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emma sandrock

on 27 February 2013

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1. Biological factors
2. Psychological factors
3. Social factors Psychological Factors Social Factors Multiple Sclerosis Biological Factors MS & social adjustment MS & the family MS & career MS & environmental factors self concept= a process, when there is a new meaning of conditions (physical self altered), self concept must be altered too (Brooks and Matson, 1977).
way of measuring adjustment, when diagnosed, forced to reconstruct everything (Brooks and Matson, 1977).
an acceptance of loss is an important step (Brooks and Matson, 1977).

relationship between duration of illness & self concept
adjustment to MS involved an improvement in self concept over time, but the improvement is mediated by the degree of impairment associated with the disease (Brooks and Matson, 1977). social- psychological adjustment model stage 1: denial
stage 2: resistance
stage 3: affirmation
stage 4: integration in a longitudinal study...
17 years, average age of participants= 52 yrs
participants with an high internal locus of control had more positive adjustment scores
those who say they cope through acceptance of disease show improvements in self concept while those reporting religion or family as major coping strategy have decreasing self concepts (in contrast to exploratory study) (Brooks and Matson, 1982). multiple sclerosis & marriage multiple sclerosis & pregnancy multiple sclerosis & relatives/friends multiple sclerosis & children onset and deterioration of MS occurring during the 9 months of pregnancy vs. 6 months immediately following birth (Lorenzi, and Ford, 2002).
increased risk of MS in nulliparous women vs parous women (Lorenzi, and Ford, 2002).
reduced frequency of relapse during pregnancy BUT with an increase in relapse rate after child birth
Verdu et al: time to wheelchair use was increased by 50% where women developed MS before pregnancy when compared with the group who had no pregnancies after their diagnosis (Lorenzi, and Ford, 2002). concerned about how MS affected their sexual relationships husbands experience difficulty performing caregiving acts (when wife has MS) acceptance= influenced by social interactions with other people and your marital partner (provides feedback about condition and appearance MEN WOMEN men being married was associated with greater acceptance of disability within society, men have fewer source of support than women so look to their wives for emotional support wives attempts to control behaviour result in increased health promoting behaviours among men felt relationship suffered when couldn't perform household duties or participate with spouse divorce rate higher in women with MS than with men negative perceptions by spouse could result in conflict within marriage and lower levels of acceptance marriage quality dependent on spouses view if impairment concerned with their partners needs, and level of conflict within marriage, acceptance and impairment increase over time, those who remained married reported higher levels of acceptance ability to maintain social contact and leisure activities correlated with the course and severity of disease
withdrawal from social activities and shrinking of circle of friends common (Hakim et al, 2000).
1 in 4 reported that the stopped visiting fiends and family members because of poor mobility (Hakim et al, 2000).
only 47% of severally disabled received visits from old friends
patients severity of disability vs. occurrence of somatic symptoms, anxiety or depressive symptoms in the carer
57% of carers reported a negative effect on their job (Hakim et all, 2000). Children whose parents had MS = greater emotional & behavioural problems, associated mostly with maternal depression and family dysfunction (Diareme, 2006)
mother's with MS presented greater problems, could be attributed to possible lower extent of children’s exposure to paternal illness due to limited involvement of fathers than mother's with child care ((Diareme, 2006).
Problems more frequent in poorly adjusted than well adjusted families of parents with MS
Good family functioning= protective factor against the development of delinquent behaviours and other aggressive manifestations in children of mothers with MS (Diareme, 2006).
child problems & maternal depression (has been found to be most important predictor of child internalizing problems) Fatigue= major issue ( less able to take care of child or activities) (Lorenzi and Ford, 2000). - loss of employment= 22% of those originally employed (Busche et al, 2003).
- greatest decrease in employment occurred in health related professions and service industries (Jackson et al, 1991).
- specific disease characteristics predictive of employment loss: mobility, hand function, fatigue, perceived cognitive impairment (Julien et al, 2008). FACTORS:
1.Greater disability
2.Progressive disease course
3.Longer disease duration
4.Older age (Busche et al, 2003). -unusual geographical distribution of MS,-low prevalence of disorder among people of East Asia descent in Canada compared with people of North European descent

-high sunlight associated with low prevalence, co-occurrence of low prevalence and high ultraviolet exposure

-strongest environmental factor associated with MS= role for vitamin D in MS, association between multivitamin intake and lower MS risk in nurses

- geographical inconsistencies? (Brooks and Matson 1977). Ebers, 2008). Nature of child's distress with their parent's illness may depend on:
1. severity
2. phase
3. prognosis of illness,
4. incapacity caused by illness
5. developmental stage of the child What is MS? Autoimmune inflammatory disease against myelin sheath
Women 3x more likely to be diagnosed Mechanism of exchange: blood-brain barrier which consists of tightly associated endothelial cells
1) When a viral infection strikes, immunological defenses penetrate the blood-brain barrier
2) Shared epitopes of viral protein and myelin associated proteins
3) T cells cross the barrier and attack
4) Initiation of inflammatory response (recruit B cells and macrophages)
5) Lesion: Demyelination Remyelination:
Oligodendrocyte-precursor cells re-express developmental genes to produce new myelin. Remyelination is a slow process and can be inefficient under repeated attack Classification Symptoms:
balance problems
uncoordinated movements
visual and verbal impairment
cognitive impairment
mood swings
disability Secondary Progressive MS (SPMS) Genetics and Environment Relapsing Remitting MS (RRMS) irradic episodes
clearly defined episodes when new symptoms appear or existing ones get worse
During remission, resume normal/nearly normal function Primary Progressive MS Slow accumulation of disability
No relapses
Overall no periods of remission
10% of people diagnosed with MS
Affect men and women equally
Diagnosed after age 40 About 50% of people with RRMS will develop SPMS within 10 years of diagnosis
Fewer remissions
Overall progressive disability Anxiety and Depression Anxiety and Depression (Dahl et al., 2009)
Depression: 25.6 % in MS patients versus 10.6 % in control group
Anxiety: 31.1 % of men with MS, 30 % of women with MS, compared to 12.1 % of control group men and 17.4 % of control group women.
Male vs Female: are men with MS affected more by depression
Suicide and Multiple Sclerosis (Siegert & Abernethy, 2004):
3126 patients vs total patient deaths: 145
-56 deaths MS complications, 19 deaths unknown, 63 deaths “other”
-18/63 deaths were suicides, with 2/19 unknown deaths suspected suicides
-Frequency of suicide is 7.5 times greater than that of the general population
Immediate family not affected (Minden, 2000) Stress and MS Can Stress Cause MS? (Engel, Meyerowitz & Mei-Tal, 1970)
28/32 patients: major life stress around time of diagnosis
Directional problem?
Favour old relationships, familiar comforts
New relationships proved very stressful
RRMS and Stress (Brown, Tennant, Sharrock, Hodgkinson, Dunn & Pollard, 2006)
Relapse Remitting Multiple Sclerosis
Worsening or appearance of new neurological symptoms
Risk Factors:
Acute Stressful events
Low on the EDSS scale
Chronic difficulties do NOT correlate to a relapse Personality Changes In MS Neurological vs Learned (Boyle, 1992):
Personality changes common in MS patients
Lesions on right parietal lobe correlate to high levels of depression
Mood Disorders (Thomas, Thomas, Hillier, Galvin & Baker, 2009):
Hereditary? Fatigue and MS Treating chronic psychological fatigue (Bol, Annelien, Duits, Raymond, Hupperts, Johan, Vlaeyen, Frans & Verhey, 2007):
Least understood aspect of MS
Traditionally thought of as a physiological symptom
The mind and body are connected: fatigue is a psychological ailment
Depression & Fatigue
Depression = Sleepless Nights = Fatigue
Drugs used to treat MS (interferon) can cause depression
Those low on extroversion and high on conscientiousness in the “big five” personality traits were more likely to experience fatigue
Physical therapy and exercise (Bol et al., 2007) Mind/Body Treatments Avoiding relapse and treating the mind (Bol et al., 2007):
-Clinical studies suggest the cognitive behavior therapy is the most effective in lessoning negative biopsychosocial aspects of MS. The use of SSRIs also has a positive effect, though it is moderate compared to CBTs
-Stress related relapse is most common in those who are in the early stages of the illness (Brown et al., 2006) Other Factors Affecting Treatment What about Psychotherapy? (Thomas et al., 2009):
Rates of depression and anxiety were significantly lower in patients receiving psychotherapy
Mean scores being 19.3 vs 23.5 in the group that did not receive psychotherapy
How can the patient help themselves?
Problem-based coping skills
Emotion-based coping skills (Siegert & Abernethy, 2004) Points of Discussion & Further Investigation Researchers do not yet have all the answers... Why are men significantly more affected by the psychological implication of MS when women are more likely to have the disease?
Relapse rate higher for males with stress
Males show more anxiety with MS compared to control group
The directional problem: does stress and depression influence MS?
Or is it more likely that MS causes depression and anxiety?
Where can researchers go from here?
Drugs that treat physical symptoms without compromising mental states
More mental health services, including CBT Patients Respond How do patients feel about the quality of their mental health care?(Buchanan et al., 2006):
1518 people with Ms were surveyed using a self-report survey
90 per cent of the participants had been diagnosed with depression in their life time
Only 26 per cent of urban patients believed they needed mental health service
Out of the 26 per cent that desired more mental health services, 72 per cent went for help
18 per cent of rural patients felt they needed mental health help
25 per cent of these individuals did not receive help because they felt it was not available where they lived THE END (World, n.d). Evidence for polygenetic epidemiology (Dyment,
Ebersa & Sadovnick, 2004)

The risk for monozygotic twins is at least 300 times
greater than that for the general population.
Canadian population-based sample of 16 000 MS cases
939 half-sibling cases
Compare recurrence risks of half sibling to full sibling of MS patient
recurrence risk: the chance that the disease will occur in another individual with similar disposition
Statistically, 50% of sibling's genes are identical and 25% for half siblings
Recurrence risk hints to genetic significance:
-32% for half-siblings
-46% for full siblings
Half-siblings raised together were compared with those not after controlling for genetic sharing
Genetic sharing and not family environment is critical for the familial aggregation of the disease
Findings are consistent with a polygenic hypothesis Smoking
Smokers are 1.6 times more likely to develop MS (Shirani and Tremlett, 2010)
2009 Swedish population study (Hedström et al., 2009)
Taking Swedish snuff for more than 15 years decreased the risk of developing MS
Smokers of both sexes had an increased risk of developing MS
Risk increases with increasing cumulative dose (p < 0.0001)
Risk persists up to 5 years after quitting
Child second-hand increases the risk of child onset
Intensification of cerebral symptoms Vitamin D
Multiple sclerosis is rare in the tropics and common in temperate regions
Serum samples from 267 MS patients were collected for 25(OH)D and 1,25(OH)2D measurement
Reduced risk with increased sunlight or Vitamin D supplementation
Lower levels of vitamin D associated with increase risk of relapse
Low circulating levels of 25(OH)D in adolescence correlate with a high susceptibility
Expanded Disability Status Scale (EDSS) scores correlate negatively with circulating levels of 25(OH)D
(Martyn and Gale, 1997) Smoking

MRI scan comparison:

368 patients with MS
240 never smokers
128 ever smokers
Cigarette smoking linked to:
Increased risk of progressive multiple sclerosis
Higher susceptibility
Increased Expanded Disability Status Scale (EDSS) scores (p = 0.004)
Increased number of lesions and lesion volume (p < 0.001)
Increased blood–brain barrier disruption
(Zivadinov et al., 2009)
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