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SEIZURE DISORDERS: Edited by Philippe Ryvlin

Behavioral interventions in epilepsy

Haut, Sheryl R.a,b; Gursky, Jonathan M.a,b; Privitera, Michaelc

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Current Opinion in Neurology: April 2019 - Volume 32 - Issue 2 - p 227-236
doi: 10.1097/WCO.0000000000000661
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Abstract

INTRODUCTION

It is clear that both patients and clinicians have an increasing interest in exploring behavioral interventions for epilepsy. The observation that changes in stress and mood appear to be related to seizure occurrence has long been reported, typically as the most frequently endorsed seizure precipitant in both questionnaire and prospective studies [1,2]. Furthermore, the high rates of comorbid depression and anxiety and impairments in quality of life (QOL) lead naturally to the attempt to address these conditions behaviorally, at least in part [3▪▪,4].

In the setting of societal awareness and familiarity with such modalities as mindfulness and wellness programs, these techniques are being observed more and more frequently in the epilepsy literature. The term ‘behavioral intervention’ is broad and can be applied to many approaches currently in use in epilepsy. These treatments range from well-recognized psychobehavioral modalities which can be considered to encompass behavioral, cognitive behavioral, and mind-body treatments [5] to forms of expressive psychotherapies such as art and music therapy. The development and utilization of web-based or app-based management programs for the self-management of epilepsy may also be viewed in the category of behavioral treatments [6▪].

Although there is robust evidence that behavioral treatments improve multiple elements of QOL, comorbid mood disorders, and medication adherence in epilepsy, the overall level of evidence that behavioral treatments can improve seizure outcomes remains limited [7,8,9▪▪]. This relates in large part to the difficulty in conducting randomized clinical trials (RCTs) for behavioral interventions [10]. Despite these limitations, there is a definite trend toward subjecting these modalities to examination in controlled studies.

Herein, we summarize the latest developments in behavioral interventions in epilepsy, attempting when possible to highlight outcomes targeted to reduction of seizure frequency, QOL, and psychiatric comorbidities. The review is arranged by treatment modality, although this is an artificial organization as there is significant overlap across these approaches, for example, the concept of self-management is itself a cognitive behavioral approach.

Box 1
Box 1:
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PSYCHOBEHAVIORAL INTERVENTIONS

Psychobehavioral interventions are defined as interventions based on the ‘theory of psychotherapy,’ and can be considered to encompass behavioral, cognitive behavioral, and mind–body treatments [5]. Many of these interventions have been examined in epilepsy; these studies have generally been small or noncontrolled studies. Given the increased general interest in these modalities and the robust supportive data, there has been significant progress toward studying these techniques in RCTs.

A 2017 Cochrane review examined RCTs and pseudo-RCTs of psychological studies in epilepsy [9▪▪]. Of 24 studies reviewed, none were included in the meta-analysis, among them are studies of cognitive behavioral therapy (CBT) [11–14], mindfulness [15▪], self-management [16], psychoeducational intervention [17,18], and depression intervention [19]. The authors conclusion was that psychological and self-management interventions improved health-related QOL and emotional well-being in adults and adolescents with epilepsy (Fig. 1) [9▪▪]. These findings led to the recent recommendation by the International League Against Epilepsy Psychology Task Force that ‘psychological interventions should be incorporated into comprehensive epilepsy care’ [3▪▪].

FIGURE 1
FIGURE 1:
Comparison of QOLIE-31 mean changes from baseline across studies. Results from the nine randomized controlled behavioral trials included in the Cochrane meta-analysis of psychological studies in epilepsy show uniform improvement in QOLIE scores across studies. QOLIE, Quality of Life in Epilepsy. Reproduced with permission from [9▪▪].

Cognitive behavioral therapy

CBT examines the relationships between thoughts, emotions, and specific outcomes, training the practitioner to replace maladaptive thought patterns with healthier cognitive and behavioral responses [20]. As above, multiple studies have demonstrated improvements in CBT for health-related QOL and comorbidity outcomes [9▪▪].

A recent review of cognitive and behavioral techniques for epilepsy highlighted that the data for improved seizure outcomes with CBT are limited [21▪▪]. The observation that CBT may reduce epileptiform activity supports this approach for seizure reduction, however [22]. Supportive data are available for the Reiter/Andrews method, an approach which relies on the assumption that the emotional content of seizure precipitation can be amenable to CBT [23]. Trigger control and aura interruption techniques are often included in this treatment, with promising results albeit typically in small and/or uncontrolled studies [24,25].

Other promising forms of CBT are acceptance and commitment therapy (ACT), discussed below as integrated with mindfulness, and motivational interviewing, a form of psychotherapy which assists the practitioner to move away from a state of uncertainty toward positive decision-making [26]. Motivational interviewing improved epilepsy medication adherence in a large 2015 randomized trial [26]. Motivational interviewing was also tested as part of the WebEase self-management program [27,28], demonstrating improvement in multiple modalities including self-efficacy and medication adherence. This technique has not been proven to reduce seizures [21▪▪].

Mind–body approaches

As per the National Center for Complementary and Integrative Health, mind–body interventions are those practices that ‘employ a variety of techniques designed to facilitate the mind's capacity to affect bodily function and symptom,’ and include a large and diverse group of techniques [29]. Although there is a robust history of smaller studies, there has been a paucity of larger and/or RCTs of these interventions in epilepsy until recently. Within the past 2 years, however, two psychobehavioral RCTs have been published with seizure frequency as either primary [30▪] or secondary [15▪] outcome.

Mindfulness

Mindfulness training directs the practitioner to focus on present moment stimuli with nonjudgment and acceptance, toward mindful attentional control [31]. In 2015, Tang et al.[15▪] reported the results of a mindfulness-based assessor blinded RCT. In the trial of 60 completed participants, 30 participants each were randomized into the mindfulness and social support (active) arm vs. social support only (attentional control) arm. Each group met four times, and participants in the mindfulness group were encouraged to practice 45 min per day.

Participants in both groups showed significant improvements in the Patient-Weighted Quality of Life In Epilepsy Inventory (QOLIE-31-P) scores, although more patients in the mindfulness group than the control group had clinically important improvements (36.6 vs. 13.3%). Both groups also showed improvements in mood scores on the Beck Anxiety Inventory and Beck Depression Inventory-II and improvements in verbal memory, with more clinically significant changes present in the mindfulness group.

Seizure control improved in both groups, with a reduction in mean seizure frequency from 9.83 at baseline to 5.90 (change −3.93, 95% confidence interval −5.79, +2.08) postintervention in the mindfulness group, and 9.00–7.33 (change −1.67, 95% confidence interval −3.03, −0.30) in the social support group. The results were statistically significant (P < 0.001) in the within-group analysis (pre and postintervention for each group), however, there was no significant difference in the amount of change seen between the two groups.

This well-designed study demonstrated a strong role for mindfulness and possibly similar modalities for improving QOL in epilepsy. The secondary outcomes including memory and seizure control also appear more robust in the mindfulness group. However, an important observation is that gains are present in the control group as well. Although this may represent the equivalent of a ‘placebo’ response, this may alternately represent a real effect from the control intervention, similar to the Stress Management for Living with Epilepsy (SMILE) study (below), underscoring the challenges in control arms of behavioral studies.

Another RCT of ‘distance delivery’ mindfulness examined the effect of a mindfulness protocol delivered via Web or phone to prevent major depressive disorder in epilepsy [32]. The Project UPLIFT study, part of the Managing Epilepsy Well Network (below) randomized 128 participants into a controlled crossover study of mindfulness vs. treatment as usual. Distance delivery mindfulness significantly reduced major depressive disorder as well as depressive symptoms [32].

Project UPLIFT included elements of ACT, a psychobehavioral technique on the borderlands between CBT and mindfulness, which has undergone evaluation in epilepsy [33,34] including a recent uncontrolled study [35]. ACT aims to train the practitioner to use acceptance and mindfulness techniques in concert with commitment to behavioral change strategies, toward increasing psychological flexibility [33,35]. This technique has been shown to reduce seizures and depression, either alone or in combination with other modalities such as mindfulness or yoga [33].

Progressive muscle relaxation

Progressive muscle relaxation (PMR) is a relaxation method in which each muscle set is tensed and relaxed for stress reduction [36]. PMR was examined for epilepsy a few decades ago [37,38] and has reemerged as a treatment in many medical conditions. The SMILE study completed 64 participants with medication-resistant focal epilepsy who were randomized to two groups in a double blinded manner [30▪]. The active intervention involved twice daily diaphragmatic breathing and PMR consisting of the progressive relaxation of 16 muscles. The focused attention control program included matched muscle movements without systematic muscle relaxation and attentional practice such as writing down daily activities. The participants underwent two in-person training sessions, and maintained daily smartphone diaries. Participants practiced with an audio file on the smartphone. The primary outcome of the SMILE study was change in seizure frequency with respect to baseline over the 3-month study period.

The two interventions both showed reductions in seizure frequency as compared with baseline although the groups did not separate significantly from each other (PMR group: 29%; focused attention control group: 25%; P = 0.38). PMR showed superior reduction of self-reported stress (P < 0.05). (Fig. 2) [30▪].

FIGURE 2
FIGURE 2:
Seizure frequency results, SMILE (Stress Management Intervention for Living with Epilepsy). Seizure frequency was reduced in both the active (PMR) and control (focused attention) groups during the 12-week intervention period as compared to the 8-week baseline. Seizure reduction (29 vs. 25%) did not differ across treatment allocation. PMR, progressive muscle relaxation. Adapted with permission from [30▪].

As in the mindfulness RCT, both the active and the control group showed improvements beyond what would have been expected as a placebo effect, based on results from reported placebo rates in epilepsy clinical trials which range from 9.9 to 19.7% [30▪]. In addition to robust seizure improvements, the efficacy appeared to increase over time, especially in the attentional control group, which is not the typical pattern of placebo response. The authors suggest that the daily monitoring of mood may itself represent a form of mindfulness [30▪].

Yoga and meditation

Yoga has become an increasingly frequent component of complementary and alternative therapies in many disorders, including epilepsy. Yoga is practiced in numerous different forms, with varying levels of attention placed on its basic components: controlled breathing, posture, meditation, and targeted flow of consciousness. Regardless of its form, yoga teaches participants to respond to internal stimuli in a conscious way, which may be particularly useful for patients suffering from various neurologic diseases, including epilepsy [39,40].

Several studies have shown that yoga can have demonstrable physiologic effects. For instance, Sahaja yoga has been shown to produce alterations in galvanic skin resistance (GSR), blood lactate level, and urinary vinyl mandelic acid. These alterations may collectively indicate reduced stress following yoga practice [41]. Additionally, Sahaja yoga has been observed to produce electroencephalography (EEG) changes in patients with epilepsy, with power spectral analysis showing a shift in frequencies from 0–8 Hz to 8–20 Hz [42]. Such EEG changes may be because of the modulation of hypothalamic and endocrine effects on the limbic and sympathetic nervous systems [39].

In recent years, a limited, but growing, body of research has investigated the potential for seizure frequency reduction with yoga and other guided meditative practices. A 2017 Cochrane systematic review of two controlled, unblinded trials encompassing 50 total epilepsy patients showed a potential beneficial effect from yoga on control of seizures [43▪]. Results of the overall efficacy analysis showed that yoga treatment was superior to no intervention and postural exercises mimicking yoga. The mean effect size varied from 1.1 to 2.1 fewer seizures per month, with additional improvements seen in seizure duration and likelihood of achieving 50% seizure reduction over 6 months. However, the review's conclusions were limited by the small number of trials included, small number of participants studied, and lack of blinding [39]. Other studies have also found decreases in seizure frequency, with 50% seizure reduction response rates ranging from 27 to 78%. Response rates tended to increase the longer participants engaged in yoga programs, with studied periods varying from 3 months to 1 year [44,45]. These studies were similarly limited by small sample sizes and the lack of blinding or randomization.

In addition to reduction in seizure frequency, yoga has long been shown to have mental health benefits among psychiatric patients, as discussed in a 2018 review [46]. The high comorbidity of psychiatric disease among epilepsy patients is well established and opens an additional potential benefit for yoga therapy. Although few studies have investigated mental health benefits among epilepsy patients in particular, a small group of epilepsy patients participating in yoga programs has scored higher on certain measures of overall QOL [33].

Bio/neurofeedback

Biofeedback comprises a set of techniques whereby the practitioner becomes aware of involuntary physiologic processes to manipulate them by conscious mental control. Neurofeedback is a form of biofeedback therapy which is based on self-modulation of features of the EEG by the practitioner [47].

A number of small studies have examined electrodermal or GSR-based biofeedback [48–50], including at least one randomized controlled single blinded study of GSR biofeedback vs. sham [48]. These studies report robust and sustained seizure reduction, and the apparent recent increase in this investigation appears well merited.

Neurofeedback has been investigated for use in epilepsy since the 1970s [51,52]. Using neurofeedback, entrainment of specific EEG frequencies is believed to influence seizure control and behavioral parameters. Typically, participants are positively reinforced for the production of specific frequencies, most commonly entrainment of slow cortical potentials or higher frequencies such as the sensorimotor rhythm.

The currently available literature is well summarized in a recent review [52]. No recent randomized controlled trials have been reported and these modalities still remain in limited recognition and use in standard epilepsy treatment. One recent follow-up study did demonstrate a sustained effect of slow cortical potential neurofeedback to reduce seizures 10 years after initial training [53], suggesting that neurofeedback may be an underutilized strategy for successful seizure control.

CREATIVE ARTS THERAPY

The National Coalition of Creative Arts Therapies Association recognizes six creative arts therapy modalities, including art therapy, dance therapy, drama therapy, music therapy, poetry therapy, and psychodrama. [54]. Two of these modalities in particular, music and art therapy, have been recently evaluated in epilepsy.

Music therapy

The effects of music on patients with epilepsy are undergoing increasing research and therapeutic investigation. Studies have focused on what has become known as the ‘Mozart effect’ [55]. Most studies have focused on Mozart's sonata for two pianos in D major K448, although other compositions and combinations of music have been studied as well. Playing Mozart has been shown to reduce seizures and produce various EEG changes, including the reduction of interictal epileptiform discharges [55]. Interestingly, comparisons between Mozart and Beethoven have shown that the latter fails to produce the same EEG changes as the former [56].

The Mozart effect is thought to be because of an increase in parasympathetic tone that occurs while listening to music [57]. Recently, therapeutic music has been shown to reduce seizure frequency in patients with drug-resistant epilepsy, especially pediatric patients and those with severe/profound intellectual disability [58–60]. There have been at least two case reports of patients who have recovered from refractory nonconvulsive status epilepticus following exposure to music therapy [61,62]. In addition to seizure reduction, one study reported decreased irritability, tearfulness, and aggression toward self and others, as well as improved daytime vigilance and nighttime sleep quality among children with drug-resistant epilepsy [58].

Although music therapy clearly requires additional investigation, its easy accessibility and virtually risk-free profile make it an appealing option for adjunctive complementary treatment in epilepsy.

Art therapy

Epilepsy has been depicted in various forms of art for centuries [63]. Many artists with epilepsy have found vivid and imaginative ways to depict their unique experiences in the preictal, ictal, and postictal states [64]. One artist's example paints a compelling picture of what it might be like to regain awareness after having suffered a seizure (Fig. 3) [64]. These illustrations portray poignant and often emotionally charged depictions of the experiences of those with epilepsy, although there has been a paucity of research investigating whether art therapy can offer quantifiable health benefits for epilepsy patients. One group in Turkey evaluated 50 stroke and epilepsy patients using the Beck Hopelessness Scale before and after an intervention involving the use of clay to make artistic figures. Although all groups trended towards improvement in the Beck Hopelessness Scale, the epilepsy subgroup did not reach statistical significance [65].

FIGURE 3
FIGURE 3:
Epilepsy art. Faces in circle, Volker Rodermund. Artist rendition of recovery from a seizure. Reprinted with permission from [64].

Another small study examined the effect of a four-session art therapy focus group on attitudes toward illness among children and adolescents with epilepsy. Although study participants were uniformly positive about their experience, no difference was seen in the Childhood Attitude Toward Illness scale following the intervention [66].

Although art therapy may be subjectively therapeutic among select patients, additional research is needed to further investigate the utility of art therapy among patients with epilepsy.

EPILEPSY SELF-MANAGEMENT

Self-management, as defined by the Agency for Healthcare Research and Quality as the ‘the help given to people with chronic conditions that enables them to manage their health on a day-to-day basis’ [67]. Self-management is an increasingly important patient-centered tool to improve outcomes in epilepsy [68].

The ‘Managing Epilepsy Well’ Network, established in 2007, has supported multiple programs geared to epilepsy self-management, including many of the studies discussed here. The use of web-based and mobile apps serve as important vehicles for delivery of these interventions, toward self-optimized seizure control and QOL. Multiple elements of self-management can be monitored using these apps, as recently reviewed (Fig. 4) [6▪].

FIGURE 4
FIGURE 4:
Distribution of epilepsy self-management modalities in currently available mobile apps. Mobile apps provide opportunities for enhanced self-management in multiple epilepsy domains ranging from seizure tracking to medication adherence, social support, and stress management. Reproduced with permission from [6▪].

Although a full review of self-management in epilepsy is outside of the scope of this review, special attention should be given to a number of recent studies. In a 2015 trial, 83 participants with epilepsy were randomized into a self-management program called program for active consumer engagement in self-management vs. usual care (program for active consumer engagement in self-management) [18]. The self-management training was delivered by a psychologist and trained peer with epilepsy, in an 8-week group that met one evening per week for 75 min. Topics included epilepsy-related medical, psychosocial, cognitive, and self-management issues. Participants in the active arm showed significant improvements in the Epilepsy Self-Management Scale as well as multiple subscales of the QOLIE-31.

The 2016 HOBSCOTCH (home based self-management and cognitive training changes lives) study randomized 66 study participants into three arms to investigate the impact of a self-management intervention targeting cognitive dysfunction on QOL and cognition in adults with epilepsy [16]. Study participants in the active arm showed improvements in QOLIE-31 and the attention domain of cognitive testing. These findings were found to be generalizable in the 2017 interim analysis of a replication study [69].

Most recently, the SMART ('Self-management for people with epilepsy and a history of negative health events’) study published in 2018 randomized 120 participants into an active arm of remotely delivered epilepsy self-management vs. waitlist control [70▪]. The intervention was developed with stakeholder participation. The self-management intervention was an initial in person group session followed by seven group format sessions delivered via the internet. Participants in the active arm had significantly fewer negative health events and improved scores on multiple QOL instruments. Seizure severity scores were not affected by the intervention [70▪].

These studies confirm an important role for epilepsy self-management programs. Seizure outcomes have generally not been reported and this remains an area of great interest.

A final word on self-management relates to the current expansion of wearable devices. These devices have introduced the ability of persons with epilepsy to self-monitor physiologic parameters possibly linked to seizure triggers. The full potential of these apps and devices is likely not yet realized, but holds great promise. A cautionary note is that optimally balancing the quality vs. quantity of this continuous stream of data poses a challenge.

CONCLUSION

The expansion of adjunctive behavioral options for the treatment of epilepsy is very promising. The current literature suggests that various behavioral therapies may be associated with fewer seizures, respite from common epilepsy comorbidities, and improvements in QOL measurements. Rigorous randomized blinded clinical trials are a few, and remain an important research need.

Behavioral therapies are likely underutilized in the epilepsy population. For motivated and interested patients, appropriately chosen behavioral therapies are a reasonable approach to adjunctive epilepsy treatment. As patient-centered approaches gain increasing recognition, it is imperative that the field of epilepsy continue to explore and encourage investigation into the wide array of potential behavioral interventions in epilepsy.

Acknowledgements

None.

Financial support and sponsorship

M.P. receives research funding from NIH 2U01NS038455–11A1, Epilepsy Foundation, GW Pharmaceuticals, SK Life Science. He serves as a consultant for SK Life Science, GW/Greenwich, Astellas (DSMB).

S.R.H. serves on the editorial board of Epilepsy and Behavior; and received unrestricted grant support from the Shor Foundation for Epilepsy Research. She serves as a consultant for Acorda (DSMB), Otsuka, and Engage Pharmaceuticals.

Conflicts of interest

There are no conflicts of interest.

REFERENCES AND RECOMMENDED READING

Papers of particular interest, published within the annual period of review, have been highlighted as:

  • ▪ of special interest
  • ▪▪ of outstanding interest

REFERENCES

1. Novakova B, Harris PR, Ponnusamy A, Reuber M. The role of stress as a trigger for epileptic seizures: a narrative review of evidence from human and animal studies. Epilepsia 2013; 54:1866–1876.
2. Haut SR, Hall CD, Masur J, Lipton RB. Seizure occurrence: precipitants and prediction. Neurology 2007; 69:1905–1910.
3▪▪. Michaelis R, Tang V, Goldstein LH, et al. Psychological treatments for adults and children with epilepsy: evidence-based recommendations by the International League Against Epilepsy Psychology Task Force. Epilepsia 2018; 59:1282–1302.

This report is a comprehensive review of psychological treatments in epilepsy, reported by the International League Against Epilepsy Psychology Task Force. The review is based largely on the 2017 Cochrane Review [9▪▪].

4. Privitera M, Walters M, Lee I, et al. Characteristics of people with self-reported stress-precipitated seizures. Epilepsy Behav 2014; 41:74–77.
5. Tang V, Michaelis R, Kwan P. Psychobehavioral therapy for epilepsy. Epilepsy Behav 2014; 32:147–155. DOI: 10.1016/j.yebeh.2013.12.004.
6▪. Escoffery C, McGee R, Bidwell J, et al. A review of mobile apps for epilepsy self-management. Epilepsy Behav 2018; 81:62–69.

Comprehensive and timely review of progress in epilepsy self-management e-tools.

7. Ramaratnam S, Baker GA, Goldstein LH. Psychological treatments for epilepsy. Cochrane Database Syst Rev 2008; 3:CD002029.
8. Jackson CF, Makin SM, Marson AG, Kerr M. Nonpharmacological interventions for people with epilepsy and intellectual disabilities (Review). Cochrane Database Syst Rev 2015; 10:9.
9▪▪. Michaelis R, Tang V, Wagner JL, et al. Psychological treatments for people with epilepsy. Cochrane Database Syst Rev 2017. 10Art No.: CD012081.

Updated systematic review of a broad range of psychological treatments in epilepsy. The review reported moderate quality evidence for psychological treatments to benefit QOL, emotional well-being and reduced fatigue.

10. Polak EL, Privitera MD, Lipton RB, Haut SR. Behavioral intervention as an add-on therapy in epilepsy: designing a clinical trial. Epilepsy Behav 2012; 25:505–510.
11. Au A, Chan F, Li K, et al. Cognitive/behavioral group treatment program for adults with epilepsy in Hong Kong. Epilepsy Behav 2003; 4:441–446.
12. Gandy M, Sharpe L, Nicholson Perry K, et al. Cognitive behaviour therapy to improve mood in people with epilepsy: a randomised controlled trial. Cogn Behav Ther 2014; 43:153–166.
13. Martinovi Z, Simonovi P, Djoki R. Preventing depression in adolescents with epilepsy. Epilepsy Behav 2006; 9:619–624.
14. Orjuela-Rojas JM, Martinez-Juarez IE, Ruiz-Chow A, Crail-Melendez D. Treatment of depression in patients with temporal lobe epilepsy: a pilot study of cognitive behavioral therapy vs. selective serotonin reuptake inhibitors. Epilepsy Behav 2015; 51:176–181.
15▪. Tang V, Poon WS, Kwan P. Mindfulness-based therapy for drug-resistant epilepsy: an assessor-blinded randomized trial. Neurology 2015; 85:1100–1107.

This report is one of the few randomized controlled behavioral trials which reported on both QOL and seizure outcomes. Improvements were demonstrated in both areas with mindfulness training.

16. Caller TA, Ferguson RJ, Roth RM, et al. A cognitive behavioral intervention (HOBSCOTCH) improves quality of life and attention in epilepsy. Epilepsy Behav 2016; 57 (Part A):111–117.
17. Helde G, Bovim G, Bråthen G, Brodtkorb E. A structured, nurse-led intervention program improves quality of life in patients with epilepsy: a randomised, controlled trial. Epilepsy Behav 2005; 7:451–457.
18. Fraser RT, Johnson EK, Lashley S, et al. PACES in epilepsy: results of a self-management randomized controlled trial. Epilepsia 2015; 56:1264–1274.
19. Ciechanowski P, Chaytor N, Miller J, et al. PEARLS depression treatment for individuals with epilepsy: a randomised controlled trial. Epilepsy Behav 2010; 19:225–231.
20. Beck AT. The current state of cognitive therapy: a 40-year retrospective. Arch Gen Psychiatry 2005; 62:953–959.
21▪▪. Leeman-Markowski BA, Schachter SC. Cognitive and behavioral interventions in epilepsy. Curr Neurol Neurosci Rep 2017; 17:1–19.

Recent review of cognitive and behavioral treatments in epilepsy. This study includes expanded analyses of modalities such as the Andrews/Reiter approach, mindfulness, yoga, and neurofeedback among others.

22. Matsuoka H, Nakamura M, Ohno T, et al. The role of cognitive-motor function in precipitation and inhibition of epileptic seizures. Epilepsia 2005; 46 (Suppl 1):17–20.
23. Reiter JM, Andrews DJ. A neurobehavioral approach for treatment of complex partial epilepsy: efficacy. Seizure 2000; 9:198–203.
24. Elsas SM, Gregory WL, White G, et al. Aura interruption: the Andrews/Reiter behavioral intervention may reduce seizures and improve quality of life: a pilot trial. Epilepsy Behav 2011; 22:765–772.
25. Michaelis R, Schonfeld W, Elsas SM. Trigger self-control and seizure arrest in the Andrews/Reiter behavioral approach to epilepsy: a retrospective analysis of seizure frequency. Epilepsy Behav 2012; 23:266–271.
26. Pakpour AH, Gholami M, Esmaeili R, et al. A randomised controlled multimodal behavioral intervention trial for improving antiepileptic drug adherence. Epilepsy Behav 2015; 52:133–142.
27. DiIorio C, Escoffery C, McCarty F, et al. Evaluation of WebEase: an epilepsy self-management web site. Health Educ Res 2008; 24:185–197.
28. DiIorio C, Bamps Y, Walker ER, Escoffery C. Results of a research study evaluating WebEase, an online epilepsy self-management program. Epilepsy Behav 2011; 22:469–474.
29. https://nccih.nih.gov/health/mindbody. [Accessed 12 December 2018]
30▪. Haut SR, Lipton RB, Cornes S, et al. Behavioral interventions as a treatment for epilepsy: a multicenter randomized controlled trial. Neurology 2018; 90:e963–e970.

This trial of PMR tested a mind–body intervention with seizure reduction as the primary outcome in a randomized controlled design. Both the active and control arm showed reduced seizure frequency.

31. Kabat-Zinn J. Mindfulness-based interventions in context: past, present, and future. Clin Psychol Sci Pract 2003; 10:144–156.
32. Thompson NJ, Patel AH, Selwa LM, et al. Expanding the efficacy of Project UPLIFT: distance delivery of mindfulness-based depression prevention to people with epilepsy. J Consult Clin Psychol 2015; 83:304–313.
33. Lundgren T, Dahl J, Yardi N, Melin L. Acceptance and commitment therapy and yoga for drug-refractory epilepsy: a randomized controlled trial. Epilepsy Behav 2008; 13:102–108.
34. McLaughlin DP, McFarland KJ. A randomized trial of a group based cognitive behavior therapy program for older adults with epilepsy: the impact on seizure frequency, depression and psychosocial well being. J Behav Med 2011; 34:201–207.
35. Dewhurst E, Novakova B, Reuber M. A prospective service evaluation of acceptance and commitment therapy for patients with refractory epilepsy. Epilepsy Behav 2015; 46:234–241.
36. Jacobson E. Progressive relaxation. Chicago: University of Chicago Press; 1938.
37. Dahl J, Melin L, Lund L. Effects of a contingent relaxation treatment program on adults with refractory epileptic seizures. Epilepsia 1987; 28:125–132.
38. Whitman S, Dell J, Legion V, et al. Progressive relaxation for seizure reduction. J Epilepsy 1990; 3:17–22.
39. Yardi N. Yoga for control of epilepsy. Seizure 2001; 10:712.
40. Mooventhan A, Nivethitha L. Evidence based effects of yoga in neurological disorders. J Clin Neurosci 2017; 43:61–67.
41. Panjwani U, Gupta HL, Singh SH, et al. Effect of Sahaja yoga practice on stress management in patients of epilepsy. Indian J Physiol Pharmacol 1995; 39:111–116.
42. Panjwani U, Selvamurthy W, Singh SH, et al. Effect of Sahaja yoga practice on seizure control & EEG changes in patients of epilepsy. Indian J Med Res 1996; 103:165–172.
43▪. Panebianco M, Sridharan K, Ramaratnam S. Yoga for epilepsy. Cochrane Database Syst Rev 2017; Art. No.: CD001524.

Updated version of a 2015 Cochrane review. Only two unblinded studies of yoga for epilepsy were adequate for review, as in 2015, and although the studies reveal a possible beneficial effect for seizure control, insufficient evidence is available.

44. Sathyaprabha TN, Satishchandra P, Pradhan C, et al. Modulation of cardiac autonomic balance with adjuvant yoga therapy in patients with refractory epilepsy. Epilepsy Behav 2008; 12:245–252.
45. Rajesh B, Jayachandran D, Mohandas G, Radhakrishnan K. A pilot study of a yoga meditation protocol for patients with medically refractory epilepsy. J Altern Complement Med 2006; 12:367–371.
46. Nyer M, Nauphal M, Roberg R, Streeter C. Applications of yoga in psychiatry: what we know. Focus 2018; 16:12–18.
47. Uhlmann C, Fröscher W. Biofeedback as complementary treatment in patients with epilepsy: an underestimated therapeutic option? Review, results, discussion. J Epileptology 2016; 24:173–180.
48. Nagai Y, Goldstein LH, Fenwick PB, Trimble MR. Clinical efficacy of galvanic skin response biofeedback training in reducing seizures in adult epilepsy: a preliminary randomized controlled study. Epilepsy Behav 2004; 5:216–223.
49. Micoulaud-Franchi JA, Kotwas I, Lanteaume L, et al. Skin conductance biofeedback training in adults with drug-resistant temporal lobe epilepsy and stress-triggered seizures: a proof-of-concept study. Epilepsy Behav 2014; 41:244–250.
50. Scrimali T, Tomasello D, Sciuto M. Integrating electrodermal biofeedback into pharmacologic treatment of grand mal seizures. Front Hum Neurosci 2015; 9:252.
51. Sterman MB, Friar L. Suppression of seizures in an epileptic following sensorimotor EEG feedback training. Electroencephalogr Clin Neurophysiol 1972; 33:89–95.
52. Birbaumer N, Elbert T, Rockstroh B, Lutzenberger W. Biofeedback of event-related slow potentials of the brain. Int J Psychol 1987; 16:389–415.
53. Strehl U, Birkle SM, Wörz S, Kotchoubey B. Sustained reduction of seizures in patients with intractable epilepsy after self-regulation training of slow cortical potentials: 10 years after. Front Hum Neurosci 2014; 8:604.
54. https://www.nccata.org. [Accessed 12 December 2018]
55. Lin LC, Lee MW, Wei R, Mozart CK, et al. 448 listening decreased seizure recurrence and epileptiform discharges in children with first unprovoked seizures: a randomized controlled study. BMC Complement Altern Med 2014; 14:17.
56. Verrusio W, Ettorre E, Vicenzini E, et al. The Mozart effect: a quantitative EEG study. Conscious Cogn 2015; 35:150–155.
57. Lin L, Chiang C, Lee M, et al. Parasympathetic activation is involved in reducing epileptiform discharges when listening to Mozart music. Clin Neurophysiol 2013; 124:1528–1535.
58. Coppola G, Toro A, Operto FF, et al. Mozart's music in children with drug-refractory epileptic encephalopathies. Epilepsy Behav 2015; 50:18–22.
59. Coppola G, Operto FF, Caprio F, et al. Mozart's music in children with drug-refractory epileptic encephalopathies: comparison of two protocols. Epilepsy Behav 2018; 8:100–103.
60. D’Alessandro P, Giuglietti M, Baglioni A, et al. Effects of music on seizure frequency in institutionalized subjects with severe/profound intellectual disability and drug-resistant epilepsy. Psychiatr Danub 2017; 29:399–404.
61. Kuester G, Rios L, Ortiz A, Miranda M. Effect of music on the recovery of a patient with refractory nonconvulsive status epilepticus. Epilepsy Behav 2010; 18:491–493.
62. Miranda M, Kuester G, Ríos L, et al. Refractory nonconvulsive status epilepticus responsive to music as an add-on therapy: a second case. Epilepsy Behav 2010; 19:539–540.
63. Rektor I, Schachter SC, Arzy S, et al. Epilepsy, behavior, and art (epilepsy, brain, and mind, part 1). Epilepsy Behav 2013; 28:261–282.
64. Schachter SC. Epilepsy and art: windows into complexity and comorbidities. Epilepsy Behav 2016; 57:265–269.
65. Akhan LU, Kurtuncu M, Celik S. The effect of art therapy with clay on hopelessness levels among neurology patients. Rehabil Nurs 2017; 42:39–45.
66. Stafstrom CE, Havlena J, Krezinski AJ. Art therapy focus groups for children and adolescents with epilepsy. Epilepsy Behav 2012; 24:227–233.
67. https://www.ahrq.gov/professionals/prevention-chronic-care/improve/self-mgmt/index.html. [Accessed 12 December 2018]
68. Bradley PM, Lindsay B, Fleeman N. Care delivery and self-management strategies for adults with epilepsy. Cochrane Database Syst Rev 2016. 2Art. No.: CD006244.
69. Streltzov N, Schimdt S, Zhao W, et al. Improving quality of life in epilepsy: replication and generalizability of an epilepsy self-management and cognitive training program (HOBSCOTCH). Neurology Apr 2017; 88 (16 Supplement): S55.003.
70▪. Sajatovic M, Colon-Zimmermann K, Kahriman M, et al. A 6-month prospective randomized controlled trial of remotely delivered group format epilepsy self-management versus waitlist control for high-risk people with epilepsy. Epilepsia 2018; 59:1684–1695.

Large randomized participatory developed trial of epilepsy self-management delivered in 8 group format sessions. Participants in the active arm had fewer negative health events and improvements in multiple QOL instruments.

Keywords:

behavioral intervention; epilepsy; mind–body; self-management; stress reduction

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