Stress management is important for everyone, but it’s especially crucial for people with ankylosing spondylitis — a type of inflammatory arthritis that primarily affects the spine. That’s because stress can exacerbate ankylosing spondylitis symptoms, including pain, according to the Spondylitis Association of America. Stress may also trigger an ankylosing spondylitis flare, a period of increased inflammation and worsening symptoms.

According to a review published in June 2017 in Frontiers in Human Neuroscience, stress can activate inflammatory responses in the brain, which can lead to excessive inflammation. Stress happens when our body’s normal feeling of stability and safety feels threatened. Stressful events or situations can trigger the body and activate the sympathetic nervous system. In turn, your body produces epinephrine and cortisol, also called “stress hormones.” Due to the nature of ankylosing spondylitis it can be difficult to untangle the origin of stress and inflammation, says John Davis, MD, a rheumatologist at the Mayo Clinic in Rochester, Minnesota. “Having an inflammatory disease and having pain ultimately creates psychological distress,” he says. “I’ve encountered patients in my practice who had a major stressful life event — say a major conflict at work or the death of a family member or spouse — and these stressful events can lead to the worsening of their condition and higher levels of inflammation,” Dr. Davis says. There are a number of factors that could lead to the flare, Davis says. Stress or a stressful event could interfere with self-care, he notes. “For example, adherence to their medication could go down and that could contribute to higher inflammation and a higher risk of flares,” he says. Stress can also directly increase inflammation: “I have seen patients where stress seemed to be associated with subsequent disease flares,” Davis says. Identify the cause of your stress It’s important to try to understand the source of your stress, says Stephanie M. Turner, MA, LPC, a therapist at WakeMed Health & Hospitals and in private practice in Raleigh, North Carolina. “Try to gain insight into the particular situation that generates fear,” she says. If you’re more aware about what causes you distress, you’re better able to create strategies to minimize those feelings. Keep a healthy perspective Once you’ve discovered the source of your stress, the next step is to make sure you’re viewing it in the proper perspective, says Turner. “The way a person views his or her circumstance is key,” she says. Certain cognitive patterns might be detrimental and cause even more stress, such as cognitive distortion, which is when our mind convinces us of something that isn’t really true, Turner says. “Catastrophizing is one example of this; when we convince ourselves that an event or situation is much worse than it really is.” According to Turner, it’s helpful to explore these cognitive patterns. One way to do this is through cognitive behavioral therapy, a type of talk therapy that can help you manage stressful situations by learning how to identify and change inaccurate or negative thinking. Ask your doctor to refer you to a cognitive behavioral therapist. Plan ahead There are times when stressful situations happen without warning, but there are things you see coming, such as family events, holidays, or work deadlines. If you’re aware of an upcoming event or change that may cause stress, prepare ahead of time, says Turner. “Say you’re aware of a future change in your work environment,” she says. “It’s important to communicate with your employer about the situation and possible accommodations.” She notes that “the little things” can make a real difference, and help you feel more in control. “You may not be able to control every aspect of the situation,” she says, “but be proactive and make a positive impact in the ways that you can.” Take a deep breath Breathing techniques can be useful tools to handle “in the moment” stressful times, says Turner. Taking slow, deep breaths can ease stress and elicit your body’s relaxation response. Try this: Sit or lie comfortably, with one hand on your chest and the other on your stomach. Breathe in slowly through your nose so you feel your stomach moving against your hand, then exhale through pursed lips. The hand on your chest should remain as still as possible. Practicing grounding techniques can also be helpful. “Grounding is a way to stay in the present, the here and now. It’s a way to quiet our brain,” says Turner, adding that it’s particularly helpful when you find yourself in a “fight or flight” situation or when your mind is in a negative place. When you bring your mind into the present moment by using your breath and your senses, it can have a very calming effect. Noticing your breath and how different parts of your body feel in relation to your surroundings can bring renewed focus to your situation. Stretch and move your body Staying physically active is one of the most important things you can do to manage ankylosing spondylitis. Moderate exercise and stretching, done with your doctor’s supervision, can help ease symptoms, increase your ability to move, and decrease stiffness. And exercise has an additional benefit: stress relief. Exercise increases the production of endorphins — your body’s “feel-good” chemicals. It can also boost your mood, allow you to focus on something other than your daily worries, and help you get better sleep. Spend time in nature You may have noticed you feel calmer or at peace after a nature hike, and science has proven that it’s not just your imagination; a walk in the woods can have real and positive effects on your state of mind. A study published in July 2015 in the journal Proceedings of the National Academy of Sciences of the United States of America examined the brains and moods of volunteers by having them take 90-minute strolls through leafy green parts of campus versus walking next to a hectic busy road near campus. Not only did the people walking amongst trees report less “brooding” and an improved mental state compared with the people near traffic, they also experienced less activity in the subgenual prefrontal cortex, the part of the brain associated with that kind of negative brain activity. Remember you’re not alone There are many factors that link stress and a chronic disease like ankylosing spondylitis, notes Turner. “The condition not only impacts how you feel, it can affect financial stability, family relationships, and work relationships, to name a few. It’s very far reaching,” says Turner. “This can be especially true when you have a condition that a lot of people don’t know about like ankylosing spondylitis; there can be a lack of understanding,” Turner says. This can make you not feel validated or “normal,” or feel like no one gets what you are going through and lead to feelings of isolation, she adds. Don’t be shy about sharing what you’re going through with your family and friends, she says. There are also resources available online, such as Facebook support groups, to help you connect with other people living with ankylosing spondylitis. Prioritize and take care of yourself Ankylosing spondylitis does create a “new normal” in terms of how a person feels from day to day due to pain and inflammation, says Davis. “Part of managing this condition is being able to prioritize what you need to do,” he says. That may mean tapering back activity on bad days, he says. People who manage ankylosing spondylitis well do what’s within their power to take care of themselves, says Davis. “They get adequate sleep, make time for exercise, take their medications as instructed and go to their healthcare appointments,” he says. And practicing this type of self-care can help you better manage stress.