Association between stressful life events and exacerbation in multiple sclerosis: a meta-analysis

Interleukin-6 as a mechanism for the adverse effects of social stress on acute Theiler's virus infection

Prior exposure to social disruption stress (SDR) exacerbates both the acute and chronic phase of Theiler's murine encephalomyelitis virus infection (TMEV; [Johnson, R.R., Storts, R., Welsh, T.H., Jr., Welsh, C.J., Meagher, M.W., 2004. Social stress alters the severity of acute Theiler's virus infection. J. Neuroimmunol. 148, 74--85; Johnson, R.R., Prentice, T.W., Bridegam, P., Young, C.R., Steelman, A.J., Welsh, T.H., Welsh, C.J.R., Meagher, M.W., 2006. Social stress alters the severity and onset of the chronic phase of Theiler's virus infection. J. Neuroimmunol. 175, 39--51]). However, the neuroimmune mechanism(s) mediating this effect have not been determined. The present study examined whether stress-induced increases in the proinflammatory cytokine interleukin-6 (IL-6) contributes to the adverse effects of SDR on acute TMEV infection. Experiment 1 demonstrated that SDR increases central and peripheral levels of IL-6 and that this effect is reversed by intracerebral ventricular infusion of neutralizing antibody to IL-6 prior to each of six SDR sessions. Although SDR reduced the sensitivity of spleen cells to the anti-inflammatory effects of corticosterone, the neutralizing antibody to IL-6 did not alter this effect. To investigate whether stress-induced increases in IL-6 contribute to the exacerbation of acute TMEV infection, Experiment 2 examined whether intracerebral administration of neutralizing antibody to IL-6 during SDR would prevent the subsequent exacerbation of acute TMEV infection. Experiment 3 then replaced the social stress with intracerebral infusion of IL-6 to assess sufficiency. As expected, prior exposure to SDR subsequently increased infection-related sickness behaviors, motor impairment, CNS viral titers, and CNS inflammation. These deleterious effects of SDR were either prevented or significantly attenuated by intracerebral infusion of neutralizing antibody to IL-6 during the stress exposure period. However, infusion of IL-6 alone did not mimic the adverse effects of SDR. We conclude that IL-6 is necessary but not sufficient to exacerbate acute TMEV infection.

Neuropsychiatric manifestations of depression in multiple sclerosis: neuroinflammatory, neuroendocrine, and neurotrophic mechanisms in the pathogenesis of immune-mediated depression

Evidence suggests that depression in multiple sclerosis (MS) is largely biologically mediated by some of the same processes involved in the immunopathogenesis of this neurologic disease. In particular, the increase in proinflammatory cytokines, activation of the hypothalamic-pituitary-adrenal (HPA) axis, and reduction in neurotrophic factors that occur in MS may each account for the increased rate of depression seen in MS. The possible contributions of these neuroinflammatory, neuroendocrine, and neurotrophic mechanisms suggest a diverse array of novel treatment strategies for depression, both in the context of inflammatory conditions as well as in idiopathic depression. Furthermore, if such processes in MS play a causative role in the pathogenesis of depression, and depression in turn has affects on neurophysiological processes related to immune function, then treatment of depression might have a positive effect on MS disease progression. This makes treating MS depression a neuropsychiatric imperative.

Stress and health: psychological, behavioral, and biological determinants

Stressors have a major influence upon mood, our sense of well-being, behavior, and health. Acute stress responses in young, healthy individuals may be adaptive and typically do not impose a health burden. However, if the threat is unremitting, particularly in older or unhealthy individuals, the long-term effects of stressors can damage health. The relationship between psychosocial stressors and disease is affected by the nature, number, and persistence of the stressors as well as by the individual's biological vulnerability (i.e., genetics, constitutional factors), psychosocial resources, and learned patterns of coping. Psychosocial interventions have proven useful for treating stress-related disorders and may influence the course of chronic diseases.

Stress and hypothalamic-pituitary-adrenal axis function in experimental autoimmune encephalomyelitis and multiple sclerosis - a review

Multiple sclerosis (MS) is an inflammatory and degenerative disease of the CNS with an assumed autoimmune-mediated pathogenesis. Stressful life events have been hypothesized as potential triggers of disease exacerbation. Animal studies using experimental autoimmune encephalomyelitis (EAE), as a model for MS, suggest that decreased hypothalamic-pituitary-adrenal (HPA) function may play a role in the increased susceptibility and severity of the disease. Histopathological studies of the hypothalamus point to disturbances in corticotropin-releasing hormone (CRH) regulation as a result of MS lesions in this area. Functional endocrine tests (e.g., the combined Dexamethasone-CRH test) showed a disturbed negative feedback after steroid application in MS patients. Hyper- and hypoactivity of the HPA axis, have been described to be associated with more severe courses. This paper presents an overview of the evidence for a role of HPA dysfunction in EAE and MS based on stress-experimental studies.

Social conflict exacerbates an animal model of multiple sclerosis

A growing body of evidence suggests that social conflict is associated with inflammatory disease onset and exacerbations in multiple sclerosis (MS) patients and in animal models of MS. This review illustrates how animal research can be used to elucidate the biobehavioral mechanisms underlying the adverse health effects of social conflict. The authors review studies indicating that social conflict exacerbates a virally initiated animal model of MS. This research suggests that the deleterious effects of social conflict may be partially mediated by stress-induced increases in pro-inflammatory cytokine levels in the central nervous system. In addition, they provide evidence that the adverse health effects of social conflict can be prevented by blocking the stress-induced increases in cytokine activity. This suggests that interventions designed to prevent or reverse the stress-induced increases in cytokine activity may be able to prevent or reverse some of the negative health effects of social conflict in humans.

Differential release of mast cell mediators and the pathogenesis of inflammation

Mast cells are well known for their involvement in allergic and anaphylactic reactions, during which immunoglobulin E (IgE) receptor (Fc epsilon RI) aggregation leads to exocytosis of the content of secretory granules (1000 nm), commonly known as degranulation, and secretion of multiple mediators. Recent findings implicate mast cells also in inflammatory diseases, such as multiple sclerosis, where mast cells appear to be intact by light microscopy. Mast cells can be activated by bacterial or viral antigens, cytokines, growth factors, and hormones, leading to differential release of distinct mediators without degranulation. This process appears to involve de novo synthesis of mediators, such as interleukin-6 and vascular endothelial growth factor, with release through secretory vesicles (50 nm), similar to those in synaptic transmission. Moreover, the signal transduction steps necessary for this process appear to be largely distinct from those known in Fc epsilon RI-dependent degranulation. How these differential mast cell responses are controlled is still unresolved. No clinically available pharmacological agents can inhibit either degranulation or mast cell mediator release. Understanding this process could help develop mast cell inhibitors of selective mediator release with novel therapeutic applications.

Multiple sclerosis patients talking with healthcare providers about emotions

The purpose of this study was to consider multiple sclerosis (MS) patients' experiences of talking with healthcare professionals about emotions and their emotional well-being both at the time of diagnosis and while they are living with the illness. Relationships between talking about emotions and positive outcomes were examined. The 145 respondents completed a paper-and-pencil survey, an Internet survey, or a telephone interview. Forty-four percent of respondents indicated that a healthcare provider had discussed their emotional well-being at the time of their diagnosis. Fifty-six percent of respondents reported that their healthcare professional had talked with them about their fears, sadness, and anger related to living with their illness. For those respondents who wanted to talk with their healthcare professional, doing so appeared to be associated with several positive outcomes. The small number (N = 22) of respondents who did not want to talk with a healthcare professional about emotions were also doing well on several measures. Nurses can help MS patients deal with their uncertainty and emotional challenges by being willing to inquire about emotions and emotional well-being.

Stress and multiple sclerosis

Increasing numbers of studies are reporting an association between stressful life events and exacerbation in multiple sclerosis. We review findings that begin to suggest psychological, social and biological factors that may be involved in this relationship. Depression, negative attributions, poor coping, and low social support have been implicated as aggravating the relationship between stress and exacerbation. A model of glucocorticoid resistance on immune cells is also presented as one potential biological mechanism. It is emphasized that to date there is no evidence of causal relationships. It is argued that a purely causal relationship, in which stressful events alone trigger exacerbation, is unlikely. Rather, we propose that stress may be one factor among many that influence risk of exacerbation.

The natural history of relapses in multiple sclerosis

Relapses are a defining feature of multiple sclerosis (MS), serving as the basis for categorizing the different phases of the disease, and providing a means of measuring treatment success, following disease activity, and defining prognostic features. While the dissociation between relapses and disease progression indicates the boundaries of relapse history in determining disease course over time, it also highlights the importance of relapses to overall disease evolution. A broad understanding of relapse definition and dynamics is important to promote accurate diagnosis, patient management, and treatment decisions. In an attempt to describe the underlying etiology and clinical impact of relapses in MS, this review will examine relapse findings from natural history studies, the utility of relapse as a predictor of disease course, the factors that may contribute to relapse, and data on relapse resolution. The relationship of clinical relapses to MRI disease activity and to the onset of progressive disease will also be addressed.

Stress regulation in multiple sclerosis: current issues and concepts

Since its first description by Charcot, psychological stress has been considered a triggering factor for exacerbations in multiple sclerosis, but until recently the clinical evidence for a causal relation was weak. Over the past years, a growing number of studies have started to elucidate this association and highlight potential mechanisms, including brain-immune communication. On 5 June 2005, a panel of international researchers discussed the current evidence. This article summarizes the observational, animal experimental, as well as human experimental findings on stress regulation in MS, as well as studies on the functioning of the major stress response systems, ie, the hypothalamo-pituitary-adrenal (HPA) axis and the autonomous nervous system (ANS) in MS. Consensus statements from the group to these aspects are given. Research objectives and strategies are delineated, as well as clinical implications.

Multiple sclerosis and behavior

Multiple sclerosis (MS) is one of the most frequently seen neurological causes of progressive disability in early to middle adulthood. The disease is variable in its presentation and course, affects roughly 100-300 per 100,000 persons within the United States alone, and is slightly more common among females than males. MS places substantial burdens on patients, families, and caregivers. It negatively affects cognitive abilities and psychiatric functioning, and can add a notably deleterious effect on a patient's quality of life. This chapter reviews the recent literature on the behavioral manifestations of MS. Cognitive domains discussed include executive functioning, processing speed, attention, learning and memory, language functioning, and visual spatial processing. Some attention will also be paid to differential diagnosis and the cognitive effects of treatment. Psychiatric manifestations are also discussed, including symptoms of depression, bipolar disorder, euphoria, pathological laughter and crying, and psychosis, as well as maladaptive personality traits. Finally, the chapter concludes with a discussion of the effects of MS on quality of life including such areas as fatigue, sexual dysfunction, pain, employment, and cognitive functioning.

Multiple Sklerose — eine neuroimmunendokrine Erkrankung

Die Multiple Sklerose (MS) ist eine chronische, entzündlich-demyelinisierende Erkrankung des Zentralnervensystems (ZNS), betrifft also Gehirn und Rückenmark, wobei heute eine autoimmune Ätiologie allgemein angenommen wird. Sie ist die häufigste Entmarkungserkrankung des ZNS in Nordeuropa und Nordamerika (Prävalenz 1:1000) und die häufigste chronisch-neurologische Erkrankung, die bei jungen Erwachsenen zu bleibender Behinderung führt.

Neuropsychiatric manifestations of depression in multiple sclerosis: neuroinflammatory, neuroendocrine, and neurotrophic mechanisms in the pathogenesis of immune-mediated depression

Evidence suggests that depression in multiple sclerosis (MS) is largely biologically mediated by some of the same processes involved in the immunopathogenesis of this neurologic disease. In particular, the increase in proinflammatory cytokines, activation of the hypothalamic-pituitary-adrenal (HPA) axis, and reduction in neurotrophic factors that occur in MS may each account for the increased rate of depression seen in MS. The possible contributions of these neuroinflammatory, neuroendocrine, and neurotrophic mechanisms suggest a diverse array of novel treatment strategies for depression, both in the context of inflammatory conditions as well as in idiopathic depression. Furthermore, if such processes in MS play a causative role in the pathogenesis of depression, and depression in turn has affects on neurophysiological processes related to immune function, then treatment of depression might have a positive effect on MS disease progression. This makes treating MS depression a neuropsychiatric imperative.

[Psychological stress, immune function and disease development. The psychoneuroimmunologic perspective]

Interdisciplinary psychoneuroimmunological (PNI) research increasingly demonstrates clinically relevant interrelations between psychological stressors and the onset or progression of chronic diseases. Disturbances of the bi-directional interaction between the nervous system, the immune system and the endocrine system have been hypothesized to be implicated in several diseases. Here, we review evidence from psychoneuroimmunology within the theoretical framework of allostatic load to conceptualize some of these associations. Interdisciplinary PNI research investigating the importance of psychological stress for the higher incidence of infections, decreased responses to vaccinations and delayed wound healing is reviewed. Furthermore, the literature supporting similar associations with regard to progression of oncological diseases and autoimmune disorders is reviewed with a focus on breast cancer and multiple sclerosis. The accumulating evidence regarding the importance of neuroendocrine-immune interaction in these diseases may thus lead to novel insights into pathogenetic mechanisms and could contribute to the development of novel preventive and therapeutic strategies.

Relationship between stress and relapse in multiple sclerosis: Part II. Direct and indirect relationships

OBJECTIVE

The aim of this two-year prospective study was to determine which factors were: (i) directly related and/or (ii) indirectly related to multiple sclerosis (MS) relapse. These factors included life-event stressors, disease, demographic, psychosocial and lifestyle factors.

BACKGROUND

Relatively little attention has been paid to the role of non-clinical relapse predictors (other than stressful life-events) in MS, or factors that indirectly impact on the stress-relapse relationship.

METHODS

A total of 101 consecutive participants with MS were recruited from two MS clinics in Sydney, Australia. Stressful life-events, depression, anxiety and fatigue were assessed at study-entry and at three-monthly intervals for two years. Disease, demographic, psychosocial and lifestyle factors were assessed at baseline. Patient-reported relapses were recorded and corroborated by neurologists or evaluated against accepted relapse criteria.

RESULTS

MS relapse was predicted by acute stressor frequency counts, coping responses that utilized social support, and being born in Australia, but not by chronic stressors, disease, demographic, psychosocial or lifestyle factors. No factors were found to indirectly impact on the stress relapse relationship.

CONCLUSIONS

The number rather than severity of stressors was most important in relation to MS relapse risk, along with coping responses that utilized social support, suggesting that MS patients should avoid situations that are likely to generate multiple stressors or which provide few avenues for social support.

Negative life events and quality of life in adults with asthma

BACKGROUND

The relationship between stress and quality of life in adults with asthma has not been well studied. Stress, quantified by negative life events, may be linked to quality of life in asthma through multiple pathways, including increase in disease severity and adverse effects on socioeconomic status (SES).

METHODS

The responses to a self-completed questionnaire assessing negative life events (NLEs) in the previous 12 months (from a 24-item checklist) among 189 adults with asthma from a well-characterised cohort were analysed. The relationship between the number of NLEs reported and asthma-specific quality of life (AQOL) was measured with the Marks instrument. General linear modelling was used to test the conjoint effects of NLEs, SES and disease severity based on the Severity of Asthma Score, a validated acute and chronic disease measure.

RESULTS

Those with annual family incomes < 60,000 dollars reported significantly more NLEs than those with higher incomes (p = 0.03). The number of NLEs did not differ significantly between those with forced expiratory volume in 1 s <80% predicted and those with >80% predicted, nor among those with lower compared with higher Severity of Asthma Score. The frequency of NLEs was associated with poorer (higher numerical score) AQOL (p = 0.002). When studied together in the same model, combinations of income level and asthma severity (greater or lesser Severity of Asthma Score; p < 0.001) and number of NLEs (p = 0.03) were both significantly associated with AQOL.

CONCLUSION

NLEs are associated with quality of life among adults with asthma, especially among those of lower SES. Clinicians should be aware of this relationship, especially in vulnerable patient subsets.

Restraint stress decreases virus-induced pro-inflammatory cytokine mRNA expression during acute Theiler's virus infection

Stressful life events have been associated with the onset and/or exacerbation of multiple sclerosis (MS). Our previous studies have indicated that restraint stress (RS) reduces inflammation and virus-induced chemokine expression in the Theiler's virus-induced demyelination (TVID) model of MS. Here we report that RS significantly reduced the virus-induced interferon-gamma mRNA levels in the brain. Additionally, mRNA levels of lymphotoxin-beta, tumor necrosis factor-alpha, and interferon-gamma in the brain were negatively correlated with viral titers in the brain. These results indicated an immunosuppressive effect of stress during early TVID causing impaired viral clearance, which may be a potential exacerbating factor for later demyelination.

Acute psychological stress alerts the adaptive immune response: Stress-induced mobilization of effector T cells

Influences of psychological stress on the acquired immune system have not consequently been investigated. We found acute psychological stress to cause an increase in CD56+ and CCR5+ effector T cells in the peripheral blood of healthy human subjects (N=22), while skin-homing CLA+ T cells decreased. At the same time, we observed a stress-induced decrease in CD45RA+/CCR7+ naive and CD45RA-/CCR7+ central memory T cells, while CD45RA-/CCR7- effector memory and CD45RA+/CCR7- terminally differentiated T cells increased. This T cell redistribution translated into an increase in T cells expressing perforin/granzyme B and in Epstein-Barr virus-specific, cytomegalovirus-specific and influenza virus-specific CD8+ T cells. Thus, acute stress seems to promote the retention of less mature T cells within lymphoid tissue or skin while effector-type T cells are mobilized into the blood in order to be able to rapidly migrate into peripheral tissues.

Frequency of current utilisation of complementary and alternative medicine by patients with multiple sclerosis

OBJECTIVE

The purpose of the study was to examine the frequency and characteristics of complementary and alternative medicine (CAM) use among patients with multiple sclerosis (MS).

METHOD

In order to collect sociodemographic and disease related variables as well as aspects of CAM utilisation 254 MS patients were examined with an interview. The investigation was completed by data of the neurological examination.

RESULTS

At the time of investigation 67.3% of the MS patients reported that they were currently using one or more CAMs. Overall, most of the overall utilized therapies (90.6%) were chosen as a complement and 9.4% as an alternative therapy. Users of complementary medicine were more severely affected by the MS than non-users and had a longer duration of illness. No sociodemographic differences were found between users and non-users. When evaluating the efficacy of CAM, patients reported improvement in 67.1%, no influence in 32.3% and worsening in 0.6% of the cases. 3.7% of the CAM therapies were accompanied by minor side effects.

CONCLUSIONS

Since MS patients are frequently using CAM despite the absence of clinically proven efficacy and appraise it positively, further research on the motivation for utilisation and on objective effects of CAM are needed.

Sex-dependent effects of chronic restraint stress during early Theiler's virus infection on the subsequent demyelinating disease in CBA mice

Chronic restraint stress, administered during early infection with Theiler's virus, was found to exacerbate the acute CNS viral infection in male and female mice. During the subsequent demyelinating phase of disease (a model of multiple sclerosis), the effect of stress on disease progression was sex-dependent. Previously stressed male mice had less severe behavioral signs of the chronic phase, better rotarod performance and decreased inflammatory lesions of the spinal cord, while the opposite pattern was observed in females. In addition, mice in all groups developed autoantibodies to MBP, PLP139-151 and MOG33-55.

A pilot, open label, clinical trial using hydroxyzine in multiple sclerosis

Multiple sclerosis (MS) is an autoimmune disorder of myelin destruction. Blood-brain-barrier (BBB) disruption precedes pathological or clinical findings and could involve mediators from perivascular brain mast cells, such as histamine and vascular endothelial growth factor (VEGF). Mast cells could be activated by many triggers, including acute stress that has been correlated with MS exacerbations. We considered that the histamine-1 (H1) receptor antagonist hydroxyzine, which also partially inhibits brain mast cells and has anxiolytic properties, may reduce MS symptoms. This open label, pilot, clinical trial investigated the effect on MS of an oral solution of hydroxyzine (100 mg per day), together with caffeine (200 mg per day) to reduce sedation. Twenty patients (8 males; 12 females) with relapsing-remitting or relapsing-progressive MS completed the study (12 +/- 1 months) and were evaluated using disability scales. Most patients on hydroxyzine (75%) remained stable or improved neurologically and all but one showed improved mood. Hydroxyzine could be used as an adjuvant in MS, but the small number of patients enrolled and the short duration of the study precludes any definitive conclusions. A double-blind, placebo-controlled study is warranted.

Recent trends in behavioral medicine

PURPOSE OF REVIEW

Behavioral medicine is an interdisciplinary field, integrating research from a variety of disciplines. This review focuses on recent advances and developments in behavioral medicine.

RECENT FINDINGS

Stress, as well as having a role in the etiology and maintenance of somatic disease and somatoform disorders, is an important factor in the behavioral medicine literature. Consequentially, recent advances in psychological interventions targeting these conditions were developed. Furthermore, a variety of psychobiological mechanistic studies investigating the dysregulations of stress axes in conditions relevant to behavioral medicine have been undertaken.

SUMMARY

Studies investigating factors and processes relevant to health and illness clearly demonstrate the impact of psychosocial factors such as stress. The biopsychosocial perspective becomes increasingly sophisticated, focusing on specific disease processes and empirically tested and effective interventions.

A temporal framework for understanding the effects of stressful life events on inflammation in patients with multiple sclerosis

A growing literature reports that stressful life events are associated with exacerbation and the subsequent development of brain lesions in patients with multiple sclerosis (MS). The evolution an MS exacerbation occurs over a period of many months and involves many different biological processes that change over time. Likewise, the experience of stress also occurs over time, with an onset, a shift from acute to chronic in some cases, and resolution. Each of these phases is associated with unique biological features. Thus, the impact of stress on MS exacerbation may depend on the temporal trajectories of stress and MS exacerbation, and when the intersection between these two trajectories occurs. This paper presents a temporal model, along with three different temporal relationships and associated mechanisms by which stress may impact MS exacerbation. These include the onset of a stressor, which may be mediated by mast cell activation, the point that a stressor begins to become chronic, which may be mediated by glucocorticoid resistance in immune cells, and the resolution of the stressor, which may be mediated by a drop in cortisol. These three hypotheses are not necessarily mutually exclusive. Data on psychosocial mediators and moderators are also briefly reviewed and future research directions are discussed.

FTY720 in multiple sclerosis: the emerging evidence of its therapeutic value

INTRODUCTION

Multiple sclerosis is a demyelinating disease of the central nervous system which can cause severe disability and has profound effects on patients' quality of life over several decades. Although there is no cure for the disease, recently developed disease-modifying agents have modest effects on the impact of disease progression. There is therefore a need for a new, effective, and well-tolerated treatment for multiple sclerosis and FTY720 (an orally administered immunomodulatory compound with a novel mechanism of action) is one of a number of agents being evaluated for the treatment of this disease.

AIMS

The objective of this article is to assess the therapeutic potential for FTY720, now in phase II clinical trials, for the treatment of multiple sclerosis through a review of the published evidence.

EMERGING EVIDENCE

There is good evidence that FTY720 achieves immunomodulation as shown by a reversible redistribution of peripheral blood lymphocytes after oral administration. Two meeting abstracts have been published showing results obtained with FTY720 in a 12-month phase II clinical trial in patients with active relapsing multiple sclerosis. There is modest evidence that FTY720 significantly improves both patient-oriented (relapse rate) and disease-oriented outcomes (inflammatory disease activity). There is good evidence that FTY720 is well tolerated.

PROFILE

Based on these early results from the clinical development program, FTY720 has the potential to be an effective disease-modifying agent for the treatment of multiple sclerosis. Further results from ongoing multinational phase III studies are awaited.

Stress and disease progression in multiple sclerosis and its animal models

Since the first description of multiple sclerosis (MS) by Charcot, stress has been hypothesized to be a potential trigger of relapses. In recent years, data from observational studies in MS patients have provided some support for an association between stress and MS relapses. Furthermore, studies employing the MS animal model experimental autoimmune encephalomyelitis have shown that certain stressors can exacerbate the disease if administered prior to disease induction. Several lines of research have explored the 2 major stress response systems--the hypothalamic-pituitary-adrenal axis and the autonomic nervous system--and their relation to disease course in MS and experimental autoimmune encephalomyelitis. These studies provide evidence that insensitivity of the immune system to signals from these systems may play a role in inflammatory events. These findings can be integrated into a biological model of stress response system alterations in MS.

Neuroimmunoendocrine circuitry of the ‘brain-skin connection’

The skin offers an ideally suited, clinically relevant model for studying the crossroads between peripheral and systemic responses to stress. A 'brain-skin connection' with local neuroimmunoendocrine circuitry underlies the pathogenesis of allergic and inflammatory skin diseases, triggered or aggravated by stress. In stressed mice, corticotropin-releasing hormone, nerve growth factor, neurotensin, substance P and mast cells are recruited hierarchically to induce neurogenic skin inflammation, which inhibits hair growth. The hair follicle is both a target and a source for immunomodulatory stress mediators, and has an equivalent of the hypothalamus-pituitary-adrenal axis. Thus, the skin and its appendages enable the study of complex neuroimmunoendocrine responses that peripheral tissues launch upon stress exposure, as a basis for identifying new targets for therapeutic stress intervention.

The role of stress-response systems for the pathogenesis and progression of MS

Disease progression in multiple sclerosis (MS)--an inflammatory demyelinating and neurodegenerative disease with a presumed T-cell driven autoimmune origin--has long been hypothesized to be associated with stress. However, this notion has only recently been supported by prospective clinical studies. Several clinical and molecular studies in MS and its animal models have recently shown disruptions in the communication between the immune system and the two major stress response systems, the hypothalamo-pituitary-adrenal (HPA) axis and the autonomic nervous system. Insensitivity to glucocorticoid and beta-adrenergic modulation might be involved in overshooting inflammation in MS, whereas hyperactivity of the HPA axis has been linked to neurodegeneration and increased disability. Here, we integrate findings from molecular, cellular, experimental, clinical and epidemiological research to describe the involvement of stress response systems in MS pathogenesis and progression.

Unkind cytokines: current evidence for the potential role of cytokines in immune-mediated depression

A great deal of interest has recently become focused on interactions between the nervous and the immune systems, including the potential for alterations in immune function to contribute to various psychiatric and neurologic disorders. Evidence suggests that cytokines may be involved in the development of depression. Immune-mediated mechanisms in the pathophysiology of some types of depression are reviewed from both clinical and animal studies and the difficulties inherent in studying the interplay of these two complex systems in the development of depression are described.

Multiple sclerosis: diagnosis and the management of acute relapses

Multiple sclerosis is an inflammatory demyelinating disease of the central nervous system that may result in a wide range of neurological symptoms and accumulating disability. Its course is unpredictable resulting in a changing pattern of clinical need. Diagnostic criteria for multiple sclerosis require objective evidence for dissemination in space and time. The diagnostic and management process should follow good practice guidelines with the person at the centre of the process. Appropriate support and information should be available from the time of diagnosis. Continuing education is key in enabling the person to actively participate in their management. In the event of an acute relapse the person should have direct access to the most appropriate local service. Provided medical causes have been excluded, corticosteroid treatment to hasten the recovery from the relapse should be considered. Management of an acute relapse should be comprehensive addressing any medical, functional, or psychosocial sequelae.