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MOOD CHANGES IN MULTIPLE SCLEROSIS

Acknowledgments The National Multiple Sclerosis Society and the Multiple Sclerosis Society of Canada wish to acknowledge the support of the physicians, researchers, therapists, nursing staff and support staff from the following institutions: • MS Center at Holy Name Medical Center, Teaneck, N.J. • Sunnybrook Health Sciences Centre, Toronto State • University of Washington, Seattle

We’d also like to thank the following individuals for so graciously giving their time and sharing their stories with us: • Ann Marie Johnson • Maria Reyes-Velarde • David Rosen

Author Laurie Budgar was the editor of Momentum, the magazine of the National MS Society, from 2012–2017. She authored the original Society book, “Mood and in MS: What You Can Do,” from which this publication is excerpted and updated. Budgar specializes in health-related writing and editing, and is also a certified speech-language pathologist. Preface Though clinicians noted mood changes associated with multiple sclerosis as early as the 19th century, symptoms associated with mood disorder have only recently begun to receive the same degree of from clinicians as physical symptoms. Mood disorder is a complex issue and despite greater awareness, continues to be under-diagnosed and under-treated. This “invisible symptom” can be a direct result of the disease process, and can change over time.

We now understand that mood and physical functioning are intricately entwined, and treating one area often brings profound improvement to other aspects of an individual’s life—and to the lives of their families.

We also now recognize that while changes in mood may not be readily apparent to outside observers, their impact on a person’s life can be profound, affecting physical, social, emotional, occupational and spiritual functioning.

Fortunately, mood changes are among the most treatable symptoms of MS. With the appropriate strategies and tools in place, people with MS can live their best lives and participate actively in their own care.

This book and the accompanying video explore why and how people with MS experience changes in mood, and provide the latest information on how these symptoms can be addressed—from physical activity, medications and counseling to self-management strategies. In the video portion of the program, you will hear from clinicians at the forefront of MS research and treatment discussing the latest advances and recommendations, as well as from individuals who have experienced these symptoms and have lessons to share.

This book provides an overview of the types of mood changes common to MS, and further outlines the most successful ways that individuals, researchers and clinicians resources for learning even more about these topics. have developed for approaching these challenges. At the back of this booklet, you’ll find visit nationalMSsociety.org or mssociety.ca, or call 1-800-344-4867 (U.S.) or We1-800-268-7582 you find (Canada). the program informative and engaging. For further information,

Best regards,

Executive Vice President, Services Interim President & CEO National MS Society MS Society of Canada What's Inside Personal Stories...... 2

Presenters...... 3

Mood Changes In MS...... 5 ...... 7 ...... 8 Who Gets Depression?...... 9 Lifting the Darkness...... 11 ...... 14 Moodiness and Irritability...... 15 ...... 16 Pseudobulbar ...... 17

Moods Matter—to Everyone...... 18

Current Research...... 21

Fatigue and Mood...... 22 Fatigue and Depression...... 23 Managing Fatigue...... 24

Summary...... 25

Resources...... 26 United States Resources...... 26 Canadian Resources...... 27 Additional Reading...... 28

Glossary...... 29

1 Personal Stories Ann Marie Johnson Diagnosed with relapsing-remitting MS in 2002 Ann Marie says she feels blessed to be free from visible MS symptoms most of the time. However, she experiences almost daily, and last summer

to beginning treatment for depression, Ann Marie retreated into , but hasbegan since experiencing regained her significant physically mood and changessocially activelikely causedlife as a by single her MS.woman. Prior She enjoys her work with developmentally disabled adults, as well as going for drives, practicing yoga and otherwise getting out to “see the world.”

Maria Reyes-Velarde Diagnosed with MS in 2000 Maria’s diagnosis has transitioned from an initial relapsing-remitting course

several years ago when conversations with her husband, which would typically beof MScalm, to secondaryincreasingly progressive became arguments. MS. Maria To first help noticed mitigate mood the changes mood-dampening from MS effects of being home alone while her husband works, Maria adopted a small dog,

a website called “Hablemos de Esclerosis Múltiple” (Let’s Talk About Multiple Sclerosis),Bon-Bon, that where is now she certifiedshares thoughts, as an emotional-support experiences and informationanimal. Maria about maintains MS in Spanish and English, and from her dual perspectives as a trained physician and as a person living with MS.

22 || MOODMOOD CHANGESCHANGES ININ MULTIPLEMULTIPLE SCLEROSISSCLEROSIS David Rosen Diagnosed with relapsing-remitting MS in 2016

MS, he remembers times when his mood became different, even “wacky.” His symptomsAs David reflects have prompted on the years him and to “change months wholeading I've up been to his and 2016 what diagnosis I've done, with to be more of a stay-at-home father and really spend my time with my family.” David and his wife, Staci, stay active with their two young children who play team sports, traveling as a family with their camper, as well as raising chickens. David tries to focus on the positive aspects of his life, crediting much of his success in that area to Staci and their children. Presenters Charles Bombardier, PhD Charles Bombardier, PhD, is a clinical psychologist and a professor in the Department of Rehabilitation Medicine at the University of Washington in Seattle. He is also associate editor of the Journal of Spinal Cord Medicine and editorial review board member for Rehabilitation Psychology. Dr. Bombardier is a National MS Society-funded researcher. He has published numerous peer- reviewed journal articles on multiple sclerosis, including several on mood changes and MS, as well as exercise and MS. His awards include The Elizabeth

Congress of Rehabilitation Medicine. and Henry Licht Award for Excellence in Scientific Writing from the American Anthony Feinstein, MD, PhD Dr. Anthony Feinstein, MD, PhD, is currently a professor of at the University of Toronto, and is chair of the Medical Advisory Committee of the MS Society of Canada. His research focuses on identifying areas of the brain that are correlated with behavior in MS, traumatic brain injury and other disorders. In 2000–2001, he was awarded a Guggenheim Fellowship to study mental health issues in post-apartheid Namibia. This led to the development of that country’s

Thefirst ratingClinical scale Neuropsychiatry for mental illness. of Multiple Subsequent Sclerosis work in, as Botswana well as other produced books that and bookcountry’s chapters, first rating and has scale published for mental wid illness ely in peer-reviewedas well. Dr. Feinstein journals. has authored

3 3 Frederick Foley, PhD Frederick Foley, PhD, is a clinical psychologist, a professor of psychology at Yeshiva University in Bronx, N.Y., and director of Neuropsychology and Psychosocial Research at the MS Center at Holy Name Medical Center in Teaneck, N.J. He has dedicated his career to improving rehabilitation in MS. His research projects have focused broadly on developing outcome measures and psychosocial treatments for depression, cognitive function and sexual function in MS. He has authored or co-authored more than 90 publications in journals and books on MS. Dr. Foley lectures internationally on psychosocial issues in MS, and has received awards from the Academy of Psychosomatic Medicine and the Consortium of Multiple Sclerosis Centers for his contributions to MS research. He has served on the New Jersey Clinical Advisory Committee of the National MS Society, and in a variety of positions (including president) on the board of the Consortium of Multiple Sclerosis Centers.

Lauren Krupp, MD Dr. Lauren Krupp has specialized in the area of multiple sclerosis for more than 30 years, and is a recognized authority in the care of children and adults with MS. Dr. Krupp leads the NYU Langone’s Multiple Sclerosis Comprehensive Care Center. She founded the International Pediatric MS Study Group, and is a founding member of the International Multiple Sclerosis Cognition Society. Dr. Krupp is a National MS Society-funded researcher. She has directed clinical trials supported by the Society and the National Institutes of Health to improve fatigue, memory and reasoning among individuals living with MS, and has published more than 100 articles on MS.

44 || MOODMOOD CHANGESCHANGES ININ MULTIPLEMULTIPLE SCLEROSISSCLEROSIS MOOD CHAMoodNG ChangesES In MS IN MS

MOOD CHANGES IN MS | 5 For many people, a diagnosis of multiple and researchers continued to focus on the sclerosis comes after a lengthy series physical symptoms of the disease until the middle of the 20th century, when among seemingly unrelated physical symptoms,of tests to find such the as underlying blurred vision, thread mood and fatigue, and the interactions overwhelming fatigue, numbness in betweenthey finally them. began As examininga result, there’s cognition, a growing awareness that managing these While these physical issues are often the invisible symptoms helps people with MS the hands or feet, or difficulty walking. better manage their physical symptoms, there are other, subtler aspects of MS participate in their own care, and create a thatfirst canto develop greatly andaffect the one’s most life. noticeable, These more empowered life. with memory and attention and concentration;include changes and such alterations as difficulty in mood, emotionally at any given time, such as depression or anxiety. These oftenMood in reflects response the toway external a person events is or changes are very common. physical concerns. Sometimes, moods are predictable: The long-anticipated birth of Though these symptoms can be a child leads to of and , “invisible” to others, they can have perhaps mixed with anxiety or hope for a very real and profound effect on the future; a leisurely afternoon with a lifestyle, employment and relationships, friend makes us feel happy, content or as people struggle to plan, organize or loved; an argument with a family member remember important details or events, leaves us angry, sad or upset. perform well at work or school, and stay engaged in their social and personal lives. Relationships between family “I was directing a meeting, and my members may be particularly affected, eyes start bawling up and watering. as spouses and children struggle to understand changes in the behavior of And I'm crying. But I can't figure their loved one. out why,” David Rosen says of These symptoms don’t exist in isolation. an experience during the months Mood changes can make some physical symptoms of MS, such as fatigue or pain, leading up to his official diagnosis feel worse. Conversely, symptoms like with MS in 2016. “Crying is not chronic pain can dampen a person’s mood. something typical of me. I'm the Changes in mood and thinking, as part type of person who could noticed by neurologist Jean-Martin control well.” Charcotof the overall in 1868. picture Nevertheless, of MS, were physicians first

6 | MOOD CHANGES IN MULTIPLE SCLEROSIS People who have been recently diagnosed Medicine at the University of Washington with MS, or whose abilities have recently in Seattle. as they adapt to their new realities. Mood changeschanged, also may can find occur that their as part moods of the shift weeks and months after diagnosis. It disease process, depending on which But grief doesn’t happen only in the first parts of a person’s brain are impacted. abilities change over the course of the A large-scale study from Canada (Marrie, disease.can ebb andWhether eachit’s a timechange a person’s in vision, et al, Neurology, 2015) suggested that mobility, self-care, memory or anything people with MS have higher rates of else—something critical to a person’s anxiety, bipolar disorder, depression sense of who they are in the world has and schizophrenia compared to people been altered. without MS. That’s what happened for Ann Marie Some of the most common mood changes Johnson, of Brooklyn, N.Y., who was that may affect a person with MS are diagnosed with relapsing-remitting MS described below. in 2002.

Grief “When I was first diagnosed,the For many people, a diagnosis of MS very thing that defines me was comes during their 20s or 30s, just as they are establishing their identities in threatened,” she says. “I couldn’t many aspects of their adult lives—in walk. I had a cane. I was wearing their careers, in their relationships, in their roles as parents, and in their flats.” Ann Marie, who is known mastery of life skills. When they learn among her friends and colleagues that they have a chronic and incurable disease, it’s both natural and expected for her of skyscraper heels, that they will go through a period of grief began to : “Would I ever be as they come to terms with the losses that surround them, and the reality that able to walk again? Would I ever things will never be the same as they once were. be able to wear my stilettos again? Some people may think that’s “People can experience a sense of yearning for what they used to have—a an issue of , but there’s an kind of disbelief about what is happening element of femininity to them,” says Charles Bombardier, PhD, a clinical psychologist and a professor that I wanted to keep.” in the Department of Rehabilitation

MOOD CHANGES IN MS | 7 And it wasn’t just about shoes; on bad Grief is healthy and normal, and people days, when her fine motor control was should allow it free expression in particularly affected, she couldn’t apply whatever manner is most effective for makeup, curl her hair or put on earrings. “And all this is part of being a woman. through these feelings with a counselor And that was being threatened.” Ann asthem. soon Many as they people arise. find If grief it helpful persists to talk Marie grieved that deeply. “It also brings for weeks or months, however, without lessening or without periods of love me like this?’” into play questions like, ‘Will anybody professionally addressed, as it could be The emotions that grief stirs up often transformingor enjoyment, into it should clinical definitely depression. be are similar to what someone experiences after the death of a loved one; however, Depression people don’t necessarily experience the It’s common to hear people use the have been taught, says Dr. Bombardier. phrase “I’m so depressed,” perhaps Instead,“five stages he says, of grief” there that are many often peopletwo main when their favorite sports team loses or when a date doesn’t work out. But in where something really bad happens. truth, depression involves more than Youphases: are feeling “The first very is pained, an intrusive an intense phase, loss. just a temporary feeling of or , or even a period of over. I’ll never be able to have what I want “blues” that lasts a few days. Usually, inYou life.’” kind of catastrophize, like ‘My life is those emotional states lift when something pleasant happens. In the second phase, Dr. Bombardier says, people experience a type of denial. Though feelings of sadness or irritability disease- are the most recognizable characteristics, modifying therapy (DMT)—things are depression also involves a loss of going“Like, to‘I don’t be OK.’ need People to take shift my into not in activities that once brought enjoyment, even believing that these bad things such as hobbies, time with friends or are there.” But the phases aren’t linear, sexual activity; depression can also he says. “It’s a process of going back bring about physical symptoms, such as and forth. Sometimes you feel totally changes in appetite, sleep, energy level overwhelmed. Other times you can’t and ability to concentrate. Depression stand that any longer so you shift away is not really the opposite of happiness;

symptoms will vary with each individual, forthand think, may be‘I don’t part ofhave the to healing worry process about however,it is the opposite just as the of vitality. symptoms The of specific MS forthis; people.” I’ll be fine.’ And this going back and itself will vary.

8 | MOOD CHANGES IN MULTIPLE SCLEROSIS it had been months since she had felt Ask yourself: like herself. “I only had this feeling of 1. During the past two weeks, not wanting to go out, not wanting to be with friends, not wanting to do much of have you often felt down, anything but be in my bed, underneath depressed or hopeless? the covers, and just turn off my brain and not think about anything.” 2. During the past two weeks, have you had little interest or Who Gets Depression? in doing things? Depression is one of the most common experiences among people with MS. Sometimes, depression occurs as a If you answered yes to one or both of reaction to living with the disease and adjusting to a new reality. People who that you are experiencing depression. It these questions, it could be an indication is important to inform your healthcare way are more prone to developing team of how you are feeling. depression,react to difficulties explains in Dr. an Anthonyemotion-focused Feinstein, a professor of psychiatry at the University For Ann Marie, grief did evolve into of Toronto, and chair of the Medical depression. She says that on days when Advisory Committee of the MS Society her MS symptoms were worse, some of Canada. Those whose coping style is things just didn’t get done. And one day, more solution-based—with a greater emphasis on solving problems and normally a very social and active person, challenges as they occur—are less likely toit was go out. just “And too difficult then one for day Ann became Marie, to develop depression, he says. many days. It became many weeks of just not wanting to go out.”

Ann Marie also abandoned the activities Half of all people with MS will she always enjoyed—cooking, walking experience a major depressive by the water, going for long drives, even simple activities like making a smoothie episode at some point in their on the weekends. But during her depression, she recalls, she didn’t want lives—a rate that’s higher than to do any of it. “When I look back,” she in the general population or in says, “I realize, there was almost a whole summer I didn’t do anything.” other chronic diseases.

Then one day, when her doctor asked her how she was feeling, she realized

MOOD CHANGES IN MS | 9 Often, depression occurs as a result of the According to Dr. Feinstein, Stefan Gold, changes in the brain that MS causes, and one of the researchers in the 2014 is unrelated to personal characteristics. study has found similar results in his Depression does not seem to be linked own studies (published in Biological to the severity of a person’s MS, either. Psychiatry, 2010). “Using a very That said, each individual’s experience of depression is different, just as it is with other symptoms of MS. For example, he’ssophisticated shown an MRI association technique between and focusing depression can range from mild to depressionon specific areasand brain of the changes.” hippocampus, severe and can occur at any point in the disease course. In addition, Dr. Feinstein notes, studies are showing that higher levels of Results from a 2014 study published cortisol—a hormone associated with in the journal Human Brain Mapping stress and fatigue—are linked to (Sicotte, Gold, et al), suggest that depression. “I think there’s fairly robust depression in MS may in fact have a evidence now to show that depression is biological basis. The researchers found a brain disease in multiple sclerosis.” that women with MS who exhibit The interferon-beta medications of tissue in the hippocampus, an area that are sometimes used to treat MS ofdepression the brain alsoclosely have associated significant with loss (Avonex®, Betaseron®, Extavia® and memory and mood. What’s more, the Rebif®) may be linked to a greater risk of depression, too, particularly for part of the hippocampus—the part that those who have a history of it. Although isresearchers responsible found for depressed that a very mood specific and research has failed to show a strong loss of interest, rather than fatigue, link between depression and these impaired sleep and other physiological medications (as noted by Patten, et al, signs of depression—was affected in in their study published in Multiple these women. (Not enough men were Sclerosis Journal in 2005), post- included in the study to determine if marketing experience led the U.S. Food the same is true for them.) The bottom and Drug Administration and Health line is that researchers were able to demonstrate that low mood in women information supplied to physicians carry with MS is directly correlated with aCanada warning to requireabout a thatpossible prescribing risk. If you’re physical changes in the brain, and is not taking one of these treatments, it’s very a failure of willpower, strength or any important to talk to your doctor about other character trait. The National MS any psychological symptoms you’re Society is funding continued research in having, especially persistent feelings of this area. sadness, hopelessness, worthlessness or a lack of interest in the activities

10 | MOOD CHANGES IN MULTIPLE SCLEROSIS that you previously enjoyed. It is also In fact, depression can cause its own important to tell your doctor about disability. “People who have depression past episodes of depression you or as well as MS may have poorer family members have had. Despite these concerns, Dr. Bombardier says, “People They may have poor relationships. shouldn’t decline taking these disease- Theyfunctioning may be and less poorer independent. quality ofThey life. may modifying therapies out of worry for stop working. Depression is associated depression, because the evidence for with people being less adherent to that is uncertain.” And even if someone medications—they may take them less does develop depression as a result of taking these medications, that risk disease- modifying therapies in a timely manner,”frequently Dr. or Bombardier not be willing says. to start Dr. Feinstein adds. “If someone develops depressionprobably doesn’t on disease-modifying outweigh the benefits, In addition, the emotional pain that treatment, the current wisdom is, if depression causes can make people feel their physical pain more acutely, modifying treatment, we don’t take them says Frederick Foley, PhD, a clinical offthey’re the drug, benefiting because from the the depression disease- can psychologist and professor of psychology get better. We just treat the depression.” at Yeshiva University in Bronx, N.Y. Dr. Foley is also director of Neuropsychology and Psychosocial Research at the MS The good news is that Center at Holy Name Medical Center in Teaneck, N.J. depression is one of the most effectively treated having a full evaluation. If you’ve been symptoms of MS. experiencingThe first step anytoward of the feeling symptoms better of is depression for more than a few weeks, it’s worth discussing them with your Lifting the Darkness neurologist. Some of the symptoms, such While depression is common and can are hallmarks of depression and of MS, occur in MS for a variety of reasons, andas difficulty your doctor concentrating will be able and to fatigue,help you that doesn’t mean it’s “normal” to be depressed simply because you have this their root cause. He or she may refer disease. No individual or family should youtake to the a psychiatristfirst steps toward, psychologist determining, have to live with the emotional pain social worker or other counselor for that depression can bring. “Life with MS further evaluation or treatment. These is hard enough without trying to do it professionals have a wealth of resources under the weight of depression,” says available to treat depression. Dr. Bombardier.

MOOD CHANGES IN MS | 11 While we need more research to help us to follow you closely and monitor the understand the best strategies for treating depression, experts typically recommend a few days to weeks when a medication is using a three-pronged approach: workingresults, but for most them. people find relief within medication, talk therapy and exercise. “The causes of depression in MS are a bit Nevertheless, it’s important to combine mysterious. But that shouldn’t take away medication with counseling; counseling from the fact that these different things provides an outlet for the many feelings help,” Dr. Bombardier notes. that arise during depression, and enables individuals to begin the problem solving necessary to actively manage Three-pronged approach: life with MS. Research in the general population also shows that results using 1. Medication a combination of treatment approaches 2. Talk therapy are superior to either method alone 3. Exercise (see, for example, the study by de Jonghe, et al, in the Journal of Affective Disorders, 2001). Ann Marie says that starting medication was a big step in helping her feel better. One type of talk therapy that research has “But even before that, it was claiming the been found to be particularly effective in people with MS is called cognitive- know what? I’m depressed.’” behavioral therapy (CBT). CBT teaches moment and saying to my doctor, ‘You people to more readily identify when Psychiatrists (who are medical doctors) they are having negative thoughts, and can prescribe medication; while they can to replace them with more positive ones. also provide counseling, they typically It’s a way of reframing how you perceive will refer patients to psychologists, something, which in turn changes how social workers or counselors. Today’s you respond to it. “Oftentimes when we’re depressed, we’re thinking in black and effective, although it may take a bit of white terms, and catastrophizing,” says antidepressant medications are quite Dr. Bombardier. “Cognitive-behavioral that works best with your particular therapy helps people think differently patience and persistence to find the one about what’s going on. It also helps you. A 2006 study showed that people people resume pleasant activities in their withchemistry, MS who and are to depressedfind the right often dose don’t for lives, and get back on track doing things receive high enough doses to be effective (Mohr, et al, published in Multiple Sclerosis Journal). For these and other Researchthat are life-affirming has shown that for them.”CBT works reasons, your healthcare team will want well even when delivered by telephone.

12 | MOOD CHANGES IN MULTIPLE SCLEROSIS A 2011 study of 127 people with MS and small studies have shown that various depression (Mohr, et al, in the Annals types of exercise, ranging from treadmill of Behavioral Medicine) found that walking to yoga to unstructured physical people who received CBT by phone activity, have improved the moods of people with MS for up to three months. considerationshowed significant for people improvements who may innot For Maria Reyes-Velarde who was mood and quality of life—an important diagnosed in 2000 and now has regularly, whether due to mobility secondary progressive MS, this came limitations,be able to come access into to a transportation therapist’s office or in the form of a small dog named Bon- some other issue. Bon. “We decided that maybe part of my problem was being alone in the house. Other forms of talk therapy also are Also, I was mostly sitting down, working useful, though most haven’t been on the computer, and I was relying more evaluated as thoroughly. Your counselor on my scooter to move. So we decided will work with you to determine what to adopt a dog. And now he makes me method is best for you. More important get up to feed him. I have to take him out, even though I don’t walk much. I roll in my scooter and he walks around. whomthan using you afeel specific comfortable. type of therapy, I started to socialize again with the however, is finding a counselor with neighbors who have dogs. Now, I don’t Self-help groups also can be useful feel that depressed. Bon-Bon has dog play resources for understanding depression and for feeling less isolated by it. that I can socialize.” dates and I have more now substitute for treatment provided by a In addition, a pair of studies done by trainedHowever, professional. they are not an adequate Dr. Bombardier and his colleagues at the University of Washington in 2013 A considerable body of research and 2014 and published by the American demonstrates that exercise is effective Psychological Association showed that in combating depression in the general when people with MS receive individual population. Increasingly, researchers they can become more physically active, improve depression in people with MS. theirtelephone depression counseling becomes about less specific severe, ways are also finding that it specifically helps and their moods improve from week to done in 1996, when JH Petajan and other week. “They might walk; some people researchersThe first study at theto demonstrate University of this Utah was might just stand more. They might go to found that after 15 weeks of aerobic the gym, or swim, or run—whatever they exercise, not only did measures of can do,” Dr. Bombardier says. He notes that for 34 percent of the people in his so did measures of depression. Recently, study, their depression severity dropped physical fitness show improvement, but

MOOD CHANGES IN MS | 13 by at least 50 percent. And by the end likelihood that it’s a result of the way of the study, he says, 30 percent of the MS changes the brain. But because people no longer met the criteria for depression is associated with suicidal depression—“just by exercising.” Given feelings, it’s imperative not to ignore it or this evidence, using CBT to promote hope it will go away. In fact, depression physical activity could be a powerful is more strongly linked with suicide method for managing depression in MS. than wheelchair use, vision loss, or any other symptom or result of living with MS. Because depression is so common, conveys—to cardiovascular health, bone people with MS may have as much as 7.5 density,The other bowel benefits and thatbladder exercise function, and times the risk of suicide as people in the more—make it an important part of any general population. And with treatment regimen geared toward better health. Of so effective and readily available, no one course, people should consult with their should have to remain depressed. physicians before embarking on any new exercise regimen. Anxiety Another approach to treating depression that is gaining more widespread in MS, affecting more than 35 percent of is electroconvulsive thoseLike depression, with the disease—again, anxiety is quite a commonnumber therapy (ECT). “ECT is very safe,” says higher than the general population. People Dr. Feinstein. It is far different than the used to believe that depression and “shock therapy” that was portrayed in anxiety were two sides of the same coin, so movies decades ago. It uses extremely to speak, but now these mood changes are small doses of electricity to stimulate increasingly seen as separate disorders. is a small risk that it could trigger a People with generalized anxiety feel relapsespecific inareas some of individualsthe brain. While with thereMS, tense and worried much of the time, doctors can often predict the likelihood and often to a greater degree than of that happening based on the level of external events would seem to demand. active disease shown on MRI (magnetic Other types of anxiety include resonance imaging) just before the attacks and obsessive-compulsive disorder, but generalized anxiety is MS patients who have not responded to much more common among people [othertreatment. treatments],” “I find ECT Dr. to Feinstein be effective says. in with MS. That’s not surprising, given the unpredictability of MS. People with The important thing is to not let the disease may feel great one day but depression go untreated. It cannot be have considerable pain, fatigue or other overcome by willpower or determination, symptoms the next. And there’s no road and is not a sign of weakness or lack map that tells them how much or how of character. As noted, there’s a high fast their disease will progress.

14 | MOOD CHANGES IN MULTIPLE SCLEROSIS “One of the things I hear very often in “I think anxiety, just like what do you expect? You’ve got a disease hererelation that’s to anxietyaffecting is young people people. saying, ‘Well, depression, is going to be [shown to be] generated by brain changes. physical disability. Of course a person’s goingThere’s to no be cure.anxious.’ There’s But significantthat’s a really It does have a profound effect simplistic approach to the problem,” says on a person’s ability to function. Dr. Feinstein. “I think anxiety, just like depression, is going to be [shown to be] We should not just view it as an generated by brain changes. It does have understandable reaction to a nasty a profound effect on a person’s ability to function. We should not just view it as disease. I think for most people, an understandable reaction to a nasty it’s going to be a lot more disease. I think for most people, it’s going to be a lot more complex than that.” complex than that.”

“I’m not someone who has a lot of anxiety or ever had a lot of stress. It’s just tasks that you manage and prioritize,” says David Rosen, diagnosed with relapsing- that people with MS who used stress remitting MS in 2016. “But yet, my body has so much anxiety at times I feel like to develop new MS brain lesions than management techniques were less like I’m missing something. Something’s people who didn’t use such tactics. More going on or I’m forgetting something. research in this area needs to be done And my whole body feels like it’s moving inside very fast. It’s a lot of anxiety now.” Your doctor or mental health professional before drawing definitive conclusions. Many antidepressant medications of treatments for you. effectively treat both depression and can help you find the right combination Moodiness and Irritability can work well for short periods of time, butanxiety. carry Specific the risk anti-anxiety of dependence. medications CBT While people who experience depression and other forms of psychotherapy can and anxiety with MS may feel that they’re be very effective for anxiety disorders. stuck in one all the time, other And yoga and meditation can help calm people with MS can have the opposite the nervous system and reduce activity problem. Family members often report in the parts of the brain that govern the stress response. A 2012 study, published shifts in mood, seeming peaceful one that the person with MS has frequent by David Mohr, PhD, in Neurology, found moment and moody, irritable or angry

MOOD CHANGES IN MS | 15 the next. While these changes in mood Bipolar Disorder sometimes result from responses to external events, they also can occur People who have this condition experience without any triggers—an aspect that alternating episodes of depression and mania. Mania refers to periods of for the person experiencing the mood hyperactivity, excessive cheerfulness shiftsmakes and them for difficult his or her to understand,family, friends both or irritability, rapid speech and similar and colleagues. symptoms. Extreme changes in energy, activity, sleep and behavior go along This type of moodiness can be part of with these changes in mood. A person depression, or it can exist on its own. may be having an episode of bipolar “Depression is sadness, but it can also disorder if they have a number of manic be irritability; sometimes you get a or depressive symptoms for most of the combination of the two,” says Dr. Feinstein. day, nearly every day, for at least one or “So a loved one starts noticing a change in two weeks. the person’s behavior. They’ve become a bit more short- tempered or a bit snappy. They do things that are out of keeping Bipolar disorder affects about with their usual character,” he explains. 13 percent of people with MS, Maria began experiencing this after she compared with less than 5 percent was diagnosed in 2000. “It used to be of the general population. that I would just bark when there was an injustice or there was something wrong. The shift became more apparent when I Researchers who conducted a study of mood disorders in MS (MG Carta, et al, reason. Something that didn’t bother me Journal of Affective Disorders, 2013) started fighting with my husband without before all of a sudden became a really big found that bipolar disorder is often issue and I had very little tolerance for it.” unrecognized by the medical community and as a result is under-diagnosed. They Irritability and moodiness can also be noted that manic symptoms may be seen symptomatic of many other medical by the individual as positive periods that conditions, so it’s important to talk with offer relief from depression. your healthcare team if you experience Depression and mania (or , a you understand why these mood changes term for episodes of mania that are less frequent changes in mood. They can help are happening and, importantly, what can intense or prolonged) can sometimes be done about them. occur with the high-dose corticosteroids

16 | MOOD CHANGES IN MULTIPLE SCLEROSIS that are often used to treat MS relapses, between the person’s outward display so it’s important to let your doctor of emotion and how he or she is actually know if you have a history of bipolar feeling. “It’s kind of like the brakes on our disorder or depression if he or she is are worn out,” Dr. recommending this treatment. Bombardier says.

PBA is typically treated with either Pseudobulbar Affect antidepressants or Nuedexta®, a About 10 percent of people who have medication approved in 2010 that is MS may experience involuntary bouts thought to work in the areas of the brain of uncontrollable laughing or crying. that control emotion. While PBA has not This phenomenon, called pseudobulbar been shown to respond to CBT or other affect, or PBA, occurs as a result of the talk-based approaches, medications are changes that MS causes in the brain. usually effective within 48 to 72 hours. “It appears to be more closely associated Because PBA can be so upsetting to the with progressive forms of MS,” notes person who has it, and to his or her Dr. Feinstein. family, it’s important to seek counseling to learn how to handle these episodes Sometimes, PBA episodes exaggerate when they do occur. an emotion that a person is feeling; other times, there’s no connection at all

MOODMOOD CHANGES CHANGES IN MSIN MS | 17 | 17 Moods Matter—to Everyone MDS MAER TO EVERYONE

18 | MOOD CHANGES IN MULTIPLE SCLEROSIS Moods play a central role in most that they married, and they don’t know people’s lives, whether or not they where the change has come from. To have MS. A person’s emotional state can them, multiple sclerosis is a disease of walking or of balance or of vision or— functioning. For example, someone who is but now they’ve got someone whose depressedinfluence his is orlikely her tophysical feel more and fatigued, cognitive personality has changed, and they struggle to deal with that.” move more slowly. have difficulty concentrating, and even Depression affects children too— People who feel depressed or anxious are especially when it’s expressed as often reluctant to participate in social or irritability, Dr. Feinstein says. “Kids may community activities, which can lead to a be struggling to understand why Dad is sense of isolation, which in turn creates changing. Why has he become so angry? even more depression or anxiety. Why is he snapping? The whole dynamic within the family can change and Family and personal relationships are affected, as well. Loved ones may be within families.” depression can produce significant crises change in attitude, and what theymystified might at have what done they to see bring as a itsudden on. This is true of children as well as adults. diagnosisThese changes of MS. were But recognizingdifficult for David’sand Family members also may feel their acknowledgingfamily—particularly the changes before hishas official helped own spectrum of emotions, ranging from them cope and move forward. concern to at having to “pick up the slack.” And of course “There were times when my was family members affected by MS can out of control. That’s not typical of me,” experience their own sadness, anxiety David says. “It’s sad that my family had to and even depression. see the anger that I’ve portrayed at times, but now that I know it’s part of a disease and I have a little more recognition of or spouse to live with someone who’s how I’m acting, honestly I think the depressed.“It can be very If you difficult look at for the a partnerfeatures relationship with my wife has gotten of depression, which include social much stronger.” withdrawal, irritability, poor self-esteem, lack of sex drive, sleep disturbance, Staci, David’s wife, has learned to give changes in appetite, one can readily see him space. “I understand that he’s going how symptoms like that can spill over through a lot. And sometimes it’s like, you and affect family members as well,” says learn not to react. Now I kind of just have Dr. Feinstein. “Spouses and partners will to take a step back and realize, he’s just tell me that this is not the same person going through something.”

MOODS MATTER—TO EVERYONE | 19 Since MS affects the whole family, it’s It may be easier during challenging times important to keep lines of communication to exercise, attend a support group, have open, and also to consider family a weekly date night, cook nutritious counseling. The Society in the United meals, meditate, pray, listen to music, States and Canada have tools to help you take bubble baths, or whatever makes discuss MS with your family and age you feel nurtured, when you already appropriate literature for children. have a routine in place. And the payoff of doing them can be enormous—helping Employers may notice a drop in to relieve the stress of living with MS, attendance, productivity or your ability to and keeping you engaged in your life and stay focused on a task. Your for your work may also be noticeably doing the things that have typically given different. A recent study of working youyour pleasure, treatment. it mightIf you befind appropriate yourself not to people with MS found that 14 percent ask yourself if you’re depressed. reported absenteeism—missing work due to health problems—and 47 percent Ann Marie says that when she looks back, reported “presenteeism"—impairment she realizes that, in addition to taking while working. People lost more work time her antidepressant medication, one of (12 percent) due to working at less than the most helpful practices for her was full capacity than they did due to simply writing in her journal, which she used to not showing up (4 percent lost time). vent about what was happening to her. According to the researchers, statistically She recalls writing about how certain friends were making her feel, as well as between presenteeism and increasing things at work that upset her. She wrote disability,significant fatigue, correlations depression, were found anxiety when her legs and hands hurt. “A lot of

(Glanz, et al, Value in Health, 2012). bothers Ann Marie,’ both physically and and reduced quality of life add in after life emotionally,”my writing went she intosays. this “I was whole writing ‘what just Perhaps most importantly, mood shifts can to talk about how I felt in the moment. affect your ability and willingness to either So in the very beginning, it wasn’t too initiate treatment for your MS and its pleasant. It was very angry. But then symptoms, or to adhere to the treatment it changed. As the months went on, it plan. That can have long-lasting results in became very positive.” Ann Marie says terms of your disease course. that when she began feeling better, she put away the old journal and started a For that reason and all the others new one. “My new book started with: discussed, it’s important to have a self- This is the day I try.” care routine.

20 | MOOD CHANGES IN MULTIPLE SCLEROSIS Current ResearchCURRENT RESEARCH

Research is continuing to investigate “We really need more well-controlled, the causes and most effective treatments randomized clinical trials to determine for mood changes in MS. A guideline how effective antidepressant therapy is released by the American Academy of in MS, and if we need to give different doses of anti-depressants, or different in 2016) underscored the need for this combinations of anti-depressants in Neurology (AAN) in 2013 (and reaffirmed persons with MS,” says Dr. Foley. In addition, 115 existing studies on emotional disorders he says, “Developing valid and reliable ongoing scientific inquiry when it reviewed screening tools is very important to detect evidence to recommend or to discourage these problems in persons with MS.” With usein MS, of anyand particularfound that treatment— there was insufficient improved diagnostic tools, “People with MS pharmaceutical or otherwise—for mood can get screened, properly assessed, and disorders in MS. The AAN also concluded treated for these problems.” that more research has to be done so that clinicians have a greater certainty that the As researchers continue to examine the diagnostic tests and screening tools they’re effects of counseling, medication, exercise using are correctly identifying people who and more, there is great hope that we will soon have the answers at hand. would benefit from treatment.

CURRENTCURRENT RESEARCH RESEARCH | 21| 21 FATIGUE Fatigue and Mood & MOOD

22 | MOOD CHANGES IN MULTIPLE SCLEROSIS Fatigue is one of the most prevalent Fatigue also can be the result of sleep symptoms of MS, affecting about 90 disorders, which are common in MS. percent of people with the disease Sleep apnea and periodic limb at some point. Fatigue is not just a movement disorder (related to restless physical symptom, however; it is also leg syndrome) seem to occur more one of the most common symptoms of depression. A change in mood can general population. affect fatigue, and vice versa, ultimately frequently in people with MS than in the creating changes in social and family Other symptoms common to MS, such relationships, work and self-care. as depression and bladder problems,

Because fatigue is an “invisible” night’s sleep. symptom, people who lack knowledge can make it difficult to get a good about MS may assume that a person Of course, other factors, such as with the disease is exaggerating about medications and other medical the degree of his or her exhaustion conditions, can lead to fatigue, so it’s or, worse, simply being lazy. But it’s important to have your healthcare team important for everyone affected by MS do a complete evaluation. No matter to understand that MS-related fatigue is what, it’s important to recognize the unlike the kind of tiredness that people effects fatigue may have on other areas without MS may experience after a long of one’s life. day at work; instead, it feels like an overwhelming lack of energy, and may Fatigue and Depression be unrelated to the type or degree of activity a person is participating in. Like A depressed person may sleep a lot, or most other MS symptoms, it seems to feel too exhausted to leave the house be caused by the changes in the brain to go to work or engage in activities that the disease brings; one theory they usually enjoy. Unfortunately, this is that the damaged central nervous can become self-perpetuating, as lack system must work much harder than it of activity may lead to deteriorating would in a healthy individual to create physical health, which leads to even the same level of functioning. Fatigue more fatigue and depression, causing appears to affect people with MS a person to engage in less activity. In of time since diagnosis or the severity ofequally, disease regardless activity. of age, gender, length short, depression intensifies fatigue, and fatigue intensifies depression.

FATIGUE AND MOOD | 23 Of course, not all instances of MS- related fatigue will lead to depression, notes Dr. Lauren Krupp, who leads “Most people with MS find that the NYU Langone’s Multiple Sclerosis their energy level wanes as the Comprehensive Care Center. “There are plenty of people with MS who are not day wears on, particularly in the depressed, and yet have this severe sense afternoon,” Dr. Krupp says. So of exhaustion. However, you can easily imagine how, if you feel vulnerable, at the earlier part of the day may the mercy of forces that you can’t control, be the best time to do the most it can make fatigue much worse. So it’s very important to try to control the demanding tasks. People should disease, and not let the disease control also consider taking breaks you. That’s an approach that can be throughout the day to refuel. minimizing fatigue.” very life-affirming and can be helpful in “In contrast to people who don’t If fatigue does lead to depression, it may have MS, the person with MS is take treatment with an antidepressant medication to break out of these working with a gas tank that is cycles, but usually the treatment is half full. So they’ve got to be very that treating depression can improve judicious in how they cognitionquite effective; (Demaree, research et al, has Cognitive shown spend that gas.” Neuropsychiatry, 2003) and fatigue (Mohr, et al, Psychosomatic Medicine, 2003)—and then people can take better care of themselves.

Managing Fatigue A comprehensive treatment plan may The bottom line is that fatigue and include lifestyle changes. For example, mood appear to be interrelated. For “We know that exercise helps fatigue,” these reasons, anyone who experiences says Dr. Krupp. worsening fatigue should be evaluated Another important lifestyle measure is by his or her healthcare team, so the energy conservation. For many people, that means thinking about when they feel addressed before they begin to impact their best. othercontributing areas of factors one’s life.can be identified and

24 | MOOD CHANGES IN MULTIPLE SCLEROSIS mindfulness—a way of learning how Summary toDr. approach Krupp notes thinking that a in technique a positive called way Mood plays an important role in how and focus on the present—can also be a person feels, and how well he or she is able to interact with the world and published in one of the key neurology participate in his or her own life. Any journalsbeneficial. showing “A very thatexciting mindfulness, study was changes to mood should be addressed when used by people with MS, was separately and collectively. The role of fatigue in these changes should also be in their fatigue” (Grossman, et al, considered. Neurologyassociated with, 2010). a significant reduction Unlike physical changes that occur in the Depending on individual circumstances, disease, such as visual disturbances or some medications, such as amantadine readily apparent to others. That’s why treating fatigue. Treatment options vary it’sgait helpful difficulties, to know mood your changes body, spiritare not and accordingor modafinil to (Provigil)the cause andmay type be useful of fatigue for mind, and speak up when something is a person is experiencing. The Patient different. As with physical symptoms, Centered Outcomes Research Institute the earlier these are diagnosed, the more is funding a randomized, double-blind, successfully you’ll be able to manage placebo-controlled clinical trial at the them—and live your best life. University of California, San Francisco, to evaluate the effects of several drugs in reducing fatigue—and improving which at the time of print, is in progress. the quality of life—in patients with MS,

FATIGUE AND MOOD | 25 Mood Resources Emotional Health (nationalMSsociety.org/ United States Resources emotionalhealth) The National MS Society has an extensive An overview and links to more in-depth library of resources about MS, including discussions about how MS can affect publications about treatment options, mood and the expression of emotions, symptom management and living well and information about the steps to with MS. getting help.

The Society’s MS Navigators also offer Depression (nationalMSsociety.org/depression) living with MS. These highly skilled An overview and links to more in- professionalsassistance in answering can help you questions connect about to depth discussions and videos about resources in your community, access depression in people with MS. It provides optimal healthcare, meet workplace information about how to distinguish challenges, understand health insurance, depression from normal grieving and plan for the future and much more. how it may be treated. Whether you are a person living with MS, a family member or someone who Suicidal Feelings cares about a person with MS, you can Severe depression can be a life- call an MS Navigator at 1-800-344-4867 threatening condition because it may during standard business hours, Monday include suicidal feelings. One study through Friday. You can also email us at found that the risk of suicide was 7.5 [email protected] or times higher among persons with MS facebook.com/ than the general population. If you are NavigatorMS. having thoughts about harming yourself find us on Facebook at or feel you are at risk of hurting yourself The following articles and brochures, or someone else, call the National Crisis available online or by calling 1-800-344- Hotline at 1-800-273-TALK (8255) or text 4867, may prove especially helpful in “ANSWER” to 839863. learning more about how mood, fatigue and cognitive changes interact with a The Shifting Tides of Moods in MS person’s experience of MS. (MomentumMagazineOnline.com) Grief, depression, anxiety and shifting The companion video, Managing moods are common emotional symptoms Mood in MS, is available online at in MS. This article discusses why they nationalMSsociety.org/video by occur and what to do about them, calling 1-800-344-4867. including tips from experts and people living with the disease.

26 | MOOD CHANGES IN MULTIPLE SCLEROSIS Fatigue Everyday Matters Fatigue (nationalMSsociety.org/ (nationalMSsociety.org/fatigue) everydaymatters) An overview and links to in-depth The National MS Society’s Everyday information about how MS can affect fatigue, and information on how to company, was an interactive national Matters, supported by Genzyme, a Sanofi manage it. project that uncovered stories of real people facing—and meeting—the Fatigue: Take Control everyday challenges that MS can bring on (video and program) the path to one’s best life. (nationalMSsociety.org/video) Educational videos An extensive look at how medicine, (nationalMSsociety.org/ exercise, managing your environment educationalvideos) and making proactive energy choices can help to manage the fatigue associated The Society offers a variety of online with MS. educational programs, including MS basics, symptom management, relationships, employment and research. Comprehensive Wellness Transcripts and podcasts are available for Stress most programs. (nationalmssociety.org/stress) An overview and additional information about the impact stress can have on MS Canadian Resources and information on how to cope. The Multiple Sclerosis Society of Canada offers many helpful resources. The Live Fully, Live Well following publications are available by (nationalMSsociety.org/ calling 1-844-859-6789 to speak with an livefullylivewell) MS Navigator or online at mssociety.ca/ A comprehensive wellness program resources/library. from the National MS Society and Can Do MS®, designed for people living with MS and Your Emotions MS and their support partners. Live This booklet explains the effects that MS Fully, Live Well covers topics affecting may have emotionally and psychologically the whole family living with MS in order on individuals. It describes common to strengthen relationships, increase reactions to chronic disease and the usual understanding and promote improved stages of adjustment to MS in a positive and easy-to-understand manner. health and quality of life.

RESOURCES | 27 Living Well with MS: Additional Reading Mind Matters This resource helps people understand The following resources may also the connection between MS and be useful: depression, and provides solutions that Facing the Cognitive Challenges may help to manage depression and of Multiple Sclerosis, 2nd edition; Jeffrey N. Gingold; 2011, Demos Health improveLiving Well quality With of MS: life. Managing Fatigue Improving Your Memory for Dummies; This booklet includes information on John B. Arden; 2002, Wiley Publishing the impact of MS fatigue, its causes and Mental Sharpening Stones: Managing diagnosis, as well as a section on different the Cognitive Challenges of MS; strategies and medications for managing this common symptom. Jeffrey N. Gingold; 2009, Demos Health

Fatigue and MS MS and Your Feelings: Handling the (information sheet) Ups and Downs of Multiple Sclerosis; Fatigue can be one of the most disabling Allison Shadday, LCSW; 2006, symptoms of MS. According to some Hunter House studies, more than 90 percent of people The MS Workbook: Living Fully with MS experience fatigue. with Multiple Sclerosis; Robert T. Fraser, et al; 2006, New Harbinger Publications

The Stress and Mood Management Program for Individuals with Multiple Sclerosis; David Mohr; 2009, Oxford University Press

Staying Smart (stayingsmart.org.uk) Website designed for people who want to know (or know more) about how MS can affect thinking.

28 | MOOD CHANGES IN MULTIPLE SCLEROSIS COUNSELOR – A person trained to Glossary give guidance on personal, social or psychological problems. AEROBIC EXERCISE – A type of physical exercise that increases heart rate and DEPRESSION – A persistent state of respiration. low mood that is unaffected by external events or enjoyable interactions. About – An emotional state ANXIETY half of all people with MS will experience characterized by tension, worry, a major depressive episode at some point nervousness or uneasiness, often out of in their lifetimes. proportion to external events. About 35 percent of people with MS experience DISEASE-MODIFYING TREATMENT anxiety. (DMT) – A medication that reduces the – ATTENTION AND CONCENTRATION altering the immune response. Broadly, these terms refer to the ability to frequency and severity of MS attacks by ELECTROCONVULSIVE THERAPY or information. (ECT) – A procedure used to treat filter out distractions and focus on a task severe depression that involves passing – A condition, BIPOLAR DISORDER extremely small amounts of electric formerly known as manic-depressive current through the brain to produce a disorder, in which a person alternates small, controlled seizure. between low and high moods, as well as low and high levels of energy. About 13 FATIGUE – One of the most common percent of people with MS experience symptoms of MS. MS-related fatigue these changes. refers to an overwhelming feeling of tiredness that can occur at any time, – A broad term that COGNITION regardless of the amount of intensity of encompasses a person’s ability to activity or sleep. pay attention, process and remember information, plan, organize and reason, FINE MOTOR CONTROL – The ability to among other high-level brain skills. coordinate muscles, bones and nerves to Cognitive impairment, a common produce precise movements. symptom of MS, refers to any degree of HIPPOCAMPUS – A structure in the weakening of those skills. brain that’s believed to play an important COGNITIVE-BEHAVIORAL THERAPY role in both . (CBT) – A type of talk therapy that INTERFERON-BETA MEDICATIONS – focuses primarily on the present, with Interferons are a group of natural an emphasis on problem solving. In CBT, proteins that are produced by human people learn how to identify distorted cells in response to viral infection and thinking, modify their negative beliefs other conditions. They were named for and behaviors, and relate to others in their ability to interfere with viruses. different, more productive way. Interferon beta is produced mainly by

GLOSSARY | 29 white blood cells and certain connective PSYCHIATRIST – A medical doctor tissue cells. Several of the approved who specializes in the diagnosis and disease-modifying therapies use treatment of emotional disorders, interferon beta to reduce the immune including the prescribing of medication, attack in MS. and may also be involved in research. LESIONS PSYCHOLOGIST – A person with a damage that occurs in the central master’s or doctoral (PhD) degree with nervous system – Plaques, as the scarring result ofor MSother a focus on brain-behavior relationships, disease activity. who diagnoses and treats emotional disorders and/or conducts research, and MEMORY – The ability to recall information. There are several types is permitted in some states to prescribe of memory, such as the ability to recall medication. Some psychologists events from the immediate past or specialize in neuropsychology. from long ago, as well as the ability to RELAPSING-REMITTING MS – The most common disease course— activities, such as tying a shoelace or drivingrecall sequences a car. for performing certain attacks of new or increasing neurologic symptoms.is characterized These by attacks—also clearly defined MOOD how a person is feeling emotionally at called relapses or exacerbations— any given – A time. temporary It may changestate that as reflectsa result are followed by periods of partial or of external events, thoughts or physical complete recovery (remissions). During concerns. remissions, all symptoms may disappear, or some symptoms may continue MRI – Short for magnetic resonance and become permanent. However, imaging, an MRI is a test that uses a there is no apparent progression of the disease during the periods of the brain, spinal cord or other parts of remission. At different points in time, themagnetic body. It’sfield currently to produce the an most image reliable of RRMS can be further characterized as means of detecting MS lesions. either active (with relapses and/or PROGRESSIVE MS – In very evidence of new MRI activity) or not general terms, refers to MS that gets progressively worse over time, without relapses and remissions. periodactive, asof welltime as following worsening a relapse) (a confirmed or increasenot worsening. in disability over a specified PSEUDOBULBAR AFFECT – A condition in which people experience involuntary TALK THERAPY – A general term for a bouts of uncontrollable laughing or crying that are unrelated to their mood. during which people may discuss their This occurs in approximately 10 percent emotionsrange of techniques and behaviors. used in counseling, of people with MS.

30 | MOOD CHANGES IN MULTIPLE SCLEROSIS GLOSSARY | 31 Published in partnership with:

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