What is the neuropsychological profile that people with multiple sclerosis typically present?

On the occasion of World Multiple Sclerosis Day, general health psychologist and neuropsychologist Conchi Moreno Rodríguez discusses in this article cognitive dysfunction and emotional regulation in people with multiple sclerosis.

Multiple sclerosis (MS) is a neurodegenerative disease that mainly affects young adults. Its symptomatology is very diverse: sensory, motor, visual, bladder, cognitive, emotional symptoms and fatigue, among others. Specifically, neuropsychology focuses on cognitive dysfunction, whose pattern is broad, and its objective is to investigate and treat it since it significantly influences the quality of life of these people.

What is multiple sclerosis?

Multiple sclerosis is a demyelinating, chronic and autoimmune disease characterized by loss of myelin and axonal degeneration, leading to the development of multifocal lesions, called plaques, in the CNS (Mahad, Trapp and Lassmann, 2015; Mcalpine, 1973).

Various hypotheses about the etiology of the disease are still considered; nevertheless, it remains unknown, but everything points to a multifactorial origin, with notable influence from genetic predisposition and environmental factors (Arruti, Castillo-Triviño, Egüés and Olascoaga, 2015; Briggs, et al., 2019).

Multiple sclerosis is one of the leading causes of neurological disability among young adults, and its clinical manifestations usually occur between ages 20 and 40, being more frequent in women than in men (3:1) (Kingwell et al., 2013).

What types of multiple sclerosis exist and what are their clinical characteristics?

Phenotypes of multiple sclerosis

• Relapsing-remitting multiple sclerosis (RRMS): It is characterized by the appearance of defined relapses together with periods of partial or full recovery of symptoms. More than 80% of the multiple sclerosis population presents this phenotype.
• Secondary progressive multiple sclerosis (SPMS): It is defined by a persistence and/or increase in disability. Relapses are not clearly delineated. About 50% of patients with RRMS develop this progressive form approximately ten years after disease onset.
• Primary progressive multiple sclerosis (PPMS): It is characterized by a progression of clinical symptoms from the onset, with minimal improvements. This phenotype is uncommon with a prevalence of about 10%.

Cognitive functions most affected by multiple sclerosis: attention, memory and processing speed

Neuropsychology of multiple sclerosis: cognitive pattern

The prevalence of neurocognitive disorder in multiple sclerosis ranges between 40% and 75% (Chiaravalloti and DeLuca, 2008; Matias-Guiu et al., 2017; Peyser, Rao, La Rocca and Kapplan, 1990). Although cognitive decline is commonly mild, approximately 10% to 20% of the population may meet criteria for major neurocognitive disorder or dementia (Benedict and Bobholz, 2007).

The predominantly most affected cognitive functions are complex attention, processing speed, memory and learning processes, and executive functions, among others. Although impairment can be present from early stages of the disease, its frequency increases in progressive forms (Matias-Guiu et al., 2017).

Attention

Among the different attentional processes, deficits in sustained, selective and divided attention have been observed (De Sonneville et al., 2002).

Processing speed

In multiple sclerosis slowing of information processing speed is particularly characteristic. This cognitive function is often affected from early stages of the disease, observed in all phenotypes, but it seems to be more affected in progressive forms of MS (Papathanasiou, Messinis, Georgiou and Papathanasopoulos, 2014).

Memory processes

Performance in memory processes is usually quite low in multiple sclerosis. Several studies have tried to explain memory deficits to understand the mechanisms that lead to this impairment, which has given rise to several hypotheses:

1. First, some indicate that it may be due to alterations in retrieval as the primary cause of this dysfunction (Rao, Leo and Aubin-Faubert, 1989).
2. Second, other research points out that encoding and organizational processes are the main responsible processes, with retrieval stages being a secondary impairment (Lafosse, Mitchell, Corboy and Filley, 2013).
3. Third, others indicate that in the early stages of multiple sclerosis memory failures are mainly related to dysfunctions in retrieval processes, whereas in advanced stages of the disease it is the encoding stage that gives rise to these alterations (Brissart, Morele, Baumann and Debouverie, 2012).

Executive functioning

Executive functions are another set of cognitive functions that are often affected in people with multiple sclerosis. Within the different processes associated with executive functioning, poor performance is observed in inhibitory control, cognitive flexibility, working memory, abstract reasoning and verbal fluency (Cerezo, Martín and Aladro, 2015; Cores, Vanotti, Garcea, Osorio and Politis, 2017; Kouvatsou, Masoura, Kiosseoglou and Kimiskidis, 2019).

It should be noted that the study of cognitive performance in multiple sclerosis has focused mainly on functions such as memory and processing speed, while executive functions have been less investigated, despite their relevance for monitoring and regulating cognitive, behavioral and emotional aspects.

Visuospatial and visuoconstructive functions

Some authors indicate that between 21% and 26% of patients with multiple sclerosis show impairment in these functions. However, these cognitive domains have not been widely studied and there have even been limitations in the in-depth analysis of such alterations since it is suggested that this may be due to primary visual deficits (Marasescu, García and Benito, 2016).

Neuroimaging techniques and cognition in multiple sclerosis: What has been found?

The most used technique for clinical follow-up of patients is magnetic resonance imaging since, thanks to it, one can observe whether there are new lesions or a reactivation of existing ones.

The use of MRI and cognitive functioning

Although magnetic resonance imaging has been widely applied to observe the relationship between changes in the neuroanatomical substrate of the disease and cognition in people with multiple sclerosis, currently more modern techniques such as functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI) have provided new evidence that conventional MRI did not capture (Labbe et al., 2018; Roman and Arnett, 2016).

On the one hand, fMRI has offered images about the neuroplasticity processes that may be related to cognitive impairment in early stages of MS (De Giglio, Tommasin, Petsas and Pantano). On the other hand, DTI has revealed microstructural alterations in normal-appearing white and gray matter from early stages of the disease, and a relationship between white and gray matter damage and overall cognitive impairment can be observed (Zhang et al., 2016).

Cognitive dysfunction and emotional regulation in people with multiple sclerosis

Due to the unpredictable course of the disease, the presence of
uncertainty is common, particularly in early stages, regarding the evolution and severity of symptoms.

The most common psychopathologies are anxiety and depression. The prevalence of anxious symptomatology ranges between 44.5% and 57%, while depressive symptoms are around 50% approximately (Boeschoten et al., 2017; Butler, Matcham and Chalder, 2016).

The study of the relationship between anxious-depressive symptomatology and cognitive function has yielded contradictory results, but a more consistent relationship has been observed with the subjective perception of cognitive decline (Wallis, Köhler and van Heugten, 2020).

Therapeutic interventions, such as the cognitive-behavioral psychological approach, have a positive effect on the described emotional symptomatology and on subjective cognitive perception.

Why is psychological intervention so important?

Its importance lies in improving quality of life, since both the diagnosis and the variety of symptoms that accompany the disease pose a great challenge for those who suffer from it. Likewise, it is essential because the presence of depressive and anxious symptomatology can contribute to poor treatment adherence (Bruce et al., 2010).

Conclusions

Multiple sclerosis (MS) is a neurodegenerative disease with a wide range of symptoms, including cognition. Cognitive impairment is highly prevalent in patients with multiple sclerosis and its diagnosis has a considerably significant impact, since it affects all domains that determine quality of life (personal, social, academic, work…). Therefore, not only diagnosis but also appropriate treatment to improve and adapt, as much as possible, the person’s functionality is extremely relevant.

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“This article has been translated. Link to the original article in Spanish:”
¿Cuál es el perfil neuropsicológico que suelen presentar las personas con esclerosis múltiple?