Let's Open Up the Subject of "Personality Change"
Eighty percent of the people who have MS and experience some psychological problem can cope and/or change and get on with their lives.
"1 cry a lot." "My friends say I've gotten moody." "I feel like a Doctor Jekyll and Mr: Hyde." "My family is ready to throw me out.
"Personality" is a question of enormous interest to our readers. But it is not a question that has a simple answer, primarily because "personality change" or as it should be more accurately referred to, psychological change, is not a simple topic. It covers a lot of territory, much of it still uncharted. Moreover, it's a subject often complicated by a highly charged emotional atmosphere, overlapping symptoms and loose terminology. Depending on whom you ask, psychological changes can mean anything from a declining IQ to ordinary Monday blues and crankiness.
Neurologists say that demyelination can cause structural changes in the brain which in turn can affect one's cognitive and emotional responses. But relatively little is known about exactly what damage causes which symptoms or whether there always is damage. At the same time research has shown there can be emotional responses, not structural in nature, but still connected to MS. "It's a murky area," one expert says. let's begin to dispel a bit of the murkiness with a brief overview of some of the facets of psychological change.
Cognitive means having to do with the mind, the intelligence. Cognitive changes i.e. changes in the ability of the intelligence to function - can sometime be attributed to MS plaques in the brain. Such changes can result in impairment of verbal fluency, a tendency to repeat oneself and some memory loss. Many authorities have been hesitant to make definite statements about cognitive changes and MS because estimates in the past fell in the meaninglessly wide range of 2-72 percent.
However, one recent study in the Netherlands showed that about 17.5 percent of MS subjects with slight physical disabilities had mild cognitive impairments. And an Israeli investigation by Kahana & Associates determined that the probability that an individual will have intellectual changes during the course of MS may be as high as 20-30 percent.
Fortunately, these impairments in MS do not extend to a general breakdown of cognitive functions, such as is seen in Alzheimer's Disease. Individuals with MS rarely have difficulty with basic speech, reading and writing, or even performing mathematical computations.
Most likely to be affected are short-term memory- such as what you ate for breakfast or read in the morning paper -and conceptual reasoning - the ability to solve complex and abstract problems that require prolonged concentration and organizational abilities.
Cognitive change has been a hush-hush phrase for a long time. Physicians have been hesitant to discuss it for fear that their patients will panic. Dr. Randolph Schiffer, assistant professor of neurology and psychiatry at Strong Memorial Hospital, Rochester, NY, comments that in one study neurologists underestimated cognitive impairments in people with MS by 50 percent. Other physicians are not even aware of the work being done in this area. In any case, as with diagnosis, patients seem to indicate they would rather know.
Jack Petajan, M.D., professor of neurology and director of the MS Clinic, University of Utah, explains matter-of-factly to his patients with such symptoms that "thought processes may slow down or memory may be somewhat delayed, just as nerve impulses mediating motor function (affecting physical movement and coordination) are slowed." There seem to have been no adverse reactions to his sharing that information.
Emotional Changes: Depression
Depression is a common MS symptom. Dr. Stephen Rao, associate professor of neurology and psychiatry at the Medical College of Wisconsin, says it affects 30-40 percent of individuals with MS. The ques-tion is, is it associated with mild neurological damage and cognitive changes or is it simply an emotional reaction to the limitations and stress of the disease and its physical symptoms?
Dr. Nicholas La Rocca says the "most prominent psychological feature of MS is depression." The assistant professor of neurology at Albert Einstein School of Medicine in New York City, who co-authored two chapters in Dr. Labe Scheinberg's Multiple Sclerosis: A Guide for Patients and Their Families, adds, "What is still hotly debated is whether this depression is a normal reaction to having a chronic, disabling condition, or whether it is a real psychological abnormality. There is also the possibility that certain areas of the brain could influence experience and expression, explaining some cases of depression." So the answer is, "we don't really know yet."
There is still another complicating aspect to depression. Authorities caution that true depression often is confused with the fatigue that many individuals with MS experience. In the case of fatigue, the lethargy lifts, whereas in real depression the lethargy is chronic and is often accompanied by a sense of worthlessness brought on by the limitations that MS can impose. Chronic, lingering depression characterized by irrational, prolonged weeping, indifference, irritability, loss of sleep and listlessness has become "so common among MSers that it is now recognized as a specific symptom of MS," according to Dr. John K. Wolf in his book, Mastering Multiple Sclerosis. Dr. Randall Schapiro, in Symptom Management in Multiple Sclerosis adds that depression often is outwardly expressed as anger. The person with MS "feels betrayed by his own body. The anger alienates others just when support is most needed."
What to do? "Family members and/or therapists can provide encouragement and assistance in becoming active and productive in new ways within the scope of physical ability," says one New York psychiatrist. "It is also helpful if family members refrain from allowing the anger to alienate them. And, with the aid of a therapist, recognition of the constructive role anger can play can help counteract the depression," he says. When other strategies do not work, sometimes medication will. Dr. Wolf recommends amitriptyline, but cautions -obviously - that your own doctor's advice should be followed.
Emotional Changes: Inappropriate Responses:
Outbursts of weeping: "There is a condition of periodic depression-like outbursts of weeping and laughing that usually does not reflect actual sadness and is not depression," La Rocca says. This condition, which has been described as a kind of emotional spasticity, probably results from structural change. It also has been called "emotional incontinence." It generally lasts only a few minutes, or even less, so that a person need not be overly concerned by this phenomenon. Moreover, a study done by Dr. Schiffer shows that there may be some benefit from the use of amitriptyline.
Euphoria: Euphoria usually has little or nothing to do with being happy. It happens in two ways: In one situation, individuals appear optimistic or even laugh when actually they feel depressed. In the other situation, the person may really feel optimistic, even if the emotion appears to others as exaggerated or inappropriate, considering the individual's difficult situation. "This symptom is found in only a very small minority of patients," Rao says. "Euphoria typically accompanies severe brain damage."
Here the questions arises what is euphoria and what is optimism? Where does one end and the other begin? The question is when is optimistic too optimistic. Unrealistic optimism often accompanies a loss of intellectual function," La Rocca says. "In some cases it may be an extreme coping strategy, but most clinicians regard it as a physical change in the brain related to MS. It's also possible for this kind of euphoria to flip easily into depression."
Schiffer, on the other hand, states that real optimism, even if sometimes it is deemed inappropriate, "can protect individuals from some of the despair and pain they would otherwise be subjected to as the disease advances." It helps them to maintain their activity and productivity.
There are other behaviorial changes that appear to be symptoms of simple emotional problems, but they can be indicative of a serious structural change. Fortunately, such severe structural changes affect only about five percent of those with MS, according to Dr. Rao. And just as other symptoms of MS can shift into remission, these structurally based changes have been known to improve on their own.
So Where Does All This Leave US?
If we add up the percentages of people with MS who have suffered some kind of severe personality change due to neurological or structural reasons, we get a very small percentage. That means the vast majority of people with personality and behavioral problems are reflecting emotional and psychological stress. (Garden variety irritability, impatience, occasional listlessness even frequent blues all fall into this category.) And that means most people are in a position to do something about their situation.
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