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Controlling Stress

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Stress is a double challenge for people with ME/CFS and fibromyalgia. Illness adds new sources of stress, such as the ongoing discomfort of symptoms, uncertainty about the future and financial pressure.

In addition, ME/CFS and FM are very stress-sensitive illnesses, so that the effects of a given level of stress are greater than they would be for a healthy person.

Thus, you face a double challenge related to stress: your stresses are multiplied at a time when you are more vulnerable to the effects of stress. This combination makes addressing stress a high priority.

By using stress management techniques such as those described in this chapter, you can learn how to interrupt the cycle in which symptoms and stress reinforce one another.

Sources and Signs of Stress

One reason that stress is such a big challenge in ME/CFS and FM is that it can come from many different sources. They include:

Symptoms   Ongoing discomfort is debilitating and worrisome
Limits   Frustration due to smaller energy envelope
Loss   Many losses: health, income, friends, etc.
Isolation   Stress from time alone and from feeling different
Money   Financial pressure
Relationships   Often strained; some may end
Thoughts   Unrealistic expectations or feeling helpless
Uncertainty   Worry about the future
Sound & Light   Sensitivity to sense data
  Sensitivity to foods and/or chemicals

Any of the following can indicate that you are under stress.

  • Muscle tension (especially in head, neck & shoulders)
  • Feeling anxious or nervous
  • Moodiness
  • Feeling depressed
  • Nervous movement (e.g. tapping fingers or feet)
  • Irritability
  • Sleep problems (trouble falling asleep or staying asleep)
  • Grinding teeth or clenching jaw

Approaches to Managing Stress

Because stress is so common and so debilitating, we recommend that people with ME/CFS and FM use multiple techniques to manage it. Many people in our program manage stress with pacing strategies such as reducing their activity level, learning to say "no," taking daily rests and using routine.

Some describe a change in their employment situation as a stress reduction measure. These work changes have included switching from full-time to part-time work, moving to a less demanding job, working from home, adopting a flexible schedule, and taking early retirement.

Other frequently-used approaches include doing a daily relaxation procedure, de-cluttering (e.g. reorganizing the kitchen or discarding unused possessions), limiting exposure to the media, limiting contact with some people, avoiding crowds, getting help with household chores and making mental adjustments (such as letting go of unrealistic expectations).

Because there are so many causes of stress, it pays to use a variety of approaches to manage it. One person in our program says, "I do a variety of things to manage stress, such as deep breathing, listening to relaxation tapes, getting regular massages, walking with my dog, and writing in my journal."

Another writes, "The ways I try to handle stress are: meditating daily, scheduling a regular time [to go to] bed each night, keeping our home an emotionally welcoming place for my husband, engaging in pleasurable activities, and avoiding unwanted situations [that] drain my energy."

We will explore two categories stress management: stress reduction and stress avoidance. The first involves retraining yourself, learning how to respond differently to stressors so that they do not have the same effect as in the past. The second approach is preventive, taking measures to avoid stressful circumstances.

Stress Reduction

Often, how we view and react to a stressor determines how much stress we experience. For example, if you worry in response to an increase in symptoms, you may tense your muscles. Muscle tension can create pain, draining energy and causing fatigue.

By learning to relax, you can lessen muscle tension and ease symptoms. This is one example of how to reduce the impact of stressors by changing your response. Here are 14 stress reduction strategies to consider.


When we become stressed in the face of challenge, we often respond with a fight-or-flight reaction. Adrenaline flows, and we feel charged up. If the challenge is brief, the initial reaction is followed by relaxation. If, however, you feel yourself to be under constant threat, as you may if you are always in pain, your body stays in a state of tension.

Physically relaxing activities counteract both the physical and the emotional aspects of stress. Through relaxation, you can reduce muscle tension and anxiety. Relaxation is also very helpful for pain control. Combining rest with a relaxation procedure or meditation can be an even more effective means of stress reduction.

Examples of stress reduction procedures include focusing on your breathing, the body scan, progressive relaxation, and guided imagery. (You can find step-by-step instructions for these and other relaxation procedures in Chapter 13 of The Patient's Guide to Chronic Fatigue Syndrome and Fibromyalfia.)

Because everyone is different, some techniques work well for one person and other techniques work better for another. In particular, techniques using imagery seem very helpful to some people, but not useful to others. Try several techniques to see what works for you. Also, you may find that a particular technique works for a while, and then becomes ineffective. If that happens, try something else.

It usually takes several weeks or more of practice to develop skill in using a technique, so allow some time before expecting results. To be fair, you should practice four or five times a week, setting aside ten to 20 minutes for each session and choosing a time when you won't be disturbed. Learning concentration is a common problem when doing a relaxation practice. The mind tends to wander, so having patience is necessary.

There are many good relaxation and meditation tapes available today. Some have step-by-step instructions to lead you through a relaxation procedure, while others have music or relaxing sounds from nature. You may want to use such tapes or record your own from the techniques you find on our website or elsewhere. If relaxation makes you anxious or seems unpleasant, try other stress reduction techniques.

Formal relaxation procedures work for many people, but other, less formal approaches can help, too. These include exercise, baths, massage, acupuncture, rest and listening to relaxation tapes or music.

Mental Adjustments
Your thoughts can be another source of stress. For example, you may have unrealistic expectations for yourself. You may think that, as a "good mother" or "good wife," you should keep the house as you did before becoming ill. If that's the case, you can reduce suffering by changing your expectations, so they better match your current abilities.

A number of people in our program refer to themselves as "recovering perfectionists." Becoming aware of and changing the standards you have for yourself reduces stress and helps you avoid overdoing.

It may also help to change your expectations about how others view you. As one person said, "I let go of expecting people to respond to me the way I think they ‘should'. For example, I let go of expecting that people will understand my disease. So with no expectations, I [feel] less resentment, which leads to less stress in life."

Thoughts can increase stress is through our "self talk," the internal dialogue we have with ourselves, especially about negative events. For some people, an increase in symptoms may trigger thoughts like "I'm not getting anywhere," "I'll never get better" or "It's hopeless."

Negative thoughts like these can then make you feel anxious, sad and helpless. The thoughts and the stress they create may make your symptoms worse and trigger another round of negative thoughts. The cycle can be very demoralizing, leading to an overly pessimistic view of your situation and making it difficult to motivate yourself to do things to feel better.

But you can learn how to recognize and change habitual negative thoughts so that your self-talk is more realistic and more positive. There are many self-help manuals for doing this. Our favorite is the one by Greenberger and Padesky. (See References, at the end of this article.)

Others include books by Burns and Seligman. Also, you can get professional help; look for a counselor who specializes in Cognitive Therapy, also called Cognitive Behavioral Therapy (CBT).

Supportive Relationships: Family, Friends and Professionals

Good relations are a buffer against stress. Feeling connected to people who understand and respect you reduces anxiety and counteracts depression. Beyond that, talking to another person may help you clarify your situation or the response you receive may enable you to see your life in a different, more constructive way.

You may receive such support from family members, friends, other people with ME/CFS and FM or therapists. Support also means practical assistance, which might include such things as shopping, cooking, bill paying or housecleaning. For more on this topic, see the section on relationships.

Problem Solving

Taking practical steps to improve your situation can also help reduce anxiety and worry. A member of one of our groups, who suffers from severe brain fog, reported that she had gone to the emergency room after taking her medications three times in one day.

Worried that brain fog might lead her to make the same mistake again, she asked her group for suggestions and adopted one of them: a pill box with compartments for each day of the week. She reported that the pillbox was a stress minimizer, greatly reducing her fear of repeating her mistake.

Another person in our program reported, "I have spent quite a bit of time analyzing my activities, everything from how long I stayed somewhere to ways to minimize pain in doing chores. From this analysis, I have tried many different ideas that have proved to be very helpful, such as a book holder for the newspaper."

Educating yourself about ME/CFS and FM can be a great stress reducer, as you replace fears with facts. One place to start is with the articles in the Basics: ME/CFS & FM 101 archive.  

Pleasurable Activities

Doing things that bring you pleasure can distract you from stress and reduce preoccupation with problems. Listening to or playing music or engaging in other artistic pursuits are good stress reducers. The same can be said of reading a good book, seeing an engrossing movie, spending time in nature and talking with a friend.

The key is to find an activity in which you can become absorbed. By immersing yourself, you interrupt the worry cycle, distract yourself from symptoms and experience some relaxing pleasure.

Exercise and Movement

Exercise is a natural stress reducer, since it causes your body to produce endorphins and other soothing body chemicals. A similar effect can be obtained through other forms of movement. If you are worried, just getting up and moving around can help break the spell.


Writing may be useful as a stress reducer. You might find it helpful to write out what's bothering you as a way of venting frustration and lessening worry. Another use of journaling is to help you change perspective on your life. Some people have told us they found it very helpful to keep a journal in which they note positive events every day.

Over time, they found that their mental attitude toward their illness and their life changed in a positive direction. See Joan Buchman's article The Healing Power of Gratitude. For a model of a gratitude journal, see Sarah Ban Breathnach's book Simple Abundance Journal of Gratitude.

Talking and Being Listened To

It is not surprising that, in a survey, talking to a friend was rated as the number one way to combat worry. Talking to someone you trust provides reassurance and connectedness to dispel worry. According to Edward Hallowell, studies have shown that talking to another person changes what is happening in your brain at a physical level.

Laughter and Humor

This is another good stress reducer. Watching a funny movie, reading a humorous book, looking at favorite cartoons or laughing with friends can be a great release. Like exercise, laughter promotes the production of endorphins, brain chemicals that produce good feelings and reduce pain.

Research suggests that it can strengthen the immune system, counteract depression and even provide a substitute for aerobic exercise. Short periods of laughter can double your heart rate for three to five minutes. A natural tension reducer, laughter produces relaxation for up to 45 minutes.


For some people, just having time alone can be helpful. One person wrote, "I spend much of my time in quiet, relaxing activities such as reading, needlework, etc. If I have a day that does not allow me to participate in these activities to some minimal extent, I find myself extremely tense, stressed out and emotional."


By speaking up for yourself, setting limits and saying "No," you protect yourself and avoid doing things that intensify symptoms. For example, you can teach your family and friends to respect your need for rest times and can make your limits clear by telling others how long you'll talk on the phone or how much time you will spend at a party.

By having a "voice," you reduce the stress that results from keepings things inside.

Also, learn to delegate and ask for help. Others often feel as helpless as you about your illness; asking them to help you in some specific way replaces the sense of helplessness with a feeling of accomplishment.


Prescription medications can be helpful as part of a stress management program. As one person in our program wrote, "I resisted the idea [of medications] for a long time, and now kick myself for having done so. [Zoloft] has helped level off my reactions to everyday stress and evened out my mood."

Stress Avoidance

Stress avoidance is preventive, using self-observation to learn how stress affects you and then taking measures to avoid stressful circumstances. For example, you may notice that when you hit a limit, any further activity will intensify your symptoms.

In such circumstances, rest can reduce the stress on your body. Having good relationships are a buffer against stress. People with supportive relationships have lower anxiety and depression.

Overall, the idea of prevention is to avoid generating a stress response by avoiding stressful situations. Fewer stress hormones means more time for your body to repair itself. The main ways that people in our groups prevent stress are by avoiding stress triggers and by using pacing, order and routine.

Avoiding Stress Triggers
There are three types of stress triggers: substances that create allergic reactions, situations that produce sensory overload and certain people. You can reduce symptoms by avoiding foods and other substances to which you are allergic or sensitive, minimizing situations that create sensory overload and limiting contact with anxious, negative or overly-demanding people.

If you are particularly sensitive to light, noise or crowds, or experience sensory overload in other ways, avoiding or limiting your exposure to those situations can help you control symptoms.

For example, if you are susceptible to sensory overload, you may socialize mostly at home or in small groups, limit your time in crowded stores or go to restaurants at off-peak times.

Also, many people with ME/CFS and FM are selective about their exposure to television and movies, avoiding material that is emotionally arousing or has rapid scene changes. Some people have "media fasts," periods in which they watch no television, listen to no radio and ignore newspapers.

Some people with ME/CFS and FM experience high levels of stress when they interact with people who are anxious, negative or demanding. Responses they have made include talking with the person, limiting contact, getting professional help, and ending the relationship.

As one person wrote, "I have cut people out of my life that only irritate or don't support me. It was a hard thing to do but has made a big difference in how I feel."

Pacing, Order and Routine
Pacing strategies reduce stress. Reducing activity level, scheduling activity based on priorities, having short activity periods, scheduling important tasks for your best time of day, taking regular rests, and taking time for meditation or prayer all help control stress.

As one person wrote, "I found that I could avoid much stress by knowing my limits. Planning too many activities in one day or scheduling them too close together are big stress triggers, so I try to prevent their activation by limiting the number of activities in a day and by giving myself plenty of time in between activities."

Another way to reduce stress is through routine: doing things in familiar ways and living your life according to a schedule reduces stress by reducing decision making and increasing predictability. It takes more energy to respond to a new situation than it does to something familiar, so by reducing the surprises and novelty in life, you reduce your stress.

Some people with ME/CFS and FM create routine by living their lives according to a plan. By living their plan, they reduce the surprises and emotional shocks in their lives, and thereby reduce their stress.

One wrote, "Up until two years ago my life had little routine in it and the result was frequent, lengthy crashes. My life was one big roller coaster. Now that I have a regular schedule, I can plan much better. Routine may sound boring, but it's a must for me."

Another said, "Having a regular routine has been very useful, because having a predictable life has been the most effective way for me to reduce stress. A life with few surprises has reduced the pressure on me and given my body more time to heal."


Burns, David. Feeling Good. New York: Morrow, 1999.

Greenberger, Dennis and Christine Padesky. Mind Over Mood: Change How You Feel by Changing the Way You Think. New York: Guilford Press, 1995.

Hallowell, Edward. Worry. New York: Ballantine Books, 1997.

Seligman, Martin. Learned Optimism. New York: Knopf, 2006.