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

Conchi Moreno Rodríguez, a general health psychologist and neuropsychologist, discusses cognitive dysfunction and emotional regulation in people with multiple sclerosis in this post.

Multiple sclerosis (MS) is a neurodegenerative disease that primarily affects young adults. Its symptomatology is diverse, including sensory, motor, visual, bladder, cognitive, emotional symptoms, and fatigue, among others. Specifically, neuropsychology focuses on cognitive dysfunction, which has a broad pattern, and aims to investigate and treat it, as it significantly influences the quality of life of these individuals.

What is multiple sclerosis?

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

Currently, several hypotheses about the etiology of the disease are still being considered; however, it remains unknown, but it seems likely that the origin is multifactorial, with significant influences 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 typically occur between 20 and 40 years of age, being more frequent in women compared to 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): Characterized by the occurrence of defined relapses with partial or total recovery of symptoms. This phenotype is present in over 80% of the multiple sclerosis population.
Secondary progressive multiple sclerosis (SPMS): Defined by persistence and/or increase in disability. Relapses are not clearly defined. About 50% of patients with RRMS develop this progressive form approximately ten years after the onset of the disease.
Primary progressive multiple sclerosis (PPMS): Characterized by a progression of clinical symptoms from the onset, with minimal improvements. This phenotype is uncommon, with a prevalence of 10%.

Which cognitive functions are most often affected in multiple sclerosis?

Neuropsychology of multiple sclerosis: cognitive pattern

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

The predominantly affected cognitive functions are complex attention, processing speed, memory and learning processes, and executive functions, among others. Although the impairment can be present from the 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 the early stages of the disease, observed in all phenotypes, but appears more affected in the progressive forms of MS (Papathanasiou, Messinis, Georgiou, and Papathanasopoulos, 2014).

Mnesic processes

Mnesic performance is generally quite low in multiple sclerosis. Several studies have attempted to explain the memory deficiencies to understand the mechanisms leading to such impairment, giving rise to several hypotheses:

First, some suggest it may be due to alterations in recall/retrieval as the primary cause of the dysfunction (Rao, Leo, and Aubin-Faubert, 1989).
Secondly, other research indicates that encoding and organization processes are the main responsible, with recall/retrieval stages being a secondary impairment (Lafosse, Mitchell, Corboy, and Filley, 2013).
Thirdly, others suggest that in early stages of multiple sclerosis, mnesic failures are mainly related to dysfunctions in retrieval processes, while in advanced stages of the disease, the encoding stage is responsible for these alterations (Brissart, Morele, Baumann, and Debouverie, 2012).

Executive functioning

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

It is worth noting that the study of cognitive performance in multiple sclerosis has primarily focused on functions such as memory and processing speed, while executive functions have been less researched, despite their importance in 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 been limitations in delving into these alterations, as 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 commonly used technique for clinical follow-up of patients is magnetic resonance imaging since, thanks to it, it is possible to observe if 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 there are more current techniques such as functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI) that 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 of 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, showing a relationship between white and gray matter damage with overall cognitive impairment (Zhang et al., 2016).

Cognitive dysfunction and emotional regulation in people with multiple sclerosis

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

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

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

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

Why is psychological intervention so important?

Its importance lies in improving quality of life, as both the diagnosis and the variety of symptoms accompanying the disease pose a great challenge for those who suffer from it. Furthermore, it is crucial because the presence of depressive and anxious symptoms 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 significantly considerable impact, as it affects all domains that determine quality of life (personal, social, academic, occupational…). Therefore, it is extremely relevant not only to diagnose but also to provide appropriate treatment to improve and adapt the functionality of the person as much as possible.

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What is multiple sclerosis?