1. Stress and Seizure Control A Holistic approach
Jaishree Narayanan
Department Of Neurology
Northshore University Health System

2. Stress and Seizures Seizures are unpredictable.
This is one of the most disabling features of seizures.
This is the reason for seizure related accidents.
This causes a feeling of loss of control and psychosocial distress.
Unpredictability of seizures leads to stress.

3. Stress and Seizures
Whether stress triggers seizures is unclear but some patients do report an association.

4. Seizure anticipation
Some patient report “prodrome” before their seizures.
There is a lot of variability between individuals in the prodrome and hence they are poorly characterized.
They can involve sensory, behavioral, cognitive or emotional changes and are different in different patients (Kotwas et al.,2016)
The are recognized by 6.9%-39% of patients in different studies (Hughes et al., 1993, Scaramelli et al., 2008, Schulze-Bonhage et al., 2006)

5. Self control of seizures based on anticipation
Many patients use these prodromal symptoms to anticipate their seizures and develop preventive techniques.
Almost 80% of the patients with prodrome who report using preventive strategies, report success (Lee et al. 2006)

6. Strategies used: Emotional strategies
Emotional strategies: Relaxing, Positive thoughts, Neutral emotional state. These are more often used by patients who report stress as a trigger for their seizures. In one study 57% of these patient reported using these strategies and 88% of them reported reduction in frequency of seizures (Privitera at el., 2014)

7. Strategies used: Cognitive strategies
These are control strategies.
They can consist of concentrating intensely.
Focusing attention on something else.
20%-56% of patients with prodrome use these strategies. Of these 70% report success in doing so (Rajna et al., 1997, Pinikahna et al., 2009)

8. Strategies used : Behavioral strategies
These are usually prevention strategies.
They usually involve preparing for the consequences of a seizure – sitting down, alerting someone etc.
Adopting a lifestyle conducive to preventing seizures – no alcohol, no sleep deprivation.
Also techniques to prevent the seizure itself – breathing fresh air, take a deep breath.

9. Seizure anticipation
Perceived self control – these techniques give a perceived self control and this can improve quality of life and reduce stress.
Seizure anticipation can help this.
Seizure Alert dogs (SADs): Exactly what changes they detect is unclear. They essentially are trained to detect tonic-clonic seizures.
There are no studies designed to study this objectively – unclear if they predict or detect seizures.
Patients have reported reduction in seizures with SADs (Strong et al., 2001)
Pets have a positive impact on the psychological and physical health of the patient and this could contribute (McConnell et al., 2011).

10. Seizure anticipation
Biosensor devices: wrist bracelet: accelerometry detection : 94% seizure detection (Dolgin et al., 2014, Poh et al., 2012)
Useful in patients without alert systems.
Also in patients with an aura or prodrime so they can better recognize them and develop preventive strategies.

11. Seizure anticipation E diaries – better than paper diaries.
If patients keeps this, they can then compare with other events and recognize their triggers.
This then gives better self control because the patient can avoid precipitating factors.

12. Stress and seizure control strategies
Cognitive Behavioral Therapies
These try to increase the percieved self control of seizures.
They can also reduce stress in the ‘mind Body approach”
This involves mindfulness, relaxation techniques, meditation and yoga.
One Yoga technique the patient is taught to reflexively hold their breath as if startled when the patient experiences an aura and this helps stop the seizure (Saxena et al. 2011)
Normalization of EEG was seen after prolonged meditation (Cochrane review)
They are known to reduce perceived stress.
Mindfulness and yoga showed a positive effect on well being and seizure frequency in refractory epilepsy (Lundgren et al., 2008)

13. Stress and seizure control strategies
Arousal based approaches:
Operant conditioning, aura interruption and systematic densensitization.
Biofeedback: The aim is to teach patients how to voluntarily reduce cortical excitation or increase peripheral sympathetic arousal. The technique was shown to provide 50% seizure reduction in the feedback group and no reduction in the control group (Nagai et al., 2003)

14. Conclusion
Stress reduction techniques can be effective in some patients especially if seizure anticipation can be improved.

15. Thanks for your attention