What is the impact of stress and fear on the healing process?

From the Guidelines

Stress and fear have a profoundly negative impact on the healing process, and addressing these psychological factors is crucial to improving outcomes, as evidenced by the most recent study in 2023 1. The effects of stress and fear on healing are multifaceted, involving physiological responses that redirect resources away from repair functions. When the body experiences stress or fear, it releases cortisol and adrenaline, hormones that prepare for "fight or flight" by increasing heart rate and blood pressure while suppressing immune function. This hormonal response reduces the efficiency of inflammatory processes necessary for wound healing, decreases white blood cell activity needed to fight infection, and constricts blood vessels that deliver oxygen and nutrients to injured tissues.

Key Findings

• Chronic stress particularly damages healing by maintaining elevated cortisol levels, which can delay wound closure, increase infection risk, and prolong recovery times 1.
• The prevalence of depression and anxiety disorders among patients with cancer is significantly higher than in the general population, with estimates suggesting that up to 20.7% of patients with cancer experience mood disorders, and 10.3% experience anxiety disorders 1.
• Reducing stress and fear can significantly improve healing outcomes by allowing the body to allocate resources toward repair rather than defense, and healthcare providers should consider addressing psychological factors alongside physical treatments 1.

Recommendations

• Patients should employ stress-reduction techniques like deep breathing, meditation, or guided imagery for 10-15 minutes twice daily to help counteract the effects of stress and fear on healing.
• Adequate sleep (7-9 hours nightly), proper nutrition rich in protein and vitamins C and D, and social support also help normalize stress hormone levels and promote healing.
• Healthcare providers should prioritize addressing psychological factors, such as stress and fear, alongside physical treatments to improve healing outcomes, as supported by the American Society of Clinical Oncology guideline adaptation 1 and the 2023 guideline update 1.

From the Research

Impact of Stress and Fear on Healing

• Stress and fear can have a significant impact on the healing process, with studies showing that psychological stress can complicate normal wound healing 2.
• The physiological changes brought about by psychological stress can affect the neural, humoral, and immunological systems, leading to decreased expression of pro-inflammatory cytokines and poor angiogenesis, matrix regeneration, and delayed healing 2.
• Fear and anxiety before surgery can also complicate wound healing, with two different pathways involved: one directly through the hypothalamic-pituitary-adrenal axis and sympathetic-adrenomedullary axis, and another indirectly through negative psychological stressors such as anxiety, depression, and social isolation 2.

Effects of Stress Reduction on Healing

• Studies have shown that stress reduction techniques such as yoga and meditation can reduce stress and anxiety levels, which can in turn improve the healing process 3, 4.
• A six-week yoga and meditation intervention was found to decrease stress and anxiety levels in college students, with significant changes in categorical data from pre- to post-intervention 3.
• An 8-week training program in mindfulness meditation or yoga was found to modify heart rate variability and improve mindfulness skill and concentration performance, contributing to decreased relative power of the low-frequency band and increased relative power of the high-frequency band 4.

Relationship Between Psychological Factors and Healing

• Studies have found a significant relationship between psychological factors such as anxiety and depression and delayed healing in chronic wounds 5.
• Higher scores on the Hospital Anxiety and Depression Scale (HAD) were associated with delayed healing, with patients scoring in the top 50% of total HAD scores being four times more likely to have delayed healing than those scoring in the bottom 50% 5.
• The relationship between healing of chronic wounds and anxiety and depression as measured by the HAD was statistically significant, suggesting that psychological factors play a role in the healing process 5.

Effects of SSRIs on Fear Learning

• Selective serotonin reuptake inhibitors (SSRIs) have been found to reduce contextual fear expression and facilitate extinction learning to cue, with chronic treatment exerting a stronger anxiolytic effect on cued fear expression than acute treatment 6.
• The efficacy of SSRIs may be related to their effects on contextual fear expression and extinction to cue, rather than fear acquisition, although the effects of SSRIs on unconditioned fear responses may provide further insight into the actions of SSRIs 6.