The third major pillar of epilepsy treatment—using psychological approaches papers presented at the 23rdinternational epilepsy congress (prague) 1999

Psychological approaches to seizure control in epilepsy have been known and practised since antiquity: indeed, in ancient times they must have been preferable to the alternatives which included drinking urine from a shoe, blood letting and insufflations of ‘mans scull pulverised’. The author of the Hippocratic tract On the Sacred Disease seemed to understand the concept of behavioural countermeasures when he wrote ‘To abolish this disease, one must apply the element which is opposed to it, and not what is favourable and habituated’1. Later, Galen, perhaps influenced by his teacher Pelops, advocated the use of a ligature to inhibit the spread of focal motor seizures2 and this continued to be used in medical practice up to the time of Hughlings Jackson3 and Gowers4. Both these nineteenth century authors remarked on the longer-term beneficial effects on seizure phenomenology. However, with the medicalization of epilepsy practice in the twentieth century and its containment in the domain of pharmacology, surgical interest in psychological therapy for epilepsy waned, but never completely disappeared. In recent years interest has been rekindled partly because of developing knowledge that many seizures are clearly provoked (currently acknowledged even by the most conservative neurologists) and that most are arousal mediated5. A worldwide enquiry in 1989, launched jointly by the Universities of Mainz and Boston, suggested that the time had come for cross-cultural collaboration: thanks to grants from the ‘Friends of Mainz University’ and the Dr Hans Berger Clinic in Breda, the international network ‘Self Control in Epilepsy’ was developed as a forum to improve conditions for research and mutual exchanges of information between more than 100 scientists and clinicians. In 1997 the International Bureau for Epilepsy acknowledged the therapeutic potential of these approaches and shortly thereafter appointed a commission into behavioural methods, whose primary task was to promote research, education, counselling and treatment strategies. This led to presentations in the field at the 23rd International Epilepsy Congress in Prague, most of which are printed here. Two of the presentations have already been published in Seizure6, 7. Emphasizing the need for systematic, carefully prepared and designed research in this field, some lectures consisted exclusively or primarily of reviews and meta-analyses on as yet neglected subtopics such as yoga (Sridharan Ramaratnam, Nandan Yardi) and nocturnal epileptic seizures (Bernhard Müller). Other lecturers concentrated on clinical investigations of single components of psychological approaches which have already been established in some centres, such as the significant dependency of major types of emotionrelated seizure precipitation on the lateralization of the epileptic focus (Donna Andrews)6, the positive impact of learning seizure control by means of two types of biofeedback (respiration and slow cortical potentials) on depression and control orientation, which may develop as an additional factor in maintaining seizure control (Carmen Uhlmann), and the potential role of specifically trained dogs for early aura detection, with the remarkable ‘side-effect’ of seizure reduction (Stephen Brown). Indication-specific, clinical studies were reported on various neurobehavioural treatment concepts for juvenile myoclonic epilepsy (Zarko Martinovic) and complex partial epilepsy (Joel Reiter)7, each with comparable results in that psychological approaches are effective and hence should be offered to all patients with these diagnoses. Since the room allocated for the 2nd Behavioural scientific session in Prague was too small for those interested to attend, a further workshop was held. This allowed an extended presentation of clinical practice: first, a person with epilepsy who is in the process of learning seizure control described and discussed his gradually developed techniques of ‘cognitive restructuring of experiential seizures’, allowing him to regulate the frequency and duration as well as—from negative to positive—symptoms and contents of his partial seizures (John Benak). Second, snapshots on counselling were provided by Donna Andrews who succeeded in taking control of her own symptomatic partial epilepsy more than 30 years ago, and by the neurologist whom she had convinced of her approach (Joel Reiter). Finally, another presentation included the video-documentation of a profoundly disabled patient who had learnt to control diurnal and