BMJ  2004;328:287 (31 January), doi:10.1136/bmj.328.7434.287

Letter

Stress and exacerbations in multiple sclerosis

Whether stress triggers relapses remains a conundrum

The first 150 words of the full text of this article appear below.

EDITOR—The front page of the BMJ of 20 September 2003 carries the title: "Relapse in multiple sclerosis: stressful life events increase exacerbations." Buljevac et al present evidence that psychological stress is associated with a doubling in risk of relapse.¹ Two issues arise.

Firstly, this study has limitations, some of which are clearly acknowledged by the authors. The most critical limitation of the study is recall bias. Patients having a relapse are more likely to seek an explanation and hence report stressful events during preceding weeks. In other diseases such as myocardial infarction, patients commonly attribute their illnesses to psychological factors.²

Secondly, association does not equate to causality. An alternative hypothesis is that "psychological stress" and neurological relapse are different temporally disseminated manifestations of the same underlying disease process. Magnetisation transfer changes precede the traditional radiological signs accompanying clinically overt neurological relapse by up to three months.³ Subclinical reversible . . . [Full text of this article]

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igalea@soton.ac.uk

CNS Inflammation Group, University of Southampton, Southampton SO16 7PX

School of Psychology, University of Southampton, Southampton SO17 1BJ

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