The role of trauma in multiple sclerosis and neuropsychotherapy

The articles in the “Expert Opinion” section cover some of the most important and debated topics in their respective clinical areas. Because of the level of depth attained, the texts may contain very complex terms and concepts. Use of the glossary may help in understanding these articles, and other, more popular content on the site will help clarify the topics covered.

The relationship constantly experienced with people with multiple sclerosis (MS) during evaluations and psychological pathways has brought to light a recurring aspect of considerable importance, namely the frequent presence of traumatic events in life histories, experienced during childhood but also as adults. Stressful events that often occur in conjunction with relapses or disease progressions or events that are very distant in time but often poorly processed internally.

We know that childhood trauma significantly affects a child’s psychological, social, emotional, and cognitive development, but it is now clear from scientific research that there are also consequences for brain development and neuropsychological function, child and adult. The scientific evidence available today, however preliminary, suggests that stress response systems play a major role. The experience of trauma appears to activate an abnormal stress response, which interferes with the physiological development of areas of the encephalon that are more vulnerable to stressogenic stimuli, negatively affecting several cognitive domains.

Traumatic childhood experiences, therefore, affect normal brain development through abnormal activation of these biological stress systems [1], which, evolutionarily useful in defending us from environmental dangers, however, become dysfunctional when they are activated in a paroxysmal manner; so much so that major alterations in the myelination mechanisms of the developing brain have been frequently observed, adversely affecting the structures richest in myelin fibers and affecting cognitive abilities, particularly executive functions.

The course of knowledge and assessment, from a biopsychosocial perspective, of a person diagnosed with multiple sclerosis, that is, with a total view of the person from all points of view, allows for effective neuropsychotherapeutic treatment that can intervene on cognitive deficits and psychological impairment.

The medical literature of the past two decades has been extensively devoted to investigating the role of acute stress, or rather the psycho-neuro-endocrine-immunological response to psychological trauma, as a trigger for the onset or exacerbation of multiple sclerosis.

The 2000 study, published in Neurology by Mohr et al. [2], examines the relationship between stressful life events and psychological distress and the subsequent development of gadolinium-enhancing brain lesions (Gd+). For the sample examined by the study (36 patients with R-R MS), an increased likelihood of developing new brain lesions (Gd+ 8 weeks later) following conflict and routine disruption due to stressful events was found. The study result follows the hypothesis that trauma and psychological distress are associated with disease exacerbation in MS. This is the first prospective longitudinal study of the relationship between stressful life events, psychological distress and disease activity as measured by brain magnetic resonance imaging (Gd+).

An article in the British journal BMJ [3] studied the relationship between stressful non-disease-related life events and the occurrence of exacerbations in relapsing-remitting forms, and came to the same conclusions: traumatic events were associated with increased exacerbations in multiple sclerosis. Of the 73 patients included in the study, aged 18-55 years and provided with motor skills, 96% (70 people) reported at least one stressful event. During the study there were 134 flare-ups in 56 patients and 136 infections in 57 patients.

An article in the Journal of Pharmacology and Experimental Therapeutics [4] studied at macroscopic levels the cellular mechanism involved in stress, illustrating that both the hormone implicated in the stress response, responsible for corticotropin, and mast cells were involved in the regulation of the blood-brain barrier and were probably also responsible for the inflammatory disorders of the brain aggravated by acute stress.

There is now a great deal of research supporting the thesis that there is a relationship between psychological stress, clinical aggravation and the development of new brain injury, and even more researchers are highlighting how chronic, life-threatening neurodegenerative diseases can be associated with post-traumatic stress disorder (PTSD). The study by Obstacles et al. (2013) [5] was an investigation of the prevalence of post-traumatic stress disorder in MS patients and the identification of significant determinants of PTSD. Two hundred thirty-two MS patients were consecutively recruited and screened for the presence of PTSD using the Event Scale-Revised Impact, corroborated by the DSM-IV structured clinical interview. In addition, participants were administered the Hospital Anxiety and Depression Scale and the Fatigue Severity Scale. Twelve patients (12/232, 5.17%) were diagnosed as having PTSD. The authors find that further research on the psychological characteristics of neurodegenerative diseases is needed in order to plan appropriate treatments and improve patients’ quality of life.

Reading these results highlights that the immune system responds to the body’s signals of distress: it usually tends to maintain the person’s integrity, but when emotional trauma is intense and violent, psychic integrity may falter. The feeling of inadequacy that often accompanies these states of emotional distress is the same situation experienced by the immune system; its action may become confused, and autoimmune disease may present more easily. Multiple sclerosis with its many aspects affects all areas of functioning of the individual: physical, psychological, cognitive, behavioral and affective/relational. When faced with a person in distress, who requires help, it is important to know the organic pathology from which he or she suffers: which means realizing what etiopathogenetic factors may have triggered it, what symptoms it may cause, what therapies he or she will have to face, and what repercussions all this may entail in his or her relationships and general (work and social) functioning. By no means should the person’s personal history and prevailing psychological set-up be overlooked, as well as the family and social context in which he or she is embedded: all aspects that make each pathology subjective, as will have to be the treatment appropriate to the specific problems.

Neurological pathology, in particular, needs a multifactorial reading, so as not to risk overlooking important elements.

To succeed in this framing, the biopsychosocial model, which considers the state of health and disease as determined by both biological and psychological and social factors, comes to the rescue. This model, which analyzes the concurrence of multiple variables, promotes the obligatory relationship between the various professionals, the patient and the family. The psychologist-psychotherapist must assume skills from neuropsychology, neurology and psychotherapy so that the patient is treated with respect to both past and current personality, cognitively and socially, to ensure optimal integration into daily life.

Neuropsychotherapy is a demonstration of the usefulness of the holistic view of the individual toward successful rehabilitation strategies, where negative feelings related to the loss of normal functioning, the acceptance and recovery work of present deficits, the search for new existential balances, and the reinforcement of self-esteem are processed simultaneously, so that there can be a functional social integration. In this perspective, taking charge of the patient aims to define and rehabilitate the deficits but also to integrate the individual’s resources into his or her life context [6].

Bibliography

  1. De Bellis MD. Developmental traumatology: the psychobiological development of maltreated children and its implications for research, treatment, and policy. Dev Psychopathol 2001;13(3):539-64.
  2. Mohr DC, Goodkin DE, Bacchetti P, et al. Psychological stress and the subsequent appearance of new brain MRI lesions in MS. Neurology 2000 Jul 12;55(1):55-61.
  3. Buljevac D, Hop WC, Reedeker W, et al. Self reported stressful life events and exacerbations in multiple sclerosis: prospective study. BMJ 2003 Sep 20;327(7416):646.
  4. Esposito P, Chandler N, Kandere K, et al. Corticotropin-releasing hormone and brain mast cells regulate blood-brain-barrier permeability induced by acute stress. J Pharmacol Exp Ther 2002 Dec;303(3):1061-6.
  5. Ostacoli L, Carletto S, Luigi Picci R. Prevalenza e determinanti significativi del disturbo post-traumatico da stress in un ampio campione di pazienti con sclerosi multipla. Giornale di psicologia clinica in contesti medici 2013;20:240-6.
  6. Melia C. Una prospettiva olistica della riabilitazione: la Neurospicoterapia. https://neuropsicoclinic.com/una-prospettiva-olistica-della-riabilitazione-la-neuropsicoterapia/

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