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

adolescent girl

Article  in  European Child & Adolescent Psychiatry · October 1999

DOI: 10.1007/s007870050134 · Source: PubMed

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

C. Pegna Panic disorder or temporal lobe epilepsy:

A. Perri
C. Lenti A diagnostic problem in an adolescent girl

Abstract Similarities in the clinical episodes were very frequent and

Accepted: 23 October 1998
presentation of panic disorder and
temporal lobe epilepsy suggest
that the two disorders are related
and can lead to diculties in a
C. Pegna á A. Perri á Prof. C. Lenti (&) di€erential diagnosis. We describe
Istituto di Scienze Neurologiche e the case of a young girl su€ering
Psichiatriche from paroxysmal anxiety, dereal-
dell'lnfanzia e dell'Adolescenza ization±depersonalization and au-
Via Besta 1
Milano tonomic symptoms, lasting from
Italia seconds to several minutes; these
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

Introduction attacks (12) compared with 3.8% in the general

Common manifestations of complex partial epilepsy
(CPE), mainly originating in the right temporal lobe,
are: sudden onset of fear, derealization±depersonaliza-
tion (DD), autonomic symptoms such as tachycardia,
tachypnea and abdominal discomfort. These manifesta-
tions 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 ten-
dency 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 adoles-
cents (20). No single clinical sign is generally path-
ognomonic 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
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.
238 European Child & Adolescent Psychiatry, Vol. 8, No. 3 (1999)
Ó Steinkop€ Verlag 1999

Table 1 Main features di€erentiating epileptic seizures from panic
attacks
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
older sister, all healthy. There was a family history of
panic disorder (paternal uncle) but not of epilepsy.
Seizures Panic 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 manifes-
++ ±
tation 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.

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 phenomenologi-
cally 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
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 conscious-
ness; 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 under-
standing 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. 239
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 auto-
nomic 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 condi-
tion 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
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.

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