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© Med Sci Monit, 2006; 12(9): HY21-31 WWW. M ED S CI M ONIT .

PMID: 16940938

Received: 2006.06.19
Accepted: 2005.07.03 Relaxation: Molecular and physiological significance
Published: 2006.09.01

Authors’ Contribution: George B. Stefano1 DEG, Gregory L. Fricchione2 EF, Tobias Esch3 EF
A Study Design
B Data Collection 1
Neuroscience Research Institute, State University of New York College at Old Westbury, NY, U.S.A.
C Statistical Analysis 2
Department of Psychiatry, Massachusetts General Hospital, Boston, MA, U.S.A.
D Data Interpretation 3
Division of Integrative Health Promotion, Coburg University of Applied Sciences, Coburg, Germany
E Manuscript Preparation
F Literature Search Source of support: Supported in part by grants MH 47392 and DA 09010 (GBS)
G Funds Collection

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.

key words: relaxation response • nitric oxide • belief • limbic system • norepinephrine • morphine •

Full-text PDF:

Word count: 5731
Tables: —
Figures: 3
References: 145

Author’s address: 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:

Current Contents/Clinical Medicine • SCI Expanded • ISI Alerting System • Index Medicus/MEDLINE • EMBASE/Excerpta Medica • Chemical Abstracts • Index Copernicus HY21
Hypothesis Med Sci Monit, 2006; 12(9): HY21-31

BACKGROUND or regulate the many individual neural processes that poten-

tially summate a decision-making process. That is, the brain
It is reasonable to propose that our bodies contain natural- represents only neural tissues organized into various neural
ly occurring antibiosenescent, health maintaining and anti- patterns that can work together or separately. Without a uni-
stress processes, involving immune, vascular and neural sys- fying component being able to cope with a focus, the signif-
tems, that serve to maintain our life for a reasonable period icance and uniqueness of this coping strategy would be lost.
of time, and that the vigor of these processes, in part, de- These individual processes (storing sensory information and
termine our mean life span. In most mammals, once these motor responses in many brain compartments, along with
protective systems diminish in their capacity, their repro- the multitude of simultaneous integration processes) are ex-
ductive life has also ended. In man, however, in part aided tremely complex and varied. Moreover, a unified entity, a
by our integrative capacity, our life span is extended well “mind”, would only be involved with experience-related phe-
beyond our reproductive years. It would not be surpris- nomena (both exteroceptive and interoceptive) since this is
ing, therefore, to find critical neuronal processes linked the realm in which coping strategies are designed [4].
to man’s cognitive ability that have the ability to promote
health. These constitutive processes would manifest them- One may speculate that cognitive abilities arose or evolved
selves above background activity during times of need, e.g., because highly complex sensory-motor integration mecha-
stress, when an increase in a health-related cognitive stim- nisms were already in place (an organized brain) on which
ulus initiates this innate, non-cognitive protective neural this “highly developed” coping strategy could be based.
process to become evident. We speculate that the ability to Moreover, cognitive coping uses this foundation as its op-
relax is a major physiological process, which emerges when erating platform. That is, cognition must be able to activate
“conditions” are appropriate. normal non-cognitive stress phenomena as well as deacti-
vate them at the appropriate time, i.e, relaxation. Indeed,
WHAT IS RELAXATION? the subtleties of the integration would be hard to discern, as
would the exact stimulus of a complex sensory experience.
For more than 30 years, Herbert Benson and colleagues, build- Yet, this would not take away from the existence of the con-
ing on the work of Swiss Nobel Prize laureate Dr. Walter R. nection/integration, it only further dramatizes its complex-
Hess, have described a physiological response, termed the “re- ity. Thus, for example, we can predict that both cognitive
laxation response”, that they describe as being the opposite and non-cognitive coping would be able to influence im-
of the stress response [1]. It results in decreased metabolism, mune phenomena via neuro-immune, vascular-immune and
heart rate, blood pressure, and rate of breathing, as well as a neuro-vascular mechanisms. Based on the above, the mind
decrease in brain activity [2]. Recently, we have added nitric depends on the underlying neural substrates to manifest it-
oxide (NO) as a molecule involved in this learned response self. Thus, both consciously and unconsciously, it should be
[3–5]. Clearly, this response embodies actions that one would able to influence its underlying foundation.
associate with relaxation. We surmise the relaxation response
is part of a larger physiological process, which can simply be Belief has an emotional component in that the brain moti-
referred to as relaxation. In this regard, we also surmise that vation and reward circuitry will be reinforced with a positive
the ability of a practitioner or person to elicit the relaxation emotional valence attached to the believed in person, idea or
response is strengthened by the trust or belief in the expected thing [4,7–9,12,13]. This emotionalized memory, replete with
outcomes as well as the belief that a particular environment “somatic markers”, i.e., bodily sensations that accompany emo-
is safe or suitable to relax [6]. In fact, the strength of the fi- tion and set the feeling tone, “feels right” to the person [14].
duciary relationship between physician and patient appears Clearly, emotion can be viewed as a process reinforcing a be-
to play a direct role in the effectiveness of medical treatment lief so that rationality cannot “weigh” the belief down into a
[4,6–10]. Thus, it would appear that there are larger physio- lack of activity (see [11,15]). Indeed, belief in regard to a ther-
logical processes allowing for relaxation to occur. However, apy, doctor, or personal religion may stimulate physiological
the exact mechanism or combination of cascading mecha- processes, enhancing naturally occurring “healthy” processes
nisms involved until now has escaped detection. by augmenting their level of performance [11,15].

WHAT IS THE MIND? Furthermore, belief, trust, pleasure and love via limbic as
well as other central nervous system (CNS) and peripheral
Before going further we must define the term “mind.” For nervous system (PNS) processes (see [4,7–9,13,16] for de-
us, it was enticing to think that the chance alteration of ge- tails on the hard wiring of these processes) are involved in
netic or neural pathways leading to cognitive processes also relaxation because they are critical factors in the conscious
provided such endowed animals with an additional survival or unconscious decision making that takes place in determin-
coping strategy [11] and that these cognitive coping abil- ing whether it is safe or not safe to relax (Figure 1). Given
ities provided such organisms with a competitive edge for this, can a person’s belief in an expected outcome actually
survival. The burgeoning of cognitive theory and therapy affect the expected outcome? We believe the answer is yes,
in the recent past is testimony to the insight that altering barring organic disease in the sensory, integrative or mo-
and improving cognitive coping mechanisms can help dissi- tor component of the processing pathway.
pate the emotional ravages attendant to the stress response.
Interestingly, cognition may also contribute to stress when Thus, cognitive and non-cognitive neural processes origi-
it cannot be turned off [12]. nating in the brain/mind may communicate through sim-
ple signaling pathways to intimately link the CNS and the
In order for cognitive ability to develop and succeed, how- diffuse immune system, including vascular components.
ever, there must first be a unifying consciousness to control While many of the body’s processes occur without cogni-

Med Sci Monit, 2006; 12(9): HY21-31 Stefano GB et al –Neural processes in relaxation

Figure 1. As described in the text, it is surmised
that the adrenergic/sympathetic system
Cholinergic trigger- Conscious and Unconscious is always on, maintaining an alert
Nicotine status, which provides high survival
enhances value. However, after cognitive and
non cognitive limbic associated neural
morphine processes have determined it is safe
release Limbic Involvement 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
First and Always Stress Response and subsequent nitric oxide signaling.
Dopamine Norepinephrine This signaling suppresses further
catecholamine metabolism to
Rapidly Inhibits norepinephrine while simultaneously
Morphine liming its signaling capabilities, i.e.,
Relaxation nitric oxide inhibits dopamine beta
hydroxylase. Thus, relaxation appears
If appropriate – depends to result from general inhibition of the
Nitric oxide on safe environment-Activation active sympathetic tone.

tive input, the use of cognitive intervention or awareness [20,27]. A brief physical or mental “assault” may allow an
as a coping strategy allows us to manipulate non-cognitive organism, through various detailed allostatic compensatory
processes, implying that the “mind” can intervene and im- mechanisms, to “deal” with both an appraised or perceived
pose change in physiological systems. Indeed, this change stress. If the situation were to continue chronically, the or-
can be both beneficial and pathological. Non-cognitive ganism might become vulnerable, susceptible to negative as-
processes, therefore, may exist to promote health and cog- pects of the stress response, such as in the case of prolonged
nition itself may stimulate these health-promoting mecha- immune down-regulation [28–32]. Moreover, our physio-
nisms when properly activated or called upon. logical and psychological stress response “systems” plainly
function or were designed to function over the short term,
Clearly, this type of “hard” non-cognitive and “soft” cognitive i.e., fight or flight, not for prolonged periods of time. Given
linkage is instrumental in the concept of the mind-body phe- the signal molecule commonalties and similarities found
nomenon. We believe it is also quite important in understand- in diverse organisms during the course of evolution, not
ing relaxation, since it also may represent a physical manifes- to mention the common design of animal nervous systems
tation of this phenomenon. Admittedly, these processes are regardless of phyla [24,33–38], it is not surprising to learn
called on in many animals in a very unconscious way, indicat- they also similarly exhibit stress responses [24].
ing that they may be of primal origin, i.e., antibiosenescent.
The pathological effects of stress are those induced by long-
STRESS term stress. This is what Hans Selye referred to as the “gen-
eral adaptation syndrome”, when a particular stressor (high-
Stress describes a challenge that forces biological organ- ly emotional situation, physical abuse, etc.) remains for a
isms to react in order to adapt (keep balanced) and stay long period of time [39]. Here, the persistent elevated stress
“healthy”, i.e., survive [17]. Simply defined, stress repre- response causes the system to function at its full capacity.
sents an event or stimulus that alters the existing immedi- This cannot continue for extended periods of time without
ate organismic homeostasis or “allostasis” [18]. Through metabolic detriment to the organism [17,22,23,40]. Thus,
an extremely complicated allostatic process, all living or- short-term stress processes are beneficial because we can
ganisms maintain their survival in the face of both exter- overcome a particular obstacle. Long-term expression of
nally and internally generated “stressors”. This apparent these processes can be viewed as detrimental. Our physio-
harmonization is constantly challenged often to the point logic systems are not designed for long-term stress, such as
of threat [12,17,19–24]. Thus, the stress responses (physio- prolonged immune compromise. We may also bring upon
logical processes that occur in the face of stress, e.g., fight- ourselves a long-term stress resulting from our perception of
or-flight response) can be viewed as being highly protec- the stressor itself. Perhaps, with the appearance of cognitive
tive. The broad spectrum of stimuli capable of engaging appraisal capabilities, human beings were, as a side effect,
the stress response is remarkable and reflects how well in- able to translate the short-term stress process into a longer-
tegrated our perceptions of the physical, psychological and term stress process simply by thinking about it and moreo-
social worlds are [25]. Biochemical (neurotransmitter, pep- ver dwelling on it (such as contemplating a boss firing you
tides, steroids), physiological (heart rate, blood pressure) for several months, cognitive “constipation”) [12].
and behavioral (anxiety, depression, tension) concomitants
of stress may co-mediate a disease response [26]. Furthermore, as just noted, chronic stress can impact many
physiological systems. In part, the reason for this may be that
Another important element of stressful stimulation may be at the core of many disorders one may find a proinflamma-
the duration or time component of the noxious stimulus tory situation that manifests itself in diverse tissues, differ-

Hypothesis Med Sci Monit, 2006; 12(9): HY21-31

Figure 2. The “Ying-Yang” nature of the excitation

Tyrosine and relaxation pathways manifests
itself in the biochemical pathway for
synthesizing dopamine and morphine,
DOPA Tyramine both arising from common precursors.
Despite the common precursor one
pathway initiates activation whereas
DA, Various cellular compartments the opiate pathway initiates down
regulation and mediates pleasure and
Requires Requires down regulation/calm, reward signaling that can only emerge
Excitation/Activation restore homeostasis once no life threatening phenomena
are perceived. Given this common
NE Norcocolarine component of both pathways we
Reticuline surmise that endogenous auto regulators
Salutaridine determine which activity emerges. This
E Thebaine may also help explain the significance
of emotion as a trigger for this pathway
Codeine whose outcome depends on what
Activation-Maintain a state
Morphine emotion is evoked. It also, based on
of high alertness, energy
Morphine 6 glucuronide neuroanotomical data, provides a critical
understanding for profound behavioral
Down regulate the activation, modifications that can occur in addiction,
restore homeostasis for example

ently masking the commonality [41]. In this regard, various (cNOS) is stimulated, NO release occurs for a short period
integrative medical techniques may be efficacious because of time, but this level of NO can exert profound physiolog-
they too exhibit commonalities [7–9] not only in regard to ical actions for a longer period of time [32,45]. NO is not
shared signal molecules, i.e., opioid, and neural circuit, i.e., only an immune, vascular and neural signaling molecule, it
limbic, components but their ability to depend on trust and is also antibacterial, antiviral, scavenges free radicals, and it
belief, inducing a state of relaxation. Moreover, it may be down-regulates endothelial and immunocyte activation and
the ability to induce relaxation that breaks the negative im- adherence, thus performing vital physiological activities,
pact of chronic stress [12]. Thus, it is not surprising to find including vasodilation [32,46–48]. Thus, NO has the poten-
that integrative/complementary medical techniques appear tial to protect an organism from microbes and physiologic
to have a general global impact on diverse disorders [42– disorders such as hypertension, and also diminishes exces-
44] given the relationship they have with stress, i.e., calm- sive immune and endothelial activation [3,46]. Indeed, its
ing or stress reduction. constitutive presence may set the tone for the activation of
these cells and its absence or presence at lower levels may
RELAXATION set the stage for progressive deterioration, i.e., Alzheimer’s
Disease (see [3,45,49]).
NO activity
The significance of cNOS-derived NO may also be ascer-
Briefly, we surmise that relaxation represents an equally real tained by the number of chemical messengers that can stim-
physiological process, allowing for physiological recovery ulate its production. For example, the endocannabinoids,
and promoting health by terminating the other physiologi- anandamide and 2-arachidonyl-glycerol (2-AG), are nat-
cal process normally associated with stress (Figure 1). In this urally occurring cNOS-derived NO-stimulating signaling
regard, it represents a naturally occurring proactive protec- molecules that are also constitutively expressed [32,50–61].
tive mechanism that, once stimulated, provides a beneficial Anandamide, an endogenous endocannabinoid, can also
outcome for the individual invoking the process [42–44]. We cause NO release from human immune cells, neural tissues
surmise that the molecular components of this process must and human vascular endothelial cells [53,62]. Anandamide
be constitutively expressed so that it can continually be “felt” can also initiate invertebrate immune cell cNOS-derived
as well as be stimulated to rapidly increase its desired bene- NO [50].
ficial effect. This aspect of relaxation is important in termi-
nating, for example, alert states such as found in the stress Estrogen can also stimulate cNOS-derived NO in human im-
response once a perceived threat ends (Figure 1). The ina- mune and vascular cells [62–64]. It can also perform this
bility to invoke relaxation may be an important factor in al- function in invertebrates, stimulating cNOS-derived NO re-
lowing chronic stress to gain a foothold in a person’s mind lease from neural tissues [65,66].
translating into pathophysiological disorders [12].
Recent work from our laboratory has revealed that morphine
Background molecular processes can be made by normal healthy animal cells, including hu-
man cells [67,68] (Figure 2). This supports the previous-
We surmise constitutive NO signaling is critical in relax- ly found opiate receptor subtype μ3, cloned from human
ation [12,32,40]. When constitutive nitric oxide synthase immune, vascular and neural tissues, which is selective for

Med Sci Monit, 2006; 12(9): HY21-31 Stefano GB et al –Neural processes in relaxation

CNS and Adrenal Gland Figure 3. Peripheral manifestations of molecular
components of relaxation. In order to
be effective and have the potential to
Morphine exert a therapeutic outcome relaxation
must be broad in its ability to induce
widespread down regulation while
μ3 simultaneously not completely altering
Blood Vessel an animals excitatory alert processes
Endothelium to the point where they are rendered
Nitric oxide useless. Hence it not surprising to find
the mu3 opiate receptor, which is opiate
Vasodilation alkaloid selective and opioid peptide
WBC Down regulate proinflammatory events insensitive, present on diverse tissue
types where it is coupled to constitutive
Antibacterial, antiviral, scavenges free radicals nitric oxide release, which we also have
Inhibits norepinephrine synthesis linked to global down regulation and
Neuron Inhibits immunocyte adherence thus, exerting therapeutic actions that
Inhibits smooth muscle contraction are equally diverse
Activates Reward Centers - Feels Good [42,43,43,118,119,144,145].
Calms Nervous tissues

the opiate alkaloids morphine and morphine-6-glucuro- by norepinephrine (NE) levels, which initially go up [78].
nide and not opioid peptides [69], demonstrating a spe- This appears also to be the case for falling in love and en-
cific morphinergic signaling mechanism in animal tissues. joying pleasurable experiences, since this does, for exam-
Furthermore, μ3 opiate receptors stimulated by morphine ple, represent the risk of rejection [8,13,79,80]. Regarding
are coupled to cNOS-derived NO release, resulting in the the vasodilator peripheral heat-warming processes, we
down-regulation of immune, vascular, gut and neural tis- speculate that this involves NO [4]. In regard to the sense
sues [3,70–74]. Thus, besides well known cNOS-derived NO of well-being, we can assume that this process may also in-
stimulators, i.e., acetylcholine (ACh) [75,76], newer chem- volve opioid signaling molecules, which are involved with
ical messengers have been discovered, which are also asso- reward processes [8].
ciated with NO coupling.
In examining a potential mechanism for relaxation, besides
Why are there so many pathways that lead to cNOS-de- the over-riding CNS output via the autonomic nervous sys-
rived NO release? We believe that each signaling system tem, peripheral neuro-vascular processes would appear to
performs this common function under different circum- be important [4] (Figure 3). We surmise NO to be of fun-
stances. Endogenous morphine [32], given its long latency damental importance because of the increase in peripher-
before increases in its levels are detected, arises after trau- al temperature, i.e., vasodilation [81]. With reference to
ma/inflammation and, through a NO mechanism, down- the peripheral vasculature, we find nerve terminals in the
regulates these processes in neural, vascular and immune vessels that when stimulated by nicotine, result in vasocon-
tissues [28,55,77]. Anandamide, as part of the ubiquitous striction followed by vasodilation [82], indicating a cholin-
arachidonate and eicosanoid signaling cascade, serves to ergic mechanism. Clearly, this phenomenon is in line with
maintain and augment tonal NO in vascular tissues [32,59]. new data demonstrating nicotine stimulation of endogenous
Estrogen, through NO release, provides an additional path- morphine from nervous tissue, resulting in morphine NO
way by which the system can down-regulate immunocyte and coupling and vasodilation, i.e., relaxation [78,83–86]. The
vascular function in women [62]. This may be due to both vasoconstriction component of the biphasic nicotine effect
the immune and vascular trauma associated with cyclic re- is mediated by alpha-1-adrenoceptors stimulated by NE lib-
productive activities, such as endometrial buildup, when a erated from peripheral sympathetic adrenergic nerves [4].
high degree of vascular and immune activities are occur- Studies suggest that, because of insensitivity to atropine, ACh
ring. Given the extent of proliferative growth capacity dur- does not mediate the nicotine-induced vasodilation [82].
ing peak estrogen levels in this cycle, NO may function to Instead it is mediated from nerve endings in which a NO
enhance down-regulation of the immune system to allow generating system and ACh may coexist [87]. Thus, nicotine
for these changes. Clearly, therefore, enhanced cNOS ac- stimulates the adrenergic and nitroxidergic nerves inner-
tivity is beneficial within the concept and time framework vating, for example, the temporal arterial wall of denuded
of relaxation. endothelium in superficial dog tissue, resulting in contrac-
tion and a rapidly developing vascular relaxation, the latter
Proposed signaling in relaxation being mediated by cyclic GMP (cGMP) [88]. Slow relaxa-
tion caused by nicotine is associated with the elevation of
Individuals who are relaxing experience peripheral vasodi- cGMP production via activation of guanylate cyclase, which
lation, warming of the skin, a decrease in heart rate and an appears to be mediated by prostaglandin I2 [88].
overwhelming sense of well-being only when this can occur
in a safe and trusted environment (see [4]). Counter-intu- However, newer experimental results allow us to modify this
itively, there may be initial sympathetic activation, as noted interpretation. Namely, nicotine can stimulate the release of

Hypothesis Med Sci Monit, 2006; 12(9): HY21-31

endogenous morphine from adrenal tissues and white blood ly, the relaxation response [78] may, in a sense, represent
cells, adding this opiate alkaloid into the immediate environ- the left over flow of the earlier mild sympathetic stimula-
ment [83,89,90]. It is critical to note that, as documented tion, i.e., also representing work initiation in a different sit-
earlier, endogenous morphine signaling is coupled to cNOS- uation, i.e., stress response.
derived NO release in these tissues. In individuals shown to
relax via lowering their blood pressure by listening to mu- Complicating this matter is the data indicating that ACh
sic, higher opiate alkaloid levels were found in their plasma inhibits, acting via prejunctional muscarinic, not nicotin-
along with a significant alteration of the μ3 receptor levels ic receptors, the synthesis and release of NO while concur-
on blood cells and a lowering of plasma proinflammatory cy- rently antagonizing the release of NE [92,95]. However, the
tokine levels (i.e., immune down-regulation) [86,91], dem- response to exogenous NO is not influenced by ACh [93].
onstrating the involvement of opiate alkaloids in this ability In addition, the secondary vasodilation to electrical nerve
to relax at the peripheral level. Supporting this hypothesis stimulation appears to be attenuated by treatment with ACh
further is the vasodilator effect, which requires NO, resulting in a concentration-dependent manner [93]. These findings
in the lowering of blood pressure and the ability of morphine suggest that ACh plays an essential role in vascular NO regu-
to release NO from immune and vascular cells as discussed lation (Figure 3). It may be the factor adjusting the interac-
earlier. This release may be the actual event contributing to tion of NO and NE, simultaneously exerting its own vascular
the observed vasodilation and increase in peripheral skin action, i.e., stimulating endothelial NO release maybe via the
temperature associated with relaxing (Figure 3). release of endogenous morphine [83,89,106,107] (Figure
3). Others found that beta(2)-adrenoceptor antagonists
Taken together, we surmise that NE initially promotes a slight blocked the relaxation induced by nicotine. Furthermore,
vasoconstriction of the artery during the initial phase of re- they demonstrated that beta(2)-adrenoceptor immunore-
laxation (“getting in the mood”), indicating a slight enhance- activities and NADPH diaphorase reactivities were colocal-
ment of sympathetic activity upon stimulation (Figure 1). ized in the same nerve fibers in basilar and middle cerebral
This may also serve to demonstrate that sympathetic tone al- arteries [103]. The authors speculate that NE acts on presy-
ways manifests itself until its influence is diminished. This is naptic beta(2)-adrenoceptors located on the NO nerve ter-
immediately followed by the release of NO from the nitrox- minals to release NO resulting in vasodilation.
idergic nerve or from an immune and/or vascular source,
which mediates a concentration-dependent vasodilation. In We also surmise, based on current studies, that endothelial-
monkeys, the cerebral arterial diameter under resting con- derived NO, released through normal pulsations due to vas-
ditions is maintained by tonic release of NO from the nerve cular dynamics responding to the heart beat [32,73,108], as
(10–20%) or from the nerve and endothelium (30%) [92]. well as ACh-stimulated endothelial NO release (via nicotinic
This observation is supported by other data from our lab- processes), may contribute to the effect of NO in inhibiting
oratory since basal NO is cNOS-derived and keeps partic- NE processes as well as inducing smooth muscle relaxation.
ular types of cells in a state of inhibition [3]. Endogenous Furthermore, vascular pulsations may be of sufficient strength
superoxide dismutase (SOD) in the cerebral artery appears to also stimulate neuronal NOS-derived NO release, limiting
to protect the relaxation, induced by NO from perivascular any basal NE actions. Interestingly, nitrosative stress, medi-
nerves, from the NO scavenger action of superoxide anion ated by involvement of the reactive nitrogen oxide species
[93]. We surmise that this NO then produces the longer-lived N2O3, does inhibit dopamine-b-hydroxylase, inhibiting NE
phenomenon of smooth muscle relaxation. In another re- synthesis and contributing to the regulation of neurotrans-
port, it was found that NE vascular hyper-responsiveness in mission and vasodilatation [109,110]. This system may pro-
hypertension is dependent on an impairment of NO activ- vide an autoregulatory mechanism involved in the neuron-
ity that is realized through NE-induced oxygen free radical al control of peripheral vasomotor responses. Furthermore,
production [94], demonstrating an important contribution the ability of nicotine to release morphine from adrenal and
to the understanding of this regulatory process. immune tissues helps explain the source of NO [83,89,90],
which results from the newly released morphine and μ3 cou-
In regard to a nervous origin of relaxation, the location of pling to NO release on these critical tissues.
the NO-releasing nerve, nitroxidergic nerve, has continued
to be a subject of debate. Various findings lead us to be- In conclusion, relaxation peripherally appears to be mediat-
lieve that the nitroxidergic nerve is located in the proximi- ed by a system of regulation involving NO, NE, ACh and mor-
ty of the adrenergic sympathetic nerve bundle [88,95–101]. phine as neurotransmitters and local hormones. Contingent
Furthermore, the NE-stimulated vasoconstriction is followed on the preliminary vasoconstriction and depolarization of
by relaxation that is suppressed by L-NA, a NOS inhibi- the membrane initiated by the release of NE, vasodilation is
tor [102], supporting its interaction via a NE mechanism mediated by NO liberated from vasodilator nerves and maybe
[103]. Secondly, nicotine-induced relaxation is abolished other tissues that activate guanylate cyclase in smooth mus-
by guanethidine, tetrodotoxin, and pretreatment with 6- cle and produce cGMP. During this stage, NO and NE ex-
hydroxydopamine, all causing destruction of the sympa- ist simultaneously. Due to the signaling cascade of NO, NE
thetic nerve, and demonstrating again the NE component no longer mediates vasoconstriction. Instead, NO activates
[104]. Furthermore, we have demonstrated that eNOS-de- guanylate cyclase, which produces vasodilation and the re-
rived NO can inhibit NE neural release in animal vascula- laxation under a depolarized membrane state.
ture [53]. Recently, we have also demonstrated that, once
NO is present, smooth muscle cells from rat and human CNS involvement
arteries fail to contract in response to NE [105], demon-
strating that when the balance shifts to NO, NE cannot ini- The CNS regulating pathways and processes integral to me-
tiate vasoconstriction. Thus, the NE reported in, specifical- diating this process stimulate NE release either alone or in

Med Sci Monit, 2006; 12(9): HY21-31 Stefano GB et al –Neural processes in relaxation

combination with NO (see [4]). If NE is released alone, va-

soconstriction occurs. If NE is released with NO, we surmise
ated release of NO from rat brain hippocampus and amy-
gdala and endogenous morphine’s presence in these tissues
an initial short-lived vasoconstriction occurs followed by a [117]. Furthermore, DA can serve as a endogenous mor-
prolonged vasodilation mediated directly by NO. In this re- phine precursor [67,68] (Figure 2).
gard, if basal/tonal NE is present, NO overrides this effect
(Figure 1). If ACh is present, we surmise that its inhibition Supporting this hypothesis are other studies linking relax-
of NE, causing loss of sympathetic tone, and its stimulation ation characteristics with that of pain. Once individuals are
of endothelial-derived NO, may also result in vasodilation. exposed to painful stimuli such as a penetrating needle they
The important point at this stage of explaining relaxation experience peripheral vasodilation, warming of the skin
is that, at last, we are beginning to see a mechanism that [123–126], an increase in heart rate and a sense of agita-
can explain its characteristics and simultaneously provide tion, all as a potential result of circulating catecholamines
an explanation for its health benefits, i.e., via cNOS-derived and/or NO [127]. It is the function of the amygdala and
NO (see [3,32,45,47,48]). related subcortical regions to aid in the relief of these pain
states [113,128,129]. In examining a potential mechanism
There are several key areas of the CNS involved in relaxa- for this relief, besides the over-riding CNS output via the
tion processing. Subsequent to thalamic routing, there is autonomic nervous system, peripheral neuro-vascular proc-
quick transit of crude data to the amygdala and a slower esses would appear to be important. Again, we surmise that
more considerate flow of information to the primary sen- NO and its relation with prostaglandins are of fundamen-
sory cortex, with subsequent routing of more refined infor- tal importance in this response because of the increase in
mation to the amygdala and the hippocampus, areas classi- peripheral temperature, i.e., vasodilation, in the ensuing
cally involved in emotion and memory – critical functions inflammatory response [123–126]. Indeed this is precise-
of the so-called limbic system of the brain (Figure 1). The ly the pathway, which is inhibited with non-steroidal anti-
quick route allows the organism to be rapidly responsive to inflammatory drugs (NSAID). Interestingly, as noted ear-
a fearful prompt. The more sophisticated appraisal route lier, N2O3 does inhibit dopamine hydroxylase, inhibiting
permits the limbic system to operate with more reliable in- NE synthesis and contributing to the regulation of neuro-
formation that may allow the amygdala to stand down and transmission and vasodilation [4,110]. This system may pro-
for relaxation to re-emerge if the decisions to be made are vide an autoregulatory mechanism involved in the neuronal
safe and clear cut ones. If the decisions to be made are not control of peripheral vasomotor responses as they relate to
clear cut and are conflicted in some way the anterior cin- pain control, where induction of a catecholamine-inhibit-
gulate cortex must make a response selection based on the ing substance may autoregulate the vasomotor response in
cognitive data from cortical regions and the emotional data response to nitrosative stress (see [130] for the role of nit-
from the limbic system [111]. Hyperactivation of the anteri- rosative stress in neuropathic pain).
or cingulate as seen in functional neuroimaging of depres-
sion and in pain states can be modified when the prefron- This line of research allows us to further speculate that phys-
tal cortex is stimulated by conscious positive expectation iological relaxation emerged from this pathway, once the
and the relaxation that accompanies it [112]. proinflammatory element, under the right circumstances,
was removed. This probably was associated first with physi-
Hence, it is no surprise that these limbic and paralimbic ological states requiring a less alert state, such as sleep-like
areas are of great importance to relaxation, as well as pain activity. Later, when cognition evolved, it also became asso-
modulation. We surmise the proximity and shared “wiring” ciated with our ability to determine a safe environment in
of these two functions represents a critical point whereby which relaxation may emerge. In either event, it would be
evaluations are made on whether or not the situation is ap- critical to have endogenous morphine involved because of
propriate to relax. This proximity and sharing of common its analgesic action and ability to down-regulate immune
neural circuits is a critical survival element in animal evo- processes [30,32], effectively separating the two functions,
lution, allowing excitation to take over rapidly should the which would be critical to relaxation. Indeed, cognitive func-
situation arise. Importantly, the central nucleus of the amy- tions and devices that show their performance (EEG, fMRI,
gdala is most strongly modulated by dopamine (DA), NE, SPECT, etc.) reveal a clear distinction between sleep and re-
epinephrine and serotonin [113,114]. The basal nuclei laxation, and relaxation not only leads to an overall decrease
receive moderately high inputs of DA, NE and serotonin in brain activity but simultaneously to an increase in specif-
[113,114], each of which has been demonstrated to exert ic parts of the brain, e.g., related to cognition [131–133].
their desired effect, in part, via NO [115–119]. Another critical component of this determination, whether
to be alert or relax, is having morphine synthesis take place
We surmise that the centrally released NE exerts effects in via the catecholamine pathway in animals, including man
the periphery via cardiovascular circuitry [4] by initially pro- [67,68]. Again, this pathway behaviorally allows for excita-
moting a slight vasoconstriction of the peripheral artery dur- tion to occur as synthesis proceeds via DA and secondari-
ing the amygdalar response to relaxation input as part of the ly NE, followed by down-regulation via morphine and mor-
limbic system’s inherent mechanism to maintain homeosta- phine-6-glucuronide signaling, as it goes to its end at opi-
sis and decrease pain perception via descending spinal path- ate alkaloid synthesis [67,68].
ways resulting in endogenous opiate analgesia [115,116].
In fact, reports have found endogenous morphine within THE HYPOTHESIS
the structure of the hippocampus and amygdala, i.e., lim-
bic system [117,120–122]. In addition, this morphine may cNOS-derived NO appears to be critical for relaxation be-
activate pleasure pathways via NO in rat brain hippocam- cause it has the ability to block a sympathetic response sim-
pus [112]. Studies from our laboratory confirm the medi- ply by having its release occur beyond the basal level, which

Hypothesis Med Sci Monit, 2006; 12(9): HY21-31

will lead to vasodilation and peripheral sense of warmth. Its burst of NO, we can enhance the inhibition of NF-kB activa-
presence can also explain the paradox of the presence of NE tion, limiting the extent and the severity of a proinflammato-
in plasma while vasodilation is taking place [78]. Recently, ry situation. Does this occur during long-term stress or does
we demonstrated that during the relaxation response NO the proinflammatory mechanism become desensitized and
levels are increased [5], further supporting the critical role over-stimulated by a relentless insult, so that NO is formed
of NO in this process. through inducible NOS, which not only becomes detrimen-
tal to the cells, but to the entire organism? We believe the
Additionally, endogenous morphine signaling appears to play latter situation emerges with chronic stress and may give rise
a major role in relaxation. Many immune processes perpet- to certain degenerative diseases [17,22,23,40,139]. For ex-
uate and become embellished with time by the recruitment ample, if a proinflammatory challenge is overwhelming or
of cells, and through beneficial yet sometimes harmful sig- persistent, iNOS production may reflect a last ditch attempt
naling molecules such as the proinflammatory cytokines. to overcome antigenic stress while also trying to dampen a
These molecules can all be down-regulated by morphine, potentially destructive proinflammatory blaze. The resulting
which is released following stress or trauma [30,32], specifi- overproduction of NO is unfortunately toxic [4].
cally through cNOS-derived NO under certain circumstanc-
es. Thus, morphine may help overcome over-stimulated im- In speculating on an overall theory as to what constitutes
mune, vascular and neural tissues [32,68]. As such, it may be relaxation, we offer the following hypothesis: Neural proc-
part of the immune system regulation that prevents the all esses (CNS integrating limbic circuits), involving NO and
too common ravages of what Bone called “immunologic dis- morphine, activate downstream signaling molecules that
sonance”, including the systemic inflammatory response syn- stimulate cNOS-derived NO release from immune, neural
drome (SIRS) which sometimes culminates in the often lethal and vascular tissues. Prior to NO release this process also in-
multiple organ dysfunction syndrome (MODS) [134]. vokes the release of NE and opioid peptides. The presence
of NO is deduced by its vasodilating actions and the lack of
It is possible that some individuals may be deficient in this vascular sensitivity toward NE and by direct measurement
regulatory process, leading, when challenged, to the unreg- [5]. Relaxation can be cognitively learned, e.g., relaxation
ulated and potentially damaging immune responses of SIRS response. Taken together, this potential is always present
and MODS. We have found, for example, that in the immune and only after removing the sympathetic and stress reac-
disorder histiocytic medullary reticulosis or malignant histi- tions (e.g., disinhibition [3]), does it emerge. It is probably
ocytosis [135] a morphine-selective receptor, μ3, was not ex- this process along with many others that provide for mam-
pressed, and granulocytes and monocytes cultured from this malian longevity, i.e., it is antibiosenescent.
patient could not be down-regulated when exposed to mor-
phine. The foundation of the concept that morphine is criti- Its expression probably also differs among individuals, and
cal to relaxation or a down-regulation of excitatory processes the strength of one’s beliefs or an animal’s individual his-
is supported by these preliminary clinical findings, as well as tory may also exert a profound impact on the heightened
the fact that it can be made by human white blood cells and expression of these proactive innate protective responses
the μ3 opiate receptor subtype is found on these tissues as well that originate from the CNS.
[68,69]. Furthermore, high morphine levels have been found
in rat limbic tissues associated with NO release [117]. Relaxation takes place in that emotionalized transitional re-
lationship found in a person when we are in a trusted and
ASSOCIATED MOLECULAR MECHANISMS safe environment. Here, belief is critical. Once this condi-
tion is met then, and only then, will relaxation occur. This
The physiological significance of cNOS-derived NO, and attachment-based solace exhibits salutary effects on the lim-
for that matter morphine-stimulating NO release, is that it bic neural processes in the brain’s motivation and reward
can influence proinflammatory and stress situations, pre- circuitry responsible for regulating the stress response and
sumably bringing both the “acute phase response” and the immune response systems via constitutive NO pathways
“acute stress response” under control [45,54,55]. We pro- [7–9,13,16,32,140–142]. Hence, relaxation is real and an
pose that cNOS-derived NO initiates these events in part by important physiological process. It can be integrated in
its ability to modify the function of the transcription factors, self-care-oriented medical settings, i.e, stress management,
i.e., NF-kB [136–138]. NF-kB binding sites are present in where it has demonstrated its value.
the promoter regions of proinflammatory genes such as tu-
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