Impact of cognitive impairment on coping strategies in multiple sclerosis

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Abstract

Objectives: To assess the impact of cognitive impairment (CI) on coping strategies in multiple sclerosis (MS). Materials and methods: Sixty-three patients (40 women, 55 relapsing-remitting and 8 secondary progressive, age 42.6 ± 10.1 years, Expanded Disability Status Scale 2.2 ± 1.7) were assessed using the Coping Orientation for Problem Experiences-New Italian version Inventory, the Beck Depression Inventory and the Rao's Brief Repeatable Battery. Results: MS patients were less likely to use positive and problem-focused strategies, whereas avoiding strategies were adopted more frequently. Twenty-three (36.5%) cases were CI. We found no differences in the type of coping between CI and cognitively preserved patients. Scores on the Stroop test (beta = −0.91, p = 0.04) and on the Word List Generation (beta = 1.15, p = 0.04) were associated with poorer coping strategies. Conclusions: Our study suggests that cognitive functioning (in particular on sustained attention and aspects of executive function) must be considered in a comprehensive account of the factors contributing to successful coping in MS patients.

Introduction

Multiple sclerosis (MS) is a chronic inflammatory disorder of the Central Nervous System typically affecting young adults. Beyond physical disability, cognitive impairment is recognized as a core feature of the disease, with prevalence estimates ranging from 40 to 65% [1]. Functions most commonly involved include memory, complex attention, information processing speed and executive functions, whereas language and attention span are relatively preserved. Cognitive impairment can have a dramatic impact on a patient's quality of life (QoL) influencing role fulfillment in work and social life, independently of physical disability [1]. Depression, too, is highly prevalent in MS subjects, with estimates ranging from 18 to 54% [2], and is considered to be the single most important determinant of QoL in MS subjects [2]. Depression and cognitive impairment often coexist [1] and can interact in a complex manner.

As in any other chronic disease, as well as in MS, coping is known to be an important mediator of psychological well-being. The concept of coping was defined in the 1960s as “the overall cognitive and behavioral efforts to master, reduce or tolerate inside or outside demands which threaten or surpass personal resources” [3]. Two general coping strategies have been distinguished, problem-focused coping (PFC) and emotional-focused coping (EFC). The former includes efforts to do something active to alleviate stressful circumstances, whereas the latter includes efforts to regulate the emotional consequences of stressful events. Denial, seeking emotional social support, turning to religion or resignation are some examples [4]. An additional distinction that is often made in the literature is between active and avoidant coping strategies. Generally speaking, active coping strategies are considered to be better ways to deal with stressful events, whereas avoidant coping strategies appear to be a risk factor for an adverse response to stressful events [4].

Among the factors that may influence coping strategies in MS, there is emerging evidence pointing to the negative impact of depression, whereas little is known about the role of cognitive dysfunction. Arnett et al. [5] found that cognitive impairment was related to higher depression levels when patients adopted avoidance strategies. More recently, Ehrensperger et al. [6] reported that performances on tests evaluating divided attention and premorbid verbal intelligence were significant predictors of patient cognitive capacities. It is conceivable that cognitive dysfunction may interfere with the ability of patients to develop effective adaptive coping skills. In particular, problems in planning, problem solving, self monitoring and flexibility may be especially relevant in influencing the ability of the subject to identify and negotiate with others the changes that are necessary for adjusting to the disease demands.

The aim of this study was to investigate coping strategies and related demographic and clinical features in a clinic-based sample of MS patients, with a specific focus on the possible impact of cognitive functioning.

Section snippets

Participants

The study included patients with an MS diagnosis according to the McDonald's criteria [7], who were consecutively referred to the MS Center of the Neurological Department of the University of Florence. Exclusion criteria were relapse and/or corticosteroid therapy one month prior to testing, history of psychotic disorders or drug or alcohol abuse which might interfere with neuropsychological performance.

All participants signed an informed consent and the study was approved by the Ethical

Sample characteristics

Sixty-three patients were recruited for this study. The main demographic and clinical characteristics of the study sample are reported in Table 1. Fifty-five (87.3%) patients had a relapsing-remitting (RR), and the remaining 8 a secondary progressive (SP) (12.7%) course.

Mean score on the BDI was 12.1 ± 9.7. Specifically, 19 (30.2%) patients had moderate to severe depression and the remaining 44 (69.8%) were not depressed or had mild depression.

Coping strategies and neuropsychological performance

In comparison with the Italian normative data [8], MS

Discussion

The aim of this study was to examine coping styles in MS patients and their clinical and demographic correlates, with particular focus on cognitive functioning.

There is consistent evidence in the literature that the use of PFC instead of EFC strategies is associated with a better adjustment to disease-related challenges. In one study, the use of PFC accounted for 40% of the variance [13]. In comparison with the general population, people with MS are less likely to adopt PFC styles and

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