Rationale:
Obsessive-Compulsive Disorder (OCD) is characterized by compulsions and irrational, intrusive obsessions. Prior studies have documented OCD in patients with epilepsy, with presentation often varying by epilepsy type. Temporal Lobe Epilepsy (TLE) is frequently associated with interictal behavior syndrome, including altered religiosity between seizures (Aycicegi-Dinn et al., 2008). Neural dysfunction within the frontal-cingulate-thalamic-limbic circuit has been implicated in both OCD and epilepsy (Kaplan, 2011). We present a case that illustrates the pathophysiological link between TLE and religious-themed OCD (scrupulosity).Methods: N/A
Results:
A 41-year-old woman with childhood-onset OCD and TLE underwent a right anterior temporal lobectomy in 2004 for medically refractory focal epilepsy. She remained largely seizure-free from 2004 until 2019 with her anti-seizure medications narrowed to levetiracetam monotherapy. Her OCD was that of the scrupulosity subtype and was under control initially after her epilepsy surgery.
Then, in mid-2020, she reported a recurrence of scrupulosity-type OCD with intrusive religious obsessions (e.g., fear of forgetting prayers, inadequate love for Jesus) accompanied by insomnia and anxiety. This coincided with a recurrence of her auras, described as butterflies in stomach with heart racing. She followed closely also with psychiatry for her OCD and was also undergoing cognitive behavioral therapy.
In early 2022, she experienced a rare focal-to-bilateral tonic-clonic seizure, accompanied by worsening of her scrupulosity. She was referred to the Epilepsy Monitoring Unit, where right temporal seizures were captured. MRI brain showed stable postsurgical right temporal changes.
Around Easter 2022, during an office visit, she had to be referred to the Emergency Department for psychosis related to worsening scrupulosity. She perseverated about “not being enough for God” with constant prayers; she was hospitalized in the psychiatric inpatient unit. She also had hypergraphia at this time. She reported also worsening auras at this time.
After psychiatric stabilization, due to the ongoing breakthrough seizures, cenobamate was initiated. This led to seizure-freedom and a notable improvement and control of her scrupulosity OCD. Her psychiatric medications were then narrowed and reduced with continued control of her scrupulosity OCD, suggesting this issue was exacerbated by a peri-ictal state.
Conclusions:
This case highlights a compelling link between TLE and scrupulosity-type OCD. The relationship between focal epilepsy and obsessive religious ideation suggests shared pathophysiologic mechanisms involving limbic and fronto-temporal networks (Kaplan, 2011; Devinsky & Schachter, 2009). These findings reinforce prior associations between TLE and interictal hyperreligiosity (Waxman & Geschwind, 1975; Aycicegi-Dinn et al., 2008) and support the need for integrated neuropsychiatric care in epilepsy. Funding: None