The use of psychotherapy in epilepsy is a complicated topic, because it always has to take into account the neurological dimension of the underlying epileptic disorder as well as the specific psychiatric vulnerability epilepsy engenders. As a result, the following cannot provide a simple set of treatment rules. Instead, it presents:
1. Introductory comments on the complex relation between (neurological) epilep-tological and psychotherapeutic approaches.
2. This is followed by four case reports to give some idea of how the general rules of diagnosis have to be applied in an individual way to produce a unique treatment in every single case.
3. Then, some ideas are presented on indications and contraindications.
4. Finally, findings from a posttreatment comparison of conventional inpatient treatment of epilepsy vs. treatment supplemented by psychotherapy are reported to help decide whether psychotherapy is in any way effective in treating epilepsy or is only well-intended.
Despite the above-mentioned complexity, it is easy to gain an overview on psychotherapy in the treatment of epilepsy because there seems to be practically no recent literature on the topic. The indices of major modern textbooks on epileptol-ogy refer to psychotherapies exclusively in connection with pseudoseizures (Engel and Pedley, 1997) or give, at best, the terse reference that 'this modality is largely neglected in the literature on epilepsy for several reasons' (Stagno, 1993, p. 1154). Except for pseudoseizures, psychotherapeutic procedures have not been addressed in any relevant epileptological journals during the last 10 years.
It is quite remarkable, and almost worth studying in its own right, that psychotherapy in the treatment of epilepsy has hardly ever been a subject of scientific research, even though there is no denying the frequency of psychological disturbances in such patients. In line with the situation in the literature, medical care reveals a disproportionately high number of secondary psychological disturbances in epilepsy patients but a disproportionately low level of psychotherapeutic assistance. This has less to do with the psychotherapists themselves, despite the frequent truism that psychotherapy could aggravate an epilepsy and is, therefore, contrain-dicated. It is far more the case that epileptology itself has remained conspicuously silent as far as demands for the development of psychotherapeutic concepts for its clients are concerned.
To some extent, this may be due to the way in which epileptologists often view psychotherapists: namely, as little more than those who seem to have all the time at their disposal that one would wish for one's own work. They also make comparatively little use of the available psychotherapeutic treatments compared to what are considered to be potent drug options. Finally, clinicians often view psychotherapists as persons who always only confirm what they know and anticipate already: particularly overprotective mothers, destructive fathers, strangulated affect in the patients or some kind of spectacular narratives from a patient's prior life that only get in the way of the abstraction necessary in clinical work.
Finally, there are a few major differences in the ways of thinking themselves that create major handicaps to the integration of epileptological and psychotherapeu-tic perspectives: whereas the epileptologist strives continuously to test whether external treatments such as new drugs or, if necessary, surgery should be applied, the psychotherapist focuses specifically on the action potentials of the patients themselves, be they in developing an individual technique for stopping seizures, improving insight or correcting problematic patterns of interpersonal interactions.
Instead of relying on the positive, visible findings of neuro-imaging techniques, neurophysiology and neuropsychology, psychotherapy focuses on the gaps and contradictions that first make it possible to grasp defensive mechanisms such as projections, denials and isolations with all their intra- and interindividual consequences.
In contrast to the usual and necessary practice in epileptology of advancing knowledge by tracing back the disorder increasingly more precisely to a circumscribed cause that is localized as accurately as possible, psychotherapy is concerned with how symptoms are embedded in a person's individual life context. Hence, a psychotherapeutic diagnosis is based on the idea that by creating a suitable setting, cautious interventions and on-line observations of the interplay in the counselling session, the decisive problem areas for the patients will be revealed in interaction and also become accessible to modification.
Furthermore, there is also a justifiable apprehension that focusing on, for example, defensive processes or (counter) transference might lead to the neglect of physical aspects that are just as essential for treatment. Each recognized dimension added to the relevant data field, in this case, the usual discourse on epileptology (i.e. case history, EEG and, not least, neuro-imaging techniques) multiplies the number of interactions that need to be taken into account, and produces not only a factual increase in knowledge but also an equally factual increase in potentially confusing complexity. A reluctance to tackle such a lack of transparency and a preference to narrow the field to neurological treatments has a certain cognitive rationality and is indubitably better than forcing oneself to take more demanding perspectives, particularly when they are not encouraged by the hospital or surgery framework.
Nonetheless, epileptologically difficult treatment situations often emerge in which it is popular to talk about a 'noncompliance' or 'pharmacoresistance' that apparently cannot be explained further. These are situations in which the integration of a psychotherapeutic approach can bring about a decisive change in the course of treatment. However, it is harder to recognize such a need for psychotherapy in patients with epilepsy than in those without such an organic disease: many treatment problems are attributed too hastily to the epilepsy or to the seizures as such, to the medication or also to accompanying neuropsychological deficits rather than being conceived as problems accessible to psychotherapy. This neglects the problems due to either more or less unconscious conflicts (e.g. of identity, self-esteem or dependency) or so-called ego-structural deficits (e.g. a highly reduced perception of self and/or other; inadequate self-control; unstable affect; or immature defence mechanisms such as, in particular, denial or dissociation, neurotic or even psychotic projection and unstable attachment behaviour).
In the following, four short case reports will be used to illustrate how epilepto-logical, psychiatric, and, in the stricter sense, psychotherapeutic dimensions interrelate.
The first patient has an epilepsy with focal and generalized seizures plus perimenstrually peaking diffuse tonic-clonic seizures with onset at 15 years. Although her left-cephalic aura indicated a right-temporal focus, photosensitivity and corresponding spike-waves as well as a hereditary factor pointed to a generalized disorder.
The patient was resistant to phenytoin and carbamazepine and was referred to us with a relatively high phenobarbital level.
The admission interview was characterized by the recurring and piercingly expressed theme that her last physician had said he was referring her to us after telling her that he had 'nothing left up his sleeve'.
'Yes, and then, for a while, I had a doctor who was on television, and everybody gave him a lot of praise, and he almost cost me my life and treated me with valproic acid until I was in a coma.'
Another recurring phrase was, 'I can't fall into the open arms of a doctor.'
Hence, these and similar communications linked together major therapeutic, erotic and destructive ideas of reference in an indiscriminable, confusing and entangled manner.
We admitted her for inpatient treatment with the diagnosis of an agitated depression plus occasionally severe suicidal intent.
Initially - after the experiences reported above - she must almost have thought we wanted to murder her when we proposed changing her medication to the combination of valproic acid and lamotrigine that is particularly promising for such mixed epilepsies.
Against the background of such breakdown fantasies, the planned changeover was even more difficult because it also included an inpatient phenobarbital detoxification with all the risks of seizures in withdrawal. None of those involved were spared in any way.
The patient was good at eliciting a number of strong reactions whose impact was bound to remain destructive as long as it was not understood as an actualization and externaliza-tion of her self- and self-esteem conflict and associated fears of doom and destruction. Although the wish for a less exhausting patient is understandable in such phases of treatment, it would only make the therapeutic relationship superficial or lead to a cessation of treatment.
A few themes recurred during treatment:
1. Poisoning by the prior therapist along with the peevish reproach that, nowadays, it seemed that such poisonings were simply taken for granted.
2. The father's working in the garden.
3. Buying expensive shoes.
4. Her mother's own occasional seizure 20 years before.
Although this list may seem absurd, its contents provided opportunities for symbolic understanding.
In her accounts of weekend visits to her parents that always featured her father working in the garden, the patient found a way to leave behind all her bitterness and was at times so warm-heartedly humorous as to not only disclose the both decisive and psychosexually fixated relationship with her father but also enable her to become aware of this through a reflective self-distancing.
The patient's rather strange deliberations over whether to buy a wonderful pair of very expensive winter boots not only reflected her self-conflict ranging from her emerging identity plans and oppressive material restrictions, but it was also capable of being named as such. This was joined by dreams that made it possible for her to see the possibility of taking an intermediate position somewhere between delusions of grandeur and depression.
At the same time, the mother started to recollect her single occasional seizure 30 years before that, as now threatening the daughter, had led her to give up a career as a school teacher while also suggesting a biological flaw in the family on which the daughter had fixated in anxious anticipation.
One may consider that all this has little to do with the epilepsy but perhaps with a completely independent narcissistic neurosis. However, it is precisely the specific constellation of connections in each single case between (a) directly seizure-related breakdown experiences, (b) the narcissistic crises associated with every seizure for many patients, (c) the cumulative growth of resignation, (d) the fragility of self-esteem and (e) the ambivalence towards medicines that, like a disappointing object, are perceived simultaneously as an indispensable protection but also repeatedly as a failure and disappointment that makes it necessary for the therapist to consider not only the epilepsy and its best possible pharmacotherapy, but also the ego-structural sequelae of both the seizures themselves and the medicines.
Naturally, it is impossible to reach a final decision on whether the long-term reduction in anxiety and calming of this patient is due to her now being free from seizures for a complete year, to the withdrawal from phenobarbital, to the combined treatment with valproic acid and lamotrigine or to the processing of the above-mentioned (in this case, self- and oedipal) conflicts with the resulting increase in internal latitude. Whatever the case, the psychotherapeutic setting was certainly necessary to generate a tolerance for the difficult changeover without which it would have been impossible to contain a patient in such a pre-carius condition. After freedom from seizures had been achieved, I found it more than ironic when the patient told me how her mother had asked her impatiently during her menstruation whether she had had another seizure. After the second seizure-free menstruation, the mother surprised the patient one morning by telling her that she had had her first seizure for 30 years the night before, or at least she had woken up after biting her tongue.
The next patient, a 28-year-old male with a right-hemisphere epilepsy and cerebral hemi-hypotrophy and somatosensory auras, frontal hypermotor and generalized tonic-clonic seizures had not, at the time of admission, left his parent's home for more than 10 years because of his fear of having a seizure on the street.
The drug changeover was accompanied by two half-hour psychotherapy sessions per week. A number of these sessions were characterized by the patient's complaints over the way seizures prevented him from getting anywhere in life along with my personal tiredness in reaction to this that was almost impossible to control. After I had turned up late for several of our sessions, I realized how far the patient seemed to accept my tardiness with complete indifference. I mentioned this to him, and this transformed my role from a sacrosanct physician into that of an assailable other, leading to an incredible change: unexpectedly, I became the focus of very excessive demands. He simply thought that I or the hospital should help him to find not only a flat and a job but also, when possible, a mate. Hence, a regression to the level of grandiose infantile wishes had occurred. Several sessions pursued a kind of reality test of the patient's wishes that led inevitably to disappointed anger and the necessary emotional counter-control of the therapist known in the literature as containing. After a hefty but brief depressive reaction, the patient found his way out of his regressive arrest and began to structure his future in small practical steps rather than getting caught up in grandiose desires. He worked out his own desensitization programme to overcome his fear of the streets that was soon a success. In addition, he managed to learn the necessary DC potential shifts in a biofeedback treatment so that although auras continue to occur daily, these have not turned into major seizures for more than 18 months.
The next 30-year-old patient with a focal epilepsy and right-temporal lobe hypotrophy was admitted with such prior diagnoses as an 'abnormal personality development with depressions and anxiety states' and even a tentative diagnosis of 'onset of psychosis with auditory hallucinations'. A diagnostic phase within a preoperative institute had taken a relatively turbulent course in interactive terms.
Alongside improving antiepileptic drug therapy, the 3.5-month treatment consisted initially in a very cautious approach to her strange and prolonged disturbances to perception and experience. For a long time, these led to a threatening atmosphere that was hard to understand. In the past, her so-called auditory (pseudo) hallucinations had led to the tentative diagnosis of a psychosis, and these were currently also the reason for major disintegration anxieties expressed in, for example, the sensation 'then, I feel like a dictionary in which more and more pages are simply blank' or 'everything I want to think gets sucked out of my brain as if it was a dry sponge'.
During psychotherapy, it took some time to verbalize the various episodic sensations to which she was exposed because of the difficulty of putting the quality of these experiences into words. It was also necessary to distinguish very slowly and carefully her auras from other episodes that had the character of anticipatory anxiety or mental disintegration anxiety. This also made it possible to calm down the patient's own apprehension that she was facing a creeping psychotic disintegration, an apprehension that she would suddenly start to project on her communication partner with corresponding surges in anger when treatment first commenced.
Hence, in this case, it was the verbalization of what was experienced in the auras that helped to make the repeated sudden affects and intensively conflictual relationship patterns accessible to a more relaxed self-observation. The patient developed more precise differentiations of affect, and the initially threatening quality of the treatment atmosphere gradually disappeared.
The final 19-year-old patient was referred to us after spending 11 months in a psychiatric hospital for adolescents. For several years, she had been treated by an epileptic outpatient department for the prior diagnosis of a focal frontal epilepsy. Our own diagnosis, in contrast, was very clearly an idiopathic generalized epilepsy with myoclonic and generalized tonic-clonic seizures.
Correcting the diagnosis was important, because the administration of lamotrigine and valproic acid led immediately to a remarkable improvement in her seizures. Only isolated relapses occurred either when the patient was woken abruptly or when medication had not been taken. Nonetheless, such irregularities were very frequent because of her very irregular bedtimes as well as a failure to take medication. Encouraged by the impressive initial effect of changing her drugs, we thought that the disruptive gaps in compliance could be closed through simple advice. However, contact with the patient then became reduced: she appeared to draw back from her previous attentiveness into a dour, seemingly almost unreachable silence. After an exhausting processing that confronted major familial scotom-ization tendencies in her life history, it emerged that at the age of 10-14 years, that is, at the onset of her epilepsy, her mother had blocked any adequate pharmacotherapy due to her own fears of poisoning engendered by her personal psychotic development. Her father, in contrast, had advised her emphatically to take her medicine, but had been unable to assert himself. The reconstruction of this history in conjunction with the impression that the patient 'drifted off' precisely when attempting to discuss the background of her clearly self-injurious noncompliance revealed the intrapsychological conflict behind the biographical drama: by switching apparently meaninglessly between adequate and inadequate health behaviour, the patient subconsciously maintained the inner relationship to both her father and her mother. Compliance would have meant the loss of the internal mother. It is precisely when such a meaning of noncompliance becomes recognized that compliance becomes conceivable and, indeed, unproblematic.
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