Table of Contents
Primary Category
Behavioral Neurology
P-Category
Secondary Category
S-Category
Authors:
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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.
Further Reading
Teixeira A.L. (2021) Peri-Ictal and Para-Ictal Psychiatric Phenomena: A Relatively Common Yet Unrecognized Disorder. In: . Current Topics in Behavioral Neurosciences. Springer, Berlin, Heidelberg. https://doi.org/10.1007/7854_2021_223
Bibliography
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- Baetz M, Bowen RC. Efficacy of divalproex sodium in patients with panic disorder and mood instability who have not responded to conventional therapy. Can J Psychiatry. 1998 Feb;43(1):73-7. doi: 10.1177/070674379804300109. PMID: 9494751.
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- Kaplan HI, Sadock BJ, Grebb JA. Synopsis of psychiatry. Baltimore (MD):Williams & Wilkins; 1994. p. 574
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- Nor Asyikin Fadzil, Norili Farhana Ahmad Saberi, Maruzairi Husain, Zahiruddin Othman.Ictal Fear Presenting as Panic Attacks International Medical Journal Vol. 27, No. 1, pp. 6 - 7 , February 2020 School of Medical Sciences, Universiti Sains Malaysia Kubang Kerian, 16150 Kelantan, Malaysia
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- Siân A Thompson, John S Duncan, Shelagh J M Smith Partial seizures presenting as panic attacks BMJ 2000;321:1002 doi: https://doi.org/10.1136/bmj.321.7267.1002
- The neuroanatomy of panic disorder: The emerging role of the right parahippocampal region, Journal of Anxiety Disorders, Volume 6, Issue 2,1992,Pages 181-188,ISSN 0887-6185,https://doi.org/10.1016/0887-6185(92)90016-Z.
- Teixeira A.L. (2021) Peri-Ictal and Para-Ictal Psychiatric Phenomena: A Relatively Common Yet Unrecognized Disorder. In: . Current Topics in Behavioral Neurosciences. Springer, Berlin, Heidelberg. https://doi.org/10.1007/7854_2021_223
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