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Personality characteristics in MS patients: The role of avoidant personality
Clinical Neurology and Neurosurgery 144 (2016) 23–27
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Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Personality characteristics in MS patients: The role of avoidant personality Amin Mohamadi a , Mahsa Davoodi-Makinejad a , Amirreza Azimi b , Shahriar Nafissi c,∗ a b c
Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran Department of Neurology, Tehran University of Medical Sciences, Tehran, Iran Department of Neurology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
a r t i c l e
i n f o
Article history: Received 29 June 2015 Received in revised form 17 February 2016 Accepted 26 February 2016 Available online 3 March 2016 Keywords: Multiple sclerosis Quality of life Personality characteristics
a b s t r a c t Objectives: Quality of life (QOL) is markedly affected by multiple sclerosis (MS). Particular personality characteristics (PC) of MS patients can affect their QOL. We designed the present study to determine the role of various PCs on QOL in MS patients accounting for other clinical factors. Methods: QOL, PC, physical disability, and mental status were recorded in 83 MS patients referred to two academic hospitals of Tehran University of Medical Sciences in 2011–2012. Results: The mean age of enrolled patients was 31.54 ± 7.38 (range: 14–50) years and 74 (89.2%) were female. Mean disease duration was 4.55 ± 4.70 years. Seventy-seven patients (92.8%) had relapsing–remitting disease, five (6%) had primary progressive, and one showed a secondary progressive course. Correlation between total QOL scores in MS patients and disease duration, cognitive impairment, and physical disability was significant (all p < 0.001). Obsessive-compulsive personality was the most frequent PC (43.4%) in our patients. Only avoidant personality had a significant negative correlation with all components of QOL (Beta: 0.33, p < 0.00). In addition, avoidant personality, physical disability, and mental status were found to be three predictors of QOL with all its components. Conclusion: Avoidant personality appears to be an important predictor of poor QOL in MS patients. In addition, avoidant coping strategies appear to be associated with adverse response to stressful events in these patients. These findings suggest the need for psychological intervention for improving the coping strategies and QOL in MS patients. © 2016 Published by Elsevier B.V.
1. Introduction Approximately, 3 million individuals are affected by multiple sclerosis (MS) worldwide [1]. According to data obtained from the Iranian MS society, approximately 50,000 patients, i.e., 60–70 patients per 100,000 individuals in the Iranian population, have this disease [2,3]. This disease is a considerable burden on social and family life of MS patients, affecting all the aspects of their quality of life (QOL). Thus, patients gradually feel loss of competency and
Abbreviations: MS, multiple sclerosis; QOL, quality of life; PC, personality characteristics; MCMI-III, millon clinical multiaxial inventory III; MMSE, mini mental status examination; EDSS, expanded disability status scale; SD, standard deviation; RRMS, relapsing–remitting MS; PPMS, primary progressive MS. ∗ Corresponding author at: Department of Neurology, Shariati Hospital, Tehran University of Medical Sciences, North Karegar Street, Tehran 14114, Iran. E-mail addresses: [email protected] (A. Mohamadi), Mahsa [email protected] (M. Davoodi-Makinejad), amirreza [email protected] (A. Azimi), nafi[email protected], s nafi[email protected] (S. Nafissi). http://dx.doi.org/10.1016/j.clineuro.2016.02.035 0303-8467/© 2016 Published by Elsevier B.V.
persuasion [4–6]. Patients suffering from debilitating and chronic diseases such as MS face numerous problems that can affect patient participation in activities related to health promotion. This may lead to secondary complications and restrictions on independent living, with a considerably negative impact on the QOL of patients. In recent years, the QOL of patients with chronic diseases such as MS has been seriously considered [7–9]. QOL is a matter expressed by the patient; in other words, it is based on the perception and individual experience [10]. Therefore, both subjective, which is known as subjective well-being and objective that is known as healthrelated QOL, measures can be affected by personal traits in various conditions and disorders [11–15]. MS is an inflammatory demyelinating disease of the central nervous system, which causes axonal and neuronal loss in both white and gray matter [16]. The possible association of neuroanatomical and personality changes in MS have been noted recently, particularly with multiple active lesions arising within or adjacent to the cortex [17]. Furthermore, reduction of extraversion, openness,
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A. Mohamadi et al. / Clinical Neurology and Neurosurgery 144 (2016) 23–27
and conscientiousness found in MS patients are strongly correlated with a reduced cerebral cortex volume [18]. Personality traits in MS patients have been evaluated using different instruments in previous studies [6,18–24]. Recently, Zarbu et al. have shown that QOL of patients with MS is affected by personality traits [15]. We designed present study to assess the role of different PC on QOL of patients with MS accounting for demographic and other clinical variables. We have used a disease specific health-related QOL instrument, Multiple Sclerosis Impact Scale 29 (MSIS-29) [25] to measure objective QOL and Millon clinical multiaxial inventory III (MCMI-III) [26] to assess personality characteristic that is shown its validity in non-psychological conditions including MS [27,28].
Table 1 The mean scores of the EDSS; MMSE; and total, physical, and mental QOL in different disease courses. Mean (±SD)
P-Value:
MMSE
RRMS PPMS Total
28.09 (1.664) 25.40 (4.33) 27.92(1.97)
0.010
EDSS
RRMS PPMS Total
1.93(1.59) 4.10 (2.01) 2.11(1.73)
0.001
Total QOL
RRMS PPMS Total
38.07 (27.89) 64.28 (31.89) 40.08 (28.70)
0.070
Physical QOL
RRMS PPMS Total
31.75 (27.93) 60.00 (31.62) 34.00 (28.99)
0.034
Mental QOL
RRMS PPMS Total
30.64 (20.67) 41.53 (18.87) 31.37 (20.31)
0.498
2. Material and methods 2.1. Patients The present investigation is a cross-sectional study performed on 83 MS patients, referred to two educational hospitals of Tehran University of Medical Sciences in 2011–2012. Patients with definite MS, according to the McDonald revised criteria, were included in the study [29]. Exclusion criteria were current chronic disease other than MS and MS exacerbation. The patients were recruited consecutively from outpatient neurology clinics of two neurology referral hospitals in Tehran after obtaining informed consent from all research participants. 2.2. Survey tools We assessed the QOL of the patients using the validated Persian version of MSIS-29 [30]. The MSIS-29 was developed as a patient-based objective measure to assess impact of MS patients’ health-related QOL [25]. It measures both physical and psychological impact of MS and consists of 20 physical and nine psychological questions, the score of which is denoted within 0–100. The higher score indicates poorer QOL. None of the PC determination tools has been validated in a MS population; therefore, MCMI-III, a general psychological assessment tool, was applied to determine various PC [26]. MCMI-III is a personality scale developed for adult patients in clinical setting to determine 14 personality disorders and 10 clinical syndromes. However, it has been also used in non-psychological populations [31,32]. MCMI-III is a self-reported questioner that contains 175 true or false questions. Then patients’ raw scores are converted to base range [1–15] and a base range score of >75 is considered clinically significant. We used a validated Persian version and assigned the major PC based on Persian MCMI-III to the patients [33]. Physical disability was measured by the application of the Expanded Disability Status Scale (EDSS), with a range of 0 as normal to 10 as dead [15]. The cognitive condition of patients was evaluated by the only validated questionnaire in the Persian language at the time of performing the study, the Mini Mental Status Examination (MMSE) with a maximum score of 30. Scores of <25 were correlated with impaired cognitive function [16]. An experienced MS neurologist determined MMSE and EDSS scores. 2.3. Statistical analysis Results were summarized as mean and standard deviation (SD). Mean QOL score of individuals who have or do not have particular PCs were compared by independent t-test. In addition, mean EDSS and MMSE scores of different PCs were compared by analysis of variance. Mann–Whitney U test was used for comparison of the mean EDSS, MMSE, and QOL scores among the two disease courses, relapsing–remitting and primary progressive courses.
RRMS: relapsing–remitting MS; PPMS: primary progressive MS.
Pearson’s correlation and chi-square test were used to assess any relation between study variables where applicable. A stepwise linear regression model (P to enter = 0.05; P to leave = 0.10) was then conducted to predict QOL in all its aspects. For predicting total QOL score, variables including avoidant and histrionic personalities, disease course and duration, EDSS score, and MMSE score were included as independent variables in our regression model. For predicting mental QOL score, avoidant, histrionic, and borderline personalities; disease duration; EDSS score; and MMSE score were used as independent variables. For predicting physical QOL scores, avoidant and narcissistic personalities, disease course, age, disease duration, EDSS score, and MMSE score were applied. For all statistical analysis, a p-value of <0.05 was considered statistically significant. 3. Results In this study, 83 patients with the mean age of 31.54 (±7.38) years were enrolled. Seventy-four patients (89.2%) were women. Mean disease duration was 4.55 (±4.70) years. Seventy-seven patients (92.8%) had a relapsing–remitting course, five patients (6%) had primary progressive course, and one patient had a secondary progressive course. No significant difference between sexes in mental, physical, and total QOL scores was observed. Furthermore, age did not demonstrate significant correlation with QOL or any of its components. Disease duration showed significant correlation with total QOL (coefficient of 0.321, p-value < 0.01) and physical QOL (coefficient of 0.353, p-value < 0.01) but not with mental QOL. In addition, among various disease courses, only physical QOL showed significant disease courses (Table 1). Fig. 1 shows the prevalence of different PCs in the study participants. In our study, we found only eight major PCs from 24 possible characteristics using the MCMI-III instrument. From these eight different PCs, only avoidant personality was associated with higher QOL score in all its components. No significant differences between mean age, disease duration, and EDSS score in the two groups of patients with and without avoidant personality were observed. Borderline and histrionic personalities were associated with higher and lower mental QOL scores, respectively. Fig. 2 compares the 95% confidence interval means of mental, physical, and total QOL scores between our study participants with or without particular PC. No significant difference in EDSS and MMSE scores between different PCs was observed. The mean EDSS score in the two groups of
A. Mohamadi et al. / Clinical Neurology and Neurosurgery 144 (2016) 23–27
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Table 2 Predictors of low QOL among study patients. Predictors
Beta
P-Value
Avoidant EDSS MMSE
0.318 0.329 −0.248
0.001 0.001 0.012
Avoidant EDSS MMSE
0.295 0.557 −0.199
<0.001 <0.001 <0.001
Avoidant EDSS MMSE
0.337 0.496 −0.212
<0.001 <0.001 0.015
Mental QOL score
0.321
Physical QOL score
0.440
Total QOL score
Fig. 1. Bar chart of prevalence of various PCs in study participants. Because some patients may have more than one PC, the total sum of these percentages exceeds 100%.
patients with and without obsessive-compulsive personality was significantly different (p < 0.01). No other significant differences between the mean EDSS scores in the two groups of patients with and without each PC were found. The mean scores of QOL in all components, physical disability and mental status amongst patients with a relapsing–remitting course and those with a primary progressive course are summarized in Table 1. Only one participant had a secondary progressive course; therefore, we could not use this patient’s data for comparative analysis. However, for calculating the total mean (±SD), data of this patient was included. Among the QOL components, physical QOL was significantly different between the different disease courses. In addition, MMSE and EDSS scores were also significantly different between disease courses. EDSS and QOL scores showed a significant correlation with a coefficient of 0.550; a similar result was obtained for the correlation between mental and physical QOL scores (all p < 0.01). EDSS showed a significant correlation with disease duration and age, with a coefficient of 0.418 and 0.238, respectively. MMSE scores and age showed a significant correlation, with a coefficient of −0.398 (p < 0.01), whereas the score had a significant correlation with EDSS score, with a coefficient of −0.260 (p < 0.05). All QOL scores showed a significant correlation with MMSE score (coefficient: −0.359 for total, −0.351 for mental, and −0.347 for physical QOL scores).
R square
0.466
As is shown in Table 2, avoidant personality was the only PC that predicted poor QOL in all its components. Other similar predictors were MMSE and EDSS scores. 4. Discussion Health-related QOL is affected by individual persuasion, as are PCs, thus the role of personality traits has been focus of studies in many chronic conditions such as neurologic disease [13,14,34]. We designed the present study to determine the prevalence of PCs in MS patients and their role in health-related QOL measures accounting for demographics and other clinical variables. Previous studies have shown that physical disability, depression, self-reported fatigue, and cognitive impairment were the most important components in the lowering of patient QOL [7–9]. Similarly we observed a significant correlation between QOL of MS patients and disease duration, and MMSE and EDSS scores, which show mental and disability status, respectively. Notably, the QOL of MS patients had a significant correlation with avoidant personality. In MS patients, this type of PC had an independent role, in predicting lower QOL in all its aspects. The management of stressful situations, such as being diagnosed with a chronic illness, is particularly affected by an individual’s personality. Personality can influence exposure, reaction, and ability to cope with stress [35]. Choosing a specific coping strategy, particularly in MS patients, is related to their PCs [24]. Empathy, agreeableness, and conscientiousness are reduced among MS patients compared with neuroticism, which is elevated [18]. Higher
Fig. 2. The mean total, physical, and mental QOL score, with 95% confidence interval, between different PCs. +: Participants who have the PCs. −: Participants who do not have the PCs.
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neuroticism is related to lower health-related QOL [6]. The higher scores on neuroticism suggest that the self-reporting of patients with MS highly involves dissatisfaction, consistent with an avoidant personality. Physical disability, depression, and fatigue are predictors of the physical aspect of QOL, whereas psychological QOL is strongly predicted by cognitive impairment [9]. The association between PC and QOL among MS patients may also be related with different coping strategies in various PCs. A simplified style of problem solving has also been reported to affect the coping strategies in these patients. This phenomenon has neurological and psychological bases [17]. Defective coping strategies also can diminish familial and social engagement, leading to poor QOL in MS patients [6,7]. Using Rorschach test, Oˇzura et al. found the typical problemsolving style in majority of MS patients includes the attempt to simplify situations. Generally, these patients try to avoid emotional and cognitive complexity, instead of working toward managing difficult situations [6]. However, this simplifying style is effective and beneficial for some MS patients; it may enable them to protect themselves from the disorganization resulting from their illness [6]. However, avoiding problem solving strategies may not only lead to patients separating from the emotionally and interpersonally complex situations but also may lead to feelings of low self-esteem. The major limitation of this study was the survey tools used. First, to the best of our knowledge, none of the tools used to determine PC have been previously found to have adequate reliability and validity for use in MS patients. Therefore, we had to use the general questionnaire MCMI-III. It is possible that diseaserelated variables may have influenced patients’ responses and affected interpretation of the study results. Hence, we suggest that researchers design another study in future for validating a determination tool for measuring PC in MS patients. Second, at the time of study [2011–2012], none of the cognitive condition evaluating tools in the Persian language had been found to be adequately reliable or valid for application to MS patients. Thus, we had to use the MMSE questionnaire, which is known to have lower sensitivity and specificity in comparison to other available tools [36,37]. It should be mentioned that Minimal Assessment of Cognitive Function in Multiple Sclerosis was validated for the Persian language in June 2012. Therefore, it is suggested that Persian language researchers should use this version for their studies [38].
[8]
[9]
[10] [11] [12]
[13]
[14] [15]
[16]
[17]
[18]
[19] [20]
[21]
[22]
[23]
[24]
[25]
5. Conclusion [26]
This study supports the role of avoidant problem solving strategies in MS and introduces avoidant personality as a predictor of lower QOL among MS patients. Furthermore, the study emphasizes the need of clearer guidance and communication for these patients to improve their QOL.
[28]
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Contents lists available at ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Personality characteristics in MS patients: The role of avoidant personality Amin Mohamadi a , Mahsa Davoodi-Makinejad a , Amirreza Azimi b , Shahriar Nafissi c,∗ a b c
Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran Department of Neurology, Tehran University of Medical Sciences, Tehran, Iran Department of Neurology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
a r t i c l e
i n f o
Article history: Received 29 June 2015 Received in revised form 17 February 2016 Accepted 26 February 2016 Available online 3 March 2016 Keywords: Multiple sclerosis Quality of life Personality characteristics
a b s t r a c t Objectives: Quality of life (QOL) is markedly affected by multiple sclerosis (MS). Particular personality characteristics (PC) of MS patients can affect their QOL. We designed the present study to determine the role of various PCs on QOL in MS patients accounting for other clinical factors. Methods: QOL, PC, physical disability, and mental status were recorded in 83 MS patients referred to two academic hospitals of Tehran University of Medical Sciences in 2011–2012. Results: The mean age of enrolled patients was 31.54 ± 7.38 (range: 14–50) years and 74 (89.2%) were female. Mean disease duration was 4.55 ± 4.70 years. Seventy-seven patients (92.8%) had relapsing–remitting disease, five (6%) had primary progressive, and one showed a secondary progressive course. Correlation between total QOL scores in MS patients and disease duration, cognitive impairment, and physical disability was significant (all p < 0.001). Obsessive-compulsive personality was the most frequent PC (43.4%) in our patients. Only avoidant personality had a significant negative correlation with all components of QOL (Beta: 0.33, p < 0.00). In addition, avoidant personality, physical disability, and mental status were found to be three predictors of QOL with all its components. Conclusion: Avoidant personality appears to be an important predictor of poor QOL in MS patients. In addition, avoidant coping strategies appear to be associated with adverse response to stressful events in these patients. These findings suggest the need for psychological intervention for improving the coping strategies and QOL in MS patients. © 2016 Published by Elsevier B.V.
1. Introduction Approximately, 3 million individuals are affected by multiple sclerosis (MS) worldwide [1]. According to data obtained from the Iranian MS society, approximately 50,000 patients, i.e., 60–70 patients per 100,000 individuals in the Iranian population, have this disease [2,3]. This disease is a considerable burden on social and family life of MS patients, affecting all the aspects of their quality of life (QOL). Thus, patients gradually feel loss of competency and
Abbreviations: MS, multiple sclerosis; QOL, quality of life; PC, personality characteristics; MCMI-III, millon clinical multiaxial inventory III; MMSE, mini mental status examination; EDSS, expanded disability status scale; SD, standard deviation; RRMS, relapsing–remitting MS; PPMS, primary progressive MS. ∗ Corresponding author at: Department of Neurology, Shariati Hospital, Tehran University of Medical Sciences, North Karegar Street, Tehran 14114, Iran. E-mail addresses: [email protected] (A. Mohamadi), Mahsa [email protected] (M. Davoodi-Makinejad), amirreza [email protected] (A. Azimi), nafi[email protected], s nafi[email protected] (S. Nafissi). http://dx.doi.org/10.1016/j.clineuro.2016.02.035 0303-8467/© 2016 Published by Elsevier B.V.
persuasion [4–6]. Patients suffering from debilitating and chronic diseases such as MS face numerous problems that can affect patient participation in activities related to health promotion. This may lead to secondary complications and restrictions on independent living, with a considerably negative impact on the QOL of patients. In recent years, the QOL of patients with chronic diseases such as MS has been seriously considered [7–9]. QOL is a matter expressed by the patient; in other words, it is based on the perception and individual experience [10]. Therefore, both subjective, which is known as subjective well-being and objective that is known as healthrelated QOL, measures can be affected by personal traits in various conditions and disorders [11–15]. MS is an inflammatory demyelinating disease of the central nervous system, which causes axonal and neuronal loss in both white and gray matter [16]. The possible association of neuroanatomical and personality changes in MS have been noted recently, particularly with multiple active lesions arising within or adjacent to the cortex [17]. Furthermore, reduction of extraversion, openness,
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A. Mohamadi et al. / Clinical Neurology and Neurosurgery 144 (2016) 23–27
and conscientiousness found in MS patients are strongly correlated with a reduced cerebral cortex volume [18]. Personality traits in MS patients have been evaluated using different instruments in previous studies [6,18–24]. Recently, Zarbu et al. have shown that QOL of patients with MS is affected by personality traits [15]. We designed present study to assess the role of different PC on QOL of patients with MS accounting for demographic and other clinical variables. We have used a disease specific health-related QOL instrument, Multiple Sclerosis Impact Scale 29 (MSIS-29) [25] to measure objective QOL and Millon clinical multiaxial inventory III (MCMI-III) [26] to assess personality characteristic that is shown its validity in non-psychological conditions including MS [27,28].
Table 1 The mean scores of the EDSS; MMSE; and total, physical, and mental QOL in different disease courses. Mean (±SD)
P-Value:
MMSE
RRMS PPMS Total
28.09 (1.664) 25.40 (4.33) 27.92(1.97)
0.010
EDSS
RRMS PPMS Total
1.93(1.59) 4.10 (2.01) 2.11(1.73)
0.001
Total QOL
RRMS PPMS Total
38.07 (27.89) 64.28 (31.89) 40.08 (28.70)
0.070
Physical QOL
RRMS PPMS Total
31.75 (27.93) 60.00 (31.62) 34.00 (28.99)
0.034
Mental QOL
RRMS PPMS Total
30.64 (20.67) 41.53 (18.87) 31.37 (20.31)
0.498
2. Material and methods 2.1. Patients The present investigation is a cross-sectional study performed on 83 MS patients, referred to two educational hospitals of Tehran University of Medical Sciences in 2011–2012. Patients with definite MS, according to the McDonald revised criteria, were included in the study [29]. Exclusion criteria were current chronic disease other than MS and MS exacerbation. The patients were recruited consecutively from outpatient neurology clinics of two neurology referral hospitals in Tehran after obtaining informed consent from all research participants. 2.2. Survey tools We assessed the QOL of the patients using the validated Persian version of MSIS-29 [30]. The MSIS-29 was developed as a patient-based objective measure to assess impact of MS patients’ health-related QOL [25]. It measures both physical and psychological impact of MS and consists of 20 physical and nine psychological questions, the score of which is denoted within 0–100. The higher score indicates poorer QOL. None of the PC determination tools has been validated in a MS population; therefore, MCMI-III, a general psychological assessment tool, was applied to determine various PC [26]. MCMI-III is a personality scale developed for adult patients in clinical setting to determine 14 personality disorders and 10 clinical syndromes. However, it has been also used in non-psychological populations [31,32]. MCMI-III is a self-reported questioner that contains 175 true or false questions. Then patients’ raw scores are converted to base range [1–15] and a base range score of >75 is considered clinically significant. We used a validated Persian version and assigned the major PC based on Persian MCMI-III to the patients [33]. Physical disability was measured by the application of the Expanded Disability Status Scale (EDSS), with a range of 0 as normal to 10 as dead [15]. The cognitive condition of patients was evaluated by the only validated questionnaire in the Persian language at the time of performing the study, the Mini Mental Status Examination (MMSE) with a maximum score of 30. Scores of <25 were correlated with impaired cognitive function [16]. An experienced MS neurologist determined MMSE and EDSS scores. 2.3. Statistical analysis Results were summarized as mean and standard deviation (SD). Mean QOL score of individuals who have or do not have particular PCs were compared by independent t-test. In addition, mean EDSS and MMSE scores of different PCs were compared by analysis of variance. Mann–Whitney U test was used for comparison of the mean EDSS, MMSE, and QOL scores among the two disease courses, relapsing–remitting and primary progressive courses.
RRMS: relapsing–remitting MS; PPMS: primary progressive MS.
Pearson’s correlation and chi-square test were used to assess any relation between study variables where applicable. A stepwise linear regression model (P to enter = 0.05; P to leave = 0.10) was then conducted to predict QOL in all its aspects. For predicting total QOL score, variables including avoidant and histrionic personalities, disease course and duration, EDSS score, and MMSE score were included as independent variables in our regression model. For predicting mental QOL score, avoidant, histrionic, and borderline personalities; disease duration; EDSS score; and MMSE score were used as independent variables. For predicting physical QOL scores, avoidant and narcissistic personalities, disease course, age, disease duration, EDSS score, and MMSE score were applied. For all statistical analysis, a p-value of <0.05 was considered statistically significant. 3. Results In this study, 83 patients with the mean age of 31.54 (±7.38) years were enrolled. Seventy-four patients (89.2%) were women. Mean disease duration was 4.55 (±4.70) years. Seventy-seven patients (92.8%) had a relapsing–remitting course, five patients (6%) had primary progressive course, and one patient had a secondary progressive course. No significant difference between sexes in mental, physical, and total QOL scores was observed. Furthermore, age did not demonstrate significant correlation with QOL or any of its components. Disease duration showed significant correlation with total QOL (coefficient of 0.321, p-value < 0.01) and physical QOL (coefficient of 0.353, p-value < 0.01) but not with mental QOL. In addition, among various disease courses, only physical QOL showed significant disease courses (Table 1). Fig. 1 shows the prevalence of different PCs in the study participants. In our study, we found only eight major PCs from 24 possible characteristics using the MCMI-III instrument. From these eight different PCs, only avoidant personality was associated with higher QOL score in all its components. No significant differences between mean age, disease duration, and EDSS score in the two groups of patients with and without avoidant personality were observed. Borderline and histrionic personalities were associated with higher and lower mental QOL scores, respectively. Fig. 2 compares the 95% confidence interval means of mental, physical, and total QOL scores between our study participants with or without particular PC. No significant difference in EDSS and MMSE scores between different PCs was observed. The mean EDSS score in the two groups of
A. Mohamadi et al. / Clinical Neurology and Neurosurgery 144 (2016) 23–27
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Table 2 Predictors of low QOL among study patients. Predictors
Beta
P-Value
Avoidant EDSS MMSE
0.318 0.329 −0.248
0.001 0.001 0.012
Avoidant EDSS MMSE
0.295 0.557 −0.199
<0.001 <0.001 <0.001
Avoidant EDSS MMSE
0.337 0.496 −0.212
<0.001 <0.001 0.015
Mental QOL score
0.321
Physical QOL score
0.440
Total QOL score
Fig. 1. Bar chart of prevalence of various PCs in study participants. Because some patients may have more than one PC, the total sum of these percentages exceeds 100%.
patients with and without obsessive-compulsive personality was significantly different (p < 0.01). No other significant differences between the mean EDSS scores in the two groups of patients with and without each PC were found. The mean scores of QOL in all components, physical disability and mental status amongst patients with a relapsing–remitting course and those with a primary progressive course are summarized in Table 1. Only one participant had a secondary progressive course; therefore, we could not use this patient’s data for comparative analysis. However, for calculating the total mean (±SD), data of this patient was included. Among the QOL components, physical QOL was significantly different between the different disease courses. In addition, MMSE and EDSS scores were also significantly different between disease courses. EDSS and QOL scores showed a significant correlation with a coefficient of 0.550; a similar result was obtained for the correlation between mental and physical QOL scores (all p < 0.01). EDSS showed a significant correlation with disease duration and age, with a coefficient of 0.418 and 0.238, respectively. MMSE scores and age showed a significant correlation, with a coefficient of −0.398 (p < 0.01), whereas the score had a significant correlation with EDSS score, with a coefficient of −0.260 (p < 0.05). All QOL scores showed a significant correlation with MMSE score (coefficient: −0.359 for total, −0.351 for mental, and −0.347 for physical QOL scores).
R square
0.466
As is shown in Table 2, avoidant personality was the only PC that predicted poor QOL in all its components. Other similar predictors were MMSE and EDSS scores. 4. Discussion Health-related QOL is affected by individual persuasion, as are PCs, thus the role of personality traits has been focus of studies in many chronic conditions such as neurologic disease [13,14,34]. We designed the present study to determine the prevalence of PCs in MS patients and their role in health-related QOL measures accounting for demographics and other clinical variables. Previous studies have shown that physical disability, depression, self-reported fatigue, and cognitive impairment were the most important components in the lowering of patient QOL [7–9]. Similarly we observed a significant correlation between QOL of MS patients and disease duration, and MMSE and EDSS scores, which show mental and disability status, respectively. Notably, the QOL of MS patients had a significant correlation with avoidant personality. In MS patients, this type of PC had an independent role, in predicting lower QOL in all its aspects. The management of stressful situations, such as being diagnosed with a chronic illness, is particularly affected by an individual’s personality. Personality can influence exposure, reaction, and ability to cope with stress [35]. Choosing a specific coping strategy, particularly in MS patients, is related to their PCs [24]. Empathy, agreeableness, and conscientiousness are reduced among MS patients compared with neuroticism, which is elevated [18]. Higher
Fig. 2. The mean total, physical, and mental QOL score, with 95% confidence interval, between different PCs. +: Participants who have the PCs. −: Participants who do not have the PCs.
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neuroticism is related to lower health-related QOL [6]. The higher scores on neuroticism suggest that the self-reporting of patients with MS highly involves dissatisfaction, consistent with an avoidant personality. Physical disability, depression, and fatigue are predictors of the physical aspect of QOL, whereas psychological QOL is strongly predicted by cognitive impairment [9]. The association between PC and QOL among MS patients may also be related with different coping strategies in various PCs. A simplified style of problem solving has also been reported to affect the coping strategies in these patients. This phenomenon has neurological and psychological bases [17]. Defective coping strategies also can diminish familial and social engagement, leading to poor QOL in MS patients [6,7]. Using Rorschach test, Oˇzura et al. found the typical problemsolving style in majority of MS patients includes the attempt to simplify situations. Generally, these patients try to avoid emotional and cognitive complexity, instead of working toward managing difficult situations [6]. However, this simplifying style is effective and beneficial for some MS patients; it may enable them to protect themselves from the disorganization resulting from their illness [6]. However, avoiding problem solving strategies may not only lead to patients separating from the emotionally and interpersonally complex situations but also may lead to feelings of low self-esteem. The major limitation of this study was the survey tools used. First, to the best of our knowledge, none of the tools used to determine PC have been previously found to have adequate reliability and validity for use in MS patients. Therefore, we had to use the general questionnaire MCMI-III. It is possible that diseaserelated variables may have influenced patients’ responses and affected interpretation of the study results. Hence, we suggest that researchers design another study in future for validating a determination tool for measuring PC in MS patients. Second, at the time of study [2011–2012], none of the cognitive condition evaluating tools in the Persian language had been found to be adequately reliable or valid for application to MS patients. Thus, we had to use the MMSE questionnaire, which is known to have lower sensitivity and specificity in comparison to other available tools [36,37]. It should be mentioned that Minimal Assessment of Cognitive Function in Multiple Sclerosis was validated for the Persian language in June 2012. Therefore, it is suggested that Persian language researchers should use this version for their studies [38].
[8]
[9]
[10] [11] [12]
[13]
[14] [15]
[16]
[17]
[18]
[19] [20]
[21]
[22]
[23]
[24]
[25]
5. Conclusion [26]
This study supports the role of avoidant problem solving strategies in MS and introduces avoidant personality as a predictor of lower QOL among MS patients. Furthermore, the study emphasizes the need of clearer guidance and communication for these patients to improve their QOL.
[28]
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