Personality profiles and clinical syndromes of patients with tonic-clonic seizures

© 2018 The Authors; Tabriz University of Medical Sciences This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Personality profiles and clinical syndromes of patients with tonic-clonic seizures

Epilepsy is one of the common chronic neurological disorders with an incidence rate of 3% in the normal population. The term epilepsy refers to recurrent attacks, which means sudden and alternating over-discharge of the brain neurons. 1,2 Evaluation of the neurobiological, psychological and social variables has proven that out of the seven predictive psychopathologic determinants in patients with epilepsy, six factors are psycho-social (e.g., perceived stigma, attitude toward illness, and family factors) in nature. 1 Personality is a consistent set of characteristics and trends that identify those similarities and differences in the psychological behavior of individuals (thoughts, emotions, and actions), which are continuous in time and may not be recognized or easily understood by the social and biological pressures of the immediate situations. 3 Personality traits of the individuals act as factors in determining their behavior. 4 Epilepsy can be clinically accompanied by a change in the feelings, behavior, perception, and level of consciousness. 5 The studies have shown that the prevalence of psychiatric disorders such as depression in patients with epilepsy is higher than normal people. 6 Jolfaei et al. reported that epileptic patients suffer from personality disorders. Depressive personality disorder was the most common personality disorder (19%); in general, 36% of patients suffered from at least one personality disorder. 7 Sato et al. stated that epileptic patients suffer from personality disorders. 8 Sondergaard et al. reported that avoidant and dependent personality disorders are the most common illnesses diagnosed in these patients. 9 Namazi et al. concluded that personality characteristics of extroversion and failure-tolerance are partial predictors of the seizures. 10 Also, Doldan et al. reported that irritability, aggression, and feeling of guiltiness are some of the hallmarks of patients with frontal lobe epilepsy. 11 Wichowicz et al. suggested that antisocial personality factors, sensitivity, quirky behavior, and histrionic behavior are seen among epileptic patients. 12 As the epileptic patients are suffering from co-morbidities or negative outcomes, as well as the gap of knowledge in the fields of personality aspects and also existing paradoxical results in some research studies caused to this study to evaluate the profiles and clinical syndromes in epileptic patients in Tabriz, Iran.
The study population included patients with tonic-clonic seizures registered in Tabriz Epilepsy Association in 2015. According to the statistics issued by the mentioned association, 320 patients lived in Tabriz. The patients were recruited through a convenience sampling method. To determine the sample size, Cochran's sample size formula, as well as PASS 11 software (Jerry Hintze, Kayville, Utah, USA) were used, in which the sample sizes were estimated to be 74 for both cases and controls, using the statistical population of 320. To examine the variables of the study, a demographic questionnaire and Millon multiaxial inventory (MCMI) were used. Control counterparts were selected from among non-epileptic people who were either the patients' relatives or referred for another medical condition, through clinical interviews.
MCMI-III (1994) is a self-assessment scale with 175 yes/no items, which measures 14 clinical personality patterns and is used for the adults of ≥ 18 years old. This test is a most widely used psychological test which has been translated into several languages and has been standardized in Iran for twice. The second and third versions of this test were standardized by Khwaja Mughi 13  Data were obtained via interview, and questionnaires. If after the description of the study, the selected subjects agreed to participate in the project and signed the written consent, the MCMI-III questionnaire was implemented. If they did not accept to participate in the study, they were excluded from the study and another person was replaced.
The principles of anonymity and confidentiality of information were explained to the participants. Data from questionnaires were analyzed by SPSS software (version 18, SPSS Inc., Chicago, IL, USA) using descriptive statistics [(mean, frequency, percentage, standard deviation (SD)] and inferential statistics using the Student's independent t-test, Spearman correlation, and the results were considered statistically significant with P value < 0.05.
The demographic characteristics of the participants are shown in table 1 by the groups and variables. The age of participants ranged from 18 to 64 years old with a mean of 29.82 ± 9.98. In the control group, the mean age was 33.57 ± 9.56.
The mean and SD of the MCMI scores are shown in table 2 based on group separations. Figures 1 and 2 illustrate the psychological profiles of the participants by the group.   Table 3 shows the results of a significant difference of MCMI between two sexes.
The data in table 3 show that people with epilepsy had a significant difference in comparison with non-epileptic individuals, except in debasement index scales and negativistic personality patterns.
Histrionic and obsessive personality scales had relatively high elevations in the control subjects, which these two scales generally did not indicate a disorder. According to the results of empirical research, these two scales have positive and negative correlations with mental health and mental disorders scales, respectively. The histrionic scale was the most elevated scale among the non-clinical population, especially among women, so that these individuals have sociable and extrovert character, lacking the histrionic personality disorders.   The obsession scale had more elevation among the non-clinical population who underwent tests. The individuals with high scores in obsessive scales were dutyregulated, rule-obedient, and disciplined, having an obsessive personality, not an obsessive personality disorder.
No significant difference was found between age and personality scales. There was a significant positive correlation between narcissistic personality pattern, obsessive personality pattern, and clinical pattern of post-traumatic stress with education. Moreover, there was a significant negative correlation between the pattern of sadistic personality disorder, schizotypal personality disorder, borderline personality disorder, somatoform clinical pattern, mania, and thought disorder with education. There was a significant negative relationship between sex and schizoid and antisocial personality pattern. Furthermore, there was a positive relationship between sex and drug dependence. A significant positive relationship was found between marriage and masochistic personality, and also between the economy and the schizoid personality pattern.
According to the results, there was no difference between demographic variables. Although previous studies had found most patients with low educational and economic levels, such findings were not obtained in our study. The average age of patients was 31.70 in our study. Also, in this study, the majority of patients were illiterate (40.0%); most patients were poor (59.3%) and their employment rate was 3.5%, that is, the majority of patients were in low socioeconomic classes.
Psychiatric disorders are more common in the single men with low socioeconomic status who are dissociable and illiterate, while in our study, most patients had high school diploma and a middle economic status. Later, 32.0% of patients had psychotic disorders similar to schizophrenia. Depressive disorders were the most common form of neuropsychological changes in epileptic patients, second to the behavioral disorders. Epileptic-related temperamental disorders were reported in 5 cases with maniac manifestations. From all patients, 25.3% of patients had a history of suicidal ideation, of which 13 committed suicides. In patients suffered from epilepsy for 15-20 years, especially from the temporal lobe type, the distribution of neuropsychiatric disorders is more common. While the final base rating (BR) grades of epileptic participants in our study did not reach diagnostic level which indicated no specific psychiatric disorder, in the histrionic scale had high-level elevation in the non-epileptic people, indicating no psychiatric disorders. 15 In a study, Bahraynian and Karamad investigated the anxiety levels in patients with epilepsy. This study showed that 44.9% epileptic patients had anxiety disorder. The highest prevalence of anxiety was in patients with generalized seizure, single and unemployed women. 16 Inconsistent with the above finding, our study showed that in the anxiety scale, the average score of all samples was 9.30, that is 9.71 in men and 8.79 in women, indicating the low level of anxiety in the epileptic people, but its high levels in the non-epileptic individuals.
Zahiroddin and Ghoreishi in a research study showed that 51.6% of epileptic patients (generalized tonic-clonic epilepsy) suffered from mild to moderate depression based on Beck test, 17 but this feature was not obtained in our study. The scale of depression pattern, the clinical pattern of dysthymia, and the major depression of the Millon test among the participants was an indicator of the low level of depression among the epileptic patients, which was not enough to reach the diagnostic threshold.
Although Salehi et al. showed that the mental status of epileptic patients and normal people was different and the former is in much worse condition, 18 our study depicted that epileptic people have lower scores in the Millon scales than non-epileptic people, having a better mental health condition. Banihashemian and EtesamiPour in a study concluded that epileptic people had higher scores in obsessive disorder, 19 but our study did not achieve such an outcome, though this scale has a high elevation in the normal people, not indicating a disorder. Unlike epileptic patients, normal individuals reported a higher level of obsession characteristics.
In the study by Noohi et al., primarily, the symptoms of depression and obsessivecompulsive disorder, and secondly, the symptoms of generalized anxiety and phobia symptoms were the causes of morbidity in the epileptic patients at the intervals between the epileptic seizures. 20 On the contrary, our findings did not find the symptoms of depression, obsessivecompulsive disorder generalized anxiety, and phobia at the higher levels.
In a study conducted by Najafi et al. on the epileptic patients through Minnesota multiphasic personality inventory (MMPI) test, they had higher scores in hypochondria (Hs), depression (D) and hysteria (Hy) scales compared with the control group. They also concluded that epileptic patients are more likely to suffer from psychiatric disorders than the general population. 21 In our study, these cases were not confirmed, and a finding showed that the epileptic patients have significantly lower scores than the non-epileptic people.
Mokhber et al. showed that 74.0% of patients with temporal lobe epilepsy had at least one type of diseased personality trait, which it was estimated to be 31.5% in the control group. The prevalence of the prominent personality disorders was 27.2% among the epileptic patients, compared with 8.8% of the control group, which this difference was, statistically, significant. The most common personality disorders in these people were borderline and anti-social disorders, which were evaluated to be significantly higher than the control group. 22 Likewise, in our study, the schizoid, antisocial and drug dependence scores were higher than other scales, and there was a meaningful difference between the groups. But, in these two groups, normal people had higher scores in these scales.
Jolfaei et al. examined the personality traits by MCMI-III. Their results showed that the most common personality disorder was depressive personality disorder (19%). In total, 36% of the patients suffered from at least one personality trait. The occupationaleducational status was much worse in patients with personality disorders. Epilepticrelated characteristics did not have meaningful relationship with personality disorders. 7 In our study, though epileptic and normal individuals were significantly different in Milton's personality and clinical patterns, the latter had higher elevation and lower mental health than the former. No significant difference was found in their occupation, education, and so on.
In the results of a review, Victoroff reported that borderline personality disorder is the most common type of personality disorder among the epileptic patients. 2 In this regard, inconsistent with this finding, we achieved antisocial and schizoid personality. In our study, in the epileptic (all and men), the highest scores were related to narcissistic, obsessive and negativistic personality patterns, while among the women, the highest average was related to histrionic and obsessive personality; also in the normal people, the highest scores were found in the similar scales.
King et al. showed that 54, 51, and 38% of the epileptic patients had symptoms of schizophrenia, depression, and hysterical symptoms, respectively. Also, 45% of the samples had the least mental complaints. In addition, 30% of patients were at the upper limits of the profile while 20% lay in middle limits. 23 In our study, all participants were under the cutting line, but the highest scores were related to narcissistic, obsessive, and negativistic personality patterns in all the participants among men, while among the women, the highest average was related to histrionic and obsessive personality.
Reuber et al. investigated the multidimensional personality evaluation of epileptic patients and the patients with psychological non-epileptic seizures. In this study, 85 patients with psychological nonepileptic seizure and 63 patients with epilepsy were selected and studied from the hospitals in Bonn, Germany, in addition to 100 healthy people. The results showed that personality disorders among patients with psychological non-epileptic seizure were more in comparison with two groups of healthy people and epileptic people. Also, personality disorders were much more common among epileptic groups than healthy people. 24 Beyenburg et al. in their own study reported that between 50 to 60% of the patients with chronic epilepsy suffered at least from one type of mood disorder or anxiety, such as depression or obsessive disorder, before having epilepsy. 25 Given that patient records were not available, we concluded that most scores were related to narcissistic, obsessive, and negativistic personality patterns in all participants, as well as in the men, while the most frequent average was related to histrionic and obsessive personality in the women.
In a study by Sondergaard et al. to assess the personality disorders in the epileptic patients, avoidant and dependent personality disorders were considered the most commonly diagnosed personality disorders in these patients. 9 The highest scores among our participants were related to narcissistic, obsessive, and negativistic personality patterns in all participants, as well as in men, while these scores were related to histrionic and obsessive personality in the women.
The results of the current study are inconsistent with most studies, although some similarities are seen. The study showed that among all people, as well as man epileptic participants, the highest scores were related to narcissistic, obsessive and negativistic personality patterns, while among the epileptic women and the control group, the highest average was related to histrionic and obsessive personalities. According to the results, there was no difference between demographic variables. Although previous studies had found most patients with low educational and economic levels, such a finding was not obtained in our study.
It is highly recommended that other groups of patients, people with different educational levels, with more compatible control counterparts a larger statistical community in the provinces or several provinces and regions, and more assessment scales such as screening scales could be considered for the future studies.
Individuals with epilepsy, unlike nonepileptic ones, had lower scores in personality and clinical scales, despite having greater tendency to expose their problems. The highest score of non-epileptic group was seen in histrionic and obsessive scales. There were significant differences between the two groups in all areas except for the debasement index (Z score) and the negativistic personality disorder. The profile obtained from the non-epileptic people had the highest degree of coordination with other studies, in which the epileptic individuals had very lower scores, which is an issue requires consideration.
We are very thankful for patients with epilepsy who participated in our research study. The authors would like to express their gratitude toward all people who helped us throughout doing this study, all hospital personnel, nurses, and clinical staff.
Ali Reza Shafiee-Kandjani devised the project, the main conceptual ideas and outline. Mohammad Yahyavimazraeh-Shadi worked out almost all of the technical details, and Salman Safikhanlou performed the numerical calculations for the suggested experiment. Asghar Arfaie revised technical details, and Mohsen Jafarzadeh-Gharehziaaddin wrote and revised the manuscript.
There was no funding for this research study.
Authors have no conflict of interest.
Not indicated.