Epilepsy & Behavior 29 (2013) 581–584

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Brief Communication

The coping styles and health-related quality of life of South African patients with psychogenic nonepileptic seizures Gretha Cronje ⁎, Chrisma Pretorius Stellenbosch University, Department of Psychology, Wilcocks Building, Victoria Street, Stellenbosch 7130, South Africa

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Article history: Received 29 July 2013 Revised 17 September 2013 Accepted 29 September 2013 Available online 26 October 2013 Keywords: Nonepileptic seizures Health-related quality of life Coping Stigma Stress Conversion South Africa

a b s t r a c t Objective: The primary aim of this study was to explore a possible association between the coping styles and the health-related quality of life (HRQOL) of patients with psychogenic nonepileptic seizures (PNES) in the South African context. Methods: Twenty-two patients with PNESs with confirmatory video-EEG were matched by age and gender with a healthy control group. Participants had to complete self-reported measures of HRQOL and coping strategies. Data analysis consisted of performing Pearson correlations, analysis of variances, and regression analysis. Results: The results indicated that the HRQOL scores of the group with PNESs were significantly lower than the HRQOL scores of the healthy control group. The participants with PNESs utilized significantly more escape– avoidance and distancing coping strategies in comparison to the healthy control group. The results also indicated that the avoidance coping strategies utilized by participants with PNESs had a significant negative effect on their HRQOL. Conclusions: The findings of this study provided greater insight into the coping strategies utilized by participants with PNESs, which have been identified as risk factors in PNESs. This is the first study of this nature of people with PNESs in South Africa. © 2013 Elsevier Inc. All rights reserved.

1. Introduction Psychogenic nonepileptic seizures (PNESs) are episodes that resemble epileptic seizures but are not associated with abnormal electric discharges in the brain. These episodes may be caused by an underlying psychic conflict or psychological problem and are usually considered to be beyond patients' voluntary control [1]. Psychogenic nonepileptic seizures are manifestations of debilitating diseases that necessitate several adjustments in a patient's life, and that may become chronic. Factors that might influence the HRQOL in patients with PNESs are still poorly understood. Previous research indicates that depression, aspects of family functioning [2], and seizure frequency [3] may be associated with low HRQOL in patients with PNESs. Research focusing on chronic illnesses indicates that coping styles play a major role in HRQOL [4,5]. The literature on PNESs suggests that avoidance coping is a prominent coping strategy for patients with PNESs [6–8]. Avoidance coping can be seen as a deliberate effort to avoid the problem [9]. Moreover, research has shown that the scores of patients with PNESs on the HRQOL measure are significantly lower than those of groups with epilepsy and healthy control groups [2,7].

⁎ Corresponding author. E-mail addresses: [email protected] (G. Cronje), [email protected] (C. Pretorius). 1525-5050/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.yebeh.2013.09.045

Therefore, it can be hypothesized that an individual's personal coping style may play an important role in his/her quality of life. However, no research into the association between specific coping styles and HRQOL of patients with PNESs could be found. Therefore, the primary aim of this study is to explore if a relationship between coping styles and the HRQOL of patients with PNESs exists. 2. Methods Participants were recruited over a 9-month period from the Epilepsy Unit at the Constantiaberg Medi-Clinic and the Department of Neurology at the Tygerberg Hospital in the Western Cape of South Africa. Patients with PNESs (aged 14 years and older) with confirmed video-EEG were included in the study. Patients with PNESs with comorbid epilepsy were excluded from the study. Although most of the PNES studies compare patients with PNESs with patients with epilepsy as a control group, the validity of such a comparison is questionable [7]. Therefore, this study compared the results with those of a healthy control group. Participants in the healthy control group were matched by age and gender and were excluded from the study if they had a history of seizures of any kind and/or had been diagnosed with a psychiatric/ psychological disorder within the past year. Advertisements and flyers were used to attract participants for the healthy control group. The advertisements and flyers were put up at a private practice of a general practitioner and at Stellenbosch University. A reason for this recruitment technique was the time limit of the study. Another reason was

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to attract participants with similar socioeconomic status and education levels. In South Africa, only people who have access to medical aid utilize the services of a private practitioner or private hospital, which is where most of the patients with PNESs were recruited from. The unknown prevalence rate of PNESs in South Africa made it difficult to determine the type and number of participants to select for the healthy control group beforehand. This was a quantitative cross-sectional study that formed part of a larger study. Ethical approval for this study was obtained from the Health Research Ethics Committee at Stellenbosch University (protocol number: N11/08/267). Participants had to give written informed consent to participate in this study. Participants also had to complete a demographic questionnaire as well as self-reported measures of HRQOL (SF-36v2 Health Survey) [10] and coping strategies (Ways of Coping (WOC)) [9]. Analyses of variances were performed to explore the differences between the group with PNESs and the healthy control group on the various measurement instruments. The association between specific coping strategies and HRQOL was investigated by calculating Pearson's correlation coefficient. Multiple regressions were conducted to determine the extent to which HRQOL could be accounted for by each of the coping strategies.

3. Results Forty-four participants (22 in the group with PNESs and 22 in the healthy control group) completed the study. Most of the participants with PNESs (17 of the 22) were female. The mean age of the group with PNESs was 32.77 years (with a SD of ±14.40). Although the participants with PNESs of this study were only matched with the healthy control group by age and gender, the distribution of the socioeconomic status of these groups was very similar. Most of the participants with PNESs and control group participants regarded their household income as falling within the middle-income group. Half of the group with PNESs and the control group were single, and the other 50% were married. In both groups, more than a third of the participants were employed full-time. Only 24% of the participants with PNESs had received tertiary education, whereas 59% of the control group had received tertiary education. The results indicated that the HRQOL scores of the group with PNESs were significantly lower than the HRQOL scores of the healthy control group on all the SF-36v2 subscales, as indicated in Table 1. The results Table 1 ANOVA results of the SF-36v2 Health Survey and the WOC for the group with PNESs and the control group.

SF-36v2 subscales (0–100) General health Physical functioning Role limitation: physical Role limitation: emotional Social functioning Bodily pain Vitality Mental health

PNES (n = 22)

Control (n = 22)

Mean

±SD

Mean

±SD

F

p

56.29 65.00 42.90 43.94 35.23 41.48 41.76 51.21

±23.62 ±30.59 ±35.53 ±35.28 ±30.04 ±27.27 ±21.16 ±20.50

90.91 95.00 96.31 93.56 93.18 91.71 72.16 88.79

±9.08 ±8.86 ±6.30 ±16.05 ±18.79 ±10.62 ±17.11 ±7.91

41.20 19.52 48.20 36.06 58.86 64.79 27.44 64.33

b0.01⁎⁎⁎ b0.01⁎⁎⁎ b0.01⁎⁎⁎ b0.01⁎⁎⁎ b0.01⁎⁎⁎ b0.01⁎⁎⁎ b0.01⁎⁎⁎ b0.01⁎⁎⁎

7.09 10.09 9.59 10.64 6.64 4.45 6.27 12.18

±4.43 ±3.19 ±4.71 ±4.41 ±3.44 ±3.04 ±5.28 ±4.65

.95 1.64 .20 .40 4.28 1.31 14.56 .23

.33 .21 .66 .53 .05⁎ .26 .00⁎⁎⁎ .64

Ways of Coping Questionnaire subscales Confrontive coping 8.41 ±4.54 Self-controlling 11.82 ±5.46 Seeking social support 10.27 ±5.48 Planful problem solving 9.77 ±4.70 Distancing 9.32 ±5.01 Accepting responsibility 5.73 ±4.23 Escape–avoidance 13.05 ±6.43 Positive reappraisal 11.36 ±6.62 ⁎ p b .10. ⁎⁎⁎ p b .01.

Table 2 Pearson's correlation between the HRQOL and WOC for the group with PNESs. Ways of Coping Questionnaire subscales

R

p

Confrontive coping Self-controlling Seeking social support Planful problem solving Distancing Accepting responsibility Escape–avoidance Positive reappraisal

−.05 −.33 −.07 −.12 −.18 −.27 −.40 −.25

.83 .14 .80 .60 .43 .22 .07⁎ .25

⁎ p b .10.

show a significant difference between the mean scores of the group with PNESs and the healthy control group on two of the WOC subscales, the escape–avoidance and distancing subscales. The results also indicated (refer to Table 2) that the escape–avoidance coping strategy correlated significantly with a negative HRQOL for patients with PNESs. Table 3 illustrates the results of the best-subset regression analysis that was conducted to determine which of the eight coping strategies of the WOC predicted HRQOL. The summary of the best-subset regression indicated that the subscales self-control, seeking social support, accepting responsibilities, and positive reappraisal did not contribute to a better fit (R2) of the regression model; therefore, they were excluded from the multiple regression analysis. As illustrated in Table 3, the escape–avoidance coping strategy was a significant negative predictor of HRQOL (β = −3.44, p b .01). The distancing coping strategy was a significant negative predictor (at the 10% significance level) of HRQOL (β = −1.40, p b .10). However, the confrontive coping strategy was the only significant positive predictor (at the 5% significance level) of HRQOL (β = 2.52, p b .05). Further, Table 3 illustrated that the four subscales of the WOC scale together accounted for 56% of the variance in the HRQOL total score of this sample. This result was significant at the 1% level (F(4,39) = 12.45, p b .00000). These results indicate that the coping strategies used by the participants may have a significant effect on their HRQOL. 4. Discussion Research focusing on self-report investigations found that patients with PNESs were more likely to use escape–avoidance coping styles to manage stress than the healthy control groups [6,8]. The findings of a study that investigated automatic threat-avoidance tendencies of patients with PNESs in relation to stress and cortisol levels were in line with the findings of the abovementioned self-report studies. They also found that patients with PNESs showed increased avoidance behavior to social threat cues [11]. Thus, our findings support the notion that patients with PNESs tend to avoid rather than approach stressful situations [6,12]. Research has also theorized that the tendency of avoidance behavior in individuals may make them more vulnerable to developing PNESs [6,11]. In support of Frances et al. [6], but contrary to the findings of Goldstein et al. [8], the patients with PNESs in this study scored significantly higher Table 3 Multiple regression of the SF-36v2 Health Survey on the WOC scale. Predictor

Standardized β

Std. error of B

B

t-Ratio

p

Confrontive coping Planful problem solving Distancing Escape–avoidance

.42 .18 −.23 −.87

.16 .12 .13 .15

2.52 1.08 −1.40 −3.44

2.70 1.5 −1.81 −5.88

.01⁎⁎ .14 .08⁎ .00⁎⁎⁎

F(4,39) = 12.45, R = .75, R2 = 56%, R2 (adjusted) = 52%, SE = 18.62. ⁎ p b .10. ⁎⁎ p b .05. ⁎⁎⁎ p b .01.

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on the distancing coping strategy than those in the healthy control group. Although no significant correlation could be found between distancing coping strategy and the HRQOL of the participants with PNESs, it emerged as a significant negative predictor of HRQOL for this sample. Distancing strategies may be a useful coping technique in certain situations. However, the recurrent use of distancing coping strategies may affect the individual's social functioning and have a negative effect on his/her life [6,9]. From the results of the study, it is evident that PNESs have a very negative effect on an individual's well-being, but often, seizure frequency on its own does not explain low self-reported HRQOL. Studies indicate that the reduction of seizure frequency does not always translate into equal improvement in the HRQOL of patients with PNESs [3,13]. A possible reason for this may be related to the coping strategies utilized by patients with PNESs. A study that examined the relationship between coping style and perceived HRQOL in patients with epilepsy, compared with individuals from the Dutch population, found that patients with epilepsy more often tend to use an avoidance coping style [5]. They also suggested that the patient's coping style may be more important in predicting the mental component of HRQOL than seizure frequency. Furthermore, researchers report that patients with PNESs use even higher levels of avoidance behavior than patients with epilepsy [12] and that their HRQOL are also lower than those of patients with epilepsy [2]. The results of this study indicate that, for the participants with PNESs, avoidance coping strategies correlated significantly with low HRQOL. Therefore, it may be possible that, even though the seizure frequency of patients with PNESs may decline, they will still report a low HRQOL because of their tendency to use less effective coping strategies, such as escape–avoidance coping. Moreover, in line with previous studies [4,5], the results of this study suggested that the avoidance coping strategy emerged as a significant negative predictor of the HRQOL of this sample. Research found that when the patients experienced more disease-related symptoms, they tended to avoid certain situations, which in turn had a negative effect on their HRQOL [4]. Therefore, it could be speculated that when patients with PNESs experience more symptoms (such as a nonepileptic seizure), they will avoid situations and triggers that may lead to it. This restricted lifestyle may cause the individual to avoid certain activities, such as social or other extracurricular activities, thereby decreasing their HRQOL. One must be careful about labeling avoidance coping as an inadequate coping strategy, as no coping process is universally good or bad. The context should always be taken into account, and the coping style should match the situation [9]. Therefore, if, following a set of nonepileptic seizures, a person felt that people treated them as inferior because of the event, it would be understandable if they avoided certain social activities which made them feel stigmatized. However, the recurrent use of avoidant coping is likely to lead to failure in seeking psychological help and maintain psychological distress [6]. If patients fail to express their emotions, it may leave these emotions unresolved, which can, in turn, negatively affect the patients' health [6]. A multidisciplinary approach that also takes the coping styles of the person into account might be the best approach with which to treat these individuals [3]. Studies focusing on the treatment of PNESs indicate that the HRQOL of patients with PNESs should also be measured, not only the reduction of seizures, when determining the effectiveness of treatment [13,14]. Treatment programs that specifically address avoidance coping strategies as part of their cognitive behavioral treatment (CBT) have been developed [15]. Research emanating from these programs compared CBT with standard medical care (SMC) as a treatment for PNESs. The researchers reported that the CBT group had more patients who had become seizure-free or had a reduction in PNES frequency than those in the SMC group. Improvement in self-related social functioning was also found. Research suggests that when the coping skills of patients with PNESs are addressed during psychological treatment, their HRQOL

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seems to improve, and they seem to make use of more effective coping strategies [3]. Therefore, it is important that generic HRQOL measures should be used as an outcome measure in PNES studies [14]. Certain limitations should be highlighted with regard to the current study. A possible limitation of the study is that the socioeconomic status and educational level of the participants in the group with PNESs and the control group were not matched. However, previous researchers indicate that the predictive IQ level of the participants in both the group with PNESs and the nonclinical control group did not have a significant effect on their way of coping [8]. The fact that patients with epilepsy were not used as a control group could be seen as a limitation of the present study. It was not possible to identify whether the coping strategies utilized by the patients with PNESs were related to having seizures per se or whether this was related to having nonepileptic seizures. Unfortunately, in this study, we did not test whether a correlation between seizure frequency and HRQOL exists for the patients with PNESs and, therefore, we cannot comment on whether seizure frequency had a negative effect on HRQOL in the group with PNESs. Psychiatric measures were also not used to assess the potential influence of psychiatric conditions on the self-reported health status (HRQOL) of the participants. The current study was cross-sectional in nature and as such provides limited insight into the HRQOL and the coping strategies of patients with PNESs. Further longitudinal studies may contribute a better understanding to the contribution of HRQOL and the coping strategies of patients with PNESs over time. Finally, the reliance on the use of self-reported measures to assess coping strategies and perceived health status may not reflect actual behavior. However, the SF-36v2 and the coping measurement (WOC) have been used widely and are regarded as valid and reliable measures. Therefore, accepting these limitations, the results highlight the perceived low HRQOL and the coping strategies used by individuals with PNESs. 5. Conclusion In line with international research [2,7], these results indicate that PNESs have a negative effect on the HRQOL of individuals diagnosed with this disorder in South Africa. The novelty of this study is that, for the first time, an association between the use of avoidance coping strategies and the low HRQOL in patients with PNESs is suggested. However, the design does not permit conclusions on causality. Consequently, the findings cannot be generalized validly beyond this particular population. More research is required to understand the interaction between seizure frequency, stigma, HRQOL, and the coping strategies used by patients with PNESs. Disclosure agreement Gretha Cronje reports no disclosures. Dr. Pretorius reports no disclosures. Acknowledgments The authors would like to thank Prof. Martin Kidd, Stellenbosch University, Department of Statistics and Actuarial Sciences, for his assistance with the statistical analysis; Dr. James Butler, Neurologist at Constantiaberg Medi-Clinic, for his referrals and assistance with the data collection process; and Prof. Jonathan Carr and the staff at the Division of Neurology at Tygerberg Hospital for their referrals. References [1] Griffith NM, Szaflarski JP. Epidemiology and classification of psychogenic nonepileptic seizures. In: Schachter SC, LaFrance Jr WC, editors. Gates and Rowan's nonepileptic seizures. 3rd ed. Cambridge: Cambridge University Press; 2010. p. 3–16. [2] LaFrance Jr WC, Alosco ML, Davis JD, Tremont G, Ryan CE, Keitner GI, et al. Impact of family functioning on quality of life in patients with psychogenic nonepileptic seizures versus epilepsy. Epilepsia 2011;52(2):292–300.

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[3] Kuyk J, Siffels MC, Bakvis P, Swinkels WAM. Psychological treatment of patients with psychogenic non-epileptic seizures: an outcome study. Seizure 2008;17: 595–603. [4] Hesselink AE, Pennix BWJH, Schlösser MAG, Wijnhoven HAH, van der Windt DAWM, Kriegsman DMW, et al. The role of coping resources and coping style in quality of life of patients with asthma or COPD. Qual Life Res 2004;13:509–18. [5] Westerhuis W, Zijlmans M, Fischer K, van Andel J, Leijten FSS. Coping style and quality of life in patients with epilepsy: a cross sectional study. J Neurol 2011;258: 37–43. [6] Frances PL, Baker GA, Appleton PL. Stress and avoidance in pseudoseizures: testing the assumption. Epilepsy Res 1999;34:241–9. [7] Mercer G, Martin RC, Reuber M. Health related quality of life: utility and limitation in patients with psychogenic nonepileptic seizures. In: Schachter SC, LaFrance Jr WC, editors. Gates and Rowan's nonepileptic seizures. 3rd ed. Cambridge: Cambridge University Press; 2010. p. 149–56. [8] Goldstein LH, Drew C, Mellers J, Mitchell-O'Malley S, Oakley DA. Dissociation, hypnotisability, coping styles and health locus of control: characteristics of pseudoseizure patients. Seizure 2000;9:314–22.

[9] Folkman S, Lazarus RS. Manual for Ways of Coping Questionnaire. California: Consulting Psychologist Press, Inc.; 1988. [10] Ware Jr JE, Kosinski M, Bjorner JB, Turner-Bowker DM, Gandek B, Maruish ME. User's manual for the SF-36v2TM Health Survey. 2nd ed. Lincoln: Quality Metric Incorporated; 2007. [11] Bakvis P, Spinhoven P, Zitman FG, Roelofs K. Automatic avoidance tendencies in patients with psychogenic nonepileptic seizures. Seizure 2011;20:628–34. [12] Goldstein LH, Mellers JDC. Ictal symptoms of anxiety, avoidance behavior, and dissociation in patients with dissociative seizures. J Neurol Neurosurg Psychiatry 2006;77:616–21. [13] Reuber M, Mitchell AJ, Howlett S, Elger CE. Measuring outcome in psychogenic nonepileptic seizures: how relevant is seizure remission? Epilepsia 2005;46(11): 1788–95. [14] LaFrance Jr WC, Alper K, Babcock D, Barry JJ, Benbadis S, Caplan R, et al. Nonepileptic seizures treatment workshop summary. Epilepsy Behav 2006;8:451–61. [15] Goldstein LH, Chalder T, Chigwedere C, Khondoker MR, Moriarty J, Toone BK, et al. Cognitive-behavioral therapy for psychogenic nonepileptic seizures. Neurology 2010;74(24):1986–94.

The coping styles and health-related quality of life of South African patients with psychogenic nonepileptic seizures.

The primary aim of this study was to explore a possible association between the coping styles and the health-related quality of life (HRQOL) of patien...
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