**4. Discussion**

The COVID-19 pandemic was demonstrated to cause an increased level of anxiety and depression, and a worse sleep quality in MS patients throughout different countries [2,10–13]. The Italian authors of [14] reported a greater prevalence of severe stress (measured in PSS-10) in MS subjects, in comparison with the healthy controls or the patients with migraine. The results of PSS-10 in our study indicate a moderate or high level of perceived stress in a vast majority of respondents (more than 80%). The international cohort surveys, conducted during the pandemic, also revealed a moderate to high level of stress in healthy adults, with mean PSS-10 score up to 19 points [15,16]. MS subjects are considered to have greater susceptibility to stress, due to the background of the disease (autoimmune response associated with autonomic and endocrine dysregulation) and its specificity (long-lasting and unpredictable course, accumulating disability). However, a diverse range of PSS-10 score had been obtained in the studies in this field [17–22], which suggests individual differences in perception of stress in MS population. With regard to the pandemic, no comparative studies were conducted with the use of PSS-10, but a prevalence of anxiety and depression in MS patients did not increase in comparison with the pre-pandemic assessment [10,23]. Thus, it remains disputable whether the pandemic has indeed enhanced distress experienced by MS patients.

There is some evidence [3,24–26] that people with MS tend to undertake passive and emotion-focused coping strategies, which makes them more vulnerable to stressful life events. However, adaptation to the limitations posed by a disease, as well as psychological support, may cause a shift towards more active and effective coping. The Brief-COPE results showed that the respondents to our survey overall preferred problem-focused coping, with planning, active coping and positive reframing as the most frequently used strategies. In another study, Spanish MS patients, surveyed during the pandemic, favored active confrontation and religion, while their use of emotional support, humor and positive re-evaluation was less frequent than in healthy controls [4]. The Italian survey [13] also indicated preference for positive attitude, problem solving and turning to religion among MS patients. It is worth highlighting that epidemic restrictions significantly limited the access to the sources of instrumental (from health-care and rehabilitation facilities) and emotional (contacts with family and friends) support which provide a basis for relevant coping strategies [13]. MS patients perceived especially a decrease in social support as a major negative impact of lockdown [3,14]. In healthy adults, positive coping strategies were shown to moderate a distress caused by the pandemic [27,28], but it was suggested that preferred strategies might reflect a temporary reaction to an unprecedented traumatic situation, and not necessarily a usual coping model [27]. In our study group, the increased level of stress was associated with a weaker preference for problem-focused coping. Supposedly coping strategies in MS subjects have developed in the long-term course of disease but were additionally affected by a temporary pandemic distress.
