MS and anger outbursts

Mood swings and MS

The question

Why does my mood change from calm and easy going to stressed and lacking in patience within minutes? It can then switch back just as easily. Could my fatigue be contributing? How can I track the triggers and help control my emotions?

Annie’s answer

Mood swings are very common in MS. They may arise as part of an emotional reaction to the illness, or may arise from depression and anxiety. Occasionally, the illness can affect the emotional control centres of the brain. Mood swings can seem to come ‘out of the blue’ and it can be difficult to identify specific triggers that set them off. Fatigue is a very common cause of daytime moodiness and, as you suggest, may play a role in your mood.

Mood changes usually do have triggers. The most common trigger is a negative automatic thought (NAT) that happens so quickly we are not even aware of it. Cognitive therapy helps patients identify their thoughts, and the way that thoughts influence feelings and behavior. For example, a negative thought, e.g. “I can’t cope with one more thing going wrong today” is more likely to leave us feeling stressed and anxious. A more helpful thought, e.g. “I am going to talk to my partner about how I can share some of my day to day responsibilities so that I don’t feel exhausted” is likely to make us feel a sense of relief and hope.

Keeping a mood diary can be a valuable way of identifying triggers. Note the time of day, and what thoughts went through your mind (such as, “I don’t have the energy to do everything the way I did before, I am letting everyone down”). Then note how that thought made you feel. You may find that the same negative thoughts go through your mind day in and day out. Once you have kept a diary for a few days, try to find a more helpful way of thinking about the situation, e.g. “I’ll have a 20 minute nap after lunch every day, then I will have more energy for cooking”. If you are saying the word should to yourself, drop it, and say something like, “I would like…or I can…”. Self-criticism is a major factor in low mood.

Ups and downs are a normal part of life, but the strategies above can help you catching them early and turn them around. Communicate to others how you feel, and make sure that you have a balance of pleasurable and fulfilling activities. Seeking support from your MS nurse or a clinical psychologist can help you tackle the stresses that may be maintaining your poor sleep and anxiety.

Annie has been working as a clinical neuropsychologist for 25 years, in both the NHS and private practice. She has a Ph.D. in Clinical Neurosciences from the University of Edinburgh.

What’s Behind Your MS Mood Swings?

For some of the 2.3 million people with multiple sclerosis (MS) worldwide, mood swings may come on fast and furious – and understanding why can be complicated. As a chronic and unpredictable condition, MS can of course take a toll on your emotional health. But there also may be medical reasons for the outbursts.

3 Causes of MS-Related Mood Swings

MS is an autoimmune disorder that occurs when the immune system attacks the central nervous system – the brain, spinal cord, and optic nerves, according to the National Multiple Sclerosis Society (NMSS). “Living with a chronic and progressive disease can certainly create feelings of anxiety or anger,” explains Barry Hendin, MD, a clinical professor of neurology at the University of Arizona and chief of the neurology service at Banner Good Samaritan Hospital in Phoenix. That’s one potential culprit of MS-related mood swings. Another: Some MS medications, including corticosteroids, may affect a person’s emotions.

While these two mood swing triggers are common in many other chronic conditions too, there’s a third factor that makes MS unique: Emotional changes can be a symptom of the disease itself.

“With MS, organic changes occur in the brain, and they differ from the depression or anxiety that a person may feel when they are dealt a diagnosis of other chronic diseases,” explains Carrie Sammarco, DrNP, FNP-C, a nurse practitioner at the NYU Langone Multiple Sclerosis Comprehensive Care Center in New York City.

Specifically, MS causes demyelination and damage to nerves in the brain. When a part of the brain that regulates emotion is damaged, it can trigger feelings of anger, depression, or anxiety. “We think it could be a loss of an inhibitory mechanism so emotions are released,” adds Karen Blitz, DO, an assistant professor at the Hofstra North Shore-LIJ School of Medicine and director of the North Shore-LIJ Multiple Sclerosis Center in East Meadow, New York.

Moodiness, also known as “emotional lability,” can cause a person with MS to experience rapid-fire mood changes, according to the NMSS. “They can get snappy with a loved one, and then feel guilty and say, ‘I don’t understand – everything is great with us,’” Dr. Sammarco says.

Another manifestation of MS-related emotional lability is known as the pseudobulbar affect (PBA). “This can include crying or laughing hysterically at inappropriate times,” Dr. Blitz says.

Many people with MS may not realize that these outbursts are related to physical changes caused by the disease. “I always explain that these emotional flare-ups are a part of an underlying neurologic issue,” Blitz says. “It’s comforting for family members to know that these sudden mood changes don’t always mean their loved one with MS is sad or angry or being rude by laughing at the wrong time.”

At the same time, it can be difficult to tell what is really driving the moodiness of someone with MS, Dr. Hendin says. It’s likely that all of the three aforementioned factors play a role, he explains.

Managing Your Changing Moods

Here are several steps you can take to help alleviate MS-related moodiness:

Talk about it. “If your doctor doesn’t ask about moodiness when he asks about other MS symptoms, such as gait or vision, bring it up,” Sammarco says. “Bring a family member or partner to your doctor’s appointment who may have some insight into your moods.” Your doctor can help you understand these mood changes, recommend therapy or counseling, and potentially prescribe medications that can help balance your moods.

Ask to be evaluated for PBA. “If we do a full assessment and find that the outbursts are caused by PBA and disrupting a person’s life, we do have treatments available,” Blitz says.

Get regular sleep. The importance of sleep in regulating mood can’t be overstated. “Being overly fatigued can trigger MS symptoms,” Hendin says. Talk to your doctor about your sleep quality.

Eat a healthy diet. A well-balanced diet – one that includes fresh fruits and vegetables, low-fat protein, and low-fat dairy – can help your body function properly, have a positive impact on your MS symptoms, and lower your risk of other diseases.

Stay connected. Reaching out to family or friends or joining a support group can help mitigate feelings of loneliness or isolation. “Joining an MS support group can give you an outlet,” Hendin says. “You can vent and share your feelings with others who can relate.”

Be active. “Exercising is a natural antidepressant,” says Hendin, adding that people with MS should exercise to the best of their ability. If you’re unsure of the best type of exercise for your abilities, discuss your options with your doctor, nurse practitioner, or physical therapist.

Stick with your MS treatment plan. Getting good control over MS and its symptoms can help alleviate much of the moodiness associated with the disease. “We can alter the course of this disease, and that will have a positive effect on moods,” Hendin says.

Address other causes of depression or anxiety. There may also be something else going on that is affecting moods, Hendin says. If you’re experiencing depression or anxiety, talk therapy and medications may be recommended.

Ali Garzuzi, a 36-year-old Chandler, Arizona-based registered nurse and patient of Hendin, says she used to drift off to sleep easily, but that changed when she was diagnosed with MS. The anxiety of not knowing what the future held was keeping her up at night – which didn’t just lead to moodiness, it also put her at risk for an MS flare brought on by lack of sleep. She now takes anti-anxiety medications to stop racing thoughts and get the sleep she needs. “It helps calm my nerves and anger from thoughts like ‘why me,’ and it allows me to fall asleep,” she says.

If you’re experiencing depression or anxiety, discuss it with your doctor so you can get the help you need.

High unexpressed anger in multiple sclerosis patients linked to nervous system damage, not disease severity

Italian researchers assessed 195 patients with MS, using a range of scales that measure anger, depression and anxiety, and then compared them with the general population.

They were surprised by the results, which showed that while patients experienced almost twice the normal level of withheld anger and exerted low levels of control on their anger, their expressed anger levels were similar to the general population.

This, together with the fact that the elevated withheld anger levels were not related to the severity of the patients’ MS, suggests that these inconsistent changes were caused by nervous system damage, rather than an emotional reaction to the stress of the disease.

“We believe that the higher levels of withheld anger shown by the study subjects is due to demyelination, loss of the substance in the white matter that insulates the nerve endings and helps people receive and interpret messages from the brain” explains lead researcher Dr Ugo Nocentini from the IRCCS S Lucia Foundation in Rome.

“The way we process anger is controlled by complex interconnections between the subcortical and cortical systems, notably the amygdale and basal ganglia and the medial prefrontal cortex. We believe that the demyelination process that causes the root symptoms of MS also disrupts the pathways that control how we deal with withheld anger.”

The patients who took part in the study comprised 150 with relapsing-remitting MS and 45 with progressive MS. More than two-thirds (68 per cent) were women, the average age of the participants was 40 and the average time since diagnosis was 11 years.


Researchers evaluated the participants using the State Trait Anger Expression Inventory, the Chicago Multiscale Depression Inventory and the State Trait Anxiety Inventory.

The researchers then looked at age and sex-matched subjects in the general population and identified the levels of anger experienced by the 25 per cent of people with the highest scores.

They found that MS patients:

  • Were more than twice as likely to experience high levels of withheld anger, with 60 per cent of patients recording the same high levels as the top 25 per cent of the general population.
  • Exerted a low level of control on their anger, with just 11 per cent of patients reporting the same high levels of control compared to the top 25 per cent of the general population.
  • Were about the same as non MS patients when it came to expressed anger, with 30 per cent of patients reporting the same high levels as the top 25 per cent of the general population.

During the study the authors also compared the anger scores against selected demographic and clinical characteristics and found they were independent of age, education, disease duration and course, disability and fatigue severity. The only notable difference was that women reported higher levels of current anxiety.

“Our findings clearly show that anger characteristics in MS patients differ from those observed in the general population and the overall results surprised the research team” concludes Dr Nocentini.


“For example, patients reported low levels of anger control and high levels of withheld anger, yet the scores for expressed anger were similar to those of the general population.

“We would have expected greater consistency between withheld and expressed anger and higher levels of expressed anger as a consequence of low anger control.”

The authors conclude that damage to the fibres in the areas of the brain where anger issues are processed is the most logical explanation. They also say the findings have important implications for clinical practice.

“Anger disrupts interpersonal relationships and this is particularly true for withheld anger, which might go unrecognised by other people” says Dr Nocentini. “Withheld anger has been reported to be associated with physical problems, in particular high blood pressure and vascular disorders, and may have a negative effect on the general health of MS patients.

“Because withheld anger has no, or few, overt manifestations, and is unlikely to be recognised by clinicians or reported by patients, it is important that MS patients are asked if they experience abnormal anger.”

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