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Integrating Mind, Brain, Body, and Spirit in Treating Epilepsy
Adrienne Richard
Tlie integrated approach to epilepsy brings together all the aspects of the individual that are affected by this unpredictable chronic condition: the neurological, the behavioral, the psychological, and the spiritual and creative.
Adrienne Richard is the co-author, with Joel Reiter, of Epilepsy: A New Approach (Prentice-Hall 1990) and has written for many publications, including Psychological Perspectives and Medical Self-Care, on the treatment of epilepsy.
Epilepsy can be thought of as the mind-body condition par excellence. It involves mind, brain, body, and even spirit. In these few pages I would like to propose a new way to look at epilepsy, an integrated approach that includes its varied aspects of mind, brain, body, and spirit. This way of seeing epilepsy leads inevitably to a new paradigm of treatment, one that includes the capacity of individuals to control their seizures using techniques of the mind.
An epileptic seizure is an event that occurs in the brain and affects various parts of the body, even consciousness itself. Although most neurologists today do not consider a seizure to be controllable by individual action, since antiquity people have been known to exercise such control. Hippocrates, or those writing under his name, observed that children and adults could hold off a seizure until they reached a safe place. Gestate Flaubert amused himself by setting a seizure in motion and then blocking it. Many people with seizures believe they have aborted them from time to time.
It is a curious attribute of epilepsy to be a constant physical condition in the brain - an injury, abnormality, whatever - while the actual seizures usually occur only from time to time, often many times a day or a week but rarely continuously (status epilepticus is the exception). At these times for some reason, the brain's natural defenses against seizure are breached, and the individual's seizure threshold is surpassed. Everyone, it is assumed, has a seizure threshold, more easily breached for some than for others. Why does this occur when it occurs and not at other times? This is the prime question underlying the possibility of using self-mediated acts to control epilepsy. Understanding why a seizure breaks through at a certain moment is critical to all seizure-specific approaches and to ail integrated view of epilepsy and its treatment.
ADVANCES, The journal of Mind-Body Health Vol.8, No.4 Fall 1992
RICHARD
I am convinced that an integrated approach to epilepsy is the approach of the future, and I am convinced by two developments in particular. For almost a century epilepsy treatment his depended on pharmaceuticals, and their limits are now being recognized. An example of the shift is the recent statement by Jerome Engel, Jr., a leading figure in contemporary epileptology (Engel, Jr. 1989):
Epileptologists have relied heavily on pharmacological therapy, which is usually nonspecific and associated with disturbing side effects. Both basic and clinical research should focus an improving present alternative therapeutic approaches and finding new ones that may interfere more directly with precipitating and predisposing factors to prevent epileptic seizures without producing additional symptoms.
The second development is the growing importance of preventive medicine. In preventive care the patient is involved in the healing process. Acute episodes of chronic conditions are prevented by the patient, and the patient learns about and observes his or her own processes.
The newness of an integrated approach to epilepsy lies in its comprehensiveness. It brings together all the aspects of the individual that are affected by this unpredictable chronic condition: the neurological, the behavioral, the psychological, and the spiritual and creative. What is remarkable to me about these four views of epilepsy is that each sees epilepsy in its own particular way, but no one way excludes or invalidates the others.
The Medical Approach
Epilepsy falls within the medical province of neurology. Historically, knowledge in the neurosciences has depended heavily on research done on, to, or with individuals with epilepsy. In late nineteenth-century Paris, the neurologist Jean Charcot observed the differences between epilepsy and "hystero-epilepsy," which today would be called pseudo-seizures or psychogenic seizures. The women's prison hospital he headed became famous and notorious for his flamboyant methods and public presentations and for the younger neurologists and psychiatrists who studied with him - Freud, Janet, and Bleuler, among others. In Charcot's office hung a picture of the British neurologist, John Hughlings Jackson. Jackson also investigated epilepsy, intuiting before x-ray and electroencephalography the functions of specific areas of the brain and bringing his great knowledge and understanding to the experience of epilepsy.
Knowledge of the brain was extended much further through the investigations of the great Canadian neurosurgeon, Wilder Penfield. Epilepsy and the Functional Anatomy of the Human Brain (I 954) records his extraordinary work. Most recently, knowledge of the different functions of the brain hemispheres developed from surgery severing the corpus collosum in persons with intractable seizures. It is difficult to imagine modern neuroscience without research on epilepsy.
ADVANCES, The journal of Mind-Body Health Vol.8, No.4 Fall 1992
RICHARD
Today, neurology sees the epileptic seizure as an electrochemical event that occurs in the brain. It begins among a few neurons in a specific place, sometimes detectable (in 50 to 60 percent of the cases) and sometimes not (idiopathic). For reasons not yet understood, certain neurons become hyperexcitable and repeatedly experience electrical discharges. These discharges trigger discharges in neighboring neurons, and in this way the process spreads to other parts of the brain, giving the seizure its characteristic outward expression.
The primary medical treatment, medication, is designed to forestall this sequence, so that the seizure does not develop. Through anticonvulsants, many persons are helped with little or no disruption to their lives.
Some types of seizures, however, are resistant to medication, and some people do not tolerate the medications well. Others do not want to take drugs for various reasons. The medications are usually taken over a long term, and their toxicity is recognized today. v
vThe prospect of less toxic, more effective drugs may not be too far off. According to Stephen Schachter, "M.D., who is on the staff of Bethlsrael Hospital's
There may also be more personal side effects that erode an individual's sense of integrity. A young man forgets what he is talking about in mid-sentence, an experience he never suffered before medication. To her chagrin, a svelte young woman on a certain anticonvulsant gains 20 pounds. An older man must walk like a sailor because he feels unsteady on his feet. A business woman's hands shake uncontrollably as she holds the company report. Many people are left mentally foggy and slow. These are not life-threatening side effects, but they seriously undermine a sense of confidence and competence.
Some individuals with epilepsy would recognize the dilemma of the surgeon with Tourette's syndrome, as described by neurologist Oliver Sacks (1992) in a recent article in The New Yorker, "A Neurologist's Notebook: A Surgeon's Life." The surgeon, Sacks reports, "cannot tolerate" the drugs that would reduce his symptoms of uncontrollable movements and gestures because "they reduce him as well so that he no longer feels fully himself" (Sacks' italics).
In the medical approach, surgical removal of the minute epileptic locus in the brain is an increasingly viable option. With recent technological advances, physicians have gained an unprecedented ability to identify and surgically excise epileptic foci. Nonetheless, the more people are referred for surgery, the more nervous many observers become. The media coverage extolling this procedure unwittingly raises many concerns about these referrals. In this period of limited resources and rising health costs, hospitals are eager for profitable procedures - and surgery is profitable. People with uncontrolled epilepsy who seek surgery are desperate and depend on the neurosurgical staff to act in the patient's interest, not its own or the hospital's. Further, surgery for the removal of the epileptic focus does not always eliminate seizure activity. In some cases-the necessary removal of a tumor or an arteriovascular malformation, for example-seizures may begin as an aftermath of surgery.
ADVANCES, The journal of Mind-Body Health Vol.8, No.4 Fall 1992
RICHARD
Comprehensive Epilepsy Center in Boston and who has been involved with drug research for six or seven years, "The drugs now under development are likely to be ones that interact with those aspects of nerve function involved in epilepsy. The current testing process will produce a new generation of drugs which are proven safer and more effective [than those now available]." (Personal Communication)
Behavioral treatment of epilepsy differs radically from medical treatment in asserting that extrinsic factors are more important in seizure control than are neurons and brain chemistry and that a seizure can be regarded and effectively treated as a learned response.
In addition, surgery may be resorted to without the patient making the life-style changes that will make the surgery maximally effective. Seizure-triggering situations and experiences may continue if the patient is not aware of their consequences or is unwilling to avoid or alter such triggers. Chronic stress and tension, unresolved emotional issues, alcoholic and caffeinated beverages, exposure to certain chemicals, habitual shallow breathing patterns, and poor eating habits and nutrition top the list.
On a recent visit to the multidisciplinary Bethel (pronounced bay-tl) Epilepsy Center near Bielefeld, Germany, I sat in on a discussion between the psychologist in charge of nonmedical programs and the referring neurologist as they reviewed the problems they faced in persuading a surgical candidate to make changes her life before the surgery. They did not want to go forward until the changes were made in order to give surgery its greatest chance to be beneficial. One American behavioral psychologist his found postsurgery clients less able to make changes.
These caveats notwithstanding, the pharmacological treatment and surgical possibility of the medical approach are essential components in an integrated approach to epilepsy. | 
