Elsevier

Epilepsy & Behavior

Volume 22, Issue 2, October 2011, Pages 279-284
Epilepsy & Behavior

Motivation, psychopathology, locus of control, and quality of life in women with epileptic and nonepileptic seizures

https://doi.org/10.1016/j.yebeh.2011.06.020Get rights and content

Abstract

To examine factors that may potentially aid in the differential diagnosis and subsequent tailoring of treatment for patients with epileptic (ES) and psychogenic nonepileptic (PNES) seizures, thirty female patients with PNES and 51 female patients with temporal lobe epilepsy were assessed in the areas of motivation, psychopathology, health-related locus of control (HRLOC), and health-related quality of life (HRQOL). The two groups demonstrated equivalent levels of motivation, clinically elevated yet comparable mood symptoms, and no general differences in HRLOC. Despite similar mood disturbances in both groups, the participants with PNES had a later age of seizure onset, exhibited greater personality disturbances, attributed more control over their condition to nonphysicians, and endorsed a greater negative impact of their seizures on physical and emotional aspects of HRQOL. Preliminary analyses suggest that chronic anxiety and overall HRQOL may be core discriminators between these seizure groups. Addressing such issues may prove useful in tailoring more specific treatments for these etiologically disparate conditions.

Highlights

► Both groups demonstrated equivalent motivation, elevated yet comparable mood symptoms and no general HRLOC differences. ► PNES patients demonstrated greater personality disturbances. ► PNES patients attributed greater control over their condition to non-physicians in comparison to TLE patients. ► PNES patients endorsed a greater negative impact of their seizures on physical and emotional aspects of HRQOL. ► Chronic anxiety and overall HRQOL were significant predictors of group membership.

Introduction

After decades of research in the area of psychogenic nonepileptic seizures (PNES), a consensus regarding the specific profile differences between such patients and those with epileptic seizures (ES) has not been clearly established [1], [2], [3]. Nonepileptic activity is estimated to occur in 5–20% of outpatients and 10–40% of inpatients referred for epilepsy evaluations, constituting a sizable population for which diagnostic accuracy remains questionable [4], [5]. Given that both nonepileptic and epileptic episodes can present clinically similar features, video electroencephalographic (VEEG) monitoring is currently the gold standard for distinguishing these etiologically disparate events [6]. However, in addition to the limited availability of this technology, the high comorbidity of PNES in ES conditions and the absence of EEG abnormalities in some patients with epilepsy during VEEG monitoring warrant the development of additional or alternative diagnostic methods [1], [7].

Although both patients with ES and those with PNES exhibit impaired performance on objective measures of neuropsychological functioning, the causal mechanism(s) underlying such demonstrations in patients with PNES has yet to be established [1], [2], [3], [8], [9]. While Binder et al. propose that individuals with PNES may possess limited psychological resources, presumably as a result of psychopathology [10], others have suggested that high anxiety may be a principal characteristic of the psychopathology characterizing patients with PNES and that this personality trait may actually confer risk for the initial development of the condition [11]. A pessimistic attributional style has also been proposed as an explanation for the impaired neurocognitive performance of patients with PNES [11], [12], and chronic anxiety could be the result of this enduring personality trait, as prolonged exposure to cortisol elevations produced by such stress may potentially impair memory by inflicting damage to the hippocampus [13]. Although few studies have examined the health-related locus of control (HRLOC) of patients with PNES [14], [15], [16], the results of preliminary investigations suggest that patients with PNES have a greater external locus of control than those with ES, and that such orientation may reflect a consistent personality characteristic that could potentially contribute to their underlying psychopathology and lower health-related quality of life (HRQOL) [15], [16].

Decreased HRQOL in patients with PNES and ES has typically been attributed to the general experience and stigma of such disorders, as well as the affective symptomatology frequently observed in these patient populations [17], [18]. Although some investigators hold that current mood state is the most significant predictor of HRQOL in patients with PNES and ES [19], a recent study conducted by Testa et al. suggests that more chronic aspects of mood and personality (e.g., emotional dysregulation and somatization tendencies) are of greater significance than current mood state in the prediction of HRQOL of patients with PNES [20]. Although no study to date has evaluated group differences in effort, psychopathology, HRLOC, and HRQOL in a single sample, concomitant evaluation of these factors may further differentiate between seizure groups and aid in tailoring unique and more effective treatments. As gender has been shown to significantly influence the presentation of psychopathology in patients with PNES [21], limiting our focus to women, who constitute the majority of this patient population [22], [23], [24], may aid in the prevention of potential gender effects. The purpose of the present study was to compare suspect effort, mood (anxiety and depression), personality characteristics, HRLOC, and HRQOL in a sample of female patients with PNES and female patients with temporal lobe epilepsy (TLE).

Section snippets

Methods

Thirty consecutive female patients diagnosed with PNES and 51 with TLE (23 right TLE and 28 left TLE) who underwent comprehensive neurological examinations (including VEEG monitoring and structural neuroimaging) and neuropsychological assessment were recruited for participation during an 18-month period. Neurocognitive results have been presented for a subset of these participants (33 with PNES and 25 with left TLE) [22]. Exclusion criteria included: (1) estimated IQ score < 70; (2) current or

Demographic variables

The PNES and TLE groups did not differ in age, level of education, or testing setting. However, a significant between-group difference was observed for age at onset and years of seizure activity, with patients with PNES reporting a later age at symptom onset and a shorter duration of seizures. Of these two variables, only age at onset was significantly correlated with the outcome measures—specifically several MMPI-2 scales as well as the Physical Functioning subscale and total score of the

Discussion

The current study provides further information regarding the characterization of motivation, psychological functioning, HRLOC, and HRQOL in women with PNES compared women with TLE. In this sample, both seizure groups showed equivalent effort that was within the normal range, as well as moderate self-reported depression and anxiety symptomatology. However, patients with PNES evidenced symptoms of psychological disturbance that appear to be of a chronic nature (e.g., somatization, multiple health

Acknowledgments

Funding was not provided for this study. We thank our patients for their participation in our clinical research.

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