Amygdalar hyperactivity, a fear-related link between panic disorder and mesiotemporal epilepsy

The sudden onset, short duration and stereotyped features of panic attacks, and the fear aura of seizures starting at the mesial aspects of the temporal lobe, suggest common mechanisms underlying panic disorder (PD) and mesiotemporal epilepsy (MTLE). However, current consensus emphasizes the importance of differentiating the two entities based on 1) intact consciousness in panic attacks, 2) poor response to antiepileptics, and 3) unsuccessful electrophysiological attempts to demonstrate a relationship. We report two cases with a diagnosis of PD that had been partially responsive to first line treatments. During the EEG session, both patients developed panic symptoms with minimal EEG changes in response to paper bag-hyperventilation (PB-HV), and several minutes later presented a clear ictal EEG pattern associated with very different clinical symptoms, but both with strong fear content. Z-scored LORETA analysis showed increased current source densities (CSD) at the right amygdala in both subjects during the induced panic symptoms. Several areas were involved during the seizure, different in each subject. Yet, a very significant increase at the amygdala was found in both cases. The LORETA Z-scored source correlation (LSC) analysis also showed similar abnormal patterns during the panic symptoms in both patients, and marked differences during the seizure. These findings show a major role of amygdalar hyperactivity in both fear-related conditions for the two patients, and are discussed in relation to existing models of PD in general. Abnormal overactivation at mesiotemporal regions is poorly represented at the surface recordings but can be detected by the appropriate analytical techniques.