Stress regulation in multiple sclerosis: current issues and concepts

A Self-Reported Study on Explanatory Variables of Stress in Multiple Sclerosis Patients: Exploring the Effect of Physical Conditions and Emotion Regulation Processes

BACKGROUND

Multiple sclerosis (MS)-linked stress is frequent, multidetermined and facilitates the onset/exacerbation of MS. However, few explanatory models of stress analysed the joint explanatory effect of emotion regulation and clinical outcomes of MS in those patients.

OBJECTIVE

This study explored whether self-reported MS-related conditions (number of relapses, fatigue and global disability) and specific emotion regulation processes (experiential avoidance and self-compassion) explain stress symptoms in MS patients.

METHODS

The MS sample comprised 101 patients with MS diagnosis receiving treatment in hospitals and recruited through the Portuguese MS Society. The no-MS sample included 134 age-, sex- and years of education-matched adults without MS recruited from the general Portuguese population. Both samples did not report other neurological disorders. Data were collected using self-response measures.

RESULTS

All potential explanatory variables differed significantly between samples, with higher scores found in MS patients. In MS clinical sample, those variables and years of education correlated with stress symptoms and predicted stress symptoms in simple linear regression models. These results allowed their selection as covariates in a multiple linear regression model. Years of education, the number of relapses, fatigue and experiential avoidance significantly predicted 51% of stress symptoms' total variance.

CONCLUSIONS

This study provides preliminary evidence on the importance of clinicians and researchers considering the simultaneous contribution of years of education, the number of perceived relapses, fatigue and experiential avoidance as factors that can increase vulnerability to stress in MS patients. Psychological intervention programmes that tackle these factors and associated stress symptomatology should be implemented.

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.

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.

Coping with stress during the first wave of the COVID-19 pandemic by Turkish people with Multiple Sclerosis: The relationship between perceived stress and quality of life

Background

Multiple sclerosis (MS) is a chronic inflammatory disease and acute exacerbations are also a part of the clinical course. The presence of the disease and relapses cause stress in people with MS (pwMS). For this reason, stress coping strategies of the patients are important in reducing perceived stress. Our aim in this study is to evaluate which strategies pwMS use during the COVID-19 pandemic, the effect of the strategies on perceived stress, their relationship with relapses and their role on quality of life (QoL).

Methods

An online form including Perceived Stress Scale (PSS; 10 items), Coping with Experienced Problems Scale (Brief-COPE; 28 items) and SF-12 were sent to 340 pwMS under our follow-up.

Results

During the COVID-19 pandemic, we found that the patients used the strategies of turn to religion, planning and acceptance at a high rate. PSS score was high in 23 (11.2%) of the patients. The patients with low perceived stress used the acceptance strategy more (P=0.008). We found a negative correlation between physical component summary (PCS) of SF-12 and denial (r=-0.2, p<0.001) and distraction (r =-0.1, p=0.04). A negative correlation was found between mental component summary (MCS) of SF-12 and behavioral disconnection (r=-0.2, p=0.006). There was a positive correlation between MCS and humor (r=0.1, p=0.04), use of instrumental support (r=0.2, p=0.009), planning (r=0.1, p=0.04), and positive reframing (r=0.2, p=0.002).

Conclusion

PwMS have been successful in coping with stress in the first half of the pandemic with the combination of emotional and problem-focused strategies. Acceptance strategy was highly adopted by patients with low PSS, and the tendency to use the active coping strategy together with the acceptance strategy was high in patients without relapses. Adoption to emotional strategies may have prevented the severe deterioration in QoL in this study group in the early period of 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.

Understanding barriers, enablers, and long-term adherence to a health behavior intervention in people with multiple sclerosis

Background: The optimal management strategy for multiple sclerosis (MS), and many other chronic diseases, likely involves health behavior modification. Multimodal behavioral interventions may be most effective, but little is known about long-term adherence in people with MS.Methods: This qualitative study assessed barriers and enablers to long-term adherence by people with MS who self-selected for a 5-day health behavior intervention 3-5 years prior. Thirteen women and five men participated in semi-structured phone interviews, which were transcribed and thematically analyzed.Results: The experience was described as useful for information gathering, decision making, and practical strategies regarding health behaviors. The majority still followed supplementation and dietary recommendations most of the time, although consuming non-recommended food while eating out was common. Support at home, ability and enjoyment in food preparation, and ability to resist unhealthy foods were both barriers and enablers. Adherence to "time-consuming" exercise and meditation recommendations were less common and episodic. Many reported competing interests on time from work and family; and barriers including injuries and symptoms, weather, financial or geographical barriers, and lack of person-centred support and motivation. Increased fitness and mobility, weight loss, and a sense of accomplishment and control were advantages and motivators. Practical and attitudinal strategies employed included planning, tailoring activities to ability and preference, and self-monitoring.Conclusion: While most people attempted to engage with all components of the intervention initially, only some still engaged with all components, and none to the recommended levels. These data can inform future quantitative studies and health behavior interventions.Implications for rehabilitationA multimodal group lifestyle intervention may be useful to assist people with multiple sclerosis in information gathering, decision making, attitudinal changes, and practical strategies regarding health behaviors; as well as providing a sense of hope for the future and control over wellbeing.While participants are unlikely to engage with all components of a multimodal intervention to the recommended level, they are likely to make improvements to one or more health behaviors.Experiential learning, including going through recipes and ingredient lists, and practicing meditation and physical exercises, is helpful to instigate behavior change.The initiation and maintenance of behavior change was assisted by support from family, friends, and health practitioners; and practical strategies employed by participants, including planning, self-monitoring, and tailoring activities to ability and preference.

Into the Moment: Does Mindfulness Affect Biological Pathways in Multiple Sclerosis?

Mindfulness was introduced in the Western world by Jon Kabat-Zinn in 1979. He defined it as "awareness that arises through paying attention, on purpose, in the present moment, non-judgmentally." Since then, research on mindfulness-based interventions (MBIs) has increased exponentially both in health and disease, including in patients with neurodegenerative diseases such as dementia and Parkinson's disease. Research on the effect of mindfulness and multiple sclerosis (MS) only recently gained interest. Several studies completed since 2010 provided evidence that mindfulness improves quality of life (QoL), depression and fatigue in MS patients. In addition to patient-reported outcome measures, potential effects on cognitive function have been investigated only to a very limited extent. However, research on laboratory biomarkers and neuroimaging, capable to deliver proof-of-concept of this behavioral treatment in MS, is mainly lacking. In this perspective, we illustrate possible neurobiological mechanisms, including the tripartite interaction between the brain, the immune system and neuroendocrine regulation, through which this treatment might affect multiple sclerosis symptoms. We propose to (1) include immunological and/or neuroimaging biomarkers as standard outcome measures in future research dedicated to mindfulness and MS to help explain the clinical improvements seen in fatigue and depression; (2) to investigate effects on enhancing cognitive reserve and cognitive function; and (3) to investigate the effects of mindfulness on the disease course in MS.

Chronic mild stress exacerbates severity of experimental autoimmune encephalomyelitis in association with altered non-coding RNA and metabolic biomarkers

The causal factors determining the onset and severity of multiple sclerosis (MS) are not well understood. Here, we investigated the influence of chronic stress on clinical symptoms, metabolic and epigenetic manifestations of experimental autoimmune encephalomyelitis (EAE), a common animal model of MS. Lewis rats were immunized for monophasic EAE with MBP_69-88 and were exposed to chronic stress for 37days starting 7days prior to immunization. The exposure to stress accelerated and exacerbated the clinical symptoms of EAE. Both stress and EAE also disrupted metabolic status as indicated by trace elemental analysis in body hair. Stress particularly exacerbated chlorine deposition in EAE animals. Moreover, deep sequencing revealed a considerable impact of stress on microRNA expression in EAE. EAE by itself upregulated microRNA expression in lumbar spinal cord, including miR-21, miR-142-3p, miR-142-5p, miR-146a, and miR-155. Stress in EAE further up-regulated miR-16, miR-146a and miR-155 levels. The latter two microRNAs are recognized biomarkers of human MS. Thus, stress may synergistically exacerbate severity of EAE by altering epigenetic regulatory pathways. The findings suggest that stress may represent a significant risk factor for symptomatic deterioration in MS. Stress-related metabolic and microRNA signatures support their value as biomarkers for predicting the risk and severity of MS.

Corticosteroid receptor expression and in vivo glucocorticoid sensitivity in multiple sclerosis

To estimate the efficiency of glucocorticoid signaling in multiple sclerosis in vivo, we measured mRNA expression of glucocorticoid receptor (GR), mineralocorticoid receptor (MR) and four genes regulated by GR and implicated in immune function, in whole blood. GR expression and MR expression were significantly lower in 52 patients than in 18 controls. In contrast, expression of GR regulated genes was increased (significantly for glucocorticoid induced leucine zipper, GILZ), especially in mildly impaired patients. Reduced GR expression appears to be compensated, either by hyperactive hypothalamo-pituitary-adrenal axis or by intracellular adaptations.

The effects of massage therapy on multiple sclerosis patients' quality of life and leg function

Background. Massage therapy is a noninvasive treatment that many individuals with multiple sclerosis (MS) use to supplement their conventional treatment. Objective. We hypothesize that massage therapy will improve the leg function and overall quality of life (QoL) of MS patients. Design. A two-period (rest, massage) crossover design was used. Twenty-four individuals with MS ranging from 3.0 to 7.0 on the Expanded Disability Status Scale (EDSS) received Swedish massage treatments for four weeks. Exercise capacity and leg function as well as QoL were assessed using the Six-Minute Walk Test (6MWT) and the Hamburg Quality of Life in Multiple Sclerosis (HAQUAMS) instrument, respectively. Assessments were measured before and after a massage period and a rest period where no massages were employed. Results. The results displayed no significant changes in 6MWT distances or HAQUAMS scores. However, the participants perceived improvement in overall health as expressed in written comments. Conclusions. Massage is a safe, noninvasive treatment that may assist MS patients in managing the stress of their symptoms. Future studies with larger sample size and cortisol measures are warranted.

Perceived stress in multiple sclerosis: the potential role of mindfulness in health and well-being

Stressful life events are associated with worsening neurological symptoms and decreased quality of life in multiple sclerosis (MS). Mindful consciousness can alter the impact of stressful events and has potential to improve health outcomes in MS. This study evaluated the relationship between trait mindfulness and perceived stress, coping, and resilience in people with MS. Quality of life was assessed as a secondary outcome. One hundred nineteen people with confirmed MS completed the Five-Facet Mindfulness Questionnaire, Perceived Stress Scale, Brief Coping Orientation for Problem Experiences, Connor-Davidson Resilience Scale, and Medical Outcome Study Short Form-36. Greater trait mindfulness was significantly associated with decreased psychological stress, better coping skills, increased resilience, and higher quality of life. After investigators controlled for confounders, mindfulness accounted for 25% of the variation in perceived stress scores and 44% of the variation in resilience scores. Results support further investigation of mindfulness training to enhance psychological resilience and improve well-being for those living with MS.

State vocational rehabilitation services and employment in multiple sclerosis

Background:

Obtaining and maintaining suitable employment can be a significant challenge for people with multiple sclerosis (MS).

Objective:

The objective of this article is to identify what vocational rehabilitation (VR) services helped MS clients obtain and maintain employment, after controlling for the effect of demographic covariates and disability-related government benefits.

Methods:

We retrieved data from the Rehabilitation Services Administration (RSA) 911 database in the fiscal year (FY) 2009, and used VR services as predictors to predict employment outcomes of people with MS by hierarchical logistic regression.

Results:

A total of 924 out of 1920 MS clients (48.1%) were successfully employed after receiving VR services. Logistic regression analysis results indicated that cash benefits (OR =0.51, p < 0.001) and public medical benefits (OR =0.76, p < 0.01) were negatively associated with employment outcomes, whereas counseling and guidance (OR = 1.68, p < 0.001), job placement assistance (OR = 2.43, p < 0.001), on-the-job supports (OR = 1.62, p < 0.01), maintenance services (OR = 1.59, p < 0.01), and assistive technology services (OR =2.09, p < 0.001) were significant predictors of positive employment outcomes.

Conclusion:

VR services were found to be associated with employment status. MS patients experiencing problems obtaining or maintaining employment should be encouraged to pursue services from state VR agencies.

End-point effector stress mediators in neuroimmune interactions: their role in immune system homeostasis and autoimmune pathology

Much evidence has identified a direct anatomical and functional link between the brain and the immune system, with glucocorticoids (GCs), catecholamines (CAs), and neuropeptide Y (NPY) as its end-point mediators. This suggests the important role of these mediators in immune system homeostasis and the pathogenesis of inflammatory autoimmune diseases. However, although it is clear that these mediators can modulate lymphocyte maturation and the activity of distinct immune cell types, their putative role in the pathogenesis of autoimmune disease is not yet completely understood. We have contributed to this field by discovering the influence of CAs and GCs on fine-tuning thymocyte negative selection and, in particular, by pointing to the putative CA-mediated mechanisms underlying this influence. Furthermore, we have shown that CAs are implicated in the regulation of regulatory T-cell development in the thymus. Moreover, our investigations related to macrophage biology emphasize the complex interaction between GCs, CAs and NPY in the modulation of macrophage functions and their putative significance for the pathogenesis of autoimmune inflammatory diseases.

Patients with multiple sclerosis in a war zone: coping strategies associated with reduced risk for relapse

The objective of this article is to examine the role of coping strategies in multiple sclerosis outcomes among civilians under a military attack during the 2006 war between Hezbollah and Israel. Participants were 156 patients with relapsing—remitting multiple sclerosis. We analysed the relationships between coping and emotional distress and between coping and multiple sclerosis exacerbation. We also assessed a model of the relationship between perceived stress, event-related stress, and coping with increased risk of multiple sclerosis exacerbations using multivariate logistic regression. Ways of coping and subjective stress were evaluated by means of structured interviews using questionnaires previously validated. The more distressed our respondents were during the war, the more likely they were to employ a variety of ways of coping. Correlation coefficients between coping scores and perceived war stress ranged from 0.2 to 0.44 ( p < 0.001—0.01). Correlation coefficients between the various coping scores and broader indices of distress ranged from 0.28 to 0.5 ( p < 0.001). Of the remitting patients during and following the war, 47.1% reported the use of ‘direct coping and planning’, compared to 16.7% of patients who relapsed during the same period ( p = 0.014). ‘Direct coping and planning’ was negatively related to exacerbation of multiple sclerosis symptoms (OR = 0.1, 95% CI = 0.02—0.5). The Nagelkerke R2 was 0.26. Our findings point to an association between ‘direct coping and planning’ and reduced multiple sclerosis relapse rate during wartime. Further research should explore whether the employment of specific ways of coping can reduce the risk for relapse among patients with multiple sclerosis during periods of distress.

Psychopathology in multiple sclerosis: diagnosis, prevalence and treatment

Multiple sclerosis (MS) is a chronic inflammatory disorder of the central nervous system. Demyelinization of nerve fibres not only affects the motor and sensory systems functionally, but may also cause psychopathological signs and symptoms. In addition to the psychiatric manifestations of MS, many patients have reactive psychological problems that are often hard to distinguish from the 'organic' causation of psychopathology. In any event, psychiatric comorbidity in MS deserves greater clinical attention than has been previously paid, because the presence of psychopathology may have deleterious effects on the disease process and impair coping with disability.

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

Purpose

The aims of this study were first, to examine the general relation between stressful life events (SLEs) and clinical relapses in women with multiple sclerosis (MS) and second, to investigate the relations of the specific stressor attributes of duration, type, and severity on MS exacerbations.

Methods

Twenty six ambulating women with relapsing-remitting MS were followed-up for a mean of 56.3 weeks. Patients documented SLEs weekly in self report diaries which were then collected at regular pre-scheduled clinic visits every 4 weeks. SLEs were classified as short-term if they had subjectively no lasting effect and long-term if they had a subjectively felt psychological impact that lasted at least 10–14 days after the event. The severity of SLEs was determined using the Recent Life Change Questionnaire.

Results

Experiencing three or more SLEs, during a 4-week period, was associated with a 5-fold increase of MS relapse rate (95% CI 1.7–16.4, p = 0.003). The presence of at least one long-term SLE was associated with three times (95% CI 1.01–9.13, p < 0.05) the rate of MS exacerbation during the following 4 weeks. There was no significant association between the severity (95% CI 0.99–1.01, p > 0.05) or the type (χ2 = 7.29, df = 5, p > 0.05) of stressor and the risk for relapse.

Conclusion

Ambulatory women with relapsing-remitting MS who experience cumulative SLEs may be at a greater risk for relapse. Duration is the only stress attribute that seems to increase the risk for relapsing in contrast to stress type and stress severity that were not found to interact with MS exacerbation.

Psychological aspects of multiple sclerosis

A significant incidence and prevalence of psychological disorders in multiple sclerosis (MS) has been reported. Their underlying mechanisms and the extent to which they are reactive to psychosocial factors or symptoms of the pathological process itself, remain unclear. Depression is the predominant psychological disturbance with lifetime prevalence around 50% and annual prevalence of 20%. Depression is commoner during relapses, may exacerbate fatigue and cognitive dysfunction and no firm evidence exists of its induction by interferon; instead, treating depression improves adherence to disease-modifying drugs. Anxiety is also frequent, occurs in newly diagnosed patients, and its co-morbidity with depression has been suggested to increase the rate of suicidal ideation. The relationship between stress and MS is an attractive issue because some studies pointed to an association between stressful life-events and MS onset/relapses; however, the evidence supporting this hypothesis is not conclusive so far. Other psychiatric illnesses, as bipolar affective disorder, pathological laughing and crying or psychosis occur less frequently in MS. Therapeutic strategies include psychotherapy, cognitive behavioural therapy, strengthen of coping, and specific medications. The "art" of the MS team in providing the best individualized care is emphasized, aiming to reduce the burden of the disease and improve the patients' quality of life.