Anxiety Overview:

Anxiety disorders among multiple sclerosis patients are often undetected or overlooked in the treatment of MS.  It has been estimated that up to 50% of patients endure some levels of anxiety from mild to quite severe.  Research has suggested that anxiety disorders appear to be more prominent early in the disease and is often accompanied by depression though people who endure life with MS may experience anxiety throughout the course of the disease.

Tragically the combination of severe and severe anxiety create an emotional toxic mix that has resulted in MS having some of the highest rates of suicide among chronic diseases.  It is important for patients who are experiencing chronic depression and anxiety to reach out to their health care team as treatments are available to help the quality of life and help resolve these emotions.

There is no scientific evidence that anxiety is directly related to physical disease processes but rather the effects and impacts of MS create an emotional state that drive’s a person towards anxiety.  In the similar context, people who live with multiple sclerosis often have higher rates of bipolar disorder which may be connected to physical disease processes.  The reality is, science just does not know at this point in time.

As with many diseases, alcohol consumption may increase anxiety levels.

If you or a loved one living with multiple sclerosis have bout’s of anxiety OR DEPRESSION it is important to communicate with your healthcare team and consider an appointment with a mental wellness professional.  Depression is often accompanied by anxiety however the anxiety side of the emotions are seldom announced and thus go unaddressed.

Multiple Sclerosis can present many challenges over the course of the disease that while may not be directly causal by disease activity, emotions are quite real and thus need to be addressed and navigated with a qualified mental wellness professional.

It is NOT a good idea generally to have a neurologist assess a patient’s mental wellness solely but instead, the patient should have a care team to best manage and mitigate the physical and emotional aspects of multiple sclerosis.

There are many mechanisms to help cope with anxiety from medications to social interactions or a variety of activities.  It is important to acquire an accurate assessment of you or your loved ones MS to create a strategy to help manage the disease.  For example, if a patient is enduring severe pain attempting to manage other physical or emotional symptoms becomes very difficult.  Thus the first priority in symptoms management may be working towards eliminating pain and exploring what options exist and systematically trying them to see which works best towards quality of life.

Many multiple sclerosis patients require comprehensive care and thus a comprehensive care team need be assembled, neurologist, psychologist, psychiatrist, physical therapist, occupational therapist, social coordination, perhaps even a dietician.  Point being,  best outcomes, and quality of life depend on the quality of care.  Do not settle for less.

General Categorization of Anxiety Disorders:

  • Panic disorder. People with this condition have feelings of terror that strike suddenly and repeatedly with no warning. Other symptoms of a panic attack include sweating, chest pain, palpitations (unusually strong or irregular heartbeats), and a feeling of choking. It can feel like you’re having a heart attack or “going crazy.”  If you feel you may be having a panic attack with heart pain do not hesitate to call your emergency service.
  • Social anxiety disorder. Also called social phobia, this involves overwhelming worry and self-consciousness about everyday social situations. The worry often centers on a fear of being judged by others or behaving in a way that might cause embarrassment or lead to ridicule.
    • Specific phobias. These are intense fears of a specific object or situation, such as heights or flying. The level of fear is usually inappropriate to the situation and may cause you to avoid common, everyday situations.
  • Generalized anxiety disorder. This is excessive, unrealistic worry and tension, even if there’s little or nothing to provoke the anxiety.

Symptoms:

Generally speaking most anxiety disorders present with both psychological and physiological symptoms.  Generalized anxiety disorder (GAD) is thought to be most common in MS patients followed by obsessive-compulsive disorder (OCD) however, panic attacks, phobias, anger or rage attacks, sudden bursts of overwhelming emotions also do occur.  Women are at higher risk than men of experiencing anxiety especially if they have a history of depression, social stress or excessive use of alcohol.

Some examples of physiological symptoms include:

  • Trembling
  • Increased heart rate or heart palpitations
  • Dry mouth
  • Shortness of breath
  • Nausea
  • Hot or cold sensations
  • Tingling in fingers or toes
  • Lightheadedness
  • Faintness/fatigue
  • Muscular tension
  • Restlessness
  • Insomnia, specifically difficulty falling asleep
  • Frequent urination

Examples of psychological symptoms include:

  • Chronic unhappiness
  • Frequent worry, guilt, or feeling out of control
  • Indecisiveness
  • Feelings of inadequacy, feeling criticized, or easily embarrassed
  • Rigidity, which is to be inflexible and less willing to make changes
  • Hostility, feeling anger toward others
  • Repeating certain behaviors or ruminative thoughts (pondering over something repeatedly)
  • Over-anticipating things
  • Excessive concern with physical health
  • Negative thinking about the future
  • Racing thoughts

Diagnosing Anxiety:

Numerous screening tools and/or questionnaires can be used to assess levels of patient anxiety.

These include:

  • The Hamilton Anxiety Scale (HAS)
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  • Hospital Anxiety and Depression Scale (HAD)
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  • State-Trait Anxiety Inventory (STAI)
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The Hamilton Anxiety Scale (HAS) & Hospital Anxiety and Depression Scale (HAD) rate 14 anxiety aspects and about seven minutes to administer and complete.

The State-Trait Anxiety Inventory (STAI) has 40 self-reported items towards anxiety.

Feel free to download copies, fill them out, bring them to your next visit to your neurologist and/or general practitioner or even distribute them at your local support group or online.

Those who are anxious typically know that they are, however, if depression is also present, it is often assumed that depression takes precedence or that its treatment may lower the anxiety. Often, if you suffer from both depression and anxiety, a different kind of medication is needed, such as one of the SSRIs that treats both disorders.

Treating Anxiety:

 There are numerous prescription medications to help cope with anxiety but as noted above anxiety is often coupled with depression.  In the clinical environment, there is often an assumption made that treating depression will reduce anxiety and thus treating the depression supersedes treating the anxiety.  In some patients this is true and others not.  Medications called “selective serotonin reuptake inhibitors (SSRIs)” can address both disorders.  It is very important that a proper, professional assessment of the patient’s emotional wellbeing take place.  In multiple sclerosis, a MS aware psychologist or psychiatrist can literally be the difference between the good quality of life versus emotional misery.
  • Medication: Drugs used to reduce the symptoms of anxiety disorders include many antidepressants, certain anticonvulsant medicines and low-dose antipsychotics, and other anxiety-reducing drugs.
  • Psychotherapy: Psychotherapy (a type of counseling) addresses the emotional response to mental illness. It is a process in which trained mental health professionals help people by talking through strategies for understanding and dealing with their disorder.
  • Cognitive-behavioral therapy: This is a particular type of psychotherapy in which the person learns to recognize and change thought patterns and behaviors that lead to troublesome feelings.
  • Dietary and lifestyle changes
  • Relaxation therapy

Medications:

For some, an antidepressant, such as certain selective serotonin reuptake inhibitors (SSRIs) that work on depressive and anxious symptoms, is indicated. Examples include Celexa® (citalopram) or Lexapro® (escitalopram). Additionally, Effexor® (venlafaxine) or Cymbalta® (duloxetine hydrochloride) may also be considered. Specific anti-anxiety medications like Valium® (diazepam) may work on an as-needed basis, but these tend to have short half-lives. This means that they work only for short periods of time or to aid sleep, but they are not designed for long-term use.

Lowering anxiety requires many steps that include learning stress-reduction techniques.

Psychotherapy, Cognitive Behavioral and Relaxation Therapies:

These techniques include:

  • Interrupting and changing both “all or nothing” types of thinking, as well as catastrophic thinking, where an individual dwells on the worst possible outcomes
  • Incorporating exercise into lifestyle where possible
  • Breaking down fearful concerns into manageable, “present-oriented” solutions, aimed at resolving the issues at hand
  • Problem-solving one step at a time
  • Allowing and normalizing feelings of loss of control, while allowing the effect of any losses to be grieved and expressed

Meditation, Yoga, Tai Chi, Guided Imagery or activities such as adult coloring, video gaming, crafting are but a few techniques to help self-manage anxiety but should not be considered as a complete substitute for seeking professional medical advice from a mental wellness professional.

Prioritizing tasks, using lists allow for better control over potential stressors in daily living with multiple sclerosis.  Many patients have found developing a more spiritual connection via religion in life has had a significant calming effect on anxiety as well as helping numerous other mental wellness aspects of MS.

Lifestyle:

Alcohol, smoking cigarettes or e-cigarettes and caffeine (coffee, tea, cola, soft drinks, energy drinks and chocolate) should be avoided when coping with anxiety symptoms.

Diet and dietary supplements can also impact emotional wellness.  Supplementation and/or dietary aspects of life should be discussed with your neurologist, mental wellness professional and preferably a skilled dietician so as the patient’s current nutritional requirement are met but not exceeded to a point resulting in physical or emotional distress.

Ask your doctor, pharmacist or dietician before taking any over-the-counter medicines, supplements or herbal remedies. Many contain chemicals that can increase anxiety symptoms.

MS is a complex disease and often needs a complex team oriented health care focus.  Unfortunately, many patients and families do not pursue or attempt demand more granular professional management of their disease.  In recent years it has been clearly shown that best case long-term outcomes in multiple sclerosis are often directly related to a more personalized wellness regimen.

Seeking a Mental Wellness Professional:

Multiple sclerosis is a complex chronic disease and a mental wellness professional should be in every patient’s quality of life toolkit.

Some questions to ask of potential mental wellness professionals (psychologist and/or psychiatrist) are:

  1. Do you have experience working with anxiety, depression and emotional characteristics of MS patients?
  2. What types of therapies do you use? (Cognitive therapy, psychodynamic therapy, group therapy, etc.)
  3. Can you work closely with my current care team?
  4. Are your services covered by my insurance?
  5. Do you employ specific relaxation techniques such as guided imagery, meditation, biofeedback, hypnotherapy, and eye movement desensitization and reprocessing (EMDR) to lower stress and anxiety reactions? (EMDR is a newer, less-traditional type of psychotherapy that works to reduce emotional problems.)
  6. Do you also work with care partners and family members?
  7. How do you feel about using medications to help treat anxiety?