The importance of psychotherapy in multiple sclerosis

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Chronic or degenerative physical diseases are now widely prevalent, especially in more developed countries, and come to affect about a quarter of the population.

Focal point for the successful outcome of treatment and for the maintenance and improvement of quality of life is the psychosocial dimension of the person who has the disease, and not the disease itself [1]. In fact, people react to life events according to their own subjectivity, which leads to the development of different adaptive balances according to personal resources and those from the context in which the person lives; resources that are able to support the patient and make him or her feel like an active protagonist in the management of the disease.

The first goal of the system of care is to establish and maintain a functional therapeutic alliance between patient and physician, namely, the sharing between the two parties of goals regarding the treatment of the disease, the clear definition of mutual tasks, and the bond of trust and respect that is established within the relationship itself [2]. Another important goal is to assess stress, psychological distress, and psychological disorders triggered or aggravated by the disease.

The role of psychology thus centers on these aspects: psychological assessment and support for building an alliance and adherence to therapy, which affect the course of the disease, complications, and quality of life.

Neurological conditions, including multiple sclerosis, are increasingly being studied in their relationships with the external environment [3], the body’s internal state, and lifestyle, thanks to interdisciplinary research, which includes psychology and clinical psychotherapy in the analysis of these conditions.

The systems approach, also definable as biopsychosocial, to neurological disease has been prompted by scientific evidence on the influence of behavior on brain plasticity: psyche, culture, and the whole organism interact on the arrangement of nerve circuits, shaping them in adaptive and maladaptive directions.

The scientific literature has agreed for years now on the presence in comorbidity of psychological disorders in patients with chronic and degenerative neurological diseases.

In people with multiple sclerosis, the prevalence in the field of psychopathology is mood disorders, especially depressive episodes, both compared with the general population and with other neurological diseases. In addition to mood disorders, states of anxiety and pathological stress are found, with a higher incidence in the first two years after diagnosis.

The psychological issues experienced by multiple sclerosis patients are multiple, complex, and affect caregivers, family members, and partners, being an extremely variable and diagnosable disease at a young age.

These people must be evaluated and taken care of in a timely manner, also to maintain a positive rate of adherence to therapy, a key factor in the smooth course of the disease. At the same time, an analysis of the quality of life and the socio-relational and work context is imperative.

There are many studies and meta-analyses demonstrating the improvement of people with chronic pathology who have undertaken psychotherapy, especially when compared with those who have used only drug therapy for the management of psychic symptoms [4].

In a 2009 meta-analysis [5], the effect of psychotherapy on the subjects studied was high for both psychopathological aspects and somatic symptoms and adaptive functions, both in the short term (3 months after the end of psychotherapy treatment) and in the long term (9 to 60 months after the end of treatment), which highlights the effect of change and restructuring produced by psychotherapy.

But what is psychotherapy?

In 1872 English physician Daniel Hack Tuke coined the term psychotherapeutic healing, that is, healing of the body by means of the patient’s psychic functions.

Frederik Willem van Eeden in 1889 also used the term psychotherapy to mean healing of the body by means of the mind assisted by the impulse of one mind on the other.

In Italy, psychotherapeutic practice was regulated only in 1989 by the Ossicini Law, which established its legal requirements: only psychologists and physicians can land the specialization in psychotherapy, which can be practiced following regular registration with the professional order.

Psychotherapy is a medical act based on three basic assumptions: the setting (the place and time of treatment), transference (the patient’s relationship with the therapist), and interpretation (the actual therapeutic act).

This is followed by another question, what does psychotherapy treat?

The psychic symptom with which the patient comes to formulate a request for help represents a vital signal indicating that something deep has entered a crisis; the psychic processing of this state of distress or suffering can lead to the evolutionary overcoming of what has entered a crisis. Psychotherapy has in it an intentionality of cure, a striving toward the healing of the patient, which consists of identifying the pathogen (the root cause) and then, through the relationship with the therapist, recovering what the illness had injured in terms of vitality, affectivity and thought [6].

Psychotherapy is the treatment of the mind, that is, that aspect of us that deals with perceiving the world, particularly the human world, and interacting with it [7].

To understand the concept of mental illness, it is essential to know the physiology of the mind, which is born healthy and can develop pathology due to environmental factors, traceable to invalid or even unhealthy interhuman relationships [8].

When the mind is functioning well the relationship and exchange between the external and internal worlds is preserved, when something is wrong this exchange is compromised and the reading of what we have inside us and what is around us is impaired, imagination and vitality, purely human skills, are reduced or depleted.

The person cannot understand what he or she feels, what is the meaning of things, struggles to understand others and experience healthy relationships; even to the point of altered physical perception, as the highest degree of severity.

The consequences of this malaise may be abnormal behaviors or heavy moods such as anxieties, phobias, incoherent thoughts, even not externally visible, which, however, can invalidate all fields of action of the person suffering from it.

The task of psychotherapy is thus to trace the illness in behavior, in the conscious mind and, for the psychotherapist with psychodynamic training, in the nonconscious mind, proper to dreams but also “visible and knowable” in deep interhuman relationships, including the psychotherapeutic one.

The Psychological Research-Intervention Protocol “Therapeutic Adherence in Patients with Multiple Sclerosis,” carried out at the Azienda Ospedaliera S. Maria di Terni since 2015 with the collaboration of the Complex Structure of Neurology and the Hospital Psychology Service, is a further demonstration of this.

This Research aimed to improve adherence to drug therapy by keeping the psychological variable under control; starting from the fact that improving the representation of illness, anxiety and depressive states, guarantees: adequate stress management, greater awareness of all aspects of the disease itself and an appropriate psycho-behavioral response, which could result in better adherence to therapy.

Seventy-eight people diagnosed with multiple sclerosis were involved, including 44 patients belonging to the experimental group, who benefited from psychotherapy following a clinical evaluation, and 34 patients belonging to the control group, who were administered only the stress, anxiety and depression assessment (DASS 21) and treatment adherence (Morisky Test) tests.

The first year of the project (which started in February 2015 and ended in January 2016) had shown a lack of significance in some aspects and correlations due to a small sample size, which, however, had nevertheless let interesting results emerge. The control group had remained unchanged in the months between the first psychological evaluation and the second, about 9 months apart.

The experimental group, on the other hand, had shown a clear change between the first assessment and the second, which had taken place after individual psychotherapy; in particular, the states of stress and depression reported by people at the first interview had decreased in intensity, while anxiety had shown no significant changes. At the same time, the measurement of medication adherence had shown a significant increase after the psychological course.

At the end of the second year (February 2015-February 2017), following the statistical analysis but also a qualitative analysis of the project, the following emerged.

The control group, which did not benefit from a psychotherapy course but only from psychological assessment and counseling, showed no changes at the psychological level and in terms of treatment adherence, other than an increase in depression levels. Untreated psychological states tend, according to this analysis, to remain unchanged over time or worsen, but without demonstrating a verifiable negative impact on treatment adherence.

The experimental group, which benefited from individual or group psychotherapy pathways, with possible caregiver involvement, showed improvement in psychological risk states, such as anxiety, stress, and depression, but especially improvement in the level of treatment adherence. Although there are no statistically significant correlations between these aspects, it is clear that work on the psychological level, results in an improvement of the patient’s self-perception, also in relation to the disease.

In light of the above, we can consider the objectives of the research-intervention project achieved and thus verified the usefulness of psychotherapy in the treatment of Multiple Sclerosis, especially in terms of improved quality of life.

Bibliography

  1. Lazzari D. La psiche tra salute e malattia. Ed. Edra, Milano, 2019.
  2. Horvath AO, Re ACD, Flückiger C, Symonds D. Alleanza in psicoterapia individuale. In JC Norcross Ed., 2011.
  3. Mirza A, King A, Troakes C, Exley C. Aluminium in brain tissue in familial Alzheimer’s disease. J Trace Elem Med Biol 2017;40:30-6.
  4. Porcelli P. La psicoterapia nelle malattie somatiche. In: D. Lazzari, Psicoterapia: effetti integrati, efficacia e costi benefici. Tecniche Nuove, Milano, 2013.
  5. Abbass A, Kisely S, Kroenke K. Short-term psychodynamic psychotherapy for somatic disorders. Systematic review and meta-analysis of clinical trials. Psychother Psychosom 2009;78(5):265-74.
  6. Bilardi G, Solari S, Testa L. La Psicoterapia. Cura e guarigione della malattia mentale. Edizioni L’Asino D’Oro, Roma, 2016.
  7. Colamedici D, Masini A, Roccioletti G. La medicina della mente. Storia e metodo della psicoterapia di gruppo. Edizioni L’Asino D’Oro, Roma, 2011.
  8. Fagioli M. Istinto di morte e conoscenza. Edizioni L’Asino D’Oro, Roma, 2010.
  9. Pepoli A, De Luca F, Passantino F, Ruiz L. Progetto di presa in carico multidisciplinare dei pazienti con Sclerosi Multipla: presentazione di un modello di integrazione in ambito ospedaliero. Link Rivista Scientifica di Psicologia, in collaborazione con FISP. Vol. 1-2, 2019.

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