Version July 2025
INTRODUCTION —
Functional seizures, also known as psychogenic nonepileptic seizures (PNES), are nonepileptic events resembling seizures or syncopal attacks. The management and prognosis of functional seizures are discussed in this review. The etiology, epidemiology, clinical manifestations, and diagnosis of functional seizures are reviewed separately. (See "Functional seizures: Etiology, clinical features, and diagnosis".)
Other nonepileptic paroxysmal disorders are discussed elsewhere. (See "Nonepileptic paroxysmal disorders in adolescents and adults".)
CLINICAL MANIFESTATIONS AND DIAGNOSIS —
The etiology, epidemiology, clinical manifestations, and diagnosis of functional seizures are reviewed here briefly and discussed in detail separately. (See "Functional seizures: Etiology, clinical features, and diagnosis".)
●Functional seizures are events thought to have mainly psychologic origins. They clinically mimic epileptic seizures or syncope but are not associated with abnormal neuronal activity, epileptiform activity on EEG, or reduced perfusion to the brain. (See "Functional seizures: Etiology, clinical features, and diagnosis", section on 'Etiology'.)
●Functional seizures include a variety of clinical manifestations, some of which are suggestive, although not independently diagnostic, in distinguishing functional seizures from other diagnoses (table 1A-B). (See "Functional seizures: Etiology, clinical features, and diagnosis", section on 'Clinical manifestations'.)
●The diagnosis of functional seizures is generally established by video-electroencephalography (EEG) monitoring, in which captured clinical events are examined in conjunction with EEG activity. Other tests (interictal EEG, neuroimaging, and laboratory studies) are used primarily to investigate alternative etiologies and are not diagnostic of functional seizures. (See "Functional seizures: Etiology, clinical features, and diagnosis", section on 'Diagnostic evaluation'.)
EXPLAINING THE DIAGNOSIS
Challenges — Presenting the diagnosis of functional seizures to patients can be challenging and should not be done until the diagnostic evidence is as conclusive as it can be [1,2]. (See "Functional seizures: Etiology, clinical features, and diagnosis", section on 'Diagnostic evaluation'.)
Published strategies for communicating the diagnosis of functional seizures to patients [3-7] have elements in common. Adverse responses do occur, including anger (which may be prognostically bad) [8,9] and exacerbation of events [8,10]. What the content of the conversation is will depend on what tests have been carried out, what interventions are proposed, and other factors.
Our approach — The following scheme approximately summarizes the author's practice. Note that while causes are mentioned in a general way, no questions regarding causes specific to the patient are asked at this early stage.
●Go through the description of the events with the patient and caregiver, confirm that the recorded events are the same as the habitual event, and clarify whether any other event types have occurred. For example, some validation of the alarming and disruptive effect of the attacks on the patient and caregiver may be helpful here.
●Explain how electroencephalography (EEG) works and how the recording of events has led to the diagnosis.
●Explain that the events may be related to emotional or psychological issues, or to past or present factors in the patient's life, but are not due to a medical condition, specifically not epilepsy.
●Volunteer potential causes, being clear that "specimen" causes (ie, examples) are being discussed.
●Volunteer that this type of event is seen commonly and happens to ordinary people.
●Volunteer that you understand that the events are not under conscious control, but that patients can learn to control them.
●Volunteer that while patients may have high levels of anxiety or have low mood, the events are not associated with psychiatric illness, and that you do not consider that the patient is "crazy."
●Explain that the events are not amenable to drug treatment, but that psychological intervention is used. Describe what psychological intervention is likely to consist of.
Therapeutic implications — One striking characteristic of functional seizures as a disorder is that a significant minority of patients, varying from 17 to 40 percent [1,5,10-17], stop having events on delivery of the diagnosis. The evidence for this is observational, though examination of the timing of cessation of events suggests that the delivery of the diagnosis is causal [18]. There is also convincing evidence that some aspects of health care utilization improve (ie, demand for health services is reduced) with communication of the diagnosis [19-21], even in those patients in whom the functional seizures themselves do not abate [10]. This includes emergency health care. We have no good information on what aspects of the diagnosis conversation are likely to be the most therapeutic. In this regard, it is striking that the study with the lowest remission rate [5] also found that their information was rated by patients as highly acceptable and understandable.
FOLLOW-UP
Continued neurology involvement — Neurologic follow-up, preferably with an epilepsy specialist, is required for all patients with both functional seizures and epileptic seizures [22]. It is also required for patients with a diagnosis of "functional seizures only" to monitor the safe withdrawal of antiseizure medications, answer patient questions, and reinvestigate if new events appear.
Coordination among clinical caregivers — Maintenance of communication among neurologic, psychiatric, and primary care clinicians is required for optimal care of patients with functional seizures. This communication minimizes the potential for mixed and conflicting messages from different clinicians that may contribute to poor outcome [8].
The neurologist can be regarded as the "guardian" of the diagnosis of functional seizures. Patients who have been diagnosed with functional seizures may express a lack of understanding of the diagnosis, despite a thorough diagnostic discussion that the patient reported to have understood at the time [8,23]. Patients may also report new and different events or may describe new symptoms to the psychologist or psychiatrist that cause diagnostic concern. In these circumstances, it is advised that the psychologist or psychiatrist suspend treatment (which will not, in any event, make progress while there is diagnostic doubt in the mind of the patient, relatives, or the clinician) and promptly send the patient back to the neurologist for further explanation or evaluation. Criteria for this step should be agreed upon beforehand as part of a management plan. Some experts advise that patients with functional seizures only (no epilepsy) should not be discharged from the neurologist's care until the patient, family, and caregivers accept the fact that the patient does not have epilepsy; neurologic care can then be discontinued once patient has safely withdrawn from antiseizure medication and has fully transitioned to psychologic or psychiatric care [2,24]. However, offering follow-up to patients who are completely unwilling to accept the diagnosis is counterproductive, in our experience, as it undermines the "no epilepsy" part of the diagnostic message. It is also our experience that when patients do not accept the diagnosis, they are often unwilling to attend follow-up in any event.
Withdrawal of antiseizure medication — For patients on antiseizure medication who have a diagnosis of functional seizures only (ie, no epilepsy), antiseizure medication should be gradually withdrawn [4]. The perceived risk of uncovering an unrecognized controlled epilepsy will vary from patient to patient. One study found that in patients with the following characteristics, the risk of an emerging epilepsy on withdrawal was low [25]:
●All current types of events described by patient and eyewitnesses recorded and identified as functional seizures
●No descriptions of past events raising suspicion of epilepsy rather than functional seizures
●No history of events during childhood
●No interictal epileptiform abnormalities on electroencephalography (EEG)
The highest risk for seizure relapse in patients was within the initial several months after discontinuation of antiseizure medication therapy [25]. Therefore, supervision of withdrawal should be close during this period, and patients should be advised to report any events different from the recent (diagnosed as functional seizures) events. Any such events may have to be recorded on video EEG, which combines extended EEG monitoring with time-locked video acquisition that allows for analysis of clinical and electrographic features during a captured event. (See "Functional seizures: Etiology, clinical features, and diagnosis", section on 'Video-EEG monitoring'.)
There is a tendency for physicians who diagnose patients with functional seizures only to leave them on antiseizure medications "just in case" of an underlying epilepsy. However, leaving a patient on antiseizure medications tends to undermine a "functional seizures only" diagnostic message and makes therapy difficult, while continuing to expose the patient to the risk of antiseizure medication side effects. Early withdrawal of antiseizure medications may be associated with some benefits, including decreased use of rescue antiseizure medication treatment, less emergency health care utilization, and higher employment rates at 18 months [26].
Neuropsychological testing and psychiatric evaluation — Psychometric testing can be helpful in identifying or defining cognitive deficits (eg, low intelligence quotient, poor executive function) that might guide or impact the success of interventions. A broader neuropsychological assessment can also identify comorbidities requiring treatment in themselves, such as anxiety and depression, and can identify potential causal factors and targets for intervention [27]. Psychiatric evaluation can elicit clinical features that may establish a diagnosis of depression, anxiety, somatic symptom disorder, a dissociative disorder, and other disorders [4,28-31]. Psychological or psychiatric evaluation may establish rapport that allows disclosure of traumatic events, which may be targets for intervention. (See "Functional seizures: Etiology, clinical features, and diagnosis", section on 'Psychopathology'.)
What is done in practice often reflects local availability of services and the willingness of patients to be referred. We offer psychologic or psychiatric referral and would refer for psychometric testing if a relevant cognitive deficit is suspected.
INTERVENTIONS
Psychotherapy — Although some patients stop having events on being given the diagnosis of functional seizures (see 'Therapeutic implications' above), many continue to do so and require treatment. Psychotherapies are the mainstay of treatment, delivered by a psychologist or psychiatrist.
●Cognitive behavioral therapy – Cognitive behavioral therapy (CBT) is a widely used brief psychosocial intervention that is composed of a variety of therapeutic approaches. Observational case series and small randomized trials suggested that CBT might be helpful in reducing seizures and improving psychosocial functioning [32-36]. However, a reasonably large randomized trial of 368 patients found that a functional seizures-specific CBT approach was not effective in reducing event frequency or severity [37]. Some secondary outcomes, such as quality of life, psychosocial functioning, and others were significantly better in the treatment arm, suggesting that CBT may nonetheless have some non-seizure-specific benefits.
●Mindfulness-based therapy – Mindfulness-based therapy (MBT) may be beneficial for patients who have functional seizures, but data are sparse. Basic elements of mindfulness meditation include self-regulation of attention and taking a nonjudgmental stance towards one's experience. One observational study enrolled 49 patients with functional seizures in a 12-session MBT program [38]. At study conclusion, the 12-session program was completed by 26 patients; in this group, a 50 percent or greater reduction in the frequency of functional seizures was self-reported by 70 percent, and remission of functional seizures was reported by 50 percent. The high drop-out rate limits the strength of these findings. (See "Complementary and alternative treatments for anxiety symptoms and disorders: Physical, cognitive, and spiritual interventions", section on 'Mindfulness meditation'.)
●Traditional psychotherapy – Traditional psychotherapy has been used in patients with functional seizures with mixed success [16,39,40]. Group therapy sessions also employ traditional psychodynamic or psychoeducational techniques, and small observational studies have reported decreased episode frequency and/or improvement in psychosocial comorbidities in some patients with functional seizures [41-45]. The high prevalence of family problems in patients with functional seizures suggests that family-related interventions may be useful, but these have not been systematically studied [46].
●Psychodynamic interpersonal therapy – Psychodynamic interpersonal therapy is an alternative form of psychotherapy. In a case series of 47 patients with functional seizures, this intervention was associated with seizure remission in 25 percent and a >50 percent seizure reduction in 40 percent [47].
Response to psychiatric or psychological interventions is variable [4,48]. Interventions are often individualized according to the underlying psychiatric diagnosis (or psychological formulation). We have used a "toolbox" approach, whereby initial triage identifies issues that are thought to be causative, and a therapy type or types is chosen accordingly. As an example, when social factors predominate in causing or maintaining functional seizures, then family therapy, interpersonal therapy, or social interventions may be used, whereas where reaction to past trauma is prominent, mindfulness, counseling, and acceptance and commitment therapy might be used [27]. Whatever approach is taken, treatment recommendations are mostly based upon clinical experience and the results of observational studies; there have been few randomized treatment trials for functional seizures [34].
The evaluation of talking therapies (ie, psychotherapies) in functional seizures is challenging. Patients tend not to agree to take part in trials and may comply poorly with trial protocols. Trial design can also be challenging: the choice of control intervention can be difficult, and the opportunity for blinding is limited. The psychiatric conditions associated with or underlying functional seizures are variable [1], and the relevance of subgroup issues to treatment choice is not well understood. All these factors limit the quantity and quality of evidence available for evaluation of therapies.
Barriers to effective treatment of functional seizures patients also include unwillingness to accept a psychological diagnosis or attend therapy, poor compliance, financial and insurance-related limitations, and difficulty finding psychiatric and psychological clinicians who are experienced and comfortable with treating functional seizures.
Role of pharmacotherapy — We do not treat functional seizures using pharmacotherapy. Antidepressants and anxiolytics may be prescribed on an individualized basis but have had mixed results in open-label studies of functional seizures [41,49,50]. In a pilot study, 38 patients with functional seizures were randomly assigned to treatment with flexible-dose sertraline or placebo [51]. Active treatment was associated with a nonsignificant reduction in frequency of functional seizures. Another pilot study found no benefit of sertraline except when combined with CBT [34].
Patients with both functional seizures and epilepsy may be on inappropriately high doses of antiseizure medication (ASM). Differentiating epileptic seizures and functional seizures so that ASMs can be titrated against ES only can be challenging. However, a retrospective study of 139 patients with dual diagnosis found that safe reduction of ASM was possible in 44 [52].
DRIVING SAFETY —
There are few data regarding driving safety in patients with functional seizures, and the little available evidence has not demonstrated that patients with functional seizures are at increased risk of motor vehicle crashes [2,53-56].
However, patients often report that their events are sudden and unpredictable, and in some territories (including New Zealand), this mandates a stand down from driving independent of diagnosis. We advise three months free of events before driving can resume. Guidance that follows a more individualized model has been published in the form of an International League Against Epilepsy Task Force report [57]. The foregoing applies when the diagnosis of functional seizures is confirmed and there is confidence that there is not a comorbid epilepsy.
PROGNOSIS —
The prognosis for patients with functional seizures is guarded. Many patients will continue to have functional seizures after diagnosis and treatment. Even patients whose functional seizures cease may have substantial psychiatric morbidity and functional limitations long term.
●Seizure freedom – Most studies that have assessed the prognosis in patients diagnosed with functional seizures suggest that only a minority (25 to 38 percent) of patients achieve seizure freedom [8,10,14,28,58-60]. While some evidence suggests that children and younger people do better [61-65], this evidence remains inconsistent, possibly due to smaller study size and other methodologic issues.
●Psychiatric and psychosocial status – While outcome is often reported as a percent of those with seizure remission, this narrow measure does not necessarily reflect the overall clinical outcome with respect to psychiatric and psychosocial status [28,32,58,66]. As an example, in one study, 56 percent of patients overall continued to depend on state-supported financial benefits at four years after diagnosis of functional seizures [28,58]. The percentage was lower, but still substantial (43 percent), among those in episode remission. Other studies have also found that occupational status, while more likely to improve if functional seizures cease, often does not improve, even when episodes remit [67,68]. Some studies suggest that psychosocial issues and depression, rather than persistent functional seizures, are more directly related to disability and reduced quality of life [32,69].
●Risk of suicide – Both attempted and completed suicides have been reported in some series with follow-up [32,67,70]. In one of these cohorts, suicide attempts were equally frequent (11 of 56 patients overall) in those with or without seizure remission [67].
●Mortality – Several studies suggest that there may be a modest increase in premature mortality in patients with functional seizures [71-73]. One study found that much of this can be attributed to comorbidity and suicide [73].
●Development of new complaints – Some patients may develop new somatic complaints after remission of functional seizures, especially headaches [74]. Other studies suggest that development of new somatic complaints is uncommon and similarly frequent in those with persistent functional seizures versus functional seizures in remission [14,75].
●Predictors of outcome – Many cohort studies have examined potential predictors of outcome, generally focusing on seizure outcome. The results of this exercise have been quite variable and may be affected by the compositions of cohorts, the datasets, methods of analysis, and other factors. Some factors inconsistently associated with a worse prognosis include [3,10,12,14,24,28,39,59,67,76-79]:
•Longer duration of symptoms
•Older age at onset
•Lower educational level, lower intelligence quotient
•More isolation, more limited family support
•Dependent lifestyle
•No formal treatment plan
•Unrelieved stressors (eg, ongoing abuse, family conflict)
•Anger, rejection of functional seizures diagnosis
•More severe underlying psychiatric disorder, especially severe or generalized somatization or dissociative symptoms
There is no consistent association between clinical semiology (ie, the clinical features of a seizure including subjective symptoms and objective signs [80], which may in any event change with time [12,81]) and prognosis [79,82].
SUMMARY AND RECOMMENDATIONS
●Functional seizures, also known as psychogenic nonepileptic seizures (PNES), are events thought to have mainly psychologic origins. Functional seizures include a variety of clinical manifestations, some of which are suggestive, although not independently diagnostic, in distinguishing functional seizures from other conditions in the differential diagnoses (table 1A-B).
The diagnosis of functional seizures is generally established by video-electroencephalography (EEG) monitoring. The clinical features and diagnosis of functional seizures are reviewed in detail separately. (See "Functional seizures: Etiology, clinical features, and diagnosis".)
●The diagnosis of functional seizures, once established, should be presented to patients and their families in a supportive, nonjudgmental fashion. (See 'Explaining the diagnosis' above.)
●In patients with a diagnosis of functional seizures only (ie, no epilepsy), antiseizure medications should be gradually withdrawn, with appropriate supervision. (See 'Withdrawal of antiseizure medication' above.)
●Neurologic follow-up should be maintained after a diagnosis of functional seizures to monitor the safe withdrawal of antiseizure medications, answer patient questions, reinvestigate if new events appear. (See 'Follow-up' above.)
●There is little evidence for any treatment for functional seizures. Psychological intervention is mainly used, including CBT approaches. Evidence from a randomized trial found no benefit of CBT for seizure events, but some benefit for non-seizure outcomes. (See 'Psychotherapy' above.)
●Pharmacotherapy is not effective for functional seizures but should be used as indicated to treat psychiatric comorbidity. (See 'Role of pharmacotherapy' above.)
●The prognosis for patients with functional seizures is guarded. Many patients will continue to have functional seizures after diagnosis and treatment. Even patients whose functional seizures cease may have substantial psychiatric morbidity and long-term functional limitations. (See 'Prognosis' above.)
ACKNOWLEDGMENTS —
The UpToDate editorial staff acknowledges David K Chen, MD, who contributed to earlier versions of this topic review.
The editorial staff at UpToDate would also like to acknowledge Alan Ettinger, MD, MBA, who contributed to an earlier version of this topic review.
