Review articleCognitive behavioral therapies and multiple sclerosis fatigue: A review of literature
Introduction
Multiple sclerosis (MS) is a chronic inflammatory and neurodegenerative disease of the central nervous system (CNS) that usually appears between 20 and 40 years of age. From a pathophysiological perspective, the disease is characterized by processes of demyelination and axonal loss. Depending on the location and extent of lesions, patients would experience various symptoms such as motor weakness, sensory deficit, impaired balance, and urinary disturbance, to cite a few. Recent years have seen a growing interest in studying the emotional and cognitive deficits in MS population. In fact, psychiatric comorbidities can affect up to 95% of MS patients at some point during their lifetime [1]. As for cognitive decline, it would occur in up to 65% of patients and may involve any cognitive domain such as working memory, information processing speed, attention, learning and executive function, but also social cognition which has recently gained more interest in MS [2], [3]. Another important debilitating symptom of this disease is fatigue which could affect up to 75–90% of MS patients [4], [5], [6]. No clear definition exists in the literature regarding this complaint which is usually perceived as a ‘lack of energy’, ‘lack of motivation’, ‘tiredness’, ‘exhaustion’ or ‘subjective lack of mental or cognitive energy’ [6]. Most importantly, fatigue can drastically impact patients’ quality of life (QoL) and may result in serious socio-economic difficulties, namely loss of employment [6]. Despite its debilitating nature, the available pharmacological interventions are limited by their modest efficacy and numerous side effects [4], [6]; and this constitutes a real challenge for health care providers in charge of this population. Facing this reality, there was a growing interest in the application of non-pharmacological interventions for the treatment of this symptom. Among these approaches, psychotherapies seem to be of great interest in this context. In particular, cognitive behavioral therapies (CBT), have been tried and could play a role in the management of MS fatigue.
The aim of the current work is to review the available literature on CBT in MS. First, an overview of the pathophysiology of MS fatigue will be provided. This will be followed by a brief definition of CBT along with the relevant studies performed in the context of MS fatigue. Finally, some recommendations will be given for future studies aiming to enhance their outcome in the management of this difficult-to-treat symptom. Pharmacological and other alternative interventions are discussed elsewhere and are beyond the scope of the present work [4], [5], [6], [7], [8].
Section snippets
Pathophysiology of fatigue in multiple sclerosis
Before dealing with the therapeutic options of MS fatigue, it is essential to understand the pathophysiology of this symptom. In recent works, fatigue has been suggested to arise from the underlying pathophysiological mechanisms of the disease itself. In other words, the immune dysregulation, which stands at the origin of MS, would result in demyelination, neurodegeneration and synaptopathy in several brain areas that take part in what was described as the ‘cortico-striato-thalamo-cortical
Study selection
A research was conducted independently by both coauthors according to PRISMA guidelines [14] in order to identify original research articles published till January 2018 in English and French languages about CBT in MS fatigue. Only studies that considered fatigue as the primary outcome were considered for this review. The following key terms were used: (‘multiple sclerosis’ OR ‘MS’) AND (‘fatigue’) AND (‘cognitive behavioral therapy’ OR ‘CBT’ OR ‘cognitive therapy’ OR ‘CT’ OR ‘behavioral
Conclusion
The aim of this review was to analyze the available data regarding CBT in MS fatigue. An inconsistency exists among the available literature regarding the adapted methods where they included patients with primary or secondary fatigue and applied CBT or CBT-components that varied in intensity (6–12 weekly sessions, each 25 to 120-min in duration) and were administered solely or combined with other interventions (i.e. energy effectiveness or phone call support). Interventions were delivered in an
Disclosure
This work did not receive any specific grant. MAC declares no conflict of interest. SSA declares having received travel grants or compensation from Genzyme, Biogen, Novartis and Roche.
References (34)
- et al.
Fatigue in multiple sclerosis – insights into evaluation and management?
Neurophysiologie Clinique/Clin Neurophysiol
(2017) - et al.
The treatment of fatigue by non-invasive brain stimulation
Neurophysiol Clin
(2017) - et al.
Understanding multiple sclerosis fatigue: a synthesis of biological and psychological factors
J Psychosom Res
(2006) - et al.
Fatigue and social impairment in multiple sclerosis: the role of patients' cognitive and behavioral responses to their symptoms
J Psychosom Res
(2006) - et al.
An examination of four models predicting fatigue in multiple sclerosis
Arch Clin Neuropsychol
(2005) - et al.
The science of cognitive therapy
Behav Ther
(2013) - et al.
A pilot randomised controlled trial of an Internet-based cognitive behavioural therapy self-management programme (MS Invigor8) for multiple sclerosis fatigue
Behav Res Ther
(2012) - et al.
Development and preliminary evaluation of a cognitive behavioural approach to fatigue management in people with multiple sclerosis
Patient Educ Couns
(2010) - et al.
Psychiatric presentation in multiple sclerosis: could it be the tip of the iceberg?
Rev Bras Psiquiatr
(2017) Cognition in multiple sclerosis
Curr Opin Neurol
(2011)
Cognition in multiple sclerosis: state of the field and priorities for the future
Neurology
Fatigue in multiple sclerosis: neural correlates and the role of non-invasive brain stimulation
Front Cell Neurosci
Multiple sclerosis fatigue, its neural correlates, and its modulation with tDCS
Fortschr Neurol Psychiatr
A scoping review of rehabilitation interventions that reduce fatigue among adults with multiple sclerosis
Disabil Rehabil
A randomized controlled trial of cognitive behavior therapy for multiple sclerosis fatigue
Psychosom Med
Preferred reporting items for systematic reviews and metaanalyses: the PRISMA statement
BMJ
Reduction in disability in a randomized controlled trial of telephone-administered cognitive-behavioral therapy
Health Psychol
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2022, Annals of Physical and Rehabilitation MedicineCitation Excerpt :Mindfullnes-based Stress Reduction (MBSR) was effective on anxiety, fatigue, and QoL at up to 6 months’ follow-up [58,59]. CBT, MBSR and relaxation therapy were effective regarding fatigue and mental health [39,60]. CBT should not be the only rehabilitation approach [61] and may be combined with non-invasive brain stimulation to achieve a long-term effect on fatigue [39].