Obsessive-compulsive symptoms in patients with temporal lobe epilepsy

Personality disorders in people with epilepsy: a review

Epileptologists and psychiatrists have long observed a correlation between epilepsy and personality disorders (PDs) in their clinical practice. We conducted a comprehensive PubMed search looking for evidence on PDs in people with epilepsy (PwE). Out of over 600 results obtained without applying any time restriction, we selected only relevant studies (both analytical and descriptive) limited to English, Italian, French and Spanish languages, with a specific focus on PDs, rather than traits or symptoms, thus narrowing our search down to 23 eligible studies. PDs have been investigated in focal epilepsy (predominantly temporal lobe epilepsy - TLE), juvenile myoclonic epilepsy (JME) and psychogenic non-epileptic seizures (PNES), with heterogeneous methodology. Prevalence rates of PDs in focal epilepsy ranged from 18 to 42% in surgical candidates or post-surgical individuals, with Cluster C personality disorders or related traits and symptoms being most common. In JME, prevalence rates ranged from 8 to 23%, with no strong correlation with any specific PDs subtype. In PNES, prevalence rates ranged from 30 to 60%, with a notable association with Cluster B personality disorders, particularly borderline personality disorder. The presence of a PD in PwE, irrespective of subtype, complicates treatment management. However, substantial gaps of knowledge exist concerning the neurobiological substrate, effects of antiseizure medications and epilepsy surgery on concomitant PDs, all of which are indeed potential paths for future research.

Defining repetitive behaviours in frontotemporal dementia

Repetitive behaviours are common manifestations of frontotemporal dementia (FTD). Patients with FTD exhibit various types of repetitive behaviours with unique behavioural and cognitive substrates, including compulsivity, lack of impulse control, stereotypy and hoarding. Other sources of repetitive behaviours, such as restrictive interests and insistence on sameness, may also be seen in FTD. Although repetitive behaviours are highly prevalent and potentially discriminatory in this population, their expression varies widely between patients, and the field lacks consensus about the classification of these behaviours. Terms used to describe repetitive behaviours in FTD are highly heterogeneous and may lack precise definitions. This lack of harmonization of the definitions for distinct forms of repetitive behaviour limits the ability to differentiate between pathological behaviours and impedes understanding of their underlying mechanisms. This review examines established definitions of well-characterized repetitive behaviours in other neuropsychiatric disorders and proposes operational definitions applicable to patients with FTD. Building on extant models of repetitive behaviours in non-human and lesion work and models of social behavioural changes in FTD, we describe the potential neurocognitive bases for the emergence of different types of repetitive behaviours in FTD and their potential perpetuation by a predisposition towards habit formation. Finally, examples of distinct therapeutic approaches for different forms of repetitive behaviours are highlighted, along with future directions to accurately classify, measure and treat these symptoms when they impair quality of life.

CBD treatment following early life seizures alters orbitofrontal-striatal signaling during adulthood

Obsessive compulsive disorder (OCD) is a comorbid condition of epilepsy and often adds to the burden of epilepsy. Both OCD and epilepsy are disorders of hyperexcitable circuits. Fronto-striatal circuit dysfunction is implicated in OCD. Prior work in our laboratory has shown that in rat pups following a series of flurothyl-induced early life seizures (ELS) exhibit frontal-lobe dysfunction along with alterations in electrographic temporal coordination between the orbitofrontal cortex (OFC) and dorsomedial striatum (DMS), circuits implicated in OCD. Here, we studied the effects of ELS in male and female rat pups on OCD-like behaviors as adults using the marble burying test (MBT). Because cannabidiol (CBD) is an effective antiseizure medication and has shown efficacy in the treatment of individuals with OCD, we also randomized rats to CBD or vehicle treatment following ELS to determine if CBD had any effect on OCD-like behaviors. While the flurothyl model of ELS did not induce OCD-like behaviors, as measured in the MBT, ELS did alter neural signaling in structures implicated in OCD and CBD had sex-dependent effects of temporal coordination in a way which suggests it may have a beneficial effect on epilepsy-related OCD.

Inhibitory control deficits in patients with mesial temporal lobe epilepsy: an event-related potential analysis based on Go/NoGo task

Objective

Neuropsychiatric comorbidities are common among patients with mesial temporal lobe epilepsy (MTLE). One of these comorbidities, impulsivity, can significantly impact the quality of life and prognosis. However, there have been few studies of impulsivity in these patients, and the existing findings are inconsistent. The present study investigates impulsivity in MTLE patients from the perspective of inhibitory control and its underlying processes using event-related potentials (ERPs) initiated using a Go/NoGo task.

Methods

A total of 25 MTLE patients and 25 age-, gender-, and education-matched healthy controls (HCs) completed an unequal visual Go/NoGo task. Different waveforms as well as behavioral measures were analyzed between Go and NoGo conditions (N2d and P3d). Impulsivity was also assessed using self -rating scales, and clinical variables that may be related to ERPs were explored.

Results

Compared with HCs, MTLE patients exhibited significantly longer reaction time (RT) (p = 0.002) and lower P3d especially at the frontal electrode sites (p = 0.001). In the MTLE group, the seizure frequency (p = 0.045) and seizure types (p < 0.001) were correlated with the P3d amplitude. A self-rated impulsivity assessment revealed that MTLE patients had higher non-planning (p = 0.017) and total scores (p = 0.019) on the BIS-11 as well as higher DI (p = 0.010) and lower FI (p = 0.007) on the DII.

Conclusion

The findings demonstrate that the presence of inhibitory control deficits in patients with MTLE are characterized by deficits in the late stage of inhibition control, namely the motor inhibition stage. This study improves our understanding of impulsivity in MTLE patients and suggests that ERPs may constitute a sensitive means of detecting this trait.

Obsessive-compulsive symptoms and dissociative experiences: Suggested underlying mechanisms and implications for science and practice

A strong and specific link between obsessive-compulsive disorder or symptoms (OCD/S) and a tendency for dissociative experiences (e.g., depersonalization-derealization, absorption and imaginative involvement) cannot be explained by trauma and is poorly understood. The present theoretical formulation proposes five different models conceptualizing the relationship. According to Model 1, dissociative experiences result from OCD/S through inward-focused attention and repetition. According to Model 2, dissociative absorption causally brings about both OCD/S and associated cognitive risk factors, such as thought-action fusion, partly through impoverished sense of agency. The remaining models highlight common underlying causal mechanisms: temporo-parietal abnormalities impairing embodiment and sensory integration (Model 3); sleep alterations causing sleepiness and dreamlike thought or mixed sleep-wake states (Model 4); and a hyperactive, intrusive imagery system with a tendency for pictorial thinking (Model 5). The latter model relates to Maladaptive Daydreaming, a suggested dissociative syndrome with strong ties to the obsessive-compulsive spectrum. These five models point to potential directions for future research, as these theoretical accounts may aid the two fields in interacting with each other, to the benefit of both. Finally, several dissociation-informed paths for further developing clinical intervention in OCD are identified.

An ecological approach to identify distinct neural correlates of disinhibition in frontotemporal dementia

Disinhibition is a core symptom of many neurodegenerative diseases, particularly frontotemporal dementia, and is a major cause of stress for caregivers. While a distinction between behavioural and cognitive disinhibition is common, an operational definition of behavioural disinhibition is still missing. Furthermore, conventional assessment of behavioural disinhibition, based on questionnaires completed by the caregivers, often lacks ecological validity. Therefore, their neuroanatomical correlates are non-univocal. In the present work, we used an original behavioural approach in a semi-ecological situation to assess two specific dimensions of behavioural disinhibition: compulsivity and social disinhibition. First, we investigated disinhibition profile in patients compared to controls. Then, to validate our approach, compulsivity and social disinhibition scores were correlated with classic cognitive tests measuring disinhibition (Hayling Test) and social cognition (mini-Social cognition & Emotional Assessment). Finally, we disentangled the anatomical networks underlying these two subtypes of behavioural disinhibition, taking in account the grey (voxel-based morphometry) and white matter (diffusion tensor imaging tractography). We included 17 behavioural variant frontotemporal dementia patients and 18 healthy controls. We identified patients as more compulsive and socially disinhibited than controls. We found that behavioural metrics in the semi-ecological task were related to cognitive performance: compulsivity correlated with the Hayling test and both compulsivity and social disinhibition were associated with the emotion recognition test. Based on voxel-based morphometry and tractography, compulsivity correlated with atrophy in the bilateral orbitofrontal cortex, the right temporal region and subcortical structures, as well as with alterations of the bilateral cingulum and uncinate fasciculus, the right inferior longitudinal fasciculus and the right arcuate fasciculus. Thus, the network of regions related to compulsivity matched the "semantic appraisal" network. Social disinhibition was associated with bilateral frontal atrophy and impairments in the forceps minor, the bilateral cingulum and the left uncinate fasciculus, regions corresponding to the frontal component of the "salience" network. Summarizing, this study validates our semi-ecological approach, through the identification of two subtypes of behavioural disinhibition, and highlights different neural networks underlying compulsivity and social disinhibition. Taken together, these findings are promising for clinical practice by providing a better characterisation of inhibition disorders, promoting their detection and consequently a more adapted management of patients.

The neurologist who could not stop rhyming and rapping

.A neurologist, at age 55, developed an irrepressible urge to rhyme after a series of strokes and seizures. His strokes included right posterior cerebellar and right thalamic infarctions, and his subsequent focal-onset seizures emanated from the left frontotemporal region. On recovery, he described the emergence of an irresistible urge to rhyme, even in thought and daily speech. His pronounced focus on rhyming led him to actively participate in freestyle rap and improvisation. This patient's rhyming and rapping may have been initially facilitated by epileptiform activation of word sound associations but perpetuated as compensation for impaired cerebellar effects on timed anticipation.

The relation of major depression, OCD, personality disorders and affective temperaments with Temporal lobe epilepsy

BACKGROUND

In patients with temporal lobe epilepsy (TLE), studies demonstrate frequent comorbidity with mood disorders, personality disorders (especially obsessive-compulsive disorder) and major depression, but there are conflicting findings. This study aimed to investigate psychiatric comorbidities and affective temperament among TLE patients and to explore the relationships between obsessive compulsive disorder, other personality disorders, major depression and affective temperament in order to clarify the mediator effect of TLE in these relationships.

METHODS

Thirty patients with TLE and 30 healthy volunteers were included. The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), the Structured Clinical Interview for DSM III-R Axis II Disorders (SCID-II), Hamilton Anxiety (HAM-A) scale, Hamilton Depression (HAM-D) scale, Beck Suicidal Ideation Scale (BSSI) and Yale Brown Obsession Compulsion Scale (YBOCS) were applied and evaluated by a psychiatrist. Additionally, all individuals completed The Temperament Evaluation of Memphis, Pisa, Paris and San Diego (TEMPS-A).

RESULTS

Patients with temporal lobe epilepsy had higher scores in TEMPS-A, HAM-A, HAM-D, YBOCS and BSSI. Major depression, obsessive compulsive disorder and dependent and antisocial personality disorders were prevalent in patients. With respect to affective temperaments, depressive, cyclothymic and anxious temperaments were associated with obsessive compulsive disorder comorbidity; whereas, depressive and anxious temperaments were found to be associated with major depression comorbidity in patients with TLE. Furthermore, cluster A and cluster C personality disorders were associated with affective temperaments in patients with TLE. Affective temperaments had no correlation with illness duration, seizure frequency, depression severity and suicidal thoughts, but obsessions and compulsions. Suicidal thoughts were associated with obsessions and compulsions.

CONCLUSION

Affective temperaments are core personality traits with biological background and they may provide a foundation for psychiatric disorders, especially mood disorders. Considering that TLE originates from abnormalities in brain circuitry, it may form a basis for psychiatric disorders. Therefore, psychiatric evaluation to determine comorbidities may be beneficial to increase the quality of life of patients with TLE.

Plasticity-Related Activity in the Hippocampus, Anterior Cingulate, Orbitofrontal, and Prefrontal Cortex Following a Repeated Treatment with D2/D3 Agonist Quinpirole

Quinpirole (QNP) sensitization is a well-established model of stereotypical checking relevant to obsessive-compulsive disorder. Previously, we found that QNP-treated rats display deficits in hippocampus-dependent tasks. The present study explores the expression of immediate early genes (IEG) during QNP-induced stereotypical checking in the hippocampus, anterior cingulate cortex (ACC), orbitofrontal cortex (OFC), and medial prefrontal cortex (mPFC). Adult male rats were injected with QNP (0.5 mg/mL/kg; n = 15) or saline (n = 14) daily for 10 days and exposed to an arena enriched with two objects. Visits to the objects and the corners of the arena were recorded. QNP-treated rats developed an idiosyncratic pattern of visits that persisted across experimental days. On day 11, rats were exposed to the arena twice for 5 min and sacrificed. The expression of IEGs Arc and Homer1a was determined using cellular compartment analysis of temporal activity by fluorescence in situ hybridization. IEG-positive nuclei were counted in the CA1 area of the hippocampus, ACC, OFC, and mPFC. We found significantly fewer IEG-positive nuclei in the CA1 in QNP-treated rats compared to controls. The overlap between IEG expressing neurons was comparable between the groups. We did not observe significant differences in IEG expression between QNP treated and control rats in ACC, OFC, and mPFC. In conclusion, treatment of rats with quinpirole decreases plasticity-related activity in the hippocampus during stereotypical checking.

Differences in obsessive-compulsive symptom dimensions between patients with epilepsy with obsessive-compulsive symptoms and patients with OCD

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.

Functional connectivity of the raphe nucleus as a predictor of the response to selective serotonin reuptake inhibitors in obsessive-compulsive disorder

Selective serotonin reuptake inhibitors (SSRIs) are first-line pharmacological agents for treating obsessive-compulsive disorder (OCD). However, because nearly half of patients show insufficient SSRI responses, serotonergic dysfunction in heterogeneous OCD patients should be investigated for precision medicine. We aimed to determine whether functional connectivity (FC) of the raphe nucleus (RN), the major source of most serotonergic neurons, was altered in OCD patients and could predict the SSRI response. A total of 102 medication-free OCD patients and 101 matched healthy control (HC) subjects participated in resting-state functional magnetic resonance imaging. Among them, 54 OCD patients were treated with SSRIs for 16 weeks, resulting in 26 responders and 28 nonresponders. Seed-based whole brain FC with the RN as a seed region was compared between the OCD and HC groups, as well as between SSRI responders and nonresponders. FC cluster values showing significant group differences were used to investigate factors correlated with symptomatic severity before treatment and predictive of SSRI response. Compared to HCs, OCD patients exhibited significantly larger FC between the RN and temporal cortices including the middle temporal gyrus (MTG), paracingulate gyrus, amygdala, hippocampus, putamen, thalamus, and brain stem. Greater RN-left MTG FC was positively correlated with OC symptom severity at baseline. In addition, larger FC of the RN-left MTG was also found in SSRI nonresponders compared to responders, which was a significant predictor of SSRI response after 16 weeks. The FC of RN may reflect the neurobiological underpinning of OCD and could aid future precision medicine as a differential brain-based biomarker.

Relationship between symptom dimensions and white matter alterations in obsessive-compulsive disorder

OBJECTIVE

To investigate the relationship between the severities of symptom dimensions in obsessive-compulsive disorder (OCD) and white matter alterations.

METHODS

We applied tract-based spatial statistics for diffusion tensor imaging (DTI) acquired by 3T magnetic resonance imaging. First, we compared fractional anisotropy (FA) between 20 OCD patients and 30 healthy controls (HC). Then, applying whole brain analysis, we searched the brain regions showing correlations between the severities of symptom dimensions assessed by Obsessive-Compulsive Inventory-Revised and FA in all participants. Finally, we calculated the correlations between the six symptom dimensions and multiple DTI measures [FA, axial diffusivity (AD), radial diffusivity (RD), mean diffusivity (MD)] in a region-of-interest (ROI) analysis and explored the differences between OCD patients and HC.

RESULTS

There were no between-group differences in FA or brain region correlations between the severities of symptom dimensions and FA in any of the participants. ROI analysis revealed negative correlations between checking severity and left inferior frontal gyrus white matter and left middle temporal gyrus white matter and a positive correlation between ordering severity and right precuneus in FA in OCD compared with HC. We also found negative correlations between ordering severity and right precuneus in RD, between obsessing severities and right supramarginal gyrus in AD and MD, and between hoarding severity and right insular gyrus in AD.

CONCLUSION

Our study supported the hypothesis that the severities of respective symptom dimensions are associated with different patterns of white matter alterations.

Psychopathology in adolescents with TLE and FLE

BACKGROUND

To describe the rates and types of psychiatric disorders among adolescents with chronic symptomatic epilepsies and to evaluate syndrome-specific differences between temporal lobe (TLE) and frontal lobe (FLE) epilepsies.

METHODS

A cross-sectional single-center study design applying the Youth Self Report (YSR) to investigate psychopathological symptoms and the Weinberger Adjustment Inventory (WAI) to investigate personality dimensions was used. Consecutive adolescents between 14 and 18 years of age with drug-resistant symptomatic TLE and FLE were investigated during pre-surgical evaluation prior to epilepsy surgery. Data from twenty-eight patients (19 with TLE and 9 with FLE) were analyzed for this report.

RESULTS

Compared with the test norm, higher prevalence rates and a wider range of psychopathological symptoms were seen in patients with TLE. This result was not seen in patients with FLE. Concerning personality dimensions, significantly higher values of repressive defensiveness and significantly lower values of positive emotion and confidence were found in patients with TLE. In contrast, significantly lower levels of distress and significantly higher levels of repressive defensiveness and denial of distress were seen in patients with FLE. Comparing TLE with FLE, a significantly higher mean score for distress, and a significantly lower mean score for positive emotion and denial of distress were found in patients with TLE.

CONCLUSION

In summary, psychiatric comorbidity was frequently found in this sample of youths with chronic drug-resistant localization-related epilepsies. Although results have to be interpreted with caution because of the small sample size, psychiatric symptomatology was significantly different between TLE and FLE. Our results show that continuous and syndrome-specific psychiatric monitoring is essential in young patients with epilepsy.

Anxiety disorders in people with epilepsy

Anxiety disorders are frequent, though probably underdiagnosed, comorbidities in epilepsy. Epilepsy and anxiety may share common neurobiological correlates as shown in animal models and suggested by studies demonstrating anxiety disorders before the manifestation of epilepsy. Comorbid anxiety disorders have a major impact on the affected patients' quality of life and may increase the risk for suicidality. Successful treatment of the epilepsy may alleviate anxiety symptoms. Treatment of anxiety is based on selective serotonin reuptake inhibitors, benzodiazepines (although only as second-line choices), and psychotherapy. Specific AEDs (especially pregabalin) have been shown to have anxiolytic properties. This paper is aimed at reviewing anxiety disorders in patients with epilepsy discussing current scientific evidence about pathophysiology, clinical aspects, and treatment strategies.

[Psychiatric disorders and associated factors in patients with epilepsy in Fez, Morocco]

BACKGROUND

The prevalence of psychiatric disorders in epileptic patients remains unclear.

OBJECTIVE

This study was conducted in order to determine the prevalence and nature of the psychiatric disorders and the associated factors in patients with idiopathic epilepsy.

METHODS

A cross-sectional study was conducted over a period of eighteen months in the psychiatric unit of the University Hospital Hassan II of Fez (Morocco). A questionnaire was completed by the included patients, which specified: the socio-demographic data, personal and family history, and the clinical features of epilepsy and its management. Psychiatric disorders were identified by the Mini International Neuropsychiatric Interview test (MINI). The severity of the depression and anxiety symptoms was investigated using the Beck Depression Inventory (BDI) and the Hamilton Rating Scale.

RESULTS

Eighty-nine patients met the inclusion criteria. The average age of patients was 29.7±10.8years. Mood disorders were the leading psychiatric comorbidity: 32.6% among which 25.8% of major depressive episodes, 15.7% of dysthymia and 2.2% of hypomanic episodes. Anxiety disorders came second: 28.1% (among which 19.1% panic disorder, 13.5% agoraphobia, 12.4% generalized anxiety disorder, 10.1% social phobia and 4.5% post-traumatic stress disorder). Female gender, unemployment and poor compliance to antiepileptic drugs are all risk factors for the occurrence of psychiatric disorders in this population.

Cerebral white matter volume changes in patients with obsessive-compulsive disorder: Voxel-based morphometry

AIMS

We carried out a voxel-based morphometry (VBM) study to evaluate cerebral white matter (WM) volume alteration in obsessive-compulsive disorder (OCD) and its correlation with the scores of the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS).

METHODS

Fourteen patients with OCD, who were diagnosed using the DSM-IV-TR, and 14 age-matched healthy controls participated. The high-resolution magnetic resonance imaging data were analyzed by voxel-based morphometry and Statistical Parametric Mapping 8.

RESULTS

There was no significant difference in the total intracranial volumes between OCD patients and healthy controls. However, patients with OCD showed significantly increased WM volumes in the right dorsolateral prefrontal cortex, middle frontal gyrus, precuneus, and inferior parietal lobule compared with healthy controls. In addition, the OCD patients showed a positive correlation between the WM volumes of the dorsolateral prefrontal cortex and Y-BOCS scores (r = 0.334, P = 0.03 and Pearson's correlation coefficient = 0.58) rating for the severity of OCD symptoms.

CONCLUSIONS

WM volume variations of the specific brain regions in patients with OCD will be helpful to understand the neural connectivity associated with a symptom of OCD. Furthermore, the findings would be valuable to aid the diagnostic accuracy of OCD in connection with morphometric magnetic resonance imaging analysis.

Third International Congress on Epilepsy, Brain, and Mind: Part 2

Epilepsy is both a disease of the brain and the mind. Here, we present the second of two papers with extended summaries of selected presentations of the Third International Congress on Epilepsy, Brain and Mind (April 3-5, 2014; Brno, Czech Republic). Humanistic, biologic, and therapeutic aspects of epilepsy, particularly those related to the mind, were discussed. The extended summaries provide current overviews of epilepsy, cognitive impairment, and treatment, including brain functional connectivity and functional organization; juvenile myoclonic epilepsy; cognitive problems in newly diagnosed epilepsy; SUDEP including studies on prevention and involvement of the serotoninergic system; aggression and antiepileptic drugs; body, mind, and brain, including pain, orientation, the "self-location", Gourmand syndrome, and obesity; euphoria, obsessions, and compulsions; and circumstantiality and psychiatric comorbidities.

Obsessive-compulsive symptoms and their impacts on psychosocial functioning in people with epilepsy

Background and Purpose

Obsessive-compulsive symptoms (OCS) in people with epilepsy (PWE) have not been studied systematically. We evaluated the severity, predictors, and psychosocial impact of OCS in PWE.

Methods

We recruited PWE who visited our epilepsy clinic and age-, gender-, and education-matched healthy controls. Both PWE and healthy controls completed the Maudsley Obsessional-Compulsive Inventory (MOCI), which measures OCS. PWE also completed the Beck Depression Inventory (BDI) and the Quality of Life in Epilepsy Inventory-31 (QOLIE-31). We examined the severity of OCS in PWE relative to healthy controls. Predictors of OCS and the QOLIE-31 score were measured by regression analyses. A path analysis model was constructed to verify interrelations between the variables.

Results

The MOCI total score was significantly higher in PWE than in healthy controls (p=0.002). OCS were found in 20% of eligible patients. The strongest predictor of the MOCI total score was the BDI score (β=0.417, p<0.001), followed by EEG abnormality (β=0.194, p<0.001) and etiology (β=0.107, p=0.031). Epileptic syndrome, the side of the epileptic focus, and action mechanisms of antiepileptic drugs did not affect the MOCI total score. The strongest predictor of the QOLIE-31 overall score was the BDI score (β=-0.569, p<0.001), followed by seizure control (β=-0.163, p<0.001) and the MOCI total score (β=-0.148, p=0.001). The MOCI total score directly affected the QOLIE-31 overall score and also exerted indirect effects on the QOLIE-31 overall score through seizure control and the BDI score.

Conclusions

OCS are more likely to develop in PWE than in healthy people. The development of OCS appears to elicit psychosocial problems directly or indirectly by provoking depression or uncontrolled seizures.

Multivariate pattern analysis of DTI reveals differential white matter in individuals with obsessive-compulsive disorder

Diffusion tensor imaging (DTI) studies have revealed group differences in white matter between patients with obsessive‐compulsive disorder (OCD) and healthy controls. However, the results of these studies were based on average differences between the two groups, and therefore had limited clinical applicability. The objective of this study was to investigate whether fractional anisotropy (FA) of white matter can be used to discriminate between patients with OCD and healthy controls at the level of the individual. DTI data were acquired from 28 OCD patients and 28 demographically matched healthy controls, scanned using a 3T MRI system. Differences in FA values of white matter between OCD and healthy controls were examined using a multivariate pattern classification technique known as support vector machine (SVM). SVM applied to FA images correctly identified OCD patients with a sensitivity of 86% and a specificity of 82% resulting in a statistically significant accuracy of 84% (P ≤ 0.001). This discrimination was based on a distributed network including bilateral prefrontal and temporal regions, inferior fronto‐occipital fasciculus, superior fronto‐parietal fasciculus, splenium of corpus callosum and left middle cingulum bundle. The present study demonstrates subtle and spatially distributed white matter abnormalities in individuals with OCD, and provides preliminary support for the suggestion that that these could be used to aid the identification of individuals with OCD in clinical practice. Hum Brain Mapp 35:2643–2651, 2014. © 2013 The Authors Human Brain Mapping Published by Wiley Periodicals, Inc..

Psychopathological and peripheral levels of neurobiological correlates of obsessive-compulsive symptoms in patients with epilepsy: a hospital-based study

OBJECTIVES

Obsessive-compulsive symptoms (OCSs) and disorder (OCD) are often underdiagnosed in the out-patient epilepsy clinic. This work aimed at determining the risks and comorbidities (psychopathological and neurobiological correlates) of OCSs in treated adults with idiopathic epilepsy recruited from a university hospital.

METHODS

Psychiatric evaluation was done using DSM-IV (The Diagnostic and Statistical Manual of Mental Health Disorders). Obsessive-compulsive disorder was identified using the Mini International Neuropsychiatric Interview (MINI). The Beck Depression Inventory (BDI-II), Hamilton Anxiety Rating Scale (HAM-A), and Yale-Brown Obsessive Compulsive Scale (Y-BOCS) were used to determine the severity of the related psychiatric symptoms.

RESULTS

Out of 474 patients screened, included in this study were 107 with no psychiatric symptoms and 188 with OCSs [classified as those with at least OCSs=93; mild OCSs=36; moderate, severe, and extreme OCSs=59]. A hundred healthy subjects were included as controls. Blood concentrations of serotonin, adrenaline, noradrenaline, and dopamine were measured. Compared with controls, patients with OCSs had higher frequencies of depression and anxiety. Low concentrations of serotonin, adrenaline, noradrenaline, and dopamine were reported regardless of the presence or the absence of psychiatric symptoms, OCS severities, and antiepileptic drug (AED)-related variables (dose and serum drug level). Significant correlations were identified between Y-BOCS, BDI-II, and HAM-A scores, age, age at onset, and concentrations of noradrenaline.

CONCLUSION

This study indicates that a) OCSs are common in patients with epilepsy. Male sex, age, duration of illness, seizure focus, lateralization, and intractability to AEDs are its main risks; b) depression and anxiety are comorbid psychopathologies; and c) serotonin, catecholamines, and dopamine are linked to epilepsy-related variables and its comorbid psychopathies but not to its medications.

Psychosocial adjustment of epilepsy patients in Cyprus

This study investigated aspects of psychosocial adjustment in epilepsy patients in Cyprus. Sixty-three patients under 55 years of age with idiopathic or symptomatic epilepsy and 89 neurologically matched healthy volunteers participated. Subjects completed the State and Trait Anxiety Inventory and the Beck Depression Inventory; patients with epilepsy also completed the Epilepsy Foundation Concerns Index. Results showed that patients with symptomatic epilepsy had significantly higher scores on state and trait anxiety and depressive symptoms. Sociodemographic characteristics including gender, marital status, and education levels contributed to differences in trait and state anxiety, depressive symptom scales, autonomy concerns, and fear for seizure recurrence. Variables such as poor seizure control and use of polytherapy were associated with lower adjustment scores and reduced psychosocial outcome. Finally, patients with epilepsy scored significantly higher on depression and anxiety symptoms. The results provide further evidence on challenges patients with epilepsy face and on the need for implementing psychosocial prevention programs.

Structural brain MR imaging changes associated with obsessive-compulsive disorder in patients with multiple sclerosis

BACKGROUND AND PURPOSE

Psychiatric symptoms occur in approximately 30% of patients with MS. Such symptoms include OCD, which may interfere heavily with the patient's daily life. We hypothesized that the widespread involvement of both GM and WM, which characterizes MS, may be responsible for the occurrence of OCD when specific brain structures are affected. The aim of this study was to evaluate the relationship between GM and WM tissue damage and OCD in patients with MS.

MATERIALS AND METHODS

We evaluated 16 patients with relapsing-remitting MS who had been diagnosed with OCD on the basis of the Diagnostic and Statistical Manual of Mental Disorders (4th edition) and 15 age- and sex-matched patients with relapsing-remitting MS with no psychiatric disorders as a CG. The MR study (1.5T) included 3D T1-weighted fast-field echo sequences, DTI (32 directions), and conventional MRI. Images were processed using SPM5, FSL, and Jim 5.0 software to evaluate VBM, TBSS, and global and regional LV, respectively.

RESULTS

The VBM analysis revealed a set of clusters of reduced GM volume in the OCD group, compared with the CG, located in the right inferior and middle temporal gyri and in the inferior frontal gyrus. TBSS did not detect any differences in the FA values between the 2 groups; global and regional LV values also did not differ significantly between the 2 groups.

CONCLUSIONS

Our study suggests that OCD in MS may be caused by damage in the right frontotemporal cortex.

Obsessive-compulsive disorder in chronic epilepsy

There is a long-recognized association between obsessive-compulsive disorder (OCD) and chronic epilepsy, most notably refractory temporal lobe epilepsy (TLE). The literature documents this association with case reports, patient series, and some larger controlled studies that reveal that almost a quarter of patients with TLE exhibit OCD features, which may go unrecognized. Obsession features with ordering, symmetry, exactness, handwashing, and religiosity occur more often in persons with right- or left-sided epileptic foci than in those with idiopathic generalized epilepsies or controls. Neurobiological and social factors suggest abnormalities of the frontal-thalamic-pallidal-striatal-anterior cingulate-frontal circuits stemming from the observation that certain diseases, damage, or surgery along these circuits may produce or, conversely, reduce OCD in TLE. This review explores the literature on case reports, case series, and larger retrospective controlled studies and looks at the associations of epilepsy with OCD. Contemporary speculation on the theoretical neurobiological underpinnings provides some basis on how and where to direct treatment. Invasive deep brain stimulation has triggered recent controversy on newer treatment modalities.

Did Herbert Spencer have reading epilepsy?

Herbert Spencer, the nineteenth-century philosopher, has frequently been dismissed as a "fantastical hypochondriac" (as his most recent biographer, Mark Francis, terms him). Yet he left a record in his Autobiography of symptoms that suggest a very different diagnosis. Abruptly at age 35, he found that the activity of reading, previously indulged in without difficulty, triggered paroxysmal episodes of disturbing "head-sensations" including "giddiness" (so Spencer described them); these severely curtailed his ability to carry out his philosophical studies. Of all possible explanations for such episodes, none seems as likely as reading epilepsy. Enduring preconceptions about Spencer's presumed neurosesmay have kept modern historians from appreciating that Spencer suffered from a legitimate, if esoteric, neurological malady.

Psychiatric symptomatologies and disorders related to epilepsy and antiepileptic medications

INTRODUCTION

Psychiatric comorbidities (such as depression, anxiety, psychosis, inattention, obsession, personality traits, aggression and suicide) are frequent in patients with epilepsy and have a significant impact on medical management and quality of life.

AREAS COVERED

A literature search was performed in MEDLINE for epidemiological, longitudinal, prospective, double-blind clinical trial studies published between 1990 and 2011 using the following words: epilepsy, antiepileptic drugs (AEDs), behavioral/emotional/psychiatric comorbidities, suicide and aggression. In this review, the author discusses: i) the characterization and prevalence of behavioral disturbances associated with epilepsy, ii) variables correlated with behavioral comorbidities which include: psychosocial-, clinical- and treatment-related variables, iii) the complex mechanisms of behavioral comorbidities associated with epilepsy, which include both psychosocial (functional) and organic; the process of epileptogenesis, neuronal plasticity, abnormalities in hypothalamic-pituitary axis and neurotransmitters and pathways are fundamental determinants, iv) the negative psychotropic effects of AEDs and their mechanisms and v) the suggested biopsychosocial model of management (pharmacological and non-pharmacological).

EXPERT OPINION

The relationship between psychiatric disorders and epilepsy has relevant therapeutic implications which should be directed towards a comprehensive biopsychosocial approach that focuses on the whole person rather than simply on the disease process.

Microstructural brain abnormalities in patients with obsessive-compulsive disorder: diffusion-tensor MR imaging study at 3.0 T

PURPOSE

To use diffusion-tensor (DT) magnetic resonance (MR) imaging to explore the integrity and connectivity of brain white matter in patients with obsessive-compulsive disorder (OCD) and to correlate DT parameters with clinical measures.

MATERIALS AND METHODS

This study was approved by the local ethical committee, and written informed consent was obtained from all participants. DT imaging was performed by using a 3.0-T MR imager in 23 patients with OCD and 23 healthy control subjects matched for age, sex, education level, and handedness. By using voxel-based analysis, fractional anisotropy (FA) and axial and radial diffusivities were compared between patients and control subjects with a two-sample t test and were tested for correlation with symptom severity, as measured by using the Yale-Brown Obsessive-Compulsive Scale and obsessive-compulsive subscale scores, and with illness duration, as measured by using simple regression in statistical parametric mapping program.

RESULTS

Compared with control subjects, OCD patients demonstrated significantly increased FA in the genu and body of corpus callosum and white matter of right superior frontal gyrus and corpus callosum; no areas of significantly decreased FA were found. For areas of increased FA, axial diffusivity was higher than that in control subjects, while radial diffusivity was not significantly different. The FA values in the white matter of left middle temporal gyrus in OCD patients correlated positively with clinical measures (r = 0.542, P < .001).

CONCLUSION

OCD is associated with axonal microstructural abnormalities within the white matter, which may indicate impaired axonal integrity and increased connectivity. The positive correlation between DT abnormalities and symptom severity suggests that DT imaging may be of clinical value in measuring and following disability in OCD patients.

Study of DSM-IV Axis I psychiatric disorders in patients with refractory complex partial seizures using a short structured clinical interview

Psychiatric disorders are a source of significant comorbidity in patients with refractory epilepsy, yet are often underrecognized. We assessed the prevalence of DSM-IV Axis I psychiatric disorders using a short structured clinical interview (Mini-International Psychiatric Interview [MINI]) in patients with medically refractory complex partial seizures. Consecutive patients with refractory epilepsy being evaluated with video/EEG monitoring and imaging for seizure focus localization and lateralization underwent MINI evaluation to assess for the presence of psychiatric disorders. Among 117 patients (74 male, 43 female) studied, 57 (48.7%) had at least one psychiatric disorder; 19 (16.2%) had depression, 10 (8.5%) dysthymia, 27 (23.0%) anxiety disorder, and 11(9.4%) other disorders. Most clinical features and epilepsy-related variables had no significant association with psychiatric disorder on logistic regression analysis. Almost half of the patients with refractory focal seizures have a coexistent psychiatric disorder, and its presence or absence cannot be predicted by their clinical profiles. All patients should be assessed and treated for psychiatric comorbidity to improve overall quality of life.

Epilepsy and obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) has long been associated with epilepsy. The link with temporal lobe (usually refractory) epilepsy (TLE) is particularly prominent. Of TLE patients, 10% to 22% of patients may have OCD, often underdiagnosed in the outpatient clinic. Data on the links include case reports, case series, and controlled studies. Three larger, controlled studies in TLE patients, using comprehensive epilepsy and OCD classifications, in aggregate, have noted the obsessive qualities of washing, symmetry/exactness, and ordering, with a greater preoccupation with certain aspects of religion, compared with controls or patients with idiopathic generalized epilepsy. TLE foci may be either left- or right-sided. Social and neurobiological factors are involved in OCD in TLE. The neurobiology implicates a pathophysiological or structural impairment of the orbitofrontal-thalamic, and frontothalamic-pallidal-striatal-anterior cingulate-frontal circuits. Discrete anatomic lesions in these pathways, or their surgical removal, may induce (or conversely) improve OCD in TLE patients.

Obsessive-compulsive disorder and related disorders: a comprehensive survey

Our aim was to present a comprehensive, updated survey on obsessive-compulsive disorder (OCD) and obsessive-compulsive related disorders (OCRDs) and their clinical management via literature review, critical analysis and synthesis. Information on OCD and OCRD current nosography, clinical phenomenology and etiology, may lead to a better comprehension of their management. Clinicians should become familiar with the broad spectrum of OCD disorders, since it is a pivotal issue in current clinical psychiatry.

New-onset obsessive-compulsive disorder following neurosurgery for medication-refractory seizure disorder

A 31-year-old man with medication-refractory seizures in the context of right mesial temporal lobe sclerosis and right occipital encephalomalacia is described. He experienced the onset of obsessive-compulsive symptoms following resection of the right hippocampus and right occipital pole. Semistructured psychiatric evaluation was conducted 16 months after surgery. Results indicated that he fulfilled diagnostic criteria for obsessive-compulsive disorder (OCD) and that he was not depressed at the time of the evaluation. Total score on the Yale-Brown Obsessive Compulsive Scale was 24, indicating moderate symptom severity, and he had prominent symptoms related to contamination, washing, checking, repeating rituals, and ordering. He also reported significant problems with "not just right" experiences. Treatment with sertraline resulted in apathy. To our knowledge, the present case is only the fourth reported of de novo onset OCD following neurosurgery for seizure disorder, and the first in a patient without either preexisting obsessive traits or an OCD spectrum disorder.

A comparative study of obsessive-compulsive disorder and other psychiatric comorbidities in patients with temporal lobe epilepsy and idiopathic generalized epilepsy

Our aim was to assess the associations of temporal lobe epilepsy (TLE) and idiopathic generalized epilepsy (IGE) with comorbid psychiatric conditions, especially obsessive-compulsive disorder (OCD), in a comparative design. We evaluated 29 patients with TLE, 27 patients with IGE, and 30 healthy controls. The Structured Clinical Interview for DSM-IV (SCID), Yale-Brown Obsessive Compulsive Scale (Y-BOCS) Symptom Checklist, and Beck Depression Inventory (BDI) were administered. Among patients with TLE, 75.9%, and among patients with IGE, 48.1% had at least one Axis I psychiatric disorder. Clinically meaningful obsessive-compulsive symptoms (CM-OCS) were noted in 10 patients with TLE and in 3 patients with IGE, and this difference was statistically significant (P<0.05). CM-OCS were present in 9 of 18 patients with left-sided TLE, but in only 1 of 11 patients with right-sided TLE. Higher comorbidity in TLE suggests that involvement of the temporal lobe may play a role in the development of specific psychopathological syndromes.

Depression and anxiety in children and adolescents with epilepsy: prevalence, risk factors, and treatment

Among the psychiatric comorbid conditions in children and adolescents with epilepsy, depression and anxiety disorders require further attention because they carry the risk of reduced quality of life and life-threatening complications (e.g., suicide). Research in recent years has shed light on both the prevalence of emotional problems in youth with epilepsy and the safety and efficacy of treatment options. A number of challenges exist in treating patients with epilepsy. This is particularly true when seizures are difficult to control and medication regimens are more complex. Some pharmaceutical options may provide assistance with both seizures and emotional distress, but care is needed when considering such treatment approaches. In addition, integration of mental health professionals into the care of patients is necessary when cases are complicated and risk factors are high. Thorough methods to accurately diagnose emotional conditions and regular monitoring of symptoms can help prevent serious problems that can negatively affect the success of children and adolescents in everyday life. Collaboration between disciplines offers the best hope for early identification and treatment of these conditions.

The major symptom dimensions of obsessive-compulsive disorder are mediated by partially distinct neural systems

Obsessive-compulsive disorder (OCD) is a clinically heterogeneous disorder characterized by multiple, temporally stable symptom dimensions. Preliminary functional neuroimaging studies suggest that these symptom dimensions may have distinct neural substrates. Whole-brain voxel-based morphometry was used to examine the common and distinct neuroanatomical (structural) substrates of the major symptom dimensions of OCD. First, we compared 55 medication-free patients with OCD and 50 age-matched healthy control subjects. Multiple regression analyses were then used to examine the relationship between global and regional grey matter (GM) and white matter (WM) volumes and symptom dimension scores within the patient group. OCD patients showed decreased GM volume in left lateral orbitofrontal (BA47), left inferior frontal (BA44/45), left dorsolateral prefrontal (BA9) and right medial prefrontal (BA10) cortices and decreased bilateral prefrontal WM volume. Scores on the 'symmetry/ordering' dimension were negatively correlated with 'global' GM and WM volumes. Scores on the 'contamination/washing' dimension were negatively correlated with 'regional' GM volume in bilateral caudate nucleus and WM volume in right parietal region. Scores on the 'harm/checking' dimension were negatively correlated with regional GM and WM volume in bilateral temporal lobes. Scores on the 'symmetry/ordering' dimension were negatively correlated with regional GM volume in right motor cortex, left insula and left parietal cortex and positively correlated with bilateral temporal GM and WM volume. The results remained significant after controlling for age, sex, educational level, overall illness severity, global WM and GM volumes and excluding patients with comorbid depression. The reported symptom dimension-specific GM and WM alterations support the hypothesis that OCD is an etiologically heterogeneous disorder, with both overlapping and distinct neural correlates across symptom dimensions. These results have clear implications for the current neuroanatomical model of OCD and call for a substantial revision of such model which takes into account the heterogeneity of the disorder.

Gustav Flaubert's "nervous disease": an autobiographic and epileptological approach

More than 20 years ago, complex partial epilepsy of occipital-temporal origin was suggested as having been the "nervous disease" of Gustave Flaubert, one of the most famous French novelists. The aim of the present work, therefore, was to reevaluate the diagnosis of Flaubert's "nervous disease" in the light of reemerged biographic information and letters, as well as the numerous scientific advances in epilepsy and its psychopathology in recent years. If the semiology of the reported attacks is considered, epilepsy ranks among the most probable diagnoses. In our opinion, psychopathological considerations suggest primary involvement of mesial temporal lobe structures with typical findings of ictal and interictal mood behavior.

White matter abnormalities in drug-naïve patients with obsessive-compulsive disorder: a diffusion tensor study before and after citalopram treatment

OBJECTIVE

The aim was to investigate the white matter abnormalities of drug-naïve patients with obsessive-compulsive disorder (OCD) using diffusion tensor-imaging and the white matter changes in the patients after pharmacotherapy.

METHOD

Thirteen drug-naïve OCD patients and 13 age- and sex-matched healthy comparison subjects were examined using diffusion tensor-imaging and structural magnetic resonance imaging. Measurements were made in OCD patients before and after 12 weeks of citalopram treatment.

RESULTS

Compared with controls, the drug-naïve OCD patients showed significant increases in fractional anisotropy (FA) in the corpus callosum, the internal capsule and white matter in the area superolateral to the right caudate. The increases in FA were mostly no longer observed in patients after 12 weeks of treatment compared with controls.

CONCLUSION

Our findings suggest that white matter alterations are associated with the pathophysiology of OCD, and the abnormalities may be partly reversible with pharmacotherapy.

Interictal Depression, Anxiety, Personality Traits, and Psychological Dissociation in Patients with Temporal Lobe Epilepsy (TLE) and Extra-TLE

PURPOSE

This study was performed to investigate the relation between symptoms of interictal depression, anxiety, personality traits, and psychological dissociation with the localization and lateralization of the epileptogenic zone in patients with partial epilepsy.

METHODS

All patients were diagnosed according to the localization-related concept of the 1989 International League Against Epilepsy (ILAE) Classification of Epilepsies and Epileptic Syndromes, and the localization and lateralization of the epileptogenic zone was established by using the clinical criteria for noninvasive presurgical evaluation. This resulted in 67 patients with temporal lobe epilepsy (TLE) and 64 patients with extra-TLE. All patients were assessed on the various aspects of psychopathology by using a comprehensive battery of standardized diagnostic instruments.

RESULTS

We did not find the hypothesized excess of psychiatric symptoms in patients with (mesial) TLE in comparison with patients with extra-TLE. We also found no differences between patients with the lateralization of epilepsy in the left versus the right hemisphere.

CONCLUSIONS

TLE per se cannot be considered a risk factor in developing more or more severe symptoms of psychopathology in patients with partial epilepsy. Concomitant factors, such as the duration of epilepsy, seizure frequency, and frontal lobe dysfunction may play an additional role. Our findings support the hypothesis of a multifactorial explanation for the psychiatric symptoms in patients with epilepsy.

Obsessionality, obsessive-compulsive disorder, and temporal lobe epilepsy

We evaluated the prevalence of obsessive-compulsive disorder (OCD) in patients with temporal lobe epilepsy (TLE) and we investigated the hypothesis that obsessionality may represent a trait in TLE. Eighty-two consecutive patients with epilepsy, 62 with TLE and 20 with idiopathic generalized epilepsy (IGE), and 82 matched healthy controls were evaluated using the SCID-IP, Y-BOCS, MMPI-2 (specifically the Psychasthenia and Obsessiveness scales), BDI, and STAI Y1 and Y2. Nine of the TLE patients, none of the IGE patients, and one of the controls had a diagnosis of OCD. Psychasthenia and Obsessiveness scores were significantly higher in the TLE than in the IGE and control groups. Patients with TLE and OCD differed significantly with respect to history of depression when compared with patients with TLE without OCD, whereas there were no differences in age at onset and duration of epilepsy, seizure pattern and frequency, MRI features, laterality of the EEG focus, antiepileptic drug therapy and combinations, and BDI scores.

Anxiety in patients with epilepsy: systematic review and suggestions for clinical management

Up to 50 or 60% of patients with chronic epilepsy have various mood disorders including depression and anxiety. Whereas the relationship between epilepsy and depression has received much attention, less is known about anxiety disorders. It is now recognized that anxiety can have a profound influence on the quality of life of patients with epilepsy. The relationship between anxiety disorders and epilepsy is complex. It is necessary to distinguish between different manifestations of anxiety disorder: ictal, postictal, and interictal anxiety. Preexisting vulnerability factors, neurobiological factors, iatrogenic influences (antiepileptic drugs, epilepsy surgery), and psychosocial factors are all likely to play a role, but with considerable individual differences. Despite the high prevalence of anxiety disorders in patients with epilepsy, there are no systematic treatment studies or evidence-based guidelines for best treatment practice. Nevertheless, a practical approach based on the temporal relationship between anxiety and epileptic seizures allows clinicians to consider appropriate treatment strategies to reduce the psychiatric comorbidity in patients with epilepsy.