Comparison of the Effect of Lazarus Multimodal Approach and Cognitive-Behavioral Therapy on Psychological Distress, Working Memory, and Anxiety in Patients with Multiple Sclerosis

Document Type : Original Article


1 Department of Psychology, Kish International Branch, Islamic Azad University, Kish Island, Iran.

2 Department of Psychology, Semnan Branch, Islamic Azad University, Semnan, Iran.

3 Department of Psychology, Karaj Branch, Islamic Azad University, Karaj, Iran.



Background: Multiple sclerosis is considered a chronic disease in which physical and mental disorders are common among these patients.
Objectives: This study aimed to compare the effectiveness of Lazarus multimodal therapy and cognitive-behavioral therapy on psychological distress, working memory, and anxiety in patients with multiple sclerosis.
Methods: The research method was a quasi-experimental research with pre-test, post-test, and follow-up and a control group. The statistical population of the study was the patients who were members of the "MS Patient Support Society" in Tehran who had been referred to this center during January and March 2017. The sample consisted of 48 people selected by convenience sampling method from members of the MS community. The data were obtained through the Kessler psychological distress scale (K10), the Wechsler's Working Memory Index, and the Beck Anxiety Inventory (BAI). The repeated measurement method and SPSS.22 software were used to analyze data.
Results: Findings showed that Lazarus Multimodal Approach and cognitive behavioral therapy had a significant effect on decreasing anxiety (p <0.001), psychological distress (p <0.001), and increasing working memory (p <0.001). The Lazarus Multimodal Approach was more effective than cognitive-behavioral therapy in decreasing anxiety, psychological distress, and increasing working memory (p <0.001).
Conclusion: It can be concluded that Lazarus' Multimodal Approach and cognitive behavioral therapy was effective on anxiety, psychological distress, and working memory and can be used to reduce psychological problems in patients with multiple sclerosis.


1. Montalban X, Hauser SL, Kappos L, Arnold DL, BarOr A, Comi G, De Seze J, Giovannoni G, Hartung HP,
Hemmer B, Lublin F. Ocrelizumab versus placebo in primary progressive multiple sclerosis. New England
Journal of Medicine. 2017;376(3):209-20.
2. Théaudin M, Romero K, Feinstein A. In multiple sclerosis anxiety, not depression, is related to gender.
Multiple Sclerosis Journal. 2016;22(2):239-44.
3. Rossi S, Studer V, Motta C, Polidoro S, Perugini J,Macchiarulo G, Giovannetti AM, Pareja-Gutierrez L, Calò
A, Colonna I, Furlan R. Neuroinflammation drives anxiety and depression in relapsing-remitting multiple sclerosis.
Neurology. 2017;89(13):1338-47.
4. Cénat JM, Hébert M, Blais M, Lavoie F, Guerrier M,Derivois D. Cyberbullying, psychological distress and
self-esteem among youth in Quebec schools. Journalof affective disorders. 2014;169: 7-9. https://doi.
5. Bariola E, Lyons A, Leonard W, Pitts M, Badcock P, Couch M. Demographic and psychosocial factors
associated with psychological distress and resilience among transgender individuals. American journal of public
health. 2015;105(10):2108-16.
6. Zhang R, Picchioni M, Allen P, Toulopoulou T.Working memory in unaffected relatives of patients with
schizophrenia: a meta-analysis of functional magnetic resonance imaging studies. Schizophrenia bulletin.
7. Trujillo JP, Gerrits NJ, Veltman DJ, Berendse HW,van der Werf YD, van den Heuvel OA. Reduced neural
connectivity but increased taskÔÇÉrelated activity during working memory in de novo P arkinson patients.
Human brain mapping. 2015;36(4):1554-66.
8. Meyer L, Cunitz K, Obleser J, Friederici AD. Sentence processing and verbal working memory in a white-matterdisconnection patient. Neuropsychologia. 2014;61: 190-6.
9. Hulst HE, Goldschmidt T, Nitsche MA, De Wit SJ,Van Den Heuvel OA, Barkhof F, Paulus W, Van Der
Werf YD, Geurts JJ. rTMS affects working memory performance, brain activation and functional connectivity
in patients with multiple sclerosis. Journal of Neurology,Neurosurgery & Psychiatry. 2017;88(5):386-94. https://
10.Sklenarova H, Krümpelmann A, Haun MW, Friederich HC, Huber J, Thomas M, Winkler EC, Herzog W,
Hartmann M. When do we need to care about the caregiver? Supportive care needs, anxiety, and depression
among informal caregivers of patients with cancer and cancer survivors. Cancer. 2015;121(9):1513-9. https://doi.
11. Fowler CJ. The effectiveness of bladder rehabilitation in multiple sclerosis. Journal of Neurology, Neurosurgery
& Psychiatry. 2010 Sep 1;81(9):944.
12. Karami A, Arian SK, Soltani Khorshid H, Khanabadi M. Exploring the effectiveness of group training based
on Lazarus multifaceted approach on women’s marital satisfaction. Quarterly Journal of Women and Society.
13. Tehrani A, Heidari H. The effect of group training based on Lazarus Multimodal Approach on the happiness
of women in Islamshahr, Iran. Journal of Fundamentals of Mental Health. 2015;17(2):98-102.
14. Clayton NA, Ward EC, Maitz PK. Intensive swallowing and orofacial contracture rehabilitation after severe burn:
a pilot study and literature review. Burns. 2017;43(1): e7-17.
15. Bahramkhani, M. Effectiveness of Lazarus Multimodal Approach on expanded disability status in patients with
multiple sclerosis. Journal of Fundamentals of Mental Health, 2011;13(50):47-136.
16. Sotardi VA, Bosch J, Brogt E. Multidimensional influences of anxiety and assessment type on task
performance. Social Psychology of Education.2020;23(2):499-522.
17. Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, Normand SL, Walters EE, Zaslavsky AM. Short
screening scales to monitor population prevalences and trends in non-specific psychological distress.
Psychological medicine. 2002;32(6):959-76.
18. Dadfar M, Atef Vahid MK, Lester D, Bahrami F. Kessler psychological distress scale (K6): psychometric
testing of the Farsi form in psychiatric outpatients. Advances in Bioresearch. 2016;7(2):105-8.
19. Wechsler D. The measurement and appraisal of adult intelligence. 1985.
20. Nikravesh M, Jafari Z, Mehrpour M, Kazemi R, Shavaki YA, Hossienifar S, Azizi MP. The paced auditory
serial addition test for working memory assessment: Psychometric properties. Medical journal of the Islamic
Republic of Iran. 2017;31:61.
21. Beck AT, Clark DA. Anxiety and depression: An information processing perspective. Anxiety research.
1988 Jan 1;1(1):23-36.
22. Toosi F, Rahimi C, Sajjadi S. Psychometric properties of beck depression inventory-II for high school children
in Shiraz City, Iran. International journal of school health. 2017;4(3):1-6.
23. Ghasemian D, Kuzehkanan AZ, Hassanzadeh R. Effectiveness of MBCT on decreased anxiety and
depression among divorced women living in Tehran, Iran. Journal of Novel Appplied Sciences. 2014;3(3):256-9.
24. Lazarus AA. Multimodal Approach: A SevenPoint Integration. 2006. med:psych/9780195165791.003.0005
25. Biggs A, Brough P, Drummond S. Lazarus and Folkman's psychological stress and coping theory. The handbook
of stress and health: A guide to research and practice.2017:351-64.
26. Rogissart A, Martinent G. The effects of a multimodal intervention program on national competitive swimmers'
state anxiety and coping. 2017;2(6): 589-612.
27. Sah AP, Liang K, Sclafani JA. Optimal multimodal analgesia treatment recommendations for total joint
arthroplasty: a critical analysis review. JBJS reviews. 2018 Jun 1;6(6):7-18.
RVW.17.00137 8 Shahlapour S. et al.
28. Bean BA, Connor PM, Schiffern SC, Hamid N. Outpatient shoulder arthroplasty at an ambulatory surgery
center using a multimodal pain management approach. JAAOS Global Research & Reviews. 2018;2(10):51-59.
29. Ofole NM. Evidence based therapeutic outcome of Multimodal Approach on sexual decisions of students in
River State Remedial Study Centres. African Research Review. 2016;10(3):55-71.
30. Mallol-Ragolta A, Dhamija S, Boult TE. A multimodal approach for predicting changes in ptsd symptom severity.
InProceedings of the 20th ACM International Conference on Multimodal Interaction 2018 (pp. 324-333). https://doi.