Intolerance of Uncertainty: Shaping an Agenda for Research on Coping with Multiple Sclerosis

Association of Anxiety with Uncinate Fasciculus Lesion Burden in Multiple Sclerosis

Importance

Multiple sclerosis (MS) is an immune-mediated neurological disorder that affects 2.4 million people world-wide, and up to 60% experience anxiety.

Objective

We investigated how anxiety in MS is associated with white matter lesion burden in the uncinate fasciculus (UF).

Design

Retrospective case-control study of participants who received research-quality 3-tesla (3T) neuroimaging as part of MS clinical care from 2010-2018. Analyses were performed from June 1st to September 30th, 2024.

Setting

Single-center academic medical specialty MS clinic.

Participants

Participants were identified from the electronic medical record. All participants were diagnosed by an MS specialist and completed research-quality MRI at 3T. After excluding participants with poor image quality, 372 were stratified into three groups which were balanced for age and sex: 1) MS without anxiety (MS+noA, n=99); 2) MS with mild anxiety (MS+mildA, n=249); and 3) MS with severe anxiety (MS+severeA, n=24).

Exposure

Anxiety diagnosis and anxiolytic medication.

Main Outcome and Measure

We first evaluated whether MS+severeA patients had greater lesion burden in the UF than MS+noA. Next, we examined whether increasing anxiety severity was associated with greater UF lesion burden. Generalized additive models were employed, with the burden of lesions (e.g. proportion of fascicle impacted) within the UF as the outcome measure and sex and spline of age as covariates.

Results

UF burden was higher in MS+severeA as compared to MS+noA (T=2.02, P=0.045, Cohen's f 2=0.19). A dose-response effect was also found, where higher mean UF burden was associated with higher anxiety severity (T=2.08, P=0.038, Cohen's f 2=0.10).

Conclusions and Relevance

We demonstrate that overall lesion burden in UF was associated with the presence and severity of anxiety in patients with MS. Future studies linking white matter lesion burden in UF with treatment prognosis are warranted.

Measuring Intolerance of Uncertainty After Acquired Brain Injury: Factor Structure, Reliability, and Validity of the Intolerance of Uncertainty Scale-12

Intolerance of uncertainty (IU) is a risk factor for poor mental health. Acquired brain injury (ABI; for example, stroke, traumatic brain injury) often brings considerable uncertainty and increased mood disorder vulnerability. The Intolerance of Uncertainty Scale-Short Form (IUS-12) is a brief, well-validated IU measure in non-ABI samples, comprising two subscales, namely, Prospective Anxiety and Inhibitory Anxiety. Here, for the first time, we investigated its reliability and validity (N = 118), and factor structure (N = 176), in ABI. Both subscales had high test-retest reliability (intraclass correlation coefficients [ICCs] of .75 and .86) and were significantly associated with mood disorder symptoms. The two-factor model was superior to a one-factor IU model fit. Some fit statistics were less than optimal (standardized root mean square residual [SRMR] = 0.06, root mean square error of approximation [RMSEA] = 0.09); hence, exploration of other factor structures in other ABI samples may be warranted. Nonetheless, the IUS-12 appears suitable in ABI.

Profile and burden of the family caregiver: the caring experience in multiple sclerosis. An observational study

BACKGROUND

The broad implications of caring for a family member with a chronic medical condition, such as MS, can lead caregivers to experience a high burden of care. The aim of the study was to describe profile of MS caregivers and their burden and to explore potential factors influencing this burden.

METHODS

200 family caregivers of a person with MS completed survey questionnaires across a cross-sectional study. Many information were collected: caregiver socio-demographic and health-related data, caregiving activities, knowledge of MS, coping strategies, mood, social support received and care recipient information. Caregiving burden was measured by the ZBI (Zarit Burden Interview). The extent to which the variables explained caregiver burden was analyzed using a hierarchical approach.

RESULTS

68% of the caregivers reported a perceived burden of care (ZBI score > 20). Our results show that physical and mental related-health variables are important predictive factors of the care burden, explaining much of the observed variance (40.9%).

CONCLUSION

Family caregivers in MS continue to make up the shortfall produce by national health and welfare systems. We highlighted the importance of good physical and mental health in decreasing perceived burden. Working to alleviate psychological distress through mechanisms focus on reducing worries and perceived burden may be a valid approach.

Examination of the level of tolerance of uncertainty and psychological wellness of patients with epilepsy

AIM

This study was conducted to examine the level of intolerance of uncertainty and the psychological well-being of patients with epilepsy (PWE).

METHODS

This descriptive and cross-sectional study was conducted with 201 patients in a university hospital in Van, which is a province in eastern Turkey. Personal information form, intolerance of uncertainty scale, and the psychological well-being scale were prepared by the researcher in line with the literature and used to collect data. An independent sample t-test, one-way analysis of variance (ANOVA), post hoc (Tukey, LSD), correlation, and regression analyses were used to analyze the data.

RESULTS

In this study, the mean total score of PWE for the intolerance to uncertainty scale was found as 37.144 ± 9.202. Among the sub-dimensions, the mean prospective anxiety score was found as 21.821 ± 5.416 and the mean inhibitory anxiety score was 15.323 ± 4.695. The mean total score of the psychological well-being scale was found as 28.975 ± 6.622. It was determined that there was a significant relationship between the total score of the intolerance of uncertainty scale and the total score of the psychological well-being scale of the PWE who participated in the study (F = 14.314; p = 0.000 < 0.05). It was observed that the total score of intolerance of uncertainty was decreased as the total level of psychological well-being was increased (ß = -0.186).

CONCLUSION

It was found that PWE had higher levels of intolerance of uncertainty and lower levels of psychological well-being. It was also determined that the total score of psychological well-being was decreased as the total score of intolerance of uncertainty was increased.

RECOMMENDATIONS

For preventing the negative consequences of intolerance of uncertainty in PWE, it is recommended to inform nurses to increase the level of psychological well-being as a result of raising awareness about their concerns by conducting studies to increase the level of intolerance to uncertainty. It is also recommended to carry out studies on intolerance of uncertainty and psychological well-being in advanced and larger sample groups.

Do Resident Coaching Programs Benefit their Coaches? Impact of a Professional Development Coaching Program on The Coaches

BACKGROUND

Coaching has been shown to decrease physician burnout; however, coachee outcomes have been the focus. We report the impact of coaching on women-identifying surgeons who participated as coaches in a 9-month virtual program.

METHODS

A coaching program was implemented in the Association of Women Surgeons (AWS) to determine the effects of coaching on well-being and burnout from 2018 to 2020. AWS members volunteered and completed training in professional development coaching. Pre- and post-study measures were assessed, and bivariate analysis performed based on burnout and professional fulfillment score.

RESULTS

Seventy-five coaches participated; 57 completed both pre- and post-study surveys. There were no significant changes in burnout or professional fulfillment including the Positive Emotion, Engagement, Relationship, Meaning, and Accomplishment scale, hardiness, self-valuation, coping, gratitude, or intolerance of uncertainty scores from baseline to post-survey. On bivariate analysis, hardiness was associated with lower burnout throughout the duration of the program. Coaches with lower burnout at the end of the program met with their coachee more frequently than coaches with higher burnout [mean (SD) 3.95(2.16) versus 2.35(2.13) p = 0.0099].

DISCUSSION

Burnout and professional fulfillment demonstrated no change in women surgeons who participated as professional development coaches. Those with lower burnout and higher professional fulfillment at the end of the program were found to have higher hardiness, which may be worth future investigation.

CONCLUSIONS

Acquisition of coaching skills did not directly improve well-being in faculty who participated in a resident coaching program. Future studies would benefit from control groups and exploration of qualitative benefits of coaching.

The role of uncertainty intolerance in adjusting to long-term physical health conditions: A systematic review

Long-term physical health conditions (LTPHCs) are associated with poorer psychological well-being, quality of life, and longevity. Additionally, individuals with LTPHCs report uncertainty in terms of condition aetiology, course, treatment, and ability to engage in life. An individual's dispositional ability to tolerate uncertainty-or difficulty to endure the unknown-is termed intolerance of uncertainty (IU), and may play a pivotal role in their adjustment to a LTPHC. Consequently, the current review sought to investigate the relationship between IU and health-related outcomes, including physical symptoms, psychological ramifications, self-management, and treatment adherence in individuals with LTPHCs. A systematic search was conducted for papers published from inception until 27 May 2022 using the databases PsycINFO, PubMed (MEDLINE), CINAHL Plus, PsycARTICLES, and Web of Science. Thirty-one studies (N = 6,201) met the inclusion criteria. Results indicated that higher levels of IU were associated with worse psychological well-being outcomes and poorer quality of life, though impacts on self-management were less clear. With the exception of one study (which looked at IU in children), no differences in IU were observed between patients and healthy controls. Although findings highlight the importance of investigating IU related to LTPHCs, the heterogeneity and limitations of the existing literature preclude definite conclusions. Future longitudinal and experimental research is required to investigate how IU interacts with additional psychological constructs and disease variables to predict individuals' adjustment to living with a LTPHC.

Imposter Syndrome Among Surgeons Is Associated With Intolerance of Uncertainty and Lower Confidence in Problem Solving

BACKGROUND

Feelings of imposter syndrome (inadequacy or incompetence) are common among physicians and are associated with diminished joy in practice. Identification of modifiable factors associated with feelings of imposter syndrome might inform strategies to ameliorate them. To this point, though, no such factors have been identified.

QUESTION/PURPOSE

Are intolerance of uncertainty and confidence in problem-solving skills independently associated with feelings of imposter syndrome after accounting for other factors?

METHODS

This survey-based experiment measured the relationship between feelings of imposter syndrome, intolerance of uncertainty, and confidence in problem-solving skills among musculoskeletal specialist surgeons. Approximately 200 surgeons who actively participate in the Science of Variation Group, a collaboration of mainly orthopaedic surgeons specializing in upper extremity illnesses primarily across Europe and North America, were invited to this survey-based experiment. One hundred two surgeons completed questionnaires measuring feelings of imposter syndrome (an adaptation of the Clance Imposter Phenomenon Scale), tolerance of uncertainty (the Intolerance of Uncertainty Scale-12), and confidence in problem-solving skills (the Personal Optimism and Self-Efficacy Optimism questionnaire), as well as basic demographics. The participants were characteristic of other Science of Variation Group experiments: the mean age was 52 ± 5 years, with 89% (91 of 102) being men, most self-reported White race (81% [83 of 102]), largely subspecializing in hand and/or wrist surgery (73% [74 of 102]), and with just over half of the group (54% [55 of 102]) having greater than 11 years of experience. We sought to identify factors associated with greater feelings of imposter syndrome in a multivariable statistical model.

RESULTS

Accounting for potential confounding factors such as years of experience or supervision of trainees in the multivariable linear regression analysis, greater feelings of imposter syndrome were modestly associated with higher intolerance of uncertainty (regression coefficient [β] 0.34 [95% confidence interval (CI) 0.16 to 0.51]; p < 0.01) and with lower confidence in problem-solving skills (β -0.70 [95% CI -1.0 to -0.35]; p < 0.01).

CONCLUSION

The finding that feelings of imposter syndrome may be modestly to notably associated with modifiable factors, such as difficulty managing uncertainty and lack of confidence in problem-solving, spark coaching opportunities to support and sustain a surgeon's mindset, which may lead to increased comfort and joy at work.

CLINICAL RELEVANCE

Beginning with premedical coursework and throughout medical training and continuing medical education, future studies can address the impact of learning and practicing tactics that increase comfort with uncertainty and greater confidence in problem solving on limiting feelings of imposter syndrome.

Prognostic uncertainty in multiple sclerosis: A concept analysis

AIM

To report an analysis of the concept of prognostic uncertainty in patients with multiple sclerosis (MS).

BACKGROUND

The complexity and ambiguity involved in a diagnosis of MS lead to the occurrence of prognostic uncertainty among patients. A concept analysis is presented that analyses what prognostic uncertainty means to those experiencing the transition between relapsing-remitting multiple sclerosis and secondary progressive multiple sclerosis.

DESIGN

Concept analysis.

DATA SOURCES

PubMed, Ovid Medline, Cumulative Index for Nursing and Allied Health Literature databases were searched for literature published within the last 10 years using combinations of the terms prognostic and diagnostic uncertainty, and multiple sclerosis along with archival referencing.

METHODS

The Walker and Avant method was used to analyse the concept of prognostic uncertainty in patients with MS.

RESULTS

The defining attributes identified that provide additional context to prognostic uncertainty are illness uncertainty, intolerance of uncertainty and progressive dwindling. Related, contrary, model and borderline cases are presented to further discuss the application of the key attributes to the concept.

CONCLUSION

There are limited data on prognostic uncertainty and multiple sclerosis; however, patients and physicians express uncertainty in understanding one's disease trajectory and determining when a patient with relapsing-remitting multiple sclerosis has entered the secondary progressive multiple sclerosis disease course leading to ineffective communication and frustration.

RELEVANCE TO CLINICAL PRACTICE

Genetics and genomics have the potential to provide a prognostic factor for addressing the concept of uncertainty as it relates to persons with multiple sclerosis. Moving beyond the concept analysis, a case is made for nurse involvement in genetic and genomic research to conduct trials, translate, and apply these findings to clinical practice and nursing curricula, addressing the uncertainty experienced by those afflicted with chronic illnesses, such as multiple sclerosis.

The effectiveness of group intervention focused on intolerance of uncertainty on psychological distress and quality of life in multiple sclerosis patients

AIM AND BACKGROUND

Multiple sclerosis (MS) is a long-course incurable disease as well as an unknown prognosis causing patients to experience a variety of psychological outcomes. Meanwhile, inability to control the disease-related uncertainty leads to the use of maladaptive coping strategies, causing more psychological distress. This study investigated the effectiveness of intervention focused on the intolerance of uncertainty on psychological distress and quality of life in MS patients.

MATERIALS AND METHODS

This research adopted a true experimental design. All phases of the study were conducted online due to the COVID-19 pandemic during 2021 in Tehran. The statistical population of the study was purposefully selected from among MS patients and was randomly assigned to three groups of 20: IU intervention and two control groups (cognitive behavioral therapy (CBT) and treatment as usual (TAU) groups). The study included pre-test, post-test, and follow-up stages. The outcome measures of the study included the Depression Anxiety Stress Scale (DASS-21) as well as Multiple Sclerosis Quality of Life-54 (MSQoL-54). Mixed analysis of variance was used to analyze the data.

RESULTS

The results showed that IU intervention compared to CBT, is more effective on psychological distress (depression P = 0.006, anxiety P = 0.01, and stress P = 0.01) and quality of life (P = 0.001) in MS patients. Nonetheless, IU-focused intervention is more effective than TAU on psychological distress (depression P = 0.0001, anxiety P = 0.0001, stress P = 0.0001) as well as quality of life (P = 0.0001) in these patients.

CONCLUSIONS

IU-based intervention can reduce psychological distress and improve quality of life of MS patients. Accepting uncertainty can reduce the anxiety and stress of MS patients which can increase the quality of life of these patients.

Stress, anxiety, intolerance of uncertainty, and psychological well-being characteristics of pregnant women with and without threatened miscarriage: a case-control study

The aim of this study was to examine the stress, anxiety, intolerance of uncertainty, and psychological well-being of pregnant women with and without threatened miscarriage. This is a case-control study. The research was carried out between January 2022 and March 2022 in the early pregnancy service and obstetrics clinic of the only training and research hospital in a province in the Central Anatolian Region of Turkey. Two hundred and one pregnant women with threatened miscarriage constituted the study group and 201 pregnant women without threatened miscarriage constituted the control group. A total of 402 pregnant women were included in the study. Stress, anxiety, and intolerance of uncertainty were found to be important risk factors affecting the psychological well-being of pregnant women with threatened miscarriage at a rate of 52% (F = 63,196, p < 0.001). In addition, the pregnant women with threatened miscarriage had higher levels of stress, anxiety, and intolerance of uncertainty, and their psychological well-being was considerably lower compared to pregnant women without threatened miscarriage (p < 0.05). There was a moderate and negative relationship between psychological well-being and intolerance of uncertainty (p < 0.05). It was determined that stress, anxiety, and uncertainty of pregnant women with threatened miscarriage were considerably higher compared to controls, and their psychological well-being was adversely affected. Health professionals should evaluate the levels of anxiety, stress, intolerance of uncertainty, and psychological well-being of pregnant women, especially in the routine follow-up of pregnant women with threatened miscarriage, and they should provide holistic care, not only physiologically but also bio-psychosocially.IMPACT STATEMENTWhat is already known on this subject? Although there are many studies on the emotional and psychological effects of miscarriage, there are limited studies on the effect of threatened miscarriage on the mental health of pregnant women.What do the results of this study add? Stress, anxiety, and intolerance to uncertainty were found to be important associated risk factors that negatively affect the psychological well-being of pregnant women with threatened miscarriage. It was determined that the pregnant women with threatened miscarriage had higher levels of stress, anxiety, intolerance to uncertainty, and their psychological well-being was much lower than the pregnant women without threatened miscarriage. It was determined that there was a moderate and negative relationship between the mean psychological well-being of pregnant women and the mean scores of intolerance to uncertainty.What are the implications of these findings for clinical practice and/or further research? This is the first case-control study to examine the determination of stress, anxiety, intolerance to uncertainty and psychological well-being of pregnant women with and without threatened miscarriage. Health professionals should evaluate the anxiety, stress, intolerance of uncertainty levels and psychological well-being of pregnant women, especially in the routine follow-up of risky pregnant women, and should provide holistic care not only physiologically but also bio-psychosocially to these pregnant women with a holistic approach.

Challenges and positive impact of rare cancer caregiving: A mixed-methods study of caregivers of patients with Erdheim-Chester disease and other histiocytic neoplasms

Background

The importance of deriving benefit and meaning has been identified among cancer caregivers, but this has yet to be examined in the context of rare cancers. We sought to characterize unmet needs and experiences of caregivers of patients with Erdheim-Chester disease (ECD) and other histiocytic neoplasms (HN) and to identify factors associated with finding benefit and meaning-making in providing care for patients with rare cancers.

Methods

Caregivers of patients with ECD and other HN completed quantitative surveys. Linear univariable regression modeling examined associations between unmet needs, social and family support, and intolerance of uncertainty with benefit finding and meaning-making. A subset participated in qualitative interviews assessing experiences of rare cancer caregiving that were analyzed with applied thematic analysis (NCT039900428).

Findings

Of caregivers (N = 92, M = 54 years old, 68% female) of patients with ECD (75%) and other HN (25%), 78% reported moderately or severely unmet support needs, most frequently informational (58%) and psychological/emotional (66%) needs. Caregivers with unmet informational, psychological/emotional, and social support needs, difficulty tolerating uncertainty, a longer duration of the patient's illness, lower social support, more family conflict, and higher anxiety and depression symptoms demonstrated less benefit finding and meaning-making (ps <.05). Qualitative interviews (N = 19) underscored information and support needs and the capacity to derive meaning from caregiving.

Interpretation

Rare cancer caregivers report numerous unmet information and support needs, needs that arise from disease rarity itself and which are associated with diminished capacity for deriving benefit and meaning from caregiving. Findings highlight targets for interventions to improve support for caregivers with HN and other rare cancers.

Funding

NIH P30 CA008748 (PI: Craig Thompson, MD), NIH T32 CA009461 (H.M.; PI: Jamie Ostroff, PhD), Frame Family Fund (E.L.D.), Applebaum Foundation (E.L.D.).

The role of expectations and future-oriented cognitions in quality of life of people with multiple sclerosis: A systematic review

PURPOSE

Multiple Sclerosis (MS) is a highly variable condition characterised by uncertainty of disease course which can make formation of expectations about the future difficult. This systematic review aimed to examine associations between expectations, or Future Oriented Cognitions (FOCs), and Quality of Life (QOL) in people with MS (PwMS).

METHODS

Following PRISMA guidelines, literature up to October 2019 was searched using Medline, EMBASE, PsycINFO and Web of Science. Quantitative studies that investigated relationships between FOCs and QOL in PwMS (assessed using a standardised QOL assessment) were considered for inclusion. After data extraction, results were analysed using narrative synthesis, focusing on the valence of FOCs (positive, negative, unvalenced). Quality appraisal was conducted using the Mixed Methods Appraisal Tool (MMAT). All stages of the review were patient-led by a person with MS.

RESULTS

A total of 13 studies met the review inclusion criteria, with a combined sample size of 4,179. Of these studies, 11 involved measures of positive FOCs, most commonly self-efficacy, one measured a negative FOC, with one FOC unclassified. Nine studies found significant associations between QOL and self-efficacy. Although other positively valenced constructs were less frequently reported, significant associations with higher QOL were also evidenced.

CONCLUSIONS

Identifying ways to foster positive FOCs, particularly self-efficacy, may have beneficial effects on QOL. More research is needed to understand the impacts of negative FOCs on QOL to determine whether these processes could be meaningfully targeted in interventions.

Patients' experiences of self-identification, seeking support, and anticipation of potential relapse in multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) relapses are associated with increased disability, reduced quality of life and negative psychosocial impacts. However, they often go unrecognised; people with MS (MSers) may face barriers to self-identification of relapses or seeking support for them. The charity Shift.ms sought to better understand 1) MSers' challenges in self-identifying potential relapses, 2) where MSers' seek support for potential relapses, and 3) the impact of the anticipation of relapses on MSers' wellbeing and daily living.

METHODS

Shift.ms developed a patient perspective 8-question pilot survey (included likert-style, multiple-choice, and optional free-text responses) and shared it with Shift.ms' international online community (n = 20,052). Descriptive quantitative analysis, and content analysis and thematic analysis of qualitative free-text responses were used.

RESULTS

1,737 MSers responded. Just under one third (29.9%) of MSers reported that it takes them 24 h or less to self-identify a potential relapse, while more than half (54.5%) reported that identification occurs within 48 h; 55% MSers felt that the "at least 24 h" clinical criterion of relapse classification was appropriate. Challenges to relapse self-identification included confounding background symptoms or infection, variability of relapse symptoms, and individualistic nature of MS. Fatigue was reported to be the most common symptom of relapse (75%), however fatigue was also the symptom most commonly mistaken for relapse (40%). Barriers to relapse self-identification were a shorter duration since MS diagnosis and a perceived lack of consensus around relapse classification. Respondents reported they most often seek relapse support/advice from healthcare professionals (HCPs) (37.1%), family/friends (32.1%), or not at all (16.9%). Rather than temporal criteria (i.e. the 24 h criterion), participants felt that severity of symptoms could play a more critical role in whether to seek support for a potential relapse. Barriers to seeking support/advice included variability in HCP advice and feelings of invalidation. Anticipation of relapses negatively impacted MSers wellbeing; led to reduced participation in activities, and the development of adjustment/coping strategies. Relapse triggers included stress, reduced self-care, infection/illness; 78.5% reported stress or anxiety had triggered relapse.

CONCLUSIONS

These findings highlight difficulties MSers face in self-identifying relapses, barriers to accessing support, and impact of anticipation of relapses. They also highlight opportunities for improved MSer and HCP communication, dialogue and two-way education to help optimise patient access to relapse support and intervention.

How Patients with an Uncertain Diagnosis Experience Intolerance of Uncertainty: A Grounded Theory Study

PURPOSE

To develop a conceptual framework to explain how patients with uncertain diagnoses experience intolerance of uncertainty (IU) in order to achieve an in-depth understanding of the process of facing uncertainty in this population.

PATIENTS AND METHODS

A grounded theory study using semi-structured interviews was conducted with 21 patients with uncertain diagnoses in China from December 2018 to March 2019. The coding process followed the procedures of Strauss and Corbin: open coding, axial coding, and selective coding.

RESULTS

We developed a conceptual framework called 'Facing an Uncertain Diagnosis'. This framework considers not only the external and internal context of IU generation but also the ongoing process of how IU impacts patients' psychological status, cognitive response, behavior, and decision making.

CONCLUSION

We suggest that healthcare professionals should be aware of the high level of IU and its psychological, cognitive, and behavioral manifestations in patients with uncertain diagnoses. Healthcare professionals should also be more cautious in shared decision making with patients with uncertain diagnoses.

Willingness to obtain COVID-19 vaccination in adults with multiple sclerosis in the United States

BACKGROUND

As vaccines for the coronavirus become available, it will be important to know the rate of COVID-19 vaccine acceptability in adults with multiple sclerosis (MS), given that vaccination will be a key strategy for preventing SARS-CoV-2 infections. Using a national sample of adults with MS in the United States obtained early in the COVID-19 pandemic, the current study aimed to: (1) assess willingness to get a COVID-19 vaccine when available; (2) determine demographic, MS, and psychosocial correlates of vaccine willingness; and (3) measure where people with MS get their COVID-19 information and their perceived trustworthiness of such sources, which may influence COVID-19 vaccine willingness.

METHODS

Adults with MS (N = 486) living in the United States completed a cross-sectional online survey (between 10 April 2020 and 06 May 2020) about their willingness to receive a COVID-19 vaccination once available. Participants also completed measures to describe the sample and to assess factors potentially related to vaccine willingness, including demographics, MS-specific variables, psychological measures, COVID-19 information sources, and perceived trustworthiness of their information sources.

RESULTS

Approximately two-thirds of the participants (66.0%) reported a willingness to obtain a future COVID-19 vaccine, whereas 15.4%of the sample was unwilling. Greater willingness to receive the vaccine was associated with having a higher level of education and holding a higher perception of one's risk of catching COVID-19. Participants reported accessing COVID-19 information from many different sources. Approximately a third (31.6%) of the sample reported getting their information from healthcare providers. Healthcare providers and the National MS Society had the highest perceived trustworthiness for COVID-19 information. The perceived trustworthiness of information sources was highly associated with vaccine willingness.

CONCLUSION

Early in the pandemic, willingness to get a COVID-19 vaccine was not universal in this large sample or people living with MS. Vaccine willingness was associated with a few variables including education level, perceived risk for COVID-19 infection, and trust in COVID-19 information sources. These results have important implications for guiding healthcare providers and the MS community as COVID-19 vaccines become widely available.

Development of a Web-Based Mindfulness Program for People With Multiple Sclerosis: Qualitative Co-Design Study

Background

Mindfulness-based stress reduction is an efficacious treatment for people with chronic health problems; however, it is highly intensive and time-consuming, which is a barrier for service provision.

Objective

This study aims to develop an internet-delivered adapted version of mindfulness-based stress reduction for people with multiple sclerosis to make the intervention more accessible.

Methods

We co-designed a web-based mindfulness program with end users, that is, people with multiple sclerosis (N=19). Iterative feedback was also collected from a subsample of the initial group of end users (n=11), and the program was reviewed by experts (n=8).

Results

We identified three main themes common to people with multiple sclerosis: dealing with uncertainty and fears for the future, grief and loss, and social isolation. These themes were incorporated into narratives throughout the program. People with multiple sclerosis who reviewed the program gave feedback that the program was relatable, feasible, and acceptable. Experts agreed that the program appropriately represented the main tenets of mindfulness. Iterative feedback was used to further refine the program.

Conclusions

The web-based mindfulness program that we developed was viewed positively by both experts and end users. The program reflects common concerns for people with multiple sclerosis and has the potential to meet important unmet psychological needs. A randomized controlled trial was planned to determine the efficacy of the program.

Literature Review: Psychological Resilience Factors in People with Neurodegenerative Diseases

BACKGROUND

Psychological distress is frequently observed in neurodegenerative diseases (NDDs) having a significant impact on function, quality of life (QOL), caregiver burden, and illness cost. As higher psychological resilience can protect against negative outcomes and aid in the successful adjustment to illness, identifying resilience factors is important. Understanding what enhances or lowers psychological resilience allows us to offer support/interventions to people with NDDs and their carers starting early in the disease process.

OBJECTIVE

To investigate factors associated with psychological resilience in NDDs by completing a systematic review of relevant studies.

METHOD

Five electronic databases were searched for studies relating to psychological resilience in NDDs. Eighteen articles were reviewed using a narrative synthesis approach.

RESULTS

Studies with varied aims and methodologies were found. The identified factors were categorized into core, internal, and external resilience. Regarding core factors contradicting evidence was found about the relationship between resilience and physical function. Fatigue, however, appears to be associated with less resilience. A limited number of studies focused on pain and demographics. Of internal resilience factors, studies found positive associations between higher resilience and improved mental health, even over time. Resilience appears to correlate positively with various psychological and QOL factors. Importantly, external resilience factors (e.g., social connectedness and intervention) were discovered to be linked to resilience. The evidence for resilience-enhancing intervention suggests that resilience can be modified.

CONCLUSION

Various factors were identified to be associated with psychological resilience in NDDs. As resilience appears to be modifiable, it is important to focus on resilience-enhancing interventions for people with NDDs.

Views of the Future of Partners of People with Multiple Sclerosis Who Attended a Lifestyle Modification Workshop: A Qualitative Analysis of Perspectives and Experiences

People with multiple sclerosis (PwMS) often experience uncertainty and fear about their futures. Partners of PwMS may share their concerns and experience fears about their own futures, limitations on their lives, ability to work, and becoming a carer. For PwMS, modification of lifestyle-related risk factors has been associated with improved health outcomes. For PwMS who attended residential lifestyle modification workshops (RLMW), sustained improved health outcomes have been demonstrated. Whether improved outcomes for PwMS who engage with lifestyle modification translate to improved partner perceptions of the future, is yet to be explored. We explored the perspectives of partners of PwMS who had attended a RLMW and the impact that the person with MS’s illness and their engagement with lifestyle modification had on their partners’ views of the future. Analysis of 21 semi-structured interviews used a methodology informed by Heidegger’s Interpretive Phenomenology. Three themes emerged: ‘uncertainty’, ‘planning for the future’ and ‘control, empowerment and confidence’. Subthemes included MS and lifestyle modification being a catalyst for positive change; developing a sense of control and empowerment; and hope, optimism and positivity. Lifestyle modification may provide benefits, not only to PwMS, but also to their partners, and should be considered part of mainstream management of MS.

Distress and risk perception in people living with multiple sclerosis during the early phase of the COVID-19 pandemic

Background

People living with MS during COVID-19 are experiencing the disruptions of the pandemic and concerns that their health status may place them at greater risk for worse COVID-19 outcomes.

Objective

This study sought to understand how people living with MS in the United States experienced distress and perceived their COVID-19-related risk during the first surge of the pandemic.

Methods

This was a web-based, self-report survey of people with MS who were living in the United States during the early stage of COVID-19. Primary outcomes were depression, anxiety, and positive-affect and well-being. Participants (N = 491) also provided data on demographics, MS-related factors, COVID-19 factors, and psychological coping.

Results

Psychological distress was associated with age, psychological coping strategies, and having had symptoms consistent with COVID-19, but not with MS disease-related variables and COVID-19 risk factors. Perception of COVID-19-related risk was associated with age, MS disease severity, COVID-19-related factors, and anxiety.

Conclusion

This study demonstrated that even during COVID-19, distress and risk perception are primarily driven by psychological factors, experiencing symptoms consistent with COVID-19 and age, with minimal contribution from individual differences in health status, providing an impetus for continued efforts to optimize psychological interventions for people living with MS.

Caregiver Burden in Multiple Sclerosis: Recent Trends and Future Directions

Purpose of Review

In spite of recent advances in treatment, many people with multiple sclerosis (MS) require ongoing care and support. Informal caregivers can experience burden as a result of their role, with possible implications for quality of life (QOL). We review recent research examining MS caregiver experience to (1) understand current risk factors for caregiver burden and (2) identify possible strategies for increasing carer well-being.

Recent Findings

MS caregiver experience is highly variable and can be predicted by a variety of care recipient, caregiver and contextual factors. Burden is not the only characteristic associated with care, with positive consequences also reported. Emerging research suggests a number of ways in which carers can be better supported.

Summary

Identifying and meeting the needs of MS caregivers offers the best way of delivering tailored support. Future research should focus on the development of psychosocial supports, while acknowledging the needs of those caring for different MS patient populations.

Does Intolerance of Uncertainty Affect the Magnitude of Limitations or Pain Intensity?

BACKGROUND

Intolerance of uncertainty-the tendency to overestimate the chance of and be unwilling to accept potential, but unlikely, negative outcomes in uncertain situations-is a cognitive construct that has been shown to affect symptoms and limitations for patients with traumatic and nontraumatic upper-extremity conditions. Cognitive flexibility and tolerance of uncertainty can be trained and practiced, with the potential to increase musculoskeletal health. However, to our knowledge, the degree to which intolerance of uncertainty might be associated with symptom intensity and the magnitude of limitations in adults with upper-extremity problems has not been characterized.

QUESTIONS/PURPOSES

After accounting for personal and social factors, is intolerance of uncertainty independently associated with (1) the magnitude of physical limitations and (2) pain intensity?

METHODS

In this cross-sectional, observational study, 139 new and returning patients presenting to one of four orthopaedic offices in a large urban area completed the Intolerance of Uncertainty Scale (a validated measure of the level of comfort with uncertain situations), the Patient-reported Outcomes Measurement Information System-Physical Function Upper Extremity computer adaptive test (to measure the magnitude of limitations), and an 11-point ordinal measure of pain intensity. The mean age of the 139 participants was 51 years ± 16 years and 55% (76 of 139) were men. Participants presented to the clinics with a wide variety of upper-extremity conditions, such as trigger finger, distal radius fractures, lateral epicondylitis, or non-specific shoulder pain. We also assessed sex, race, marital status, education level, income, public versus private insurance, area deprivation index, and the participant's self-perception of their healthcare experience through a multiple-choice question (answer choices: none, some, a little, and a lot of experience). The following patient characteristics were more common in our study participants: white, employed, part of a married or unmarried couple, and private insurance coverage. We created two multivariable linear regression models to assess factors independently associated with the magnitude of limitations and pain intensity.

RESULTS

After controlling for potentially confounding variables including sex, insurance, area deprivation index, and type of visit, we found that fewer physical limitations were associated with a greater intolerance of uncertainty (regression coefficient [β] -0.30; 95% confidence interval, -0.50 to -0.10; p = 0.003; semi-partial r = 0.07; adjusted r for the full model = 0.16), as was being a man (β 3.2; 95% CI, 0.08-6.3; p = 0.045; semi-partial r = 0.03) and having private insurance coverage (β 5.2; 95% CI, 2.1-8.2; p = 0.001; semi-partial r = 0.08). After controlling for one important potentially confounding variable, the level of education, greater pain intensity was associated with a greater intolerance of uncertainty (β 0.08; 95% CI, 0.02-0.14; p = 0.009; semi-partial r = 0.05; adjusted r for the full model = 0.08).

CONCLUSIONS

Intolerance of uncertainty-a byproduct of cognitive bias and error, which are elements of the normal functioning of the human mind-increases limitations and pain intensity across diagnoses, independent of demographic and social factors. Future studies can address the effect of strategies that incorporate mindset training (for example, cognitive behavioral therapy and its derivatives) on musculoskeletal symptoms and limitations.

LEVEL OF EVIDENCE

Level II, prognostic study.

What Is Missing for You to Be Happy? Comparison of the Pursuit of Happiness Among Cancer Patients, Informal Caregivers, and Healthy Individuals

CONTEXT

After cancer diagnosis, personal value priorities may change in a way that would transform such values and how life is perceived by cancer patients and their caregivers, including happiness and its pursuit.

OBJECTIVES

The objective of the study was to analyze and compare what cancer patients, informal caregivers, and healthy population believe that would make them happy.

METHODS

A qualitative content analysis was performed on the responses to a single question: "What is missing for you to be happy?" Narratives of cancer patients (n = 242, face-to-face interview), informal caregivers (n = 125, face-to-face interview), and healthy participants (n = 1,671, recruited through social media, online survey) were analyzed. Word clouds were created for each group of participants. Contents were identified and frequencies were compared among participants by means of chi-square and Fisher's exact tests.

RESULTS

Overall, participants were pursuing better health (n = 288, 14.1%), better interpersonal relationships (n = 456, 22.4%), money (n = 412, 20.2%), and work-related aspects (n = 481, 23.6%). Cancer patients and informal caregivers sought better health and cure more often than when compared to healthy people (P < 0.001). Among cancer patients, survivors' profile tended to be similar to that of the healthy population concerning what they need to be happy. Unexpectedly, "cure" (22.7%) was more frequent among participants with incurable cancer.

CONCLUSION

Regardless of the group they were in, participants sought happiness in what they considered to be important to their lives, but it was something they did not have at the time of the interview. Psychoeducational and cognitive-behavioral strategies focused on how to deal with life expectations among people facing cancer are awaited.

A comparative study of uncertainty and coping strategies of patients with multiple sclerosis for members and nonmembers in peer groups

Patients with multiple sclerosis (MS) experience a high level of uncertainty and face serious difficulty in coping effectively with their conditions. We compared the rate of uncertainty and coping strategies of women patients in members and nonmembers of peer groups. Our results showed that uncertainty level for patients who are members in peer groups was less than that of the nonmember patients in peer groups. Moreover, we observed that people who are members in peer groups employed problem-oriented coping strategies more than the nonmember patients in the peer group.

Acceptance of Mobile Health Apps for Disease Management Among People With Multiple Sclerosis: Web-Based Survey Study

Background

Mobile health (mHealth) apps might have the potential to promote self-management of people with multiple sclerosis (MS) in everyday life. However, the uptake of MS apps remains poor, and little is known about the facilitators and barriers for their efficient utilization, such as technology acceptance.

Objective

The aim of this study was to examine the acceptance of mHealth apps for disease management in the sense of behavioral intentions to use and explore determinants of utilization among people with MS based on the Unified Theory of Acceptance and Use of Technology (UTAUT).

Methods

Participants for this Web-based cross-sectional study were recruited throughout Germany with the support of regional MS associations and self-help groups. To identify determinants of intention to use MS apps, a measure based on the UTAUT was adapted with 4 key determinants (performance expectancy, effort expectancy, social influence, and facilitating conditions) and extended by Intolerance of Uncertainty (IU) and electronic health literacy. Potential influencing effects of both MS and computer self-efficacy (C-SE) as mediators and fatigue as a moderator were analyzed using Hayes’s PROCESS macro (SPSS version 3.0) for IBM SPSS version 24.0.

Results

A total of 98 participants (mean age 47.03 years, SD 10.17; 66/98, 67% female) with moderate fatigue levels completed the survey. Although most participants (91/98, 92%) were daily smartphone users, almost two-thirds (62/98, 63%) reported no experience with MS apps. Overall, the acceptance was moderate on average (mean 3.11, SD 1.31, minimum=1 and maximum=5), with lower scores among persons with no experience (P=.04) and higher scores among current users (P<.001). In multiple regression analysis (R²=63% variance explained), performance expectancy (beta=.41) and social influence (beta=.33) were identified as significant predictors of acceptance (all P<.001). C-SE was confirmed as a partial mediator in the relationship between IU and acceptance (indirect effect: B=−.095, 95% CI −0.227 to −0.01). Furthermore, a moderated mediation by C-SE was shown in the relationship between IU and behavioral intentions to use MS apps for low (95% CI −0.42 to −0.01) and moderate levels (95% CI −0.27 to −0.01) of fatigue.

Conclusions

Overall, this exploratory pilot study indicates for the first time that positive expectations about the helpfulness for self-management purposes and social support might be important factors to be considered for improving the acceptance of MS apps among smartphone users with MS. However, given some inconsistent findings, especially regarding the role of effort expectancy and IU and self-efficacy, the conceptual model needs replication with a larger sample of people with MS, varying more in fatigue levels, and a longitudinal assessment of the actual usage of MS apps predicted by acceptance in the sense of behavioral intentions to use.

The Mindful Body: A Phenomenology of the Body With Multiple Sclerosis

For people living with multiple sclerosis (MS), one's own body may no longer be taken for granted but may become instead an insistent presence. In this article, we describe how the body experience of people with MS can reflect an ongoing oscillation between four experiential dimensions: bodily uncertainty, having a precious body, being a different body, and the mindful body. People with MS can become engaged in a mode of permanent bodily alertness and may demonstrate adaptive responses to their ill body. In contrast to many studies on health and illness, our study shows that the presence of the body may not necessarily result in alienation or discomfort. By focusing the attention on the body, a sense of well-being can be cultivated and the negative effects of MS only temporarily dominate experience. Rather than aiming at bodily dis-appearance, health care professionals should therefore consider ways to support bodily eu-appearance.

Beyond Disease: Happiness, Goals, and Meanings among Persons with Multiple Sclerosis and Their Caregivers

The experience of persons with multiple sclerosis (MS) and their caregivers is usually investigated in terms of emotional distress and health-related quality of life, while well-being indicators remain largely underexplored. In addition, findings are often interpreted from the clinical perspective, neglecting socio-cultural aspects that may crucially contribute to individuals' functioning. At the methodological level, most studies rely on scaled instruments, not allowing participants to freely express their needs and resources. Based on the bio-psycho-social perspective endorsed by the International Classification of Functioning, well-being indicators were investigated among 62 persons with MS (PwMS), their 62 caregivers and two control groups, matched by age and gender. Participants completed the Positive Affect Negative Affect Schedule (PANAS), the Satisfaction with Life Scale (SWLS), and the Eudaimonic and Hedonic Happiness Investigation instrument (EHHI). EHHI provides information on participants' happiness, goals and meanings through scaled and open-ended questions, contextualized within major life domains. No relevant differences emerged among PwMS and caregivers, compared with the respective control groups, as concerns life domains associated with happiness, goals and meaning. Participants across groups prominently mentioned family, highlighting its intrinsic value and its relevance as a sharing context; health did not represent a major theme for PwMS; community, society and religion/spirituality issues were substantially neglected by all participants. PwMS and caregivers reported lower levels of positive affect than their control groups, while no substantial differences emerged for negative affect, happiness and meaningfulness levels in life and across most domains. Results suggest that the experience of MS is associated with well-being in relevant life domains, such as family and close relationships. Although PwMS and caregivers identified a lower number of goals and meaning-related opportunities compared to control groups, they showed a positive adjustment to disease through the development of personal and family resources. These assets are often undervalued by health professionals and social institutions, while they could be fruitfully exploited through the active involvement of PwMS and their families as expert and exemplary informants in initiatives aimed at promoting the well-being of individuals and communities

Helping families thrive in the face of uncertainty: Strengths based approaches to working with families affected by progressive neurological illness

BACKGROUND

Management of the uncertainty inherent in a diagnosis of a progressive neurological illness is one of the major adjustment tasks facing those affected and their families. A causal relationship has been demonstrated between perceived illness uncertainty and negative psychological outcomes for individuals with progressive neurological illness. Whilst there is a small and promising intervention literature on the use of a range of individually focused strengths based psychological interventions there appears to be little guidance available how clinicians might help those family members of those affected.

OBJECTIVE

To undertake a systematic review of the evidence on the use of strengths based, family focused interventions that target illness uncertainty.

METHODS

A systematic literature search was undertaken using the National Library for Health abstract database.

RESULTS

Five papers were included in the review, only two of which were published in peer reviewed journals. All five reported on strengths based approaches that could be used with families but only two explicitly identified illness uncertainty as a target. Outcome measures were heterogeneous so data could not be aggregated for meta-analysis. The results suggested that these interventions showed promised but the review highlighted a number of methodological issues which mean that the results must be interpreted with caution.

CONCLUSIONS

There is very little evidence of the use of strengths based approaches to helping families manage the uncertainty associated with progressive neurological illness despite it having been identified as a key target for intervention. The review highlights the need for the development of an intervention framework to address this key clinical issue and suggests one model that might show promise.

Coping strategies and adjustment to multiple sclerosis among recently diagnosed patients: the mediating role of sense of coherence

Objective:

To examine the relationship between coping strategies (problem solving, emotional release, and avoidance) and adjustment (health-related quality of life, depression, and affective well-being) in a group of recently diagnosed multiple sclerosis patients (up to three years since diagnosis), and to explore the mediating role of sense of coherence between coping strategies and adjustment.

Design:

Cross-sectional.

Setting:

Multiple Sclerosis Clinic Centre.

Subjects:

A total of 102 patients (61.8% women; age (years): M = 35.8, SD = 11.9; 95% with a relapsing–remitting form of multiple sclerosis; Expanded Disability Status Scale score, between 1 and 4).

Interventions:

Not applicable.

Main measures:

Coping with multiple sclerosis (problem solving, emotional release, and avoidance), sense of coherence, health-related quality of life (SF-12), depression (CES-D), and affective well-being (PANAS).

Results:

Problem solving was linked to higher mental health ( β = 0.28) and higher affective well-being ( β = 0.36), emotional release was related to lower depression ( β = −0.22); avoidance was associated to higher mental health ( β = 0.25), higher affective well-being ( β = 0.24), and lower depression ( β = −0.29 ) (all betas were significant at p < 0.05). Sense of coherence mediated the relationship between emotional release and depression (Sobel z-value = −2.00; p < 0.05) and the relationship between avoidance and all the indicators of adjustment (mental health: Sobel z-value = 1.97; depression: Sobel z-value = −2.02; affective well-being: Sobel z-value= 2.05; p < 0.05).

Conclusions:

Emotional and avoidant coping strategies seem to be adaptive among recently diagnosed multiple sclerosis patients. A mediating role between coping strategies and adjustment is played by sense of coherence.