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Doi:10.1016/j.yebeh.2008.02.009

Available online at www.sciencedirect.com Epilepsy & Behavior 13 (2008) 102–108 Acceptance and Commitment Therapy and yoga for drug-refractory epilepsy: A randomized controlled trial Tobias Lundgren a,*, JoAnne Dahl a, Nandan Yardi b, Lennart Melin a a Department of Psychology, University of Uppsala, Uppsala, Sweden Received 4 January 2008; revised 7 February 2008 Objective. There is a need for controlled outcome studies on behavioral treatment of epilepsy. The purpose of this study was to eval- uate 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-ver- ified epilepsy diagnosis with drug-refractory seizures. Participants were randomized into one of two groups: ACT or yoga. Therapeuticeffects 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 duringa 5-week period, and booster sessions at 6 and 12 months posttreatment. Seizure index was continuously assessed during the 3-monthbaseline 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 oflife significantly as measured by one of two quality-of-life instruments. The ACT group increased their quality of life significantly ascompared with the yoga group as measured by the WHOQOL-BREF, and the yoga group increased their quality of life significantlyas 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.
Ó 2008 Elsevier Inc. All rights reserved.
Keywords: Epilepsy; Acceptance and Commitment Therapy; Yoga; India adverse side effects and are not economically available tothe majority of people Seizures are only a small part Research suggesting that behavioral treatments can of the overall problems associated with epilepsy. Persons influence the seizure process is substantial However, who have seizures more frequently have psychiatric disor- there are few signs that these low-cost, noninvasive inter- ders like depression, anxiety, and low quality of life as com- ventions are integrated into everyday treatment of epilepsy.
pared with those with other chronic illnesses . The Antiepileptic drugs (AEDs) are normally the only treat- stigmatization problems associated with epilepsy are well ment offered to those who have epilepsy despite the fact documented . These conclusions suggest that persons that they do not function effectively for everyone, entail with epilepsy and related problems need to be treated witha broad behavioral approach The project describedhere evaluates the effect of two active treatments, both of * Corresponding author. Address: Department of Psychology, Uppsala which address the larger context of epilepsy and quality University, Tra¨dga˚rdsgatan 20, Box 1225, 751 42 Uppsala, Sweden. Fax: yoga—in patients with drug-refractory seizures.
1525-5050/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.yebeh.2008.02.009 T. Lundgren et al. / Epilepsy & Behavior 13 (2008) 102–108 An epileptic seizure is, according to the behavior model, Gerbarg suggest that yoga training stimulates the defined as a complex involving a biological predisposition vagus nerve, and stimulation of the vagus nerve has been to ‘‘seize” and internal and external contextual factors that shown to decrease seizure frequency by 28–38% increase or decrease the probability of seizure occurrence Yoga has been demonstrated to increase quality of life . The epileptic seizure is seen as a chain of behavior, and decrease psychiatric problems for those who have epi- and analysis of that chain includes elicitation, inhibition, lepsy . The aim of the yoga training described in this and the seizure function A tailormade program is devel- study was to prevent and decrease seizure behavior and oped based on the behavior analysis and includes preven- tive strategies, seizure management, and interventions Between 25 and 40% of those with epilepsy treated with dealing with the functions of seizure behavior . The pharmacotherapy have uncontrolled seizures, experience aim of applied behavior analysis is to predict and affect adverse side effects from medication, suffer from stigmati- behavior. The goal of the intervention is to decrease seizure zation, and have a higher degree of psychiatric disorders activity and increase quality of life.
as compared with those with other chronic illnesses. For Applied behavior analysis and learning theory have, in those who have epilepsy and related problems it is impor- recent years, taken important steps in the development of tant to develop, evaluate, and implement a complementary a theoretical and clinical understanding of human func- treatment model in the everyday treatment of epilepsy tioning . One recently developed model in behavior The Cochrane Library has expressed the need for therapy is Acceptance and Committment Therapy (ACT).
well-designed, controlled outcome studies evaluating the ACT is based on behavior psychology and grounded in a effect of behavioral treatment of epilepsy The aim of new theory of language and cognition called Relational this study was to evaluate and compare the effects of two Frame Theory (RFT) . The effect of ACT has been active treatments for epilepsy: ACT and yoga.
evaluated in chronic illnesses such as epilepsy , diabetesand pain and the results are promising. ACT has also been evaluated in psychiatric disorders like depres-sion, anxiety, stigmatization problems, and social phobia with good effects . The aim of ACT is to create psycho-logical flexibility and stimulate activity in directions that In this randomized, controlled, two-group study with repeated mea- sures, participants were assigned to either ACT or yoga treatment using persons consider meaningful and vital, so-called valued a computerized randomization table . The design involved four ses- directions. Psychological flexibility around difficult emo- sions: one individual session, two group sessions, and one individual ses- tions and thoughts that function as a barrier to valued sion. Booster sessions occurred at 6 and 12 months. The individual actions is created using acceptance and mindfulness pro- sessions and booster sessions were each 1.5 hours long and the group ses- cesses. Acceptance refers to an active willingness to experi- sions were 3 hours, for a total therapy time of 12 hours, for eachparticipant.
ence emotions, bodily sensations, and thoughts withouttrying to control or manipulate them . Mindfulness isa process through which emotions, thoughts, and sensa- tions are experienced here and now in a conscious flow Eighteen adults ranging between 18 and 55 years living in southwest The psychological flexibility developed through accep- India participated in the study. All participants were recruited from an tance and mindfulness helps patients to act instead of react outpatient clinic. Inclusion criteria were: ability and willingness to partic- to bodily sensations ACT for epilepsy is built on basic ipate in the treatment program, a minimum of three seizures during the behavior processes and focuses on both quality of life and past 3 months, and an EEG-verified diagnosis of epilepsy. One participant the seizure pattern. The aim of an ACT treatment for epi- was excluded because of an ongoing progressive illness.
summarizes the demographic data for the participants receiv- lepsy is to increase psychological flexibility around the ing ACT and yoga treatments. There were no noticeable differences chain of seizure development, decrease the epilepsy-related between the groups in background variables.
experiential avoidance, broaden the behavior repertoire,and motivate activity in the chosen valued direction.
Reducing experiential avoidance with behavior methodsmay decrease the triggering function of experiences related Seizure index was assessed at a 3-month baseline and during the 12 months of follow-up using a seizure diary. Quality of life was assessed Similarly to biofeedback training and relaxation, yoga prior to the initiation of treatment, after treatment, and at the 6- and12-month follow-ups. The treatments were administered over a 5-week may have an effect on the probability of seizure occurrence period at a clinic for epilepsy in southwest India. Two clinical psycholo- because of the effect it has on brain wave activity and arou- gists (first and second authors) trained in ACT and behavioral treatment sal level . Research shows that sudden changes in of epilepsy were responsible for the ACT part of the study. A yoga teacher cortical activity and arousal level affect the probability of from the outpatient clinic was responsible for the yoga treatment. Physi- seizure occurrence . Studies on biofeedback demon- cians and a clinical psychologist, employed at the outpatient clinic,assisted with translations during assessment of dependent variables, indi- strate that persons in a laboratory using video/EEG can be vidual sessions, and group sessions. Participating staff were given a half- trained to generate brain waves that affect the probability day ACT workshop to ensure treatment integrity, and the assessment of seizure occurrence Furthermore, Brown and and treatment sessions were videotaped and audiotaped for the same pur- T. Lundgren et al. / Epilepsy & Behavior 13 (2008) 102–108 participants to built broader behavior repertoires in valued directions Demographic and clinical characteristics of the ACT and yoga groups using such processes as values clarification, acceptance, defusion, mindful-ness, commitment , functional analysis of seizure chains, and The aims of sessions 1 and 2 are described below. The ACT protocol 2.4.1.1. Session 1: Individual session. The aims of session 1 were to: 1. Use the values compass and the bull’s-eye to establish values as the 2. Examine discrepancies between how the participant wants to live and how he or she, in fact, is living currently.
3. Identify barriers and obstacles to the participant’s valued life.
4. Examine the participant’s reactions or ways of relating to described 5. Examine the ‘‘function” of the participant’s strategies in reducing or controlling these obstacles, which in ACT is called creative 6. Commit to the personal valued directions described in the beginning of 2.4.1.2. Session 2: Group session (six to eight participants). The aims of session 2 were to present, practically demonstrate, and provide the oppor- tunity for participants to experience the following components of ACT: 1. Self as context versus self as content using the mindfulness exercise 2. Living a valued life versus living a life in avoidance. Exercise: Discrim- inating your own values from rules of conduct.
3. Seeing thoughts as thoughts versus seeing thoughts as true obstacles to a valued life. Exercise: ‘‘Kick your butts,” showing how sentences like ‘‘I want to have an intimate relationship but I have epilepsy” leads to 4. Acceptance of what cannot be changed (thoughts and feelings) and changing what can be changed. To illustrate, a dramatization of the ‘‘bus metaphor” was used: Participant attempts to drive the bus of life in a valued direction and all the thought obstacles that come up are personified by bus passengers (members of the group) who argue and fight with the driver to bully him or her off course. The object is to relate to these obstacles in a manner of acceptance and, at the sametime, keep on course.
5. Commitment to taking steps in valued directions even in the face of pose. The ACT protocol was adjusted to the Indian context after discus- emotional difficulties related to epilepsy and life. Exercise: Participants sions with the participating staff to avoid unnecessary misunderstandings take turns standing up at the end of session and stating: (a) a valued caused by language problems and cultural differences. Prescriptions and direction, (b) the identified ‘‘thought” obstacles often related to epilepsy dosages of antiepileptic drugs remained constant throughout the study.
but also to life in general, (c) how he or she typically handles these obsta- Changes in either prescriptions or dosages were exclusion criteria.
cles, (d) the experience of the workability of those coping strategies, and Excluded participants were offered full treatment.
(e) a commitment to take a step in the valued direction today.
In addition, behavior technology of seizure control was presented as a simple ABC (antecedents, behavior, and consequences) chain of events.
Participants recorded seizure chains, and typical patterns of high- and The independent variable comprised the two active treatment condi- low-risk for seizures were investigated. Participants practiced interrupting tions: ACT and yoga. The ACT treatment protocol was designed using seizures with the simplest countermeasure techniques to arrest an ongoing ACT and a clinical handbook in the treatment of epilepsy . Both the ACT and yoga treatment protocols were designed for this project andadjusted for the Indian context. The yoga treatment protocol was designed using the texts by Yardi and Chopra and Simon A video sum- The aim of the yoga condition was to teach participants to respond mary of both the ACT and yoga interventions is available for download to internal stimuli in a conscious way, to decrease seizure activity and increase quality of life. The training was aimed at helping participantsdecrease behaviors that were under discriminative control of fears, thoughts, and emotions associated with epilepsy. The yoga training for The aim in using ACT was to increase psychological flexibility around epilepsy had two main features: stimulating activity in directions the participants’ life barriers including seizures and fear of seizures and participants considered meaningful and using yoga techniques to improve activity in personally chosen valued directions. Therapists helped decrease the risk of epileptic seizures. The yoga program focused on T. Lundgren et al. / Epilepsy & Behavior 13 (2008) 102–108 three different physical dimensions and two psychological dimensions to unite the mind, body, and soul. The physical dimensions are called Pra-nayama (‘‘controlled deep breathing”), Asanas (‘‘physical postures”), and Effects of the two treatment conditions with respect to Dhyana (‘‘meditation”) The psychological dimensions are calledYama (‘‘harmony with others”) and Niyama (‘‘harmony with yourself”).
each of the dependent variables before and after treatment The yoga teacher integrated the teaching of Pranayama, Asanas, Dhyana and the teaching of Yama and Niyama into a four-session protocol tofulfill the aim of the study. Furthermore, the yoga teacher included sig- nificant others during the sessions for two purposes: (1) to increase thelikelihood that the yoga training would be maintained without the trai-ner being present, and (2) to increase the likelihood that significant oth- ers would be supportive. The yoga focused on general well-being and as well as seizure frequency, it is seen that all partici- reduction in seizure index. The yoga teacher and the participants dis- pants in the study decreased their seizure frequency cussed barriers to living a life considered important. Accepting private and duration at follow-up and that 5 of 10 participants events and living meaningful lives were essential parts of the treatment.
The teacher used metaphors, direct instructions, and encouragement to in the ACT group and 4 of 8 in the yoga group were sei- help the participants to be active in areas considered important. Exam- ples of such domains are: relationships, work, health, and leisure time.
The sessions were videotaped and audiotaped to ensure treatment outlines the results for those in the ACT and yoga groups with respect to seizure index before and after The dependent variables in the study were seizure index (seizure fre- treatment. There is a significant reduction in seizure index quency  seizure duration) and quality of life. The instruments used to in both groups over time. Because of significant pretreat- measure the dependent variables in the study were a seizure diary, the ment group differences, change scores were used, and the Satisfaction with Life Scale (SWLS), and the World Health Organiza- results indicated that the ACT group changed significantly tion Quality of Life instrument, short version (WHOQOL-BREF). Sei- more as compared with the yoga group.
zure frequency and duration were continuously reported in a seizurediary 3 months prior to the intervention (baseline) and prospectivelyduring the 15-month project. The participants completed the quality- of-life instruments SWLS and WHOQOL-BREF prior to the start ofthe intervention, after treatment, and at the 6- and 12-month follow- The SWLS consists of five statements with which the client can results at baseline, after treatment, at the 6- and 12-month either strongly agree or strongly disagree on a scale of 1–7. According follow-ups. There was not a significant interaction effect in to Diener and colleagues the SWLS has been demonstrated to the SWLS (F(3,48) = 0.49, NS) and WHOQOL-BREF have strong internal consistency (Cronbach’s a = 0.87) and moderatetemporal stability (test–retest 0.82). The SWLS has been shown tocorrelate with 10 other measurements of subjective well-being, r $ Epilepsy diagnosis and mean seizure frequency and duration pre- and The WHOQOL-BREF has a reported Cronbach a of 0.81–0.90. The instrument comprises four quality-of-life domains: psychological health, physiological health, social relationships, and environmental health. The discriminant validity was satisfactory, and the instrument did not exhibitany ceiling or floor effects Analysis of variance was carried out using Statistica 6.0 The sei- zure index was analyzed using independent and dependent t tests on pre- to postchange scores. Change scores focus on improvements from the pre- test to the posttest and were used because of significant pretreatment dif- ferences. To detect differences between groups over time with respect tothe SWLS and WHOQOL-BREF, mixed ANOVAs (2 groups  4 time periods) and one-way ANOVAs were conducted. Cohen’s d effect sizes Written informed consent was obtained from each participant in the study. Participants were provided with written and verbal information that participation in the study was voluntary and could be terminated at any time and that all information gathered in the study would be trea- ted as confidential. Participants signed separate informed consent formsgiving therapists permission to videotape and audiotape during the a GTC, generalized tonic–clonic seizures; PC, partial complex seizures; T. Lundgren et al. / Epilepsy & Behavior 13 (2008) 102–108 present study contributes to the research base on treatment of epilepsy in at least three ways: (1) Complementary treat- ments help those with epilepsy, both by enhancing quality of life and by decreasing seizure activity; (2) interventions can be integrated into an outpatient clinic, even across cul- tures, with good results; (3) treatment of epilepsy can be noninvasive and low cost and can be conducted even in the presence of language barriers and cultural differences.
The ACT and yoga protocols contained similarities, which raise questions about the processes through which the two treatments work. Both protocols include mindful- ness training, acceptance of private events, discussions about losses of meaningful life directions, commitment to important life directions, and inclusion of significant others during both individual and group sessions. Acceptance, mindfulness, and life fulfillment processes are of well- known utility as coping strategies in the treatment of epi- lepsy . Practicing mindfulness may help participants not to react to bodily sensations and, instead, to become aware of emotions, thoughts, and sensations and con- sciously choose actions moment by moment. Mindfully choosing actions instead of experiencing oneself as being under the control of bodily sensations, thoughts, and mem- ories associated with epilepsy may create a sense of self-effi-cacy and decrease epileptogenic activity. Mindfulness, (F(3,48) = 2.77, NS). Effect sizes were calculated using the biofeedback, and relaxation contain similarities with mean of all post measure points. As outlined in , the respect to the focus of affecting cortical activity. In previ- participants in the ACT group increased their quality of life ous research, biofeedback and relaxation have been shown significantly according to the WHOQOL-BREF. The ACT to decrease seizure activity and similar results may group exhibited a strong effect from pretest to posttest on be obtained when practicing mindfulness.
the SWLS, but the changes in the group over time were Acceptance of private events together with mindfulness not significant. The participants in the yoga group may have helped the participants to persist in reclaiming increased their quality of life significantly according to a valued life even in the face of epilepsy and related prob- the SWLS, but did not show any significant changes or lems. Persistence in the face of emotional difficulties and strong effects using the WHOQOL-BREF.
acceptance of private events have, in previous research,been demonstrated to correlate positively with higher qual-ity of life and lower psychiatric problems . Sensations, thoughts, and emotions that previously functioned as trig-gers for seizures may not necessarily lead to a full-blown The results of the current study demonstrated that seizure following an acceptance and mindfulness interven- tion. Acceptance and mindfulness skills may increase the decreased seizure index and quality of life. The ACT treat- seizure threshold in a similar way as biofeedback and ment led to a significantly larger decrease in seizure index lead to a decrease in epileptogenic activity.
as compared with the yoga treatment. The results from Therapists in both groups helped participants to investi- the quality-of-life measure indicated that quality of life gate valued life directions and stimulate consistent activi- increased significantly for participants in both groups over ties. Increasing activity in valued directions has been the 1-year follow-up period by one of two instruments. The shown to increase quality of life and has been an T. Lundgren et al. / Epilepsy & Behavior 13 (2008) 102–108 important part of psychotherapy for persons with epilepsy.
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