The impact of stressful life events on risk of relapse in women with multiple sclerosis: A prospective study

Stress and Multiple Sclerosis - Systematic review and meta-analysis of the association with disease onset, relapse risk and disability progression

OBJECTIVE

This systematic review and meta-analysis address the evidence on the association of psychological stressors with onset of multiple sclerosis, inflammatory disease activity (relapses or new disease activity on magnetic resonance imaging, MRI) and disability progression.

METHODS

PubMed was searched from 1946 to 15 July 2022. Studies and certain stressors were selected when they assessed stressors independent from stress elicited by the disease process itself. Risk of bias was assessed by the CASP Case Control Study Checklist and the CASP Cohort Study Checklist. Normal-Normal Hierarchical Model (NNHM) for random-effects meta-analysis was used in the Bayesian framework.

RESULTS

30 studies reporting data from 26 cohorts reporting on 24.781 cases could be identified. Ten studies addressed stressors and MS disease onset showing a weak to modest effect of psychological stressors. A meta-analysis of three studies investigating diagnosed stress disorders and MS risk showed a 1.87-fold (CI 1.061 to 3.429) increased MS risk. Stress and MS relapse risk were addressed in 19 heterogeneous studies. Meta-analyses from two independent cohorts investigating the same military threat of a population showed a threefold increased risk for relapses in association with war (relapse rate: 3.0, CI 1.56 to 5.81). In addition, two studies confirmed an association of stressful life events and MRI activity. Three studies of stressors and disease progression were included indicating some effect on disease progression.

CONCLUSIONS

Taken together studies indicate a minor to modest impact of psychological stressors on disease onset, inflammatory activity and progression of MS. Possible case-selection bias and lack of confounder analysis were present in many studies.

Stressful life events and depression and fatigue in people with multiple sclerosis: a cross-sectional analysis of an international cohort

BACKGROUND

Relationships between stressful life events (SLEs) and health outcomes in people living with multiple sclerosis (plwMS), beyond relapse, are not well-established. We examined associations between SLEs and fatigue and symptoms of depression in plwMS.

METHODS

948 participants were queried whether they had experienced any of the 16 SLEs (Holmes-Rahe Social Readjustment Rating Scale) in the preceding 12 months. SLEs were summated to estimate SLE number and SLE load (weighted for the degree of associated stress). Cross-sectional associations between SLE (number, load and individual) and fatigue, and depressive symptoms were examined using log-binomial or log-multinomial regression adjusted for age, sex, relapse symptoms, education, MS type at baseline, disability, fatigue, comorbidity, depression, and antidepressant/antifatigue medications, as appropriate. Sub-analyses restricted to SLEs with a negative emotional impact were performed.

RESULTS

Median SLE number and load were 2 (IQR 1-2) and 57 (IQR 28-97), respectively. SLE number and load were not associated with a higher prevalence of fatigue, or depressive symptoms, even when restricting analyses to SLEs with a perceived negative emotional impact. A new relationship or family member with a negative impact was associated with a threefold and 2.5-fold higher prevalence of depressive symptoms, respectively. Serious illness was associated with a 28% higher prevalence of depressive symptoms.

CONCLUSION

Psychological support for SLEs, and/or intervention targeted to SLE appraisal, may be beneficial in mitigating the adverse effects of SLEs with a perceived negative emotional impact on depressive symptoms in plwMS. Potential associations between serious illness and increased prevalence of depressive symptoms may warrant further investigation.

The bidirectional effect of stress and functionality in multiple sclerosis and the interaction role of anxiety, coping and social support

OBJECTIVE

The present study aims to analyse the bidirectional hypothesis between stress and multiple sclerosis with several measures of stress, impairment and functionality, considering also the interaction role of stress-related psychosocial factors such as anxiety, coping and social support.

METHODS

A one-year follow-up was conducted with 26 people with multiple sclerosis. Participants reported i) at baseline, anxiety (State-Trait Anxiety Inventory), and social support (Multidimensional Scale of Perceived Social Support); ii) daily, Ecological Momentary Assessment through self-reported diaries of stressful events and coping strategies; iii) monthly, the perceived stress (Perceived Stress Scale), iv) trimonthly, the self-reported functionality (Functionality Assessment in multiple sclerosis) and v) at baseline and at the end, neurologist rated impairment (Expanded Disability Status Scale). Mixed-effect regression models were conducted.

RESULTS

The bidirectional hypothesis was confirmed with perceived stress and self-reported functionality, which were negatively related in both directions. Coping and anxiety showed an interaction effect: active coping increased functionality only with high levels of stress, and high-trait anxiety showed lower functionality whereas low-trait anxiety showed higher functionality but only with low stress levels.

CONCLUSION

People with multiple sclerosis may benefit from different types of psychological therapies, from gold-standard therapies like Cognitive Behavioural Therapy to third-waves therapies like Dialectical Behaviour Therapy or mindfulness, that focus on dealing with stress and affective symptoms, adjusting to the disease, and to improving their overall quality of life. More research is needed in this field under the biopsychosocial model.

Relationships between childhood trauma and multiple sclerosis: A systematic review

OBJECTIVE

Adverse Childhood Experiences (ACEs), such as physical, emotional, and sexual abuse trigger inflammatory changes and have been associated with many causes of morbidity and mortality, including autoimmune diseases. Although Multiple Sclerosis (MS) is a debilitating neurological autoimmune disease, literature linking ACEs and MS is understudied. The aim of this review was to examine the 1) state of the literature, and 2) relationships between childhood adversity and the prevalence and physical clinical features of MS (e.g., age at onset, relapses, pain, fatigue, disability).

METHODS

A comprehensive search was preformed through five databases and by hand using the ancestry and descendancy approach for connections to papers published through January 20th, 2022. Studies were screened by independent reviewers using Rayyan.ai, and critically appraised for both quality and reporting transparency.

RESULTS

Twelve studies examined relationships between any ACE(s) and the prevalence or physical clinical features of MS. There was considerable variance in the measurement of stressors, confounders, and categorization of MS; however most studies (n = 10) demonstrated an association between ACEs and MS (alone or grouped with other similar diagnoses), or physical clinical features.

CONCLUSION

Although there are few studies in this area, it is of quickly growing interest. These results should be cautiously interpreted, yet highlight the need for continued work to disentangle and discern true associations.

Impact of the covid-19 pandemic on the psychological status and cortisol level of multiple sclerosis patients

This study aimed to compare the changes in psychological status and cortisol level between multiple sclerosis (MS) patients and a healthy control group (HC). One hundred and fifty-five MS patients and 165 HC subjects had completed questionnaires consisting of 36-Item short health survey (SF-36), Hamilton Anxiety Rating Scale (HAM-A), Beck Depression Inventory-II (BDI-II), and fatigue severity score (FSS) before and after (one year from onset) COVID-19 pandemic. The salivary cortisol level was also measured again in 26 MS patients and 14 control individuals. MS patients had lower scores of mental and physical components of quality of life (MCS and PCS), but higher HAM-A, FSS, and BDII scores than HC Before and after COVID-19. There were significant changes in scores of MCS, BDI-II, HAM-A, and FSS after the COVID-19 outbreak in MS patients, but not in PCS score. In HC group, we observed significant changes in scores of MCS, BDI-II, and FSS, but not in scores of PCS and HAM-A. Compared to HC, the MS patients reported greater deterioration in the overall mental health component of their health-related quality of life, and their levels of anxiety and fatigue over the study period. The change of cortisol levels was non-significant with a small effect size.

Association between relapses, stress, and depression in people with multiple sclerosis during the COVID-19 pandemic

Background

Stress is a potential trigger for clinical and radiological activity in Multiple Sclerosis (MS). COVID-19 pandemic has been a relevant source of mental distress in people with MS (pwMS) and deeply impacted on disease management.

Objective

To investigate the association between stress, anxiety, depression, and risk of relapse during the COVID-19 pandemic.

Methods

From an electronic database used for clinical practice, we extracted data of relapsing–remitting (RR) or relapsing-progressive (RP) MS patients and calculated the annualized relapse rate (ARR) during 2019 and 2020. From 01/12/2020 to 30/12/2020, enrolled patients were invited to fill in a Google Forms survey to investigate depression, anxiety, stress, and Post-Traumatic Stress Disorder (PTSD).

Results

We selected 216 patients with RR or RP-MS to calculate ARR: compared to 2019, in 2020 there was a significant increase in ARR (p = 0.0142).

Over 216 selected pwMS, 154 completed the survey. Matching the survey responses and incidence of relapses in 2020, there was a significant association between relapses and stress (p = 0.030) and relapses and depression (p = 0.011), but not between relapses and anxiety (p = 0.130) or PTSD (p = 0.279).

Conclusions

Our results support the hypothesis that pandemic-related stress is associated to clinical exacerbations, both as a possible consequence of the COVID-19 impact on MS care.

Beyond the neuron: Role of non-neuronal cells in stress disorders

Stress disorders are leading causes of disease burden in the U.S. and worldwide, yet available therapies are fully effective in less than half of all individuals with these disorders. Although to date, much of the focus has been on neuron-intrinsic mechanisms, emerging evidence suggests that chronic stress can affect a wide range of cell types in the brain and periphery, which are linked to maladaptive behavioral outcomes. Here, we synthesize emerging literature and discuss mechanisms of how non-neuronal cells in limbic regions of brain interface at synapses, the neurovascular unit, and other sites of intercellular communication to mediate the deleterious, or adaptive (i.e., pro-resilient), effects of chronic stress in rodent models and in human stress-related disorders. We believe that such an approach may one day allow us to adopt a holistic "whole body" approach to stress disorder research, which could lead to more precise diagnostic tests and personalized treatment strategies. Stress is a major risk factor for many psychiatric disorders. Cathomas et al. review new insight into how non-neuronal cells mediate the deleterious effects, as well as the adaptive, protective effects, of stress in rodent models and human stress-related disorders.

Burden of COVID-19 Pandemic Perceived by Polish Patients with Multiple Sclerosis

People with multiple sclerosis (MS) were expected to be particularly affected by the COVID-19 pandemic. The purpose of the study was to evaluate the burden of pandemic, perceived by Polish MS patients, with regard to major contributing factors. The survey, conducted in August/September 2020, included: Perceived Stress Scale (PSS-10), Coping Orientations to Problems Experienced (Brief–COPE), questions on demographic data, MS characteristics, and health-related and social aspects of pandemic burden. Relationships were searched between PSS-10 and Mini-COPE results and other analyzed items, using U Mann–Whitney test, Kruskal–Wallis ANOVA rank test and Spearman rank correlation. The survey was answered by 287 MS patients (208 female, 79 male, aged 21–69 years). Since March 2020, 2.4% of respondents had been positive for COVID-19 and 5.2% had undergone a quarantine. Mean PSS-10 score was 19.99, with moderate or high level of stress in 83.3% of respondents. Problem-focused strategies were more frequently used than emotion-focused strategies (1.76 vs. 1.16). Higher PSS-10 score was associated with comorbidities (H = 4.28), increase in major MS symptoms during the pandemic (21.92 vs. 18.06), experience of healthcare limitations (21.12 vs. 17.98), work-related (22.58 vs. 18.69), financial (22.70 vs. 18.83) and family-related problems (22.54 vs. 17.73) due to pandemic restrictions. A coping model was associated with functional disability and limitations to daily activities (H = 7.81). During the first stage of the pandemic, MS patients reported increased level of stress and preferred problem-focused coping. The level of stress and coping showed more relationships with pandemic impact upon social issues than with MS-related variables.

The Level of Stress and Coping Strategies in Patients with Multiple Sclerosis and Their Relationships with the Disease Course

Objectives: Stress is supposed to be linked with a background of multiple sclerosis (MS) and the disease course. Design: The study aimed to assess the level of stress and coping strategies in MS patients within a year of follow-up and to investigate the relationships between these aspects and factors related—or not—to MS. Methods: In 65 patients with MS, the Perceived Stress Scale (PSS-10), Type D Scale (DS14) and Coping Orientations to Problems Experienced (COPE) were performed at baseline and after a year. Baseline PSS-10, DS-14 and COPE scores were analyzed with regard to demographics, MS duration, treatment, indices of disability and self-reported stressful events (SEs). Final PSS-10 and COPE results were analyzed with reference to MS activity and SE within a year of follow-up. Results: Initially, 67% of patients reported a moderate or high level of stress and 31% met Type-D personality criteria. Diverse coping strategies were preferred, most of which were problem-focused. The negative affectivity DS-14 subscore (NEG) was correlated with disability level. Non-health-related SEs were associated with higher PSS-10 and NEG scores. After a year, the mean PSS-10 score decreased, while COPE results did not change significantly. Non-health-related SEs were associated with a higher PSS-10 score and less frequent use of acceptance and humor strategies. Those with an active vs. stable MS course during the follow-up did not differ in terms of PSS-10 and COPE results. Conclusions: MS patients experienced an increased level of stress. No significant relationships were found between stress or coping and MS course within a year. Non-health-related factors affected measures of stress more than MS-related factors.

Understanding and managing the impact of the Covid-19 pandemic and lockdown on patients with multiple sclerosis

INTRODUCTION

Covid-19 has been sweeping over the world for more than a year. People with Multiple Sclerosis (MS) might be particularly vulnerable either for the disease iteself or for the ongoing immune treatment. The aim of this review is to understand the impact of the Covid-19 pandemic and lockdown on patients with MS and to provide evidence-based advice to ensure them a high standard of care even during the pandemic.

AREAS COVERED

Literature search was conducted in the Scopus, Web of Science, Pubmed electronic databases, and articles reference lists to investigate the effect of Covid-19 on MS patients' treatment, access to health-care services and mental-health.The search terms 'multiple sclerosis' AND 'Covid-19' were combined with each of the following term 'disease modifying treatment,' 'steroids,' 'vaccination,' 'mental health,' 'stress,' 'quality of life,' 'management,' 'impact,' 'recommendations,'.

EXPERT OPINION

To ensure MS control during the pandemic, minimizing the risk of Covid-19 contagion, face-to-face visits may be implemented with televisits. Management of relapses and DMTs schedule should be adapted based on the specific benefit/risk ratio for each patient, considering disease activity, disability, comorbidities. Vaccination should be strongly recommended. Telerehabilitation and online psychological support programs should be encouraged to preserve motor performances and mental health.

The Role of Stress Perception and Coping with Stress and the Quality of Life Among Multiple Sclerosis Patients

Purpose

Multiple sclerosis (MS) is one of the most common neurological disorders and a cause of disability in young adults. Adequate stress management in MS patients may merit the benefits of both physical and psychological well-being. This study aimed to evaluate the quality of life in MS patients and its correlation with stress levels and coping strategies.

Methods

This descriptive and correlational study was conducted among 109 patients diagnosed with relapsing-remitting MS (RRMS). The study was based on a questionnaire designed by the authors and the following standardized questionnaires: the Perceived Stress Scale (PSS-10), the Inventory for Measuring Coping with Stress (Mini-COPE), and the Multiple Sclerosis International Quality of Life Questionnaire (MusiQoL).

Results

Data analysis showed that 47.71% of the patients experienced a high level of stress, and the most often used strategies under challenging situations included seeking emotional support (2.11) and active coping (1.96). Also, it showed that when the level of stress is higher, the QOL in all domains is lower. Coping strategies such as sense of humor, turning to religion, self-distraction, denial, venting, substance use, behavioral disengagement, and self-blame are negatively correlated with the quality of life of MS.

Conclusion

Quality of life in MS patients is negatively affected by a higher level of perceived stress. The use of coping strategies such as active coping, positive reframing, acceptance, and seeking emotional and instrumental support is positively correlated with the quality of life of MS patients.

Perceived stress and social support in a large population of people with multiple sclerosis recruited online through the COVID-19 pandemic

BACKGROUND AND PURPOSE

The COVID-19 emergency may cause post-traumatic stress disorder (PTSD), and with regard to people with MS (pwMS) chronic exposure to a wide range of challenging life events has been shown to be correlated with worsening of neurological symptoms, increased lesion burden on brain magnetic resonance imaging and relapses. The aim was to investigate perceived stress, depression, perceived social support, habits and behaviour changes in pwMS through COVID-19 in comparison to a control group.

METHODS

A web-based survey was posted on SMsocialnetwork.com to investigate perceived stress (using the Perceived Stress Scale), depression (with Patient Health Questionnaire 2) and perceived social support (using Social Provision Scale 10 item) in pwMS and a control group through the COVID-19 pandemic. A secondary group of people with migraine was investigated.

RESULTS

In all, 1286 answers from 612 pwMS and 674 control people were included in the final analysis. The answers from 318 people with migraine were included for a secondary analysis. A higher proportion of pwMS were depressed (43.1% vs. 23.1%; p < 0.001), had a high level of perceived stress (58% vs. 39.8%; p < 0.001) and felt significantly less social support (median 33 vs. 35; Q1-Q3 28-36 vs. 32-37; p < 0.001) compared to the control group. A higher percentage of people with migraine were depressed (50% vs. 43%, p = 0.04) compared to pwMS.

CONCLUSIONS

Considering the negative impact that prolonged stress may have on clinical and radiological disease activity of pwMS, and bearing in mind that a beneficial effect has been demonstrated and achieved with stress management, it is suggested to promote stress control in these patients during the COVID-19 pandemic.

Environmental enrichment alleviates the deleterious effects of stress in experimental autoimmune encephalomyelitis

Background

Clinical observations support the hypothesis that stressful events increase relapse occurrence in multiple sclerosis patients, while stress-reduction strategies can modulate this effect. However, a direct cause-effect relationship between stress level and relapse cannot be firmly established from these data.

Objectives

The purpose of this work was to address whether modulation of stress could interfere with symptom relapse in an animal model of multiple sclerosis with relapsing-remitting course.

Methods

Mice bred in standard or enriched environment were subjected to repeated acute stress during the remission phase of relapsing-remitting PLP-induced experimental autoimmune encephalomyelitis.

Results

We report that repeated acute stress induced a twofold increase in relapse incidence in experimental autoimmune encephalomyelitis. On the other hand, environmental enrichment reduced relapse incidence and severity, and reversed the effects of repeated acute stress.

Conclusion

These data provide the platform for further studies on the biological processes that link stress and multiple sclerosis relapses in a suitable animal model.

Psychological Stress, Intestinal Barrier Dysfunctions, and Autoimmune Disorders: An Overview

Autoimmune disorders (ADs) are multifactorial diseases involving, genetic, epigenetic, and environmental factors characterized by an inappropriate immune response toward self-antigens. In the past decades, there has been a continuous rise in the incidence of ADs, which cannot be explained by genetic factors alone. Influence of psychological stress on the development or the course of autoimmune disorders has been discussed for a long time. Indeed, based on epidemiological studies, stress has been suggested to precede AD occurrence and to exacerbate symptoms. Furthermore, compiling data showed that most of ADs are associated with gastrointestinal symptoms, that is, microbiota dysbiosis, intestinal hyperpermeability, and intestinal inflammation. Interestingly, social stress (acute or chronic, in adult or in neonate) is a well-described intestinal disrupting factor. Taken together, those observations question a potential role of stress-induced defect of the intestinal barrier in the onset and/or the course of ADs. In this review, we aim to present evidences supporting the hypothesis for a role of stress-induced intestinal barrier disruption in the onset and/or the course of ADs. We will mainly focus on autoimmune type 1 diabetes, multiple sclerosis and systemic lupus erythematosus, ADs for which we could find sufficient circumstantial data to support this hypothesis. We excluded gastrointestinal (GI) ADs like coeliac disease to privilege ADs not focused on intestinal disorders to avoid confounding factors. Indeed, GIADs are characterized by antibodies directed against intestinal barrier actors.

Factors associated with relapses in relapsing-remitting multiple sclerosis: A systematic review and meta-analysis

BACKGROUND

The relapse is character of relapsing-remitting multiple sclerosis. The therapeutic goal is to reduce the risk of relapse. Factors associated with relapses can help to manage and prevent relapses. In addition, patients and doctors all pay attention to it. However, there are differences between studies. Our aim is to summarize factors associated with relapses in relapsing-remitting multiple sclerosis (RRMS).

METHODS

PubMed, EMBASE, Web of science, Cochrane library, CNKI, Wanfang, SinoMed, and VIP were searched to identify risk factors about relapses in RRMS, which should be in cohort or case-control studies. This article was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The quality of studies was evaluated by the Newcastle-Ottawa Scale (NOS). Meta-analysis, subgroup and sensitivity analyses, and publication bias were all performed with Stata. This research has been registered on the international prospective register of systematic reviews (PROSPERO, CRD42019120502).

RESULTS

43 articles were included. Infection, postpartum period, risk gene, stress, and vitamin D were risk factors for relapses in RRMS. Pregnancy period was the protective factor. Among those, infection increased the risk of relapses in infection period (relative risk [RR], 2.07 [confidence interval (CI), 1.64 to 2.60]). Women in the postpartum period increased the risk of relapses compared with women before pregnancy (RR, 1.43 [CI, 1.19 to 1.72]), or women in pregnancy period (RR, 2.07 [CI, 1.49 to 2.88]). Women in the pregnancy period decreased the risk of relapses (RR, 0.56 [CI, 0.37 to 0.84]) compared with women before pregnancy. However, fewer studies, heterogeneity, and sample size were the limitations.

CONCLUSION

It is reliable to adopt results about infection, pregnancy period, and postpartum period.

Effects of Death Anxiety on Perceived Stress in Individuals With Multiple Sclerosis and the Role of Self-Transcendence

Stress is a commonly reported concern of individuals with chronical diseases, including multiple sclerosis (MS). This study sought to investigate the relationships between self-transcendence, death anxiety, and perceived stress among individuals with MS from Iran. A second aim of the study was to assess the buffering effect of self-transcendence in the relationship between death anxiety and perceived stress. Two hundred and fifteen participants with MS from four hospitals completed measures assessing self-transcendence, death anxiety, and perceived stress. Using structural equation modeling, death anxiety was found to be positively related to perceived stress. In addition, there was a negative relationship between self-transcendence and perceived stress. Results of the study suggest that self-transcendence is a buffer in the link between death anxiety and perceived stress for individuals with MS. The findings demonstrate the importance of self-transcendence in decreasing the effects of death anxiety on perceived stress and have clinical implications for health professionals.

Can a stress management programme reduce stress and improve quality of life in people diagnosed with multiple sclerosis?

Background

Despite evidence of perceived stress as a risk factor for multiple sclerosis activity, the evidence for managing stress is limited.

Objective To evaluate a stress management programme on perceived stress and quality of life, over 6 months.

Methods

One hundred people with multiple sclerosis were randomly assigned to either a stress management programme of mindfulness, meditation and progressive muscle relaxation, or wait list. Perceived stress and quality of life were assessed at three intervals across 6 months. Salivary cortisol levels were assessed at two intervals: baseline and first follow-up.

Results

The stress management programme did not significantly reduce perceived stress, when comparing mean scores. Secondary analysis using median scores found a significant improvement for quality of life, favouring the intervention group.

Conclusion

Stress management had no significant effect on the primary outcome of perceived stress but did improve quality of life in a secondary analysis of median scores.

Stress-full life events and multiple sclerosis: A population-based incident case-control study

AIM

While sizeable evidence regarding the association between stressful-life events and multiple sclerosis (MS) disease activity (clinical and/or radiological) was previously documented, their relation to MS risk is controversial. We aimed to investigate the possible association of stressful-life events and multiple sclerosis risk after adjustment for relevant confounders in an Iranian population.

METHOD

This was a population-based incident case-control study that recruited 547 MS cases and 1057 healthy controls between August 2013 and February 2015, Tehran. The patients were identified using the Iranian MS Society based on 2010 McDonald criteria. We used standard random digit dialing protocol for control selection. Logistic regression model was applied to estimate the odds ratios (95% CI) adjusted for physical activity, age, gender, tobacco smoking, waterpipe smoking and passive smoking.

RESULTS

While total life events number was not associated with risk of MS, homeless periods OR 3.85 (1.65-8.90), p = 0.002 as well as divorce OR 2.11 (1.24-3.58), p = 0.005 increased the risk of MS. However, marriage OR 0.59 (0.41-0.86), p = 0.006, death of ones' dear OR 0.60 (0.44-0.82), p = 0.002 and joblessness OR 0.61 (0.41-0.91) reduced the risk of MS.

CONCLUSION

We could not detect a statistically significant role for the total stressful life event during the last 3 years and MS diagnosis. However, there is some evidence confirming the possible role of some individual life events, i.e. divorce and periods of homelessness as potential risk factors for MS and conversely, having married as a protective factor in MS onset.

The role of stress in the mosaic of autoimmunity: An overlooked association

Stress is defined as the pscyophysiological reaction in which the steady state is disturbed or threatened. Stress is not always perceived as a negative response. Stress results when environmental demands exceed an individuals' adaptive capacities. Autoimmune diseases are heterogeneous group of chronic diseases which occur secondary to loss of self antigen tolerance. The etiopathogenesis of autoimmune disease is uncertain. Genetic factors as well as environmental factors appear to interplay, leading to a cascade of events resulting in disease onset. Stress has been postulated to play a role in disease onset in the genetically susceptible patients. During the stress response, catecholamines and glucocorticoids are released from locus coeruleus and adrenal gland. These biomolecules exert control over various immune cells in the innate and adaptive arms of the immune system, thereby altering the cytokine profile released. The increase of IL-4 promotes T-helper 2 (T_h2) cell differentiation, while the decrease in IL-12 and the increased IL-10 production reduce the number of T-helper 1 (T_h1) cells. The relationship between stress and autoimmune diseases is intricate. Stress has been shown to be associated with disease onset, and disease exacerbations in rheumatoid arthritis, systemic lupus erythematosus, inflammatory bowel disease, multiple sclerosis, Graves' disease as well as other autoimmune conditions. In certain conditions such as psoriasis, stress has been implicated in delaying lesion clearance upon the application of standard treatment regimes. Finally, psychological therapy and cognitive behavioral therapy aimed to reduce stress levels was shown to be effective in influencing better outcomes in many autoimmune diseases. The purpose of this paper is to closer inspect the clinical evidence regarding the role of stress on influencing the various aspects of disease entities.

Impact of short-term cycle ergometer training on quality of life, cognition and depressive symptomatology in multiple sclerosis patients: a pilot study

In this pilot study, we investigate whether a routine cycle ergometry training programme has therapeutic potential in individuals with multiple sclerosis (MS) by improving quality of life (QOL) and depressive symptomatology, while ameliorating cognitive disturbances. Healthy volunteers and MS patients cycled for 30 min at 65-75% age-predicted maximal heart rate on a recumbent ergometer, with this session repeated twice a week for 8 weeks. QOL, depressive symptomatology and cognitive function were assessed pre- and post-exercise using the MS Quality of Life-54 (MSQOL-54) questionnaire, 16-item Quick Inventory of Depressive Symptomatology (QIDS-SR₁₆) questionnaire and the Cambridge Neuropsychological Test Automated Battery (CANTAB), respectively. We determined that QOL was lower in MS patients, compared to healthy subjects, with a reduction in physical and mental health summary scores observed. Exercise improved both physical and mental health scores in MS patients. In support of this, exercise was shown to reduce depressive symptomatology in MS patients. Exercise was also associated with an improvement in visual sustained attention, executive function/cognitive flexibility and hippocampal-dependent visuospatial memory in patients. Overall, this study identifies a short-term exercise programme that improves physical and mental health, while reducing depressive symptomatology and cognitive dysfunction in MS.

Application of the Betty Neuman systems model in the nursing care of patients/clients with multiple sclerosis

Objective

This study aimed to assess the application of the Betty Neuman systems model to the care of patient/clients with multiple sclerosis.

Methods

This clinical study resulted from the application of the nursing process to a patient/client admitted with multiple sclerosis in the neurological ward of a hospital in an urban area of Iran.

Results

A patient/client was evaluated according to the Neuman model. Intrapersonal stressors (physiological, psychological, socio-cultural, and spiritual), interpersonal stressors (being away from family and children) and extra-personal stressors (aggression and psychological pressure from the spouse) were found. Based on the examination, 12 nursing diagnoses based on the taxonomy of the North American Nursing Diagnosis Association International, and nursing care based on three levels of prevention that are important in the view of Neuman, are presented. The results were used in the classification of nursing interventions and the classification and nursing outcomes respectively.

Conclusions

The results suggest the desirability of care and patient/client satisfaction in the evaluation of nursing care based on the Neuman model. The model can be used as a framework to help nurses care for patients/clients. Thus, the application of this model and other models is recommended in the nursing care of patients/clients.

Role of chronic stress and depression in periodontal diseases

An extensive body of experimental and clinical evidence documents the negative impact of chronic psychological stress and depression on the immune system and health. Chronic stress and depression can result in general dysregulation of the immune system, of both cellular and humoral pathways, which may contribute to pathogenic infection and concomitant periodontal tissue destruction. In general, the evidence is consistent with the hypothesis that stress can modify the host defense and progression of periodontal infections in patients susceptible to periodontitis. However, substantial evidence also indicates that these conditions can mediate risk for disease, including periodontitis, through changes in health-related behaviors, such as oral hygiene, smoking and diet. The unequivocal interpretation of studies has also been hampered, in part, by issues related to conceptualization of stress and depression, as well as commonly associated comorbidities, such as diabetes, that can modify the onset and progression of periodontal disease. In addition, stress and depression appear to fall into a spectrum, ranging from mild to severe, involving a complex interaction of genetic background, coping strategies and environment. Differences in the conceptualization of stress and depression are probably important in assessing associations with other biologic and clinical measures. Future studies are necessary to clarify the complex interactions of chronic stress and depression in periodontal diseases.

Role of socioeconomic position in multiple sclerosis etiology

Multiple sclerosis (MS) is a debilitating autoimmune disease with a prominent inflammatory component. There have been strides identifying genetic and environmental MS risk factors, though much of the disease risk remains unknown. Recent large observational studies suggest adverse socioeconomic position increases the risk for MS, however the mediating biological processes are not understood. We hypothesize a prominent role for stress response, both the autonomic nervous system and the hypothalamic–pituitary–adrenal axis, which become maladaptive under frequent or chronic stimulation resulting in a proinflammatory phenotype. Thus, adverse SEP and chronic stress may predispose individuals for MS.

Stress and multiple sclerosis: A systematic review considering potential moderating and mediating factors and methods of assessing stress

Research about the effects of stress on multiple sclerosis has yielded contradictory results. This study aims to systematically review the evidence focusing on two possible causes: the role of stress assessment and potential moderating and mediating factors. The Web of Knowledge (MEDLINE and Web of Science), Scopus, and PsycINFO databases were searched for relevant articles published from 1900 through December 2014 using the terms "stress*" AND "multiple sclerosis." Twenty-three articles were included. Studies focused on the effect of stress on multiple sclerosis onset (n = 9) were mostly retrospective, and semi-structured interviews and scales yielded the most consistent associations. Studies focused on multiple sclerosis progression (n = 14) were mostly prospective, and self-reported diaries yielded the most consistent results. The most important modifying factors were stressor duration, severity, and frequency; cardiovascular reactivity and heart rate; and social support and escitalopram intake. Future studies should consider the use of prospective design with self-reported evaluations and the study of moderators and mediators related to amount of stress and autonomic nervous system reactivity to determine the effects of stress on multiple sclerosis.

Major stressful life events in adulthood and risk of multiple sclerosis

OBJECTIVE

It is unclear whether psychological stress is associated with increased risk of multiple sclerosis (MS). We studied the association between major stressful life events and MS in a nationwide cohort study using death of a child or a spouse or marital dissolution as indicators of severe stress.

METHODS

We created two study cohorts based on all Danish men and women born 1950-1992. One cohort consisted of all persons who became parents between 1968 and 2010, and another cohort consisted of all persons who married between 1968 and 2010. Members of both cohorts were followed for MS between 1982 and 2010 using data from the National Multiple Sclerosis Registry. Associations between major stressful life events and risk of MS were evaluated by means of MS incidence rate ratios (RR) with 95% confidence interval (CI) obtained in Poisson regression analyses.

RESULTS

During approximately 30 million person-years of follow-up, bereaved parents experienced no unusual risk of MS compared with parents who did not lose a child (RR=1.12 (95% CI 0.89 to 1.38)). Likewise, neither divorced (RR=0.98 (95% CI 0.89 to 1.06)) nor widowed (RR=0.98 (95% CI 0.71 to 1.32) persons were at any unusual risk of MS compared with married persons of the same sex.

CONCLUSIONS

Our national cohort study provides little evidence for a causal association between major stressful life events (as exemplified by divorce or the loss of a child or a spouse) and subsequent MS risk.

Nerve-derived transmitters including peptides influence cutaneous immunology

Clinical observations suggest that the nervous and immune systems are closely related. For example, inflammatory skin disorders; such as psoriasis, atopic dermatitis, rosacea and acne; are widely believed to be exacerbated by stress. A growing body of research now suggests that neuropeptides and neurotransmitters serve as a link between these two systems. Neuropeptides and neurotransmitters are released by nerves innervating the skin to influence important actors of the immune system, such as Langerhans cells and mast cells, which are located within close anatomic proximity. Catecholamines and other sympathetic transmitters that are released in response to activation of the sympathetic nervous system are also able to reach the skin and affect immune cells. Neuropeptides appear to direct the outcome of Langerhans cell antigen presentation with regard to the subtypes of Th cells generated and neuropeptides induce the degranulation of mast cells, among other effects. Additionally, endothelial cells, which release many inflammatory mediators and express cell surface molecules that allow leukocytes to exit the bloodstream, appear to be regulated by certain neuropeptides and transmitters. This review focuses on the evidence that products of nerves have important regulatory activities on antigen presentation, mast cell function and endothelial cell biology. These activities are highly likely to have clinical and therapeutic relevance.

An explanation of how migraine headaches can trigger relapse in systemic lupus erythematosus

Except for a few diseases of molecular mimicry such as rheumatic fever, post-streptococcal glomerulonephritis in children, and gluten-sensitive enteropathy, the cause of autoimmune diseases is unknown. Most autoimmune diseases are remitting-relapsing and the pathophysiology of either the initial attack or subsequent relapses is a mystery. Migraine headaches in systemic lupus erythematosus patients are statistically associated with disease activity, i.e. the patients with bad lupus are the ones who get migraine. T lymphocytes reactive against self are normally suppressed by immunoregulatory T cells (Tregs), but suppression can be broken by CD28 ligation of Tregs. This raises intracellular levels of H2O2, which is a second messenger in the CD28 signaling cascade. Migraine headaches are often accompanied by systemic platelet activation and a brief but intense platelet oxidative burst which raises extracellular H2O2 levels to the point where H2O2 diffusing passively across lymphocyte cell membranes can raise intracellular H2O2 sufficiently to turn off regulatory T cell function via the CD28 signaling cascade. Passive diffusion of H2O2 mimics the effect of H2O2 formation triggered by CD28 ligation. This eliminates the immunosuppressive hold of Tregs on self-reactive T cells and the development or worsening of autoimmune disease ensues spontaneously.

Daily hassles reported by Dutch multiple sclerosis patients

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

Exacerbation history is associated with medication and appointment adherence in MS

Disease-modifying treatments are designed to prevent exacerbations in multiple sclerosis (MS). To date, few studies have examined the relationship between disease activity and treatment adherence in MS. The primary aim of this study was to examine the association between disease activity (e.g., annualized relapse rates), medication adherence, and appointment adherence in relapsing-remitting MS. Retrospective exacerbation and appointment data were collected and used to predict prospective medication adherence. Results indicated that patients with higher annualized relapse rates missed fewer doses of medication and were less likely to miss appointments. Conversely, patients with relatively stable disease were more likely to demonstrate poor medication adherence and poor appointment adherence. Patients who missed more appointments also missed more doses of their disease modifying medication. Future studies may wish to examine clinical methods designed to improve immunotherapy adherence among patients who are in relatively symptom-free stages of relapsing-remitting MS.

Evidence for CRHR1 in multiple sclerosis using supervised machine learning and meta-analysis in 12,566 individuals

The primary genetic risk factor in multiple sclerosis (MS) is the HLA-DRB1*1501 allele; however, much of the remaining genetic contribution to MS has yet to be elucidated. Several lines of evidence support a role for neuroendocrine system involvement in autoimmunity which may, in part, be genetically determined. Here, we comprehensively investigated variation within eight candidate hypothalamic-pituitary-adrenal (HPA) axis genes and susceptibility to MS. A total of 326 SNPs were investigated in a discovery dataset of 1343 MS cases and 1379 healthy controls of European ancestry using a multi-analytical strategy. Random Forests, a supervised machine-learning algorithm, identified eight intronic SNPs within the corticotrophin-releasing hormone receptor 1 or CRHR1 locus on 17q21.31 as important predictors of MS. On the basis of univariate analyses, six CRHR1 variants were associated with decreased risk for disease following a conservative correction for multiple tests. Independent replication was observed for CRHR1 in a large meta-analysis comprising 2624 MS cases and 7220 healthy controls of European ancestry. Results from a combined meta-analysis of all 3967 MS cases and 8599 controls provide strong evidence for the involvement of CRHR1 in MS. The strongest association was observed for rs242936 (OR = 0.82, 95% CI = 0.74-0.90, P = 9.7 × 10(-5)). Replicated CRHR1 variants appear to exist on a single associated haplotype. Further investigation of mechanisms involved in HPA axis regulation and response to stress in MS pathogenesis is warranted.

Modifiable factors influencing relapses and disability in multiple sclerosis

A growing body of literature indicates that the natural course of multiple sclerosis can be influenced by a number of factors. Strong evidence suggests that relapses can be triggered by infections, the postpartum period and stressful life events. Vaccinations against influenza, hepatitis B and tetanus appear to be safe. Surgery, general and epidural anaesthesia, and physical trauma are not associated with an increased risk of relapses. Factors that have been associated with a reduced relapse rate are pregnancy, exclusive breastfeeding, sunlight exposure and higher vitamin D levels. A number of medications, including hormonal fertility treatment, seem to be able to trigger relapses. Factors that may worsen progression of disability include stressful life events, radiotherapy to the head, low levels of physical activity and low vitamin D levels. Strong evidence suggests that smoking promotes disease progression, both clinically and on brain magnetic resonance imaging. There is no evidence for an increased progression of disability following childbirth in women with multiple sclerosis. Moderate alcohol intake and exercise might have a neuroprotective effect, but this needs to be confirmed.

Effects of escitalopram on stress-related relapses in women with multiple sclerosis: an open-label, randomized, controlled, one-year follow-up study

A growing body of evidence supports the association between Stressful Life Events (SLEs) and increased risk for relapse in Multiple Sclerosis (MS). In this open-label, randomized, controlled, one-year prospective study we investigated the effects of escitalopram on stress-related relapses in 48 women with relapsing-remitting MS. Patients were randomly assigned either to receive escitalopram 10mg/day (e-group, N=24) or to continue with treatment as usual, as a control group (c-group, N=24). SLEs were documented weekly in self-report diaries and were classified afterwards as short- or long-term depending on their psychological impact as this was subjectively felt by the patient. The cumulative risk for relapse was 2.9 times higher for controls than for escitalopram-treated patients (95% CI=1.7-5.1, p<0.001) and it was influenced only by long-term SLEs. In the e-group only 3 or more long-term SLEs were associated with a significant increase of the risk of a relapse during the following 4 weeks, and this risk was 4 times lower compared to the c-group. Our study shows preliminary evidence that escitalopram may constitute an effective and well-tolerated treatment option for the prevention of stress-related relapses in women with MS.

Psychological stress and wound healing in humans: a systematic review and meta-analysis

OBJECTIVE

The current review aims to synthesize existing knowledge about the relationship between psychological stress and wound healing.

METHODS

A systematic search strategy was conducted using electronic databases to search for published articles up to the end of October 2007. The reference lists of retrieved articles were inspected for further studies and citation searches were conducted. In addition, a meta-analysis of a subset of studies was conducted to provide a quantitative estimation of the influence of stress on wound healing.

RESULTS

Twenty-two papers met the inclusion criteria of the systematic review and a subsample of 11 was included in a meta-analysis. The studies assessed the impact of stress on the healing of a variety of wound types in different contexts, including acute and chronic clinical wounds, experimentally created punch biopsy and blister wounds, and minor damage to the skin caused by tape stripping. Seventeen studies in the systematic review reported that stress was associated with impaired healing or dysregulation of a biomarker related to wound healing. The relationship between stress and wound healing estimated by the meta-analysis was r=-0.42 (95% CI=-0.51 to -0.32) (P<.01).

CONCLUSION

Attention now needs to be directed towards investigating potential moderators of the relationship, mediating mechanisms underpinning the association, as well as the demonstration of a causal link by the development of experimental interventions in healthy populations.