epearls newsletter, July 2009:
Introduction
In light of my interest in panic disorder, this month’s e-pearls is devoted to the relationship between panic attacks and partial seizures. The fact that partial seizures can present as panic attacks is a perfect example of the overlap between neurology and mental health, and underscores the need for mental-health practitioners to have some basic awareness of medicine and physiology.
A Few Words About Seizures
First of all, I’m sure many of you are wondering what partial seizures are. Perhaps they can best be explained by first contrasting them with generalized seizures.
A true, physiologic seizure is always associated with some sort of abnormal electrical discharge in the brain (as you might recall, the brain works by generating lots of small electrical discharges; we can see these by placing electrodes on the scalp, and routing them through an EEG machine).
Sometimes, and for lots of different reasons, one or another of these electrical discharges may grow and spread abnormally to other parts of the brain, which in turn generate their own abnormal discharges. This has a cascading effect, and within a few seconds, the entire cerebral cortex can be discharging in synchrony. When this happens, a grand mal seizure may result.
As their name suggests, generalized seizures affect the entire brain, and are associated with impairment of consciousness. Grand mal seizures are one example of this type, and consist of full loss of consciousness, jerking of all four limbs, and a period of confusion following the event (the patient is said to be post-ictal during the latter, simply meaning after the ictus, or seizure).
Partial seizures, on the other hand, do not spread very far. In these types of spells, the electrical discharges are pretty much confined to whatever area they are first generated in; depending upon where they originate, many different types of symptoms can result. For instance, when they occur in the temporal lobe, fear, dizziness, elevated heart rate, and flushing of the skin, among others, may occur. In other words, there is considerable overlap between the symptoms that may occur in partial seizures and the symptoms that typically occur during panic attacks.
Partial Seizures Presenting as Panic Attacks: Two Case Summaries
Case 1–A 68 year old man with a four-year history of attacks:
These attacks were stereotyped, or similar each time, consisting of “pins and needles” in the head, spreading to torso and limbs, followed by dry mouth, nausea, and a feeling of unease. The patient would appear pale, sweaty, agitated, and tearful. The spells would appear and disappear gradually. Referral was made first to a cardiologist, then a psychiatrist, and panic disorder was diagnosed. Over three years, group psychotherapy and medication did not help. EEG and video monitoring were ultimately performed, which showed the spells to be due to a partial seizure emanating from the right hemisphere. The spells responded to treatment with an anti-epileptic drug.
Case 2–A 30 year old woman presents with 10 years of stereotyped spells:
The spells began with pain in the head, hyperventilation, and palpitations (a feeling of rapid or irregular heartbeat), followed by tingling of the left face and arm, diminished hearing, pain in the left side of the chest, fear, and a dry mouth. The symptoms built up and diminished gradually, lasting for 15-30 minutes. Initial treatment for seizures was not successful, and panic disorder was then diagnosed. Further testing six years later including EEG monitoring showed the spells to be associated with seizure activity in the left hemisphere; the patient’s husband reported that the patient had repetitive chewing and swallowing movements during the spells just prior to her re-evaluation. Scarring of the left hippocampus was seen on MRI. The spells abated after a different anti-epileptic drug was begun.
Discussion
From the above cases, it should be evident that indeed partial seizures can be mistaken for panic attacks. What clues, if any, might there be in the case descriptions that these spells might be seizures and not panic attacks?
In the first case, the development of panic attacks for the first time at the age of 64 is worrisome. Panic disorder is only rarely first diagnosed after age 45; this fact alone suggests the need for further medical investigation. Secondly, even though numbness and tingling are included in the DSM-IV description of panic, I would be concerned when these symptoms are prominent (as they were in this case) and occur in a certain order. In other words, the fact that the tingling developed in a stereotyped pattern, always preceding the other symptoms, would be worrisome to me.
In the second case, I would again be concerned about the patient’s complaints of numbness, this time involving the left side, and diminished hearing. I get worried whenever someone tells me that a particular sensory symptom always occurs on one side only. In addition, the description of repetitive motor activity (swallowing and chewing movements) is a huge red flag. Whenever these kinds of movements are present, it is very suggestive of a seizure.
In conclusion, one should always be looking for anything in the client’s description of their panic attacks that is atypical; to that end, it might also help to get the description of a witness, if possible. Finally, when in doubt, do not hesitate to refer the client for a neurological evaluation.
Reference
Thompson, S. A., Duncan, J. S., & Smith, S. J.M. (2000). Partial seizures presenting as panic attacks. The British Medical Journal, 321, 1002-1003.
