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

Comparative study of perceived invalidating environment and stress coping strategies between patients with drug resistant epilepsy and functional dissociative seizures

BACKGROUND AND OBJECTIVES

We investigated perceived invalidating environment during childhood and stress-coping strategies in patients with; functional dissociative seizures (FDS, n=26), drug-resistant epilepsy patients with no psychiatric comorbidity (DREnc, n=23), and drug-resistant epilepsy patients with psychiatric comorbidity (DREpc, n=34).

DESIGN/METHODS

We performed a cross-sectional study. Patients underwent Video Electroencephalography to confirm the diagnosis and completed a psychiatric assessment supported by clinical instruments. Invalidating environment and stress coping were studied through the ICES and CAE questionaries, respectively. A series of multinomial logistic regression analyses were performed with the explored variables.

RESULTS

The maternal negative response model predicted a higher probability of FDS condition. A chaotic family type increased the likelihood of DREpc instead of FDS. DREpc and FDS patients displayed many different behaviors to cope with stress other than trying to solve the problem, the most used strategy in the DREnc group. Parental invalidation was higher in DREpc than in FDS.

CONCLUSIONS

Our results deepen the data provided by previous studies indicating that multiple variables of biosocial origin have significant effects on these groups of patients. The presence of an invalidating environment may predict FDS but also the presence of psychiatric disorders among DRE. Psychotherapeutic strategies to enhance these variables might be necessary for this population.

Peri-ictal activation of dorsomedial dorsal raphe serotonin neurons reduces mortality associated with maximal electroshock seizures

Over one-third of patients with epilepsy will develop refractory epilepsy and continue to experience seizures despite medical treatment. These patients are at the greatest risk for sudden unexpected death in epilepsy. The precise mechanisms underlying sudden unexpected death in epilepsy are unknown, but cardiorespiratory dysfunction and arousal impairment have been implicated. Substantial circumstantial evidence suggests serotonin is relevant to sudden unexpected death in epilepsy as it modulates sleep/wake regulation, breathing and arousal. The dorsal raphe nucleus is a major serotonergic center and a component of the ascending arousal system. Seizures disrupt the firing of dorsal raphe neurons, which may contribute to reduced responsiveness. However, the relevance of the dorsal raphe nucleus and its subnuclei to sudden unexpected death in epilepsy remains unclear. The dorsomedial dorsal raphe may be a salient target due to its role in stress and its connections with structures implicated in sudden unexpected death in epilepsy. We hypothesized that optogenetic activation of dorsomedial dorsal raphe serotonin neurons in TPH2-ChR2-YFP (n = 26) mice and wild-type (n = 27) littermates before induction of a maximal electroshock seizure would reduce mortality. In this study, pre-seizure activation of dorsal raphe nucleus serotonin neurons reduced mortality in TPH2-ChR2-YFP mice with implants aimed at the dorsomedial dorsal raphe. These results implicate the dorsomedial dorsal raphe in this novel circuit influencing seizure-induced mortality. It is our hope that these results and future experiments will define circuit mechanisms that could ultimately reduce sudden unexpected death in epilepsy.

Psychological precursors of epileptic seizures

Psychological stress is the most commonly self-reported precursor of epileptic seizures. However, retrospective and prospective studies remain inconclusive in this regard. Here, we explored whether seizures would be preceded by significant changes in reported stressors or resource utilization. This study is based on high-frequency time series through daily online completion of personalized questionnaires of 9-24 items in epilepsy outpatients and compared responses 1-14 days before seizures with interictal time series. Fourteen patients (79% women, age = 23-64 years) completed daily questionnaires over a period of 87-898 days (median = 277 days = 9.2 months). A total of 4560 fully completed daily questionnaires were analyzed, 685 of which included reported seizure events. Statistically significant changes in preictal compared to interictal dynamics were found in 11 of 14 patients (79%) across 41 items (22% of all 187 items). In seven of 14 patients (50%), seizures were preceded by a significant mean increase of stressors and/or a significant mean decrease of resource utilization. This exploratory analysis of long-term prospective individual patient data on specific stressors and personal coping strategies generates the hypothesis that medium-term changes in psychological well-being may precede the occurrence of epileptic seizures in some patients.

First unprovoked seizures among soldiers recruited to the Israeli Defense Forces during 10 consecutive years: A population-based study

OBJECTIVE

The management of patients after a first unprovoked seizure (FUS) can benefit from stratification of the average 50% risk for further seizures. We characterized subjects with FUSs, out of a large generally healthy homogenous population of soldiers recruited by law to the Israeli Defense Forces, to investigate the role of the type of service, as a trigger burden surrogate, in the risk for additional seizures.

METHODS

Soldiers recruited between 2005 and 2014, who experienced an FUS during their service, were identified from military records. Subjects with a history of epilepsy or lack of documentation of FUS characteristics were excluded from the study. Data on demographics and military service and medical details were extracted for the eligible soldiers.

RESULTS

Of 816 252 newly recruited soldiers, representing 2 138 000 person-years, 346 had an FUS, indicating an incidence rate of 16.2 per 100 000 person-years. The FUS incidence rate was higher in combat versus noncombat male and female soldiers (p < .0001). Most subjects (75.7%) were prescribed antiseizure medications (ASMs), and 29.2% had additional seizures after the FUS. Service in combat units, abnormal magnetic resonance imaging, and being prescribed ASMs were correlated with a lower risk of having multiple seizures (95% confidence interval [CI] = .48-.97, .09-.86, .15-.28, respectively). On multivariate analysis, service in combat units (odds ratio [OR] = .48 for seizure recurrence, 95% CI = .26-.88) and taking medications (OR = .46, 95% CI = .24-.9) independently predicted not having additional seizures.

SIGNIFICANCE

FUS incidence rate was higher in combat soldiers, but they had a twofold lower risk of additional seizures than noncombat soldiers, emphasizing the value of strenuous triggers as negative predictors for developing epilepsy. This suggests a shift in the perception of epilepsy from a "yes or no" condition to a continuous trend of predisposition to seizures, warranting changes in the ways etiologies of epilepsy are weighted and treatments are delivered.

Intravenous perampanel as an alternative to the oral formulations in Japanese patients with epilepsy

OBJECTIVE

Perampanel is an oral anti-seizure medication, which is approved in Japan for focal-onset seizures, with/without focal to bilateral tonic-clonic seizures, as monotherapy/adjunctive therapy in patients aged 4 years and older. Treatment for generalized tonic-clonic seizures as adjunctive therapy in patients aged 12 years and older is approved as well. We evaluated the feasibility of intravenous (IV) administration of perampanel as an alternative to oral administration.

METHODS

Study 240 (NCT03754582) was an uncontrolled, open-label study of IV perampanel, conducted in 21 Japanese patients with epilepsy who received a stable dose of 8-12 mg/day of oral perampanel. Patients received 30-minute IV infusions at equivalent daily doses of oral perampanel for 4 days, then were switched back to oral perampanel. Safety, tolerability, plasma concentration, and maintenance of efficacy throughout the transition between IV and oral dosing of perampanel were assessed. As supportive data, a subgroup analysis was also conducted using data from healthy Japanese subjects (n = 18) who were enrolled in Study 050 (NCT03376997) investigating the pharmacokinetics and safety of IV perampanel in healthy subjects who received an IV infusion (30-, 60-, or 90-minute) of perampanel 12 mg and a single oral administration of perampanel 12-mg tablet.

RESULTS

In Study 240, the transition between 30-minute IV and oral perampanel dosing was associated with a ≤1.4-fold increase in the mean change in maximum observed concentration of perampanel. Seizure outcomes demonstrated no considerable changes in efficacy before, during, or after 30-minute IV dosing of perampanel. The safety profiles were similar between IV and oral formulations. In Study 050, the pharmacokinetics of 30- or 60-minute IV infusion of perampanel further support the interchangeability between oral and IV formulations in the Japanese subjects.

SIGNIFICANCE

These results support that 30-minute IV perampanel may be a potential short-term alternative to oral formulations for patients with epilepsy.

Stress and Epilepsy: Towards Understanding of Neurobiological Mechanisms for Better Management

Stress has been identified as a major contributor to human disease and is postulated to play a substantial role in epileptogenesis. In a significant proportion of individuals with epilepsy, sensitivity to stressful events contributes to dynamic symptomatic burden, notably seizure occurrence and frequency, and presence and severity of psychiatric comorbidities [anxiety, depression, posttraumatic stress disorder (PTSD)]. Here, we review this complex relationship between stress and epilepsy using clinical data and highlight key neurobiological mechanisms including the hypothalamic-pituitary-adrenal (HPA) axis dysfunction, altered neuroplasticity within limbic system structures, and alterations in neurochemical pathways such as brain-derived neurotrophic factor (BNDF) linking epilepsy and stress. We discuss current clinical management approaches of stress that help optimize seizure control and prevention, as well as psychiatric comorbidities associated with epilepsy. We propose that various shared mechanisms of stress and epilepsy present multiple avenues for the development of new symptomatic and preventative treatments, including disease modifying therapies aimed at reducing epileptogenesis. This would require close collaborations between clinicians and basic scientists to integrate data across multiple scales, from genetics to systems biology, from clinical observations to fundamental mechanistic insights. In future, advances in machine learning approaches and neuromodulation strategies will enable personalized and targeted interventions to manage and ultimately treat stress-related epileptogenesis.

Seizure-related stress and arousal responses mediate a relationship between anxiety trait and state in epilepsy

BACKGROUND

Epilepsy causes substantial psychological distress and anxiety, primarily due to seizures. However, the impact of stress responses and changes in arousal and their association with anxiety patterns in patients with epilepsy (PWE) remains unclear. This study aimed to investigate the relationships among seizures, stress and arousal characteristics, and trait and state anxiety characteristics in PWE.

METHODS

Our sample consisted of 159 outpatients with epilepsy recruited from five institutions in Japan in 2020. Participants completed the State-Trait Anxiety Inventory-Form JYZ (STAI) and the Japanese-Stress Arousal Check List (J-SACL). We analyzed the correlations between inventory scores and clinical information. Using principal component analysis (PCA), we derived epilepsy-specific stress/arousal characteristics, which accounted for high arousal and low-stress levels, termed epilepsy-specific stress or arousal response (ESAR), from the J-SACL scores. We conducted a mediation analysis to assess the mediating role of ESAR in the relationship between traits and state anxiety.

RESULTS

We found significant correlations between J-SACL stress and arousal factors (r = -0.845, p < 0.001), ESAR and seizure frequency (r = -0.29, p < 0.001), ESAR and trait anxiety scores on the STAI (r = -0.77, p < 0.0001), and ESAR and state anxiety scores on the STAI (r = -0.60, p < 0.0001). Mediation analysis supported by the Monte Carlo method revealed that ESAR significantly mediated the association between trait and state anxiety.

CONCLUSIONS

These findings elucidate the epilepsy-specific stress and arousal characteristics and their roles in mediating traits and state anxiety. These results may reflect the long-term clinical course and unique emotion recognition tendencies in epilepsy.

Virtual Reality Therapy for People With Epilepsy and Related Anxiety: Protocol for a 3-Phase Pilot Clinical Trial

BACKGROUND

Anxiety is one of the most common psychiatric comorbidities in people with epilepsy and often involves fears specifically related to the condition, such as anxiety related to the fear of having another seizure. These epilepsy- or seizure-related fears have been reported as being more disabling than the seizures themselves and significantly impact quality of life. Although research has suggested that exposure therapy (ET) is helpful in decreasing anxiety in people with epilepsy, no research to our knowledge has been conducted on ET in people with epilepsy using virtual reality (VR). The use of novel technologies such as an immersive VR head-mounted display for ET in this population offers several benefits. Indeed, using VR can increase accessibility for people with epilepsy with transportation barriers (eg, those who live outside urban centers or who have a suspended driver's license owing to their condition), among other advantages. In the present research protocol, we describe the design of an innovative VR-ET program administered in the home that focuses on decreasing anxiety in people with epilepsy, specifically anxiety related to their epilepsy or seizures.

OBJECTIVE

Our primary objective is to examine the feasibility of the study protocol and proposed treatment as well as identify suggestions for improvement when designing subsequent larger clinical trials. Our secondary objective is to evaluate whether VR-ET is effective in decreasing anxiety in a pilot study. We hypothesize that levels of anxiety in people with epilepsy will decrease from using VR-ET.

METHODS

This mixed methods study comprises 3 phases. Phase 1 involves engaging with those with lived experience through a web-based questionnaire to validate assumptions about anxiety in people with epilepsy. Phase 2 involves filming videos using a 360° camera for the VR-ET intervention (likely consisting of 3 sets of scenes, each with 3 intensity levels) based on the epilepsy- and seizure-related fears most commonly reported in the phase 1 questionnaire. Finally, phase 3 involves evaluating the at-home VR-ET intervention and study methods using a series of validated scales, as well as semistructured interviews.

RESULTS

This pilot study was funded in November 2021. Data collection for phase 1 was completed as of August 7, 2022, and had a final sample of 18 participants.

CONCLUSIONS

Our findings will add to the limited body of knowledge on anxiety in people with epilepsy and the use of VR in this population. We anticipate that the insights gained from this study will lay the foundation for a novel and accessible VR intervention for this underrecognized and undertreated comorbidity in people with epilepsy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05296057; https://clinicaltrials.gov/ct2/show/NCT05296057.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/41523.

The impact of early-life environment on absence epilepsy and neuropsychiatric comorbidities

This review discusses the long-term effects of early-life environment on epileptogenesis, epilepsy, and neuropsychiatric comorbidities with an emphasis on the absence epilepsy. The WAG/Rij rat strain is a well-validated genetic model of absence epilepsy with mild depression-like (dysthymia) comorbidity. Although pathologic phenotype in WAG/Rij rats is genetically determined, convincing evidence presented in this review suggests that the absence epilepsy and depression-like comorbidity in WAG/Rij rats may be governed by early-life events, such as prenatal drug exposure, early-life stress, neonatal maternal separation, neonatal handling, maternal care, environmental enrichment, neonatal sensory impairments, neonatal tactile stimulation, and maternal diet. The data, as presented here, indicate that some early environmental events can promote and accelerate the development of absence seizures and their neuropsychiatric comorbidities, while others may exert anti-epileptogenic and disease-modifying effects. The early environment can lead to phenotypic alterations in offspring due to epigenetic modifications of gene expression, which may have maladaptive consequences or represent a therapeutic value. Targeting DNA methylation with a maternal methyl-enriched diet during the perinatal period appears to be a new preventive epigenetic anti-absence therapy. A number of caveats related to the maternal methyl-enriched diet and prospects for future research are discussed.

Felt stigma may potentiate the relationship between perceived stress and depressive symptoms in persons with epilepsy

PURPOSE

This study assessed the strengths of association among perceived stress, felt stigma, and depression in adults with epilepsy, and evaluated whether felt stigma altered the association between perceived stress and depression.

METHODS

This multicenter, cross-sectional study included adults with epilepsy. Depression was assessed using the Beck Depression Inventory (BDI), and perceived stress was evaluated using the 10-item Perceived Stress Scale. Felt stigma was determined using the three-item Stigma Scale for Epilepsy, with individuals categorized as positive for felt stigma if they answered "yes" to at least one of these items. A hierarchical linear regression analysis and an analysis of covariance with interaction terms were performed.

RESULTS

The 316 adults with epilepsy included 171 men and 145 women; of these, 109 (34.5%) reported felt stigma. A hierarchical linear regression analysis showed that perceived stress was the most important correlate of depressive symptoms, followed by felt stigma, being unemployed, recurrence of generalized or focal to bilateral tonic-clonic seizures, and being married. The model explained 54.0% of the variance of BDI scores. Significant interactions between felt stigma and perceived stress on BDI scores was identified in both crude and adjusted models (p < 0.05 each). Specifically, in an adjusted model, BDI scores were more strongly associated with perceived stress in persons with (p < 0.001, partial eta² = 0.225) than without (p < 0.001, partial eta² = 0.205) felt stigma.

CONCLUSIONS

Perceived stress was the most significant correlate of depressive symptoms in adults with epilepsy, followed by felt stigma. The interaction between perceived stress and felt stigma on depressive symptoms was significant. These findings may help in developing cognitive behavioral therapy for stigma and stress management in persons with epilepsy.

Perceived stress, resilience, and stress coping in patients with drug resistant epilepsy and functional dissociative seizures

PURPOSE

Depression and anxiety are psychiatric disorders related to chronic stress, commonly found in patients with drug-resistant epilepsy (DRE) and functional dissociative seizures (FDS). The present study compares the levels of perceived stress, resilience, and the styles of stress coping among patients with DRE (n=60), FDS (n=28), and controls (n=31).

METHODS

We performed a cross-sectional study. All patients underwent Video Electroencephalography to confirm the diagnosis and completed the psychiatric assessment (SCID I and II of DSM IV) supported by several instruments validated in Spanish.

RESULTS

FDS scored higher in perceived stress (p = 0.004) with lower levels of resilience compared to controls (p = 0.01). Stress coping subscales show higher scores in negative self-focus and hostility in patients with FDS compared to controls (p=0.003). Similarly, DRE patients scored higher in perceived stress (p = 0.001), and presented lower levels of resilience (p = 0.004) with higher levels of hostility compared to controls (p=0.02). However, no significant differences were found between FDS and DRE on stress coping variables. Anxiety scores and depression rates were higher in the FDS group compared to DRE (p=0.008) and higher in DRE compared to controls (p<0.05). A positive correlation between depression and perceived stress was found (r = 0.6, p=0.0001).

CONCLUSIONS

Our results delineate a more detailed picture of the psychological profile of this population, emphasizing the importance of stress factors in patients with FDS and DRE. Combined intervention strategies which enhance stress coping may be appropriate to direct treatment and psychotherapy.

DFP-Induced Status Epilepticus Severity in Mixed-Sex Cohorts of Adult Rats Housed in the Same Room: Behavioral and EEG Comparisons

Sex is a biological variable in experimental models. In our previous diisopropylfluorophosphate (DFP) studies, female rats required a higher dose of DFP to achieve a somewhat similar severity of status epilepticus (SE) as males. In those studies, male and female rats were bought separately from the same vendor, housed in different rooms, and the DFP used was from different batches. We had also shown that surgery for epidural electrodes implantation reduces the threshold for SE. Our recent study in the soman (GD) model using a mixed-sex cohort of rats housed individually but in the same room showed that females achieved significantly higher SE severity than males for the same dose of GD. In this study, we demonstrate that housing the mixed-sex cohorts in the same room and treating them with DFP (4 mg/kg, s.c.) from the same pool, though from different batches, yielded reproducible SE severity in both sexes and both telemetry (surgery) and non-telemetry (non-surgery) groups. We conducted experiments in four mixed-sex cohorts of adult Sprague-Dawley rats. In females, the surgery for implanting the telemetry devices reduced the latency to convulsive seizure (CS) and increased SE severity compared to non-telemetry females. However, there were no sex differences in latency or SE severity within telemetry or non-telemetry groups. Once animals reached CS stage ≥3, they remained in CS stage in both sexes until midazolam was administered. Midazolam (3 mg/kg, i.m.) treatment 1-one-hour post-DFP significantly reduced epileptiform spikes in both sexes. The mortality was only 2% in 24 h. Irrespective of sex or stage of estrous cycle or surgery, the animals had continuous convulsive SE for ∼40 min. In telemetry rats, electrographic changes correlated with behavioral seizures. However, there was a significant difference in SE severity and the latency between directly-observed behavioral CS and EEG-based CS quantification in both sexes. Overall, these results suggest that housing both sexes in the same room and treating with DFP in a mixed-sex cohort from the same pool of reagents will minimize variability in SE severity. Such rigorous experiments will yield better outcomes while testing disease-modifying agents in epilepsy models.

Use of Interval Therapy with Benzodiazepines to Prevent Seizure Recurrence in Stressful Situations

Introduction: Antiseizure medications (ASMs) control 70–75% of seizures. Accepting stress as a trigger for seizures, intervention, at the time of predictable stress, should offer a therapeutic option. Mode of intervention: Intervention requires the maintenance of an accurate seizure diary to identify a recurring pattern. With a questioning approach to that diary, the clinician may intervene when stressful provocateurs occur. Benzodiazepines, such as clobazam, initiated prior to the predictable stress, and continued until after it has passed, should be short lived, making serious adverse effects unlikely. Benzodiazepines have a dual benefit, being both anxietolytic and raising the seizure threshold in patients with epilepsy. Discussion: Many patients claim stress provokes their seizures and may not be aware the stress was the provocateur, until after a seizure occurred, leading to a retrospective claim of the relationship. To confirm the relationship, permitting preventative measures, before exposure to provocative factors, often unable to be avoided, requires maintenance and review of a detailed diary. Interval temporary use of benzodiazepines, such as clobazam, or alternatively clonazepam, diazepam or nitrazepam, offers a reasonable response to obviate subsequent seizures, and should be continued, for a brief period, after the risk has abated. Subsequent review of the diary, over a period of repeated exposures to the identified stress, will confirm or refute the therapeutic effect. Conclusion: Judicious use of interval therapy, with one of the benzodiazepines, covering the period of stressful provocation, offers adjunctive treatment of possible refractory epilepsy, based upon the review of the strictly maintained epilepsy/seizure diary.

Seizure triggers identified postictally using a smart watch reporting system

Persons with epilepsy (PWE) often report that seizure triggers can influence the occurrence and timing of seizures. Some previous studies of seizure triggers have relied on retrospective daily seizure diaries or surveys pertaining to all past seizures, recent and/or remote, in respondents. To assess the characteristics of seizure triggers at the granularity of individual seizures, we used a seizure-tracking app, called EpiWatch, on a smart watch system (Apple Watch and iPhone) in a national study of PWE. Participants tracked seizures during a 16-month study period using the EpiWatch app. Seizure tracking was initiated during a pre-ictal state or as the seizure was occurring and included collection of biosensor data, responsiveness testing, and completion of an immediate post-seizure survey. The survey evaluated seizure types, auras or warning symptoms, loss of awareness, use of rescue medication, and seizure triggers for each tracked seizure. Two hundred and thirty four participants tracked 2493 seizures. Ninety six participants reported triggers in 650 seizures: stress (65.8%), lack of sleep (30.5%), menstrual cycle (19.7%), and overexertion (18%) were the most common. Participants often reported having multiple combined triggers, frequent stress with lack of sleep, overexertion, or menses. Participants who reported triggers were more likely to be taking 3 or more anti-seizure medications compared to participants who did not report triggers. Participants were able to interact with the app and use mobile technology in this national study to record seizures and report common seizure triggers. These findings demonstrate the promise of longitudinal, self-reported data to improve our understanding of epilepsy and its related comorbidities.

Early Impact of the COVID-19 Pandemic on Outpatient Neurologic Care in Hawai'i

In March 2020, Hawai'i instituted public health measures to prevent the spread of Coronavirus disease 2019 (COVID-19), including stay-at-home orders, closure of non-essential businesses and parks, use of facial coverings, social distancing, and a mandatory 14-day quarantine for travelers. In response to these measures, Hawai'i Pacific Neuroscience (HPN) modified practice processes to ensure continuity of neurological treatment. A survey of patients was performed to assess the impact of the COVID-19 pandemic and pandemic-related practice processes for quality improvement. Overall, 367 patients seen at HPN between April 22, 2020, and May 18, 2020, were surveyed via telephone. Almost half (49.6%) participated in a telemedicine appointment, with the majority finding it easy to use (87.4%) and as valuable as face-to-face appointments (68.7%). Many (44.5%) patients said they would have missed a health care appointment without the availability of telemedicine, and 47.3% indicated they might prefer to use telemedicine over in-person appointments in the future. Many reported new or worsening mental health problems, including depression (27.6%), anxiety (38.3%), or sleep disturbances (37.4%). A significant number reported worsening of their condition, with 33.1% of patients who experience migraines reporting increased symptom severity or frequency, 45.8% patients with Alzheimer's disease reporting worsened symptoms, 38.5% of patients with Parkinson's disease who had a recent fall, and 50.0% of patients with multiple sclerosis experiencing new or worsened symptoms. Insights from this survey applied to the practice's pandemic-related processes include emphasizing lifestyle modification, screening for changes in mental health, optimizing treatment plans, and continuing the option of telemedicine.

Mutants of the Zebrafish K+ Channel Hcn2b Exhibit Epileptic-like Behaviors

Epilepsy is a chronic neurological disorder that affects 50 million people worldwide. The most common form of epilepsy is idiopathic, where most of the genetic defects of this type of epilepsy occur in ion channels. Hyperpolarization-activated cyclic nucleotide-gated (HCN) channels are activated by membrane hyperpolarization, and are mainly expressed in the heart and central and peripheral nervous systems. In humans, four HCN genes have been described, and emergent clinical data shows that dysfunctional HCN channels are involved in epilepsy. Danio rerio has become a versatile organism to model a wide variety of diseases. In this work, we used CRISPR/Cas9 to generate hcn2b mutants in zebrafish, and characterized them molecularly and behaviorally. We obtained an hcn2b mutant allele with an 89 bp deletion that produced a premature stop codon. The mutant exhibited a high mortality rate in its life span, probably due to its sudden death. We did not detect heart malformations or important heart rate alterations. Absence seizures and moderate seizures were observed in response to light. These seizures rarely caused instant death. The results show that mutations in the Hcn2b channel are involved in epilepsy and provide evidence of the advantages of zebrafish to further our understanding of the pathogenesis of epilepsy.

Case Report: Hypopituitarism Presenting With Nonconvulsive Status Epilepticus

Introduction: Hypopituitarism is defined as one or more partial or complete pituitary hormone deficiencies. Nonconvulsive status epilepticus (NCSE) refers to a state of continuous or repetitive seizures without convulsions. In this paper, we review a case of an old female patient with hypopituitarism who presented with NCSE, which is rare in the clinic.

Case Report: This paper describes a 67-year-old female patient with hypopituitarism who presented as NCSE. She had surgical resection of pituitary tumor half a year before the seizures and did not get regular hormone replacement therapy. She presented general convulsive status epilepsy as the initial symptom and got sedation and antiepileptic drug in the emergency room. The seizure was terminated but the patient fell in coma in the following days. The patient had magnetic resonance imaging (MRI) and other inspects, and EEG showed epileptic discharges. Combining these clinical symptoms and examinations, we made the diagnosis of NCSE. Finally, she regained consciousness after the treatment with diazepam.

Conclusion: This case report and literature review investigated the possible mechanism of hypopituitarism presenting with NCSE.

Stress-Associated Molecular and Cellular Hippocampal Mechanisms Common for Epilepsy and Comorbid Depressive Disorders

The review discusses molecular and cellular mechanisms common to the temporal lobe epileptogenesis/epilepsy and depressive disorders. Comorbid temporal lobe epilepsy and depression are associated with dysfunction of the hypothalamic-pituitary-adrenocortical axis. Excessive glucocorticoids disrupt the function and impair the structure of the hippocampus, a brain region key to learning, memory, and emotions. Selective vulnerability of the hippocampus to stress, mediated by the reception of glucocorticoid hormones secreted during stress, is the price of the high functional plasticity and pleiotropy of this limbic structure. Common molecular and cellular mechanisms include the dysfunction of glucocorticoid receptors, neurotransmitters, and neurotrophic factors, development of neuroinflammation, leading to neurodegeneration and loss of hippocampal neurons, as well as disturbances in neurogenesis in the subgranular neurogenic niche and formation of aberrant neural networks. These glucocorticoid-dependent processes underlie altered stress response and the development of chronic stress-induced comorbid pathologies, in particular, temporal lobe epilepsy and depressive disorders.

Past Trauma Is Associated With a Higher Risk of Experiencing an Epileptic Seizure as Traumatic in Patients With Pharmacoresistant Focal Epilepsy

Objective: The present study aimed to evaluate the prevalence of traumatic experienced seizures (TES) and of postepileptic seizure PTSD (PS-PTSD) in patients with pharmacoresistant focal epilepsy and to explore the determining factors of TES.

Methods: We conducted an observational study enrolling 107 adult refractory epilepsy patients. We used the DSM-5 criteria of traumatic events and PTSD to define TES and PS-PTSD. We assessed all traumatic life events unrelated to epilepsy, general and specific psychiatric comorbidities, and quality of life.

Results: Nearly half (n = 48) of the 107 participants reported at least one TES (44.85%). Among these, one-third (n = 16) developed PS-PTSD. The TES group was more likely to experience traumatic events unrelated to epilepsy (p < 0.001), to have generalized anxiety disorder (p = 0.019), and to have specific psychiatric comorbidities [e.g., interictal dysphoric disorder (p = 0.024) or anticipatory anxiety of seizures (p = 0.005)]. They reported a severe impact of epilepsy on their life (p = 0.01). The determining factors of TES according to the multifactorial model were the experience of trauma (p = 0.008), a history of at least one psychiatric disorder (p = 0.03), and a strong tendency toward dissociation (p = 0.03).

Significance: Epileptic seizures may be a traumatic experience in some patients who suffer from pharmacoresistant epilepsy and may be the source of the development of PS-PTSD. Previous trauma unrelated to epilepsy and psychiatric history are determining factors of TES. These clinical entities should be explored systematically.

Impact of Stress on Epilepsy: Focus on Neuroinflammation-A Mini Review

Epilepsy, one of the most common neurological disorders worldwide, is characterized by recurrent seizures and subsequent brain damage. Despite strong evidence supporting a deleterious impact on seizure occurrence and outcome severity, stress is an overlooked component in people with epilepsy. With regard to stressor duration and timing, acute stress can be protective in epileptogenesis, while chronic stress often promotes seizure occurrence in epilepsy patients. Preclinical research suggests that chronic stress promotes neuroinflammation and leads to a depressive state. Depression is the most common psychiatric comorbidity in people with epilepsy, resulting in a poor quality of life. Here, we summarize studies investigating acute and chronic stress as a seizure trigger and an important factor that worsens epilepsy outcomes and psychiatric comorbidities. Mechanistic insight into the impact of stress on epilepsy may create a window of opportunity for future interventions targeting neuroinflammation-related disorders.

Understanding Sunflower syndrome: Results of an online questionnaire

OBJECTIVE

To characterize the clinical phenotype, treatments, and impact on quality of life of Sunflower syndrome.

METHODS

A 138-question survey was created focusing on seizure description, disease course, treatment history, medical history, family history, and aspects of quality of life of individuals with Sunflower syndrome. The survey was administered to individuals with Sunflower syndrome who experience hand waving episodes (HWE) and/or their caregivers via Research Electronic Data Capture (REDCap).

RESULTS

Sixty-eight responses were included in analysis. Seventy-one% of respondents were female. The mean age of participants was 13.6 years, with 84% of respondents under the age of 18. The average age of onset of HWE was 6.7 years. HWE frequency varied from a few episodes per week to multiple episodes per hour. Sixty-two% of participants experienced other seizure types. Participants had been on an average of 1.9 anti-seizure medications with varying efficacy. Other methods to reduce HWE included wearing a hat or sunglasses, hand holding, using special tinted lenses, and avoiding the sun and bright lights. Sixty-nine% of participants reported anxiety or depression related to their epilepsy, and 65% said their HWE affected their social life.

SIGNIFICANCE

Sunflower syndrome is a highly stereotyped, refractory epilepsy which significantly impacts the lives of affected individuals. It remains underrecognized and poorly understood. These results characterize Sunflower syndrome in a large population of affected individuals and provides a basis for future research to better understand the epilepsy and improve clinical care.

Remote and Long-Term Self-Monitoring of Electroencephalographic and Noninvasive Measurable Variables at Home in Patients With Epilepsy (EEG@HOME): Protocol for an Observational Study

Background

Epileptic seizures are spontaneous events that severely affect the lives of patients due to their recurrence and unpredictability. The integration of new wearable and mobile technologies to collect electroencephalographic (EEG) and extracerebral signals in a portable system might be the solution to prospectively identify times of seizure occurrence or propensity. The performances of several seizure detection devices have been assessed by validated studies, and patient perspectives on wearables have been explored to better match their needs. Despite this, there is a major gap in the literature on long-term, real-life acceptability and performance of mobile technology essential to managing chronic disorders such as epilepsy.

Objective

EEG@HOME is an observational, nonrandomized, noninterventional study that aims to develop a new feasible procedure that allows people with epilepsy to independently, continuously, and safely acquire noninvasive variables at home. The data collected will be analyzed to develop a general model to predict periods of increased seizure risk.

Methods

A total of 12 adults with a diagnosis of pharmaco-resistant epilepsy and at least 20 seizures per year will be recruited at King’s College Hospital, London. Participants will be asked to self-apply an easy and portable EEG recording system (ANT Neuro) to record scalp EEG at home twice daily. From each serial EEG recording, brain network ictogenicity (BNI), a new biomarker of the propensity of the brain to develop seizures, will be extracted. A noninvasive wrist-worn device (Fitbit Charge 3; Fitbit Inc) will be used to collect non-EEG biosignals (heart rate, sleep quality index, and steps), and a smartphone app (Seer app; Seer Medical) will be used to collect data related to seizure occurrence, medication taken, sleep quality, stress, and mood. All data will be collected continuously for 6 months. Standardized questionnaires (the Post-Study System Usability Questionnaire and System Usability Scale) will be completed to assess the acceptability and feasibility of the procedure. BNI, continuous wrist-worn sensor biosignals, and electronic survey data will be correlated with seizure occurrence as reported in the diary to investigate their potential values as biomarkers of seizure risk.

Results

The EEG@HOME project received funding from Epilepsy Research UK in 2018 and was approved by the Bromley Research Ethics Committee in March 2020. The first participants were enrolled in October 2020, and we expect to publish the first results by the end of 2022.

Conclusions

With the EEG@HOME study, we aim to take advantage of new advances in remote monitoring technology, including self-applied EEG, to investigate the feasibility of long-term disease self-monitoring. Further, we hope our study will bring new insights into noninvasively collected personalized risk factors of seizure occurrence and seizure propensity that may help to mitigate one of the most difficult aspects of refractory epilepsy: the unpredictability of seizure occurrence.

International Registered Report Identifier (IRRID)

PRR1-10.2196/25309

Does Stress Trigger Seizures? Evidence from Experimental Models

This chapter describes the experimental evidence of stress modulation of epileptic seizures and the potential role of corticosteroids and neurosteroids in regulating stress-linked seizure vulnerability. Epilepsy is a chronic neurological disorder that is characterized by repeated seizures. There are many potential causes for epilepsy, including genetic predispositions, infections, brain injury, and neurotoxicity. Stress is a known precipitating factor for seizures in individuals suffering from epilepsy. Severe acute stress and persistent exposure to stress may increase susceptibility to seizures, thereby resulting in a higher frequency of seizures. This occurs through the stress-mediated release of cortisol, which has both excitatory and proconvulsant properties. Stress also causes the release of endogenous neurosteroids from central and adrenal sources. Neurosteroids such as allopregnanolone and THDOC, which are allosteric modulators of GABA-A receptors, are powerful anticonvulsants and neuroprotectants. Acute stress increases the release of neurosteroids, while chronic stress is associated with severe neurosteroid depletion and reduced inhibition in the brain. This diminished inhibition occurs largely as a result of neurosteroid deficiencies. Thus, exogenous administration of neurosteroids (neurosteroid replacement therapy) may offer neuroprotection in epilepsy. Synthetic neurosteroid could offer a rational approach to control neurosteroid-sensitive, stress-related epileptic seizures.

The Impact of the COVID-19 Pandemic on People With Epilepsy. An Italian Survey and a Global Perspective

Objectives: We explored the impact of the coronavirus disease-19 (COVID-19) emergency on the health of people with epilepsy (PwE). We also investigated their attitude toward telemedicine.

Methods: The PubMed database up to September 10, 2020 was searched for questionnaire-based studies conducted in PwE during the COVID-19 emergency, and the literature retrieved was reviewed. In addition, all patients who had a telephone consultation with our center between May 7 and July 31, 2020 were invited to fill in a 57-item online questionnaire focusing on epilepsy and comorbidities, any changes in lifestyle or clinical conditions and any emergency-related problems arising during the COVID-19 emergency, and their views on telemedicine. Associations between variables were detected through X² test and Fisher's exact test. Univariate and multivariate logistic regression models were used to evaluate the effects of different factors on clinical conditions.

Results: Twelve studies met the literature search criteria. They showed that the rate of seizure worsening during the emergency ranged from 4 to 35% and was mainly correlated with epilepsy severity, sleep disturbances and COVID-19-related issues. Our questionnaire was filled in by 222 PwE or caregivers. One hundred (76.6%) reported unchanged clinical conditions, 25 (11.3%) an improvement, and 27 (12%) a deterioration. Reported clinical worsening was associated with a psychiatric condition and/or medication (OR = 12.59, p < 0.001), sleep disorders (OR = 8.41, p = 0.001), limited access to healthcare (OR = 4.71, p = 0.016), and experiencing seizures during the emergency (OR = 4.51, p = 0.007). Telemedicine was considered acceptable by 116 subjects (52.3%).

Conclusions: Most PwE did not experience a significant change in their clinical conditions during the COVID-19 emergency. However, severity of epilepsy, concomitant disability, comorbid psychiatric conditions, sleep disorders and limited access to healthcare may affect their health.

Effect of meditation on intracerebral EEG in a patient with temporal lobe epilepsy: A case report

Meditation has been deemed a miracle cure for a wide range of neurological disorders. However, it is unclear whether meditation practice would be beneficial for patients suffering from epilepsy. Here we report on the comparison of the effects of focused-attention meditation and a control task on electroencephalographic (EEG) activity in a patient undergoing stereoencephalographic (SEEG) investigation for drug-resistant epilepsy. The patient routinely practiced focused-attention meditation and reported that she found it beneficial. During the SEEG investigation, intracerebral EEG data were recorded during meditation as well as during mind-wandering task. The EEG data were analyzed for type of electrical activity (labeled) by two expert epileptologists. We found that the proportion of EEG segments containing activity classified as interictal epileptiform discharges (IEDs; abnormal electrical activity that occurs between seizures) increased significantly during meditation practice. Although the finding was surprising, this increase in IEDs may not correlate with an increase in seizure frequency, and the patient might still benefit from practicing meditation. The finding does, however, warrant further studies on the influence of meditation on epileptic activity.

Epilepsy in time of COVID-19: A survey-based study

Objectives

Collateral damage may occur in epilepsy management during the coronavirus (COVID‐19) pandemic. We aimed to establish the impact of this pandemic on epilepsy patients in terms of patient‐reported seizure control and emerging symptoms.

Materials & Methods

This is a cross‐sectional study including consecutive patients assessed by telephone contact in an epilepsy clinic during the first month of confinement. Demographic and clinical characteristics were recorded, and a 19‐item questionnaire was systematically completed. Data regarding the impact of confinement, economic effects of the pandemic, and subjective perception of telemedicine were recorded. Additional clinical data were obtained in patients with a COVID‐19 diagnosis.

Results

Two hundred and fifty‐five patients were recruited: mean age 48.2 ± 19.8 years, 121 (47.5%) women. An increase in seizure frequency was reported by 25 (9.8%) patients. Sixty‐eight (26.7%) patients reported confinement‐related anxiety, 22 (8.6%) depression, 31 (12.2%) both, and 72 (28.2%) insomnia. Seventy‐three (28.6%) patients reported a reduction in economic income. Logistic regression analysis showed that tumor‐related epilepsy etiology [OR = 7.36 (95% CI 2.17‐24.96)], drug‐resistant epilepsy [OR = 3.44 (95% CI 1.19‐9.95)], insomnia [OR = 3.25 (95% CI 1.18‐8.96)], fear of epilepsy [OR = 3.26 (95% CI 1.09‐9.74)], and income reduction [OR = 3.65 (95% CI 1.21‐10.95)] were associated with a higher risk of increased seizure frequency. Telemedicine was considered satisfactory by 214 (83.9%) patients. Five patients were diagnosed with COVID‐19, with no changes in seizure frequency.

Conclusions

The COVID‐19 pandemic has effects in epilepsy patients. Patients with tumor‐related, drug‐resistant epilepsy, insomnia, and economic difficulties are at a higher risk of increased seizure frequency. Telemedicine represents a suitable tool in this setting.

Physical exercise and seizure activity

Neuroprotective and antiepileptogenic therapies have been extensively investigated for epilepsy prevention and treatment. This review gives an overview of the promising contribution of the ketogenic diet, a complementary treatment, on the intestinal microbiota to reduce seizure susceptibility. Next, the relevance of physical exercise is extensively addressed as a complementary therapy to reduce seizure susceptibility, and thereby impact beneficially on the epilepsy condition. In this context, particular attention is given to the potential risks and benefits of physical exercise, possible precipitant factors related to exercise and proposed mechanisms by which exercise can reduce seizures, and its antiepileptogenic effects. Finally, this review points to emerging evidence of exercise reducing comorbidities from epilepsy and improving the quality of life of people with epilepsy. Based on evidence from current literature, physical or sport activities represent a potential non-pharmacological intervention that can be integrated with conventional therapy for epilepsy.

Psychological treatments for people with epilepsy

BACKGROUND

Given the significant impact epilepsy may have on the health-related quality of life (HRQOL) of individuals with epilepsy and their families, there is increasing clinical interest in evidence-based psychological treatments, aimed at enhancing psychological and seizure-related outcomes for this group. This is an updated version of the original Cochrane Review published in Issue 10, 2017.

OBJECTIVES

To assess the impact of psychological treatments for people with epilepsy on HRQOL outcomes.

SEARCH METHODS

For this update, we searched the following databases on 12 August 2019, without language restrictions: Cochrane Register of Studies (CRS Web), which includes randomized or quasi-randomized controlled trials from the Specialized Registers of Cochrane Review Groups including Epilepsy, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid, 1946 to 09 August 2019), and PsycINFO (EBSCOhost, 1887 onwards), and from PubMed, Embase, ClinicalTrials.gov, and the World Health Organization 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. For the operational definition of 'psychological treatments', we included a broad range of skills-based psychological treatments and education-only interventions designed to improve HRQOL, seizure frequency and severity, as well as psychiatric and behavioral health comorbidities for adults and children with epilepsy. These psychological treatments were compared to treatment as usual (TAU), an active control group (such as social support group), or antidepressant pharmacotherapy.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 36 completed RCTs, with a total of 3526 participants. Of these studies, 27 investigated skills-based psychological interventions. The remaining nine studies were education-only interventions. Six studies investigated interventions for children and adolescents, three studies investigated interventions for adolescents and adults, and the remaining studies investigated interventions for adults. Based on satisfactory clinical and methodological homogeneity, we pooled data from 11 studies (643 participants) that used the Quality of Life in Epilepsy-31 (QOLIE-31) or other QOLIE inventories (such as QOLIE-89 or QOLIE-31-P) convertible to 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 in the QOLIE-31 total score (mean improvement of 5.23 points, 95% CI 3.02 to 7.44; P < 0.001), and the overall QoL score (mean improvement of 5.95 points, 95% CI 3.05 to 8.85; P < 0.001) exceeded the threshold of minimally important change (MIC: total score: 4.73 points; QoL score: 5.22 points), indicating a clinically meaningful postintervention improvement in HRQOL. We downgraded the certainty of the evidence provided by the meta-analysis due to serious risks of bias in some of the included studies. Consequently, these results provided moderate-certainty evidence that psychological treatments for adults with epilepsy may enhance overall HRQOL.

AUTHORS' CONCLUSIONS

Implications for practice: Skills-based psychological interventions improve HRQOL in adults and adolescents with epilepsy. Adjunctive use of skills-based psychological treatments for adults and adolescents with epilepsy may provide additional benefits in HRQOL when these are incorporated into patient-centered management. We judge the evidence to be of moderate certainty.

IMPLICATIONS FOR RESEARCH

Investigators should strictly adhere to the CONSORT guidelines to improve the quality of reporting on their interventions. A thorough description of intervention protocols is necessary to ensure reproducibility. When examining the effectiveness of psychological treatments for people with epilepsy, the use of standardized HRQOL inventories, such as the Quality of Life in Epilepsy Inventories (QOLIE-31, QOLIE-31-P, and QOLIE-89) would increase comparability. Unfortunately, there is a critical gap in pediatric RCTs and RCTs including people with epilepsy and intellectual disabilities. Finally, in order to increase the overall quality of RCT study designs, adequate randomization with allocation concealment and blinded outcome assessment should be pursued. As attrition is often high in research that requires active participation, an intention-to-treat analysis should be carried out. Treatment fidelity and treatment competence should also be assessed. These important dimensions, which are related to 'Risk of bias' assessment, should always be reported.

The role of cortisol in trust behavior: Results from an experimental study on healthy controls and patients with juvenile myoclonic epilepsy

Trust is one of the foundations of human society and pervades all aspects of human live. Research on humans focused primarily on identifying the biological basis of trust behavior in healthy subjects, and this evidence hints to certain brain areas, hormones, and genetic factors to be fundamentally involved. The contribution of cortisol in trust has not yet elicited much attention in research, especially when specifically examined at basal cortisol levels. Trust has been previously studied in some neurological diseases but not in patients with epilepsy, and the influence of hormones on trust in these diseases remains yet unknown. Against this background, we designed an experimental study with a group of patients with juvenile myoclonic epilepsy and a group of healthy controls to compare trust behavior and plasma cortisol levels between the two groups. This economic game is frequently used in research to operationalize trust behavior. All participants further underwent neuropsychological assessment. Our results showed that there was no significant difference in trust behavior during the trust game, but a trend toward lower trust in patients. Furthermore, there was a significant difference in cortisol levels between groups with lower levels in patients. Interestingly, cortisol levels correlated with trust only in the patient group, but not in the control group. Future studies should specifically differentiate the effect of induced cortisol increases (e.g., acute stress) versus the effect of basal cortisol levels reflecting homeostasis or chronic stress on trust behavior and leverage the potential of comparison between patients and healthy controls.

When Drugs Do Not Work: Alternatives to Antiseizure Medications

PURPOSE OF REVIEW

Despite the increase in the number of novel antiseizure medications over the past 20 years, approximately one-third of patients will not have adequate seizure control on medications. For these patients, additional options need to be considered, including dietary, device, and surgical treatments. In addition, many complementary therapies can be considered as adjunctive treatment, with the intent of improving quality of life for persons with epilepsy and potentially allowing for improvement in seizure control.

RECENT FINDINGS

This review outlines established and developing treatments for drug-resistant epilepsy. Surgical treatments, including resective surgery and vagus nerve stimulation, have been routine care for several decades. In the last several years, new neurostimulation options have been approved (responsive neurostimulation and deep brain stimulation) or are under development (continuous subthreshold cortical stimulation). For patients with lesion or well-defined seizure-onset zones, less invasive options including laser ablation and ultrasound therapy provide the potential for faster recovery times and less morbidity. Not all therapies are in the pharmacological or surgical arenas. This review also explores the evidence for complementary treatments, including relaxation and meditation techniques, and art and music therapy. Despite the range of antiseizure medications available, they still provide inadequate for a large number of patients with epilepsy, either due to ongoing seizures or intolerable side effects. Complementary therapies, including diet, meditation techniques, and music therapy, provide compelling treatment options to improve quality of life while potentially improving seizure control. In appropriate patients, stimulation devices or surgical resection can offer options for significant seizure reduction or even cure. The full range of therapeutics should be considered for each patient with epilepsy when they are struggling with inadequate seizure control or side effects with traditional pharmacological treatment.

Prevalence and psychopathologic significance of hallucinations in individuals with a history of seizures

OBJECTIVE

A relationship between seizure activity and hallucinations is well established. The psychopathologic significance of hallucinations in individuals with seizures, however, is unclear. In this study, we assessed the prevalence of auditory and visual hallucinations in individuals who reported a seizure history and investigated their relationship with a number of mental disorders, suicidal ideation, and suicide attempts.

METHODS

Data were from the "Adult Psychiatric Morbidity Survey," a population-based cross-sectional survey. Auditory and visual hallucinations were assessed using the Psychosis Screening Questionnaire. Mental health disorders were assessed using the Clinical Interview Schedule. Logistic regressions assessed relationships between hallucinatory experiences and mental disorders, suicidal ideation, and suicide attempts.

RESULTS

A total of 14 812 adults (58% female; mean [standard error of the mean; SEM] age 51.8 [0.15]) completed the study; 1.39% reported having ever had seizures (54% female), and 8% of individuals with a seizure history reported hallucinatory experiences (odds ratio [OR] 2.05, 95% confidence interval [CI] 1.24-3.38). Individuals with seizures had an increased odds of having any mental disorder (OR 2.34, 95% CI 1.73-3.16), suicidal ideation (OR 2.38, 95% CI 1.77-3.20), and suicide attempt (OR 4.15, 95% CI 2.91-5.92). Compared to individuals with seizures who did not report hallucinatory experiences, individuals with seizures who reported hallucinatory experiences had an increased odds of any mental disorder (OR 3.47, 95% CI 1.14-10.56), suicidal ideation (OR 2.58, 95% CI 0.87-7.63), and suicide attempt (OR 4.61, 95% CI 1.56-13.65). Overall, more than half of individuals with a seizure history who reported hallucinatory experiences had at least one suicide attempt. Adjusting for psychopathology severity did not account for the relationship between hallucinatory experiences and suicide attempts.

SIGNIFICANCE

Hallucinatory experiences in individuals with seizures are markers of high risk for mental health disorders and suicidal behavior. There is a particularly strong relationship between hallucinations and suicide attempts in individuals with seizures. Clinicians working with individuals with seizures should routinely ask about hallucinatory experiences.

Behavioral interventions in epilepsy

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.

Mechanisms of Psychiatric Comorbidities in Epilepsy

Psychiatric illnesses, including depression and anxiety, are highly comorbid with epilepsy (for review see Josephson and Jetté (Int Rev Psychiatry 29:409-424, 2017), Salpekar and Mula (Epilepsy Behav 98:293-297, 2019)). Psychiatric comorbidities negatively impact the quality of life of patients (Johnson et al., Epilepsia 45:544-550, 2004; Cramer et al., Epilepsy Behav 4:515-521, 2003) and present a significant challenge to treating patients with epilepsy (Hitiris et al., Epilepsy Res 75:192-196, 2007; Petrovski et al., Neurology 75:1015-1021, 2010; Fazel et al., Lancet 382:1646-1654, 2013) (for review see Kanner (Seizure 49:79-82, 2017)). It has long been acknowledged that there is an association between psychiatric illnesses and epilepsy. Hippocrates, in the fourth-fifth century B.C., considered epilepsy and melancholia to be closely related in which he writes that "melancholics ordinarily become epileptics, and epileptics, melancholics" (Lewis, J Ment Sci 80:1-42, 1934). The Babylonians also recognized the frequency of psychosis in patients with epilepsy (Reynolds and Kinnier Wilson, Epilepsia 49:1488-1490, 2008). Despite the fact that the relationship between psychiatric comorbidities and epilepsy has been recognized for thousands of years, psychiatric illnesses in people with epilepsy still commonly go undiagnosed and untreated (Hermann et al., Epilepsia 41(Suppl 2):S31-S41, 2000) and systematic research in this area is still lacking (Devinsky, Epilepsy Behav 4(Suppl 4):S2-S10, 2003). Thus, although it is clear that these are not new issues, there is a need for improvements in the screening and management of patients with psychiatric comorbidities in epilepsy (Lopez et al., Epilepsy Behav 98:302-305, 2019) and progress is needed to understand the underlying neurobiology contributing to these comorbid conditions. To that end, this chapter will raise awareness regarding the scope of the problem as it relates to comorbid psychiatric illnesses and epilepsy and review our current understanding of the potential mechanisms contributing to these comorbidities, focusing on both basic science and clinical research findings.

Self-compassion and adjustment in epilepsy and psychogenic nonepileptic seizures

PURPOSE

Self-compassion has been associated with a set of adaptive coping strategies, which in turn explain better adjustment in individuals with chronic illnesses such as inflammatory bowel disease and arthritis. The aim of this study was to investigate whether self-compassion is associated with adjustment in people with epilepsy (PWE) and people with psychogenic nonepileptic seizures (PWPNES). Adjustment was measured via coping efficacy, quality of life (QoL), anxiety, and depression.

METHOD

A cross-sectional questionnaire design was employed. People with epilepsy (N = 74), PWPNES (N = 46), and controls (N = 89), recruited from outpatient seizure clinics and online, completed questionnaires about their self-compassion, coping efficacy, QoL, anxiety, and depression levels.

RESULTS

Overall, self-compassion was associated with adjustment in PWE and PWPNES. Self-compassion was negatively related to anxiety and depression in PWE, PWPNES, and controls and positively related to coping efficacy in PWE and PWPNES. Self-compassion was also positively related to QoL in PWE and controls; however, this relationship was not significant in PWPNES.

CONCLUSION

Self-compassion is associated with better adjustment in PWE and PWPNES. Implications of these findings for psychotherapeutic interventions for individuals with seizure disorders and future research are discussed.

Relief Following Chronic Stress Augments Spreading Depolarization Susceptibility in Familial Hemiplegic Migraine Mice

Cortical spreading depolarization (CSD) is the electrophysiological substrate of migraine aura, and a putative trigger of trigeminovascular activation and migraine headache. Many migraineurs report stress or relief after a stress triggers an attack. We tested whether various stress conditions might modulate CSD susceptibility and whether this is dependent on genetic factors. Male and female wild type and familial hemiplegic migraine type1 (FHM1) knock-in mice heterozygous for the S218L missense mutation were subjected to acute or chronic stress, or chronic stress followed by relief (36 h). Acute stress was induced by restraint and exposure to bright light and white noise (3 h). Chronic stress was induced for 28 days by two cycles of repeated exposure of mice to a rat (7 days), physical restraint (3 days), and forced swimming (3 days). Electrical CSD threshold and KCl-induced (300 mM) CSD frequency were determined in occipital cortex in vivo at the end of each protocol. Relief after chronic stress reduced the electrical CSD threshold and increased the frequency of KCl-induced CSDs in FHM1 mutants only. Acute or chronic stress without relief did not affect CSD susceptibility in either strain. Stress status did not affect CSD propagation speed, duration or amplitude. In summary, relief after chronic stress, but not acute or chronic stress alone, augments CSD in genetically susceptible mice. Therefore, enhanced CSD susceptibility may explain why, in certain patients, migraine attacks typically occur during a period of stress relief such as weekends or holidays.

Cortisol levels and seizures in adults with epilepsy: A systematic review

Stress has been suggested as a trigger factor for seizures in epilepsy patients, but little is known about cortisol levels, as indicators of stress, in adults with epilepsy. This systematic review summarizes the evidence on this topic. Following PRISMA guidelines, 38 articles were selected: 14 analyzing basal cortisol levels, eight examining antiepileptic drugs (AEDs) effects, 13 focused on seizure effects, and three examining stress. Higher basal cortisol levels were found in patients than in healthy people in studies with the most homogeneous samples (45% of 38 total studies). Despite heterogeneous results associated with AEDs, seizures were related to increases in cortisol levels in 77% of 38 total studies. The only study with acute stress administration found higher cortisol reactivity in epilepsy than in healthy controls. In studies using self-reported stress, high seizure frequency was related to increased cortisol levels and lower functional brain connectivity. Findings suggest that epilepsy could be considered a chronic stress model. The potential sensitizing role of accumulative seizures and issues for future research are discussed.

Coping with stress: A pilot study of a self-help stress management intervention for patients with epileptic or psychogenic nonepileptic seizures

PURPOSE

Many patients with epilepsy or psychogenic nonepileptic seizures (PNES) experience high levels of stress. Although psychological interventions have been developed for seizure disorders, few patients can currently access them. We aimed to assess the acceptability and feasibility of a self-help intervention targeting stress in patients with seizures, and to provide preliminary evidence for its effectiveness.

METHOD

Patients were recruited from outpatient neurology clinics and randomized to an immediate intervention group (n = 39), who received the intervention at baseline, or a delayed intervention group (n = 43), who received the intervention one-month postbaseline. Participants completed self-report questionnaires measuring stress (Smith Stress Symptom Inventory [SSSI]), anxiety (Generalized Anxiety Disorder 7-item Scale [GAD-7]), depression (Neurological Disorders Depression Inventory for Epilepsy [NDDI-E]), quality of life (European Quality of Life - 5 Dimensions [EQ-5D]), and seizure severity and frequency (Liverpool Seizure Severity Scale [LSSS-3]) at baseline, and at one- and two-month follow-up. Participants also provided telephone feedback. The intervention consisted of a self-help stress management workbook based on an integrative stress model framework.

RESULTS

Although the rate of participants failing to return follow-up information at two months was approximately 50%, those who completed the trial found the intervention acceptable; with the majority rating it as helpful (63.6%) and that they would recommend it to others with seizures (88.1%). A significant reduction in self-reported stress (P = .01) with a medium effect size (d_z = 0.51) was observed one-month postintervention. There were no significant changes in any other measures.

CONCLUSION

The intervention was perceived to be acceptable, safe, and helpful by participants. It could be a useful complementary treatment option for reducing stress experienced by patients living with seizure disorders. Further evaluation in a larger trial is warranted.

Affect-induced reflex seizures (AIRS): A case series based on a systematic literature review

Seizures are commonly thought to occur in a spontaneous, unpredictable manner. However, it is well-established that a subset of patients with epilepsy can experience reflex seizures that are consistently elicited by a specific stimulus. While various forms of reflex epilepsy have been documented in the literature, acute affective states have not been commonly described as a potential reflex seizure trigger. We performed a systematic literature review to determine if acute emotional states can trigger reflex seizures. We included any case in which reflex seizures repeatedly occurred in response to a patient-specific stimulus that was reported as emotionally relevant by the authors. This yielded our case series of ten patients who have been described to have reflex seizures in response to emotional stimuli. We characterized features of these cases including the following: age, gender, developmental and psychiatric history, seizure semiology and duration, emotional triggers, other reflex triggers, relationship between reflex triggers and seizures, investigations, localization, final diagnosis, treatment, and outcome. Considerable variability was found between cases. A trend toward limbic seizure semiology with psychic aura originating in networks involved in emotional processing was noted, with temporal lobe epilepsy being the most common, although without clear laterality or gender predominance. In addition, the report of a significant life stressor occurring at epilepsy onset in three of ten patients as well as the initial suspicion that reflex epileptic seizures were psychogenic in three cases both emphasize the role of electroencephalography in assessment of such presentations to avoid missing a diagnosis of epilepsy. Findings from these ten cases suggest that a patient-specific affective stimulus may trigger reflex seizures in a subset of patients, and that this could be underrecognized or mislabeled as nonepileptic. We encourage future studies with larger numbers to further characterize this phenomenon. Insights gained may enhance our understanding of seizure localization and bear potential treatment implications.

On the role of corticosterone in behavioral disorders, microbiota composition alteration and neuroimmune response in adult male mice subjected to maternal separation stress

Experiencing psychosocial adversities in early life such as maternal separation (MS) increases the risk of psychiatric disorders. Immune-inflammatory responses have imperative roles in the pathophysiology of psychiatric disorders. MS relatively changes the composition of intestinal microbiota leading to an overactivation of the hypothalamic-pituitary-adrenal (HPA) axis, and subsequently increases the corticosterone level. In this study, we aimed to evaluate the role of corticosterone in behavioral changes and microbiota modifications in a mouse model of MS afflicted neuroinflammatory response in the hippocampus. For this purpose, 180 min of MS stress was applied to mice at postnatal day (PND) 2-14 followed by behavioral tests including forced swimming test (FST), splash test, open field test (OFT) and elevated plus maze (EPM) at PND 50-52. For evaluating the role of corticosterone, mice were subjected to adrenalectomy. Using real-time RT-PCR, the expression of inflammatory genes was determined in the hippocampus and colon tissues. We found that MS provoked depressive- and anxiety-like behaviors in adult male mice. In addition, MS was able to active a neuroimmune response in the hippocampus, motivate inflammation and histopathologic changes in the colon tissue and modify the composition of gut microbiota as well. Interestingly, our findings showed that adrenalectomy (decline in the corticosterone level), could modulate the above-mentioned negative effects of MS. In conclusion, our results demonstrated that overactivation of HPA axis and the subsequent increased level of corticosterone could act, possibly, as the deleterious effects of MS on behavior, microbiota composition changes and activation of neuroimmune response.

Characteristics of large patient-reported outcomes: Where can one million seizures get us?

Objective

To analyze data from Seizure Tracker, a large electronic seizure diary, including comparison of seizure characteristics among different etiologies, temporal patterns in seizure fluctuations, and specific triggers.

Methods

Zero‐inflated negative binomial mixed‐effects models were used to evaluate temporal patterns of seizure events (during the day or week), as well as group differences in monthly seizure frequency between children and adults and between etiologies. The association of long seizures with seizure triggers was evaluated using a mixed‐effects logistic model with subject as the random effect. Incidence rate ratios (IRRs) and odds ratios were reported for analyses involving zero‐inflated negative binomial and logistic mixed‐effects models, respectively.

Results

A total of 1,037,909 seizures were logged by 10,186 subjects (56.7% children) from December 2007 to January 2016. Children had more frequent seizures than adults did (median monthly seizure frequency 3.5 vs. 2.7, IRR 1.26; p < 0.001). Seizures demonstrated a circadian pattern (higher frequency between 07:00 a.m. and 10:00 a.m. and lower overnight), and seizures were reported differentially across the week (seizure rates higher Monday through Friday than Saturday or Sunday). Longer seizures (>5 or >30 min) had a higher proportion of the following triggers when compared with shorter seizures: “Overtired or irregular sleep,” “Bright or flashing lights,” and “Emotional stress” (p < 0.004).

Significance

This study explored a large cohort of patients with self‐reported seizures; strengths and limitations of large seizure diary databases are discussed. The findings in this study are consistent with those of prior work in smaller validated cohorts, suggesting that patient‐recorded databases are a valuable resource for epilepsy research, capable of both replication of results and generation of novel hypotheses.

Stress, seizures, and epilepsy: Patient narratives

In epilepsy, individual seizures can be triggered by a variety of external and internal stimuli. One of the most common trigger factors reported by patients is stress. However prevalent, stress-related triggering of episodes seems underappreciated in epilepsy for various reasons, and its misinterpretation often leads to other diagnoses, e.g., psychogenic nonepileptic seizures (PNES) or normal reactions. This article illustrates the significant role of stress as a seizure-provoking factor by referring to nine patient narratives. From this perspective, it appears that there are characteristic patterns of stress triggering, e.g., stress-induced sleep disruption, forms of acute stress, or relaxation after stress. Sometimes seizures are mistaken as symptoms of stress. Patient narratives contain interesting clues relating reports about stress and seizure histories to different epilepsy syndromes as well as nonepileptic episodes in a way that can strongly support the diagnostic process. A narrative approach is particularly valuable in this context. Therefore, accounts of stress triggering in seizures and other episodes should not be neglected, but rather taken seriously, sought and actively explored as a crucial element when taking clinical histories in patients with episodic attacks.

Behavioral interventions as a treatment for epilepsy: A multicenter randomized controlled trial

OBJECTIVE

To evaluate the effect of a stress-reduction intervention in participants with medication-resistant epilepsy.

METHODS

Adults with medication-resistant focal epilepsy (n = 66) were recruited from 3 centers and randomized to 1 of 2 interventions: (1) progressive muscle relaxation (PMR) with diaphragmatic breathing, or (2) control focused-attention activity with extremity movements. Following an 8-week baseline period, participants began 12 weeks of double-blind treatment. Daily self-reported mood and stress ratings plus seizure counts were completed by participants using an electronic diary, and no medication adjustments were permitted. The primary outcome was percent reduction in seizure frequency per 28 days comparing baseline and treatment; secondary outcomes included stress reduction and stress-seizure interaction.

RESULTS

In the 66 participants in the intention-to-treat analysis, seizure frequency was reduced from baseline in both treatment groups (PMR: 29%, p < 0.05; focused attention: 25%, p < 0.05). PMR and focused attention did not differ in seizure reduction (p = 0.38), although PMR was associated with stress reduction relative to focused attention (p < 0.05). Daily stress was not a predictor of seizures.

CONCLUSIONS

Both PMR and the focused-attention groups showed reduced seizure frequency compared to baseline in participants with medication-resistant focal seizures, although the 2 treatments did not differ. PMR was more effective than focused attention in reducing self-reported stress.

CLINICALTRIALSGOV IDENTIFIER

NCT01444183.

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.