A Case Report on Obsessive-Compulsive Disorder with Co-Morbid Temporal Lobe Epilepsy in A 30-Year-Old Male

Abstract

Co-occurrence of Obsessive-Compulsive Disorder (OCD) and temporal lobe epilepsy (TLE) is uncommon but clinically significant due to overlapping symptomatology and complex treatment implications. We report the case of a 30-year-old man diagnosed with OCD with fair to good insight, alongside a history of temporal lobe epilepsy. The patient exhibited classical obsessive-compulsive symptoms alongside episodic disturbances in awareness. Comprehensive evaluation, including EEG and MRI, confirmed left temporal lobe epilepsy. Multimodal treatment involving pharmacotherapy and cognitive-behavioral therapy led to symptomatic improvement. The case highlights the importance of neuropsychiatric assessment and integrated management in comorbid psychiatric and neurological conditions.

Keywords

Introduction

Obsessive-Compulsive Disorder (OCD) is a chronic psychiatric disorder characterized by intrusive thoughts (obsessions) and repetitive behaviors or mental acts (compulsions) that the individual feels driven to perform in response to the obsessions. ¹The severity and insight into these symptoms vary, affecting the course and response to treatment.3 Insight plays a crucial role in determining prognosis and therapeutic approach. ² Temporal Lobe Epilepsy (TLE), a common form of focal epilepsy, originates in the medial or lateral temporal lobes and is associated with a wide array of neuropsychiatric symptoms. These include fear, hallucinations, emotional dysregulation, and in rare cases, symptoms overlapping with obsessive-compulsive phenomena.³
Although comorbidity between epilepsy and OCD is uncommon, their coexistence is clinically significant.

 Shared neuroanatomical circuits—particularly involving the orbitofrontal cortex, basal ganglia, and temporal regions—have been implicated in both disorders.⁴ This overlap can complicate diagnosis and management, requiring a multidisciplinary approach. This report highlights a rare presentation of OCD in a patient with co-morbid TLE, emphasizing diagnostic clarity and tailored treatment.

Case Presentation

A 30-year-old man, employed as an accountant, presented with a 3-year history of intrusive doubts about contamination, symmetry, and harm coming to loved ones unless he performed repetitive handwashing, checking, and counting rituals. These behaviors were time-consuming (3–4 hours/day), distressing, and interfered with his work. He acknowledged the irrationality of his symptoms and attempted to resist them, indicating fair to good insight. In addition, he reported episodic events over the past 5 years involving sudden fearfulness, olfactory hallucinations (smell of burning rubber), déjà vu, and brief lapses in awareness lasting 1–2 minutes. Post-episode confusion was noted. These episodes were initially misattributed to anxiety.

Course in Ward

The patient underwent a comprehensive diagnostic workup. The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) score was 27, indicating moderate to severe OCD. Electroencephalography (EEG) revealed interictal epileptiform discharges in the left temporal region, while MRI brain showed left-sided hippocampal sclerosis, consistent with Temporal Lobe Epilepsy. Neuropsychological evaluation indicated mild memory deficits. A clinical diagnosis of Obsessive-Compulsive Disorder with fair to good insight (F42.1 – ICD-10) and Temporal Lobe Epilepsy with complex partial seizures was made. The patient was initiated on pharmacological treatment including Sertraline 100 mg/day, titrated to 150 mg/day, for OCD symptoms; Clobazam 10 mg/day for anxiety and seizure control; and Oxcarbazepine 600 mg/day, gradually increased to 1200 mg/day, for seizure management. Once seizure frequency decreased, Cognitive Behavioral Therapy (CBT) with Exposure and Response Prevention (ERP) was introduced. Psychoeducation for the patient and his family was also provided, focusing on understanding the nature of his dual diagnosis, medication adherence, and coping strategies.

Outcome and Follow-up

At 3-month follow-up, OCD symptoms reduced by 40% on Y-BOCS and seizure frequency declined significantly, with only one episode in the last month.
Insight remained intact; patient demonstrated greater control over compulsions.

DISCUSSION

The present case illustrates the clinical complexity and diagnostic challenges involved in treating a patient with both Obsessive-Compulsive Disorder and Temporal Lobe Epilepsy. It is well established that the temporal lobe has significant connections with limbic structures and the prefrontal cortex, regions implicated in both seizure generation and the pathophysiology of OCD. The orbitofrontal-striatal-thalamic circuit, involved in compulsivity, is anatomically close to the temporal lobe. Thus, a disruption in this network due to epileptogenic activity may precipitate or exacerbate obsessive-compulsive symptoms.⁵ This case is further notable because the patient retained fair to good insight, a favorable prognostic factor in OCD. He was able to recognize the irrationality of his thoughts, which facilitated therapeutic engagement. However, the presence of TLE necessitated a nuanced approach to pharmacological treatment. While SSRIs like sertraline remain the first-line pharmacotherapy for OCD, care must be taken to avoid lowering seizure threshold. The addition of oxcarbazepine, a mood-stabilizing anticonvulsant with a safer profile, allowed for effective seizure control without exacerbating psychiatric symptoms. CBT with exposure and response prevention was initiated cautiously after seizure frequency declined. It served to reduce compulsive behaviors and improve emotional regulation. The patient's responsiveness to both medications and therapy underscores the importance of collaborative care between psychiatry and neurology. Furthermore, psychoeducation for the patient and family was crucial in reducing stigma, improving treatment adherence, and promoting long-term stability.

CONCLUSION

The co-occurrence of OCD and TLE necessitates careful neuropsychiatric assessment to distinguish between symptoms and tailor treatment. Insight plays a crucial role in treatment outcomes. A multidisciplinary approach combining pharmacological and psychological strategies is essential for holistic care.

PATIENT CONSENT

Written informed consent was obtained from the patient for publication of this case report. Efforts have been made to ensure anonymity.

CONFLICT OF INTEREST

The authors declare no conflict of interest

REFERENCE

1. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).
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3. Isaacs, M. L., & Troster, A. I. (2013). Obsessive-compulsive symptoms in patients with temporal lobe epilepsy. Neuropsychology Review, 23(3), 271–288.
4. Saxena, S., & Rauch, S. L. (2000). Functional neuroimaging and the neuroanatomy of OCD. Psychiatr Clin North Am, 23(3), 563–586.
5. Isaacs ML, Troster AI. Obsessive-compulsive symptoms in patients with temporal lobe epilepsy. Neuropsychol Rev.2013;23(3):271–288.