All of the participants were interviewed by a neuropsychologist who elicited whether there was a history of trauma. Trauma was classified as physical abuse (i.e. bruising, broken bones, whip marks, stab wounds, concussions) or rape/sexual abuse (i.e. touching/fondling and/or forced oral sex or vaginal/anal intercourse). Since some patients had experienced multiple traumatic events age of the first traumatic episode was classified as “age of abuse.” Age of PNES onset and duration were noted.
The standard battery of tests administered to our patients with PNES at the Northeast Regional Epilepsy Group includes 10 cognitive tests that assess intelligence, pre-morbid intelligence, verbal and visual memory, attention, executive functions, speech and language, and fine motor skills and five psychological measures. Because of the substantial load of cognitive testing administered to our patients, the Test of Memory Malingering (TOMM) has been added to the battery with the purpose of examining the validity of our results.
Seven measures from the Northeast Regional Epilepsy Group PNES neuropsychological battery were used for analysis in this study. Five of these are psychological measures: Coping Inventory for Stressful Situations (CISS), State Trait Anger Expression Scale-2 (STAXI-2), Toronto Alexithymia Scale-20 (TAS-20), Trauma Symptom Inventory 2 (TSI 2), and the Minnesota Multiphasic Personality Inventory-2-RF (MMPI-2-RF). The Test of Memory Malingering (TOMM) and Wechsler Abbreviated Scales of Intelligence (WASI) were utilized as part of exclusion criteria demands. The WASI was also examined to determine whether there was a correlation between IQ and coping strategies.
We also examined the relationship of the psychological measures to demographic variables, including age at onset of PNES, years of duration of PNES, history of any abuse, and type of abuse (physical, sexual, or both).
The CISS is a paper-and-pencil self-report scale that was developed to assess three coping strategies that the respondent typically uses when confronted with stressful situations: Task-Oriented, Emotion-Oriented and Avoidance. It can be used with normal and clinical populations. The adult version of the CISS is based on three normative samples including adults (249 males, 289 females), college students (471 males, 771 females), and psychiatric inpatients (164 males, 138 females). The CISS provides norms for adults and psychiatric inpatients. There are a total of 48 items (e.g. focus on the problem and see how well I can solve it, get angry, go out for a snack or meal) on which respondents are asked to indicate “how much you engage in these types of activities when you encounter a difficult, stressful, or upsetting situation”. Raw scores are converted to T scores which is a type of standard score with a mean of 50 and a standard deviation of 10. Interpretive guidelines for “elevated” T scores are that 61–65 (87–94th%ile) are “above average, 66–69 (95–97th%ile) are “much above average”, and 70 (≥99th%ile) or higher are very much above average. Linear T scores do not transform the actual distribution of the variables in any way. The present study compared participant scores to adult “normal” norms in accordance with typical clinical practice.
Validity of the multidimensionality of the CISS scales and construct validity of the scales have been examined with college, adult and inpatient samples. Factor analysis produced congruence coefficients comparing each of the three factors above 0.95 for all three samples. This supports that the CISS independently assesses for the three Task-Oriented, Emotion-Oriented and Avoidance focused scales. Construct validity of the CISS has been conducted as for coping (Ways of Coping Questionnaire – WCQ), psychopathology (Basic Personality Inventory – BPI and MMPI-2), depression (Beck Depression Inventory – BDI), anxiety (Endler Multidimensional Anxiety Scales – EMAS), somatic complaints (Psychosomatic Symptom Checklist – PSC), neuroticism and extraversion (Eysenck Personality Inventory – EPI). For a comprehensive description of these studies the reader is directed to the CISS Professional Manual.
Coping Inventory for Stressful Situations(CISS).
In sum, results from these studies have shown that CISS Emotion-Oriented coping is strongly positively related to depression, anxiety, neuroticism, and somatization. Task-Oriented coping is negatively related to depression and unrelated to anxiety, somatization, neuroticism and extraversion. Avoidance-Focused coping was unrelated to depression, low or unrelated to anxiety, and correlated positively to somatization.
One of the three stress coping strategies is Task-Oriented coping which refers to purposeful Task-Oriented efforts aimed at solving the problem, cognitively restructuring the problem or attempts to alter the situation. The emphasis is on the task or planning and direct attempts to solve the problem. Emotion-Focused coping refers to emotional reactions that are self-oriented. The aim is to reduce stress and reactions include emotional responses, self-preoccupation and fantasizing. Avoidance coping refers to activities and cognitive changes aimed at avoiding the stressful situation via distancing or distracting oneself with other situations or tasks or via social diversion.
Professional manual for the state-trait anger expression inventory-2.
is a 57-item self-report measure which consists of three main scales: State Anger Scale, which measures the intensity of anger feelings and the extent to which a person feels like expressing anger at a particular time; the Trait Anger Scale, which measures how often angry feelings are experienced over time and thus provides a sense of the degree to which anger may or may not be a chronic part of the person's temperament, and an Anger Expression Index, which is a general index of anger expression based on responses to the anger control and expression subscales. Satisfactory factor loadings for the 57 items and adequate concurrent validity have been determined between the STAXI-2 subscales and other measures of hostility and personality (Budd-Durkee Hostility Inventory, MMPI Hostility scale, Eysenck Personality Questionnaire, State Trait Personality Inventory). Higher scores reflect stronger endorsements of anger symptoms within that domain.
- Bagby R.M.
- Parker J.D.
- Taylor G.J.
The twenty-item toronto alexithymia scale – I. Item selection and cross-validation of the factor structure.
is self-report scale used to measure alexithymia composed of 20 items that are rated on a 5 point scale, ranging from 1 (strongly agree) to 5 (strongly disagree). A score equal to or less than 51 represents “non-alexithymia”, whereas a score equal to or greater than 61 represents “alexithymia”. This measure has demonstrated good internal consistency (Cronbach's alpha = .81) and test–retest reliability (.77, p
< .01) and has also demonstrated adequate levels of convergent and concurrent validity. Higher scores reflect greater alexithymia.
Trauma symptom inventory™-2 professional manual.
is a 136 item self-report measure that is used to evaluate acute and chronic posttraumatic symptomology in adults. The instrument provides 10 clinical scales, but only five were included for analyses due to overlap with other psychological inventories (TSI 3 assesses anger, TSI 5 assesses avoidance approaches, and the TSI 9 assesses impaired self-reference which are otherwise being assessed by our other measures) or divergence from study focus (TSI 7 and 8 assess dysfunctional sexual behaviors). The scales that were examined included TSI1- Anxious Arousal (anxiety and autonomic hyperarousal), TSI2- Depression; TSI4-
Intrusive Experiences (i.e. nightmares, flashbacks, upsetting memories; TSI 5- Dissociation (cognitive disengagement, depersonalization, derealization, emotional numbing and out-of-body experiences); and TSI10- Tension Reduction Behavior (involvement in distracting external activities as a way to reduce painful internal states including for example, substance use and sexual acting out). A T
score of 65 and above is considered clinically elevated and a T
score of 35 and less is considered significantly reduced.
Ben-Porath YS, Tellegen A. Minnesota multiphasic personality inventory-2-RF™ (MMPI-2-RF®).
is a self-report measure of psychopathology and personality. The test is comprised of 338 true–false items that measure of psychopathology and personality and is intended for adults (18 and older). There are 9 validity scales as well as 3 Higher-Order (H-O) scales and 9 Restructured Clinical (RC) scales. As per the MMPI 2RF manual, an entire profile is rendered invalid if F-r ≥ 120 and/or Fp-r ≥ 100 as with Scales VRIN and TRIN > 80; none of the individuals in this sample presented with scores in these ranges. The Higher-Order scale of Emotional/Internalizing Dysfunction (EID) is of particular interest given its broad assessment of overall emotional dysfunction. The Restructured Clinical scales (RC1: Somatic Complaints; RC2: Low Positive Emotions; RC3: Cynicism) are also of special interest given their potential relationship to PNES. Consequently, these four scales were used for analyses. Higher scores reflect greater psychopathology.
Test of memory malingering.
is a 50-item visual recognition test sensitive to motivation and effort that is specifically designed to differentiate between authentic memory impairments and malingering. It is a test of “effort” and as such has been classified as a symptom validity test (SVT) or Performance Validity Test (PVT). The TOMM numerical scores combined with situational variables assist the neuropsychologist in making a clinical decision about the effort that is being put forth on testing. The two decision rules stated in the TOMM manual were used to classify test takers. Scores that fulfill either or both rules raise serious questions about the individual's motivation to perform well on other tests and raise concerns about the validity of other scores. A cut off score of 45 on Trial 2 had a high specificity correctly classifying 95% of all non-demented patients.
Wechsler abbreviated scale of intelligence.
consists of four subtests: Vocabulary, Similarities, Block Design, and Matrix Reasoning. The four-subtest form results in Verbal (VIQ), Performance (PIQ), and Full Scale (FSIQ) scores.
Analyses were conducted over three steps. The first step was to determine the number of patients that endorsed using the CISS subscales (Task-Oriented, Emotion-Focused and Avoidance) to an extent that deviated significantly from normal adult means (≥1.5 standard deviation) as that is the cut off used in clinical practice (Task Oriented scale: a T score of less than 35; Emotion oriented and Avoidance scales: a T score greater than 65). One-way analysis of variance (ANOVA) with dummy coding was used to compare the T scores of the three coping strategies, and chi-square was used to compare the frequency of elevations between the three coping strategies.
The second step we took was to determine the psychological factors associated to predominant stress coping strategies, the primary outcome measures used were the CISS Task-Oriented, Emotion-Focused and Avoidance-Oriented Scores. Pearson product-moment correlation was used to measure the association of the psychological measures (TAS-20, TSI 2, STAXI-2 and MMPI-2-RF), quantitative demographic and clinical variables with the CISS scores. A Bonferroni's adjustment was made for each of the CISS tasks correlations to account for experiment-wise error.
An independent T test was used to assess whether the presence or absence of a history of abuse and type of abuse associated with CISS scores.
Our third step was to use stepwise linear regression to determine predictors of the CISS scores separately for each of the three CISS factors; a p value of less than 0.05 was considered significant. The scales from the psychological measures mentioned above were used as predictors (TAS-20; TSI Anxious Arousal, Depression; Intrusive Experiences; Dissociation, and Tension Reduction; STAXI-2 State Anger, Trait Anger, and Anger Expression Index; and MMPI-2-RF EID, RC1, RC2, and RC3 scales).
Sixty of the subjects who participated in a prior publication in which quality of life and anger expression in PNES were examined participated in this present series.
- Myers L.
- Lancman M.
- Laban-Grant O.
- Matzner B.
- Lancman M.
Psychogenic non-epileptic seizures: predisposing factors to diminished quality of life.
The current sample differs in that it includes 4 additional males and a total of 22 new subjects as compared to the last publication. Mean age and education are similar in both samples.
Institutional Review Board approval for an anonymous archival record review was obtained with removal of non-relevant PHI (Copernicus IRB NRE1-11-155).