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The case described above illustrates the common confusion between panic attacks resulting from a panic disorder and ictal fear or ictal panic, which is the expression of simple (and complex) partial seizures that typically originate in mesial temporal structures. In this chapter, we review the clinical differences between these two conditions, their relatively frequent comorbidity, and the involvement of common neurobiological mechanisms and neuroanatomical structures that explain such comorbidity.


Panic Attacks Versus Ictal Fear


Panic disorder is a neuropsychiatric disorder that presents with recurrent panic attacks.1 According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV),2 the criteria of panic attacks include a discrete period of intense fear or discomfort, in which four or more of the following symptoms develop abruptly and reach a peak within 10 min: (1) cardiopulmonary symptoms that can present as chest pain or discomfort, sensations of shortness of breath or smothering, palpitations, pounding heart, or accelerated heart rate; (2) neurologic symptoms, including trembling or shaking, paresthesias (numbness or tingling sensation), dizziness, unsteady gait, light-headedness, or faintness; (3) psychiatric symptoms, including feelings of derealization (feelings of unreality) or depersonalization (being detached from oneself), fear of losing control or going crazy, and fear of dying; (4) autonomic symptoms, such as sweating, chills, or hot flushes, and gastrointestinal symptoms, such as feeling of choking, nausea, or abdominal distress.


Case Study

A 34-year-old woman was taken to the emergency room after being witnessed as having a generalized tonic-clonic (GTC) seizure. The patient had been in good health until the time of this seizure, with the exception of self-described panic attacks, which she had been experiencing for the previous 6 years. She described the attacks as a “panicky” feeling associated with a sensation of déjà vu and of “butterflies” in her stomach going up to her neck, often accompanied by a nauseous feeling, which at times was followed by copious salivation. The episodes lasted between 15 and 30 sec and occurred both in an awake state and out of sleep. Their average frequency had initially been two to five per month, with an increased frequency during the 2 days preceding her menstrual periods, at which time she could have up to three attacks in 1 day. In those days she typically complained of feeling tired and having problems with concentration and completing complex cognitive tasks. During the past year, the frequency of her attacks had increased to 6 to 10 per month, and on the day of her GTC, she had experienced 6 attacks.

She had been treated initially with alprazolam and then with various selective serotonin reuptake inhibitors (SSRIs) without remission of her attacks. In the past year, she had decided to stop all psychotropic medication.

Following the GTC, a brain computed tomography (CT) scan with and without contrast was done; it was reported to be unremarkable. An electroencephalography (EEG) study done ...

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