An Evaluation of Depression, Anxiety Attacks, and Occasional Feelings of 'Unreality'

"In these stories, the identities and locations have been changed to ensure client confidentiality.”

 A 48 year old attorney was referred because he was suffering from depression and anxiety attacks that were getting worse despite taking antidepressant medication prescribed by his internist.  Three years prior to his coming into the office, this client suffered a concussion while he and a friend were performing maintenance on an antique sports car.  A hammer slipped from the friend’s hand and struck the client in the forehead.  The client received five stitches and was reported to have suffered a mild concussion.

Now three years later, in addition to the depression and the anxiety, he was having “spells” and was referred to a neurologist.  The neurology work-up revealed a normal EEG and a normal neurologic exam.  The client was referred to a psychologist for treatment of “anxiety or panic attacks.”  The psychologist did not feel the presentation was typical for panic disorder and referred the client for a psychiatric evaluation.

A careful history by the psychiatrist revealed that approximately one year after the injury, the client began to have subtle and mild episodes of altered consciousness that would occur up to 3-4 times a day, lasting 10-15 seconds. These episodes were described by others as follows:  he would suddenly gaze off into space, his face would “look funny,” he looked like he might begin to weep,  would rub his thighs and turn his head.  The client described that at times he had the feeling that things got out of focus and he would have “feelings of unreality.”  These episodes of confusion were followed up by feeling “shaky” and having a “heavy heartbeat.”  The episodes were so brief and subtle that they had never been properly addressed prior to the careful psychiatric history. Because of the history of mild concussion, and the constellation of symptoms with which he presented, a recommendation was made for anticonvulsant (anti-seizure)  treatment that would also improve his depression. 

The client was placed on Lamictal.  All symptoms went away after two months of treatment.