Background: The stigma of epilepsy is pervasive in developing country contexts and negatively affects the psychological and social wellbeing of its sufferers. The experience of stigma varies across settings and probably relate to disease severity and social characteristics. This study sought to describe the extent and correlates of perceived and enacted stigma among outpatients with epilepsy. Methods: The participants were consecutively presenting epilepsy outpatients in a tertiary facility that attended clinic regularly and had no overt medical or psychiatric co-morbidities. The patients were interviewed with a semi-structured questionnaire. Results: There were 93 participants with a mean age of 30.2 ± 10.3 years and 57.0% were males. The experience of stigma was reported by 46.2% and 67.7% of the participants for perceived and enacted stigma, respectively. Over one-third of the patients had suffered burns or a similar injury in the past. The correlates of perceived stigma were rural residence, lower levels of education, and longer duration of illness. Gender, age and frequency of seizures were not statistically significant determinants. The correlates of enacted stigma were being single, older age, rural residence, and longer duration of epilepsy. A past history of burns and disclosure of epilepsy to individuals outside the family added to the likelihood of experiencing stigma. Conclusion: The burden of epilepsy related social stigma is high in Nigeria. Cultural stereotypes and misconception add to this. There is need for appropriate culture-congruent educational interventions to provide the right information about epilepsy and debunk the misconceptions and myths associated with the condition. This will need to be coupled with astute clinical management of cases and active case finding. Both qualitative and longitudinal quantitative studies would be required to deepen our understanding of the lived reality of grappling with stigma in our setting.
Epilepsy causes significant and worrisome life disruption, morbidity and uncertainty among its sufferers and these are related to the nature of the neurological condition [
It has been surmised that the psychosocial limitations that accompany epilepsy, especially in relation to interpersonal relationships and employment are more likely to result from the stigma that is associated with the disorder than from the epileptic seizures per se [
Some of the consequences of having a stigmatized identity for individuals with epilepsy include high rates of anxiety, depression and decreased life satisfaction [
The understanding of stigmatization in epilepsy and its correlates is relevant to the management of the condition in Africa [
The epilepsy treatment gap in Sub-Saharan Africa results from several factors, including belief systems that attribute epilepsy to supernatural rather than medical causes, paucity of healthcare infrastructure, inadequate trained health personnel and the direct and indirect cost of epilepsy care [
The enactment of stigma against individuals with epilepsy is poignantly felt in the context of employment [
In the African setting, burns is considered as the quintessential stigmata of chronic epilepsy [
The major aim of this study was to determine the frequency of experience of stigmatization and its correlates among individuals attending a tertiary facility that provides treatment for epilepsy and other neurological conditions in south-east Nigeria.
This was a cross-sectional descriptive study conducted among individuals receiving treatment for epilepsy in a tertiary referral specialist hospital. The study was conducted between April and September 2016.
This study was carried out at the outpatient neurology service of the University of Nigeria Teaching Hospital, Ituku Ozalla, a foremost tertiary referral and teaching centre for individuals with epilepsy and other neurological disorders.
The participants for this study were individuals who were receiving treatment for epilepsy and met the following inclusion criteria: 1) Being free from co-morbid physical illnesses like diabetes, hypertension, HIV/AIDS, cardiac, renal or related systemic diseases; 2) Being free from major psychiatric disorders or learning disability; 3) Maintaining a regular clinic attendance over the preceding six months; 4) Being on regular anti-epileptic drug regimen and 5) Gave consent to participate in the study. All patients with pseudoseizures and recently diagnosed epilepsy were excluded from the study.
The sample consisted of consecutively presenting patients who attended the clinic for their epilepsy treatment. Individuals who were considered potential candidates for study recruitment were requested to participate after due explanation about the study had been given. All consenting persons were interviewed in a private room using the study questionnaires.
The participants who met the outlined inclusion criteria were interviewed with a semi-structured questionnaire, specifically designed by the investigators after a review of the relevant literature. The questionnaire sought to elicit data on socio- demographic variables (sex, age, marital status and education), seizure-related variables (age of onset of seizures, duration of epilepsy and recent seizure frequency). The data on the seizure type was extracted from the patients’ charts. In addition, data pertinent to the evaluation of stigma experience was also collected. In this regard, the scale for collection of stigma data designed for European studies [
The study was conducted after ethical clearance had been obtained from the Hospital Ethical Committee. Also prospective participants were informed that they would not suffer any adverse care effects if they chose not to participate in the study and also that if they chose to participate, their responses would be treated with the utmost of confidentiality and anonymity.
The collected data were analyzed using SPSS version 15, after due data cleaning. The outcomes of the analyses were expressed as frequencies, rates, and percentages duely presented in tables. The mean and median were the principal measures of central tendency explored in the study. The bivariate relationships between variables were explored using the chi squared test for comparison of proportions, and analysis of variance (ANOVA) for comparing the differences in means. The level of statistical significance for all analyses was set at p<.05.
The participants consisted of 93 patients, 57.0% of whom were males. The participants had a mean age of 30.2 ± 10.3 years and a range of 14 - 67 years. The male participants were slightly older than the females (mean of 30.9 ± 10.8 years versus 29.4 ± 9.6 years (p = 0.483). Over two-thirds of the participants, 65 (69.9%) were single whereas 17 (18.3%) were married. There were slightly more urban than rural dwellers among the participants 48 (51.6%) versus 45 (48.4%). More than half of the participants, 53 (57.0%) had secondary school education, whereas 31 (33.3%) had primary school education or none. The details of the sample socio-demographic characteristics are provided in
The majority of the participants (74.3%) were characterized as having generalized tonic-clonic seizures, 16.1% had partial seizures and 9.6% had partial seizures with generalization. The mean duration of suffering epilepsy among the participants was 11.1 ± 9.7 years with a range of 1 - 39 years whereas the mean age of onset for the seizures was 26.9 ± 5.0 years.
Characteristic | Number (N = 93) | Percent (%) |
---|---|---|
Sex | ||
Male | 53 | 57.0 |
Female | 40 | 43.0 |
Age (Years) | ||
Mean | 30.2 | |
Standard Deviation | 10.3 | |
Median | 29. 0 | |
Range | 14 - 67 | |
Marital Status | ||
Single | 65 | 69.9 |
Married | 17 | 18.3 |
Separated, divorced or Widowed | 11 | 11.8 |
Place of Residence | ||
Rural | 45 | 48.4 |
Urban | 48 | 51.6 |
Education | ||
Primary school Education or None | 31 | 33.3 |
Secondary school Education | 53 | 57.0 |
Tertiary Level Education | 9 | 9.7 |
Seizure-related Variable | Number (N = 93) | Percent (%) |
---|---|---|
Seizure type | ||
Partial seizures | 15 | 16.1 |
Partial seizure with secondary generalization | 9 | 9.6 |
Generalized tonic-clonic seizures | 69 | 74.3 |
Seizure duration (Years) | ||
Mean | 11.1 | |
Standard Deviation | 9.7 | |
Range | 1 - 39 | |
Age of onset of Seizures (Years) | ||
Mean | 26.9 | |
Standard deviation | 5.0 | |
Range | 7 - 62 | |
Seizure Frequency in the past Six Months | ||
≤5 | 69 | 74.2 |
6 - 10 | 17 | 18.3 |
>10 | 7 | 7.5 |
Of the 93 participants, 43 (46.2%) reported having experienced perceived stigma. Nineteen participants (20.4%) stated that they had had the experience of being avoided by other people, 16.1% (15 out of 93) had felt that other people were uncomfortable with them whilst 9.7% felt that people looked down on them on account of suffering epilepsy. The details of the responses are displayed in
In a similar vein, 67.7% (63 out of 93) had experienced enacted stigma in the course of living with epilepsy. Forty out of 93 (43.0%) reported that they had experienced being told they were possessed, 34.4% affirmed they had been avoided by other people whilst 33.3% stated that they had experienced being told they were witches.
Related to this, 34.4% of the participants admitted they had suffered burns or other severe bodily injury from epilepsy, 32.3% affirmed that they experienced restriction or special protection from their family members and 23.7% stated that individuals outside their close family knew about their epileptic condition. A higher proportion of the participants who had suffered burns or related injuries reported experiencing perceived stigma (65.6% versus 36.1%, p < 0.05) as well as enacted stigma (81.3% versus 60.7%; p < 0.05), in comparison with individuals who had not endorsed these experiences. Similarly, 77.3% of the individuals whose epileptic condition were known to people outside their family had experienced perceived stigma, whereas only the 36.6% of the persons who felt stigmatized even though their seizures were not known to people who were not their close relatives (p < 0.05). A similar observation was made in relation to enacted stigma (81.8% versus 63.4%; p < 0.05). Also, among individuals who felt they were being restricted and given extra protection by their families, a higher proportion reported experiencing perceived stigma than those who were not (70.0% versus 34.9%; p < 0.05). This was also the case in relation to enacted stigma (83.3% versus 60.3%; p < 0.05).
Component Items | Experience of Perceived Stigma‡ | |||
---|---|---|---|---|
YES | NO | |||
Number | Percent | Number | Percent | |
Have you ever felt that on account of epilepsy: | ||||
1) Some people are uncomfortable with you | 15 | 16.1% | 78 | 83.9% |
2) Some people look down on you and treat you like an inferior person | 9 | 9.7% | 84 | 90.3% |
3) Some people avoid you | 19 | 20.4% | 74 | 79.6% |
Total experience of perceived stigma | 43 | 46.2% | 50 | 53.8% |
‡Derived from Scale for Epilepsy Stigma [
Component Items | Experience of Enacted Stigma | |||
---|---|---|---|---|
YES | NO | |||
Number | Percent | Number | Percent | |
Have you ever experienced any of the following: | ||||
1) Have you ever been told that you are possessed? | 40 | 43.0% | 53 | 57.0% |
2) Have you ever been told that you are a witch? | 31 | 33.3% | 62 | 66.7% |
3) Have you ever been told you will never marry? | 12 | 12.9% | 81 | 87.1% |
4) Have you ever been told you will never get a good job? | 14 | 15.1% | 79 | 84.9% |
5) Have you ever been told that you will never be able to keep a job? | 14 | 15.1% | 79 | 84.9% |
6) Have you ever been told that you should never play or interact with others? | 23 | 24.7% | 70 | 75.3% |
7) Have you ever been avoided by other people? | 32 | 34.4% | 61 | 65.6% |
8) Have you ever been treated badly by healthcare workers? | 3 | 3.2% | 90 | 96.8% |
9) Have you ever been treated badly by your family members? | 12 | 12.9% | 81 | 87.1% |
Total enacted stigma experience† | 63 | 67.7% | 30 | 32.3% |
Stigma promoting factors | Presence of stigma promoting factor | |||
YES | NO | |||
Number | Percent | Number | Percent | |
Have you ever sustained burns or any other severe injury on account of your condition? | 32 | 34.4% | 61 | 65.6% |
Do you receive extra protection or restrictions from your family members? | 30 | 32.3% | 63 | 67.7% |
Do people outside your close family know about your condition? | 22 | 23.7% | 71 | 76.3% |
†Many respondents endorsed more than one form of enacted stigma.
The experience of perceived stigma was higher among females (52.5%) relative to males (41.5%). The observed difference was however not statistically significant (p = 0.293). The experience of perceived stigma was higher among individuals aged 30 - 40 years (50.0%) relative to those aged ≤29 years (44.7%) and ≥45 years (40.0%) respectively. However, this observed difference was not statistically significant (p > 0.05). Similarly, individuals who were currently single (single, divorced, separated, or widowed) reported experiencing perceived stigma more than currently married individuals (48.7% versus 35.3%). However, this difference did not attain statistical significance (p > 0.05). The relationship between the socio-demographic variables and the experience of stigma is depicted in
Demographic variables | Perceived Stigma | |||||
---|---|---|---|---|---|---|
YES | NO | Analysis | ||||
N | % | N | % | X2 | P value | |
Sex | ||||||
Male | 22 | 41.5% | 31 | 58.5% | ||
Female | 21 | 52.5% | 19 | 47.5% | 1.11 | 0.293 |
Age (Years) | ||||||
≤29 | 21 | 44.7% | 26 | 55.3% | ||
30 - 44 | 18 | 50.0% | 18 | 50.0% | .41 | >0.05 |
≥45 | 4 | 40.0% | 6 | 60.0% | ||
Marital Status | ||||||
Currently Single | 37 | 48.7% | 39 | 51.3% | 1.00 | >0.05 |
Currently Married | 6 | 35.3% | 11 | 64.7% | ||
Place of Residence | ||||||
Urban | 15 | 31.3% | 33 | 68.7% | 8.96 | 0.003 |
Rural | 28 | 62.2% | 17 | 37.8% | ||
Education | ||||||
None or primary | 21 | 67.7% | 10 | 32.3% | 8.66 | 0.005 |
Secondary or higher | 22 | 35.5% | 40 | 64.5% | ||
Enacted Stigma | ||||||
Sex | ||||||
Male | 33 | 62.3% | 20 | 37.7% | ||
Female | 30 | 75.0% | 10 | 25.0% | 1.69 | 0.193 |
Age (Years) | ||||||
≤29 | 16 | 34.0% | 31 | 66.0% | ||
30 - 44 | 6 | 16.7% | 30 | 83.3% | ||
≥45 | 8 | 80.0% | 2 | 20.0% | 14.22 | 0.001 |
Marital Status | ||||||
Currently Single | 56 | 73.7% | 20 | 26.3% | ||
Currently Married | 7 | 41.2% | 10 | 58.8% | 6.72 | <0.01 |
Place of Residence | ||||||
Urban | 28 | 58.3% | 20 | 41.7% | ||
Rural | 35 | 77.8% | 10 | 22.2% | 4.02 | 0.045 |
Education | ||||||
None or primary | 24 | 77.4% | 7 | 22.6% | ||
Secondary or higher | 39 | 62.9% | 23 | 37.1% | 1.99 | >0.05 |
The experience of perceived stigma was higher among rural residents relative to urban dwellers (62.2% versus 31.3%). The observed difference was strongly statistically significant (p < 0.01). Similarly the experience of perceived stigma was higher among individuals with little or no education (67.7%) relative to individuals who had attended secondary schools or higher institutions (35.5%). The observed difference was strongly statistically significant (p < 0.01).
With regard to duration of seizures and the experience of perceived stigma, the highest level of perceived stigma (61.8%) was observed among individuals who had suffered the condition for longer than 10 years whereas the lowest level (27.8%) was observed among individuals who had suffered the condition for 5 years or less. Persons that had suffered the condition for 6 - 10 years had an intermediate level of stigma experience (52.2%). These differences were statistically significant (p < 0.01).
Seizure-related Variables | Perceived Stigma | |||||
---|---|---|---|---|---|---|
NO | YES | Analysis | ||||
N | % | N | % | X2 | P Value | |
Duration of Suffering Epilepsy (Years) | ||||||
≤5 | 10 | 27.8% | 26 | 72.2% | ||
6 - 10 | 12 | 52.2% | 11 | 47.8% | 7.99 | |
>10 | 21 | 61.8% | 13 | 38.2% | <0.05 | |
Seizure Frequency in the past 6 months | ||||||
≤5 | 27 | 39.1% | 42 | 60.9 | ||
≥6 | 16 | 66.7% | 8 | 33.3% | 5.46 | <0.05 |
Age of Onset of Seizures | ||||||
<20 years | 17 | 38.6% | 27 | 61.4% | ||
≥20 years | 26 | 53.1% | 23 | 46.9% | 1.94 | >0.05 |
Enacted Stigma | ||||||
Duration of Suffering Epilepsy (Years) | ||||||
≤5 | 19 | 52.8% | 17 | 47.2% | ||
6 - 10 | 17 | 73.9% | 6 | 26.1% | ||
>10 | 27 | 79.4% | 7 | 20.6% | 6.21 | <0.05 |
Seizure Frequency in the past 6 months | ||||||
≤5 | 46 | 66.7% | 23 | 33.3% | ||
≥6 | 17 | 70.8% | 7 | 29.2% | 0.14 | >0.05 |
Age of Onset of Seizures | ||||||
<20 years | 36 | 81.8% | 8 | 18.2% | ||
≥20 years | 27 | 55.1% | 22 | 44.9% | 7.57 | <0.01 |
Regarding the seizure frequency in the preceding 6 months, individuals who had 6 or more seizures were more likely to report perceived stigma (66.7%) than individuals who had 5 seizures or less (39.1%). The observed difference was statistically significant (p < 0.05). Also, individuals whose onset of epilepsy started after the age of 20yrs were more likely to report experiencing perceived stigma (53.1%) than individuals whose onset of epilepsy occurred before the age of 20 yrs (38.6%). However, the observed difference was not statically significant (p > 0.05).
There was a higher rate of reporting of enacted stigma among females relative to males (75.0% versus 62.3%). However, this difference did not attain statistical significance. Individuals who were currently single reported experiencing enacted stigma more frequently than those who were currently married (73.7% versus 41.2%). The observed difference was strongly statistically significant (p < 0.01). The experience of enacted stigma was highest among older individuals (≥45 years) (80.0%) and lowest among persons aged 30 - 40 years (16.7%) whereas the youngest age group (≤29 years) had a rate that was intermediate (34.0%). This difference was strongly statistically significant (p = 0.001).
There was a higher frequency of reporting of enacted stigma among rural residents relative to urban dwellers (77.8% versus 58.3%). The difference in rates was statistically significant (p < 0.05). Similarly, there was a higher rate of reporting of enacted stigma among individuals with little or no education relative to those who attained higher levels of education (secondary school or higher) (77.4% versus 62.9%). However this observed difference did not attain statistical significance (p > 0.05).
The report of experiencing enacted stigma was related to the duration of suffering the condition. Of the individuals who had suffered epilepsy for ten years or longer, 79.4% reported having experienced enacted stigma, 73.9% of the individuals who had suffered the condition for 6 - 10 years affirmed having the experience, whereas individuals who had suffered the condition for 5 years or less, were the least likely to report having experienced enacted stigma (52.8%). The observed differences were strongly statistically significant (p < 0.01).
There was a relatively higher level of reporting of enacted stigma among individuals that had a higher seizure frequency (70.8%) relative to the group that had five or fewer seizures in the preceding six months (66.7%). However, this difference did not attain statistical significance (p > 0.05). The experience of enacted stigma was much higher among individuals whose seizures started before the age of 20 years (81.8%) relative to the group whose seizures began after the age of 20 years (55.1%). The observed difference was strongly statistically significant (p < 0.01).
Finally, 65.6% of individuals who had suffered burns or other severe injury reported experiencing perceived stigma whereas only 36.1% had perceived stigma among persons who had not suffered such injuries. The observed difference was statistically significant (p < 0.01). Similarly, 77.3% of individuals who stated that their suffering epileptic seizures were known to persons outside their families reported experiencing perceived stigma. This is in contrast to the 36.6% rate of experience perceived stigma among individuals who felt that their seizures were not known to people outside their families. The observed difference was statistically significant (p < 0.001).
With regard to enacted stigma, 81.3% of persons who had experienced burns or other sever injury from epilepsy reported suffering enacted stigma, whereas only 60.7% of those who had not suffered burns or such an injury had experienced enacted stigma. The observed difference was statistically significant (p < 0.05). Also, among individuals who stated that their epileptic condition was
Seizure-promoting factors | Presence of Seizure Promoting Factor | |||||
---|---|---|---|---|---|---|
YES | NO | Analysis | ||||
N | % | N | % | X2 | P value | |
Experienced burns or severe injury | ||||||
Yes | 21 | 65.6 | 11 | 34.4 | ||
No | 22 | 36. 1 | 39 | 63.9 | 7.38 | <0.01 |
Awareness of the condition to outsiders | ||||||
Yes | 17 | 77.3 | 5 | 22.7 | 11.17 | <0.001 |
No | 26 | 36.6 | 45 | 63.4 | ||
Given extra protection or restrictions | ||||||
Yes | 21 | 70.0 | 9 | 30.0 | 10.06 | <0.001 |
No | 22 | 34.9 | 41 | 65.1 | ||
Enacted Stigma | ||||||
Experienced burns or severe injury | ||||||
Yes | 26 | 81.3 | 6 | 18.7 | ||
No | 37 | 60.7 | 24 | 39.3 | 4.77 | <0.05 |
Awareness of the condition to outsiders | ||||||
Yes | 18 | 81.8 | 4 | 18.2 | 2.61 | >0.05 |
No | 45 | 88.2 | 6 | 11.8 | ||
Given extra protection or restrictions | ||||||
Yes | 25 | 83.3 | 5 | 16.7 | 4.93 | <0.05 |
No | 38 | 60.3 | 25 | 39.7 |
known to individuals outside their families, 81.8% had experienced enacted stigma, in comparison with the 88.2% rate among those whose epileptic conditions were not known to persons outside their families. The observed difference was however not statistically significant (p > 0.05). Related to this, 83.3% of the individuals who stated that they had been receiving extra protection or restrictions from their families reported experiencing enacted stigma, in contrast to the 60.3% rate observed among individuals who had not affirmed receiving this kind of protection or restrictions from their families. The observed difference in rates was statistically significant (p < 0.05).
The results of this study show that social stigma is a major concern among the epileptic patients that are being treated in south-east Nigeria. The findings showed that 46.2% and 67.7% of the participants had experienced perceived and enacted stigma respectively. This is similar to the findings of studies in the developing countries [
Having inadequate information about epilepsy is one of the major drivers and perpetuating factors for epilepsy stigma [
A number of misconceptions and wrong causal attribution attend the experience of epilepsy in Nigeria. The consequence of this is that epilepsy is greatly feared and misunderstood [
The implication of these is that efforts need to be made to improve the understanding about epilepsy among the general public in order to improve the quality of life of the sufferers and their social acceptance. The negative social perception of epileptic individuals limits their access to social resources and capital [
Our results showed that the reports of perceived and enacted stigma were disproportionately more likely to arise from females than males. The reports of previous research projects showed that there appear to be divergent findings in respect of the relationship between gender and the experience of stigma. Whereas some studies showed the absence of statistically significant gender differences in the experience of stigma [
In this study, the feeling of stigmatisation was also greater among individuals who were currently single (single, divorced, separated, or widowed) relative to married persons. This may be related to the fact that the salience of seizure experience and the fear of rejection were more intensely felt by individuals that have need for intimate partners compared with individuals in more stable relationships. This feeling of stigmatisation is more intensely felt in circumstances where the concealment of the epilepsy history and the fear of detection co-exist, a situation that is more poignant in intimate relationships. This view is supported by the findings of a study conducted in India which showed that the majority of the epileptic women surveyed had concealed the condition from their intending marital partners prior to marriage [
We did not observe any significant age differences in the experience of perceived stigma. On the other hand, we observed an association between age and enacted stigma. The least level of enacted stigma was reported by individuals aged 45 years and older, whereas younger groups reported higher levels of enacted stigma. Many previous reports had documented higher rates of stigmatization among younger patients [
Similarly, we found that the reporting of perceived and enacted stigma was more prevalent among rural than urban residents. Previous reports had documented this pattern [
The stigma counteracting effect of higher education had been documented in some studies [
Among the seizure?related variables explored in this study, we found that the duration of illness was associated with the experience of both perceived and enacted stigma. This is similar to the findings of the phenomenon in other settings [
The contribution of epilepsy-related injuries like burns in promoting stigma in Africa has been previously highlighted through empirical studies [
Some of the limitations of this study are worthy of note. First, the study was focused on individuals that were receiving active treatment for epilepsy in a specialist referral facility. The findings may therefore not be representative of the population of all persons suffering epilepsy in the south-east Nigeria. Next, the small size of the study sample probably affected the power of the statistical analyses to detect differences in proportions, and this could have influenced the findings. Also, the assessment of perceived stigma was done with a three-item instrument developed in European populations. It is not clear to what degree the findings would have differed if more complex ethnographically derived instruments had been utilized for stigma measurement. We are also mindful of the effects of recall bias and social desirability response set on the levels of stigma elicited in this study. However, the influence of these factors cannot be completely eliminated in social research studies of this nature.
Nonetheless, it can be surmised from this study that both perceived and enacted stigma are major concerns among individuals receiving treatment for epilepsy in south-east Nigeria. The experience of enacted stigma is undergirded by the belief that epilepsy is a contagious disease and negatively influences the extent of social participation of the sufferers. Dealing with stigma requires giving greater attention to understanding the perception of the condition by the general public and fashioning appropriate educational interventions to bridge the identified knowledge gap. Having improved accessibility to effective treatment for all sufferers will contribute to better seizure control and possibly improved public acceptance. The design of more focused quantitative studies using larger samples will help to validate the findings of this study whereas the conduct of qualitative studies with individual patients will help to deepen the understanding of the lived realities of persons grappling with stigma on a day-to-day basis.
Achor, J.U., Ezeala-Adikaibe, B.A., Obayi, O.N., Ezeruigbo, C.F.S., Ekenze, O.S. and Onodugo, O.D. (2017) The Stigma of Epilepsy among Outpatients in a Tertiary Hospital in South- East Nigeria. Open Journal of Psychiatry, 7, 344-364. https://doi.org/10.4236/ojpsych.2017.74029