Relationship between stress and relapse in multiple sclerosis: Part II. Direct and indirect relationships

Stressful life events and depression and fatigue in people with multiple sclerosis: a cross-sectional analysis of an international cohort

BACKGROUND

Relationships between stressful life events (SLEs) and health outcomes in people living with multiple sclerosis (plwMS), beyond relapse, are not well-established. We examined associations between SLEs and fatigue and symptoms of depression in plwMS.

METHODS

948 participants were queried whether they had experienced any of the 16 SLEs (Holmes-Rahe Social Readjustment Rating Scale) in the preceding 12 months. SLEs were summated to estimate SLE number and SLE load (weighted for the degree of associated stress). Cross-sectional associations between SLE (number, load and individual) and fatigue, and depressive symptoms were examined using log-binomial or log-multinomial regression adjusted for age, sex, relapse symptoms, education, MS type at baseline, disability, fatigue, comorbidity, depression, and antidepressant/antifatigue medications, as appropriate. Sub-analyses restricted to SLEs with a negative emotional impact were performed.

RESULTS

Median SLE number and load were 2 (IQR 1-2) and 57 (IQR 28-97), respectively. SLE number and load were not associated with a higher prevalence of fatigue, or depressive symptoms, even when restricting analyses to SLEs with a perceived negative emotional impact. A new relationship or family member with a negative impact was associated with a threefold and 2.5-fold higher prevalence of depressive symptoms, respectively. Serious illness was associated with a 28% higher prevalence of depressive symptoms.

CONCLUSION

Psychological support for SLEs, and/or intervention targeted to SLE appraisal, may be beneficial in mitigating the adverse effects of SLEs with a perceived negative emotional impact on depressive symptoms in plwMS. Potential associations between serious illness and increased prevalence of depressive symptoms may warrant further investigation.

Psychosocial Aspects of Rehabilitation in Neurodegenerative Diseases and Fields of Approach

Psychosocial health is a concept included in definition of health by World Health Organization and corresponds to state of emotional and social well-being. In the context of neurological disorder, psychosocial health refers to social reintegration and psychological adjustment. Studies reporting that neurological diseases are associated with negative psychosocial health outcomes such as a decrease in the quality of life, a decrease in ability to establish and maintain social relationships, and an increase in high levels of depression, stress and anxiety have increased in recent years. Therefore, it is important to consider programs and interventions that can improve the psychosocial health of people with neurodegenerative diseases. Currently, it is not clear which psychosocial approaches can produce definitively positive results. The aim of this study is to examine how being an individual with Multiple Sclerosis and Parkinson's, which are the most common neurodegenerative diseases in the clinic, affects psychosocial health in the rehabilitation process and the existing evidence-based psychosocial approaches. For this purpose, a descriptive review was prepared by scanning English and Turkish articles with keywords on psychotherapeutic, psychosocial and mindfulness-based interventions and stress management, published in the determined databases in the last 10 years. Studies have shown that psychosocial approaches such as interventions for acquisition of social integration and adaptive coping strategies, cognitive and social behavioral therapy methods, concentration and movement-based mind-body exercises are effective in rehabilitation of neurodegenerative diseases. These approaches were reported to have benefits in reducing anxiety, depression and fatigue, improving sleep quality and quality of life, relationships, employment, level of participation, motivation and self-efficacy in exercise and physical activity, improving physical functions, facilitating difficult and personal experiences and adaptation to new life in rehabilitation processes and more evidence-based studies are needed.

The bidirectional effect of stress and functionality in multiple sclerosis and the interaction role of anxiety, coping and social support

OBJECTIVE

The present study aims to analyse the bidirectional hypothesis between stress and multiple sclerosis with several measures of stress, impairment and functionality, considering also the interaction role of stress-related psychosocial factors such as anxiety, coping and social support.

METHODS

A one-year follow-up was conducted with 26 people with multiple sclerosis. Participants reported i) at baseline, anxiety (State-Trait Anxiety Inventory), and social support (Multidimensional Scale of Perceived Social Support); ii) daily, Ecological Momentary Assessment through self-reported diaries of stressful events and coping strategies; iii) monthly, the perceived stress (Perceived Stress Scale), iv) trimonthly, the self-reported functionality (Functionality Assessment in multiple sclerosis) and v) at baseline and at the end, neurologist rated impairment (Expanded Disability Status Scale). Mixed-effect regression models were conducted.

RESULTS

The bidirectional hypothesis was confirmed with perceived stress and self-reported functionality, which were negatively related in both directions. Coping and anxiety showed an interaction effect: active coping increased functionality only with high levels of stress, and high-trait anxiety showed lower functionality whereas low-trait anxiety showed higher functionality but only with low stress levels.

CONCLUSION

People with multiple sclerosis may benefit from different types of psychological therapies, from gold-standard therapies like Cognitive Behavioural Therapy to third-waves therapies like Dialectical Behaviour Therapy or mindfulness, that focus on dealing with stress and affective symptoms, adjusting to the disease, and to improving their overall quality of life. More research is needed in this field under the biopsychosocial model.

Allostatic load index in patients with multiple sclerosis: A case-control study

Elevated allostatic load (AL) index is a cumulative measure of biological dysregulations associated with stress exposure. It has been reported that stress plays an important role in the pathophysiology of multiple sclerosis (MS). However, the AL index has not been investigated in this population so far. Therefore, we aimed to investigate the AL index in patients with MS compared to healthy controls. A total of 90 patients with relapsing-remitting MS (76.7% females) and 47 healthy controls (76.6% females) were included in the study. The AL index was computed based on percentile distributions of 18 biomarkers. The AL index was significantly higher in patients with MS compared to healthy controls (2.74 ± 0.99 vs. 1.96 ± 0.71, p < 0.001), even after adjustment for age and education. With respect to specific AL biomarkers, individuals with MS had significantly lower resting heart rate, the levels of high-density lipoproteins and dehydroepiandrosterone sulfate as well as significantly higher level of hsCRP and albumin compared to healthy controls. There were no significant correlations of the AL index with depressive and anxiety symptoms, perceived stress, type D personality traits, insomnia, the odds of using specific coping strategies as well as MS-related clinical characteristics. These findings indicate that the AL index is increased in patients with MS. However, the exact mechanisms underlying this observation remain unknown and require additional studies.

Dietary Supplementation With Acer truncatum Oil Promotes Remyelination in a Mouse Model of Multiple Sclerosis

Background

Multiple sclerosis is a chronic demyelinating disease of uncertain etiology. Traditional treatment methods produce more adverse effects. Epidemiological and clinical treatment findings showed that unknown environmental factors contribute to the etiology of MS and that diet is a commonly assumed factor. Despite the huge interest in diet expressed by people with MS and the potential role diet plays in MS, very little data is available on the role of diet in MS pathogenesis and MS course, in particular, studies on fats and MS. The oil of Acer truncatum is potential as a resource to be exploited in the treatment of some neurodegenerative diseases.

Objective

Here, we investigated the underlying influences of Acer truncatum oil on the stimulation of remyelination in a cuprizone mouse model of demyelination.

Methods

Cuprizone (0.2% in chow) was used to establish a mouse model of demyelination. Acer truncatum oil was administrated to mice during remyelination. Following techniques were used: behavioral test, histochemistry, fluorescent immunohistochemistry, transmission electron microscope.

Results

Mice exposed to cuprizone for 6 weeks showed schizophrenia-like behavioral changes, the increased exploration of the center in the open field test (OFT), increased entries into the open arms of the elevated plus-maze, as well as demyelination in the corpus callosum. After cuprizone withdrawal, the diet therapy was initiated with supplementation of Acer truncatum oil for 2 weeks. As expected, myelin repair was greatly enhanced in the demyelinated regions with increased mature oligodendrocytes (CC1) and myelin basic protein (MBP). More importantly, the supplementation with Acer truncatum oil in the diet reduced the schizophrenia-like behavior in the open field test (OFT) and the elevated plus-maze compared to the cuprizone recovery group. The results revealed that the diet supplementation with Acer truncatum oil improved behavioral abnormalities, oligodendrocyte maturation, and remyelination in the cuprizone model during recovery.

Conclusion

Diet supplementation with Acer truncatum oil attenuates demyelination induced by cuprizone, indicating that Acer truncatum oil is a novel therapeutic diet in demyelinating diseases.

The Level of Stress and Coping Strategies in Patients with Multiple Sclerosis and Their Relationships with the Disease Course

Objectives: Stress is supposed to be linked with a background of multiple sclerosis (MS) and the disease course. Design: The study aimed to assess the level of stress and coping strategies in MS patients within a year of follow-up and to investigate the relationships between these aspects and factors related—or not—to MS. Methods: In 65 patients with MS, the Perceived Stress Scale (PSS-10), Type D Scale (DS14) and Coping Orientations to Problems Experienced (COPE) were performed at baseline and after a year. Baseline PSS-10, DS-14 and COPE scores were analyzed with regard to demographics, MS duration, treatment, indices of disability and self-reported stressful events (SEs). Final PSS-10 and COPE results were analyzed with reference to MS activity and SE within a year of follow-up. Results: Initially, 67% of patients reported a moderate or high level of stress and 31% met Type-D personality criteria. Diverse coping strategies were preferred, most of which were problem-focused. The negative affectivity DS-14 subscore (NEG) was correlated with disability level. Non-health-related SEs were associated with higher PSS-10 and NEG scores. After a year, the mean PSS-10 score decreased, while COPE results did not change significantly. Non-health-related SEs were associated with a higher PSS-10 score and less frequent use of acceptance and humor strategies. Those with an active vs. stable MS course during the follow-up did not differ in terms of PSS-10 and COPE results. Conclusions: MS patients experienced an increased level of stress. No significant relationships were found between stress or coping and MS course within a year. Non-health-related factors affected measures of stress more than MS-related factors.

Exploration of the Effects of Protective Person–Environment Factors Between Functional Impairments and Stress in Individuals With Multiple Sclerosis: Mediation and Moderation Analyses

Functional impairments can lead to stress in individuals with multiple sclerosis (MS). The study examined protective person and environment factors (i.e., positive cognitive stress appraisal, core self-evaluations [CSE], resilience, hope, spirituality, social support, and environmental supports) as both mediators and moderators of this association to guide understanding of the experience of stress in this population. The sample consisted of 373 participants with MS. In simple mediation analyses, positive cognitive stress appraisal, CSE, resilience, hope, social support, and environmental supports served as a partial mediator between functional impairments and stress. In a parallel mediation analysis, significant unique indirect effects were observed for two of the seven hypothesized mediator variables (CSE and environmental supports). Separate moderator tests provided support for the CSE variable as a protective factor. The positive association between functional impairments and stress was weaker for persons reporting high CSE compared with those reporting low CSE. The findings provide implications for rehabilitation counseling practices by promoting CSE and environmental supports in improving rehabilitation and psychosocial outcomes for individuals with MS.

Fear of relapse in patients suffering from RRMS influence their quality of life

Multiple Sclerosis (MS) is a chronic, potentially debilitating disease that affects millions of patients worldwide. About 85% of patients experience a disease subtype characterised by relapses and remittance (RRMS). While many studies have investigated factors influencing patients'' health-related quality of life (HRQoL) in RRMS, none have taken patients' fear of relapses into account. In this study, we measured the patients' self-reported HRQoL, fear of relapse (FoR), health anxiety (HA), number of relapses, duration of disease, type of medication and perceived level of side effects. Treating neurologists provided an estimate of patients' disease severity. All covariates and demographic (personal and disease-related) characteristics were included in regression modelling of their association with HRQoL. The model showed that HRQoL was most strongly associated with disease severity estimated by neurologists, which was highly correlated with the number of relapses and disease duration. However, upon adjustment for FoR (in the presence of all covariates), this association between disease severity and HRQoL attenuated, and FoR remained the only covariate significantly associated with HRQoL. Notably, our modelling also revealed a significant association between HA and FoR in RRMS patients. This study's findings have important implications for the management of MS in RRMS patients and point to the critical roles of FoR and HA as drivers of HRQoL in RRMS. Given the importance of HRQoL to the patient experience and economically, we argue that a more nuanced understanding is needed of the subjective nature of quality of life and its determinants. Interventions aimed at reducing psychological distress and anxiety should be explored.

Coping strategies in relapsing-remitting multiple sclerosis non-depressed patients and their associations with disease activity

Few studies evaluated coping strategies in people with multiple sclerosis (pwMS) in relation to annualized relapse rate (ARR) and lesion load (LL). Overall, results might have been influenced by the inclusion of depressed patients. To investigate the coping strategies and their association to disease activity, we studied relapsing-remitting pwMS accurately selected to avoid the confounding effect of depression. Sixty-seven relapsing-remitting pwMS and 67 healthy subjects (HS) underwent to Coping Orientation to Problems Experienced (I-COPE) and Coping Inventory for Stressful Situation (CISS) and Beck Depression Inventory-II. Cognitive performances, ARR, physical disability and magnetic resonance imaging T2-LL were assessed for correlation with coping and depression scores. pwMS showed lower scores than HSs on social support and turning to religion subscales of I-COPE and on emotion dimension of CISS. In pwMS, higher ARR was related to higher positive attitude and lower score on the turning to religion subscale of I-COPE. The present study revealed a less employment of emotion-based coping strategies in pwMS. A scarce use of faith for support and a frequent adoption of a positive attitude were associated with an increase of MS activity in terms of ARR.

Assessment of mental health, knowledge, and attitude of patients with multiple sclerosis and neuromyelitis optica spectrum disorder in response to 2019 novel coronavirus

Background

With the recent pandemic of the novel coronavirus disease (COVID-19), multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD) patients for their compromised immune system have been in significant concern. Awareness and attitude about this virus have an important impact on infection prevention and coping with stress and anxiety. So we conducted this study to assess knowledge, attitude, and mental health status in MS and NMOSD patients within the COVID-19 pandemic.

Method

In this cross-sectional study, the link of Depression Anxiety Stress Scales-21 (DASS-21) and a self-administered structured questionnaire were sent through social media to MS and NMOSD patients and two control groups consisting of healthy and migraine individuals.

Results

A total of 223 MS patients, 41 NMOSD, 29 migraine, and 245 healthy subjects participated in this study. MS patients had higher total DASS scores compared to healthy participants (p = 0.012). There were no significant differences among the study groups regarding knowledge and attitude. In MS patients, physical comorbidity was associated with a total score of attitude (OR 1.59, 95% CI 0.53, 2.66, p = 0.004). We did not find association between other demographic and clinical variables with DASS scores, attitude, and knowledge in MS patients.

Conclusion

The current data highlight the necessity of attitude, knowledge, and mental health assessment among MS and NMOSD patients. Further studies in other countries need to be carried to assess these points among MS and NMOSD patients.

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.

Effects of Death Anxiety on Perceived Stress in Individuals With Multiple Sclerosis and the Role of Self-Transcendence

Stress is a commonly reported concern of individuals with chronical diseases, including multiple sclerosis (MS). This study sought to investigate the relationships between self-transcendence, death anxiety, and perceived stress among individuals with MS from Iran. A second aim of the study was to assess the buffering effect of self-transcendence in the relationship between death anxiety and perceived stress. Two hundred and fifteen participants with MS from four hospitals completed measures assessing self-transcendence, death anxiety, and perceived stress. Using structural equation modeling, death anxiety was found to be positively related to perceived stress. In addition, there was a negative relationship between self-transcendence and perceived stress. Results of the study suggest that self-transcendence is a buffer in the link between death anxiety and perceived stress for individuals with MS. The findings demonstrate the importance of self-transcendence in decreasing the effects of death anxiety on perceived stress and have clinical implications for health professionals.

A case-control study of psychosocial factors and their relationship to impairment and functionality in multiple sclerosis

The stress effect on multiple sclerosis remains unclear. Moderating psychosocial factors may be involved. This study compares some of them in people with multiple sclerosis and healthy controls, and their association with disease parameters. Coping style, social support, anxiety, alexithymia and early-life stress were measured, along with impairment and functionality. People with multiple sclerosis scored significantly higher on anxiety, alexithymia, and avoidance and instinctive coping but lower in social support. No differences were found in early-life stress. Impairment was related to avoidance, and functionality to avoidance and anxiety. Psychotherapeutic approaches focused on these psychosocial factors may improve functionality, impairment and quality of life in people with multiple sclerosis.

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.

Effect of a transactional model education program on coping effectiveness in women with multiple sclerosis

OBJECTIVES

Multiple sclerosis (MS) is a chronic and progressive disease that causes stress due to its unpredictability and lack of definitive treatments. This study examined the effects of an educational program using a transactional model to help women with MS cope with their disease.

MATERIALS AND METHODS

In a randomized clinical trial, 80 female patients from the MS Society of Iran were randomized to the intervention (n = 40) or a control group (n = 40). Outcomes were assessed using Cohen's Perceived Stress Scale (PSS) and the Jalowiec Coping Scale (JCS), which were completed by both groups at baseline, 1 month, and 3 months after the intervention. The intervention consisted of six educational sessions administered over 2 months based on a transactional model. The data were analyzed using repeated measures ANOVA.

RESULTS

Average PSS scores decreased significantly over time in the intervention group, while increasing in the control group. Between-group differences were significant at both 1-month and 3-month follow-up (p < .001). Both problem-focused and emotion-focused coping styles improved over time in use and effectiveness in the intervention group, whereas little or no change occurred in these coping behaviors in the control group.

CONCLUSION

The transactional model-based education program tested here was successful in reducing stress levels and increasing healthy coping styles in women with MS. If these findings are replicated in future studies, widespread adoption of this program may help women with MS cope more successfully with their disease.

Stressful life events and the risk of initial central nervous system demyelination

BACKGROUND

There is substantial evidence that stress increases multiple sclerosis disease activity, but limited evidence on its association with the onset of multiple sclerosis.

OBJECTIVE

To examine the association between stressful life events and risk of first demyelinating event (FDE).

METHODS

This was a multicentre incident case-control study. Cases ( n = 282 with first diagnosis of central nervous system (CNS) demyelination, including n = 216 with 'classic FDE') were aged 18-59 years. Controls without CNS demyelination ( n = 558) were matched to cases on age, sex and study region. Stressful life events were assessed using a questionnaire based on the Social Readjustment Rating Scale.

RESULTS

Those who suffered from a serious illness in the previous 12 months were more likely to have an FDE (odds ratio (OR) = 2.35 (1.36, 4.06), p = 0.002), and when we limited our reference group to those who had no stressful life events, the magnitude of effect became stronger (OR = 5.41 (1.80, 16.28)). The total stress number and stress load were not convincingly associated with the risk of an FDE.

CONCLUSION

Cases were more likely to report a serious illness in the previous 12 months, which could suggest that a non-specific illness provides an additional strain to an already predisposed immune system.

Treating Post-traumatic Stress Disorder in Patients with Multiple Sclerosis: A Randomized Controlled Trial Comparing the Efficacy of Eye Movement Desensitization and Reprocessing and Relaxation Therapy

OBJECTIVE

Multiple Sclerosis (MS) is a demyelinating autoimmune disease that imposes a significant emotional burden with heavy psychosocial consequences. Several studies have investigated the association between MS and mental disorders such as depression and anxiety, and recently researchers have focused also on Post-traumatic Stress Disorder (PTSD). This is the first study that investigates the usefulness of proposing a treatment for PTSD to patients with MS.

METHODS

A randomized controlled trial with patients with MS diagnosed with PTSD comparing Eye Movement Desensitization and Reprocessing (EMDR; n = 20) and Relaxation Therapy (RT; n = 22). The primary outcome measure was the proportion of participants that no longer meet PTSD diagnosis as measured with Clinician Administered PTSD Scale 6-months after the treatment.

RESULTS

The majority of patients were able to overcome their PTSD diagnosis after only 10 therapy sessions. EMDR treatment appears to be more effective than RT in reducing the proportion of patients with MS suffering from PTSD. Both treatments are effective in reducing PTSD severity, anxiety and depression symptoms, and to improve Quality of Life.

CONCLUSION

Although our results can only be considered preliminary, this study suggests that it is essential that PTSD symptoms are detected and that brief and cost-effective interventions to reduce PTSD and associated psychological symptoms are offered to patients, in order to help them to reduce the psychological burden associated with their neurological condition.

TRIAL REGISTRATION

NCT01743664, https://clinicaltrials.gov/ct2/show/NCT01743664.

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.

Stress and multiple sclerosis: A systematic review considering potential moderating and mediating factors and methods of assessing stress

Research about the effects of stress on multiple sclerosis has yielded contradictory results. This study aims to systematically review the evidence focusing on two possible causes: the role of stress assessment and potential moderating and mediating factors. The Web of Knowledge (MEDLINE and Web of Science), Scopus, and PsycINFO databases were searched for relevant articles published from 1900 through December 2014 using the terms "stress*" AND "multiple sclerosis." Twenty-three articles were included. Studies focused on the effect of stress on multiple sclerosis onset (n = 9) were mostly retrospective, and semi-structured interviews and scales yielded the most consistent associations. Studies focused on multiple sclerosis progression (n = 14) were mostly prospective, and self-reported diaries yielded the most consistent results. The most important modifying factors were stressor duration, severity, and frequency; cardiovascular reactivity and heart rate; and social support and escitalopram intake. Future studies should consider the use of prospective design with self-reported evaluations and the study of moderators and mediators related to amount of stress and autonomic nervous system reactivity to determine the effects of stress on multiple sclerosis.

The Effect of Biofeedback as a Psychological Intervention in Multiple Sclerosis: A Randomized Controlled Study

BACKGROUND

Relaxation, mindfulness, social support, and education (RMSSE) have been shown to improve emotional symptoms, coping, and fatigue in multiple sclerosis (MS). Biofeedback was trialed as a psychological intervention, designed to improve self-control, in two groups of patients with MS. Both groups received RMSSE, and one group additionally received biofeedback.

METHODS

Forty people with relapsing-remitting MS were recruited from three sites in Sydney, Australia. The mean disability score (Expanded Disability Status Scale; EDSS) was 2.41 ± 1.46 (95% confidence interval [CI], 1.46-3.36); the mean age in years was 45.9 ± 12.42 (95% CI, 41.92-49.87). Participants were randomly assigned to two active treatment groups (n = 20 per group). All participants received one 1-hour session per week for 3 weeks of RMSSE, while biofeedback equipment measured breathing rate and muscle tension. Members of one group used biofeedback screens to regulate physiological response.

RESULTS

Whole-group pre- and post-treatment scores demonstrated a reduction of 38% for anxiety and 39% for depression scores (P = .007 and P = .009, respectively). A post-treatment comparison failed to demonstrate any significant difference between the two active treatment groups in anxiety and depression scores. The biofeedback group showed significant pre- to post-treatment improvement or trends toward improvement in anxiety, fatigue, and stress (P = .05, .02, and .03, respectively). Comparison of pre-post treatment results between groups showed improvements for the biofeedback group in breathing rate and muscle tension (P = .06 and .09).

CONCLUSIONS

For relapsing-remitting MS patients receiving biofeedback in addition to RMSSE, there was a demonstrable reduction in anxiety, fatigue, and stress. There was also a trend toward significant reduction of breathing rate and muscle tension in favor of biofeedback.

Facial and bodily emotion recognition in multiple sclerosis: the role of alexithymia and other characteristics of the disease

Multiple sclerosis (MS) may be associated with impaired perception of facial emotions. However, emotion recognition mediated by bodily postures has never been examined in these patients. Moreover, several studies have suggested a relation between emotion recognition impairments and alexithymia. This is in line with the idea that the ability to recognize emotions requires the individuals to be able to understand their own emotions. Despite a deficit in emotion recognition has been observed in MS patients, the association between impaired emotion recognition and alexithymia has received little attention. The aim of this study was, first, to investigate MS patient's abilities to recognize emotions mediated by both facial and bodily expressions and, second, to examine whether any observed deficits in emotions recognition could be explained by the presence of alexithymia. Thirty patients with MS and 30 healthy matched controls performed experimental tasks assessing emotion discrimination and recognition of facial expressions and bodily postures. Moreover, they completed questionnaires evaluating alexithymia, depression, and fatigue. First, facial emotion recognition and, to a lesser extent, bodily emotion recognition can be impaired in MS patients. In particular, patients with higher disability showed an impairment in emotion recognition compared with patients with lower disability and controls. Second, their deficit in emotion recognition was not predicted by alexithymia. Instead, the disease's characteristics and the performance on some cognitive tasks significantly correlated with emotion recognition. Impaired facial emotion recognition is a cognitive signature of MS that is not dependent on alexithymia.

Functional relapses in pediatric multiple sclerosis

Multiple sclerosis in children is characterized by more frequent relapses than in adult patients. Diagnosing and treating youth with multiple sclerosis present a number of challenges including differentiating organic relapses from functional symptoms. However, there is no literature describing coexistence of functionality in pediatric multiple sclerosis. Here, we report 2 cases in which inconsistency between clinical history, physical examination, imaging, and atypical disease progression led to suspicion of functional relapses. The purpose of this study is to raise awareness of functional relapses, as prompt recognition can prevent overtreatment and iatrogenic risks in children and adolescents with multiple sclerosis. Underlying psychiatric issues also need to be addressed.

Life events and the onset of celiac disease from a patient's perspective

Stressful events have been investigated in various immune-mediated diseases but not in celiac disease. Our aim was to examine the relationship of stressful events assessed by the standardized interview of Paykel with the diagnosis of celiac disease in comparison to patients, with a diagnosis of gastroesophageal reflux disease used as the control group. Adults with celiac disease (n = 186) reported more frequent and more severe life events in the years prior to the diagnosis than control patients (n = 96) (67.2% vs. 37.5%, p < 0.001, mean Paykel score 11.5 vs. 13.4, p = 0.001, respectively). Findings were not significantly different between celiac disease and control patients for the time lapse between the event and the diagnosis (mean 5.5 vs. 5.7 months). Pregnancy was defined as a negative event by 20.3% of celiac women, but never by control women. Findings were confirmed when analyses were repeated in the subgroup of patients of both groups with diagnosis made within one year of onset of symptoms. Data indicate that, before diagnosis, the number of stressful events in celiac disease was more frequent although less severe than in the control group suggesting that life events may favor the clinical appearance of celiac disease or accelerate its diagnosis.

Prospective examination of anxiety and depression before and during confirmed and pseudoexacerbations in patients with multiple sclerosis

OBJECTIVE

This study was designed to determine whether pseudoexacerbations and confirmed MS exacerbations are preceded by or concurrent with increased anxiety or depressive symptoms.

METHODS

This was a secondary analysis of 121 patients with MS who were observed for 48 weeks during a randomized controlled trial. Participants completed monthly self-reports on depressive and anxiety symptoms. Patient-reported exacerbations were assessed through a telephone-administered symptom checklist and neurologic examination.

RESULTS

Both pseudoexacerbations and confirmed exacerbations were associated with concurrent somatic depressive (β = .16 and β = .33, respectively; p values < .05), affective depressive (β = .17 [p = .02] and β = .12 [p = .06]), and anxiety symptoms (β = .24 and β = .20, p values < .01), controlling for baseline symptoms. Preexisting somatic and affective depressive symptoms predicted amplified relationships between concurrent confirmed exacerbations and these symptoms (β = .19 and β = .20, respectively; p values < .01). A standard deviation increase in anxiety symptoms relative to baseline predicted subsequent onset of pseudoexacerbations (odds ratio = 1.54, p = .02), whereas increased somatic depressive symptoms predicted confirmed exacerbations (odds ratio = 1.59, p = .01).

CONCLUSIONS

Patients with MS experiencing pseudoexacerbations or confirmed exacerbations should be assessed and monitored for depressive and anxiety symptoms, and confirmed exacerbations are particularly concerning in patients with a history of depression. The psychological or psychiatric antecedents of MS exacerbations generate new hypotheses on etiologies of confirmed exacerbations and pseudoexacerbations.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00147446.

Chronic social stress impairs virus specific adaptive immunity during acute Theiler's virus infection

Prior exposure to social disruption (SDR) stress exacerbates Theiler's murine encephalomyelitis virus (TMEV) infection, a model of multiple sclerosis. Here we examined the impact of SDR on T cell responses to TMEV infection in SJL mice. SDR impaired viral clearance and exacerbated acute disease. Moreover, TMEV infection alone increased CD4 and CD8 mRNA expression in brain and spleen while SDR impaired this response. SDR decreased both CD4(+) and CD8(+) virus-specific T cells in CNS, but not spleen. These findings suggest that SDR-induced suppression of virus-specific T cell responses contributes to impairments in viral clearance and exacerbation of acute disease.

Daily hassles reported by Dutch multiple sclerosis patients

There is growing evidence for the association between stress and relapse risk in multiple sclerosis (MS). The current study focuses on daily hassles, which by their chronic and accumulating nature can cause considerable psychosocial stress. The main aim was to investigate the frequency, associated distress and type of daily hassles encountered by Dutch MS patients from a large community-based sample. We further examined factors associated with high levels of psychosocial stress. Questionnaires concerning demographics, disease characteristics, physical functioning, daily hassles, fatigue, depression and anxiety were completed by 718 MS patients. Three patients younger than 18 were excluded, resulting in 715 patients. Compared with published norm data, more than 50% of the participants reported a high number of daily hassles (57.5%) and high levels of associated distress (55.7%). Frequently mentioned daily hassles concern personal functioning and social developments. A logistic regression model revealed that being female, being younger, having a higher educational level, using benzodiazepines, exhibiting more symptoms of anxiety, and a higher physical impact of fatigue were all independently associated with high levels of psychosocial stress. Our findings may alert clinicians of the high prevalence and impact of daily hassles in MS and underline the need to incorporate stress and anxiety management strategies in (psycho)therapeutic interventions.

Exercise, Diet, and Stress Management as Mediators Between Functional Disability and Health-Related Quality of Life in Multiple Sclerosis

The main objective of this study was to examine the mediational and moderational effect of exercise, diet, and stress management on the relationship between functional disability and health-related quality of life. Quantitative descriptive research design using multiple regression and correlation techniques was used. Participants were 215 individuals with multiple sclerosis (MS). Outcome measure used was health-related quality of life as measured by the Medical Outcomes Study (MOS) Short-Form Health Survey (SF-12v2). Functional disability and health-promoting behaviors including exercise, diet, and stress management were found to be associated with health-related quality of life. Exercise and stress management (but not diet) were partial mediators between functional disability and health-related quality of life. Exercise was found to be a moderator between functional disability and health-related quality of life. Exercise had a stronger effect on health-related quality of life for individuals with lower functional disability than people with higher functional disability. Health-promoting behaviors are important for health-related quality of life, and health-related quality of life in turn is related to better employment outcomes. Health-promoting behaviors can also mediate the relationship between functional disability and health-related quality of life. Rehabilitation counselors should consider including health promotion interventions in vocational rehabilitation services for individuals with MS.

Stress and depression symptoms in patients with multiple sclerosis: the mediating role of the loss of social functioning

OBJECTIVE

Depression symptoms are very frequent in patients with multiple sclerosis (MS) and have been associated with several quality of life indicators, especially physical and social functioning. The objectives were as follows: (i) to analyse the extent to which the loss of physical and social functioning may explain the depression symptoms observed in 65 Spanish patients diagnosed with MS; and (ii) to analyse the degree to which loss of social functioning may act as a mediator between depression symptoms and the stress associated with the disease.

MATERIALS AND METHODS

Participants were 65 Spanish patients diagnosed with MS and recruited from several MS centres and foundations.

RESULTS

The loss of social functioning had greater explanatory power as regards depression symptoms than did the loss of physical functions. Social functioning was also found to have an important mediating effect between MS stress and depression symptoms: specifically, more than half (52%) of the relationship between MS stress and depression symptoms was mediated by the perceived loss of social functions in Spanish patients with MS.

CONCLUSION

The importance of social functioning for Spanish patients with MS may have noteworthy implications when designing prevention and treatment programmes aimed at improving their quality of life.

Evidence for CRHR1 in multiple sclerosis using supervised machine learning and meta-analysis in 12,566 individuals

The primary genetic risk factor in multiple sclerosis (MS) is the HLA-DRB1*1501 allele; however, much of the remaining genetic contribution to MS has yet to be elucidated. Several lines of evidence support a role for neuroendocrine system involvement in autoimmunity which may, in part, be genetically determined. Here, we comprehensively investigated variation within eight candidate hypothalamic-pituitary-adrenal (HPA) axis genes and susceptibility to MS. A total of 326 SNPs were investigated in a discovery dataset of 1343 MS cases and 1379 healthy controls of European ancestry using a multi-analytical strategy. Random Forests, a supervised machine-learning algorithm, identified eight intronic SNPs within the corticotrophin-releasing hormone receptor 1 or CRHR1 locus on 17q21.31 as important predictors of MS. On the basis of univariate analyses, six CRHR1 variants were associated with decreased risk for disease following a conservative correction for multiple tests. Independent replication was observed for CRHR1 in a large meta-analysis comprising 2624 MS cases and 7220 healthy controls of European ancestry. Results from a combined meta-analysis of all 3967 MS cases and 8599 controls provide strong evidence for the involvement of CRHR1 in MS. The strongest association was observed for rs242936 (OR = 0.82, 95% CI = 0.74-0.90, P = 9.7 × 10(-5)). Replicated CRHR1 variants appear to exist on a single associated haplotype. Further investigation of mechanisms involved in HPA axis regulation and response to stress in MS pathogenesis is warranted.

Recognition of the kind of stress coping in patients of multiple sclerosis

BACKGROUND

Investigations have shown that some factors like stress can increase the recurrence and severity of multiple sclerosis (MS). Considering the direct influences of depression and anxiety on our body immunity system, and also the relation between stress and factors, such as Insulin Growth Factor (IGF-1), involved in neurogenesis and myelin repairing, it is an essential issue to identify the most common method used in relieving stress by such patients.

OBJECTIVE

To identify the type of common coping methods for stressful situation.

MATERIALS AND METHODS

This case-control study was performed on 50 patients of both the genders with MS in Esfahan (Esfahan MS Association). The data were collected and then analyzed using analysis of variance (ANOVA) method with the help of SPSS software version 15. P value less than 0.05 was considered as statistically significant.

RESULTS

In our study, coping method for stressful situation was significantly different in MS patients versus the healthy group (P=0.02). Descriptive indices showed that these patients use avoidant method more commonly than the control group (mean=45.01, SD=8.9 vs. mean=40.8, SD=11.8, respectively).

CONCLUSION

Due to the different methods used by MS patients to cope with stressful situation in comparison with the healthy ones, more appropriate techniques can be introduced to modify them, and hence, less stress-induced side effects could be expected in this population.

Chronic restraint stress during early Theiler's virus infection exacerbates the subsequent demyelinating disease in SJL mice: II. CNS disease severity

Theiler's murine encephalomyelitis virus (TMEV) infection is a well-characterized model of multiple sclerosis (MS). Previous research has shown that chronic restraint stress (RS) during early TMEV infection exacerbates behavioral signs of the disease. The present data suggest that RS-induced increases in CNS inflammation, demyelination, and axonal degeneration may underlie this exacerbation. In addition, we report that males exhibit greater CNS inflammation and higher numbers of demyelinating lesions while females show greater susceptibility to RS-induced exacerbation. These findings indicate that RS during early TMEV infection increases CNS lesion formation during the late phase and suggest that the effects of RS are sex-dependent.

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.

Restraint stress fails to render C57BL/6 mice susceptible to Theiler's virus-induced demyelination

OBJECTIVES

Multiple sclerosis is a degenerative disease of the CNS with a pathology consistent with immunological mediation. Although its cause is unknown, multiple factors are thought to influence both the onset and exacerbation of the disease, including both genetic background as well as environmental factors.

METHODS

We are interested in the effect of psychological stress on the onset and exacerbation of Theiler's virus-induced demyelinating disease (TVID), a murine model of MS in which viral persistence facilitates demyelination. In the current study, we determined whether chronic restraint stress (RS)-induced immunosuppression could result in the establishment of a persistent CNS infection in the normally TVID-resistant C57BL/6 mouse strain, resulting in demyelination.

RESULTS

Our data indicated that RS repeated over the course of 7 days was not sufficient to cause decreases in virus-specific adaptive immunity, and did not significantly alter CNS viral levels. Furthermore, chronic repeated RS lasting until 4 weeks after infection altered neither the development of virus-specific IgG nor motor function determined by Rotarod analysis. In addition, histological analysis of the CNS of stressed mice indicated no inflammation or demyelination on day 193 after infection.

CONCLUSION

These results suggest that stress alone is not sufficient to overcome genetic resistance to TVID in the C57BL/6 mouse strain.

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.

Anxiety and depression among subjects attending genetic counseling for hereditary cancer

OBJECTIVES

The main aims of the study were to investigate changes in anxiety and depression over time in subjects attending genetic counseling (GC) for hereditary cancer, and secondly, to identify psychological, social, and medical variables associated with the course and outcome of anxiety and depression.

METHODS

Of 275 eligible individuals, 221 consented to participate, 214 returned the baseline questionnaire, and were included in a prospective multi-center study. Questionnaires were mailed to the subjects before and after the GC.

RESULTS

The mean values for anxiety and depression were quite low at all assessments. Mixed linear analyzes revealed that both anxiety and depression declined over time. Higher age, GC-related self-efficacy, and social support were associated with lower levels of anxiety. More social support, satisfaction with GC, self-rated physical function, and GC-related self-efficacy were associated with lower levels of depression. The effects of social support on both anxiety and depression had a significant interaction with time.

CONCLUSION

The results support the buffer theory, which proposes that social support acts as a buffer, protecting people from the potentially pathogenic influence of stressful life events, such as GC.

PRACTICE IMPLICATIONS

Subjects with less social support and less GC-related self-efficacy seem to be more vulnerable to anxiety and depression and should be offered extra attention by counselors.

Psychological aspects of multiple sclerosis

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

Stress and hypothalamic-pituitary-adrenal axis function in experimental autoimmune encephalomyelitis and multiple sclerosis - a review

Multiple sclerosis (MS) is an inflammatory and degenerative disease of the CNS with an assumed autoimmune-mediated pathogenesis. Stressful life events have been hypothesized as potential triggers of disease exacerbation. Animal studies using experimental autoimmune encephalomyelitis (EAE), as a model for MS, suggest that decreased hypothalamic-pituitary-adrenal (HPA) function may play a role in the increased susceptibility and severity of the disease. Histopathological studies of the hypothalamus point to disturbances in corticotropin-releasing hormone (CRH) regulation as a result of MS lesions in this area. Functional endocrine tests (e.g., the combined Dexamethasone-CRH test) showed a disturbed negative feedback after steroid application in MS patients. Hyper- and hypoactivity of the HPA axis, have been described to be associated with more severe courses. This paper presents an overview of the evidence for a role of HPA dysfunction in EAE and MS based on stress-experimental studies.