Intervention to Reduce Perceived Cognitive Impairment in Multiple Sclerosis

Multiple sclerosis (MS) is among the most prevalent autoimmune diseases among young and middle-aged adults. Up to 65% of MS patients experience objective cognitive impairment including problems with information processing speed, memory, and executive functioning. However, patients commonly overestimate the extent of their cognitive dysfunction which can result in inaccurate perceptions of their true cognitive abilities. Exaggerated perceptions of cognitive impairment are predictive of future decline and associated with depression, anxiety, and reduced quality of life. Despite this, no study has examined an intervention aimed at changing misperceptions related to perceived cognitive impairment in MS when objective measures are incongruent with self-reported cognitive symptoms. The purpose of the present study is to develop and pilot a brief intervention for MS patients who perceive cognitive impairment, but perform in the normal or expected range on objective measures of cognition.

Concern over worsening cognitive functioning has been shown to significantly impact patients' lives. More than half of all MS patients demonstrate clinically significant cognitive dysfunction, making it one of the leading causes of disability in MS. Cognitive deficits often manifest in areas associated with information processing speed, memory, and executive functioning. Resulting sequela can have profound implications on employment, interpersonal relationships, and activities of daily living. Despite the prevalence of cognitive dysfunction in MS, most studies find little to no relationship between perceived and objective cognition in MS. Research shows that some patients overestimate the extent of their cognitive deficits. PCI is associated with poor self-efficacy, social, and occupational difficulties. Evidence suggests that negative emotional states may contribute to overestimated PCI in MS. Exaggerated perceptions of impaired cognition may be intensified by the presence of other MS symptoms, which can affect the way patients report disease activity to healthcare providers and complicate detection of relevant disease symptomatology.

Overestimating cognitive impairment has been observed in other patient populations, but it is especially problematic in MS and can provide an opportunity to inform patients about discrepancies between perceived and objective cognitive functioning. Since physicians spend significant amounts of time negating unsubstantiated healthcare concerns, an intervention aimed at decreasing PCI in MS may improve long-term healthcare outcomes as well as the quality of time that physicians spend with patients. Neuropsychological test results can be used as objective evidence against perceived cognitive impairment to change patients perceptions, if conveyed in an appropriate and nonthreatening manner.

Educating patients about the influence of emotional dysfunction and misattribution as it relates to PCI may also decrease concern regarding cognitive decline and MS. Specifically, internal processes such as emotional dysfunction, including a globally negative world view can increase dissociative experiences that cause patients to misattribute normal cognitive errors as MS-related cognitive decline. This model may inform patients understanding of medically unsubstantiated PCI, allowing them to consider alternative factors associated with common cognitive errors aside from MS.

Although many studies have aimed to improve cognition in MS through pharmacological treatments, cognitive rehabilitation, and psychotherapy, to the investigators knowledge, this is the first study to examine a psychoeducational intervention to decrease exaggerated perceptions of cognitive impairment in MS. For the present study, the investigators will develop a brief computer-based intervention for MS patients who perceive cognitive decline incongruent with objective measures of cognition. The proposed intervention will incorporate feedback from neuropsychological tests, including comparisons of perceived and objective performance. The intervention will also introduce psychoeducation about causes of PCI, such as emotional distress, attention, and misattribution. It is hoped that by combining neuropsychological test feedback and psychoeducation, patients may better understand differences between perceived and objective cognition, which in turn, may reduce concern and offer alternative explanations for PCI.

Goals and Hypotheses

For the current study, the investigators will develop a brief computer-based intervention for MS patients who perceive cognitive decline that is incongruent with objective measures of cognitive functioning. The project will accomplish the following specific aims:

1. Develop and assess the feasibility and acceptability of a brief, single-session, computerized intervention (cognitive feedback and psychoeducation; CFP) as part of a randomized controlled pilot trial to reduce perceived cognitive impairment and distress associated with perceived cognitive impairment that is incongruent with objective measures of cognition in MS patients.
2. Examine whether the intervention reduces distress related to perceived cognitive deficits. The investigators hypothesize that patients in the CFP group will report less distress over perceived cognitive impairment compared to the control group immediately after and one week following the intervention.
3. Examine patients understanding of factors that contribute to perceived and objective cognitive impairment in MS. The investigators hypothesize that patients in the CFP group will have an increased understanding of the role that negative emotion, misattribution, and other secondary factors play in the formation of perceived cognitive deficits when compared to patients assigned to the HEH group.

Eligibility Criteria:
Inclusion Criteria:

* diagnosis of MS by a board-certified neurologist
* a total score \> 40 on the Perceived Deficits Questionnaire (PDQ) based on previous research that identifies this cutoff score as clinically significant in the MS population and two standard deviations below average in the general population (Ruth Ann Marrie, Gordon J. Chelune, Deborah M. Miller, \& Jeffrey A. Cohen, 2005)
* score in the low average or better range on the Wechsler Test of Adult Reading (WTAR)
* average score equal to or greater than the 16th percentile on the Hopkins Verbal Learning Test (HVLT), Symbol Digit Modalities Test (SDMT), Controlled Oral Word Association Test (COWAT), and Wisconsin Card Sorting Task (WCST)
* average T score on the HVLT, SDMT, COWAT, and WCST no more than one standard deviation below the WTAR T score
* access to a computer and a personal email account
* English-speaking

Exclusion Criteria:

* no severe sensory, motor, physical, or neurological impairment that would make participation in the study insurmountable
* no history of nervous system disorder other than MS