Received: 12 November 2021 Accepted: 7 August 2022 DOI: 10.1002/pmh.1564 RESEARCH ARTICLE Influence of personality profile in patients with drug- resistant epilepsy on quality of life following surgical treatment: A 1-year follow-up study Elena Iurina1 | Eva Bailles2 | Mar Carreño3,4,5 | Antonio Donaire3,4,5 | Jordi Rumià3,4 | Teresa Boget3,4,5 | Núria Bargallo4,5 | Xavier Setoain3,4,5,6 |Pedro Roldan3,4 | Estefanía Conde-Blanco3,4,5 | María Centeno3,4,5 | Luis Pintor3,4,5,7 1 Department of Psychiatry and Forensic Medicine, Autonomous University of Abstract Barcelona (UAB), Barcelona, Spain The objectives of this study are to determine the influence of personality pro- 2 Mental Health Service, Nostra Senyora file in patients with drug-resistant epilepsy on quality of life (QoL) after surgi- de Meritxell Hospital, Les Escaldes, cal treatment and compare the results with a non-surgical control group at the Andorra 3 Clinical Institute of Neurosciences, 1-year follow-up. We conducted a prospective, comparative, controlled study, Hospital Clinic of Barcelona, Barcelona, including 70 patients suffering from drug-resistant epilepsy. Demographic, psy- Spain chiatric, neurological, and psychological data were recorded at the baseline 4 Epilepsy Unit, Hospital Clinic of and at the 1-year follow-up. Assessment of personality dimensions was per- Barcelona, Barcelona, Spain 5 formed using the NEO-FFI-R questionnaire; severity of anxiety and depression Biomedical Research Institute August Pi i Sunyer (IDIBAPS), Hospital Clinic of were assessed by the Hospital Anxiety and Depression Scale (HADS), and QoL Barcelona, Barcelona, Spain was evaluated using the QOLIE-31. At the 1-year follow-up, comparing the 6 Biomedical Imaging Group, Biomedical control and the surgical groups, we detected differences in scores of most items Research Networking Center in Bioengineering, Biomaterials and of QoL, which were higher in those patients who had undergone surgery. High Nanomedicine (CIBER-BBN), Barcelona, levels of Conscientiousness and Openness to experience at the baseline in Spain patients who underwent surgery predicted better post-surgical outcomes in the 7 Department of Medicine, University of QoL scores, whereas high neurotic patients showed worse QoL results. Postop- Barcelona (UB), Barcelona, Spain erative changes in QoL in patients were associated with the personality profile Correspondence at the baseline. QoL measures significantly improved in the surgical group Elena Iurina, Department of Psychiatry and Forensic Medicine, Autonomous compared with the non-surgical group but were not associated with baseline University of Barcelona (UAB), Barcelona or postoperative seizure frequency at 1 year. 08007, Spain. Email: iurinaelena1990@gmail.com INTRODUCTION et al., 2020). Not only the disease itself, but the social stigma, side effects of anti-seizure medications, high level Epilepsy is associated with a high burden on health care of psychiatric, and other clinical comorbidity contribute and low quality of life (QoL) index in patients (Deleo to the low level in QoL scores in patients (Paschal This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2022 The Authors Personality and Mental Health Published by John Wiley & Sons Ltd. Personal Ment Health. 2022;1–12. wileyonlinelibrary.com/journal/pmh 1 2 IURINA ET AL. et al., 2007). However, QoL depends on individual per- METHODS ception, which, in turn, develops from an individual's personality (Ramanaiah et al., 1997). Personality profile Design correlates with the QoL of patients suffering from epi- lepsy according to the literature (Rassart et al., 2020; Rose A prospective, comparative, controlled study was carried et al., 1996; Shamsi et al., 2020). out in which a surgical group of drug-resistant epilepsy Surgical therapy is a treatment of choice in refractory patients was compared with a control group, composed epilepsy cases, which can lead to a seizure-free outcome of refractory epilepsy patients treated with anti-seizure and improve QoL. If the personality profile in patients medications. Both groups were followed up during 1 year suffering from epilepsy influences their QoL during the after being included in the study. disease, it can also affect the QoL perception following recovery due to surgical treatment. Indeed, the results of the research of Rose and colleagues (Rose et al., 1996) Setting and participants showed that preoperative neuroticism had an important influence on postoperative psychosocial adjustment and This study was conducted at the Hospital Clinic of health-related QoL, which did not depend on the postop- Barcelona from November 2013 to May 2018 and was erative seizure outcome. Patients with high neuroticism approved by the Hospital Ethics Committee. Subjects were and low extraversion were predisposed to greater depres- recruited from our Epilepsy Unit of the Neurology Service, sion after surgery; high neuroticism was also associated which receives referrals from the whole of Spain because with disrupted family dynamics following surgical treat- our center is one of the hospitals in Spain, where patients ment (Wilson et al., 2010). can receive surgical treatment of refractory epilepsy. The This study aims to determine the possible contribu- flow chart in Figure 1 shows the recruitment process. tion of personality profile in patients with drug-resistant A statistical software to calculate sample size was epilepsy to changes in the QoL following surgical treat- used (SPSS Sample Power 3.0.1, Armonk, NY: IBM ment and to compare the results with the non-surgical Corp.). We assumed that the mean difference in QOLIE- control group at the 1-year follow-up. 31 scores is 7.3 (corresponding to means of 52.9 in FIGURE 1 Flow chart showing the recruitment process INFLUENCE OF PERSONALITY PROFILE IN PATIENTS WITH DRUG-RESISTANT EPILEPSY ON QUALITY OF LIFE FOLLOWING SURGICAL 3 TREATMENT: A 1-YEAR FOLLOW-UP STUDY surgical group versus 45.6 in non-surgical group) and the Hospital Anxiety and Depression Scale (HADS) was pooled within-group standard deviation is 10.8 (based on applied for evaluating depression (HAD-D) and anxiety SD = 10.2 and N = 69 in surgical group and SD = 12.2 (HAD-A) (Herrero et al., 2003). It contains 14 items, 7 of and N = 29 in control group) (Elliott et al., 2012). A max- which are for self-assessing the level of depression and imum acceptable error of 5% was applied. We obtained a 7 for anxiety. Every subscale should be scored by the sample size of 39 cases for each group with an 80% patient from 0 to 3 according to the severity of the item. confidence. Accordingly, the patient can score from 0 to 21 points on Our sample size (28 and 42 patients in each group) each scale. More than 10 points out of 21 in every sub- has the statistical power of 73%. scale is considered as a probable indicator of clinical anx- The general evaluation protocol consisted of the fol- iety or depression. lowing points: All participants signed informed consent; Evaluations of personality dimensions and QoL were the patients were evaluated to confirm the diagnosis of performed by a clinical psychologist using NEO-FFI-R refractory epilepsy according to the International League (Aluja et al., 2005), and the Spanish version of the Against Epilepsy protocol (Scheffer et al., 2017) and were QOLIE-31 scale was applied to evaluate the QoL in the assessed for the possibility of surgical intervention. Suit- patients (Torres et al., 1999). ability for surgery was decided by the epilepsy committee The revised NEO Five-Factor Inventory (NEO-FFI) is at a weekly meeting based on the complete protocol out- a short version of the Revised NEO Personality Inventory comes, such as results of clinical examination, neuropsy- (NEO-PI-R) questionnaire and has 60 items (12 per chological tests, video-EEG, magnetic resonance imaging domain) for self-assessing the five major personality (MRI) with gadolinium, and invasive methods like brain dimensions: neuroticism, extraversion, openness to expe- electrodes surgically implanted in a cortical subdural rience, agreeableness, and conscientiousness. The patient way, or with depth electrodes. The most important exclu- had to indicate his/her degree of agreement with the sion criteria were a failure to determine accurately the statement using a score from 0 to 4 from “total disagree- epileptogenic focus or to find an epileptogenic zone ment” to «totally agree», respectively. The minimum pretty enough dangerous to foster severe functional dam- score for each domain is 0, and the maximum is 48. age after surgery. Anyway, every patient is always evalu- The QOLIE-31 is a valid and reliable measure of QoL ated in a personalized manner. in patients with epilepsy. It is a self-reported question- Inclusion criteria of the study were the following: age naire comprising two factors (emotional and psychologi- 18 years or older, no history of neurosurgery, a full-scale cal effects and medical and social effects), seven IQ score of 70 or higher, absence of serious medical subscales, and 31 items. Items are measured on 4- to pathology except epilepsy, including dementia, schizo- 6-point Likert scales, with a maximum total score of 100. phrenia or other chronic psychosis, and non-epileptic psy- Higher scores indicate a better QoL. chogenic seizures. Patients who presented with any of the These measures were given during routine clinical following comorbidities were excluded: severe medical follow-up as part of psychological and psychiatric assess- pathology, severe dementia, nonepileptic seizures, previ- ment at 12 months. ous surgery for epilepsy, and intellectual disability that would prevent patients answering all questionnaires on their own. Those, who met the inclusion criteria of the Procedure study, but had contraindications for the surgical treatment according to the decision of the multidisciplinary team of All patients with drug-resistant epilepsy who decided to the Epilepsy Committee, formed the control group. undergo surgery were admitted for a wider study to which they gave informed consent. Patients were referred for admission to the neurology ward for a 1-week evalua- Clinical assessments tion. After presurgical evaluation, the committee board made a decision on the suitability or not of surgical Demographic, clinical, psychiatric, and psychological var- intervention. iables were collected. The demographic data collection Those, who had contraindications for surgical inter- sheet included age, gender, education, occupation, and vention, formed the control group and underwent all marital state; clinical data included information about assessment procedures at the same time intervals, respec- etiology of epilepsy, localization, and lateralization of epi- tively, to the surgical intervention group at the baseline leptogenic foci, number of seizures at the beginning of and 1 year after surgery. During the follow-up period, the disease, number of seizures in the last 6 months, and patients were maintained on a stable medication regi- age of the epilepsy onset. The Spanish version of men. The postoperative evaluation at the 1-year 4 IURINA ET AL. TABLE 1 Sociodemographic variables at baseline and differences between groups Whole sample group Surgical group Control group Differences between (n = 70) (n = 28) (n = 42) surgical and control % Mean SD % Mean SD % Mean SD group, p value Sociodemographic Age 36.94 10.93 35.00 8.49 38.24 12.22 0.195 Gender: Women 55.7 53.6 57.1 0.810 Men 44.3 46.4 42.9 Education: Basic education 45.7 46.4 45.2 0.898 Secondary 37.1 39.3 35.7 education Higher education 17.1 14.3 19 Occupation: Inactive 28.6 14.3 38.1 0.075 Housewife/student 21.4 21.4 21.4 Active 50 64.3 40.5 Marital state: Married 57.1 64.3 52.4 0.576 Separated/widow/ 12.9 7.1 16.7 ers Single 28.6 28.6 28.6 No data 1.4 0 2.4 Neurologic Idiopathic etiology 60.0 64.3 57.1 1.000 Type of seizures: No seizures 1.4 0 2.4 0.649 Focal onset impaired 50.0 57.1 45.2 awareness seizures Other focal onset 15.7 14. 16.7 seizures Unknown onset 20 14.3 23.8 tonic–clonic seizures Generalized 10.0 14.3 7.1 seizures Locus: Temporal 57.1 64.3 52.4 0.693 Extratemporal 24.3 25.0 23.8 Unestablished 15.7 10.7 19 Hemisphere: Right 44.3 42.9 45.2 0.406 Left 37.1 46.4 31 Bilateral 12.9 7.1 16.7 Unknown 1.4 0 2.4 193.6 180.34 139.57 120.77 229.62 204.46 0.068 INFLUENCE OF PERSONALITY PROFILE IN PATIENTS WITH DRUG-RESISTANT EPILEPSY ON QUALITY OF LIFE FOLLOWING SURGICAL 5 TREATMENT: A 1-YEAR FOLLOW-UP STUDY TABLE 1 (Continued) Whole sample group Surgical group Control group Differences between (n = 70) (n = 28) (n = 42) surgical and control % Mean SD % Mean SD % Mean SD group, p value Age (month) of epilepsy onset Number of seizures 21.11 35.71 26.04 37.52 17.83 34.52 0.040* at the baseline (per Median:7.0; Median: 9.0; Median:6.0; month) IQR: 25.5 IQR: 25.8 IQR: 16.0 Psychiatric assessment HADS scale: HADS-depression 3.93 3.41 4.59 4.09 3.49 2.86 0.308 HADS-anxiety 6.59 3.52 7.33 3.89 6.10 3.21 0.203 Psychological assessment: QOLIE: Seizure worry 45.65 9.67 45.17 9.51 45.72 10.05 0.734 Overall quality of 45.78 8.33 44.06 8.91 46.76 7.95 0.157 life Emotional well- 46.08 10.01 46.41 10.83 45.68 9.68 0.824 being Energy/fatigue 50.45 8.34 49.12 8.50 50.89 8.02 0.277 Cognitive function 47.17 11.64 44.56 11.54 48.65 11.70 0.125 Medication effects 48.40 9.33 47.78 9.37 48.73 9.67 0.647 Social functioning 42.67 9.39 40.82 10.15 43.68 8.82 0.179 Total quality of life 44.40 9.77 42.26 10.12 45.90 9.49 0.140 NEO: Neuroticism 25.53 6.85 26.66 6.90 24.78 6.77 0.264 Extraversion 26.61 5.90 25.87 6.30 27.10 5.65 0.395 Openness to 27.55 6.27 27.46 6.51 27.60 6.19 0.923 experience Agreeableness 32.73 5.07 33.82 5.36 32.00 4.79 0.141 Conscientiousness 32.48 5.90 33.45 6.95 31.84 5.86 0.267 Note: Groups are similar to each other in presurgical evaluation in demographic, psychiatric, neurological, and neurosurgical variables, except the number of seizures per month—this variable was higher in the surgical group. Abbreviation: IQR, interquartile range. *p < 0.05. **p < 0.001. follow-up involved psychiatric evaluation (HADS) and Distributions of variables were examined by clinical psychology assessment (QOLIE). Postsurgical sei- Kolmogorov–Smirnov test for the whole sample and by zure outcome was determined during the follow-up visits Shapiro–Wilk test for each group. Appropriate tests were by the treating neurologist 1 year after surgical applied for further analysis. Data were analyzed with an intervention. intention-to-treat approach to see if drop-out patients were different from the patients who finished the follow- up. Descriptive analysis of all variables was performed at STATISTICAL ANALYSIS the baseline. The group of controls and the surgical group were compared with detect initial differences between Statistical analysis was performed using Version 22 of groups, using a Student's t test, Fisher's exact test, and SPSS for Windows, and differences were considered sig- Mann–Whitney U test, according to the type of every var- nificant at p < 0.05. iable and its distributions. Also, both groups were 6 IURINA ET AL. compared at the 1-year follow-up in HADS, QoL, and sei- Descriptive analysis at baseline and zure frequency. Changes in mood, QoL, and seizure fre- comparison between groups quency at the 1-year follow-up were evaluated by Student's t test or Mann–Whitney U test. Those variables Sociodemographic, clinical, and neuropsychiatric vari- of mood and QoL tests, that reached statistical signifi- ables at the baseline in the whole sample and the differ- cance at the 1-year follow-up, were introduced into ences between the groups are shown in Table 1: Groups regression analyses. Pearson or Spearman correlation are similar to each other in presurgical evaluation in analysis was applied to determine the contribution of demographic, psychiatric, and neurological variables, each variable of personality in changes in mood and QoL. except the number of seizures per month—this variable We conduct an exploratory study aiming to discover was higher in the surgical group (Mean = 26.06, potential correlations between personality at the baseline SD = 37.52) compared with the controls (Mean = 17.83, and changes in QoL after surgical treatment. Because the SD = 34.52; p = 0.040*). study is exploratory, we are rather interested in keeping As differences in the number of seizures at the the type II errors as low as possible; thus, we do not use baseline (per month) were found, a comparison was any corrections for multiple testing. made whether this variable affects the QoL. No correlations between QoL items and the seizure fre- quency were found in both groups of patients at the RESULTS baseline. Table 2 shows association of personality and QoL at Of 80 eligible patients, 70 completed the neuropsychiatric the baseline in whole sample of patients: A higher score assessment at the 1-year follow-up. There were no statis- of Neuroticism was associated with worse QoL, and tical differences in sociodemographic, clinical, and neu- higher scores in Extraversion and Openness to experience ropsychiatric variables between included patients and connected with better QoL. patients who did not complete the 1-year follow-up Table 3 demonstrates association between (n = 10). The final sample consisted of 28 patients who HADS and QoL at the baseline in the whole sample: underwent surgery and 42 patients who were not suitable Higher scores of HADS were associated with for the surgical treatment (control group). worse QoL. TABLE 2 Association of personality and QoL at the baseline. Whole sample. Pearson or Spearman correlation Neuroticism Extraversion Openness to experience Agreeableness Conscientiousness Seizure worry r= 0.170 r = 0.165 r = 0.085 r = 0.148 r= 0.179 p = 0.161 p = 0.175 p = 0.488 p = 0.226 p = 0.141 Overall quality of life r= 0.118 r = 0.197 r= 0.192 r = 0.059 r= 0.015 p = 0.334 p = 0.104 p = 0.114 p = 0.630 p = 0.901 Emotional well-being r= 0.393 r = 0.064 r = 0.270 r = 0.102 r = 0.184 p = 0.001** p = 0.600 p = 0.025* p = 0.404 p = 0.130 Energy/fatigue r= 0.362 r = 0.185 r= 0.120 r= 0.062 r = 0.069 p = 0.002* p = 0.129 p = 0.324 p = 0.613 p = 0.576 Cognitive function r= 0.358 r = 0.222 r = 0.108 r = 0.114 r = 0.159 p = 0.002* p = 0.067 p = 0.377 p = 0.352 p = 0.193 Medication effects r= 0.229 r = 0.120 r= 0.075 r = 0.075 r = 0.059 p = 0.058 p = 0.324 p = 0.540 p = 0.540 p = 0.628 Social functioning r= 0.389 r = 0.269 r= 0.007 r = 0.116 r= 0.006 p = 0.001** p = 0.025* p = 0.956 p = 0.344 p = 0.958 Total QoL r= 0.460 r = 0.291 r = 0.078 r = 0.125 r = 0.064 p = 0.000** p = 0.015* p = 0.523 p = 0.307 p = 0.601 Note: A higher score of Neuroticism was associated with worse QoL, and higher scores in Extraversion and Openness to experience connected with better QoL. Abbreviation: QoL, quality of life. *p < 0.05. **p < 0.001. INFLUENCE OF PERSONALITY PROFILE IN PATIENTS WITH DRUG-RESISTANT EPILEPSY ON QUALITY OF LIFE FOLLOWING SURGICAL 7 TREATMENT: A 1-YEAR FOLLOW-UP STUDY Changes in 1-year follow-up and their 0.435** 0.483** associations with mood, personality, and Total QoL p = 0.000 p = 0.000 seizure frequency r= r= The meanings of QoL, HADS, and seizure frequency at the 1-year follow-up and their difference from baseline to functioning the 1-year follow-up for each group (surgical and non- 0.341** ,435** surgical) were described independently. The seizure fre- p = 0.005 p = 0.000 quency variable indicates the number of seizures per Social month. Also, these variables were compared between our r= r= groups of patients. The results are shown in Table 4. The majority of patients (22 of 28; 78.6%) from the surgical group became seizure-free in the 1-year follow- Medication up. 0.214 0.213 p = 0.082 p = 0.084 Table 4 shows that at the 1-year follow-up comparing effects the control and the surgical group, we detected differ- r= r= ences in most items of QoL, which were higher in postop- erative patients. HADS scores were higher in the control group, compared with the surgical group at the 1-year 0.432** follow-up. Differences were observed in the seizure fre- 0.277* Cognitive p = 0.023 p = 0.000 function quency between our groups of patients with higher scores in the controls. Analyses were performed to explore the r= r= associations of QoL changes and personality at the base- line (Table 5). Table 5 shows a high baseline level of Conscientious- 0.367** 0.286* ness in postoperative patients predicted a better outcome p = 0.002 p = 0.019 Energy/ fatigue in three of eight QoL subscales (Overall QoL: r = 0.530, r= r= p = 0.004**, Social functioning: r = 0.418, p = 0,030*; Total QoL: r = 0.499; p = 0.008**) and high baseline level of Openness to experience scale predicted better outcome to one subscale (Medication effects: r = 0.500, Emotional well- Association between HADS and QoL at the baseline. Whole sample p = 0,008**); high baseline score of Neuroticism pre- 0.420** 0.250* dicted worse QoL outcome in one of eight QoL subscale p = 0.000 p = 0.041 (Overall QoL: r = 0.382; p = 0.049*). being r= r= A comparison was made to show whether significant changes in QoL or HADS from the baseline measurement to the 1-year time point were depended on the seizure Overall quality of frequency at the baseline, at the 1-year follow-up, and Note: Higher scores of HADS were associated with worse QoL. pre-post differences seizures frequency (Table 6). 0.049 0.051 Table 6 demonstrates that an increase in HADA in p = 0.696 p = 0.685 the 1-year follow-up in the control group correlated with life r= r= seizure frequency in the 1-year follow-up (r = 0.318; p = 0.046*). The surgical group increased in 7 of 8 QoL 0.365** 0.328** scales, some of which correlated with seizure variables. p = 0.002 p = 0.007 An increase in item Seizure worry negatively correlated Seizure Abbreviation: QoL, quality of life. worry with seizure frequency at the 1-year follow-up r= r= (r = 0.394; p = 0.042*); positive changes in Energy/ fatigue were negatively correlated with the seizure fre- *p < 0.05. **p < 0.001. quency at the baseline (r = 0.383; p = 0.048*). Also, an HADS-anxiety depression increase of this subscale was associated with good post- TABLE 3 surgical seizure outcome (we used a variable that indi- HADS- cated a difference in the seizure frequency from the baseline to the 1-year follow-up): r = 0.423, p = 0.028*. 8 IURINA ET AL. TABLE 4 Quantitative changes in variables of interest at the 1-year follow-up Surgical Control Differences (baseline- Differences (baseline- Differences Results 1 year) Results 1 year) between Mean SD Mean SD p Mean SD Mean SD p groups, p value QOLIE: Seizure 57.93 8.23 13.07 11.28 0.000** 48.72 12.45 2.75 10.83 0.121 0.003** worry Overall 53.37 10.84 9.74 12.86 0.001** 43.55 11.95 2.93 13.39 0.180 0.002** quality of life Emotional 52.89 11.22 6.39 11.63 0.005** 44.51 12.01 1.38 12.89 0.507 0.008** well-being Energy/ 56.19 9.61 7.18 11.10 0.002* 49.39 9.19 1.74 12.20 0.378 0.007** fatigue Cognitive 48.35 10.62 3.35 10.32 0.104 47.43 12.48 1.20 9.94 0.457 0.813 function Medication 52.69 7.96 5.10 9.27 0.008** 48.09 10.48 0.87 10.95 0.621 0.059 effects Social 49.52 9.24 9.22 9.66 0.000** 43.83 10.09 0.79 9.64 0.960 0.034* functioning Total QoL 53.31 11.14 10.19 10.86 0.000** 44.47 11.94 1.10 11.10 0.539 0.012* HADS scale HADS- 3.53 3.32 1.36 3.47 0.146 5.28 3.99 1.68 4.29 0.015* 0.018* depression HADS- 5.35 4.08 1.9 4.23 0.116 7.93 4.39 1.51 3.78 0.016* 0.037* anxiety Seizure 0.96 2.99 25.07 37.81 0.000* 15.56 21.21 2.68 25.54 0.866 0.000** frequency Median: IQR: Median: IQR: 0.0 0.0 5.0 12.5 Note: “Results” column shows Mean and standard deviations (also “Median” and “IQR” for seizure frequency variable) of the variables at the 1-year follow-up. The “Differences” column indicates the differences between meanings at the baseline and at the 1-year follow-up. At the 1-year follow-up comparing the control and the surgical group, we detected differences in most items of QoL, which were higher in the patients who underwent surgery. HADS scores were higher in the control group, compared with the surgical group at the 1-year follow-up. Differences in the seizure frequency between our groups of patients were observed, with higher scores in the controls. Abbreviations: IQR, interquartile range; QoL, quality of life. *p < 0.05. **p < 0.001. Favorable changes in the subscale Medication effects neg- and Openness to experience showed better QoL out- atively correlated with the seizure frequency at the 1-year comes following surgical treatment at the 1-year follow-up (r = 0.437, p = 0.023*). follow-up, whereas patients with high levels of neuroticism performed worse in the postsurgical QoL results. DISC USS I ON Studying the influence of personality (MMPI-2 and Neuroticism dimension only from the NEO questionnaire The present study aims to determine the possible influ- were applied) in patients with drug-resistant epilepsy on ence of the personality profile in patients with drug- changes in the QoL following surgery, the authors resistant epilepsy on QoL following surgical treatment (Derry & Wiebe, 2000; Rose et al., 1996) reported that the and to compare the results with the non-surgical control neuroticism negatively influenced the QoL after surgery. group at the 1-year follow-up. These results are in the line with our research. We also The most important outcome of our study was that find that Neuroticism was a predictor of a poor patients with high baseline levels of Conscientiousness postsurgical QoL. INFLUENCE OF PERSONALITY PROFILE IN PATIENTS WITH DRUG-RESISTANT EPILEPSY ON QUALITY OF LIFE FOLLOWING SURGICAL 9 TREATMENT: A 1-YEAR FOLLOW-UP STUDY TABLE 5 Association of personality profile at the baseline and changes in subscales of QoL in the surgical group Openness to Neuroticism Extraversion experience Agreeableness Conscientiousness Changes in seizure worry r= 0.171 r= 0.119 r = 0.218 r = 0.141 r= 0.354 baseline/1-year follow-up p = 0.395 p = 0.555 p = 0.276 p = 0.484 p = 0.070 Changes in overall quality of life r = 0.382* r= 0.201 r= 0.085 r= 0.167 r= 0.530** baseline/1-year follow-up p = 0.049 p = 0.314 p = 0.673 p = 0.405 p = 0.004 Changes in emotional well-being r = 0.150 r= 0.130 r= 0.014 r = 0.000 r= 0.107 baseline/1-year follow-up p = 0.456 p = 0.517 p = 0.943 p = 0.999 p = 0.595 Changes in energy/fatigue r = 0.209 r= 0.158 r= 0.310 r= 0.306 r= 0.258 baseline/1-year follow-up p = 0.295 p = 0.432 p = 0.116 p = 0.120 p = 0.194 Changes in cognitive function r= 0.030 r= 0.155 r= 0.171 r= 0.171 r= 0.449 baseline/1-year follow-up p = 0.881 p = 0.439 p = 0.394 p = 0.395 p = 0.019* Changes in medication effects r= 0.144 r = 0.079 r= 0.500** r = 0.038 r= 0.081 baseline/1-year follow-up p = 0.474 p = 0.695 p = 0.008 p = 0.850 p = 0.689 Changes in social functioning r= 0.161 r = 0.106 r = 0.024 r= 0.059 r= 0.418* baseline/1-year follow-up p = 0.421 p = 0.597 p = 0.904 p = 0.769 p = 0.030 Changes in Total QoL r = 0.043 r= 0.125 r= 0.118 r= 0.141 r= 0.499** baseline/1-year follow-up p = 0.832 p = 0.536 p = 0.558 p = 0.483 p = 0.008 Note: Patients with high baseline levels of Conscientiousness and Openness to experience showed better QoL outcomes following surgical treatment at the 1-year follow-up, whereas patients high in Neuroticism showed worse QoL. *p < 0.05. **p < 0.001. A higher score of Neuroticism was associated with It seemed that some personality traits, such as consci- a worse QoL in patients at the baseline in our entiousness, openness to experience, extroversion, and research. These results correlated with the results agreeableness, protect the QoL in patients, and poten- obtained by the other researchers in studies with tially favorable attributes can sometimes reinforce nega- people with epilepsy (Margolis et al., 2018; Rose tive tendencies. et al., 1996). Indeed, according to the researches with healthy peo- Talking about high scores of Conscientiousness and ple, individuals high in Openness and Conscientiousness Openness to experience as a predictor of better postsurgi- tend to engage in more adaptive and flexible coping in cal QoL in other diseases we can refer to research the face of stress (Lee-Baggley et al., 2005; Watson & (Stanisz et al., 2020) studied women after prophylactic Hubbard, 1996). People high in conscientiousness may adnexectomy: higher levels of conscientiousness, open- achieve more goals, as they tend to persist when faced ness to experience, extroversion, and agreeableness were with illness-related constraints, potentially resulting in a associated with better QoL outcomes following surgical better QoL. In addition, people high in conscientiousness treatment. At the same time, highly neurotic patients had are typically described as attentive, organized, and plan- lower QoL. ful. Surgical treatment in particular, and the burden of Highly conscientious patients suffering from cardio- the disease in general, suppose an increase in stress, and vascular diseases tend to display higher satisfaction with high levels of these personality features are predictors of life in a longitudinal study in 9 months follow-up good coping with stress in a longitudinal period. (Tabernero et al., 2019). These characteristics might make it more difficult for Why do people with high levels of neuroticism show patients to cope with epilepsy-related factors like social low scores of QoL? isolation, restrictions in work and study activities, stigma, High levels of neuroticism are typically associated and many others and affect the QoL significantly. with pessimism, vulnerability to stress, and high negative This is confirmed by our results that QoL at the base- affectivity (Afshar et al., 2015). Neurotic patients fre- line was associated with personality and HADS but not quently use maladaptive coping strategies in dealing with with the seizure frequency. Gilliam (Gilliam, 2002) illness-related challenges, such as avoidant or passive reported no association between seizure frequency and coping strategies. QoL in patients suffering from epilepsy. 10 IURINA ET AL. TABLE 6 Association of significantly changed variables of interest and seizure frequency variables at the 1-year follow-up Control group Spearman correlation Seizure frequency at Seizure frequency at the Changes in seizure frequency the baseline 1-year follow-up baseline/1-year follow-up Changes in HADA r= 0.154; p = 0.342 r= 0.318; p = 0.046* r = 0.269; p = 0.193 baseline/1-year follow-up Changes in HADD r= 0.286; p = 0.073 r= 0.270; p = 0.092 r= 0.373; p = 0.066 baseline/1-year follow-up Surgical group Seizure frequency at Seizure frequency at the Changes in seizure frequency the baseline 1-year follow-up baseline/1-year follow-up Changes in seizure worry r = 0.131; p = 0.515 r= 0.394; p = 0.042* r= 0.053; p = 0.792 baseline/1-year follow-up Changes in overall quality of life r= 0.131 r = 0.260 r= 0.199 baseline/1-year follow-up p = 0.515 p = 0.190 p = 0.320 Changes in emotional well-being r= 0.250 r = 0.119 r= 0.333 baseline/1-year follow-up p = 0.208 p = 0.556 p = 0.089 Changes in energy/fatigue r= 0.383 r = 0.232 r= 0.423 baseline/1-year follow-up p = 0.048* p = 0.243 p = 0.028* Changes in medication effects r= 0.015 r = 0.437 r= 0.134 baseline/1-year follow-up p = 0.941 p = 0.023* p = 0.505 Changes in social functioning r= 0.097 r = 0.246 r= 0.198 baseline/1-year follow-up p = 0.631 p = 0.215 p = 0.322 Changes in total QoL r= 0.201 r = 0.307 r= 0.324 baseline/1-year follow-up p = 0.314 p = 0.119 p = 0.099 Note: An increase in HADA in the control group correlated with seizure frequency in the 1-year follow-up. The surgical group increased in 7 of 8 QoL scales; some of which correlated with seizure variables. Abbreviation: QoL, quality of life. *p < 0.05. **p < 0.001. Research (Endermann & Zimmermann, 2009) con- variable. Also, the study is limited by the small sample cluded that neuroticism had more impact on the QoL size (n = 31). than seizure frequency in people with epilepsy. Villeneuve (2004) reviewed articles evaluated quality- Johnson et al. (2004) reported on seizure frequency of-life scales for patients with drug-resistant partial epi- reduces QoL but appears less powerful predictor of QoL lepsy in his study. The analysis of the literature identified than HADS. Differences with our results could appear 22 articles focusing on the impact of epilepsy on QoL in because different approaches for evaluating seizure sever- adults. Different QoL scales were reviewed, and QOLIE- ity were used: Johnson and colleagues applied The Liver- 31 was applied in one reviewed study only. The author pool Seizure Severity Scale. Also, differences occur in the reported that being seizure free is necessary but not sample: Patients with temporal lobe epilepsy only were enough to have a good level of QoL. Also, the study con- included in their study. cluded QoL scores were lesser in depressed patients, Some authors reported on the association of QoL with which is in the line with our results. seizure frequency and depression (Mehta et al., 2014; Thus, it seems that the QoL depends more on the Villeneuve, 2004). Mehta with colleagues (Mehta individual perception of stress, and coping strategies, et al., 2014) reported on the association of 3 of 8 QoL which is mediated by the personality characteristics and scales with seizure frequency and 7 of 8 QoL scales with mood, than on objective clinical factors in patients suffer- depression level. The authors evaluated seizure frequency ing from severe chronic diseases, for example, seizure fre- by three levels (0, 1, or >1) rather than as a continuous quency in patients with refractory epilepsy. INFLUENCE OF PERSONALITY PROFILE IN PATIENTS WITH DRUG-RESISTANT EPILEPSY ON QUALITY OF LIFE FOLLOWING SURGICAL 11 TREATMENT: A 1-YEAR FOLLOW-UP STUDY LIMITATIONS Research in Medical Sciences: The Official Journal of Isfahan University of Medical Sciences, 20(4), 353–358. Aluja, A., García, O., Rossier, J., & García, L. F. (2005). Comparison The main limitation of this study occurs due to the small of the NEO-FFI, the NEO-FFI-R and an alternative short ver- sample size. Due to ethical reasons, the distribution for sion of the NEO-PI-R (NEO-60) in Swiss and Spanish samples. groups of surgical treatment or controls depended on the Personality and Individual Differences, 38, 591–604. https://doi. patient's suitability and was not randomized. All psycho- org/10.1016/j.paid.2004.05.014 logical and psychiatric data were self-reported. Deleo, F., Quintas, R., Pastori, C., Pappalardo, I., Didato, G., di Giacomo, R., et al. (2020). Quality of life, psychiatric symptoms, and stigma perception in three groups of persons C O N C L U S IO N with epilepsy. Epilepsy & Behavior, 110, 107170. https://doi.org/ 10.1016/j.yebeh.2020.107170 Epub 2020 Jun 5. PMID: 32512366 Derry PA, Wiebe S. Psychological adjustment to success and to People with epilepsy with high baseline levels of Consci- failure following epilepsy surgery. The Canadian Journal of Neu- entiousness and Openness to experience showed better rological Sciences. 2000;27 Suppl 1:S116–20; discussion S121–5. QoL outcomes following surgical treatment at the 1-year https://doi.org/10.1017/s0317167100000779. PMID: 10830338. follow-up, whereas patients high in Neuroticism showed Elliott, I., Kadis, D. S., Lach, L., Olds, J., McCleary, L., Whiting, S., a worse QoL. The findings of the study show clinical psy- Snyder, T., & Smith, M. L. (2012 Sep). Quality of life in young chologists, psychiatrists, and patients that some personal- adults who underwent resective surgery for epilepsy in child- hood. Epilepsia, 53(9), 1577–1586. https://doi.org/10.1111/j. ity features can have an impact on postsurgical QoL. 1528-1167.2012.03594.x Epub 2012 Jul 19. PMID: 22812675 People being evaluated for surgical treatment for epilepsy Endermann, M., & Zimmermann, F. (2009 Apr). Factors associated who are identified as having vulnerable personalities with health-related quality of life, anxiety and depression should be offered appropriate psychological support. among young adults with epilepsy and mild cognitive impair- ments in short-term residential care. Seizure, 18(3), 167–175. CONFLICTS OF INTEREST https://doi.org/10.1016/j.seizure.2008.08.013 Epub 2008 Sep 26. None of the authors has any conflict of interest to PMID: 18823801 disclose. Gilliam, F. (2002). Optimizing health outcomes in active epilepsy. Neurology, 58(8 Suppl 5), S9–S20. https://doi.org/10.1212/wnl. 58.8_suppl_5.s9 PMID: 11971128 E TH IC S ST A T EME N T Herrero, M. J., Blanch, J., Peri, J. M., de Pablo, J., Pintor, L., & This study was conducted at the Hospital Clinic of Barce- Bulbena, A. (2003). A validation study of the hospital anxiety lona from November 2013 to May 2018 and was approved and depression scale (HADS) in a Spanish population. General by the Hospital Ethics Committee. Hospital Psychiatry, 25(4), 277–283. https://doi.org/10.1016/ s0163-8343(03)00043-4 PMID: 12850660 DATA AVAILABILITY STATEMENT Johnson, E. K., Jones, J. E., Seidenberg, M., & Hermann, B. P. (2004). The relative impact of anxiety, depression, and clinical The data that support the findings of this study are avail- seizure features on health-related quality of life in epilepsy. 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