The stigma of epilepsy: a European perspective

Chronic illness, reproductive health and moral work: women's experiences of epilepsy

BACKGROUND

The impact of chronic illness on families has long been noted in the literature, but in such studies families appear as ready-formed entities. This exploratory qualitative study addresses the largely unacknowledged work involved in the production of families and the maintenance of reproductive health by women with epilepsy, a condition whose symptoms and treatment have serious implications for all aspects of reproductive health.

METHODS

Qualitative in-depth interviews were conducted with a sample of 15 women aged 20-40 years diagnosed with epilepsy and recruited from across the UK. The women had a range of neurological symptoms and hence different diagnostic categories; most had been diagnosed during childhood or adolescence. Ten women had at least one child.

RESULTS

Women's experiences of healthcare services for key phases of reproduction are explored. While some women reported that they had received good healthcare, others reported that they were given inadequate information and that advice was offered too late to enable them to take appropriate action.

DISCUSSION

Management of both epilepsy and reproductive health involves work with a significant moral dimension, the accomplishment of which is contingent on appropriate and timely advice from healthcare practitioners.

Truly enthralling: epileptiform events in film and on television--why they persist and what we can do about them

Seizures and epilepsy have been portrayed in film since 1900 and on television since the 1950s, but unlike many other conditions, their depictions have not improved with increased scientific understanding. At this time, most individuals who are under 45 years of age will never witness a seizure. Thus, their information about what seizures are comes from depictions in film and on television. Because especially on television these fictive and often erroneous images are increasing, many think of them as accurate. The research addresses three questions in relation to these images: How do directors use the images? Why do uses of seizures in visual media not reflect contemporary scientific knowledge? Why have they persisted and increased in use? Data consist of material from 242 films and television episodes. The general category of seizures includes seizures in characters said to have epilepsy or some other condition, seizures related to alcohol/drug use, feigned or pseudoseizures, and a "throwaway" category. The research demonstrates how epileptiform events drive the narrative, support the genre, evoke emotional reactions, highlight traits of characters with seizures, accentuate traits of other characters through their responses, act as catalysts for action, and enhance voyeuristic experience. Through connecting categories, we explain a basic social process (Glaser, 2007). The conclusion is that these images are so enthralling that their use is likely to persist. The authors suggest that advocates acknowledge this and then find ways to have more continuing characters with correctly depicted epilepsy be part of television series as a way of exploring the truly enthralling dimensions of the condition.

Epilepsy stigma perception in an urban area of a limited-resource country

OBJECTIVE

To estimate the perception of stigma attached to epilepsy in an urban society of a limited-resource country, Brazil.

METHODS

We applied a validated Stigma Scale of Epilepsy (SSE) cross-sectionally to 1850 people from all regions within the metropolitan area of Campinas, following a sampling selection methodology (95% confidence interval and error of 2.3).

RESULTS

The overall score for epilepsy stigma perception was 42 (range, 3-98; SD, 14). The SSE score for women was higher (43) than that for men (40). With respect to religion, Spiritism had the lowest SSE score (35) compared with Catholic, Evangelical, other, and no religion. Level of education was inversely related to SSE scores; illiterate people had higher SSE scores (45) than people with higher education (37).

CONCLUSION

This is one of the first systematic assessments of epilepsy stigma perception in an urban area of a limited-resource country. It was found that the magnitude of stigma is different within segments of the local society, highlighting that sociocultural factors such as gender, religion, and level of education may be important predictors of stigma.

Stigma scale of epilepsy: validation process

PURPOSE: To validate a Stigma Scale of Epilepsy (SSE). METHODS: The SSE was completed by 40 adult with epilepsy attending an Outpatient Epilepsy Clinic at the University Hospital of UNICAMP, and by 40 people from the community. People were interviewed on an individual basis; a psychologist read the questions to the subjects who wrote the answers in a sheet. The procedure was the same for all the subjects and completion took around ten minutes. RESULTS: The SSE has 24 items. The internal consistency of the SSE showed alpha Cronbach’s coefficient 0.88 for the patients with epilepsy and 0.81 for the community. The overall mean scores of the Stigma Scale of Epilepsy formula were: 46 (SD=18.22) for patients and 49 (SD=13.25) for the community where a score of 0 would suggest no stigma, and 100 maximum stigma. DISCUSSION: The SSE has satisfactory content validity and high internal consistency. It allows the quantification of the perception of stigma by patients and people from community; this can then be used for interventional studies, such as mass media campaign in minimizing the negative facets of stigma.

Stigma and attitudes on epilepsy a study: with secondary school students

PURPOSE: To evaluate whether an inappropriate attitude towards a person having an epileptic seizure contributes to the stigma found in society and whether an appropriate attitude helps to diminish it in the short term; to perform a long term investigation about information remembered and stigma perception after an educational lecture. METHOD: This study was performed in two steps: Step 1. Students of first year of high school of two schools in Campinas completed a questionnaire including the Stigma Scale of Epilepsy following a seizure demonstration. They were divided into three groups: a) one group had a demonstration of proper attitudes towards someone having an epileptic seizure; b) one group was shown incorrect procedures; c) control group. After the completion of the questionnaire, an educational lecture about epilepsy was given. Step 2: six months later, the questionnaire was re-administered. RESULTS: The comparison between the four groups (step 1 and step 2) show a significant difference (Anova (3,339)=2.77; p=0.042). Pairwise comparison using Fisher's Least-Significant-Difference Test showed a significant difference between the group shown incorrect procedures (step 1) versus step 2, and the control group (step 1) versus step 2, but no difference between the group shown correct procedures (step 1) versus step 2. DISCUSSION: Exhibiting proper attitudes towards a person experiencing an epileptic seizure may cause significant differences among the subjects’ degrees of stigma towards people with epilepsy. It is therefore fundamental that there should be de-stigmatization campaigns provided, to correct information and provide appropriate education.

Daily life in epilepsy: patients' experiences described by emotions

OBJECTIVE

According to the literature, emotions are closely related to health and well-being. The aim of this study was to illuminate the impact of epilepsy on daily life in young adulthood, described by the patients' emotions.

METHOD

Young adults, 18-27 years of age (n=95/102), answered a questionnaire eliciting descriptions of their daily lives with epilepsy in their own words. A content analysis was performed, and the material was categorized, according to the Belief Desire Theory of Emotions.

RESULTS

The patients experienced positive (confidence, hope, harmony, and forbearance); negative (anxiety, despair, fear, resignation, indignation, sadness, insecurity, and anger); and self-evaluating emotions (being valuable, being insignificant, shame, guilt, and self-doubt). Two different groups of patients could be identified: one group whose members regarded themselves as "healthy" and another group whose members regarded themselves as being ill or "handicapped". The "healthy" group was active and flexible, focusing on possibilities and planning how to handle negative emotions. The "handicapped" group was passive and resigned to the epilepsy in a negative way, afraid of being exposed. They focused on obstacles, and their negative emotions were also directed toward the self.

CONCLUSION

This study pointed out the importance of paying attention to the role of emotions in the experiences and well-being of patients with epilepsy.

Epilepsy and employment: literature review

OBJECTIVE

The aim of this review is to increase understanding of the factors that affect the regular employment positions of people with epilepsy by means of the World Health Organization International Classification of Functioning, Disability, and Health (ICF) model.

METHOD

Thirty-four primary research articles describing factors associated with employment for people with epilepsy are reviewed.

RESULTS

People with epilepsy may face a number of complex and interacting problems in finding and maintaining employment. Stigma, seizure severity, and psychosocial variables such as low self-esteem, passive coping style, and low self-efficacy have been implicated as factors that play an important role in predicting employment. Findings demonstrate the need for specific employment training programs.

CONCLUSION

We recommend specific training interventions that focus on increasing the self-efficacy and coping skills of people with epilepsy so that these individuals will be able to accept their disorder and make personal and health-related choices that help them to achieve better employment positions in society.

Clinical characteristics associated with psychosocial functioning among patients with uncomplicated epilepsy in Spain

OBJECTIVE

To identify the clinical characteristics associated with poor psychosocial functioning among Spanish patients with epilepsy but no other neurological or psychiatric disorder.

METHODS

Between May and September 2001 a survey among patients with epilepsy was carried out in 32 Spanish health care centres. The selection criteria of patients were attendance to a routine neurologist visit, to be aged between 25 and 64 and not having another additional neurological handicap (n=812). Psychosocial function was elicited through six indicators: educational level, marital status, unemployment status, restricted car driving, self-perception of epilepsy as an important limiting factor in the educational level achieved and, among unemployed, as the cause of their unemployment. Multiple logistic regression models were fitted in order to calculate adjusted odds ratios (aOR) and their 95% confidence intervals.

RESULTS

After simultaneously adjusting for socio-demographic variables and clinical characteristics, the six outcomes analysed increased with seizure frequency. Moreover, all the outcomes except low educational level were also related to early age at onset of epilepsy. Although no relation with objective educational level was found, there was a strong association between early age at onset of symptoms and self-perception of epilepsy as an important limiting factor of educational achievement.

CONCLUSION

These findings emphasize the need for more effective treatment of epilepsy and also highlight the importance of a psychosocial approach to management of epilepsy for patients with an early onset of symptoms in order to prevent social limitations in adult life.

The quality of life, mental health, and perceived stigma of leprosy patients in Bangladesh

The present study aims to determine the quality of life (QOL) and general mental health of leprosy patients compared with the general population, and evaluate contributing factors such as socio-economic characteristics and perceived stigma. A total of 189 patients (160 outpatients, 29 inpatients) and 200 controls without leprosy or other chronic diseases were selected from Dhaka district, Bangladesh, using stratified random sampling. A Bangladeshi version of a structured questionnaire including socio-demographic characteristics-the Bangla version of the World Health Organization Quality of Life Assessment BREF (WHOQOL-BREF)-was used to assess QOL; a Self-Reporting Questionnaire (SRQ) was used to evaluate general mental health; the Barthel Index to control activities of daily living (ADL); and the authors' Perceived Stigma Questionnaire was used to assess perceived stigma of patients with leprosy. Medical records were examined to evaluate disability grades and impairment. QOL and general mental health scores of leprosy patients were worse than those of the general population. Multiple regression analysis revealed that factors potentially contributing to the deteriorated QOL of leprosy patients were the presence of perceived stigma, fewer years of education, the presence of deformities, and a lower annual income. Perceived stigma showed the greatest association with adverse QOL. We conclude that there is an urgent need for interventions sensitive to the effects of perceived stigma, gender, and medical conditions to improve the QOL and mental health of Bangladeshi leprosy patients.

Social functioning and psychological well-being of 347 young adults with epilepsy only--population-based, controlled study from Finland

PURPOSE

To explore social functioning and psychological well-being in a population-based cohort of epilepsy patients compared to matched controls.

METHODS

A random sample of patients with epilepsy (N = 347) and a healthy control group (N = 430) matched for age, gender and domicile were identified through National Registry of Social Insurance Institution in Finland. The data were collected by postal questionnaire assessing various factors related to social and psychological well-being and were analyzed by using linear regression analysis to compare the study and control groups.

RESULTS

The age at onset of epilepsy was significantly associated with the level of further education and the level of seizure control with the employment status. The patients with epilepsy and lower level of basic education had also significantly lower level of further education, employment, and fewer social relations. Some differences in psychological well-being were also seen in those with matriculation examination when compared to matched controls.

CONCLUSIONS

In young adults with well-controlled epilepsy and successful basic education, social functioning is comparable with healthy peers. The importance of all social and educational support during the time of basic education may be crucial to favorable intellectual, functional, and social development later in life. Both professional and informal support is needed in adjunct to conventional treament of epilepsy, which is emphasized.

Quality of life in young adults with uncomplicated epilepsy

This aim of this study was to illuminate quality of life (QOL) of young adults with epilepsy. Subjects (n=102) answered the Quality of Life Index (QLI) questionnaire together with an overall open question (n=95/102) regarding the impact of epilepsy on daily life. The highest QOL was reported in relation to the family domain, and the lowest, in relation to the psychological/spiritual domain. Overall the participants were satisfied with their lives. Most important were the well-being of their families, their relationships with their spouses, and their ability to control their lives. Half of the participants experienced a negative effect of epilepsy on their daily lives. Of those, 70% considered the effect insignificant or small. This study supports the conclusions that uncomplicated epilepsy does not significantly affect QOL in young adulthood and that the risk of social isolation due to uncomplicated epilepsy is not significantly increased.

Measuring health-related stigma--a literature review

Stigma related to chronic health conditions such as HIV/AIDS, leprosy, tuberculosis, mental illness and epilepsy is a global phenomenon with a severe impact on individuals and their families, and on the effectiveness of public health programmes. To compare stigma measurement in different disciplines, a literature review was conducted. References were obtained through a search of literature databases and through examining relevant bibliographies. Sixty-three papers were selected that addressed the issue of measurement of stigma or related constructs and that contained a sample of the instrument or items used. Five unpublished studies were also included in the review. The aspects of health-related stigma used for assessment can be grouped in five categories. First, the experience of actual discrimination and/or participation restrictions on the part of the person affected; second, attitudes towards the people affected; third, perceived or felt stigma; fourth, self or internalized stigma; and fifth, discriminatory and stigmatizing practices in (health) services, legislation, media and educational materials. Within each of these areas, different research methods have been used, including questionnaires, qualitative methods, indicators and scales. The characteristics of the instruments considered most promising are described and compared. The purpose of stigma assessment is to increase our understanding of stigma and its determinants and dynamics, to determine its extent or severity in a given setting or target group and to monitor changes in stigma over time. The conclusions from this review are that (a) the consequences of stigma are remarkably similar in different health conditions, cultures and public health programmes; (b) many instruments have been developed to assess the intensity and qualities of stigma, but often these have been condition-specific; and (c) development of generic instruments to assess health-related stigma may be possible. To achieve this aim, existing instruments should be further validated, developed or adapted for generic use, where possible.

Percepção de estigma na epilepsia

INTRODUÇÃO: Pessoas com epilepsia frequentemente vivenciam o estigma, muitas vezes mais prejudicial que a própria condição em si. De maneira geral, pode-se dizer que a epilepsia é uma das condições que mais afeta o comportamento e a qualidade de vida, não só da pessoa que tem epilepsia, mas também da família toda, especialmente devido ao estigma existente. Por isso, dizemos que a epilepsia causa um impacto bio-psicosocial na vida das pessoas. Porém, este aspecto do estigma na epilepsia é pouco abordado, especialmente em países em desenvolvimento, como o Brasil, onde superstições, atitudes negativas e falta de informação dificultam a relação da comunidade com a epilepsia. OBJETIVO: Este artigo tem o objetivo de discutir aspectos relevantes do estigma na epilepsia: conceituação e modelos de estigma na área médica e social; estigma e qualidade de vida; fatores operantes; aspectos neurobiológicos e estratégias para se lidar com o estigma na epilepsia. CONCLUSÕES: Este artigo mostrou uma visão geral do estigma englobando seus diferentes aspectos. Pelo fato de ser um conceito multifatorial, o combate ao estigma requer também uma intervenção ampla, envolvendo as áreas médica, psicológica e social. O entendimento do processo do estigma contribui para uma mudança da interpretação social da epilepsia, rumo a construção de uma sociedade mais justa e tolerante, na qual as diferenças sejam respeitadas.

What about us?

RATIONALE

It is known that epilepsy has a severe impact in the quality of life of the patients; however, it affects the lives of all family members. The psychosocial repercussions of epilepsy are often of greater significance than the seizures themselves.

METHODS

This was a prospective study, conducted from January 2005 to December 2005 at the pediatric epilepsy clinic of our University Hospital. Parents were interviewed by one of the authors according to a structured questionnaire about the impact of epilepsy in the life of the siblings of children with epilepsy.

RESULTS

One hundred and twenty-seven children, siblings of 78 patients with epilepsy were evaluated. From the 127 siblings of children with epilepsy, 60 were girls and 67 were boys. Ages ranged from 5 to 18 years old (mean=11.7 years). After the diagnosis of epilepsy, the siblings had only negative feelings toward the disease, mostly sadness and fear.

CONCLUSION

Our data showed that the impact of epilepsy in the lives of siblings of children with epilepsy is much more severe than previously suspected.

High school students' knowledge, attitude, and practice with respect to epilepsy in Kerala, southern India

Very little information is available on knowledge, attitude, and practice (KAP) with respect to epilepsy among schoolchildren from developing countries. We quantified KAP with respect to epilepsy among 1213 tenth-grade students of Kerala, southern India. Ninety-eight percent of them had heard or read about epilepsy. However, nearly 60% of students thought that epilepsy was a form of insanity. Allopathic treatment was preferred by more than half of the respondents; however, many had faith in exorcism and visiting religious places as ways to cure epilepsy. Half of the students considered epilepsy a hindrance to education, employment, and marriage. Thirteen percent would be unwilling to sit adjacent to or play with a child with epilepsy. We conclude that although familiarity with epilepsy was high among high school students in Kerala, misconceptions and negative attitudes were alarmingly high. Persistent and effective information campaigns, therefore, are necessary to change their attitudes toward fellow students with epilepsy.

Epilepsy in North America: A Report Prepared under the Auspices of the Global Campaign against Epilepsy, the International Bureau for Epilepsy, the International League Against Epilepsy, and the World Health Organization

In North America, overall epilepsy incidence is approximately 50/100,000 per year, highest for children below five years of age, and the elderly. The best data suggest prevalence of 5-10/1000. Potential effects of gender, ethnicity, access to care and socioeconomic variables need further study. Studies of epilepsy etiology and classification mainly were performed without modern imaging tools. The best study found an overall standardized mortality ratio (SMR) for epilepsy relative to the general population of 2.3. There is evidence to suggest a greater increase in patients with symptomatic epilepsy, particularly children. People with epilepsy are more likely to report reduced Health-related Quality of Life than controls. They have reduced income, and are less likely to have full-time employment. They suffer from persistent stigma throughout the region, in developed as well as developing countries. Poor treatment access and health care disparities for people with epilepsy may be related to insufficient economic resources, rural isolation, gender, ethnicity, and lack of public and physician knowledge of modern approaches to epilepsy care. Despite high costs and severe disability, epilepsy may attract somewhat less research funding from public and private sources than other less common chronic neurological disorders. A Plan for Epilepsy in North America should address: basic and clinical research; primary prevention research; translation to care; stigma, quality of life, and self-management; industry relations; government and regional relations; and regional integration and resource sharing.

Interventions to reduce epilepsy-associated stigma

Epilepsy-associated stigma has long been recognized as a significant cause of psychosocial morbidity for people with epilepsy. This paper reviews the available literature addressing interventions aimed at reducing epilepsy-associated stigma and briefly discusses future that may assist in the development of effective interventions.

Knowledge, attitudes, behaviors, and practices regarding epilepsy among Zambian clerics

BACKGROUND

Epilepsy carries a high burden of social morbidity. An understanding of who propagates stigma and the determinants of stigmatizing attitudes is needed to develop effective interventions. Clerics represent an especially influential social group in Africa. Therefore, we conducted a survey of the knowledge, attitudes, behavior, and practices of Zambian clerics with respect to epilepsy.

METHODS

We studied clerics in one large rural region as well as in the capital city. The rural survey was conducted door-to-door. In the urban areas, central administration for multiple denominations assisted in survey delivery. The survey, adapted from previously published instruments, included cleric-specific questions and demographic data. Composite scores for knowledge and tolerance were developed. Determinants of higher knowledge and tolerance were assessed.

RESULTS

Almost all Zambian clerics know someone with epilepsy and have witnessed a seizure. More than 40% report having a family member with epilepsy. Unfortunately, this familiarity is not associated with more knowledge or tolerance for the condition. Younger clerics, urban dwellers, those with fewer children, and those with more years of formal education were significantly more tolerant. More knowledgeable clerics are more likely to recommend that a person with epilepsy seek care from a physician rather than a traditional healer. Formal education was the most important factor in determining tolerance toward epilepsy.

CONCLUSIONS

Zambian clerics are very familiar with epilepsy, yet have relatively little knowledge of the etiology. Many view traditional healers as the appropriate care provider for epilepsy. To decrease stigma and improve the quality of advice offered by clerics to their congregations, educational programs focusing on the biomedical nature of the disorder are needed, particularly in rural regions.

Epilepsy among the homeless: prevalence and characteristics

Homelessness is associated with several risk factors for epileptic seizures. Epilepsy is a stigmatizing condition, which can lead to problematic social adjustment and competence. We found a markedly higher prevalence of seizures among the homeless than that estimated in the general population, with a large majority of non-alcoholic etiology. Unexpected proportion of subject taking treatment and compliance rate call for reflection on the optimal management of epilepsy in this population.

Ultimate success in epilepsy - the patient's perspective

Most people with epilepsy can live outwardly normal lives, but fear about impending seizures, driving restrictions, lack of independence, employment and social problems, medication-related adverse effects and the presence of cognitive or psychiatric complications are all concerns readily identified by affected individuals. While seizure control is the overriding goal of treatment, it is essential to realize the importance that patients place on other aspects of daily functioning. While many of the concerns identified by patients can only be managed by improved social support, others (e.g. neuropsychological impairment, medication-related adverse events, cognitive impairment, sleep disturbance) may be amenable to therapy (if available) or to the selection of a more appropriate antiepileptic drug. Each antiepileptic drug has a unique pharmacodynamic and tolerability profile. Awareness by the treating clinician of the pharmacological profile of each drug may help to minimize unwanted treatment-related effects and possibly improve the outcome of treatment from an epilepsy patient's perspective. Therefore, in order to achieve true treatment success, clinicians need to understand how individuals perceive their disorder and, where possible, address those factors that adversely affect patient quality of life. For the person with epilepsy, successful treatment involves beneficial effects on social, vocational and psychological function. This extends beyond seizure control to freedom from the fear associated with seizures, confidence in pharmacological therapy and improvements in health-related quality of life.

A structured, nurse-led intervention program improves quality of life in patients with epilepsy: a randomized, controlled trial

We tested the hypothesis that structured epilepsy nursing improves quality of life (QOL). One hundred fourteen adult patients with uncontrolled epilepsy were randomly assigned to either an intervention group or a control group. The intervention group was offered an interactive, 1-day group education program followed by extended nurse follow-up and counseling. The nurse was present at as many outpatient consultations as possible and performed repeated consultations by telephone. All patients completed the QOLIE-89 before randomization and after 2 years. QOL was significantly improved from inclusion to completion of study in the intervention group (P=0.019), mainly in the subitems for Health Discouragement (P=0.01), Medication Effects (P=0.035), and Physical Role Limitations (P=0.05). To our knowledge, this is the first study to demonstrate a significant effect of a structured nurse-led intervention program in QOL of patients with epilepsy.

Anxiety in patients with epilepsy: systematic review and suggestions for clinical management

Up to 50 or 60% of patients with chronic epilepsy have various mood disorders including depression and anxiety. Whereas the relationship between epilepsy and depression has received much attention, less is known about anxiety disorders. It is now recognized that anxiety can have a profound influence on the quality of life of patients with epilepsy. The relationship between anxiety disorders and epilepsy is complex. It is necessary to distinguish between different manifestations of anxiety disorder: ictal, postictal, and interictal anxiety. Preexisting vulnerability factors, neurobiological factors, iatrogenic influences (antiepileptic drugs, epilepsy surgery), and psychosocial factors are all likely to play a role, but with considerable individual differences. Despite the high prevalence of anxiety disorders in patients with epilepsy, there are no systematic treatment studies or evidence-based guidelines for best treatment practice. Nevertheless, a practical approach based on the temporal relationship between anxiety and epileptic seizures allows clinicians to consider appropriate treatment strategies to reduce the psychiatric comorbidity in patients with epilepsy.

Epilepsy-associated stigma in sub-Saharan Africa: the social landscape of a disease

Many studies in developed regions of the world have confirmed that stigma contributes substantially to the psychological and social burden of epilepsy. Relatively few studies of epilepsy-associated stigma have been conducted in Africa, where much of the world's burden of epilepsy exists. In sub-Saharan Africa (SSA), particularly in rural regions, close family ties, communal living situations, and traditional belief systems undoubtedly influence the expression of stigmatization. A review of the epidemiologic, anthropologic, and sociologic studies of epilepsy in SSA provides significant insights into how people with epilepsy (PWE) are perceived by their communities and families and how these perceptions translate into limited social and economic opportunities and possibly worsen the physical vulnerability of PWE in this region. The medical community is not exempt from the social process of stigmatization, and poor public health infrastructure and medical services undoubtedly contribute to the cycle of epilepsy-associated stigma through wide treatment gaps, poor seizure control, and high rates of seizure-related injury. In this review, we extrapolate data from existing studies of epilepsy in SSA coupled with our own experience providing epilepsy care in the region to give an overview of the social landscape of this common, devastating condition.

[The second step in the construction of a stigma scale of epilepsy]

RATIONALE

The issue of stigmatization is one of the most common psychosocial problems faced by people with epilepsy.

PURPOSE

A second step towards the development of a scale to measure epilepsy stigma.

METHOD

We applied a closed questionnaire to 12 patients and 32 relatives from the Epilepsy Outpatient Clinic at the University Hospital of Campinas.

RESULTS

The results are grouped in three main domains: medical, social and personal areas. Medical: the subjects did not know exactly what epilepsy is or how it is caused; nonetheless they know how to treat it. Social: the most important areas that people with epilepsy are discriminated are at work and social relationships. Patients also complained about their lack of freedom and limits on recreation activities. Personal Area: subjects apparently have the same feelings and thoughts about epilepsy and seizures.

CONCLUSION

This study analyzed the most common aspects presented in the questionnaire to assess epilepsy stigma for the Brazilian culture which are the base to the elaboration of a stigma scale of epilepsy.

Development and validation of a health related quality of life questionnaire for Brazilian children with epilepsy: preliminary findings

PURPOSE: To construct a multidimensional questionnaire that analyses the epileptic child quality of life from the parental point of view. METHOD: The pilot questionnaire was composed of 157 questions distributed in several dimensions. Fifty-one epileptic children's parents answered the questionnaire. The instrument was tested in its diverse properties: frequency of endorsement, homogeneity (Cronbach alpha), criterion and face validity, and later it was reduced. RESULTS: Endorsement frequency excluded 65 questions that did not attain a minimum of 5% response per item. Cronbach alpha was as follows: physical (0.93), psychological (0.91), social (0.91), familiar (0.70), cognitive (0.92), medical (0.30) and economical (0.37). Patient groups, in relation to seizure control, significantly differed only in physical domain and total score, although there was a trend to differences in other domains. The final questionnaire (QVCE50) has 50 items, with good homogeneity in the physical, psychological and cognitive domains. CONCLUSION: QVCE-50 is a promissing Brazilian HRQL questionnaire for children with epilepsy.It needs to be applied in a larger population to confirm its psychometric properties.

Factors contributing to the stigma of epilepsy

PURPOSE

To evaluate the factors, including personality and coping styles, likely to be influential in enhancing the social stigma of epilepsy.

METHODS

Data were collected from 400 adults with epilepsy recruited from 10 epilepsy centers in Korea. Clinical information about seizures was obtained by neurologists, and other information was collected from self-completed questionnaires, including those measuring stigma scales.

RESULTS

Thirty-one percent of people with epilepsy felt stigmatized by their condition and in 9% of these the stigma was severe. Multivariate analysis identified experiences of actual discrimination from society, introverted personality, problem solving controllability, and emotional subscale of QOLIE-31 as being independently associated with the social stigma of epilepsy.

CONCLUSIONS

Episodes of discrimination, coping strategies, and personality may be important in feeling the stigma of epilepsy. These findings may provide a basis for further studies to clarify the causative factors generating the stigma of epilepsy.

The relationship between illness severity, sociodemographic factors, general self-concept, and illness-specific attitude in Swedish adolescents with epilepsy

PURPOSE

The aim of this study was to describe the relationship between the epilepsy condition (illness severity), sociodemographic factors, general self-concept, and illness-specific attitude in adolescents with uncomplicated epilepsy.

METHODS

Adolescents, aged 13-22, fulfilling criteria registered in four Swedish hospitals, answered questionnaires (n = 149). The instruments "I think I am" and "Sense of coherence" measured the patients' general self-concept. The "Child Attitude Toward Illness Scale" measured illness-specific attitude. A summary score (index) calculated from seizure frequency, seizure type, and antiepileptic drug (AED) with side effects measured "Illness Severity".

RESULTS

Illness severity was significantly related to the participants' general self-concept, as well as to their attitude toward their condition; i.e. higher illness severity scores were correlated with lower sense of coherence (SOC), poorer self-esteem, and a more negative attitude towards the epilepsy condition. Females had more severe illness according to the Illness Severity Index, with almost 80% found in the moderate and high severity groups as compared to 63% of males in the moderate/high severity groups.

CONCLUSIONS

It was concluded that the severity of the epilepsy condition was related to the adolescents' general self-concept and illness-specific attitude, but further research is needed to understand the causality of the relationship. The brief assessment of illness severity, constructed and used in this study should be addressed and developed further.

Public Knowledge, Private Grief: A Study of Public Attitudes to Epilepsy in the United Kingdom and Implications for Stigma

PURPOSE

For many people with epilepsy, the continuing social reality of their condition is as a stigma, thus representing a source of much private grief. To understand fully the nature of epilepsy stigma, it is important to examine attitudes and beliefs of not just the "targets" but also of the "perceivers" of stigma. Perceivers may hold erroneous beliefs and stereotypes that lead them to have negative expectations of people affected by epilepsy. This study examined levels of knowledge and attitudes among perceivers of epilepsy stigma in the U.K.

METHODS

A random sample of >1,600 members of the general public was interviewed as part of the bimonthly UK Omnibus Survey. The response rate was 62%.

RESULTS

One fourth of informants knew someone with epilepsy and one half had witnessed a seizure. One half agreed that people with epilepsy are treated differently by others, and themes of exclusion, restriction, and nonnormality were commonly cited as reasons for this. Epilepsy ranked second in a range of health conditions, in terms of which would cause them greatest concern if informants had to work with someone so affected. Responses to a series of attitude statements indicated that most held highly favorable attitudes; but one fifth agreed with the statement that people with epilepsy have more personality problems than do others. Responses were influenced by informants' sociodemographic characteristics.

CONCLUSIONS

The survey revealed attitudes and knowledge gaps that have the potential for discriminatory behavior. There are implications for how public education campaigns should be implemented, and who should be targeted.

Reaction to epilepsy in the workplace

PURPOSE

The purpose of this study was to determine the characteristics of epilepsy that produce avoidant behavior in the workplace and therefore contribute to the actual stigma that persons with epilepsy are subjected to on the job.

METHODS

We developed a survey consisting three vignettes briefly describing a coworker with either depression, multiple sclerosis, or epilepsy. Each vignette was followed by eight identical questions addressing the level of comfort during interactions with the vignette subject. The epilepsy vignette did not describe a seizure. The surveys were hand-distributed in two companies in New York City and returned anonymously by mail. The results of the responses to each illness were compared by chi2, and the responses were correlated with demographic information by using Pearson's correlation.

RESULTS

Seventy-four of 200 distributed questionnaires were returned. Respondents reported more anxiety at the thought of interacting with a coworker with epilepsy than with depression or multiple sclerosis, but this difference did not reach significance. Worry about sudden, unpredictable behavior for the coworker with epilepsy was significantly greater than that with multiple sclerosis (p = 0.014). The level of comfort regarding providing first aid for the coworker with epilepsy was significantly less (p = 0.018) than that for depression and multiple sclerosis. Lower job level and lower income level correlated with more social discomfort for all three illnesses.

CONCLUSIONS

The idea of a having a coworker with epilepsy may produce some social avoidance. However, the worry about a sudden, unpredictable event and the discomfort regarding providing first aid for a coworker with epilepsy is significant when compared with that with depression or multiple sclerosis. These findings suggest that education about first aid for epilepsy will reduce the worry and discomfort surrounding persons with epilepsy in the workplace.

Treatments and perceptions of epilepsy in Kashmir and the United States: a cross-cultural analysis

Treatments and perceptions of epilepsy have been found to vary across cultures. This study draws on a comparison of two patient samples, one from the United States (n=28), the other from Kashmir (n=29), to gauge the similarities and differences in social perceptions of epilepsy, attitudes toward conventional and alternative treatments, practice of conventional and alternative treatments, and selected quality-of-life issues. While both the Kashmiri and American patients interviewed were prescribed a similar regimen of traditional antiepileptic drugs, a wider range of drugs and treatments were available to and used by the latter. The use of adjunctive spiritual therapies was more prevalent in the Kashmiri sample, and the use of alternative, nonpharmacological therapies was more prevalent in the American sample. Quality of life for the Kashmiri patients sampled was found to be poorer in terms of educational and occupational opportunities, feelings of stigmatization, and openness with others about the illness. Although the two patient populations interviewed differed in their access to resources and approaches to the disorder, both samples were found to be similar overall in many attitudes and practices relating to epilepsy and its treatment.

Measuring stigma in children with epilepsy and their parents: instrument development and testing

PURPOSE

The goal of this work is to describe psychometric properties of two scales measuring perceived stigma in children with epilepsy and their parents.

METHODS

Data were collected for the parent scale in two samples: parents of 173 children with epilepsy and of 224 children with new-onset seizures. The child scale was tested in the chronic sample. Content validity, internal consistency reliability, and construct validity were tested.

RESULTS

Both scales had strong internal consistency reliability and construct validity. Higher scores were associated with greater seizure severity scores. In the parent scale, lower scores were associated with more positive mood, less worry, and more family leisure activities. In the child scale, higher scores were correlated with more negative attitude, greater worry, poorer self-concept, and more depression symptoms.

CONCLUSIONS

Both scales were found to have strong psychometric properties. They are short, and items are easy to understand. These scales have potential for use in research and in the clinical setting to measure stigma.

Treatment of depression in patients with epilepsy: problems, pitfalls, and some solutions

Many people with epilepsy suffer from comorbid depression. Despite this, there have been few studies addressing the treatment of depression in this population, and the literature on psychiatric management techniques in patients with epilepsy is composed largely of opinions rather than evidence from randomized, controlled trials or other systematic investigations. Antidepressant drugs, including tricyclics and selective serotonin reuptake inhibitors, can be used to treat patients with epilepsy and comorbid depression. Nonpharmacological treatment options include vagus nerve stimulation, transcranial magnetic stimulation, and psychological therapies including cognitive-behavioral therapy, individual or group psychotherapy, patient support groups, family therapy, and counseling. Another important area that remains largely uninvestigated is psychiatric research in patients with epilepsy in non-Western cultures (with the exception of Japan). Factors such as problems with access to and acceptability of therapies in many developing nations have further implications for the treatment of psychiatric disorders in epilepsy.

Health-related quality of life in youth: a comparison between adolescents and young adults with uncomplicated epilepsy and healthy controls

PURPOSE

To describe health-related quality of life (HRQOL) in adolescents and young adults with uncomplicated epilepsy and to compare it with a random sample of the general population.

METHODS

Young people, aged 13-22 years, meeting the criteria and registered in four Swedish hospitals answered questionnaires (n = 158/193) on HRQOL together with 282 (n = 282/390) random controls living in the same areas in Sweden. The instruments used were "I think I am," "Youth Self Report," "Sense of coherence," and "Family APGAR." Data were analyzed by using factorial analysis of variance.

RESULTS

Girls had a poorer HRQOL than boys. The epilepsy group reported lower competence (i.e., they were less active, had lower social competence and poorer school achievement). Both groups had an overall positive self-esteem. Differences between girls in the epilepsy and control groups were small, whereas differences among boys were more evident. Older age was related to poorer HRQOL in both groups.

CONCLUSIONS

This study points out the importance of being observant of signs of stigmatization in adolescents with epilepsy.

The association of stigma with self-management and perceptions of health care among adults with epilepsy

OBJECTIVE

The purpose of this study was to examine the perception of stigma among adults with epilepsy including its association with epilepsy self-management and perceptions of health care.

METHODS

Participants for the study were recruited from two epilepsy centers and a neurology clinic. Individuals agreeing to participate in the study were asked to complete three assessments each 3 months apart. Data were collected from 320 adult men and women with epilepsy; 314 provided responses on stigma and were included in this analysis.

RESULTS

Participants ranged in age from 19 to 75 years (mean=43). Fifty percent of the sample was female, and 80% was white. The mean age of seizure onset was 22 years, and 76% of participants reported having had a seizure within the past year. Analysis suggests levels of perceived stigma are similar for men and women and across ethnic and age groups. However, participants who were not married or living with a partner, were not working for pay, and had limited income reported higher levels of stigma than did married participants, those working for pay, and those in higher income brackets. Participants reporting higher levels of stigma included those who had their first seizure before the age of 50 and a seizure in the last year. Participants whose seizures interfered more with activities, who rated their seizures as under less control, and who were not legally able to drive also reported higher levels of stigma. Tests of association between stigma and health-related variables revealed that participants reporting higher levels of perceived stigma also reported lower levels of self-efficacy to manage epilepsy; more negative outcome expectancies related to treatment and seizures; and lower levels of medication management, medication adherence, and patient satisfaction. However, they also reported greater management of information related to seizures. In regression analysis, income, age at first seizure, seizures during the past year, lower self-efficacy, negative outcome expectancies for seizures, and less patient satisfaction explained 54% of the variance in perceived stigma.

CONCLUSIONS

The results of the study suggest that perceived stigma is significant for people with epilepsy and is associated with factors that are known to be important in the management of epilepsy. Understanding who is at greatest risk for feeling stigmatized could lead to the development of preventive measures.

Seizures and therapy in adolescents with uncomplicated epilepsy

PURPOSE

This study aimed to describe seizures and their therapy among Swedish adolescents, aged 13-22, with active but uncomplicated epilepsy.

METHOD

The adolescents answered questionnaires (158/193). Data were also obtained from medical records.

RESULTS

Epileptic seizure types could be specified in 92.1% of the cases. Predominant types were Primary Generalised Tonic-Clonic Seizures and Partial Complex Seizures with Secondary Generalisation. Clinical diagnoses by physicians were unspecified in 25.8%. Ninety percent were on antiepileptic drugs (AEDs), most commonly valproate and carbamazepine. New AEDs were used in 9.3% of the cases and polytherapy in 13.9%. More than 40% of the respondents had seizures despite AED treatment. Side effects of AEDs were experienced by 61%, most commonly tiredness, concentration difficulties and headache. Patients on polytherapy experienced significantly more side effects. The choice of a new AED over a traditional one was not related to seizure type or seizure control.

CONCLUSIONS

Many adolescents had persistent seizures despite treatment at a specialist regional epilepsy centre. This, plus the high reported rate of side effects of AED treatment, suggests that treatment is not optimal for the group studied. As traditional AEDs strongly dominated treatment possibly newly marketed AEDs are underused in this group.

Stigma in the lives of adolescents with epilepsy: a review of the literature

The World Health Organization, the Centers for Disease Control and Prevention, and the Epilepsy Foundation have recently focused attention on problems experienced by people with epilepsy as a result of stigma. Stigma is associated with poor psychosocial health outcomes in people with epilepsy, and its effects may be strongly felt by adolescents who are already dealing with the challenges of developing self-identity and self-esteem. This review synthesizes the empirical literature on stigma in the lives of adolescents with epilepsy. Beginning research indicates that stigma is related to quality of life in adolescents with epilepsy, although existing measures may not yet fully capture how this stigma is experienced. For example, instead of reporting stigma actually experienced, adolescents report limiting disclosure of their illness, perhaps because they anticipate being stigmatized in a peer social environment that fosters misconceptions about people with epilepsy. Recommendations for future research are discussed.

Cross-cultural differences in levels of knowledge about epilepsy

PURPOSE

To study how much people with epilepsy in Europe know and understand about their condition and how this might affect their lives.

METHODS

Clinical, demographic, psychosocial details and information assessing knowledge were collected by using self-completion questionnaires mailed to members of epilepsy support groups.

RESULTS

Data were collected from 6,156 people with epilepsy from ten European countries. There were significant between-country differences in all variables considered. Overall levels of knowledge were acceptable when measured by the epilepsy knowledge questionnaire (EKQ, medical items). However, there were some gaps in knowledge, particularly in issues relating to medication and cause of epilepsy.

CONCLUSIONS

This is the largest study of its kind to date. Results clearly highlighted that levels of knowledge differed significantly between countries. Overall, people with epilepsy are reasonably well informed about epilepsy, although some gaps in knowledge were evident.

Standard magnetic resonance imaging is inadequate for patients with refractory focal epilepsy

OBJECTIVES

Patients with intractable epilepsy may benefit from epilepsy surgery especially if they have a radiologically demonstrable cerebral lesion. Dedicated magnetic resonance imaging (MRI) protocols as performed at epilepsy surgery centres can detect epileptogenic abnormalities with great sensitivity and specificity. However, many patients with epilepsy are investigated with standard MRI sequences by radiologist outside epilepsy centres ("non-experts"). This study was undertaken to compare standard MRI and epilepsy specific MRI findings in patients with focal epilepsy.

METHODS

Comparison of results of standard MRI reported by "non-expert" radiologists, standard MRI evaluated by epilepsy "expert" radiologists, and epilepsy specific MRI read by "expert" radiologists in 123 consecutive patients undergoing epilepsy surgery evaluation between 1996 and 1999. Validation of radiological findings by correlation with postoperative histological examination.

RESULTS

Sensitivity of "non-expert" reports of standard MRI reports for focal lesions was 39%, of "expert" reports of standard MRI 50%, and of epilepsy dedicated MRI 91%. Dedicated MRI showed focal lesions in 85% of patients with "non-lesional" standard MRI. The technical quality of standard MRI improved during the study period, but "non-expert" reporting did not. In particular, hippocampal sclerosis was missed in 86% of cases. Neuropathological diagnoses (n=90) were predicted correctly in 22% of "non-expert" standard MRI reports but by 89% of dedicated MRI reports.

CONCLUSIONS

Standard MRI failed to detect 57% of focal epileptogenic lesions. Patients without MRI lesion are less likely to be considered candidates for epilepsy surgery. Patients with refractory epilepsy should be referred to an MRI unit with epileptological experience at an early point.

ILAE/WHO "Out of the Shadows Campaign" Stigma: does the flag identify the cargo?

People with epilepsy around the globe are confronted with different levels and types of stigmatization, which may vary greatly among geographical regions and cultures. Furthermore, striking differences in social research into the stigma surrounding epilepsy can be seen across cultures. For instance, research projects taking place in Europe and North America place greater emphasis on perceived stigma (i.e., the type/amount of discrimination a person expects to encounter), whereas studies in the southern hemisphere (e.g., Africa south of the Sahara) emphasize enacted stigma (i.e., the type/amount of discrimination actually encountered). Cross-cultural research into the stigma of epilepsy may benefit from a multidisciplinary team from various cultural backgrounds, to develop a shared theoretical framework and shared research tools, which allow for contextual and cross-cultural adaptation.

Stigma, epilepsy, and quality of life

Despite advances in the understanding and treatment of epilepsy within the past several decades, people with this disorder continue to be stigmatized by it. Though attitudes toward people with epilepsy have improved over the years, for many people with epilepsy, stigma continues to adversely impact their psychological well-being and quality of life. The stigma of epilepsy can be linked to a number of factors, including underresourced medical services, poor seizure control, and inadequate knowledge of epilepsy. Neither informal stigma nor formal discrimination is inevitable for epilepsy patients; however, for many individuals, epilepsy remains a defining feature of their identity, and such issues are a source of considerable concern for a number of patients.

People with epilepsy: what do they know and understand, and how does this contribute to their perceived level of stigma?

Understanding the factors that contribute to the process of stigmatization of those with epilepsy may be an important element in the management of this condition. This study was designed to determine the contribution of clinical, demographic, and psychosocial variables to the stigma of epilepsy in adults. More than 6000 adults from 10 European countries were surveyed. Almost half of respondents reported that they had difficulty accepting their illness, and 17% felt stigmatized by it. A number of factors were predictive of stigma, including seizure frequency, knowledge of epilepsy, duration of epilepsy, and seizure type. The relative contributions of these factors varied depending on the country of origin of those surveyed. Further research is warranted to determine societal influences on the process of stigmatization.

Stigma and epilepsy

For individuals with epilepsy in the United States and other countries, stigma can be one of the most distressing consequences of having seizures, along with the unpredictability of future seizures and the inability to drive. The impact of stigma on the lives of epilepsy patients is far reaching, frequently including effects on interpersonal relationships, general health, employment opportunities, and overall quality of life. Education about epilepsy directed at the broader community, as well as at the individual with epilepsy, is the most effective means of addressing misperceptions and fear. Epilepsy advocacy organizations, such as the Epilepsy Foundation, are important allies in this effort.

Social functioning, psychological functioning, and quality of life in epilepsy

PURPOSE

Part of our research intended to explain "Quality of Life" (QoL) differences between people with epilepsy. To this end, a series of already existing generic and disease-specific health status measures were used. In this study, they were considered as determinants of people's QoL, whereas QoL itself was conceived as a general "value judgment" about one's life.

METHODS

From the records of four outpatient clinics, 210 persons with epilepsy were randomly selected. During their visit to the outpatient clinic, they completed a questionnaire assessing, among other things, health perceptions and social and psychological functioning. Additional information about their medical and psychosocial status was gathered from the patient files. Data were analysed by using a hierarchical regression analysis.

RESULTS

In decreasing order of importance, "psychological distress," "loneliness," "adjustment and coping," and "stigma perception" appeared to contribute most significantly to the outcome QoL as judged by the patients themselves, regardless of their physical status. In the final model, none of the clinical variables (onset, seizure frequency, side effects of antiepileptic drugs) contributed significantly anymore to the patients' "quality-of-life judgement." Apparently the effect of other variables such as seizure frequency and health perceptions, medication and side effects, life fulfillment, self-esteem, and mastery is mediated by these variables.

CONCLUSIONS

Because all of the variance in QoL of the patients was explained by the psychosocial variables included in this study, health professionals should be aware of the significance of the psychosocial functioning of the patients and the role it plays in the achievement of a good QoL. Both informal and professional support may be an adjunct to conventional treatment. In future research, this issue should be given high priority.

Epilepsy in Estonia: a quality-of-life study

PURPOSE

To study the impact of epilepsy and its treatment on people with epilepsy in Estonia and to analyze how it is affected by the characteristics of epilepsy.

METHODS

Clinical and demographic data about patients were obtained from medical notes and mailed self-completed questionnaires (including the RAND 36-Items Health Survey 1.0 (RAND-36)).

RESULTS

Information was collected from 203 patients aged 20-74 years, who all had active epilepsy. A third of the respondents had been seizure free during the last year. Eighty-four percent were receiving monotherapy. More than half of respondents felt stigmatized by epilepsy, 24.7% of them highly so. A third were working full-time, 31.9% were underemployed workers, and 11%, unemployed. Sixty-two percent of these same unemployed or underemployed workers considered their epilepsy to be a significant reason for this situation. Overall, 44% believed they had been treated unfairly at work or when trying to get a job. Study respondents scored lower in all domains on the RAND-36 than did persons from the control group. The biggest differences were found in five domains: Social functioning, Role limitations-physical, Role limitations-emotional, General health, and Vitality.

CONCLUSIONS

The clinical characteristics of this study were similar to those of most other series of prevalence cases of epilepsy. The level of employment among persons with epilepsy was not lower than that in the general population. The percentage of stigmatization was high. There were significant differences in the way respondents scored on the stigma scale and on the RAND-36 domains when measuring their health status, depending above all on seizure frequency and type.

Neuropsychological effects of epilepsy and antiepileptic drugs

Epilepsy and its treatment can have deleterious cognitive and behavioural consequences. Affected individuals have a higher prevalence of neuropsychological dysfunction than the general population because of complex interactions among several multifaceted and overlapping influences--for example, underlying neuropathologies, ictal and interictal neuronal discharges, a plethora of antiepileptic drugs, and numerous psychosocial issues. Research into the clinical relevance of these factors has been dogged by a range of methodological pitfalls including lack of standardisation of neuropsychological tests, small numbers and multiple testing, and statistical failure to appreciate differential effects of interactive elements in individual patients. Although antiepileptic drugs can impair neuropsychological functioning, their positive effect on seizure control might improve cognition and behaviour. Each person should be assessed individually with respect to factors unique to his or her seizure disorder and its treatment.