Psychological aspects of multiple sclerosis

Difficulties with emotion regulation in multiple sclerosis: Links to executive function, mood, and quality of life

INTRODUCTION

Little is known about the influence of multiple sclerosis (MS) on the regulation of emotion. The current study tested whether people with MS report more emotion regulation difficulties than healthy controls. The relationship between emotion regulation and other important variables (mood, quality of life, and executive function) was explored. Mediation models were used to further understand the links between emotion regulation, depressed mood, and executive function in MS.

METHOD

A total of 31 people with MS and 31 controls completed the Difficulties in Emotion Regulation Scales and measures of executive function (fluency and a go/no-go task), mood (Hospital Anxiety and Depression Scales), and a multidimensional assessment of quality of life (World Health Organization Quality of Life, brief version).

RESULTS

People with MS reported experiencing more difficulties in emotion regulation than controls. Mediation analyses indicated that depression mediated the emotion regulation difficulties in MS, while executive dysfunction did not. Difficulties in emotion regulation predicted poorer psychological and social quality of life in MS, independent of problems with executive function.

CONCLUSIONS

People with MS experience difficulties in emotion regulation, which predict poorer quality of life. These results indicate that emotional control skills should be investigated in further detail when considering interventions to enhance well-being in MS.

Physical disability, anxiety and depression in people with MS: an internet-based survey via the UK MS Register

INTRODUCTION

People with Multiple Sclerosis are known to have a relatively high prevalence of both anxiety and depression. Studies of the relationship between physical disability and mental health in people with MS have reported mixed results, showing the need for further work.

METHODS

Between May 2011 and April 2012, 4516 people completed the MSIS-29 (v.1) and HADS scales via the dedicated internet site of the UK MS Register within a 7 day time window. These responses were linked with basic demographic and descriptive data and analysed in SPSS (v.20).

RESULTS

The proportions of people experiencing anxiety or depression increased with physical disability such that 38.0% of respondents with low, and 66.7% with high disability reported at least mild anxiety, and 17.1% of people with low, and 71.7% with high disability experienced at least mild depression. The multiple regression model explained 18.4% of the variance in anxiety with MSIS-29-PHYS score being the strongest predictor of anxiety. The model for depression explained 37.8% of the variance with MSIS-29-PHYS score being the strongest predictor. Some of the other variables included showed negative associations with anxiety and depression, indicating that the influence of physical disability on mental wellbeing could be underestimated.

CONCLUSIONS

This study indicates that there is a positive relationship between physical disability and anxiety and depression, that physical disability impacts on anxiety and depression to differing extents, and that the effects vary with gender, age, disease course and disease duration. We have shown that physical disability is a predictor of anxiety and depression, and that other factors may mask the extent of this effect. Whether the causes of anxiety and depression are reactive, organic or a combination, it is essential that mental wellbeing is given due attention in caring for people with MS so that all their health needs can be met.

Validation of mood measures for people with multiple sclerosis

BACKGROUND

Valid assessments are needed in order to identify anxiety and depression in people with multiple sclerosis (MS). The objective of this study was to assess the validity of questionnaire measures of mood in people with MS.

METHODS

People with MS were recruited from a clinic database and asked to complete and return a questionnaire containing the Beck Anxiety Inventory (BAI), Beck Depression Inventory-II (BDI-II), and Hospital Anxiety and Depression Scale (HADS). Those who returned the questionnaire were invited to complete a structured clinical interview, which was blind to the results of the questionnaire.

RESULTS

The BDI-II and HADS were both found to be valid measures to detect depression and anxiety in people with MS. An optimum cutoff score of 23 for the BDI-II yielded high sensitivity (85%) and high specificity (76%). An optimum cutoff score of 11 for the HADS demonstrated high sensitivity and specificity for both the Anxiety subscale (sensitivity 90%, specificity 92%) and the Depression subscale (sensitivity 77%, specificity 81%). The BAI had high sensitivity (80%) but poor specificity (46%) for detecting anxiety.

CONCLUSION

The BDI-II and HADS can be used to identify mood disorders in people with MS.

Meditation as an adjunct to the management of multiple sclerosis

Background. Multiple sclerosis (MS) disease course is known to be adversely affected by several factors including stress. A proposed mechanism for decreasing stress and therefore decreasing MS morbidity and improving quality of life is meditation. This review aims to critically analyse the current literature regarding meditation and MS. Methods. Four major databases were used to search for English language papers published before March 2014 with the terms MS, multiple sclerosis, meditation, and mindfulness. Results. 12 pieces of primary literature fitting the selection criteria were selected: two were randomised controlled studies, four were cohort studies, and six were surveys. The current literature varies in quality; however common positive effects of meditation include improved quality of life (QOL) and improved coping skills. Conclusion. All studies suggest possible benefit to the use of meditation as an adjunct to the management of multiple sclerosis. Additional rigorous clinical trials are required to validate the existing findings and determine if meditation has an impact on disease course over time.

Relationship between disease-modifying therapy and depression in multiple sclerosis

Many prescribers of disease-modifying therapies (DMTs) for multiple sclerosis (MS) believe that interferon beta (IFNβ) is more likely than glatiramer acetate (GA) to increase depression during the course of MS treatment. Therefore, newly diagnosed patients with a history of depression are often placed on GA therapy from the onset of MS treatment. The aim of this study was to examine the relationship between DMT type and depression among patients with relapsing-remitting MS (RRMS). Patients with RRMS who were examined from 2000 to 2007 and who remained on a single course of therapy (either an IFNβ or GA) were included in a retrospective review of medical records. Patients were asked to complete the Beck Depression Inventory (BDI) at treatment initiation and every 6 months thereafter for up to 4 years. Only patients who had completed a BDI within 6 weeks of starting their DMT were included in the analysis. No significant differences in mean change in BDI score were observed from baseline to 48 months between the IFNβ and GA subgroups. Additionally, no significant differences in mean BDI score change were observed between antidepressant-treated and non-antidepressant-treated patients within the IFNβ or GA subgroup. Neither IFNβ nor GA therapy appears to exacerbate depressive symptoms in patients with RRMS who remain on their initial therapy.

Longitudinal study of alexithymia and multiple sclerosis

OBJECTIVE

The aim of this study was to investigate the course of alexithymia and its relation with anxiety and depression in patients with multiple sclerosis (MS), over a period of 5 years.

METHODS

Sixty-two MS patients were examined at two timepoints, 5 years apart, and they answered questionnaires collecting socio-demographic, medical, and psychological data (depression, anxiety, alexithymia).

RESULTS

Our data show that emotional disorders remain stable over time in patients with MS, particularly as regards alexithymia and anxiety. Conversely, the rate of depression decreased between the two evaluations, falling from 40% to 26%. The two dimensions of alexithymia (i.e., difficulty describing and difficulty identifying feelings) were correlated with anxiety and depression, whereas the third component of alexithymia (externally oriented thinking) was independent, and was the only component to change over time, with a significant fall observed at 5 years.

CONCLUSION

Alexithymia was associated with increased severity of anxiety and attack relapses.

The effects of a group-based cognitive behavioral therapy on people with multiple sclerosis: a randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of a cognitive behavioral group-based intervention aimed at reducing depression and fostering quality of life and psychological well-being of multiple sclerosis patients through the promotion of identity redefinition, sense of coherence, and self-efficacy.

DESIGN

A randomized controlled trial.

SETTING

Non-medical setting, external to the Multiple Sclerosis Clinic Centre.

SUBJECTS

Eighty-two patients: 64% women; mean age 40.5, SD = 9.4; 95% with relapsing-remitting multiple sclerosis; Expanded Disability Status Scale (EDSS) between 1 and 5.5 were included in the study.

INTERVENTIONS

Patients were randomly assigned to an intervention group (five cognitive behavioral group-based sessions, n = 41) or to a control group (three informative sessions, n = 41).

MAIN MEASURES

Depression (CES-D), Quality of life (MSQOL revised), Psychological well-being (PANAS), Identity Motives Scale, Sense of Coherence (SOC), and Self Efficacy in Multiple Sclerosis.

RESULTS

Quality of life increased in the intervention group compared with the control at 6-months follow-up (mean change 0.72 vs. -1.76, p < 0.05). Well-being in the intervention group increased for males and slightly decreased for females at 6-months follow-up (mean change 6.58 vs. -0.82, p < 0.05). Contrasts revealed an increase in self-efficacy in the intervention group at posttreatment compared with the control (mean change 2.95 vs. -0.11, p < 0.05). Depression tended to lower, while identity and coherence increased in the intervention group compared with the control, though the differences were not significant.

CONCLUSIONS

Preliminary evidence suggests that intervention promotes patients' quality of life and has an effect on psychological well-being and self-efficacy.

Determinants of sexual dysfunction in women with multiple sclerosis

Background

The aim of present study was to determine disease-related and psychological risk factors for sexual dysfunction in women with multiple sclerosis (MS).

Methods

This was a clinical-based study conducted from September 2009 to June 2010 in Tehran, Iran. A consecutive sample of female patients with MS was recruited from an outpatient clinic. The Female Sexual Function Index (FSFI) was used to evaluate sexual function. In addition neurological impairment was measured using the Kurtzke Expanded Disability Status Scale (EDSS), and depression was assessed using the Beck Depression Inventory-II (BDI-II). Univariate and multiple logistic regression analyses were performed in order to examine the association between sexual dysfunction and independent variables.

Results

In all, 226 women participated in the study. Of these, 125 women (55.3%) met the criteria for sexual dysfunction. The mean age of participants was 35.7 years (SD = 8.07). The results obtained from multiple logistic regression analysis indicated that the disease duration (OR for the disease duration of equal or greater than 9 years = 3.13, %95 CI = 1.29-7.57, P = 0.01), the disease course (OR for secondary progressive MS = 3.96, %95 CI = 1.55-10.10, P = 0.004) and the BDI score (OR = 1.11, %95 CI = 1.07-1.16, P < 0.001) were significant factors contributing to sexual dysfunction in these patients.

Conclusions

The findings from this study indicated that the duration and severity of the disease in addition to depression were the most significant factors that contributed to sexual dysfunction in women with multiple sclerosis. The burden of disease and sexual dysfunction suggests the need for further attention to this patient population.

Cost-effectiveness of an adjustment group for people with multiple sclerosis and low mood: a randomized trial

OBJECTIVE

To evaluate the cost effectiveness of a psychological adjustment group shown to be clinically effective in comparison with usual care for people with multiple sclerosis.

DESIGN

Randomized controlled trial with comparison of costs and calculation of incremental cost effectiveness ratio.

SETTING

Community.

PARTICIPANTS

People with multiple sclerosis were screened on the General Health Questionnaire 12 and Hospital Anxiety and Depression Scale, and those with low mood were recruited.

INTERVENTIONS

Participants randomly allocated to the adjustment group received six group treatment sessions. The control group received usual care, which did not include psychological interventions.

MAIN MEASURES

Outcomes were assessed four and eight months after randomization, blind to group allocation. The costs were assessed from a service use questionnaire and information provided on medication. Quality of life was assessed using the EQ-5D.

RESULTS

Of the 311 patients identified, 221 (71%) met the criteria for having low mood. Of these, 72 were randomly allocated to receive treatment and 79 to usual care. Over eight months follow-up there was a decrease in the combined average costs of £378 per intervention respondent and an increase in the costs of £297 per patient in the control group, which was a significant difference (p=0.03). The incremental cost-effectiveness ratio indicated that the cost per point reduction on the Beck depression inventory-II was £118.

CONCLUSION

In the short term, the adjustment group programme was cost effective when compared with usual care, for people with multiple sclerosis presenting with low mood. The longer-term costs need to be assessed.

The epidemiology and pathophysiology of pseudobulbar affect and its association with neurodegeneration

Pseudobulbar affect is a disorder resulting from neurologic damage manifesting as sudden, stereotyped affective outbursts that are not reflective of internal emotion. A literature review was completed to examine the current understanding of the epidemiology, characterization, diagnosis, pathophysiology, and treatment of pseudobulbar affect. This review revealed that it is common in neurodegenerative disorders but is poorly recognized, placing significant impacts on patients and their families. The disorder appears to result from a disruption of the cortico-limbic-subcortical-thalamic-pontocerebellar network involved in emotional expression and regulation with resulting disruptions of neurotransmitter systems. Effective treatment is available with agents such as selective serotonin reuptake inhibitors and dextromethorphan combined with quinidine, but further well-designed comparative studies are needed. Advances in technology such as neuroimaging may enhance knowledge about the pathophysiology of this disorder, and help guide future interventions.

The Gap in the Current Research on the Link between Health Locus of Control and Multiple Sclerosis: Lessons and Insights from a Systematic Review

Multiple sclerosis (MS) is a chronic neurological disease whose etiology has not been fully understood yet in detail. Empirical findings show how psychosocial symptoms are very important features of the clinical presentation of MS, having a deep impact on patient's quality of life, and thus psychological coping strategies may play a central role in reducing the burden of the disease and improving patient's satisfaction of life. MS progression and relapses/exacerbations are unpredictable and may depend on factors such as stressor chronicity, frequency, severity, type, and individual patient characteristics such as depression, personality, locus of control (LOC), optimism, and perceived social support. Due to its importance for health-care delivery, rehabilitation, and nursing, here, we make a systematic review on the current state-of-the-art studies concerning the relationship between LOC and MS, according to the PRISMA guidelines, and we assess the quality and the completeness of the studies using the CONSORT instrument, underpinning their limitations, and suggesting how to fill the gap in this research field.

Cognitive impairment is correlated with reduced quality of life in patients with clinically isolated syndrome

OBJECTIVE

To evaluate the quality of life (QoL) and potential QoL determinants in patients with clinically isolated syndrome (CIS).

METHODS

Eighteen CIS patients and eighteen controls were submitted to QoL evaluation with Functional Assessment of Multiple Sclerosis QoL instrument (FAMS). Cognition was evaluated with specific battery tests; Anxiety and depression with Beck Anxiety (BAI) and Depression (BDI) Inventories and Neurological disability with Guy's Neurological Disability Scale (GNDS).

RESULTS

There was a significant difference in QoL between CIS patients and controls. CIS patients had worse performance in Paced Auditory Serial Addition 2 seconds (p=0.009) and fluency tests (p=0.0038). There was a significant difference in BAI (p=0.003), but no significant difference in BDI between patients and controls. There were significant correlations between QoL measure and verbal fluency and Stroop's test.

CONCLUSIONS

Cognition, but not anxiety, depression and disability, was associated with reduced quality of life.

A large-scale study of anxiety and depression in people with Multiple Sclerosis: a survey via the web portal of the UK MS Register

Introduction

Studies have found that people with Multiple Sclerosis experience relatively high rates of anxiety and depression. Although methodologically robust, many of these studies had access to only modest sample sizes (N<200). The aims of this study were to use responses gained via the web portal of the UK MS Register (N>4000) to: describe the depression and anxiety profiles of people with MS; to determine if anxiety and depression are related to age or disease duration; and to assess whether the levels of anxiety and depression differ between genders and types of MS.

Methods

From its launch in May 2011 to the end of December 2011, 7786 adults with MS enrolled to take part in the UK MS Register via the web portal. The responses to the Hospital Anxiety and Depression Scale (HADS) were collated with basic demographic and descriptive MS data provided at registration and the resulting dataset was analysed in SPSS (v.16).

Results

The mean HADS score among the 4178 respondents was 15.7 (SE 0.117, SD 7.55) with a median of 15.0 (IQR 11). Anxiety and depression rates were notably high, with over half (54.1%) scoring ≥8 for anxiety and 46.9% scoring ≥8 for depression. Women with relapsing-remitting MS were more anxious than men with this type (p<0.001), and than women with other types of MS (p = 0.017). Within each gender, men and women with secondary progressive MS were more depressed than men or women with other types of MS (p<0.001, p<0.001).

Conclusions

This largest known study of its kind has shown that anxiety and depression are highly prevalent in people with MS, indicating that their mental health needs could be better addressed. These findings support service planning and further research to provide the best care for people with MS to help alleviate these debilitating conditions.

Daily hassles reported by Dutch multiple sclerosis patients

There is growing evidence for the association between stress and relapse risk in multiple sclerosis (MS). The current study focuses on daily hassles, which by their chronic and accumulating nature can cause considerable psychosocial stress. The main aim was to investigate the frequency, associated distress and type of daily hassles encountered by Dutch MS patients from a large community-based sample. We further examined factors associated with high levels of psychosocial stress. Questionnaires concerning demographics, disease characteristics, physical functioning, daily hassles, fatigue, depression and anxiety were completed by 718 MS patients. Three patients younger than 18 were excluded, resulting in 715 patients. Compared with published norm data, more than 50% of the participants reported a high number of daily hassles (57.5%) and high levels of associated distress (55.7%). Frequently mentioned daily hassles concern personal functioning and social developments. A logistic regression model revealed that being female, being younger, having a higher educational level, using benzodiazepines, exhibiting more symptoms of anxiety, and a higher physical impact of fatigue were all independently associated with high levels of psychosocial stress. Our findings may alert clinicians of the high prevalence and impact of daily hassles in MS and underline the need to incorporate stress and anxiety management strategies in (psycho)therapeutic interventions.

Carnitine for fatigue in multiple sclerosis

BACKGROUND

Fatigue is reported to occur in up to 92% of patients with multiple sclerosis (MS) and has been described as the most debilitating of all MS symptoms by 28% to 40% of MS patients.

OBJECTIVES

To assess whether carnitine (enteral or intravenous) supplementation can improve the quality of life and reduce the symptoms of fatigue in patients with MS-related fatigue and to identify any adverse effects of carnitine when used for this purpose.

SEARCH METHODS

A literature search was performed using Cochrane MS Group Trials Register (09 September 2011), Cochrane Central Register of Controlled Trials (CENTRAL) "The Cochrane Library 2011, issue 3", MEDLINE (PubMed) (1966-09 September 2011), EMBASE (1974-09 September 2011), and www.clinicaltrials.gov for ongoing trials retrieval. Reference lists of review articles and primary studies were also screened. A hand search of the abstract book of recent relevant conference symposia was also conducted. Personal contact with MS experts and a manufacturer (Source Naturals, United States) of carnitine formulation was contacted to determine if they knew of other clinical trials. No language restrictions were applied.

SELECTION CRITERIA

Full reports of published and unpublished randomized controlled trials and quasi-randomized trials of any carnitine intervention in adults affected by multiple sclerosis with a clinical diagnosis of fatigue associated with multiple sclerosis were included.

DATA COLLECTION AND ANALYSIS

Data from the eligible trials was extracted and coded using a standardized data extraction form and entered into RevMan 5. Discrepancies were to be resolved by discussion with a third reviewer, however this was not necessary.The quality items to be assessed were method of randomization, allocation concealment, blinding (participants, investigators, outcome assessors and data analysis), intention-to-treat analysis and completeness of follow up.

MAIN RESULTS

The search identified one ongoing randomized, placebo-controlled, cross-over trial (expected completion 2013) and one completed randomized, active-comparator, cross-over trial. In the completed study, adult patients with relapsing-remitting and secondary progressive MS were exposed to both acetyl L-carnitine 2 grams daily and amantadine 200 mg daily The effects of carnitine on fatigue are unclear. There was no difference between carnitine and amantadine for the number of patients withdrawing from the study due to an adverse event (relative risk ratio 0.20; 95% confidence interval 0.03 to 1.55) and no patients experienced a serious adverse event in either treatment group. Mortality and quality of life were not reported.

AUTHORS' CONCLUSIONS

There is insufficient evidence that carnitine for the treatment of MS-related fatigue offers a therapeutic advantage over placebo or active comparators. Results of the ongoing trial are eagerly anticipated in order to provide clarity.

Health-related quality of life outcomes at 1 and 5 years after a residential retreat promoting lifestyle modification for people with multiple sclerosis

There is a strong body of evidence that supports the use of non-drug therapies in the management of people with multiple sclerosis (MS). A 5-day residential retreat for people with MS in Victoria, Australia, promotes lifestyle modification within a patient-centred model of care. Analysis of the health-related quality of life (HRQOL) of the retreat participants was undertaken using the MSQOL-54, prior to attendance, 1 and 5 years after the retreat. 274 retreat participants (71%) completed baseline questionnaires. Despite the usually progressive nature of MS, the cohort demonstrated clinically and statistically significant improvements in HRQOL. One year after attending the retreat, median improvements of 11.3% were observed in the overall quality of life domain (p < 0.001); 18.6% in the physical health composite (p < 0.001); and 11.8% in the mental health composite (p < 0.001). In the subset of 165 who had reached the 5-year time-point, there was a 19.5% median improvement in overall quality of life (p < 0.001); 17.8% in the physical health composite (p < 0.001) and 22.8% in the mental health composite (p < 0.001), compared to baseline. Attendance at a retreat promoting lifestyle modification for the integrated management of MS appears to have positive effects on short and medium-term HRQOL. Non-drug therapies should be considered as part of any comprehensive treatment plan for people with MS.

Anxiety and depressive symptoms in clinically isolated syndrome and multiple sclerosis

Depression and anxiety have been reported in patients with multiple sclerosis (MS) and in patients with clinically isolated syndrome (CIS). However, the precise mechanisms that lead to depressive and anxiety symptoms in these patients are still unclear. In this study we evaluated with the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI) patients with MS and CIS and compared them to controls. We also correlated BDI and BAI scores with clinical parameters. Kruskall-Wallis followed by Dunn's Multiple Comparison Test, Chi-square and Spearman test were used. Patients with MS had higher depressive and anxiety scores than controls. The BDI and BAI scores of patients with CIS were not significantly different from controls. There was a positive correlation between BDI, BAI and EDSS. Our results corroborate the view that MS patients have higher depression and anxiety levels than control subjects. Anxiety and depressive symptoms also seem to progress according to the severity of the disease.

Social cognition impairments in relapsing-remitting multiple sclerosis

Theory of Mind (ToM) is the ability to attribute independent mental states to self and others to explain and predict behavior. Impairment of ToM is well established in developmental pathologies. In neurological populations, investigation of ToM is still rare but data suggest that ToM impairment could contribute to behavioral and social disturbances. In addition to neurological signs, multiple sclerosis (MS) presents with disorders of cognition and behavior directly related to brain damage. The aim of this study was to assess ToM abilities and recognition of facial emotional expression in adults with MS. We compared 64 patients with relapsing MS and 30 matched healthy controls on three levels of ToM tasks, a facial emotion recognition task, and a neuropsychological assessment. MS patients performed significantly worse than controls in emotion recognition and all ToM tasks (p < .02). These deficits were not correlated with demographic variables or neuropsychological test performance. These findings underscore the importance of assessing ToM and facial recognition in MS, as dysfunction in these areas may impact upon social interaction and, thus, impair quality of life for both patients with MS and their families.

Depression and anxiety in a Portuguese MS population: associations with physical disability and severity of disease

BACKGROUND

Mood disorders, namely depression and anxiety, have been well documented in patients with Multiple Sclerosis (MS). However, the putative associations between clinical features and mood disorders have not been well established.

OBJECTIVES

To detect anxiety and depression in MS patients; and to investigate possible associations with clinical factors.

SUBJECTS AND METHODS

325 consecutive patients with MS and 183 healthy subjects answered the Hospital Anxiety and Depression Scale (HADS), a self-rating questionnaire. Multiple Regression Analysis and Multivariate Analysis of Covariance were applied to assess the effect of demographic and clinical factors on HADS' anxiety and depression scores, using age and disease duration as covariates. Logistic Regression Analysis was used to study the influence of these factors on anxiety and depression, as defined by two different cut-off scores (i.e., 8 and 11).

RESULTS

Levels of anxiety and depression were significantly higher (p<0.001) for MS patients group than healthy subjects. Age, disease duration, age at onset, Kurtzke Expanded Disability Status Scale, and Multiple Sclerosis Severity Scale were positively associated with depression scores. Low education (i.e., <9 years) in MS was significantly associated with more anxiety and depression symptoms.

CONCLUSIONS

The study findings support a close linkage between depressive mood and physical manifestations of MS.

Electroconvulsive therapy in a patient with multiple sclerosis and recurrent catatonia

Catatonia is a rare complication of multiple sclerosis (MS). We present a case of a 28-year-old inpatient with MS successfully treated with electroconvulsive therapy (ECT) after developing a catatonic syndrome. A subsequent relapse also responded to ECT, after which the patient received maintenance ECT for 13 months without complications. Follow-up 18 months later did not reveal any evidence of neurological deterioration. We conclude that ECT was a safe and effective treatment in this MS patient.

[Diagnostic work-up and treatment of acute psycho-organic syndrome]

Organische Ursachen akuter psychiatrischer Syndrome stellen die wichtigste Differenzialdiagnose bei psychiatrischen Akutaufnahmen, im Konsiliardienst und ambulanten Notdienst dar. Gerade mit der wachsenden Gruppe älterer Patienten treten Delirien, oft multifaktoriell ausgelöst, sehr häufig auf. Trotz ihrer ungünstigen Prognose bleiben sie allerdings zu oft unerkannt und unbehandelt. Medikamentöse, akutneurologische, infektiöse, metabolische und andere somatische Ursachen müssen differenzialdiagnostisch fundiert durch Anamnese, körperlichen Befund, Labor und Bildgebung ausgeschlossen werden. Erstmanifestationen wie auch psychiatrische Begleitsymptome stellen oft eine differenzialdiagnostische Herausforderung dar, auch in der teilweise allerdings nicht sicher möglichen Abgrenzung von reaktiven psychischen Störungen.

Bestätigt sich eine organische Ursache, ist die Therapie primär ursachenorientiert und erst in einem zweiten Schritt symptomatisch mit antipsychotischer, antidepressiver oder sedierender Medikation. Einer iatrogenen Verursachung von Delirien sowie deren Prävention gilt ein besonderes Augenmerk, um die medizinische Qualität gerade für Ältere zu verbessern.

Quality of life in multiple sclerosis: effects of current treatment options

Multiple sclerosis is the most common non-traumatic neurodegenerative disease in adults. Most of the patients present with both physical and mental deficits which reflect the dissemination of the lesions in the central nervous system, produced by the inflammatory process. The incomplete recovery after relapses, the accumulation of new deficits and the progressive nature of the condition interfere with daily activities of individuals and have a negative impact on their well-being. Indeed, studies show that quality of life measurements are constantly lower in patients with multiple sclerosis. Estimation of health-related quality of life is being increasingly recognized as necessary when analysing the effectiveness of treatment modalities and for the follow up of patients with chronic diseases such as multiple sclerosis. Current immunomodulatory interventions that are shown to reduce the frequency of relapses and delay disease progression might also have a positive effect on quality of life measurements. Additive pharmacological agents that target cognitive impairments and common symptoms such as depression, fatigue and pain, along with life-style modifications and rehabilitation programmes are also important for the appropriate management that aims to improve quality of life.

Personality characteristics and disorders in multiple sclerosis patients: assessment and treatment

Multiple sclerosis (MS) is a major inflammatory and demyelinating disease of the central nervous system. Although a significant incidence and prevalence of psychological disorders in MS has been reported there is limited data on the prevalence of personality disorders (PD) in these patients. Recent findings indicate the need for early diagnosis and treatment of PD in MS patients in the interests of prognosis, conformity to treatment and patient's quality of life improvement. This article summarizes existing evidence on prevalence, types and diagnostic criteria of PD in MS, clinical manifestations of personality pathology or changes in MS patients, and instruments currently used for diagnosis and assessment of PD in this group of patients. Underlying mechanisms suggested as causes of personality changes in MS patients are also discussed. The article reviews therapeutic strategies, including pharmacotherapy and psychotherapy interventions and emphasizes the need for a multidisciplinary approach to patient's treatment.

Anxiety, depression and impaired health-related quality of life are therapeutic challenges in patients with multiple sclerosis

Anxiety, depression and impaired health-related quality of life (HRQoL) are commonly reported in patients with multiple sclerosis (MS) and are of great interest for therapeutic approaches. Based on regional differences a quantitative assessment of these factors in comparison to the general population, and the consideration of demographic cofactors, would be useful when designing specific interventions. We adopted such an approach in a German cohort of MS patients. Anxiety, depression (HADS) and HRQoL (SF-36) were measured in 49 consecutive outpatients with MS and compared to age- and gender-adjusted control groups (n=1330 for HADS; n=5087 for SF-36) extracted from German National Health Surveys. Patients with MS showed significantly increased levels of anxiety and depression as well as decreased HRQoL with the exception of mental health; the effect sizes ranged from 0.39 (depression) to 1.06 (physical functioning). As could be expected, MS patients with relapsing-remitting clinical course had better physical functioning than patients with secondary progressive MS. There were strong relations between anxiety and depression (r=0.54; P<0.01), and between neurological impairment (EDSS) and physical functioning (r=−0.80; P<0.001) as well as depression (r=0.48; P<0.05). This investigation of MS patients confirms the prevalence and impact of anxiety, depression and most of the HRQoL dimensions in MS patients and provides evidence for the usefulness of a quantitative comparison to a region-specific general population as a starting point for therapeutic approaches.

Psychopathology in multiple sclerosis: diagnosis, prevalence and treatment

Multiple sclerosis (MS) is a chronic inflammatory disorder of the central nervous system. Demyelinization of nerve fibres not only affects the motor and sensory systems functionally, but may also cause psychopathological signs and symptoms. In addition to the psychiatric manifestations of MS, many patients have reactive psychological problems that are often hard to distinguish from the 'organic' causation of psychopathology. In any event, psychiatric comorbidity in MS deserves greater clinical attention than has been previously paid, because the presence of psychopathology may have deleterious effects on the disease process and impair coping with disability.