Psychopathological and peripheral levels of neurobiological correlates of obsessive–compulsive symptoms in patients with epilepsy: A hospital-based study
Highlights
► Obsessive–compulsive symptoms are common in patients with idiopathic epilepsy. ► Male sex, age, and seizure type and side are also risks for OCSs and epilepsy. ► Intractability to antiepileptic medications is a main risk for OCSs and epilepsy. ► Depression and anxiety are common comorbidities of OCSs and epilepsy.
Introduction
Epilepsy is one of the most common neurological and medical disorders, with a prevalence of ~ 8.2–12.9 per 1000 in the general population [1]. Fortunately, the majority (~ 65–80%) of patients with epilepsy of unknown etiology (idiopathic or primary epilepsy) become seizure-free after treatment with antiepileptic drugs (AEDs) for at least 2–5 years, while the seizures of the remaining (~ 20–35%) are difficult to control even with the addition of 2nd or 3rd AED (conventional or new) for a significant period of time (intractable or refractory epilepsies) [2]. Patients with recurrent, intractable, or refractory seizures are at increased risk for a number of medical, endocrinal, and neurobehavioral (such as cognitive, emotional, and psychosocial) abnormalities or comorbidities which are related to epilepsy itself and/or its medications [3], [4], [5], [6]. Sometimes, such comorbidities negatively impact the patient's quality of life. It has been estimated that approximately 70–88% of patients with epilepsy have inter-ictal psychiatric symptoms and disorders (such as depression, anxiety, psychosis, obsession–compulsion, personality disorders, aggression, and even suicide) [5], [6], [7], [8], [9], [10], [11], [12], [13].
Obsession is the 3rd most frequent psychiatric comorbidity with epilepsy after depression and anxiety. Obsessive–compulsive symptoms (OCSs) and disorder (OCD) have a prevalence of 10–25%, particularly with temporal lobe epilepsy (TLE), compared with 2.5–3% in the general population [14]. Obsessive–compulsive disorder is defined as a range of clinical characteristics with two major components: a) the intrusion of thoughts and ideas which are often allied with compulsive actions and b) the resulting trigger of abnormal behaviors or rituals. Obsessive–compulsive symptoms are seen in OCD itself or other psychiatric conditions (depression, anxiety, psychosis, personality disorders, etc.). In epilepsy, intrusive thoughts such as imaginary sins or mistakes, religiosity, symmetry/exactness, indecision, checking behaviors, doubting, ordering, hoarding, excessive writing, and over-representation of contamination themes such as hand washing and emotional dyscontrol are commonly seen OCSs [10], [11], [12], [13].
The exact mechanisms which associate epilepsy with OCD are complex and less understood. Studies implicate structural or pathophysiologic abnormalities of certain brain areas and their related connections (such as the frontal lobe, temporal lobe, cingulate region, limbic system, basal ganglia, and thalamic, orbito-fronto-thalamic, and fronto-thalamic-pallidal-striatal-anterior cingulate-frontal circuits, and amygdala-cingulate network) and their connections and neurobiologic mediators (such as glutamate, serotonin, dopamine, and gammaaminobutyric acid or GABA) as causes of OCSs and OCD in patients with epilepsy [15], [16], [17], [18], [19], [20], [21]. These implications are mainly based on the structural and functional comorbidities between OCD and other neuropsychiatric disorders [5], [15], [18], [19] and the observations of improvement or induction of OCSs and changes in functional neuroimaging in patients with TLE or refractory epilepsy after surgical intervention (temporal lobectomy) [22], [23], [24], [25], [26], [27].
Obsessive–compulsive symptoms and obsessive–compulsive disorder are often underdiagnosed in the out-patient epilepsy clinic. This work was undertaken to determine the risks and comorbidities (psychopathological and peripheral blood neurobiologic correlates) of OCSs in adult patients with idiopathic epilepsy recruited from a university hospital.
Section snippets
Patient selection (demographic and clinical evaluation)
The out-patient epilepsy clinic of the Department of Neurology and Psychiatry of Assiut University Hospital manages patients from low-income families and those who are not covered by insurance service. Nearly 474 adults with idiopathic epilepsy are regularly and monthly attending the clinic for follow-up and to receive AEDs. Each patient's seizure type was diagnosed according to Berg et al. [28]. Patients were treated with AEDs which included: carbamazepine (CBZ), valproate (VPA), or
Statistical analyses
Calculations were done using the statistical package SPSS, version 12.0. Data were presented as mean ± SD (Standard Deviation) when normally distributed and mean (quartiles) when not normally distributed (e.g., scores of BDI-II, HAM-A, and Y-BOCS and blood concentrations of serotonin, catecholamines, and dopamine). Kolmogorov–Smirnov test was used to test the parameter distribution. Student's t test was used for comparison of means of normally distributed parameters, while Mann–Whitney U test was
Demographic and clinical characteristics (Table 1)
In this study, the final statistical analyses were done on a total of 295 patients (male = 160; female = 135) which included those with no psychiatric symptoms = 107, those with OCSs = 188, and healthy subjects as controls = 100. Patients had a mean age of 32.35 ± 6.25 years (versus 29.14 ± 6.90 years for control subjects; P = 0.328). The majority of patients had complex partial seizures of frontal or temporal lobe onset with secondary generalization and predominantly left-sided epileptic foci. Patients were
Discussions
Obsessive–compulsive symptoms of different severities are common in adult patients with idiopathic epilepsy. Here, we reported a prevalence of 20.04% compared with the reported figures in the general population (2.5–3%) [14]. Obsessive–compulsive symptoms were in the form of religiosity, checking, doubting, and hand washing. This prevalence is relatively higher compared with many previous reports (10–25%) [15] which is explained by the fact that patients were recruited from a tertiary referral
Conclusions
The results of this study indicate that a) OCSs are common in patients with epilepsy; b) male sex, age, seizure focus, lateralization of epileptic foci, and intractability to AEDs are the main risks and depression and anxiety are common comorbidities with epilepsy; c) AED-related variables (dose, duration of treatment, and drug level of AEDs) are not associated with OCSs; and d) comorbid psychiatric symptoms (such as depression, anxiety, and OCSs) are linked to epilepsy-induced abnormalities in
Conflict of interest
The authors declare that they have no competing interests. Authors did not funds to conduct this work and all aspects of the study were the authors' responsibility.
Authors' contribution
SAH did the clinical evaluation of the patients, collection of serum samples, participated in the design of the study and statistical analysis, and drafted the manuscript. YME did the psychiatric evaluation, helped in the clinical evaluation of the patients, and participated in the design of the study. HAA did the lab evaluation. All authors helped in the statistical analyses and drafting of the manuscript. All authors read and approved the final manuscript.
Acknowledgment
We thank the psychologists and the paramedical staff members of the psychiatric unit and the out-patient epilepsy clinic of the Department of Neurology and Psychiatry, Assiut Egypt for their help and for caring for the patients throughout the study.
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2020, Neurochemistry InternationalCitation Excerpt :Epidemiological studies have shown that the incidence of depression and anxiety is greater than 55% in patients with epilepsy (Adams et al., 2008; Amelia et al., 2017), and these symptoms may aggravate the epileptic condition and affect patient's quality of life (Amelia et al., 2017; Anna et al., 2019). Most data generally suggest that depression and anxiety disorders in epilepsy may be mediated via the interplay of neurobiological and psychosocial factors (Sherifa et al., 2013; Barbara and Stanisław, 2016). Several studies have suggested that inflammation in the brain contributes to depressive and anxious behaviors in animal models of TLE (Xie et al., 2014; Yam et al., 2018), but the exact molecular mechanisms are still poorly understood.
Factors associated with obsessive–compulsive symptoms in people with epilepsy
2020, Epilepsy and BehaviorCitation Excerpt :We did not find any studies that used the OCI-R to measure OCS in PWE. Anxiety was strongly related to the OCS in PWE in the present study, consistent with the link(s) between anxiety and/or depression and OCS [3,4,8,9]. After controlling for anxiety, epilepsy severity was identified as an independent factor associated with OCS.