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Differences in obsessive–compulsive symptom dimensions between patients with epilepsy with obsessive–compulsive symptoms and patients with OCD
Epilepsy & Behavior 102 (2020) 106640
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Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Differences in obsessive–compulsive symptom dimensions between patients with epilepsy with obsessive–compulsive symptoms and patients with OCD Esin Evren Kilicaslan a,⁎, H.Sabiha Türe b, Meltem İzci Kasal a, Nebile Nur Çavuş a, Dilek Altın Akyüz b, Galip Akhan b, Lutfullah Besiroglu a a b
Izmir Katip Celebi University, Atatürk Education and Training Hospital, Psychiatry Department, Basin Sitesi, 35150 Izmir, Turkey Izmir Katip Celebi University, Atatürk Education and Training Hospital, Neurology Department, Basin Sitesi, 35150 Izmir, Turkey
a r t i c l e
i n f o
Article history: Received 1 July 2019 Revised 28 September 2019 Accepted 28 September 2019 Available online xxxx Keywords: Epilepsy Obsessive–compulsive symptoms Obsessive–compulsive disorder Depression Schizotypy Dissociation
a b s t r a c t Clinical correlates of obsessive–compulsive symptoms (OCS) were evaluated in 100 adult consecutive outpatients with epilepsy, using the Obsessive–Compulsive Inventory (OCI-R), Beck Depression Inventory (BDI), Dissociative Experiences Scale (DES-II), and the Schizotypal Personality Questionnaire (SPQ). Dimensional Yale– Brown Obsessive–Compulsive Scale (DY-BOCS) was applied to determine the types and severity of OCS to the 45 patients with epilepsy who were over 21 points on the OCI-R scale and 30 patients who were with diagnosed obsessive–compulsive disorder (OCD) among the patients in the psychiatry outpatient clinic, as a control group. As a result, it was found that patients with epilepsy with OCS tend to have more symmetry/exactness obsessions and compulsions, whereas patients with OCD had significantly more contamination/cleaning and aggressiveness obsessions and compulsions. In addition, OCS was found to be significantly higher in temporal lobe epilepsy (TLE) and extratemporal epilepsy than generalized epilepsy. However, OCS were correlated with depression, dissociation, and schizotypy in patients with epilepsy, while only depression was predictive when regression analysis was performed for OCS. This study is the first study to compare patients with OCD with patients with epilepsy in terms of the nature of OCS and first identified the differences in OCS dimensions between patients with epilepsy with OCS and patients with OCD. © 2019 Elsevier Inc. All rights reserved.
1. Introduction Epilepsy, a key neurological disorder with significant global burden of illness [1] affecting 0.3–0.8% of the population [2–4], may negatively impact quality of life and mental health with associated psychiatric symptoms and diagnoses. These psychiatric symptoms and diagnoses may precede the diagnosis of epilepsy [5]; further psychiatric symptoms may occur interictal, periictal, and postictal [6]. It has been shown that psychiatric disorders are more common in individuals with epilepsy than in society and they are significantly unnoticed [6]. The lifetime prevalence of any mental health disorder in people with epilepsy was 35.5% compared with 20.7% in those without epilepsy [7]. There is also an increased risk for suicidal ideation [7,8]. Anxiety and depression symptoms, mood disorders, and psychotic disorders were most commonly investigated in the studies on the relationship between epilepsy and psychiatric disorders. ⁎ Corresponding author at: İzmir Katip Çelebi Üniversitesi, Atatürk Eğitim ve Araştırma Hastanesi, Psikiyatri Kliniği, Basın Sitesi, Karabağlar, 35150 Izmir, Turkey. E-mail address: [email protected] (E.E. Kilicaslan).
https://doi.org/10.1016/j.yebeh.2019.106640 1525-5050/© 2019 Elsevier Inc. All rights reserved.
Obsessive–compulsive disorder (OCD) was relatively less studied compared to other psychiatric disorders. On the other hand, the presence of obsessive–compulsive symptoms (OCS) in patients with temporal lobe epilepsy (TLE) [9], changes in OCD symptoms after epileptic surgery [10,11], and the findings of several studies showing abnormalities in frontotemporal areas in electroencephalography (EEG) in patients with OCD [12–14], suggest that there may be a relationship between OCD and epilepsy. However, literature on the relationship between OCD and epilepsy reveals confounding results, and studies are methodologically inadequate; the frequency and nature of OCS is not well known in patients presenting to epilepsy clinics. Although the relationship between OCS and chronic epilepsy is mainly focused on refractory TLE [15], conflicting results have also been reported. In one study, no evidence was found to support the notion that lateralized epileptogenic lesions are associated with different levels of depression, obsessionality, or personality traits [16]. The first publications that reported a relationship between TLE and OCD in the literature are case studies [17–19]. Isaacs et al. indicated a 22% prevalence of OCS in a group of 30 patients with drug-resistant TLE and reported that OCS in patients with TLE include more control, symmetry, hoarding, and washing/cleaning
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[9]. Monaco et al. [20] and Ertekin et al. [21] reported that patients with TLE had higher OCD comorbidity than patients with idiopathic generalized epilepsy (IGE). In a study with OCS in 39% of patients with epilepsy, the main risk factors were male sex, age, duration of disease, seizure focus (temporal and frontal lobe epilepsies NIGE), lateralization, and intractability to antiepileptic drugs [22]. Finally, Bird et al. reported that the majority of patients in a case series of 10 people living with both OCD and epilepsy suffered with TLE [23]. In these studies, patients with TLE were mostly taken into consideration and compared with healthy controls or patients with IGE. Despite the interest in a possible link between epilepsy and psychiatric disorders, such as, depression and schizophrenia, there is only one study investigating associations between epilepsy and different dimensions of schizotypy. In this study, schizotypal symptoms were found to be associated with early onset of seizures and diagnosis of TLE, and thus, the relationship between schizotypy and epilepsy was confirmed [24]. On the other hand, it has been suggested that patients with OCD with high schizotypy have more severe OCD symptoms and a worse prognosis [25,26], and it has been proposed that patients with OCD with high schizotypy represent a valid subtype of OCD [27]. In this context, schizotypy and obsessive–compulsive symptomatology in patients with epilepsy may have an association and need to be investigated. In this study, we sought to investigate clinical correlates of OCS in patients with epilepsy, and whether there are any differences in OCS dimensions between patients with epilepsy with OCS and patients with OCD. In addition, we aimed to investigate the relationship between OCS and psychopathology areas, such as, depression, dissociation, and schizotypy. 2. Methods 2.1. Participants and procedures The patients followed in the Epilepsy Outpatient Clinic of Izmir Katip Çelebi University, Atatürk Training and Research Hospital, were included in the study consecutively. Patients with additional neurological disorders other than epilepsy; patients with epilepsy because of secondary reasons, such as, head trauma, metabolic problems, intracranial events, etc.; those with a still severe medical condition (such as, endocrinological diseases, diseases of the respiratory system, or cardiovascular system); people with alcohol or substance use disorder and those with mental retardation were not included in the study. One of the consecutive patients refused to participate in the study, and 4 patients could not complete the scales due to cognitive impairment. As a result, 100 patients with epilepsy aged between 18 and 65 years who agreed to participate voluntarily were included. Written informed consent was obtained from all patients. An accredited Clinical Research Ethics Committee approved the study protocol. Sociodemographic characteristics, age at onset of epilepsy, duration of seizures, type of epilepsy, and antiepileptic drugs were recorded in the neurology outpatient clinic. Epilepsy types were grouped as focal and generalized epilepsies according to the International League Against Epilepsy (ILAE) 2010 classification [28], and they were divided into subgroups as temporal and extratemporal epilepsy in focal epilepsies. After the records were completed in the neurology clinic, all participants were given Obsessive–Compulsive Inventory-Revised (OCI-R), Beck Depression Inventory (BDI), Schizotypal Personality Questionnaire (SPQ), and Dissociative Experiences Scale (DES-II). Patients who scored greater than 21 points on the OCI-R scale were referred to the psychiatry outpatient clinic. Dimensional Yale–Brown Obsessive–Compulsive Scale (DY-BOCS) was applied to these patients to determine the types and severity of obsessive–compulsive symptoms. Patients who were with diagnosed OCD without neurological disease among the patients in the psychiatry outpatient clinic were taken as the control group. As in the group of patients with epilepsy, patients with a still severe medical
condition, people with alcohol or substance use disorder, and those with mental retardation or psychosis were not included in the study. After the diagnosis was confirmed by Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) Axis I Disorders (SCID-I), DY-BOCS, OCI-R, BDI, SPQ, and DES-II were applied. Approval for the analysis was obtained from the Izmir Katip Celebi University Institutional Review Board. Statistical analyses were performed using SPSS Version 24.0 for Windows. The patients were evaluated as 3 groups. 1. Patients with epilepsy with lower OCS: patients with epilepsy; OCI-R scores below 21 points; 55 patients. 2. Patients with epilepsy with higher OCS: patients with epilepsy; OCIR scores more than 21 points; 45 patients. 3. Control group of patients with OCD; 30 patients. We used chi-square test for categorical data and one-way analysis of variance (ANOVA) for comparing the three groups. Pearson correlation analysis was performed to determine the phenomenological differences between patients with OCD and patients with epilepsy with OCS. Multinomial logistic regression analysis was performed to determine the factors associated with the emergence of OCS in patients with epilepsy. 2.2. Measures Symptoms of OCD were assessed with the OCI-R. The OCI-R is an 18item self-report measure assessing the presence and severity of OCD symptoms; each rated from 0 (not at all) to 4 (extremely). The measure yields a total score of 0–72 and is divided into six subscales containing 3 items each. The OCI-R demonstrates good test–retest reliability and convergent and discriminant validity [29]. A cutoff point of 21 is recommended as indicative of clinically significant OCD [29]. The DY-BOCS was utilized to evaluate the presence and severity of OCD symptom dimensions. “The DY-BOCS self-report is composed of an 88-item self-report checklist, designed to provide a detailed description of obsessions and compulsions that are divided into six different obsessive–compulsive symptom dimensions: (1) obsessions about harm due to aggression/injury/violence/natural disasters, and related compulsions; (2) obsessions concerning sexual/moral/religious obsessions, and related compulsions; (3) obsessions about symmetry/”justright” perceptions, and compulsions to count or order/arrange; (4) contamination obsessions and cleaning compulsions; (5) obsessions and compulsions related to hoarding; and (6) miscellaneous obsessions and compulsions that relate to somatic concerns and superstitions, among other symptoms [30].” The clinical severity of each dimension (both current and previous/worst ever) is evaluated in terms of frequency, distress, and interference, with a maximum score of 15, five for each aspect. It also provides an assessment of the overall severity of OCD, which ranges from 0 to 15 for symptoms and 0 to 15 for the associated overall impairment. Checking and repetitive compulsions, avoidant behaviors, and mental rituals are investigated within each dimension. Therefore, whereas the Y-BOCS assesses the severity of (grouped) obsessions and compulsions, the DY-BOCS, by means of a more comprehensive symptom checklist, evaluates obsessions, compulsions, and avoidance grouped by their specific content into different dimensions. Only the categorical outcomes (lifetime occurrence of each symptom dimension, except miscellaneous) were analyzed in this study, to be consistent with the lifetime evaluation of comorbid disorders [30]. Participants completed the SPQ, designed to measure all nine diagnostic criteria for schizotypal personality disorder. Each “yes” response counts as one point, and 9 subscale scores were computed as the total score for all items associated with each subscale. Domain scores were derived by summing of relevant subscale scores [31]. The DES-II is a 28-item scale developed by Bernstein and Putnam. For each item of the scale, the subjects score between 0 and 100; the
E.E. Kilicaslan et al. / Epilepsy & Behavior 102 (2020) 106640 Table 1 Demographic and clinical characteristics of the groups.
Gender Marital status Epilepsy seizure frequency (per month) Duration of epilepsy (yrs) Epilepsy type
Seizure type
EEG result MRI pathology MTS Age Education (yrs)
Female Male Married Single b1 1–5 5–10 N10 b1 1–5 5–10 N10 Focal Generalized Simple partial Complex partial Secondarily generalized Myoclonic Tonic Tonic–clonic Temporal Extratemporal Generalized Absent Present Absent Present
Patients with epilepsy with lower OCS n:55 (% 55)
Patients with epilepsy with higher OCS n:45 (% 45)
Control group of patients with OCD
n
%
N
%
n
%
34 21 24 31 31 15 1 8 2 8 7 38 36 19 7
61.8 38.2 43.6 56.4 56.3 27.2 1.8 14.5 3.6 14.5 12.7 69.1 65.4 34.6 12.6
26 19 23 22 22 18 2 3 2 9 9 25 33 12 3
57.8 42.2 51.1 48.9 48.9 40.0 4.4 6.6 4.4 20.0 20.0 55.6 73.3 26.7 6.6
21 9 17 13
70.0 1.155 0.562 30.0 56.7 1.416 0.493 43.3 3.442 0.328
X
P
2.011 0.570
0.718 0.397 2.705 0.745
27 48.4 26 57.8 11 20.0 7 0 0 1 1.8 10 18.2 37 67.1 5 9.1 12 21.8 28 50.9 26 49.1 45 83.8 9 16.2 34.27 ± 10.45 10.02 ± 4.02
15.6
1 2.2 1 2.2 6 15.6 29 64.4 12 26.7 3 6.6 24 51.9 20 48.1 39 84.2 5 15.8 34.56 ± 9.82 8.87 ± 3.56
3
however, there was a statistically significant difference in EEG results between the patients with epilepsy with higher OCS and lower OCS (p b .016) (Table 1). Two patients with normal EEG were not shown in the table. Forty-four percent of the patients with TLE, 71% of the patients with extratemporal epilepsy, and 20% of the patients with generalized epilepsy scored in the clinical range on the OCI-R. A one-way ANOVA revealed a statistically significant difference between the groups on the OCI-R measure, and a Games–Howell posthoc test showed that the group of patients with generalized epilepsy obtained significantly lower OCI-R scores than the group of patients with TLE (p b .038) and the group of patients with extratemporal epilepsy (p b .034) (Table 2). The SPQ, DES, and BDI scores were significantly higher in patients with epilepsy with higher OCS than patients with epilepsy with lower OCS (Table 3). When patients with epilepsy with higher OCS were compared with patients with OCD, in terms of the total score and subscale scores of the SPQ, DES-II, and BDI, no difference was found. At the same time, DY-BOCS symmetry/exactness scores were higher in patients with epilepsy with higher OCS, but this difference was not significant (p b .121). However, contamination (p b .008), aggressiveness (p b .043) and the total score of the DY-BOCS (p b .001) were significantly higher in patients with OCD (Table 4). Logistic regression analysis was performed to determine the factors associated with the emergence of obsessive–compulsive symptoms in patients with epilepsy, and EEG result, SPQ scores, DES-II scores, and BDI scores were considered as possible predictors; only depression was found as a predictor of OCS (Table 5). 4. Discussion
8.318 0.016⁎
0.790 0.475 0.557 0.327 34.63 ± 12.97 10.77 ± 3.30
0.890 0.137
OCS: Obsessive–Compulsive Symptoms, OCD: Obsessive–Compulsive Disease, MTS: Mesial Temporal Sclerosis. ⁎ p b .05.
mean score of the total score is calculated, and the result is obtained. The scores above 30 indicate the presence of dissociative disorder [32]. The BDI is a 21-item self-report instrument intended to assess the existence and severity of symptoms of depression. Each of the 21 items corresponds to a symptom of depression and is rated on a 4-point scale from 0 to 3. A total score is determined by aggregating the item responses and may range from 0 to 63 (normal to severe). The BDI scores above the 14 cutoff may indicate the presence of depression [33]. The Structured Clinical Interview for DSM-IV Axis I Disorders Clinical Version (SCID-CV) is a semistructured interview for diagnosing the major DSM-IV Axis I disorders. The SCID-I is designed to yield a reliable and valid DSM-IV Axis I diagnosis and is considered the standard research tool for this purpose. The SCID-I is ordinarily administered in a single setting and takes 45–90 min [34].
The present study investigated the prevalence of OCS in a sample of 100 patients with epilepsy. Forty-five percent of the patients scored in the clinical range on the OCI-R (i.e., they had scores greater than 21). This rate was reported 22% in patients with TLE in Isaac's study [9] and 39.6% in patients with epilepsy in Hamed's study [22], and is considerably higher than the 2.5% prevalence rate observed in the general population. When sociodemographic and clinical variables were compared between patients with and without OCS, only EEG result was found to be significantly different (p b .016). Previous clinical studies investigating OCS in patients with TLE [9] or comparing only patients with TLE and IGE [20,21] were found to be OCS-linked with TLE. We investigated all patients with epilepsy and classified as temporal, extratemporal, and generalized according to their EEG results. The OCS were significantly higher in patients with TLE and extratemporal epilepsy than in patients with generalized epilepsy. This result is consistent with Hamed [22], who report that temporal and frontal lobe epilepsies as risk factors for OCS in patients with epilepsy. The coexistence of OCD with TLEs suggests that temporal lobe and limbic system may play a role in the pathogenesis of OCD. Neuroimaging studies in individuals with OCD report increased metabolism in temporolimbic structures, such as, the hippocampus and amygdala [35]. Locatelli et al. [12] suggested that patients with OCD
Table 2 One-way ANOVA showing the difference between the groups on OCI-R scores. EEG result
3. Results Temporal
In our study, no difference was found between the three groups in terms of age, gender, marital status, and duration of education (Table 1). There was no difference in the seizure frequency, duration of epilepsy, type and subtype of epilepsy, magnetic resonance imaging (MRI) pathology and presence of mesial temporal sclerosis (MTS);
Extratemporal Generalized ⁎ p b .05.
n
OCS score Mean + Std. deviation
66 25.27 ± 15.8 17 30.00 ± 18.3 15 15.53 ± 12.3
EEG result
Mean difference
extratemporal −4.727 generalized 9.739⁎ temporal 4.727 generalized 14.467⁎ temporal −9.739⁎ extratemporal −14.467⁎
p
0.600 0.038 0.600 0.034 0.038 0.034
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E.E. Kilicaslan et al. / Epilepsy & Behavior 102 (2020) 106640
Table 3 SPQ, DES, and BDI scores in patients with epilepsy with lower and higher OCS. N
Mean ± Std. deviation
T
55 45 55 45 55 45 55 45 55 45 55 45 55 45 55 45 55 45 55 45 55 45 55 45
2.02 ± 1.9 4.49 ± 2.5 1.22 ± 1.0 2.16 ± 1.8 1.96 ± 1.8 413 ± 2.2 2.73 ± 2.0 4.38 ± 1.8 3.16 ± 2.5 5.62 ± 2.3 2.47 ± 2.3 4.31 ± 2.3 2.60 ± 2.2 4.98 ± 2.3 1.04 ± 1.62 3.09 ± 2.3 2.35 ± 2.5 4.82 ± 2.7 19.98 ± 12.9 37.38 ± 14.0 9.67 ± 8.6 22.36 ± 10.3 13.44 ± 17.1 30.24 ± 20.7
−5.648⁎ −5.484 −3.303⁎ −3.149 −5.431⁎ −5.305 −4.173⁎
SPQ IoR OBoMT Ş UPE Sus ESA CA NCF OoEB OS Total BDI DES-II
EPLO EPHO EPLO EPHO EPLO EPHO EPLO EPHO EPLO EPHO EPLO EPHO EPLO EPHO EPLO EPHO EPLO EPHO EPLO EPHO EPLO EPHO EPLO EPHO
−4.204 −5.053⁎ −5.114 −3.981⁎ −3.985 −5.257⁎ −5.235 −5.258⁎ −5.082 −4.737⁎ −4.716 −6.444⁎ −6.389 −6.703⁎ −6.579 −4.450⁎ −4.369
EPLO: patients with epilepsy with lower OCS, EPHO: patients with epilepsy with higher OCS, OBoMT: odd beliefs or magical thinking, UPE: unusual perceptual experiences, IoR: ideas of reference, Sus: suspiciousness, ESA: excessive social anxiety, NCF: no close friends, CA: constricted affect, OoEB: odd or eccentric behavior, and OS: odd speech. ⁎ p b .05.
had abnormal EEG abnormalities in the temporal lobe and this showed that temporal structures could play a role in the pathogenesis of OCD. There are, however, also studies identifying abnormally high activities throughout the frontal cortex and subcortical structures in the frontal lobe of patients with OCD [36]. Some authors also report that 92% of patients with OCD with normal EEG have a frontotemporal paroxysmal rhythmic activity in magnetoencephalography, which measures cortical brain activity higher than EEG [37]. Case studies also provide a variety of information about the role of localization of epilepsy on OCS. Cases of OCD developed following the onset of TLE [38], OCS improved after surgery [39], and new-onset OCD following resection of the right hippocampus and right occipital pole [11] were reported. In a review describing 37 case reports with 71 patients, brain lesions in the corticostriatothalamic circuit, especially the basal ganglia, internal capsule, and frontal lobes were found to be linked to the symptoms of OCD [40].
Table 4 DY-BOCS scores in patients with epilepsy with higher OCS and patients with OCD. DY-BOCS Aggressiveness Sexual/religious Symmetry/exactness Contamination/Cleaning Hoarding Somatic Other Total
EPHO OCD control EPHO OCD control EPHO OCD control EPHO OCD control EPHO OCD control EPHO OCD control EPHO OCD control EPHO OCD control
n
Mean ± Std. deviation
t
45 30 45 30 45 30 45 30 45 30 45 30 45 30 45 30
3.42 ± 3.9 5.30 ± 3.9 1.16 ± 2.5 1.43 ± 3.0 4.42 ± 3.5 3.07 ± 3.9 2.76 ± 3.5 5.43 ± 5.0 0.84 ± 2.1 0.83 ± 2.2 1.00 ± 2.8 0.57 ± 1.9 0.31 ± 1.5 0.67 ± 2.3 9.31 ± 6.2 14.93 ± 2.8
−2.062* −2.064 −0.436 −0.418 1.569 1.541 −2.713* −2.537 0.022 0.022 0.738 0.790 −0.818 −0.752 −3.826* −3.838
EPHO: patients with epilepsy with higher OCS.
Table 5 Logistic regression analyses onto obsessive compulsive symptoms in patients with epilepsy.
Step 1a
EEG result SPQtotal BDI DES-II Constant
Beta
Standard error
Wald
df
p
OR⁎
−0.086 0.037 0.100 0.014 −3.582
0.390 0.025 0.037 0.015 0.770
0.048 2.148 7.257 0.818 21.630
1 1 1 1 1
0.826 0.143 0.007 0.366 0.000
0.918 1.038 1.105 1.014 0.028
a Variable(s) entered on step 1: EEG result, SPQ Total, BDI, DES-II. ⁎ p b .05, OR: Odds Ratio
In general, the prevalence of OCS varies according to the methodological differences, nosological factors, and the cultural and religious characteristics of the sample [41]. Isaacs et al. [9] reported that symptoms of control, symmetry, hoarding and washing / cleaning were more common in patients with TLE. In a study in our country, Ertekin et al. [21] reported that patients with epilepsy with OCD the most common obsessions are symmetry/precision and aggression while the most common compulsions are arrangement/sorting, washing/cleaning, and checking. We compared the patients with epilepsy with patients with OCD in our study. Patients with OCD had significantly more contamination/ cleaning and aggressiveness obsessions and compulsions compared to patients with epilepsy with higher OCS. In addition, although not statistically significant, patients with epilepsy with higher OCS tended to have more symmetry/exactness obsessions and compulsions than patients with OCD. The fact that the OCS of patients with epilepsy differ in terms of the dimensions of OCS from patients with OCD may point to the neurobiological mechanisms in the etiology of OCS seen in patients with epilepsy. Our study is unique because it is the only study comparing patients with OCD with patients with epilepsy in terms of the nature of obsessions and compulsions, but there is a clear need for studies of larger sample populations to characterize the types of OCS in patients with epilepsy. In addition, in terms of religious obsessions, no difference was found between patients with epilepsy with OCS and patients with OCD; this may be due to the fact that both patient groups had the same religious and cultural characteristics. In patients with epilepsy with higher OCS, the higher SPQ, DES, BDI, and DY-BOCS scores compared to those with lower OCS showed that the increase in OCS in these patients was accompanied by a deterioration in their overall psychopathology. Previous researches in a nonclinical sample [42] and in an OCD sample [43] have suggested that schizotypal, dissociative, and imaginative processes may play a role in OCS. However, although we found a correlation between the dissociation, schizotypy, and depression scores in our study, it was revealed that only depression was predictive when regression analysis was performed for OCS. To date, in three of the studies conducted in epilepsy and OCD comorbidity, depression was found to be the most common psychiatric disorder associated with OCD [20–22]. Both neurobiological and psychosocial factors may contribute to this association. Restrictions and disability in daily routines, living with a chronic disease, or low quality of life may facilitate the development of comorbid psychiatric conditions, especially depression. However, in a review about psychiatric comorbidity in epilepsy, in the susceptibility of these patients to psychiatric disorders, the chronicity of epilepsy seems to be an important factor, it was concluded that brain dysfunction can pose an additional hazard, probably related to the involvement of the limbic system [44]. The main cause of refractory epilepsy is MTS, representing between 50% and 70% of cases and characterized, pathologically, by neuronal loss, atrophy, and gliosis of the temporal structures [45–47]. Previous studies have shown that damage to the left mesial temporal lobe is associated with a wide range of psychopathological features, particularly anxiety disorders and hypothesized that right–left hippocampal asymmetry
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can influence mood regulation yielding higher rates of depressive and anxiety symptoms [48,49]. Nevertheless, in our study, the presence of MTS did not make any difference in terms of obsessive–compulsive symptomatology. Some limitations of the current study should be mentioned. First, this was a cross-sectional analysis. Second, patients were recruited from a tertiary referral hospital (a university hospital), and therefore, there may be a bias due to the patients having had severe and intractable epilepsies. Third, the diagnosis of OCD in patients with epilepsy was not based on a structured interview. The fourth limitation is that the number of excluded patients was not determined in our study.
5. Conclusion In addition to confirming the fact that OCS are common in patients with epilepsy, the results of our study suggest that OCS is associated with TLE and extratemporal epilepsy. Depression, dissociation, and schizotypy were found to be higher in patients with epilepsy with high OCS scores compared to patients with epilepsy with low OCS scores; however, with logistic regression, only depression was found as a predictor of OCS in patents with epilepsy. Additionally, this investigation first identified differences in OCS dimensions between patients with epilepsy with OCS and patients with OCD, thereby suggesting a neurobiological basis in the etiology of OCS in patients with epilepsy. Future investigations should explore these issues in larger populations with multicenter trials to gain a better understanding the pathophysiologic mechanisms of OCS in patients with epilepsy.
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Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Differences in obsessive–compulsive symptom dimensions between patients with epilepsy with obsessive–compulsive symptoms and patients with OCD Esin Evren Kilicaslan a,⁎, H.Sabiha Türe b, Meltem İzci Kasal a, Nebile Nur Çavuş a, Dilek Altın Akyüz b, Galip Akhan b, Lutfullah Besiroglu a a b
Izmir Katip Celebi University, Atatürk Education and Training Hospital, Psychiatry Department, Basin Sitesi, 35150 Izmir, Turkey Izmir Katip Celebi University, Atatürk Education and Training Hospital, Neurology Department, Basin Sitesi, 35150 Izmir, Turkey
a r t i c l e
i n f o
Article history: Received 1 July 2019 Revised 28 September 2019 Accepted 28 September 2019 Available online xxxx Keywords: Epilepsy Obsessive–compulsive symptoms Obsessive–compulsive disorder Depression Schizotypy Dissociation
a b s t r a c t Clinical correlates of obsessive–compulsive symptoms (OCS) were evaluated in 100 adult consecutive outpatients with epilepsy, using the Obsessive–Compulsive Inventory (OCI-R), Beck Depression Inventory (BDI), Dissociative Experiences Scale (DES-II), and the Schizotypal Personality Questionnaire (SPQ). Dimensional Yale– Brown Obsessive–Compulsive Scale (DY-BOCS) was applied to determine the types and severity of OCS to the 45 patients with epilepsy who were over 21 points on the OCI-R scale and 30 patients who were with diagnosed obsessive–compulsive disorder (OCD) among the patients in the psychiatry outpatient clinic, as a control group. As a result, it was found that patients with epilepsy with OCS tend to have more symmetry/exactness obsessions and compulsions, whereas patients with OCD had significantly more contamination/cleaning and aggressiveness obsessions and compulsions. In addition, OCS was found to be significantly higher in temporal lobe epilepsy (TLE) and extratemporal epilepsy than generalized epilepsy. However, OCS were correlated with depression, dissociation, and schizotypy in patients with epilepsy, while only depression was predictive when regression analysis was performed for OCS. This study is the first study to compare patients with OCD with patients with epilepsy in terms of the nature of OCS and first identified the differences in OCS dimensions between patients with epilepsy with OCS and patients with OCD. © 2019 Elsevier Inc. All rights reserved.
1. Introduction Epilepsy, a key neurological disorder with significant global burden of illness [1] affecting 0.3–0.8% of the population [2–4], may negatively impact quality of life and mental health with associated psychiatric symptoms and diagnoses. These psychiatric symptoms and diagnoses may precede the diagnosis of epilepsy [5]; further psychiatric symptoms may occur interictal, periictal, and postictal [6]. It has been shown that psychiatric disorders are more common in individuals with epilepsy than in society and they are significantly unnoticed [6]. The lifetime prevalence of any mental health disorder in people with epilepsy was 35.5% compared with 20.7% in those without epilepsy [7]. There is also an increased risk for suicidal ideation [7,8]. Anxiety and depression symptoms, mood disorders, and psychotic disorders were most commonly investigated in the studies on the relationship between epilepsy and psychiatric disorders. ⁎ Corresponding author at: İzmir Katip Çelebi Üniversitesi, Atatürk Eğitim ve Araştırma Hastanesi, Psikiyatri Kliniği, Basın Sitesi, Karabağlar, 35150 Izmir, Turkey. E-mail address: [email protected] (E.E. Kilicaslan).
https://doi.org/10.1016/j.yebeh.2019.106640 1525-5050/© 2019 Elsevier Inc. All rights reserved.
Obsessive–compulsive disorder (OCD) was relatively less studied compared to other psychiatric disorders. On the other hand, the presence of obsessive–compulsive symptoms (OCS) in patients with temporal lobe epilepsy (TLE) [9], changes in OCD symptoms after epileptic surgery [10,11], and the findings of several studies showing abnormalities in frontotemporal areas in electroencephalography (EEG) in patients with OCD [12–14], suggest that there may be a relationship between OCD and epilepsy. However, literature on the relationship between OCD and epilepsy reveals confounding results, and studies are methodologically inadequate; the frequency and nature of OCS is not well known in patients presenting to epilepsy clinics. Although the relationship between OCS and chronic epilepsy is mainly focused on refractory TLE [15], conflicting results have also been reported. In one study, no evidence was found to support the notion that lateralized epileptogenic lesions are associated with different levels of depression, obsessionality, or personality traits [16]. The first publications that reported a relationship between TLE and OCD in the literature are case studies [17–19]. Isaacs et al. indicated a 22% prevalence of OCS in a group of 30 patients with drug-resistant TLE and reported that OCS in patients with TLE include more control, symmetry, hoarding, and washing/cleaning
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E.E. Kilicaslan et al. / Epilepsy & Behavior 102 (2020) 106640
[9]. Monaco et al. [20] and Ertekin et al. [21] reported that patients with TLE had higher OCD comorbidity than patients with idiopathic generalized epilepsy (IGE). In a study with OCS in 39% of patients with epilepsy, the main risk factors were male sex, age, duration of disease, seizure focus (temporal and frontal lobe epilepsies NIGE), lateralization, and intractability to antiepileptic drugs [22]. Finally, Bird et al. reported that the majority of patients in a case series of 10 people living with both OCD and epilepsy suffered with TLE [23]. In these studies, patients with TLE were mostly taken into consideration and compared with healthy controls or patients with IGE. Despite the interest in a possible link between epilepsy and psychiatric disorders, such as, depression and schizophrenia, there is only one study investigating associations between epilepsy and different dimensions of schizotypy. In this study, schizotypal symptoms were found to be associated with early onset of seizures and diagnosis of TLE, and thus, the relationship between schizotypy and epilepsy was confirmed [24]. On the other hand, it has been suggested that patients with OCD with high schizotypy have more severe OCD symptoms and a worse prognosis [25,26], and it has been proposed that patients with OCD with high schizotypy represent a valid subtype of OCD [27]. In this context, schizotypy and obsessive–compulsive symptomatology in patients with epilepsy may have an association and need to be investigated. In this study, we sought to investigate clinical correlates of OCS in patients with epilepsy, and whether there are any differences in OCS dimensions between patients with epilepsy with OCS and patients with OCD. In addition, we aimed to investigate the relationship between OCS and psychopathology areas, such as, depression, dissociation, and schizotypy. 2. Methods 2.1. Participants and procedures The patients followed in the Epilepsy Outpatient Clinic of Izmir Katip Çelebi University, Atatürk Training and Research Hospital, were included in the study consecutively. Patients with additional neurological disorders other than epilepsy; patients with epilepsy because of secondary reasons, such as, head trauma, metabolic problems, intracranial events, etc.; those with a still severe medical condition (such as, endocrinological diseases, diseases of the respiratory system, or cardiovascular system); people with alcohol or substance use disorder and those with mental retardation were not included in the study. One of the consecutive patients refused to participate in the study, and 4 patients could not complete the scales due to cognitive impairment. As a result, 100 patients with epilepsy aged between 18 and 65 years who agreed to participate voluntarily were included. Written informed consent was obtained from all patients. An accredited Clinical Research Ethics Committee approved the study protocol. Sociodemographic characteristics, age at onset of epilepsy, duration of seizures, type of epilepsy, and antiepileptic drugs were recorded in the neurology outpatient clinic. Epilepsy types were grouped as focal and generalized epilepsies according to the International League Against Epilepsy (ILAE) 2010 classification [28], and they were divided into subgroups as temporal and extratemporal epilepsy in focal epilepsies. After the records were completed in the neurology clinic, all participants were given Obsessive–Compulsive Inventory-Revised (OCI-R), Beck Depression Inventory (BDI), Schizotypal Personality Questionnaire (SPQ), and Dissociative Experiences Scale (DES-II). Patients who scored greater than 21 points on the OCI-R scale were referred to the psychiatry outpatient clinic. Dimensional Yale–Brown Obsessive–Compulsive Scale (DY-BOCS) was applied to these patients to determine the types and severity of obsessive–compulsive symptoms. Patients who were with diagnosed OCD without neurological disease among the patients in the psychiatry outpatient clinic were taken as the control group. As in the group of patients with epilepsy, patients with a still severe medical
condition, people with alcohol or substance use disorder, and those with mental retardation or psychosis were not included in the study. After the diagnosis was confirmed by Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) Axis I Disorders (SCID-I), DY-BOCS, OCI-R, BDI, SPQ, and DES-II were applied. Approval for the analysis was obtained from the Izmir Katip Celebi University Institutional Review Board. Statistical analyses were performed using SPSS Version 24.0 for Windows. The patients were evaluated as 3 groups. 1. Patients with epilepsy with lower OCS: patients with epilepsy; OCI-R scores below 21 points; 55 patients. 2. Patients with epilepsy with higher OCS: patients with epilepsy; OCIR scores more than 21 points; 45 patients. 3. Control group of patients with OCD; 30 patients. We used chi-square test for categorical data and one-way analysis of variance (ANOVA) for comparing the three groups. Pearson correlation analysis was performed to determine the phenomenological differences between patients with OCD and patients with epilepsy with OCS. Multinomial logistic regression analysis was performed to determine the factors associated with the emergence of OCS in patients with epilepsy. 2.2. Measures Symptoms of OCD were assessed with the OCI-R. The OCI-R is an 18item self-report measure assessing the presence and severity of OCD symptoms; each rated from 0 (not at all) to 4 (extremely). The measure yields a total score of 0–72 and is divided into six subscales containing 3 items each. The OCI-R demonstrates good test–retest reliability and convergent and discriminant validity [29]. A cutoff point of 21 is recommended as indicative of clinically significant OCD [29]. The DY-BOCS was utilized to evaluate the presence and severity of OCD symptom dimensions. “The DY-BOCS self-report is composed of an 88-item self-report checklist, designed to provide a detailed description of obsessions and compulsions that are divided into six different obsessive–compulsive symptom dimensions: (1) obsessions about harm due to aggression/injury/violence/natural disasters, and related compulsions; (2) obsessions concerning sexual/moral/religious obsessions, and related compulsions; (3) obsessions about symmetry/”justright” perceptions, and compulsions to count or order/arrange; (4) contamination obsessions and cleaning compulsions; (5) obsessions and compulsions related to hoarding; and (6) miscellaneous obsessions and compulsions that relate to somatic concerns and superstitions, among other symptoms [30].” The clinical severity of each dimension (both current and previous/worst ever) is evaluated in terms of frequency, distress, and interference, with a maximum score of 15, five for each aspect. It also provides an assessment of the overall severity of OCD, which ranges from 0 to 15 for symptoms and 0 to 15 for the associated overall impairment. Checking and repetitive compulsions, avoidant behaviors, and mental rituals are investigated within each dimension. Therefore, whereas the Y-BOCS assesses the severity of (grouped) obsessions and compulsions, the DY-BOCS, by means of a more comprehensive symptom checklist, evaluates obsessions, compulsions, and avoidance grouped by their specific content into different dimensions. Only the categorical outcomes (lifetime occurrence of each symptom dimension, except miscellaneous) were analyzed in this study, to be consistent with the lifetime evaluation of comorbid disorders [30]. Participants completed the SPQ, designed to measure all nine diagnostic criteria for schizotypal personality disorder. Each “yes” response counts as one point, and 9 subscale scores were computed as the total score for all items associated with each subscale. Domain scores were derived by summing of relevant subscale scores [31]. The DES-II is a 28-item scale developed by Bernstein and Putnam. For each item of the scale, the subjects score between 0 and 100; the
E.E. Kilicaslan et al. / Epilepsy & Behavior 102 (2020) 106640 Table 1 Demographic and clinical characteristics of the groups.
Gender Marital status Epilepsy seizure frequency (per month) Duration of epilepsy (yrs) Epilepsy type
Seizure type
EEG result MRI pathology MTS Age Education (yrs)
Female Male Married Single b1 1–5 5–10 N10 b1 1–5 5–10 N10 Focal Generalized Simple partial Complex partial Secondarily generalized Myoclonic Tonic Tonic–clonic Temporal Extratemporal Generalized Absent Present Absent Present
Patients with epilepsy with lower OCS n:55 (% 55)
Patients with epilepsy with higher OCS n:45 (% 45)
Control group of patients with OCD
n
%
N
%
n
%
34 21 24 31 31 15 1 8 2 8 7 38 36 19 7
61.8 38.2 43.6 56.4 56.3 27.2 1.8 14.5 3.6 14.5 12.7 69.1 65.4 34.6 12.6
26 19 23 22 22 18 2 3 2 9 9 25 33 12 3
57.8 42.2 51.1 48.9 48.9 40.0 4.4 6.6 4.4 20.0 20.0 55.6 73.3 26.7 6.6
21 9 17 13
70.0 1.155 0.562 30.0 56.7 1.416 0.493 43.3 3.442 0.328
X
P
2.011 0.570
0.718 0.397 2.705 0.745
27 48.4 26 57.8 11 20.0 7 0 0 1 1.8 10 18.2 37 67.1 5 9.1 12 21.8 28 50.9 26 49.1 45 83.8 9 16.2 34.27 ± 10.45 10.02 ± 4.02
15.6
1 2.2 1 2.2 6 15.6 29 64.4 12 26.7 3 6.6 24 51.9 20 48.1 39 84.2 5 15.8 34.56 ± 9.82 8.87 ± 3.56
3
however, there was a statistically significant difference in EEG results between the patients with epilepsy with higher OCS and lower OCS (p b .016) (Table 1). Two patients with normal EEG were not shown in the table. Forty-four percent of the patients with TLE, 71% of the patients with extratemporal epilepsy, and 20% of the patients with generalized epilepsy scored in the clinical range on the OCI-R. A one-way ANOVA revealed a statistically significant difference between the groups on the OCI-R measure, and a Games–Howell posthoc test showed that the group of patients with generalized epilepsy obtained significantly lower OCI-R scores than the group of patients with TLE (p b .038) and the group of patients with extratemporal epilepsy (p b .034) (Table 2). The SPQ, DES, and BDI scores were significantly higher in patients with epilepsy with higher OCS than patients with epilepsy with lower OCS (Table 3). When patients with epilepsy with higher OCS were compared with patients with OCD, in terms of the total score and subscale scores of the SPQ, DES-II, and BDI, no difference was found. At the same time, DY-BOCS symmetry/exactness scores were higher in patients with epilepsy with higher OCS, but this difference was not significant (p b .121). However, contamination (p b .008), aggressiveness (p b .043) and the total score of the DY-BOCS (p b .001) were significantly higher in patients with OCD (Table 4). Logistic regression analysis was performed to determine the factors associated with the emergence of obsessive–compulsive symptoms in patients with epilepsy, and EEG result, SPQ scores, DES-II scores, and BDI scores were considered as possible predictors; only depression was found as a predictor of OCS (Table 5). 4. Discussion
8.318 0.016⁎
0.790 0.475 0.557 0.327 34.63 ± 12.97 10.77 ± 3.30
0.890 0.137
OCS: Obsessive–Compulsive Symptoms, OCD: Obsessive–Compulsive Disease, MTS: Mesial Temporal Sclerosis. ⁎ p b .05.
mean score of the total score is calculated, and the result is obtained. The scores above 30 indicate the presence of dissociative disorder [32]. The BDI is a 21-item self-report instrument intended to assess the existence and severity of symptoms of depression. Each of the 21 items corresponds to a symptom of depression and is rated on a 4-point scale from 0 to 3. A total score is determined by aggregating the item responses and may range from 0 to 63 (normal to severe). The BDI scores above the 14 cutoff may indicate the presence of depression [33]. The Structured Clinical Interview for DSM-IV Axis I Disorders Clinical Version (SCID-CV) is a semistructured interview for diagnosing the major DSM-IV Axis I disorders. The SCID-I is designed to yield a reliable and valid DSM-IV Axis I diagnosis and is considered the standard research tool for this purpose. The SCID-I is ordinarily administered in a single setting and takes 45–90 min [34].
The present study investigated the prevalence of OCS in a sample of 100 patients with epilepsy. Forty-five percent of the patients scored in the clinical range on the OCI-R (i.e., they had scores greater than 21). This rate was reported 22% in patients with TLE in Isaac's study [9] and 39.6% in patients with epilepsy in Hamed's study [22], and is considerably higher than the 2.5% prevalence rate observed in the general population. When sociodemographic and clinical variables were compared between patients with and without OCS, only EEG result was found to be significantly different (p b .016). Previous clinical studies investigating OCS in patients with TLE [9] or comparing only patients with TLE and IGE [20,21] were found to be OCS-linked with TLE. We investigated all patients with epilepsy and classified as temporal, extratemporal, and generalized according to their EEG results. The OCS were significantly higher in patients with TLE and extratemporal epilepsy than in patients with generalized epilepsy. This result is consistent with Hamed [22], who report that temporal and frontal lobe epilepsies as risk factors for OCS in patients with epilepsy. The coexistence of OCD with TLEs suggests that temporal lobe and limbic system may play a role in the pathogenesis of OCD. Neuroimaging studies in individuals with OCD report increased metabolism in temporolimbic structures, such as, the hippocampus and amygdala [35]. Locatelli et al. [12] suggested that patients with OCD
Table 2 One-way ANOVA showing the difference between the groups on OCI-R scores. EEG result
3. Results Temporal
In our study, no difference was found between the three groups in terms of age, gender, marital status, and duration of education (Table 1). There was no difference in the seizure frequency, duration of epilepsy, type and subtype of epilepsy, magnetic resonance imaging (MRI) pathology and presence of mesial temporal sclerosis (MTS);
Extratemporal Generalized ⁎ p b .05.
n
OCS score Mean + Std. deviation
66 25.27 ± 15.8 17 30.00 ± 18.3 15 15.53 ± 12.3
EEG result
Mean difference
extratemporal −4.727 generalized 9.739⁎ temporal 4.727 generalized 14.467⁎ temporal −9.739⁎ extratemporal −14.467⁎
p
0.600 0.038 0.600 0.034 0.038 0.034
4
E.E. Kilicaslan et al. / Epilepsy & Behavior 102 (2020) 106640
Table 3 SPQ, DES, and BDI scores in patients with epilepsy with lower and higher OCS. N
Mean ± Std. deviation
T
55 45 55 45 55 45 55 45 55 45 55 45 55 45 55 45 55 45 55 45 55 45 55 45
2.02 ± 1.9 4.49 ± 2.5 1.22 ± 1.0 2.16 ± 1.8 1.96 ± 1.8 413 ± 2.2 2.73 ± 2.0 4.38 ± 1.8 3.16 ± 2.5 5.62 ± 2.3 2.47 ± 2.3 4.31 ± 2.3 2.60 ± 2.2 4.98 ± 2.3 1.04 ± 1.62 3.09 ± 2.3 2.35 ± 2.5 4.82 ± 2.7 19.98 ± 12.9 37.38 ± 14.0 9.67 ± 8.6 22.36 ± 10.3 13.44 ± 17.1 30.24 ± 20.7
−5.648⁎ −5.484 −3.303⁎ −3.149 −5.431⁎ −5.305 −4.173⁎
SPQ IoR OBoMT Ş UPE Sus ESA CA NCF OoEB OS Total BDI DES-II
EPLO EPHO EPLO EPHO EPLO EPHO EPLO EPHO EPLO EPHO EPLO EPHO EPLO EPHO EPLO EPHO EPLO EPHO EPLO EPHO EPLO EPHO EPLO EPHO
−4.204 −5.053⁎ −5.114 −3.981⁎ −3.985 −5.257⁎ −5.235 −5.258⁎ −5.082 −4.737⁎ −4.716 −6.444⁎ −6.389 −6.703⁎ −6.579 −4.450⁎ −4.369
EPLO: patients with epilepsy with lower OCS, EPHO: patients with epilepsy with higher OCS, OBoMT: odd beliefs or magical thinking, UPE: unusual perceptual experiences, IoR: ideas of reference, Sus: suspiciousness, ESA: excessive social anxiety, NCF: no close friends, CA: constricted affect, OoEB: odd or eccentric behavior, and OS: odd speech. ⁎ p b .05.
had abnormal EEG abnormalities in the temporal lobe and this showed that temporal structures could play a role in the pathogenesis of OCD. There are, however, also studies identifying abnormally high activities throughout the frontal cortex and subcortical structures in the frontal lobe of patients with OCD [36]. Some authors also report that 92% of patients with OCD with normal EEG have a frontotemporal paroxysmal rhythmic activity in magnetoencephalography, which measures cortical brain activity higher than EEG [37]. Case studies also provide a variety of information about the role of localization of epilepsy on OCS. Cases of OCD developed following the onset of TLE [38], OCS improved after surgery [39], and new-onset OCD following resection of the right hippocampus and right occipital pole [11] were reported. In a review describing 37 case reports with 71 patients, brain lesions in the corticostriatothalamic circuit, especially the basal ganglia, internal capsule, and frontal lobes were found to be linked to the symptoms of OCD [40].
Table 4 DY-BOCS scores in patients with epilepsy with higher OCS and patients with OCD. DY-BOCS Aggressiveness Sexual/religious Symmetry/exactness Contamination/Cleaning Hoarding Somatic Other Total
EPHO OCD control EPHO OCD control EPHO OCD control EPHO OCD control EPHO OCD control EPHO OCD control EPHO OCD control EPHO OCD control
n
Mean ± Std. deviation
t
45 30 45 30 45 30 45 30 45 30 45 30 45 30 45 30
3.42 ± 3.9 5.30 ± 3.9 1.16 ± 2.5 1.43 ± 3.0 4.42 ± 3.5 3.07 ± 3.9 2.76 ± 3.5 5.43 ± 5.0 0.84 ± 2.1 0.83 ± 2.2 1.00 ± 2.8 0.57 ± 1.9 0.31 ± 1.5 0.67 ± 2.3 9.31 ± 6.2 14.93 ± 2.8
−2.062* −2.064 −0.436 −0.418 1.569 1.541 −2.713* −2.537 0.022 0.022 0.738 0.790 −0.818 −0.752 −3.826* −3.838
EPHO: patients with epilepsy with higher OCS.
Table 5 Logistic regression analyses onto obsessive compulsive symptoms in patients with epilepsy.
Step 1a
EEG result SPQtotal BDI DES-II Constant
Beta
Standard error
Wald
df
p
OR⁎
−0.086 0.037 0.100 0.014 −3.582
0.390 0.025 0.037 0.015 0.770
0.048 2.148 7.257 0.818 21.630
1 1 1 1 1
0.826 0.143 0.007 0.366 0.000
0.918 1.038 1.105 1.014 0.028
a Variable(s) entered on step 1: EEG result, SPQ Total, BDI, DES-II. ⁎ p b .05, OR: Odds Ratio
In general, the prevalence of OCS varies according to the methodological differences, nosological factors, and the cultural and religious characteristics of the sample [41]. Isaacs et al. [9] reported that symptoms of control, symmetry, hoarding and washing / cleaning were more common in patients with TLE. In a study in our country, Ertekin et al. [21] reported that patients with epilepsy with OCD the most common obsessions are symmetry/precision and aggression while the most common compulsions are arrangement/sorting, washing/cleaning, and checking. We compared the patients with epilepsy with patients with OCD in our study. Patients with OCD had significantly more contamination/ cleaning and aggressiveness obsessions and compulsions compared to patients with epilepsy with higher OCS. In addition, although not statistically significant, patients with epilepsy with higher OCS tended to have more symmetry/exactness obsessions and compulsions than patients with OCD. The fact that the OCS of patients with epilepsy differ in terms of the dimensions of OCS from patients with OCD may point to the neurobiological mechanisms in the etiology of OCS seen in patients with epilepsy. Our study is unique because it is the only study comparing patients with OCD with patients with epilepsy in terms of the nature of obsessions and compulsions, but there is a clear need for studies of larger sample populations to characterize the types of OCS in patients with epilepsy. In addition, in terms of religious obsessions, no difference was found between patients with epilepsy with OCS and patients with OCD; this may be due to the fact that both patient groups had the same religious and cultural characteristics. In patients with epilepsy with higher OCS, the higher SPQ, DES, BDI, and DY-BOCS scores compared to those with lower OCS showed that the increase in OCS in these patients was accompanied by a deterioration in their overall psychopathology. Previous researches in a nonclinical sample [42] and in an OCD sample [43] have suggested that schizotypal, dissociative, and imaginative processes may play a role in OCS. However, although we found a correlation between the dissociation, schizotypy, and depression scores in our study, it was revealed that only depression was predictive when regression analysis was performed for OCS. To date, in three of the studies conducted in epilepsy and OCD comorbidity, depression was found to be the most common psychiatric disorder associated with OCD [20–22]. Both neurobiological and psychosocial factors may contribute to this association. Restrictions and disability in daily routines, living with a chronic disease, or low quality of life may facilitate the development of comorbid psychiatric conditions, especially depression. However, in a review about psychiatric comorbidity in epilepsy, in the susceptibility of these patients to psychiatric disorders, the chronicity of epilepsy seems to be an important factor, it was concluded that brain dysfunction can pose an additional hazard, probably related to the involvement of the limbic system [44]. The main cause of refractory epilepsy is MTS, representing between 50% and 70% of cases and characterized, pathologically, by neuronal loss, atrophy, and gliosis of the temporal structures [45–47]. Previous studies have shown that damage to the left mesial temporal lobe is associated with a wide range of psychopathological features, particularly anxiety disorders and hypothesized that right–left hippocampal asymmetry
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can influence mood regulation yielding higher rates of depressive and anxiety symptoms [48,49]. Nevertheless, in our study, the presence of MTS did not make any difference in terms of obsessive–compulsive symptomatology. Some limitations of the current study should be mentioned. First, this was a cross-sectional analysis. Second, patients were recruited from a tertiary referral hospital (a university hospital), and therefore, there may be a bias due to the patients having had severe and intractable epilepsies. Third, the diagnosis of OCD in patients with epilepsy was not based on a structured interview. The fourth limitation is that the number of excluded patients was not determined in our study.
5. Conclusion In addition to confirming the fact that OCS are common in patients with epilepsy, the results of our study suggest that OCS is associated with TLE and extratemporal epilepsy. Depression, dissociation, and schizotypy were found to be higher in patients with epilepsy with high OCS scores compared to patients with epilepsy with low OCS scores; however, with logistic regression, only depression was found as a predictor of OCS in patents with epilepsy. Additionally, this investigation first identified differences in OCS dimensions between patients with epilepsy with OCS and patients with OCD, thereby suggesting a neurobiological basis in the etiology of OCS in patients with epilepsy. Future investigations should explore these issues in larger populations with multicenter trials to gain a better understanding the pathophysiologic mechanisms of OCS in patients with epilepsy.
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