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Epilepsy & Behavior


ARTICLE in EPILEPSY & BEHAVIOR NOVEMBER 2010
Impact Factor: 2.26 DOI: 10.1016/j.yebeh.2010.10.011 Source: PubMed

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Monica Ferlisi

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Retrieved on: 01 October 2015

Epilepsy & Behavior 20 (2011) 107110

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Epilepsy & Behavior


j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / ye b e h

Case Report

Fear as the only clinical expression of affective focal status epilepticus


Francesco Brigo , Monica Ferlisi, Antonio Fiaschi, Luigi Giuseppe Bongiovanni
Department of Neurological, Neuropsychological, Morphological and Movement Sciences, University of Verona, Verona, Italy

a r t i c l e

i n f o

Article history:
Received 20 September 2010
Revised 8 October 2010
Accepted 11 October 2010
Available online 16 November 2010
Keywords:
Affective focal status epilepticus
Electroencephalography
Fear

a b s t r a c t
Affective seizures consist of fear, depression, joy, and (rarely) anger. A correct diagnosis is often delayed as the
behavioral features, like fear, are interpreted as psychiatric disorders. We describe a patient with affective
focal status epilepticus (AFSE) in which fear was the only clinical manifestation. We present electroencephalographic correlates and discuss the diagnostic difculties that can be encountered in similar cases. AFSE
with fear as the only clinical expression may represent a diagnostic challenge. When fear is the only or the
prominent behavioral feature, seizures may be diagnosed as panic attacks, leading to erroneous therapy. In
such situations, electroencephalography is an essential tool in differentiating between psychiatric disorders
and epileptic events.
2010 Elsevier Inc. All rights reserved.

1. Introduction
Affective seizures consist of fear, depression, joy, and (rarely)
anger [1]. A correct diagnosis is often delayed because the behavioral
features, like fear, are interpreted as psychiatric disorders. Fear as an
ictal symptom was described by Hughlings Jackson in 1880, and is
usually associated with involvement of the amygdala [2,3] or anterior
cingulate and orbitofrontal regions [4]. Reported cases of status
epilepticus with fear as the only clinical expression are extremely rare
in the literature [57].
We describe a patient with affective focal status epilepticus (AFSE)
for whom fear was not a vague feeling but was the only clinical
manifestation. We present electroencephalographic correlates and
discuss the diagnostic difculties that can be encountered in similar cases.
2. Case report
A right-handed 60-year-old woman was brought to the emergency
room of our hospital by her husband, who was worried because of a
sudden change in her behavior. Over the preceding days, she had
experienced several episodes characterized by fear and anxiety that
lasted only a few minutes. On the morning of the day she was brought
to the emergency room, the patient had another episode of fear that
lasted much longer than the previous episodes.
With respect to her past medical history, she had had a
hysterectomy for uterine prolapse. One year before her presentation
at the emergency room, she had been diagnosed with a B-cell nonHodgkin's primary cerebral lymphoma in the right parietal region. She
Corresponding author. Department of Neurological, Neuropsychological, Morphological and Movement Sciences, University of Verona, Piazzale L.A. Scuro, 37134 Verona,
Italy. Fax: + 39 0458124873.
E-mail address: dr.francescobrigo@gmail.com (F. Brigo).
1525-5050/$ see front matter 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.yebeh.2010.10.011

underwent surgical removal of the tumor 1 month later and then


received chemotherapy (methotrexate and cytarabine) and adjuvant
radiotherapy (36 Gy + 9 Gy). She was also taking levetiracetam
(2000 mg/day) as antiepileptic treatment because she had had a
generalized tonicclonic seizure a few days before cerebral surgery;
nobody witnessed this seizure, which was not preceded by any auras
with localizing value.
On clinical examination she appeared afraid and continuously
complained about her physical conditions. Her facial expression
suggested fear; she was weeping and did not want to be left alone. She
was nevertheless oriented to person, place, and time. The neurological
examination was normal excepted for mild left hemiparesis. There
were neither limb nor oroalimentary automatisms, and no posturing,
rotation, or clonic movements. Routine laboratory data were normal.
The ECG revealed tachycardia (125 bpm).
The physician who rst saw the patient interpreted her symptoms
as a psychiatric disturbance, panic attacks, although the condition
persisted much longer (several hours) than panic attacks. Because of
her previous cerebral pathology, a decision was made to obtain an
EEG. Unexpectedly, the EEG recording showed continuous, rhythmic
2.5-Hz spikewave activity lateralized to the right with maximal
amplitude in the right parietotemporal region (Fig. 1A). The onset of
such paroxysmal activity was not recorded. The EEG was recorded for
20 minutes before administration of a benzodiazepine. Four milligrams of intravenous lorazepam rapidly decreased (Fig. 1B) and then
stopped the epileptiform EEG abnormalities except for paroxysmal
discharges in the right parietotemporal region. Twenty minutes after
lorazepam administration, the patient was awake and alert, showing
no appreciable mental or emotive disturbances. When questioned
postictally, she did not express fear, but remembered having
experienced fear. The interictal EEG showed polymorphic irregular
theta sequences over the right parieto-temporo-occipital region
(Fig. 2).

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F. Brigo et al. / Epilepsy & Behavior 20 (2011) 107110

Fig. 1. (A) Continuous, rhythmic 2.5-Hz spikewave activity lateralized to the right, with maximal amplitude in the parietotemporal region. Sensitivity: 10 V/mm; TC 0.1 second;
HF: 30.0. (B) Attenuation of epileptiform discharges after intravenous administration of lorazepam. Note the phase reversal on T6. Sensitivity: 10 V/mm; TC 0.1 second; HF: 30.0.

F. Brigo et al. / Epilepsy & Behavior 20 (2011) 107110

109

Fig. 2. Interictal EEG revealing polymorphic irregular theta sequences in the right parietotemporal region.

Brain MRI revealed signs of previously performed surgery in the right


parieto-occipital region. T2-weighted scans showed a porencephalic
lesion with altered signal in that region. Similar ndings in the right
frontal lobe, anterior to the rolandic ssure, were suggestive of
vasogenic edema. After administration of gadolinium, a focus of
enhanced signal in the pons, right of the middle line, was detected.
These MRI ndings ruled out a recurrence of tumor in supratentorial
regions. Lumbar puncture results were normal, except for the presence
of some reactive CD3+ lymphocytes unrelated to the lymphoma.
3. Discussion
Since Hughlings Jackson's rst description, fear had been recognized as an affective state that can occur during seizures. The
characteristics of ictal fear that suggest epilepsy as its cause are its:
sudden, usually unprovoked onset out of context; stereotypy;
association with other recognized epileptic clinical manifestations;
close temporal relationship to partial or generalized attacks; and the
associated specic EEG changes [8]. The diagnosis of fear as an
epileptic expression is often delayed because it is usually interpreted
as a psychiatric disorder [911].
There exist only a few previous reports describing status
epilepticus with fear as the only clinical expression [57]. The patient
we described had simple, not complex, AFSE, because she was fully
oriented and reactive, her cognition was not impaired, and postictally
she remembered having experienced fear.
It was difcult to recognize her symptoms as epileptic phenomena
because fear was the only clinical manifestation; the patient was
neither confused nor disoriented. Only the EEG recording allowed us
to diagnose an epileptic event. From a clinical point of view, there

were no features suggesting such a diagnosis. A clear correlation


between EEG abnormalities and behavioral changes was observed
because of the electroclinical response to intravenous administration
of a benzodiazepine. However, recurrence and clinical response to
intravenous administration of lorazepam alone cannot be considered
a useful diagnostic criterion for differentiating between panic attacks
and affective seizures, as they may occur in both situations. The EEG is
therefore paramount in differential diagnosis.
Our patient had had a generalized tonicclonic seizure previously,
but it was neither witnessed not preceded by any symptoms with
localizing value. It was therefore impossible to dene, only on a
clinical basis, the epileptogenic and symptomatogenic zones, although
probably they were located near the right parieto-occipital region
(where surgery was later performed). It was the AFSE with fear as the
only clinical feature that for the rst time allowed us to suggest that
both clinical features and EEG paroxysms were due to an epileptic
discharge probably originating from the right parietotemporal region
and subsequently spreading to the amygdalohippocampal region
(electroclinical correlation), although it was not possible to identify
with certainty the primary epileptogenic focus.
As demonstrated by this case, ictal fear may represent a diagnostic
challenge. It is necessary to keep a low threshold for EEG monitoring
in patients in whom the setting (brain lesion, previous tumor/surgery,
etc.) calls for vigilance. In such situations, electroencephalography is
an essential tool in differentiating between psychiatric disorders and
epileptic events.
Conict of interest statement
None of the authors has any conict of interest to disclose.

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F. Brigo et al. / Epilepsy & Behavior 20 (2011) 107110

References
[1] Blume WT, Lders HO, Mizrahi E, Tassinari C, van Emde Boas W, Engel Jr J. Glossary
of descriptive terminology for ictal semiology: report of the ILAE Task Force on
Classication and Terminology. Epilepsia 2010;42:12128.
[2] Glascher J, Adolph R. Processing of the arousal of subliminal and supraliminal
emotional stimuli by the human amygdale. J Neurosci 2003;23:1027482.
[3] Gloor P, Olivier A, Quesney LF, Andermann F, Horowitz S. The role of the limbic
system in experiential phenomena of temporal lobe epilepsy. Ann Neurol
1982;12:12944.
[4] Biraben A, Taussig D, Thomas P, et al. Fear as the main feature of epileptic seizures.
J Neurol Neurosurg Psychiatry 2001;70:18691.
[5] Henriksen GF. Status epilepticus partialis with fear as clinical expression: report of
a case and ictal EEG ndings. Epilepsia 1973;14:3946.

[6] McLachlan RS, Blume WT. Isolated fear in complex partial status epilepticus. Ann
Neurol 1980;8:63941.
[7] Zappoli R, Zaccara G, Rossi L, Arnetoli G, Amantini A. Combined partial temporal
and secondary generalized status epilepticus: report of a case with fear bouts
followed by prolonged confusion. Eur Neurol 1983;22:192204.
[8] Williams D. The structure of emotions reected in epileptic experiences. Brain
1956;79:2967.
[9] Thompson SA, Duncan JS, Smith SJ. Partial seizures presenting as panic attacks. Br
Med J 2000;321:10023.
[10] Huppertz HJ, Schulze-Bonhage A. Distinguishing between partial seizures and
panic attacks: epileptic panic attacks are not limited to adults. Br Med J 2001;322:
864.
[11] Hurley RA, Fisher R, Taber KH. Sudden onset panic: epileptic aura or panic
disorder? J Neuropsychiatry Clin Neurosci 2006;18:43643.