Elsevier

General Hospital Psychiatry

Volume 51, March–April 2018, Pages 85-89
General Hospital Psychiatry

Obsessive-compulsive symptoms in adults with Lyme disease

https://doi.org/10.1016/j.genhosppsych.2018.01.009Get rights and content

Abstract

Objective

This study examined the phenomenology and clinical characteristics of obsessive compulsive symptoms (OCS) in adults diagnosed with Lyme disease.

Method

Participants were 147 adults aged 18–82 years (M = 43.81, SD = 12.98) who reported having been diagnosed with Lyme disease. Participants were recruited from online support groups for individuals with Lyme disease, and completed an online questionnaire about their experience of OCS, Lyme disease characteristics, and the temporal relationship between these symptoms.

Results

OCS were common, with 84% endorsing clinically significant symptoms, 26% of which endorsed symptoms onset during the six months following their Lyme disease diagnosis and another 51% believed their symptoms were temporally related. Despite the common occurrence of OCS, only 44% of these participants self-identified these symptoms as problematic. Greater frequency of Lyme disease symptoms and disease-related impairment was related to greater OCS. In the majority of cases, symptom onset was gradual, and responded well to psychological and pharmacological treatment. Around half of participants (51%) reported at least some improvement in OCS following antibiotic treatment.

Conclusions

This study highlights the common co-occurrence of OCS in patients with Lyme disease. It is unclear whether OCS are due to the direct physiological effects of Lyme disease or associated immunologic response, a psychological response to illness, a functional somatic syndrome, or some combination of these.

Introduction

Lyme disease (LD) is the most common vector borne illness in the United States [1]. LD is an infection caused by the Borrelia burgdorfi bacteria, and is transmitted primarily via tick bites [2]. Typical manifestations usually emerge within days or weeks following the bite, and include a localized skin rash, followed by some flu-like symptoms (e.g., fatigue, fever/chills, headache, stiff neck and joint pain) [3]. Diagnosis is usually confirmed via physician observations of clinical manifestation (e.g., erythema migrans rash of at least 5 cm in diameter) and often includes laboratory confirmation of exposure to the Borrelia burgdorfi bacteria (e.g., serological tests such as the enzyme-linked immunosorbent assay (ELISA) or the Western Blot test) [1]. The Centre for Disease Control requires a two-tier approach to serologic confirmation of LD infection, with positive results on both the enzyme immunoassay (e.g., ELISA) and immunoblot (e.g., Western Blot) tests. In addition to infecting the host with LD, coinfections such as babesiosis and ehrlichiosis are common [4,5]. Symptoms of LD vary greatly, and can include musculoskeletal symptom (e.g., arthritis), neurological symptoms (e.g., lymphocytic meningitis, cranial neuritis, radiculopathy, encephalomyelitis with intrathecal antibody production), or cardiac symptoms (e.g., second or third degree atrioventricular conduction delays). If treated early, symptoms can be transient and mild, and remit. However if left untreated, the course can be characterised by a waxing and waning course of symptoms. In addition to these physiological and neurological symptoms, neuropsychological studies have found some cognitive impairments in a portion of patients with LD, namely in memory, concentration, learning and conceptual ability [[6], [7], [8], [9]]. Many of these cognitive impairments associated with Lyme encephalopathy improve following antibiotic treatment [2,7,8].

Neurological symptoms are well-recognised symptoms of LD and occur in approximately 15–40% of patients [2]; however there is less understanding about the neuropsychiatric effects. Conditions including depression, mania, delirium, dementia, psychosis, obsessions and compulsions, and panic attacks have all been reported to occur after infection with LD [2,10], however causality has not been established [3]. For example, although elevated rates of depression have been noted in LD patients, greater rates of depression are commonly noted in a range of medical populations compared with controls [3]. Positive serological tests alone are not sufficient for diagnosis, or for symptoms to be attributable to LD. LD has often been presumed to be a functional or psychogenic disorder as a result of inadequate sensitivity and specificity of serologic tests [11] and both underdiagnosis and overdiagnosis of Lyme disease has been reported in the context of primary or prominent neuropsychiatric symptoms [3,11]. Late stage manifestations of LD often include mild to severe encephalopathy, polyneuropathy and profound fatigue. These symptoms can often be complex to differentiate from psychiatric symptoms, as patients commonly present with irritability, tearfulness, depressed mood, and concentration and sleep problems [9]. Memory loss, word finding problems and polyneuropathy may assist with differential diagnosis in favour of LD [9]. Other psychiatric symptoms such as paranoia, hallucinations, panic attacks, bipolar disorder, dementia, agitation, and anorexia have also been noted [9,[12], [13], [14]]. In a study of 200 seropositive patients, Fallon, Nields, Burrascano, Liegner, DelBene and Liebowitz [9] found that neuropsychiatric symptoms were common, with 94% of patients experiencing fatigue, 83% experiencing memory problems, 70% experiencing photophobia, 69% experiencing word reversal when speaking or letter reversals when writing, 57% experiencing spatial disorientation, 48% experiencing auditory hypersensitivities, 33% experiencing taste hypersensitivities, and 25% experiencing olfactory hypersensitivity. This study also found that psychiatric symptoms were common, with 64% reporting irritability and/or emotional lability.

There has been an ongoing interest in the relationship between immune mechanisms and Obsessive Compulsive Symptoms (OCS) [15]. For example, elevated rates of OCS have been noted in adults with lupus [16]. Obsessions are characterised by recurrent and persistent thoughts, urges or images that are experienced as unwanted and distressing [17]. Compulsions are stereotyped patterns of repetitive behaviours and rituals (e.g., handwashing, ordering, checking) or mental acts (e.g., counting, repeating words) [17]. LD has been identified as a potential trigger for OCS and tic symptoms in children with Pediatric Acute-onset Neuropsychiatric Syndrome (PANS), with remission of symptoms following antibiotic treatment [5,[18], [19], [20], [21]]. The presence of obsessional thoughts and checking compulsions along with sudden onset anxiety were noted in one case study of a patient with LD [12].

To our knowledge, this is the first systematic study of OCS amongst patients that self-report chronic LD. This study aimed to examine the phenomenology and clinical characteristics of OCS in adults self-reporting as diagnosed with LD.

Section snippets

Participants

Participants were 147 adults aged 18–82 years (M = 43.81, SD = 12.98) with LD recruited from online forums. Participants were primarily female (n = 117; 79.59%) and Caucasian (n = 146; 99.32%). Participants were recruited via online support groups for individuals with Lyme disease (Lymenet, MDJunction: Lyme Support and Lyme Connect) to participate in a study about “Lyme disease and associated problems”. Participants were excluded if their LD diagnosis had not been confirmed by a physician (per

Results

Average scores on the OCI-R and SDS indicated elevated average levels of OCS and functional impairment related to LD (i.e., ≥21 for OCI-R and >5 for SDS; see Table 2). A total of 37.4% of participants (n = 55) endorsed believing that they were currently experiencing OCS (n = 13; 8.8% missing), despite the majority of participants (n = 124; 84.4%) exceeding the clinical cut-off on the OCI-R (≥21) indicating the likely presence of OCD. Of the 124 participants who exceeded the OCI-R cut-off, only

Discussion

This study examined the phenomenology and clinical correlates of OCS in adults with LD. Although few studies have discussed OCS either co-occurring with LD, or as a psychiatric symptom of LD, results indicated that these symptoms were common with 84% endorsing clinically significant OCS. Despite this, less than half (44%) of participants who reported clinically significant OCS identified themselves as experiencing OCS. Improving recognition of OCS in patients with LD has the potential to

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author disclosure

Carly Johnco and Brittany Speisman report no proprietary or commercial conflicts of interest in any concept discussed in this article. Eric Storch receives research funding from National Institutes of Health, All Children's Hospital Research Foundation, and International OCD Foundation. He receives book royalties from Elsevier, Springer, Wiley, American Psychological Association, and Lawrence Erlbaum. Tanya Murphy receives funding from the National Institutes of Health, Centre for Disease

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      In addition, history of non-streptococcal throat infections is associated with increased risk of OCD, tic disorder, or any psychiatric disorder (Orlovska et al., 2017), and in a nationwide pediatric study, any treated infection since birth was associated with increased risk of subsequent treatment for any psychiatric disorder in adolescence, including OCD (Köhler-Forsberg et al., 2019). Associations between multiple non-streptococcal pathogens and onset of OCD symptoms have been suggested, including Borna disease viruses, Borrelia burgdorferi, Herpes simplex virus 1, Mumps orthorubulavirus, Mycoplasma pneumoniae, Toxoplasma gondii, and varicella-zoster virus, with no association with human immunodeficiency viruses (Akaltun et al., 2018; Dietrich et al., 2005; Flegr and Horáček, 2017; Johnco et al., 2018; Khanna et al., 1997b, 1997a; Miman et al., 2010, 2018; Murphy et al., 2015; Sutterland et al., 2015; Ursoiu et al., 2018; Yaramiş et al., 2009). To date, only one study of gut microbial ecology in youth with a history of PANDAS/PANS has been completed (see Table 1).

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