A review of stress-relapse interactions in multiple sclerosis: important features and stress-mediating and -moderating variables

Impact of the first Gulf war on multiple sclerosis risk in Kuwait: a quasi-experimental study

OBJECTIVE

It has been reasoned that stressful life events tend to alter immune function thereby increasing the susceptibility to autoimmune diseases including multiple sclerosis (MS). Using the database of Kuwait National MS Registry, this quasi-experimental study assessed the impact of the first Gulf War (Iraqi invasion of Kuwait in 1990) on MS risk in Kuwait.

METHODS

MS incidence data from 1980 to 2019 were obtained from the Kuwait National MS Registry. Annual age-standardized incidence rates (ASIRs) (per 10⁵ person-years) were computed using the World Standard Population as a reference. Interrupted time series analysis with the option of autoregressive order (1) was used to evaluate the impact of the first Gulf War on MS risk by treating 1990 as an intervention year.

RESULTS

Estimated baseline annual ASIR (per 10⁵ person-years) was 0.38 (95% CI: -1.02, 1.78; p = 0.587). MS ASIRs (per 10⁵ person-years) tended to increase significantly every year prior to 1990 by 0.45 (ASIR per 10⁵ person-years = 0.45; 95% CI: 0.15, 0.76; p = 0.005). During the first year of the first Gulf War, there seemed to be a non-significant increase (step change) in ASIRs (per 10⁵ person-years) of MS (ASIR per 10⁵ person-years = 0.85; 95% CI: - 5.16, 6.86; p = 0.775) followed by a non-significant increase in the annual trend in MS ASIRs per 10⁵ person-years (relative to the preintervention trend i.e., the difference between the pre-first Gulf War versus the post-first Gulf War trends) by 0.65 (ASIR per 10⁵ person-years = 0.65; 95% CI: - 0.22, 1.52; p = 0.138). However, a postestimation measure of the post-first Gulf War trend was statistically significant (ASIR per 10⁵ person-years = 1.10; 95% CI: 0.40, 1.80; p = 0.003), which implies that the post-first Gulf War trend in the annual ASIRs (per 10⁵ person-years) inclined to be the same as was the pre-first Gulf War (i.e., counterfactual of the pre-first Gulf War trend in annual ASIRs (per 10⁵ person-years) as if no first Gulf War took place).The Durbin-Watson test statistic (d = 1.89) showed almost non-significant autocorrelations across the time series observations on ASIRs (per 10⁵ person-years).

CONCLUSIONS

This study suggests that the first Gulf War was not significantly associated with the increasing trend in MS risk at population level in Kuwait neither with any short-term change nor with secular trend. Future studies may consider confirming the role of conflict-related stress or other stressful life events in potential exacerbation of MS risk along with unraveling biologically plausible mechanistic pathways.

Predictors of Mood Disorders in Parents With Multiple Sclerosis: The Role of Disability Level, Coping Techniques, and Perceived Social Support

BACKGROUND

Being a parent can be demanding and stressful, especially for people with chronic diseases such as multiple sclerosis (MS). Parenting can be disrupted by flareups, disease worsening, and other MS symptoms, including mobility problems, pain, fatigue, and cognitive impairment. Mood disorders, such as depression and anxiety, have been found to occur at much higher rates in people with MS than in the general population. Surprisingly, less is known about which factors may predict mood disorders in parents with MS. This study aims to identify potential demographic, clinical, and self-reported predictors that contribute to mood disorders measured by the Hospital Anxiety and Depression Scale.

METHODS

A total of 285 parents with MS completed an anonymous online questionnaire combining sociodemographic, clinical, and family characteristics and scales, validated in Italian, related to coping strategies and social support. Associations between each variable and mood disorders were assessed using univariate and multivariate logistic regression analyses.

RESULTS

Disability level, emotional and dysfunctional coping strategies, and perceived social support were significant predictors of mood disorders in parents with MS.

CONCLUSIONS

These findings confirm the importance of identifying risk factors for mood disorders in parents with MS so that early intervention can minimize mood disruptions caused by the disease.

The Development and Psychometric Validation of the Brief Disability-Related Stress Scale in Individuals With Multiple Sclerosis

Disability-related stress is the unique stressful experiences and challenges people with disabilities encounter. The goal of the study was to develop and validate the Brief Disability-Related Stress Scale ( BDRSS) in a sample of people with multiple sclerosis (MS). Findings demonstrated that the BDRSS is unidimensional and has good psychometric properties (internal consistency reliability coefficient [Cronbach’s α = .86]). The BDRSS was also found to correlate with the Perceived Stress Scale–10 ( PSS-10; r = .69). Results of this study suggested the potential clinical utility of incorporating the BDRSS in rehabilitation, mental health, and neuropsychology settings to assess stressors experienced by people with MS.

Psychometric Properties of the HADS Measure of Anxiety and Depression Among Multiple Sclerosis Patients in Croatia

Depression and anxiety are common complaints in patients with multiple sclerosis (MS). The study objective was to investigate the factor structure, internal consistency, and correlates of the Croatian version of the Hospital Anxiety and Depression Scale (HADS) in patients with MS. A total of 179 patients with MS and 999 controls were included in the online survey. All subjects completed the HADS and self-administered questionnaires capturing information of demographic, education level, disease-related variables, and the Multiple Sclerosis Impact Scale-29 (MSIS-29). Psychometric properties were examined by estimating the validity, reliability, and factor structure of the HADS in patients with MS. The two HADS subscales (anxiety and depression) had excellent internal consistencies (Cronbach’s α value 0.82–0.83), and factor analysis confirmed a two-factor structure. The convergent validity of the HADS subscales appeared to be good due to the significant correlations between HADS and MSIS-29. Receiver operating characteristic (ROC) analysis indicates that the HADS subscales have a significant diagnostic validity for group differentiation. Hierarchical regression analysis using MSIS-29 subscales as criterion variables showed consistent evidence for the incremental validity of the HADS. The HADS is a reliable and valid self-assessment scale in patients with MS and is suggested to be used in clinical monitoring of the psychiatric and psychological status of patients with MS.

The Role of Stress Perception and Coping with Stress and the Quality of Life Among Multiple Sclerosis Patients

Purpose

Multiple sclerosis (MS) is one of the most common neurological disorders and a cause of disability in young adults. Adequate stress management in MS patients may merit the benefits of both physical and psychological well-being. This study aimed to evaluate the quality of life in MS patients and its correlation with stress levels and coping strategies.

Methods

This descriptive and correlational study was conducted among 109 patients diagnosed with relapsing-remitting MS (RRMS). The study was based on a questionnaire designed by the authors and the following standardized questionnaires: the Perceived Stress Scale (PSS-10), the Inventory for Measuring Coping with Stress (Mini-COPE), and the Multiple Sclerosis International Quality of Life Questionnaire (MusiQoL).

Results

Data analysis showed that 47.71% of the patients experienced a high level of stress, and the most often used strategies under challenging situations included seeking emotional support (2.11) and active coping (1.96). Also, it showed that when the level of stress is higher, the QOL in all domains is lower. Coping strategies such as sense of humor, turning to religion, self-distraction, denial, venting, substance use, behavioral disengagement, and self-blame are negatively correlated with the quality of life of MS.

Conclusion

Quality of life in MS patients is negatively affected by a higher level of perceived stress. The use of coping strategies such as active coping, positive reframing, acceptance, and seeking emotional and instrumental support is positively correlated with the quality of life of MS patients.

The Epidemiology of COVID-19 and MS-Related Characteristics in a National Sample of People With MS in China

Few studies have focused on immune status and disease activity in MS patients during the coronavirus disease 2019 (COVID-19) pandemic. The aim of this study is to investigate immune status, COVID-19 infection, and attacks in MS patients during the pandemic. An online questionnaire about COVID-19 infection, MS attack, and MS treatment during the pandemic was administered to all 525 MS patients registered in our hospital database from January 1, 2011, to June 1, 2020. Only 384 responded, of which 361 patients could be included in the final analysis. During the pandemic, 42.1% of the 361 patients and 65.0% of the 234 patients on immunotherapies were exposed to teriflunomide. Compared to patients who didn't receive treatment, patients exposed to DMTs had significantly lower levels of neutrophils (P < 0.01) and immunoglobulin G (P < 0.01), and patients exposed to immunosuppressants had significantly lower levels of immunoglobulin G (P < 0.05). Over 80% of our patients followed effective protective measures and none of the 361 MS patients in our cohort contracted COVID-19. Patients whose treatment was disrupted had a significantly higher annualized relapse rate (ARR) during than before the pandemic (P < 0.01), while the ARR of patients with continuous treatment or without treatment remained unchanged. During the pandemic, the risk of MS attack due to treatment disruption possibly outweighs the risk of COVID-19 infection under preventive measures, and MS treatment maintenance might be necessary.

Antidepressants on Multiple Sclerosis: A Review of In Vitro and In Vivo Models

Background

Increased prevalence of depression has been observed among patients with multiple sclerosis (MS) and correlated with the elevated levels of proinflammatory cytokines and the overall deregulation of monoaminergic neurotransmitters that these patients exhibit. Antidepressants have proved effective not only in treating depression comorbid to MS, but also in alleviating numerous MS symptoms and even minimizing stress-related relapses. Therefore, these agents could prospectively prove beneficial as a complementary MS therapy.

Objective

This review aims at illustrating the underlying mechanisms involved in the beneficial clinical effects of antidepressants observed in MS patients.

Methods

Through a literature search we screened and comparatively assessed papers on the effects of antidepressant use both in vitro and in vivo MS models, taking into account a number of inclusion and exclusion criteria.

Results

In vitro studies indicated that antidepressants promote neural and glial cell viability and differentiation, reduce proinflammatory cytokines and exert neuroprotective activity by eliminating axonal loss. In vivo studies confirmed that antidepressants delayed disease onset and alleviated symptoms in Experimental Autoimmune Encephalomyelitis (EAE), the most prevalent animal model of MS. Further, antidepressant agents suppressed inflammation and restrained demyelination by decreasing immune cell infiltration of the CNS.

Conclusion

Antidepressants were efficient in tackling numerous aspects of disease pathophysiology both in vitro and in vivo models. Given that several antidepressants have already proved effective in clinical trials on MS patients, the inclusion of such agents in the therapeutic arsenal of MS should be seriously considered, following an individualized approach to minimize the adverse events of antidepressants in MS patients.

Psychological Resilience and Vulnerability as Mediators Between Adverse Life Events and Fatigue, Motor Dysfunction, and Paresthesia in Multiple Sclerosis

OBJECTIVE

Adverse life events have been associated with exacerbating multiple sclerosis (MS) symptoms, but results have been variable, raising the question on the role of other psychological factors. This study examined the role of psychological resilience and vulnerability as mediators between adverse life events on MS symptoms.

METHODS

Participants with MS (N = 1239) were aged 18 to 81 years (mean [SD] = 45.6 [10.4] years), and 84.5% were female. MS symptoms were measured by the modified Fatigue Severity Scale, modified Fatigue Assessment Scale, Motor Dysfunction Assessment Scale, Paraesthesiae Spell Duration Scale, and the Paraesthesiae Cumulative Duration Scale. Psychological measures included the Connor-Davidson Resilience Scale, Resilience Scale for Adults, Psychological Vulnerability Scale, the vulnerability section of the Defence Style Questionnaire, and the Adverse Life Events Assessment Scale. Regression analyses and structural equation modeling were performed.

RESULTS

Adverse life events during the preceding 60 days were associated with fatigue, motor dysfunction, and paresthesia, but with small effect sizes (β from 0.07 to 0.15; p ≤ .014). A structural equation model by which resilience mediated less and vulnerability more MS symptoms after adverse life events during the preceding 60 days showed a statistically significant fit with the data of a moderate to good degree (p < .001; goodness-of-fit statistic = 0.725; root mean square error of approximation = 0.047). Vulnerability played a markedly larger role than did resilience.

CONCLUSION

The results suggest that psychological resilience and vulnerability play mediating roles in the relation between adverse life events and MS symptoms, but other psychological factors also need to be investigated.

Multiple Sclerosis Exacerbation Associated With High-Altitude Climbing Exposure

The spectrum of the neurological effects of high-altitude exposure can range from high-altitude headache and acute mountain sickness, to the more severe end of the spectrum with high-altitude cerebral edema. In general, patients with known unstable preexisting neurological conditions and those patients with residual neurological deficits from a preexisting neurological condition are discouraged from climbing to high altitudes because of the risk of exacerbation or worsening of symptoms. Although multiple sclerosis exacerbations can be triggered by environmental factors, high-altitude exposure has not been reported as a potential trigger. We are reporting the case of a multiple sclerosis exacerbation presenting in an active duty U.S. Air Force serviceman upon ascending and descending Mt. Fuji within the same day.

Social disruption alters pain and cognition in an animal model of multiple sclerosis

Although pain and cognitive deficits are widespread and debilitating symptoms of multiple sclerosis (MS), they remain poorly understood. Theiler's murine encephalomyelitis virus (TMEV) infection is an animal model of MS where disease course is exacerbated by prior stressors. Here chronic infection coupled with prior social stress increased pain behavior and impaired hippocampal-dependent memory consolidation during the demyelinating phase of disease in SJL mice. These results suggest that the TMEV model may be useful in investigating pain and cognitive impairments in MS. However, in contrast to prior Balb/cJ studies, stress failed to consistently alter behavioral and physiological indicators of disease course.

Meditation as an adjunct to the management of multiple sclerosis

Background. Multiple sclerosis (MS) disease course is known to be adversely affected by several factors including stress. A proposed mechanism for decreasing stress and therefore decreasing MS morbidity and improving quality of life is meditation. This review aims to critically analyse the current literature regarding meditation and MS. Methods. Four major databases were used to search for English language papers published before March 2014 with the terms MS, multiple sclerosis, meditation, and mindfulness. Results. 12 pieces of primary literature fitting the selection criteria were selected: two were randomised controlled studies, four were cohort studies, and six were surveys. The current literature varies in quality; however common positive effects of meditation include improved quality of life (QOL) and improved coping skills. Conclusion. All studies suggest possible benefit to the use of meditation as an adjunct to the management of multiple sclerosis. Additional rigorous clinical trials are required to validate the existing findings and determine if meditation has an impact on disease course over time.

The Gap in the Current Research on the Link between Health Locus of Control and Multiple Sclerosis: Lessons and Insights from a Systematic Review

Multiple sclerosis (MS) is a chronic neurological disease whose etiology has not been fully understood yet in detail. Empirical findings show how psychosocial symptoms are very important features of the clinical presentation of MS, having a deep impact on patient's quality of life, and thus psychological coping strategies may play a central role in reducing the burden of the disease and improving patient's satisfaction of life. MS progression and relapses/exacerbations are unpredictable and may depend on factors such as stressor chronicity, frequency, severity, type, and individual patient characteristics such as depression, personality, locus of control (LOC), optimism, and perceived social support. Due to its importance for health-care delivery, rehabilitation, and nursing, here, we make a systematic review on the current state-of-the-art studies concerning the relationship between LOC and MS, according to the PRISMA guidelines, and we assess the quality and the completeness of the studies using the CONSORT instrument, underpinning their limitations, and suggesting how to fill the gap in this research field.

Factors affecting anxiety in multiple sclerosis

PURPOSE

Anxiety is common in people with multiple sclerosis (MS). Little is known about the factors related to anxiety. The aim was to identify factors associated with the presence of anxiety.

METHODS

This was a cohort study. Participants were sent questionnaires to measure factors potentially related to anxiety. The factors included disability, depression, self-efficacy, locus of control, general stress, psychological distress and factors specific to MS. Participants with significant levels of anxiety, as measured by the Hospital Anxiety and Depression Scale (HADS), were compared to those who were not anxious.

RESULTS

Of the 157 participants who took part, 89 (57%) were clinically anxious. Participants who were anxious had a lower level of self-efficacy (p < 0.001), higher level of disability (p < 0.001), higher level of depression (p < 0.001) and higher level of stress (p < 0.001). The regression analysis showed that experiencing depression (χ(2) = 5.05, OR = 1.32, p < 0.05) was the only factor that significantly predicted whether someone was anxious or not, accounting for 46% of the variance.

CONCLUSION

There was a high prevalence of anxiety in people with MS. Depression, low levels of self-efficacy, disability and stress increased the likelihood of experiencing anxiety.

Social disruption induced priming of CNS inflammatory response to Theiler's virus is dependent upon stress induced IL-6 release

Chronic social disruption stress (SDR) exacerbates acute and chronic phase Theiler's murine encephalomyelitis virus (TMEV) infection, a mouse model of multiple sclerosis. However, the precise mechanism by which this occurs remains unknown. The present study suggests that SDR exacerbates TMEV disease course by priming virus-induced neuroinflammation. It was demonstrated that IL-1β mRNA expression increases following acute SDR; however, IL-6 mRNA expression, but not IL-1β, is upregulated in response to chronic SDR. Furthermore, this study demonstrated SDR prior to infection increases infection related central IL-6 and IL-1β mRNA expression, and administration of IL-6 neutralizing antibody during SDR reverses this increase in neuroinflammation.

Physical activity, social support, and depression: possible independent and indirect associations in persons with multiple sclerosis

The present study examined the pattern of associations among physical activity, social support, mobility disability, perceived stress, and depressive symptoms in relapsing-remitting MS (RRMS). Persons (N = 218) with RRMS completed a battery of questionnaires that was sent and returned through the United States Postal Service (USPS). Bivariate correlation analysis indicated that physical activity and social support were both inversely associated with depressive symptoms (r's = -0.288 and -0.386, p ≤ 0.05, respectively). Multiple linear regression analysis indicated that physical activity (β = -0.21, p = 0.002) and social support (β = -0.37, p = 0.0001) were independently associated with depressive symptoms. Path analysis confirmed that the associations between physical activity and social support with depressive symptoms were indirect via mobility disability and perceived stress. Collectively, the evidence indicates that physical activity and social support are independently and indirectly associated with depression via mobility disability and perceived stress in relapsing-remitting MS. This supports the design of interventions and programs that target physical activity and social support for reducing depressive symptoms among persons with MS.

Effects of escitalopram on stress-related relapses in women with multiple sclerosis: an open-label, randomized, controlled, one-year follow-up study

A growing body of evidence supports the association between Stressful Life Events (SLEs) and increased risk for relapse in Multiple Sclerosis (MS). In this open-label, randomized, controlled, one-year prospective study we investigated the effects of escitalopram on stress-related relapses in 48 women with relapsing-remitting MS. Patients were randomly assigned either to receive escitalopram 10mg/day (e-group, N=24) or to continue with treatment as usual, as a control group (c-group, N=24). SLEs were documented weekly in self-report diaries and were classified afterwards as short- or long-term depending on their psychological impact as this was subjectively felt by the patient. The cumulative risk for relapse was 2.9 times higher for controls than for escitalopram-treated patients (95% CI=1.7-5.1, p<0.001) and it was influenced only by long-term SLEs. In the e-group only 3 or more long-term SLEs were associated with a significant increase of the risk of a relapse during the following 4 weeks, and this risk was 4 times lower compared to the c-group. Our study shows preliminary evidence that escitalopram may constitute an effective and well-tolerated treatment option for the prevention of stress-related relapses in women with MS.

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

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

Relationship between psychosocial factors and onset of multiple sclerosis

OBJECTIVE

The aim of this study was to investigate the influence of psychosocial variables on patients with multiple sclerosis (MS) and the relationship between these variables and the onset of MS.

BACKGROUND

The current evidence indicates that many types of psychosocial factors are involved in the development and relapse of MS, and it has been suggested that they could serve as predictors as well. So far, little has been reported on the effect of psychosocial factors on MS and the relationship between psychosocial factors and the onset of MS.

METHODS

Forty-one patients, 15 males and 26 females, average age 37.44 +/- 12.24 years (mean +/- SD), were evaluated by the Life Event Scale, Eysenck Personality Questionnaire, Social Support Revaluate Scale and Symptom Check List 90 and compared with 41 equivalent healthy control subjects, 15 males and 26 females, average age 36.38 +/- 12.84 years (mean +/- SD). Disease, demographic, psychosocial and lifestyle factors were measured at baseline. Patients with MS were first diagnosed by 3 neurologists according to the Poser (1983) MS diagnostic criteria.

RESULTS

Significant differences were found between the MS and the control group in their negative emotions and symptoms such as depression, anxiety, obsession, phobia, tense interpersonal relationship and somatization disorder. Significant differences were found between the two groups in the total number of negative life events, their family problems and the utilization of social support. The scores for various negative emotions in the MS group correlated positively with those for neuroticisms in personality type, and negatively with those for introverted and extroverted personality. Many kinds of negative emotions in the MS group correlated positively with the total number of life events, negative life events and family problems. Many kinds of negative emotions in the MS group correlated negatively with the utilization of social support.

CONCLUSION

The psychosocial factors are closely associated with MS onset and may play important roles in the development of the disease.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Influence of anxiety and reported stressful life events on relapses in multiple sclerosis: a prospective study

Objective

Self-reported stressful life events and infections have been associated with relapses in multiple sclerosis. Also, anxiety has been reported to influence other diseases of unpredictable course. To study relation of self-reported stressful life events, levels of anxiety, and episodes of infection, with relapses of the disease in women with multiple sclerosis.

Methods

This is a one-year prospective study. Thirty seven women with multiple sclerosis were regularly seen every four weeks, for one year. They were keeping diaries of events they considered stressful. These events were ranked according to the Holmes and Rahe Social Readjustment Rating Scale. Their anxiety levels were assessed with the Hamilton rating scale for anxiety. Relapses and episodes of infection were verified at additional visits. Results were studied using a survival analysis model adapted for several recurrent events.

Results

A total of 291 stressful events, 37 episodes of infection, and 48 relapses, were registered. High level of anxiety were stongly related to the number and the severity of reported stressful events during the preceding period and with the advent of a relapse in the following period (Hamilton score greater than 18 is associated with 4.2 times the rate of relapsing and three or more reported stressful events with 5.7 times the rate of relapsing).

Conclusions

Anxiety and self-reported stressful events may in fact be two measures of the same underlying emotional factor, which plays an important role on the course of the disease, in addition to episodes of infection.

Palliative care in amyotrophic lateral sclerosis, Parkinson's disease, and multiple sclerosis

BACKGROUND

Amyotrophic lateral sclerosis, Parkinson's disease, atypical parkinsonian syndromes, and multiple sclerosis are progressive neurologic disorders that cumulatively afflict a large number of people. Effective end-of-life palliative care depends upon an understanding of the clinical aspects of each of these disorders.

OBJECTIVES

The authors review the unique and overlapping aspects of each of these disorders with an emphasis upon the clinical management of symptoms.

DESIGN

The authors review current management and the supporting literature.

CONCLUSIONS

Clinicians have many effective therapeutic options to choose from when managing the symptoms produced by these disorders.

Relation between anxiety, depression and locus of control of patients with multiple sclerosis

This study was concerned with examining relation between anxiety, depression and locus of control (LC) in Croatian multiple sclerosis (MS) patients in order to determine an indication for psychotherapeutic intervention. The participants were 457 MS patients attending central state medical rehabilitation program at Varaždinske Toplice, asked to fill in the locus of control inventory and Crown-Crisp Experiential Index (CCEI) questioner of personality in the clinical setting. In order to determine whether locus of control changes along natural course of MS, patients were grouped according to the duration of the disease: less than five years, five to 10 years and more than 10 years. The results demonstrated that 405 (88.6%) MS patients exhibited external locus of control while 52 (11.4%) had internal locus of control. Moreover, as the disease progressed, locus of control shifted more to externality. Analysis of gathered data confirms connectivity of external locus of control with anxiety and depression. Results of anxiety and depression level on CCEI questionnaire show continuously increased values regardless on duration of illness. Croatian MS patients like other chronically ill externally oriented patients' show more maladaptive behaviour, which has been strongly linked to anxiety and depression and this, is indication for psychotherapeutic support. Multiple Sclerosis 2007; 13: 1065—1067. http://msj.sagepub.com

Differential release of mast cell mediators and the pathogenesis of inflammation

Mast cells are well known for their involvement in allergic and anaphylactic reactions, during which immunoglobulin E (IgE) receptor (Fc epsilon RI) aggregation leads to exocytosis of the content of secretory granules (1000 nm), commonly known as degranulation, and secretion of multiple mediators. Recent findings implicate mast cells also in inflammatory diseases, such as multiple sclerosis, where mast cells appear to be intact by light microscopy. Mast cells can be activated by bacterial or viral antigens, cytokines, growth factors, and hormones, leading to differential release of distinct mediators without degranulation. This process appears to involve de novo synthesis of mediators, such as interleukin-6 and vascular endothelial growth factor, with release through secretory vesicles (50 nm), similar to those in synaptic transmission. Moreover, the signal transduction steps necessary for this process appear to be largely distinct from those known in Fc epsilon RI-dependent degranulation. How these differential mast cell responses are controlled is still unresolved. No clinically available pharmacological agents can inhibit either degranulation or mast cell mediator release. Understanding this process could help develop mast cell inhibitors of selective mediator release with novel therapeutic applications.

Stress regulation in multiple sclerosis: current issues and concepts

Since its first description by Charcot, psychological stress has been considered a triggering factor for exacerbations in multiple sclerosis, but until recently the clinical evidence for a causal relation was weak. Over the past years, a growing number of studies have started to elucidate this association and highlight potential mechanisms, including brain-immune communication. On 5 June 2005, a panel of international researchers discussed the current evidence. This article summarizes the observational, animal experimental, as well as human experimental findings on stress regulation in MS, as well as studies on the functioning of the major stress response systems, ie, the hypothalamo-pituitary-adrenal (HPA) axis and the autonomous nervous system (ANS) in MS. Consensus statements from the group to these aspects are given. Research objectives and strategies are delineated, as well as clinical implications.