Do positive or negative stressful events predict the development of new brain lesions in people with multiple sclerosis?

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.

Similar neural pathways link psychological stress and brain-age in health and multiple sclerosis

Clinical and neuroscientific studies suggest a link between psychological stress and reduced brain health in health and neurological disease but it is unclear whether mediating pathways are similar. Consequently, we applied an arterial-spin-labeling MRI stress task in 42 healthy persons and 56 with multiple sclerosis, and investigated regional neural stress responses, associations between functional connectivity of stress-responsive regions and the brain-age prediction error, a highly sensitive machine learning brain health biomarker, and regional brain-age constituents in both groups. Stress responsivity did not differ between groups. Although elevated brain-age prediction errors indicated worse brain health in patients, anterior insula-occipital cortex (healthy persons: occipital pole; patients: fusiform gyrus) functional connectivity correlated with brain-age prediction errors in both groups. Finally, also gray matter contributed similarly to regional brain-age across groups. These findings might suggest a common stress-brain health pathway whose impact is amplified in multiple sclerosis by disease-specific vulnerability factors.

C-Reactive Protein Levels and Gadolinium-Enhancing Lesions Are Associated With the Degree of Depressive Symptoms in Newly Diagnosed Multiple Sclerosis

Background: Inflammation is essential for the pathogenesis of multiple sclerosis (MS). While the immune system contribution to the development of neurological symptoms has been intensively studied, inflammatory biomarkers for mental symptoms such as depression are poorly understood in the context of MS. Here, we test if depression correlates with peripheral and central inflammation markers in MS patients as soon as the diagnosis is established. Methods: Forty-four patients were newly diagnosed with relapsing-remitting MS, primary progressive MS or clinically isolated syndrome. Age, gender, EDSS, C-reactive protein (CRP), albumin, white blood cells count in cerebrospinal fluid (CSF WBC), presence of gadolinium enhanced lesions (GE) on T1-weighted images and total number of typical MS lesion locations were included in linear regression models to predict Beck Depression Inventory (BDI) score and the depression dimension of the Symptoms Checklist 90-Revised (SCL90RD). Results: CRP elevation and GE predicted significantly BDI (CRP: p = 0.007; GE: p = 0.019) and SCL90RD (CRP: p = 0.004; GE: p = 0.049). The combination of both factors resulted in more pronounced depressive symptoms (p = 0.04). CSF WBC and EDSS as well as the other variables were not correlated with depressive symptoms. Conclusions: CRP elevation and GE are associated with depressive symptoms in newly diagnosed MS patients. These markers can be used to identify MS patients exhibiting a high risk for the development of depressive symptoms in early phases of the disease.

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.

Stressful life events can predict post-stroke fatigue in patients with ischemic stroke

OBJECTIVE

To investigate whether stressful life events (SLEs) can predict post-stroke fatigue (PSF) in patients with acute ischemic stroke (AIS).

METHODS

This prospective cohort study included data from patients with AIS who were followed up to 2-year interview. PSF was assessed at admission and at 6 (n = 916), 12 (n = 880), and 24 (n = 857) months with the fatigue severity scale (FSS). SLEs were measured with the Social Readjustment Rating Scale questionnaire at 6, 12 and 24 months' interview.

RESULTS

A significant dose-response association was found between SLEs and FSS score across all examined time-points: compared with those did not experience SLEs, FSS score was higher for those experiencing SLEs ≥3 at 6 months (β 0.53, 95% CI 0.28-0.78), 12 months (β 0.54, 95% CI 0.30-0.78) and 24 months (β 0.48, 95% CI 0.29-0.68). Longitudinal analyses indicated a significantly positive relationship between the number of SLEs and FSS score (SLEs: ≥3 vs. 0, β 0.14, 95% CI 0.09-0.19). Moreover, a distinct interaction of follow-up time and SLE numbers on FSS score was observed (p < 0.05), which means elevated exposure to SLEs during follow-up was associated with a lower rate of fatigue decline. A similar association was found in SLE load analysis.

CONCLUSION

Patients with severe fatigue were more likely to report increased number of SLEs in the previous 6 months, which could suggest that a non-specific stressful event leads to an extra burden to an already vulnerable psychological system.

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.

Patient and Provider Insights into the Impact of Multiple Sclerosis on Mental Health: A Narrative Review

Multiple sclerosis (MS) is a chronic disease in which the immune system attacks the central nervous system, causing inflammation and neurodegeneration. People living with MS may experience a variety of symptoms as a consequence of this process, including many “invisible” symptoms that are internally manifested and not seen by others. Of the invisible symptoms of MS, which we have reviewed in a companion article, mood and mental health disorders are of particular concern due to their high prevalence and significant impact on patient quality of life. In this review, we showcase the experiences of patient authors alongside perspectives from healthcare provider authors as we promote awareness of the common mental health conditions faced by those living with MS, such as depression, anxiety, adjustment disorder, bipolar disorder, psychosis, and suicidal ideation. Many of these conditions stem in part from the increased stress levels and the many uncertainties that come with managing life with MS, which have been exacerbated by the environment created by the coronavirus disease 2019 (COVID-19) pandemic. A patient-centered interdisciplinary approach, routine screening for mental health changes, and referral to specialists when needed can normalize discussions of mental health and increase the likelihood that people living with MS will receive the support and care they need. Management techniques such as robust social support, cognitive behavioral therapy, mindfulness-based interventions, and/or pharmacotherapy may be implemented to build resilience and promote healthy coping strategies. Increasingly, patients have access to telehealth options as well as digital apps for mental health management. Taken together, these approaches form an integrative care model in which people living with MS benefit from the care of medical professionals, a variety of support networks/resources, and self-management techniques for optimal mental health care.

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.

Using hypnoanalysis and guided imagery to identify and manage emotional aspects of multiple sclerosis

BACKGROUND

To date, no studies have used hypnosis to examine and manage the potential emotional causes of multiple sclerosis (MS) in the scientific field; therefore, we decided to compare the effectiveness of hypnoanalysis and guided imagery for determining and manage these emotional causes.

METHODS

Fifteen participants with severe MS were included and assigned into 2 groups: hypnoanalysis and guided imagery. In the hypnoanalysis group, the participants underwent 10 hypnotic sessions to understand events related to the cause of the disease, which were restructured (the events were modified by adding the psychological resources that each involved person needed); in addition, other techniques were used to investigate the causes and solutions according to the participants' unconscious. The guided imagery group received 10 group sessions of body relaxation and guided imagery, which were recorded for practice at home. Outcome measures, namely, disability (the Expanded Disability Status Scale, EDSS), quality of life (QoL, measured with the SF-36) and number of relapses, were evaluated 4 months previous the intervention, at baseline, post-intervention, and 3 months later.

RESULTS

Hypnoanalysis revealed that stressful events and psychoemotional maladaptive patterns acted as causal, detonating, or aggravating factors of disease, and psychoemotional changes were the most frequent and varied solutions. No changes were observed in disability between the two groups. The guided imagery group showed an improvement in 2 subscales of QoL when compared with the hypnoanalysis group (which disappeared at the follow-up); this difference is probably due to the increased number of sessions and probably due to psychoemotional maladaptive patterns being more frequently mentioned than difficult circumstances in life and/or unsolved past events. However, the techniques used in hypnoanalysis were effective in understanding the potential emotional causes of MS, which showed high intra- and inter-participant consistency.

CONCLUSIONS

The daily use of guided imagery overcame the restructuring of negative past events to improve QoL in patients with MS.

TRIAL REGISTRATION

ACTRN12618002024224 (retrospectively registered).

[Radiologically isolated syndrome: prognosis and predictors of conversion to multiple sclerosis]

Increased sensitivity and availability of magnetic resonance imaging (MRI) in neurological routine practice led to the fact that more and more experts began to encounter changes typical for multiple sclerosis (MS) according to MRI in the absence of anamnestic and clinical indications of damage to the central nervous system (CNS). This nosological form has been defined as a radiologically isolated syndrome (RIS). More and more RIS cases convert to MS (up to 30% in the first 5 years after RIS diagnosis). At the moment, there are no biological markers that allow combining RIS and MS into one pathological process and early treatment with disease-modifying drugs (DMT). Prospective studies are actively being conducted to identify demographic, clinical, neuroimaging and biochemical conversion predictors. The identification of the molecular biological RIS features, combining these changes with MS, is an urgent scientific task and will allow timely initiation of therapy of the pathological process already at the subclinical stage.

Development and Validation of Fear of Relapse Scale for Relapsing-Remitting Multiple Sclerosis: Understanding Stressors in Patients

Chronic diseases are associated with patients' long-term stress and development of fear to things related to the source of stress. Better management of a patients' condition requires investigation of the underlying mechanisms that contribute to the process of development of chronic stress. Multiple Sclerosis (MS) is a debilitating chronic disease in most cases diagnosed after a relapse and characterized by the periodic occurrence of relapses in most patients. Due to the unpredictable course of the disease and relapses, patients with Relapsing-Remitting MS (RRMS) may deal with the stress of anticipation of relapse and its unpredictable consequences. The role of relapses and related stress on patients' quality of life has not been previously investigated. This study is the first effort to develop a self-report measure of Fear of Relapse (FoR) in patients with RRMS. Thirty-one items were extracted from in-depth clinical interviews with 33 RRMS patients to develop the preliminary version of the scale. Subsequently, 168 RRMS patients completed the questionnaire, the Intolerance of Uncertainty Scale (IUS) and Depression, Anxiety, and Stress Scale (DASS). Fifty-one patients completed the scale one more time a month later. Factor analysis revealed three components, and five items failed to load on any of them. To test the FoR's independence from similar measures, responses to 26 items were pooled once with DASS items and once with IUS items, and each time were subjected to confirmatory factor analysis (two-component solution). Despite significant correlations between FoR, DASS, and IUS Independent loadings of items belonging to FoR and DASS, and FoR and IUS revealed independence and unique contribution of FoR to the evaluation of patients. Cronbach's alpha for the 26-item version was 0.92. Test-retest reliability for total score was equal to 0.74. These findings provide preliminary evidence of the validity and reliability of the measure. This scale can help researchers and clinicians to have a more comprehensive understanding of patients' experience with the uncertain nature of MS, which is necessary for future efforts to address this stressor by targeting the underlying mechanism.

[Norepinephrine and intestinal microbiome in the early stages of demyelination: clinical-immunological parallels]

Biogenic amines are key mediators of neuroimmune interaction and may influence on multiple sclerosis (MS) pathogenesis and MS course. At the same time, the role of biogenic amines in immunoregulation of early stages of demyelination, in particular clinically isolated syndrome (CIS) and radiologically isolated syndrome (RIS) is still unclear. This literature review addresses a role of norepinephrine in the regulation of neuroimmune interactions in the early stages of the demyelination. Neuropsychological disorders, immunological characteristics, gut-brain axis as well as the role of norepinephrine in these interactions in patients with CIS, RIS and early MS are discussed.

Behavioural phenotypes in the cuprizone model of central nervous system demyelination

The feeding of cuprizone (CPZ) to animals has been extensively used to model the processes of demyelination and remyelination, with many papers adopting a narrative linked to demyelinating conditions like multiple sclerosis (MS), the aetiology of which is unknown. However, no current animal model faithfully replicates the myriad of symptoms seen in the clinical condition of MS. CPZ ingestion causes mitochondrial and endoplasmic reticulum stress and subsequent apoptosis of oligodendrocytes leads to central nervous system demyelination and glial cell activation. Although there are a wide variety of behavioural tests available for characterizing the functional deficits in animal models of disease, including that of CPZ-induced deficits, they have focused on a narrow subset of outcomes such as motor performance, cognition, and anxiety. The literature has not been systematically reviewed in relation to these or other symptoms associated with clinical MS. This paper reviews these tests and makes recommendations as to which are the most important in order to better understand the role of this model in examining aspects of demyelinating diseases like MS.

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.

A 67-item stress resilience item bank showing high content validity was developed in a psychosomatic sample

OBJECTIVES

To develop the first item bank to measure stress resilience (SR) in clinical populations.

STUDY DESIGN AND SETTING

Qualitative item development resulted in an initial pool of 131 items covering a broad theoretical SR concept. These items were tested in n = 521 patients at a psychosomatic outpatient clinic. Exploratory and confirmatory factor analysis, as well as other state-of-the-art item analyses and item response theory were used for item evaluation and calibration of the final item bank.

RESULTS

Of the initial item pool of 131 items, we excluded 64 items (54 factor loading <0.5, four residual correlations >0.3, two nondiscriminative item response curves, and four differential item functioning). The final set of 67 items indicated sufficient model fit in confirmatory factor analysis and item response theory analyses. In addition, a 10-item short form with high measurement precision (SE ≤ 0.32 in a theta range between -1.8 and +1.5) was derived. Both the SR item bank and the SR short form were highly correlated with an existing static legacy tool (Connor-Davidson Resilience Scale).

CONCLUSION

The final SR item bank and 10-item short form showed good psychometric properties. When further validated, they will be ready to be used within a framework of computer-adaptive tests for a comprehensive assessment of the stress construct.

Adverse Childhood Experiences Are Linked to Age of Onset and Reading Recognition in Multiple Sclerosis

Background

Adverse childhood experiences (ACEs) exert a psychological and physiological toll that increases risk of chronic conditions, poorer social functioning, and cognitive impairment in adulthood.

Objective

To investigate the relationship between childhood adversity and clinical disease features in multiple sclerosis (MS).

Methods

Sixty-seven participants with MS completed the ACE assessment and neuropsychological assessments as part of a larger clinical trial of cognitive remediation.

Results

Adverse childhood experience scores, a measure of exposure to adverse events in childhood, significantly predicted age of MS onset (r = –0.30, p = 0.04). ACEs were also linked to reading recognition (a proxy for premorbid IQ) (r = –0.25, p = 0.04). ACE scores were not related to age, current disability, or current level of cognitive impairment measured by the Symbol Digit Modalities Test (SDMT).

Conclusion

Childhood adversity may increase the likelihood of earlier age of onset and poorer estimated premorbid IQ in MS.

Stressful life events and the risk of initial central nervous system demyelination

BACKGROUND

There is substantial evidence that stress increases multiple sclerosis disease activity, but limited evidence on its association with the onset of multiple sclerosis.

OBJECTIVE

To examine the association between stressful life events and risk of first demyelinating event (FDE).

METHODS

This was a multicentre incident case-control study. Cases ( n = 282 with first diagnosis of central nervous system (CNS) demyelination, including n = 216 with 'classic FDE') were aged 18-59 years. Controls without CNS demyelination ( n = 558) were matched to cases on age, sex and study region. Stressful life events were assessed using a questionnaire based on the Social Readjustment Rating Scale.

RESULTS

Those who suffered from a serious illness in the previous 12 months were more likely to have an FDE (odds ratio (OR) = 2.35 (1.36, 4.06), p = 0.002), and when we limited our reference group to those who had no stressful life events, the magnitude of effect became stronger (OR = 5.41 (1.80, 16.28)). The total stress number and stress load were not convincingly associated with the risk of an FDE.

CONCLUSION

Cases were more likely to report a serious illness in the previous 12 months, which could suggest that a non-specific illness provides an additional strain to an already predisposed immune system.

Reserve and Reserve-building activities research: key challenges and future directions

Background

The concept of Cognitive Reserve has great appeal and has led to an interesting and important body of research. We believe, however, that it is unnecessarily limited by ‘habits’ of measurement, nomenclature, and intra-disciplinary thinking.

Main body

A broader, more comprehensive way of conceptualizing Reserve is proposed that invokes a broader measurement approach, nomenclature that uses specific terms embedded in a theoretical model, and crosses disciplines.

Conclusion

Building on this comprehensive conceptualization, we will discuss fruitful directions for future research.

The effects of progressive muscular relaxation as a nursing procedure used for those who suffer from stress due to multiple sclerosis

Objective:

to evaluate the effect of progressive muscle relaxation as a nursing procedure on the levels of stress for sufferers of multiple sclerosis.

Method:

random clinical trials conducted at the Neurology outpatients unit at a University Hospital. The sample consisted of 40 patients who were being monitored as outpatients (20 in a control group and 20 in an experimental group). The Progressive Muscle Relaxation technique was used. The control variables were collected through interviews that were recorded on forms and on the Perceived Stress Scale that we used. Five meetings were held every fortnight covering a period of eight weeks. The experimental group was advised to carry out daily progressive muscle relaxation activities. After eight weeks of these activities, they were evaluated again to measure their levels of stress. In order to analyze the data used, the software package Statistics for Social Sciences version 19.0 was used.

Results:

the application of the t test showed a significant reduction in the Perceived Stress Scale scores in the experimental group (p<0.001), which in turn proved that there was a reduction in the levels of stress after the application of the relaxation practic-es.

Conclusion:

the progressive muscle relaxation activities contributed to the reduction in stress levels for multiple sclerosis suffers and thus can be used in nursing for patients. Clinical Trials Identifier: NCT 02673827.

Depression in multiple sclerosis: effect of brain derived neurotrophic factor Val66Met polymorphism and disease perception

BACKGROUND AND PURPOSE

Depression is common amongst subjects with multiple sclerosis (MS), and several investigations have explored different determinants of this condition, including physical disability, psychological and psychosocial factors. The brain derived neurotrophic factor (BDNF) Val66Met polymorphism has been associated with depression. The aim of this study was to analyze the influence of disease-related factors, BDNF Val66Met polymorphism and perception of disease on the severity of depression in MS.

METHOD

In total, 136 MS patients (88 women) were recruited and genotyped for BDNF rs6265 polymorphism at nucleotide 196 (G/A) using 'high resolution melting'. Depressive symptoms were assessed by the Multiple Sclerosis Depression Rating Scale. Perception of health status was assessed using the SF-36 questionnaire.

RESULTS

A multivariable linear regression model showed that the best predictors of depression were the SF-36 General health (β = -0.209; P = 0.013), Mental health (β = -0.410; P < 0.001) and Social activity (β = -0.195; P = 0.035) scores; physical disability (assessed by the Extended Disability Status Scale score) was directly correlated to depression severity on univariate analysis, but it was not a relevant predictor of depression on multivariate analysis; other variables directly related to the disease (treatment, annual relapsing rate) and the BDNF Val66Met polymorphism were not significantly associated with depression.

CONCLUSION

Perception of the health status is the principal predictor of depressive symptoms in our sample. This result supports the hypothesis that the subjective interpretation of the disease's consequences is one of the main factors in determining depression in MS.

Antivirus immune activity in multiple sclerosis correlates with MRI activity

OBJECTIVE

The objective of this study was to determine whether reactivation of Epstein-Barr (EBV) or activation of the anti-EBV immune response correlates with MS disease activity on MR imaging.

METHODS

Subjects with early, active relapsing-remitting MS were studied for 16 weeks with blood and saliva samples collected every 2 weeks and brain MRI performed every 4 weeks. We isolated peripheral blood mononuclear cells from each blood sample and tested the immune response to EBV, autologous EBV-infected lymphoblastoid cell lines (LCL), human herpesvirus 6 (HHV6), varicella zoster virus (VZV), tetanus, and mitogens. We measured the proliferative response and the number of interferon-γ secreting cells with ELISPOT. We measured the amounts of EBV, HHV6, and VZV DNA in blood and saliva with quantitative PCR. On MRI, we measured number and volume of contrast enhancing and T2 lesions. We tested for correlation between the immunologic assays and the MRI results, assessing different time intervals between the MRI and immunologic assays.

RESULTS

We studied 20 subjects. Ten had enhancing lesions on one or more MRI scans and one had new T2 lesions without enhancement. The most significant correlation was between proliferation to autologous LCL and the number of combined unique active lesions on MRI 4 weeks later. Both proliferation and number of cells secreting interferon-γ in response to LCL correlated with the number of enhancing lesions 8 weeks later.

CONCLUSIONS

We find evidence for correlation of antiviral immune responses in the blood with subsequent disease activity on MRI scans.

Magnitude and concurrence of anxiety and depression among attendees with multiple sclerosis at a tertiary care Hospital in Oman

Background

Anxiety, depression and functional impairments are commonly reported by persons with multiple sclerosis (PwMS) but no data, to our knowledge, has emerged from an Arab Islamic population. The study aims to investigate the prevalence of anxiety, depression and related disabilities among PwMS attending tertiary care in Sultan Qaboos University Hospital (SQUH), one of the urban hospitals in Oman.

Methods

Consecutive and consenting PwMS (n = 57) and healthy subjects (n = 53) completed the following measures: Hospital Anxiety and Depression Scale (HADS) which was used to measure anxiety (cut-point >7) and depression (>7); and Expanded Disability Status Scale (EDSS) to measure the level of disability (≥5). Characteristics such as socio-demographic and clinical variables were also explored.

Results

Fifty seven subjects with multiple sclerosis (MS) met the inclusion criteria. The majority of them were females who were 40 years old or younger and the majority were employed and unmarried. Approximately 86 % of the participants were using beta interferon, 96 % scored ≥5 in EDSS. MS of the Relapsing-Remitting type constituted the majority of the cohort (94 %). Approximately 35 % and 51 % endorsed symptoms of anxiety and depression respectively. The MS group scored significantly higher than controls on HADS measurements of depression and anxiety.

Conclusion

Disability and symptoms of anxiety and depression are common among the PwMS attendees of tertiary care hospital in Oman. Such psychosocial variables have been largely unreported emerging from non-western populations. As these variables are strong indicators of the burden of MS, resolute effort is needed to address such psychosocial dysfunctions in the algorithms of care for PwMS in the Arab Islamic part of the world.

A systems approach to stress, stressors and resilience in humans

The paper focuses on the biology of stress and resilience and their biomarkers in humans from the system science perspective. A stressor pushes the physiological system away from its baseline state toward a lower utility state. The physiological system may return toward the original state in one attractor basin but may be shifted to a state in another, lower utility attractor basin. While some physiological changes induced by stressors may benefit health, there is often a chronic wear and tear cost due to implementing changes to enable the return of the system to its baseline state and maintain itself in the high utility baseline attractor basin following repeated perturbations. This cost, also called allostatic load, is the utility reduction associated with both a change in state and with alterations in the attractor basin that affect system responses following future perturbations. This added cost can increase the time course of the return to baseline or the likelihood of moving into a different attractor basin following a perturbation. Opposite to this is the system's resilience which influences its ability to return to the high utility attractor basin following a perturbation by increasing the likelihood and/or speed of returning to the baseline state following a stressor. This review paper is a qualitative systematic review; it covers areas most relevant for moving the stress and resilience field forward from a more quantitative and neuroscientific perspective.

Managing psychological stress in the multiple sclerosis medical visit: Patient perspectives and unmet needs

Psychological stress can negatively impact multiple sclerosis. To further understand how stress is addressed in the multiple sclerosis medical visit, 34 people with multiple sclerosis participated in focus groups. Transcripts were analyzed by inductive thematic analysis. The majority of participants did not discuss stress with their provider, citing barriers to communication such as lack of time, poor coordination between specialties, physician reliance on pharmaceutical prescription, and patient lack of self-advocacy. Participants recommended several ways to better manage psychological well-being in the clinical setting. These findings provide a foundation for future studies aimed at minimizing the detrimental effect of stress in multiple sclerosis.