The role of stress as a trigger for epileptic seizures: a narrative review of evidence from human and animal studies

Psychological treatments for people with epilepsy

BACKGROUND

Given the significant impact epilepsy can have on the health-related quality of life (HRQoL) of individuals with epilepsy and their families, there is great clinical interest in evidence-based psychological treatments, aimed at enhancing psychological well-being in people with epilepsy. A review of the current evidence was needed to assess the effects of psychological treatments for people with epilepsy on HRQoL outcomes, in order to inform future therapeutic recommendations and research designs.

OBJECTIVES

To assess the effects of psychological treatments for people with epilepsy on HRQoL outcomes.

SEARCH METHODS

We searched the following databases on 20 September 2016, without language restrictions: Cochrane Epilepsy Group Specialized Register, CENTRAL, MEDLINE PsycINFO, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP). We screened the references from included studies and relevant reviews, and contacted researchers in the field for unpublished studies.

SELECTION CRITERIA

We considered randomized controlled trials (RCTs) and quasi-RCTs for this review. HRQoL was the main outcome measure. For the operational definition of 'psychological treatments', we included a broad range of treatments that used psychological or behavioral techniques designed to improve HRQoL, seizure frequency and severity, and psychiatric comorbidities for adults and children with epilepsy, compared to treatment as usual (TAU) or an active control group.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by the Cochrane Collaboration.

MAIN RESULTS

We included 24 completed RCTs, with a total of 2439 participants. Eleven studies investigated psychological interventions, such as cognitive, behavioral, and mindfulness-based interventions. The remaining studies were classified as educational interventions (N = 7), self-management interventions (N = 3), adherence interventions (N = 1), and mixed interventions (N = 2). Two studies investigated interventions for children and adolescents, and five studies investigated interventions for adolescents and adults. Based on satisfactory clinical and methodological homogeneity, we pooled data from six adult studies, two studies on adolescents and adults, and one on adolescents and young adults (468 participants) for HRQoL, measured with the Quality of Life in Epilepsy-31 (QOLIE-31). We found significant mean changes for the QOLIE-31 total score and six subscales (emotional well-being, energy and fatigue, overall QoL, seizure worry, medication effects, and cognitive functioning). The mean changes of the QOLIE-31 total score (mean improvement of 5.68 points (95% CI 3.11 to 8.24; P < 0.0001), and three subscales, emotional well-being (mean improvement of 7.03 points (95% CI 2.51 to 11.54; P = 0.002); energy and Fatigue (mean improvement of 6.90 points (95% CI 3.49 to 10.31; P < 0.0001); and overall QoL (mean improvement of 6.47 points (95% CI 2.68 to 10.25; P = 0.0008) exceeded the threshold of minimally important change (MIC), indicating a clinically meaningful post-intervention improvement of QoL. We downgraded the quality of the evidence provided by the meta-analysis because of serious risk of bias in some of the included studies. Consequentially, these results provided evidence of moderate quality that psychological treatments for adults with epilepsy may enhance overall QoL in people with epilepsy.

AUTHORS' CONCLUSIONS

Implications for practice: Psychological interventions and self-management interventions improved QoL, and emotional well-being, and reduced fatigue in adults and adolescents with epilepsy. Adjunctive use of psychological treatments for adults and adolescents with epilepsy may provide additional benefits to QoL in those who incorporate patient-centered management.

IMPLICATIONS FOR RESEARCH

Authors should strictly adhere to the CONSORT guidelines to improve the quality of reporting on their interventions. A thorough description of the intervention protocol is necessary to ensure reproducibility.When researching psychological treatments for people with epilepsy, the use of Quality of Life in Epilepsy Inventories (QOLIE-31, QOLIE-31-P, and QOLIE-89) would increase comparability. There is a critical gap in pediatric RCTs for psychological treatments, particularly those that use an epilepsy-specific measure of HRQoL.Finally, in order to increase the overall quality of study designs, adequate randomization with allocation concealment and blinded outcome assessment should be pursued when conducting RCTs. As attrition is often high in research that requires active participant participation, an intention-to-treat analysis should be carried out.

An Atypical Porencephalic Cyst Manifesting as a Simple Partial Seizure: A Case Report and Literature Review

Background

Porencephaly is an extremely rare neurological disease characterized by the presence of solitary or multiple degenerative cerebrospinal fluid (CSF) cavities within the brain parenchyma.

Case Report

We describe a case involving a 23-year-old male who presented with involuntary movements of the left upper limb of 6 months' duration. A diagnosis of porencephaly was confirmed by magnetic resonance imaging (MRI).

Conclusion

The rarity of occurrence and atypical presentation of such a lesion present a challenge to clinicians. Little is known about the pathogenesis and appropriate management of porencephaly. Further studies of the implications of porencephaly for neurodevelopment and behavior are needed.

The psychological nature of seizure conditions

Background/Aims:

Epilepsy is a long-term health condition that is associated with multiple biological, psychological and behavioural factors. Psychogenic or non-epileptic conditions have caused much debate and controversy among clinicians and researchers. This paper outlines comprehensive assessments with the aim of describing the psychological nature of different types of seizure conditions.

Methods:

The retrospective study reports on a range of self-report psychometric data of 26 patients with epileptic, non-epileptic, or both types of seizure conditions. The Hospital and Anxiety and Depression Scale, the Dissociative Experiences Scale and the Emotional Processing Scale were used to assess psychological functioning and emotional distress. The Quality of Life in Epilepsy Inventory and the MOS Short-Form Health Survey 36 were administered to evaluate subjective experiences related to quality of life and disability.

Results:

Epileptic and non-epileptic seizures are formulated in the background of biopsychosocial stress theories. The questionnaire outcomes revealed complex profiles. All patient groups reported reduced quality of life. Differential patterns of psychological distress were discovered for both diagnostic groups.

Conclusion:

The findings from this heterogeneous clinical population suggest that patients with epileptic and non-epileptic conditions demonstrate secondary psychological and functional difficulties. Future systematic research is required to establish valid measures of long-term psychosocial strain and to provide evidence for the link between maladaptive physiological mechanisms and psychological problems (and vice versa).

Stress regulation in drug-resistant epilepsy

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.

Monte Carlo simulations of randomized clinical trials in epilepsy

Background

The placebo response in epilepsy randomized clinical trials (RCTs) has recently been shown to largely reflect underlying natural variability in seizure frequency. Based on this observation, we sought to explore the parameter space of RCT design to optimize trial efficiency and cost.

Methods

We used one of the world's largest patient reported seizure diary databases, SeizureTracker.com to derive virtual patients for simulated RCTs. We ran 1000 randomly generated simulated trials using bootstrapping (sampling with replacement) for each unique combination of trial parameters, sweeping a large set of parameters in durations of the baseline and test periods, number of patients, eligibility criteria, drug effect size, and patient dropout. We studied the resulting trial efficiency and cost.

Results

A total of 6,732,000 trials were simulated, drawing from 5097 patients in the database. We found that the strongest regression predictors of placebo response were durations of baseline and test periods. Drug effect size had a major impact on trial efficiency and cost. Dropout did not have a major impact on trial efficiency or cost. Eligibility requirements impacted trial efficiency to a limited extent. Cost was minimized while maintaining statistical integrity with very short RCT durations.

Discussion

This study suggests that RCT parameters can be improved over current practice to reduce costs while maintaining statistical power. In addition, use of a large‐scale population dataset in a massively parallel computing analysis allows exploration of the wider parameter space of RCT design prior to running a trial, which could help accelerate drug discovery and approval.

Diurnal patterns and relationships between physiological and self-reported stress in patients with epilepsy and psychogenic non-epileptic seizures

PURPOSE

Patients with epilepsy and those with psychogenic non-epileptic seizures (PNES) experience high levels of stress and stress is one of the most frequently self-identified seizure precipitants. Although stress is a multifaceted phenomenon, few studies have systematically examined its different components in patients with seizures. The aim of this study was therefore to describe diurnal patterns of psychological and physiological measures of stress in patients with epilepsy and patients with PNES, and explore their relationships to each other in order to improve our understanding of the mechanisms underlying stress and seizure occurrence in these patients.

METHOD

A range of stress markers including self-reported stress, salivary cortisol, and heart rate variability (HRV) were explored in adult patients with refractory epilepsy (N=22) and those with PNES (N=23) undergoing three- to five-day video-telemetry.

RESULTS

A diurnal pattern was observed in the physiological measures, characterized by higher levels of physiological arousal in the mornings and lower levels at night in both patients with epilepsy and PNES. The physiological measures (cortisol and HRV) were associated with each other in patients with epilepsy; no close relationship was found with self-reported stress in either of the two patient groups.

CONCLUSION

The findings contribute to and expand on previous studies of the patterns of stress in patients with seizures. The results also indicate a discrepancy between patients' physiological responses and their subjective stress perceptions, suggesting that simple self-reports cannot be used as a proxy of physiological arousal in patients with seizures and stress. Stress in these patient groups should be studied using a combination of complementary measures.

Psychiatric lifetime diagnoses are associated with a reduced chance of seizure freedom after temporal lobe surgery

OBJECTIVE

To examine whether psychiatric comorbidity is a predictor of long-term seizure outcome following temporal lobe epilepsy surgery.

METHODS

A sample of 434 adult patients who received temporal lobe resection to treat epilepsy between 1991 and 2009 and were psychiatrically assessed before surgery were followed for 2 years to assess seizure outcome. Stepwise multivariate logistic regression analyses were used to assess the impact of psychiatric variables on complete seizure freedom (Engel class IA), and freedom from disabling seizures (Engel class I). Lifetime histories of three psychiatric syndromes (PS: psychosis; depression; other) and five personality disorders (PD: DSM-IV Clusters A, B, and C; organic personality disorder; other) were considered as predictors, complemented by age at onset, duration of epilepsy, type of lesion (mesiotemporal sclerosis vs. other), and year of surgery.

RESULTS

Seizure-freedom rates were significantly higher (p < 0.001) in patients with no history of PS or PD (N = 138; Engel class IA: 61.6%; Engel class I: 87.7%) than in those with any PS or PD (N = 296; Engel class IA: 39.5%; Engel class I: 58.8%). Particularly low seizure-freedom rates were found in patients with a diagnosis of psychosis (N = 32, Engel class IA: 21.9%; Engel class I: 40.6%), organic PD (N = 48, Engel class IA: 25.0%; Engel class I: 35.4%) or a double diagnosis of PS plus PD (N = 97; Engel class IA: 27.8%; Engel class I: 45.5%). No other variables emerged as significant risk factors in multivariate logistic regression analyses.

SIGNIFICANCE

Patients with and without psychiatric comorbidities can benefit from temporal lobe epilepsy surgery; however, psychiatric comorbidities are negatively associated with postoperative seizure-freedom rates. Surgical outcome is related to the type and extent of preoperative psychiatric morbidity, which underscores the prognostic value of presurgical psychiatric evaluation. The data support the argument that there are common pathogenetic mechanisms underlying both epilepsy and psychiatric conditions.

Understanding the self-management skills of persons with epilepsy

PURPOSE

To determine whether the self-management skills of persons with epilepsy (PWE) vary across the different domains of the Epilepsy Self-Management Scale (ESMS).

METHODS

172 PWE completed a survey questionnaire as well as the ESMS.

RESULTS

Using ANOVA with pairwise comparison, the mean item scores of the medication, seizure, and safety management subscales of the ESMS were significantly higher than the lifestyle and information management subscales (p<0.01). The mean item score for the lifestyle management subscale was significantly higher than the information management subscale (p<0.01).

CONCLUSION

PWE in our population performed differently across the various domains of the ESMS and did worse on the lifestyle and information management subscales. We discuss the implications of this on patient counseling and education.

Increased hair cortisol and antecedent somatic complaints in children with a first epileptic seizure

OBJECTIVE

Stress is the most frequent seizure-precipitating factor reported by patients with epilepsy, while stressful life events may increase seizure susceptibility in humans. In this study, we investigated the relations between both biological and behavioral measures of stress in children with a first epileptic seizure (hereafter called seizure). We hypothesized that hair cortisol, a biomarker of chronic stress reflecting approximately 3months of preceding exposure, might be increased in children with a first seizure. We also employed standardized questionnaires to examine presence of stress-related behavioral markers.

METHODS

This was a cross-sectional clinical study investigating stress-related parameters in children with a first seizure (First Epileptic Seizure Group (FESG), n=22) in comparison to healthy children without seizures (Control Group, n=29). Within 24h after a first seizure, hair samples were collected from children for the determination of cortisol. In parallel, perceived stress and anxiety and depressive symptoms were examined with appropriate self- and parent-completed questionnaires, and history of stressful life events during the past year was recorded. Emotional and behavioral problems were also assessed by parent-reported validated and widely-used questionnaires.

RESULTS

Higher hair cortisol measurements were observed in the FESG than control children (7.5 versus 5.0pg/mg respectively, p=0.001). The former were more likely to complain of somatic problems than the latter (59.8 vs. 55.4 according to DSM-oriented Scale, p=0.021); however, there were no differences in perceived stress and anxiety or depressive symptoms between the two groups. Using ROC analysis of hair cortisol measurements for predicting disease status, the maximum sensitivity and specificity were observed for a cut-off point of 5.25pg/mg.

SIGNIFICANCE

Increased hair cortisol indicates chronic hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis prior to the first seizure. This might have contributed to the epileptogenesis process and may help explain the higher incidence of antecedent somatic complaints in the first seizure group.

Stress as a seizure precipitant: Identification, associated factors, and treatment options

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.

Vocational factors which predict seizure prognosis in young adults during military service

BACKGROUND

The vocational parameters regarding epilepsy are not well established. Our aim was to assess the risk of seizures as a function of occupational stress and disease severity in military recruits of the IDF (Israel Defense Force) and to examine the effect of new classification criteria (used between the late nineties and early two thousands) in comparison with that of previous criteria (used during the mid-eighties to mid-nineties).

METHODS

The medical records of over 150,000 18-year-old men recruited to the IDF between the mid-nineties and the mid-two thousands were used to assemble a cohort, which was followed for a period of 36months. The severity of the disease was determined according to 3 categories, according to the medical history. The recruits were subdivided according to their occupational categories to Combat Units (CUs), Maintenance Units (MUs), and Administrative Units (AUs). We compared the incidence rates of the different groups with the findings from a previous follow-up.

RESULTS

The annual incidence rates during 36months of follow-up were 0.026%, 4.7%, and 8.8%, in categories 1 to 3, respectively. The relative risk of seizure incidence in CU and MU was lower than in AU (0.42 and 0.81, p<0.0001). Similar findings were found in other disease categories.

CONCLUSIONS

Job assignment to CU (less convenient conditions like sleep deprivation and strenuous physical activity) did not increase the incidence of seizures. It was found that EEG examination is an important criterion in the vocational evaluation of subjects that have had one or more seizures. This study supports the establishment of vocational criteria and recommends the integration of people diagnosed with epilepsy in most occupations.

Perceived stress and its predictors in people with epilepsy

OBJECTIVE

Perceived stress in people with epilepsy (PWE) is one of the major precipitants for seizures. We investigated the degree of perceived stress in PWE and its predictors. We also aimed to reveal the interrelationships among the predictors.

METHODS

This was a case-control study. Consecutive patients visiting a tertiary care epilepsy clinic completed self-reported questionnaires including the Perceived Stress Scale (PSS), Revised Stigma Scale (RSS), Korean version of the Neurological Disorders Depression Inventory for Epilepsy (K-NDDI-E), Generalized Anxiety Disorder - 7 (GAD-7), and short forms of the Patient-Reported Outcomes Measurement Information System - Sleep Disturbance (PROMIS-SD) and Patient-Reported Outcomes Measurement Information System - Sleep-Related Impairment (PROMIS-SRI) scales.

RESULTS

The mean score of the PSS was significantly lower in patients with well-controlled epilepsy (WCE) and higher in those with uncontrolled epilepsy compared with controls. Although several factors including demographic, socioeconomic, psychosomatic, and epilepsy-related factors were associated with the PSS score, the strongest predictor for the PSS score was the K-NDDI-E score, followed by the PROMIS-SRI score, the GAD-7 score, and seizure control. Psychosomatic factors exerted both a direct effect on the PSS score and an indirect effect on the PSS score through seizure control.

CONCLUSION

Rapid detection and appropriate management of psychiatric and sleep-related problems in PWE may lessen stress and aid in preventing further seizures.

Depression and anxiety in people with epilepsy: Why should we identify?

Introduction. People with epilepsy (PWE) have a higher risk of developing depression and anxiety than people without epilepsy. However, understanding and management of that issue remain under-recognized.

Aim. To emphesize: a) the relationship between depression, anxiety, and epilepsy, and b) to suggest practical strategies for their identification by clinicians.

Methods. The current literatures was reviewed investigating the impact of depression and anxiety in PWE and those examining the validity of simple screening tools for the detection of depression and anxiety.

Review. Approximately one quarter of PWE have been known to be suffered from depression. The frequency of depression and anxiety was closely related to poor seizure control. Depression and anxiety have been reported to have a bidirectional relationship with epilepsy. The higher degree of depression and anxiety was more likely to elicit the suicidal ideation and attempt, adverse events and poor compliance of antiepileptic drugs, poor surgical outcome, and eventually, poor quality of life. Furthermore, depression and anxiety were closely associated with perceived stigma, obsessive-compulsive symptom, aggression, fatigue, and perceived stress.

Conclusions. Clinicians who take care of PWE in a busy clinical setting should identify their psychiatric problems by brief screening tools and treat them instantly to minimize their negative impacts.

Hypothalamic-pituitary-adrenocortical axis dysfunction in epilepsy

Epilepsy is a common neurological disease, affecting 2.4million people in the US. Among the many different forms of the disease, temporal lobe epilepsy (TLE) is one of the most frequent in adults. Recent studies indicate the presence of a hyperactive hypothalamopituitary- adrenocortical (HPA) axis and elevated levels of glucocorticoids in TLE patients. Moreover, in these patients, stress is a commonly reported trigger of seizures, and stress-related psychopathologies, including depression and anxiety, are highly prevalent. Elevated glucocorticoids have been implicated in the development of stress-related psychopathologies. Similarly, excess glucocorticoids have been found to increase neuronal excitability, epileptiform activity and seizure susceptibility. Thus, patients with TLE may generate abnormal stress responses that both facilitate ictal discharges and increase vulnerability for the development of comorbid psychopathologies. Here, we will examine the evidence that the HPA axis is disrupted in TLE, consider potential mechanisms by which this might occur, and discuss the implications of HPA dysfunction for seizuretriggering and psychiatric comorbidities.

Self-control of epileptic seizures by nonpharmacological strategies

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.

Experiencing neonatal maternal separation increased the seizure threshold in adult male mice: Involvement of the opioid system

Experiencing early-life stress has been considered as a potent risk factor for the development of many of brain disorders, including seizures. Intervening mechanisms through which neonatal maternal separation (MS) alters the seizure susceptibility in adulthood have not been well studied. In the current study, by applying 180 min of MS stress (PND 2-14), we determined the seizure susceptibility and considered the role of the opioid system. Maternal separation increased the seizure threshold, and administration of anticonvulsant/proconvulsant doses of morphine (1 and 30 mg/kg, respectively) reversed the impact of MS. Using tail flick and hot plate tests, we exposed animals to 30 min Restraint stress (RS) and found that MS decreased the pain threshold, suggesting the hyporesponsiveness of the opioid system. These results supported the abnormal seizure activity observed in the MS mice and suggested that abnormalities in the opioid system following MS alter seizure susceptibility in later life.

Childhood trauma in patients with self-reported stress-precipitated seizures

OBJECTIVE

Stress is the most commonly reported precipitant of epileptic seizures, but the mechanism by which stress precipitates seizures and the risk factors for stress as a seizure precipitant are poorly understood. Previously, we observed higher levels of anxiety symptoms in patients with epilepsy who reported stress as a seizure precipitant. Given that childhood trauma increases the risk of general psychiatric symptom burden, including anxiety symptoms, we sought to examine the relationship between childhood adversity and stress as a seizure precipitant.

METHODS

Sequential outpatients (N=236) evaluated at the Epilepsy Center of the University of Cincinnati Neuroscience Institute who had previously enrolled in an earlier study of stress and seizures were enrolled. Subjects either endorsed stress as a seizure precipitant [Stress (+)] or not [Stress (-)]. The Childhood Trauma Questionnaire Short Form (CTQ-SF), a 28-question scale that evaluates 5 domains of childhood adversity (physical abuse, physical neglect, emotional abuse, emotional neglect, and sexual abuse) was sent via mail and returned on paper or electronically from participants. Total CTQ-SF score and CTQ-SF domain scores were compared between Stress (+) and Stress (-) groups using Wilcoxon rank sum test. Spearman's rank correlation between CTQ-SF scores with depression and anxiety was also determined, and these analyses were followed by a multivariate analysis to identify the association of childhood trauma with other factors including anxiety and depression.

RESULTS

A total of 119 out of 236 CTQ-SFs that were sent out were completed. Response rates were 91/195 for Stress (+) and 28/41 for Stress (-). The Stress (+) group reported higher scores in emotional abuse compared with the Stress (-) group (p=0.029); CTQ-SF total scores were higher in the Stress (+) group compared with the Stress (-) group (p=0.08), and sexual abuse scores were higher in Stress (+) group (p=0.07), but there were no statistically significant differences for other types of trauma. Depression and anxiety scores were higher in the Stress (+) group, but anxiety was the only independent factor associated with the Stress (+) group in the multivariate analysis (p=0.0021).

CONCLUSION

Patients with epilepsy who report stress as a seizure precipitant are more likely to endorse a history of childhood traumatic experiences, particularly emotional abuse, compared with those who do not perceive stress as a precipitant. Further study is needed to identify how childhood trauma interacts with anxiety in modulating stress response in patients with epilepsy.

Brain-skin connection: stress, inflammation and skin aging

The intricate relationship between stress and skin conditions has been documented since ancient times. Recent clinical observations also link psychological stress to the onset or aggravation of multiple skin diseases. However, the exact underlying mechanisms have only been studied and partially revealed in the past 20 years or so. In this review, the authors will discuss the recent discoveries in the field of “Brain-Skin Connection”, summarizing findings from the overlapping fields of psychology, endocrinology, skin neurobiology, skin inflammation, immunology, and pharmacology.

Impact of sleep duration on seizure frequency in adults with epilepsy: a sleep diary study

BACKGROUND

Prolonged sleep deprivation activates epileptiform EEG abnormalities and seizures in people with epilepsy. Few studies have addressed the effect of chronic partial sleep deprivation on seizure occurrence in populations with epilepsy. We tested the primary hypothesis that partial sleep deprivation over 24- and 72-hour periods increases seizure occurrence in adults with epilepsy.

METHODS

Forty-four subjects completed a series of self-reported instruments, as well as 1-month sleep and seizure diaries, to characterize their sleep and quality of life. Diaries were used to determine the relationship between seizure occurrence and total sleep time 24 and 72h before seizure occurrence using random effects models and a logistic regression model fit by generalized estimating equations.

RESULTS

A total of 237 seizures were recorded during 1295 diary days, representing 5.5±7.0 (mean±SD) seizures per month. Random effects models for 24- and 72-hour total sleep times showed no clinically or statistically significant differences in the total sleep time between preseizure periods and seizure-free periods. The average 24-hour total sleep time during preseizure 24-hour periods was 8min shorter than that during seizure-free periods (p=0.51). The average 72-hour total sleep time during preseizure periods was 20min longer than that during seizure-free periods (p=0.86). The presence of triggers was a significant predictor of seizure occurrence, with stress/anxiety noted most often as a trigger. Mean total sleep time was 9h, and subjects took an average of 12±10 naps per month, having a mean duration of 1.9±1.2h. Daytime sleepiness, fatigue, and insomnia symptoms were commonly reported.

CONCLUSIONS

Small degrees of sleep loss were not associated with seizure occurrence in our sample of adults with epilepsy. Our results also include valuable observations of the altered sleep times and frequent napping habits of adults with refractory epilepsy and the potential contribution of these habits to quality of life and seizure control.

A systems approach to stress, stressors and resilience in humans

The paper focuses on the biology of stress and resilience and their biomarkers in humans from the system science perspective. A stressor pushes the physiological system away from its baseline state toward a lower utility state. The physiological system may return toward the original state in one attractor basin but may be shifted to a state in another, lower utility attractor basin. While some physiological changes induced by stressors may benefit health, there is often a chronic wear and tear cost due to implementing changes to enable the return of the system to its baseline state and maintain itself in the high utility baseline attractor basin following repeated perturbations. This cost, also called allostatic load, is the utility reduction associated with both a change in state and with alterations in the attractor basin that affect system responses following future perturbations. This added cost can increase the time course of the return to baseline or the likelihood of moving into a different attractor basin following a perturbation. Opposite to this is the system's resilience which influences its ability to return to the high utility attractor basin following a perturbation by increasing the likelihood and/or speed of returning to the baseline state following a stressor. This review paper is a qualitative systematic review; it covers areas most relevant for moving the stress and resilience field forward from a more quantitative and neuroscientific perspective.

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

The present proof-of-concept study investigated the feasibility of skin conductance biofeedback training in reducing seizures in adults with drug-resistant temporal lobe epilepsy (TLE), whose seizures are triggered by stress. Skin conductance biofeedback aims to increase levels of peripheral sympathetic arousal in order to reduce cortical excitability. This might seem somewhat counterintuitive, since such autonomic arousal may also be associated with increased stress and anxiety. Thus, this sought to verify that patients with TLE and stress-triggered seizures are not worsened in terms of stress, anxiety, and negative emotional response to this nonpharmacological treatment. Eleven patients with drug-resistant TLE with seizures triggered by stress were treated with 12 sessions of biofeedback. Patients did not worsen on cognitive evaluation of attentional biases towards negative emotional stimuli (P>.05) or on psychometric evaluation with state anxiety inventory (P = .059); in addition, a significant improvement was found in the Negative Affect Schedule (P = .014) and in the Beck Depression Inventory (P = .009). Biofeedback training significantly reduced seizure frequency with a mean reduction of -48.61% (SD = 27.79) (P = .005). There was a correlation between the mean change in skin conductance activity over the biofeedback treatment and the reduction of seizure frequency (r(11) = .62, P = .042). Thus, the skin conductance biofeedback used in the present study, which teaches patients to achieve an increased level of peripheral sympathetic arousal, was a well-tolerated nonpharmacological treatment. Further, well-controlled studies are needed to confirm the therapeutic value of this nonpharmacological treatment in reducing seizures in adults with drug-resistant TLE with seizures triggered by stress.

Psychobehavioral therapy for epilepsy

Growing evidence suggests a bidirectional interaction between epileptic seizures and psychological states, fuelling the interest in the development and application of psychobehavioral therapy for people with epilepsy (PWE). The objective of this article is to review the various psychobehavioral therapies in regard to their application, hypothesized mechanisms, and effectiveness. Most psychobehavioral therapy aims at improving psychological well-being and seizure control. Behavioral approaches, cognitive-behavioral therapy (CBT), and mind-body interventions are the most widely applied approaches for PWE. Cognitive-behavioral therapy, mind-body approaches, and multimodel educative interventions have consistently demonstrated positive effects on enhancing well-being. Nevertheless, the effects on seizure control remain inconsistent, partly attributable to small clinical trials and inadequate control groups. Assessor-blinded randomized controlled trials with sufficient power and carefully defined therapeutic components corresponding with objective and subjective outcome measures are recommended for future trial designs.

Early-life stress impacts the developing hippocampus and primes seizure occurrence: cellular, molecular, and epigenetic mechanisms

Early-life stress includes prenatal, postnatal, and adolescence stress. Early-life stress can affect the development of the hypothalamic-pituitary-adrenal (HPA) axis, and cause cellular and molecular changes in the developing hippocampus that can result in neurobehavioral changes later in life. Epidemiological data implicate stress as a cause of seizures in both children and adults. Emerging evidence indicates that both prenatal and postnatal stress can prime the developing brain for seizures and an increase in epileptogenesis. This article reviews the cellular and molecular changes encountered during prenatal and postnatal stress, and assesses the possible link between these changes and increases in seizure occurrence and epileptogenesis in the developing hippocampus. In addititon, the priming effect of prenatal and postnatal stress for seizures and epileptogenesis is discussed. Finally, the roles of epigenetic modifications in hippocampus and HPA axis programming, early-life stress, and epilepsy are discussed.