Anxiety in epilepsy

Seizures arising from the limbic network, including the amygdala, may produce fear-related symptoms (there are commonly other symptoms related to temporal lobe seizure accompanying this symptom, such as déjà vu, epigastric rising sensation, or olfactory hallucination (Hingray et al, 2019)

Types of anxiety specific to patients with epilepsy (Hingray et al, 2019)

• Peri-ictal anxiety
  • Preictal, preceding the seizure (prodromes, 5 minutes – 48 hours before)
  • Ictal, part of the seizure (including auras – 5 minutes – a few seconds preceding, as well as ictal fear)
  • Postictal, occurring within 72 hours of the seizure (often accompanied by dysphoria)
• Interictal anxiety occurring independent of seizures
  • Anticipatory anxiety of epileptic seizures – excessive fear of having a seizure
  • Seizure phobia – excessive fears of seizures, often associated with avoidance surrounding circumstances associated with previous seizures
  • Epileptic social phobia – fear of being seen by others while having a seizure
  • Epileptic panic disorder – specific panic disorder associated with agoraphobia
• Iatrogenic
  • Medication side-effects (levetiracetam, topiramate, perampanel, zonisamide)
  • Withdrawal of medication (pregabalin, benzodiazepines, gabapentin, divalproex)
  • Antiepileptic medication inducing metabolism

Differentiating panic attack vs ictal fear: (Hingray et al, 2019)

• Duration: ictal fear typically lasts between 30 seconds to 2 minutes, a panic attack is generally considerably longer (5 - 15 minutes)
• Consciousness: ictal fear may or may not proceed to loss of consciousness, panic attacks generally do not
• Anticipatory anxiety: often present in panic attacks, can occur in ictal fear
• Agoraphobia: often present in panic attacks, can occur in ictal fear
• Deja vu / olfactory hallucinations: very rare in panic attacks, more commonly associated with ictal fear
• Automatisms: common with progression to complex partial seizures, very rare in panic attacks
• Salivation: increased in ictal fear, decreased in panic attacks
• EEG: ictal usually abnormal, interictal often abnormal; panic attacks have normal EEG
• MRI: patients with ictal fear may have abnormal mesial temporal structures, patients with panic attacks should have normal MRI
• Antidepressant treatment: ineffective in ictal fear, may be helpful in panic attacks
• Antiseizure medication: usually effective for ictal fear, not helpful for panic attacks

References

Hingray, C., McGonigal, A., Kotwas, I. & Micoulaud-Franchi, J.-A. The Relationship Between Epilepsy and Anxiety Disorders. Curr. Psychiatry Rep. 21, 40 (2019). https://pubmed.ncbi.nlm.nih.gov/31037466/