Review
Stress hormones and immune function
Jeanette I. Webster Marketon a,b
, Ronald Glaser a,c,*
a
Institute for Behavioral Medicine Research, The Ohio State University Medical Center, USA
b
Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Internal Medicine, The Ohio State University Medical Center, USA
c
Department of Molecular Virology, Immunology and Medical Genetics, The Ohio State University Medical Center, 2175 Graves Hall,
333 W. 10th Avenue, Columbus, OH 43210, USA
Received 26 February 2007; accepted 1 September 2007
Available online 14 February 2008
Abstract
Over the past 20 years we have demonstrated both in animal models and in human studies that stress increases neuroendocrine hormones,
particularly glucocorticoids and catecholamines but to some extent also prolactin, growth hormone and nerve growth factor. We
have also shown that stress, through the action of these stress hormones, has detrimental eﬀects on immune function, including reduced
NK cell activity, lymphocyte populations, lymphocyte proliferation, antibody production and reactivation of latent viral infections. Such
eﬀects on the immune system have severe consequences on health which include, but are not limited to, delayed wound healing, impaired
responses to vaccination and development and progression of cancer. These data provide scientiﬁc evidence of the eﬀects of stress on
immune function and implications for health.
Ó 2008 Elsevier Inc. All rights reserved.
Keywords: Stress; Neuroendocrine; Immune; Glucocorticoids; Catecholamines; Immunity
1. Introduction
For many years it has been known that stress is detrimental
to health. In 1974 Hans Seyle deﬁned stress as
‘‘the non-speciﬁc response of the body to any demand
imposed upon it” [1]. This deﬁnition of stress was later
modiﬁed in 1992 by Chrousos and Gold and the term
‘‘non-speciﬁc” replaced by the hypothesis that above a
threshold intensity any stressor would elicit the ‘‘stress syndrome”
[2]. Stress can occur in a variety of forms, physical
or psychological, acute or chronic. It is possible and probable
that diﬀerent forms of stress will have diﬀerent eﬀects
on the stress hormones released and on immune function.
Stress is known to cause the release of several stress hormones—primarily
glucocorticoids though activation of
the hypothalamic–pituitary–adrenal (HPA) axis and catecholamines
through the sympathetic nervous system. For
over two decades we have investigated the eﬀects of various
forms of stress, both in human studies and in animal models,
on neuroendocrine hormones and on cellular aspects of
both the innate and adaptive immune responses. The ﬁndings
of these studies are reviewed here.
2. Models of stress
Over the years we have used numerous models of stress
in our studies. In human subjects these have included laboratory-induced
stressors such as a speech stress test and
mental arithmetic stress test [3], life stressors such as medical
students undergoing examination stress, marital stress,
physical training stress in West Point Cadets, caregivers of
Alzheimer’s or dementia patients, breast cancer patients,
pain following surgery, and psychological stressors such
as feelings of loneliness, depression and even aging. In animals
a number of stress models have been used. These
include rotational stress, footshock, restraint stress and
0008-8749/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.cellimm.2007.09.006
*
Corresponding author. Address: Department of Molecular Virology,
Immunology and Medical Genetics, The Ohio State University Medical
Center, 2175 Graves Hall, 333 W. 10th Avenue, Columbus, OH 43210,
USA. Fax: +1 614 292 1011.
E-mail address: Ronald.glaser@osumc.edu (R. Glaser).
www.elsevier.com/locate/ycimm
Available online at www.sciencedirect.com
Cellular Immunology 252 (2008) 16–26
social disruption stress. For rotational stress the animal’s
cage is slowly rotated to induce mild spatial disorientation
[4]. This increases plasma corticosterone and epinephrine
levels but has no eﬀect on norepinephrine [5,6]. Signaled
footshock involves a light stimulus followed by a mild electric
shock to the foot pads [7]. This increases plasma corticosterone
and decreases hypothalamic norepinephrine
[8,9]. Restraint stress involves physically restraining animals
in a well ventilated tube [10]. This increases plasma
corticosterone [11,12]. Social disruption stress involves
social reorganization following addition of an ‘‘aggressor”
to a group of mice [12]. This also increases plasma corticosterone
[12].
3. Neuroendocrine responses to stress
Stress, both physical and psychological, results in neuroendocrine
signals being released from the brain that
can aﬀect immune function. The main two neuroendocrine
pathways activated in response to stress that control
the immune system are the HPA axis which results
in release of glucocorticoids, and the sympathetic nervous
system which results in release of catecholamines, epinephrine
and norepinephrine. However, there are other
neuroendocrine factors that are released following stress
that also regulate the immune system, including prolactin,
growth hormone (GH) and nerve growth factor
(NGF) (Fig. 1). We have published both human studies
and animal studies which show that these immune-modulating
hormones are released following a variety of
stressors.
3.1. The hypothalamic–pituitary–adrenal (HPA) axis
One of the main mechanisms by which the brain controls
the immune system is through activation of the
HPA axis. Upon stimulation, either physical from the
periphery via cytokines or psychological, corticotrophin
releasing hormone (CRH) is secreted from the paraventricular
nucleus (PVN) of the hypothalamus. This then
stimulates the anterior pituitary to secrete adrenocorticotropin
hormone (ACTH) into the systemic circulation.
Fig. 1. Stress-associated modulation of the hormone response by the central nervous system. Upon experiencing a stressor, the hypothalamic–pituitary–
adrenal (HPA) axis and the sympathetic nervous system are activated resulting in release of glucocorticoids and catecholamines which are able to
modulate various aspects of the immune system. In addition, the pituitary hormones prolactin and growth hormone are also released which also can
modulate the immune system. Figure reproduced from Glaser and Kiecolt-Glaser [104].
J.I. Webster Marketon, R. Glaser / Cellular Immunology 252 (2008) 16–26 17
This, in turn, induces the adrenal glands to synthesize and
secrete glucocorticoids. In humans, the natural glucocorticoid
is cortisol whereas in rodents it is corticosterone.
Physiological levels of glucocorticoids are thought to be
immunomodulatory whereas stress levels are immunosuppressive.
For a review on the mechanisms by which glucocorticoids
modulate the immune system, refer to the
review by us [13].
As noted earlier both social disruption stress and
restraint stress in mice cause activation of the HPA axis
resulting in increased serum corticosterone levels [12]. We
have also shown that in human studies, a variety of stressors
cause increases in plasma ACTH and cortisol levels.
Acute stress using a mental math and speech stress test
increased ACTH and cortisol in mid-aged and older
women [3]. Examination stress in medical students caused
an increase in daytime, but not nocturnal, ACTH with
no change in cortisol compared to baseline levels taken a
month earlier. However, if the group of students was limited
to those that perceived the most stress during exams
then an increase in plasma cortisol levels was seen during
the exam period. Interestingly, the eﬀect of examination
stress on daytime ACTH was only observed in the fall
and not in the spring, suggesting seasonal variations in
HPA axis activation [14]. Extreme exercise stress also
increases both ACTH and cortisol [15] and in another
study, an increase in cortisol was seen in psychiatric
patients who had high scores on the UCLA loneliness scale
[16].
Marital stress increases plasma cortisol and ACTH
levels but the interactions are complicated with diﬀerences
occurring between the wives and husbands and also
diﬀerences in newly married couples compared to couples
who have been married for a number of years. ACTH
but not cortisol was increased during marital stress in
newly married couples and correlated with hostile behavior
[17] and troubled marriages 10 years later [18]. Interestingly,
relative power in the relationship in newly
married couples determined endocrine responses following
a conﬂict. The wives showed increased ACTH
responses to conﬂict only when the husband was the
more powerful partner in the relationship. In addition,
cortisol declined when they were more powerful or had
equal power in the relationship. When the husband has
power there was no decline in cortisol following conﬂict.
ACTH levels following conﬂict decline in the husbands
but when the wives were more powerful or if power
was shared this decline in ACTH took longer to occur.
Likewise cortisol levels in the husbands declined following
conﬂict but in the case of equal power this decline
took longer to occur [19]. In older couples, marital stress
increased plasma cortisol [20], which correlated with
‘‘wife negative-husband withdrawal” behavior during
conﬂict [20,21]. Lower marital satisfaction and negative
behavior during conﬂict correlated with higher levels of
cortisol and ACTH following conﬂict in the wives of
older couples but not the husbands [22]. These studies
show that a number of diﬀerent stressors result in the
activation of the HPA axis and release of glucocorticoids,
an aﬀect that has been observed in many diﬀerent situations
by diﬀerent researchers [23–26].
Cortisol elicits its many actions through a cytosolic
receptor, the glucocorticoid receptor (GR). Upon ligand
binding, GR dissociates from a protein complex, translocates
to the nucleus where it binds to speciﬁc DNA
sequences to modulate gene transcription [27,28]. In addition,
GR can also interfere with the signaling pathways
of other transcription factors such as NFjB and AP-1 to
repress transcription of many inﬂammatory molecules
[29]. Examination stress in medical students decreased the
peripheral blood leukocyte glucocorticoid receptor mRNA
compared to 1 month prior to exams, although protein levels
were not measured [30]. The observation of decreased
glucocorticoid receptors during stress when there is an
increase in the ligand, cortisol, has also been shown by
other researchers [31–33] and may be a result of homologous
down regulation [34].
3.2. The sympathetic nervous system
Activation of the sympathetic nervous system results in
secretion of acetyl choline from the pre-ganglionic sympathetic
ﬁbers in the adrenal medulla. This induces secretion
of epinephrine into the systemic blood supply. Norepinephrine
is released from the nerve terminals in the vicinity
of immune cells. These catecholamines have many
immunomodulatory eﬀects which have been the subject
of many recent reviews [35–37] and will not be discussed
here.
The sympathetic nervous system is also activated by
stress resulting in the release of norepinephrine and epinephrine.
A mental math and speech stress test increases
epinephrine and norepinephrine [3,38]. Increased epinephrine
and norepinephrine were correlated with hostile
behavior and with ‘‘wife negative-husband withdrawal”
behavior during conﬂict in newly married couples [17,21]
and correlated with divorce or troubled marriages 10 year
later [18]. In older couples, increased norepinephrine correlated
with lower marital satisfaction and negative behaviors
during conﬂict in the wives, but not in the husbands
[22]. These results show that various forms of stress activate
the sympathetic nervous system and result in catecholamine
release.
Catecholamines bind to the b2-adrenergic receptor and
stimulate activation of a G-coupled protein which results
in increased intracellular cAMP [39]. Over the period of a
year with 3 examination periods, plasma and intracellular
cAMP increased with continued examination stress. There
was no diﬀerence in the ﬁrst exam period in ﬁrst year medical
students but there was a signiﬁcant increase in the 2nd
and 3rd examination periods in that year [40]. These data
suggest that increased catecholamine release during examination
stress results in increase b2-adrenergic receptor
activation.
18 J.I. Webster Marketon, R. Glaser / Cellular Immunology 252 (2008) 16–26
3.3. Prolactin
Prolactin is secreted from the anterior pituitary gland
and from many extra-pituitary sites including immune
cells [41]. It is immunostimulatory and is proposed to
act as a counter measure to glucocorticoids [42–44]. In
the rat, prolactin has been shown to be released during
stress, although stress-induced decreases in prolactin can
occur under certain stress conditions, such as during the
proestrous afternoon surge or during the nocturnal surge
of pseudopregnancy [45]. Examination stress in medical
students had no eﬀect on plasma prolactin [46] but serum
prolactin decreased with hostile behavior during conﬂict
in newly married couples who also reported high marital
satisfaction [17]. These data suggest that some forms of
stress may increase prolactin release. Prolactin has been
shown to be increased by stress in other studies [47–49]
but is not as well studied as glucocorticoids and
catecholamines.
3.4. Growth hormone (GH)
Growth hormone (GH), like prolactin, is also secreted
from the anterior pituitary gland but can also be produced
by immune tissues thereby having an autocrine/paracrine
eﬀect on immune cells [43,50]. It is also immunostimulatory
and suggested to counteract the eﬀects of glucocorticoids
[43,44]. GH has also been suggested to act as a cytokine
promoting cell cycle progression of lymphoid cells [50].
Many of the eﬀects of GH are mediated through GHinduced
production of insulin-like growth factor-1 (IGF-
1). Examination stress in medical students does not aﬀect
plasma GH levels [46]. Interestingly, GH secretion was
higher in the fall than in the spring [46], suggesting a seasonal
eﬀect on this immune-related hormone. Plasma GH
levels were increased with hostile behavior during conﬂict
in newly married couples who claimed high marital satisfaction
[17]. However, in caregivers of Alzheimer’s patients
GH mRNA levels in PBMCs and B lymphocytes was
decreased compared to controls [51,52]. These data show
that GH is increased by stress as has been shown by other
researchers [49].
3.5. Nerve growth factor (NGF)
Nerve growth factor (NGF) is a neurotrophic hormone
that can regulate the immune response. NGF can function
through the hypothalamus to activate the HPA axis [53]. In
addition, NGF can function as an autocrine/paracrine factor
to regulate immune cells. It promotes proliferation and
diﬀerentiation of T and B lymphocytes and acts as a survival
factor for memory B lymphocytes [54]. It has also
been shown to be increased following stressful life events
[54,55]. Caregivers of Alzheimer’s patients expressed
increased blood NGF levels compared to controls and
the amount of NGF also positively correlated with high
perceived stress and depression [56].
4. Eﬀect of stress on immune function
Stress has been shown to have detrimental eﬀects on the
immune system. These include changes in lymphocytes
populations, in the ratio of helper:suppressor T cells,
decreased lymphocyte proliferation, NK cell number and
activity, impaired antibody responses and reactivation of
latent viral infections (Fig. 2).
4.1. Natural killer (NK) cell activity
Natural killer NK cells are a type of cytotoxic T lymphocyte
that is part of the innate immune system. They primarily
kill viral infected cells and cancer but will also kill
bacteria, parasites and fungi. Their activity is tightly regulated
and these cells can be activated by interferon c
(IFNc) and interleukin-2 (IL-2). Thus, increased NK cells
and increased activity, as determined by lysis of target cells,
is needed to ﬁght infection or cancer. Decreased NK cell
number and NK activity occurs following a variety of
stressors which would result in decreased responses to
infection.
We have shown that in mice, restraint stress decreases
NK cell activity following footpad infection with herpes
simplex virus-1 (HSV-1) [57]. In addition, we have shown
that in human subjects, examination stress decreased NK
cell activity compared to a month earlier [58–60]. Students
who were higher scorers for stressful life events on the brief
symptom inventory (BSI) or loneliness on the UCLA loneliness
scale showed a lower level of NK cell activity [58].
Fig. 2. Stress aﬀects various aspects of the immune system. Stress can
reduce NK cell activity, reduce the number of lymphocytes, decrease the
ratio of helper to suppressor T cells, decrease antibody production,
reactivate latent viruses and modulate cytokine production.
J.I. Webster Marketon, R. Glaser / Cellular Immunology 252 (2008) 16–26 19
Continuing caregivers of Alzheimer’s patients and those
that had been bereaved for 2 years or less showed low cytotoxic
NK response when stimulated with rIFNc or rIL-2
[61,62]. In the absence of these cytokines there was no difference
between continuing caregiver, bereaved caregiver
or controls [61,62]. These results diﬀer from those obtained
with medical students, however, there are two major diﬀerences,
the age of the subject and the type of stressor, acute
versus chronic [61].
Psychiatric patients who had high scores on the UCLA
loneliness scale, also showed decreased NK cell activity
[16]. Lower NK cell activity was also seen in subjects
who exhibited more negative or hostile behaviors following
a discussion on marital problems [63]. In a group of
patients who had recently undergone surgery for breast
cancer, reported stress correlated with lower NK cell activity
and diminished responses of NK cells to IFNc [64].
However, the acute stress of a mental arithmetic stress test
increased NK cell numbers and cytotoxicity [38]. Interestingly
relaxation techniques, but not social contact, in a
study of geriatric people in an independent-living facility
signiﬁcantly increased the NK cell activity [65]. These data
show that stress decreases NK cell activity, thereby removing
the protective eﬀects of these cells and possibly leading
to increased viral infections and even cancer. Reduced NK
cell activity has been found in other studies on the eﬀects of
stress on immune function [66,67].
4.2. T lymphocyte populations
Lymphocytes play an important role in cell-mediated
immunity. They can be diﬀerentiated from NK cells and
B lymphocytes by the presence of the T cell receptor on
the cell surface. T lymphocytes can be divided into subgroups:
cytotoxic T cells (CTL) (also known as CD8+ T
cells) which destroy cells that are recognized as foreign or
non-self; helper T cells (also known as CD4+ T cells) which
secrete cytokines and prompt B lymphocytes to synthesize
antibodies; memory T cells which are antigen-speciﬁc T
cells that may be either CD4+ or CD8+; regulatory T cells
(also known as suppressor T cells) which act on helper T
cells to suppress antibody production.
We have shown that examination stress in medical students
causes a decrease in total T lymphocytes, helper T
lymphocytes and suppressor T lymphocytes compared to
6 weeks earlier [59,68]. There was also a decreased ratio
of helper T lymphocytes to suppressor T lymphocytes
[59]. Such a decreased ratio of helper to suppressor T cells
was also seen in men with poor marital quality [69]. Interestingly,
employment of relaxation techniques in medical
students increased the percentage of helper T lymphocytes
[59]. Mental arithmetic stress test also increased CD8+
(cytotoxic) T lymphocytes [38]. Memory T cell killing of
Epstein-Barr virus (EBV) transformed autologous B lymphocytes
was decreased in medical students experiencing
exam stress during a series of 3 examination periods over
a year compared to baseline measurements taken 1 month
before each exam [40]. The ability of memory T cells to
proliferate in response to 5 of 6 puriﬁed EBV polypeptides
was also decreased during examination stress compared to
a month prior [70]. Caregivers of dementia patients also
exhibited poor memory T cell proliferation in response to
a HSV-1 antigen compared to controls [71].
Caregivers of Alzheimer patients have an increase in IL-
10+ in both CD4+ and CD8+ T lymphocytes but no
change in IFNc+/CD8+, IFNc+/CD4+, IL-2+/CD8+,
or IL-2+/CD4+ cells. The diﬀerence in the percentage of
IL-10+ cells between caregivers and age-matched controls
was also dependent on age, with there being a greater difference
at a younger age and diminished diﬀerences as age
increased [72]. This indicates that stress increases the Th2
cells that produce the Th2 cytokine IL-10, possibly through
the actions of glucocorticoids that are known to induce a
shift from Th1 to Th2 cytokine production [73].
4.3. B lymphocytes and antibodies
B cells are involved in the humoral immune response.
When a B cell comes into contact with a foreign antigen,
in engulfs the antigen and digests it and then displays fragments
of the antigen on MHC molecules. These then
attract T cells which recognize the speciﬁc MHC–peptide
complex. Cytokines secreted by the T cell activate the B cell
and trigger its proliferation and diﬀerentiation into a
plasma cell. Plasma cells produce antigen-speciﬁc antibodies.
We have shown that stress aﬀects diﬀerent serum
immunoglobulins in the absence of infection. In one study,
plasma IgA increased during examination stress compared
to 1 month earlier but IgG, IgM, and salivary IgA did not
change [58]. However, in another study, examination stress
caused signiﬁcant increases in IgG, IgM and IgA [74]. In
mice, we have shown that footshock decreased serum
IgM produced against HSV-1 compared to controls [7].
4.4. Lymphocyte proliferation
During infection lymphocytes proliferate. The proliferation
of lymphocytes following stimulation by a mitogen
(blastogenesis) can be used as an in vitro measure of the
body’s response to challenge by an infectious agent. Phytoheamagglytinin
(PHA), a plant lectin, primarily stimulates
T lymphocytes whereas pokeweed mitogen (PWM) stimulates
B lymphocytes and concanavalin A (Con A) stimulates
both T and B lymphocytes. Stress reduces
lymphocyte proliferation following infection in animal
models and mitogen stimulated proliferation in human
studies.
In mice, footshock stress and restraint stress decreased
CTL responses in spleens and lymph nodes of HSV-1infected
mice [7,11,57] and reduced HSV-1-induced lymphadenopathy
(swelling of the lymph nodes) in a mouse
model of HSV infection. Adrenalectomy had no eﬀect on
the restraint stress decrease observed in HSV-induced lymphadenopathy
suggesting that this occurs through an adre-
20 J.I. Webster Marketon, R. Glaser / Cellular Immunology 252 (2008) 16–26
nal-independent mechanism. However, adrenalectomy did
reverse restraint stress prevention of expansion of CTL
[11]. Exogenous corticosterone alone was unable to suppress
CTL expansion. However, when combined with
restraint stress in these adrenalectomized animals corticosterone
was able to suppress CTL expansion. This suggests
that CTL development is dependent on two factors—one
adrenal-dependent and one adrenal-independent [11].
RU486, a glucocorticoid receptor antagonist, prevented
the restraint stress decrease in lymphocyte proliferation in
the lymph nodes following footpad HSV-1 infection.
Nadolol, a b-adrenergic antagonist, was unable to prevent
restraint stress decrease in lymphocyte proliferation in this
model and a combination of both RU486 and nadolol had
a similar eﬀect of RU486 alone suggesting that b-adrenergic
receptors do not modulate lymph node cellularity in
this model of HSV-1 infection. However, nadolol was able
to partially reverse restraint stress suppression of HSV-1specifc
CTL activation suggesting that b-adrenergic receptors
were involved here. In this study RU486 alone had no
eﬀect on CTL activation but RU486 and nadolol together
fully reverse restraint stress suppression of HSV-1 CTL
activation suggesting that both glucocorticoids and catecholamines
are involved in stress-induced suppression of
CTL activation [10].
We have also shown a poor T lymphocyte proliferation
response to PHA or Con A in psychiatric patients who had
high scores on the UCLA loneliness scale [16], in patients
who had recently undergone surgery for breast cancer
[64,75], in caregivers of dementia patients [76], in medical
students undergoing exam stress [68], in women with poor
marital quality [77], in subjects who exhibited more negative
or hostile behaviors following a discussion on marital
problems [63], and following a mental arithmetic stress test
[38].
Interestingly intervention therapy in small group sessions
reduced stress, improved mood, changed health
behaviors and helped compliance in the maintenance of
cancer treatment. The intervention resulted in either a stable
or an increase in T cell proliferation over the 4 month
period in patients who had undergone breast cancer surgery
[75]. In medical students the use of hypnotic-relaxation
techniques protected the ability of T lymphocytes to
proliferate from the eﬀects of examination stress [78].
Active coping or avoidance coping strategies enhanced
PHA or Con A proliferation of lymphocytes during stress
[79]. These data show that stress can reduce the proliferation
of T cells in response to mitogens and antigens, resulting
in the reduction of the number of circulating cytotoxic
T cells and helper T cells.
4.5. Cytokines
Cytokines are inﬂammatory molecules that are released
by many cell types and are important in both the innate
and adaptive immune responses. Cytokines can act in an
autocrine, paracrine or endocrine fashion and are highly
pleomorphic. Cytokines can be subdivided in to Th1 and
Th2 cytokines, which are produced by type 1 and type 2
helper T cells respectively. Th1 cytokines include IL-1,
IL-2, IL-6, IFNc and tumor necrosis factor a (TNFa)
whereas Th2 cytokines include IL-4, IL-5, IL-10 and IL-
13. IL-1 and IL-6 are pro-inﬂammatory cytokines that
are ampliﬁers of T and B lymphocyte proliferation. IL-2
is important in the defense against microbial infection.
TNFa is involved in systemic inﬂammation.
Caregivers of Alzheimer patients have increased plasma
IL-6 compared to controls [80,81]. In a longitudinal study
over a period of 6 years, caregivers and former caregiver’s
showed an increase in plasma IL-6 levels that increased at
a rate four times faster than those of age-matched controls
[80]. Local IL-6 production at the site of dermal
wounds was lower in couples experiencing marital stress.
However, plasma IL-6 levels were higher in high-hostile
couples the morning after a conﬂict [82]. People with
more depressive symptoms had an increase in plasma
IL-6, which was further increased following vaccination
with an inﬂuenza virus vaccine [83]. Peripheral blood leukocytes
from caregivers produced lower levels IL-2 and
IL-1b in response to the inﬂuenza virus HA protein but
there was no change in serum IL-6 levels [84]. Examination
stress was associated with a decrease in IL-2 receptor
(IL-2R) mRNA levels and protein expression in peripheral
blood leukocytes compared to baseline [85]. Examination
stress was also associated with a decrease in the
production of IFNc by peripheral blood leukocytes stimulated
with Con A or PHA in medical students compared
to 1 month prior to exams [30,40,60]. As for IL-6, local
TNFa production at the wound sites was lower in couples
experiencing marital stress. However, plasma TNFa levels
were higher in high-hostile couples the morning after a
conﬂict [82]. As already described, stress appears to
increase serum IL-6 levels in chronically stressed older
adults. IL-6 is a marker of inﬂammation and it has been
previously noted that stress hormones can induce IL-6
[73]. Generally, glucocorticoids are thought to cause a
shift from Th1 to Th2 cytokines by downregulating Th1
cytokines such IFNc and upregulating Th2 cytokines such
as IL-10 [73].
4.6. C-reactive protein (CRP)
C-reactive protein (CRP) is a plasma protein that is produced
in the acute phase response by the liver. CRP is
increased during inﬂammation and can by used as a marker
of inﬂammation. Caregivers of Alzheimer’s patients have
increased plasma CRP compared to controls [81]. Using
a structural modeling equation, an association between
pain and CRP was only found in caregivers whereas an
association between hostility and CRP was found in both
caregivers and controls [81]. This suggests that pain
together with chronic stress may be detrimental in older
adults. During examination stress no change in plasma
CRP was seen [58].
J.I. Webster Marketon, R. Glaser / Cellular Immunology 252 (2008) 16–26 21
4.7. Reactivation of latent viruses
Our laboratory and others have shown that stress can
induce the reactivation of latent herpes viruses, as shown
by antibody titers to viral proteins and the detection of
viral DNA. In mice latently infected with HSV-1, footshock
induced the reactivation of latent HSV-1 [7] and
social disruption stress, but not restraint stress, caused
reactivation of latent HSV-1 in latently infected mice [12].
In human studies, we have shown that antibody titers to
EBV, HSV-1 and cytomegalovirus (CMV) were increased
in medical students with examination stress [40,86], in caregivers
of dementia patients [71], in women characterized as
high stress reactors [87], in men and women with poor marital
quality [69,77], and in subjects who exhibited more negative
or hostile behaviors following a discussion on marital
problems [63]. A 6 week training of orientation, military
training and extreme exercise in West Point cadets undergoing
‘‘Cadet Basic Training” (CBT) did not change the
steady state expression of latent EBV, however EBV reactivation
did occur when the cadets were taking ﬁnal examinations
similar to the results we obtained in our medical
students exam studies. No change was observed in HSV-1
or HSV-6 antibodies during CBT or examination stress.
These data suggest that diﬀerent stressors can have diﬀerent
eﬀects on the reactivation of latent EBV [88] and in
some ways are similar to the results we obtained in the
study with mice latently infected with HSV-1 previously
described [12].
In vitro cell culture studies have conﬁrmed that HPA
axis hormones, glucocorticoids, ACTH and CRH can reactivate
latent EBV [87,89], thereby suggesting the mechanism
by which stress can reactivate latent herpes viruses.
Interestingly, muscle relaxation techniques and guided
imagery, but not social contact, signiﬁcantly decreased
antibody titers to HSV-1 (reﬂecting better control over
the latent virus by the cellular immune response) in older
individuals in an independent-living facility [65]. Others
have also shown the beneﬁts of behavioral interventions
on immune function [90], reactivation of latent herpes
viruses [91], and the progression of cancer [92,93].
5. Implications for health
The eﬀects of stress hormones on immune function
described above have numerous implications for health.
Three of these—vaccination, cancer and wound healing—
are discussed below (Fig. 3).
5.1. Stress and vaccination
Since stress has such detrimental eﬀects on the immune
system, we investigated the eﬀect of stress on the ability
to respond to a vaccination. In the case of a viral vaccine,
it is necessary to induce both an antibody response and a
virus-speciﬁc T cell response for protection, which is not
the case for a bacterial vaccine which induces only an antibody
response. In both situations, at least a four fold
increase in IgG antibody is considered the rule for ‘‘a
take”. Caregivers of patients with dementia showed lower
IgG antibody titers following pneumococcal vaccination
3 and 6 months following vaccination compared to former
caregivers or controls. No diﬀerences were seen earlier at 2
weeks or 1 month following vaccination [94]. This suggests
that chronic stress may aﬀect IgG stability or the number
of IgG producing cells following vaccination [94]. Caregivers
also showed a poorer antibody and very speciﬁc T cell
responses 1 month after an inﬂuenza virus vaccination [84].
In a study with medical students, students were given a series
of 3 hepatitis B vaccinations on the 3rd day of a 3 day
examination period. Students who were less stressed and
anxious had higher antibody titers and a more vigorous
T cell response to the vaccine than classmates who were
more stressed and anxious six months after the initial injection
[95].
5.2. Stress and cancer
Stress eﬀects may inﬂuence the incidence and progression
of cancer. As already discussed, stress decreases the
number and activity of NK cells. These cells are important
for their ability to kill tumor cells. In addition, faulty DNA
repair can lead to the development of transformed cells.
We have shown in an animal model that rotational stress
reduced the levels of methyltransferase, a DNA repair
enzyme synthesized in response to a carcinogen [4]. In addition,
the peripheral blood leukocytes (PBLs) from psychiatric
in-patients had poorer DNA repair in response to
X-irradiation than cells from normal control subjects.
Within the patient group, the high-distress subgroup had
Fig. 3. Stress aﬀects immune function which has implications for health.
These include delayed wound healing, impaired vaccine responses, cancer
and reactivation of latent herpes viruses.
22 J.I. Webster Marketon, R. Glaser / Cellular Immunology 252 (2008) 16–26
signiﬁcantly poorer DNA repair than the low distress subgroup
[96].
The sympathetic nervous system may also aﬀect tumor
progression. We have shown that norepinephrine increases
the angiogenic cytokines matrix metalloproteinase-2
(MMP-2), MMP-9 and vascular endothelial growth factor
(VEGF) in nasopharyngeal carcinoma (NPC) cell lines
which results in increased invasiveness of these cells. Propanadol,
a b-blocker, was able to prevent induction of these
genes and prevent invasiveness [97]. Norepinephrine has
also been shown to increase the invasiveness of ovarian
cancer cells also through induction of MMPs [98]. These
data suggest that stress impairs normal DNA repair, and
NK cell activity possibly increasing the incidence of cancer
and may also increase the invasiveness of at least some cancers
through regulation of angiogenesis.
5.3. Stress and wound healing
Wound healing occurs in three overlapping stages.
Inﬂammation plays a role in the early stages of wound
healing in which bacteria and damaged tissue are phagocytized
and then neutrophils migrate to the site and induce
transcriptional activation that regulates cell fate and function
and promotes wound healing. We have shown that
stress impairs wound healing in dermal blister wounds
and in punch biopsy wounds by slowing the wound healing
process, through an increase in cortisol which can inhibit
the process of cellularization, decrease GH and down regulate
the production of pro-inﬂammatory cytokines at the
wound site.
Blister wounds healed more slowly in couples experiencing
marital stress and hostile behaviors [82]. In women with
higher perceived stress, IL-1a and IL-8 levels were reduced
in blister wounds [99]. Stress also decreased GH levels at
blister wound sites and impaired wound healing. Using
DNA array technologies, stress was shown to have an overall
suppressive eﬀect on the neutrophil transcriptome which
caused a shift towards genes involved in cell cycle arrest,
death and inﬂammation [100]. Wound healing of a punch
biopsy was found to be delayed in patients experiencing
pain following surgery [101] and in caregivers of Alzheimer’s
patients compared to controls [102]. Interestingly,
exercise was found to accelerate wound healing of a punch
biopsy wound in older adults [103]. These data show that
stress delays wound healing possibly through glucocorticoid
repression of local cytokine products and neutrophil
accumulation at the site of the wound.
6. Conclusion
Stress, through the actions of stress hormones, has many
detrimental eﬀects on immune function which in turn have
implications for health. Interestingly, the use of relaxation
techniques has been shown to reverse some of these deleterious
eﬀects on immune function. Thus, the role of stress in
disease, and the usefulness of practices that reduce stress
should not be underestimated.
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