Psychological profiles in patients with medically ...

Seizure 1999; 8: 304–309

Article No. seiz.1999.0294, available online at http://www.idealibrary.com on

Psychological profiles in patients with medically refractory epilepsy †

VESLEMØY P. WATTEN & REIDULF G. WATTEN

‡

†

Røysumtunet Centre for Rehabilitation and; ‡ Department of Health and Social Science, Lillehammer College, and Institute of Psychology, Norweigan University of Science and Technology, Trondheim, Norway. Correspondence to: Reidulf G. Watten, Department of Health and Social Science, Lillehammer College, 2801 Lillehammer, Norway

The aim of this study was to explore whether patients with epilepsy show characteristic psychological profiles which might be risk factors for epileptic seizures. The instruments used in the case-control study were the Millon Behavioural Health Inventory (MBHI) and the Arnett Inventory of Sensation Seeking (AISS). A sample of hospitalized patients with medically refractory epilepsy (n = 15) and a sample of healthy controls (n = 15) matched on age and gender. Compared to the controls, the patients with epilepsy showed different psychological profiles. The patients with epilepsy showed significantly higher scores on the basic coping styles MBHI Inhibition style and MBHI Sensitivity style, and lower scores on the MBHI Sociability and the MBHI Confidence. The epilepsy group also exhibited elevated scores on the MBHI psychogenic attitude scales Chronic tension, Recent stress, Pre-morbid pessimism, Social alienation and Somatic anxiety. The patient group had lower sensation-seeking scores on the AISS Novelty scale, the AISS Intensity scale and in AISS Total scores. Some patients with medically refractory epilepsy show dysfunctional coping styles. These factors should be taken into consideration in treatment and rehabilitation planning. The findings point to psychological risk factors for eliciting epileptic seizures. Key words: epilepsy; personality; sensation seeking.

INTRODUCTION While a number of studies have shown that epilepsy may lead to considerable psychosocial problems for patients with epilepsy, only a few studies have looked at how psychological factors influence the disease itself1 . This issue is of clinical interest because an increasing number of studies suggest a relationship between emotions and the occurrence of seizures. For instance, Puskarich et al.2 found that progressive relaxation training had a positive effect upon seizure frequency. Kloster et al.3 estimated that in about 50% of patients with various forms of epilepsy referred to a tertiary epilepsy centre, psychosocial factors, most notably reduction of anxiety, played a crucial role in reduction of seizures, confirming the suggestions made by Rodin more than thirty years ago that the patients’ personality was an important prognostic factor in the development of epilepsy4 . The effects of psychological treatment upon seizures are also poorly investigated, although a few studies 1059–1311/99/050304 + 06

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point to a therapy effect. For instance, Gillham5 reported that psychological treatment showed a significant reduction in seizure frequency at 6-month followup, suggesting that it is important to investigate relations between specific psychological functions such as the role of coping styles, psychological defence and emotional control, and seizures. Snyder6 , exploring the effects of stressors, coping mechanisms, and perceived health in persons with epilepsy, found that patients employing problem-oriented strategies perceived their health as better than those who rated their health as poor. Finally, Sikic et al.7 , employing the Eysenck Personality Inventory for juniors, found that children with epilepsy were significantly more introverted than the healthy controls, but there were no significant differences in neuroticism. In the current study we have examined more closely the issue of a possible link between psychological factors and epilepsy by investigating the association between epilepsy and individual basic coping styles, and a specific personality trait denoted sensation seeking. c 1999 British Epilepsy Association

Psychological profiles in patients with medically refractory epilepsy

These issues are important with respect to both treatment, rehabilitation, and general quality of life.

MATERIALS AND METHODS Subjects The epilepsy group (n = 15; 4 women and 11 men, mean age 35.4 years) comprised patients with epilepsy admitted to the short-term department at the Røysumtunet Rehabilitation Centre in the time period from August 1995 until April 1997. This department is rather small, having only 11 beds. We included only those patients who were hospitalized for a minimum of 6 weeks. Patients admitted for shorter periods were excluded from the investigation. During the investigation period, some of the patients were re-admitted. The main diagnosis for the epilepsy group was ICD-9, code 345.4 (partial epilepsy). The majority of the subjects had exhibited CPA seizures and/or GTC seizures. The main causes for the epilepsy, when known, were encephalitis, cerebral palsy or birth traumas. Two-thirds of the patients had their first epileptic seizure in early childhood (0–5 years), three patients as teenagers (14–16 years) and two patients as adults. All the patients were treated daily with from two to five antiepileptica, and many of them also with one neurolepticum. All the patients received state disablement benefit. In addition, some of them had sheltered employment. Most of the patients had no daily activity outside their homes. The mean education level was 9 years primary school. The control group (n = 15) was selected from a sample of healthy students and matched with the epilepsy group on age (mean age: 34.7 years) and gender (4 women and 11 men). The controls had never experienced epileptic seizures or similar symptoms, and none had been admitted to hospital for serious medical or psychiatric illness. Although the two groups differed in terms of level of education, stable personality traits such as basic coping styles showed very low correlation with intellectual abilities8 .

Assessment of personality Personality was assessed using the Millon Behavioural Health Inventory (MBHI)9 . The MBHI is a widely used personality inventory originally developed to assess specific psychosocial factors and decisionmaking processes and issues relevant for medical patients. The MBHI consists of 150 true–false items such as ‘I have almost never been sick’, ‘People can influence me quite easily’, ‘A quiet hobby is more fun for

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me than a party’, ‘I like to arrange things down to the last detail’ (for further descriptors the manual should be consulted)10 . MBHI provides information on (i) basic coping styles, (ii) psychogenic attitudes, (iii) psychosomatic correlates, and (iv) prognostic indices. We only used the coping and psychogenic attitude scales. Basic coping styles reflect the ways individuals tend to approach other people and difficult life situations. Psychogenic attitudes refer to personal feelings and perceptions regarding aspects of psychological stress which might aggravate the course of the current disease. There are five subscales denoted Chronic Tension, Recent Stress, Premorbid Pessimism, Social Alienation and Somatic Anxiety. These components reflect hopelessness, degree of social support, and hypochondriac tendencies. Statistical data on the basic psychometric properties of the MBHI are given elsewhere9, 10 . Although the MBHI has been used in several other Scandinavian investigations11–13 , population norms for clinical or normal samples have not been developed. For this reason, we used the raw scores of the subjects instead of computed base-rate scores.

Assessment of sensation seeking Sensation seeking is assessed using the Arnett Inventory of Sensation Seeking (AISS)14 . The AISS focuses on novelty and intensity of stimulation of the senses. Contrary to the SSS-V (Sensation Seeking Scale Form V), the AISS does not contain items which are intrinsically age related (i.e. items involving physical strength or stamina), nor items containing legal- or norm-breaking behaviour. In total, the AISS consists of 20 items with two subscales of 10 items each, Novelty and Intensity (Fig. 3). The Novelty subscale consists of items such as ‘I would have enjoyed being one of the first explorers of an unknown land’, ‘I can see how it would be interesting to marry someone from a foreign country’ and ‘I would often like to have the radio or TV on while I’m doing something else, such as reading or cleaning up’. The Intensity subscale consists of items such as ‘When I listen to music, I like it to be very loud’, ‘It would be interesting to see a car accident happen’, and ‘I like the feeling of standing next to the edge on a high place and looking down’. The response formats are a Likert type (1–4). Psychometric properties are presented and discussed in Arnett14 . PROCEDURE Information about personality and sensation seeking was obtained by using the MBHI and the AISS as

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V. P. Watten & R. G. Watten

50 Epilepsy (n = 15) Controls (n = 15)

Raw scores

40

P < 0.001

30

NS P < 0.05

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NS NS

P < 0.05 NS

P < 0.05

10 0 Introv. Inhib. Coop. Soci.

Conf. Force. Resp.

Sens.

Fig. 1: Mean raw scores on the eight MBHI basic coping styles for epileptic patients and controls. Introv. = Introversive, Inhib. = Inhibited, Coop. = Cooperative, Soci. = Sociable, Conf. = Confident, Force. = Forceful, Resp. = Respectful, Sens. = Sensitive. Standard deviations of the scales are indicated on top of the bars.

30 Epilepsy (n = 15)

Raw scores

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Controls (n = 15)

20 P < 0.001

15

P < 0.001 P< 0.05 P < 0.01

10

P < 0.05

5 0 Chr. tension Rec. stress Prem. pess

Soc. alien Som. anxiety

Fig. 2: Mean raw scores on the MBHI psychogenic attitude scales for the epilepsy group and the control. Chr. tension = Chronic tension, Rec. stress = Recent stress, Prem. pess. = Premorbid pessimism, Soc. alien. = Social alienation, Som. anxiety = Somatic anxiety. Standard deviations are indicated on top of the bars.

structured interviews. Contrary to ordinary paper-andpencil administration of the questionnaire, each item was read slowly to the patients until the test administrator was sure that the subjects had understood the question. For healthy controls, the MBHI was administered in about 20 minutes and the AISS in about 5 minutes, and both questionnaires were completed in one session. The epilepsy group needed from 3– 5 hours to complete the MBHI and approximately 1 hour to complete the AISS, and on average six sessions were needed to complete the questionnaires. RESULTS The differences in raw scores were tested with series of analyses of variances (ANOVAs) in a factorial design where dependent variables were the grouping variables (patients/controls), and the independent variables were the raw scores on the MBHI and the AISS. Figure 1 shows the MBHI results for the two groups

on basic coping styles. There were significant differences between the patients and controls on four of the MBHI basic coping styles and the five MBHI psychogenic attitude scales. Compared to the controls, the epilepsy group had significantly higher scores on the Inhibition scale (F(1, 28) = 5.7, P < 0.05) and the Sensitivity scale (F(1, 28) = 4.1, P < 0.05), but showed significantly lower scores on the Sociability style (F(1, 28) = 34.5, P < 0.001) and the Confidence style (F(1, 28) = 4.3, P < 0.05). There were no significant differences for the other basic coping styles. Figure 2 depicts the results on MBHI Psychogenic attitude scales. There were significant differences between the patients with epilepsy and the controls on five of the scales. The patients had significantly elevated scores on the MBHI Chronic tension (F(1, 28) = 6.1, P < 0.05), the MBHI Recent stress scale (F(1, 28) = 5.8, P < 0.05), the MBHI Premorbid pessimism (1, 28) = 16.8, P < 0.001, the MBHI

Psychological profiles in patients with medically refractory epilepsy

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80 Epilepsy (n = 15) Controls (n = 15)

Raw scores

60 P < 0.001

40 P < 0.001

P < 0.001

AISS Novelty

AISS Intensity

20

0 AISS Total Score

Fig. 3: Mean sensation-seeking scores on the AISS Novelty scale, the AISS Intensity scale and the AISS Total score for the epilepsy group and the controls. Standard deviations of the scales are indicated on top of the bars.

Social alienation scale (F(1, 28) = 15.1, P < 0.001), and the Somatic anxiety scale (F(1, 28) = 8.2, P < 0.01). There were no significant differences on the other scales. Figure 3 shows the result on AISS sensation seeking. The epilepsy group had significantly lower AISS Novelty scores (F(1, 28) = 46.1, P < 0.001), lower AISS Intensity scores (F(1, 28) = 27.6, P < 0.001) and lower AISS total scores (F(1, 28) = 49.4, P < 0.001).

DISCUSSION Compared to normal, healthy controls, patients with epilepsy were different in affective and behavioural modes of relationships with other people. First, the epilepsy group exhibited elevated scores on the MBHI Inhibited style. High scores on this scale portray individuals as shy, ill-at-ease, hesitant, and concerned with possible (negative) reactions by other people. They are easily hurt, and they often fear that others try to take advantage of them. Accordingly, they have a tendency to keep problems and reactions to themselves, and an effort is needed to establish a good relationship with them. Since the epilepsy group showed elevated scores on the Inhibited style and on the Sensitivity style, lower scores than the controls on the MBHI Sociability style and the MBHI Confidence style were expected. Sociability is associated with traits revealing positive affects, as is evidenced from MBHI’s relationship with other diagnostic inventories. For instance, Millon et al.10 report that sociability correlates positively with CPI-Social presence (California Personality Inventory), CPI-Well-being and CPI-Sociability, but shows negative correlation with MMPI-Depression (Minnesota Multi-Personality Inventory) and MMPI-Social Introversion. High scorers

on MBHI-Sociability scale are portrayed as talkative, charming, outgoing, normally displaying positive affectivity. Individuals with high scores on the Confidence scale tend to act in a calm and confident manner. MBHI-Confidence correlates negatively with MMPIdepression, but positively with the CPI-Sociability and CPI-Dominance. MBHI-Confidence is also negatively related to self-report of bodily symptoms; quite contrary to the Sensitivity dimension. The epilepsy group also showed elevated scores on this dimension; primarily reflecting lower emotional stability, poor selfcontrol and less subjective well-being10 . The epilepsy group exhibited considerably less need for novelty seeking and sensory stimulation, as reflected by lower scores on the AISS Novelty scale, the AISS Intensity scale and the AISS total score. Sensation seeking is positively correlated with sociability and thrill- and adventure-seeking behavior14 . Thus, the epilepsy group’s elevated scores on Inhibition and lowered scores on the Sociability style correspond well with lowered Sensation seeking scores. In general, the epilepsy group’s results on the MBHI and the AISS portray a group of people with an elevated level of ‘inner’ emotional tension showing less need for external stimuli. They appear to be reserved, contemplative, socially distant and can easily be disturbed by too much sensory stimulation, probably leading to behavioural inhibition and introversion in order to protect themselves from being overwhelmed by impressions. Over time, they might also develop social withdrawal leading to a lower sociability, social competence and confidence, probably due to less opportunity to learn social skills. However, low sociability should not be interpreted as loneliness or a sign of depression. Several studies have shown that, in general, people with epilepsy all-in-all have fewer accidents than the

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average population. This applies to accidents at home, leisure activities and accidents at work15, 16 . The cause of this remain unclear, and clinicians have suggested a cautious lifestyle17 . However, lifestyle is highly correlated with personality factors and the described psychological profile in the current study is consistent with a very careful approach to everyday life. Thus, the reported findings on accidents are to be expected according to our results. The introverted, inhibited style is associated with increased level of cortical arousal. Hans Eysenck18 was one of the first investigators to point out the relationship between personality types and cortical arousal, postulating that extroverts have a lowered cortical arousal, while introverts have an elevated cortical arousal. Consequently, extroverts seek out to get more external sensory stimulation, whereas introverts try to reduce the sensory stimulation. Both groups try to achieve an optimal level of arousal. Eysenck’s pioneering findings have been supported by experimental evidence showing differences in sensory thresholds and psychomotor control between extroverts and introverts19 . For instance, several studies have shown differences between introverts and extroverts in neurobiological functions such as motor performance20 , psychophysiological motor response (such as the Hoffman reflex)21 and brain dopamine levels; although the findings here are more equivocal22, 23 . With reference to the psychological profile shown by the epilepsy group, a short comment on the effects of vagus nerve stimulation (VNS) should be made. VNS is an effective therapy for some patients since the VNS could be considered as a deactivating procedure. The brain areas which seem to be involved in the VNS, namely the hypothalamus, the amygdala, and the limbic forebrain are directly connected with the vagus nucleus and are involved in seizure inhibition. Indirect connections with the cortex, the cerebellum and several areas in the thalamus are also described24, 25 . For more than twenty years it has also been known that these areas are involved in the deactivating, physiological relaxation response26 . Thus, VNS stimulation probably reduces the elevated cortical arousal in inhibited people. When the VNS is not successful, one of the reasons might, therefore, be the underlying psycho-biological coping style associated with a low level of cortical arousal. In such cases we would not expect that a deactivating procedure, such as the VNS, would work. Accordingly, psychological profiles might predict which patients would profit from VNS therapy. However, this hypothesis should be investigated more closely. In the search for a better treatment of the group of medically refractory patients, coping styles and emotional expressions should be considered. For instance, expression of manifest, negative emotions (e.g. anger,

V. P. Watten & R. G. Watten

anxiety, temper tantrums etc.) might cause problems. Such emotional reactions are often experienced by the surroundings (i.e. the staff in the hospital, staff at work, families) as unpleasant or threatening and will most often be treated with behaviour-modification procedures or agreements in order to ‘control’ the reactions. Such emotionally suppressing procedures might prolong an elevated ‘inner’ tension level. When the emotional tension gets too high and becomes intolerable, patients with epilepsy, and who in addition show a repressive, inhibited coping style, might ‘solve’ the increased activation with a seizure attack. Thus, the underlying basic coping style in persons with epilepsy might be one risk factor, not per se, but in interaction with other risk factors and the medical condition. Inhibited individuals, such as the patients with epilepsy in the current study, often display poor social and emotional coping skills and are therefore especially vulnerable in social situations with a high level of emotional tension (i.e. interpersonal conflicts, new social situations, new people, new places). Clinical observations and psychological treatment studies underscore the suggestions5 . In Gilham’s study5 , the educational treatment was designed to improve coping skills. The groups involved showed a significant reduction in seizure frequency at 6-month follow-up, and a significant improvement on psychological symptoms. Our own clinical experience is in agreement with these findings. Even hospitalized patients with a medically refractory epilepsy seem to benefit from psychological treatment aimed at developing self-efficacy, functional coping styles and more differentiated, flexible and adequate ways of expressing positive and negative emotions. Future studies should attend more closely to this issue.

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