Elevated moral condemnation of third-party violations in multiple sclerosis patients

Distinguishing the role of positivity bias, cognitive impairment and emotional reactivity in the deontological preference in multiple sclerosis during moral dilemmas: a social cognition study protocol

Background

Multiple sclerosis (MS) is a chronic inflammatory and neurodegenerative disease of the central nervous system characterized by a broad and unpredictable range of symptoms, including cognitive and sociocognitive dysfunction. Among these social-cognitive functions, moral judgment has been explored in persons with MS (PwMS) using moral dilemmas, where participants must decide whether to sacrifice one person to save a greater number. Opting for such a sacrifice reflects utilitarian reasoning (sacrificing one for the benefit of many is deemed acceptable), while refusing reflects deontological reasoning (such sacrifice is considered morally wrong). Compared to controls, PwMS have been shown to make greater deontological moral choices in such dilemmas.

Objectives

While PwMS have demonstrated a higher tendency for deontological moral choices in moral dilemmas compared to controls, the underlying determinants of this reasoning pattern remain unclear. In this project, we aim to investigate cognitive, emotional, and motivational factors that may explain deontological decision-making in MS.

Methods and analysis

We will recruit a sample of 45 PwMS and 45 controls aged 18-55 years. The type of response, deontological or utilitarian, to a series of 20 vignettes of moral dilemmas will constitute the primary outcomes. Global cognitive performance, positivity bias, alexithymia and empathy levels as well as emotional reactivity measured by electrodermal activity (EDA) during moral dilemmas will be secondary outcomes.

Ethics and dissemination

Ethics approval was granted by a national ethical committee (CPP Ouest III, national number 2023-A00447-38). The project is sponsored by the ARSEP Foundation. Findings will be presented at national and international conferences, as well as published in peer-reviewed scientific journals.

Explicit and implicit abilities in humor processing in patients with relapsing-remitting multiple sclerosis

Sociocognitive impairment is well known in the relapsing-remitting form of multiple sclerosis (RR-MS). The purpose of the present study was to assess explicit and implicit humor abilities in this population. Based on clinical observation and contrary to the current cognitive model, we hypothesized that implicit performances (happy facial expressions) would be better than explicit ones (humor judgment assessed by explicit humor comprehension, subjective feeling of amusement as a conscious appreciation of funniness, and verbal justifications of funniness). Twenty-five RR-MS patients and twenty-five healthy participants completed the tasks. Their face was filmed during humor ratings. Patients' results suggest that 32% of them showed an impairment in explicit humor comprehension, with normal facial expressions. Both groups found great difficulty in justifying the cause of their amusement. All these results may suggest the existence of a supplementary implicit pathway in humor processing. The preservation of this implicit pathway may be advantageous for future remediation. Contrary to the current model, we found that the subjective feeling of amusement was preserved when comprehension was impaired. Further studies will be needed to clarify this component, and adjust the theoretical modeling.

[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.

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.

Multimodal emotion perception in young and elderly patients with multiple sclerosis

BACKGROUND

Studies suggest that emotion recognition and empathy are impaired in patients with MS (pwMS). Nonetheless, most studies are restricted to young samples, to facial emotion recognition and to self-report assessments of empathy. The aims of this study are to determine the impact of MS and age on multimodal emotion recognition (facial emotions and vocal emotional bursts) and on socioemotional sensitivity (as reported by the participants and their informants). We also aim to investigate the associations between emotion recognition, socioemotional sensitivity, and cognitive measures.

METHODS

We recruited 13 young healthy controls (HC), 14 young pwMS, 14 elderly HC and 15 elderly pwMS. They underwent a short neuropsychological battery, an experimental emotion recognition task including facial emotions and vocal emotional bursts. Both participants and their study informants completed the Revised-Self Monitoring Scale (RSMS) to assess the participant's socioemotional sensitivity.

RESULTS

There was a significant effect of age and group on recognition of both facial emotions and emotional vocal bursts, HC performing significantly better than pwMS, and young participants performing better than elderly participants (no interaction effect). The same effects were observed on self-reported socioemotional sensitivity. However, lower socioemotional sensitivity in pwMS was not reported by the informants. Finally, multimodal emotion recognition did not correlate with socioemotional sensitivity, but it correlated with global cognitive severity.

CONCLUSION

PwMS present with multimodal emotion perception deficits. Our results extend previous findings of decreased emotion perception and empathy to a group of elderly pwMS, in which advancing age does not accentuate these deficits. However, the decreased socioemotional sensitivity reported by pwMS does not appear to be observed by their relatives, nor to correlate with their emotion perception impairments. Future studies should investigate the real-life impacts of emotion perception deficits in pwMS.

Theory of Mind and Empathy in Adults With Epilepsy: A Meta-Analysis

Mounting evidence suggests that social cognitive abilities [including theory of mind (ToM) and empathy] are impaired in adult patients with epilepsy. Although the deficits in overall ToM in epilepsy have been documented well, the effects of epilepsy on empathic ability and specific subcomponents of ToM remain unclear. The primary aim of this study was to provide the first meta-analytic integration of ToM and empathy in adult patients with epilepsy, and to decompose these constructs to clearly differentiate their distinct (cognitive ToM and affective empathy) and overlapping (affective ToM/cognitive empathy) components. This meta-analysis included 28 studies. Adult patients with temporal lobe epilepsy (TLE) and frontal lobe epilepsy (FLE) showed impairments in cognitive ToM and affective ToM/cognitive empathy compared to the healthy controls (HCs); no group differences were identified for affective empathy. Besides, cognitive ToM was impaired in adult patients with idiopathic generalized epilepsy (IGE) and focal seizures (caused by epileptogenic foci) outside the temporal and frontal lobes (extra-TLE/FLE) and no group differences were evident for affective ToM/cognitive empathy compared to the HCs. Moreover, relative to the HCs, no group differences were identified for affective empathy in adult patients with IGE. Additionally, no (statistically) significant difference was observed between the magnitude of ToM/empathy impairment in adult patients who underwent and those who did not undergo epilepsy surgery. These quantitative findings suggest differential impairment of the core aspects of social cognitive processing in adult patients with epilepsy, which may contribute to the development of structured cognitive interventions (i.e., social cognitive training) for adult patients with epilepsy.

An fMRI investigation of the intention-outcome interactions in second- and third-party punishment

Second-party punishment (SPP) and third-party punishment (TPP) are two basic forms of costly punishment that play an essential role in maintaining social orders. Despite scientific breakthroughs in understanding that costly punishment is driven by an integration of the wrongdoers' intention and the outcome of their actions, so far, few studies have compared the neurocognitive processes associated with the intention-outcome integration between SPP and TPP. Here, we combined economic exchange games measuring SPP and TPP with functional magnetic resonance imaging (fMRI) to compare the neuropsychological architectures underlying the intention-outcome integration during one-shot interactions with anonymous partners across four types of norm violations (no norm, accidental, attempted, and intentional violations). Our behavioral findings showed that third-parties punished only attempted norm violations less frequently than second-parties. Our neuroimaging findings revealed higher activities in the right temporoparietal junction (TPJ) and dorsolateral prefrontal cortex (dlPFC) for attempted norm violations during TPP relative to SPP; more activities in these regions with less punishment frequency; and enhancement of functional connectivity of the right TPJ with the right dlPFC and dorsomedial PFC. Our findings demonstrated specific psychological and neural mechanisms of intention-outcome interactions between SPP and TPP -helping to unravel the complex neurocognitive processes of costly punishment.

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.

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.

Impairment in oral medical comprehension in multiple sclerosis

In multiple sclerosis (MS), medical comprehension of website information and informed consent is reported to be impaired. The aim of the present study was to investigate oral medical comprehension of literal, figurative and humorous language in MS through videos of physician-patient exchanges. A group of 35 MS patients was compared to a control group (38 healthy participants). Participants were shown twelve filmed sketches consisting of a patient's question followed by the doctor's response and had to choose the meaning of the physician's response among three possibilities. Group analyses (non-parametric tests, Mann-Whitney) revealed significantly lower scores for MS patients compared to controls for figurative and humorous items. The opposite was observed for literal items. At the individual level, 17% of MS patients were impaired in their comprehension of figurative items and 32% for humorous items. Among them, 20% were impaired in both categories, 20% selectively in figurative comprehension and 60% selectively in humorous comprehension. These preliminary results suggest that a high proportion of MS patients (40%) may be impaired in the non-literal comprehension of simple medical responses. The better performances obtained for literal items suggest a more concrete linguistic decoding in MS. On a theoretical level, the double dissociations shown between figurative and humorous items in patients are not compatible with a serial model of linguistic processing.

Impairments of humour comprehension in multiple sclerosis

BACKGROUND

Sociocognition is an important field of neuropsychology involving human interactions. In relapsing-remitting multiple sclerosis, it was recently demonstrated that sociocognition is severely and precociously impaired. Among sociocognitive abilities, humour has not yet been considered in this disease despite its important social functions, including during doctor-patient communication. Its main functions are to reduce stress when interactions become strained and to convey difficult messages in a gentle form. Thus, the inability to perceive this second degree of language is likely to generate a major social handicap. As humour is a higher cognitive process, its assessment requires the control of lower levels according to a serial model.

METHODS

The present humour comprehension protocol, based on a serial cognitive model, consisted of a first incongruity detection step (normality identification task) and a second incongruity resolution step (funniness identification task). This protocol was administered using both verbal and visual material (stories and cartoons). For each type of material, the participant had to decide which of three proposed endings was normal (normality identification) and which was funny (funniness identification). A group of 21 relapsing-remitting multiple sclerosis patients was compared to a control group of 38 healthy participants. In view of the severe impairment demonstrated for MS patients in other sociocognitive abilities, we predicted a deficit of humour comprehension in these patients in comparison with healthy participants. In reference to the serial model of humour, and considering the variability of MS lesions, our main goal was to test the hypothesis of a primary deficit in incongruity resolution (selective to funniness identification) in some MS patients whereas others may suffer a non-specific comprehension impairment (affecting both normality and funniness identification).

RESULTS

Group analyses (non-parametric tests, Mann-Whitney) revealed lower scores for relapsing-remitting multiple sclerosis patients compared to controls for the visual tasks (normality and funniness). No significant difference was found in the verbal tasks. At the individual level, 62% of relapsing-remitting multiple sclerosis patients showed impairment compared to controls for the funniness tasks. Moreover, 38% presented a selective deficit in the funniness tasks.

CONCLUSION

These preliminary results suggest that a high proportion of relapsing-remitting multiple sclerosis patients may be impaired in humour comprehension, some as a primary deficit and others as a secondary deficit to more general comprehension difficulties. On a theoretical level, the dissociations obtained between verbal and visual material do not support an amodal humour comprehension model.

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.

Moral Judgment: An Overlooked Deficient Domain in Multiple Sclerosis?

Multiple sclerosis (MS) is a chronic inflammatory and neurodegenerative disease of the central nervous system through which patients can suffer from sensory, motor, cerebellar, emotional, and cognitive symptoms. Although cognitive and behavioral dysfunctions are frequently encountered in MS patients, they have previously received little attention. Among the most frequently impaired cognitive domains are attention, information processing speed, and working memory, which have been extensively addressed in this population. However, less emphasis has been placed on other domains like moral judgment. The latter is a complex cognitive sphere that implies the individuals’ ability to judge others’ actions and relies on numerous affective and cognitive processes. Moral cognition is crucial for healthy and adequate interpersonal relationships, and its alteration might have drastic impacts on patients’ quality of life. This work aims to analyze the studies that have addressed moral cognition in MS. Only three works have previously addressed moral judgement in this clinical population compared to healthy controls, and none included neuroimaging or physiological measures. Although scarce, the available data suggest a complex pattern of moral judgments that deviate from normal response. This finding was accompanied by socio-emotional and cognitive deficits. Only preliminary data are available on moral cognition in MS, and its neurobiological foundations are still needing to be explored. Future studies would benefit from combining moral cognitive measures with comprehensive neuropsychological batteries and neuroimaging/neurophysiological modalities (e.g., functional magnetic resonance imaging, tractography, evoked potentials, electroencephalography) aiming to decipher the neural underpinning of moral judgement deficits and subsequently conceive potential interventions in MS patients.

The behavioral and neural basis of empathic blame

Mature moral judgments rely both on a perpetrator’s intent to cause harm, and also on the actual harm caused–even when unintended. Much prior research asks how intent information is represented neurally, but little asks how even unintended harms influence judgment. We interrogate the psychological and neural basis of this process, focusing especially on the role of empathy for the victim of a harmful act. Using fMRI, we found that the ‘empathy for pain’ network was involved in encoding harmful outcomes and integrating harmfulness information for different types of moral judgments, and individual differences in the extent to which this network was active during encoding and integration of harmfulness information determined severity of moral judgments. Additionally, activity in the network was down-regulated for acceptability, but not blame, judgments for accidental harm condition, suggesting that these two types of moral evaluations are neurobiologically dissociable. These results support a model of “empathic blame”, whereby the perceived suffering of a victim colors moral judgment of an accidental harmdoer.

Social cognition in aggressive offenders: Impaired empathy, but intact theory of mind

Aggressive, violent behaviour is a major burden and challenge for society. It has been linked to deficits in social understanding, but the evidence is inconsistent and the specifics of such deficits are unclear. Here, we investigated affective (empathy) and cognitive (Theory of Mind) routes to understanding other people in aggressive individuals. Twenty-nine men with a history of legally relevant aggressive behaviour (i.e. serious assault) and 32 control participants were tested using a social video task (EmpaToM) that differentiates empathy and Theory of Mind and completed questionnaires on aggression and alexithymia. Aggressive participants showed reduced empathic responses to emotional videos of others' suffering, which correlated with aggression severity. Theory of Mind performance, in contrast, was intact. A mediation analysis revealed that reduced empathy in aggressive men was mediated by alexithymia. These findings stress the importance of distinguishing between socio-affective and socio-cognitive deficits for understanding aggressive behaviour and thereby contribute to the development of more efficient treatments.

Neuroanatomical correlates of forgiving unintentional harms

Mature moral judgments rely on the consideration of a perpetrator’s mental state as well as harmfulness of the outcomes produced. Prior work has focused primarily on the functional correlates of how intent information is neurally represented for moral judgments, but few studies have investigated whether individual differences in neuroanatomy can also explain variation in moral judgments. In the current study, we conducted voxel-based morphometry analyses to address this question. We found that local grey matter volume in the left anterior superior temporal sulcus, a region in the functionally defined theory of mind or mentalizing network, was associated with the degree to which participants relied on information about innocent intentions to forgive accidental harms. Our findings provide further support for the key role of mentalizing in the forgiveness of accidental harms and contribute preliminary evidence for the neuroanatomical basis of individual differences in moral judgments.