Abstract

Purpose: Self-esteem (SE), or one's sense of competence and worth, is reduced in many mental and physical
disorders. Low SE is associated with perceived stigma and disability and poor treatment outcomes. The present
study examined implicit and explicit SE (automatic and deliberate views about the self) in people with epilepsy
and people with psychogenic nonepileptic seizures (PNESs). Discrepancies between implicit SE and explicit SE
have been found to correlate with psychological distress in disorders often associated with PNESs but are
relatively unexplored in PNESs. We hypothesized that, compared with epilepsy, PNESs would be associated
with lower self-reported SE and greater discrepancies between implicit SE and explicit SE.
Methods: Thirty adults with PNESs, 25 adults with epilepsy, and 31 controls without a history of seizures were
asked to complete the Rosenberg Self-esteem Scale as a measure of explicit SE and an Implicit Relational
Assessment Procedure as a measure of implicit SE. The State–Trait Anxiety Inventory and Patient Health
Questionnaire—15 (a somatic symptom inventory) were also administered.
Results: We found significant group differences in explicit (p b 0.001) but not implicit SE. Patients with PNESs
reported lower SE than the other groups. No group differences were found in implicit SE. Implicit–explicit SE
discrepancies were larger in the group with PNESs than in the other groups (p b 0.001). Higher frequency of
PNESs (but not epileptic seizures) was associatedwith lower explicit SE (rs=−.83, p b 0.01) and greater SE discrepancies
(i.e., lower explicit relative to implicit SE; rs = .65, p b 0.01). These relationships remained significant
when controlling for anxiety and somatization.
Conclusion: Patients with PNESs had lower explicit SE than those with epilepsy or healthy controls. In keeping
with our expectations, there were greater discrepancies between implicit SE and explicit SE among patients
with PNESs than in the other groups. Our results, including the strong relationship between PNES frequency,
anxiety, and explicit–implicit SE discrepancies, support the interpretation that PNESs serve to reduce cognitive
dissonance, perhaps protecting patients' implicit SE.