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Integrating Mind, Brain, Body, and Spirit in Treating Epilepsy (Cont.)
The Behavioral Approaches
There are various behavioral approaches to epilepsy. Some seek to interrupt seizures, others to prevent them. So far, the most effective are the interruptive techniques of behavioral psychologists. Here I will discuss these techniques and report as well on the interruptive techniques of biofeedback and the preventive techniques of relaxation and nutrition.
Behavioral Psychology
Behavioral psychologists take the same view of the seizure sequence that neurologists do: that it entails the rapid firing of certain neurons and the engagement of secondary neurons, so that larger areas of the brain are involved, and the seizure exhibits its characteristic traits according to the regions affected. Where behavioral psychologists differ from neurologists is in the importance of so-called extrinsic factors in the genesis and treatment of an epileptic seizure.
ADVANCES, The journal of Mind-Body Health Vol.8, No.4 Fall 1992
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In behavioral psychology, the seizure is seen as a sequence of behaviors that can be interrupted by appropriate and timely behavioral strategies, thereby aborting the seizure. As British psychiatrist and eminent epileptologist Peter Fenwick (1991) writes: "A complete treatment of epilepsy is not just the administration of drugs; rather, it also includes (a) teaching patients about their brain and its functioning, and (b) how the patients' feelings, thinking, and behavior can all be used in the control of their epilepsy."
Today, by and large, behavioral strategies come into play as last resorts. In one situation medications are not doing the job, or high levels threaten the liver or the ability of the blood to clot. Surgery is out of the question. The patient may be too foggy to function. When the neurologist exhausts the medical repertoire, he or she may consider behavioral methods and refer the patient to a behavioral psychologist. In another situation a person who has achieved control through medication for a period of time (usually two years) may be able to ease off the medication but is often afraid to do so. A lawyer, for example, fears a seizure may occur under stress in court. Learning self-control strategies alleviates this anxiety.
Behavioral methods have a certain taint they must overcome. Since many individuals with cerebral palsy, developmental disabilities, and intellectual damage have epilepsy, some behavioral psychologists work exclusively with them, and in some quarters behavioral methods have come to be associated with mental retardation. (In the case of de-institutionalized developmentally disabled people, who may spend much of their lives in day centers where the staff is often untrained and merely custodial, drug dosages tend to be high and to go higher when seizures break through, further debilitating an already debilitated population. A staff trained in behavioral interventions can help to reduce seizure occurrence and drug amounts and can greatly augment the well-being and mental functioning of these individuals.)
Behavioral methods also suffer from a general distaste for the vocabulary of "conditioning" and "behavior modification." One of the seminal papers in behavioral intervention for epilepsy, Robert Efron's "The Conditioned Inhibition of Uncinate Fits" (Efron 1957), involves classic conditioning. Today, behavioral psychology has moved past its origins in experimental work with laboratory animals. The term "behavior modification," made popular by B. F. Skinner, is less frequently heard. Other terms are preferred. One is "overt conditioning," used by both behavior psychologists/epileptologists Joseph Cautela (1991) and Peter Fenwick (1991), meaning learned and self-applied strategies. California epilepsy researcher and clinician Donna Andrews uses "behavior adaptation" because it conveys the meaning of conscious choice and self-imposed change. In addition, most rewards these days are not the once-ubiquitous M&Ms but self-chosen ones, even in the case of profoundly retarded children. With normally functioning adults, rewards are often simply visualizations of pleasant and relaxed circumstances-the delights of Ben & Jerry's Heath Bar Crunch or a sunny patio comer on a wintry day.
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Systematic behavior analysis and intervention strategies have developed out of research and clinical practice over the past 40 years. Since Robert Efron's illuminating case study (1957) of a woman patient who blocked her seizures first with the scent of jasmine and later with the imagined scent, research activity on behavioral control of seizures has increased to the point where behavior psychologist David Mostofsky describes it as an "explosion of writing" in the field. F. M. Forster published an influential paper on reflex epilepsy in 1967. In 1973, R. B. Flannery, Jr. and Joseph R. Cautela's "Seizures: Controlling the Uncontrollable" appeared. It was followed by R. G. Feldman and N. N. Paul's "Identity of Emotional Triggers in Epilepsy" (1976). David Mostofsky's work with Barbara Balaschak appeared in 1977. Their compendium, "Psychobiological Control of Seizures," was the first, to my knowledge, to gather together the behavioral techniques validated for seizure control. The 1980s saw the publication of important British researchers like Peter Fenwick (1981), D. Chadwick and E. H. Reynolds (1985), and the Swedish work of Lennart Melin and Lars Lund with the American JoAnne Dahl (Melin, Dahl, Lund 1981). These are highlights of the literature. (A complete overview of these decades will appear in Mostofsky and Loyning, Neurobehavioral Treatment of Epilepsy, to be published in 1993 by Album Publishers.)
It should be noted, however, that developments in self-control of seizures rarely came to the attention of patients. An exception is the practice of neurologist Joel Reiter and behavioral psychologist Donna Andrews in Santa Rosa, California (Reiter, Andrews, Janis 1987).
How does behavior analysis and intervention strategy proceed? All behavioral interventions are predicated on the observation of a warning signal, an "aura," that indicates the seizure is beginning. These early warnings are highly individualistic and can be virtually anything. A bad smell, irritability, hearing mental music, a shaky feeling, and unaccountable fear are common. In most cases the same warning signals will occur each time a seizure threatens.
I would urge every person with epilepsy who has experiences of intense intuition and imagination and mystical experience to honor them, write them down, draw, or paint them.
Many people with epilepsy, over 60 percent, observe their aura without any assistance from an observer. To this percent can be added another 15 percent whose aura can be detected by a family member or trained observer. Once the aura is noted, the individual can learn to use this prodromal indication and act to abort the seizure, using one or another behavioral technique. Adults and children, both normally functioning and otherwise, can follow this procedure.
The sequence from aura to seizure to aftermath was first observed in antiquity and underlies all behavioral interventions. JoAnne Dahl, an American psychologist working in Sweden and a leading figure in behavioral research and practice, has developed a precise protocol for behavior analysis and intervention. She writes:
ADVANCES, The journal of Mind-Body Health Vol.8, No.4 Fall 1992
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Behavior medicine treatment strategy entails (1) a behavior analysis of the complex relationships between seizure behavior and specific facilitating factors unique for each individual, and (2) individually tailored treatment programs including: changing sensitivity level to offending stimuli; learning seizure inhibition techniques; programming of environmental contingencies so seizure behavior is not reinforced (Dahl 1992).
The antecedents, response or behavior, and consequences are sometimes called the "A-B-Cs" of learned behavior (Cautela 1991). In epilepsy, antecedents are the aura and/or triggering circumstances and conditions; the behavior, the seizure; and the consequences, the rewards or punishments that reinforce seizure occurrence. "A behavioral diagnosis," according to Dr. Dahl, "requires a professional assessment of the seizure antecedents or precipitory factors, the seizure response, and the consequences of seizures." These entail minute observation and detailed interviews, simultaneous electroencephlograms, and videotapes.
Although behavioral treatment shares much with the medical view, it differs radically in its assertion that extrinsic factors are more important in seizure control than intrinsic ones - conditions of neurons and brain chemistry-and that a seizure can be regarded and effectively treated as a learned response. The record of both children and adults bringing their seizures under control or eliminating them entirely confirms this contention (Dahl, Melin, and Lessner 1988; Andrews 1989).
How are seizures deliberately interrupted? There are several approaches. Dr. Dahl, in her ten-year experience in Swedish hospitals, finds that 'arousal interventions" have been most effective. She prefers what she calls a "countermeasure"-using a whiff or strong scent when the aura is a bad odor, for example, or putting the hand down when it rises automatically as the seizure begins. She stresses that seizures will not be alleviated if they are being encouraged by some external response that in one way or another "rewards" the seizures or if they are desired for some inner reason.
Other neurologists and behavioral psychologists have found interventions to be effective that have no relationship to aura or seizure. In one well-known case in the literature, a man has a musical aura, which gives him time to imagine himself going fishing, a visualization that prevents his seizure (Pritchard et al. 1985). In another case a woman, alerted by a feeling of fear, gives herself a surge of anger that blocks seizure development. She simply tells herself silently and vehemently, "You can't do this to me!" (Personal communications from the patient and the neurologist.) A recent study (Rajna and Lona 1989) reports that sensory stimulation using smell, sounds, touch, light, and movement "promptly inhibited the seizure" in 79 out of 140 observations of seizures. There was no relationship to type of aura.
Like the woman who uses anger, individuals find their own peculiar strategies of intervention. Often the strategies have been reported in the literature, particularly by Mostofsky and Balaschak (1977). In neurological practice these idiosyncratic interventions are likely to be dismissed or ignored rather than recognized, encouraged, and built on. "Clearly, more studies are required in this area," Peter Fenwick (1991) writes, "firstly to determine the actual strategies the patients use, and secondly to find how frequently patients employ these methods of seizure limitation."
ADVANCES, The journal of Mind-Body Health Vol.8, No.4 Fall 1992
RICHARD
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