Abstract
<title>Abstract</title> <p> <bold>Background:</bold> Ictal fear and panic attacks may share closely overlapping affective, autonomic, and somatic manifestations, creating a substantial diagnostic challenge. Focal aware seizures, particularly those arising from mesial temporal and limbic regions, can therefore be mistaken for panic disorder. Recurrent, stereotyped panic-like episodes that remain refractory to adequate psychiatric treatment should prompt reconsideration of the initial diagnosis and assessment for possible neurological causes. <bold>Case Presentation</bold> : We present a case of a man in his twenties presented with a two-year history of abrupt, recurrent panic episodes lasting few minutes consisting of shortness of breath, chest heaviness, tingling sensation in extremities and sense of impending doom. Various anxiolytics were tried; however, no improvement was noted subjectively nor on objective scales. Secondary depressive symptoms developed during treatment which was managed successfully with antidepressants. The patient eventually became benzodiazepine dependent but remained refractory to adequate treatment trials. Neuroimaging and a routine electroencephalography performed previously were within normal limits. However, given the limited sensitivity of a standard interictal EEG and the unavailability of prolonged video-EEG monitoring because of financial constraints, the diagnosis was reassessed. A probable focal seizure disorder was suspected on clinical grounds, and an empirical trial of anti-seizure medication was initiated. The patient showed marked improvement within one week, with near-complete resolution of the episodes within two weeks. <bold>Conclusion:</bold> This case highlights the importance of revisiting the diagnosis and assessing for any underlying organic causes as the initial step before the final step of labelling any case as treatment resistance. Abrupt, stereotyped, recurrent panic-like episodes that persist despite appropriate psychiatric treatment warrant diagnostic reassessment before being labelled treatment-resistant panic disorder. Normal neuroimaging and routine interictal EEG do not exclude focal epilepsy. Although the marked response to levetiracetam strengthened the clinical suspicion of focal aware seizures in this case, treatment response alone is not diagnostic, and electroclinical confirmation with prolonged video-EEG remains necessary. </p>