5. Meditation and epilepsy

Meditation

Neuron Overexcitability
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Epilepsy is a pathophysiological disease that has been treated by the use of antiepileptic medication and surgery[1]. These therapy treatments are effective in addressing the immediate pathology of the disease however; the psychiatric symptoms and their effect on the quality of life are not addressed by these forms of treatment. The pathology of some types of epilepsy, brain structures affected by epilepsy and meditation will be elucidated. Finally, the UPLIFT program will be discussed as a pilot program that has been conducted using mindfulness meditation to address depression in epileptic patients

Epilepsy Pathology

The brain regions that are less active during goal oriented behaviours are the precuneus, medial frontal and temporoparietal cortices as observed in Lauf's paper [2] the results of their paper showed that in patients with focal epilepsy, particularly temporal lobe epilepsy (TLE) there was a common decrease in resting state activity. Patients affected by TLE were highly influenced by Interictal epileptic discharges (IED) unlike their extra-TLE counter parts. This finding does not mean that extra-TLE patients are not affected by the IED but are influenced to a different degree than TLE patients. EEG- fMRI methodology was shown to be an effective way to study IEDs.
The structural and functional disturbances in mesial temporal lobe epilepsy studied by Liao’s group [3] have shown that the decreased connectivity in the DMN may be due to degeneration of the structural connectivity between the Posterior Cingulate Cortex (PCC) / Precuneus (PCUN) and the bilateral mesial temporal lobes. These studies that look into the DMN have an important correlation to the study of meditation. Meditation practices reduce activity of the DMN which is responsible for mind wandering [10].
The cognitive impairment that characterizes atypical absence seizures is indicative of the role of the thalamo-hippocampal circuitry [4]. According to the review by Onat, the characteristics of atypical absence seizures include: lasting longer than typical absence seizures, refractory to medication and consciousness may be present sometimes during the occurrence of a seizure. Atypical absence epilepsy is still being studied to find out why it does not respond to medication, however due to the circuitry that is similar to that which is employed in meditation; meditation may be used as a therapeutic technique.
The diagnosis of depression and epilepsy are dissimilar but due to the observed effects of antidepressants on reducing the incidence of epileptic fits and anticonvulsants improving the outcomes in affective disorder suggest that these two disorders share a common factor in the biological pathway. In addition, deficits in the serotonergic and noradrenergic system have been proposed to explain the dysfunctional episodes that patients with epilepsy and affective disorder go through[5].

Psychiatric symptoms of epilepsy

In the paper by Zentano et al (2007) a population based analysis of the psychiatric comorbidity in epilepsy was studied. The results of the study were: persons living with epilepsy were more likely than persons without the disease to report lifetime anxiety disorders [6]. Therefore, it is important to understand the correlation of psychiatric symptoms with epilepsy to improve the overall quality of life of patients with epilepsy.
In review of previous studies, the most prevalent psychiatric conditions affecting patients with epilepsy are as follows: psychoses, neuroses, mood disorders, personality disorders and behavioural problems [8]. The results of Zentano’s group which focused on the numerical prevalence are illustrated below

Psychiatric conditions and their prevalence in epileptic patients
Mood disorder including dysthymia (lifetime) 34.2%
Mood/anxiety disorder (12 month) 19.9%
Major depressive disorder (lifetime) 17.4%
Mood disorders (12 month) 14.1%
Anxiety disorders 12.8%
Panic disorder 5.6%
Another study looked into self –reporting as a method of determining prevalence of depression and anxiety in epileptic persons. Due to the large sample of respondents, income and race/ethnicity were adjusted to come up with accurate results[8]. The conclusion of the study found that adults who reported having a seizure disorder or epilepsy were twice as likely to self-report that they experienced depression or anxiety in the previous year . Unlike most studies which are carried out in tertiary institutions, this study was administered to the general population through the mail, this may account for the high number of respondents and their willingness to talk about the frequency of seizures , depression and anxiety without the intimidating verbal interviews.

Methodology: EEG and fMRI

In the paper by Ohana [9] the methodology of studying the DMN is shifted from imaging to neurodynamics by the use of electroencephalogram functional connectivity (EEG-FC) instead of an MRI or fMRI. The results of the study show that EEG-FC is useful in studying DMN activity and that the practice of mindfulness meditation shows reduced DMN activity through the method of EEG-FC.

The image illustrates the use of SPECT to illuminate the changes that meditation brings about[14]. In Figure 1, the scans show that when the participant is at rest, there is increased blood being pumped into the prefrontal cortex and the anterior cingulate gyrus after participating in the meditation practice.

Kirtan Kriya meditation
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Figure 1 (A) Before the 8 week meditation program (B) After the 8 week meditation program

Neural basis of meditation

In the study by Brewer [10] they hypothesised that experienced insight meditators would reduce the recruitment of the Default Mode Network (DMN) which is responsible for mind wandering. Brewer’s group observed that in insight meditators, the two primary nodes (mPFC and PCC) of the DMN showed relatively decreased activation in meditation as compared to the controls. The studies done support the Default Mode interference hypothesis which states the DMN can re-emerge to take over goal-oriented tasks and create a cyclical performance deficit. The results from their study show that through the specific training of insight meditation, the activity of the DMN is reduced hence it may serve as a low-cost therapy for neuropathologies associated with loss of cognitive control and recruitment of the DMN network for example IEDs.
A frequent practice in meditation is associated with increased thickness in regions of the cortical layer in the brain that is responsible for processing interoceptive, somatosensory, auditory and visual stimuli[11] This study proves beneficial in arguing for the case of the use of meditation traditions to refocus the cognitive disruptions associated with epilepsy. Thickening of the cortices provides a biological response to meditation, the pattern in which the cortical region is thickened is dependent on the tradition of the meditation[11] . This is because each meditation tradition focuses on different themes for example concentration meditation focuses on attention, metta focuses on compassion while tai chi involves the use of exercise to quiet the mind.

Therapy feasibility

In response to the lack of studies done on Mindfulness Cognitive Behavioural Therapy (MCBT) in people diagnosed with epilepsy, the UPLIFT program was undertaken by the Thompson group [12]. The study was carried out online and through the phone to help epileptic patients improve their quality of life by providing them an avenue to discuss the psychiatric symptoms that accompany being diagnosed with Epilepsy. Depression and anxiety were the two most common psychiatric symptoms associated with epilepsy in this study.
In another study carried out in Hong Kong, cognitive behavioural therapy was used to treat adults diagnosed with epilepsy. The lack of control that most epileptic patients face has been recorded as an etiological factor in the development of psychosocial problems and it is for this reason the research group focused on these two aspects: cognitive restructuring and seizure control [13]. The results of the study showed a noted improvement in the well-being subscale as well as the seizure and stress management subscales.

In conclusion the use of meditation traditions as a therapeutic approach to treat epilepsy and improve the quality of life of patients is a plausible and feasible mode of treatment.

Bibliography
1. Bain, P., Blass, J., Jenkins, H., & Johnson, M. (2012). Epilepsy. Current Medical Literature, 28(3), 88-90.
2. Laufs, Helmut, Khalid Hamandi, Afraim Salek-Haddadi, Andreas K Kleinschmidt, John S Duncan, and Louis Lemieux. “Temporal Lobe Interictal Epileptic Discharges Affect Cerebral Activity in ‘Default Mode’ Brain Regions.” Human Brain Mapping 28, no. 10 (2007): 1023–1032.
3. Liao W, Zhiqiang Z, Zhengyong P, Dante M, Jurong D, Xujun D, Cheng L, et al. “Default Mode Network Abnormalities in Mesial Temporal Lobe Epilepsy: A Study Combining fMRI and DTI.” Human Brain Mapping 32, no. 6 (2011): 883–895. : full source reference
4. Onat, Yılmaz F, Luijtelaar G, Nehlig A, and Snead C. 2013. "The Involvement of Limbic Structures in Typical and Atypical Absence Epilepsy." Epilepsy Research 103 (2-3): 111-123.
5. Jobe PC. Common pathogenic mechanisms between depression and epilepsy: an experimental perspective. Epilepsy Behav. Oct 2003;4 Suppl 3:S14-24.
6. Zenteno, Jose F., Scott B., Jetté N, Williams J, and Wiebe S. 2007. "Psychiatric Comorbidity in Epilepsy: A Population-Based Analysis." Epilepsia 48 (12): 2336-2344
7. Gaitatzis A, Trimble MR, Sander JW. (2004a) The psychiatric comorbidityof epilepsy. Acta Neurol Scand 110:207–220.
8. Kobau R, Gilliam F, Thurman DJ. Prevalence of self-reported epilepsy or seizure disorder and its associations with self-reported depression and anxiety: results from the 2004 HealthStyles Survey. Epilepsia. Nov 2006;47(11):1915-21
9. Ohana A, Glicksohn J, and Goldstein A. “Mindfulness-Induced Changes in Gamma Band Activity - Implications for the Default Mode Network, Self-Reference and Attention.” Clinical Neurophysiology : Official Journal of the International Federation of Clinical Neurophysiology 123, no. 4 (2012): 700–710.
10. Brewer J, Worhunsky P, Gray J, Tang Y, Weber J, and Kober H. “Meditation Experience Is Associated with Differences in Default Mode Network Activity and Connectivity.” Proceedings of the National Academy of Sciences 108, no. 50 (2011): 20254–20259.
11. Lazar, S.W., C.E. Kerr & R.H.Wasserman, et al. 2005.Meditation experience is associated with increased cortical thickness. Neuroreport 16: 1893–1897.
12. Thompson N, Walker E, Obolensky N, Winning A, Barmon C, DiIorio C, and Compton M. “Distance Delivery of Mindfulness-Based Cognitive Therapy for Depression: Project UPLIFT.” Epilepsy and Behavior 19, no. 3 (2010): 247–254.
13. Au A, Chan F, Li K, Leung P, Li P, Chan J. Cognitive-behavioral group treatment program for adults with epilepsy in Hong Kong. Epilepsy Behav 2003;4:441–6
14. Newberg, A. B., Serruya, M., Wintering, N., Moss, A. S., Reibel, D., & Monti, D. A. (2014). Meditation and neurodegenerative diseases. Annals of the New York Academy of Sciences, 13071(1), 112-123. doi:10.1111/nyas.12187et al

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