Multiple sclerosis (MS) is the prototype inflammatory autoimmune disorder of the central nervous system and potentially the most common cause of neurological disability in young adults.[1] Epilepsy is more common among patients with MS than in the general population, and a diagnosis of MS increases the risk of epilepsy.[2] MS remains a difficult disease for which solutions seem attainable yet remain elusive.[1] The identified risk factors for MS are low vitamin D levels, a history of Epstein–Barr virus, smoking, and obesity, especially during childhood. On the other hand, complex interactions between genetic, environmental, and lifestyle factors affect the risk for MS as well as the disease course.[3] Factors proposed as potential moderators and mediators between stress and MS include stressor properties, environmental factors, and patients' biological, social, and psychological characteristics.[4] Spiritual distress is defined as “a disruption in the life principle that pervades a person's entire being and that integrates and transcends one's biological and psychological nature.”[5] Herein, we discussed the relationship between MS and spiritual distress to attract attention to the possible role of spiritual distress in patients with MS.

In the process of MS, the psychosocial factors and the symptoms of MS are often interrelated, and they affect both the development and outcome of the disease. As a result, they can deteriorate and ameliorate the symptoms of MS. Conversely, the symptoms can affect the psychological state of patients. For example, symptoms such as pain, fatigue, emotional changes, and cognitive impairment are closely related to psychosocial factors.[6] Liu et al[6] found significant differences in negative emotions and symptoms such as depression, anxiety, horror, obsession, tense interpersonal relationships, and somatization disorder between the MS group and the control group. Compelling evidence has been found for a link between major life events and risk of MS—most events significantly increased disease risk by 17 and 30%.[7] The studies showed an association between MS relapse and stress, regardless of the timing of stress exposure. However, the link between stress and MS onset was conflicting for both childhood and adult stress exposures.[7] [8] [9] In stress progression studies, instruments and designs based on self-evaluation and subjective measures have shown more consistent results than objective ones or instruments based on standard stressors. This means that patients' subjective appraisal of the stress could be an important predictor of MS relapse and onset.[10]

Spirituality is the high states, blessings, tastes, and happiness that a person feels in his own conscience and soul when he fulfills the de facto gratitude by acting in accordance with Allah's orders and prohibitions with his material organs, intangible feelings, and letaif (subtle faculties). Spirituality is a dimension of religion. As a person obeys Allah's orders and prohibitions, the letaif within him/her emerge, develop, and mature, and thus his/her spirituality becomes stronger. As a result of the disturbance in a person's religious belief, his/her spirituality is negatively affected, and then spiritual distress occurs. In fact, spiritual distress is a disturbance in a person's religious belief system. The diagnosis of spiritual distress is defined by indicators that are present: spiritual pain, spiritual alienation, spiritual anxiety, spiritual guilt, spiritual anger, spiritual loss, and spiritual despair.[5] Spiritual distress may manifest as symptoms in any area of a person's experience—physical (e.g., intractable pain), psychological (e.g., anxiety, depression, hopelessness), religious (e.g., crisis of faith), or social (e.g., breakdown of human relationships).[11] Spiritual distress may also exacerbate physical suffering, and it can greatly affect quality of life.[12] Most physicians believe that spiritual suffering tends to intensify physical pain and that physicians should seek to relieve such suffering. Physicians who believe they should address spiritual suffering just as much as physical pain report more success in relieving patient's suffering. In this study, religious affiliations of the physicians was categorized as None, Hindu, Jewish, Muslim, Roman Catholic/Eastern Orthodox, evangelical Protestant, nonevangelical Protestant, and other religion.[13] Klimasiński et al[14] reported that almost all patients with chronic diseases showed signs of spiritual distress, and more than half expressed spiritual needs. The most important predictor of having spiritual needs was recognizing faith as a resource.[14]

In conclusion, biological, social, and psychological factors are important predictors of MS relapse and onset. It is well-known that spiritual distress may cause physical, psychological, and social disorders. So, we strongly believe that spiritual distress is responsible from MS onset and relapse in some patients; however, randomized controlled trials including large patient series should be performed about this subject. We also think that MS relapse can be prevented by strengthening spirituality because the cure for spiritual distress is to strengthen spirituality. People must know Allah and obey Allah's orders and prohibitions in order for spirituality to become stronger. For the Monarch of the universe is One, the key to all things is with Him, the reins of all things are in His hand, everything will be resolved by His command. If you find Him, you will be saved from endless indebtedness, countless fears.[15]