Abstract & Commentary
Source: Buljevac D, et al. Self reported stressful life events and exacerbations in multiple sclerosis: Prospective study. BMJ. 2003;327:646.
Buljevac and colleagues assessed whether life events that are perceived as stressful by patients themselves are associated with exacerbations. This prospective study followed 74 ambulatory relapsing-remitting multiple sclerosis patients (EDSS 0-6) who had at least 2 exacerbations in the 24 months before inclusion into the study. Seventy of the 73 patients (96%) reported at least 1 stressful event over an average follow-up time of 1.4 years. Throughout the study, 134 exacerbations occurred in 56 patients, and 136 infections occurred in 57 patients. MS patients who experienced a stressful event had more than a twofold increased risk of having a relapse during the subsequent 4 weeks (relative risk 2.2%, 95% CI, 1.2-4.0; P = .014). Infections were associated with a threefold increase in the relative risk of exacerbation, but this effect was found to be independent of experienced stress.
Previous studies have defined precipitants for MS exacerbations, most notably infections. The attack rate also increases in the first 3 months postpartum and during menses. Psychological stress has been implicated as a determinant of disease activity in MS since the time of Charcot. While neurologists anecdotally appear to observe a correlation between life stress and worsening disease, prior controlled studies have failed to document such a relationship. While Buljevac et al linked stressful events with a twofold risk of exacerbation, there was no attempt to perform baseline psychological surveys or depression inventories to see if certain patient profiles were more likely to relapse in stressful circumstances. The inciting mechanism behind stress and the induction of inflammatory demyelinating disease is not known but could result from activation of the hypothalamic-pituitary-adrenal axis and cytokine networks. Nonetheless, given the results of the above study, clinicians should recognize that stress may be a negative influence on the disease course. It might be of benefit to provide a variety of stress management strategies to help reduce the potential for exacerbations. — Brian R. Apatoff, Associate Professor of Neurology, New York Presbyterian Hospital-Cornell Campus, Assistant Editor, Neurology Alert.