Importance of Video-EEG Monitoring in the Diagnosis of Refractory Panic Attacks

Partial seizures can be misdiagnosed as panic attacks. There is considerable overlap of symptoms between temporal lobe seizures and panic attacks making the diagnosis extremely challenging. Temporal lobe seizures can present with intense fear and autonomic symptoms which are also seen in panic disorders. This results in delay in diagnosis and management. We report an interesting case of a young woman who was diagnosed with right temporal lobe seizures with symptoms suggestive of a panic attack. We report an interesting case of a 24-year-old woman who sustained a motor vehicle accident at the age of sixteen resulting in significant head trauma. She was an unrestrained passenger and suffered major injuries, including an epidural hematoma. She was hospitalized and was in a coma for 3.5 months. She underwent extensive speech and physical therapy after the incident. She had residual mild cognitive decline and developed episodes characterized by anxiety, fear, whole body tingling, and associated autonomic symptoms lasting between one and two minutes. Interestingly, there was preservation of consciousness and speech during these episodes. She is able to carry on a normal conversation during and after the event. She does have a psychiatric history which includes depression and prolonged periods of irritability resulting in verbal outbursts even before the accident. She was admitted to the psychiatry facility a few years ago as a result of a hypomanic episode. Given her history, panic attacks were still high on the differential diagnosis. She was referred to an outside neurologist based on her history of head trauma and refractory nature of the episodes; seizures were considered in the differential diagnosis because of head trauma and abnormal imaging. Her electroencephalogram (EEG) was negative but magnetic resonance imaging did show encephalomalacia in the right temporal lobe. She was given a trial of valproic acid which did not affect the frequency of spells. She was eventually switched to a low dose of Lamotrigine XR 100？mg daily for mood stabilization and 4 possible seizures. She continues to have these episodes with a frequency of one to two per week. She was referred to our epilepsy center eight years after head trauma because of refractory panic attacks and suspicion of seizures due to head trauma. She was admitted to the inpatient unit for intensive video-EEG monitoring to capture these spells for definitive diagnosis. We were able to capture a few of her stereotypical episodes and they did correlate with abnormal brain waves. EEG revealed seizure