Seizures initially diagnosed as panic attacks: case series

Panic attack symptoms differentiate patients with epilepsy from those with psychogenic nonepileptic spells (PNES)

Psychogenic nonepileptic spells (PNES) are frequently challenging to differentiate from epileptic seizures. The experience of panic attack symptoms during an event may assist in distinguishing PNES from seizures secondary to epilepsy. A retrospective analysis of 354 patients diagnosed with PNES (N=224) or with epilepsy (N=130) investigated the thirteen Diagnostic and Statistical Manual-IV-Text Revision panic attack criteria endorsed by the two groups. We found a statistically higher mean number of symptoms reported by patients with PNES compared with those with epilepsy. In addition, the majority of the panic attack symptoms including heart palpitations, sweating, shortness of breath, choking feeling, chest discomfort, dizziness/unsteadiness, derealization or depersonalization, fear of dying, paresthesias, and chills or hot flashes were significantly more frequent in those with PNES. As patients with PNES frequently have poor clinical outcomes, treatment addressing the anxiety symptomatology may be beneficial.

Evidence-Based Treatment of Anxiety in Patients With Cancer

Anxiety is a dynamic response to perceived threat that is common among patients with cancer and fluctuates at critical points in the disease trajectory. A substantial minority of patients may experience clinically significant anxiety resulting from a range of potential etiologic factors. This review summarizes evidence-based recommendations for treatment of anxiety in oncology settings. Recommendations are based on the nature and time course of anxiety and the results of meta-analyses, systematic reviews, and individual trials in cancer populations. The evidence-based literature supports the use of psychosocial and psychopharmacologic treatments to prevent or alleviate anxiety symptoms. Conclusions are tempered by study heterogeneity and methodologic limitations and a lack of trials that included patients with clinically significant anxiety. In oncology settings, accessibility and acceptability of evidence-based treatments vary, and patients may seek a variety of resources to manage cancer concerns. Treatment planning should incorporate contributing factors to anxiety and patient preferences for psychiatric care.

Amygdalar hyperactivity, a fear-related link between panic disorder and mesiotemporal epilepsy

The sudden onset, short duration and stereotyped features of panic attacks, and the fear aura of seizures starting at the mesial aspects of the temporal lobe, suggest common mechanisms underlying panic disorder (PD) and mesiotemporal epilepsy (MTLE). However, current consensus emphasizes the importance of differentiating the two entities based on 1) intact consciousness in panic attacks, 2) poor response to antiepileptics, and 3) unsuccessful electrophysiological attempts to demonstrate a relationship. We report two cases with a diagnosis of PD that had been partially responsive to first line treatments. During the EEG session, both patients developed panic symptoms with minimal EEG changes in response to paper bag-hyperventilation (PB-HV), and several minutes later presented a clear ictal EEG pattern associated with very different clinical symptoms, but both with strong fear content. Z-scored LORETA analysis showed increased current source densities (CSD) at the right amygdala in both subjects during the induced panic symptoms. Several areas were involved during the seizure, different in each subject. Yet, a very significant increase at the amygdala was found in both cases. The LORETA Z-scored source correlation (LSC) analysis also showed similar abnormal patterns during the panic symptoms in both patients, and marked differences during the seizure. These findings show a major role of amygdalar hyperactivity in both fear-related conditions for the two patients, and are discussed in relation to existing models of PD in general. Abnormal overactivation at mesiotemporal regions is poorly represented at the surface recordings but can be detected by the appropriate analytical techniques.