Pseudoexacerbation caused by Stress or Flare?

[carriefromMI]

I've had MS for 10 years and when I'm having an attack I never know if its an attack or not right away. This is one of those times again. It started 3 days ago. Old symptoms coming back, fatigue, numbness but the worst is dizziness. I am dealing with a lot of stress this week at work but have definitely delt with worse stress and no symptom issues in the past. Would you say it's a true flare or pseudo exacerbation due to stress? I will be calling my Dr Monday if it persists.

[bree2013]

Carrie,

Unfortunately I can't give you an answer as to whether these recents symptoms indicated a true flare or pseudo exacerbation as I am new to this and still learning.

Regarding your dizziness: I have recently been experiencing dizziness also. It happens when I awake -- just laying there can cause it. Nauseousness ensues but I do start to feel a bit better late afternoon. I have an appointment with an ENT on Wednesday to see if it's perhaps just an inner ear issue.

One of our posters, KatieAgain, posted this informative "manifesto" under DIZZINESS explaining the two types of dizziness: Peripheral and Central Nervous System. It also explains Vestibular Therapy and The Epley Manuver which have shown to be successful in treating Peripheral dizziness.

I hope your doctor can determine which type you're suffering from and give you relief -- better yet, I hope this symptom disappears on its own. Please let us know how it goes.

Good luck,
Bree

[AriD]

Hi Carrie. Hope you are feeling better. I find my symptoms get worse when I overdo (work, family,etc) and I start wondering if I'm having a relapse or not. The symptoms can last several days especially if I don't get a day or two of rest. The fatigue is overwhelming and my dizziness weakness and clumsiness get much worse. Sometimes everything calms down once I have some downtime. MS is so confusing and overwhelming. I really hope you are doing better this week and not having a relapse. Take care

[jennyver]

Definitely confusing

Hi Carrie,

I sure hope you're feeling better by now. I can totally relate to your feelings of confusion regarding flares & pseudoexacerbations. I was diagnosed 3+ years ago and I still can't tell the difference.

We've had an incredibly stressful few months, starting with my teen being hospitalized for depression and continuing through listing our house and moving to a new house a couple of weeks ago because I needed a ranch house.

I noticed (not unexpectedly) that my fatigue, balance and walking stamina were markedly worse about 10 days ago. After 3 days of this, I called my neuro. I had always been told that if a new or worsening symptom lasts more than a day, that's a flare.

The neuro sent me for a full MRI battery -- two days in the tube! And then called to tell me that I appear to be stable, there are no active lesions, and to continue on my current treatment. What?!? It's now 10 days later and I'm not any better. I would swear I'm in a flare, but my MS-specialist neuro says no.

So apparently, I still don't know the difference....

[BigA]

I've always struggled with this. I know I had a real exacerbation once because of stress, because things hung around long after and those things can still show up.

My rule is - if you're not sure, then it's probably not a real one. This is true even though the textbook definition of a real exacerbation says something like "new or stronger old sensations/issues lasting 48 hours". if that were true, then I've had 64 exacerbations, because if I get low on sleep, say a deficit at the beginning of the week that I never catch up on, then I will have symptoms longer than 48 hours. They will, however, get better once I've rested.

But let's say it is a real exacerbation - what would you do? you're not going to go through a course of steroids for a small one, are you? I recently had a rash of symptoms that I think is caused by my body reacting to allergies and lack of sleep. I called my Dr. and just let them know for the record so that in the course of years, he may say that I call in every April and report the same things.

[AriD]

It is so confusing. Supposedly a true relapse will show a flare on MRI but then my neurologist has said that you can have a flair and it won't show on the MRI. So who knows if it's real or "pseudo". Sometimes my neurologist will give me a course of steroids just to see if my symptoms improve and I can get back to baseline. They used to help a lot but not as much any more. Neurologist says this may be because I'm transitioning to secondary progressive. So now is it flare, pseudo exacerbation, or resistant to steroids because it's secondary not RRMS???? Hope you are feeling better though!!

[BigA]

If you can do without the steroids, you're better off. It's only when they restore function that can't wait.

FYI, it is believed that steroids don't heal you any more than time- they just do it faster. So sparing yourself the treatment can be better.

I'm convinced some doctors give steroids like doctors used to give out antibiotics. The patient wants something and there is supposedly little harm.

So you can decide and although it's true that an attack might not show on your MRI, if you have nothing new next time, you could think that it was not an attack.

[Thinkimjob]

Big A, I could not agree more! If I counted all the pseudo flares that lasted longer than 48 hours, but went away when I had some rest, I'd be up there in the hundreds.

I do believe pseudo flares are early signs of underlying myelin/nerve damage, and I don't think we give them enough attention. Since they're not 'real' they don't count in the DMD/T efficacy statistics.

Nearly all the pseudo stuff I've had has come back to stay after later 'real' flares.

Pseudo flares are the canary in the mine shaft, IMHO.

[BigA]

Job, I think it can go both ways. Sometimes people mistake fatigue for an attack and get unneeded steroids. What I think you are describing are sub-clinical relapses. Who's to say the disease goes dormant between attacks? If you've ever lived in a place with earthquakes, they happen, say once every 10 years, some just shaking and some with damage. But if you went to your local geologic lab, they could show you that, in fact, earthquakes occur every day; they're just too small to notice.

So what to do? IMHO: If you can do without steroids, then do without. If you're unsure if you've had a relapse, you probably have not. In 10 years, however, you'll know whether those were 500 pseudoexacerbations or 500 subclinical ones. But we should remain hopeful, especially if you believe you are doing well.