Social cognition according to cognitive impairment in different clinical phenotypes of multiple sclerosis

The neural substrates of social cognition deficits in newly diagnosed multiple sclerosis patients

OBJECTIVE

Cognitive and affective symptoms in multiple sclerosis (MS) can be independently impaired and have different pathways of progression. Cognitive alterations have been described since the earliest MS stages; by contrast, the social cognition (SC) domain has never been investigated in the first year from MS diagnosis. We aimed to evaluate SC and unravel its neural bases in newly diagnosed MS patients.

METHODS

Seventy MS patients underwent at diagnosis a 3 T-MRI and a neuropsychological/SC assessment (median time between diagnosis and MRI/cognitive evaluation = 0 months). We tested two matched reference samples: 31 relapsing-remitting MS patients with longer course (mean ± SD disease duration = 7.0 ± 4.5 years) and 38 healthy controls (HCs). Cortical thicknesses (CTh) and volumes of brain regions were calculated.

RESULTS

Newly diagnosed MS patients performed significantly lower than HCs in facial emotion recognition (global: p < 0.001; happiness: p = 0.041, anger: p = 0.007; fear: p < 0.001; disgust: p = 0.004) and theory of mind (p = 0.005), while no difference was found between newly diagnosed and longer MS patients. Compared to lower performers, higher performers in facial emotion recognition showed greater volume of amygdala (p = 0.032) and caudate (p = 0.036); higher performers in theory of mind showed greater CTh in lingual gyrus (p = 0.006), cuneus (p = 0.024), isthmus cingulate (p = 0.038), greater volumes of putamen (p = 0.016), pallidum (p = 0.029), and amygdala (p = 0.032); patients with higher empathy showed lower cuneus CTh (p = 0.042) and putamen volume (p = 0.007).

INTERPRETATIONS

SC deficits are present in MS patients since the time of diagnosis and remain persistent along the disease course. Specific basal, limbic, and occipital areas play a significant role in the pathogenesis of these alterations.

Mentalizing self mind but not others: Self-reported mentalization difficulties in multiple sclerosis

BACKGROUND

Mentalization can be defined as a mental process by which an individual directly or indirectly perceives and interprets one's own and others' behavior, emotions, beliefs, and needs based on designed mental states. Mentalization problems may be linked to remove associative white matter fiber disconnection. Multiple sclerosis (MS) is one of the diseases with white matter lesions. By comparing MS patients with healthy controls, it was aimed to assess whether MS patients' mentalization skills are affected.

METHOD

This study involved 243 participants (170 healthy controls and 73 patients with MS). All the participants completed a sociodemographic questionnaire and the Mentalization Scale (MentS).

RESULTS

While it was discovered that MentS scores for the dimension of others-based mentalization (MentS-O) were statistically lower in MS group, there was no statistically significant difference between the groups in terms of the dimensions of motivation to mentalize (MentS-M) and self-based mentalization (MentS-S) scores.

CONCLUSION

We may conclude that MS patients have trouble comprehending other people's thoughts. This effect can be one of the causes of MS patients' issues with social cognition.

Investigating the relationship of theory of mind and empathy with neuroimaging, neuropsychological, and neuropsychiatric data in persons with multiple sclerosis

Theory of Mind (ToM) is understanding others' minds. Empathy is an insight into emotions and feelings of others. Persons with multiple sclerosis (pwMS) may experience impairment in ToM and empathy. To investigate ToM, empathy, and their relationship with neuroimaging, neuropsychological, and neuropsychiatric data. 41 pwMS and 41 HC were assessed using RMET for ToM, EQ, BICAMS, HADS. Cortical and subcortical gray matter volumes were calculated with Freesurfer from 3T MRI scans. pwMS showed lower EQ scores (44.82 ± 11.9 vs 51.29 ± 9.18, p = 0.02) and worse RMET performance (22.37 ± 4.09 vs 24,47 ± 2.93, p = 0.011). Anxiety and depression were higher in pwMS. EQ correlated with subcortical (amygdala) and cortical (anterior cingulate) volumes. RMET correlated with cortical volumes (posterior cingulate, lingual). In regression analysis, amygdala volume was the single predictor of empathy performance (p = 0.041). There were no significant correlations between social cognitive tests and general cognition. A weak negative correlation was found between EQ and the level of anxiety (r = -0.342, p = 0.038) The present study indicates that pwMS have impairment on ToM and empathy. The performance of ToM and empathy in MS is linked to the volumes of critical brain areas involved in social cognition.

Is impairment of facial emotion recognition independent of cognitive dysfunction in multiple sclerosis?

BACKGROUND

Emotions expressed on the face play a key role in social cognition and communication by providing inner emotional experiences. This study aimed to evaluate facial emotion identification and discrimination and empathy abilities in patients with MS and whether it is related to cognitive dysfunction.

METHODS

One hundred twenty patients with relapsing-remitting MS and age- and sex-matched 120 healthy controls were enrolled in the study. All the subjects were evaluated with the Facial Emotion Identification Test (FEIT), Facial Emotion Discrimination Test (FEIDT), and Empathy Quotient (EQ). We used the Beck Depression Inventory (BDI) for depression and detailed cognitive tests, including the Montreal Cognitive Assessment (MoCA), the Symbol Digit Modalities Test (SDMT), and the Paced Auditory Serial Addition Test (PASAT). The quality of life was assessed with Multiple Sclerosis Quality of Life-54 (MSQL-54).

RESULTS

Patients with MS were 37.6 ± 9.5 years old, had a mean disease duration of 8.8 ± 6.6 (8-28) years, and a mean EDSS score of 1.6 ± 1.3 (0-4.5). We found significant differences in the identification of facial emotions, discrimination of facial emotions, and empathy in MS patients compared to controls (p < 0.05). Especially the recognition of feelings of sadness, fear, and shame was significantly lower in MS patients. The multivariate logistic regression analysis showed low SDMT and FEIDT scores which showed an independent association with MS.

CONCLUSIONS

Our findings indicate that facial emotion recognition and identification deficits are remarkable among patients with MS and emotion recognition is impaired together with and independently of cognitive dysfunction in MS patients.

Assessing social cognition in patients with schizophrenia and healthy controls using the reading the mind in the eyes test (RMET): a systematic review and meta-regression

The reading the mind in the eyes test (RMET) - which assesses the theory of mind component of social cognition - is often used to compare social cognition between patients with schizophrenia and healthy controls. There is, however, no systematic review integrating the results of these studies. We identified 198 studies published before July 2020 that administered RMET to patients with schizophrenia or healthy controls from three English-language and two Chinese-language databases. These studies included 41 separate samples of patients with schizophrenia (total n = 1836) and 197 separate samples of healthy controls (total n = 23 675). The pooled RMET score was 19.76 (95% CI 18.91-20.60) in patients and 25.53 (95% CI 25.19-25.87) in controls (z = 12.41, p < 0.001). After excluding small-sample outlier studies, this difference in RMET performance was greater in studies using non-English v. English versions of RMET (Chi [Q] = 8.54, p < 0.001). Meta-regression analyses found a negative association of age with RMET score and a positive association of years of schooling with RMET score in both patients and controls. A secondary meta-analysis using a spline construction of 180 healthy control samples identified a non-monotonic relationship between age and RMET score - RMET scores increased with age before 31 and decreased with age after 31. These results indicate that patients with schizophrenia have substantial deficits in theory of mind compared with healthy controls, supporting the construct validity of RMET as a measure of social cognition. The different results for English versus non-English versions of RMET and the non-monotonic relationship between age and RMET score highlight the importance of the language of administration of RMET and the possibility that the relationship of aging with theory of mind is different from the relationship of aging with other types of cognitive functioning.

Theory of mind, emotion recognition and emotional reactivity factors in early multiple sclerosis: Results from a South American cohort

OBJECTIVES

To study different components of social cognition and quality of life in patients with early multiple sclerosis and low Expanded Disability Status Scale and to test the influence of cognitive performance, fatigue and neuropsychiatric symptoms on social cognition performance.

METHODS

Thirty-four patients with relapsing-remitting MS, with ≤2 years of disease duration and scores ≤2 on the EDSS and 30 healthy controls underwent neuropsychological assessment with the Brief Repeatable Neuropsychological Test Battery. Components of social cognition, such as emotion recognition, theory of mind, empathy, and emotional reactivity, were assessed with the Reading the Mind in the Eyes test, the Faux Pas task, the International Affective Imagery System, and the Empathy Quotient. Anxiety, depression, fatigue and quality of life were measured.

RESULTS

Patients showed significant differences in verbal memory, executive functions and social cognition, especially emotion recognition and ToM. Regarding emotional reactivity, patients showed a positive bias in the interpretation of the valence of neutral images.

CONCLUSIONS

Patients with early MS showed impairments in several components of social cognition independent of cognitive performance, neuropsychiatric symptoms and fatigue. Social cognition deficits may be present in MS even in the early stages.

Relationship between emotion recognition and cognition in multiple sclerosis: a meta-analysis protocol

Introduction

Multiple sclerosis (MS) is a chronic inflammatory and neurodegenerative disease of the central nervous system characterised by a broad and unpredictable range of symptoms, including cognitive and socio-cognitive dysfunction. Alongside the well-known deficits in information processing speed (IPS), executive functioning and episodic memory, recent evidence also highlighted socio-cognitive impairments in MS, such as emotion-recognition deficits. Recently, several studies investigated the association between emotion-recognition and cognitive impairment to assess whether social cognition is parallel to (or even dependent on) general cognitive dysfunction. Yet, there have been inconsistent findings, raising the need for a meta-analysis of the literature.

Objectives

The aim of the present paper is to outline the protocol for an upcoming meta-analysis we designed to clarify these conclusions.

Methods and analysis

We plan to estimate combined effect sizes for the association between emotion-recognition and cognitive impairment in MS across three cognitive domains (IPS, executive functions and episodic memory) and 7 emotion scores of interests (total and by 6-basic emotions subscores). Further, we plan to investigate whether identified variables are the cause for heterogeneity in any combined association. To that end, we will conduct additional meta-regression analyses to explore whether overall correlations differ according to clinical characteristics of MS patients (ie, disease duration, MS-phenotype, severity of depression and disability). Ultimately, this study will provide support either for an association of these disorders (in which emotion-recognition deficits might result from more fundamental cognitive dysfunction), or for two distinct sets of symptoms which may occur independently, for targeted patient profiles.

[Alexithymia in Multiple Sclerosis - Narrative Review]

Alexithymia is a multidimensional construct of personality implicating difficulties in identifying and describing another's feelings, and externally oriented thinking. It is broadly reported in psychiatric patients but has gained little attention regarding its occurrence and pathophysiology in multiple sclerosis (MS). This narrative review aims to address prevalence, etiology, neurobiological, and clinical findings of alexithymia. The prevalence of alexithymia in MS ranges from 10 to 53%. There seems to be an association with anxiety, depression, fatigue, and some aspects of social cognition, while the relationship with clinical and classical cognitive variables was rarely evaluated. Only a few studies referred to its pathophysiology assuming an aberrant interhemispheric transfer or regional cerebral abnormalities. The prevalence of alexithymia in MS and the potential negative impact on quality of life and interpersonal communication could severely impact clinical MS management and a screnning for these factors should be mandatory. Thus, further evaluation is needed concerning its relationship with clinical, emotional, and cognitive confounders. Large-scale studies employing neuroimaging techniques are needed for a better understanding of the neural underpinnings of this MS feature.

A 20-Year Systematic Review of the 'Reading the Mind in the Eyes' Test across Neurodegenerative Conditions

Social cognition has a broad theoretical definition, which includes the ability to mentalise, i.e., recognise and infer mental states to explain and predict another's behaviour. There is growing recognition of the clinical, diagnostic, and prognostic value of assessing a person's ability to perform social cognitive tasks, particularly aspects of theory of mind, such as mentalising. One such measure of mentalising is the 'Reading the Mind in the Eyes' test (RMET). This systematic review and meta-analysis consider performance on the RMET, applied to people with neurodegenerative conditions in matched control studies, since its publication in 2001. Overall, this review includes 22 papers with data from N = 800 participants with neurodegenerative conditions: Alzheimer's disease, n = 31; Parkinson's disease, n = 221; Lewy body dementia, n = 33; motor neuron disease, n = 218; Huntington's disease n = 80; multiple sclerosis, n = 217; and N = 601 matched typical controls. Our meta-analyses show that deficits in mentalising, as measured by the RMET, are consistently reported across neurodegenerative conditions, with participants in both early and late disease stages being affected. Social cognition is an emerging field of cognitive neuroscience requiring specific and sensitive measurement across each subdomain. Adult-based meta-normative data feature, for which future groups or individuals could be compared against, and hypotheses relating to the source of these mentalising deficits are further discussed. This review was registered with PROSPERO (CRD42020182874).

Cognitive impairment in multiple sclerosis: "classic" knowledge and recent acquisitions

Multiple sclerosis (MS) is a central nervous system (CNS) disease characterized by inflammation, axonal demyelination, and neurodegeneration, which can have a strong impact on all aspects of the life of the patient. Multiple sclerosis causes motor, sensory, cerebellar, and autonomic dysfunctions, as well as cognitive and psychoemotional impairment. The most frequently compromised cognitive domains are complex attention/information processing, memory, executive and visuospatial functions. Recently, alterations have also been evidenced in complex cognitive functions, such as social cognition, moral judgment, and decision-making. Cognitive impairment is characterized by high variability and can affect work skills, social interactions, coping strategies and more generally the quality of life of patients and their families. With the use of sensitive and easy-to-administer test batteries, an increasingly accurate and early diagnosis is feasible: this allows to determine the effectiveness of possible preventive measures, to predict the future progression of the disease and to improve the quality of life of patients. There is currently limited evidence regarding the efficacy, on cognitive impairment, of disease-modifying therapies. The most promising approach, which has received strong empirical support, is cognitive rehabilitation.

Emotional Recognition and Its Relation to Cognition, Mood and Fatigue in Relapsing-Remitting and Secondary Progressive Multiple Sclerosis

(1) Background: Emotional recognition (ER), the ability to read into others' minds and recognize others' emotional states, is important in social environment adaptation. Recently it has been found that ER difficulties affect patients with multiple sclerosis (pMS) and relate to different gray matter atrophy patterns from secondary progressive (SP-pMS) and relapsing-remitting (RR-pMS). The aim of this study was to compare the performances of the two MS phenotypes on the Reading the Mind in the Eyes test (RMEt) and other cognitive, mood and fatigue measures. We also examined associations between performance on the RMEt and cognitive, mood and fatigue variables. (2) Methods: A total of 43 pMS (27RR-pMS/16SP-pMS) underwent a clinical assessment, the RMEt, the cognitive battery, and completed mood and fatigue questionnaires. Both groups' performances on the RMEt were then correlated with all these measures. (3) Results: the RMEt scores of RR-pMS were significantly correlated with the impairment degree in some cognitive scores. SP-pMS scores correlated mainly with fatigue, anxiety, anger and depression. (4) Conclusions: ER performances relate to cognitive aspects in RR-pMS, whereas mainly to mood outcomes in the SP-pMS group. We can hypothesize that deficits in ER are a further sign of disease progression. Our data support the different roles of cognitive and emotional deficits related to different disease courses and lesional correlates.

The relationship between alexithymia, reading the mind in the eyes and cognition in patients with multiple sclerosis

AIM

The purpose of this study was to determine the frequency of alexithymia, difficulty in recognizing one's own and others' emotions, to determine the ability to read the mind in the eyes that evaluates the emotions of others, and to assess the relationship between these parameters and demographic characteristics, cognition, anxiety and depression in people with multiple sclerosis (PwMS).

MATERIAL AND METHOD

Seventy patients presenting to the neurology clinic and diagnosed with MS and 70 healthy volunteers with similar demographic characteristics were included in the study. The California Verbal Learning Test II (CVLT II), Symbol Digit Modalities Test (SDMT), Revised Brief Visuospatial Memory Test (BVMT-R), and Trail-Making Test (TMT) were applied to determine all participants' cognitive status. All participants were also administered Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Toronto Alexithymia Scale-20 (TAS-20), Reading the Mind in the Eyes Test (RMET), Fatigue Impact Scale (FIS) and Short Form 36 Health Survey (SF-36) for quality of life.

RESULTS

Alexithymia levels were higher in the PwMS than in the control group, 24.2% of the PwMS and 4.2% of the control group being alexithymic. The PwMS group exhibited poorer performance on all cognitive tests and in BDI, BAI, FIS and SF-36 scale scores than the control group. No difference was determined between the groups' RMET scores. Depression and anxiety levels increased in line with alexithymia levels in the PwMS group, while RMET scores decreased. No association was determined between alexithymia levels and age, sex, duration of disease, degree of disability, cognition, or fatigue. RMET scores were not affected by age, sex, duration of disease, degree of disability, anxiety, or fatigue, but were lower among individuals with poor cognition and in depressive patients.

CONCLUSION

Neuropsychiatric symptoms have been the subject of considerable research in MS in recent years and these clinical characteristics in patients have begun being closely monitored. PwMS are capable of experiencing difficulty in identifying emotions in themselves and others, and their social lives can be affected. In addition, the fact that this exhibits an association with cognition based on RMET is particularly noteworthy.

The TRACK-MS Test Battery: A Very Brief Tool to Track Multiple Sclerosis-Related Cognitive Impairment

Tracking cognition in patients with multiple sclerosis (MS) is important for detection of disease progression but it is often not performed in routine settings due to time constraints. This exploratory cohort study aims to develop a very brief repeatable tracking tool with comparable test quality criteria to the current gold standard, the Brief International Cognitive Assessment for MS (BICAMS). The study included 88 participants (22 healthy controls, 66 MS patients) who were examined at baseline and at one-year follow-up. As a validity criterion for the six administered cognitive tests, we assessed the difference between MS patients and HC, and the correlation with MS-related disability. Combining the two tests with the highest validity-the Controlled Oral Word Association Test and Symbol Digit Modalities Test-yielded an administration time of 5 min. Comparing this new TRACK-MS test battery with the 15 min BICAMS indicated that TRACK-MS showed larger differences between MS patients and healthy controls, a higher correlation with MS-related disability, smaller practice effects, and a good test-retest reliability. We provide evidence that TRACK-MS, although faster to administer, showed at least comparable quality criteria as the BICAMS. As the study was exploratory, replication of these results is necessary.

Perspective taking deficits and their relationship with theory of mind abilities in patients with relapsing-remitting multiple sclerosis (RRMS)

Introduction and objectives: In recent years, research has reported that between 45% and 70% of patients with Multiple Sclerosis (MS) have cognitive deficits, the most prominent being those associated with the frontal lobe. Among these deficits, we can find Theory of Mind (ToM), which is the ability to infer feelings and thoughts of others. Although it has been suggested that ToM relies on more basic skills, such as perspective taking (PT), no studies have investigated this association in patients with MS. The aim of this study was to investigate PT abilities in patients with MS and to establish their relationship with ToM deficits. Material and methods: 36 patients with relapsing-remitting multiple sclerosis (RRMS) and 42 healthy controls matched by age, sex and educational level were evaluated. Both groups were tested to estimate premorbid and current intellectual capacity, PT, ToM (Reading the Mind in the Eyes Test -RMET- and Faux Pas) and complementary scales (fatigue, depression and disability). Results: Patients with RRMS presented significant differences from controls in both PT and ToM tests. The PT test showed positive correlation with RMET, one of our ToM tests. Conclusion: The results show that there is a relationship between ToM and PT abilities. Our findings are of clinical and academic relevance to both the assessment and interpretation as well as the rehabilitation of social deficits in MS.

Amygdala network reorganization mediates the theory of mind performances in multiple sclerosis

Theory of mind (ToM) seems to be affected in multiple sclerosis (MS). MRI studies suggested a role of the amygdala in social cognitive performances. Therefore, we explored the role of the amygdala network in ToM using a multimodal MRI approach. In MS, patients with impaired ToM showed contradictory dysexecutive neuropsychological profile. Therefore, we compared neural networks involved in ToM and executive functions (EFs). Twenty patients with relapsing-remitting MS and 15 matched healthy controls were selected. ToM (Faux Pas test and mind stories) and EFs were assessed within and outside the scanner. All subjects underwent a battery of neuropsychological tests. Multimodal MRI with structural (diffusion imaging) and functional (resting-state and task-based) sequences was used to analyze the role and connections of the amygdala in ToM functioning. Cognitive and ToM performances were similar between patients and controls. Resting-state data revealed decreased connectivity of the left amygdala with frontal areas in patients compared to controls (p < 0.0001). During the task-based functional MRI, patients demonstrated increased connectivity between the amygdala and several cerebellar and left temporal regions (all p < 0.05). The microstructural alterations between the left amygdala and left temporal regions were associated with increased functional connectivity within the same pathway (r = 0.74; p < 0.01). No overlap was observed between functional networks involved in ToM and EFs. Our study demonstrates more connectivity recruitment between the amygdala and cerebellar and temporal regions in MS patients to reach preserved ToM performance. Microstructural abnormalities have been related to this compensatory network. Finally, different networks were involved in EFs and ToM.

Resting-State Functional Brain Connectivity for Human Mentalizing: Biobehavioral Mechanisms of Theory of Mind in Multiple Sclerosis

Although neural hubs of mentalizing are acknowledged, the brain mechanisms underlying mentalizing deficit, characterizing different neurological conditions, are still a matter of debate. To investigate the neural underpinning of Theory of Mind (ToM) deficit in Multiple Sclerosis (MS), a region of interest (ROI)-based resting-state fMRI study was proposed. 37 MS patients (23 females, mean age=54.08±11.37 years, median Expanded Disability Status Scale=6.00) underwent an MRI and a neuro-psychosocial examination, and were compared with 20 sex-age-education matched healthy subjects. A neuroanatomical ToM model was constructed deriving 11 bilateral ROI, then between and within-functional connectivity (FC) were assessed to test for group differences. Correlation with psychosocial scores was also investigated. Lower ToM performance was registered for MS both in cognitive and affective ToM, significantly associated with processing speed. A disconnection between limbic-paralimbic network and prefrontal execution loops was observed. A trend of aberrant intrinsic connectivity in MS within the anterior cingulate cortex (ACC) was also reported. Finally, a correlation between cognitive ToM and intrinsic FC was detected in ACC and dorsal striatum, belonging to the limbic-paralimbic network, likely explaining the behavioral deficit in MS. The results suggest that aberrant intrinsic and extrinsic connectivity constitutes a crucial neural mechanism underlying ToM deficit in MS.

Relapsing-remitting and secondary-progressive multiple sclerosis patients differ in decoding others' emotions by their eyes

BACKGROUND AND PURPOSE

Difficulties in emotion processing and social cognition identified in multiple sclerosis (MS) patients have a potential impact on their adaptation to the social environment. We aimed to explore the neural correlates of emotion recognition in MS and possible differences between relapsing-remitting MS (RRMS) and secondary progressive MS (SPMS) patients by the Reading the Mind in the Eyes test (RMEt).

METHODS

A total of 43 MS patients (27 RRMS, 16 SPMS) and 25 matched healthy controls (HC) underwent clinical assessments, RMEt, and a high-resolution T1-weighted 3-T magnetic resonance imaging (MRI) scan. The number of correct answers on the RMEt was compared between groups. T1-weighted volumes were processed according to an optimized voxel-based morphometry (VBM) protocol to obtain gray matter (GM) maps. Voxelwise analyses were run to assess potential associations between RMEt performance and regional GM volumes.

RESULTS

Taken altogether, MS patients reported significantly lower performance on the RMEt compared to HC. When dividing the patients into those with RRMS and those with SPMS, only the latter group was found to perform significantly worse than HC on the RMEt. VBM analysis revealed significant association between RMEt scores and GM volumes in several cortical (temporoparieto-occipital cortex) and subcortical (hippocampus, parahippocampus, and basal ganglia) brain regions, and in the cerebellum in SPMS patients only.

CONCLUSIONS

Results suggest that, in addition to other clinical differences between RRMS and SPMS, the ability to recognize others' emotional states may be affected in SPMS more significantly than RRMS patients. This is supported by both behavioral and MRI data.

Theory of mind and its neuroanatomical correlates in people with multiple sclerosis

Background Theory of mind (ToM) is one of the several different concepts in social cognition and is defined as the ability to access the mental states of others or to adopt the point of view of others. Although studies have shown that ToM is impaired in people with multiple sclerosis (MS), the results based on individual ToM tasks are conflicting; some studies have shown deficits only in the 'Reading the Mind in the Eyes' Test (RMET), while others have reported poor performance in the Faux Pas Test (FPT) as well as RMET. Furthermore, little is known about the relationship between ToM performance and neuroanatomical characteristics in MS. This study investigated ToM impairment and its relationship to regional brain volume or cortical thickness in people with MS. Methods This cross-sectional study included 20 participants with relapse-onset MS and 27 age- and sex-matched volunteers as healthy controls (HC). All the participants underwent neuropsychological (NP) tests as well as ToM tasks, including RMET and FPT. Participants with MS underwent brain MRI within 6 months before and after undergoing the NP and ToM tests. Regional volume of subcortical structures or cortical thickness were analysed based on 3D T1-weighted images using FreeSurfer software. Results Both RMET and FPT scores were significantly lower in participants with MS than in HC (p = 0.0049, p = 0.0071, respectively). Imaging analyses showed that FPT scores, but not RMET scores, were positively correlated with the right thalamus (R² = 0.26, p = 0.012) and left pallidum (R² = 0.39, p = 0.0021) volumes after adjusting for age. Furthermore, surface-based morphometry revealed significant correlation between age-adjusted cortical thickness of ten cortical areas, including the fusiform gyrus, orbitofrontal cortex, temporal-parietal junction, and superior temporal gyrus, and FPT scores. Conclusions These study findings showed that both RMET and FPT performances are impaired in participants with MS. Furthermore, FPT deficits, but not RMET deficits, were significantly associated with the volume of two subcortical structures as well as the thickness of ten cortical areas, suggesting that FPT is an appropriate task to access ToM performance in MS.

Characterization of alexithymia in clinically isolated syndrome

BACKGROUND

In multiple sclerosis (MS), the prevalence of alexithymia, defined as an inability to identify and describe emotions, is close to 50% but the prevalence of this symptom in clinically isolated syndrome (CIS) is unknown. Characterizing alexithymia at an early stage of the disease can help to clarify psychobehavioural disturbances in CIS patients.

METHODS

Forty CIS patients, who fulfilled the MRI criteria for dissemination in space, were matched with 40 healthy subjects. They completed self-assessment scales for alexithymia, depression, anxiety, apathy and empathy. Cognitive functions were assessed using a battery of neuropsychological tests.

RESULTS

The mean delay (± standard deviation) between the occurrence of CIS and inclusion in the study was 3.9 (2.8) months. The frequency of alexithymia was higher in CIS patients than in controls, with a prevalence of 42% (P<0.0001). Alexithymia correlated with anxiety and depression but not with cognition. Alexithymia was dependent only on depression (P=0.003).

CONCLUSION

Alexithymia, characterized by difficulty identifying feelings, is present in patients in the early stage of MS, and seems to be strongly associated with depression. Difficulty in social interaction could be a risk of future affective disorders.

Social cognition and executive functioning in multiple sclerosis: A cluster-analytic approach

Multiple sclerosis (MS) is associated with deficits in social cognition, the process underlying social interaction and cognitive function. However, the relationships between executive impairment and social cognition remain unclear in MS. Previous studies exclusively focused on group comparisons between healthy controls and patients with MS, treating the latter as a homogeneous population. The variability of socio- and neurocognitive profiles in this pathology therefore remains underexplored. In the present study, we used a cluster analytic approach to explore the heterogeneity of executive and social cognition skills in MS. A total of 106 patients with MS were compared with 53 healthy matched controls on executive (e.g., working memory) and social cognition (facial emotion recognition and theory of mind) performances. A cluster analysis was then performed, focusing on the MS sample, to explore the presence of differential patterns of interaction between executive and social cognition difficulties and their links to sociodemographic, clinical and cognitive variables. We identified three distinct functional profiles: patients with no executive or social cognition deficits (Cluster 1); patients with difficulties in facial emotion recognition and theory of mind and, to a lesser extent, executive functioning (Cluster 2); and patients with executive functioning difficulties only (Cluster 3). Clinical characteristics (disease duration, disability, fatigue) did not differ between clusters. CONCLUSIONS: These results suggest that there are qualitative differences in the social cognition and executive difficulties that are commonly found among patients with MS. If replicated, the identification of these profiles in clinical practice could allow for more individualized rehabilitation.

Social cognition in multiple sclerosis and its subtypes: A meta-analysis

BACKGROUND

Multiple sclerosis (MS) is an immune-mediated demyelinating disease that disrupts several social cognitive abilities, including the theory of mind (ToM) and facial emotion recognition (FER). It is unclear how specific ToM subcomponents, including cognitive and affective ToM, are affected in patients with MS and the social cognitive abilities in MS subtypes.

METHODS

A search of PubMed, Web of Science, and Embase databases was conducted until June 2020. Effect sizes were calculated using Hedges g with a random-effects model.

RESULTS

A total of 45 studies were included. Relative to health controls (HCs), patients with MS and its subtypes (including relapsing-remitting MS [RRMS] and progressive MS) exhibited impairments in ToM (g = -0.77, g = -0.70, g = -0.75, respectively), cognitive ToM (g = -0.72, g = -0.83, g = -0.73, respectively), affective ToM (g = -0.84, g = -0.63, g = -0. 50, respectively), and FER (g = -0.62, g = -0.53, g = -1.07, respectively). In addition, there was no difference between progressive primary MS and secondary progressive MS in overall ToM, cognitive ToM, affective ToM, and FER. Compared to patients with RRMS, patients with progressive MS showed no difference in overall ToM, cognitive ToM, and affective ToM but had more serious defects in FER (g = -0.57).

CONCLUSIONS

These quantitative results indicate that patients with MS and its subtypes have a differential impairment of the core aspects of social cognitive processing (including ToM and FER), which may help develop the structured social cognitive interventions in MS.

Social Cognition in Multiple Sclerosis: A 3-Year Follow-Up MRI and Behavioral Study

Social cognition (SC) has become a topic of widespread interest in the last decade. SC deficits were described in multiple sclerosis (MS) patients, in association with amygdala lesions, even in those without formal cognitive impairment. In this 3-year follow-up study, we aimed at longitudinally investigating the evolution of SC deficits and amygdala damage in a group of cognitive-normal MS patients, and the association between SC and psychological well-being. After 3 years (T3) from the baseline examination (T0), 26 relapsing-remitting MS patients (RRMS) were retested with a neuropsychological battery and SC tasks (theory of mind, facial emotion recognition, empathy). A SC composite score (SCcomp) was calculated for each patient. Emotional state, fatigue, and quality of life (QoL) were also evaluated. RRMS patients at T3 underwent a 3T-MRI as performed at T0, from which were calculated both volume and cortical lesion volume (CLV) of the amygdalae. Compared to T0, at T3 all RRMS patients were still cognitive-normal and remained stable in their global SC impaired performance. At T0, SCcomp correlated with amygdala CLV (p = 0.002) while, at T3, was more associated with amygdala volume (p = 0.035) rather than amygdala CLV (p = 0.043). SCcomp change T3-T0 correlated with global emotional state (p = 0.043), depression (p = 0.046), anxiety (p = 0.034), fatigue (p = 0.025), and QoL-social functioning (p = 0.033). We showed the longitudinal stability of SC deficits in cognitive-normal RRMS patients, mirroring the amygdala structural damage and the psychological well-being. These results highlight that SC exerts a key role in MS.

Neurocognitive impairment and social cognition in multiple sclerosis

PURPOSE/AIM OF THE STUDY

The impairment of neurocognitive functions occurs in all subtypes of multiple sclerosis, even from the earliest stages of the disease. Commonly reported manifestations of cognitive impairment include deficits in attention, conceptual reasoning, processing efficiency, information processing speed, memory (episodic and working), verbal fluency (language), and executive functions. Multiple sclerosis patients also suffer from social cognition impairment, which affects their social functioning. The objective of the current paper is to assess the effect of neurocognitive impairment and its potential correlation with social cognition performance and impairment in multiple sclerosis patients.

MATERIALS AND METHODS

An overview of the available-to-date literature on neurocognitive impairment and social cognition performance in multiple sclerosis patients by disease subtype was performed.

RESULTS

It is not clear if social cognition impairment occurs independently or secondarily to neurocognitive impairment. There are associations of variable strengths between neurocognitive and social cognition deficits and their neural basis is increasingly investigated.

CONCLUSIONS

The prompt detection of neurocognitive predictors of social cognition impairment that may be applicable to all multiple sclerosis subtypes and intervention are crucial to prevent further neural and social cognition decline in multiple sclerosis patients.

Multiple sclerosis, emotion perception and social functioning

People with multiple sclerosis (MS) can experience problems in interpreting others' emotions from faces or voices. However, to date little is known about whether difficulties in emotion perception in MS are related to broader aspects of social functioning. Also, there are few studies reporting the effect of MS on more ecologically valid assessments of emotion perception using multimodal videos. The current study looks at (1) the effect of MS on perceiving emotions from faces, voices and multimodal videos; (2) the possible role of slowed processing and executive dysfunction in emotion perception problems in MS and (3) the relationship between emotion perception and broader social functioning in MS. 53 people with MS and 31 healthy controls completed tasks of emotion perception and cognition, and assessed their levels of social support and social participation. Participants with MS performed worse than demographically matched controls on all measures of emotion perception. Emotion perception performance was related to cognitive measures in those with MS. Also, significant associations were found between emotion perception difficulties in MS and poorer social function. In particular, people with MS who had poorer emotion perception also reported lower levels of social support from their friends, and regression analysis showed that this prediction was maintained even when disease severity and cognitive function were taken into account. These results show that problems with emotion perception in MS extend to more realistic tasks and may predict key aspects of social functioning.

Empathy and Theory of Mind in Multiple Sclerosis: A Meta-Analysis

Multiple sclerosis (MS) is an immune-mediated demyelinating disease of the central nervous system. Studies have shown that MS disrupts several social cognitive abilities [including empathy and theory of mind (ToM)]. Overall ToM deficits in MS are well documented, but how the specific ToM subcomponents and empathic capacity are affected remains unclear. For this meta-analysis, we searched PubMed, Web of Science, and Embase from inception to July 2020. Effect sizes were calculated using Hedges g with a random-effects model. Thirty-three studies were included. Relative to healthy controls (HCs), patients with MS were moderately impaired in overall empathy (g = -0.67), overall ToM (g = -74), cognitive ToM (g = -0.72), and the overlapping domains of cognitive empathy/affective ToM (g = -0.79); no group differences were identified for affective empathy (g = -0.19). Compared with HCs, patients with relapsing-remitting MS (RRMS) and progressive MS were impaired in overall empathy, overall ToM, cognitive ToM, and cognitive empathy/affective ToM, without significant RRMS-progressive MS differences in impairment degree. We conducted the first meta-analytic review investigating the empathy and ToM functioning patterns in patients with MS and examined the overlapping and distinct subcomponents of these constructs. The findings suggest differential impairment of the core aspects of social cognitive processing in patients with MS, which may importantly inform the development of structured social cognitive MS interventions.

State of the Art and Future Challenges in Multiple Sclerosis Research and Medical Management: An Insight into the 5th International Porto Congress of Multiple Sclerosis

The 5th International Porto Congress of Multiple Sclerosis took place between the 14th and 16th of February 2019 in Porto, Portugal. Its intensive programme covered a wide-range of themes-including many of the hot topics, challenges, pitfalls and yet unmet needs in the field of multiple sclerosis (MS)-led by a number of well-acknowledged world experts. This meeting review summarizes the talks that took place during the congress, which focussed on issues in MS as diverse as the development and challenges of progressive MS, epidemiology, differential diagnosis, medical management, molecular research and imaging tools.

A cross-sectional study of alexithymia in patients with relapse remitting form of multiple sclerosis

Background:

Alexithymia is one's incapacity to identify, comprehend, and describe emotions. There is almost no literature data about the levels of alexithymia among patients with relapse remitting type of multiple sclerosis.

Aim:

The objective of the present study was to assess the levels of alexithymia in patients with relapse remitting type of multiple sclerosis in relation to their sociodemographic variables and clinical characteristics of the disease.

Methods:

This cross-sectional study included 106 consecutively assessed patients with relapse remitting type of multiple sclerosis. In addition to the data regarding disease duration, number of demyelinating relapses, and degree of neurological disability, assessed by the expanded disability scale score (EDSS), we used Toronto alexithymia scale (TAS), fatigue severity scale (FSS) and, Hamilton scale for the assessment of anxiety and depression and sociodemographic questionnaire.

Results:

Study included 74 female and 32 male patients, with a median age of 44 years, median disease duration 90 months, and median EDSS 4. About 29.55% of patients had alexithymia and borderline alexithymia was observed in 31.15% patients. Alexithymia correlated with anxiety and depression (P < 0.01) on all TAS subscales. Higher levels of neurological disability based on EDSS, severe fatigue based on FSS scores, and severe relapse remitting type of multiple sclerosis with more relapses and longer disease duration correlated with alexithymia (P < 0.01), depression (P < 0.01), and anxiety (P < 0.01). Higher rates of alexithymia were noticed in older, unemployed, single patients, and those having fewer children.

Conclusions:

Alexithymia was found in a relatively high percentage in patients with relapse remitting type of multiple sclerosis.

A Scope of the Social Brain in Multiple Sclerosis: Insights From Neuroimaging Studies

Multiple sclerosis (MS) is the most common inflammatory neurologic disease in young adults. Its pathological mechanisms include demyelination, neurodegeneration, and synaptopathy. Cognitive deficits occur in up to 65% of individuals with MS and affect both nonsocial (eg, information processing speed, memory, and executive functions) and social (ie, emotion recognition, theory of mind, and empathy) cognitive domains. In the last 3 decades, there has been a growing interest in social cognition and its relationship with neuropsychological, sociodemographic, and disease characteristics in individuals with MS. Uncovering the neuropathological correlates of social cognitive deficits is now a crucial aim that would also help us better understand the underlying mechanisms of social cognition. We reviewed 11 neuroimaging studies to investigate social cognition in MS. These studies focused mainly on facial emotion recognition and theory of mind, with the findings suggesting that a disrupted cortico-subcortical network forms the basis of social deficits involving both domains. We then interpreted these results in the context of multiple disconnection syndrome, which occurs as a result of axonal demyelination and degeneration within the connexome of several neural hubs devoted to social cognition. Heterogeneity in social cognitive performance, observed among our study participants, is discussed with reference to the cognitive reserve and brain reserve hypotheses. These reserves may explain why individuals with comparable clinical characteristics of MS may exhibit different cognitive profiles. Further research is required to generalize these findings to the MS population and to inform the development of effective interventions to improve psychosocial functioning in individuals with MS.

Social norms in patients with relapsing-remitting multiple sclerosis: Impairment of the moral/conventional distinction?

In multiple sclerosis, conflicting results have been reported between social impairment and relatively preserved moral judgments, mainly tested with moral dilemmas. Some results even yet suggest signs of "ultra-morality" in these patients. The objective of the present study was to test this hypothesis with the moral/conventional distinction task, investigating the knowledge of social norms and the judgment of moral versus conventional transgressions. In the first condition, the permissibility of social situations was estimated. If the participant judged the situation as wrong, he had to estimate the seriousness of the transgression, to give verbal justifications and to re-estimate the permissibility when the law authorizes the act (generalization condition) and when a social authority recommends the act (dependency condition). Forty-six multiple sclerosis patients matched to healthy controls completed this task. Contrary to our hypotheses, patients showed less permissibility for moral transgressions or a higher seriousness but, unexpectedly, for conventional transgressions. Most importantly, abnormal justifications were observed (strictly moral arguments for conventional transgressions and vice versa). This suggests a lack of distinction between conventional and moral judgment in multiple sclerosis. This confusion may explain the "ultra-morality" sometimes reported, if patients base their judgment mainly on social knowledge and not on emotional processing.

Alexithymia in multiple sclerosis: Clinical and radiological correlations

BACKGROUND

Alexithymia, meaning no words for emotions is a common problem that could affect up to 53% of patients in multiple sclerosis (MS).

OBJECTIVES

To determine the frequency of alexithymia in MS and investigate MS-related abnormalities in structural magnetic resonance imaging (MRI) and their associations with fatigue and cognitive functions.

METHODS

Ninety-five patients at all stages of the disease were examined: 21 with clinically isolated syndromes (CIS), 30 with relapsing-remitting MS (RRMS), 21 with primary (PP) and 23 with secondary progressive MS (SPMS). Alexithymia was measured with the Toronto alexithymia scale (TAS-20) and correlated to cognitive functions, depression, and fatigue. Voxel-based morphometry MRI was analyzed to determine lesion load, cerebral and regional atrophy.

RESULTS

Fifty-seven of patients had alexithymia with no significant difference between the clinical phenotypes. Alexithymic patients differed from non-alexithymic patients on fatigue, depression and information processing speed. Compared to non-alexithymic patients, alexithymic patients had decreased volumes of cerebral and cerebellar white matter and there was a significant relationship between alexithymia and decreased brainstem, thalamic and corpus callosum volume.

CONCLUSION

Regardless of the phenotype of MS, alexithymia is associated with atrophy of cerebral and cerebellar white matter, brainstem, corpus callosum, and thalami.

Neuro-cognitive correlates of alexithymia in patients with circumscribed prefrontal cortex damage

Alexithymia has been extensively reported in studies of psychiatric patients. However, little attention has been paid regarding its occurrence in the context of patients with circumscribed prefrontal cortex lesions. Moreover, the neuro-cognitive impairments that lead to alexithymia remain unclear and limited numbers of studies have addressed these issues. The authors investigated the impact of prefrontal cortex lesions on alexithymia and its neuro-cognitive correlates in a population of 20 patients with focal frontal lesions, 10 patients with parietal lesions and 34 matched control participants. Alexithymia was screened using the Toronto Alexithymia Scale (TAS-20) and executive functions were assessed using a large battery of executive tasks that address inhibition, flexibility and the planning process. Results showed that patients with prefrontal cortex damage showed significantly increased difficulty in facets of identifying feelings (DIF) and externally oriented thinking (EOT) on TAS-20, compared to parietal patients and control participants. Moreover, both correlation and regression analysis revealed that higher alexithymia levels on the three facets of TAS-20 were consistently but differentially associated with impairment in inhibition, flexibility and planning tasks for frontal patients and both control groups. These findings provide clinical evidence of the implication of prefrontal cortex damage and executive control in alexithymia. Our results were also discussed in the light of the cognitive appraisal concept as a mechanism involved in emotion episode processing. This study suggests that increased neuropsychological attention should be directed to the relation between the neuro-cognitive model of executive functions and cognitive appraisal theory in processing emotion.

Cognitive Dysfunctions and Assessments in Multiple Sclerosis

Cognitive impairment has been reported at all phases and all subtypes of multiple sclerosis. It remains a major cause of neurological disability in young and middle-aged adults suffering from the disease. The severity and type of cognitive impairment varies considerably among individuals and can be observed both in early and in later stages. The areas which have commonly shown more deficits are: information processing speed, complex attention, memory, and executive function. Even though an alteration in both the white matter and in the gray matter has been found in patients with multiple sclerosis and cognitive impairment, the underlying process still remains unknown. Standardized neurological examinations fail to detect emerging cognitive deficits and self-reported cognitive complaints by the patients can be confounded by other subjective symptoms. This review is a comprehensive and short update of the literature on cognitive dysfunctions, the possible confounders and the impact of quality of life in patients with multiple sclerosis.

Assessment and Impact of Cognitive Impairment in Multiple Sclerosis: An Overview

Cognitive impairment affects 40⁻60% of patients with multiple sclerosis. It may be present early in the course of the disease and has an impact on a patient's employability, social interactions, and quality of life. In the last three decades, an increasing interest in diagnosis and management of cognitive impairment has arisen. Neuropsychological assessment and neuroimaging studies focusing on cognitive impairment are now being incorporated as primary outcomes in clinical trials. However, there are still key uncertainties concerning the underlying mechanisms of damage, neural basis, sensitivity and validity of neuropsychological tests, and efficacy of pharmacological and non-pharmacological interventions. The present article aimed to present an overview of the assessment, neural correlates, and impact of cognitive impairment in multiple sclerosis.

Social Mind and Long-Lasting Disease: Focus on Affective and Cognitive Theory of Mind in Multiple Sclerosis

The role of social cognition, including theory of mind (ToM), in affecting quality of life (QoL) along the course of diseases has been reported. This is a considerable aspect in chronic pathologies, such as multiple sclerosis (MS), in which supporting and maintaining QoL is of crucial importance. We aimed to investigate the relation between ToM, clinical variables and neuropsychological profile in a cohort of adults with long lasting disease, such as different clinical MS phenotypes (Relapsing Remitting -RR- versus Progressive -Pr). In particular, our study focuses on (1) how (affective and cognitive) ToM impairment occurs in different phenotypes, (2) whether MS ToM impairment is secondary to or independent from cognitive deficit and (3) whether ToM deficit impacts QoL. 42 adults with MS (18 M: 24 F, 52.38 ± 10.31 mean age, 21.24 ± 10.94 mean disease duration, 26 RR and 16 Pr) and 26 matched healthy controls (HC) (7 M: 19 F, 51.35 ± 12.42 mean age) were screened with a neuropsychological and ToM battery, assessing both affective and cognitive components. We found statistically significant groups differences in cognitive but not affective ToM, with a lower performance in PrMS than those with a RRMS disease course. Also, significant predictive effects of neuropsychological tests on ToM were identified in MS group. Finally, MS people with different level of affective ToM differed significantly in QoL. ToM deficit in moderately disabled people with MS involves cognitive but not affective ToM components with implications on QoL. It also appears to be related to cognitive performance. As neurological and neurocognitive profiles influence mentalizing in MS, ToM evaluation should be considered for inclusion in clinical screening.

Relationship between Social Cognition and traditional cognitive impairment in Progressive Multiple Sclerosis and possible implicated neuroanatomical regions

BACKGROUND

Cognitive impairment is a relevant contributor of the medical and social burden in Progressive MS. Social Cognition, the neurocognitive processes underlying social interaction, has been explored mainly in European and North American cohorts, influencing social aspects of quality of life (QOL) of early MS patients and families. Few studies have studied Social Cognition in Progressive MS and the literature on its neuroanatomical bases or brain atrophy measurements is still scarce.

OBJECTIVES

To explore the relationship between Social Cognition performance and its correlations with traditional cognitive domains, brain atrophy and QOL in primary and secondary Progressive MS patients.

METHODS

Cross-sectional analysis including: mini-Social-Cognition-and-Emotional-Assessment (mini-SEA), neuropsychological battery, disability, depression, fatigue, QOL, and brain volume.

RESULTS

Forty-three MS patients, 23 primary and 20 secondary Progressive, 65% women, mean age and disease duration of 57.2 and 15.7 years, respectively, with high levels of disability (median EDSS 6.0) and a widespread impairment in traditional domains (mostly episodic verbal/visual and working memories) were assessed. The Mini-SEA score was correlated with executive functions (cognitive shifts Rho:0.55; p = 0.001) analyzing the whole group, and with visual episodic memory (Rho:0.58, p = 0.009) in the primary Progressive MS group. Mini-SEA score was also correlated with total normalized grey matter volume (Rho:0.48; p = 0.004). Particularly, atrophy within bilateral cortical regions of orbitofrontal, insula and cerebellum, and right regions of fusiform gyrus and precuneus were significantly associated with higher Social Cognition impairment. In this cohort, QOL was not correlated with Social Cognition, but with EDSS, fatigue and depression.

CONCLUSIONS

In Progressive MS, Social Cognition is directly correlated with traditional cognitive domains such as executive function and episodic memory. It is also associated with global grey matter atrophy and regional atrophy within associative visual and executive cortical areas, but no correlations with QOL were found in this cohort. These findings may contribute to the understanding of the pathological bases behind Social Cognition in Progressive MS.