Panic Attacks, Spike-Wave Activity, and Limbic Dysfunction

Introduction: Several lines of evidence indicate that an increased neuronal excitability of the corpus amygdaloideum and hippocampus may be one pathophysiological condition of panic attacks. Methods: In this report, we will describe the case of a 54-year-old female patient with a depressive syndrome who first experienced very rapid atypical panic attacks with dizziness, trance-like and distorted optical perception, but without clear epileptic symptoms. Results: Several EEG recordings showed temporal sharp-waves and spike-wave patterns. Magnetic resonance imaging (MRI) revealed a hypodense area near left mesial temporal structures. Brain imaging with SPECT showed a hypoperfusion of the basal temporal cortical structures on the left side. Treatment with antidepressants had no effect, but the addition of valproic acid led to an attenuation of the panic attacks and epileptic potentials on the EEG. Discussion: A clinical trial using anti-epileptics could be successful in patients not responding to antidepressants or in the presence of epileptiform EEG activity. In this article, we will review the literature concerning the complex relationship between panic attacks and ictal activity of limbic structures and discuss the difficult diagnostic classification of atypical cases.

Key words

Ictal anxiety - panic disorder - atypical panic attacks - ictal EEG - case report

References

• 1 Baetz M, Bowen R C. Efficacy of divalproex sodium in patients with panic disorder and mood instability who have not responded to conventional therapy.  Can J Psychiatry. 1998;  43 73-77
• 2 Beauclair L, Fontaine R. Epileptiform abnormalities in panic disorder.  In Annual Convention of the Society of Biological Psychiatry,. 1986;  Abstracts 96 148
• 3 Biraben A, Taussig D, Thomas P, Even C, Vignal J P, Scarabin J M. et al . Fear as the main feature of epileptic seizures.  J Neurol Neurosurg Psychiatry. 2001;  70 186-191
• 4 Bystritsky A, Pontillo D, Powers M, Sabb F W, Craske M G, Bookheimer S Y. Functional MRI changes during panic anticipation and imagery exposure.  Neuroreport. 2001;  12 3953-3957
• 5 Carpenter L L, Leon Z, Yasmin S, Price L H. Clinical experience with mirtazapine in the treatment of panic disorder.  Ann Clin Psychiatry. 1999;  11 81-86
• 6 Cendes F, Andermann F, Gloor P, Gambardella A, Lopes C I, Watson C ,. et al . Relationship between atrophy of the amygdala and ictal fear in temporal lobe epilepsy.  Brain. 1994;  117 739-746
• 7 Dantendorfer K, Amering M, Baischer W, Berger P, Steinberger K, Windhaber J ,. et al . Is there a pathophysiological and therapeutic link between panic disorder and epilepsy?.  Acta Psychiatr Scand. 1995;  91 430-432
• 8 Dantendorfer K, Prayer D, Kramer J, Amering M, Baischer W, Berger P ,. et al . High frequency of EEC and MRI brain abnormalities in panic disorder.  Psychiatry Res. 1996;  68 41-53
• 9 Devinsky O, Sato S, Theodore W H, Porter R J. Fear episodes due to limbic seizures with normal ictal scalp EEG: a subdural electrographic study.  J Clin Psychiatry. 1989;  50 28-30
• 10 Fontaine R, Breton G, Dery R, Fontaine S, Elie R. Temporal lobe abnormalities in panic disorder: an MRI study.  Biol Psychiatry. 1990;  27 304-310
• 11 Gallinat J, Hegerl U. Elektroenzephalographie. In Hegerl U, editor Neurophysiologische Untersuchungsmethoden in der Psychiatrie. Wien; Springer 1998: pp. 15-109
• 12 Gallinat J, Hegerl U. Limbic ictus as a condition for anxiety attacks.  Nervenarzt. 1999;  70 206-215
• 13 Ghadirian A M, Gauthier S, Bertrand S. Anxiety attacks in a patient with a right temporal lobe meningioma.  J Clin Psychiatry. 1986;  47 270-271
• 14 Gloor P, Olivier A, Quesney L F, Andermann F, Horowitz S. The role of the limbic system in experiential phenomena of temporal lobe epilepsy.  Ann Neurol. 1982;  12 129-144
• 15 Harter C, Brandt C, Angenendt J. Agoraphobia with panic disorder or epilepsy? Differential diagnostic considerations in a case.  Psychiatr Prax. 2000;  27 252-254
• 16 Henriksen G F. Status epilepticus partialis with fear as clinical expression. Report of a case and ictal EEG findings.  Epilepsia. 1973;  14 39-46
• 17 Jabourian A P, Erlich M, Desvignes C, el Hadjam M, Bitton R. Panic attacks and 24-hour ambulatory EEG monitoring.  Arm Med Psychol. 1992;  150 240-244
• 18 Keck P EJ, McElroy S L, Friedman L M. Valproate and carbamazepine in the treatment of panic and posttraumatic stress disorders, withdrawal states, and behavioral dyscontrol syndromes.  J Clin Psychophannacol. 1992;  12 36-41
• 19 Keck P EJ, Taylor V E, Tugrul K C, McElroy S L, Bennett J A. Valproate treatment of panic disorder and lactate-induced panic attacks.  Biol Psychiatry. 1993;  33 542-546
• 20 Knight D C, Smith C N, Stein E A, Helmstetter F J. Functional MRI of human Pavlovian fear conditioning: patterns of activation as a function of learning.  Neuroreport. 1999;  10 3665-3670
• 21 Laidlaw J D, Khin M Z. Epilepsy mistaken for panic attacks in an adolescent girl.  BMJ. 1993;  306 709-710
• 22 Langs G, Fabisch K, Fabisch H. A case of comorbidity between panic disorder and photosensitive epilepsy.  Psychopathology. 2000;  33 271-274
• 23 Lee D O, Helmers S L, Steingard R J, DeMaso D R. Case study: seizure disorder presenting as panic disorder with agoraphobia.  J Am Acad Child Adolesc Psychiatry. 1997;  36 1295-1298
• 24 Lepola U, Nousiainen U, Puranen M, Rickkinen P, Rimon R. EEG and CT findings in patients with panic disorder.  Biol Psychiatry. 1990;  28 721-727
• 25 Lum M, Fontaine R, Elie R, Ontiveros A. Divalproex Sodium’s antipanic effect in panic disorder: a placebo-controlled study.  Biol Psychiatry. 1990;  27 164-165
• 26 McElroy S L, Keck P EJ, Lawrence J M. Treatment of panic disorder and benzodiazepine withdrawal with valproate [letter].  J Neuropsychiatry Clin Neurosci. 1991;  3 232-233
• 27 McNamara M E, Fogcl B S. Anticonvulsant-responsive panic attacks with temporal lobe EEG abnormalities.  J Neuropsychiatry Clin Neurosci. 1990;  2 193-196
• 28 Meyer M A, Zimmerman A W, Miller C A. Temporal lobe epilepsy presenting as panic attacks: detection of interictal hypometabolism with positron emission tomography.  J Neuroimaging. 2000;  10 120-122
• 29 Nordahl T E, Semple W E, Gross M, Mellman T A, Stein M B, Coyer P. et al . Cerebral glucose metabolic differences in patients with panic disorder.  Neuropsychopharmacology. 1990;  3 261-272
• 30 Pariente P D, Lepine J P, LeIIouch J. Lifetime history of panic attacks and epilepsy: an association from a general population survey.  J Clin Psychiatry. 1991;  52 88-89
• 31 Pegna C, Perri A, Lenti C. Panic disorder or temporal lobe epilepsy: A diagnostic problem in an adolescent girl.  Eur Child Adolesc Psychiatry. 1999;  8 237-239
• 32 Perna G, Bertani A, Caldirola D, Smeraldi E, Bellodi L. A comparison of citalopram and paroxetine in the treatment of panic disorder: a randomized, single-blind study.  Pharmacopsychiatry. 2001;  34 85-90
• 33 Reiman E M, Raichle M E, Robins E, Butler F K, Herscovitch P, Fox P ,. et al . The application of positron emission tomography to the study of panic disorder.  Am J Psychiatry. 1986;  143 469-477
• 34 Senkowski D, Linden M, Zubragel D, Bar T, Gallinat J. Evidence for disturbed cortical signal processing and altered serotonergic neurotransmission in generalized anxiety disorder. Biol Psychiatry (in press) 2002
• 35 Stein M B, Uhde T W. Infrequent occurrence of EEC abnormalities in panic disorder.  Am J Psychiatry. 1989;  146 517-520
• 36 Strian F. Pathogenese psychischer Storungen - die paroxysmale Angst. In MöIIer AA, Fröscher W, editors Psychische Storungen bei Epilepsie. Stuttgart; Thieme 1992: 50-54
• 37 Thomas K M, Drevets W C, Dahl R E, Ryan N D, Birmaher B, Eccard C H,. et al . Amygdala response to fearful faces in anxious and depressed children.  Arch Gen Psychiatry. 2001;  58 1057-1063
• 38 Tondo L, Burrai C, Scamonatti L, Toccafondi F, Poddighe A, Minnai G ,. et al . Carbamazepine in panic disorder [letter].  Am J Psychiatry. 1989;  146 558-559
• 39 Uhde T W, Stein M B, Post R M. Lack of efficacy of carbamazepine in the treatment of panic disorder.  Am J Psychiatry. 1988;  145 1104-1109
• 40 Vythilingam M, Anderson E R, Goddard A, Woods S W, Staib L H, Charney D S,. et al . Temporal lobe volume in panic disorder - a quantitative magnetic resonance imaging study.  Psychiatry Res. 2000;  99 75-82
• 41 Woodman C L, Noyes R J. Panic disorder: treatment with valproate.  J Clin Psychiatry. 1994;  55 134-136
• 42 Young G B, Chandarana P C, Blume W T, McLachlan R S, Munoz D G, Girvin J P. Mesial temporal lobe seizures presenting as anxiety disorders.  J Neuropsychiatry Clin Neurosci. 1995;  7 352-357
• 43 Zullino D, Baumann P. Lithium augmentation in depressive patients not responding to selective serotonin reuptake inhibitors.  Pharmacopsychiatry. 2001;  34 119-127