Partial Seizures due to Sclerosis of the Right Amygdala Presenting as Panic Disorder

Abstract

The differential diagnosis between panic disorder and focal epilepsy may sometimes pose a serious challenge. We report the case of a 32-year-old woman who complained of paroxysmal episodes of acute anxiety that evaded diagnosis for 8 years. Standard EEGs and brain CT scan showed no clear pathologic findings. Antidepressants, support psychotherapy and several courses of antiepileptic drugs were not beneficial. She was referred to our centre for a comprehensive diagnostic assessment. Clinical and standardized personality assessment did not reveal the personality organization typically associated with proneness to develop phobic anxiety disorders. Also, agoraphobic avoidance was absent, and the patient’s main worries during the episodes involved negative social judgments rather than health. A brain MRI revealed a slightly increased signal at FLAIR images in the right amygdala. Video-EEG monitoring was decisive in establishing the diagnosis of drug-resistant right mesial temporal lobe epilepsy. Anteromesial temporal lobectomy was offered and successfully performed. Pathological examination of removed brain tissue revealed amygdalar sclerosis and mild hippocampal neuronal loss. At a 6-month follow-up visit, the paroxysmal episodes had completely disappeared. Depression, anxiety and quality of life were markedly improved. This case suggests that focal epilepsy should be considered in patients with paroxysmal episodes of anxiety, especially if dissociative symptoms and atypical clinical features for panic disorder are present, and if there is no satisfactory response to adequate trials of medication and psychotherapy within one year. A careful psychopathological analysis rather than a descriptive enumeration of symptoms is needed to bring these features to light. In such cases, even if routine EEGs or MRI are inconclusive and there is no response to antiepileptic drugs, it would be advisable to perform video-EEG monitoring to rule out partial seizures.

Ictal Fear or Panic Attack, This Is the Question—A Video–EEG Study

“…The epileptogenic focus of ictal fear is usually located within the mesial structures of the right temporal lobe, with the amygdala playing a pivotal role [ 4 ]. The role of the amygdala in the genesis of ictal fear has been demonstrated through deep-brain electrical stimulation studies during pre-operative evaluations of patients referred for surgical treatment of epilepsy, as well as by MRI findings showing volumetric atrophic alterations in the amygdala in patients with ictal fear [ 31 ]. Furthermore, it is believed that within the “ictal fear circuit”, frontal lobe structures such as the anterior cingulate cortex and orbitofrontal cortex are also involved following the initial discharge from the temporal lobe [ 32 ].…”

Measurement Invariance of the Experiences in Close Relationships Questionnaire across Different Populations

“…The ECR has been widely used in the last decade to investigate links between adult attachment and a great variety of correlates, such as social competence (Mallinckrodt & Wei, 2005), coping (Wei, Heppner, & Mallinckrodt, 2003), temperament and character (Picardi et al, 2005), the Big Five personality factors (Noftle & Shaver, 2006; Picardi et al, 2005), genetic polymorphisms related to emotions and social behavior (Gillath, Shaver, Baek, & Chun, 2008), immune function (Picardi et al, 2007), skin diseases (Jankovic et al, 2009), anxiety sensitivity (Weems, Berman, Silverman, & Rodriguez, 2002), and mental disorders (Marazziti et al, 2007).…”