Journal of Psychosomatic Research, Vol. 35. No. 1, pp. 3747. 1991. Printed in Great Britain.
EMOTIONAL MULTIPLE
0022 3999/91 $3.00+ .00 ~7 1991 PergamonPressplc
STRESS
SCLEROSIS
AND
COPING
IN
(MS) EXACERBATIONS
SHARON W A R R E N , K . G . W A R R E N * a n d
RHONDA COCKERILLt
(Received 14 March 1990; accepted in revised form 26 June 1990)
Abstract--Ninety-five pairs of MS patients in exacerbation and remission were compared on emotional stress in the previous three months. Patients in exacerbation scored higher on emotional disturbance and intensity of stressful events than patients in remission, but lower on frequency of compensating uplifts. There was also a tendency for more patients in exacerbation than remission to favour emotion-focused coping techniques over problem-solving or social support. Whether patients building to an exacerbation over-react to various events or unresolved emotional stress precipitates exacerbations, MS patients might benefit from counselling in stress reduction techniques.
INTRODUCTION
APPROXIMATELY 90% of multiple sclerosis (MS) patients experience a disease course which is characterized by relapsing and remitting symptoms. In many cases, exacerbations can be attributed to active central nervous system plaques, either the formation of new plaques or the reactivation of old ones. On the other hand, there is sometimes evidence of the disease process in the absence of clinical manifestation. Lesions seen at autopsy often greatly outnumber those that have been localized on the basis of patients' signs and symptoms of neurologic dysfunction [1]. Even more puzzling is the fact that autopsies have revealed lesions in asymptomatic patients which, based on their location, would have been especially likely to give rise to abnormal signs [2, 3]. The introduction of evoked response studies has now disclosed the presence of asymptomatic lesions in living MS patients [4-7]. The computerized tomography scan [8] and magnetic resonance imaging [9, 10] have also shown lesions in MS patients that cannot be correlated with current or previously experienced symptoms. These observations raise important questions about the clinical course of multiple sclerosis. Coupled with evidence that the recurrence of old symptoms is more common than the appearance of new ones [11], they suggest that lesions can be activated or remain dormant depending upon the presence or absence of precipitating factors. If precipitating factors could be identified, then it might be possible to prevent MS exacerbations either by limiting exposure to them or interfering with the mechanisms through which these variables work. The purpose of this study was to determine whether emotional stress is associated with MS relapses. If such a relationship were observed, it might support attempts to reduce somatic symptoms through psychotherapeutic techniques aimed at controlling emotional stress. Address correspondence/reprint requests to: Dr Sharon Warren, Associate Professor, Faculty of Rehabilitation Medicine, R o o m ~ 1 1 5 S.W. Trailers, Corbett Hall, University of Alberta, Edmonton, Alberta, Canada T6G 2El. *Director, Multiple Sclerosis Research Clinic, University of Alberta, Edmonton, Canada. tAssociate Professor, Department of Health Administration, University of Toronto, Toronto, Canada. 37
38
SHARON WARREN et al. L I T E R A T U R E REVIEW
There are some reports of studies examining a possible link between emotional stress and MS exacerbations, whose results are conflicting. In 1950, Brickner and Simons [12] studied 50 MS patients for evidence that stress had precipitated exacerbations. Only 14% of patients reported that exacerbations had occurred during or following a period of unusual stress, but no validated stress measurement tools were used and there was no control group. In another uncontrolled study, McAlpine and Compston [13] reported that 33% of MS patients in their series experienced temporary exacerbation of symptoms during or immediately following periods of stress. In 1951, Pratt [14] found that 25% of MS patients reported an emotional disturbance anteceding relapses. He also observed a statistically significant difference between the proportion of MS patients and neurological controls who reported that certain emotional stimuli precipitated relapse within minutes of their occurrence; although there was no evidence of any difference between the two groups in terms of the occurrence of relapse following prolonged emotional stress. Pratt used no validated measures of stress and gave little information on the nature of his controls, so that their appropriateness (e.g. on potential for relapses) is difficult to judge. In 1986, Rabins et al. [15], asked MS patients to fill in monthly life events' diaries over a 1-yr period. Of the 87 patients who participated, 23 experienced exacerbations~ To determine whether increased stressful events commonly preceded an exacerbation, the researchers compared relapsing patients' scores in the month during which they reported an exacerbation to their mean scores for all previous months. They found no significant difference. However, the life events' scores of patients experiencing an exacerbation were not compared to those of patients in remission. It is possible that patients in exacerbation had been experiencing a sustained high level of stressful events over a period of months, so that a "patient as their own control' approach would not show a change in scores. Alternatively, stressful events may not be as important as their impact. Although they also collected monthly emotional disturbance scores using Goldberg and Hillier's General Health Questionnaire ( G H Q ) [16], Rabins e t al. did not examine the pattern of relapsing patients' scores on this variable. Such a comparison may have been useful. In a previous study using the same methodology, Dalos et al. [17] observed that emotional disturbance measures ( G H Q scores) completed by patients in the month when they experienced an exacerbation were higher than measures completed during months when they were in remission. In contrast to Dalos et al., Logsdail e t al. [18] found no difference between MS patients in exacerbation versus remission on psychiatric morbidity, although there was a trend towards higher anxiety in the relapsing patients. Logsdail e t al. did not use the G H Q to measure psychiatric symptomatology in their cross-sectional study; instead they used the Clinical Interview Schedule (CIS). Despite the lack of an association between exacerbations and psychiatric sympatomatology, these researchers did observe that morbidity was significantly correlated with patients' perception of stress and lack of social support, regardless of whether they were in exacerbation or remission. In their study Logsdail e t al. included only a total of 76 MS patients (28 in exacerbation/44 in remission), so that their power to detect an association between exacerbation and morbidity may have been limited.
Stress and coping in MS
39
Franklin et al. [19] followed 55 MS patients with relapsing-remitting MS for an average of 20 months, collecting information on the occurrence o f stressful life events every four months. Patients who reported significant negative or uncontrollable events were 3.7 times more likely to have an exacerbation than those free of such events. Finally, Grant et al. [20] compared recently diagnosed MS patients to controls on the occurrence of emotional stress prior to onset. They used the sophisticated Life Events and Difficulties Schedule [21], and found a significant excess of marked life stress in the six months previous to onset in MS patients. Although these researchers did not compare patients in exacerbation versus those in remission, they observed that the rate o f recent marked stress among patients in exacerbation was similar to the rate reported by patients experiencing their first attack (75% and 78% respectively). They concluded that environmental stress may have a similar importance in the precipitation of relapses and initial episodes. METHODS Subjects
All patients who had an appointment at the University of Alberta MS Research Clinic over a 2-yr period were considered for this study. In order to qualify, they must have been diagnosed as clinically definite by the director, using the criteria of Poser et al. [22], and had their disease course classified as relapsing retaining in nature. Patients who met these criteria and agreed to participate were referred to the study by the director as: (1) being in the midst of an exacerbation; or (2) having been in remission for at least six months, but attending the clinic for some other reasons like a regular check-up. Patients who were currently in remission, but had had a relapse in the previous six months, were excluded from the study. Exacerbations were defined as the sudden appearance of a symptom typical of multiple sclerosis, which m a y have been new to participants or experienced during a previous relapse. The director did nothing to screen patients for their stress levels prior to referring them to the study. Ninety-five per cent of patients who qualified agreed to participate, indicating little opportunity for response bias. Data collection procedures
Pateints were interviewed immediately following their medical appointment. Some basic demographic data and disease history information was recorded, including: age, sex, age at MS onset, typical annual frequency of exacerbations, most c o m m o n relapse symptom, and level of disability. Besides being asked about emotional stress, patients were asked about other lifestyle patterns and experiences so that they would be 'blinded' to the focus of the study. Distractors included were: (l) number of infections experienced, or exposed to in the home; (2) number of traumatic events, such as surgery, dental work and accidents; (3) typical diet, alcohol intake, smoking habits, medication, physical stress due to work or exercise, and any notable change in these patterns; (4) occurrence of other health-related conditions like allergy, pregnancy, or unusual fatigue. The use of fatigue as an independent variable might be questioned. Some researchers view fatigue as a neurological s y m p t o m and therefore part of an exacerbation. On the other hand, some investigators have suggested that fatigue can be a precipitating factor. For example, relapses experienced postpartum have been attributed to the fatigue involved in bringing a new baby home from the hospital [23]. Relapsing patients were asked about their lifestyle patterns and experiences during the three months prior to exacerbations, while patients in remission were asked about the three m o n t h s prior to the interview date. It was emphasized that responses should refer to the previous three-month period, not current patterns and experiences although in some instances they would be similar. The decision to question patients about their lifestyle patterns and experiences during the previous three months was somewhat arbitrary. Other researchers, including McAlpine and C o m p s t o n [13], have asked patients about the three m o n t h s prior to their last attack in studies of precipitating factors. However, Rabins et al. [15] used a one-month period based on Thygesen's work [11] and Pratt's study [14] suggests a period of minutes would be appropriate. All patients were interviewed in the offices of the MS Research Clinic by two trained interviewers, who alternated between patients in exacerbation and remission. It was not feasible to prevent interviewers from knowing the condition of patients. However, the interviewers were informed that there was conflicting
40
SHARON WARREN et al.
evidence on the role of all factors about which patients were being asked, including stress, in MS exacerbations. M e a s u r e m e n t s in emotional stress
Patients initially responded to Goldberg and Hillier's General Health Questionnaire-28 [16], which taps emotional disturbance. This questionnaire contains items on somatic symptoms, anxiety, social dysfunction, and depression. Respondents indicate to what degree they have been bothered by any of these symptoms on a four-point Likert scale from 'not at all" to ' m u c h more than usual'. Stressful events were measured using the Hassles' Scale [24]. This tool records the irritating, frustrating and distressing minor problems which people face in the normal course of living. Respondents check which hassles they have experienced and indicate their intensity on a three-point scale ('mild, moderate or severe'). Two s u m m a r y scores are generated; the number of hassles experienced; and their average intensity which is calculated by dividing the sum of the three-point intensity ratings for each checked hassle by the number of hassles experienced. Hassles have been found to predict overall health (chronic, diagnosed health problems plus somatic symptoms}, somatic symptoms alone, and psychological symptoms, better than life events [24-27]. The Uplifts' Scale [24] was used to measure the number of uplifts which a patient had experienced and their perceived intensity, using the same format as the Hassles' Scale. The assumption is that pleasant events may compensate for negative ones. Since coping is generally viewed as playing a central role in people's adaptation to stress, the Ways of Coping Checklist [28] was used to assess the coping techniques of MS patients in this study. It contains items describing a wide variety of strategies which people use to deal with taxing events; these items form eight subscales which represent: one problem-solving approach; six emotion-focused techniques (wishful thinking, detachment, accentuating the positive, self-blame, tension reduction, and keeping to self); and one mixed strategy of seeking social support. Subjects respond to each item using a four-point scale from 'does not apply" to 'used a great deal'. Subscale means can be compared to determine whether subjects emphasize problem-solving, emotion-focused coping or social support, in reference to a specific encounter. Multiple sclerosis patients in this study were asked to describe three recent events, one implying mild, one moderate and one severe stress. Coping techniques are not necessarily a reflection of coping effectiveness. Both problem-solving and emotion-focused strategies can be successful depending upon the nature of a stressful situation [29]; people often use problem-solving to manage situations over which they have some control, and emotion-focused coping to deal with unchangeable circumstances. However, at the time the study began, there was no validated coping effectiveness measure available so that the focus had to be on techniques.
RESULTS
Post-matching procedure Patients in exacerbation versus remission were post-matched on gender and age (within 5 yr), before the data were analyzed. Patients were also matched on race; all pairs but one were Caucasian. This procedure resulted in 95 pairs at the completion of the data collection period.
Group characteristics Because of the post-matching procedure, there were no differences between the two groups on gender and age distribution. Overall, females outnumbered males by 2.3 : 1; the average age of patients in exacerbation was 34 and in remission 36. A comparison of the two groups indicated that there was no significant differences on disease features. Onset age was recorded as less than 20, 20 39 or 40 plus; the majority of patients in each group reported onset between 2 0 - 3 9 y r of age (71% and 81% respectively). N u m b e r of previous relapses was divided by duration of illness to calculate average relapse rate (0.80 and 0.62). Most common relapse symptom was recorded as: visual, sensory, motor, other or combination; the majority in each group reported sensory problems as their most common relapse symptom (42% and 36%). Finally, disability status was recorded as: walking without aids, walking with aids,
Stress and coping in MS
41
or in a wheelchair; the majority of patients both in exacerbation and remission were able to walk unaided (74% and 83%). Consequently, none of these factors should have had a bearing on differences in emotional stress observed between these two groups. E m o t i o n a l stress and exacerbations
Most of the statistically significant differences between patients in exacerbation versus remission were on emotional stress. Table I shows that more patients in exacerbation (56.8%) scored five or above on the G H Q than patients in remission (28.4%). Rabins and Brooks [30] have previously used five as the cut-off score to diagnose emotional disturbance in MS patients, with 92% accuracy. In a subsequent study, Rabins et al. [15] found that 47% of MS patients scored five or above on the G H Q . The relative risk of an exacerbation associated with a score of five or above among patients in this study was 3.1. There was no difference between the two groups on frequency of daily hassles. However, the perceived intensity of hassles was greater among patients in exacerbation. Table II shows that more patients in exacerbation (52.6%) scored above the whole group mean on perceived hassles' intensity than patients in remission (34.7%). The risk associated with an increased hassles' intensity was 2.2. It may be important to note that the whole group mean was only 1.39 (SD = 0.38) of a possible 3, indicating relatively mild stress. In fact it is slightly below what Kanner et al. [24] found in a community sample. 1.47 (SD = 0.39); but this difference is not so great that it is likely to be significant, The mean number of hassles for the MS group was 22.1 (SD = 15.4), also similar to Kanner et al.'s sample at 20.5 (SD = 17.7). The fact that hassles' intensity but not frequency was related to exacerbations may support the idea that the perceived impact of events is more important than their actual number. TABLE I.--COMPAR1SONOF PATIENTSIN EXACERBATION/REMISSION ON GENERAL HEALTH QUESTIONNAIRESCORE MS patients In exacerbation In remission % Score of 0 4 Score of 5 plus Missing*
N 43.2 56.8 0.0
41 54 0
%
N
67.4 28.4 4.2
64 27 4
z~ = 12.9, 1 df, p < 0.001. *Not included in analysis. TABLE
II.
COMPARISON OF PATIENTS IN EXACERBATION/ REMISSIONON HASSLES' INTENSITY MS In exacerbation
Scored below mean ( < 1.39) Scored above mean ( ~>1.39) Missing*
patients In remission
%
N
%
N
47.4
45
64.2
61
52.6
50
34.7
33
0.0
0
1.1
1
;(c2 = 5.2, l df, p < 0.05. *Not included in analysis.
42
SHARON WARREN et al. TABLE
]I|.-~COMPARISON OF PATIENTS IN EXACERBATION/ REMISSION ON FREQUENCY OF UPLIFTS
MS patients In exacerbation In remission Scored below mean (47) Missing*
% 58.9
N 56
% 44.2
N 42
38.9
37
54.7
52
2.2
2
1.1
1
g~ = 3.92, I df, p
EMOTIONAL MULTIPLE
0022 3999/91 $3.00+ .00 ~7 1991 PergamonPressplc
STRESS
SCLEROSIS
AND
COPING
IN
(MS) EXACERBATIONS
SHARON W A R R E N , K . G . W A R R E N * a n d
RHONDA COCKERILLt
(Received 14 March 1990; accepted in revised form 26 June 1990)
Abstract--Ninety-five pairs of MS patients in exacerbation and remission were compared on emotional stress in the previous three months. Patients in exacerbation scored higher on emotional disturbance and intensity of stressful events than patients in remission, but lower on frequency of compensating uplifts. There was also a tendency for more patients in exacerbation than remission to favour emotion-focused coping techniques over problem-solving or social support. Whether patients building to an exacerbation over-react to various events or unresolved emotional stress precipitates exacerbations, MS patients might benefit from counselling in stress reduction techniques.
INTRODUCTION
APPROXIMATELY 90% of multiple sclerosis (MS) patients experience a disease course which is characterized by relapsing and remitting symptoms. In many cases, exacerbations can be attributed to active central nervous system plaques, either the formation of new plaques or the reactivation of old ones. On the other hand, there is sometimes evidence of the disease process in the absence of clinical manifestation. Lesions seen at autopsy often greatly outnumber those that have been localized on the basis of patients' signs and symptoms of neurologic dysfunction [1]. Even more puzzling is the fact that autopsies have revealed lesions in asymptomatic patients which, based on their location, would have been especially likely to give rise to abnormal signs [2, 3]. The introduction of evoked response studies has now disclosed the presence of asymptomatic lesions in living MS patients [4-7]. The computerized tomography scan [8] and magnetic resonance imaging [9, 10] have also shown lesions in MS patients that cannot be correlated with current or previously experienced symptoms. These observations raise important questions about the clinical course of multiple sclerosis. Coupled with evidence that the recurrence of old symptoms is more common than the appearance of new ones [11], they suggest that lesions can be activated or remain dormant depending upon the presence or absence of precipitating factors. If precipitating factors could be identified, then it might be possible to prevent MS exacerbations either by limiting exposure to them or interfering with the mechanisms through which these variables work. The purpose of this study was to determine whether emotional stress is associated with MS relapses. If such a relationship were observed, it might support attempts to reduce somatic symptoms through psychotherapeutic techniques aimed at controlling emotional stress. Address correspondence/reprint requests to: Dr Sharon Warren, Associate Professor, Faculty of Rehabilitation Medicine, R o o m ~ 1 1 5 S.W. Trailers, Corbett Hall, University of Alberta, Edmonton, Alberta, Canada T6G 2El. *Director, Multiple Sclerosis Research Clinic, University of Alberta, Edmonton, Canada. tAssociate Professor, Department of Health Administration, University of Toronto, Toronto, Canada. 37
38
SHARON WARREN et al. L I T E R A T U R E REVIEW
There are some reports of studies examining a possible link between emotional stress and MS exacerbations, whose results are conflicting. In 1950, Brickner and Simons [12] studied 50 MS patients for evidence that stress had precipitated exacerbations. Only 14% of patients reported that exacerbations had occurred during or following a period of unusual stress, but no validated stress measurement tools were used and there was no control group. In another uncontrolled study, McAlpine and Compston [13] reported that 33% of MS patients in their series experienced temporary exacerbation of symptoms during or immediately following periods of stress. In 1951, Pratt [14] found that 25% of MS patients reported an emotional disturbance anteceding relapses. He also observed a statistically significant difference between the proportion of MS patients and neurological controls who reported that certain emotional stimuli precipitated relapse within minutes of their occurrence; although there was no evidence of any difference between the two groups in terms of the occurrence of relapse following prolonged emotional stress. Pratt used no validated measures of stress and gave little information on the nature of his controls, so that their appropriateness (e.g. on potential for relapses) is difficult to judge. In 1986, Rabins et al. [15], asked MS patients to fill in monthly life events' diaries over a 1-yr period. Of the 87 patients who participated, 23 experienced exacerbations~ To determine whether increased stressful events commonly preceded an exacerbation, the researchers compared relapsing patients' scores in the month during which they reported an exacerbation to their mean scores for all previous months. They found no significant difference. However, the life events' scores of patients experiencing an exacerbation were not compared to those of patients in remission. It is possible that patients in exacerbation had been experiencing a sustained high level of stressful events over a period of months, so that a "patient as their own control' approach would not show a change in scores. Alternatively, stressful events may not be as important as their impact. Although they also collected monthly emotional disturbance scores using Goldberg and Hillier's General Health Questionnaire ( G H Q ) [16], Rabins e t al. did not examine the pattern of relapsing patients' scores on this variable. Such a comparison may have been useful. In a previous study using the same methodology, Dalos et al. [17] observed that emotional disturbance measures ( G H Q scores) completed by patients in the month when they experienced an exacerbation were higher than measures completed during months when they were in remission. In contrast to Dalos et al., Logsdail e t al. [18] found no difference between MS patients in exacerbation versus remission on psychiatric morbidity, although there was a trend towards higher anxiety in the relapsing patients. Logsdail e t al. did not use the G H Q to measure psychiatric symptomatology in their cross-sectional study; instead they used the Clinical Interview Schedule (CIS). Despite the lack of an association between exacerbations and psychiatric sympatomatology, these researchers did observe that morbidity was significantly correlated with patients' perception of stress and lack of social support, regardless of whether they were in exacerbation or remission. In their study Logsdail e t al. included only a total of 76 MS patients (28 in exacerbation/44 in remission), so that their power to detect an association between exacerbation and morbidity may have been limited.
Stress and coping in MS
39
Franklin et al. [19] followed 55 MS patients with relapsing-remitting MS for an average of 20 months, collecting information on the occurrence o f stressful life events every four months. Patients who reported significant negative or uncontrollable events were 3.7 times more likely to have an exacerbation than those free of such events. Finally, Grant et al. [20] compared recently diagnosed MS patients to controls on the occurrence of emotional stress prior to onset. They used the sophisticated Life Events and Difficulties Schedule [21], and found a significant excess of marked life stress in the six months previous to onset in MS patients. Although these researchers did not compare patients in exacerbation versus those in remission, they observed that the rate o f recent marked stress among patients in exacerbation was similar to the rate reported by patients experiencing their first attack (75% and 78% respectively). They concluded that environmental stress may have a similar importance in the precipitation of relapses and initial episodes. METHODS Subjects
All patients who had an appointment at the University of Alberta MS Research Clinic over a 2-yr period were considered for this study. In order to qualify, they must have been diagnosed as clinically definite by the director, using the criteria of Poser et al. [22], and had their disease course classified as relapsing retaining in nature. Patients who met these criteria and agreed to participate were referred to the study by the director as: (1) being in the midst of an exacerbation; or (2) having been in remission for at least six months, but attending the clinic for some other reasons like a regular check-up. Patients who were currently in remission, but had had a relapse in the previous six months, were excluded from the study. Exacerbations were defined as the sudden appearance of a symptom typical of multiple sclerosis, which m a y have been new to participants or experienced during a previous relapse. The director did nothing to screen patients for their stress levels prior to referring them to the study. Ninety-five per cent of patients who qualified agreed to participate, indicating little opportunity for response bias. Data collection procedures
Pateints were interviewed immediately following their medical appointment. Some basic demographic data and disease history information was recorded, including: age, sex, age at MS onset, typical annual frequency of exacerbations, most c o m m o n relapse symptom, and level of disability. Besides being asked about emotional stress, patients were asked about other lifestyle patterns and experiences so that they would be 'blinded' to the focus of the study. Distractors included were: (l) number of infections experienced, or exposed to in the home; (2) number of traumatic events, such as surgery, dental work and accidents; (3) typical diet, alcohol intake, smoking habits, medication, physical stress due to work or exercise, and any notable change in these patterns; (4) occurrence of other health-related conditions like allergy, pregnancy, or unusual fatigue. The use of fatigue as an independent variable might be questioned. Some researchers view fatigue as a neurological s y m p t o m and therefore part of an exacerbation. On the other hand, some investigators have suggested that fatigue can be a precipitating factor. For example, relapses experienced postpartum have been attributed to the fatigue involved in bringing a new baby home from the hospital [23]. Relapsing patients were asked about their lifestyle patterns and experiences during the three months prior to exacerbations, while patients in remission were asked about the three m o n t h s prior to the interview date. It was emphasized that responses should refer to the previous three-month period, not current patterns and experiences although in some instances they would be similar. The decision to question patients about their lifestyle patterns and experiences during the previous three months was somewhat arbitrary. Other researchers, including McAlpine and C o m p s t o n [13], have asked patients about the three m o n t h s prior to their last attack in studies of precipitating factors. However, Rabins et al. [15] used a one-month period based on Thygesen's work [11] and Pratt's study [14] suggests a period of minutes would be appropriate. All patients were interviewed in the offices of the MS Research Clinic by two trained interviewers, who alternated between patients in exacerbation and remission. It was not feasible to prevent interviewers from knowing the condition of patients. However, the interviewers were informed that there was conflicting
40
SHARON WARREN et al.
evidence on the role of all factors about which patients were being asked, including stress, in MS exacerbations. M e a s u r e m e n t s in emotional stress
Patients initially responded to Goldberg and Hillier's General Health Questionnaire-28 [16], which taps emotional disturbance. This questionnaire contains items on somatic symptoms, anxiety, social dysfunction, and depression. Respondents indicate to what degree they have been bothered by any of these symptoms on a four-point Likert scale from 'not at all" to ' m u c h more than usual'. Stressful events were measured using the Hassles' Scale [24]. This tool records the irritating, frustrating and distressing minor problems which people face in the normal course of living. Respondents check which hassles they have experienced and indicate their intensity on a three-point scale ('mild, moderate or severe'). Two s u m m a r y scores are generated; the number of hassles experienced; and their average intensity which is calculated by dividing the sum of the three-point intensity ratings for each checked hassle by the number of hassles experienced. Hassles have been found to predict overall health (chronic, diagnosed health problems plus somatic symptoms}, somatic symptoms alone, and psychological symptoms, better than life events [24-27]. The Uplifts' Scale [24] was used to measure the number of uplifts which a patient had experienced and their perceived intensity, using the same format as the Hassles' Scale. The assumption is that pleasant events may compensate for negative ones. Since coping is generally viewed as playing a central role in people's adaptation to stress, the Ways of Coping Checklist [28] was used to assess the coping techniques of MS patients in this study. It contains items describing a wide variety of strategies which people use to deal with taxing events; these items form eight subscales which represent: one problem-solving approach; six emotion-focused techniques (wishful thinking, detachment, accentuating the positive, self-blame, tension reduction, and keeping to self); and one mixed strategy of seeking social support. Subjects respond to each item using a four-point scale from 'does not apply" to 'used a great deal'. Subscale means can be compared to determine whether subjects emphasize problem-solving, emotion-focused coping or social support, in reference to a specific encounter. Multiple sclerosis patients in this study were asked to describe three recent events, one implying mild, one moderate and one severe stress. Coping techniques are not necessarily a reflection of coping effectiveness. Both problem-solving and emotion-focused strategies can be successful depending upon the nature of a stressful situation [29]; people often use problem-solving to manage situations over which they have some control, and emotion-focused coping to deal with unchangeable circumstances. However, at the time the study began, there was no validated coping effectiveness measure available so that the focus had to be on techniques.
RESULTS
Post-matching procedure Patients in exacerbation versus remission were post-matched on gender and age (within 5 yr), before the data were analyzed. Patients were also matched on race; all pairs but one were Caucasian. This procedure resulted in 95 pairs at the completion of the data collection period.
Group characteristics Because of the post-matching procedure, there were no differences between the two groups on gender and age distribution. Overall, females outnumbered males by 2.3 : 1; the average age of patients in exacerbation was 34 and in remission 36. A comparison of the two groups indicated that there was no significant differences on disease features. Onset age was recorded as less than 20, 20 39 or 40 plus; the majority of patients in each group reported onset between 2 0 - 3 9 y r of age (71% and 81% respectively). N u m b e r of previous relapses was divided by duration of illness to calculate average relapse rate (0.80 and 0.62). Most common relapse symptom was recorded as: visual, sensory, motor, other or combination; the majority in each group reported sensory problems as their most common relapse symptom (42% and 36%). Finally, disability status was recorded as: walking without aids, walking with aids,
Stress and coping in MS
41
or in a wheelchair; the majority of patients both in exacerbation and remission were able to walk unaided (74% and 83%). Consequently, none of these factors should have had a bearing on differences in emotional stress observed between these two groups. E m o t i o n a l stress and exacerbations
Most of the statistically significant differences between patients in exacerbation versus remission were on emotional stress. Table I shows that more patients in exacerbation (56.8%) scored five or above on the G H Q than patients in remission (28.4%). Rabins and Brooks [30] have previously used five as the cut-off score to diagnose emotional disturbance in MS patients, with 92% accuracy. In a subsequent study, Rabins et al. [15] found that 47% of MS patients scored five or above on the G H Q . The relative risk of an exacerbation associated with a score of five or above among patients in this study was 3.1. There was no difference between the two groups on frequency of daily hassles. However, the perceived intensity of hassles was greater among patients in exacerbation. Table II shows that more patients in exacerbation (52.6%) scored above the whole group mean on perceived hassles' intensity than patients in remission (34.7%). The risk associated with an increased hassles' intensity was 2.2. It may be important to note that the whole group mean was only 1.39 (SD = 0.38) of a possible 3, indicating relatively mild stress. In fact it is slightly below what Kanner et al. [24] found in a community sample. 1.47 (SD = 0.39); but this difference is not so great that it is likely to be significant, The mean number of hassles for the MS group was 22.1 (SD = 15.4), also similar to Kanner et al.'s sample at 20.5 (SD = 17.7). The fact that hassles' intensity but not frequency was related to exacerbations may support the idea that the perceived impact of events is more important than their actual number. TABLE I.--COMPAR1SONOF PATIENTSIN EXACERBATION/REMISSION ON GENERAL HEALTH QUESTIONNAIRESCORE MS patients In exacerbation In remission % Score of 0 4 Score of 5 plus Missing*
N 43.2 56.8 0.0
41 54 0
%
N
67.4 28.4 4.2
64 27 4
z~ = 12.9, 1 df, p < 0.001. *Not included in analysis. TABLE
II.
COMPARISON OF PATIENTS IN EXACERBATION/ REMISSIONON HASSLES' INTENSITY MS In exacerbation
Scored below mean ( < 1.39) Scored above mean ( ~>1.39) Missing*
patients In remission
%
N
%
N
47.4
45
64.2
61
52.6
50
34.7
33
0.0
0
1.1
1
;(c2 = 5.2, l df, p < 0.05. *Not included in analysis.
42
SHARON WARREN et al. TABLE
]I|.-~COMPARISON OF PATIENTS IN EXACERBATION/ REMISSION ON FREQUENCY OF UPLIFTS
MS patients In exacerbation In remission Scored below mean (47) Missing*
% 58.9
N 56
% 44.2
N 42
38.9
37
54.7
52
2.2
2
1.1
1
g~ = 3.92, I df, p
