Stress — Causes, Symptoms & Treatment Guide — Symptoms, Causes & Treatment | MyMedicPlus

Stress is a physiological and psychological response to a perceived demand or threat that exceeds a person's available coping resources. It is a universal human experience — acute, short-duration stress (eustress) is adaptive and performance-enhancing; it is chronic, unresolved stress that causes psychological and physical harm. Stress activates two overlapping physiological pathways: the sympatho-adrenal medullary (SAM) axis — releasing adrenaline and noradrenaline (the 'fight-or-flight' response — immediate: increased heart rate, blood pressure, and muscle blood flow), and the hypothalamic-pituitary-adrenal (HPA) axis — releasing cortisol via ACTH (longer-term: immune suppression, increased blood glucose, heightened alertness). Chronic HPA axis activation results in persistently elevated cortisol levels, associated with hippocampal neuronal atrophy, immunosuppression, weight gain (central adiposity), insulin resistance, and increased risk of depression, anxiety, cardiovascular disease, and cancer. In 2023, 74% of UK adults reported feeling overwhelmed or unable to cope with stress in the past year, and work-related stress accounts for 55% of workplace sickness absence.

Stress is highly individual — the same objective situation is experienced as stressful by some and not others, depending on cognitive appraisal (Lazarus's transactional model: whether the situation is appraised as a threat or a challenge) and perceived coping resources. Common stressors: work-related (excessive workload, lack of control, poor relationships, job insecurity — the UK's most common stress cause); financial pressure; relationship difficulties (conflict, separation, bereavement); major life events (moving, divorce, illness, new job); parenting and caregiving responsibilities; health concerns; social isolation; and environmental stressors (noise, crowding, trauma exposure). Risk factors for stress-related mental health problems: history of anxiety or depression, adverse childhood experiences (ACEs — childhood trauma, neglect, abuse), low social support, perfectionism, and neuroticism trait. Occupational groups at highest risk: healthcare workers, teachers, emergency services workers, and caregivers. Physiological stressors: chronic illness, sleep deprivation, alcohol excess, and nutritional deficiencies also activate stress pathways and reduce resilience.

Psychological symptoms: anxiety, worry, feeling overwhelmed or out of control, irritability and short temper, restlessness, difficulty concentrating, low mood, and emotional reactivity. Cognitive symptoms: racing thoughts, poor decision-making, forgetfulness, difficulty concentrating, and negative thinking patterns (catastrophising, overgeneralising). Behavioural symptoms: changes in appetite (stress-eating or appetite loss), increased alcohol or caffeine consumption, withdrawal from social activities, neglect of self-care, procrastination, and disturbed sleep. Physical symptoms (mediated by cortisol and sympathetic nervous system activation): headaches (tension headaches — frontal and occipital), muscle tension (especially neck, shoulders, and back), fatigue and low energy, gastrointestinal disturbances (nausea, diarrhoea, constipation, IBS flares), palpitations (sympathetic activation), chest tightness, breathlessness, dizziness, and sweating. Skin manifestations: exacerbation of psoriasis, eczema, and acne (cortisol exacerbates inflammatory skin conditions). Menstrual irregularity: chronic stress-related HPA activation suppresses GnRH and disrupts the hypothalamic-pituitary-gonadal axis, causing irregular or absent periods. Immune suppression: increased susceptibility to infections (colds, herpes reactivation).

Stress is a psychological state, not a DSM-5 diagnosis in itself — but it is a risk factor for and often overlaps with anxiety disorders, depression, adjustment disorder, and burnout. Clinical assessment: GP or mental health professional interview exploring the nature, duration, and impact of stressors; cognitive, emotional, and behavioural responses; functional impairment; and risk of self-harm. Validated screening tools: Perceived Stress Scale (PSS-10 — 10-item self-report questionnaire measuring subjective stress perception), PHQ-9 (depression screening), GAD-7 (anxiety screening — often elevated in stressed individuals). Work-related stress assessment: HSE Management Standards and job demands-control-support model frameworks identify modifiable occupational factors. Investigations to exclude physical causes of somatic symptoms: thyroid function tests (hypothyroidism or hyperthyroidism mimicking stress), FBC (anaemia), blood glucose, cortisol levels (not routinely measured for 'stress' — hypercortisolaemia is a complex investigation reserved for suspected Cushing's syndrome). Burnout: characterised by emotional exhaustion, depersonalisation, and reduced personal accomplishment — assessed with Maslach Burnout Inventory (MBI). Adjustment disorder: stress response exceeding normal expected severity within 3 months of an identifiable stressor.

Psychological therapies are the most effective interventions for stress-related difficulties. Cognitive behavioural therapy (CBT): addresses maladaptive thinking patterns (cognitive distortions — catastrophising, mind-reading, black-and-white thinking) and unhelpful behaviours; teaches problem-solving, cognitive restructuring, and behavioural activation; delivered via individual therapy (6-12 sessions), group therapy, or guided self-help (computerised CBT — SilverCloud, Beating the Blues — available free via IAPT in England). Mindfulness-based stress reduction (MBSR): an 8-week programme combining mindfulness meditation, body scan, and yoga; reduces stress, anxiety, and depression; reduces HPA axis activity and improves immune function; reduces burnout in healthcare workers. Acceptance and commitment therapy (ACT): focuses on psychological flexibility and values-based action rather than symptom reduction. Relaxation techniques: progressive muscle relaxation (PMR), diaphragmatic breathing (parasympathetic activation — reduces cortisol), and guided imagery — all reduce acute sympathetic activation. Exercise: 150 minutes of moderate-intensity aerobic exercise per week reduces stress and anxiety equivalent to low-dose medication; increases BDNF (brain-derived neurotrophic factor — promotes neuroplasticity), reduces cortisol, and improves sleep. Sleep hygiene optimisation: poor sleep amplifies stress reactivity — CBT for insomnia (CBT-I) is first-line. Medication: not directly indicated for stress itself; SSRIs/SNRIs for comorbid anxiety or depression (escitalopram, sertraline, venlafaxine); short-term benzodiazepines only in crisis (risk of dependence — avoid in primary care beyond 2-4 weeks). Occupational interventions: reasonable adjustments, stress risk assessments, flexible working, and Employee Assistance Programmes (EAPs). Social prescribing: social connection, volunteering, nature, and creative activities reduce stress.

Chronic unmanaged stress causes wide-ranging physiological complications through sustained HPA (hypothalamic-pituitary-adrenal) axis activation and sympathetic nervous system dysregulation. Cardiovascular disease: chronic stress elevates cortisol, catecholamines, blood pressure, heart rate, and inflammatory markers (IL-6, CRP) — increasing risk of myocardial infarction, stroke, and atrial fibrillation; work-related stress increases coronary heart disease risk by 23-40%. Immune dysfunction from chronic cortisol elevation suppresses lymphocyte function, NK cell activity, and antibody production — increasing susceptibility to infections, impairing wound healing, and potentially accelerating tumour progression. Mental health complications — major depressive disorder, generalised anxiety disorder, and burnout — develop in a substantial proportion of chronically stressed individuals; 50% of people with chronic stress develop a diagnosable mental health condition. Gastrointestinal complications include stress-related peptic ulceration (ACTH stimulates gastric acid secretion), exacerbation of inflammatory bowel disease, and irritable bowel syndrome. Musculoskeletal complications: tension headaches, migraine, temporomandibular joint disorder, and chronic back pain are amplified by stress. Sleep disorders — insomnia, non-restorative sleep, and circadian rhythm disruption — from cortisol dysregulation impair cognitive function, memory consolidation, and emotional regulation, creating a cycle that perpetuates stress. Burnout — defined as emotional exhaustion, depersonalisation, and reduced personal accomplishment — causes occupational disability and requires structured rehabilitation. Cortisol-induced metabolic effects include insulin resistance, central obesity, and increased type 2 diabetes risk.

Stress management is a learnable skill — protective resilience factors can be cultivated. Regular physical activity: 150 minutes per week of aerobic exercise is one of the most powerful stress-preventive interventions available — it reduces cortisol reactivity, improves mood, and builds psychological resilience. Sleep: prioritise 7-9 hours of quality sleep per night — sleep deprivation amplifies HPA axis reactivity and emotional volatility. Social connection: strong social support networks are the most consistent predictor of stress resilience — invest in relationships, seek community. Boundary-setting: define and communicate boundaries at work and in personal life — overcommitment is a major driver of chronic stress. Mindfulness practice: even 10-15 minutes of daily mindfulness reduces perceived stress over 8 weeks. Limit stimulants: reduce caffeine (above 400mg/day increases anxiety and disrupts sleep) and alcohol (short-term relief, longer-term cortisol elevation and mood disturbance). Time in nature: as little as 20 minutes in a natural environment significantly reduces salivary cortisol. Work organisation: adequate control, variety, and recognition in the workplace are protective (Karasek job demand-control model). Early professional help: do not wait until stress becomes burnout or depression — GP referral to IAPT (NHS Talking Therapies in England) provides free psychological support.

See a GP when stress is consistently affecting your ability to function, sleep, or maintain relationships, despite self-help efforts. Seek urgent same-day GP or mental health assessment for: thoughts of self-harm or suicide, severe anxiety or panic attacks preventing you from leaving the home or attending work, and complete inability to cope with daily tasks. Routine GP review for: stress-related physical symptoms persisting beyond 2-4 weeks (headache, chest tightness, GI symptoms — to exclude organic causes), sustained low mood, anxiety, or sleep disruption of more than 3-4 weeks, and suspected burnout. GP referral to NHS Talking Therapies (IAPT) for CBT, counselling, or mindfulness is available without a referral in England — you can self-refer at www.nhs.uk/mental-health. Workplace occupational health can assess and recommend adjustments for work-related stress. If stress is causing or exacerbating a physical condition (IBS, migraine, eczema, asthma), discuss the psychological component with your treating specialist.