitate the onset of chronic illness. Many are not recognized as stressful or as sufficiently stressful to cause symptoms as severe as a physical disease.

1) The occurrence of a stressful event in your community. A trigger can occur as the result of an event that takes place in our culture, society or community because it threatens our sense of safety in some way. It may be because it affects others we know or identify with. It can be a trigger even when it does not directly affect or involve us. Such stressors might include laws, acts of terrorism or natural disasters that threaten one’s sense of safety. They may pose risks to us because of our health, race, gender, sexual orientation, ethnicity, religious affiliation, values or other personal characteristics or qualities; or because they threaten basic resources such as a place to live, financial security, access to clean water, etc.

2) Unrecognized stress can come in the form of “trauma triggers.” Triggers are reminders of past traumatic events. They can be sights and sounds, smells or places, events, conversations or people that remind our unconscious of past events.

Such reminders evoke a nervous system response related to past traumas. These triggers are unique to you and your past. Examples of triggers could be a routine medical procedure that feels more stressful than it should because it reminds some part of you of a distressing procedure in the past; hospitalization could be a trigger if you were hospitalized as a child, for a severe or life-threatening illness, or experienced complications from medical treatment; the anniversary of a profound loss or accident can be a trigger; or unexpectedly seeing someone who caused you harm in the past.

Most triggers happen outside of our awareness.

3) Delays between a stressful event and the onset of symptoms. It is not uncommon to develop symptoms of a chronic illness weeks, months or even a year or two after a stressful event. The period of time between a stressor and the onset of symptoms is known in the trauma literature as a latency period. The delayed effects between trauma and chronic disease onset can respond to trauma treatment even when there have been long periods between old traumas, the “final stressor” and the onset of chronic illness.

4) Toxins and infections. Environmental exposures may cause disease from direct effects, such as from toxic chemicals and infections. These can also serve as a stressor that activates a cell danger response and precipitates the onset of a chronic illness.

When you have experienced trauma or chronic stress at earlier times in your life, including as far back as childhood or when you were a baby or still in the womb, it can make your immune system more sensitive to stressors of all kinds ⁽²³⁾Dube, S. R., et al. (2009). “Cumulative Childhood Stress and Autoimmune Diseases in Adults.” Psychosom Med 71 (February 1, 2009): 243-250; Full Text. It may also make your immune system less effective at coping with infection and toxicity. This may be why so many different kinds of chronic illnesses occur following infections when no specific virus or bacteria can be identified as the cause. The role of stress can also explain why some people recover fully from the same infections that trigger the onset of chronic illness in others.

Working with the effects of trauma may help reduce or mitigate the effects of infections or toxins. It can do so by reducing unconscious perceptions of threat in our nervous systems; strengthening your immune system; and improving your body’s ability to handle the normal stresses of everyday life. Trauma therapy can also reverse epigenetic changes that are influencing your health as a result of trauma ⁽²⁴⁾Yehuda, R., et al. (2013). “Epigenetic Biomarkers as Predictors and Correlates of Symptom Improvement Following Psychotherapy in Combat Veterans with PTSD.” Front Psychiatry 4: 118. Abstract or Full Text.

Prevention & Treatment of Trauma: New Tools for Chronic Disease

If you have a chronic illness or feel at risk of developing a chronic disease (due to a family history or the presence of unexplained symptoms, for example), there is much you can do.

Understanding more about trauma and how it affects your health is a place to start. Working with trauma is another, as many approaches exist that can help you to address, reduce and heal sensitivity to stress, triggers and perceptions of threat (see a list of books and therapies). Healing trauma may also prevent the onset of chronic illness or decrease the speed at which symptoms of a chronic illness sometimes develop or intensify.

You can learn more in a series of ebooks about The Chronic Illness and Trauma Connection. Book 1 provides an overview of the research showing how trauma is a risk factor and how it differs from stress. Book 2 describes different types of symptoms that are often seen in chronic illness and that are also common in trauma. Book 3 explains how links stress and trauma affect our genes and how their influences are not purely psychological as many still believe.