Acceptance and Commitment Therapy and yoga for drug-refractory epilepsy: A randomized controlled trial

Abstract

Objective

There is a need for controlled outcome studies on behavioral treatment of epilepsy. The purpose of this study was to evaluate Acceptance and Commitment Therapy (ACT) and yoga in the treatment of epilepsy.

Methods

The design consisted of a randomized controlled trial with repeated measures (N = 18). All participants had an EEG-verified epilepsy diagnosis with drug-refractory seizures. Participants were randomized into one of two groups: ACT or yoga. Therapeutic effects were measured using seizure index (frequency × duration) and quality of life (Satisfaction with Life Scale, WHOQOL-BREF). The treatment protocols consisted of 12 hours of professional therapy distributed in two individual sessions, two group sessions during a 5-week period, and booster sessions at 6 and 12 months posttreatment. Seizure index was continuously assessed during the 3-month baseline and 12-month follow-up. Quality of life was measured after treatment and at the 6-month and 1-year follow-ups.

Results

The results indicate that both ACT and yoga significantly reduce seizure index and increase quality of life over time. ACT reduced seizure index significantly more as compared with yoga. Participants in both the ACT and yoga groups improved their quality of life significantly as measured by one of two quality-of-life instruments. The ACT group increased their quality of life significantly as compared with the yoga group as measured by the WHOQOL-BREF, and the yoga group increased their quality of life significantly as compared with the ACT group as measured by the SWLS.

Conclusions

The results of this study suggest that complementary treatments, such as ACT and yoga, decrease seizure index and increase quality of life.

Introduction

Research suggesting that behavioral treatments can influence the seizure process is substantial [1], [2]. However, there are few signs that these low-cost, noninvasive interventions are integrated into everyday treatment of epilepsy. Antiepileptic drugs (AEDs) are normally the only treatment offered to those who have epilepsy despite the fact that they do not function effectively for everyone, entail adverse side effects and are not economically available to the majority of people [3], [4]. Seizures are only a small part of the overall problems associated with epilepsy. Persons who have seizures more frequently have psychiatric disorders like depression, anxiety, and low quality of life as compared with those with other chronic illnesses [5]. The stigmatization problems associated with epilepsy are well documented [6]. These conclusions suggest that persons with epilepsy and related problems need to be treated with a broad behavioral approach [7]. The project described here evaluates the effect of two active treatments, both of which address the larger context of epilepsy and quality of life—Acceptance and Commitment Therapy and yoga—in patients with drug-refractory seizures.

An epileptic seizure is, according to the behavior model, defined as a complex involving a biological predisposition to “seize” and internal and external contextual factors that increase or decrease the probability of seizure occurrence [8]. The epileptic seizure is seen as a chain of behavior, and analysis of that chain includes elicitation, inhibition, and the seizure function [9]. A tailormade program is developed based on the behavior analysis and includes preventive strategies, seizure management, and interventions dealing with the functions of seizure behavior [8]. The aim of applied behavior analysis is to predict and affect behavior. The goal of the intervention is to decrease seizure activity and increase quality of life.

Applied behavior analysis and learning theory have, in recent years, taken important steps in the development of a theoretical and clinical understanding of human functioning [10]. One recently developed model in behavior therapy is Acceptance and Committment Therapy (ACT). ACT is based on behavior psychology and grounded in a new theory of language and cognition called Relational Frame Theory (RFT) [11]. The effect of ACT has been evaluated in chronic illnesses such as epilepsy [1], diabetes [12], and pain [13] and the results are promising. ACT has also been evaluated in psychiatric disorders like depression, anxiety, stigmatization problems, and social phobia with good effects [10]. The aim of ACT is to create psychological flexibility and stimulate activity in directions that persons consider meaningful and vital, so-called valued directions. Psychological flexibility around difficult emotions and thoughts that function as a barrier to valued actions is created using acceptance and mindfulness processes. Acceptance refers to an active willingness to experience emotions, bodily sensations, and thoughts without trying to control or manipulate them [14]. Mindfulness is a process through which emotions, thoughts, and sensations are experienced here and now in a conscious flow [15]. The psychological flexibility developed through acceptance and mindfulness helps patients to act instead of react to bodily sensations [14]. ACT for epilepsy is built on basic behavior processes and focuses on both quality of life and the seizure pattern. The aim of an ACT treatment for epilepsy is to increase psychological flexibility around the chain of seizure development, decrease the epilepsy-related experiential avoidance, broaden the behavior repertoire, and motivate activity in the chosen valued direction. Reducing experiential avoidance with behavior methods may decrease the triggering function of experiences related to epilepsy [1].

Similarly to biofeedback training and relaxation, yoga may have an effect on the probability of seizure occurrence because of the effect it has on brain wave activity and arousal level [16], [17]. Research shows that sudden changes in cortical activity and arousal level affect the probability of seizure occurrence [18], [19]. Studies on biofeedback demonstrate that persons in a laboratory using video/EEG can be trained to generate brain waves that affect the probability of seizure occurrence [20]. Furthermore, Brown and Gerbarg [21] suggest that yoga training stimulates the vagus nerve, and stimulation of the vagus nerve has been shown to decrease seizure frequency by 28–38% [22], [23]. Yoga has been demonstrated to increase quality of life and decrease psychiatric problems for those who have epilepsy [16]. The aim of the yoga training described in this study was to prevent and decrease seizure behavior and increase quality of life.

Between 25 and 40% of those with epilepsy treated with pharmacotherapy have uncontrolled seizures, experience adverse side effects from medication, suffer from stigmatization, and have a higher degree of psychiatric disorders as compared with those with other chronic illnesses. For those who have epilepsy and related problems it is important to develop, evaluate, and implement a complementary treatment model in the everyday treatment of epilepsy [7], [24]. The Cochrane Library has expressed the need for well-designed, controlled outcome studies evaluating the effect of behavioral treatment of epilepsy [2]. The aim of this study was to evaluate and compare the effects of two active treatments for epilepsy: ACT and yoga.