Clinical Case Study PANIC ATTACKS IN THE DIFFERENTIAL DIAGNOSIS AND TREATMENT OF RESISTANT EPILEPSY Ma ´rcio A. Bernik, M.D.,* Ph.D., Fa ´bio M. Corregiari, M.D., and Ivan Ma ´rio Braun, M.D. 3 The authors present four patients displaying panic disorder and a history of epileptic seizures to illustrate difficulties regarding dif ferential diagnosis between epileptic seizures and panic attacks. The cases describe the aversive properties of epileptic seizures, the role of visual seizure-triggering stimuli as phobic cues, and the effectiveness and safety of clomipramine treatment of panic attacks as an adjunct to concurrent antiepileptic medication. Depression and Anxiety 15:190–192, 2002. & 2002 Wiley-Liss, Inc. Key words: panic disorder; seizures; anxiety; agoraphobia; clomipramine INTRODUCTION Epileptic seizures and panic attacks may display similar symptoms despite distinct pathophysiologies. Fear and anxiety can occur before, during, or after epileptic phenomena [Pariente, 1991]. Gloor [1982] reports that fear is the emotion most commonly associated with temporal lobe seizures. Seizures of insular and amygdala origin may also display auto- nomic symptomatology [Delgado-Escueta et al., 1986]. Differential diagnosis is usually simple because simple partial seizures displaying fear, anxiety, or autonomic features generally progress to complex partial seizures and/or generalize at some time [Young, 1995]. On the other hand, epileptic patients tend to attribute all ictal phenomena to epilepsy and comorbid panic disorder may be unrecognized [Weissman, 1990]. We report four patients who had their panic attacks misdiagnosed as treatment-resistant seizures, but who responded well to adjunctive clomipramine. CASES HISTORIES CASE 1 Mrs. C., 30 years old, had a 19-year history of secondarily generalized partial seizures with visual symptomatology (‘‘a bright point that increases until it becomes big, round, and yellow’’), progressing occasionally to tonic-clonic fits. Seizures could be visually triggered by flashes and car headlights. At 15, she began avoiding situations where her seizures could be constraining or dangerous. She feared she ‘‘would make a scene,’’ that ‘‘nobody would help,’’ or that she would ‘‘lose her identity.’’ She used to write her name on various parts of her body before facing public situations alone. Anticipatory anxiety eventually pro- gressed to ‘‘fear attacks.’’ This involved shortness of breath, tingling in her hands, palpitations, marked derealization, and a strong fear of losing control of herself. These attacks increased in frequency and were related to exposure to feared situations such as public and crowded places or places where strong visual stimuli were expected. Spontaneous panic attacks began at 20. She came to us displaying daily panic attacks. Her symptoms improved with clomipramine (CMI) 40 mg/day in addition to her antiepileptic medication [carbamazepine (CBZ) 1,200 mg/day]. CASE 2 Mr. C., a 32-year-old truck driver, had a 10-year history of secondarily generalized simple partial seizures with visual symptoms: ‘‘a black point rotating as a boomerang, growing larger and larger and becoming yellow and green as it came closer,’’ Anxiety Clinics, Institute of Psychiatry Medical School, University of Sa ˜o Paulo, Sa ˜o Paulo, Brazil *Correspondence to: Dr. Ma ´rcio Bernik, Ambulato ´rio de Ansie- dade, Instituto de Psiquiatria, Hospital das Clı ´nicas da Faculdade de Medicina da Universidade de Sa ˜o Paulo, Rua Dr. Ovı ´dio Pires de Campos s/n CEP 05403-010, Sa ˜o Paulo-SP, Brazil. E-mail: bernikma@ax.apc.org Received for publication 11 January 2001; Accepted 11 February 2002 DOI: 10.1002/da.10038 Published online in Wiley InterScience (www.interscience.wiley.com). & & 2002 WILEY-LISS, INC. DEPRESSION AND ANXIETY 15:190–192 (2002)