Relationship between optimism, disease variables, and health perception and quality of life in individuals with epilepsy.

,
in
ilv
do P
am
of.
go A
e Faculdade de Cieˆncias Humanas e Sociais, Universidade Fernando Pessoa (Porto), Porto, Portugal
Received 28 November 2006; revised 10 April 2007; accepted 13 April 2007
Keywords: Situational optimism; Quality of life; Health status; Cognitive status
of this disorder. destructive effects of epilepsy (i.e., brain damage, mental
deterioration, loss of intelligence, mental illness). Addition-
ally, epilepsy is a disorder traditionally associated with a
significant amount of stigma [8]. Despite advances in the
understanding and treatment of epilepsy within the past
several decades, people with this disorder continue to be
q 4-HGSA-Porto; 5-FCHS-Univ. FP (Research supported by a Grant
for scientific research on epilepsy and Neuroscientia-Tecnifar).
* Corresponding author. Fax: +351 226079725.
E-mail address: jlpr@fpce.up.pt (J. Pais-Ribeiro).
Epilepsy & Behavior 11 (1. Introduction
Epilepsy is the world’s most common serious neurolog-
ical disorder [1,2], and it is often surrounded by prejudice
and myth, which can be overcome only with enormous dif-
ficulty. Between 5% [1] and about 9% [3] of people experi-
ence at least one seizure at some point, but not all of those
who have an epileptic seizure develop epilepsy. Seizures are
episodic, unpredictable, uncontrollable, aversive events,
and are the main feature, or the most evident characteristic,
Research into epilepsy tends to be focused largely on
neurobiological issues. However, over the years, a body
of empirical research indicates that seizure disorders are
often associated with a variety of psychological and social
problems, as well as malaise [4–6] and social and political
isolation. The fear patients have about their seizures (or
possible seizures) is seldom assigned a significant role in
adjustment to everyday life. Many people with epilepsy
do not know others with their condition [7]. Patients have
many concerns about what they believe are the potentiallyAvailable online 29 May 2007
Abstract
Epilepsy is a relatively frequent chronic condition with an important impact on the health perception and quality of life (QOL) of
patients. The aim of the present study was to identify variables related to health status perception and QOL in persons with epilepsy.
Participants were 200 persons with epilepsy, 53.5% of whom were males. The mean age was 39.6; 95% had seizures, and 99% were taking
antiepileptic medication. The self-report questionnaire administered assessed four types of variables: demographic, disease, epilepsy-
specific optimistic attitude, and outcome variables. Results demonstrated that an optimistic orientation is related to better perception
of physical and mental health status and better perception of QOL. The variables that best predict positive outcomes are optimistic
orientation, perception of cognitive functioning, and perception of seizure control. These results question the importance attributed
to seizure characteristics for everyday functioning and everyday life of individuals with epilepsy, and stress the importance of facilitating
an epilepsy-specific optimistic orientation.
� 2007 Elsevier Inc. All rights reserved.Relationship between optimism
perception and quality of life
J. Pais-Ribeiro a,b,*, A. Martins da S
a Faculdade de Psicologia e de Cieˆncias da Educac¸a˜o, Universidade
b IBMC, Universidade do Porto, Rua do C
c ICBAS, Universidade do Porto, Largo Pr
d Hospital Geral de Santo Anto´nio, Lar1525-5050/$ - see front matter � 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.yebeh.2007.04.010disease variables, and health
individuals with epilepsy q
a b,c,d, R.F. Meneses b,e, C. Falco d
orto, Rua Dr. Manuel Pereira da Silva, 4200-392 Porto, Portugal
po Alegre, 823, 4150-180 Porto, Portugal
Abel Salazar, 2, 4099-003 Porto, Portugal
bel Salazar, 4099-001 Porto, Portugal
www.elsevier.com/locate/yebeh
2007) 33–38

Scheier and Carver [19] explain that expectation judg-
ments in many stressful encounters can range from very
sy &stigmatized by it [2], and the stigma associated with
epilepsy has been related to poor psychosocial health out-
comes, such as low self-esteem, worry, negative feelings
about life, and depression [8].
Mittan and Lock [9] report that two-thirds of the people
with epilepsy they studied believed that other peoples’ reac-
tions contributed more to their social problems than the sei-
zures themselves, and half of them considered others’
reactions worse than seizures. Stigma is still pervasive and
is manifested in various forms of social discrimination
(e.g., difficulties in obtaining a driver’s license, employment,
and health insurance) [10]. There are three erroneous beliefs
related to public ignorance and misconceptions [11]. First,
lay people tend to characterize epilepsy in terms of tonic–
clonic (grand mal) seizures, when in fact there are many dif-
ferent forms of epilepsy and seizures. Second, epilepsy is
still classified as a ‘‘mental disorder’’ rather than a physical
one. Finally, there is the association of epilepsy with numer-
ous negative, namely, antisocial, personality traits.
Today, the new generation of antiepileptic drugs and
treatment adherence (i.e., proper use of pharmacological
agents and compliance with lifestyle orientations) guaran-
tee that the majority of patients do not have seizures and
can maintain a normal life, with a low cognitive impact
of the disease. Nevertheless, epilepsy therapy may be pro-
longed, and a cure is not always attainable.
For these reasons, health status perception and quality
of life (QOL) are important health care outcomes. This
notion has been readily accepted, and has resulted in an
increased amount of research investigation into health sta-
tus perception and QOL in epilepsy [2,12,13]. In fact, one
of the main health outcomes is health status perception
[14–16], and the main tools used to assess health status per-
ception are short form measures based on those developed
for the Medical Outcomes Study [17], with SF-36 as a valid
and reliable health status measure for descriptive studies of
people with epilepsy [15].
QOL is also an important end-point reference for evalu-
ation of outcomes, being assessed by a multitude of differ-
ent approaches [18].
Because subjective experience of disease is an important
feature of epilepsy, psychological variables, namely, posi-
tive variables, can play an important role in coping with
the condition and in determining the outcome of disease.
Optimism is an important personality variable with respect
to behavioral health outcomes [19]. Scheier and Carver [19]
define optimism as ‘‘general expectations that good things
will happen’’ (p. 172). It is a relatively stable, generalized
expectation that positive outcomes will occur across impor-
tant life domains. Optimism also benefits people’s actions
and their potential to achieve in times of adversity, accord-
ing to Scheier and Carver [20]. It is a personality disposi-
tion approach to resilience derived from expectancy-value
models of motivation. These models assume that people
who have favorable expectations about outcomes that are
34 J. Pais-Ribeiro et al. / Epilepimportant to them respond to difficulties with continued
efforts, and people with unfavorable expectations are moregeneral to very specific—dispositional optimism and situa-
tional optimism. Dispositional optimism refers to general-
ized outcome expectations that good things, rather than
bad things, will happen (in opposition, pessimism refers
to the tendency to expect negative outcomes). Situational
optimism refers to the expectations an individual generates
over a particular situation. Situational optimism is the
expectation of a positive outcome in a specific situation.
Because specific expectations are more proximal to spe-
cific events than dispositional expectations, they may be
important predictors of psychological and biological
responses to specific stressors. Situational and dispositional
optimism measures have been found to be only modestly
correlated; Taylor [21] reported the highest and only signif-
icant correlation between specific outcome expectations
and generalized optimism (0.1), and studies that have
employed both measures have found that they predict dif-
ferent patterns of psychological and physical health out-
comes. Another study [22] determined that situational
optimism was a stronger predictor of mood than disposi-
tional optimism and predicted immune changes when dis-
positional optimism did not.
It is recognized that optimistic attitude, that is, the expec-
tation that good things will happen, seems to promote a
higher level of physical and psychological well-being [23].
Segerstrom et al. [22] explain that there exists a growing body
of evidence that elucidates the relationship of optimism and
other psychosocial factors to biological processes associated
with physical health. Research also suggests that more fre-
quent seizures are related to worse health status perception,
worse global QOL, and/or worse QOL in specific domains
[6,24,25]. The same holds true for another seizure-related
variable: perception of seizure control. Smith et al. [24], for
example, verified that when psychological variables are
excluded, the perception of seizure control contributes sig-
nificantly to anxiety in refractory epilepsy. Additionally,
results fromneuropsychological tests and self-reports of cog-
nitive functioning, being predictors of global QOL, affect the
QOL of persons with epilepsy [26,27].
The aim of the present study was to identify the relation-
ship between epilepsy-specific optimistic orientation and
disease variables (seizure frequency, perception of seizure
control, and perception of cognitive functioning) and out-
come variables (physical and mental health status percep-
tion and QOL).
2. Methods
Participants comprised a sequential sample of 200 outpatients with epi-
lepsy from a General University Hospital, in Porto, Portugal, with a meanlikely to stop trying. Peoples’ actions are greatly affected by
their beliefs about the probable outcomes of those actions
[19].
Behavior 11 (2007) 33–38age of 39.6 and mean level of education of 8.1 years; 53.5% were males,
63% were married or cohabitating, 95% had seizures (4.5% with >1 seizure

per week, 7.5% with 61 seizure per week, 9.5% with >1 seizure per month,
13% with 61 seizure per month, 24.5% with >1 seizure per year, 36% with
61 seizure per year, and 5% without seizures), 70.5% had only one type of
seizure, and 99% were taking antiepileptic drugs (49% monotherapy,
33.5% bitherapy, and 16.5% polytherapy). Table 1 is a cross-tabulation
of type and frequency of seizures.
A self-report questionnaire was developed to evaluate four types of
variables: demographic variables (age, education), disease variables (sei-
zure frequency, number of years with the disease, perception of seizure
control, and perception of cognitive functioning), epilepsy-specific opti-
mistic attitude, and outcome variables (QOL and mental and physical
and intermediate variables: optimistic orientation, mental
To answer the research question, we investigated the
relationship between disease variables, epilepsy-specific
optimistic orientation, health status perception, and
QOL. Because age and educational level are correlated
with some of the variables: age with optimistic orientation
[r(200) = �0.2, P = 0.001], physical health perception
[r(200) = �0.2, P = 0.0001], perception of cognitive
functioning [r(200) = �0.2, P = 0.001], and QOL
>1/year 61/year No seizures Total
2 1 1 4
28 25 0 81
6 5 0 13
30 29 2 71
0 2 2 6
6 3 0 9
3 7 5 16
Table 2
Epilepsy-specific optimistic orientation scale
Definitely
true
Mostly
true
Mostly
false
Definitely
false
My epilepsy will last for a
short time
I will probably be sick a lot in
the future
I believe I will live with this
disease for the rest of my
life
J. Pais-Ribeiro et al. / Epilepsy & Behavior 11 (2007) 33–38 35components of health status perception).
Seizure frequency was self-reported as daily, more than once per week,
once or less often week, more than once per month, once or less often per
month, more than once a year, once or less often per year, or no seizures.
Perception of seizure control was assessed with four questions from the
Liverpool Seizure Severity Scale [28]. With this scale, patients classify their
seizures on the basis of their subjective experience. The scale was designed
as a measure of outcome in the evaluation of treatment of intractable epi-
lepsy. The four items explore perception of control over seizures (‘‘When
your attacks occurred, how often have you been able to tell when you will
have them?’’ ‘‘How often have you been able to fight off your attacks?’’
‘‘How often have you had an impending sense or warning with your
attacks?’’ ‘‘How much control have you had over your attacks?’’). Patients
answer on a four-item Likert-type scale; the higher the score, the more
severe the seizures. For this sample, the internal consistency of the four
items, as measured with Cronbach’s a, is 0.90.
Perception of cognitive functioning was assessed with the question-
naire developed by Vickrey et al. [29] for epilepsy, the ESI-55. It includes
five items: difficulties in concentrating and thinking, difficulties in main-
taining focused attention for prolonged periods, difficulties in problem
solving and reasoning, memory difficulties, and difficulties with speech
and language. Patients answer on a five-item Likert-type scale, with higher
scores reflecting more favorable perceptions. The internal consistency for
this sample, as measured with Cronbach’s a, is 0.8.
Epilepsy-specific optimistic orientation was evaluated with a question-
naire developed for the present study. It includes seven items that assess
optimistic expectations regarding future health status, some of them
inverted items, as outlined in Table 2. Based on the classification of Sche-
ier and Carver [20], it is a moderately general judgment of expectation.
The seven-item questionnaire has satisfactory internal consistency (Cron-
bach’s a = 0.8, with corrected item–total correlation mainly in the 0.7’s,
between 0.5 and 0.7). Lower scores on optimistic orientation represent a
higher optimistic orientation.
Health status perception was measured with the SF-8, which is based
in the SF-36 [17]; the Portuguese version was developed by Pais-Ribeiro
[30]. It includes eight items grouped under two dimensions (four items
each) of health status perception mental and physical health perception.
Higher scores represent better health status perception. QOL was mea-
sured with one item: ‘‘Overall, how do you classify your QOL during
the last 4 weeks?’’ Patients answered on a five-item Likert-type scale rang-
ing from ‘‘weak’’ to ‘‘excellent.’’ Higher scores indicate worse QOL.
According to Idler and Benyamini [31], global assessment of health and
QOL with one item is recognized as valid and reliable.
Table 1
Types and frequency of seizure
Seizure type >1/week >1/month
Simple partial 0 0
Complex partial 6 22
Partial secondarily generalized 1 1
Generalized tonic–clonic 0 10
Tonic 2 0
Absence 0 0
Myoclonic 0 1Total 9 34health perception, physical health perception, quality of
life, and number of years with the disease. There were no
statistically significant differences between number of years
with the disease and the principal variables.Participants answered the questionnaire after providing informed con-
sent, in accordance with the Helsinki Declaration, Portuguese law, and
hospital rules. A trained psychologist helped patients, mainly those with
a lower educational level, complete the questionnaire.
3. Results
Inspecting differences based on demographic and disease
variables, we found that based on gender, patients exhibit a
statistically significant difference with respect to optimism
(t(198) = 2.2, P < 0.03), with males manifesting a higher
optimistic orientation (M = 13.2) than females (M = 14.8).
With respect to type of seizure, no statistically signifi-
cant differences were noted in the following outcomes
I believe I will recover from
my epilepsy with time
I try to see my disease in a
positive way
I believe my disease will last
for my entire life
I expect my health to get
worse75 72 10 200

[r(200) = 0.1, P = 0.04]; and educational level with opti-
mistic orientation [r(200) = �0.1, P = 0.01], physical
health perception [r(200) = 0.2, P = 0.003], perception of
cognitive functioning [r(200)= 0.1, P = 0.01], QOL
[r(200) = �0.1, P = 0.01], and perception of seizure control
[r(200) = �0.1, P = 0.01], we tested partial correlations
controlling these two variables. Partial correlations are
coefficients that describe the linear relationship between
two variables, while controlling the effects of one or more
additional variables. Table 3 outlines the correlations
between the variables studied. In this table are listed statis-
tically significant and important correlations between epi-
lepsy-specific optimistic orientation and components of
variables studied, optimism and perception of cognitive
functioning are the best predictors of each dependent
variable. Optimism is the variable that best contributes to
mental health status perception and QOL, whereas percep-
tion of cognitive functioning is the variable that best pre-
dicts physical health status. Seizure control contributes
significantly to the prediction of physical health status per-
ception but not to the prediction of mental health status
perception or QOL, and seizure frequency does not con-
tribute to the prediction of any outcome or dependent
variable.
ality of life, perception of cognitive functioning, perception of seizure control,
QOL Cognitivef Seizurec Seizuref
0.3b �0.4b 0.10 0.001
�0.6b 0.3b �0.03 0.09
�0.5b 0.6b �0.19b 0.005
�0.2b 0.07 0.05
�0.06 �0.0001
0.1
component of health perception; Physicom, physical component of health
Table 4
Standard multiple regression analysis to estimate the magnitude of
variance of prediction of physical and mental health perception and
QOL by psychological and disease variables
B SE b t P
Dependent variable: physical health perception
Intercept 11.6
Optimism �0.2 0.02 �0.3 �7.05 0.0001
Cognitivef 0.2 0.03 0.4 7.5 0.0001
Seizurec �0.1 0.03 �0.1 �3.04 0.003
Seizuref 0.06 0.08 0.03 0.7 ns
F(4,195) = 59.8, P < 0.0001
Model adjusted R2 = 0.54
Seizuref 0.02 0.04 0.03 0.5 ns
F(4,195) = 10.03, P < 0.0001
Model adjusted R2 = 0.15
a Optimism, epilepsy-specific optimistic orientation; Cognitivef, cogni-
tive functioning; Seizurec, perception of seizure control; Seizuref, seizure
frequency.
36 J. Pais-Ribeiro et al. / Epilepsy & Behavior 11 (2007) 33–38health status perception, especially the physical component
of health perception.
Higher optimistic orientation is correlated with better
perception of cognitive functioning (items from ESI-55),
better perception of physical and mental health (measured
with the SF-8), and better QOL. (Higher scores are not
‘‘better’’ for all indicators.)
Optimistic orientation is correlated with perception of
cognitive functioning, but not with perception of seizure
control nor with seizure frequency. Perception of cognitive
functioning seems to play a central role in the correlation
matrix, and does not appear to be related to seizure
features.
A standard multiple regression estimates the coefficients
of the linear equation that best predict the value of the
dependent variable. This is a reliable technique when inde-
pendent variables are correlated with one another and with
the dependent variable to varying degrees. We performed
three separate regression analyses, considering physical
health perception, mental health perception, and QOL as
dependent variables for each regression, and epilepsy-spe-
cific optimistic orientation, perception of cognitive func-
tioning, perception of seizure control, and seizure
frequency as predictors. Results are reported in Table 4.
The results highlight three variables that contribute sig-
nificantly to prediction of the physical component of health
status (physical health perception, R2a ¼ 0:5), two for the
mental component of health status (mental health percep-
tion, R2a ¼ 0:2), and two for QOL (R2a ¼ 0:1). From the
Table 3
Partial correlations between the components of health status perception, qu
and seizure frequency, controlling for age and educational level
Optimisma Mntcomp Physicomp
Optimism �0.3b �0.6b
Mntcomp 0.6b
Physicomp
QOL
Cognitivef
Seizurec
Seizuref
a Optimism, epilepsy-specific optimistic orientation; Mntcomp, mental
perception; QOL, quality of life; Cognitivef, cognitive functioning; Seizurec, p
b P < 0.0001.Dependent variable: mental health perception
Intercept 12.2
Optimisma �0.1 0.04 �0.2 �3.6 0.0001
Cognitivef 0.1 0.05 0.2 3.6 0.0001
Seizurec �0.001 0.05 �0.002 �0.02 ns
Seizuref 0.1 0.12 0.09 1.5 ns
F(4,195) = 14.1, P < 0.0001
Model adjusted R2 = 0.20
Dependent variable: quality of life
Intercept 2.3
Optimism 0.05 0.01 0.2 3.9 0.0001
Cognitivef �0.03 0.01 �0.1 �2.1 0.03
Seizurec 0.01 0.01 0.04 0.6 nserception of seizure control; Seizuref, seizure frequency.

sy &4. Discussion
One the most interesting conclusions of the present
study is that seizure frequency does not contribute to the
prediction of everyday functioning and everyday life, simi-
lar to the findings of Gilliam et al. [25], where linear regres-
sion analysis confirmed that mood had the strongest
association with subjective health, independent of seizures,
driving status, medication requirement, or employment,
and Smith et al. [32], who found that seizure frequency con-
tributed little to psychological status. In Portugal, Meneses
[33] also found that individuals with different seizure fre-
quencies did not differ in a statistically significant manner
on any of the SF-36 scores. Conversely, Jacoby et al. [6]
reported that ‘‘individuals with frequent seizures have sig-
nificantly poorer psychosocial profiles than those with
infrequent or no seizures’’ (p. 158). These authors found
that seizure activity was the most important predictor of
poorer psychosocial status. Similarly, Buck et al. [34]
reported that seizure frequency was one of the three most
important variables explaining the variation of all SF-36
scale scores.
Nationality may play a role. In fact, Buck et al. [34],
studying Europeans with epilepsy and controlling clinical
and demographic variables, noted statistically significant
differences between countries on all SF-36 scales except
Physical Functioning.
The results concerning perception of seizure control are
also worth stressing, as this variable was statistically signif-
icantly correlated only with physical health status percep-
tion, and this correlation was a weak one. Consequently,
our study demonstrates that perception of seizure control
is a poor predictor of health perception and QOL, in oppo-
sition to the findings of Collings [5] and Smith et al. [24],
where perception of seizure control was related to anxiety.
Thus, our results do not support efforts to change the per-
ception of seizure control as a first-line intervention to
improve individuals’ health status perception and QOL.
Rather, our results indicate that perception of cognitive
functioning is a good predictor of physical and mental
health status perception and QOL [26,27]. Furthermore,
our results suggest that epilepsy-specific optimistic orienta-
tion is an important psychological variable in prediction of
positive epilepsy outcomes, namely, the physical and men-
tal components of health status perception and QOL,
which is, as far as we are aware, a new finding. Therefore,
multidisciplinary intervention strategies with an impact on
perception of cognitive functioning and/or epilepsy-specific
optimistic orientation can have a profound effect on the
lives of individuals with epilepsy.
We can consider a possible overlap between variables in
the sense that the majority of psychosocial variables are
positive variables. However when we inspect Table 3, we
see that the overlap between variables is reduced, with
higher shared variance between pairs of variables around
J. Pais-Ribeiro et al. / Epilep35% for physical component of health perception and opti-
mism and 9 and 16% for mental health perception and per-ception of cognitive functioning respectively, and
optimistic orientation. We can say that we are in the pres-
ence of different constructs.
The clinical implications of the findings are that it is
important to organize support groups for individuals
with epilepsy, with the aim of developing positive expec-
tations (optimism, self-efficacy, hope), because there
exists a growing body of evidence that elucidates the
relationship of these variables and other psychosocial
factors to biological processes associated with physical
health [22], health perception, disease adjustment, and
everyday life and, probably, to improved quality of life
and epilepsy outcomes.
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