© Med Sci Monit, 2006; 12(9): HY21-31
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PMID: 16940938
Received: 2006.06.19
Accepted: 2005.07.03
Published: 2006.09.01
Authors’ Contribution:
A Study Design
B Data Collection
C Statistical Analysis
D Data Interpretation
E Manuscript Preparation
F Literature Search
G Funds Collection
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HY
Hypothesis
Relaxation: Molecular and physiological significance
George B. Stefano1 DEG, Gregory L. Fricchione2 EF, Tobias Esch3 EF
1
Neuroscience Research Institute, State University of New York College at Old Westbury, NY, U.S.A.
2
Department of Psychiatry, Massachusetts General Hospital, Boston, MA, U.S.A.
3
Division of Integrative Health Promotion, Coburg University of Applied Sciences, Coburg, Germany
Source of support: Supported in part by grants MH 47392 and DA 09010 (GBS)
Summary
There appears to be a molecular process for relaxation. Given this, we attempt to demonstrate
this phenomenon based on established molecular and physiological processes in light of our cur-
rent understanding of central and peripheral nervous system mechanisms. Central to our hypoth-
esis is the significance of norepinephrine, nitric oxide, dopamine and morphine signaling both
in the central and peripheral nervous system. We find that nitric oxide and morphine control cat-
echolamine processes on many levels, including synthesis, release and actions. We conclude that
enough scientific information exists to support these phenomena as actual physical processes that
can be harnessed to provide better patient care.
relaxation response • nitric oxide • belief • limbic system • norepinephrine • morphine •
dopamine
http://www.medscimonit.com/fulltxt.php?IDMAN=9437
5731
—
3
145
Dr. George B. Stefano, Neuroscience Research Institute, State University of New York College at Old Westbury,
Old Westbury, NY 11568, U.S.A., e-mail: gstefano@sunynri.org
HY21
Hypothesis
BACKGROUND
It is reasonable to propose that our bodies contain natural-
ly occurring antibiosenescent, health maintaining and anti-
stress processes, involving immune, vascular and neural sys-
tems, that serve to maintain our life for a reasonable period
of time, and that the vigor of these processes, in part, de-
termine our mean life span. In most mammals, once these
protective systems diminish in their capacity, their repro-
ductive life has also ended. In man, however, in part aided
by our integrative capacity, our life span is extended well
beyond our reproductive years. It would not be surpris-
ing, therefore, to find critical neuronal processes linked
to man’s cognitive ability that have the ability to promote
health. These constitutive processes would manifest them-
selves above background activity during times of need, e.g.,
stress, when an increase in a health-related cognitive stim-
ulus initiates this innate, non-cognitive protective neural
process to become evident. We speculate that the ability to
relax is a major physiological process, which emerges when
“conditions” are appropriate.
WHAT IS RELAXATION?
For more than 30 years, Herbert Benson and colleagues, build-
ing on the work of Swiss Nobel Prize laureate Dr. Walter R.
Hess, have described a physiological response, termed the “re-
laxation response”, that they describe as being the opposite
of the stress response [1]. It results in decreased metabolism,
heart rate, blood pressure, and rate of breathing, as well as a
decrease in brain activity [2]. Recently, we have added nitric
oxide (NO) as a molecule involved in this learned response
[3–5]. Clearly, this response embodies actions that one would
associate with relaxation. We surmise the relaxation response
is part of a larger physiological process, which can simply be
referred to as relaxation. In this regard, we also surmise that
the ability of a practitioner or person to elicit the relaxation
response is strengthened by the trust or belief in the expected
outcomes as well as the belief that a particular environment
is safe or suitable to relax [6]. In fact, the strength of the fi-
duciary relationship between physician and patient appears
to play a direct role in the effectiveness of medical treatment
[4,6–10]. Thus, it would appear that there are larger physio-
logical processes allowing for relaxation to occur. However,
the exact mechanism or combination of cascading mecha-
nisms involved until now has escaped detection.
WHAT IS THE MIND?
Before going further we must define the term “mind.” For
us, it was enticing to think that the chance alteration of ge-
netic or neural pathways leading to cognitive processes also
provided such endowed animals with an additional survival
coping strategy [11] and that these cognitive coping abil-
ities provided such organisms with a competitive edge for
survival. The burgeoning of cognitive theory and therapy
in the recent past is testimony to the insight that altering
and improving cognitive coping mechanisms can help dissi-
pate the emotional ravages attendant to the stress response.
Interestingly, cognition may also contribute to stress when
it cannot be turned off [12].
In order for cognitive ability to develop and succeed, how-
ever, there must first be a unifying consciousness to control
HY22
Med Sci Monit, 2006; 12(9): HY21-31
or regulate the many individual neural processes that poten-
tially summate a decision-making process. That is, the brain
represents only neural tissues organized into various neural
patterns that can work together or separately. Without a uni-
fying component being able to cope with a focus, the signif-
icance and uniqueness of this coping strategy would be lost.
These individual processes (storing sensory information and
motor responses in many brain compartments, along with
the multitude of simultaneous integration processes) are ex-
tremely complex and varied. Moreover, a unified entity, a
“mind”, would only be involved with experience-related phe-
nomena (both exteroceptive and interoceptive) since this is
the realm in which coping strategies are designed [4].
One may speculate that cognitive abilities arose or evolved
because highly complex sensory-motor integration mecha-
nisms were already in place (an organized brain) on which
this “highly developed” coping strategy could be based.
Moreover, cognitive coping uses this foundation as its op-
erating platform. That is, cognition must be able to activate
normal non-cognitive stress phenomena as well as deacti-
vate them at the appropriate time, i.e, relaxation. Indeed,
the subtleties of the integration would be hard to discern, as
would the exact stimulus of a complex sensory experience.
Yet, this would not take away from the existence of the con-
nection/integration, it only further dramatizes its complex-
ity. Thus, for example, we can predict that both cognitive
and non-cognitive coping would be able to influence im-
mune phenomena via neuro-immune, vascular-immune and
neuro-vascular mechanisms. Based on the above, the mind
depends on the underlying neural substrates to manifest it-
self. Thus, both consciously and unconsciously, it should be
able to influence its underlying foundation.
Belief has an emotional component in that the brain moti-
vation and reward circuitry will be reinforced with a positive
emotional valence attached to the believed in person, idea or
thing [4,7–9,12,13]. This emotionalized memory, replete with
“somatic markers”, i.e., bodily sensations that accompany emo-
tion and set the feeling tone, “feels right” to the person [14].
Clearly, emotion can be viewed as a process reinforcing a be-
lief so that rationality cannot “weigh” the belief down into a
lack of activity (see [11,15]). Indeed, belief in regard to a ther-
apy, doctor, or personal religion may stimulate physiological
processes, enhancing naturally occurring “healthy” processes
by augmenting their level of performance [11,15].
Furthermore, belief, trust, pleasure and love via limbic as
well as other central nervous system (CNS) and peripheral
nervous system (PNS) processes (see [4,7–9,13,16] for de-
tails on the hard wiring of these processes) are involved in
relaxation because they are critical factors in the conscious
or unconscious decision making that takes place in determin-
ing whether it is safe or not safe to relax (Figure 1). Given
this, can a person’s belief in an expected outcome actually
affect the expected outcome? We believe the answer is yes,
barring organic disease in the sensory, integrative or mo-
tor component of the processing pathway.
Thus, cognitive and non-cognitive neural processes origi-
nating in the brain/mind may communicate through sim-
ple signaling pathways to intimately link the CNS and the
diffuse immune system, including vascular components.
While many of the body’s processes occur without cogni-
Med Sci Monit, 2006; 12(9): HY21-31
CNS
Cholinergic trigger- Conscious and Unconscious
Nicotine
enhances
morphine
release Limbic Involvement
First and Always
Dopamine Norepinephrine
Rapidly Inhibits
Morphine
Relaxation
If appropriate – depends
Nitric oxide on safe environment-Activation
tive input, the use of cognitive intervention or awareness
as a coping strategy allows us to manipulate non-cognitive
processes, implying that the “mind” can intervene and im-
pose change in physiological systems. Indeed, this change
can be both beneficial and pathological. Non-cognitive
processes, therefore, may exist to promote health and cog-
nition itself may stimulate these health-promoting mecha-
nisms when properly activated or called upon.
Clearly, this type of “hard” non-cognitive and “soft” cognitive
linkage is instrumental in the concept of the mind-body phe-
nomenon. We believe it is also quite important in understand-
ing relaxation, since it also may represent a physical manifes-
tation of this phenomenon. Admittedly, these processes are
called on in many animals in a very unconscious way, indicat-
ing that they may be of primal origin, i.e., antibiosenescent.
STRESS
Stress describes a challenge that forces biological organ-
isms to react in order to adapt (keep balanced) and stay
“healthy”, i.e., survive [17]. Simply defined, stress repre-
sents an event or stimulus that alters the existing immedi-
ate organismic homeostasis or “allostasis” [18]. Through
an extremely complicated allostatic process, all living or-
ganisms maintain their survival in the face of both exter-
nally and internally generated “stressors”. This apparent
harmonization is constantly challenged often to the point
of threat [12,17,19–24]. Thus, the stress responses (physio-
logical processes that occur in the face of stress, e.g., fight-
or-flight response) can be viewed as being highly protec-
tive. The broad spectrum of stimuli capable of engaging
the stress response is remarkable and reflects how well in-
tegrated our perceptions of the physical, psychological and
social worlds are [25]. Biochemical (neurotransmitter, pep-
tides, steroids), physiological (heart rate, blood pressure)
and behavioral (anxiety, depression, tension) concomitants
of stress may co-mediate a disease response [26].
Another important element of stressful stimulation may be
the duration or time component of the noxious stimulus
Stefano GB et al –Neural processes in relaxation
Figure 1. As described in the text, it is surmised
that the adrenergic/sympathetic system
HY
is always on, maintaining an alert
status, which provides high survival
value. However, after cognitive and
non cognitive limbic associated neural
processes have determined it is safe
to reduce the level of alertness, i.e.,
relax, relaxation can proceed. This
Sympathetic Response latter process may involve a cholinergic
Flight or Fight trigger, switching to morphinergic
Stress Response and subsequent nitric oxide signaling.
This signaling suppresses further
catecholamine metabolism to
norepinephrine while simultaneously
liming its signaling capabilities, i.e.,
nitric oxide inhibits dopamine beta
hydroxylase. Thus, relaxation appears
to result from general inhibition of the
active sympathetic tone.
[20,27]. A brief physical or mental “assault” may allow an
organism, through various detailed allostatic compensatory
mechanisms, to “deal” with both an appraised or perceived
stress. If the situation were to continue chronically, the or-
ganism might become vulnerable, susceptible to negative as-
pects of the stress response, such as in the case of prolonged
immune down-regulation [28–32]. Moreover, our physio-
logical and psychological stress response “systems” plainly
function or were designed to function over the short term,
i.e., fight or flight, not for prolonged periods of time. Given
the signal molecule commonalties and similarities found
in diverse organisms during the course of evolution, not
to mention the common design of animal nervous systems
regardless of phyla [24,33–38], it is not surprising to learn
they also similarly exhibit stress responses [24].
The pathological effects of stress are those induced by long-
term stress. This is what Hans Selye referred to as the “gen-
eral adaptation syndrome”, when a particular stressor (high-
ly emotional situation, physical abuse, etc.) remains for a
long period of time [39]. Here, the persistent elevated stress
response causes the system to function at its full capacity.
This cannot continue for extended periods of time without
metabolic detriment to the organism [17,22,23,40]. Thus,
short-term stress processes are beneficial because we can
overcome a particular obstacle. Long-term expression of
these processes can be viewed as detrimental. Our physio-
logic systems are not designed for long-term stress, such as
prolonged immune compromise. We may also bring upon
ourselves a long-term stress resulting from our perception of
the stressor itself. Perhaps, with the appearance of cognitive
appraisal capabilities, human beings were, as a side effect,
able to translate the short-term stress process into a longer-
term stress process simply by thinking about it and moreo-
ver dwelling on it (such as contemplating a boss firing you
for several months, cognitive “constipation”) [12].
Furthermore, as just noted, chronic stress can impact many
physiological systems. In part, the reason for this may be that
at the core of many disorders one may find a proinflamma-
tory situation that manifests itself in diverse tissues, differ-
HY23
Hypothesis
Tyrosine
DOPA Tyramine
DA, Various cellular compartments
Requires Requires down regulation/calm,
Excitation/Activation restore homeostasis
NE Norcocolarine
Reticuline
Salutaridine
E Thebaine
Codeine
Activation-Maintain a state
Morphine
of high alertness, energy
Morphine 6 glucuronide
Down regulate the activation,
restore homeostasis
ently masking the commonality [41]. In this regard, various
integrative medical techniques may be efficacious because
they too exhibit commonalities [7–9] not only in regard to
shared signal molecules, i.e., opioid, and neural circuit, i.e.,
limbic, components but their ability to depend on trust and
belief, inducing a state of relaxation. Moreover, it may be
the ability to induce relaxation that breaks the negative im-
pact of chronic stress [12]. Thus, it is not surprising to find
that integrative/complementary medical techniques appear
to have a general global impact on diverse disorders [42–
44] given the relationship they have with stress, i.e., calm-
ing or stress reduction.
RELAXATION
NO activity
Briefly, we surmise that relaxation represents an equally real
physiological process, allowing for physiological recovery
and promoting health by terminating the other physiologi-
cal process normally associated with stress (Figure 1). In this
regard, it represents a naturally occurring proactive protec-
tive mechanism that, once stimulated, provides a beneficial
outcome for the individual invoking the process [42–44]. We
surmise that the molecular components of this process must
be constitutively expressed so that it can continually be “felt”
as well as be stimulated to rapidly increase its desired bene-
ficial effect. This aspect of relaxation is important in termi-
nating, for example, alert states such as found in the stress
response once a perceived threat ends (Figure 1). The ina-
bility to invoke relaxation may be an important factor in al-
lowing chronic stress to gain a foothold in a person’s mind
translating into pathophysiological disorders [12].
Background molecular processes
We surmise constitutive NO signaling is critical in relax-
ation [12,32,40]. When constitutive nitric oxide synthase
HY24
Med Sci Monit, 2006; 12(9): HY21-31
Figure 2. The “Ying-Yang” nature of the excitation
and relaxation pathways manifests
itself in the biochemical pathway for
synthesizing dopamine and morphine,
both arising from common precursors.
Despite the common precursor one
pathway initiates activation whereas
the opiate pathway initiates down
regulation and mediates pleasure and
reward signaling that can only emerge
once no life threatening phenomena
are perceived. Given this common
component of both pathways we
surmise that endogenous auto regulators
determine which activity emerges. This
may also help explain the significance
of emotion as a trigger for this pathway
whose outcome depends on what
emotion is evoked. It also, based on
neuroanotomical data, provides a critical
understanding for profound behavioral
modifications that can occur in addiction,
for example
[7,8,13,42,43,112,117,118,143].
(cNOS) is stimulated, NO release occurs for a short period
of time, but this level of NO can exert profound physiolog-
ical actions for a longer period of time [32,45]. NO is not
only an immune, vascular and neural signaling molecule, it
is also antibacterial, antiviral, scavenges free radicals, and it
down-regulates endothelial and immunocyte activation and
adherence, thus performing vital physiological activities,
including vasodilation [32,46–48]. Thus, NO has the poten-
tial to protect an organism from microbes and physiologic
disorders such as hypertension, and also diminishes exces-
sive immune and endothelial activation [3,46]. Indeed, its
constitutive presence may set the tone for the activation of
these cells and its absence or presence at lower levels may
set the stage for progressive deterioration, i.e., Alzheimer’s
Disease (see [3,45,49]).
The significance of cNOS-derived NO may also be ascer-
tained by the number of chemical messengers that can stim-
ulate its production. For example, the endocannabinoids,
anandamide and 2-arachidonyl-glycerol (2-AG), are nat-
urally occurring cNOS-derived NO-stimulating signaling
molecules that are also constitutively expressed [32,50–61].
Anandamide, an endogenous endocannabinoid, can also
cause NO release from human immune cells, neural tissues
and human vascular endothelial cells [53,62]. Anandamide
can also initiate invertebrate immune cell cNOS-derived
NO [50].
Estrogen can also stimulate cNOS-derived NO in human im-
mune and vascular cells [62–64]. It can also perform this
function in invertebrates, stimulating cNOS-derived NO re-
lease from neural tissues [65,66].
Recent work from our laboratory has revealed that morphine
can be made by normal healthy animal cells, including hu-
man cells [67,68] (Figure 2). This supports the previous-
ly found opiate receptor subtype μ3, cloned from human
immune, vascular and neural tissues, which is selective for
Med Sci Monit, 2006; 12(9): HY21-31
Acetylcholine
CNS and Adrenal Gland
Morphine
μ3
Blood Vessel
Endothelium
Nitric oxide
Vasodilation
WBC Down regulate proinflammatory events
Antibacterial, antiviral, scavenges free radicals
Inhibits norepinephrine synthesis
Neuron Inhibits immunocyte adherence
Inhibits smooth muscle contraction
Activates Reward Centers - Feels Good
Calms Nervous tissues
the opiate alkaloids morphine and morphine-6-glucuro-
nide and not opioid peptides [69], demonstrating a spe-
cific morphinergic signaling mechanism in animal tissues.
Furthermore, μ3 opiate receptors stimulated by morphine
are coupled to cNOS-derived NO release, resulting in the
down-regulation of immune, vascular, gut and neural tis-
sues [3,70–74]. Thus, besides well known cNOS-derived NO
stimulators, i.e., acetylcholine (ACh) [75,76], newer chem-
ical messengers have been discovered, which are also asso-
ciated with NO coupling.
Why are there so many pathways that lead to cNOS-de-
rived NO release? We believe that each signaling system
performs this common function under different circum-
stances. Endogenous morphine [32], given its long latency
before increases in its levels are detected, arises after trau-
ma/inflammation and, through a NO mechanism, down-
regulates these processes in neural, vascular and immune
tissues [28,55,77]. Anandamide, as part of the ubiquitous
arachidonate and eicosanoid signaling cascade, serves to
maintain and augment tonal NO in vascular tissues [32,59].
Estrogen, through NO release, provides an additional path-
way by which the system can down-regulate immunocyte and
vascular function in women [62]. This may be due to both
the immune and vascular trauma associated with cyclic re-
productive activities, such as endometrial buildup, when a
high degree of vascular and immune activities are occur-
ring. Given the extent of proliferative growth capacity dur-
ing peak estrogen levels in this cycle, NO may function to
enhance down-regulation of the immune system to allow
for these changes. Clearly, therefore, enhanced cNOS ac-
tivity is beneficial within the concept and time framework
of relaxation.
Proposed signaling in relaxation
Individuals who are relaxing experience peripheral vasodi-
lation, warming of the skin, a decrease in heart rate and an
overwhelming sense of well-being only when this can occur
in a safe and trusted environment (see [4]). Counter-intu-
itively, there may be initial sympathetic activation, as noted
Stefano GB et al –Neural processes in relaxation
Figure 3. Peripheral manifestations of molecular
components of relaxation. In order to
HY
be effective and have the potential to
exert a therapeutic outcome relaxation
must be broad in its ability to induce
widespread down regulation while
simultaneously not completely altering
an animals excitatory alert processes
to the point where they are rendered
useless. Hence it not surprising to find
the mu3 opiate receptor, which is opiate
alkaloid selective and opioid peptide
insensitive, present on diverse tissue
types where it is coupled to constitutive
nitric oxide release, which we also have
linked to global down regulation and
thus, exerting therapeutic actions that
are equally diverse
[42,43,43,118,119,144,145].
by norepinephrine (NE) levels, which initially go up [78].
This appears also to be the case for falling in love and en-
joying pleasurable experiences, since this does, for exam-
ple, represent the risk of rejection [8,13,79,80]. Regarding
the vasodilator peripheral heat-warming processes, we
speculate that this involves NO [4]. In regard to the sense
of well-being, we can assume that this process may also in-
volve opioid signaling molecules, which are involved with
reward processes [8].
In examining a potential mechanism for relaxation, besides
the over-riding CNS output via the autonomic nervous sys-
tem, peripheral neuro-vascular processes would appear to
be important [4] (Figure 3). We surmise NO to be of fun-
damental importance because of the increase in peripher-
al temperature, i.e., vasodilation [81]. With reference to
the peripheral vasculature, we find nerve terminals in the
vessels that when stimulated by nicotine, result in vasocon-
striction followed by vasodilation [82], indicating a cholin-
ergic mechanism. Clearly, this phenomenon is in line with
new data demonstrating nicotine stimulation of endogenous
morphine from nervous tissue, resulting in morphine NO
coupling and vasodilation, i.e., relaxation [78,83–86]. The
vasoconstriction component of the biphasic nicotine effect
is mediated by alpha-1-adrenoceptors stimulated by NE lib-
erated from peripheral sympathetic adrenergic nerves [4].
Studies suggest that, because of insensitivity to atropine, ACh
does not mediate the nicotine-induced vasodilation [82].
Instead it is mediated from nerve endings in which a NO
generating system and ACh may coexist [87]. Thus, nicotine
stimulates the adrenergic and nitroxidergic nerves inner-
vating, for example, the temporal arterial wall of denuded
endothelium in superficial dog tissue, resulting in contrac-
tion and a rapidly developing vascular relaxation, the latter
being mediated by cyclic GMP (cGMP) [88]. Slow relaxa-
tion caused by nicotine is associated with the elevation of
cGMP production via activation of guanylate cyclase, which
appears to be mediated by prostaglandin I2 [88].
However, newer experimental results allow us to modify this
interpretation. Namely, nicotine can stimulate the release of
HY25
Hypothesis
endogenous morphine from adrenal tissues and white blood
cells, adding this opiate alkaloid into the immediate environ-
ment [83,89,90]. It is critical to note that, as documented
earlier, endogenous morphine signaling is coupled to cNOS-
derived NO release in these tissues. In individuals shown to
relax via lowering their blood pressure by listening to mu-
sic, higher opiate alkaloid levels were found in their plasma
along with a significant alteration of the μ3 receptor levels
on blood cells and a lowering of plasma proinflammatory cy-
tokine levels (i.e., immune down-regulation) [86,91], dem-
onstrating the involvement of opiate alkaloids in this ability
to relax at the peripheral level. Supporting this hypothesis
further is the vasodilator effect, which requires NO, resulting
in the lowering of blood pressure and the ability of morphine
to release NO from immune and vascular cells as discussed
earlier. This release may be the actual event contributing to
the observed vasodilation and increase in peripheral skin
temperature associated with relaxing (Figure 3).
Taken together, we surmise that NE initially promotes a slight
vasoconstriction of the artery during the initial phase of re-
laxation (“getting in the mood”), indicating a slight enhance-
ment of sympathetic activity upon stimulation (Figure 1).
This may also serve to demonstrate that sympathetic tone al-
ways manifests itself until its influence is diminished. This is
immediately followed by the release of NO from the nitrox-
idergic nerve or from an immune and/or vascular source,
which mediates a concentration-dependent vasodilation. In
monkeys, the cerebral arterial diameter under resting con-
ditions is maintained by tonic release of NO from the nerve
(10–20%) or from the nerve and endothelium (30%) [92].
This observation is supported by other data from our lab-
oratory since basal NO is cNOS-derived and keeps partic-
ular types of cells in a state of inhibition [3]. Endogenous
superoxide dismutase (SOD) in the cerebral artery appears
to protect the relaxation, induced by NO from perivascular
nerves, from the NO scavenger action of superoxide anion
[93]. We surmise that this NO then produces the longer-lived
phenomenon of smooth muscle relaxation. In another re-
port, it was found that NE vascular hyper-responsiveness in
hypertension is dependent on an impairment of NO activ-
ity that is realized through NE-induced oxygen free radical
production [94], demonstrating an important contribution
to the understanding of this regulatory process.
In regard to a nervous origin of relaxation, the location of
the NO-releasing nerve, nitroxidergic nerve, has continued
to be a subject of debate. Various findings lead us to be-
lieve that the nitroxidergic nerve is located in the proximi-
ty of the adrenergic sympathetic nerve bundle [88,95–101].
Furthermore, the NE-stimulated vasoconstriction is followed
by relaxation that is suppressed by L-NA, a NOS inhibi-
tor [102], supporting its interaction via a NE mechanism
[103]. Secondly, nicotine-induced relaxation is abolished
by guanethidine, tetrodotoxin, and pretreatment with 6-
hydroxydopamine, all causing destruction of the sympa-
thetic nerve, and demonstrating again the NE component
[104]. Furthermore, we have demonstrated that eNOS-de-
rived NO can inhibit NE neural release in animal vascula-
ture [53]. Recently, we have also demonstrated that, once
NO is present, smooth muscle cells from rat and human
arteries fail to contract in response to NE [105], demon-
strating that when the balance shifts to NO, NE cannot ini-
tiate vasoconstriction. Thus, the NE reported in, specifical-
HY26
Med Sci Monit, 2006; 12(9): HY21-31
ly, the relaxation response [78] may, in a sense, represent
the left over flow of the earlier mild sympathetic stimula-
tion, i.e., also representing work initiation in a different sit-
uation, i.e., stress response.
Complicating this matter is the data indicating that ACh
inhibits, acting via prejunctional muscarinic, not nicotin-
ic receptors, the synthesis and release of NO while concur-
rently antagonizing the release of NE [92,95]. However, the
response to exogenous NO is not influenced by ACh [93].
In addition, the secondary vasodilation to electrical nerve
stimulation appears to be attenuated by treatment with ACh
in a concentration-dependent manner [93]. These findings
suggest that ACh plays an essential role in vascular NO regu-
lation (Figure 3). It may be the factor adjusting the interac-
tion of NO and NE, simultaneously exerting its own vascular
action, i.e., stimulating endothelial NO release maybe via the
release of endogenous morphine [83,89,106,107] (Figure
3). Others found that beta(2)-adrenoceptor antagonists
blocked the relaxation induced by nicotine. Furthermore,
they demonstrated that beta(2)-adrenoceptor immunore-
activities and NADPH diaphorase reactivities were colocal-
ized in the same nerve fibers in basilar and middle cerebral
arteries [103]. The authors speculate that NE acts on presy-
naptic beta(2)-adrenoceptors located on the NO nerve ter-
minals to release NO resulting in vasodilation.
We also surmise, based on current studies, that endothelial-
derived NO, released through normal pulsations due to vas-
cular dynamics responding to the heart beat [32,73,108], as
well as ACh-stimulated endothelial NO release (via nicotinic
processes), may contribute to the effect of NO in inhibiting
NE processes as well as inducing smooth muscle relaxation.
Furthermore, vascular pulsations may be of sufficient strength
to also stimulate neuronal NOS-derived NO release, limiting
any basal NE actions. Interestingly, nitrosative stress, medi-
ated by involvement of the reactive nitrogen oxide species
N2O3, does inhibit dopamine-b-hydroxylase, inhibiting NE
synthesis and contributing to the regulation of neurotrans-
mission and vasodilatation [109,110]. This system may pro-
vide an autoregulatory mechanism involved in the neuron-
al control of peripheral vasomotor responses. Furthermore,
the ability of nicotine to release morphine from adrenal and
immune tissues helps explain the source of NO [83,89,90],
which results from the newly released morphine and μ3 cou-
pling to NO release on these critical tissues.
In conclusion, relaxation peripherally appears to be mediat-
ed by a system of regulation involving NO, NE, ACh and mor-
phine as neurotransmitters and local hormones. Contingent
on the preliminary vasoconstriction and depolarization of
the membrane initiated by the release of NE, vasodilation is
mediated by NO liberated from vasodilator nerves and maybe
other tissues that activate guanylate cyclase in smooth mus-
cle and produce cGMP. During this stage, NO and NE ex-
ist simultaneously. Due to the signaling cascade of NO, NE
no longer mediates vasoconstriction. Instead, NO activates
guanylate cyclase, which produces vasodilation and the re-
laxation under a depolarized membrane state.
CNS involvement
The CNS regulating pathways and processes integral to me-
diating this process stimulate NE release either alone or in
Med Sci Monit, 2006; 12(9): HY21-31
combination with NO (see [4]). If NE is released alone, va-
soconstriction occurs. If NE is released with NO, we surmise
an initial short-lived vasoconstriction occurs followed by a
prolonged vasodilation mediated directly by NO. In this re-
gard, if basal/tonal NE is present, NO overrides this effect
(Figure 1). If ACh is present, we surmise that its inhibition
of NE, causing loss of sympathetic tone, and its stimulation
of endothelial-derived NO, may also result in vasodilation.
The important point at this stage of explaining relaxation
is that, at last, we are beginning to see a mechanism that
can explain its characteristics and simultaneously provide
an explanation for its health benefits, i.e., via cNOS-derived
NO (see [3,32,45,47,48]).
There are several key areas of the CNS involved in relaxa-
tion processing. Subsequent to thalamic routing, there is
quick transit of crude data to the amygdala and a slower
more considerate flow of information to the primary sen-
sory cortex, with subsequent routing of more refined infor-
mation to the amygdala and the hippocampus, areas classi-
cally involved in emotion and memory – critical functions
of the so-called limbic system of the brain (Figure 1). The
quick route allows the organism to be rapidly responsive to
a fearful prompt. The more sophisticated appraisal route
permits the limbic system to operate with more reliable in-
formation that may allow the amygdala to stand down and
for relaxation to re-emerge if the decisions to be made are
safe and clear cut ones. If the decisions to be made are not
clear cut and are conflicted in some way the anterior cin-
gulate cortex must make a response selection based on the
cognitive data from cortical regions and the emotional data
from the limbic system [111]. Hyperactivation of the anteri-
or cingulate as seen in functional neuroimaging of depres-
sion and in pain states can be modified when the prefron-
tal cortex is stimulated by conscious positive expectation
and the relaxation that accompanies it [112].
Hence, it is no surprise that these limbic and paralimbic
areas are of great importance to relaxation, as well as pain
modulation. We surmise the proximity and shared “wiring”
of these two functions represents a critical point whereby
evaluations are made on whether or not the situation is ap-
propriate to relax. This proximity and sharing of common
neural circuits is a critical survival element in animal evo-
lution, allowing excitation to take over rapidly should the
situation arise. Importantly, the central nucleus of the amy-
gdala is most strongly modulated by dopamine (DA), NE,
epinephrine and serotonin [113,114]. The basal nuclei
receive moderately high inputs of DA, NE and serotonin
[113,114], each of which has been demonstrated to exert
their desired effect, in part, via NO [115–119].
We surmise that the centrally released NE exerts effects in
the periphery via cardiovascular circuitry [4] by initially pro-
moting a slight vasoconstriction of the peripheral artery dur-
ing the amygdalar response to relaxation input as part of the
limbic system’s inherent mechanism to maintain homeosta-
sis and decrease pain perception via descending spinal path-
ways resulting in endogenous opiate analgesia [115,116].
In fact, reports have found endogenous morphine within
the structure of the hippocampus and amygdala, i.e., lim-
bic system [117,120–122]. In addition, this morphine may
activate pleasure pathways via NO in rat brain hippocam-
pus [112]. Studies from our laboratory confirm the medi-
Stefano GB et al –Neural processes in relaxation
ated release of NO from rat brain hippocampus and amy-
gdala and endogenous morphine’s presence in these tissues
HY
[117]. Furthermore, DA can serve as a endogenous mor-
phine precursor [67,68] (Figure 2).
Supporting this hypothesis are other studies linking relax-
ation characteristics with that of pain. Once individuals are
exposed to painful stimuli such as a penetrating needle they
experience peripheral vasodilation, warming of the skin
[123–126], an increase in heart rate and a sense of agita-
tion, all as a potential result of circulating catecholamines
and/or NO [127]. It is the function of the amygdala and
related subcortical regions to aid in the relief of these pain
states [113,128,129]. In examining a potential mechanism
for this relief, besides the over-riding CNS output via the
autonomic nervous system, peripheral neuro-vascular proc-
esses would appear to be important. Again, we surmise that
NO and its relation with prostaglandins are of fundamen-
tal importance in this response because of the increase in
peripheral temperature, i.e., vasodilation, in the ensuing
inflammatory response [123–126]. Indeed this is precise-
ly the pathway, which is inhibited with non-steroidal anti-
inflammatory drugs (NSAID). Interestingly, as noted ear-
lier, N2O3 does inhibit dopamine hydroxylase, inhibiting
NE synthesis and contributing to the regulation of neuro-
transmission and vasodilation [4,110]. This system may pro-
vide an autoregulatory mechanism involved in the neuronal
control of peripheral vasomotor responses as they relate to
pain control, where induction of a catecholamine-inhibit-
ing substance may autoregulate the vasomotor response in
response to nitrosative stress (see [130] for the role of nit-
rosative stress in neuropathic pain).
This line of research allows us to further speculate that phys-
iological relaxation emerged from this pathway, once the
proinflammatory element, under the right circumstances,
was removed. This probably was associated first with physi-
ological states requiring a less alert state, such as sleep-like
activity. Later, when cognition evolved, it also became asso-
ciated with our ability to determine a safe environment in
which relaxation may emerge. In either event, it would be
critical to have endogenous morphine involved because of
its analgesic action and ability to down-regulate immune
processes [30,32], effectively separating the two functions,
which would be critical to relaxation. Indeed, cognitive func-
tions and devices that show their performance (EEG, fMRI,
SPECT, etc.) reveal a clear distinction between sleep and re-
laxation, and relaxation not only leads to an overall decrease
in brain activity but simultaneously to an increase in specif-
ic parts of the brain, e.g., related to cognition [131–133].
Another critical component of this determination, whether
to be alert or relax, is having morphine synthesis take place
via the catecholamine pathway in animals, including man
[67,68]. Again, this pathway behaviorally allows for excita-
tion to occur as synthesis proceeds via DA and secondari-
ly NE, followed by down-regulation via morphine and mor-
phine-6-glucuronide signaling, as it goes to its end at opi-
ate alkaloid synthesis [67,68].
THE HYPOTHESIS
cNOS-derived NO appears to be critical for relaxation be-
cause it has the ability to block a sympathetic response sim-
ply by having its release occur beyond the basal level, which
HY27
Hypothesis
will lead to vasodilation and peripheral sense of warmth. Its
presence can also explain the paradox of the presence of NE
in plasma while vasodilation is taking place [78]. Recently,
we demonstrated that during the relaxation response NO
levels are increased [5], further supporting the critical role
of NO in this process.
Additionally, endogenous morphine signaling appears to play
a major role in relaxation. Many immune processes perpet-
uate and become embellished with time by the recruitment
of cells, and through beneficial yet sometimes harmful sig-
naling molecules such as the proinflammatory cytokines.
These molecules can all be down-regulated by morphine,
which is released following stress or trauma [30,32], specifi-
cally through cNOS-derived NO under certain circumstanc-
es. Thus, morphine may help overcome over-stimulated im-
mune, vascular and neural tissues [32,68]. As such, it may be
part of the immune system regulation that prevents the all
too common ravages of what Bone called “immunologic dis-
sonance”, including the systemic inflammatory response syn-
drome (SIRS) which sometimes culminates in the often lethal
multiple organ dysfunction syndrome (MODS) [134].
It is possible that some individuals may be deficient in this
regulatory process, leading, when challenged, to the unreg-
ulated and potentially damaging immune responses of SIRS
and MODS. We have found, for example, that in the immune
disorder histiocytic medullary reticulosis or malignant histi-
ocytosis [135] a morphine-selective receptor, μ3, was not ex-
pressed, and granulocytes and monocytes cultured from this
patient could not be down-regulated when exposed to mor-
phine. The foundation of the concept that morphine is criti-
cal to relaxation or a down-regulation of excitatory processes
is supported by these preliminary clinical findings, as well as
the fact that it can be made by human white blood cells and
the μ3 opiate receptor subtype is found on these tissues as well
[68,69]. Furthermore, high morphine levels have been found
in rat limbic tissues associated with NO release [117].
ASSOCIATED MOLECULAR MECHANISMS
The physiological significance of cNOS-derived NO, and
for that matter morphine-stimulating NO release, is that it
can influence proinflammatory and stress situations, pre-
sumably bringing both the “acute phase response” and the
“acute stress response” under control [45,54,55]. We pro-
pose that cNOS-derived NO initiates these events in part by
its ability to modify the function of the transcription factors,
i.e., NF-kB [136–138]. NF-kB binding sites are present in
the promoter regions of proinflammatory genes such as tu-
mor necrosis factor (TNF), interleukin (IL)-1 and IL-6 (see
[136]). Interestingly, stimulation of cells with proinflamma-
tory cytokines leads to the degradation of the NF-kB inhibi-
tor IkBa, liberating NF-kB. NF-kB is then free to activate the
transcription of some of these very same proinflammatory
cytokines. NO inhibits the expression of proinflammatory
cytokines by stabilizing the NF-kB – IkBa complex, there-
fore preventing translocation of NF-kB into the nucleus
[136,138]. NO can also interfere with the binding of NF-kB
to the promoter region of proinflammatory cytokines such
as IL-6, which causes T-cell proliferation [136,138].
Putting this in perspective, if we liberate molecules that have
the ability to stimulate constitutive NOS, producing a quick
HY28
Med Sci Monit, 2006; 12(9): HY21-31
burst of NO, we can enhance the inhibition of NF-kB activa-
tion, limiting the extent and the severity of a proinflammato-
ry situation. Does this occur during long-term stress or does
the proinflammatory mechanism become desensitized and
over-stimulated by a relentless insult, so that NO is formed
through inducible NOS, which not only becomes detrimen-
tal to the cells, but to the entire organism? We believe the
latter situation emerges with chronic stress and may give rise
to certain degenerative diseases [17,22,23,40,139]. For ex-
ample, if a proinflammatory challenge is overwhelming or
persistent, iNOS production may reflect a last ditch attempt
to overcome antigenic stress while also trying to dampen a
potentially destructive proinflammatory blaze. The resulting
overproduction of NO is unfortunately toxic [4].
In speculating on an overall theory as to what constitutes
relaxation, we offer the following hypothesis: Neural proc-
esses (CNS integrating limbic circuits), involving NO and
morphine, activate downstream signaling molecules that
stimulate cNOS-derived NO release from immune, neural
and vascular tissues. Prior to NO release this process also in-
vokes the release of NE and opioid peptides. The presence
of NO is deduced by its vasodilating actions and the lack of
vascular sensitivity toward NE and by direct measurement
[5]. Relaxation can be cognitively learned, e.g., relaxation
response. Taken together, this potential is always present
and only after removing the sympathetic and stress reac-
tions (e.g., disinhibition [3]), does it emerge. It is probably
this process along with many others that provide for mam-
malian longevity, i.e., it is antibiosenescent.
Its expression probably also differs among individuals, and
the strength of one’s beliefs or an animal’s individual his-
tory may also exert a profound impact on the heightened
expression of these proactive innate protective responses
that originate from the CNS.
Relaxation takes place in that emotionalized transitional re-
lationship found in a person when we are in a trusted and
safe environment. Here, belief is critical. Once this condi-
tion is met then, and only then, will relaxation occur. This
attachment-based solace exhibits salutary effects on the lim-
bic neural processes in the brain’s motivation and reward
circuitry responsible for regulating the stress response and
immune response systems via constitutive NO pathways
[7–9,13,16,32,140–142]. Hence, relaxation is real and an
important physiological process. It can be integrated in
self-care-oriented medical settings, i.e, stress management,
where it has demonstrated its value.
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