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Tinazzi M, Geroin C, Marcuzzo E, Cuoco S, Ceravolo R, Mazzucchi S, Pilotto A, Padovani A, Romito LM, Eleopra R, Zappia M, Nicoletti A, Dallocchio C, Arbasino C, Bono F, Magro G, Demartini B, Gambini O, Modugno N, Olivola E, Bonanni L, Zanolin E, Albanese A, Ferrazzano G, De Micco R, Lopiano L, Calandra-Buonaura G, Petracca M, Esposito M, Pisani A, Manganotti P, Tesolin L, Teatini F, Ercoli T, Morgante F, Erro R. Functional motor phenotypes: to lump or to split? J Neurol 2021; 268:4737-4743. [PMID: 33961091 PMCID: PMC8563631 DOI: 10.1007/s00415-021-10583-w] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/22/2021] [Accepted: 04/24/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Functional motor disorders (FMDs) are usually categorized according to the predominant phenomenology; however, it is unclear whether this phenotypic classification mirrors the underlying pathophysiologic mechanisms. OBJECTIVE To compare the characteristics of patients with different FMDs phenotypes and without co-morbid neurological disorders, aiming to answer the question of whether they represent different expressions of the same disorder or reflect distinct entities. METHODS Consecutive outpatients with a clinically definite diagnosis of FMDs were included in the Italian registry of functional motor disorders (IRFMD), a multicenter data collection platform gathering several clinical and demographic variables. To the aim of the current work, data of patients with isolated FMDs were extracted. RESULTS A total of 176 patients were included: 58 with weakness, 40 with tremor, 38 with dystonia, 23 with jerks/facial FMDs, and 17 with gait disorders. Patients with tremor and gait disorders were older than the others. Patients with functional weakness had more commonly an acute onset (87.9%) than patients with tremor and gait disorders, a shorter time lag from symptoms onset and FMDs diagnosis (2.9 ± 3.5 years) than patients with dystonia, and had more frequently associated functional sensory symptoms (51.7%) than patients with tremor, dystonia and gait disorders. Patients with dystonia complained more often of associated pain (47.4%) than patients with tremor. No other differences were noted between groups in terms of other variables including associated functional neurological symptoms, psychiatric comorbidities, and predisposing or precipitating factors. CONCLUSIONS Our data support the evidence of a large overlap between FMD phenotypes.
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Affiliation(s)
- Michele Tinazzi
- Neurology Unit, Movement Disorders Division, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, P.le Scuro 10, 37134, Verona, Italy.
| | - Christian Geroin
- Neurology Unit, Movement Disorders Division, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, P.le Scuro 10, 37134, Verona, Italy.
| | - Enrico Marcuzzo
- Neurology Unit, Movement Disorders Division, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, P.le Scuro 10, 37134, Verona, Italy
| | - Sofia Cuoco
- Center for Neurodegenerative Diseases (CEMAND), Department of Medicine, Surgery and Dentistry-Scuola Medica Salernitana, University of Salerno, Baronissi, SA, Italy
| | - Roberto Ceravolo
- Neurology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Sonia Mazzucchi
- Neurology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Andrea Pilotto
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,FERB Onlus, Ospedale S. Isidoro, Trescore Balneario, Bergamo, Italy
| | - Alessandro Padovani
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Luigi Michele Romito
- Parkinson and Movement Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Roberto Eleopra
- Parkinson and Movement Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Mario Zappia
- Department G.F. Ingrassia, Section of Neurosciences, University of Catania, Catania, Italy
| | - Alessandra Nicoletti
- Department G.F. Ingrassia, Section of Neurosciences, University of Catania, Catania, Italy
| | - Carlo Dallocchio
- Department of Medical Area, Neurology Unit, ASST Pavia, Pavia, Italy
| | - Carla Arbasino
- Department of Medical Area, Neurology Unit, ASST Pavia, Pavia, Italy
| | - Francesco Bono
- Botulinum Toxin Center, Neurology Unit A.O.U. Mater Domini, Catanzaro, Italy
| | - Giuseppe Magro
- Botulinum Toxin Center, Neurology Unit A.O.U. Mater Domini, Catanzaro, Italy
| | - Benedetta Demartini
- Aldo Ravelli Research Center for Neurotechnology and Experimental Brain Therapeutics, Department of Health Sciences, University of Milan, Milan, Italy
| | - Orsola Gambini
- Aldo Ravelli Research Center for Neurotechnology and Experimental Brain Therapeutics, Department of Health Sciences, University of Milan, Milan, Italy
| | | | | | - Laura Bonanni
- Department of Neuroscience, Imaging and Clinical Sciences, University G. D'Annunzio, Chieti-Pescara, Italy
| | - Elisabetta Zanolin
- Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Alberto Albanese
- Department of Neurology, IRCCS Humanitas Research Hospital, Rozzano Milan, Italy
| | - Gina Ferrazzano
- Department of Human Neurosciences, Università La Sapienza, Rome, Italy
| | - Rosa De Micco
- Department of Advanced Medical and Surgery Sciences, University of Campania-Luigi Vanvitelli, Naples, Italy
| | - Leonardo Lopiano
- Department of Neuroscience-Rita Levi Montalcini, University of Turin, Turin, Italy
| | - Giovanna Calandra-Buonaura
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS, Institute of Neurological Sciences of Bologna, Bologna, Italy
| | - Martina Petracca
- Movement Disorder Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Antonio Pisani
- IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Paolo Manganotti
- Clinical Neurology Unit, Department of Medical, Surgical and Health Services, University of Trieste, Trieste, Italy
| | - Lucia Tesolin
- Functional Movement Disorders Outpt. Clinic, Clinical Neurology and Stroke Unit Department, Central Country Hospital, Bolzano, Italy
| | - Francesco Teatini
- Functional Movement Disorders Outpt. Clinic, Clinical Neurology and Stroke Unit Department, Central Country Hospital, Bolzano, Italy
| | - Tommaso Ercoli
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Francesca Morgante
- Neurosciences Research Centre, Molecular and Clinical Sciences Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK.,Department of Experimental and Clinical Medicine, University of Messina, Messina, Italy
| | - Roberto Erro
- Center for Neurodegenerative Diseases (CEMAND), Department of Medicine, Surgery and Dentistry-Scuola Medica Salernitana, University of Salerno, Baronissi, SA, Italy
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Chelban V, Catereniuc D, Aftene D, Gasnas A, Vichayanrat E, Iodice V, Groppa S, Houlden H. An update on MSA: premotor and non-motor features open a window of opportunities for early diagnosis and intervention. J Neurol 2020; 267:2754-2770. [PMID: 32436100 PMCID: PMC7419367 DOI: 10.1007/s00415-020-09881-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 01/27/2023]
Abstract
In this review, we describe the wide clinical spectrum of features that can be seen in multiple system atrophy (MSA) with a focus on the premotor phase and the non-motor symptoms providing an up-to-date overview of the current understanding in this fast-growing field. First, we highlight the non-motor features at disease onset when MSA can be indistinguishable from pure autonomic failure or other chronic neurodegenerative conditions. We describe the progression of clinical features to aid the diagnosis of MSA early in the disease course. We go on to describe the levels of diagnostic certainty and we discuss MSA subtypes that do not fit into the current diagnostic criteria, highlighting the complexity of the disease as well as the need for revised diagnostic tools. Second, we describe the pathology, clinical description, and investigations of cardiovascular autonomic failure, urogenital and sexual dysfunction, orthostatic hypotension, and respiratory and REM-sleep behavior disorders, which may precede the motor presentation by months or years. Their presence at presentation, even in the absence of ataxia and parkinsonism, should be regarded as highly suggestive of the premotor phase of MSA. Finally, we discuss how the recognition of the broader spectrum of clinical features of MSA and especially the non-motor features at disease onset represent a window of opportunity for disease-modifying interventions.
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Affiliation(s)
- Viorica Chelban
- Department of Neuromuscular Diseases, Queen Square Institute of Neurology, University College London, London, WC1N 3BG, UK.
- Neurobiology and Medical Genetics Laboratory, "Nicolae Testemitanu" State University of Medicine and Pharmacy, 165, Stefan cel Mare si Sfant Boulevard, 2004, Chişinău, Republic of Moldova.
| | - Daniela Catereniuc
- Neurobiology and Medical Genetics Laboratory, "Nicolae Testemitanu" State University of Medicine and Pharmacy, 165, Stefan cel Mare si Sfant Boulevard, 2004, Chişinău, Republic of Moldova
- Department of Neurology, Epileptology and Internal Diseases, Institute of Emergency Medicine, 1, Toma Ciorba Street, 2004, Chişinău, Republic of Moldova
- Department of Neurology nr. 2, Nicolae Testemitanu" State University of Medicine and Pharmacy, 165, Stefan cel Mare si Sfant Boulevard, 2004, Chişinău, Republic of Moldova
| | - Daniela Aftene
- Department of Neurology, Epileptology and Internal Diseases, Institute of Emergency Medicine, 1, Toma Ciorba Street, 2004, Chişinău, Republic of Moldova
- Department of Neurology nr. 2, Nicolae Testemitanu" State University of Medicine and Pharmacy, 165, Stefan cel Mare si Sfant Boulevard, 2004, Chişinău, Republic of Moldova
| | - Alexandru Gasnas
- Department of Neurology, Epileptology and Internal Diseases, Institute of Emergency Medicine, 1, Toma Ciorba Street, 2004, Chişinău, Republic of Moldova
- Department of Neurology nr. 2, Nicolae Testemitanu" State University of Medicine and Pharmacy, 165, Stefan cel Mare si Sfant Boulevard, 2004, Chişinău, Republic of Moldova
- Cerebrovascular Diseases and Epilepsy Laboratory, Institute of Emergency Medicine, 1, Toma Ciorba Street, 2004, Chişinău, Republic of Moldova
| | - Ekawat Vichayanrat
- Autonomic Unit, National Hospital for Neurology and Neurosurgery, UCL NHS Trust, London, WC1N 3BG, UK
| | - Valeria Iodice
- Autonomic Unit, National Hospital for Neurology and Neurosurgery, UCL NHS Trust, London, WC1N 3BG, UK
| | - Stanislav Groppa
- Neurobiology and Medical Genetics Laboratory, "Nicolae Testemitanu" State University of Medicine and Pharmacy, 165, Stefan cel Mare si Sfant Boulevard, 2004, Chişinău, Republic of Moldova
- Department of Neurology, Epileptology and Internal Diseases, Institute of Emergency Medicine, 1, Toma Ciorba Street, 2004, Chişinău, Republic of Moldova
- Department of Neurology nr. 2, Nicolae Testemitanu" State University of Medicine and Pharmacy, 165, Stefan cel Mare si Sfant Boulevard, 2004, Chişinău, Republic of Moldova
| | - Henry Houlden
- Department of Neuromuscular Diseases, Queen Square Institute of Neurology, University College London, London, WC1N 3BG, UK
- Neurogenetics Laboratory, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
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Gelauff JM, Rosmalen JGM, Gardien J, Stone J, Tijssen MAJ. Shared demographics and comorbidities in different functional motor disorders. Parkinsonism Relat Disord 2019; 70:1-6. [PMID: 31785442 DOI: 10.1016/j.parkreldis.2019.11.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 11/19/2019] [Accepted: 11/21/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Functional motor disorders are often delineated according to the dominant motor symptom. In a large cohort, we aimed to find if there were differences in demographics, mode of onset, pain, fatigue, depression and anxiety and levels of physical functioning, quality of life and social adjustment between patients with different dominant motor symptoms. METHODS Baseline data from the Self-Help and Education on the Internet for Functional Motor Disorders Trial was used. Patients were divided into dominant motor symptom groups based on the diagnosis of the referring neurologist. Data on the above topics were collected by means of an online questionnaire and compared between groups using parametric and nonparametric statistics. RESULTS In 160 patients a dominant motor symptom could be determined, 31 had tremor, 45 myoclonus, 23 dystonia, 30 paresis, 31 gait disorder. No statistical differences between groups were detected for demographics, mode of onset and severity of pain, fatigue, depression and anxiety. Physical functioning was worse in the gait disorder group (median 20, IQR 25) compared to tremor (50 (55), p = 0.002) and myoclonus (50 (52), p = 0.001). Work and social adjustment was less impaired in the myoclonus group (median 20, IQR 18) compared to gait disorder (median 30, IQR18, p < 0.001) and paresis (28, IQR 10, p = 0.001). Self-report showed large overlap in motor symptoms. CONCLUSION No differences were detected between groups of functional motor symptoms, regarding demographics, mode of onset, depression, anxiety, pain and fatigue. The large overlap in symptoms contributes to the hypothesis of shared underlying mechanisms of functional motor disorders.
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Affiliation(s)
- J M Gelauff
- University of Groningen, University Medical Center Groningen, Department of Neurology, the Netherlands
| | - J G M Rosmalen
- University of Groningen, University Medical Center Groningen, Department of Psychiatry, the Netherlands; University of Groningen, University Medical Center Groningen, Department of Internal Medicine, the Netherlands
| | - J Gardien
- University of Groningen, University Medical Center Groningen, Department of Neurology, the Netherlands
| | - J Stone
- University of Edinburgh, Centre for Clinical Brain Sciences, Edinburgh, United Kingdom
| | - M A J Tijssen
- University of Groningen, University Medical Center Groningen, Department of Neurology, the Netherlands.
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Gunzler SA, Riley DE, Chen SG, Tatsuoka CM, Johnson WM, Mieyal JJ, Walter EM, Whitney CM, Feng IJ, Owusu-Dapaah H, Mittal SO, Wilson-Delfosse AL. Motor and non-motor features of Parkinson's disease in LRRK2 G2019S carriers versus matched controls. J Neurol Sci 2018; 388:203-207. [PMID: 29627023 DOI: 10.1016/j.jns.2018.03.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 02/04/2018] [Accepted: 03/14/2018] [Indexed: 11/17/2022]
Abstract
INTRODUCTION LRRK2 G2019S mutation carriers with Parkinson's disease (PD) have been generally indistinguishable from those with idiopathic PD, with the exception of variable differences in some motor and non-motor domains, including cognition, gait, and balance. LRRK2 G2019S is amongst the most common genetic etiologies for PD, particularly in Ashkenazi Jewish (AJ) populations. METHODS This cross-sectional data collection study sought to clarify the phenotype of LRRK2 G2019S mutation carriers with PD. Primary endpoints were the Movement Disorder Society Unified Parkinson Disease Rating Scale (MDS-UPDRS) and Montreal Cognitive Assessment (MoCA). Other motor and non-motor data were also assessed. The Mann-Whitney U Test was utilized to compare LRRK2 G2019S carriers with PD (LRRK2+) with non-carrier PD controls who were matched for age, gender, education, and PD duration. Survival analyses and log rank tests were utilized to compare interval from onset of PD to development of motor and non-motor complications. RESULTS We screened 251 subjects and 231 completed the study, of whom 9 were LRRK2+, including 7 AJ subjects. 22.73% of AJ subjects with a family history of PD (FH) and 12.96% of AJ subjects without a FH were LRRK2+. There were no significant differences between the 9 LRRK2+ subjects and 19 matched PD controls in MDS-UPDRS, MoCA, or other motor and non-motor endpoints. CONCLUSION Prevalence of the LRRK2 G2019S mutation in AJ and non-AJ subjects in our study population in Cleveland, Ohio was comparable to other clinical studies. There were no significant motor or non-motor differences between LRRK2+ PD and matched PD controls.
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Affiliation(s)
- Steven A Gunzler
- Parkinson's and Movement Disorders Center, Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, HAN5040, Cleveland, OH 44106, USA.
| | - David E Riley
- InMotion, 4829 Galaxy Parkway, Suite M, Warrensville Heights, OH 44128, USA
| | - Shu G Chen
- Department of Pathology, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA.
| | - Curtis M Tatsuoka
- Biostatistics, Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, HAN5040, Cleveland, OH 44106, USA.
| | - William M Johnson
- Department of Ophthalmology, Duke University School of Medicine, 2608 Erwin Rd, Durham, NC 27705, USA.
| | - John J Mieyal
- Department of Pharmacology, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA.
| | - Ellen M Walter
- Parkinson's and Movement Disorders Center, Neurological Institute, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, HAN5040, Cleveland, OH 44106, USA.
| | - Christina M Whitney
- Parkinson's and Movement Disorders Center, Neurological Institute, University Hospitals Cleveland Medical Center (retired), 11100 Euclid Avenue, HAN5040, Cleveland, OH 44106, USA
| | - I Jung Feng
- Epidemiology & Biostatistics, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA.
| | - Harry Owusu-Dapaah
- Department of Internal Medicine, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109, USA.
| | - Shivam O Mittal
- Neurology, Columbia Asia Hospitals, Sarjapur Road, Bangalore 560035, India
| | - Amy L Wilson-Delfosse
- Department of Pharmacology, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA.
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Abstract
Parkinson disease (PD) is a multisystem disorder associated with α-synuclein aggregates throughout the central, autonomic, and peripheral nervous system, clinically characterized by motor and non-motor (NM) symptoms. The NMS in PD, many of which antedating motor dysfunction and representing a preclinical phase spanning 20 or more years, are linked to widespread distribution of α-synuclein pathology not restricted to the dopaminergic nigrostriatal system that is responsible for core motor features of PD. The pathologic substrate of NM manifestations such as olfactory, autonomic (gastrointestinal, urogenital, cardia, respiratory), sensory, skin, sleep, visual, neuropsychiatric dysfunctions (cognitive, mood, dementia), and others are critically reviewed. In addition to non-nigral brainstem nuclei, α-synuclein pathology involves sympathetic and parasympathetic, enteric, cardiac and pelvic plexuses, and many other organs indicating a topographical and chronological spread, particularly in the prodromal stages of the disease. Few animal models recapitulate NMS in PD. The relationship between regional α-synuclein/Lewy pathology, neurodegeneration and the corresponding clinical deficits awaits further elucidation. Controlled clinicopathologic studies will refine the correlations between presymptomatic and late-developing NM features of PD and neuropathology, and new premotor biomarkers will facilitate early diagnosis of PD as a basis for more effective preventive and therapeutic options of this devastating disease.
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Affiliation(s)
- Kurt A Jellinger
- Institute of Clinical Neurobiology, Kenyongasse 18, 1070, Vienna, Austria.
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Benito-León J, Labiano-Fontcuberta A, Mitchell AJ, Moreno-García S, Martínez-Martín P. Multiple sclerosis is associated with high trait anger: a case-control study. J Neurol Sci 2014; 340:69-74. [PMID: 24635887 DOI: 10.1016/j.jns.2014.02.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Revised: 01/24/2014] [Accepted: 02/24/2014] [Indexed: 12/12/2022]
Abstract
INTRODUCTION In recent years there has been a focus on health-related quality of life in multiple sclerosis (MS) and in particular the importance of non-motor problems such as fatigue, pain, depression, anxiety, and cognitive disorders. However, little attention has been focused on other negative emotions, such as anger. Our purpose was to evaluate whether trait anger (a predisposition to experience frequent and intense episodes of anger over time) is different between persons with and without MS after controlling for depression, anxiety, and other socio-demographic variables. METHODS 157 consecutive MS patients were enrolled in the study and compared to eighty age, gender, and education-matched healthy controls. Participants were administered affective trait measures (Beck Depression Inventory, Beck Anxiety Inventory) and the trait anger measure (the Spanish adapted version of the State-Trait Anger Expression Inventory-2 [STAXI-2]). RESULTS MS patients had significantly higher scores on anger intensity (state anger) and trait anger than did controls. They also had a trend to experience direct anger toward other persons or objects in the environment (higher anger expression-out score) and to hold in or suppress angry feelings (higher anger expression-in score). However, in a regression analysis that adjusted for different demographic and clinical variables, we found that diagnosis category (MS patient vs. control) was associated with none of the highest quartiles of STAXI-2 scores, except for the Trait Anger scale (odds ratios between 2.35 and 3.50). CONCLUSIONS The present study provides further evidence that MS is independently associated with high trait anger.
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Affiliation(s)
- Julián Benito-León
- Department of Neurology, University Hospital "12 de Octubre", Madrid, Spain; Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain; Department of Medicine, Faculty of Medicine, Complutense University, Madrid, Spain.
| | - Andrés Labiano-Fontcuberta
- Department of Neurology, University Hospital "12 de Octubre", Madrid, Spain; Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain; Department of Medicine, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Alex J Mitchell
- Department of Psycho-oncology and Liaison Psychiatry, University of Leicester, Leicester, UK
| | - Sara Moreno-García
- Department of Neurology, University Hospital "12 de Octubre", Madrid, Spain; Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain; Department of Medicine, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Pablo Martínez-Martín
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain; National Center of Epidemiology, Carlos III Institute of Health, Madrid, Spain
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