When the Body Says No: Exploring the Stress-Disease Connection

“If you can’t say no, your body will do it for you.” You may have experienced coming down with a cold after a period of high stress. You’ve worked long days, not slept enough, and put your needs last—and as a result, your immune system is weakened and you end up sick in bed. Since you weren’t saying no to the demands of your life, your body did it for you.

The stress-disease connection is pretty obvious when it comes to the common cold, because the effects of the stress are experienced almost immediately. When it comes to chronic conditions like autoimmune diseases, cancer, and neurodegenerative diseases, the connection may not always be as clear. We adapt to increased stress levels over time, to the point that we aren’t aware of the stress. And chronic conditions develop so gradually that they often exist under the surface long before we experience any noticeable symptoms.

Dr. Gabor Maté’s phenomenal book When the Body Says No explores psychoneuroimmunoendocrinology—the science of how our psyche, nervous system, immune system, and endocrine system interact and affect our health. Dr. Maté discusses a wide range of conditions including lung, breast, prostate, and skin cancer; multiple sclerosis, rheumatoid arthritis, irritable bowel syndrome, and asthma; and amyotrophic lateral sclerosis (ALS) and Alzheimer’s disease. He weaves scientific explanations in with compelling case studies, illustrating the stress-disease connection on a highly personal level. This book is a must-read for all health professionals, anyone suffering from a chronic health condition, and anyone who has trouble saying no.

Disease is not caused by one thing, but by many interacting factors

One of the most important lessons learned from When the Body Says No is that chronic disease is very rarely caused by just one thing. We like to have black and white answers; we like to know where to place our blame. But when it comes to chronic disease, there are few definitive answers. As Dr. Maté writes, “Even where significant risks can be identified…these vulnerabilities do not exist in isolation. A systems model recognizes that many processes and factors work together in the formation of disease or in the creation of health.”

“The cure of many diseases is unknown to physicians…because they are ignorant of the whole. For the part can never be well unless the whole is well.” —Plato

Since the discovery of the double helix in 1953, the subsequent surge of genetic research, and the mapping of the human genome that was completed in 2003, we’ve become obsessed with our genes. As of 2022, there were approximately 197,779 genetic tests available globally, and the genetic testing market is projected to be valued at 43 billion dollars by 2032. But the reality is that our genes give us relatively little information about our overall health.

For example, inherited genetic mutations play a major role in only 5% to 10% of all cancers. About 10% of ALS cases are considered “familial,” and inheriting a gene for familial ALS does not guarantee that someone will develop the condition. And less than 1% of Alzheimer’s cases are inherited or “familial.” Genes are regulated—turned on and off—as a result of our environment and lifestyle (stress, diet, toxins, etc.), and most of a cell’s genes never get expressed.

Toxins are blamed for many diseases, and while exposure to certain toxins significantly increases the risk of disease, it does not guarantee it. For example, a study of over 5,000 Europeans found that among heavy smokers, the risk of lung cancer was 24.4% in men and 18.5% in women. That means that the majority of heavy smokers—75.6% of men and 81.5% of women—managed to avoid lung cancer.

Likewise, a neurotoxin called BMAA (which is produced by blue-green algae and found in seafood) clearly plays a role in developing ALS, Alzheimer’s disease, and Parkinson’s disease. In Guam, high exposure to BMAA from dietary sources contributes to ALS in up to a third of the population—a rate more than 100 times higher than in the U.S. And yet, two thirds of the population of Guam does not develop the disease, despite high exposure to the neurotoxin.

There is growing awareness about how eating animal products increases the risk of cancer. High consumption of red meat increases the risk of colon cancer by 28%, and high consumption of processed meat increases the risk by 20%. The link between cheese consumption and breast cancer is so strong that 12,000 physicians signed a petition to the FDA to put breast cancer warnings on cheese products. And a review of 47 studies found an increased risk of prostate cancer due to eating animal products. And yet, 1 in 23 people develop colon cancer, 1 in 8 women develop breast cancer, and 1 in 9 men develop prostate cancer—despite the fact that most people consume animal products regularly.

One of the biggest risk factors in disease is stress; according to Dr. Mark J. Doolittle of the Stanford Center for Integrative Medicine, “most standard medical textbooks attribute anywhere from 50 to 80 percent of all disease to stress-related origins.” The Centers for Disease Control and Prevention estimates that 75% of doctors visits are due to stress. Yet when it comes to chronic disease, the medical community seems far more concerned with genetics and potential toxin exposure than with our mental health.

In the vast majority of cases, it is not accurate to blame a single factor for a chronic disease. Our state of disease or health is the result of many interacting factors, so the more we can adopt a holistic approach to our health—one that takes into account all aspects of our biology, physiology, lifestyle, and environment—the better off we’ll be.

Psychoneuroimmunoendocrinology: How stress makes us sick

When we perceive stress, our hypothalamus releases corticotropin-releasing hormone (CRH), which in turn stimulates our pituitary gland to release adrenocorticotrophic hormone (ACTH). ACTH then stimulates our adrenal cortex to release cortisol and other corticoid hormones, which act on nearly every tissue in our body. This functional connection of the hypothalamus, pituitary gland, and adrenal glands is referred to as the HPA axis. The HPA axis is central to our stress response, and it is the mechanism by which our emotions affect our health.

Hundreds of studies show how stress alters immune function. Chronic stimulation of our stress response and the resulting imbalance of corticoid hormones leads to dysregulation of the immune system, making us less able to fight off viruses—that’s why we come down with colds after periods of high stress. But our immune system doesn’t just protect us against colds; it also kills off potentially cancerous cells and eliminates toxins. And when our immune system isn’t working correctly, it might begin attacking our bodies’ own healthy cells, resulting in an autoimmune disease.

It is far too easy to adapt to chronic stress, and this is a reason why chronic stress is so dangerous. People who tend to internalize their stress often become so accustomed to their habitual thoughts, emotions, and physiological state that they are unaware they’re experiencing stress. Internalized stress can also involve a lot of denial. If we aren’t aware of the problem, or if we’re in denial of our feelings, there’s no way for us to make a positive change.

It’s equally dangerous to be addicted to the stress response—to thrive on the rush of adrenaline we feel when we’re under stress, even if we label it as “good” stress. For some people, being relaxed feels boring and even unsettling; these people need to continually activate their stress response in order to feel normal.

The different versions of “not saying no”

Dr. Maté’s book focuses on the stress we experience as a result of not being able to say no. When we’re focused on pleasing others, don’t set limits, and put ourselves last, we experience a great deal of stress. This stress is internalized—not outwardly expressed. Some of the most stressed people may be the ones who appear to be calm, quiet, not complaining, and never angry.

There are many versions of people-pleasing and “not saying no.” Read through this list and see if any of them ring true for you.

  • You don’t like to say no or disappoint others
  • You feel obligated to help others
  • You are a caregiver for someone
  • You are an overachiever or a workaholic
  • You live in reaction to others
  • You put others’ happiness before your own
  • You’re a perfectionist
  • You’re worried about other people’s opinions or judgments
  • You feel inadequate
  • You don’t like to ask for help, or you feel that you don’t need help
  • You feel that you have to be the strong one
  • You’re hypervigilant; you feel that you need to be in control
  • You feel that you are responsible for everything
  • You feel most comfortable conforming to others’ expectations
  • You avoid conflict
  • You don’t like to offend others
  • You never feel angry; this may mean that you aren’t recognizing and processing your anger
  • You feel angry, but don’t express it outwardly

If you tend to internalize your stress in any of these ways, it means that to some extent—and maybe to a great extent—you’re repressing your emotions. Repressing emotions prevents active release of stress through either the fight or flight response. If you tend to repress or deny your emotions, not experiencing them or expressing them outwardly, you are likely triggering your stress response without being aware of it.

We’re all pretty familiar with the classic personality categories of Type A (competitive, fast-moving, hard-working, tense) and Type B (easy-going, mild-mannered, not competitive). Dr. Maté describes personality Type C, which was first proposed in relationship to skin cancer. Type C personalities may appear to be like Type B in that they are cooperative, patient, passive, and accepting. But while Type B personalities express their anger, fear, and sadness, Type Cs tend to suppress negative emotions, especially anger, while maintaining a strong and happy facade. As we’ll discuss in the next section, Type C personalities are more likely to be found in people who develop cancer and chronic autoimmune and neurodegenerative conditions. (Dr. Maté notes that Type A personalities are more prone to heart disease.)

As Dr. Maté explains thoroughly in his book, emotional coping styles are formed in childhood. And when we understand how emotions trigger the stress response and contribute to disease, it is easy to see how disease gets passed down through generations—not so much by genetics, but to a much greater extent by stress.

Emotional repression in chronic diseases

Dr. Maté devotes sections of his book to a range of diseases including lung, breast, prostate, and skin cancer; multiple sclerosis, rheumatoid arthritis, irritable bowel syndrome, and asthma; and amyotrophic lateral sclerosis (ALS) and Alzheimer’s disease. He presents a great deal of research showing the strong correlation between emotional repression and disease, and I’ll touch on a few interesting findings here.

A study followed 1400 people for ten years, and compared rate of disease to personality traits. Cancer incidence was 40 times higher among people who repressed their anger than among those who did not. Another study found the rate of lung cancer to be 5 times higher among men who did not express their emotions effectively. A 1984 study measured emotional stress in groups of people with skin cancer, heart disease, and no medical illness. While the physiological stress response was the same in all three groups, the skin cancer group was the most likely to deny awareness of feeling anxious or upset by being exposed to unpleasant and depressing stimuli.

A medical-psychiatric study of people with rheumatoid arthritis (RA) found that they had remarkably similar psychological characteristics, notably compensating hyperindependence—a belief that they could get through everything by themselves, with no help from others. Other psychological studies of RA patients have found that they tend to exhibit perfectionism, fear of their own anger, denial of hostility, and strong feelings of inadequacy.

Research shows that asthmatic children tend to receive more criticism from their parents, and when these children feel frustrated or criticized, their airways narrow. A study of over 700 ulcerative colitis patients found a high proportion of them to have obsessive-compulsive personality traits, such as conscientiousness, as well as reduced emotional expression, over-intellectualization, and rigid attitudes toward morality and standards of behavior. And studies show that between 85% and 90% of multiple sclerosis sufferers experience stressful or traumatic life events leading up to the emergence of their symptoms.

Dr. Maté describes a phenomenon that has long been observed by doctors who treat patients with ALS: the patients are almost always extremely nice people. They are pleasant and easy to deal with, don’t ask for help and never complain. Neurologists from the Cleveland Clinic presented a paper called “Why Are Patients with ALS So Nice?” at an international symposium. When technicians have completed their tests on people who may have ALS and don’t know the results yet, they often include a comment like “This patient cannot have ALS, he or she is not nice enough” and almost invariably, they are correct. ALS sufferers are also often described as being workaholics, over-achievers, and having a compulsive sense of duty to others.

Putting yourself first and feeling angry

Dr. Maté conducted over 100 interviews for his book, and observed that people with chronic disease are often “woken up” by their diagnosis. It took their body saying no for them to finally realize that they need to take care of themselves and put themselves first.

For people who love to take care of others, feel a sense of duty to serve, or derive personal fulfillment from helping people, it can be extremely challenging to put themselves first. If that describes you, you might feel selfish or guilty when you do things that are just for you. But as Ed, a prostate cancer patient interviewed by Dr. Maté, says, “If I feel guilty? Wonderful. Hallelujah! It means I must have done something right, acted on my own behalf for a change.”

If you feel a compulsive need to help others, always remind yourself that you can’t truly help anyone else if you don’t take care of yourself; this is why we put on our own oxygen mask before putting on our child’s. Gilda Radner, who suffered from ovarian cancer, wanted to help heal every cancer patient. She finally realized close to her death that she could not: “It is important to realize that you have to take care of yourself because you can’t take care of anybody else until you do.”

There is a wonderful chapter near the end of When the Body Says No in which Dr. Maté discusses the power of negative thinking. When positive thinking is not genuine—when we use it to tune out or deny negative thoughts—it is detrimental to our health. It is emotional repression. In his words, “’the power of negative thinking’ requires the removal of rose-colored glasses.”

Allowing yourself to acknowledge and process your negative emotions, including anger, is critical for your health. At the other extreme, constantly flying into fits of rage is not healthy, but there is a balance in the middle where you recognize and express your anger in a constructive way. Physician and psychotherapist Allen Kalpin describes anger as being both empowering and relaxing: “It is a physiologic experience without acting out. The experience is one of a surge of power going through the system, along with a mobilization to attack. There is, simultaneously, a complete disappearance of anxiety. When healthy anger is starting to be experienced, you don’t see anything dramatic. What you do see is a decrease of all muscle tension. The mouth is opening wider, because the jaws are more relaxed, the voice is lower in pitch because the vocal cords are more relaxed. The shoulders drop, and you see all signs of muscle tension disappearing.”

As Dr. Maté writes, “anger does not require hostile acting out.” The key is to not suppress the experience of it. Give yourself permission to feel angry.

If you want to get motivated to put yourself first, read the incredible book When the Body Says No. You’ll learn a lot about yourself and your loved ones, and most importantly, you’ll learn the importance of saying no.