The effect of war stress on multiple sclerosis exacerbations and radiological disease activity

Subclinical imaging activity in multiple sclerosis patients during war-related psychological stress

OBJECTIVES

Psychological stress has been suggested as a contributory factor in the onset and progression of multiple sclerosis (MS). The 7 October 2023 terrorist attacks in Israel caused significant psychological stress, providing a unique context to study its impact on MS activity. This study aims to assess the impact of war-related psychological stress on MS activity using magnetic resonance imaging (MRI) scans and clinical follow-up.

METHODS

This observational retrospective case-control study includes 93 patients with MS (pwMS) who had routine annual MRI scans from three periods (7 October 2021 to 7 January 2022; 7 October 2022 to 7 January 2023; and 7 October 2023 to 7 January 2024). Data were collected from medical records and MRI scans at Hadassah Medical Center. MRI scans were classified as active if new or enlarging T2 lesions and/or enhancing T1 lesions were present.

RESULTS

MRI activity significantly increased among pwMS during the first 3 months of the war compared to the corresponding period in the preceding year (11/93 vs. 23/93, P = 0.0139), with an OR of 4.0 (95% confidence interval: 1.29-16.442). pwMS with an EDSS score ≥4 showed a significant increase in MRI activity (P = 0.045), whereas no significant increase was observed in patients with an EDSS score ≤3.5 (P = 0.23). Additionally, MRI activity increased later during the war compared to the previous year (P < 0.0001).

INTERPRETATION

This study provides evidence of increased MRI-detected disease activity in pwMS during periods of war-related psychological stress. Our findings highlight the importance of considering psychological stress in MS management. Healthcare providers should be aware of the potential for increased disease activity in pwMS during extreme stress and may consider more frequent monitoring, including MRI scans, or treatment adjustments during such periods.

Stress and Multiple Sclerosis - Systematic review and meta-analysis of the association with disease onset, relapse risk and disability progression

OBJECTIVE

This systematic review and meta-analysis address the evidence on the association of psychological stressors with onset of multiple sclerosis, inflammatory disease activity (relapses or new disease activity on magnetic resonance imaging, MRI) and disability progression.

METHODS

PubMed was searched from 1946 to 15 July 2022. Studies and certain stressors were selected when they assessed stressors independent from stress elicited by the disease process itself. Risk of bias was assessed by the CASP Case Control Study Checklist and the CASP Cohort Study Checklist. Normal-Normal Hierarchical Model (NNHM) for random-effects meta-analysis was used in the Bayesian framework.

RESULTS

30 studies reporting data from 26 cohorts reporting on 24.781 cases could be identified. Ten studies addressed stressors and MS disease onset showing a weak to modest effect of psychological stressors. A meta-analysis of three studies investigating diagnosed stress disorders and MS risk showed a 1.87-fold (CI 1.061 to 3.429) increased MS risk. Stress and MS relapse risk were addressed in 19 heterogeneous studies. Meta-analyses from two independent cohorts investigating the same military threat of a population showed a threefold increased risk for relapses in association with war (relapse rate: 3.0, CI 1.56 to 5.81). In addition, two studies confirmed an association of stressful life events and MRI activity. Three studies of stressors and disease progression were included indicating some effect on disease progression.

CONCLUSIONS

Taken together studies indicate a minor to modest impact of psychological stressors on disease onset, inflammatory activity and progression of MS. Possible case-selection bias and lack of confounder analysis were present in many studies.

A single-arm, open-label pilot study of neuroimaging, behavioral, and peripheral inflammatory correlates of mindfulness-based stress reduction in multiple sclerosis

Multiple sclerosis (MS) is a chronic neurological disease frequently associated with significant fatigue, anxiety, depression, and stress. These symptoms are difficult to treat, and prominently contribute to the decreases in quality of life observed with MS. The underlying mechanisms of these "silent" symptoms are not well understood and include not just the psychological responses to a chronic disease, but also biological contributions from bidirectional psycho-neuro-immune (dys)regulation of systemic inflammatory biology. To address these issues, we conducted a prospective, observational pilot study to investigate the psychological, biological, and neuroarchitecture changes associated with a mindfulness-based stress reduction (MBSR) program in MS. The overarching hypothesis was that MBSR modulates systemic and central nervous system inflammation via top-down neurocognitive control over forebrain limbic areas responsible for the neurobiological stress response. 23 patients were enrolled in MBSR and assessed pre/post-program with structural 3 T MRI, behavioral measures, hair cortisol, and blood measures of peripheral inflammation, as indexed by the Conserved Transcriptional Response to Adversity (CTRA) profile. MBSR was associated with improvements across a variety of behavioral outcomes, as well as on-study enlargement of the head of the right hippocampus. The CTRA analyses revealed that greater inflammatory gene expression was related to worse patient-reported anxiety, depression, stress, and loneliness, in addition to lower eudaimonic well-being. Hair cortisol did not significantly change from pre- to post-MBSR. These results support the use of MBSR in MS and elucidate inflammatory mechanisms related to key patient-reported outcomes in this population.

Neurological Care of Refugees and Other Forcibly Displaced Persons

There are more than 100 million forcibly displaced persons (FDPs) in the world today, including a high number of people who experience neurologic symptoms and presentations. This review summarizes the conceptual frameworks for understanding neurological health risks and conditions across the migration journey (premigration, migration journey, and postmigration) and life span, including special attention to pediatric FDPs. The interaction with psychiatric illness is discussed, as well as the available published data on neurologic presentations in FDPs in the medical literature. A social determinant of health lens is used to provide ways in which forcible displacement can influence brain health and neurological outcomes. Priorities and future needs for the neurological care of refugees and other FDPs are suggested.

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

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

Central stress processing, T cell responsivity to stress hormones, and disease severity in multiple sclerosis

Epidemiological, clinical and neuroscientific studies support a link between psychobiological stress and multiple sclerosis. Neuroimaging suggests that blunted central stress processing goes along with higher multiple sclerosis severity, neuroendocrine studies suggest that blunted immune system sensitivity to stress hormones is linked to stronger neuroinflammation. Until now, however, no effort has been made to elucidate whether central stress processing and immune system sensitivity to stress hormones are related in a disease-specific fashion, and if so, whether this relation is clinically meaningful. Consequently, we conducted two functional MRI analyses based on a total of 39 persons with multiple sclerosis and 25 healthy persons. Motivated by findings of an altered interplay between neuroendocrine stress processing and T-cell glucocorticoid sensitivity in multiple sclerosis, we searched for neural networks whose stress task-evoked activity is differentially linked to peripheral T-cell glucocorticoid signalling in patients versus healthy persons as a potential indicator of disease-specific CNS–immune crosstalk. Subsequently, we tested whether this activity is simultaneously related to disease severity. We found that activity of a network comprising right anterior insula, right fusiform gyrus, left midcingulate and lingual gyrus was differentially coupled to T-cell glucocorticoid signalling across groups. This network’s activity was simultaneously linked to patients’ lesion volume, clinical disability and information-processing speed. Complementary analyses revealed that T-cell glucocorticoid signalling was not directly linked to disease severity. Our findings show that alterations in the coupling between central stress processing and T-cell stress hormone sensitivity are related to key severity measures of multiple sclerosis.

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.

The Impact of COVID-19 on Patients With Neuromyelitis Optica Spectrum Disorder Beyond Infection Risk

There is an increasing need for better understanding of the impact of coronavirus disease 2019 (COVID-19) on patients with neuromyelitis optica spectrum disorder (NMOSD). A few pilot studies have investigated COVID-19 infections in NMOSD, but few studies have addressed disease activity and immune status of these patients during the pandemic. We carried out a cross-sectional study to examine immune status, relapses, and COVID-19 infections in a cohort of NMOSD patients using an electronic patient registry (MSNMOBase) for multiple sclerosis and related disorders. An online questionnaire was administered to all NMOSD patients in the registry from January 1, 2011, to June 1, 2020. Clinical demographic characteristics, immune status, relapses, treatments, COVID-19 infections, and preventive measures were evaluated. Of the 752 registered patients, 535 (71.1%) with qualified data were included. A total of 486 used preventive therapies during the pandemic, including mycophenolate mofetil (71.2%), azathioprine (13.3%), and other immunosuppressants (6.4%). Neither median immune cell counts nor immunoglobulin levels (p > 0.05) were significantly different between patients with or without immunosuppression. During the pandemic, no patients were diagnosed with COVID-19, and the majority (>95%) took one or more effective protective measures (e.g., wearing a mask and social distancing). However, a significantly higher annualized relapse rate (ARR) was observed in the 33 patients with treatment interruptions due to the pandemic compared to before it (p < 0.05), whereas ARR changes were not found in patients with continuous treatments or those without treatments (p > 0.05). Interruption frequency was significantly higher in patients with relapses compared to those without (34.9 vs. 15.7%, p < 0.01). For stable NMOSD patients during the pandemic, the risk of relapse due to treatment interruption may be higher than the risk of COVID-19 infection when protective measures are used, and continuous relapse-prevention treatments may be necessary.

The emotional disorders associated with multiple sclerosis

Multiple sclerosis (MS) is associated with a high prevalence of emotional and mood disorders. Emotional disorders may worsen during illness progression and affect the quality of life of patients and their families. MS is often associated with depression, with an increased risk of suicide, poor adherence to treatment, decreased functional status, and quality of life. The diagnosis and treatment of emotional and mood disorders in these patients is often challenging since several symptoms of these disorders overlap with those of MS. Other prevalent emotional disorders in MS include bipolar disorder, anxiety disorders, emotional blunting (apathy), and pseudobulbar affect. Early recognition and treatment of these comorbidities could contribute to the reduction of disability and even to decreased mortality. The aim of this chapter is to provide an up-to-date review of mood and emotional disorders that are often associated with MS, focusing on their epidemiology, clinical features, pathogenesis, assessment, and treatment. The interplay between the psychosocial impact of the chronic disability and the demyelinating structural lesions of the brain in precipitating emotional and mood disorders is discussed, as well as its implications for diagnosis and treatment.

The impact of COVID-19 on patients with neuromyelitis optica spectrum disorder; a pilot study

Neuromyelitis optica spectrum disorder (NMOSD) is a CNS neuroinflammatory disorder, mediated by the pathogenic autoantibody aquaporin-4 (AQP4-IgG). Current treatment includes long-term use of immunomodulatory therapies, leading to increased rates of infections among this population. It is of interest therefore, to study how the COVID-19 pandemic affects NMOSD patients in terms of their disease activity. A 15-point questionnaire was administered to 33 participants living in Northern California with NMOSD, MS and other related disorders. Although none of the participants were diagnosed with COVID-19, our results show that 2 participants with NMOSD experienced new onset of neurological symptoms and 2 experienced worsening of previous neurological symptoms - suggesting a possible effect of pandemic-related stress on this CNS autoimmune disorder.

Identifying the culprits in neurological autoimmune diseases

The target organ of neurological autoimmune diseases (NADs) is the central or peripheral nervous system. Multiple sclerosis (MS) is the most common NAD, whereas Guillain-Barré syndrome (GBS), myasthenia gravis (MG), and neuromyelitis optica (NMO) are less common NADs, but the incidence of these diseases has increased exponentially in the last few years. The identification of a specific culprit in NADs is challenging since a myriad of triggering factors interplay with each other to cause an autoimmune response. Among the factors that have been associated with NADs are genetic susceptibility, epigenetic mechanisms, and environmental factors such as infection, microbiota, vitamins, etc. This review focuses on the most studied culprits as well as the mechanisms used by these to trigger NADs.

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Neurological autoimmune diseases are caused by a complex interaction between genes, environmental factors, and epigenetic deregulation.

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Infectious agents can cause an autoimmune reaction to myelin epitopes through molecular mimicry and/or bystander activation.

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Gut microbiota dysbiosis contributes to neurological autoimmune diseases.

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Smoking increases the risk of NADs through inflammatory signaling pathways, oxidative stress, and Th17 differentiation.

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Deficiency in vitamin D favors NAD development through direct damage to the central and peripheral nervous system.

Stress-full life events and multiple sclerosis: A population-based incident case-control study

AIM

While sizeable evidence regarding the association between stressful-life events and multiple sclerosis (MS) disease activity (clinical and/or radiological) was previously documented, their relation to MS risk is controversial. We aimed to investigate the possible association of stressful-life events and multiple sclerosis risk after adjustment for relevant confounders in an Iranian population.

METHOD

This was a population-based incident case-control study that recruited 547 MS cases and 1057 healthy controls between August 2013 and February 2015, Tehran. The patients were identified using the Iranian MS Society based on 2010 McDonald criteria. We used standard random digit dialing protocol for control selection. Logistic regression model was applied to estimate the odds ratios (95% CI) adjusted for physical activity, age, gender, tobacco smoking, waterpipe smoking and passive smoking.

RESULTS

While total life events number was not associated with risk of MS, homeless periods OR 3.85 (1.65-8.90), p = 0.002 as well as divorce OR 2.11 (1.24-3.58), p = 0.005 increased the risk of MS. However, marriage OR 0.59 (0.41-0.86), p = 0.006, death of ones' dear OR 0.60 (0.44-0.82), p = 0.002 and joblessness OR 0.61 (0.41-0.91) reduced the risk of MS.

CONCLUSION

We could not detect a statistically significant role for the total stressful life event during the last 3 years and MS diagnosis. However, there is some evidence confirming the possible role of some individual life events, i.e. divorce and periods of homelessness as potential risk factors for MS and conversely, having married as a protective factor in MS onset.

Factors associated with onset, relapses or progression in multiple sclerosis: A systematic review

Multiple sclerosis (MS) is a chronic disease of the central nervous system with an unidentified etiology. We systematically reviewed the literature on the possible risk factors associated with MS disease onset, relapses and progression from 1960 to 2012 by accessing six databases and including relevant systematic reviews, meta-analyses, case-control or cohort studies. The focus was on identifying modifiable risk factors. Fifteen systematic reviews and 169 original articles were quality assessed and integrated into a descriptive review. Best evidence, which included one or more prospective studies, suggested that lower exposure to sunlight and/or lower serum vitamin D levels were associated with an increased risk of developing MS onset and subsequent relapses, but a similar quality of evidence was lacking for disease progression. Prospective studies indicated that cigarette smoking may increase the risk of MS as well as accelerate disease progression, but whether smoking altered the risk of a relapse was largely unknown. Infections were implicated in both risk of developing MS and relapses, but data for progression were lacking. Specifically, exposure to the Epstein-Barr virus, particularly if this manifested as infectious mononucleosis during adolescence, was associated with increased MS risk. Upper respiratory tract infections were most commonly associated with an increase in relapses. Relapse rates typically dropped during pregnancy, but there was no strong evidence to suggest that pregnancy itself altered the risk of MS or affected long-term progression. Emerging research with the greatest potential to impact public health was the suggestion that obesity during adolescence may increase the risk of MS; if confirmed, this would be of major significance.

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

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

Multiple sclerosis in gulf war era veterans. 2. Military deployment and risk of multiple sclerosis in the first gulf war

BACKGROUND

Concern has been raised that US veterans of the 1990-1991 Gulf War (GW1) may be at increased risk to develop neurologic disease.

METHODS

An incident cohort of multiple sclerosis (MS) and other demyelinating disease (ODD) was assembled from the US military comprising the Gulf War era (1990-2007). Cases of MS and ODD meeting standard diagnostic criteria were matched to a database of all active duty personnel from the Department of Defense. Relative risk (RR) estimates for MS and all demyelinating disease based on onset, deployment status, and exposures were calculated.

RESULTS

For GW1, a total of 1,841 incident cases of definite MS and ODD were identified, with 387 among 696,118 deployed and 1,454 among 1,786,215 nondeployed personnel. The RR for MS alone among those deployed compared to those nondeployed was 0.69 (confidence interval, CI: 0.61-0.78), with 0.72 (CI: 0.62-0.83) in men and 0.96 (CI: 0.75-1.22) in women. Deployment was also nonsignificant or protective as an MS risk factor across racial groups, all age groups, and each military service. RRs for MS by service were: Air Force 0.71 (CI: 0.53-0.96), Army 0.80 (CI: 0.67-0.96), Marines 0.96 (CI: 0.63-1.47), and Navy 0.56 (CI: 0.43-0.74).

CONCLUSION

Military deployment to GW1 was not a risk factor for developing MS.

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.

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

BACKGROUND

Stressful life events have long been suspected to contribute to multiple sclerosis (MS) disease activity. The few studies examining the relationship between stressful events and neuroimaging markers have been small and inconsistent. This study examined whether different types of stressful events and perceived stress could predict the development of brain lesions.

METHOD

This was a secondary analysis of 121 patients with MS followed for 48 weeks during a randomized controlled trial comparing stress management therapy for MS (SMT-MS) to a waitlist control (WLC). Patients underwent magnetic resonance imaging (MRI) scans every 8 weeks. Every month, patients completed an interview measure assessing stressful life events and self-report measures of perceived stress, anxiety and depressive symptoms, which were used to predict the presence of gadolinium-enhancing (Gd+) and T2 lesions on MRI scans 29-62 days later. Participants classified stressful events as positive or negative. Negative events were considered 'major' if they involved physical threat or threat to the patient's family structure, and 'moderate' otherwise.

RESULTS

Positive stressful events predicted decreased risk for subsequent Gd+ lesions in the control group [odds ratio (OR) 0.53 for each additional positive stressful event, 95% confidence interval (CI) 0.30-0.91] and less risk for new or enlarging T2 lesions regardless of group assignment (OR 0.74, 95% CI 0.55-0.99). Across groups, major negative stressful events predicted Gd+ lesions (OR 1.77, 95% CI 1.18-2.64) and new or enlarging T2 lesions (OR 1.57, 95% CI 1.11-2.23) whereas moderate negative stressful events, perceived stress, anxiety and depressive symptoms did not.

CONCLUSIONS

Major negative stressful events predict increased risk for Gd+ and T2 lesions whereas positive stressful events predict decreased risk.

Stress as provoking factor for the first and repeated multiple sclerosis seizures

INTRODUCTION

Multiple sclerosis is an inflammatory, autoimmune, disease of the white mass of the brain, which sometimes may involve the gray matter (subcortical and ones in the anterior horns of the spinal cord) with the chronic nature and generally with progressive course. As a possible cause of this disease state are listed genetic predisposition, early viral infections and environmental factors, with special effects of stress as a provoking factor in first episode of the disease and relapses because stress leads to modulation of the immune system and immune response to various causes.

GOAL

To determine the existence of intense stressful events as a factor in the development of the first episode of illness and worsening of the seizures.

MATERIAL AND METHODS

We analyzed all newly discovered cases of multiple sclerosis over a two year period (January 2010 - December 2011) during the first or second hospitalization, and worsening of seizures for previously diagnosed patients in this period. In order to confirm the MS diagnosis are taken history, neurological examination, MRI of the brain, VEP, CSF examination and for those with repeated hospitalization only follow-up of EDSS scores trough neurological examination.

RESULTS

During the two year period there were 109 newly diagnosed cases of MS from which 80 F and 29 M (ratio 2.7:1), aged 17-59 years, mean age 32.93±9.69 years and 41 patients (29 F and 12M with seizures worsening in previously diagnosed disease. Disease duration was from 6 months to 17 years. 72.94% had relapsing-remitting course of the disease (RRMS) and 27.1% had secondary progressive type (SPMS). Stress as a provoking factor preceded in 47.44% the first episode of the disease, infections (respiratory) in 18.3%, and the pregnancy with postpartum period in 8.77% women, whereas in the group of patients with previously diagnosed illness relapse (n=41) showed that the infection is most common precipitating factor which preceded relapse in 58.54% of patients, stress in 29.02%) and the pregnancy with postpartum period in 12.5% of patients.

CONCLUSION

An intensive stressor is certainly one of the triggers for the development of Multiple Sclerosis, as the first episode and worsening of previously established disease.

Behavioral interventions in multiple sclerosis: a biopsychosocial perspective

Managing uncertainty is a major challenge associated with the diagnosis of multiple sclerosis (MS). In addition to physical symptoms, neuropsychiatric symptoms are highly prevalent in this disease. Depression in particular is more common in MS than in other chronic diseases. While substantial achievements have been made in the therapy of MS and an increasing number of immunomodulatory treatments are now available, the long-term benefits of these are still a matter of debate. Importantly, while the approved therapies show good efficacy on inflammatory lesions and relapse rate, and may slow certain aspects of disease progression, improvements in function have rarely been reported. On the other hand, behavioral interventions have recently been shown to significantly improve fatigue and depression as well as motor function. In addition, recent evidence suggests that group education or face-to-face behavioral interventions may decrease inflammatory disease activity (such as relapse rate or lesion formation measured by MRI). Therefore, behavioral interventions not only ameliorate symptoms but may have the potential to modify the disease process itself.

Neurological disorders in complex humanitarian emergencies and natural disasters

Complex humanitarian emergencies include the relatively acute, severe, and overwhelming health consequences of armed conflict, food scarcity, mass displacement, and political strife. Neurological manifestations of complex humanitarian emergencies are important and underappreciated consequences of emergencies in populations worldwide. This review critically assesses the existing knowledge of the range of neurological disorders that accompany complex humanitarian emergencies and natural disasters in both the acute phase of crisis and the "long shadow" that follows.