Phenomenology of obsessive compulsive disorder in patients with temporal lobe epilepsy or tourette syndrome

Revisiting the structure of the Yale Global Tic Severity Scale (YGTSS) in a sample of Chinese children with tic disorders

BACKGROUND

To the best of our knowledge, although the Chinese version of the Yale Global Tic Severity Scale (YGTSS) is widely used in child psychiatry departments in China, there is very little evidence focusing on the psychometric characteristics of the Chinese version of YGTSS. In this present study, we aim to re-examine the structure of the Chinese version of YGTSS and investigate its reliability and validity.

METHODS

A total of 367 children and adolescents with tic disorders aged 5-16 years old participated in the study. The Cronbach's alpha, test-retest reliability and concurrent validity will be calculated. Confirmatory Factor Analysis (CFA) also will be performed to assess the structure of YGTSS.

RESULTS

The Cronbach's alpha of the motor tic subscale of YGTSS was 0.84, for the phonic tic subscale of YGTSS, it was 0.90, but for the whole scale, it was 0.58. The test-retest reliability of YGTSS was 0.84. For the results of CFA, the Comparative Fit Index (CFI) of YGTSS based on the Two-Factor Model and Three-Factor Model was 0.97 and 0.96 respectively. The measurement invariance analysis suggested that the Two-Factor model of YGTSS across different age and sex groups was at the accepted level (≥0.90).

CONCLUSION

Overall, according to the results of this research, it suggested that the Chinese version of YGTSS showed good psychometric properties. It can be used in the assessment of tic disorders in the Chinese population. In the future, more comprehensive tools for assessing tics need to be further developed, which can cover the symptoms of premonitory urge and tic related obsessive-compulsive symptoms.

Clinical Features of Tourette Syndrome

Tourette syndrome is a multifaceted disorder characterized by multiple motor and at least one vocal tics that start in childhood, persist for at least 1 year, and cannot be attributed to another medical condition or exposure to medications/drugs. Clinical diagnostic criteria are available, and identification of tics is typically straightforward based on characteristic appearance and features. Diagnostic uncertainty can rarely arise in cases of mild tics, atypical features, certain psychiatric comorbidities, and other non-tic movement disorders. Comorbid psychopathology, including attention-deficit hyperactivity disorder (ADHD) and obsessive-compulsive behaviors/obsessive-compulsive disorder, affects the majority of patients and is correlated with disease severity and the presence of additional psychiatric behaviors. The severity of tics often improves after adolescence, whereas psychiatric symptoms typically persist. The subset of patients in whom tics persist into adulthood experience higher rates of anxiety, and lower self-esteem, socioeconomic status, and quality of life; the relative contribution of motor tics and psychopathology is not fully understood. This article summarizes the clinical features of Tourette syndrome, including major diagnostic criteria, unique features of tics, and key aspects that differentiate tics from common mimics and chameleons. Comorbid psychiatric conditions and their impact on phenotype and quality of life are described. Finally, current understanding of the natural history is summarized, including limited research in adults with Tourette syndrome.

The Correlation Between the Severity of Premonitory Urges and Tic Symptoms: A Meta-Analysis

Objectives: Premonitory urges (PUs) are defined as sensory experiences of pre-tic inner tension. Evidence suggests that most patients with Tourette syndrome experience PUs, which are transiently relived by the expression of tics. However, recent studies have revealed inconsistent results regarding the correlation between the severity of PUs and the severity of tic symptoms. Methods: A meta-analysis was performed to confirm the correlation between the severity of the urge and the severity of the expression of the tic. In total, 10 studies involving 626 patients with tic disorders were included in this meta-analysis. Results: The correlation coefficient (r) was extracted from each selected study, and a pooled correlation coefficient (r) and its 95% confidence intervals (CIs) were calculated. Sensitivity and subgroup analyses were performed to identify the potential sources of heterogeneity. The pooled correlation coefficient (r) of the relationship between the severity of PUs and tic symptoms was 0.296 (95% CI: 0.215-0.376) with an I² of 15.2% (95% CI: 0.00-56.5) based on a fixed effects model. The correlation was stronger in adults than in children (p = 0.03). Conclusion: A slight to moderate positive correlation was observed between the severity of PUs and tic symptoms. This correlation may be affected by the age of the patients. Further research should seek to elucidate the relationships among PUs, tic suppression, and tic expression to support the development of behavioral intervention therapies to reduce tic symptoms.

Neurobiology of the Premonitory Urge in Tourette's Syndrome: Pathophysiology and Treatment Implications

Motor and vocal tics are relatively common motor manifestations identified as the core features of Tourette's syndrome (TS). Although traditional descriptions have focused on objective phenomenological observations, such as anatomical location, number and frequency of tics, patients' first-person accounts have consistently reported characteristic subjective correlates. These sensory phenomena are often described as a feeling of mounting inner tension or urge to move ("premonitory urge"), which is transiently relieved by tic expression. This article reviews the existing literature on the clinical and neurobiological aspects of the premonitory urge in patients with TS, with focus on its pathophysiology and possible treatment implications.

Clinical characteristics of patients with epilepsy in a specialist neuropsychiatry service

Neuropsychiatry services provide specialist input into the assessment and management of behavioral symptoms associated with a range of neurological conditions, including epilepsy. Despite the centrality of epilepsy to neuropsychiatry and the recent expansion of neuropsychiatry service provision, little is known about the clinical characteristics of patients with epilepsy who are routinely seen by a specialist neuropsychiatry service. This retrospective study filled this gap by retrospectively evaluating a naturalistic series of 60 consecutive patients with epilepsy referred to and assessed within a neuropsychiatry setting. Fifty-two patients (86.7%) had active epilepsy and were under the ongoing care of the referring neurologist for seizure management. The majority of patients (N=42; 70.0%) had a diagnosis of localization-related epilepsy, with temporal lobe epilepsy as the most common epilepsy type (N=37; 61.7%). Following clinical assessment, 39 patients (65.0%) fulfilled formal diagnostic criteria for at least one psychiatric disorder; nonepileptic attack disorder (N=37; 61.7%), major depression (N=23; 38.3%), and generalized anxiety disorder (N=16; 26.7%) were the most commonly diagnosed comorbidities. The clinical characteristics of patients seen in specialist neuropsychiatry settings are in line with the results from previous studies in neurology clinics in terms of both epilepsy and psychiatric comorbidity. Our findings confirm the need for the development and implementation of structured care pathways for the neuropsychiatric aspects of epilepsy, with focus on comorbid nonepileptic attacks and affective and anxiety symptoms. This is of particular importance in consideration of the impact of behavioral symptoms on patients' health-related quality of life.

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.

Tourette syndrome and consciousness of action

BACKGROUND

Tourette syndrome (TS) is a neuropsychiatric disorder characterized by the chronic presence of multiple motor tics and at least one vocal/phonic tic since childhood. Tics typically change and vary in both intensity and severity over time, with remission and exacerbation common. In the vast majority of patients, tic expression is characteristically accompanied by discomforting bodily sensations, known as sensory phenomena or premonitory urges.

METHODS

We reviewed the existing literature on premonitory urges associated with the sense of voluntariness of action in TS.

RESULTS

Although the wish to move is perceived by the patient as involuntary, the decision to release the tic is often perceived by the patient as a voluntary capitulation to the subjective urge. Most patients with TS can exert a degree of control over the urge and constantly try to inhibit the movement. Based on these features, it has been suggested that tics performed in response to an urge to move should be classified as 'unvoluntary', as opposed to voluntary or involuntary acts. However, recent experimental data suggest that the brain areas involved in the generation of the wish to act show considerable overlap between healthy subjects and patients with TS.

DISCUSSION

The simultaneous presence of both voluntary and involuntary aspects in the expression of tic symptoms by patients with TS is consistent with the hypothesis that tics can have the same neurophysiologic substrate as voluntary acts, even though they are misperceived as being involuntary. This reinforces the view of TS as a hyperkinetic movement disorder primarily affecting the conscious experience of action.

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.

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.

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.