seizures initially diagnosed as panic attacks: case series

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Seizures initially diagnosed as panic attacks: A case series

Journal: Australian and New Zealand Journal of Psychiatry

Manuscript ID: ANP-2009-00170

Manuscript Type: Case Report

Date Submitted by the Author:

10-May-2009

Complete List of Authors: Plotnick, Adam; Royal Melbourne Hospital, Department of Neurosurgery Carney, Patrick; Royal Melbourne Hospital and University of Melbourne, Departments of Neurology, Medicine and Surgery Schweder, Patrick; Royal Melbourne Hospital, Department of Neurosurgery O'Brien, Terence; Royal Melbourne Hospital and University of Melbourne, Departments of Neurology, Medicine and Surgery Velakoulis, Dennis; Neuropsychiatry Unit, Royal Melbourne Hospital Drummond, Katharine; Royal Melbourne Hospital and University of

Melbourne, Departments of Neurology, Medicine and Surgery; Royal Melbourne Hospital, Department of Neurosurgery

Keywords: panic attack, epilepsy, organic disorders

Australian and New Zealand Journal of Psychiatry

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Seizures initially diagnosed as panic attacks: A case series

Running title: Epilepsy presenting as panic attacks

1Adam N. Plotnik MBBS

2Patrick Carney

1Patrick Schweder

2Terence J. O’Brien, MB, BS, MD, FRACP

3Dennis Velakoulis

1, 2Katharine J. Drummond MD FRACS

1Department of Neurosurgery, The Royal Melbourne Hospital, Parkville,

Victoria, Australia

2Departments of Neurology, Medicine and Surgery, The Royal Melbourne

Hospital, The University of Melbourne, Parkville, Victoria, Australia

3Neuropsychiatry Unit, Melbourne Neuropsychiatry Centre, The Royal

Melbourne Hospital and The University of Melbourne, Parkville, Victoria,

Australia

Correspondence to:

Dr Katharine J. Drummond

Department of Neurosurgery

The Royal Melbourne Hospital

Parkville VIC 3050

Page 1 of 20 Australian and New Zealand Journal of Psychiatry

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Australia

Ph: +61 3 9342 8408

Fax: +61 3 9342 7273

E-mail: [email protected]

Word count (including abstract and references): 2859

Page 2 of 20Australian and New Zealand Journal of Psychiatry

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mailto:[email protected]

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Abstract

Panic attacks and partial epileptic seizures are both brief paroxysmal episodes

that may present with similar clinical features. We present three patients with

varying intracranial pathology, in whom the presenting seizures were initially

diagnosed as panic attacks, delaying definitive treatment. The relationship

between seizures and anxiety or panic is complex and the two conditions can

co-exist. Thus, any patient with panic attacks should have a careful history and

examination. Atypical features, or failure to respond to treatment, warrant

further investigation with imaging or specialist epilepsy referral for video-EEG

monitoring.

Keywords; Panic attacks, complex partial seizures, epilepsy


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Introduction

Lesions of the central nervous system may present with symptomatology

suggestive of psychiatric conditions. This has been dramatically demonstrated

previously with psychiatric presentations of large anterior cranial fossa

meningiomas, leading to the recommendation that patients presenting with

psychiatric syndromes in middle to later life and those refractory to treatment

should undergoing imaging to avoid delay of appropriate treatment.1,2 With the

ready availability of high resolution neuroimaging, patients with persistent or

severe psychiatric symptoms should be considered for radiological and/or

electrophysiological investigation.

We present three patients seen at our institution, and the Epilepsy Unit at

the Austin Hospital, Melbourne, with brain lesions causing complex partial

seizures that were initially diagnosed and treated as panic attacks using DSM

IV criteria.3 Only the onset of generalised seizures or poor response to

treatment led to subsequent imaging or referral for video-EEG monitoring at

which time the correct diagnosis was made leading to the instigation of

successful treatment.


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Patients

Patient 1

A 46 year old man was referred to the Department of Neurosurgery after

the identification of a right temporal lobe tumour on a MRI scan performed for

investigation of a generalised seizure. He had a significant past history of

depression and a 20 year history of auditory hallucinations, mainly of hearing

someone talking behind him.

One year prior to admission, he began to experience episodes that were

diagnosed as panic attacks. In these episodes, which often occurred at night,

he would “go blank”, hyperventilate, become stiff and frozen, and clench his

jaw. He would then have an overwhelming desire to escape from the room,

associated with a feeling of panic. After these events, he was tired and it would

take some time for him to return to his normal self. Between the episodes he

was psychiatrically normal. A CT scan performed at the time of the onset of

these episodes was said to show an “old stroke”, presumably a hypodense

region in the right temporal region, but this was not available for review by us.

These episodes were managed as panic disorder by a psychiatrist with

paroxetine, with a poor clinical response, until he had a single generalised tonic-

clonic seizure. An MRI showed a right temporal non-enhancing tumour (Figure

1). Electroencephalogram (EEG) revealed slowing over the right temporal lobe

without epileptiform discharges. He was commenced on anti-epileptic

medication (phenytoin) and subsequently underwent a right temporal

craniotomy and resection of the tumour. Histopathological examination was

diagnostic of an anaplastic oligoastrocytoma. He has subsequently completed


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adjuvant radiotherapy. He has had no further seizures, including those

associated with panic, for 12 months, but had an episode of depression

associated with commencing a second anti-epileptic medication (levetiracetam).

Patient 2

A 45 year old man was referred to the Department of Neuropsychiatry

with a 3 year history of episodes diagnosed and managed as panic attacks. The

attacks were frequent, occurring almost daily, and would on occasion wake him

from sleep. Treatment with the serotonin reuptake inhibitor, paroxetine, had not

altered the frequency or severity of the attacks. The only significant past history

was of a motor vehicle accident 20 years previously during which he sustained

a right frontal lobe injury requiring a craniotomy.

The episodes generally commenced with autonomic symptoms, including

palpitations, a cold sweat, dry mouth, shallow breathing and a sense of

impending doom. In association with these attacks he described a ‘funny

feeling’ in his stomach which rose into his chest. At times, he would also display

unusual motor activity including repetitive rubbing of his fingers, chewing and lip

smacking. He did not lose consciousness during these episodes but described

a feeling of ‘detachment’. The episodes were followed by fatigue.

A routine EEG followed by video-EEG monitoring was performed. During

the inter-ictal recording there were frequent epileptiform spikes over the right

posterior frontal region. Several typical events were recorded during monitoring

which were accompanied on the EEG by focal rhythmic seizure activity over this

region. MRI scan demonstrated a large area of encephalomalacia in the right


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posterior frontal lobe, behind the region of the previous craniotomy (Figure 2) as

well as signal abnormality in the right mesial temporal region. He was

commenced on carbamazepine and has had no further events for over 12

months.

Patient 3

A 30 year old woman was referred to the Epilepsy Unit at the Austin

Hospital, Melbourne, following a generalised seizure. This seizure was

associated with sleep deprivation and excessive alcohol intake, which was

unusual for her. She had a history of depression and episodes that had been

diagnosed and managed as panic attacks. These occurred at least weekly and

usually in clusters of two or three per day. She had been referred to a

psychologist 2 years previously for counselling to manage these episodes,

which resulted in no significant change in their frequency of occurrence.

These episodes began 4 years prior to her first generalised seizure. The

initial symptoms consisted of an olfactory or gustatory aura of either burning

hair or coins. This was followed by a sense of fear or dread that she described

as “as if my family were being killed in front of me”. Witnesses observed that the

patient would usually stare and repeatedly swallow. She was unable to

communicate during the episodes but did not lose consciousness. They lasted

less than one minute and were followed by fatigue. They would often occur in

clusters and without obvious provocation.

An EEG showed slowing and sharp waves over the right temporal lobe.

MRI revealed a heterogenous lesion in the right parahippocampal gyrus


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consistent with a cavernous haemangioma (Figure 3). She was commenced on

carbamazepine, which only partially controlled her seizures. Other anti-epileptic

drugs, including lamotrigine and sodium valproate, also resulted in only partial

control. Video EEG monitoring and ictal single proton emission computed

tomography (SPECT) suggested she would benefit from resection of the lesion

in terms of seizure control.

She underwent resection of the cavernous malformation with access

through the middle temporal gyrus. The lesion was resected as a single piece

with aspiration of surrounding haemosiderin-stained brain. She made an

uncomplicated recovery and has been seizure free for more than 3 months on

her usual medications.

Discussion

These three patients, although harbouring differing intracerebral

pathology, presented with similar seizure related symptomatology with features

that led to misdiagnoses of panic attacks. A small number of similar reports in

the literature, have highlighted the diagnostic complexity of such cases and the

importance of further investigation of patients presenting panic attacks which

have atypical features or are resistant to treatment.4-9 In addition to symptoms

of anxiety or panic, on careful history such patients also manifest features

suggestive of focal epilepsy, including auras, automatisms and post-ictal

fatigue, which could reasonably have been considered an indication for early

radiological or EEG investigation. The cases highlight the similar clinical


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symptomatology of panic attacks and seizures, particularly those arising in the

frontal and temporal lobes.

Temporal and frontal lobe epilepsies may feature simple partial seizures,

complex partial seizures, secondarily generalized seizures, or combinations of

these seizure types. Simple partial seizures arising from the temporal lobe are

typified by autonomic, psychological and sensory phenomena including

olfactory and auditory hallucinations and déjà vu. There is not uncommonly an

epigastric rising sensation or abdominal discomfort. Complex partial seizures of

the temporal lobe often begin with these same symptoms followed by motor

arrest and loss of awareness, typically accompanied by oroalimentary

automatism. Post ictal confusion is common.10 Electrical stimulation studies of

the temporal lobe have elicited panic and associated somatic signs and

symptoms including dizziness, nausea, tachycardia, chest pain, altered

temperature sensations and depersonalisation.11 Seizures with features similar

to panic attack have been particularly linked to epilepsy arising in the right

temporal lobe.12 In our series, patients 1 and 3 had lesions of the right temporal

lobe. Patient 2, whose seizures appeared to arise in the right posterior frontal

lobe, also exhibited abnormalities of the right mesial temporal lobe on MRI.

Seizures in the posterior frontal lobe commonly rapidly spread to the temporal

region.

Frontal lobe partial seizures are sometimes mistaken for psychogenic

nonepileptic seizures (PNES) or “pseudoseizures”. They can occur several

times a day and frequently arise out of sleep. Complex gestural automatisms

are common. Complex partial seizures arising from the frontal lobe often have


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minimal or no post ictal confusion. Rapid secondary generalization is a frequent

feature, with status epilepticus a not-uncommon complication.10

Based on these descriptions of temporal and frontal lobe seizures, the

“panic attacks” in each of the three patients presented had features strongly

suggestive of epilepsy. Two of the patients had a type of mass lesion, including

an intrinsic brain neoplasm and a cavernous haemangioma, which has been

associated with seizures in up to 80% of patients.13-17

Panic attacks, like seizures, are unexpected, brief, paroxysmal, and self-

limiting phenomena. DSM IV classifies a panic attack as a discrete period of

intense fear or discomfort that is associated with at least four of the following:

palpitations, pounding heart or accelerated heart rate; sweating; trembling or

shaking; sensations of shortness of breath or smothering; feeling of choking;

chest pain or discomfort; nausea or abdominal distress; feeling dizzy, unsteady,

lightheaded or faint; derealisation or depersonalization; fear of losing control or

going crazy; fear of dying; paraesthesias; chills or hot flushes.3 Each of the

patients presented here had episodes with features that also typified panic

attacks, thus contributing to the diagnostic difficulty.

In addition to anxiety or panic occurring as a feature of the seizure or its

aura, anxiety symptoms are common in patients with epilepsy (reviewed in18,19).

Anxiety may occur as a pre-ictal psychological reaction to symptoms that alert

the patient to seizure onset, as a feature of the post ictal state or as a distinct

interictal behaviour.20 Patients with epilepsy have a higher incidence of

comorbid non-seizure panic attacks or anxiety disorders than the general

population,18,21,22 and these may be misdiagnosed as seizures.23 Anxiety or


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panic may be a feature of PNES in patient with or without co-existent epilepsy,

where the differential diagnosis may be particularly difficult.24 With careful

clinical evaluation, these similar symptoms can often be differentiated. For

example, the onset of ictal fear is paroxysmal and the duration is brief (30-120

sec)25 whereas panic attacks often build up over minutes with symptomatology

lasting more than five minutes.26 Furthermore, simple partial seizures

characterized by fear, anxiety or autonomic symptoms generally progress to

complex partial seizures, with change in consciousness, or generalise at some

time.4

Nonetheless, differentiating between seizures and panic attacks may be

difficult on clinical grounds alone. The patients reported here were all initially

diagnosed with, and had features of panic attacks, yet all had atypical features

to suggest seizures. Patient 1, with a right temporal anaplastic

oligoastrocytoma, had paroxysmal panic with a significant past history of

psychiatric illness, but also had oral automatisms and post-ictal fatigue. Patient

2, with post-traumatic right frontal encephalomalacia, had paroxysmal panic that

was resistant to paroxetine, but also had episodes that would wake him from

sleep, with manual and oral automatisms and post-ictal fatigue. Patient 3, with a

right parahippocampal gyrus cavernoma, had paroxysmal panic that was

resistant to psychotherapy, but the episodes were also preceded by an olfactory

or gustatory aura and had oral automatisms and post-ictal fatigue. While there

are differences between each presentation, a careful history from witnesses to

the episodes elicited a history consistent with oral automatisms and post-ictal

fatigue in all three patients.


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In conclusion, when evaluating a patient with panic attacks, it is important

to recognise that seizure symptomatology may also fulfil the DSM IV criteria for

panic disorder3,5 and that co-morbid psychiatric illness and seizures is

common.27 Failure to make the correct diagnosis may lead to a failure to control

symptoms, with prolonged suffering or delayed diagnosis of a neoplasm, or

treatable lesion, as well as exposing the patient to the physical and medical risk

of ongoing seizures. Patients with a first presentation of “panic attacks” require

a detailed history and clinical evaluation, with a high index of clinical suspicion

for epilepsy. A detailed history from witnesses to the episodes can provide

further information which leads to the diagnosis of a seizure disorder. With

readily available access to imaging, any unusual presentation of psychiatric

symptoms, or poor response to treatment, should warrant further investigation,

including referral to a specialist epilepsy unit with video-EEG monitoring.


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Figure legends

Figure 1

T1-weighted axial contrast-enhanced MRI of the brain from Patient 1. There is a

hypointense region in the right temporal lobe which does not enhance with

contrast (arrow). Following resection the lesion was found to be an anaplastic

oligoastrocytoma on histological examination.

Figure 2

Fluid attenuated inversion recovery (FLAIR) axial MRI of the brain from Patient

2. There is a previous craniotomy with partial removal of the frontal lobe (white

arrow) and signal change consistent with encephalomalacia in the region

posterior to this (black arrow).

Figure 3

T2-weighted coronal MRI of the brain from Patient 3. There is a heterogenous

lesion in the right parahippocampal gyrus (arrow) consistent with a cavernous

haemangioma.


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T1-weighted axial contrast-enhanced MRI of the brain from Patient 1. There is a hypointense region in the right temporal lobe which does not enhance with contrast (arrow). Following resection the

lesion was found to be an anaplastic oligoastrocytoma on histological examination. 127x144mm (360 x 360 DPI)


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Fluid attenuated inversion recovery (FLAIR) axial MRI of the brain from Patient 2. There is a previous craniotomy with partial removal of the frontal lobe (white arrow) and signal change

consistent with encephalomalacia in the region posterior to this (black arrow). 127x139mm (360 x 360 DPI)


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T2-weighted coronal MRI of the brain from Patient 3. There is a heterogenous lesion in the right parahippocampal gyrus (arrow) consistent with a cavernous haemangioma.

127x131mm (360 x 360 DPI)


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seizures initially diagnosed as panic attacks: case series

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