NEEDLE PHOBIA AND DMMs
The availability of disease-modifying medications (DMMs) is a big plus for patients but not if they are squeamish about self-administration. All DMMs are administered by injection. This fact adds to the anxieties with which affected patients wrangle. This is not a trivial problem, according to Mohr. He pointed out that about 7% to 22% of the general population have needle and injection phobias and far more persons—regardless of fearing needles per se—have difficulty injecting themselves.
Problems with self-injection appear to be particularly prevalent in patients with MS. Mohr found that half of patients for whom interferon ß 1a (IFN-ß-1a; Avonex), which requires weekly intramuscular injections, was prescribed were unable to inject themselves.3 Ellen Lathi, MD, director of the MS Center at Caritas St Elizabeth's Medical Center in Boston, confirmed the magnitude of this problem. She told Applied Neurology that 90% of her patients have trouble with self-injection. She added that fear of self-administration of DMMs is a major barrier to therapeutic adherence.
Lathi and her staff help patients get around their fears of DMM self-administration by providing injection training. When patients cannot inject themselves, family members and friends are enlisted and trained to administer the injections. As a last resort, Lathi has patients visit the clinic to receive injections.
Despite its restrictions and safety concerns, Lathi and Rizvi both remarked that they welcome the newly approved agent, natalizumab (Tysabri), which is administered once a month by . According to them, it provides an alternative for the many patients who cannot self-administer—or do not have someone available to administer—DMMs. Still these and other specialists agree that self-administration of MS medication is preferable to other therapeutic interventions, in part because of convenience and patient independence.
Cognitive-behavioral therapy
Recognizing the extent to which self-injection anxiety can deter patients' from receiving DMMs, Mohr, Cox, and their colleagues have developed a cognitive- behavioral treatment (CBT) program that empowers patients to self-administer DMMs. The treatment program uses a set of established techniques shown to alleviate a wide range of phobias. These include relaxation training, systematic desensitization (gradual exposure to the injection experience), and cognitive restructuring (identifying and helping the patient correct worrisome thoughts and misconceptions).4
The treatment works. In a pilot study, psychologists treated 8 patients for whom IFN-ß-1a was prescribed who were unable to give themselves intramuscular injections.3 After 6 weekly sessions, 7 (88%) of the 8 study participants were able to inject themselves. The eighth was able to do so during an additional seventh session. At 3-months' follow-up, 7 of the 8 patients continued to inject themselves.
In a second controlled study involving 30 patients, nurses at an MS center provided CBT.4 Controls received 6 weekly phone sessions that included instruction in self-injection, management of IFN-ß-1a adverse effects, and muscle relaxation, a protocol similar to the telephone education and support program offered by the manufacturer of IFN-ß-1a.
At the end of treatment, only 3 (25%) of the 12 patients who completed the control intervention were able to inject themselves, but 8 (73%) of the 11 who completed the CBT program were able to do so (P < .02).
Cox gives workshops on how to implement a CBT program. On the basis of the initial studies and the feedback she gets from the MS centers and clinics that offer the program, Mohr conjectures that close to 100% of the patients who have received CBT from clinical psychologists and about 70% who have received the treatment from nurses can successfully inject themselves. The counselor's manual and the accompanying patient workbook can be obtained from the University of California, San Francisco, Behavioral Medicine Research Center's Web site at: www.ucsf.edu/bmrc/researchprograms/MSinjection.htm.
DOES STRESS CAUSE MS?
Charcot and other clinicians of his era noted that various types of adversity precede the onset of MS, and many of Charcot's patients believed their affliction was the consequence of "grief and vexation."5 Although neurologists today are less likely than their forebears to assign an etiologic role to stressful events, most patients with MS continue to believe that psychological stress can cause or exacerbate MS.6 They may be right. A number of articles—mostly from the 1950s when psychological stress was implicated in everything from rheumatoid arthritis to peptic ulcer— document cases of patients who experienced psychological trauma preceding the onset of MS and MS exacerbations. The emotional "precipitants" covered the gamut of human troubles from illegitimate pregnancy to failed love affairs to financial reversal.
The consensus among early investigators was that distress may contribute to MS exacerbations and may contribute to the initial event. Indeed, after describing several patients in whom MS seemed to be precipitated by emotional distress, one commentator stated that "there is evidence, however inconclusive, pointing to the fact that this appalling disease is a somatic reaction to intolerable mental conflict."7 Overall, investigators acknowledged, that in the absence of controlled studies, their conclusions were tentative.
Case-control and prospective studies began to appear in the 1980s, but their results are less than conclusive. A 1999 narrative review of these studies concluded that although a "relationship between antecedent stress and either MS onset or MS exacerbation is considered possible . . . the prospective data are insufficient to establish any such relationship with reasonable medical certainty."8 In 2004, Mohr and colleagues reported the results of a of 14 controlled studies examining the relationship between stressful life events and MS exacerbations. They found that stressful life events increased the risk of MS exacerbation but only to a modest degree (effect size, d = 0.53).6
