Panic disorder or temporal lobe epilepsy: A diagnostic problem in an adolescent girl

European Child & Adolescent Psychiatry 8:237±239 (1999) Ó Steinkop€ Verlag 1999

C. Pegna A. Perri C. Lenti

Accepted: 23 October 1998

C. Pegna á A. Perri á Prof. C. Lenti (&) Istituto di Scienze Neurologiche e Psichiatriche dell'lnfanzia e dell'Adolescenza Via Besta 1 Milano Italia

CASE REPORT

Panic disorder or temporal lobe epilepsy: A diagnostic problem in an adolescent girl

Abstract Similarities in the clinical presentation of panic disorder and temporal lobe epilepsy suggest that the two disorders are related and can lead to diculties in a di€erential diagnosis. We describe the case of a young girl su€ering from paroxysmal anxiety, derealization±depersonalization and autonomic symptoms, lasting from seconds to several minutes; these

Introduction Common manifestations of complex partial epilepsy (CPE), mainly originating in the right temporal lobe, are: sudden onset of fear, derealization±depersonalization (DD), autonomic symptoms such as tachycardia, tachypnea and abdominal discomfort. These manifestations are strikingly similar to symptoms of panic attacks quali®ed by DSM-IV-criteria (2), as experienced by patients diagnosed with panic disorder (PD). In both situations fear is not provoked, has a sudden onset, and occurs without warning. These phenomenological similarities, and their tendency to present brief, intermittent, unexpected, and intense episodes, suggest that panic attack and temporal lobe epilepsy are related and sometimes makes it dicult to diagnose especially in children and adolescents (20). No single clinical sign is generally pathognomonic of epilepsy or reliably di€erentiates psychogenic seizures from epileptic ones (3). Panic attacks have often been mistaken for seizures (7) or relapses of seizures (5). Likewise, seizures have also been mistaken for panic attacks (1, 8, 10). Moreover, up to 21% of adult epileptic patients experience panic

episodes were very frequent and disabling. The interictal EEGs and MRI were normal. After having diagnosed panic disorder based mainly on the duration of the attacks and the family history, a pharmacological treatment was started. Key words Temporal lobe epilepsy ± panic attacks

attacks (12) compared with 3.8% in the general population. Even though di€erential diagnosis is complex, some anamnestic and clinical features can be helpful when diagnosing if prolonged EEG monitoring and video± EEGs are not available (Table 1). What confuses the most is the EEG pattern. In fact, interictal abnormalities may also evade detection in surface EEGs of epileptic patients. Continuous 24-hour EEG monitoring would be useful in linking ictal symptoms to speci®c EEG abnormalities, but this examination can also be disappointing, especially when attacks are rare and the patient is young. In addition, it is important to mention that a number of patients with PD show somewhat abnormal EEG activity. Prolonged ambulatory EEG monitoring with sphenoidal electrodes of 14 patients with ``atypical panic attacks'' found, e.g., that ®ve patients had focal paroxysmal EEG variations during panic attacks, two of them had normal routine EEG variations during panic attacks, another two had normal EEGs (19). Since the relationship between PD and seizures has not, up to now, received signi®cant attention in adolescents, we will present a case to contribute to this issue.

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Table 1 Main features di€erentiating epileptic seizures from panic attacks Seizures

Panic

Clinical features Prolonged duration Repetitive, stereotyped manifestations Altered consciousness Postictal confusion Post-attack agitation

++ ++

± ±

++ ++ ±

± ± +

History Family history of epilepsy Family history of panic Separation anxiety in childhood

++ ± ±

± ++ ++

EEG and neurological features Interictal abnormalities Ictal abnormalities

+ ++

± ±

±

++

++

±

Treatment Response to anxiolytics (non-benzodiazepines) Response to antiepileptics (non-benzodiazepines) Note: ++ = discriminating feature + = consistent feature ± = absent feature

Case report A 12-year-old girl was brought to our institute by her parents in October 1995. She complained of recurrent paroxysmal episodes of acute anxiety accompanied by palpitations, hyperventilation, DD, and abdominal distress. These symptoms were characterized by sudden onset, no provoked situations, and occurred mainly at home in the evening (never during sleep). The frequency was about once a week, ranging from daily to monthly. She reported two types of attacks: aborted attacks (lasting a few seconds) mainly characterized by DD and others by DD and abdominal discomfort which were the ®rst symptoms followed by long-lasting fear (not more than half an hour). The attacks were phenomenologically consistent in the course of time (the symptoms were reported with little variability during each attack). During the most severe attacks she screamed and ran about in an agitated state asking for help. The patient also occasionally experienced deja vu, not in association with other clinical manifestations. After onset of these symptoms she began to need reassurance before going to bed, to the point that she still could not get to sleep alone even after having been reassured. She developed avoidant behaviour, like not being able to have a shower alone, not being able to stay home alone, nor to be left in a room alone when she was at home in the evening, and not being able to go out alone. She lived with her parents, a twin brother, and an

older sister, all healthy. There was a family history of panic disorder (paternal uncle) but not of epilepsy. During childhood, between ages 2 and 6 years, she manifested separation anxiety. She had never had behavioural problems nor diculties at school (she was a very bright student), but showed emotional liability. She had many friends and normal relationships. The patient was evaluated by experienced child neurology and psychiatry clinicians, and the following rating scales were performed: 1) Children's Manifest Anxiety Scale (score 122); 2) Hamilton Anxiety Rating Scale: before therapy score 26, after therapy score 3. The patient denied drug abuse and her physical examination showed no abnormalities. She underwent MRI, with normal results, and EEG studies; standard EEG showed left temporal sharp waves; sleep deprivation EEG was normal and 24-hour monitoring did not evidence ictal phenomena (it is important to note that the girl had no clinical manifestation during the recordings). She refused to undergo further monitoring. Treatment was initiated with a selective serotonin reuptake inhibitor (SSRI): citalopram 20mg/day, with complete remission of the symptomatology after one month. She still sometimes experienced brief episodes of DD without fear.

Discussion The main symptoms observed in the girl, short attacks with prevalent DD and long-lasting episodes of fear preceded by abdominal discomfort, confronted us with a diagnostic dilemma. From a clinical and anamnestic point of view our intent was towards a diagnosis of PD due to: 1) the presence of a main component of DD (a possible correlate of high anxiety levels during panic attacks); 2) the prolonged duration of the attacks; 3) the absence of family history of epilepsy; 4) a history of separation anxiety in childhood; 5) probable preserved consciousness; 6) a high anxiety level. However, the stereotyped symptoms, the very early onset of the symptoms, and the temporal abnormalities in the standard EEG could also account for a diagnosis of epilepsy. Unfortunately, in a 24-hour EEG monitoring, ictal episodes were absent, so the prevalence of features in a clinical balance according to PD in respect to CPE had led to a psychiatric rather than neurological diagnosis. Finally, the response to SSRI treatment con®rmed our opinion. The reported case raises some problems in understanding the uncertain boundaries between PD and CPE. Up to now the pathophysiology of panic remains unclear, although some clinical PET and MR studies in

C. Pegna et al. Panic disorder or temporal lobe epilepsy: A diagnostic problem in an adolescent girl

adult patients have provided data on possible temporal lobe dysfunction in PD (4, 11, 17). The striking overlap in psychic, somatic, and autonomic manifestations; the observation of cases in which CPE and PD are associated (14, 16, 21); and the induction of panic attacks by stimulation of temporal limbic areas (6, 16, 20), are consistent with the close proximity of neuroanatomical structures associated with each condition and suggest the hypothesis that PD and CPE may have a common anatomo-functional substrate (13, 18). The link between these disorders is further supported by the observation that focal discharges from the

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temporal lobe often take the form of severe anxiety or panic attacks (6,14,16). The EEG pattern, as pointed out earlier, is not a striking di€erential feature in many cases; although it is normal in most cases of PD, nonspeci®c abnormalities are found in 14% to 69% of cases (10, 15, 10). The reported case, with its very early onset, together with the clinical manifestations (with DD as a prevalent feature) and the EEG abnormalities in the temporal regions seem to con®rm this opinion and stresses the importance of indicating clear guidelines in the di€erential diagnostic procedures of this disorder in childhood and early adolescence.

References 1. Alemayehu S, Bergey GK, Barry E, Krumholz A, Wolf A, Fleming CP, Frear EJ Jr (1995) Panic attacks as ictal manifestation of parietal lobe seizures. Epilepsia 36:824±30 2. American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders, DSM-IV. Washington D.C.: APA 3. Devinsky O (1998) Nonepileptic psychogenic seizures quagmires of pathophysiology, diagnosis, and treatment. Epilepsia 39:458±462 4. Fontaine R, Breton G, Dery R, Fontaine S, Elie R (1990) Temporal lobe abnormalities in panic disorder: a MRI study. Biological Psychiatry 27: 304±310 5. Genton P, Bartolomei F, Guerrini R (1995) Panic attacks mistaken for relapse of epilepsy. Epilepsia 36:48±51 6. Gloor P, Olivier A, Quesney LF (1982) The role of the limbic system in experiential phenomena of temporal lobe epilepsy. Annals of Neurology 12:129± 144 7. Hirsch E, Peretti S, Boulay C, Sellal F, Maton B (1990) Panic attacks misdiagnosed as partial epileptic seizures. Epilepsia 31:636 8. Laidlaw JDD, Zaw KM (1993) Epilepsy mistaken for panic attacks in an adolescent girl. British Medical Journal 306:709±710

9. Lee DO, Helmers SL, Steingard RJ, De Maso DR (1997) Case study: seizures disorder presenting as panic disorder with agoraphobia. Journal of American Academy of Child and Adolescent Psychiatry 36:1295±1298 10. Lepola U, Nousiainen U, Puranen M, Riekkinen P, Rimon R (1990) EEG and CT ®ndings in patients with panic disorder. Biological Psychiatry 28: 721±727 11. Nordahl TE, Semple WE, Gross M, Mellman TA, Stein MB, Goyer P, King AC, Uhde TW, Cohen RM (1990) Cerebral glucose metabolic di€erences in patients with panic disorder. Neuropsychopharmacology 3:261±272 12. Pariente PD, Lepine JP, Lellouch L (1991) Lifetime history of panic attacks and epilepsy: an association from a general population survey. Journal of Clinical Psychiatry 52:88±89 13. Roth M, Harper M (1962) Temporal lobe epilepsy and the Phobic Anxiety Depersonalization Syndrome. Part III: practical and theoretical considerations. Comprehensive Psychiatry 3:215 14. Spitz MC (1991) Disorder in seizure patient: a diagnostic pitfall. Epilepsia 32:33±38 15. Stein MB, Uhde TW (1989) Infrequent occurrence of EEG abnormalities in Panic Disorder. American Journal of Psychiatry 146:517±520

16. Stern TA, Murray GB (1984) Complex partial seizures presenting as psychiatric illness. Journal of Nervous and Mental Diseases 172:625±627 17. Strian F, Ploog D (1988) Anxiety related to central nervous system dysfunction. In: Noyes JRR, Roth M, Burrows C (Eds) Handbook of Anxiety. Vol. 2 (pp 431-475), New York: Elsevier 18. Toni C, Cassano GB, Perugi G, Murri L, Mancino, Petracca A, Akiskal H, Roth M (1996) Psychosensorial and related phenomena in panic disorder and in temporal lobe epilepsy. Comprehensive Psychiatry 37:125±133 19. Van Sweden B, Rombaut P (1987) Panic attacks and EEG abnormalities. American Journal of Psychiatry 144:12 20. Wall M, Tuchman M, Mielke D (1985) Panic attacks and temporal lobe seizures associated with a right temporal lobe arteriovenous malformation: case report. Journal of Clinical Psychiatry 46:143±145 21. Weilburg JB, Bear DM, Sachs G (1987) Three patients with concomitant panic attacks and seizure disorder: possible clues to the neurology of anxiety. American Journal of Psychiatry 144:1053±1056