Obsessive Compulsive Disorder Presenting as Neurological Emergency

By Dar, Mansoor; Wani, Rayees et al. | Indian Journal of Psychological Medicine, October-December 2015 | Go to article overview

Obsessive Compulsive Disorder Presenting as Neurological Emergency


Dar, Mansoor, Wani, Rayees, Rather, Yasir, Kawoos, Yuman, Hussain, Arshad, Margoob, Mushtaq, Dar, Mohammad, Malla, Altaf, Indian Journal of Psychological Medicine


Byline: Mansoor. Dar, Rayees. Wani, Yasir. Rather, Yuman. Kawoos, Arshad. Hussain, Mushtaq. Margoob, Mohammad. Dar, Altaf. Malla

Chronic epilepsy is leading to behavioral changes including obsessive-compulsive symptoms has been well-studied and shown to be about 22%, but the converse has not been reported. Here, we present a case discussion of a 45-year-old female, who presented with recurrent seizures with hyponatremia, which latter was ascribed to her undiagnosed obsessive compulsive disorder (OCD). This patient later did well on anti-obsessional treatment without any antiepileptic. This embarks the need for detailed psychiatric evaluation for patients in emergency care settings and gives a rare presentation of OCD.

Introduction

Obsessive compulsive disorder (OCD) can manifest with a wide range of clinical pictures. [sup][1] On the other hand, there has been a long-standing observation that patients with various types of epilepsy/seizures have a higher incidence of many psychiatric disorders including OCD. [sup][2],[3],[4],[5],[6],[7] Though the equation of seizures leading to OCD is a known phenomenon, but to our best knowledge, we could not find literature showing OCD to cause seizures directly or indirectly. Here we present a case of undetected OCD presenting as repeated seizures, which is an indirect relationship might be first of its kind in literature.

Case Report

A 45-year-old female from rural Kashmir (India), married with four children, with previous three to four admissions for generalized tonic-clonic seizures from last 3 years was presently again admitted with two episodes of generalized tonic clonic seizures. As in previous instances she again had a low serum sodium level of 115 mEq/L. Rest of the investigations viz., hemogram, liver function tests, kidney function tests, blood sugar, urine examination, calcium, potassium, chloride, protein levels and lipid levels were in normal range. Her magnetic resonance imaging scan of brain and ultrasonography abdomen was normal. Every time her seizure was ascribed to the only abnormal finding of hyponatremia of 110 mEq/L, 114 mEq/L, 121 mEq/L, in previous admissions and the 115 mEq/L at the present. There was no apparent cause for this low sodium except for high intake of thiazides at the first admission. In spite of changing thiazides, she again had seizures with hyponatremia every time. She was evaluated for other possible causes of seizures and hyponatremia, but no concrete cause was found. Subsequent cerebrospinal fluid examination was normal. One out of three electroencephalograms showed nonspecific epileptic discharges. Considering her repetitive enquiring behavior and restlessness a psychiatric evaluation was sought.

On detailed psychiatric evaluation she verbalized pathological doubts, excessive cleanliness, excessive worries, repetition of acts. Her husband corroborated the same and reported her excessive intake of water. She had typical obsessions and compulsions. Upon further interview, she said that whenever she took water she felt as if she did not take and did not get satisfied, and she took more and more water for the same. Many a times she knew that she has taken a lot of water, but she felt compelled to take more. She further said that her idea of repeatedly drinking water was useless, but she could not resist it and had taken about 6-8 L of water on the day of seizure. Same had happened in the past seizures. She also described the similar repeated intake of antihypertensive tablets (thiazides) prior to her first seizure around 3 years back. Her husband further described her habits of taking medications over the counter, from her local health workers, changing and ill formed pain and ache complaints and corroborated her behaviors of intrusiveness, excessive washing, cleaning, checking and perfectionism. She described the intrusiveness of these thoughts and the disturbance in other psychosocial spheres for more than 15 years as was also reported by the family members. …

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