Functional (psychogenic non-epileptic) seizures

Red Flags

Concurrent epilepsy and functional seizures (≈10–30% co-occurrence) — both conditions need diagnosis and tailored management; do not assume single diagnosis^[1]
Suicidal ideation, severe trauma history, or active dissociation — joint psychiatry and neurology; safety planning before any provocative testing^[1]
Status-like episodes lasting hours with normal vital signs and EEG — PNES status; admit for safety, avoid intubation if not needed, prevent iatrogenic harm^[1]
ASM polypharmacy without epilepsy diagnosis — adverse effects, cost, and false reassurance; specialist-led withdrawal indicated^[1]

First-line treatment

Interventions

Clear diagnosis communication^[1]
Use a specific positive diagnosis (functional seizures or PNES); explain it as a real and treatable disorder; involve the patient and family from the start; written take-home material; affirm that this is not 'fake' or 'in your head'
Withdraw unnecessary antiseizure medication^[1]
Specialist-led graded withdrawal of ASMs prescribed without epilepsy; faster taper than for epilepsy because safety risk is iatrogenic adverse effects, not seizure recurrence; document re-evaluation plan
Cognitive behavioural therapy adapted for PNES^[1]
First-line specific psychological treatment; 12–16 sessions; address triggers, dissociation, anxiety; self-management techniques; group or individual; outcomes equivalent at 12 months
Adjunctive therapies — psychoeducation, mindfulness, family work^[1]
Education about the brain-body connection and stress-related mechanisms; family/caregiver involvement; address school/work accommodations; physiotherapy where functional motor symptoms co-exist
Treat coexisting psychiatric conditions^[1]
SSRIs for comorbid depression or anxiety; trauma-focused therapy for PTSD; substance use disorder treatment; involve psychiatry as long-term partner
Avoid acute pharmacological 'treatment' of episodes^[1]
Do NOT routinely give benzodiazepines, intubation, or aggressive resuscitation for non-injurious functional seizure episodes; minimise iatrogenic harm; staff training in functional seizure response protocols

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
SSRI (sertraline, fluoxetine, escitalopram)^[1]	Selective serotonin reuptake inhibitor	Sertraline 50 mg PO daily start, titrate to 100–200 mg; fluoxetine 20 mg PO daily; escitalopram 10–20 mg PO daily	Sertraline ≥6 years 25 mg start; fluoxetine ≥8 years 10 mg start	First-line for comorbid depression or anxiety; review after 4–6 weeks; warn about activation in first 2 weeks; combine with psychological therapy not as substitute

SSRI (sertraline, fluoxetine, escitalopram)^[1]

Selective serotonin reuptake inhibitor

Adult: Sertraline 50 mg PO daily start, titrate to 100–200 mg; fluoxetine 20 mg PO daily; escitalopram 10–20 mg PO daily
Paediatric: Sertraline ≥6 years 25 mg start; fluoxetine ≥8 years 10 mg start

First-line for comorbid depression or anxiety; review after 4–6 weeks; warn about activation in first 2 weeks; combine with psychological therapy not as substitute

Safety-net

Avoid hospital admissions and ITU stays for non-injurious episodes — they reinforce the disorder; have a written safety plan^[1]
Engage actively in psychological therapy — outcomes are best when patient is the partner in care, not a passive recipient^[1]
Inform every clinician you see about the functional seizure diagnosis to avoid repeat unnecessary investigations and ASM prescriptions^[1]

Referral criteria

All suspected functional seizuresNeurology with access to video-EEG and psychology^[1]
Coexisting epilepsy and functional seizuresJoint epilepsy and PNES specialist clinic^[1]
Severe psychiatric comorbidity, suicidality, or dissociative symptomsPsychiatry liaison and crisis team^[1]
Failed first-line CBT or treatment-resistantTertiary functional neurological disorders centre^[1]

Clinical summary

Diagnosis, communication, and management of functional seizures, with emphasis on psychological treatment and rationalising antiseizure medication.

References

1.AAN Practice Guideline Executive Summary: Management of Functional Seizures (2026); ILAE PNES Task Force Position Paper (2026)