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.