Stress and avoidance in Pseudoseizures: testing the assumptions

Epilepsy Research 34 (1999) 241 – 249

Stress and avoidance in Pseudoseizures: testing the assumptions Philippa L. Frances a, Gus A. Baker b,*, Peter L. Appleton a a b

Department of Clinical Psychology, Uni6ersity of Wales, 43 College Road, Bangor, UK The Walton Centre for Neurology and Neurosurgery, Rice Lane, Li6erpool L9 1AE, UK

Received 17 April 1998; received in revised form 27 October 1998; accepted 29 October 1998

Abstract Twenty women and 10 men with Pseudoseizures were matched by age and gender with an epilepsy- and a healthy-control group. In response to clinical and research evidence of a relationship between Pseudoseizures and the experience of stress, it was hypothesised that people with Pseudoseizures would perceive their ongoing lives as more stressful, and use more avoidant and distancing coping, and less problem-focused coping, than people in the two control groups. Using the Perceived Stress Scale (Cohen et al., J. Health Soc. Behav. 24, 1983, 385 – 396) and the Ways of Coping, revised version (Folkman and Lazarus, Manual for Ways of Coping Questionnaire, Consulting Psychologist Press, Paola Alto, CA, 1988) the study found that people with Pseudoseizures: (1) perceived their ongoing lives as significantly more stressful; (2) were significantly more likely to use a maladaptive (escape-avoidant) coping strategy; and (3) were significantly less likely to use an adaptive (planful problem solving) approach to coping than healthy controls. The study findings indicate that people with Pseudoseizures experience lives as stressful as do people with epilepsy, and are likely to employ maladaptive coping responses. Implications for diagnosis, intervention and future research are discussed. © 1999 Published by Elsevier Science B.V. All rights reserved. Keywords: Coping; Non-epileptic attack disorder; Pseudoseizures; Stress

1. Introduction Pseudoseizures (Betts and Boden, 1992) are increasingly recognised as posing significant diagnostic and therapeutic challenges to general medical practitioners (Lowman and Richardson, * Corresponding author. Tel.: + 44-151-5294146; fax: +44151-5294703. e-mail: [email protected].

1987) and clinicians in neurological, psychological and psychiatric fields (Gates and Erdahl, 1993). Extensive medical resources and attention are allocated to this seizure-like disorder which produces such dramatic symptomatology that, if the condition were organic, would reflect serious damage, and which is, by its very nature, difficult to manage medically. When unrecognised, Pseudoseizures often result in the inappropriate use of

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anti-epileptic drugs, with associated risks of toxicity and polypharmacy (Liske and Forster, 1964), and can also lead to the use of other hazardous and inappropriate interventions; demands on health and social services; and a neglect of psychological disorder (Baker et al., 1995). Estimates of the incidence of Pseudoseizures in people presenting with apparently intractable epilepsy vary widely. Estimates range from 9% (Lesser et al., 1983), to 50% (Riley and Berndt, 1980). Estimates of the coincidence of Pseudoseizures and epileptic events also vary from around 7% (four out of 60) (King et al., 1982) to 20% (Ramani et al., 1980). Diagnoses of Pseudoseizures are made on the basis of: (1) exclusion of epilepsy and other physiological disorders; and (2) identification of psychological aspects and psycho-social histories which are consistent with empirically established psychological profiles of people with Pseudoseizures (Moore and Baker, 1997). Thus, in general, patients will firstly present with seizures which are not responsive to anticonvulsant medication, are atypical in their clinical presentation, and are unaccompanied by epileptiform activity in EEG analysis, before finally undergoing detailed psychological assessment. In psychological assessment, people with Pseudoseizures, compared to people with epilepsy, are more likely to have severe psychiatric and psychological symptoms, and experience family problems (Roy, 1982; Stewart et al., 1982; Moore, 1995; Bowman, 1993; Ramchandani and Schindler, 1993; Lancman et al., 1994). In addition they are also likely to have suffered extreme psychological trauma, and may have aspects of post traumatic stress disorder (PTSD) (Bowman and Markand, 1996). Given the numerous intrapersonal and interpersonal difficulties associated with Pseudoseizures, it is not surprising that an abundance of Pseudoseizure literature identifies stress as playing a major role in the onset of the disorder and the precipitation of seizures. Ramani and colleagues (Ramani et al., 1980) identified intrapersonal stressors including anxiety, and interpersonal stresses, such as conflicts in relationships, as immediate precipitants of seizures. Gumnit and Gates (1986) identified an

‘‘inadequate coping mechanism’’ sub-group in a study of people with Pseudoseizures. In their clinical classification of Pseudoseizures, Betts and Boden (1992) observed that tantrum-type attacks were likely to occur following environmental challenges or demands that may be difficult for the person to cope with. These observations of Pseudoseizure phenomena can be accommodated in a model which regards Pseudoseizures as a learned pattern of behaviour which is developed to enable the person to deal with extreme stressors (Ramani et al., 1980). The suggestion that the behaviour is learned is supported by evidence that Pseudoseizures tend to occur in people with either direct or vicarious experience of epilepsy or other seizure types (Roy, 1982; Hopkins, 1989; Moore, 1995). However, while the suggestion that Pseudoseizures serve as a strategy for coping with stress is plausible, scrutiny of the literature reveals that it has not been empirically tested. The current study therefore aimed to explore the relationship between Pseudoseizures and a patient’s experience of stress. The study used a contemporary approach to stress, based on a well developed model with considerable literature, which views psychological stress as a product of two central processes which mediate between the person and the environmentcognitive appraisal and coping (Lazarus, 1966; Lazarus and Folkman, 1984). In a situation deemed as challenging, a person will appraise the degree of situational threat and their ability to deal with it, and employ a particular coping strategy based on that appraisal and the emotions generated (Lazarus and Folkman, 1984). In the context of the model, and past Pseudoseizure research, it is possible that Pseudoseizures may represent an avoidant or emotionally distancing coping strategy which is applied when a person perceives the demands of life as exceedingly stressful. This notion also has intuitive appeal in that a Pseudoseizure event certainly achieves avoidance of a situation. Pseudoseizures appear to be a mechanism for avoiding responsibility and escaping from stressful situations. Such individuals might be expected to employ avoidant and distancing coping strategies rather than planful, problem-focused strategies in their approach to managing stressful situations. The current study specifically hypothesised that:

P.L. Frances et al. / Epilepsy Research 34 (1999) 241–249

1. people with Pseudoseizures are more likely to appraise their ongoing life situations as more stressful than people with genuine epilepsy and people who do not have epilepsy or Pseudoseizures. 2. people with Pseudoseizures are more likely to use escape-avoidant and distancing coping strategies and less likely to use planful-problem solving coping strategies than people with genuine epilepsy and people who do not have epilepsy or Pseudoseizures.

2. Method

2.1. Participants Ninety participants aged from 17 to 71 years were allocated to the three groups: (1) Pseudoseizures (N= 30); (2) epilepsy control (N= 30); (3) healthy controls (N = 30). Participants with Pseudoseizures and epilepsy were attending either specialised epilepsy units at the Walton Centre for Neurology and Neurosurgery or an tertiary referral centre at Glan Clwyd Hospital in North Wales. A significantly higher proportion of patients were recruited from the Walton Centre. Participants with Pseudoseizures were: (1) diagnosed by an experienced neurologist on the basis of clinical history and the results of EEG and/or ambulatory or telemetered EEG; and (2) seen by one of two clinical psychologists working in neuropsychology, with particular expertise in Pseudoseizures. Participants in the epilepsy control group had a diagnosis of intractable epilepsy made by a consultant neurologist on the basis of EEG and clinical evidence. Participants in the healthy control group were recruited on an informal and voluntary basis from hospital staff, and a local voluntary organisation (Mersey Region Epilepsy Association).

2.2. Selection procedure Patients with Pseudoseizures were attending the neuropsychology department at the Walton Centre for assessment and treatment. Patients in the

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epilepsy control group were matched in terms of age, gender. Subjects in the Pseudoseizure group were more likely to report spending longer in education than the epilepsy group, although this difference was small. Exclusion from the study occurred if results of psychological assessment (in-depth interviews conducted by a clinical psychologist) were regarded as ambiguous, if there was a possibility of patients experiencing both Pseudoseizures and epileptic attacks, or if participants were intellectually unable to understand the study questionnaires. Participants in the healthy control group were matched with the other two groups for age, gender and years in full time education although they were more likely to be single. They were excluded from the study if they had a history of seizures of any kind, (i.e. infantile febrile seizures, epileptic seizures or other seizures of known or unknown aetiology) or were unable to understand questionnaires. No attempt was made to match for the frequency or severity of seizures between the two groups as the variability in the Pseudoseizure group was enormous.

2.3. Measures 2.3.1. Coping The study used the Ways of Coping-Revised Version (Folkman and Lazarus, 1988) which assesses categories of coping described in Lazarus and Folkman’s theory of stress and coping (Lazarus and Folkman, 1984). It consists of 66 items measuring eight coping strategies (see Table 1 for definitions of scales). Three of the eight scales are relevant to hypotheses in this study. The distancing scale describes cognitive efforts towards personal detachment (e.g. tried to forget the whole thing) which includes attempts at minimising the significance of the situation and creating a positive outlook (e.g. made light of the situationrefused to get too serious about it) (Folkman et al., 1986; Folkman and Lazarus, 1988). The escape-a6oidance scale describes behavioural efforts to avoid or escape (e.g. avoided being with people in general, slept more than usual, tried to make myself feel better by eating, drinking, smoking, using drugs or medications, etc.) and wishful thinking (e.g. wished the situation would go away

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Table 1 Description of coping scales from the ways of coping (Lazarus and Folkman, 1984) Confrontive coping (six items) Distancing (six items) Self-controlling (seven items) Seeking social support (six items) Accepting responsibility (four items) Escape-avoidance (eight items) Planful problem solving (six items) Positive reappraisal (seven items)

Describes aggressive efforts to alter the situation and suggests some degree of risk-taking Describes cognitive efforts to detach oneself and to minimise the significance of the situation Describes efforts to regulate one’s feelings and actions Describes efforts to seek informational support, tangible support, and emotional support Acknowledges one’s own role in the problem with a concomitant theme of trying to put things right Describes wishful thinking and behavioural efforts to escape or avoid the problem. Items on this scale contrast with those on the distancing scale, which suggest detachment Describes deliberate problem-focused efforts to alter the situation, coupled with an analytic approach to solving the problem Describes efforts to create positive meaning by focusing on personal growth. It also has a religious dimension

or somehow be over with) (Folkman et al., 1986). The planful problem-sol6ing scale describes purposeful problem-focused efforts towards changing the situation (e.g. I knew what had to be done so I doubled my efforts to make things work) and an analytical approach to the problem (e.g. came up with a couple of different solutions to the problem) (Folkman et al., 1986). Individuals are asked to think of a specific event which occurred in the past week and which they found stressful, and indicate the extent to which they used each strategy to cope with it. Responses are entered on a four point scale. Psychometric properties of the scale have been extensively researched, and it is considered a reliable and valid instrument (Folkman and Lazarus, 1980; Vitaliano et al., 1985; Folkman and Lazarus, 1988).

2.3.2. Percei6ed stress The perceived stress scale (PSS) (Cohen et al., 1983) is a global measure which focuses on the extent to which respondents find their lives unpredictable, uncontrollable, and overloaded (Cohen and Williamson, 1988). The scale measures the degree to which situations in one’s life are appraised as stressful. It consists of 14 items referring to subjective appraisal of events occurring within the previous month. Responses are made according to a 5 point scale. It takes 5 – 10 min to complete (Cohen et al., 1983). Psychometric prop-

erties of have also been established (Cohen and Williamson, 1988).

2.4. Procedure The study procedure was adapted based on the outcome of a pilot stage. Participants were informed that the study concerned the experience of stress of people with fits and seizures of different kinds. Socio-demographic details were taken, and instructions about completing the PSS were given. Participants were asked to respond to questionnaires based on their experience in the previous 4 weeks. Before completing the Ways of Coping Checklist participants were asked to call to mind the most stressful experience they had dealt with in the previous week, and to describe it briefly to the researcher.

2.5. Statistical analysis Between groups multivariate analysis of variance (MANOVA) (Howell, 1992) was used to explore differences between all three groups in perception of stress, and in coping strategies. Multiple comparisons between means were made using one way analysis of variance, and Tukey’s honestly significant difference (HSD) post-hoc test (Leong and Austin, 1996) was applied to establish the direction of any significant results.

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Table 2 Distribution of age, years in full time education and age of onset of seizure disorder, and percentages for marital status, for the three groups Group Pseudoseizures

Epilepsy control

Healthy control

Mean age and S.D. Median age of onset and inter-quartile range Mean years in full-time education and S.D.

36.9 (13.7) 29 (18.75–36.5) 11.03 (0.9)

36.2 (12.9) 14 (12–20) 14.5 (1.1)

37.3 (13.8) Not applicable 12.2 (1.8)

Marital status Married (%) Single (%)a

43 57

47 53

27 73

a

Single includes separated, divorced and widowed.

3. Results 3.1. Descripti6e data Demographic data are presented in Table 2. Participants were aged 17 to 71 years and consisted of 60 females and 30 males (with 20 females and 10 males in each group). Groups were matched for age and gender. The age of onset of epileptic seizures ranged between 3 months and 49 (median =14), while the age of onset of Pseudoseizure episodes ranged from 6 to 70 (median = 29). This difference was highly significant (X 2 =16.17 (df,1) P = 0.0001). Following Folkman and Lazarus (1980) the stressful events described by respondents when completing the Ways of Coping questionnaire were categorised into four basic contexts-family, health, work and other. More than half of the Pseudoseizures group selected situations involving family (n=16), while six chose situations relating to health, three to work, and five to other. In the epilepsy control group, 12 participants chose situations relating to family, nine to health, five to work, and four to other. There were more subjects form the epilepsy group who chose situations relating to work than subjects from the Pseudoseizure group although this may have been an artifact of the differing employment rates between the two groups. In the healthy control group, 15 participants chose situations relating to family, eight to work and seven to other. Notably, no-one in the healthy control group chose a situation relating to their health.

3.2. Statistical analysis 3.2.1. Comparing perception of stress in the Pseudoseizures group, and the epilepsy- and healthy-control groups Examination of mean scores from the PSS showed that the trend in results was in the anticipated direction, with the Pseudoseizures group scoring highest for perceived stress, and the healthy controls scoring lowest. One way analysis of variance showed a significant difference between the three groups (F(2,87) 3.01 P= 0.05). A post-hoc Tukey’s HSD test indicated a significant difference in mean scores between the Pseudoseizures and healthy control groups at the 0.05 level (see Table 3). 3.2.2. Comparing use of escape-a6oidance, distancing and planful problem sol6ing coping strategies by the three groups Mean scores for Ways of Coping Checklist coping strategies are shown in Table 4. Of the three subscales included in the study hypotheses, Table 3 Mean PSS scores for the three groups

Pseudoseizures group Epilepsy group Healthy controls

Mean score

S.D.

Range (0–56)

29.37

10.06

9–51

27.07 23.9

8.65 7.0

6–43 12–45

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Table 4 Mean scores and S.D. for the eight ways of coping questionnaire coping strategies for all three groups

Confrontive coping Distancinga Self-controlling Seeking social support Accepting responsibility Escape-avoidancea

Pseudoseizures group

Epilepsy control group

Healthy control group

Mean

S.D.

Mean

S.D.

Mean

S.D.

0.80 1.33 1.18 1.17 1.09 1.36

0.66 0.77 0.76 0.81 0.88 0.61

1.15 1.35 1.36 1.60 1.14 1.11

0.61 0.58 0.64 0.80 0.90 0.62

0.89 0.92 1.19 1.22 0.93 0.76

0.50 0.65 0.64 0.84 0.75 0.56 0.74

Planful problem solvinga Positive reappraisal a

0.89 0.77

0.60 0.74

1.25 0.97

0.68 0.68

1.54 1.00

0.71

= Sig. F, 0.05.

the mean escape-a6oidance score was highest for the Pseudoseizures group (mean=1.36, S.D. = 0.61), the mean distancing score was highest for the epilepsy control group (mean =1.35, S.D. = 0.58), and the mean planful problem sol6ing score was highest for the healthy control group (mean =1.54, S.D.= 0.74). MANOVA tested differences between the groups regarding application of coping strategies. The overall F using Pillais trace was significant (F (16,160)= 3.71 P =0.0005). Univariate tests for significance using one way analysis of variance confirmed significant differences only in the three subscales relevant to the study hypotheses (escape-a6oidance, F (2,87) =7.58 P = .001); distancing, F (2,87)= 3.88 P =0.024; and planful problem sol6ing F (2,87)= 7.10 P =0.001). Post hoc Tukey’s HSD tests revealed that, in partial support of the hypothesis, mean escape-a6oidance scores for the Pseudoseizures group were significantly higher than for the healthy control group, while mean planful problem sol6ing scores were significantly higher for the healthy control group than for the Pseudoseizures group. Mean distancing scores were significantly higher in the epilepsy control group compared to the healthy control group, and almost identical for the epilepsy control group and the Pseudoseizures group. There were no significant differences between the Pseudoseizures group and the epilepsy control group

in level of use of any of the three hypothesised coping strategies.

4. Discussion In response to frequent but untested references in past research to a presumed role of stress in Pseudoseizures, this research study sought to investigate whether Pseudoseizures were associated with high levels of perceived stress and symptomatic of styles of coping. Within the transactional model of stress used in the study, consideration of perceived stress is fundamental, as it influences both application of coping strategies and psychological outcomes. Stress occurs when people appraise their lives as unpredictable, uncontrollable, and overloaded (Cohen and Williamson, 1988). The current results suggest that people with Pseudoseizures experience their lives as equally, and possibly more, stressful than people with epilepsy. While the recurrent experience of unpredictable paroxysmal events clearly might provoke the experience of stress (Trimble, 1990), for people with epilepsy, who live with a severely debilitating and chronic neurological disorder, (and particularly those in our sample whose epilepsy requires management at tertiary level, generally because of intractability and severity), their experience may be based on

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realistic appraisal given the constraints of their condition. However, while people with Pseudoseizures do not face the same objective constraints, they do face equally difficult issues which may be as a consequence of their own child- and adulthood experiences (Betts and Boden, 1992; Moore et al., 1994; Moore, 1995; Moore and Baker, 1997). The current results therefore suggest they may have a vulnerability to unrealistically appraise situations as threatening, and to underestimate their resources for coping. This suggestion is supported by evidence that while both people with epilepsy and people with Pseudoseizures tend to have families who are actively involved in the management of their conditions, people with Pseudoseizures perceive their families as significantly less supportive and lacking in commitment towards them (Moore et al., 1994). The finding that people with Pseudoseizures used significantly more escape-avoidance coping than people in the healthy control group, supports the postulation that Pseudoseizures are part of an avoidant behavioural repertoire (Ramani et al., 1980). In view of the perceived stress result, the finding suggests that a possible function of Pseudoseizures is the reduction of emotional distress, in response to perceived stressful situations. Further research should confirm the role of Pseudoseizures by comparing people with Pseudoseizures with a group of normal subjects with high levels of emotional distress and no history of Pseudoseizures. Unfortunately, while the avoidance of perceived stress may offer some benefit to the person with Pseudoseizures, it does so at great cost. A recurrent use of escape avoidant coping is likely to maintain and exacerbate anxiety (cf. phobic anxiety Butler, 1988). and lead to a failure to engage in appropriate problem focused coping, such as seeking psychological help. Thus the person is rendered even less able to deal with possibly exacerbated difficulties (Lazarus and Folkman, 1984), and is more likely to perceive objectively harmless situations as severely stressful. As a response to perceived stress and a means of coping, Pseudoseizures may therefore be both self-perpetuating and maladaptive. The unexpected results regarding distancing

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coping (with people with epilepsy and people with Pseudoseizures being almost identical in the level of their use of the coping strategy) can be accommodated within the dynamic model of stress used in this study in which no strategy is intrinsically maladaptive and any is appropriate in some situations and not others. Distancing strategies have been shown to be adaptive in some highly challenging circumstances (Lazarus et al., 1970; Horowitz, 1976), and for someone with intractable epilepsy, distancing coping may indeed be the most appropriate and adaptive means of dealing with difficulties. In fact, problem focused coping efforts are likely to be inappropriate and even maladaptive, as attempts to change the unchangeable are frustrated. In contrast, for a person with Pseudoseizures whose seizures are psychogenic in origin, attempts to distance oneself are likely to result in a failure to seek appropriate therapeutic support. For the healthy control group their elevated use of planful problem solving seems to be advantageous. This is evident both from their relatively low perception of stress and research in non-clinical populations which shows a negative correlation between planful problem solving and psychological symptoms (Folkman et al., 1986). Current results suggest that when healthy control subjects employ their most frequently used coping strategy, this is associated with a relatively low experience of stress. In contrast, when people with Pseudoseizures employ their most frequently used strategy, there is an associated elevation in stress perception. This would suggest that there is a reciprocal effect of coping on psychological well being, which provides protection against psychopathology for people employing planful problem solving coping, and which makes people with Pseudoseizures vulnerable to psychopathology. In fact there is abundant evidence which suggests that coping is maladaptive for people with Pseudoseizures. In addition to the current finding regarding perception of stress, there are numerous psychological and psychiatric problems associated with the occurrence of Pseudoseizures (Ramani et al., 1980; Roy, 1982; Lowman and Richardson, 1987; Betts and Boden, 1992; Moore, 1995; Bowman, 1993; Ramchandani and Schindler, 1993;

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Moore et al., 1994; Moore and Baker, 1997) and factors including anxiety, stress, depression and family dysfunction have been identified as playing a major role in the maintenance of Pseudoseizures (Moore and Baker, 1997). The results of this study highlight patterns of appraised stress and styles of coping which should prompt further enquiry for: (1) people for whom an unequivocal diagnosis of epilepsy cannot be made; or (2) people with a confirmed diagnosis of epilepsy who are experiencing psychological difficulties. In assessment, evidence that a person’s perception of stress is out of proportion with what would be expected in response to a given situation, should prompt further investigation, and would support a diagnosis of Pseudoseizures. In addition, the study results have implications for the presentation of diagnosis. If people are inclined to avoid realities because they may be overwhelmed if confronted (Lazarus and Folkman, 1984), people with Pseudoseizures may find acknowledging the reality of their problem extremely challenging. A sensitive presentation of the diagnosis is therefore of paramount importance. In light of the current findings, an appropriate therapeutic response to Pseudoseizures would be a cognitive therapy approach aimed at increasing the likelihood of effective coping by addressing dysfunctional cognitions associated with an elevated perception of stress and bolstering coping resources. In particular, the management of negative feelings must be a central theme of therapy for people with Pseudoseizures. We recognise, however, that in the presence of a history of physical or sexual abuse, many of the issues confronting people with Pseudoseizures may not be simply addressed by cognitive therapy. Effective coping does not mean freedom from negative feelings and the experience of negative feelings is an unavoidable and appropriate response to the ambiguity of many, if not most, life situations (Lazarus and Folkman, 1984). If people with Pseudoseizures were able to deal with difficult emotions, the necessity for avoidant coping may be diminished. Further research into why it is that people with Pseudoseizures construe their lives as so stressful

and whether there is a temporal relationship between the appraisal of circumstances as difficult and the occurrence of a Pseudoseizure is needed, and should ideally utilise single case designs where the same person can be observed over a number of occasions and contexts. This study provides substantive evidence for a relationship between Pseudoseizures, stress and avoidance which has been postulated, but not tested, in previous research. In the context of a heavy burden on tertiary health resources created by the problem of Pseudoseizures, and the cycles of psychological distress associated with the disorder, this research has highlighted some operational mechanisms involved in the disorder and provides an empirical basis for intervention and future research. Acknowledgements We are grateful to Miss Jayne Brooks in preparing this manuscript. References Baker, G.A., Moore, P.M., Appleton, R.E., 1995. Non epileptic attack disorders in children and adolescents: a single case study. Seizure 4, 307 – 309. Betts, T.A., Boden, S., 1992. Diagnosis, management and prognosis of a group of 128 patients with non-epileptic attack disorder. Part I. Seizure 1, 19 – 26. Bowman, E.S., Markand, O.N., 1996. Psychodynamics and psychiatric diagnoses of pseudoseizure subjects. Am. J. Psychiatr. 153, 57 – 63. Bowman, E.S., 1993. Etiology and clinical course of pseudoseizures: relationship to trauma, dissociation and depression. Psychosomatics 34, 333 – 342. Butler, G., 1988. Phobic disorders. In: Hawton, K., Salkovskis, P.M., Kirk, J., Clark, D.M. (Eds.), Cognitive Behaviour Therapy for Psychiatric Problems. A Practical Guide. Oxford University Press, Oxford, pp. 97 – 128. Cohen, S., Williamson, G.M., 1988. Perceived stress in a probability sample of the United States. In: Spacapan, A., Oskamp, A. (Eds.), The Social Psychology of Health. Sage, California. Cohen, S., Kamarck, T., Mermelstein, R., 1983. A global measure of perceived stress. J. Health Soc. Behav. 24, 385 – 396. Folkman, S., Lazarus, R.S., 1980. An analysis of coping in a middle-aged community sample. J. Health Soc. Behav. 21, 219 – 239.

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