obsessive compulsive disorder ( ocd ) can manifest with a wide range of clinical pictures . 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 .
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 .
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 .
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 .
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 .
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 .
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 .
she had been put on tablet phenytoin sodium 300 mg daily since her first seizure , without any significant benefit . on psychiatric evaluation
she was diagnosed as ocd ( international classification of diseases-10 criteria ) and put on fluvoxamine and cognitive behavioral therapy ( cbt ) , however other causes of hyponatremia and polydipsia were still being ruled out .
tablet fluvoxamine was slowly titrated from 50 to 200 mg / day over 5 weeks , and cbt sessions were also given twice weekly .
the patient showed a response to therapy . in the meantime , no apparent cause for his low serum sodium / seizure / excessive water intake could be found .
after a consensus with the neurologist , phenytoin sodium was slowly tapered from 6 month of the start of flouvoxamine , repeated electroencephalograms and serum sodium levels were followed and she was off phenytoin in 9 month . at present , after 28 months of follow - up she is significantly improved in ocd features and had no further seizures since then .
her yale - brown obsessive compulsive scale score at start and at 28 months is 29 and 10 respectively .
she scored 5 ( markedly ill ) for clinical global impressions severity ( cgi - s ) at start and at 28 months she scores 1 ( very much improved ) for cgi improvement and cgi - s also scores 1 ( normal - not at all ill , symptoms of disorder not present past 7 days ) .
presently , she is only on fluvoxamine 200 mg / day , without any antiepileptic .
as our findings and investigations , we excluded our differential diagnosis for seizures such as central nervous system infections , space occupying lesions , drug intake , metabolic causes , and other possible causes for seizures .
as has been reported , seizures could be the only obvious neurologic manifestation of more moderate levels of hyponatremia .
hyponatremia seems to be most possible cause in this case , as a correction , and future avoidance of hyponatremia prevented further seizures . in light of normal renal functions and normal metabolic profile ; a subtle , undiagnosed renal / metabolic defect can explain the development of hyponatremia in an otherwise healthy female , although development of hyponatremia with excessive water intake is known . in this case
our hypothesis of ocd leading to excessive water intake and subsequent development of hyponatremia and seizure is more tangible because treatment of ocd led to the overall improvement .
more importantly our patient is off antiepileptics , has improved oral contraceptive features and had an overall improvement and functionality .
since epilepsy affects more than 50 million people worldwide , 80% of them live in developing world and a substantial number has no attributable cause , our finding is important in finding an indirect etiology ( ocd ) of seizures .
it also points to the unawareness and the load of the psychiatric presentations in the society .
we suggest more involvement of psychiatrists in emergency units , and team approach with other specialties .
it will help in avoiding unnecessary continuous antiepileptic and more importantly it shows a different presentation of ocd ( close to psychogenic polydipsia ) for which both emergency residents and the psychiatrists should scratch into .
 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 . 