Journal of Vocational Rehabilitation 31 (2009) 75–82
`DOI:10.3233/JVR-2009-0476
`IOS Press
`
`75
`
`Multiple sclerosis: Medical and psychosocial
`aspects, etiology, incidence, and prevalence
`
`Phillip D. Rumrill Jr.
`Kent State University, Center for Disability Studies, 413 White Hall, P.O. Box 5190, Kent, OH 44242-0001, USA.
`Tel.: +1 330 672 0600; Fax: +1 330 672 2512; E-mail: prumrill@kent.edu
`
`Abstract. This article provides an overview of the etiology, incidence, and prevalence of multiple sclerosis (MS), one of the
`most common neurological disorders in the world. The author describes the demographic characteristics of people who incur
`MS, discusses the auto-immune processes that cause damage to the central nervous system, reports the most frequently occurring
`symptoms, and presents treatment and symptom management strategies that have proven efficacious in reducing the extent of
`disability associated with this chronic and unpredictable disease.
`
`Keywords: Multiple sclerosis, medical and psychological aspects, chronic illness
`
`1. Introduction
`
`Multiple sclerosis (MS) is one of the most common
`neurological diseases in the world. It is a degenera-
`tive disease of the central nervous system, primarily
`affecting the brain and the spinal cord. MS destroys the
`fatty tissue called myelin that surrounds white matter
`tracts (i.e., axons) in multiple locations in the brain and
`along the spinal cord. Myelin facilitates the axons’ con-
`duction of electrical impulses back and forth between
`the brain and the rest of the body via the spinal cord
`[7,24]. Where MS destroys or compromises the myelin,
`these electrical impulses, which coordinate all mental
`and physiological processes, are not conveyed as they
`should be. This slowed or blocked conduction of elec-
`trical impulses can have a negative impact on virtually
`every physical, sensory, mental, and emotional activity.
`Smith and Schapiro [25] described the demyelina-
`tion that occurs in MS as similar to the disruption of
`an impulse that would occur if the rubberized coat-
`ing surrounding an electrical wire were torn or cut.
`Such damage interferes with the transmission of elec-
`tricity, which is what happens in individuals with MS.
`
`For people with MS, the result is often observed as
`uncoordinated and/or awkward responses to environ-
`mental stimuli [24]. As patches of myelin deteriorate,
`they are replaced by scar tissue. The resulting lesions,
`or plaques, further interrupt the conduction of nerve
`impulses, sometimes creating a progressive and degen-
`erative course of symptoms.
`Symptoms associated with MS vary widely, and they
`are principally determined by the location and size of
`the lesions in the person’s brain and spinal cord [9,24].
`For example, frontal and parietal lobe lesions often
`result in cognitive and emotional problems, whereas
`plaques in the cerebrum, brain stem, and spinal cord
`tend to cause problems related to the physical function-
`ing of the extremities [6,7]. Visual impairments may
`result from lesions on the optic nerves or the occip-
`ital lobe. It is important to note that no two people
`with MS experience the same symptoms and course
`of illness [3]. Additional information concerning the
`medical aspects of MS can be found in Managing the
`Symptoms of Multiple Sclerosis [24], Multiple Sclero-
`sis: The Questions You Have – The Answers You Need
`[11], Multiple Sclerosis: Diagnosis, Medical Manage-
`
`1052-2263/09/$17.00 © 2009 – IOS Press and the authors. All rights reserved
`
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`ment, and Rehabilitation [2], Multiple Sclerosis: The
`Guide to Treatment and Management [19], and The MS
`Workbook [7].
`
`2. Epidemiology and etiology
`
`The National Multiple Sclerosis Society (NMSS)
`estimates the prevalence of MS in the United States
`to be between 350,000 and 400,000 cases, indicating
`that 1 in 750 people have the diagnosis at any given
`time [7,25]. It has been estimated that 10,000 new
`cases of MS are diagnosed each year in the United
`States, and this rate of incidence has steadily increased
`since the 1950s. This heightened rate of detection
`has been attributed to the advent and refinement of
`increasingly sensitive diagnostic tools such as magnetic
`resonance imaging [10]. In a worldwide study, Dean
`[4] determined that approximately 1,080,000 people
`across the globe have MS (i.e., 20.6 cases per 100,000
`people).
`Although MS can occur at any age, initial manifes-
`tations are most often evident during early adulthood,
`typically between the ages of 20 and 40 [2,6,24]. In
`fact, half of all MS diagnoses are conferred before the
`person’s 30th birthday, and three-quarters of Americans
`with MS were diagnosed before the age of 40 [7,23].
`MS is approximately two to three times more com-
`mon in women than in men, a gender ratio that is
`found in a host of other autoimmune diseases [7,26].
`The prevalence of MS also varies markedly according
`to geography. Epidemiological studies have revealed
`higher MS prevalence rates in temperate regions than
`in warmer climates. Countries that have particularly
`high rates of MS include the United Kingdom, Canada,
`Germany, Denmark, Norway, Sweden, Finland, and
`the United States [13,25]. Within the United States,
`epidemiologists have cited the 37th Parallel (which
`divides the American population roughly in half) as
`a geographic demarcation that separates areas charac-
`terized by high and low MS risks [22]. Two-thirds of
`the American MS population reside in the northernmost
`50 percent of the general populace, with the states of
`Vermont and Washington reporting the nation’s highest
`prevalence rates [7,24].
`The incidence and prevalence of MS vary signifi-
`cantly along racial lines, as well. Poser [20] pointed out
`that MS is extremely uncommon among Asian peoples,
`unknown in African blacks, and relatively infrequent
`among African Americans. He also noted that people
`of Hispanic descent are far less likely to develop MS
`
`than those of Germanic, Anglo-Saxon, and Scandina-
`vian lineages.
`The precise cause of MS remains unknown but
`experts generally believe that MS stems from a com-
`bination of immunologic, environmental, and genetic
`factors. Although studies show that certain groups (e.g.,
`women, people of Northern European descent, people
`living in the Northern Hemisphere) are more likely to
`acquire MS than others, how and why MS originates
`in an individual remain less certain. Medical scientists
`have determined that MS involves an autoimmune pro-
`cess; that is, the immune system abnormally directs
`itself against the central nervous system. Although
`the exact antigen to which immune cells are directed
`has not been identified, researchers have discovered
`which immune cells become sensitized, the process
`by which they turn on the central nervous system, and
`which receptors on the cells are attracted to the myelin
`sheath [2].
`Epidemiological studies and migration patterns indi-
`cate that people who were born in regions where there
`is a high prevalence of MS and who move to lower
`prevalence areas acquire the MS risk of their new
`homes, provided that the move takes place before the
`age of 15 [13]. From these data, some scientists have
`inferred that there is an environmental agent that acti-
`vates prior to puberty and predisposes one to develop
`MS in early or middle adulthood. Because initial expo-
`sure to many viruses occurs during childhood, and
`because viral factors have been linked to many other
`demyelinating autoimmune responses, some experts
`believe that viral “triggers” precipitate the onset of the
`illness.
`Although MS is not entirely hereditary, having a first-
`degree relative (e.g., a parent or sibling) who has the
`illness increases one’s risk of acquiring MS by a factor
`several times that of the risk in the general population
`[3,25]. Being the daughter of a person with MS makes
`one ten times more likely than the general population
`to acquire the disease during adulthood [7]. Several
`studies have also found common genes among certain
`populations in which there are high rates of MS. The
`HLA gene group is where some of the genes linked
`to MS have been found [7], although efforts to iso-
`late a single “MS gene” have proven unfruitful. Some
`neurologists and epidemiologists hypothesize that MS
`develops when a person is genetically susceptible to
`environmental agents or factors (including viruses) that
`trigger autoimmune responses [7]. That explanation
`assumes a reciprocal influence of immunologic, viral,
`and genetic factors in the development of MS, but its
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`complexity underscores why scientists have not pin-
`pointed the illness’ precise cause.
`
`3. Courses and progression
`
`The nature, severity, and number of symptoms related
`to MS vary widely among individuals, and the pat-
`terns of symptom manifestation, which are typically
`observed as cycles of relapses and remissions, cannot
`be generalized from one person to another. These pat-
`terns have, however, been broadly codified to provide
`a clearer understanding of the different courses of MS
`that people experience.Current classification standards
`in the field of neurology describe four types or courses
`of MS: (a) relapsing-remitting, (b) primary progressive,
`(c) secondary progressive, and (d) progressive relapsing
`[1,7,24,26].
`
`3.1. Relapsing-remitting MS
`
`Smith and Schapiro [25] described relapsing-
`remitting MS as marked by discernible “flare-ups”
`(also called relapses, exacerbations, or attacks), last-
`ing from days to weeks, with or without asymptomatic
`periods, beginning at the onset of the disease. These
`episodes involve acute worsening in neurological func-
`tioning, and they may be totally unpredictable. They
`are followed by partial or complete recovery periods
`(i.e., remissions). Fraser et al. [7] pointed out that
`these sporadic exacerbations occur at an average rate
`of approximately one time every 17 months. Disabil-
`ity may result from incomplete recoveries following
`relapses, but relapses tend not to become progres-
`sively severe or intense over time. Schapiro [24] noted
`that about 80 percent of MS cases begin as relapsing-
`remitting MS, making it far and away the most common
`form of the disease at the time of diagnosis.
`
`3.2. Primary progressive MS
`
`Primary progressive MS is observed when the per-
`son experiences a slow but steady decline in functioning
`from the onset of the disease. In this course, there do
`not appear to be noticeable relapses or remissions [26].
`If a person does experience a remission, it is usually
`temporary and improvement in symptoms is minor. Pri-
`mary progressive MS is commonly diagnosed in people
`who develop the disease after their 40th birthday [24],
`and this group makes up about 10 percent of the MS
`population with equal ratios of females to males [7].
`
`3.3. Secondary progressive MS
`
`Secondary progressive MS is characterized by ini-
`tial relapsing-remitting MS that subsequently develops
`into a steady progressive course, with or without flare-
`ups, remissions, or plateaus [1,26]. Over time secondary
`progressive MS results in a decline in the person’s gen-
`eral health status, and remissions become less frequent
`[7]. It is estimated that about two-thirds of people diag-
`nosed with relapsing-remitting MS eventually develop
`the secondary progressive form of the disease [7]. Cur-
`rently, physicians are not able to predict who will
`develop secondary progressive MS based on the initial
`onset of the disease [25].
`
`3.4. Progressive relapsing MS
`
`In progressive relapsing MS, the person experiences
`a steady and progressive course of declining health over
`time, but she or he also has clear and significant exac-
`erbations or relapses that occur without warning [26].
`Symptoms are always present, but they may intensify
`or decrease in severity from time to time [24]. Coupled
`with the steady progression of symptoms, this cycle
`of exacerbation can be truly debilitating. This type of
`MS is relatively rare and occurs in approximately five
`percent of cases [26].
`
`4. Diagnosis
`
`Until fairly recently, the diagnosis of MS was inferred
`from presenting symptoms as there is no genetic, bac-
`terial, or viral test that can make the diagnosis [7].
`Because central nervous system lesions can result from
`conditions other than MS (such as cancer, nutritional
`deficiencies, or traumatic brain injuries), neurologists
`would first eliminate all other possible reasons for
`lesions before making a diagnosis of MS. Hence, the
`differential diagnostic process was often long and labo-
`rious [6]. Not surprisingly, non- and mis-diagnoses
`were fairly common, and many patients were sent home
`with “possible” and “probable” MS to wait for their
`symptoms to progress before they could receive defini-
`tive diagnoses [8].
`Over the past two decades, however, the advent and
`continued refinement of magnetic resonance imaging
`(MRI) and positron emission tomography (PET) have
`enabled neurologists to make accurate MS diagnoses
`in a timely manner, sometimes even before the per-
`son evinces any symptoms [6]. The current standard
`criteria used to diagnose MS are known as McDonald
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`criteria [7,24]. These criteria require multiple abnor-
`malities on MRI and PET scans in the central nervous
`system (CNS). In descending order of prevalence, the
`CNS abnormalities observed in people with MS affect
`the following functional areas: sensation and energy,
`vision, strength and mobility, coordination, balance,
`bowel and bladder processes, sexuality, cognition, and
`affect and emotion. Although the McDonald criteria
`permit diagnoses before people have experienced MS-
`related symptoms, this is not common because it is the
`symptoms of MS that prompt people to seek medical
`attention in the first place.
`The MRI and PET scans have also shown promise
`in predicting the frequency, duration, and intensity of
`exacerbations of MS following diagnosis [19]. Even
`though not all symptoms of MS reported in clinical
`consultation are directly attributable to MRI and PET
`scan abnormalities, neurologists are able to make MS
`diagnoses with greater speed and accuracy than ever
`before. Medical technology has dramatically reduced
`the time interval between initial symptoms and diag-
`nosis, thereby enabling rehabilitation professionals to
`initiate early intervention strategies during the disease’s
`preliminary stages.
`
`5. Physiological effects
`
`Physiological symptoms of MS include fatigue,
`mobility problems, spasticity, numbness and tingling in
`the extremities, general weakness, visual impairments,
`bowel and bladder dysfunction, and sexual dysfunction.
`As previously noted, patterns of symptoms have been
`attributed to the location and size of lesions in the cen-
`tral nervous system and are specific to the individual [7].
`Even within the individual with MS, physiological and
`other effects may come and go without warning, appear
`in various combinations, or intensify in a seemingly ran-
`dom pattern [10]. Any physiological symptom(s) of MS
`may be observed in concert with or in the absence of
`any other(s).
`
`5.1. Fatigue
`
`The most common effect of MS is unquestionably
`fatigue [2,24]. Fatigue has been defined as an over-
`whelming sense of tiredness, lack of energy, and feel-
`ings of exhaustion in excess of what might be expected
`for the associated level of activity [19]. Although it does
`not always present itself as a single, easily identifiable
`symptom, fatigue affects people with MS in several spe-
`
`cific ways. Schapiro [24] identified three distinct types
`of fatigue that are commonly observed in people with
`MS: deconditioned, “short-circuiting,” and MS fatigue.
`Each has unique signs and self-care implications.
`
`5.1.1. Deconditioned fatigue
`When a person with MS experiences weakness, heat
`sensitivity, and fatigue he or she may become less active
`over time. This lack of activity creates a vicious circle,
`in which the person becomes even weaker and more
`tired [25]. Over time, the body becomes deconditioned
`to physical activity, muscles can atrophy, and secondary
`complications of inactivity often manifest themselves.
`These secondary complications include weight gain,
`hypertension and other circulatory problems, arthritis,
`and heart disease. When noticed early in the disease
`process, deconditioned fatigue can be alleviated by an
`overall wellness program that includes individualized
`exercise and nutrition plans.
`
`5.1.2. Short-circuiting
`According to Schapiro [24], “short-circuiting”
`fatigue or muscle fatigue results from physically over-
`taxing oneself. He noted that demylination along neural
`pathways leads to interruptions in the smooth trans-
`mission of electrical impulses to the extremities. This
`inefficiency results in temporary weakness of the limbs,
`which then produces the slowing and eventual stop-
`page of physical activity until the person with MS has
`rested and regained his or her energy. “Short-circuiting”
`fatigue is primarily physiological in nature and stopping
`activity to allow the nerves and muscles to restart is
`the way to manage this form of fatigue [25]. Unlike
`deconditioned fatigue, which is often progressive in
`nature and can result in permanent debilitation, “short-
`circuiting” fatigue is temporary, episodic, and managed
`fairly effectively by rest and relaxation.
`
`5.1.3. MS fatigue
`Smith and Schapiro [25] described lassitude as MS
`fatigue because it seems to be endemic to people cop-
`ing with the illness. MS fatigue is typified by an
`overwhelming sense of exhaustion or tiredness that
`affects the individual suddenly and without warning.
`These bouts of complete, physiological and psycholog-
`ical tiredness and incapacity may last for a few hours
`or for several days. Some people report that relax-
`ation or rest mitigates these symptoms, but others have
`reported that these solutions do not work for them. Las-
`situde of this type usually responds to neurochemical
`medications, and/or an individualized aerobic exercise
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`program [25]. It is also important to note that MS
`fatigue is linked, often bi-directionally, to medication
`side effects, depression, and sleep disturbances.
`Generally, all types of fatigue that are commonly
`reported by people with MS are exacerbated by stress
`and by an increase in body temperature. Because exer-
`cise, being outside in hot weather, and taking hot baths
`have been shown to increase fatigue among people with
`MS, these activities should be monitored or avoided
`whenever possible. Also, stress management regimens
`have proven to be effective means of controlling fatigue
`and allowing the person with MS to conserve energy for
`necessary daily living activities.
`
`5.2. Motor disturbances
`
`A number of physiological symptoms are related
`to motor disturbances in people with MS, including
`spacticity, weakness, and ataxia. These lead to gen-
`eral coordination, balance, and mobility impairments
`[2,24]. The extent and type of these effects vary widely
`among (and even within) people with MS, but motor
`disturbances are typically among the first manifesta-
`tions of the illness.
`
`5.2.1. Spasticity
`Spasticity is a disruption in the coordination of
`muscle contraction and relaxation. This is a common
`symptom of MS because of damage in the descending
`motor pathways that carry impulses from the spinal cord
`to control muscular reflexes. When lesions occur along
`these pathways, they cause opposite muscles within a
`group to contract and relax simultaneously, or spasm.
`Spasms are most common in the legs (flexor and exten-
`sor muscles), and people with MS most frequently
`experience spasticity at night [2,25].
`
`5.2.2. Weakness
`MS is often characterized by a loss of strength in
`major muscle groups such as those of the arms and legs.
`Smith and Schapiro [25] noted that observed weak-
`ness in people with MS more often results from poorly
`transmitted neural impulses than from deterioration of
`the muscles themselves. However, misconduction of
`impulses makes it difficult for the person with MS to
`fully utilize the affected muscles, and prolonged under-
`utilization can cause the muscles to atrophy.
`Backaches are a common secondary symptom of MS,
`most often attributable to strain resulting from compen-
`sation for weakness and fatigue in the legs [24]. Ataxia,
`one’s inability to move the arms and walk in a coordi-
`
`nated fashion, is another frequently observed effect of
`MS-related weakness.
`In combating muscular weakness, priority must be
`placed on conserving energy for activities of daily liv-
`ing and symptom management. Because some exercises
`exacerbate muscle weakness and fatigue, people with
`MS should always consult their physicians and/or phys-
`ical therapists before initiating a physical conditioning
`program.
`
`5.2.3. Ambulation
`Ambulation, the simple act of walking and getting
`around, is often impaired by such symptoms of MS
`as balance problems, hyperextension of the knees, and
`instability of the legs. A condition called foot drop [24],
`in which toes touch the ground prior to the heel, is
`caused by weak muscles in the foot. Ambulation prob-
`lems in people with MS can range from mild difficulties
`to a complete inability to stand or walk on one’s own.
`Canes, motorized scooters, and other mobility aides are
`often employed by people with MS who experience
`difficulty with ambulation.
`
`5.3. Numbness and tingling
`
`Numbness and tingling in the extremities among
`people with MS can range from “pins and needles”
`sensations to itching in an isolated area of skin or a
`more severe and painful condition termed trigeminal
`neuralgia [25]. A “pins and needles” sensation down
`the back and legs may occur when one bends his or
`her neck. Although not painful, the sensation can be
`bothersome. Trigeminal neuralgia involves the onset of
`sudden, sharp pain in one side of the face. It results
`from the discharge of impulses from the brain stem.
`The accompanying pain typically lasts for only 10 to
`15 seconds, but it is characteristically followed by a
`facial contraction, or tic [2].
`
`5.4. Tremor
`
`Tremor in the extremities and head is another com-
`mon physiological effect of MS, one that is manifested
`in a wide range of movement from fine, less notice-
`able tremors to more obvious, gross oscillations [24].
`Tremors occur in approximately 75 percent of people
`with MS and are most often seen in the upper limbs.
`They can be significantly disabling, affecting limb func-
`tion, gait, and balance [19]. Functionally speaking,
`tremors can have a deleterious impact on common
`work-related fine motor tasks such as writing, key-
`boarding, and handling small objects.
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`5.5. Visual impairments
`
`Visual impairments in individuals with MS are most
`often temporary conditions that manifest in blurred or
`double vision, although in some cases functional blind-
`ness may result. They result from optic neuritis (i.e.,
`inflammation of the optic nerve) and are frequently
`marked by dull color vision, diminished visual acuity,
`and a reduced visual field [24]. Optic neuritis is one of
`the most common early symptoms of MS [1,24], and
`it is often indicative of a more benign form of the ill-
`ness. Other MS-related visual impairments result from
`weakening of the eye muscle and nystagmus (i.e., eye
`jerking). MS-related visual impairments often lead to
`a diminished ability to drive or travel independently,
`which can cause major difficulties in terms of employ-
`ment and community living.
`
`5.6. Bowel and bladder dysfunction
`
`Bowel and bladder dysfunctions are frequent, frus-
`trating, and often embarrassing effects of MS. Polman
`et al. [19] indicated that some degree of bladder dys-
`function occurs in at least 70 percent of those diagnosed
`with MS, and up to two-thirds of all people with
`MS complain of some degree of bowel dysfunction.
`These difficulties include urgency, dribbling, hesitancy,
`frequency, constipation, and incontinence. Bowel and
`bladder dysfunctions can have a negative impact on a
`person’s daily living regimen, but they often can be
`effectively managed through medications and/or diet.
`
`5.7. Sexual dysfunction
`
`Sexual dysfunction affects up to 85 percent of men
`and up to 74 percent of women diagnosed with MS
`[5]. The effects of sexual dysfunction can be pervasive,
`often manifesting in psychological and family prob-
`lems in addition to their physiological accompaniments.
`Often associated with fatigue, specific sexual prob-
`lems frequently encountered by people with MS include
`retarded and premature ejaculation, decreased vaginal
`and penile sensation, impotence, vaginal dryness, anor-
`gasmia, decreased sex drive, and slowed response and
`arousal time [19].
`
`6. Psychological effects
`
`As if the physiological accompaniments of MS were
`not intrusive enough, the illness often has a negative
`
`impact on one’s psychological functioning. Psycholog-
`ical problems related to MS can be divided into three
`categories: (a) cognitive dysfunction, (b) affective dis-
`orders, and (c) adjustmental issues. Texts by Kalb [11]
`and Fraser et al. [6] offer more comprehensive descrip-
`tions of the psychological effects of MS.
`
`6.1. Cognitive dysfunction
`
`Although once considered symptomatic of only the
`most severe cases of MS, cognitive dysfunctions have
`been established as a common symptom of all stages
`and types of disease [10,18,24]. Smith and Schapiro
`[25] and Polman et al. [19] estimated that as many
`as 60–65 percent of people diagnosed with MS expe-
`rience some degree of measurable cognitive change.
`These changes can affect attention, conceptual reason-
`ing, executive function, and memory. Roessler, Rumrill
`and Hennessey [21] found that more than 40 percent of
`people with MS identified moderate-to-severe cogni-
`tive problems. Because MS destroys myelin anywhere
`in the central nervous system, its associated cognitive
`impairments cover a wide gamut. The MRI scan is the
`best predictor of cognitive status; the greater the num-
`ber and the more extensive the lesions that are detected,
`the more likely the person is to have cognitive impair-
`ments as a result of MS [15]. Cognitive effects tend to
`be specific and localized to observable brain lesions;
`MS does not typically precipitate a decline in general
`intellectual ability [19].
`
`6.2. Affective disorders
`
`A sizable proportion of the overall psychological
`impact of MS can be viewed in terms of affective dis-
`orders that accompany the illness. Polman et al. [19]
`noted that “psychiatric morbidity is increased in MS,
`with over 50 percent of patients being symptomatic
`at some stage” (p. 85). The most common affective
`symptoms include irritability, difficulty concentrating,
`anxiety, bipolar disorder, and depression. Foremost
`among these is depression. Approximately one-half
`of all people with MS experience at least one major
`depressive episode during the course of the illness [16].
`Clearly, depression is established as a major psycho-
`logical symptom of MS, but it has yet to be determined
`whether depressive episodes result from neurological
`abnormalities or manifest themselves as a psycholog-
`ical response to a serious illness. Bipolar disorder is
`characterized by cyclical patterns of severe depression
`interspersed with periods of mania and/or euphoria and
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`is diagnosed in approximately 15 percent of people
`with MS [14]. Euphoria, a persistent feeling of well-
`being and optimism in spite of negative circumstances,
`is often exhibited by people with MS in isolation of
`other symptoms [16]. Anxiety disorders and other neu-
`roses are also common, although they are often treated
`effectively with anti-anxiety medication [16].
`Another common psychological symptom of MS is
`pathological laughing and weeping. A person with MS
`may break into laughter or begin to weep with slight
`or no provocation, regardless of his or her underlying
`mood state. Such emotional outbursts can be func-
`tionally disabling in and of themselves, making even
`rudimentary tasks of daily living extremely difficult to
`perform [14].
`
`6.3. Psychological adjustment
`
`In addition to the cognitive and affective symptoms
`of MS, the wide-ranging physiological effects of the
`illness and its capricious course make the process of
`adjusting to such a debilitating disease a very diffi-
`cult task. A number of factors influence one’s overall
`psychological adjustment to MS. A primary determi-
`nant of adjustment is the perceived intrusiveness of the
`illness – that is, the cumulative effect of (a) functional
`deficits, physical disabilities, and stressful life events;
`(b) the unique constellation of signs, symptoms, and
`treatment constraints associated with an individual’s
`condition; (c) disease activity, life satisfaction, cop-
`ing style, and knowledge of MS; and (d) personality
`and social support systems [12]. This long list of intru-
`siveness factors clearly reflects the individual and often
`unpredictable nature of adjustment to MS.
`The far-reaching psychological accompaniments of
`MS solidify its designation as one of the most difficult
`diseases to cope with, adjust to, and, ultimately, accept
`[23]. The nature and progression of physiological and
`neurological symptoms exact a significant toll on those
`diagnosed with MS, as well as on their families and
`friends, and the adjustmental and social issues inherent
`to MS remain among the most difficult effects of the
`illness to treat.
`
`7. Treatment
`
`Just as no certainty exists as to the cause of MS, no
`vaccine or treatment modality has been reliably demon-
`strated to prevent the onset of the illness, progression
`of central nervous system lesions, or development
`
`of new lesions. Moreover, no medical procedure has
`been developed to alter or dissipate existing lesions.
`However, adrenocorticotrophic hormones and corti-
`costeroids (i.e., prednisone), along with emergent
`medications such as Avonex, Betaseron, Copaxone,
`Novantrone, Rebif, and Tysabri [26] have been shown
`to reduce the severity of exacerbations among some
`people with MS. Such treatments as fat-free diets, sun-
`flower oil, bee stings, and vitamin supplements have
`not proven efficacious in definitive clinical trials.
`Most MS treatments have been oriented toward
`catalyzing the body’s own immune responses to neuro-
`logical irregularities. One of the problems in evaluating
`the efficacy of such treatments is that it is impossible to
`determine whether improvements or remissions are the
`results of the treatment or of the natural course of the
`illness. Physicians have the ability to specify MS treat-
`ment regimens to an individual’s course and symptoms
`[17,24], but the search continues for curative treatments
`that will prevent or arrest the underlying agents of the
`disease.
`
`8. Conclusion
`
`MS is one of the most prevalent neurological dis-
`orders known to medical science. Characterized by an
`unpredictable course, the illness destroys white mat-
`ter tracts in the central nervous system. Depending
`on where the nerve damage occurs, people with MS
`evince a wide range of physiologic and psychological
`symptoms, including fatigue, mobility problems, spas-
`ticity, numbness and tingling in the extremities, general
`weakness, visual impairments, bowel and bladder dys-
`function, sexual dysfunction, cognitive disabilities,
`depression, anxiety, and diminished self-efficacy.
`Diagnosing MS has become much easier in recent
`years with the advent of magnetic resonance imag-
`ing and positron emission tomography, but the medical
`community has been unable as yet to determine the
`underlying cause of the disease. There is presently no
`cure for MS, but certain recent chemotherapeutic reg-
`imens have shown encouraging success in extending
`the duration of remissions and deintensifying exacer-
`bations of the illness.
`Women are about twice as likely as men to develop
`MS, and the illness predominates among individuals
`of white, northern European descent. The geographic
`distribution of MS is also worth noting; two-thirds of
`the American MS population reside in the northernmost
`50 percent of the United States populace.
`
`Page 7 of 8
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`82
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`P.D. Rumrill Jr. / Multiple sclerosis: Medical and psychosocial
`
`MS is distinct from other diseases in etiology, course,
`range of symptoms, and populational demography. It
`also has a unique, often deleterious impact on personal
`and social functioning. To the extent that a person’s
`work role constitutes an important element of personal
`and social functioning, the impact of MS on career
`development is an important consideration for voca-
`tional rehabilitation professionals.
`
`References
`
`[2]
`
`[1] D. Barnes, Multip