Epilepsy & Behavior 25 (2012) 358–362

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Epilepsy & Behavior

journal homepage: www.elsevier.com/locate/yebeh

Psychogenic non-epileptic seizures: Predisposing factors to diminished quality of life

Lorna Myers ⁎, Martin Lancman, Olgica Laban-Grant, Barbara Matzner, Marcelo Lancman
Northeast Regional Epilepsy Group, New York, New York, USA

a r t i c l e i n f o a b s t r a c t

Article history: Objective: The objective of this study was to examine the factors that contribute to the reports of diminished
Received 29 June 2012 quality of life (QOL) in patients with psychogenic non-epileptic seizures (PNES).
Revised 15 August 2012 Methods: We assessed 62 patients with PNES for quality of life, anger expression and personality, and psychiatric,
Accepted 18 August 2012 social and medical histories.
Available online 24 October 2012
Results: Diagnosis of depression, pain syndromes, older age of onset and shorter duration of PNES correlated with
poorer quality of life. Elevated anger state, trait and total anger scores correlated with worse quality of life and
Keywords:
Non‐epileptic
with Quality of Life in Epilepsy 31 subscales of emotional well-being, medication, cognitive and social effects,
Psychogenic seizures seizure worry, and fatigue.
Quality of life Conclusion: Our study verifies reported correlations between depression and somatic symptoms and quality of
Anger life. A novel finding is that of a relationship between quality of life in PNES and anger expression. This result
Depression has important implications for psychotherapeutic treatment of PNES in that it provides a potentially modifiable
Psychological trauma target.
Treatment
Pain
© 2012 Elsevier Inc. All rights reserved.

1. Introduction
Individuals with psychogenic non-epileptic seizures (PNES) con-
sistently report poorer overall quality of life (QOL) than those with
epileptic seizures [1]. In fact, QOL has been reported to be even
worse in patients with PNES than those with medically refractory
epilepsy [2,3]. Depressive symptoms have been reported as mediating
these differences in worse quality of life [4–6]. However, Testa et al.
[7] found that when more chronic psychological symptoms, such as
somatization and emotional distress, were included in the model, the
moderating role of mood state was not significant. Quigg [8] found
that decrease in the number of seizures was not enough to increase
QOLIE scores significantly in patients with PNES; in order to achieve
an actual increase in quality of life, seizures needed to cease entirely.
Antiepileptic drug (AED) side effects as well as depression have
been underscored as a significant contributing factor in regard to
low QOL in people with PNES [4,5,9]. Birbeck [9] has also suggested
that lower QOL in PNES may be due to a tendency towards greater
external locus control, more emotion-focused coping strategies, and
overestimates of cognitive and physical dysfunction as compared to
those with epilepsy.
Furthermore, some studies suggest that the role of family might
contribute to lower QOL. One paper by Szaflarski [5] reported that
patients with PNES perceived their families to be less committed
⁎ Corresponding author at: Northeast Regional Epilepsy Group, 820 Second Avenue,
Suite 6C, New York, NY 10017, USA. Fax: +1 212 661 7496.
E-mail address: lmyers@epilepsygroup.com (L. Myers).
and supportive. LaFrance [10] also found that the mean general func-
tioning for families with ES and PNES was unhealthy.
A handful of PNES studies have documented higher levels of anger,
hostility, angry reactions to the diagnosis, or elevated attempts to control
anger [11–13]. Zaroff et al. [14] found higher levels of anger-control-in
and anger-control-out prior to a twelve‐week group treatment program
and an increase in anger-expression-out and anger-control-in and out
subsequent to completion of the treatment. Anger expression in many
forms is thought to have a potential impact on interpersonal, occupational
and family functioning as well as self-esteem and negative evaluations by
others [15]. A relation between anger‐management styles and mood and
somatic symptoms in anxiety, somatoform disorders and dissociative
experiences has been documented [16–21].
The goal of our study was to gain understanding as to what are the
contributory factors to patients with PNES reporting such diminished
QOL. We hypothesized an association between poorer QOL and specific
psychiatric factors (diagnoses, psychiatric hospitalizations, trauma
event count, and sexual and/or physical abuse) and medical factors
(i.e. presence of medical conditions, fibromyalgia, chronic fatigue,
other pain syndromes); an association between poorer QOL and certain
social characteristics (i.e. employment, marital status, children, reli-
gious affiliation, proximity to family) and elevated anger expression,
trait and state would correlate with poorer quality of life.
2. Methods
All consecutive patients (n = 82) with diagnosis of PNES con-
firmed with inpatient video-EEG monitoring and who underwent

1525-5050/$ – see front matter © 2012 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.yebeh.2012.08.024
 L. Myers et al. / Epilepsy & Behavior 25 (2012) 358–362
our epilepsy program's PNES neuropsychological battery between
2009 and 2012 were included in this study. Neuropsychological testing
was performed on an outpatient basis.
All of the subjects were administered a comprehensive battery of
tests of neurocognitive and psychological functions and a thorough
interview including elicitation of history of psychiatric disorders
(depression, anxiety) and symptoms as well as history of sexual
and/or physical abuse and the age of onset of the abuse. Information
about mental health history and trauma history was elicited through
a history form that the patient filled out prior to the testing.
Subsequently, history and diagnostic information was obtained
through open-ended questions during the interview performed by
the licensed neuropsychologist who conducted the examination. Psy-
chopathology characterization was established by using DSM-IV
criteria. Some patients had suffered multiple traumatic events at dif-
ferent ages. The earliest age for a reported traumatic event was
recorded as “age of trauma”. The definition of sexual abuse included
diverse forms of sexual assault (i.e. touching/fondling and/or forced
oral sex or vaginal/anal intercourse). The definition of physical
abuse included a variety of physical assaults (i.e. bruising, broken
bones, whip marks, stab wounds, concussions). The variable “Trauma
History” was coded positive if either type of abuse was present. Cog-
nitive complaints count included reports of diminished memory, at-
tention, and language skills. Emotional complaints included feelings
of sadness and nervousness, loneliness and social withdrawal, and
frustration and irritability.
Psychiatric data that were collected included the presence of
psychiatric hospitalizations, traumatic event count, number of psy-
chiatric medications, and diagnoses of depression, PTSD, conversion,
generalized anxiety, somatization disorder and psychosis. Social
data included employment and marital status, having children, reli-
gious involvement and proximity to family.
Medical history that was obtained included presence of medical
conditions (e.g. cancer, lupus, orthopedic conditions), fibromyalgia,
chronic fatigue, other pain syndromes, and physical and cognitive com-
plaints. Other medical conditions included the number of co-morbid
medical conditions from the medical history.
Inclusion criteria: Patients aged 18 and higher with a confirmed
diagnosis of PNES through video-EEG (V-EEG) monitoring that had
also completed a full neuropsychological battery.
Exclusion criteria: At the outset of the study, there were a total of
82 patients who had a diagnosis of PNES. This final number was
reduced to 62. Three patients who earned a full‐scale IQ of less than
70 were excluded. Two patients who “failed” the Test of Memory
Malingering (TOMM) thereby suggesting questionable effort were
also excluded. Fifteen patients who were found to have a dual diagno-
sis of epilepsy and PNES were excluded. The diagnosis of epilepsy was
based on review and confirmation of ictal V-EEG recording by
epileptologists (ML and OL).
Four measures from the PNES neuropsychological battery em-
ployed at the Northeast Regional Epilepsy Group were used for
analysis: the Quality of Life in Epilepsy-31 (QOLIE-31), State Trait
Anger Expression Inventory—2 (STAXI-2), the Minnesota Multiphasic
Personality Inventory—2—RF (MMPI‐2‐RF), and Test of Memory
Malingering (TOMM).
The Test of Memory Malingering [22] was administered to help
neuropsychologists discriminate between malingered and true
memory impairments. Standardization of the measure was performed
on 70 cognitively intact individuals recruited from the community
ranging from 17 to 73 years, with a mean education of 12.7 years.
According to the TOMM manual, suggested interpretation of the test is
that 1) scoring lower than chance on any trial indicates the possibility
of malingering and 2) any score lower than 45 on Trial 2 indicates the
possibility of malingering.
QOLIE 31: The QOLIE-31 [23] is a 31-question inventory designed
to measure an adult's (18 years of age and older) quality of life and
359
asks about several aspects of health. It is divided into seven scales
that explore the following: emotional well-being, social functioning,
energy/fatigue, cognitive functioning, seizure worry, medication
effects and overall quality of life (a single 10-point Likert item). A
weighted average of the multi-item scale scores is used to obtain a
total score. In addition, the test utilizes a single item that assesses
overall health. When scoring, a higher t score indicates a more desir-
able quality of life. The test is designed specifically for people with
epilepsy and addresses such issues as driving, seizures and medica-
tion. Although epilepsy and PNES are not equivalent, there are impor-
tant clinical similitudes and shared concerns (i.e. “seizure” concern,
AED side effects, driving prohibition). A review of existing general
health status and quality‐of‐life scales and questionnaires did not
produce any better measure to assess the construct of QOL in this
particular population [24].
MMPI‐2-RF: The MMPI-2-RF [25] is a 338‐item self-report measure
of psychopathology and personality. The test comprises 338 true–false
items and is intended for adults (18 and older). There are 51 scales
divided into 9 categories: Validity (9 scales), Higher-Order (H-O)
(3 scales), Restructured Clinical (RC) (9 scales), Somatic/Cognitive
(5 scales), Internalizing (9 scales), Externalizing (4 scales), Interperson-
al (5 scales), Interest (2 scales), and Personality Psychopathology Five
(PSY-5) (5 scales). The Higher-Order scale “The Emotional/Internalizing
Dysfunction (EID)” is of particular interest given its broad assessment of
overall emotional dysfunction. The first three Restructured Clinical
scales (RC1: Somatic Complaints; RC2: Low Positive Emotions; RC3:
Cynicism) are of special interest given their potential relationship to
PNES. All subscale raw scores that the subject endorses are converted
into t scores.
STAXI-2: The STAXI-2 is a 57-item self-report measure which con-
sists of three main scales: 6 subscales and an overall Anger Expression
Index [26]. The five subscales include the State Anger Scale, which
measures the intensity of angry 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 experi-
enced 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;
the Anger Expression-Out, which measures how often angry feelings
are expressed in verbally or physically aggressive behavior; the Anger
Expression-In, which measures how often angry feelings are
suppressed or experienced but not expressed; the Anger Control-Out,
which measures how often the person controls the outer expression
of angry feelings; and the Anger Control‐In, which measures how
often a person attempts to control angry feelings by self-calming or
cooling off. The STAXI-2 also provides an Anger Expression Index,
which is a general index of anger expression based on responses to
the other 5 subscales. All scales are reported in t scores.
Institutional Review Board (IRB) approval for an anonymous archival
record review was obtained with removal of non-relevant PHI
(Copernicus IRB NRE1-11-155).
Table 1
Quantitative variables correlated with total QOLIE scores (n = 62).
Variables r p
Age of testing −.209 .097
Years of education .048 .705
Age of onset of NES −.348 .005
Duration of NES .254 .043
# of AEDs .076 .550
# of psych meds −.219 .083
Age of trauma −.184 .196
Other medical conditions −.431 .000
Cognitive complaints count −.395 .001
Psych hospitalizations −.028 .829
Emotional complaints −.362 .003
Types of abuse counted −.185 .144
360 L. Myers et al. / Epilepsy & Behavior 25 (2012) 358–362

Table 2 Our hypothesis of potential association between QOL and social

Correlations between MMPI‐2‐RF clinical scales and STAXI-2 scales and Total QOLIE variables (employment, marital status, having children, religious
scores.
involvement, and proximity to family) was not supported.
Test variables r p In patients with PNES, associations between QOL and medical
MMPI RC1 −.553 .000 variables were found: the number of medical conditions the patient
MMPI RC2 −.556 .000 reported (r = − .431, p b .000), the presence of other pain syn-
MMPI II RC3 −.335 .009 dromes (t = 2.122, p b .039) and number of cognitive complaints
MMPI‐2-RF EID −.613 .000
(r = − .395, p b .001) were significantly correlated to lower QOL as
State Trait Anger Expression Inventory 2nd edition (STAXI-2) Axo −.163 .337
State Trait Anger Expression Inventory 2nd edition (STAXI-2) Axi −.212 .201 seen in Table 1.
State Trait Anger Expression Inventory 2nd edition (STAXI-2) Aco .273 .097 Our hypothesis that elevations in anger expression and manage-
State Trait Anger Expression Inventory 2nd edition (STAXI-2) Aci .344 .037 ment correlated to poorer quality of life was confirmed in almost all
STAXI trait −.546 .000 respects. We obtained a positive correlation between levels of anger
STAXI state −.404 .001
control-in and quality of life (r = .344, p b .037). We obtained a nega-
STAXI total −.255 .044
tive correlation between anger state, trait and the total quality-of-life
RC1 = somatic complaints, RC2 = low positive emotions, RC3 = cynicism, EID =
score as well as between most QOLIE subscales (Table 2). Anger trait
emotional/internalization dysfunction, AX-O = anger expression out, AX-I = anger
expression in, AC-O = anger control out, AC-I = anger control in. correlated significantly with total QOLIE, seizure worry, emotional
well‐being, cognitive, medication effects and social function (respec-
tively, r = − .350 and p b .005, r = − .443 and p b .000, r = − .475
and p b .000, r = − .540 and p b .000, r = − .336 and p b .007 and
3. Analysis r = − .275 and p b .029). Anger state also correlated significantly with
overall, seizure worry, emotional well‐being, medication effects and so-
The primary outcome measure was prediction of the QOLIE Total cial function (respectively, r = −.384 and p b .002, r = −.330 and
Score (weighted average of the 7 QOLIE scales) from various psychi- p b .009, r = −.343 and p b .006, r =−.360 and p b .004 and r= −.343
atric, medical and social variables calculated, including STAXI-2 Trait and p b .006). The total anger score correlated significantly with overall,
and State Anger Indexes, MMPI‐2-RF Scales EID, RC1, RC2, and RC3, emotional well‐being and cognitive function (respectively, r= −.320
sex, age of PNES onset, history of trauma, age of earliest trauma, num- and p b .010, r= −.357 and p b .004 and r = −.293 and p b .020) as
ber of emotional, medical and cognitive complaints, and employment shown in Table 4.
and marital status. Stepwise multiple regression was used to predict An additional analysis was run excluding men in order to assess
the QOLIE Total Score from these predictors. Descriptive and demo- if results were equivalent in a homogenous sample. Results were
graphic variables were analyzed. Bonferroni's corrections for an comparable; significant correlations were found between QOL and
experiment-wise significance of p b .05 were calculated for analyses MMPI-2-RF RC1, RC2, RC3, and EID (r= −.579 and p b .000, r= −.525
with multiple variables. An independent t test was used to compare and p b .000, r = −.361 and p b .008 and r = −.581 and p b .000),
quantitative variables between two independent groups, with a STAXI trait, state and total (r= −.513 and p b .000, r= −.386 and
Bonferroni's correction applied to the multiple t-tests performed p b .004 and r = −.301 and p b .026) as well as cognitive and emotional
resulting in p b .00232 required for significance. Pearson's correlation complaints, medical and pain syndromes, depression, age of PNES onset
was used to establish correlations between two variables, with and duration.
Bonferroni's corrections applied to each set of correlations resulting The primary outcome analysis of the stepwise multiple regression
in p b .0045 required for correlations between selected MMPI-2-RF to predict the QOLIE Total Score from the predictors was significant.
scales, STAXI-2 scales, and the QOLIE Total Score and p b .0018 for cor- Four models were generated, with the best resulting in 64.8 of
relations between QOLIE subscales and the MMPI-2-RF scales and explained variance significant at F = 12.41 and p = .000007. Four
STAXI subscales. predictors were significant: MMPI-2-RF RC3 (t = − 3.06, p = .005),
age at earliest trauma (t=−2.97, p=.006), history of trauma (t=2.54,
p=.017) and STAXI Trait Anger (t=−2.51, p=.018).
4. Results
5. Discussion
Descriptive and demographic data were analyzed (Table 1), and
they revealed that 56 out of 62 were females (87.5%). Mean age was The most novel finding of this study is represented in the signifi-
40.48 (±11.879), and mean years of education were 14.6 (±2.532). cant correlation between elevated anger expression (trait) and
In our study, specific psychiatric factors correlated with poorer “cynicism” (RC3) with regard to diminished Total quality of life. The
QOL. Greater number of emotional complaints (r = − .362, p b 003) significant associations found between higher anger trait and state
correlated with poorer QOL, as did MMPI-2-RF scales including and lower scores on almost all other QOLIE subscales are also of inter-
elevations in RC1 (r = − .553, p b .000), RC2 (r = − .556, p b .000), est. These results suggest that anger expression and diminished
RC3 (r = − .335, p b .009) and Emotional Internalization Dysfunction anger-control inwards have a role in diminished quality of life that
(r = − .613, p b .000) as seen in Table 2. In addition, MMPI‐2‐RF these patients report. Research in other anxiety disorders such as
Depression and EID subscales correlated significantly with all QOLIE generalized anxiety disorder, PTSD, and panic disorder [20,21] have
subscales (Table 3). reported high levels of multiple dimensions of anger. Anger scores

Table 3
Correlations between MMPI‐2‐RF subscales and QOLIE subscales.

Variables QOLIE overall QOLIE seizure worry QOLIE emotional well-being QOLIE energy fatigue QOLIE cognitive QOLIE med effects QOLIE social

MMPI RC1 r = −.298 p = .021 r = −.373 p = .003 r = −.216 p = .097 r = −.327 p = .011 r = −.578 p = .000 r = −.273 p = .035 r = −.364 p = .004
MMPI RC2 r = −.382 p = .003 r = −.313 p = .015 r = −.460 p = .000 r = −.298 p = .021 r = −.393 p = .002 r = −.328 p = .010 r = −.422 p = .001
MMPI RC3 r = −.122 p = .352 r = −.230 p = .077 r = −.235 p = .071 r = −.284 p = .028 r = −.308 p = .017 r = −.319 p = .013 r = −.177 p = .177
MMPI 2RF EID r = −.662 p = .000 r = −.341 p = .024 r = −.667 p = .000 r = −.497 p = .001 r = −.415 p = .005 r = −.331 p = .028 r = −.303 p = .045

RC1 = somatic complaints, RC2 = low positive emotions, RC3 = cynicism, EID = emotional/internalization dysfunction.
 L. Myers et al. / Epilepsy & Behavior 25 (2012) 358–362
Table 4
Correlations between STAXI subscales and QOLIE subscales.
Variables QOLIE overall QOLIE seizure worry QOLIE emotional well-being
STAXI-2 ACI r = .352 p = .033 r = .244 p = .146 r = .306 p = .066
STAXI trait r = −.350 p = .005 r = −.443 p = .000 r = −.475 p = .000
STAXI state r = −.384 p = .002 r = −.330 p = .009 r = −.343 p = .006
STAXI total r = −.320 p = .010 r = −.221 p = .082 r = −.357 p = .004
STAXI-2 ACI = anger control-in.
in this PNES sample are similar to findings commonly reported in
these other anxiety disorders. It has been hypothesized that the associ-
ation between anger and anxiety may be linked to affective processes
that are essential to survival. For example, Barlow [27] explained anxi-
ety as the emotional correlate to the behavioral “flight” response and
anger to the behavioral “fight” response. Styles of anger experience
and expression (proneness and suppression) have been identified as
potential sources of somatization [28].
Extremes in anger in patients with PNES are a logical finding;
descriptions of upbringings in which adult caretakers have not pro-
vided healthy modeling of anger expression and management are
common. The patients have been frequently subjected to abuses
ranging back to early childhood. Anger is not an unusual emotion
associated to these memories. Angry feelings that are not successfully
modulated and managed can lead to physical and emotional distress.
The correlation between anger expression and quality of life in
PNES represents an encouraging finding for treating professionals
working with PNES sufferers. Identifying underlying processes that
sustain and interact with this condition is essential for the develop-
ment of disorder-specific treatment approaches for PNES. This finding
has this potential in that it provides an identifiable and modifiable
target for psychotherapy.
Replication of these findings is needed. If confirmed, this would
lend support to the utility of assessing anger expression in PNES
patients prior to beginning treatment and to designs of therapy
focused on specifics of anger and anger management to secondarily
impact quality of life.
Psychogenic non‐epileptic seizures coexist with many other psy-
chiatric disorders [29]. A relationship between depressive symptoms
and worse quality of life has been reported in the past [4–6]. Our
results demonstrated a correlation between lower QOL and a higher
number of emotional and cognitive complaints, as well as an eleva-
tion in the MMPI‐2-RF RC3 and Emotional/Internalizing Dysfunction
Scales. In addition, these two MMPI scales correlated with all QOLIE
31 subscales. Since four of the seven QOLIE subscales (emotional
well-being, fatigue, cognitive problems, and social) correspond to
DSM‐IV diagnostic criteria for depressive disorders, it is reasonable
to assume an association.
In 2005, Benbadis [30] reported a higher incidence of fibromyalgia
and pain syndromes in PNES. Our present study also found a greater
number of patients reported suffering from pain syndromes, though
not so with fibromyalgia. Our patients also reported having several
serious medical conditions (e.g., cancer, orthopedic problems, multiple
surgeries). The number of medical conditions the patients reported
and the presence of other pain syndromes significantly correlated
with lower QOL. This is consistent with reports that chronic physical
pain and medical concerns (i.e. cancer, lupus) can impact health-
related quality of life [31,32].
Patients who had developed PNES at an older age and who had
experienced PNES for a shorter period of time are finding that it
more strongly impacts their quality of life. Only one other similar
report of this was found in existing literature [1]. A possible explana-
tion is that those who have spent less time suffering this condition or
who lived a longer time period without it are less adjusted to it and
are finding that it impacts more on their quality of life.
361
QOLIE energy fatigue QOLIE cognitive QOLIE med effects QOLIE social
r = .057 p = .738 r = .307 p = .065 r = .234 p = .163 r = .277 p = .097
r = −.237 p = .062 r = −.540 p = .000 r = −.336 p = .007 r = −.275 p = .029
r = −.157 p = .224 r = −.213 p = .096 r = −.360 p = .004 r = −.343 p = .006
r = −.188 p = .139 r = −.293 p = .020 r = −.042 p = .741 r = .068 p = .598
A limitation of the study was that there was a disproportionate
representation of men and women, such that a comparative analysis
of gender and anger could not be performed. There have been reports
that men and women differ in terms of anger proneness and suppres-
sion which could not be evaluated in our sample. Analysis excluding
males revealed comparable results in the female sample. Future stud-
ies with equal numbers of both genders could provide more informa-
tion with regard to this. In addition, the use of the QOLIE with PNES
samples has been the subject of criticism in the past since it was not
developed for use with PNES [9]. However, at this point, the QOLIE
appears to be the most suitable measure for both these groups since
there are many shared concerns (i.e. “seizure” concern, AED side
effects, driving prohibition) that are not better assessed by other scales.
Future research directions should aim to replicate these findings
and clarify variations in anger expression in PNES patient subgroups
and determine if anger expression correlates to other factors identi-
fied in PNES. Pre- and post-assessments of treatments that provided
anger management and assertiveness training to patients with
anger‐management problems are also an important future project.
Similarly, important future directions in treatment research could
examine the impact on changes in anger experience on quality of
life post-treatment.
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