Acta Neurol Scand 2014: 129: 374–381 DOI: 10.1111/ane.12194

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd ACTA NEUROLOGICA SCANDINAVICA

Mood and coping in clinically isolated syndrome and multiple sclerosis Bianchi V, De Giglio L, Prosperini L, Mancinelli C, De Angelis F, Barletta V, Pozzilli C. Mood and coping in clinically isolated syndrome and multiple sclerosis. Acta Neurol Scand 2014: 129: 374–381. © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd. Objective – Few studies have examined behavioural changes in the early phase of multiple sclerosis (MS). The aim of the study is to investigate mood alterations and to explore coping strategies regarding patients with clinically isolated syndrome (CIS) and relapsing-remitting MS (RRMS). Materials and Methods – The communication of diagnosis was made by one neurologist using a standardized approach. Depression, anxiety and coping questionnaires were filled in within 1 month from the diagnosis and at 3, 6, 12, 18 and 24 months subsequently. Results – Thirty-nine patients were examined (11 CIS, 28 RRMS), also 39 healthy controls. At entry, patients showed a lower degree of hostile behaviour and a higher level of depression than the controls. At follow-up, a reduction in depression, anxiety and a better coping adjustment was observed. A higher reliance on ‘Accepting responsibilities’ coping score was seen in patients with higher levels of depression and anxiety. No significant differences were revealed by group comparisons between CIS and RRMS. Conclusions – This study highlights transient mood alterations and an improving of adaptive coping over a period of time in patients with CIS and RRMS. Similar emotional reactions and coping in clinical subgroups suggest that these factors are independent from the type of information provided during the communication of the diagnosis.

Introduction

Coping may be defined as the result of a stress appraisal process with the purpose of managing psychological stress (1) or as a mediating factor between chronic disease and the adjustment to the disease (2). Coping strategies are of crucial importance for patients suffering multiple sclerosis (MS) in which the course of the illness is particularly unpredictable and the future unclear. Although many people appear to have a positive adjustment to preserve their quality of life, maladaptive coping strategies are frequent and are closely linked to depression (3, 4). An effect of disease duration on coping styles has been also observed. Matson and Brooks (5) 374

V. Bianchi1, L. De Giglio1,2, L. Prosperini3, C. Mancinelli1, F. De Angelis1, V. Barletta1, C. Pozzilli3 1 MS Centre, S. Andrea Hospital, Neurological Sciences, La Sapienza University, Rome, Italy; 2 Department of Psychology, Sapienza University, Rome, Italy; 3Department of Neurology and Psychiatry, Sapienza University, Rome, Italy

Key words: multiple sclerosis; clinically isolated syndrome; diagnosis; coping; anxiety; depression V. Bianchi, MS Centre, S. Andrea Hospital, Neurological Sciences, La Sapienza University, Via di Grottarossa,1035, 00189 Rome, Italy Tel.: +39 0633775686 Fax: +39 0633775900 e-mail: [email protected] Accepted for publication September 23, 2013

have proposed a stage model of adjustment following diagnosis, in which patients progressively pass through the stages of denial, resistance, affirmation and integration. In contrast, Montel et al. (6) reported that patients with the longest disease duration used few instrumental strategies. It is possible that greater knowledge about the disorder leads to a better adjustment: in a study on patients with suspected MS, O’Connor et al. (7) observed that distress decreased significantly when the patients were given a definite diagnosis, irrespective of the diagnostic outcome. Arnett et al. (8) reported that decreased use of active coping strategies may put patients at risk of increased depressed mood, whereas increased use of active coping may result in decreased depressed mood on the long-term period.

Coping strategies in early multiple sclerosis patients In a recent study of Grytten et al. (9), the authors explore the frequency of non-starters and stoppers of disease-modifying therapy (DMT) in persons recently diagnosed with MS. The authors reported that avoidance strategy predicted nonstarting DMT. People with MS experience unpleasant and unpredictable symptoms, difficult treatment regimens with drug-related side effects and increasing level of physical disability. Specifically, wishful thinking and escape-avoidance coping were regular and strong correlates or predictors of worse adjustment (10). Coping strategies are linked to mood alterations (8). Anxiety is reported to affect 23.5–41% of people with MS (11). Estimates of the prevalence of depression range from 10 to 41.8% (12). Strong associations have been observed between depression and anxiety (12). Understanding the presence of these factors in relation to each other may provide insight into potential causes and may improve management of people with MS. Little is known about psychological distress and early adjustment in patients with clinically isolated syndrome (CIS), which frequently represents the first episode of MS (13–15). In a recent study, Fazekas et al. (16) found that avoidance temperament may be related to subclinical disease activity in early RRMS. The aim of this longitudinal, 2-year study was to investigate mood alterations and to explore coping strategies regarding subjects with a recent diagnosis of CIS and MS; we hypothesized that a decrease in psychological distress with time was associated with an active coping strategies.

data were collected for each participant. A complete neurological examination, including the Expanded Disability Status Scale (EDSS) score, was performed within 1 month from the communication of diagnosis, and patients underwent also measures of coping, depression and anxiety. Patients repeated both neurological examination and psychological measures after 3, 6, 12, 18 and 24 months. Healthy controls were assessed for anxiety, depression and coping styles only once, and they were not followed up thereafter. Communication of diagnosis

Communication of diagnosis was given by the same neurologist (CP), both in the case of patients with CIS and in those with RRMS, with the same standardized approach. Patients suffering from CIS received a clear explanation that it consists in a first clinical episode of central nervous system inflammation: ‘the risk of developing a further episode and, consequently, conversion into a definite RRMS is high, but there is still some hope of non-conversion’. At this time, detailed information on the course of the disease or possible pharmacological treatment was not provided, but a neurological reassessment and a new complete brain and spinal cord magnetic resonance imaging (MRI) within a few weeks were recommended. In the case of a diagnosis of RRMS, patients received all the information on the disease, its pathogenesis, its performance over time and the difficulty to formulate an accurate individual prognosis. Patients were also given precise instructions on the long-term therapy they will receive and any related side effects.

Materials and methods Coping, depression and anxiety measures Participant sand study design

From April 2006 to April 2008, we recruited a consecutive series of 39 patients with a diagnosis of CIS or RRMS according to revised McDonald criteria (17), referring to the MS Centre of S. Andrea Hospital in Rome, and age/sex/educational level-matched healthy volunteers who were recruited from students, residents in Neurology, administrative personnel of the Hospital and their families. Signed inform consents were obtained from all participants. The local ethical committee board provided exemption of approval for observational studies. We performed an independent, observational, prospective study. Baseline demographic (gender, age, educational level, marital status) and clinical

Coping strategies were assessed using the 66-item version of Ways of Coping Questionnaire (WCQ) (18). Evidence of construct validity is found in the fact that the result of author’s studies is consistent with our theoretical predictions, namely that as follows: (i) coping consists of both problem-focused and emotion-focused strategies and (ii) coping is a process. That is, how people cope varies in relation to the demands and constraints of the context and also in relation to change in those demands and constraints as an encounter unfolds (18). This questionnaire comprises 66 items representing different behaviours a person may use to cope with a stressful situation; patients were asked to give a score on each item depending on 375

Bianchi et al. the frequency with which they used the described behaviour. We asked them to refer to the most stressful MS-related situation they experienced in the last 2 weeks in the context of work, family or social life. 1. ‘Confrontive’ describes aggressive efforts to alter the situation and to suggest some degree of hostility and risk-taking (e.g. ‘I expressed anger to the person(s) who caused the problem’). 2. ‘Distancing’ describes cognitive efforts to detach oneself and to minimize the significance of the situation (e.g. ‘Made light of the situation; refused to get too serious about it’). 3. ‘Self-controlling’ describes efforts to regulate one’s feelings and actions (e.g. ‘I tried to keep my feelings to myself’). 4. ‘Seeking social support’ describes efforts to seek informational support, tangible support and emotional support (e.g. ‘I asked a relative of friend I respected for advice’). 5. ‘Accepting responsibility’ describes acknowledge of one’s own role in the problem with a concomitant theme of trying to put things right (e.g. ‘I made a promise to myself that things would be different next time’). 6. ‘Escape-avoidance’ describes wishful thinking and behavioural efforts to escape or avoid the problem (e.g. ‘Avoided being with people in general’). 7. ‘Planful problem solving’ describes deliberate problem-focused efforts to alter the situation, coupled with an analytic approach to solving the problem (e.g. ‘I made a plan of action and followed it’). 8. ‘Positive reappraisal’ describes efforts to create positive meaning by focusing on personal growth. It also has a religious dimension (e.g. ‘Rediscovered what is important in life’) (18). The same questionnaire was proposed to healthy subjects; we asked them to turn to a highly stressful situation occurred in the last 2 weeks, which falls into the context areas (work, family or social life) listed from matched patients. Depression and anxiety were assessed by the Hamilton Depression Scale (HAM-D) (19) and the Hamilton Anxiety Scale (HAM-A) (20), respectively. Statistical analysis

All values are expressed as a mean standard deviation (SD) or median (range). Differences between groups were tested by the Pearson’s chisquared test or the Mann–Whitney U-test, as 376

appropriate. Correlations between variables were performed by the Spearman rank coefficient. A Bonferroni correction for multiple comparisons was applied to set the two-sided statistical significance, according to the number of coping strategies assessed by the WCQ (a/8 = 0.00625). The relationship between ‘depression’, ‘anxiety’ and coping strategies was also studied by means of multivariate linear regression analyses (stepwise fashion selection for predictor inclusion: F > 1 and P ≤ 0.05; for exclusion: F ≤ 1 and P > 0.05) with the anxiety and depression score as dependent variables of two different models, and WCQ subscales and the demographic and clinical variables as covariates, (including sex, age, marital status, instruction level, EDSS score). Changes over time were measured using the Friedman test for several related samples. Statistical analyses were carried out using a PC version of Statistical Package for Social Sciences, version 16.0 (SPSS, Chicago, IL, USA). Results Participants

From April 2006 to April 2008, we recruited 39 patients (30 women and nine men) with a mean age of 28.8 (5.3) years (range 19–42) and median EDSS score of 1.5 (range 0–3.5) and 39 agematched healthy controls; all patients presented at least three lesions at MRI brain scan. Demographic characteristics and HAM-A, HAM-D and WCQ scores of the 39 patients and the 39 age-matched healthy controls are shown in Table 1. Patients did not significantly differ from healthy controls in terms of sex, educational level and marital status. Less reliance on the ‘Confrontive coping’ (P = 0.001) strategy was noted in patient group. No differences in the other WCQ subscales were recorded between the two groups (Table 1). Depression, anxiety and coping styles at diagnosis

After the communication of the diagnosis, 21 (53.8%) patients had a level of anxiety above the cut-off of normal values (

Mood and coping in clinically isolated syndrome and multiple sclerosis.

Few studies have examined behavioural changes in the early phase of multiple sclerosis (MS). The aim of the study is to investigate mood alterations a...
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