Ictal and Interictal Panic Attacks- Diagnosis and Treatment

Primary Category

Behavioral Neurology

P-Category

Secondary Category

S-Category

Authors:

Abdur Rehman,
Junaid Kalia MD

Introduction

✨

Definition of Ictal and Interictal Panic Attacks

Symptoms of panic attacks such as flashes, paresthesia, anxiety, fear , derealization and depersonalization presenting in an ictal or interictal period

It is difficult to distinguish the borders of an ictal (during a seizure) panic attack and interictal (between seizures) panic attack.

Epidemiology

Panic disorder is prevalent in 13% of patients with epilepsy.

Ictal panic constitutes 60% of all psychiatric auras.

Post-ictal panic has been found in 10% patients with treatment resistant partial epilepsy.

Ictal panic is particularly associated with seizure disorders involving the medial temporal lobe and rarely with seizures of frontal and parietal lobe origin.

Pathophysiology

Exact mechanism is not known.

Neuroanatomical structure abnormalities include

Bilateral smaller volumes of amygdala
Low gray matter density of left Parahippocampal gyrus
Lower mean volume of both temporal lobes
Presynaptic and postsynaptic 5-HT1A receptor binding is reduced in the raphe, orbitofrontal and temporal cortex and the amygdala

Neurotransmitter function disturbances include

SSRIs decrease seizure frequency in a dose dependent manner which correlates with extracellular thalamic serotonergic thalamic concentration
Flumazenil, a benzodiazepine antagonist induces panic symptoms which suggests a pathogenic role played by GABA

Clinical Presentations [Table 1]

Features	Ictal Panic Attacks	Interictal Panic Attacks
Duration	Less than 30 seconds but up to hours in complex partial status epilepticus	5-20 minutes, sometimes hours
Severity	Mild to moderate	Can worsen in severity during the postictal period with a feeling of impending doom
Timing of Occurrence	In both awake and sleep states	Mostly in awake states
Autonomic symptoms	Paroxysmal salivation which may be associated with nausea and vomiting	Range of autonomic symptoms (tachycardia, blood pressure fluctuation, diffuse diaphoresis and shortness of breath)
Unresponsiveness	Partially unresponsive , later becomes totally unresponsive	Usually fully aware
Stereotypic features	Stereotypic paroxysmal event	May or may not be stereotypic

Diagnostic Investigations

Electroencephalographic studies by capturing the events on video-EEG and using sphenoid fluoroscopy guided electrodes to identify epileptiform activity in amygdala or mesial frontal regions

Brain MRI studies to check for lesion or atrophy of mesial temporal lobe or hippocampus

Measurement of postictal serum prolactin levels within 15 minutes to rule out psychogenic seizures

Thyroid function test to rule out Hyperthyroidism

Differential Diagnosis

Panic disorder

Prolonged Q-T syndrome

Carcinoid syndrome

Hypoglycemia

Pheochromocytoma

Cushing syndrome

Psychogenic seizures

Hyperthyroidism

Treatment and Management

Accurate diagnosis and proper management is difficult if ictal panic episodes are the only manifestation of epilepsy

Anti-epileptic drug with positive psychotropic properties chosen

Divalproex sodium - 10-15 mg/kg/day , can increase 5-10 mg/kg/week , not to exceed 60 mg/kg/day
Escitalopram - 5-10mg /day , can increase 5-10/mg biweekly ,not to exceed 20mg /day
Sertraline - 25-50mg /day , can increase 25-50/mg biweekly ,not to exceed 200 mg /day
Citalopram - 10mg /day , can increase 10-20/mg biweekly ,not to exceed 60mg /day
Carbamazepine -Maintenance dose 800-1200 mg/day. Therapeutic range 4-12 mg/L. Maximum dose of 1600 mg/day
Lamotrigine - Without enzyme-inducing AEDs or valproic acid Initially 25 mg for 2 weeks, then 50 mg/day for 2 weeks and after 4 weeks may increase by 50 mg/day
Pregabalin - 150 mg/day , not to exceed 600 mg/day

Consider benzodiazepines alprazolam or lorazepam for 6-8 weeks because response to antidepressant drugs may not be apparent for 4-6 weeks

Recommend cognitive behaviour therapy

Consider pre-surgical evaluation if seizures persist after two anti-epileptic drug trials.

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