2018 Mirlohian
2018 Mirlohian
2018 Mirlohian
1
M.A. of Clinical Psychology, Najafabad Branch, Islamic Azad University, Najafabad, Iran
2
Department of Psychology, Najafabad Branch, Islamic Azad University, Najafabad, Iran
*
Corresponding author: Assistant Professor of Department of Psychology, Najafabad Branch, Islamic Azad University, Najafabad, Iran. Tel: +98-3142293030, Email:
abbas.haghayegh@gmail.com
Received 2018 March 10; Revised 2018 September 13; Accepted 2018 November 12.
Abstract
Background: Different psychological factors may explain the differences between epileptic and non-epileptic seizures. Accordingly,
the present study was conducted to compare alexithymia, perceived stress, and emotion regulation between patients with epileptic
and non-epileptic seizures.
Methods: In the present cross-sectional research, 82 patients (39 with epileptic seizures and 43 with non-epileptic seizures) were
selected. Using the Toronto Alexithymia Scale (TAS) (Bagby et al., 1994), Perceived Stress Scale (PSS) (Cohen et al., 1983) and cognitive
emotion regulation questionnaire (CERQ) (Garnefski and Kraaij, 2006), the required data were collected and then analyzed using
the SPSS-19 software.
Results: According to the results, patients with non-epileptic seizures had significantly higher scores in TAS, especially in the sub-
scales of difficulty identifying feelings and externally oriented thinking, PSS and CERQ, especially in the subscales of catastrophizing
and other-blame and lower scores in CERQ’s subscales of acceptance, positive reappraisal, and positive refocusing compared to pa-
tients with epileptic seizures (P < 0.05). The non-epileptic seizure group score was higher in the event acceptance subscale (as a
positive emotion regulation) (P < 0.05).
Conclusions: The results of this study showed that patients with epileptic seizures have a more favorable condition in terms of
alexithymia, emotion regulation, and perceived stress compared to those with non-epileptic seizures.
Keywords: Epileptic Seizure, Non-Epileptic Seizure, Alexithymia, Perceived Stress, Emotion Regulation
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Uncorrected Proof
of non-epileptic seizures it was revealed that 47% of people seizures and 16% and 13% in those with epileptic seizures,
with epilepsy also suffer from other psychiatric disorders, respectively (19).
and results of 10 other studies showed that 82% of peo- Emotion regulation is defined as strategies to repre-
ple, who completed treatment in psychology, had a seizure sent individual ways of dealing with stressful situations
reduction of 50% (11). A study from France showed that and events (20). Research findings by Baslet et al. (21),
people with psychological disorders had a higher rate of Quinn et al. (22), found that psychological non-epileptic
seizure decline (82%) and freedom from seizures (47%) in seizure is accompanied by problems, such as excessive
non-epileptic seizure compared with those, who did not arousal and unexpected experiences of need for indepen-
have psychological disorders (9). dence and avoidance.
Alexithymia is a multidimensional problem in diffi- Although comparison of the psychological indices be-
culty in identifying feelings and distinguishing physical tween epileptic and non-epileptic seizures has been an im-
feelings of emotional arousal, which refers to reduced abil- portant research topic in the field of epilepsy, research is
ity to identify and diagnose emotions (12). Laurie et al. limited in this regard. Besides, sometimes there are limita-
(2015) in a research entitled ‘quality of life, physical role tions in studies that have been done in this field. For exam-
and alexithymia in two groups of patients with epileptic ple, findings by Urbanek et al. showed that patients with
seizures and non-epileptic seizure’, showed that patients non-epileptic seizures earn higher scores on alexithymia
with non-epileptic seizures had significantly lower alex- and this is due to poor understanding of negative emo-
ithymia compared to patients with epilepsy experience tions and beliefs about feelings. However, in this study, dif-
(13). Research results of Uliaszek et al. showed that patients ficulty in describing feelings, which is one of the subscales
with non-epileptic seizures had more difficulty to identify of this structure, has not been studied (15).
and describe their feelings as well as higher levels of con-
scious thoughts than the benchmark group. The level of 2. Objectives
alexithymia and negative beliefs of emotions in patients
with non-epileptic seizures was associated with the sever- This study was designed and carried out to compare
ity of seizure, reported by the patients (3). Alexithymia is a alexithymia, perceived stress, and bad emotional dysregu-
common problem in epilepsy (14). Poor understanding of lation in patients with non-epileptic seizures and epileptic
emotions and negative beliefs about emotions are two im- seizures.
portant predictors for non-epileptic seizures (15). Plug et al.
found that the metaphors used by patients with epileptic 3. Methods
seizures to describe their attacks were internal, describing
it as randomly happening, while people with non-epileptic 3.1. Population and Sample
seizures described these cases as the space or place, which In terms of purpose, this research project was catego-
were used (16). rized as a comparative research. It should be noted that
Stress is a circular sequence that begins with an initial in this study, dependent variables consisted of emotional
assessment of the threat level and continues with the ef- collapse, perceived stress, and emotional ill-regulation.
fect of physiological and emotional changes (17). One of The independent variable was membership of individuals
the factors that can influence seizures, is the intensity of in epileptic or non-epileptic seizures. The study popula-
the stress perceived by the individual. Everyday stress and tion included all patients with a diagnosis of non-epileptic
crisis are threats of physical and mental health (18). Pa- seizures and epileptic seizures in specialized public and
tients with non-epileptic seizures often report more stress- private clinics of neurology, during years 2015 to 2016
ful and disturbing experiences as compared to the con- in Isfahan. Firstly, with coordination of a neurology ex-
trol group and use less efficient use of coping strategies pert from a private hospital and a public policlinic, us-
(17). Severe psychological trauma during childhood and ing convenience sampling, two groups of epileptic and
the associated stress is more common in people with non- non-epileptic seizure (n = 50) were selected; according to
epileptic seizures compared to the general population (16). analysis of variances, 30 subjects were necessary in each
The findings by Novakova et al. showed that anxiety (a con- groups and according to probable drop-out and decree of
struct close to stress) is a unique predictor of depression power estimation, 50 participants selected for each group.
in patients with non-epileptic seizures. The statistical re- The participants, who had the research inclusion criteria
sults (after controlling for all variables) showed depression from 10th March 2015 to 10th August 2016, and criteria for
as 45% and anxiety as 60% in patients with non-epileptic diagnosis and discrimination of these two seizures, were
checked symptoms (such as eyes’ cornea twisting, having 3.2.3. Cognitive Emotion Regulation Questionnaire
froth in the mouth, spastic, tonic and colonic movements, This questionnaire is a self-report questionnaire de-
EEG results, and prolactin levels measurement test, mea- signed in 1999 by Garnefski et al. and it was published in
sured 20 minutes after the seizure). In addition, risk of low 2001. The questionnaire is based on theoretical and prac-
blood sugar or syncope should be eliminated. Form of con- tical constructs. In this questionnaire, strategies of self-
sent to participate in the research was given to the partici- blaming, blaming others, rumination and catastrophiz-
pants, and they were provided with the relevant question- ing are regarded as negative emotion regulation strategies
naire. Due to sample loss (failure to answer or not answer- and strategies of acceptance, renewed attention to plan-
ing the questionnaire), the final sample was reduced to ning, positive re-evaluation, positive reassessment, and
39 cases of epileptic seizures and 43 cases of non-epileptic adopting a perspective are positive emotion regulation
seizures. The study inclusion criteria included providing strategies. Internal reliability of the Persian version was
an informed consent to participate in the research and ed- validated using Cronbach’s alpha for positive strategies
ucational level of above secondary school, and the exclu- and negative strategies as 0.91 and 0.87, and it was calcu-
sion criteria were not responding to more than 5% of ques- lated as 0.93 for the total inventory (26).
tions per questionnaire.
3.3. Procedure
After approval of proposal for implementing the re-
3.2. Instruments
search in the institute, two groups of epileptic and non-
3.2.1. Alexithymia Questionnaire epileptic seizure (n = 50) that qualified for inclusion cri-
This questionnaire was developed by Taylor in 1986 teria were selected. The questionnaire booklet (includ-
and in 1994 it was revised by Bagby et al. The question- ing research purpose and how to respond to the question-
naire includes 20 items in three subscales, including dif- naire) was prepared and patients were asked to complete
ficulty identifying feelings (DIF), difficulty describing feel- the questionnaires up to ten days and return them to the
ings (DDF), and externality-oriented thinking (EOT). To secretary at the health center. After collecting the data, and
check the reliability of this scale, Cronbach’s alpha for the finally scoring on the basis of the scoring instruction of
total scale (α) was obtained as 0.81, and for the three com- the questionnaire, data was compiled in the statistical soft-
ponents, it was calculated as 1 = 0.78, 2 = 0.75, and 3 = ware.
0.66. For determining validity of the scale, its correla-
3.4. Statistical Analysis
tion with the stress questionnaire was calculated as 0.23.
The Farsi version was validated by Pourhosein et al. Cron- Data obtained from the research were analyzed using
bach’s alpha coefficient for TAS-20 score, difficulty identi- SPSS-19 software by descriptive statistics and inferential
fying feelings, difficulty describing feelings, and thoughts analysis (after study of normality and equality of variances
with externality-oriented thinking was obtained as 0.83, presumptions), including MANOVA. Since the purpose of
0.80, 0.73, and 0.71, respectively. The retest reliability for this study was to examine three dependent variables and
the total score was 0.79 and it was obtained between 0.62 two independent variables, the ‘MANOVA’ method was
and 0.79 and for the three sub-scales (23). used, because in the multivariable variance analysis, two
or more dependent variables are assessed by one or more
independent categorical variables.
3.2.2. Perceived Stress Scale
This scale was developed in 1983 by Cohen et al. and
4. Results
has three versions 4-10-14, which is used to measure general
perceived stress in the past month. It measures thoughts Demographic characteristics and descriptive indexes
and feelings about stressful events, control, domination, are given in Table 1. The mean and standard deviation of
and coping with experienced stress. A higher score shows age were 36/05 ± 10.22 for epileptic and 34.81 ± 12.9 for non-
greater perceived stress. Cronbach’s alpha coefficient for epileptic groups. Also, the mean and standard deviation of
this scale was calculated as 0.74. In order to calculate the disease duration were computed as 8.23 ± 2.75 for epileptic
validity of the scale, its correlation coefficient was calcu- and 7.20 ± 2.79 for non-epileptic participants.
lated with semiotic sizes as between 0.52 to 0.76. In the val- As the results of Table 2 show, most means of compo-
idated Persian version, Cronbach’s alpha was calculated as nents of Alexithymia, negative regulation, and perceived
0.81 (24). Content validity of this questionnaire was veri- stress of non-epileptic group were lower than epileptic
fied by 10 experts (25). cases.
Table 1. Frequency and Percentage of Demographic Characteristics of Participantsa Table 2. Mean and Standard Deviation of Variables Among the Two Groups
Variable Epileptic Non-Epileptic Variables Mean ± SD Min Max
Gender Component of Alexithymia
Male 21 (53.8) 13 (30.2) Difficulty identifying feelings
Female 18 (46.2) 30 (69.8) Epileptic 17.12 ± 2.75 13 23
Educational level Non-epileptic 30.32 ± 3.24 16 35
Below high school 19 (48.7) 11 (25.6) Difficulty describing feelings
Diploma 18 (46.2) 23 (53.5) Epileptic 13.79 ± 3.41 10 19
Bachelor and 2 (5.1) 9 (20.9) Non-epileptic 12.39 ± 1.62 10 16
higher
Externality-oriented thinking
Marital status
Epileptic 21.33 ± 2.22 19 28
Single 16 (41) 19 (44.2)
Non-epileptic 25.93 ± 4.69 20 33
Married 21 (53.8) 22 (51.2)
Total alexithymia
Widow 2 (5.1) 2 (4.7)
Epileptic 52.25 ± 5.17 43 62
Economic status
Low 34 (87.2) 36 (85.4) Non-epileptic 68.65 ± 5.95 52 80
the normality of scores distribution. In this research, the Epileptic 10.33 ± 1.95 7 13
Kolmogorov-Smirnov test was used to test this hypothe- Non-epileptic 7.30 ± 3.00 4 14
sis. The hypothesis for normality of scores distribution re- Dysregulation (positive)
mains in all research variables and all groups, that is the Epileptic 50.25 ± 7.05 34 63
distribution of sample grades is normal and similar to the Non-epileptic 48.67 ± 6.77 36 62
Emotional
society, and deviation and skewness are accidental (all sig-
Self-blaming
nificant levels are greater than 0.05). Also, the assumption
Epileptic 10.51 ± 1.65 8 13
of the equality of scores variances in several groups was ap-
Non-epileptic 9.69 ± 3.71 4 15
proved for the research measures. Based on the assump-
Dysregulation (negative)
tion approval for normality and equality of variances, anal-
Rumination
ysis of variances was used to obtain inferential results. Epileptic 12.92 ± 1.93 10 15
As observed in Table 3, significance levels suggest that Non-epileptic 13.55 ± 2.59 10 18
there was a significant difference between the two groups Catastrophizing
of participants in terms of Alexithymia (P < 0.05). Thus, it Epileptic 9.02 ± 1.30 7 11
was concluded that there was a difference between epilep- Non- epileptic 13.97 ± 2.07 10 17
tic and non-epileptic people, who were different in terms Blaming others
that alexithymia was higher in non-epileptic people com- Non-epileptic 14.30 ± 3.36 8 19
pared to participants with epilepsy. Also, significance lev- Emotional dysregulation (negative)
els denote that there was a significant difference between Epileptic 39.35 ± 3.37 32 46
of perceived stress. According to the mean, it can be noted (29). When emotional information cannot be perceived
that perceived stress is higher in non-epileptic participants and evaluated in cognitive and perceptual processing, peo-
compared to epileptic participants. ple develop emotional and cognitive confusion and this
helplessness and inability disturbs organization of their
emotions and cognitions. These people are unable to iden-
5. Discussion
tify, perceive or describe their emotions due to lack of emo-
tional awareness and inability in cognitive processing of
The current study aimed at comparing alexithymia,
their emotions. If these emotions are not discharged and
perceived stress, and emotional dysregulation in epileptic
one cannot verbally express negative emotions, negative
and non-epileptic individuals.
psychological symptoms, such as depression and anxiety
The research findings showed that there is a significant
increase. People, who have the ability to recognize their
difference between scores of alexithymia and two com-
own feelings and emotional states effectively can better
ponents of difficulty identifying feeling and externality-
face life problems and they are more successful in compat-
oriented thinking in the two groups. Results corresponded
ibility with the environment and others, and as a result,
with Myers et al. they investigated the prevalence of alex-
these people have better mental health. Patients with alex-
ithymia in epileptic and non-epileptic seizures and predic-
ithymia have undifferentiated emotions and feelings asso-
tion of non-epileptic seizures, and showed that the men-
ciated with physiological arousal.
tal damage and pessimism in patients with non-epileptic
seizure are accompanied by alexithymia (27). The findings Research findings showed there is a significant differ-
of this study are consistent with the above research. Fur- ence between the two groups in terms of perceived stress,
thermore, a research by Davoodi and Afshari found that so that perceived stress was higher in non-epileptic pa-
high neuroticism and openness to experience and agree- tients than epileptic patients. These findings are consis-
ableness had a meaningful relationship with alexithymia, tent with the findings of Myers et al. (17). A study by My-
yet extraversion and conscientiousness was not relevant in ers et al. titled “Stress coping strategies in patients with
anticipation of alexithymia. Therefore, personality traits psychogenic non-epileptic seizures and how they relate to
can predict alexithymic characteristics in individuals (28). trauma symptoms, alexithymia, anger, and mood” showed
Another study by Baghian et al. (2014) showed a negative that these patients use emotion-focused strategies to deal
relationship between alexithymia and MS patients’ gen- with stress, which is successful in the short-term and focus
eral health; a higher the level of alexithymia in a patient on emotions rather than assessing and solving the prob-
was associated with lower general health. Research results lems; also, stress levels rise because of their alexithymia
of Isazadegan et al. suggested that there is a connection be- and cognitive distortions. Moreover, an investigation by
tween all alexithymia factors and mental health and its as- Shokouhi et al. stated that there is a meaningfully higher
pects. Studies suggest that alexithymia is associated with perceived stress in individuals with external attribution
some physical illnesses, such as pain, bladder inflamma- in different situations. Also, there is a difference in per-
tion, diabetes, hypertension, and heart diseases. Dubey ceived stress between individuals with uncontrollable at-
et al. believed that alexithymia is a risk factor for many tribution and those with controllable attribution in over-
psychiatric disorders because patients with this condition all, negative, and personal situations, which is higher in
show strong physical-emotional correlations. This impair- those with uncontrollable attribution (26).
ment prevents the adjustment of emotions, making it diffi- Stress acts as a chain sequence and it is created in the
cult to successfully adapt (29). However, this study showed individual in the initial evaluation of threat and continues
that individuals with non-epileptic seizures scored higher with physical and mental effects. Thus, it can be stated that
in having difficulty recognizing emotions and thinking since there is no brain cause in patients with non-epileptic
with an external orientation, and it was notable that the seizure, and one experiences seizure due to stressful situa-
overall score in non-epileptic seizure patients was higher tions or traumas, patients with non-epileptic seizure have
than those with epileptic seizures. more stress compared to patients with epileptic seizure.
These findings are indirectly consistent with the find- Given that external factors cause stress in individuals, and
ings of Myers et al. on accompaniment of trauma and since the reason for seizure in patients with non-epileptic
cynicism in patients with non-epileptic seizures and alex- seizure is not brain causes, thus, the number of seizures
ithymia (27). Dubey et al. believed that alexithymia is a in people with non-epileptic seizures is higher than those
risk factor for several psychiatric disorders, because people with epileptic seizures. People with non-epileptic seizures
with this problem cannot express their physical sensations do not want to experience seizure, thus, they avoid stress
Table 3. Results of Multivariate Analysis of Variances of Variables Among the Two Groups
Research variable Sum of Squares Degree of Freedom Mean of Squares F P Value Eta Square Statistical Power
a
Alexithymia 549.041 1 549.041 175.400 0.005 0.687 0.99
and since they are not able to cope with the source of stress, in mutuality with the family, peers, and community, it is
they tolerate more stress and are caught by seizure, and ex- plausible to think that the intervention was able to correct
perience higher frequency of seizures. their communication network.
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