Recurrent Panic-Like Episodes Refractory to Conventional Psychiatric Treatment: A Possible Presentation of Focal Preserved Consciousness Seizures- A Case Report

Technical Summary: Recurrent Panic-Like Episodes Refractory to Conventional Psychiatric Treatment

Problem Statement
The paper addresses the significant diagnostic challenge posed by the clinical overlap between Panic Disorder and Focal Aware Seizures (specifically those arising from mesial temporal and limbic regions). Both conditions share closely overlapping affective, autonomic, and somatic manifestations, such as ictal fear, shortness of breath, chest heaviness, and a sense of impending doom. This phenomenological similarity often leads to misdiagnosis, where focal seizures are incorrectly classified as primary psychiatric panic attacks. Consequently, patients may undergo prolonged periods of inadequate treatment, developing secondary depression, benzodiazepine dependence, and functional decline before the underlying neurological etiology is reconsidered. The authors posit that recurrent, stereotyped panic-like episodes refractory to adequate psychiatric trials warrant a re-evaluation for organic causes, even in the presence of normal routine neuroimaging and interictal electroencephalography (EEG).

Methodology
This study is a single-case report detailing the clinical course of a man in his twenties from rural Nepal. The methodology involved a comprehensive retrospective and prospective clinical assessment:

• Patient History: The patient presented with a two-year history of abrupt, recurrent episodes of fear, chest heaviness, and paresthesia lasting a few minutes, occurring multiple times daily without precipitating factors.
• Treatment History: The patient underwent an extensive two-year trial of various psychotropic medications (including SSRIs, TCAs, SNRIs, atypical antipsychotics, mood stabilizers, and benzodiazepines) and Cognitive Behavioral Therapy (CBT). While secondary depressive symptoms responded to antidepressants, the panic-like episodes remained refractory.
• Diagnostic Workup: Initial investigations included routine EEG, MRI brain, echocardiogram, abdominal/pelvic ultrasonography, and a full metabolic panel (CBC, RFT, LFT, TFT, RBS, Vitamin D, Vitamin B12), all of which returned within normal limits.
• Intervention: Due to the stereotyped nature of the episodes and the lack of response to psychiatric management, the clinical team reassessed the diagnosis. Given the financial constraints preventing prolonged video-EEG monitoring, an empirical trial of an anti-seizure medication (Levetiracetam) was initiated based on the suspicion of focal preserved consciousness seizures.
• Outcome Measurement: Improvement was tracked weekly using subjective patient reporting and the Panic Disorder Severity Scale (PDSS).

Key Contributions and Results

• Clinical Response: Upon the initiation of Levetiracetam (250mg twice daily, titrated to 500mg twice daily), the patient demonstrated a marked clinical response. Within one week, there was greater than 50% improvement in panic symptoms (PDSS score dropped from >19 to 8). Within two weeks, the patient reported 99–100% resolution of episodes, with the PDSS score normalizing to 1.
• Diagnostic Re-evaluation: The case demonstrates that a diagnosis of "Treatment-Resistant Panic Disorder" should not be finalized without ruling out focal epilepsy, particularly when episodes are abrupt, stereotyped, and unresponsive to standard psychiatric protocols.
• Limitations of Standard Testing: The report highlights that normal routine interictal EEG and MRI findings do not exclude focal epilepsy, as standard EEG has low sensitivity for detecting seizures in routine practice, and the specific ictal events were not captured on prolonged monitoring.
• Therapeutic Implication: The dramatic response to Levetiracetam served as supportive evidence for a focal seizure disorder, leading to a change in the working diagnosis to "Suspected Focal Preserved Consciousness Seizure."

Significance and Claims
The paper claims that the primary significance of this case lies in the necessity of revisiting established psychiatric diagnoses when the clinical course is atypical or treatment response is inadequate. The authors argue that before labeling a case as treatment-resistant, clinicians must assess for underlying organic causes, including neurological conditions that share neuroanatomical pathways with panic disorder (e.g., mesial temporal/limbic regions).

The authors explicitly state that while the marked response to Levetiracetam strengthened the clinical suspicion of focal aware seizures, treatment response alone is not diagnostic. Without electroclinical confirmation via prolonged video-EEG, the diagnosis remains clinically suspected rather than definitively proven. The paper concludes that in resource-limited settings where prolonged video-EEG is unavailable, a collaborative neuropsychiatric assessment and detailed clinical evaluation of episode patterns are critical to prevent diagnostic delay and unnecessary polypharmacy. The case serves as a reminder that abrupt, stereotyped, recurrent panic-like episodes unresponsive to adequate psychiatric treatment require a prompt reassessment for neurological etiologies.