You've Got a Friend in Me: The Importance of a Confidant and Its Role on Health and Well-Being Among Women With Multiple Sclerosis

Social connectedness is purported to be a protective or promoting factor of health.^1,2 The relative risks associated with a lack of social integration or social support are as great, if not greater than, as the risks associated with smoking, alcohol use, obesity, and cardiovascular disease (CVD).^3,4 For instance, in 1988, House et al suggested that the evidence supporting social relationships on health was stronger than the role of Type A behavior on CVD and approximated the risk of smoking.⁵ Two decades later, Holt-Lunstad et al found social support and integration to have large effects in predicting mortality than smoking, alcohol consumption, physical activity, obesity, and CVD risk.⁴ Given this, the World Health Organization has listed social support networks as a determinant of health.⁶

Today, loneliness has become an epidemic.⁷ Specifically, 1 in 4 individuals in the United States do not feel that they have a best friend to confide in.⁸ Comparable rates are found worldwide. In 2024, US Surgeon General Vivek Murthy, MD, laid out the National Strategy to Advance Social Connection. When compared with other health conditions in the US, loneliness is the most prevalent health indicator of decreasing mortality, with a higher prevalence than inactivity, obesity, and smoking.⁹ Given this risk, it is important to address the epidemic of loneliness and examine the outcomes and antecedents in hopes of assuring the maintenance of health and longevity.

It is even more essential to address loneliness among older individuals or those with a chronic illness or disability, such as multiple sclerosis (MS), as it is well appreciated that such individuals are at an increased risk for social isolation^.10,11 The emphasis on social support has always been particularly relevant to individuals with MS who report being in worse health and are also at a disadvantage when it comes to social participation because of the obstacles and challenges they face. Estimates suggest that 50% to 70% of individuals with MS experience loneliness.^11-13 In a major study looking at loneliness, nearly half of a large sample of women with MS (N = 659) reported being lonely.¹² Loneliness and/or social isolation in people with MS can be a result of many factors, including mobility issues, functional limitations, uncertainty of symptoms and disease exacerbations, unemployment, stigma, inadequate accommodation and assistive devices, disease progression, and a feeling of being misunderstood.^11,14 Hakim et al found social withdrawal and a shrinking circle of friends to be common among individuals with MS, particularly those with severe disability. More specifically, 1 out of 4 individuals reported that they stopped visiting friends and family due to poor mobility. Reports of pain, fatigue, cognitive difficulties, and bladder incontinence (and the uncertainty of such symptoms) have all been shown to contribute to social isolation.^14,15 Finally, individuals with MS also express a feeling of a lack of understanding or knowledge in those not familiar with MS, which results in further social withdrawal or isolation. A lack of understanding about MS was endorsed as the biggest issue by 78% of individuals in a study on loneliness.¹¹ Given what we know of the role of social connectedness on health and the strikingly high rates of loneliness in people with MS, it is important for care providers to routinely assess individuals’ social activities/networks and determine if loneliness is present.

The majority of existing studies on loneliness have focused on older individuals. Less information is known about the impact of loneliness on individuals with disabilities such as MS. Latinsky-Ortiz and Strober conducted one of the first studies examining the role of social integration and support on health and psychological well-being (PWB) in MS and found that although CVD risk and having a progressive MS disease course were the most significant factors associated with poorer perceived physical health, social integration was the third most important factor and played a larger role than diet and exercise. Social integration and/or social support were also significant predictors of PWB.¹⁶ These findings confirm what has been found among the general population. We aim to add to this data by examining a very specific aspect of social relationships, which is whether someone feels they have a confidant or best friend, at least 1 person they trust and with whom they can share their personal struggles.

Grose et al found that having a confidant was important to maintaining normalcy and a key part of psychosocial care for individuals with MS.¹⁷ However, the influence on health and PWB was not objectively examined. We examined the role that having a confidant plays on the health and well-being of women with MS. We decided to examine this relationship in only women for 2 primary reasons. First, women comprise the majority of people with MS. Second, the interpersonal dynamics that exist within social support networks may operate differently in men than women given longstanding social norms based on gender, and it has been suggested that the needs of men with MS are different than those of women when it comes to social support.¹⁸ Our hypothesis was that women with MS without confidants experience poorer perceived health and PWB. We also sought to quantify the impact of a confidant on perceived social support and marital/partner satisfaction.

METHODS

Procedures

All participants were enrolled in a prospective national investigation examining the factors associated with employment status in MS. As part of this study, participants completed an online survey assessing general health, MS symptomatology, PWB, social support, social integration, and marital/partner satisfaction. With the exception of the Cognitive Health Questionnaire, which is a newly developed measure, all self-report measures are widely used and well validated. All study procedures obtained ethics approval from the Kessler Foundation Institutional Review Board, and informed consent was obtained from all participants.

Participants

Eligibility criteria were being between the ages of 20 and 64 years, having a diagnosis of MS confirmed by a neurologist, being employed, and not having other neurological disorders (eg, epilepsy traumatic brain injury, stroke). For the present study, only women were included.

Measures

The 36-Item Short Form¹⁹ was used to assess general health. It covers 8 health concepts: physical functioning, bodily pain, role limitations due to physical health problems, role limitations due to personal or emotional problems, emotional well-being, social functioning, energy/fatigue, and perceived overall general health. The composite scores of physical and mental health functioning and perceived overall general health were used as indicators of functioning and health, respectively.

To assess physician care and CVD risk, participants were asked if they (1) had a primary care visit within the past year and (2) if they were under care for any medical conditions in addition to MS. Individuals who indicated receiving treatment for hyperlipidemia, hypertension, diabetes, and/or cardiac issues were classified as having CVD risk factors.

The Modified Fatigue Impact Scale²⁰ measures fatigue impact via 21 items in 3 subscales: physical, cognitive, and psychosocial functioning. Only the physical fatigue subscale was used.

The Pittsburgh Sleep Quality Index²¹ ascertains sleep quality across several domains. The scale consists of 24 items rated by the individual and 5 items rated by a bed partner.

The MOS Pain Effects Scale²² assesses the experience and impact of pain, yielding a total score from a summation of 6 items that assess the interference of pain on one's mood, physical ability, sleep, work/recreational activity, and enjoyment of life over the previous 4 weeks.

The Chicago Multiscale Depression Inventory²³ was developed specifically for use in medical populations and consists of 3 subscales: mood, evaluative, and vegetative. The mood subscale was used as the primary indicator of depression.

The State-Trait Anxiety Inventory²⁴ was used to assess anxiety. Individuals were asked to rate how they feel at this moment (state anxiety) as well as how they generally feel (trait anxiety). Scores on the trait anxiety scale were used.

The Ryff Psychological Well-Being Scale consists of 6 subscales.²⁵ The Positive Relations With Others subscale assesses the depth of connection an individual feels with others. The Autonomy subscale assesses whether one feels they are living their life in accordance with their convictions. The Personal Growth subscale rates the extent to which individuals feel they are living to their full potential and taking advantage of their talents. The Purpose in Life subscale measures how one feels regarding their life's meaning and purpose and direction. The Environmental Mastery subscale measures how well an individual feels they can manage life situations. Finally, the Self-Acceptance subscale assesses one's knowledge and acceptance of themselves and their limitations.

The Cognitive Health Questionnaire (CHQ)^26,27 was developed to assess individual engagement in lifestyle factors that may maintain or promote cognitive health. Items assess physical activity, alcohol use, smoking, social activity, intellectual activity, sleep habits, and steps taken to maintain adequate nutrition. We used 2 of the analytically derived indexes. The nutrition/exercise factor assesses breakfast and lunch consumption, fruit and vegetable consumption, use of vitamins and supplements, and frequency of light and moderate physical activity. The social/intellectual factor assesses family and friend socialization frequency, engagement in intellectual activities, and use of memory/organizational techniques. Alcohol use was also assessed by the CHQ and categorized as no use, 1 drink per day, or more than 1 drink per day.

Personality was assessed with the NEO Five-Factor Inventory-3 (NEO-FFI-3),²⁸ including discomfort in social situations and the tendency to be reclusive or avoidant of social situations. The neuroticism subscale of the NEO-FFI-3 and the social discomfort scale of the International Personality Item Pool (IPIP)²⁹ were used to determine the presence of Type D personality. T scores were calculated for the NEO-FFI-3 Neuroticism scale per manual norms. A median split was utilized for the social discomfort scale. Individuals who had a t score greater than 60 on the NEO-FFI-3 neuroticism assessment and scored high on the IPIP social discomfort scale were identified as having Type D personality.

The Community Integration Questionnaire³⁰ was developed to provide a measure of community integration after traumatic brain injury. It consists of 15 items relevant to living, loving, and working, or more formally, home integration, social integration, and productive activities. The social integration subscale assesses an individuals’ social engagement, and we employed the question Do you have a best friend in whom you confide?

The Modified Social Support Survey assesses several domains of social support, including tangible support, emotional support, affective support, and positive support.³¹

The Couples Satisfaction Index³¹ assesses relationship satisfaction and the presence and intensity of problems in a relationship.

Statistical Analyses

All statistical analyses were conducted using IBM SPSS version 26.0. Group comparisons were made between those who reported having a confidant and those who did not on measures of health, MS symptomatology, PWB, social support, and marital/partner satisfaction. Nonparametric comparison (χ²) was conducted for marital status. Subsequent stepwise linear regression analyses were conducted with health, PWB, and quality of life (QOL) as dependent variables. Independent variables were demographics (age, education, relationship status), disease variables (disease course, disease duration), health status (presence of CVD factors), health and lifestyle factors (diet/exercise, social/intellectual activities, smoking, alcohol use, visit to primary care physician in the past year), Type D personality, and reports of having a confidant.

RESULTS

A total of 160 women with MS were enrolled in the study. Of these participants, 30 (19% or nearly 1 out of 5) reported that they did not have a best friend in whom they could confide (Confidant–). Compared with those who did report having a best friend to confide in (Confidant+), there were no differences regarding age, education, relationship status, disease course, or disease duration (TABLE 1).

Table 1. Group Comparisons

When comparing the 2 groups, individuals who reported not having a confidant were found to report worse general health, more pronounced MS symptomatology, and worse PWB. Specifically, on the Short-Form Survey, a measure of health-related quality of life, individuals without a confidant described their perceived general health as worse, and they reported more severe physical and mental health difficulties or limitations. They also reported higher levels of fatigue, sleep disturbance, and pain than their counterparts who did report having a confidant. (Table 1).

On measures assessing psychological functioning, PWB, and QOL, individuals who expressed feeling as if they had a best friend or confidant reported statistically less symptoms of depression and anxiety and were less likely to be diagnosed with depression or anxiety. They also reported statistically greater PWB and QOL, including satisfaction with life and feelings of flourishing (Table 1). Conversely, consistent with their reports of not having a confidant, individuals without a best friend expressed a lower sense of perceived social support and partner satisfaction, which reached statistical significance (Table 1).

When examining the role of having a confidant and other lifestyle factors related to health, having a confidant was a significant predictor of greater self-reported physical health following CVD risk and diet and exercise, accounting for an additional 2% of the variance. Age also contributed another 2% variance. Together, 13% of the variance was explained by these aforementioned factors. Similarly, when examining factors associated with self-reported mental health, having a confidant added 2% variance after personality factors and engagement in social and intellectual activities were considered. Age contributed another 2%. Together, these factors accounted for 33% of the variance (TABLE 2).

DISCUSSION

Of the lifestyle behaviors examined, only physical activity was associated with functional capabilities. Consistent with previous work,¹⁰ mood and fatigue, rather than resilience, had a significant direct effect on functioning. This is also true for a diagnosis of progressive MS, which has also been associated with greater functional limitations.³⁴ However, resilience did have a positive, significant indirect effect, with physical activity explaining its relationship with functioning. This is consistent with the hypothesis that higher resilience would be associated with greater physical activity engagement,¹⁵ which in turn would be connected to better functional capabilities.¹³

As part of the comprehensive care model for MS, both pharmacological and nonpharmacological treatments are necessary.³⁵ While some individuals may be predisposed, resilience in response to chronic health conditions can be learned over time via intervention.³⁶ As such, fostering resilience may be an approach to promote physical activity engagement and indirectly improve functional capabilities. Despite the benefits of physical activity,^11-13,³⁷ many individuals with MS do not meet the recommended 150 minutes per week.³⁸ Several physical activity barriers (eg, limited social support, low confidence, and depression)^38,39 could be addressed through a resilience-building intervention focused on increasing coping strategies and support systems.^19,40-44 Some programs specifically address physical activity engagement.⁴⁵ However, while improvements in physical HRQOL have been found,^40,42 to date, no study has included physical activity as an outcome. Future studies should investigate whether resilience-building interventions can be used to improve physical activity engagement and, subsequently, functional outcomes in individuals with MS.

Given their effects on MS-related disability,¹⁴ it was unexpected that alcohol misuse and smoking were not related to functioning; however, this may be due to less than 5% of participants being either current smokers (n = 3) or having unhealthy alcohol use (n = 2), defined as a score of 5 or above on the AUDIT-C.⁴⁶ In addition, participants may have made less healthy dietary choices, reducing the strength of the relationship between diet and functional outcomes. Although there was a positive association between diet and resilience (r = 0.25, P = .049), the average diet score was 7.02 (SD = 2.75). Comparatively, resilient older adults with MS had an average score of 9.86 (SD = 3.40) on the same measure, while those with low resilience had an average score of 8.98 (SD = 3.13).¹⁵ As such, the relationship between resilience, lifestyle, and functioning should be reexamined in a larger sample with a greater representation of certain behaviors.

The small sample size should also be taken into consideration when interpreting the results of the mediation, as it was only powered to detect large effects with the number of included variables. As such, the finding that resilience does not have a direct effect on functional capabilities should be interpreted with caution and verified in a larger sample. While the model was theoretically based, the data were cross-sectional; thus, causal conclusions cannot be definitively made. Furthermore, it is likely that some of the relationships examined are bidirectional (eg, lower functional capabilities contributing to decreased physical activity engagement). Functional capabilities were also measured via self-report. Although self-report and performance-based functional measures are correlated,⁴⁷ there is not a perfect agreement. While the depression and anxiety items of the SymptoMScreen have been validated against traditionally used scales,²⁴ the fatigue item has not been validated against measures such as the Modified Fatigue Impact Scale. In addition, most participants were White and had a relapsing form of MS, limiting the generalizability of the results. Finally, as the SLIQ Physical Activity score was used, a closer examination of the type and level of physical activity could not be done. Future research may examine the specific types of physical activity, confirmed objectively with an accelerometer, and their relationships with resilience and functioning.

CONCLUSIONS

Evidence suggests that resilience may indirectly contribute to functional capabilities through physical activity engagement. These findings highlight the important role of resilience in promoting well-being in individuals with MS and potential pathways for increasing activity engagement.

PRACTICE POINTS

• Individuals who are resilient can maintain stability in their well-being when faced with challenges related to multiple sclerosis (MS). Resilience may contribute directly to functional outcomes or indirectly through other mechanisms, such as engagement in healthy lifestyle behaviors.
• In people with MS, greater resilience was associated with more physical activity, which in turn was connected to better functional capabilities. Resilience did not directly impact functioning after considering factors such as mood and fatigue.
• Resilience-building interventions may be an approach to increase activity engagement and improve functioning in individuals with MS.