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Skin conductance biofeedback training in adults with drug-resistant temporal lobe epilepsy and stress-triggered seizures: A proof-of-concept study

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... The first fully randomized controlled trial of structured GSR biofeedback training in patients with drug-resistant epilepsy elicited a reduction in seizure frequency of 50% or more in 60% of patients allocated to the active therapy group (Nagai et al., 2004b). In parallel to our current work, the efficacy of GSR biofeedback is supported by findings of recent independent studies, drawing from our group's earlier published works (Micoulaud-Franchi et al., 2014;Kotwas et al., 2017). The clinical benefit of GSR biofeedback therapy can persist over time: a subset of patients who kept over four years of seizure records demonstrated no apparent re-increase after N50% seizure reduction (Nagai and Trimble, 2014). ...
... After a month of autonomic biofeedback therapy, 45% of these patients reported seizure reduction of N 50%. These results are similar to those of the previous single-blinded sham-controlled RCT (Nagai et al., 2004b) and independent studies with open label (Micoulaud-Franchi et al., 2014) and case control study (Kotwas et al., 2017). ...
... Our findings reinforce the accumulating independent evidence supporting the effectiveness of autonomic biofeedback therapy in reducing the frequency of epileptic seizures (Nagai et al., 2004b;Nagai and Trimble, 2014;Micoulaud-Franchi et al., 2014;Kotwas et al., 2017). Moreover, our study extends the theoretical and neuroscientific understanding of body-brain interactions relevant to epilepsy management, by providing fresh empirical data regarding the neural mechanisms through which autonomic biofeedback training may promote seizure reduction. ...
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Background: Thirty-percent of patients with epilepsy are drug-resistant, and might benefit from effective noninvasive therapeutic interventions. Evidence is accumulating on the efficacy of autonomic biofeedback therapy using galvanic skin response (GSR; an index of sympathetic arousal) in treating epileptic seizures. This study aimed to extend previous controlled clinical trials of autonomic biofeedback therapy with a larger homogeneous sample of patients with temporal lobe epilepsy. In addition, we used neuroimaging to characterize neural mechanisms of change in seizure frequency following the therapy. Methods: Forty patients with drug-resistant temporal lobe epilepsy (TLE) (age: 18 to 70years old), on stable doses of anti-epileptic medication, were recruited into a controlled and parallel-group trial from three screening centers in the UK. Patients were allocated to either an active intervention group, who received therapy with GSR biofeedback, or a control group, who received treatment as usual. Allocation to the group was informed, in part, by whether patients could travel to attend repeated therapy sessions (non-randomized). Measurement of outcomes was undertaken by an assessor blinded to the patients' group membership. Resting-state functional and structural MRI data were acquired before and after one month of therapy in the therapy group, and before and after a one-month interval in the control group. The percentage change of seizure frequency was the primary outcome measure. The analysis employed an intention-to-treat principle. The secondary outcome was the change in default mode network (DMN) and limbic network functional connectivity tested for effects of therapy. The trial was registered with the National Institute for Health Research (NIHR) portfolio (ID 15967). Findings: Data were acquired between May 2014 and October 2016. Twenty participants were assigned to each group. Two patients in the control group dropped out before the second scan, leaving 18 control participants. There was a significant difference in reduction of seizure frequency between the therapy and control groups (p<0.001: Mann Whitney U Test). The seizure frequency in the therapy group was significantly reduced (p<0.001: Wilcoxon Signed Rank Test) following GSR biofeedback, with a mean seizure reduction of 43% (SD=± 32.12, median=-37.26, 95% CI -58.02% to -27.96%). No significant seizure reduction was observed in the control group, with a mean increase in seizure frequency of 31% (SD=±88.27, median=0, 95% CI -12.83% to 74.96%). The effect size of group comparison was 1.14 (95% CI 0.44 to 1.82). 45% of patients in the therapy group showed a seizure reduction of >50%. Neuroimaging analysis revealed that post-therapy seizure reduction was linearly correlated with enhanced functional connectivity between right amygdala and both the orbitofrontal cortex (OFC) and frontal pole (FP). Interpretation: Our clinical study provides evidence for autonomic biofeedback therapy as an effective and potent behavioral intervention for patients with drug-resistant epilepsy. This approach is non-pharmacological, non-invasive and seemingly side-effect free.
... Nevertheless, this study demonstrated a significant reduction in seizure frequency with a response rate of 60% controlling for non-specific effects of therapist contact. The efficacy of GSR biofeedback has since been replicated in three studies (11)(12)(13). ...
... The degree of the functional connectivity changes was related to the reduction of patients' seizure frequency, such that patients who achieved greater right amygdala-OFC functional connectivity demonstrated a larger reduction in seizure frequency after 1 month of GSR biofeedback training. Psychological outcomes (reductions in anxiety and depression) did not account for either the seizure reduction (11)(12)(13), or functional connectivity changes (13). This indicates that changes in mental health states (such as anxiety and depression) are not necessarily direct contributing factors in reducing seizures. ...
... All studies investigated adult patients with drug resistant epilepsy (failure to respond to at least two appropriate anti-epileptic drugs). Three of the four studies focused on patients with temporal lobe epilepsy (TLE) (11)(12)(13). The average age of patients were similar, with slight differences reflecting differences in the age inclusion criteria. ...
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Objectives: Dynamic changes in psychophysiological arousal are directly expressed in the sympathetic innervation of the skin. This activity can be measured as tonic and phasic fluctuations in electrodermal activity [Galvanic Skin Response (GSR)/skin conductance]. Biofeedback training can enable an individual to gain voluntary control over this autonomic response and its central correlates. Theoretically, control of psychophysiological arousal may be harnessed as a therapy for epilepsy, to mitigate pre-ictal states. Evidence is accumulating for the clinical efficacy of GSR biofeedback training in the management of drug resistant epilepsy. In this review, we analyse current evidence of efficacy with GSR biofeedback and evaluate the methodology of each study. Method: We searched published literature pertaining to interventional studies of GSR biofeedback for epilepsy, through MEDLINE and Cochrane databases (1950–2018). Using percentage seizure reduction as an indicator of therapeutic efficacy induced by GSR biofeedback, we used meta-analytic methods to summarize extant findings. We also compare and contrast study design with relevance to the interpretation of outcomes. Results: Out of 21 articles retrieved for GSR/EDA/Skin conductance biofeedback, four studies were identified as interventional trials, involving 99 patients with drug-resistant epilepsy in total. Three of these studies included a control group and a positive therapeutic effect of biofeedback was reported in each of these. The difference in seizure frequency percentage (Biofeedback—Control) was between −54.4 and −74.0% with an overall weighted mean difference of −64.3% (95% CI: −85.4 to −43.2%). The response rates (proportion of patients manifesting >50% reduction in seizure frequency) varied from 45 to 66% across studies. Significance: This timely evaluation highlights the potential value of GSR biofeedback therapy, and informs the optimal study design of larger scale studies that are now required to more definitively establish the utility of this non-invasive, non-pharmacological interventional approach for drug-resistant epilepsy.
... The first, concerning seizure frequency, skin conductance is related to peripheral sympathetic nervous activity fluctuation that can be considered as a relevant physiological target for the nonpharmacological management of epilepsy (Kotwas et al., 2015). Two previous studies with small samples showed a mean reduction of about 50% of seizures in respectively 10 (Nagai et al., 2004b), and 11 patients with TLE and stresstriggered seizures (Micoulaud-Franchi et al., 2014) after 12 sessions. The second concerns psychiatric comorbidities. ...
... The second concerns psychiatric comorbidities. Micoulaud-Franchi et al. (2014) found significant reduction of depressive symptoms and perception of negative affects after treatment that were independent of reduced seizure frequency. Biofeedback is a method involving cognitive, mainly attentional, control strategies. ...
... Material and sessions protocol were the same as used by (Micoulaud-Franchi et al., 2014). ...
Article
This study investigates the physiological basis of effects of skin conductance biofeedback on anxiety disorders, depressive disorders and stress in drug-resistant temporal lobe epilepsy (TLE). This method presents an interest in seizure reduction and improvement in psychiatric comorbidities frequently associated with TLE. Our goal was to better understand the impact of biofeedback on seizure control and on emotional regulation. Fifteen patients with TLE were treated with 12 skin conductance biofeedback sessions and compared with 15 control TLE patients on a waiting list. They were evaluated in terms of seizure frequency, clinical evaluations of anxiety and depression and skin conductance responses (SCR) to five emotions: fear, disgust, sadness, happiness and peacefulness induced by short films. Biofeedback training significantly reduced seizure frequency with a mean reduction of -47.42% in the biofeedback group, while the control group did not differ at the two time measures. A significant improvement was found for depression and trait-anxiety in the biofeedback group but not in the control group. There were no differences on SCR on any emotion after biofeedback treatment. A correlation was found between mean change in SCR over the biofeedback treatment and the reduction of seizure frequency, but not between SCR changes and scores on psychiatric comorbidities. These results show independent effect of biofeedback on mood and seizure control. Improvements in anxiety and depressive symptoms were not related to SCR, whereas improved seizure control was, suggesting differential mechanisms underlying these two phenomena.
... Moreover, there was a positive correlation between reduction in seizure frequency and degree of patients' improvement in EDA over BFK sessions. Similar results, associated with a positive effect on psychometric evaluation of depression and negative affects, have been reported in patients with stress-triggered seizures (the "emotional vulnerability" group of patients with TLE identified by Lanteaume et al.) [79], suggesting an additional positive effect of this method on well-being. This improvement in well-being could be explained by an effect of increased self-efficacy and PSC since patients could learn to inhibit their seizures to some degree using their own strategies. ...
... Using different methods within an adequate time window may be very helpful for patients in the management of their disease. For example, strategies learned in biofeedback sessions seem to be effective for seizure onset control [75,79]. These strategies could be particularly effective when applied during preictal periods. ...
Article
Despite the unpredictability of epileptic seizures, many patients report that they can anticipate seizure occurrence. Using certain alert symptoms (i.e., auras, prodromes, precipitant factors), patients can adopt behaviors to avoid injury during and after the seizure or may implement spontaneous cognitive and emotional strategies to try to control the seizure itself. From the patient's view point, potential means of enhancing seizure prediction and developing seizure control supports are seen as very important issues, especially when the epilepsy is drug-resistant. In this review, we first describe how some patients anticipate their seizures and whether this is effective in terms of seizure prediction. Secondly, we examine how these anticipatory elements might help patients to prevent or control their seizures and how the patient's neuropsychological profile, specifically parameters of perceived self-control (PSC) and locus of control (LOC), might impact these strategies and quality of life (QOL). Thirdly, we review the external supports that can help patients to better predict seizures. Finally, we look at nonpharmacological means of increasing perceived self-control and achieving potential reduction of seizure frequency (i.e., stress-based and arousal-based strategies). In the past few years, various approaches for detection and control of seizures have gained greater interest, but more research is needed to confirm a positive effect on seizure frequency as well as on QOL.
... While the first group have great potential in chronic stress management, the second group may be more relevant for managing stress reflex responses (Table 3). All appear to have an effect on both patient well-being and seizure control [140][141][142]. All these methods are based on the observation of one's own mental state and physical activities, using attention training and process-oriented awareness. ...
... In addition to a mean reduction of seizures of about 50% with a positive correlation between reduction in seizure frequency and degree of patients' improvement in EDA over biofeedback sessions [164] a positive effect on psychometric evaluation of depression and negative affect has been reported in patients with stress-triggered seizures [140]. These results suggest an additional positive effect of this method on well-being. ...
Article
The prevalence of psychological distress, especially depressive and anxiety disorders, is higher in epilepsy than in other chronic health conditions. These comorbid conditions contribute even more than epileptic seizures themselves to impaired quality of life in patients with epilepsy (PWE). The link between these comorbidities and epilepsy appears to have a neurobiological basis, which is at least partly mediated by stress through psychological and pathophysiological pathways. The impact of stress in PWE is also particularly important because it is the most frequently reported seizure trigger. It is therefore crucial for clinicians to take stress-related conditions and psychiatric comorbidities into account when managing PWE and to propose clinical support to enhance self-control of stress. Screening tools have been specially designed and validated in PWE for depressive disorders and anxiety disorders (e.g. NDDI-E, GAD-7). Other instruments are useful for measuring stress-related variables (e.g. SRRS, PSS, SCS, MHLCS, DSR-15, ERP-R, QOLIE-31) in order to help characterize the individual "stress profile" and thus orientate patients towards the most appropriate treatment. Management includes both pharmacological treatment and nonpharmacological methods for enhancing self-management of stress (e.g. mindfulness-based therapies, yoga, cognitive-behavioral therapies, biofeedback), which may not only protect against psychiatric comorbidities but also reduce seizure frequency.
... Micoulaud-Franchi et al. [48] replicated the methods of Nagai et al. [45] in 11 adults with drug-resistant, stressactivated temporal lobe epilepsy (TLE). The authors assessed skin conductance with visual biofeedback in an effort to increase levels of peripheral sympathetic arousal and reduce cortical excitability, and patients were encouraged to practice these self-regulation skills in seizure-prone situations. ...
... The advantages of using a GSR target include an increase in patient self-control and compared to some other types of biofeedback, easy operation of equipment, lesser expense, and the targeting of a specific relevant physiological activity [48]. The literature in this area seems to be contradictory, however, and the direction of the association between GSR and seizure threshold is not always clear [50]. ...
Article
Full-text available
Purpose of review: Cognitive and behavioral treatments for epilepsy offer several advantages, as they are relatively low cost, are non-invasive, lack serious side effects, and facilitate patient participation. Their role in the management of epilepsy, however, is unclear. The following manuscript will critically review the efficacy data regarding psychological treatments for seizure reduction. Recent findings: Encouraging results have been found for the cognitive behavioral therapy-based Reiter/Andrews approach and mindfulness or arousal-based programs (e.g., yoga, meditation, relaxation, and biofeedback). Most studies attained responder rates between 45 and 90%. Cognitive and behavioral interventions may be considered as low-risk adjuncts to standard therapies. Efficacy data are limited, however, by small numbers of subjects, inadequate randomization, controls, and blinding, brief trial durations, varying methodologies, and variability in the presentation of results. Additional clinical trials are warranted.
... While the first group have great potential in chronic stress management, the second group may be more relevant for managing stress reflex responses (Table 3). All appear to have an effect on both patient well-being and seizure control [140][141][142]. All these methods are based on the observation of one's own mental state and physical activities, using attention training and process-oriented awareness. ...
... In addition to a mean reduction of seizures of about 50% with a positive correlation between reduction in seizure frequency and degree of patients' improvement in EDA over biofeedback sessions [164] a positive effect on psychometric evaluation of depression and negative affect has been reported in patients with stress-triggered seizures [140]. These results suggest an additional positive effect of this method on well-being. ...
Article
The prevalence of psychological distress, especially depressive and anxiety disorders, is higher in epilepsy than in other chronic health conditions. These comorbid conditions contribute even more than epileptic seizures themselves to impaired quality of life in patients with epilepsy (PWE). The link between these comorbidities and epilepsy appears to have a neurobiological basis, which is at least partly mediated by stress through psychological and pathophysiological pathways. The impact of stress in PWE is also particularly important because it is the most frequently reported seizure trigger. It is therefore crucial for clinicians to take stress-related conditions and psychiatric comorbidities into account when managing PWE and to propose clinical support to enhance self-control of stress. Screening tools have been specially designed and validated in PWE for depressive disorders and anxiety disorders (e.g. NDDI-E, GAD-7). Other instruments are useful for measuring stress-related variables (e.g. SRRS, PSS, SCS, MHLCS, DSR-15, ERP-R, QOLIE-31) in order to help characterize the individual “stress profile” and thus orientate patients towards the most appropriate treatment. Management includes both pharmacological treatment and nonpharmacological methods for enhancing self-management of stress (e.g. mindfulness-based therapies, yoga, cognitive-behavioral therapies, biofeedback), which may not only protect against psychiatric comorbidities but also reduce seizure frequency.
... Moreover, there was a positive correlation between reduction in seizure frequency and degree of patients' improvement in EDA over BFK sessions. Similar results, associated with a positive effect on psychometric evaluation of depression and negative affects, have been reported in patients with stress-triggered seizures (the "emotional vulnerability" group of patients with TLE identified by Lanteaume et al.) [79], suggesting an additional positive effect of this method on well-being. This improvement in well-being could be explained by an effect of increased self-efficacy and PSC since patients could learn to inhibit their seizures to some degree using their own strategies. ...
... Using different methods within an adequate time window may be very helpful for patients in the management of their disease. For example, strategies learned in biofeedback sessions seem to be effective for seizure onset control [75,79]. These strategies could be particularly effective when applied during preictal periods. ...
Article
Full-text available
Despite the unpredictability of epileptic seizures, many patients report that they can anticipate seizure occurrence. Using certain alert symptoms (i.e., auras, prodromes, precipitant factors), patients can adopt behaviors to avoid injury during and after the seizure or may implement spontaneous cognitive and emotional strategies to try to control the seizure itself. From the patient's view point, potential means of enhancing seizure prediction and developing seizure control supports are seen as very important issues, especially when the epilepsy is drug-resistant. In this review, we first describe how some patients anticipate their seizures and whether this is effective in terms of seizure prediction. Secondly, we examine how these anticipatory elements might help patients to prevent or control their seizures and how the patient's neuropsychological profile, specifically parameters of perceived self-control (PSC) and locus of control (LOC), might impact these strategies and quality of life (QOL). Thirdly, we review the external supports that can help patients to better predict seizures. Finally, we look at nonpharmacological means of increasing perceived self-control and achieving potential reduction of seizure frequency (i.e., stress-based and arousal-based strategies). In the past few years, various approaches for detection and control of seizures have gained greater interest, but more research is needed to confirm a positive effect on seizure frequency as well as on QOL.
... Varying body temperature causes changes in skin resistance due to a momentary boost in the conductance of skin that is proportional to sweat discharge (Healey and Picard 2005). The galvanic skin response (GSR) provides an electrical measure of skin resistance by measuring the difference in skin conductance between two body parts (Micoulaud-Franchi et al. 2014). There are two types of GSR measurement: endosomatic and exosomatic. ...
Article
Full-text available
Complaints of stress are common in modern life. Psychological stress is a major cause of lifestyle-related issues, contributing to poor quality of life. Chronic stress impedes brain function, causing impairment of many executive functions, including working memory, decision making and attentional control. The current study sought to describe newly developed stress mitigation techniques, and their influence on autonomic and endocrine functions. The literature search revealed that the most frequently studied technique for stress mitigation was biofeedback (BFB). However, evidence suggests that neurofeedback (NFB) and noninvasive brain stimulation (NIBS) could potentially provide appropriate approaches. We found that recent studies of BFB methods have typically used measures of heart rate variability, respiration and skin conductance. In contrast, studies of NFB methods have typically utilized neurocomputation techniques employing electroencephalography, functional magnetic resonance imaging and near infrared spectroscopy. NIBS studies have typically utilized transcranial direct current stimulation methods. Mitigation of stress is a challenging but important research target for improving quality of life.
... Among these, Biofeedback (BFK) represents a noninvasive biobehavioral treatment that enables a patient to gain volitional control over a specific physiological process. BFK has already shown its value when applied to patients with epilepsy (Sterman and Friar, 1972; Rockstroh et al., 1993; Nagai et al., 2004a; Nagai, 2011; Micoulaud-Franchi et al., 2014a,b). Scrimali et al. (2015) have rightly pointed out the potential usefulness of electrodermal biofeedback in the management of refractory epilepsy. ...
... Biofeedback detects and presents physiological signals such as heart rate, respiration, muscle activity, or skin temperature from the user's body, and by making users aware of these signals, helps them to gain control over them (Schwartz et al., 2008;Micoulaud-Franchi et al., 2014). The concept has demonstrated value for stress reduction in studies on stress management for hospital nurses (Cutshall et al., 2011) and for veterans suffering with Post Traumatic Stress Disorder after 9/11 (Reyes, 2014). ...
Article
Full-text available
Introduction: Stress is one of the leading global causes of disease and premature mortality. Despite this, interventions aimed at reducing stress have low adherence rates. The proliferation of mobile phone devices along with gaming-style applications allows for a unique opportunity to broaden the reach and appeal of stress-reduction interventions in modern society. We assessed the effectiveness of two smartphone applications games combined with biofeedback in reducing stress. Methods: We compared a control game to gaming-style smartphone applications combined with a skin conductance biofeedback device (the Pip). Fifty participants aged between 18 and 35 completed the Trier Social Stress Test. They were then randomly assigned to the intervention (biofeedback game) or control group (a non-biofeedback game) for thirty minutes. Perceived stress, heart rate and mood were measured before and after participants had played the games. Results: A mixed factorial ANOVA showed a significant interaction between time and game type in predicting perceived stress [F(1,48) = 14.19, p < 0.001]. Participants in the biofeedback intervention had significantly reduced stress compared to the control group. There was also a significant interaction between time and game in predicting heart rate [F(1,48) = 6.41, p < 0.05]. Participants in the biofeedback intervention showed significant reductions in heart rate compared to the control group. Discussion: This illustrates the potential for gaming-style smartphone applications combined with biofeedback as stress reduction interventions.
... In line with EEG NF, a biofeedback technique focusing on skin conductance was recently studied in a randomized blind trial, confirming the effectiveness of this technique, with approximately 50% reduction in seizure frequency [69]. This method was also effective in treating a subgroup of patients with pharmacoresistant temporal lobe epilepsy whose seizures were triggered by stress [67]. This last study is indeed of interest in its study of a specific subgroup of epilepsy patients, since very heterogeneous populations in terms of epilepsy type and severity tend to characterize previous EEG NF studies. ...
Article
The technique of electroencephalographic neurofeedback (EEG NF) emerged in the 1970s and is a technique that measures a subject's EEG signal, processes it in real time, extracts a parameter of interest and presents this information in visual or auditory form. The goal is to effectuate a behavioural modification by modulating brain activity. The EEG NF opens new therapeutic possibilities in the fields of psychiatry and neurology. However, the development of EEG NF in clinical practice requires (i) a good level of evidence of therapeutic efficacy of this technique, (ii) a good practice guide for this technique. Firstly, this article investigates selected trials with the following criteria: study design with controlled, randomized, and open or blind protocol, primary endpoint related to the mental and brain disorders treated and assessed with standardized measurement tools, identifiable EEG neurophysiological targets, underpinned by pathophysiological relevance. Trials were found for: epilepsies, migraine, stroke, chronic insomnia, attentional-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, major depressive disorder, anxiety disorders, addictive disorders, psychotic disorders. Secondly, this article investigates the principles of neurofeedback therapy in line with learning theory. Different underlying therapeutic models are presented didactically between two continua: a continuum between implicit and explicit learning and a continuum between the biomedical model (centred on "the disease") and integrative biopsychosocial model of health (centred on "the illness"). The main relevant learning model is to link neurofeedback therapy with the field of cognitive remediation techniques. The methodological specificity of neurofeedback is to be guided by biologically relevant neurophysiological parameters. Guidelines for good clinical practice of EEG NF concerning technical issues of electrophysiology and of learning are suggested. These require validation by institutional structures for the clinical practice of EEG NF.
... Different treatments have been used to attempt to target stress and reduce seizures. Interventions targeting psychological change, education, and self-management skills have been used [52][53][54][55][56][57][58][59][60][61][62][63][64][65]. A recent review article evaluated psychobehavioral therapies in improving seizure control [52]. ...
Article
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Stress is a common and important seizure precipitant reported by epilepsy patients. Studies to date have used different methodologies to identify relationships between epilepsy and stress. Several studies have identified anxiety, depression, and childhood trauma as being more common in patients with epilepsy who report stress as a seizure precipitant compared to patients with epilepsy who did not identify stress as a seizure precipitant. In one survey study it was found that a majority of patients with stress-triggered seizures had used some type of stress reduction method on their own and, of those who tried this, an even larger majority felt that these methods improved their seizures. Additionally, small to moderate sized prospective trials, including randomized clinical trials, using general stress reduction methods have shown promise in improving outcomes in patients with epilepsy, but results on seizure frequency have been inconsistent. Based on these studies, we recommend that when clinicians encounter patients who report stress as a seizure precipitant, these patients should be screened for a treatable mood disorder. Furthermore, although seizure reduction with stress reduction methods has not been proven in a randomized controlled trial, other important endpoints like quality of life were improved. Therefore, recommending stress reduction methods to patients with epilepsy appears to be a reasonable low risk adjunctive to standard treatments. The current review highlights the need for future research to help further clarify biological mechanisms of the stress-seizure relationship and emphasizes the need for larger randomized controlled trials to help develop evidence based treatment recommendations for our epilepsy patients.
... This observed effect of EDA biofeedback was sustainable: a subset of patients voluntarily kept a seizure diary for a much longer term (over 3 years after treatment) and these records suggesting that the treatment may prompt long term neurobiological changes that maintain efficacy in seizure control (Nagai and Trimble, 2014). The clinical trial findings were recently replicated and showed similar results to the initial clinical trial (Micoulaud-Franchi et al., 2014). ...
Article
Full-text available
This manuscript considers the central but neglected role of the autonomic nervous system in the expression and control of seizures in Epilepsy and tics in Tourette Syndrome (TS). In epilepsy, consideration of autonomic involvement is typically confined to differential diagnoses (e.g. syncope), or in relation to Sudden Unexpected Death in Epilepsy (SUDEP). Investigation is more limited in Tourette Syndrome. The role of the autonomic nervous system in the generation and prevention of epileptic seizures is largely overlooked. Emotional stimuli such as anxiety and stress are potent causes of seizures and tic activity in Epilepsy and TS, respectively. This manuscript will describe a possible neural mechanism by which afferent autonomic projections linked to cognition and behaviour influence central nervous system thalamo-cortical regulation, which appears to be an important means for controlling both seizure and tic activity. It also summarizes the link between the integrity of the default mode network and autonomic regulation in patients with epilepsy as well as the link between impaired motor control and autonomic regulation in patients with TS. Two neurological conditions; epilepsy and TS were chosen, as seizures and tics represent parameters that can be easily measured to investigate influences of autonomic functions. The EDA biofeedback approach is anticipated to gain a strong position within the next generation of treatment for epilepsy, as a non-invasive technique with minimal side effects. This approach also takes advantage of the current practical opportunity to utilize growing digital health technology.
... 41 Finally, a seizure detector incorporating EDA could be suitable for other important applications, such as identifying triggering factors reflected in autonomic activations (e.g., stress or deep sleep) or using EDA biofeedback for training patients to prevent epileptic seizures. 42 ...
Article
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Objective: New devices are needed for monitoring seizures, especially those associated with sudden unexpected death in epilepsy (SUDEP). They must be unobtrusive and automated, and provide false alarm rates (FARs) bearable in everyday life. This study quantifies the performance of new multimodal wrist-worn convulsive seizure detectors. Methods: Hand-annotated video-electroencephalographic seizure events were collected from 69 patients at six clinical sites. Three different wristbands were used to record electrodermal activity (EDA) and accelerometer (ACM) signals, obtaining 5,928 h of data, including 55 convulsive epileptic seizures (six focal tonic-clonic seizures and 49 focal to bilateral tonic-clonic seizures) from 22 patients. Recordings were analyzed offline to train and test two new machine learning classifiers and a published classifier based on EDA and ACM. Moreover, wristband data were analyzed to estimate seizure-motion duration and autonomic responses. Results: The two novel classifiers consistently outperformed the previous detector. The most efficient (Classifier III) yielded sensitivity of 94.55%, and an FAR of 0.2 events/day. No nocturnal seizures were missed. Most patients had <1 false alarm every 4 days, with an FAR below their seizure frequency. When increasing the sensitivity to 100% (no missed seizures), the FAR is up to 13 times lower than with the previous detector. Furthermore, all detections occurred before the seizure ended, providing reasonable latency (median = 29.3 s, range = 14.8-151 s). Automatically estimated seizure durations were correlated with true durations, enabling reliable annotations. Finally, EDA measurements confirmed the presence of postictal autonomic dysfunction, exhibiting a significant rise in 73% of the convulsive seizures. Significance: The proposed multimodal wrist-worn convulsive seizure detectors provide seizure counts that are more accurate than previous automated detectors and typical patient self-reports, while maintaining a tolerable FAR for ambulatory monitoring. Furthermore, the multimodal system provides an objective description of motor behavior and autonomic dysfunction, aimed at enriching seizure characterization, with potential utility for SUDEP warning.
... The clinical effectiveness of this EDA biofeedback protocol has already been demonstrated in people with intractable epilepsy, with mean seizure reduction rates of around 50% as well as responder rates (subjects having ≥50% seizure reduction) of approximately 50% after 12 sessions of EDA biofeedback (Nagai et al., 2004c(Nagai et al., , 2018Micoulaud-Franchi et al., 2014;Kotwas et al., 2018). Furthermore, the aforementioned studies reported positive correlations between the increase in EDA over the biofeedback sessions and the extent of seizure reduction. ...
Article
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There is evidence that biofeedback of electrodermal activity (EDA) can reduce seizure frequency in people with epilepsy. Prior studies have linked EDA biofeedback to a diffuse brain activation as a potential functional mechanism. Here, we investigated whether short-term EDA biofeedback alters EEG-derived large-scale functional brain networks in people with epilepsy. In this prospective controlled trial, thirty participants were quasi-randomly assigned to one of three biofeedback conditions (arousal, sham, or relaxation) and performed a single, 30-min biofeedback training while undergoing continuous EEG recordings. Based on the EEG, we derived evolving functional brain networks and examined their topological, robustness, and stability properties over time. Potential effects on attentional-executive functions and mood were monitored via a neuropsychological assessment and subjective self-ratings. Participants assigned to the relaxation group seemed to be most successful in meeting the task requirements for this specific control condition (i.e., decreasing EDA). Participants in the sham group were more successful in increasing EDA than participants in the arousal group. However, only the arousal biofeedback training was associated with a prolonged robustness-enhancing effect on networks. Effects on other network properties were mostly unspecific for the different groups. None of the biofeedback conditions affected attentional-executive functions or subjective behavioral measures. Our results suggest that global characteristics of evolving functional brain networks are modified by EDA biofeedback. Some alterations persisted after the single training session; however, the effects were largely unspecific across the different biofeedback protocols. Further research should address changes of local network characteristics and whether multiple training sessions will result in more specific network modifications.
... Novel frameworks are under investigation to improve processing of EDA signals [34]. There are also suggestions to utilize EDA signals in closed-loop biofeedback training, which may have the potential to reduce seizure frequency in patients with temporal seizures [35,36]. ...
Article
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Purpose: Status epilepticus is an often apparently randomly occurring, life-threatening medical emergency which affects the quality of life in patients with epilepsy and their families. The purpose of this review is to summarize information on ambulatory seizure detection, seizure prediction, and status epilepticus prevention. Method: Narrative review. Results: Seizure detection devices are currently under investigation with regards to utility and feasibility in the detection of isolated seizures, mainly in adult patients with generalized tonic-clonic seizures, in long-term epilepsy monitoring units, and occasionally in the outpatient setting. Detection modalities include accelerometry, electrocardiogram, electrodermal activity, electroencephalogram, mattress sensors, surface electromyography, video detection systems, gyroscope, peripheral temperature, photoplethysmography, and respiratory sensors, among others. Initial detection results are promising, and improve even further, when several modalities are combined. Some portable devices have already been U.S. FDA approved to detect specific seizures. Improved seizure prediction may be attainable in the future given that epileptic seizure occurrence follows complex patient-specific non-random patterns. The combination of multimodal monitoring devices, big data sets, and machine learning may enhance patient-specific detection and predictive algorithms. The integration of these technological advances and novel approaches into closed-loop warning and treatment systems in the ambulatory setting may help detect seizures sooner, and tentatively prevent status epilepticus in the future. Conclusions: Ambulatory monitoring systems are being developed to improve seizure detection and the quality of life in patients with epilepsy and their families.
... However, while some participants repeatedly exhibit strong dilations, others achieve no or only marginal differences from baseline mean. Be that as it may, in the past, such a biofeedback approach has been successfully applied to control various physiological parameters like cardiac activity [Sakakibara et al. 1994] or skin conductance changes [Micoulaud-Franchi et al. 2014]. ...
Conference Paper
Physiological responses are generally involuntary; however, real-time feedback enables, at least to a certain extent, to voluntary control automatic processes. Recently, it was demonstrated that even pupil dilation is subject to controlled interference. To address effects of training on the ability to exercise control on pupil dilation, the current study examines repeated exercise over seven successive days. Participants utilize self-induced changes in arousal to increase pupil diameter, real-time feedback was applied to evaluate and improve individual performance. We observe inter-individual differences with regard to responsiveness of the pupillary response: six of eight participants considerably increase pupil diameter already during the first session, two exhibit only slight changes, and all showed rather stable performance throughout training. There was a trend towards stronger peak amplitudes that tend to occur increasingly early across time. Hence, higher cognitive control on pupil dilations can be practiced by most users and may therefore provide an appropriate input mechanism in human-computer interaction.
... Further studies are needed to better understand emotional processing and regulation in these patients, in order to better orientate therapeutic approaches to the frequently associated psychiatric comorbidity. Management by SCR biofeedback has already shown some efficacy on these comorbidities in patients with TLE and stress-sensitivity (Micoulaud-Franchi et al., 2014). Insofar as this approach aims to increase skin conductance over sessions in order to reduce the seizure onset, this increase could also underlie its efficacy on depressive and anxiety disorders. ...
Article
Background:: Temporal lobe epilepsy (TLE) and psychogenic non-epileptic seizures (PNES) are conditions frequently associated with dysfunction in emotional regulation leading to increased risk of affective disorders. This study investigates emotional processing with an objective measure of emotional reactivity in patients with TLE and patients with PNES. Methods:: 34 patients with TLE and 14 patients with PNES were evaluated on skin conductance responses (SCR) to emotions induced by short films and compared to 34 healthy controls. An attention and a suppression condition were performed while viewing the films. Results:: The both groups of patients disclosed lower SCR to emotions compared to controls, mainly in suppression condition. While TLE patients had lower SCR in attention condition than controls for fear, sadness and happiness, PNES had lower SCR only for happiness. In suppression condition, both had lower SCR than controls except for peacefulness in both groups and sadness in PNES. Subjective evaluations revealed that both patient's groups scored a higher intensity for sadness than controls in attention and lower for in fear and disgust in suppression only in TLE. Limitations:: The sample size in the PNES group and the lack of a control group with similar levels of mood symptoms limited the interpretation of our results. Conclusion:: As no correlation were found between SCR to emotions and scores of affective disorders, this pattern of responses might be underpinned by specific pathophysiological and cognitive mechanisms related to TLE and to PNES. Thus, therapeutic approaches targeting emotional autonomic responses can be of interest in the management of these conditions.
... Stress is a commonly reported seizure precipitant in patients with epilepsy [1,2]. Stress is a complex phenomenon, but can be defined in terms of its biological, environmental, and psychological aspects, whereby external demands exceed adaptive capacity [3]. Trials of stress reduction in epilepsy have been reported with mixed results, but most of these studies have been uncontrolled [4]. ...
... Derived from operant conditioning approaches using positive physiologic reinforcement, neurofeedback and biofeedback methods are noninvasive bio-behavioral technique providing control strategies to regulate physiological activity, aimed at reducing acute anxiety and/or seizures. Applied to epilepsy, neurofeedback targeting SCP [33] and skin conductance (SC) biofeedback have shown clinical value in reduction of seizures and psychiatric comorbidity [66,67]. Neurophysiological mechanisms are unknown. ...
Article
Full-text available
Purpose of Review The current review aims at providing an overview of relevant aspects of anxiety symptoms and anxiety disorders (AD) in adults patients with epilepsy (PWE). Recent Findings Firstly, the appropriate diagnosis of type of anxiety symptoms and AD in PWE will be presented. Anxiety symptoms are often peri-ictal and classified in relation to their temporal occurrence to seizures. Anxiety symptoms are of three types: preictal (preceding a seizure), ictal (presenting as part of the seizure symptoms and signs), and postictal (occurring within 72 h of a seizure). AD are diagnosed in the interictal period and occur independently of seizures. Four specific AD in PWE can be objectified: anticipatory anxiety of epileptic seizures (AAS), seizure phobia, epileptic social phobia, and epileptic panic disorder. Secondly, the bidirectional pathophysiological relationship between anxiety and epilepsy will be described. Anxiety is a trigger for seizures in some patients, and the notion of stress and arousal is essential to understand the relationship between anxiety and seizure. Moreover, seizures arising from the limbic network especially involving amygdala, which may express fear-related semiology, provide insight into the pathophysiology of AD comorbidities. Thirdly, the methods of screening for AD and anxiety symptoms will be detailed. Fourthly, the pharmacological and psychobehavioral management of anxiety symptoms and AD in PWE will be presented. Arousal-based approaches for preictal and ictal symptoms and anxiety-based approaches for postictal and interictal symptoms will be presented. Summary Despite lack of evidence-based approaches, it is recognized that management of epilepsy is not only about controlling seizures, but also depends heavily on detecting, correctly diagnosing, and appropriately managing anxiety symptoms and AD comorbidities, in order to maximize quality of life. Improving self-control and self-efficacy is of fundamental importance in the management of PWE. Further rigorously designed studies focusing on anxiety symptoms and AD are essential to improve the overall care of PWE.
... Thus, heart rate based biofeedback paradigms have the potential to enhance 'interoceptive exposure' in the management of anxiety disorders. There is evidence to support the notion that autonomic biofeedback training may also diminish symptoms in other patient groups with stress-sensitive neuropsychiatric and medical disorders, including epilepsy (Nagai et al., 2004a;Micoulaud-Franchi et al., 2014), tic disorder (Nagai et al., 2009) and cardiovascular disease (Moravec and McKee, 2011). There is therefore broader utility of biofeedback approaches in managing dissociative neuropsychiatric symptoms (Sedeño et al., 2014). ...
Article
Full-text available
The control of physiological arousal can assist in the regulation of emotional state. A subset cortical and subcortical brain regions are implicated in autonomic control of bodily arousal during emotional behaviours. Here, we combined human functional neuroimaging with autonomic monitoring to identify neural mechanisms that support the volitional regulation of heart rate, a process that may be assisted by visual feedback. During functional magnetic resonance imaging, fifteen healthy adults performed an experimental task in which they were prompted voluntarily to increase or decrease cardiovascular arousal (heart rate) during true, false or absent visual feedback. Participants achieved appropriate changes in heart rate, without significant modulation of respiratory rate, and were overall not influenced by the presence of visual feedback. Increased activity in right amygdala, striatum and brainstem occurred when participants attempted to increase heart rate. In contrast, activation of ventrolateral prefrontal and parietal cortices occurred when attempting to decrease heart rate. Biofeedback enhanced activity within occipito-temporal cortices, but there was no significant interaction with task conditions. Activity in regions including pregenual anterior cingulate and ventral striatum reflected the magnitude of successful task performance, which was negatively related to subclinical anxiety symptoms. Measured changes in respiration correlated with posterior insula activation and heart rate, at a more lenient threshold, change correlated with insula, caudate and midbrain activity. Our findings highlight a set of brain regions, notably ventrolateral prefrontal cortex, supporting volitional control of cardiovascular arousal. These data are relevant to understanding neural substrates supporting interaction between intentional and interoceptive states related to anxiety, with implications for biofeedback interventions, e.g. real-time fMRI, that target emotional regulation
... Derived from operant conditioning approaches using positive physiologic reinforcement, neurofeedback and biofeedback methods are non-invasive bio-behavioural technique providing control strategies to regulate physiological activity, aimed at reducing acute anxiety and/or seizures. Applied to epilepsy, neurofeedback targeting SCP [33] and skin conductance (SC) biofeedback has shown clinical value in reduction of seizures and psychiatric comorbidity [66,67]. Neurophysiological mechanisms are unknown. ...
Article
Purpose of Review: The current review aims at providing an overview of relevant aspects of anxiety symptoms and anxiety disorders (AD) in adults patients with epilepsy (PWE). Recent Findings: Firstly, the appropriate diagnosis of type of anxiety symptoms and AD in PWE will be presented. Anxiety symptoms are often peri-ictal and classified in relation to their temporal occurrence to seizures. Anxiety symptoms are of 3 types: pre-ictal (preceding a seizure), ictal (presenting as part of the seizure symptoms and signs), and postictal (occurring within 72 hours of a seizure). AD are diagnosed in the interictal period and occur independently of seizures. Four specific AD in PWE can be objectified: anticipatory anxiety of epileptic seizures (AAS), seizure phobia, epileptic social phobia, and epileptic panic disorder. Secondly, the bidirectional pathophysiological relationship between anxiety and epilepsy will be described. Anxiety is a trigger for seizures in some patients, and the notion of stress and arousal is essential to understand the relationship between anxiety and seizure. Moreover, seizures arising from the limbic network especially involving amygdala, which may express fear-related semiology, provide insight into the pathophysiology of AD comorbidities. Thirdly, the methods of screening for AD and anxiety symptoms will be detailed. Fourthly, the pharmacological and psychobehavioral management of anxiety symptoms and AD in PWE will be presented. Arousal based approaches for preictal and ictal symptoms and anxiety based approaches for postictal and interictal symptoms will be presented. Summary: Despite lack of evidence-based approaches, it is recognized that management of epilepsy is not only about controlling seizures, but also depends heavily on detecting, correctly diagnosing and appropriately managing anxiety symptoms and AD comorbidities, in order to maximize quality of life. Improving self-control and self-efficacy is of fundamental importance in the management of PWE. Further rigorously designed studies focusing on anxiety symptoms and AD are essential to improve the overall care of PWE.
... Further studies are needed to better understand emotional processing and regulation in these patients, in order to better orientate therapeutic approaches to the frequently associated psychiatric comorbidity. Management by SCR biofeedback has already shown some efficacy on these comorbidities in patients with TLE and stress-sensitivity (Micoulaud-Franchi et al., 2014). Insofar as this approach aims to increase skin conductance over sessions in order to reduce the seizure onset, this increase could also underlie its efficacy on depressive and anxiety disorders. ...
Article
Toniazzo, et al.. Subjective and physiological response to emotions in temporal lobe epilepsy and psychogenic non-epileptic seizures. Journal of Affective Disorders, Elsevier, 2019, 244, pp.
... In line with EEG NF, a biofeedback technique focusing on skin conductance was recently studied in a randomized blind trial, confirming the effectiveness of this technique, with approximately 50% reduction in seizure frequency [69]. This method was also effective in treating a subgroup of patients with pharmacoresistant temporal lobe epilepsy whose seizures were triggered by stress [67]. This last study is indeed of interest in its study of a specific subgroup of epilepsy patients, since very heterogeneous populations in terms of epilepsy type and severity tend to characterize previous EEG NF studies. ...
Article
Summary The technique of electroencephalographic neurofeedback (EEG NF) emerged in the 1970s and is a technique that measures a subject’s EEG signal, processes it in real time, extracts a parameter of interest and presents this information in visual or auditory form. The goal is to effectuate a behavioural modification by modulating brain activity. The EEG NF opens new therapeutic possibilities in the fields of psychiatry and neurology. However, the development of EEG NF in clinical practice requires (i) a good level of evidence of therapeutic efficacy of this technique, (ii) a good practice guide for this technique. Firstly, this article investi- gates selected trials with the following criteria: study design with controlled, randomized, and open or blind protocol, primary endpoint related to the mental and brain disorders treated and assessed with standardized measurement tools, identifiable EEG neurophysiological tar- gets, underpinned by pathophysiological relevance. Trials were found for: epilepsies, migraine, stroke, chronic insomnia, attentional-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, major depressive disorder, anxiety disorders, addictive disorders, psychotic disorders. Secondly, this article investigates the principles of neurofeedback therapy in line with learn- ing theory. Different underlying therapeutic models are presented didactically between two continua: a continuum between implicit and explicit learning and a continuum between the biomedical model (centred on ‘‘the disease’’) and integrative biopsychosocial model of health (centred on ‘‘the illness’’). The main relevant learning model is to link neurofeedback therapy with the field of cognitive remediation techniques. The methodological specificity of neuro- feedback is to be guided by biologically relevant neurophysiological parameters. Guidelines for good clinical practice of EEG NF concerning technical issues of electrophysiology and of learn- ing are suggested. These require validation by institutional structures for the clinical practice of EEG NF.
... With very short response time falling in the range of below two seconds, skin conductance activity (SCA) feedback-known also as EDA (electrodermal activity) or GSR (galvanic skin response) feedback-provides superb sensitivity to emotional changes [25]. This biofeedback technique receives a lot of attention as a complementary epilepsy treatment with encouraging outcomes reported regarding its efficiency [47][48][49][50]. Other medical uses have been and are being studied, including employment of this technique in support of controlling glucose levels in type 2 diabetes [51], treatment of Tourette syndrome [52], and headaches [53]. ...
Article
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Background: The aim of this article is to present a short review of noninvasive, nonpharmacological treatment methods used in somatic illnesses that fall under the umbrella of approach called behavioral medicine. Methods: The narrative review method was applied in the study. Science paper databases, including PubMed, had been used to retrieve papers on therapeutic methods used in clinical setting that meet the broad criteria of behavioral medicine definition as stated in the Charter of International Behavioral Medicine Society. Results: Main groups of methods, disorders in which they are being employed and their effectiveness, have been identified. Conclusions: Behavioral medicine is grouping treatment methods and interventions that hold large potential for clinical setting. Two groups of methods can be distinguished by the scrutiny and level of evidence gathered in their effectiveness assessment; for biofeedback, guided imagery, and hypnosis techniques, comprehensive evidence reports in the framework of U.S. Evidence Synthesis Program exist. Meditation techniques, disclosure therapies, and relaxation methods are less well assessed. Broader employment of behavioral medicine therapies in clinical setting is possible after addressing two major problems in the field, which are deficiencies in quality evidence of effectiveness for many of the methods and their insufficiencies in underlying therapeutic mechanism knowledge.
... Both measures have demonstrated to depict changes in bodily arousal and to allow a reliable assessment of the affective state [13,14]. Also, they have been implemented successfully in recent studies on biofeedback [15,16], whereas, to our knowledge, neither of the two have been applied in sham feedback research yet. Whether this is due to a publication bias or these measures are actually suited to support the proposed technique will be examined hereinafter. ...
Article
Full-text available
Biofeedback constitutes a well-established, non-invasive method to voluntary interfere in emotional processing by means of cognitive strategies. However, treatment durations exhibit strong inter-individual variations and first successes can often be achieved only after a large number of sessions. Sham feedback constitutes a rather untapped approach by providing feedback that does not correspond to the participant's actual state. The current study aims to gain insights into mechanisms of sham feedback processing in order to support new techniques in biofeedback therapy. We carried out two experiments and applied different types of sham feedback on skin conductance responses and pupil size changes during affective processing. Results indicate that standardized but context-sensitive sham signals based on skin conductance responses exert a stronger influence on emotional regulation compared to individual sham feedback from ongoing pupil dynamics. Also, sham feedback should forego unnatural signal behavior to avoid irritation and skepticism among participants. Altogether, a reasonable combination of stimulus features and sham feedback characteristics enables to considerably reduce the actual bodily responsiveness already within a single session.
... A meta-analysis of EEG-biofeedback studies in drug-refractory patients 36 , extracting data from 10 of at that time 63 such studies which had been undertaken, found that 74% of patients (n=87) responded, with significant (61%) reduction in median seizure frequency overall. More recently, a small study (n=11) using skin conductance biofeedback has shown promising initial results, with an almost 50% reduction in seizure frequency over 12 sessions 37 . Although a 2008 systematic review 38 of psychological treatments in epilepsy found no evidence of benefit, this largely reflected methodological deficiencies and the limited number of studies included. ...
Article
People with epilepsy report that stress is their most common trigger for seizures and some believe it caused their epilepsy in the first place. The extensive preclinical, epidemiological and clinical studies examining the link between stress and epilepsy have given confusing results; the clinical studies in particular are fraught with confounders. However stress is clearly bad for health, and we now have substantial preclinical evidence suggesting that chronic stress worsens epilepsy; in selected cases it may even be a causal factor for epilepsy. Healthcare professionals working with people with epilepsy should pay more attention to stress in clinical practice. This review includes some practical advice and guidance for stress screening and management.
Article
Full-text available
The shelter-in-place orders across the U.S. in response to the COVID-19 pandemic forced many relationships once sustained by in-person interaction into remote states through computer-mediated communication (CMC). Work, school, holidays, social engagements, and everyday conversations formerly experienced through rich and contextual in-person interactions instead have taken place on messaging, voice, and video chatting platforms that diminish or altogether lack many social cues and other qualities critical to social interaction. The difficulties feeling connected to one another observed during this period have stressed the need for novel forms of communication that enable deeper interactions. Social biosensing, the interpersonal sharing of physiological information, has shown promise facilitating social connection at a distance. In the present research we document the experiences of nine pairs of friends (N = 18) who navigated living through a shelter-in-place order, reporting on their experiences sharing their electrodermal activity (EDA) in response to short videos. Participants described the artificial and unnatural nature of communicating using typical forms of CMC and a range of interpretations of EDA as both emotional response and as representative of personal characteristics. We implemented a phased approach to study the temporal nature of forming an understanding of unfamiliar yet intimate data like EDA. Our results indicate typologies of meaning-making processes: “stablers”, “broadeners”, and “puzzlers”. We also interpreted our findings through the lens of intersubjectivity, analyzing how analogical apperception and dialogical interaction both play a role in participants’ meaning-making about their own and their partner’s biosensory information. We conclude with implications from this work pertinent to intersubjectivity theorists, social biosensing researchers, and CMC system designers and developers.
Article
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Classical teaching in epileptology localizes the origins of focal seizures solely in the cerebral cortex, with only inhibitory effects attributed to subcortical structures. However, electrophysiological and neuroimaging studies over the last decades now provide evidence for an initiation of epileptic seizures within subcortical structures. Intrinsic epileptogenicity of hypothalamic hamartoma has already been established in recognition of subcortical epilepsy, whereas a seizure-generating impact of dysplastic cerebellar lesions remains to be clarified. Herein, we examine the supportive evidence and clinical presentation of cerebellar seizures and review therapy options.
Article
Dans le traitement de l’epilepsie pharmacoresistante, parmi les approches non-pharmacologiques, il existe des methodes cognitivo-psychologiques. Le biofeedback est une de ces methodes dont quelques etudes montrent une reduction des crises a long terme [2] ; [3] . Le biofeedback, qui consiste en des strategies cognitives ayant pour but de moduler l’etat du systeme nerveux autonomique, aurait un effet positif sur l’activite cerebrale et sur la frequence des crises. Des etudes recentes chez les patients souffrant d’epilepsie utilisent la conductance cutanee (galvanic skin response) comme parametre physiologique. Le sujet recoit en temps reel (par une interface informatique adaptee) les mesures physiologiques transformees en stimuli visuel, et se sert de cette information pour adapter ses strategies cognitives afin d’optimiser son etat psychophysiologique et d’obtenir un benefice therapeutique. Une boucle cognitivo-physiologique est donc mise en place. Les mecanismes de l’efficacite du biofeedback chez les patients souffrant d’epilepsie restent inconnus ; la mise en place, la strategie au debut des crises pourrait mettre le systeme nerveux en etat « d’eveil neuro-vegetatif » et ainsi modifier l’activite epileptique. Alors que l’interet principal du biofeedback chez les patients souffrant d’epilepsie est une reduction des crises, l’effet sur la cognition est inconnu. Des etudes chez des sujets non-epileptiques montrent une amelioration des parametres cognitifs tel que le QI, l’attention, la memoire auditive et la memoire du travail [1] . On peut faire l’hypothese que le biofeedback, en modulant le « resting state » du cerveau epileptique, pourrait influencer le fonctionnement cognitif, surtout lorsque les troubles cognitifs sont aggraves par des activites epileptiques intercritiques. En effet, le biofeedback est base sur une theorie cognitive de « controle de soi », necessitant l’apprentissage des strategies cognitives pour etre efficace. Nous proposons des pistes de recherche pour explorer les interactions entre le biofeedback et la cognition chez le patient souffrant d’epilepsie.
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Biofeedback methods represent side effect free complementary options in the treatment of epilepsy. In this paper we review the current status of these methods in terms of clinical study results and their evaluation by systematic review papers. Possible mechanisms of action in biofeedback methods are discussed. To present the current status of biofeedback methods applied to patients with epilepsy. With a literature search up to 10/2016 we screened publications containing the search terms “biofeedback”, “neurofeedback” or “neurotherapy” and “epilepsy” or “seizure” for intervention and population search terms respectively. Four different techniques of biofeedback were used to improve seizure frequency in patients with epilepsy. Three of these techniques, measuring EEG (slow cortical potentials and sensory motor rhythm) or electrodermal activity (galvanic skin response, GSR) seem to be promising methods for successful seizure control. Nevertheless, methodological standards in the conducted trials were too low for assured empirical evidence in their efficacy. Biofeedback methods could be applied to patients to a greater extent. Probably due to the missing empirical evidence of efficacy and the high demand on patients’ and therapists’ time and commitment and therefore low cost effectiveness, these methods are hardly offered. Especially the relatively new approach of GSR biofeedback represents a promising option here.
Article
Purpose of review: Behavioral intervention describes multiple modalities of treatments which are of increasing interest in epilepsy. This review addresses recent behavioral clinical trials in epilepsy including cognitive behavioral therapy (CBT), mindfulness, progressive muscle relaxation (PMR), and self-management. Results and conclusions from updated Cochrane reviews and the recent International League Against Epilepsy Psychology task force are presented. Recent findings: Two recent large randomized controlled trials (mindfulness and progressive muscle relaxation) reported improved seizure frequency with behavioral treatments. In both studies, participants in both the active and the attentional control arms showed significant seizure reduction, whereas quality of life and stress reduction were better noted in the active arms. Additional behavioral modalities have reported improved seizure control including yoga, bio/neurofeedback, and music therapy.Significant improvements in multiple quality of life, cognitive domains, and medication adherence have been reported from randomized and open label trials of cognitive behavioral therapy, and self-management programs. Multiple promising self-management programs have been recently reported, often utilizing the power of web-based apps, and digitally delivered group therapy. In 2018, the International League Against Epilepsy Psychology task force recommended that 'psychological interventions should be incorporated into comprehensive epilepsy care.' Summary: Behavioral treatments are successful and likely underutilized in the treatment of epilepsy. Given the challenge of conducting randomized clinical trials of behavioral therapy, much remains to be studied. However, for motivated and interested patients, appropriately chosen behavioral therapies appear to be important adjuncts to standard therapy. The timing is currently optimal to take best advantage of smartphone apps and web-based delivery systems, both for research and therapeutic purposes.
Article
Objective: Biofeedback therapy using electrodermal activity (EDA) is a new noninvasive therapy for intractable epilepsy. However, the characteristics of EDA in patients with epilepsy are little known; therefore, we assessed the EDA characteristics in patients with epilepsy. Methods: A cross-sectional observational study was conducted in 22 patients with epilepsy and 24 healthy individuals. We collected information on demographic characteristics, EDA, and state anxiety from both groups, and epilepsy diagnosis, seizure number per month, disease duration, and number of antiepileptic drugs (AED) from the epilepsy group. A wristband device was used to measure resting EDA from both wrists for 10 min under controlled temperature and humidity. We compared the EDA levels between the epilepsy group and the control group and examined correlations between EDA and epilepsy-associated factors in the epilepsy group. Results: A decreasing trend in EDA was observed during the first 1 min from the start of the measurement in 22 patients with epilepsy (with or without seizures) compared with healthy controls (P = 0.12). However, a significant decrease in EDA was found in 18 patients with epilepsy with seizures compared with healthy controls (-0.48 versus -0.26; P = 0.036). Furthermore, seizure frequency showed a significant inverse correlation with EDA in the epilepsy group (ρ = -0.50, P = 0.016). However, neither disease duration nor the number of drugs prescribed correlated with EDA in the epilepsy group . Significance: Marginally decreased EDA was observed in patients with epilepsy, and significantly decreased EDA was found in patients with a higher seizure frequency. The present findings shed light on the appropriateness of EDA-biofeedback therapy in epilepsy.
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The aim of this study is to determine the incorporations of PHT radiolabeled with 131I (131I-PHT) on U-87 MG, Daoy and A549 cancerous cell lines. For this, cold and radio-labeling studies were carried out. The radio-labeling yield of 131I-PHT was obtained about 95 %. Subsequently, cell culture studies were carried out and radio-labeling yields of 131I, 131I-PHT on U-87 MG, Daoy and A549 cancerous cells were investigated. Cell culture studies demonstrated that the incorporation values of 131I-PHT on the three cell lines decreased with increasing radioactivity. Consequently, 131I-PHT may be a good radiopharmaceutical for targeting radionuclide therapy of Central Nervous System Tumors.
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Biofeedback is a complementary non-pharmacological and non-surgical therapeutic developed over the last thirty years in the management of drug-resistant epilepsy. Biofeedback allows learning cognitive and behavioral strategies via a psychophysiological feedback loop. Firstly, this paper describes the different types of biofeedback protocols used for the treatment of drug-refractory epilepsy and their physiological justifications. Secondly, this paper analyzes the evidence of effectiveness, from a medical point of view, on reducing the numbers of seizures, and from a neurophysiological point of view, on the changing brain activity. Electroencephalography (EEG) biofeedback (neurofeedback) protocol on sensorimotor rhythms (SMR) has been investigated in many studies, the main limitation being small sample sizes and lack of control groups. The newer neurofeedback protocol on slow cortical potential (SCP) and galvanic skin response (GSR) biofeedback protocols have been used in a smaller number of studies. But, these studies are more rigorous with larger sized samples, matched control groups, and attempts to control the placebo effect. These protocols also open the way for innovative neurophysiological researches and may predict a renewal of biofeedback techniques. Biofeedback would have legitimacy in the field of clinical drug-resistant epilepsy at the interface between therapeutic and clinical neurophysiology.
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Stress is one of the most frequently self-identified seizure triggers in patients with epilepsy; however, most previous publications on stress and epilepsy have focused on the role of stress in the initial development of epilepsy. This narrative review explores the causal role of stress in triggering seizures in patients with existing epilepsy. Findings from human studies of psychological stress, as well as of physiologic stress responses in humans and animals, and evidence from nonpharmacologic interventions for epilepsy are considered. The evidence from human studies for stress as a trigger of epileptic seizures is inconclusive. Although retrospective self-report studies show that stress is the most common patient-perceived seizure precipitant, prospective studies have yielded mixed results and studies of life events suggest that stressful experiences only trigger seizures in certain individuals. There is limited evidence suggesting that autonomic arousal can precede seizures. Interventions designed to improve coping with stress reduce seizures in some individuals. Studies of physiologic stress using animal epilepsy models provide more convincing evidence. Exposure to exogenous and endogenous stress mediators has been found to increase epileptic activity in the brain and trigger overt seizures, especially after repeated exposure. In conclusion, stress is likely to exacerbate the susceptibility to epileptic seizures in a subgroup of individuals with epilepsy and may play a role in triggering "spontaneous" seizures. However, there is currently no strong evidence for a close link between stress and seizures in the majority of people with epilepsy, although animal research suggests that such links are likely. Further research is needed into the relationship between stress and seizures and into interventions designed to reduce perceived stress and improve quality of life with epilepsy.
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Background: Seizure prediction would be clinically useful in patients with epilepsy and could improve safety, increase independence, and allow acute treatment. We did a multicentre clinical feasibility study to assess the safety and efficacy of a long-term implanted seizure advisory system designed to predict seizure likelihood and quantify seizures in adults with drug-resistant focal seizures. Methods: We enrolled patients at three centres in Melbourne, Australia, between March 24, 2010, and June 21, 2011. Eligible patients had between two and 12 disabling partial-onset seizures per month, a lateralised epileptogenic zone, and no history of psychogenic seizures. After devices were surgically implanted, patients entered a data collection phase, during which an algorithm for identification of periods of high, moderate, and low seizure likelihood was established. If the algorithm met performance criteria (ie, sensitivity of high-likelihood warnings greater than 65% and performance better than expected through chance prediction of randomly occurring events), patients then entered an advisory phase and received information about seizure likelihood. The primary endpoint was the number of device-related adverse events at 4 months after implantation. Our secondary endpoints were algorithm performance at the end of the data collection phase, clinical effectiveness (measures of anxiety, depression, seizure severity, and quality of life) 4 months after initiation of the advisory phase, and longer-term adverse events. This trial is registered with ClinicalTrials.gov, number NCT01043406. Findings: We implanted 15 patients with the advisory system. 11 device-related adverse events were noted within four months of implantation, two of which were serious (device migration, seroma); an additional two serious adverse events occurred during the first year after implantation (device-related infection, device site reaction), but were resolved without further complication. The device met enabling criteria in 11 patients upon completion of the data collection phase, with high likelihood performance estimate sensitivities ranging from 65% to 100%. Three patients' algorithms did not meet performance criteria and one patient required device removal because of an adverse event before sufficient training data were acquired. We detected no significant changes in clinical effectiveness measures between baseline and 4 months after implantation. Interpretation: This study showed that intracranial electroencephalographic monitoring is feasible in ambulatory patients with drug-resistant epilepsy. If these findings are replicated in larger, longer studies, accurate definition of preictal electrical activity might improve understanding of seizure generation and eventually lead to new management strategies. Funding: NeuroVista.
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Objective: The intent of this manuscript was to review all published studies on slow cortical potentials (SCP) neurofeedback for the treatment of ADHD, with emphasis on neurophysiological rationale, study design, protocol, outcomes, and limitations. Method: For review, PubMed, MEDLINE, ERIC, and Google Scholar searches identified six studies and six subsequent publications. In addition to five studies focusing on children with Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV)-diagnosed ADHD, one study reports on adults. Results: SCP protocols utilize unipolar-electrode placement at Cz, randomized bidirectional signal regulation, feedback/transfer trials, and discrete feedback/rewards. Results demonstrated learning of SCP self-regulation, moderate to large within group effect sizes for core ADHD symptom reduction, and enhancement of event-related potentials/electroencephalogram components. Neurophysiological and session variables were predictive of treatment outcome, but open questions of specific and nonspecific effects remain. Study limitations and future directions are discussed. Conclusion: SCP is an efficacious and standardized neurofeedback protocol that addresses behavioral and neurophysiological deficits in ADHD.
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Recent investigations have suggested that the occurrence of epileptic seizures is not completely random. In particular, various types of psychological changes or life events may act as triggering factors. To identify a possible link between self-perception of the impact of affective precipitants, cognitive responses modulated by aversive information and brain metabolic modifications in patients with temporal lobe epilepsy (TLE). The extent to which seizures were elicited or not by emotional precipitants was estimated using a self-reported scale, allowing distinction of two groups: 'Emo-TLE' group (patients reporting to have seizures triggered by emotional events) and 'Other-TLE' group, which were compared with healthy individuals ('control' group). Attentional biases were investigated using the probe detection paradigm, using negative and neutral stimuli. Interictal brain metabolism was studied using FDG-PET, and comparison was made between controls, Emo-TLE and Other-TLE groups. Patients with emotional vulnerability (Emo-TLE) disclosed specific attentional biases towards negative stimuli compared with the Other-TLE and control groups. Patients with Emo-TLE also exhibited specific hypometabolism in the anterior temporal lobe, including amygdala and hippocampus. The degree of attentional biases correlated with decreased metabolism in these regions. This investigation shows that the impact of affective events is the result of self-perception and also that it might be determined by specific cognitive and brain metabolic modifications in TLE.
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A fundamental issue in human development concerns how the young infant's ability to recognize emotional signals is acquired through both biological programming and learning factors. This issue is extremely difficult to investigate because of the variety of sensory experiences to which humans are exposed immediately after birth. We examined the effects of emotional experience on emotion recognition by studying abused children, whose experiences violated cultural standards of care. We found that the aberrant social experience of abuse was associated with a change in children's perceptual preferences and also altered the discriminative abilities that influence how children categorize angry facial expressions. This study suggests that affective experiences can influence perceptual representations of basic emotions.
Book
Electrodermal activity is one of the most frequently used psychophysiological evaluations in psychology research. Based on the 1992 edition of this work Electrodermal Activity covers advances in the field since the first publication in 1992. The current volume includes updated information on brain imaging techniques such as PET and fMRI, which provide further insight into the brain mechanisms underlying EDA. In addition, this volume is able to describe more reliably hypotheses that have been successfully tested since the first publication. © Springer Science+Business Media, LLC 2012. All rights reserved.
Article
Biofeedback is a complementary non-pharmacological and non-surgical therapeutic developed over the last thirty years in the management of drug-resistant epilepsy. Biofeedback allows learning cognitive and behavioral strategies via a psychophysiological feedback loop. Firstly, this paper describes the different types of biofeedback protocols used for the treatment of drug-refractory epilepsy and their physiological justifications. Secondly, this paper analyzes the evidence of effectiveness, from a medical point of view, on reducing the numbers of seizures, and from a neurophysiological point of view, on the changing brain activity. Electroencephalography (EEG) biofeedback (neurofeedback) protocol on sensorimotor rhythms (SMR) has been investigated in many studies, the main limitation being small sample sizes and lack of control groups. The newer neurofeedback protocol on slow cortical potential (SCP) and galvanic skin response (GSR) biofeedback protocols have been used in a smaller number of studies. But, these studies are more rigorous with larger sized samples, matched control groups, and attempts to control the placebo effect. These protocols also open the way for innovative neurophysiological researches and may predict a renewal of biofeedback techniques. Biofeedback would have legitimacy in the field of clinical drug-resistant epilepsy at the interface between therapeutic and clinical neurophysiology.
Article
We report data from two patients, followed over 3 years after electrodermal biofeedback treatment. Patients were trained three times each week for four weeks to increase their sympathetic arousal using electrodermal biofeedback. This treatment was directed at enabling the patients to change their psychophysiological state as a countermeasure to prevent seizures. Both patients voluntarily kept a record of seizure frequency over the year preceding the treatment and continued to record their seizures for up to 3 years after the termination of biofeedback treatment. Both patients showed a marked reduction in seizure frequency (54.9% and 59.8%) during the month of biofeedback treatment. This improvement was maintained over the subsequent years. We highlight the therapeutic potential of biofeedback interventions that enable patients to volitionally control their state of physiological arousal in the management of drug-resistant epilepsy.
Article
Emotions color in a singular way our everyday life and constitute important determinants of human cognition and behavior. Emotional regulation is an essential process involved in neuropathophysiology and therapeutic efficacy in many psychiatric disorders. Yet, traditional psychiatric therapeutic has focused on symptomatic rather than neurophysiological criteria. Therefore, it was proposed to teach patients to modify their own brain activity directly, in order to obtain a therapeutic effect. These techniques, which are named neurofeedback, were originally developed using electroencephalography. Recent technical advances in fMRI enable real-time acquisition, and open opportunities to its utilization in neurofeedback. This seems particularly interesting in emotion regulation, which, at a neurofunctional level, lies on cortico-limbic pathways that, in great parts, were previously identified by traditional fMRI paradigms. This emotion regulation plays a central role in the etiopathogeny psychiatric, especially depressive and anxious, disorders. It is possible to devise new therapeutic strategies and research approach for addressing directly the neurophysiological processes of emotion regulation by integrating the neurofunctional activities of a subject. These prospects seem to be in line with the neurophenomenology project, which proposes to establish a link between subjective experiences and objective neurophysiological measures.
Article
La réaction électrodermale (RED) est un index physiologique ancien, qui a fait l’objet d’un intérêt constant, malgré la mauvaise réputation attachée au « détecteur de mensonge ». Cet intérêt devrait croître dans l’avenir en fonction du développement des recherches portant sur l’aspect neurobiologique des émotions, dont elle est un index. Les données apportées récemment par l’imagerie fonctionnelle cérébrale à la signification de cet index devraient y ajouter un intérêt supplémentaire. Les auteurs revoient donc les différentes notions liées à la mesure de la RED, tant sur le plan pratique que sur celui de ses mécanismes, en espérant être utiles à la fois aux auteurs désirant utiliser cette variable, comme aux lecteurs souhaitant en posséder une vision critique.
Article
In recent studies of the structure of affect, positive and negative affect have consistently emerged as two dominant and relatively independent dimensions. A number of mood scales have been created to measure these factors; however, many existing measures are inadequate, showing low reliability or poor convergent or discriminant validity. To fill the need for reliable and valid Positive Affect and Negative Affect scales that are also brief and easy to administer, we developed two 10-item mood scales that comprise the Positive and Negative Affect Schedule (PANAS). The scales are shown to be highly internally consistent, largely uncorrelated, and stable at appropriate levels over a 2-month time period. Normative data and factorial and external evidence of convergent and discriminant validity for the scales are also presented. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Article
The present research explored the strategies individuals with epilepsy use to manage seizure activity by using a survey method (n=105). Analysis suggests that participants' strategies are more likely cognitive or behavioral in nature, rather than emotional. Furthermore, strategy usage varied by whether participants experienced a global perception or an immediate perception of seizure susceptibility. Cognitive strategies were more likely used in response to immediate awareness of seizure risk (p<.01), whereas behavioral strategies corresponded to a global awareness of risk, though this finding did not quite reach significance (p=.06). The present research 1) provides new information regarding the relationship between awareness of seizure susceptibility and strategy use by individuals with epilepsy to manage seizure activity and 2) developed two new scales (Cognitive, Behavior, & Emotional Strategies for Seizure Control Scale and Perception of Seizure Control Scale) for future research and clinical use.
Article
Electrodermal activity (EDA) is an early physiological index and the subject of constant interest, in spite of the bad reputation attached to "lie detectors". This interest is expected to increase in the future, following the development of research related to the neurobiological aspect of emotions of which it is an index. Recent data provided by functional cerebral imaging has added to the significance of this index and should result in further interest. The authors thus re-examined the various notions related to measuring EDA, and its practical aspect as well as its mechanisms. EDA should be useful both for authors wishing to use this variable and for readers wishing to form their own critical point of view. The article first defines the various terms used to qualify EDA. Then, it analyses the mechanisms occurring at the sweat glands' level, showing that a distinct innervation of the sweat glands causes sweat to be released in the excretory channels, thereby allowing the recording of a negative surface potential in parallel to the lowering of skin conductance. Arguments are then pointed out to illustrate that the potential's positive phase following this first answer occurs in the case of high intensity stimulations. The study of the central command of sudation demonstrates that, several areas are involved and that different functions such as thermal regulation and motricity may interfere with emotive reactions. Difficulties regarding the mode of measurement of these answers as to their number and amplitude are also brought to light. A particular interest of measuring EDA is its ability to highlight individual characteristic and unconscious emotional reactivity. Subjects who constitutionally present many spontaneous and therefore habitual EDA can indeed be opposed to subjects whose EDA reflexes are very few and hardly habitual. A theory suggests that for the first category, whose subjects are named labiles, emotional control may be at the origin of EDA. This characteristic brings to mind the case of antisocial subjects whose rate of EDA is also reduced, although for the latter a primitive drop in behavioral inhibition is involved. The production of EDA in response to non-conscious emotive stimulations can be objectified in the rare cases of prosopagnosia. These subjects who are unable to recognize familiar faces can produce EDA when presented faces with an emotional load. These cases contrast with the delusional denial of the Capgras syndrome where subjects do not present EDA, suggesting that the dysfunction of visual analysis occurs at a different level. There are other rare cases represented by cortical blindness where EDA shows that an unconscious emotional analysis is preserved. These subjects are known however to be capable of unconscious visual discriminations, which are possibly accompanied by EDA. This possibility of a "blind vision" is experimentally studied via subliminal vision testing (backward masking tests). These demonstrate that a rudimentary visual analysis is carried out in the subcortical circuits while taking into account the affective aspect of stimulations. Present or future data should allow a greater comprehension of electrodermal signals, making it possible to overcome the difficulties related to their interpretation and facilitate their applications.
Article
Emotions color in a singular way our everyday life and constitute important determinants of human cognition and behavior. Emotional regulation is an essential process involved in neuropathophysiology and therapeutic efficacy in many psychiatric disorders. Yet, traditional psychiatric therapeutic has focused on symptomatic rather than neurophysiological criteria. Therefore, it was proposed to teach patients to modify their own brain activity directly, in order to obtain a therapeutic effect. These techniques, which are named neurofeedback, were originally developed using electroencephalography. Recent technical advances in fMRI enable real-time acquisition, and open opportunities to its utilization in neurofeedback. This seems particularly interesting in emotion regulation, which, at a neurofunctional level, lies on cortico-limbic pathways that, in great parts, were previously identified by traditional fMRI paradigms. This emotion regulation plays a central role in the etiopathogeny psychiatric, especially depressive and anxious, disorders. It is possible to devise new therapeutic strategies and research approach for addressing directly the neurophysiological processes of emotion regulation by integrating the neurofunctional activities of a subject. These prospects seem to be in line with the neurophenomenology project, which proposes to establish a link between subjective experiences and objective neurophysiological measures. Copyright © 2012 Elsevier Masson SAS. All rights reserved.
Article
Previous reviews about psychological interventions focused on refractory epilepsy patients and were inconclusive; this review investigates what the contribution of the psychologist can be for the large group of patients with relatively well-controlled epilepsy. This review was restricted to the literature reporting on adult patients with relatively well-controlled epilepsy. A literature search on the effect of psychological interventions was conducted using Medline and PsychInfo, including those studies published through March 2002. Applying strict inclusion criteria, a total of seven studies were identified. Four studies incorporated a waiting-list control group. Of these, one study addressing cognitive rehabilitation reported positive results on psychological outcome and one intervention based on comprehensive care led to seizure reduction, whereas all other studies were plagued too much by methodological inadequacies to allow firm conclusions to be drawn. Recommendations for future intervention studies, such as standardized interventions, controlling for positive attention, outcome measures without overlap with the intervention, and a follow-up measurement, are given. It is concluded that a concerted effort to assemble larger patient groups in randomized-controlled studies is a prerequisite to acquiring well-founded knowledge about psychological interventions in patients with relatively well-controlled epilepsy.
Article
Peri-ictal behavioral and cognitive changes contribute substantially to disability and distress among people with epilepsy. Psychosis, depression, and suicide may all occur as complications of seizures. Greater appreciation and understanding of the peri-ictal period is clinically important and might open novel therapeutic windows. At the same time this period provides a model for understanding basic mechanisms underlying mood and thought disorders and the substrates of cognition, volition, emotion, and consciousness. This review will discuss behavioral and cognitive antecedents of seizures, including the preictal milieu, reflex seizures, and self-induced seizures. Behavioral and cognitive treatment approaches that have been undertaken are reviewed. Both acute and delayed postictal emotional, behavioral, and cognitive changes will be discussed. Finally, possible mechanisms by which epileptic brain activity and behavior may modify each other are considered.
Article
Neurofeedback (NF), a type of neurobehavioral training, has gained increasing attention in recent years, especially concerning the treatment of children with ADHD. Promising results have emerged from recent randomized controlled studies, and thus, NF is on its way to becoming a valuable addition to the multimodal treatment of ADHD. In this review, we summarize the randomized controlled trials in children with ADHD that have been published within the last 5 years and discuss issues such as the efficacy and specificity of effects, treatment fidelity and problems inherent in placebo-controlled trials of NF. Directions for future NF research are outlined, which should further address specificity and help to determine moderators and mediators to optimize and individualize NF training. Furthermore, we describe methodological (tomographic NF) and technical ('tele-NF') developments that may also contribute to further improvements in treatment outcome.
Article
Depression has a high prevalence among patients with temporal lobe epilepsy (TLE). A pilot study was carried out to evaluate group cognitive-behavioral therapy (CBT) as a treatment for depression in patients with TLE. Twenty-three outpatients with TLE and major depressive disorder, according to DSM-IV criteria, were enrolled and divided into two groups to receive 16 weekly sessions of CBT. The primary outcome measures were depression severity (assessed with the Beck Depression Inventory) and quality of life (measured with the Quality of Life in Epilepsy-31). Sixteen patients (70%) completed at least 80% of the sessions. From week 8, CBT had a significant positive effect on severity of depression that lasted until the end of treatment. A significant improvement in quality of life was also observed. CBT seems to be a useful intervention for treating depression and improving quality of life in patients with TLE.
Article
Background: Psychological interventions such as relaxation therapy, cognitive behaviour therapy, bio-feedback and educational interventions have been used alone or in combination in the treatment of epilepsy, to reduce the seizure frequency and improve the quality of life. Objectives: To assess whether the treatment of epilepsy with psychological methods is effective in reducing seizure frequency and/or leads to a better quality of life. Search strategy: We searched the Cochrane Epilepsy Group's Specialized Register (1 July 2007), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2007), and MEDLINE (1966 to March 2007). No language restrictions were imposed. We checked the reference lists of retrieved studies for additional reports of relevant studies. Selection criteria: Randomized or quasi-randomized studies assessing one or more types of psychological or behaviour modification techniques for people with epilepsy. Data collection and analysis: Two review authors independently assessed the trials for inclusion and extracted data. Primary analyses were by intention to treat. Outcomes included reduction in seizure frequency and quality of life. Main results: We found three small trials (50 participants) of relaxation therapy. They were of poor methodological quality and a meta-analysis was therefore not undertaken. No study found a significant effect of relaxation therapy on seizure frequency. Two trials found cognitive behavioural therapy (CBT) to be effective in reducing depression, among people with epilepsy with a depressed affect, whilst another did not. Two trials of CBT found improvement in quality of life scores. One trial of group cognitive therapy found no significant effect on seizure frequency while another trial found statistically significant reduction in seizure frequency as well as in seizure index (product of seizure frequency and seizure duration in seconds) among subjects treated with CBT. Two trials of combined relaxation and behaviour therapy and one of EEG bio-feedback and four of educational interventions did not provide sufficient information to assess their effect on seizure frequency. One small study of galvanic skin response biofeedback reported significant reduction in seizure frequency. Combined use of relaxation and behaviour modification was found beneficial for anxiety and adjustment in one study. In one study EEG bio-feedback was found to improve the cognitive and motor functions in individuals with greatest seizure reduction. Educational interventions were found to be beneficial in improving the knowledge and understanding of epilepsy, coping with epilepsy, compliance to medication and social competencies. Authors' conclusions: In view of methodological deficiencies and limited number of individuals studied, we have found no reliable evidence to support the use of these treatments and further trials are needed.
Article
Biofeedback is a noninvasive behavioral treatment that enables a patient to gain volitional control over a physiological process. As a treatment for epilepsy, biofeedback interventions were explored from as early as the 1970s, concentrating on sensory motor rhythm (SMR) as a neurophysiologic parameter. Whereas SMR biofeedback aims to modulate frequency components of the electroencephalography (EEG), slow cortical potential (SCP) biofeedback (which was introduced in the 1990s) focuses on the regulation of the amplitude of cortical potential changes (DC shift). In its application to epilepsy, biofeedback using galvanic skin response (GSR), an electrodermal measure of sympathetic activity, is a relatively new cost-effective methodology. The present article first reviews biofeedback using SMR and SCP, for which efficacy and neural mechanisms are relatively well characterized. Then recent data regarding promising applications of GSR biofeedback will be introduced and discussed in detail.
Article
To investigate the concurrent validity and reliability of the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID), a short structured diagnostic interview for DSM-IV and ICD-10 psychiatric disorders in children and adolescents. Participants were 226 children and adolescents (190 outpatients and 36 controls) aged 6 to 17 years. To assess the concurrent validity of the MINI-KID, participants were administered the MINI-KID and the Schedule for Affective Disorders and Schizophrenia for School Aged Children-Present and Lifetime Version (K-SADS-PL) by blinded interviewers in a counterbalanced order on the same day. Participants also completed a self-rated measure of disability. In addition, interrater (n = 57) and test-retest (n = 83) reliability data (retest interval, 1-5 days) were collected, and agreement between the parent version of the MINI-KID and the standard MINI-KID (n = 140) was assessed. Data were collected between March 2004 and January 2008. Substantial to excellent MINI-KID to K-SADS-PL concordance was found for syndromal diagnoses of any mood disorder, any anxiety disorder, any substance use disorder, any ADHD or behavioral disorder, and any eating disorder (area under curve [AUC] = 0.81-0.96, kappa = 0.56-0.87). Results were more variable for psychotic disorder (AUC = 0.94, kappa = 0.41). Sensitivity was substantial (0.61-1.00) for 15/20 individual DSM-IV disorders. Specificity was excellent (0.81-1.00) for 18 disorders and substantial (> 0.73) for the remaining 2. The MINI-KID identified a median of 3 disorders per subject compared to 2 on the K-SADS-PL and took two-thirds less time to administer (34 vs 103 minutes). Interrater and test-retest kappas were substantial to almost perfect (0.64-1.00) for all individual MINI-KID disorders except dysthymia. Concordance of the parent version (MINI-KID-P) with the standard MINI-KID was good. The MINI-KID generates reliable and valid psychiatric diagnoses for children and adolescents and does so in a third of the time as the K-SADS-PL.
Article
Electrodermal activity (EDA) is a sensitive index of sympathetic nervous system activity. Due to the lack of sensors that can be worn comfortably during normal daily activity and over extensive periods of time, research in this area is limited to laboratory settings or artificial clinical environments. We developed a novel, unobtrusive, nonstigmatizing, wrist-worn integrated sensor, and present, for the very first time, a demonstration of long-term, continuous assessment of EDA outside of a laboratory setting. We evaluated the performance of our device against a Food and Drug Administration (FDA) approved system for the measurement of EDA during physical, cognitive, as well as emotional stressors at both palmar and distal forearm sites, and found high correlations across all the tests. We also evaluated the choice of electrode material by comparing conductive fabric with Ag/AgCl electrodes and discuss the limitations found. An important result presented in this paper is evidence that the distal forearm is a viable alternative to the traditional palmar sites for EDA measurements. Our device offers the unprecedented ability to perform comfortable, long-term, and in situ assessment of EDA. This paper opens up opportunities for future investigations that were previously not feasible, and could have far-reaching implications for diagnosis and understanding of psychological or neurological conditions.
Article
Emotional distress is one of the most frequently reported seizure precipitants in epilepsy, but little is known about its causes and processes. Interestingly, it is now accepted that emotional distress, such as anxiety, may be accompanied by evolutionary adaptation, or abnormal attentional vigilance toward threatening stimuli. The goal of this research was to study the link between emotional seizure precipitants and pathological attention-related biases toward threat in temporal lobe epilepsy (TLE). To this aim, patients were asked to report the extent to which seizures were elicited or not by emotional precipitants, allowing distinction of two groups: "Emo-TLE" group and "Other-TLE" group. Attentional biases were investigated by comparing patients' emotional Stroop and dot detection paradigms with those of healthy individuals (control group). We found that the Emo-TLE group was characterized by attentional bias toward threatening stimuli compared with neutral stimuli and compared with the other two groups. We thus hypothesize that attentional biases related to threat in patients with TLE may sustain emotional vulnerability and seizure occurrence.
Article
To examine the immediate and sustained effects of volitional sympathetic modulation, using galvanic skin response (GSR) biofeedback training on cortical excitability in patients with drug-resistant epilepsy. Ten patients undertook 12 sessions of GSR biofeedback training over 1 month, during which they were trained to increase sympathetic arousal, using GSR biofeedback. Contingent negative variation (CNV) (a slow cortical potential reflecting cortical arousal and excitability) and the related post imperative negative variation (PINV) were quantified before and after biofeedback treatment. A significant reduction in CNV amplitude was observed in both the short-term (within the first session, after 10 minutes of GSR biofeedback) and long-term (sustained after 12 training sessions). Specifically, the change in baseline CNV amplitude after the 12 training sessions correlated with a percentage reduction in seizure frequency. Furthermore, changes in baseline amplitude of the PINV also correlated with seizure reduction. Our findings demonstrate that behavioral enhancement of peripheral sympathetic tone (GSR) is associated with modulation of indices of cortical excitability. Moreover, GSR biofeedback training over repeated sessions was associated with a chronic baseline reduction in slow cortical potentials and concurrent therapeutic improvement.
Article
A common goal of biofeedback is self-control of physiologic responses. The conceptions and paradigms of the literature on self-control of motoric and cognitive responses were surveyed to provide a basis for the self-control of physiologic responses. An operational definition of self-control was advanced, and self-control was placed in the framework of a general self-management strategy which included discrimination and maintenance components.
Article
In recent studies of the structure of affect, positive and negative affect have consistently emerged as two dominant and relatively independent dimensions. A number of mood scales have been created to measure these factors; however, many existing measures are inadequate, showing low reliability or poor convergent or discriminant validity. To fill the need for reliable and valid Positive Affect and Negative Affect scales that are also brief and easy to administer, we developed two 10-item mood scales that comprise the Positive and Negative Affect Schedule (PANAS). The scales are shown to be highly internally consistent, largely uncorrelated, and stable at appropriate levels over a 2-month time period. Normative data and factorial and external evidence of convergent and discriminant validity for the scales are also presented.
Article
Presented a discrimination GSR classical conditioning paradigm embedded within a masking task to 56 college students. The probability that Ss would become aware of the relation between the CS and the UCS was experimentally manipulated using verbal instructions. In addition, technique was devised which permitted the measurement of awareness concurrent with the measurement of conditioning. The CS-UCS interval was divided into 2 subintervals: a short-latency orienting response (OR) interval and a longer-latency anticipatory response (AR) interval. Results reveal that GSR discrimination conditioning in the OR and AR interval occurred (a) only among individual Ss who were aware, (b) only among groups of Ss for whom the probability of awareness was experimentally facilitated, and (c) only at the time that awareness was expressed. Data are consistent with the hypothesis that awareness of the CS-UCS relation is a necessary but not sufficient factor in GSR discrimination classical conditioning. (16 ref)
An experiment was performed to investigate the self-regulation of slow cortical potentials (SCP) found in a previous study (Elbert et al. 1979). Seventeen subjects received continuous visual feedback of their actual cortical shift perceptible as a rocket moving across a TV-screen during intervals of 6 sec; subjects had to direct the rocket into one of two goals representing more or less cortical negativity, depending on the pitch of two signal tones. Within two identical experimental sessions feedback trials alternated with test trials without feedback. Highly significant differences of SCP between the two required polarities were demonstrated. The most pronounced differences were observed during test trials without feedback of the second session in which a positive shift below baseline level occurred when positivity (or less negativity) was required.
Article
In a recent article in this Journal, Ramanaiah, Franzen, and Schill criticized the factor structure of the State-Trait Anxiety Inventory (STAI-Form X) and the psychometric properties of individual state and trait anxiety items. Logical arguments, data from recent exploratory and confirmatory factor analyses of the revised STA1 (Form Y), and information about the construction and validation of the STAI were presented to refute these criticisms.
Article
The present study aimed at investigating to what extent the regulation of excitability in cortical networks, as indicated by surface-negative slow cortical potentials (SCPs), is impaired in epileptic patients and to what extent training of SCP self-regulation by means of biofeedback and instrumental learning procedures might affect seizure frequency. Twenty-five patients suffering from drug-refractory epilepsies (complex focal, grand mal, and absence type of seizures) participated in 28 1-h sessions of feedback and instrumental conditioning of their SCPs. Subjects' EEGs were obtained from the vertex. Depending on discriminative stimuli DC shifts towards increased or suppressed negativity relative to the pre-trial baseline were demonstrated by on-line visual feedback during intervals of 8 s each; each session comprised 110 trials. While performance on the SCP self-regulation task was initially below normal (as compared to healthy subjects), significant increases in SCP control were achieved by the patients across the 28 training sessions. In 18 patients at least 1-year follow-up data are available. Changes in seizure frequency were related to transfer of SCP control with six of the patients becoming seizure-free. Age affected the ability to acquire SCP control and its impact on seizure frequency.
Article
Colored photographic pictures that varied widely across the affective dimensions of valence (pleasant-unpleasant) and arousal (excited-calm) were each viewed for a 6-s period while facial electromyographic (zygomatic and corrugator muscle activity) and visceral (heart rate and skin conductance) reactions were measured. Judgments relating to pleasure, arousal, interest, and emotional state were measured, as was choice viewing time. Significant covariation was obtained between (a) facial expression and affective valence judgments and (b) skin conductance magnitude and arousal ratings. Interest ratings and viewing time were also associated with arousal. Although differences due to the subject's gender and cognitive style were obtained, affective responses were largely independent of the personality factors investigated. Response specificity, particularly facial expressiveness, supported the view that specific affects have unique patterns of reactivity. The consistency of the dimensional relationships between evaluative judgments (i.e., pleasure and arousal) and physiological response, however, emphasizes that emotion is fundamentally organized by these motivational parameters.
Article
Of the approximately 2 million Americans with a diagnosis of epilepsy who are treated with antiepileptic drugs, 20 percent continue to have seizures1; this group of patients accounts for over 75 percent of the cost of epilepsy in the United States.2 For many of those with medically refractory epilepsy, their disability can be completely eliminated by surgical intervention. Only a small percentage of potential surgical candidates, however, are currently referred to epilepsy-surgery centers.3 Overview The classic 1886 paper of Victor Horsley4 heralded the modern era of epilepsy surgery, and the introduction of electroencephalography (EEG) in the first half of . . .
Article
Using a process model of emotion, a distinction between antecedent-focused and response-focused emotion regulation is proposed. To test this distinction, 120 participants were shown a disgusting film while their experiential, behavioral, and physiological responses were recorded. Participants were told to either (a) think about the film in such a way that they would feel nothing (reappraisal, a form of antecedent-focused emotion regulation), (b) behave in such a way that someone watching them would not know they were feeling anything (suppression, a form of response-focused emotion regulation), or (c) watch the film (a control condition). Compared with the control condition, both reappraisal and suppression were effective in reducing emotion-expressive behavior. However, reappraisal decreased disgust experience, whereas suppression increased sympathetic activation. These results suggest that these 2 emotion regulatory processes may have different adaptive consequences.
Article
Recent attempts to clarify the pathogenesis of pharmacoresistant epilepsies arrive at the conclusion that intractable epilepsies might be prevented by earlier, more effective pharmacotherapy. In this paper the problem of intractability is examined from a psychological point of view. Sixteen patients with intractable epilepsies were trained in techniques of self control (SC) in addition to ongoing pharmacological treatment. The SC training consisted of detailed self observation which aimed at identifying warning signals of a beginning seizure and seizure-provoking factors and the development of 'counter measures' (behavioural measures to interrupt a beginning seizure and to neutralize provoking factors). After SC training, all those patients who successfully managed to deal with their identified problems (strong psychic stress and/or poor intuitive SC abilities) achieved a significant improvement of seizure control: 68% obtained 80-100% reduction and 12% obtained 60-70% reduction of seizures. None changed for the worse. These findings suggested that psychological methods of seizure control can contribute to improving long-standing intractable epilepsies. Offered early in the process of epilepsy they may even help to prevent the development of intractability. A new kind of polytherapy is proposed, consisting of a combination of pharmacological and SC therapy.
Article
We evaluated self-perception of seizure precipitants in 149 adult subjects with epilepsy: 71% of the subjects reported at least one factor that, according to the perception, increased the risk of suffering from a seizure. The subjects most often reported psychological stress, change of weather and sleep deprivation. Among the disease-related factors, seizure frequency and the state of consciousness at the onset of the seizures influenced perception of precipitants. Furthermore the perception of some precipitants was dependent on such social variables as rural versus urban surroundings. It is argued that the perception of seizure precipitants is the result of a combination of physiologically based temporal and causal correlations and of beliefs of the patient about such relationships. Hence reports of seizure precipitants are determined by somatic as well as psychological factors. Efforts to clarify the relationship between possible precipitants and the occurrence of seizures should be intensified. In addition the great importance of seizure precipitants in lay theories of epilepsies should be considered in counselling patients with epilepsies.
Article
The Mini-International Neuropsychiatric Interview (M.I.N.I.) is a short structured diagnostic interview, developed jointly by psychiatrists and clinicians in the United States and Europe, for DSM-IV and ICD-10 psychiatric disorders. With an administration time of approximately 15 minutes, it was designed to meet the need for a short but accurate structured psychiatric interview for multicenter clinical trials and epidemiology studies and to be used as a first step in outcome tracking in nonresearch clinical settings. The authors describe the development of the M.I.N.I. and its family of interviews: the M.I.N.I.-Screen, the M.I.N.I.-Plus, and the M.I.N.I.-Kid. They report on validation of the M.I.N.I. in relation to the Structured Clinical Interview for DSM-III-R, Patient Version, the Composite International Diagnostic Interview, and expert professional opinion, and they comment on potential applications for this interview.
Article
This study was set up in order to investigate the prevalence and nature of seizure precipitants and self-control behaviours in adults with intractable seizures. A semi-structured interview was conducted with 100 patients attending neurology or neuropsychiatry epilepsy out-patient clinics. The interview included six questions regarding seizure precipitants, the extent to which the patients seek and avoid precipitants, and their ability to induce or abort seizures. The study revealed that over 90% of the participants could identify at least one seizure precipitant. Stress, depression, tiredness and the menstrual cycle were the most common precipitants reported. In addition, 65% of the participants could identify at least one 'low-risk' situation in which seizures were unlikely to occur. Fifteen percent reported they could induce a seizure, 52% said that they consciously try to avoid seizure precipitants and 47% said they could sometimes stop their seizures from happening. These results indicate that the majority of the sample could identify factors which trigger their seizures, and that some of the participants engage in attempts to reduce their seizure frequency by avoiding these factors and by controlling the onset of their seizures. The possible mechanisms involved in the relationship between precipitants and seizure genesis are discussed.
Article
More than 30 percent of patients with epilepsy have inadequate control of seizures with drug therapy, but why this happens and whether it can be predicted are unknown. We studied the response to antiepileptic drugs in patients with newly diagnosed epilepsy to identify factors associated with subsequent poor control of seizures. We prospectively studied 525 patients (age, 9 to 93 years) who were given a diagnosis, treated, and followed up at a single center between 1984 and 1997. Epilepsy was classified as idiopathic (with a presumed genetic basis), symptomatic (resulting from a structural abnormality), or cryptogenic (resulting from an unknown underlying cause). Patients were considered to be seizure-free if they had not had any seizures for at least one year. Among the 525 patients, 333 (63 percent) remained seizure-free during antiepileptic-drug treatment or after treatment was stopped. The prevalence of persistent seizures was higher in patients with symptomatic or cryptogenic epilepsy than in those with idiopathic epilepsy (40 percent vs. 26 percent, P=0.004) and in patients who had had more than 20 seizures before starting treatment than in those who had had fewer (51 percent vs. 29 percent, P<0.001). The seizure-free rate was similar in patients who were treated with a single established drug (67 percent) and patients who were treated with a single new drug (69 percent). Among 470 previously untreated patients, 222 (47 percent) became seizure-free during treatment with their first antiepileptic drug and 67 (14 percent) became seizure-free during treatment with a second or third drug. In 12 patients (3 percent) epilepsy was controlled by treatment with two drugs. Among patients who had no response to the first drug, the percentage who subsequently became seizure-free was smaller (11 percent) when treatment failure was due to lack of efficacy than when it was due to intolerable side effects (41 percent) or an idiosyncratic reaction (55 percent). Patients who have many seizures before therapy or who have an inadequate response to initial treatment with antiepileptic drugs are likely to have refractory epilepsy.
Article
We used event-related fMRI to measure neural activity in volunteer subjects during acquisition of an implicit association between a visual conditioned stimulus (CS+) (angry face) and an auditory unconditioned stimulus (UCS) (aversive, loud noise). Three distinct functional regions were identified within left amygdala: a UCS (noise)-related lateral region, a CS+-related ventral region, and a dorsal region where CS+-related responses changed progressively across the learning session. Differential neural responses to the visual CS+ were also evoked in extrastriate and auditory cortices. Our results indicate that learning an association between biologically salient stimuli of different sensory modalities involves parallel changes of neural activity in segregated amygdala subregions and unimodal sensory cortices.
Article
To define behaviours and to identify psychological, demographic, and epilepsy-related variables associated with high as opposed to low perceived self-control of seizures. In a semistructured interview, 100 adults with intractable seizures were asked about their seizure precipitants and attempts at self-control of seizures. They also completed four psychological questionnaires. Latent Class Analysis was used to analyse the interview data to create two groups, High Controllers and Low Controllers, who were then compared on demographic, epilepsy, and psychological characteristics. Being able to identify and seeking out low-risk-for-seizure situations, avoiding high-risk-for-seizure situations, and making attempts at seizure inhibition were seizure behaviours that discriminated High from Low Controllers. The general probability of being a High Controller was greater than that of being a Low Controller. Perceived high self-control of seizures was associated with low chance-health locus of control. For Low Controllers, current age, age at onset of seizures, and duration of epilepsy history were related to psychological variables. A significantly higher proportion of the Low Controllers than High Controllers were women. Many people with intractable seizures do not accept their epilepsy as a condition over which they have no control. Perceived self-control of seizures, however, involves a complex interaction between epilepsy and psychological factors, with health locus of control an apparently important discriminator between High and Low Controllers.
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To compare self-regulation of low-frequency EEG components (slow cortical potentials, SCPs) with other methods of seizure control for patients with drug-refractory partial epilepsy and to separate the real anticonvulsive effect from placebo effects. Results of a treatment program of SCP self-regulation (experimental group) are compared with two groups of patients, one of which learned self-control of respiratory parameters (end-tidal CO2 and respiration rate: RES group); the other received medication with new anticonvulsive drugs (AEDs) in combination with psychosocial counseling (MED group). Clinical, cognitive, behavioral, and personality measures were assessed before and after treatment. In addition, to control for placebo responses, patients repeatedly estimated their beliefs in the efficiency of the respective treatment, their satisfaction and expectations, and the quality of the relationship with their therapists. SCP and MED groups showed a significant decrease of seizure frequency, but the RES group did not. Clear positive changes in the sociopsychological adjustment were obtained in all three groups, with the maximal improvement being attained in the RES group. All kinds of therapy result in considerable improvement of patients' emotional state, which may in part be due to potential placebo effects: however, this improvement is not related to the quality of the therapeutic effect proper (i.e., seizure reduction). Traditional double-blind control group designs are inappropriate for behavioral interventions or treatments with psychoactive pharmacologic drugs. Rather, specific tests can be developed to control the placebo effect and to separate it from the genuine therapeutic effects.