Functional/dissociative seizures …

Wesley T Kerr MD PhD

Epilepsy & Seizures

Updated 03.11.2026
Released 07.26.1994
Expires For CME 03.11.2029

Functional/dissociative seizures

Author: Wesley T Kerr MD PhD

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Editor: John M Stern MD

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Functional/dissociative seizures

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Introduction

Overview

The term “functional/dissociative seizures” refers to seizures that are associated with an increased connection between limbic or emotional brain areas and higher-level motor networks. Most commonly, but not exclusively, these seizures are associated with biopsychosocial stressors and are not caused by epileptic abnormality. Clinicians can choose to use either functional seizures, dissociative seizures, or both. The previously used terms “pseudoseizures” and “psychogenic nonepileptic seizures” were felt to be confusing, misleading, offensive, and potentially harmful by patients with the condition.

Functional seizures often challenge even experienced epilepsy experts in their diagnosis because of their behavioral overlap with epileptic seizures, their potential co-occurence with epilepsy, and the limited quality of patient and witness descriptions of seizures. Once diagnosed, they pose the additional challenges of understanding their cause and providing effective treatment. In this review, the fundamental clinical aspects of functional seizures are surveyed, including issues of differential diagnosis, prognosis, and management.

Key points

	• Functional seizures may appear similar to epileptic seizures and often result in misdiagnosis as epilepsy.
	• Functional seizures are involuntary and often disabling.
	• Accurate and early diagnosis of functional seizures leads to more appropriate and effective healthcare resource utilization.
	• With neurobehavioral targeted towards functional seizures, roughly 80% of patients will have a greater than 50% reduction in seizure frequency and improvement in quality of life.
	• Functional seizures should not be treated as epileptic seizures. Antiseizure medications with psychotropic effects can treat psychiatric comorbidities in patients with functional seizures but are not recommended as first-line treatments.
	• Benzodiazepines or other pharmaceutical rescue medications are not recommended for functional seizures, except in uncommon situations.

Historical note and terminology

In 2025, the International League Against Epilepsy completed a 5-year effort to address terminology choices (65). In academic writing, the term functional/dissociative seizures is preferred. In clinical practice, clinicians can choose between functional seizures, dissociative seizures, or a mixture of those terms. This consensus statement aimed to address the substantial debate and strong disagreement regarding the appropriate and sensitive terminology regarding patients’ events. This debate intensified in 2020 (10; 11; 15; 82; 150). Although inaccurate and offensive terminology is widespread, the goal of this terminology is to reduce the real harm caused by older terms to the therapeutic relationship between patient and provider, especially in the emergency setting (127). Current work aims to evaluate if migrating terminology to these new terms improves the iatrogenic stigmatizing behavior, or if the iatrogenic stigma also migrates with the terminology.

The term “functional seizures” unifies the condition with the broader category of functional neurologic disorders, including functional tremor, functional weakness, and functional cognitive disorders.

Although we chose to use the term functional seizures for almost all patients, the term “dissociative seizures” is appropriate because during events, the patient’s physical movements or mental status dissociate from conscious control. This descriptor can be helpful in patients with PTSD and other dissociative experiences. However, there was concern in the United States about the stigma attached to dissociative identity disorder.

Each of the following phrases is typically used and acceptable for clinical practice:

• Functional seizures
• Dissociative seizures
• Functional neurologic disorder with seizures or attacks (ICD-10 F44.5)

In our clinical practice, we emphasize that these terms describe seizures not caused by epilepsy, otherwise known as “nonepileptic.” However, the term “nonepileptic” is not needed in the name of the condition. To draw an analogy to headaches, tension headaches are not called nonmigrainous headaches. In cases where a psychiatric etiology is resisted, the general term “nonepileptic seizures” can be used, but this introduces another possible inaccuracy by technically including episodes that are not functional but manifest similarly as a mimic of epilepsy (eg, convulsive syncope).

Prior to this statement in 2025, the recommended term was any of the following terms, but these were offensive to as many as one in four patients with the condition (139; 138).

• Psychogenic nonepileptic seizures
• Psychogenic nonepileptic attacks
• Psychogenic nonepileptic attack disorder

Some patients and a minority of providers consider “psychogenic” a pejorative term because it is connected to the stigma of psychological disease. It also emphasizes the psychological contributors to the condition, which is a barrier to recognition of the broader biopsychosocial contributors. In addition to psychological contributors, there are also biological factors (eg, concussion, epilepsy) and social factors (eg, ongoing abuse, financial strain due to unemployment without disability).

The discussion regarding the noun balances the assumed interpretation of the word “seizure” with the nonspecific nature of the terms “attack” or “events.” Although both providers and the lay public tend to understand a seizure as an epileptic seizure, the Greek word originally means “to take hold.” By removing the term “seizure,” one can clearly express that antiseizure medication should not be used to treat them. However, the patient’s lived experience of the events is similar to seizures, and untrained observers describe the events as seizures, so changing the term would constantly challenge the patient’s understanding of how to describe the events; also, the terms “events” or “attacks” diminish the severity of the term and are nonspecific. Additionally, as LaFrance discussed, many patients with functional seizures have been attacked physically, sexually, and emotionally, and the seizures are very different from these original attacks, so the term “attacks” is less desirable (89; 76). Yet another alternative includes “convulsions,” which does not describe the substantial population of patients with nonmotor psychogenic nonepileptic seizures (08).

The discussion regarding the descriptor focuses on choosing a term that highlights the appropriate psychiatric mechanism while not offending patients. The terms “hystericoepilepsy” and “pseudoseizure” are both offensive to patients and not appropriate descriptors because these seizures are not a subtype of epilepsy, and they are not “fake” or “false” (138). Instead, they are a different diagnosis and markedly disabling to the patient. We highly discourage the use of these terms. Similarly, we highly discourage describing epileptic seizures as “true” or “real.” The previous term of “psychogenic” was a corollary of “epileptogenic,” which describes the brain abnormality that is necessary and sufficient for the occurrence of epileptic seizures. However, the root word of “psycho” can make the patient feel as though they are labeled as a “psycho” in lay terms and is similar in its offensiveness to pseudoseizures in patient surveys (138). “Functional” is a neutral term that does not offend as commonly, but is a code word without much meaning, and does not match the dysfunction caused by the seizures. In contrast, the terms “dissociative” and “conversion disorder” have specific definitions in psychiatry and suggest psychiatric mechanisms that have yet to be established. The ICD-10 and DSM-5 classify functional seizures under conversion disorder and no longer require identification of a stressor causing the events because, in about 10% to 15% of patients, a stressor cannot be identified. This nosology reflects how functional seizures do not fit under the subtypes of dissociative disorders in the DSM-5.

The descriptor “nonepileptic” can be used instead of or in addition to the descriptors above. In patients resistant to the stigma of psychiatric disorders, the nonspecific term “nonepileptic seizures” can maintain the therapeutic alliance while also motivating acute removal of antiseizure medication prior to discharge from video-EEG units, which may improve future outcomes (42). In our opinion, the term nonepileptic seizures is unnecessarily vague because it does not adequately distinguish psychogenic nonepileptic seizures from physiologic nonepileptic seizures, including but not limited to convulsive syncope, complex migraines, movement disorders, parasomnias, or other paroxysmal events. Further, this equates to defining nonepileptic seizures by what they are not, which does not reflect the current understanding that functional neurologic disorders can be a positive diagnosis with clear associated factors. The concept that functional neurologic disorders is a diagnosis of exclusion may lead to delays in appropriate care and thereby worse outcomes (79; 83).

In general, we recommend choosing the terminology that the provider feels can be understood and accepted by the patient as descriptive of their seizures. Anecdotally, some patients have felt empowered when we involved them in the decision regarding how to describe their events.

Clinical manifestations

Presentation and course

Functional seizures are involuntary, intermittent events that resemble epileptic seizures but have an etiological association with a history of biopsychosocial stressors (26; 87). Those biopsychosocial stressors can include “big T Trauma” as well as contributors that may or may not be recognized as significant stressors. Functional seizures can have certain characteristic manifestations called “positive diagnostic signs” that help to differentiate them from epileptic seizures: duration longer than 5 minutes, asynchronous arrhythmic movements, waxing and waning intensity, spread or evolution based on patterns not aligned with neuronal organization, hip-thrusting, high seizure frequency, non-stereotyped seizure manifestations, ictal psychotic hallucinations, closed eyes, and pre-ictal headache (75; 106). Although other descriptors of behavior have been described, the following occur less often: gradual onset, asymmetrical thrashing movements of the limbs and side-to-side head movements (rather than bilaterally symmetrical tonic-clonic movements), opisthotonic posturing, lack of stereotypic pattern, talking or screaming throughout the seizure, weeping, prolonged bilateral involvement without impairment of consciousness, sudden return to consciousness following a prolonged generalized seizure, and resolution with whispering or rapid and non-stertorous breathing (25; 155; 29; 134; 128).

Functional seizure

This 61-year-old woman presented with acute onset pelvic thrusting simulating generalized tonic-clonic seizures. There is slight opisthotonic posturing without impairment of consciousness. The patient demonstrated sudden return...
Functional seizures with dystonic posturing enhanced by suggestion

This young woman experiences functional seizures, including severe dystonic and other movements and postures induced by suggestion, indicative of a functional neurologic disorder. (Contributed by Dr. Joseph Jankovic.)

Functional seizures can mimic epileptic ictal events exactly, including pupillary dilation, urinary and fecal incontinence, tongue-biting, Babinski responses, and even bodily injury due to events that occur during an episode (97; 75).

However, ictal events that appear not to respect conventional understanding of neuroanatomical correspondences or have highly unusual features, including those previously mentioned as typical of functional seizures, can occasionally be epileptic (132; 113). Patients and witnesses also may be no more accurate than chance at recalling details of the seizures (141; 142). Consequently, it can be extremely dangerous to make a diagnosis of functional seizures based on description or observation of the ictal event alone (13; 91). We find that patients report of a large list of comorbidities, especially migraines, chronic pain, and asthma; many medications for those conditions and other historical factors (eg, concussion, older age of onset, and major psychological trauma including sexual abuse) may be at least as helpful as descriptions of ictal behavior (77; 76). To assist clinicians in differentiation, multiple likelihood scores to differentiate functional seizures from epilepsy have been developed using a limited number of questions (78; 151; 157), including the functional seizures likelihood score.

Studies show that neurology trainees and internal medicine physicians have an area under the receiver operating characteristic curve (AUC) of around 75% when distinguishing between functional seizures and epileptic seizures using video recordings without EEG (135). Although videos of seizures were available in less than 1% of patients queried, when they were available, they were helpful (145). With the adoption of smartphones, more recent studies estimate this yield of ictal videos when requested is around 30% (05). Although the AUC of experienced epileptologists was 90%, there is significant morbidity inherent in misclassified cases in both cases of error. For example, 10% of cases of empirically treated “status epilepticus” in the ESETT trial were determined to have prolonged functional seizures, leading to known iatrogenic risks associated with large doses of sedating medication, intubation, and hospitalization in the intensive care unit (72; 70).

We use the strong phrase that presumptive diagnosis of functional seizures without ictal observation was dangerous based on direct observations of harm. We have records of sudden unexpected death in epilepsy in patients thought to have functional seizures alone based on 5 days of nonictal video-EEG, including withdrawal of antiseizure medications, whose antiseizure medication was discontinued long-term. Additionally, we have records of patients who had sudden, unexpected death due to other etiologies (eg, cardiomyopathy in pregnancy) that were misidentified as functional seizures, and, thereby, the diagnostic evaluation and treatment of the mimics of functional seizures were not pursued prior to death.

Prognosis and complications

With targeted neurobehavioral therapy, around 30% of patients will be seizure-free, and a total of 80% will have at least a 50% reduction in seizure frequency (98; 59). Prognosis was worse for patients whose delay from first seizure to diagnosis of functional seizures was prolonged; who have co-occuring epileptic seizures; whose personalities have greater somatization or dissociation, or include positive phenomena; or for patients who receive disability benefit, have higher anxiety and depression scores, are at an older age at onset, are unemployed, have more functional symptoms, have lower educational qualification, and have a lesser belief in the diagnosis and in CBT as “logical” treatment (125; 58). A small study of 26 patients demonstrated that patients who rated the explanation of the diagnosis as “satisfactory” had a marked reduction in healthcare utilization, but patients who rated the explanation as “unsatisfactory” had either continued high costs or an increase in healthcare costs (95).

As an example of the difference between correlation and causation, our opinion is that the worse prognosis in patients receiving disability benefits may be due to increased underlying severity of the condition as well as biopsychosocial burden of low socioeconomic status, including but not limited to, housing insecurity, food insecurity, and reduced resources to engage in therapy (eg, not being able to afford books as a therapy resource). For that reason, we encourage clinicians to support disability applications by people with functional seizures based on an honest description of their condition and experienced disability. Denial of disability benefits combined with reduced capacity to be employed due to frequent seizures can increase, as compared to decrease, biopsychosocial contributors to seizures. However, the patient behavior of withdrawing from all activities and reliance on others, including clinicians, to address their seizures is also harmful; therefore, we encourage discussion of disability as a method to enable engaging in treatment with the medium- and long-term goal of return to work and other activities.

There are two key barriers to treatment for functional seizures: lack of availability of trained psychological or psychiatric care providers and nonadherence to neurobehavioral therapy. At the time of diagnosis, cessation of all antiseizure medications in patients without epilepsy and motivational interviewing have been shown to improve attendance at subsequent appointments (148). Due to functional disorders existing at the intersection between mental health care and neurology, many therapists are uncomfortable with or unfamiliar with the treatment for functional seizures. Counselors, therapists, or psychiatrists who misinterpret the seizures as epileptic, despite more definitive video-EEG documentation of seizures, can confuse patients and thereby be counterproductive (127; 64). Additionally, fewer than 20 centers in the United States provide specialized neurobehavioral treatment (17). To address this limitation in access to providers familiar with the condition, a randomized trial for neurobehavioral therapy for functional seizures in the United Kingdom showed that therapists could provide effective therapy with relatively limited additional training (59). Unfortunately, the common experience of providers running clinics for functional seizures is that there are many more patients with needs than there is capacity to see them. Often, delays to the onset of functional seizure–specific treatment after diagnosis and referral can exceed 6 to 12 months.

Similar to epileptic seizures, functional seizures impact patients’ lives beyond the times of the seizures; therefore, patient outcome should not be based solely on reductions in seizure frequency (115). Seizure impact spans multiple aspects of quality of life and may be greater than the impact of epileptic seizures (143; 73). Prognosis in children may be better than in adults (158). An Australian investigation suggests that patients with functional seizures have a 2.6 times higher standardized mortality ratio than the general population, not significantly different from the rate of SUDEP in patients with epilepsy (110; 108). Importantly, a quarter of those deaths were suicide (110). This 2.4 times elevation of mortality compared to standardized controls was demonstrated within the United States (81). In these cases, and in another Australian study, this elevated mortality was associated with comorbidities as compared to the seizures themselves. Therefore, we emphasize holistic care of both the seizures and comorbidities.

We suggest that neurologists continue to be involved in the care of patients with functional seizures because, while uncommon, patients can develop non-seizure functional neurologic disorders during the treatment course, and cessation of antiseizure medications can reveal comorbid epileptic seizures. Neurologists can also reaffirm the diagnosis of functional seizures to avoid recreating the diagnostic evaluation during periods of seizure worsening. Additionally, neurologists can screen for and address common neurologic comorbidities that contribute to disability and reduced quality of life, like migraines.

Clinical vignette

A 25-year-old woman developed episodes of loss of consciousness at 15 years of age. The initial episodes were a sudden loss of consciousness with collapse and without associated movements. A cardiac evaluation identified baseline low blood pressure and an abnormal tilt table test, so treatment with midodrine and nadolol was begun. This treatment was effective for about 2 years. The episodes then returned during the patient’s first year of college but were different at their onset, which became a shaking of the right shoulder that spread across the entire right side. Around this time, the patient identified the development of a persisting right hemiparesis that continues to impair ambulation to the extent that a cane is necessary. Based on the development of shaking, epilepsy was diagnosed, and levetiracetam replaced the other medications. With this treatment, the episodes were controlled again. The episodes returned and increased in frequency despite continued treatment with levetiracetam. Their current manifestation does not include asymmetric shaking and instead is intermittent truncal contractions that sometimes are associated with oral injury or urinary incontinence. The episodes last 2 to 30 minutes and resolve with headache and fatigue.

To address the underlying diagnosis, video-EEG monitoring was performed. Two episodes were recorded and identified by the patient’s mother as similar to the habitual episodes. The episodes included intermittent truncal movements not typical of epileptic seizures, and the EEG was normal both during and between the episodes. Neurologic examination identified an inconsistent and variable right-sided weakness, and MRI of the brain was normal. The diagnosis was changed to functional seizures, and a psychiatric consultation did not identify a formal diagnosis of a psychiatric disorder. The psychiatrist agreed with the diagnosis of functional neurologic disorder with associated biopsychosocial stressors. No risk factors for functional seizures were identified. However, the patient’s interaction with her family demonstrated an abnormal dependence on them that was in conflict with her stated desires. Furthermore, she demonstrated no negative emotions when discussing the dependence or her seizures. With the patient’s understanding of the new diagnosis, levetiracetam was discontinued, and neurobehavioral therapy was recommended. Due to the reported improvement on levetiracetam, the patient was hesitant to discontinue it. She consented to discontinuation after engaging in neurobehavioral therapy and continued follow-up with her neurologist to evaluate ongoing progress.

Biological basis

Etiology and pathogenesis

Traditionally, functional seizures are classified as within the umbrella functional neurologic disorders, which sometimes also have features of dissociative disorder, which is a different category in the DSM-5 (04). Regardless of the classification, the causative etiology of functional seizures is not well established. The factors associated with functional seizures are heterogeneous and can include mild traumatic brain injury, epileptic seizures, various forms of psychological disorders, emotional conflicts, inappropriate coping mechanisms (eg, substance use, gambling), and psychoses (54; 129; 104).

Functional neurologic disorders have been attributed to impairment in connectivity between neuroanatomic areas involved in emotion regulation and areas involved in motor planning and conscious awareness (40). Impairment in awareness of internal body sensations can be called impaired interoception (internal perception). Patients with functional neurologic disorder often have difficulty consciously characterizing their emotions or feelings with words. This has been termed alexithymia, and individuals with functional seizures are more likely to have alexithymia than control individuals with epilepsy (71). Other related conditions associated with impaired interoception and alexithymia include complex PTSD and autism. Concurrent with the massive increase in awareness of adult identification of level 1 autism is increased evidence for a mechanistic relationship between functional neurologic disorder and autism (30; 53; 60; 137).

Ineffective coping responses also may contribute because patients with functional seizures more often employ emotion-focused or avoidance-oriented strategies than the more effective task-oriented approach (107). Overall, the presence of trauma, abuse, or neglect during childhood was associated with the subsequent development of functional seizures (71; 107). In military veterans, there is significant comorbidity with posttraumatic stress (44). It is important to emphasize that 10% to 15% of patients with functional neurologic disorders do not recognize psychological stressors as contributing to their symptoms; therefore, some patients may resist etiological descriptions or delivery of the diagnosis that rely entirely on psychological factors. In addition to these psychologically based associations, functional neurologic disorders are associated with mild traumatic brain injury and other reportedly mild biological stressors, such as vaccinations and mild viral illnesses (51; 63).

Identifying the primary and secondary factors that contribute to or perpetuate the functional seizures is important because identification of triggers and developing alternative coping strategies is one of the tenets of successful treatment (57; 90). Psychodynamics may differ depending on the type of functional ictal manifestations (118). Personality abnormality can be present with features that most often resemble borderline or avoidant personality disorder, or an overly controlled or somaticizing personality (124; 32; 24). Epileptic seizures can also progress into functional seizures, and functional behaviors can exaggerate or elaborate epileptic auras (36).

Functional seizure disorders are neurobehavioral conditions and, as such, are due to abnormality in the complex behavioral systems within the brain. Brain imaging of patients with functional seizures demonstrates subtle quantitative abnormalities in structure and resting state functional MRI when compared to controls (38; 88; 101; 61; 144; 83). One finding is greater functional connectivity between the insula and both the precentral sulcus and the parietal lobe (152). Moreover, this abnormality correlates with the dissociation score. Large-scale brain networks also differ from controls with increased local specialization and decreased global integration, which indicates a global network with less efficient information propagation (39). These regions have incomplete overlap with regions associated with impaired emotion regulation, as well as depression, bipolar disorder, schizophrenia, posttraumatic stress disorder, and mild traumatic brain injury (47). The clinical implications of this finding are rudimentary at this time.

Functional neurologic disorders: alterations in activity and connectivity

(Contributed by Dr. Wesley Kerr.) Also see: Pick S, Goldstein LH, Perez DL, et al. Emotional processing in functional neurologic disorder: a review, biopsychosocial model and research agenda. J Neurol Neurosurg Psychiatry 2019;...

Another perspective on the etiology of functional seizures and other functional neurologic disorders is based on a model comprising abnormal inferences within cognition and perception (46). Essentially, abnormal top-down modulation may result from prior beliefs and experiences and produce abnormal behavior. From extracranial and intracranial electroencephalographic recordings of functional seizures, this may involve the posterior parietal cortex, which is an area involved in self-referential cognition (07).

Furthermore, structural brain damage is not uncommon among patients with functional seizures (96; 12; 80), especially when it affects the nondominant hemisphere (37).

Lastly, there are new post-treatment studies, including structural neuroimaging, that demonstrate changes in the left uncinate fasciculus as well as other regions in patients who improved psychosocial functioning with treatment, as compared to their prior neuroimaging and patients who did not improve with treatment (105). These studies were small, and some of these changes were also associated with improvement in other mental health symptoms evident in depression scores. Therefore, it is unclear if this post-treatment change represents a signal unique to functional seizures, a signal of improvement in other mental health, or both.

Although these factors may be present in 80% to 90% of patients, there are patients for whom none of these factors were present, and the diagnosis of functional seizures was clear. Irrespective of the presence of significant trauma or psychiatric comorbidity, patients benefit from neurobehavioral therapy. These patients who don’t have clear mental health contributors often struggle to identify how traditional therapy approaches would benefit their seizures; they often will engage more with neurobehavioral therapy focused on the functional seizures

Differential diagnosis

Confusing conditions

Functional seizures need to be distinguished from epileptic seizures as well as intermittent nonepileptic events due to systemic, neurologic, or other psychiatric disturbances. Frontal lobe seizures are most commonly misdiagnosed as functional (132), but, in video-EEG populations, functional seizures are epidemiologically more common than confirmed frontal lobe epilepsy (85). Patients with both epileptic and functional seizures pose the most difficult diagnostic dilemmas. In addition, some patients with focal seizures with loss of awareness or focal to generalized seizures that are well controlled with medication may highlight or elaborate on residual auras (54). These apparent functional events, therefore, have an epileptic basis that, if diagnosed, might be treatable. On the other hand, epileptic seizures can occasionally be precipitated by psychological factors, a condition that has been referred to, confusingly, as psychogenic epileptic seizures.

History, careful description of typical ictal events, physical examination, and routine laboratory studies (including EEG) may be sufficient to permit identification of a specific epileptic condition or raise concern about the existence of a systemic, neurologic, or psychiatric illness associated with nonepileptic intermittent behavioral disturbances. However, an abnormal (even epileptiform) EEG can occasionally be seen in people with functional seizures who do not have epilepsy (122; 01).

With the increasing recognition of autism in adults, the interaction between autism and functional neurologic disorder is an area of active investigation. In profound autism, the struggles to communicate needs effectively can result in voluntary behaviors that appear similar to functional seizures, but are attempts to communicate. In level 1 or level 2 autism, autistic meltdowns and shutdowns can phenomenologically be described as functional seizures. Autistic meltdowns can appear like hypermotor functional seizures with body shaking, screaming, and autonomic arousal. Milder meltdowns can include repetitive self-stimulatory behaviors (eg, rubbing, rocking, picking, jiggling). Autistic shutdowns can appear like a functional coma or a lack of response to the outside world. Milder shutdowns can include focal language deficits or increased sensory sensitivity. If the patient interacts with these events as part of their autism, then adding the label of functional seizures may not be helpful. If the patient is resistant to a label of autism or feels that their autism is separate, the label of functional seizures can assist the patient in engaging in treatment. Although the treatment for functional seizures was developed for neurotypical people, neurobehavioral therapy has many elements of autism-affirming care. Therefore, a therapist or counselor with experience in autism can emphasize different aspects of neurobehavioral therapy that may resonate more with autistic people. One of the principles of autism-affirming care is that suppression can be analogous to shoving a gremlin in a box: it works temporarily, but the gremlin must eventually get out. If we don’t let it out, it’ll get angrier and angrier until it breaks out without our consent, which can be a meltdown, shutdown, or functional seizure. If we open the box in a controlled manner, dealing with the gremlin can be both uncomfortable and rewarding because it can address the issue in the medium- and long-term.

For patients with nonepileptic events without positive diagnostic signs of functional seizures, even if they were observed on video-EEG, the differential diagnosis of paroxysmal events can be broad. Cardiac arrhythmias, dysautonomia, and convulsive syncope can, but do not always, include presyncopal feelings that commonly are described as nonspecific. Based on the definition of syncope as compared to pre-syncope, these can include lapse of consciousness without an EEG correlate and, occasionally, normal blood pressures due to disorders of the autonomic system. Alternatively, migraine with aura can include focal deficits in speech as well as loss of consciousness. When clinicians observe these events without positive signs of functional seizures, premature closure on functional seizures is not appropriate. Additional evaluation for other conditions may reveal other treatment approaches that can be beneficial

Functional seizures are not a form of malingering, which would involve epileptic-like events that are consciously feigned; nor are they factitious seizures, which would involve a seizure history or actual events that are fabricated solely for the purpose of gaining patient status (Munchausen syndrome) (130). "Factitious seizures by proxy" refers to a situation where an individual, usually a relative of the patient, fabricates the seizure history or seizures in order to have the patient admitted to a hospital (41).

Associated or underlying disorders

Functional seizures are part of the umbrella of functional neurologic disorders. Each of the functional neurologic disorders shares a common mechanism and phenomenology. The line differentiating functional seizures from functional movement disorder is blurry in that functional seizures typically are episodic, whereas functional movement disorder typically has more consistent symptoms. That difference leads to practical implications where functional movement may benefit more from physical therapy, occupational therapy, vestibular therapy, and other more physically interactive therapies. The episodic nature of functional seizures makes it challenging for these therapies to engage with the functional symptoms directly; therefore, the focus of functional seizure care commonly is neurobehavioral therapy.

More than 50% of people with functional seizures also likely have functional cognitive dysfunction. Some patients report that the disability from the cognitive impairment or brain fog was more than the seizures. As long as patients are cognitively aware enough to engage in neurobehavioral therapy, the presence of co-occurring cognitive symptoms may not require supplementing treatment modalities (eg, cognitive rehabilitation). Neurobehavioral therapy for the functional seizures also likely benefits the cognitive symptoms. After completion of functional seizure treatment, if there are remaining cognitive symptoms, the patient could engage in subsequent treatments focused on cognition (eg, cognitive rehabilitation).

Based on the shared mechanisms of functional neurologic disorder, the co-occurrence of different functional symptoms is common. Over the course of treatment, the functional symptoms can transition. If the patient is concerned that new or different symptoms have another etiology because functional seizures do not protect them from other conditions, re-evaluation by neurology or the appropriate specialty may be warranted. If the symptoms are a mild variation of the primary functional symptoms, then that evaluation may focus on reassurance without additional diagnostic workup.

Diagnostic workup

In distinguishing between epileptic seizures and functional seizures, the physician should initiate an initial neurologic evaluation that is appropriate to the type of epilepsy suspected. If nonepileptic seizures due to medical, neurologic, or other psychiatric causes are considered, then additional testing needs to focus on these likely causes. To differentiate nonepileptic seizures from malingering, which is rare (less than 1% of patients), it is important to document potential primary or secondary gain.

The diagnosis of functional seizures should be considered based on the patient’s history and reported or observed semiology. There are multiple interview-based or questionnaire-based clinical scores to identify patients who were more likely to have functional seizures (77; 76; 82; 151; 157). Due to evidence that longer delay to diagnosis is associated with poor long-term outcome, functional seizures should not be viewed as a diagnosis of exclusion (156; 18; 68; 120; 114). The level of evidence needed for the diagnosis of functional seizures is summarized in Table 1 (91).

Table 1. Diagnostic Levels of Certainty for Functional Seizures Reproduced from LaFrance and Colleagues with permission

Diagnostic level	History	Event witness	EEG findings
Possible	Consistent with functional seizures	Non-clinician or self-report	No epileptiform activity on routine or sleep-deprived interictal EEG
Probable	Consistent with functional seizures	Clinician-reviewed video or in-person clinician observation	No epileptiform activity on routine or sleep-deprived interictal EEG
Clinically established	Consistent with functional seizures	Seizure-experienced clinician reviewed video or in-person clinician observation (no EEG)	No epileptiform activity on routine or sleep-deprived ictal EEG during a typical event
Documented	Consistent with functional seizures	Video-EEG with typical seizure and seizure-experienced clinician	No epileptiform activity immediately before, during, or after a typical event with ictal video-EEG
Adapted with permission from (91).

As suggested by their prominent place in the diagnostic certainty criteria, videos of seizures can be particularly helpful. However, it can be difficult to obtain videos of sufficient quality. A high-quality patient- or caregiver-provided video should record the ictal period in its entirety; include the patient’s entire body within view; record as much of the postictal period as possible; and ensure proper lighting, sound, and focus while maintaining interaction with the patient to assess responsiveness (145). This high-quality video, however, may only be available for less than 1% of patients unless these videos are specifically requested (145). When requested, around 30% of patients may be able to obtain sufficient-quality video for diagnosis. When a quality video was viewed by an epileptologist, the accuracy of the diagnosis of functional seizures was 95%, but this accuracy diminished substantially with level of expertise, including an area under the receiver operating characteristic curve (AUC) of 89% for neurologists, 71% for emergency physicians, 69% for nurses with experience in epilepsy, and 49% for other nurses (23).

Additional tests can influence the likelihood of the diagnosis, including but not limited to, psychological measures, psychiatric assessment, review-of-systems questionnaires, self-protective maneuvers during the event, as well as preserved memory during generalized convulsive episodes (140; 32; 33; 24; 126). To date, the sensitivity and specificity of serum markers taken around the event are limited because these also are unchanged in some epileptic seizures (25; 03; 31; 28; 33). Some patients with functional seizures also have a template of a friend or relative with epileptic seizures (154). Furthermore, demonstration of brain damage, or even epileptic seizures, does not necessarily prove that the patient does not also have functional seizures (96; 31; 84).

When clinical doubt persists following observation of the seizure with either video or EEG, it may be necessary to perform video-EEG monitoring to record the habitual seizures (149). Due to frequent emergency room visits and lost productivity from frequent seizures, the cost of untreated functional seizures was estimated to be 21,000 euros per patient per year (16; 99). Although inpatient video-EEG monitoring is costly, it has been found to produce a subsequent decrease in total healthcare costs, even with increased behavioral health costs (02). Inpatient video-EEG monitoring is most helpful when seizures involve impairment of consciousness because focal seizures with intact awareness commonly have no EEG correlates, and a negative ictal EEG recording cannot rule out epilepsy for these events. Moreover, movement artifact on the EEG may give the appearance of epileptic abnormality to less experienced EEG interpreters (18). In some patients, ictal or peri-ictal heart rate, or heart rate variability, may distinguish between epileptic and functional seizures (109; 117; 121), and ictal SPECT can be helpful (34).

Examination of the patient during the behavioral seizure can also be useful, particularly when conscious behavior is demonstrated in an apparently unconscious patient (145). This can lead to erroneous conclusions, however, when the examiner is not familiar with ictal signs and symptoms. For instance, certain myoclonic phenomena can be bilaterally synchronous and relatively long-lasting without loss of consciousness (eg, paroxysmal kinesigenic dyskinesia), and patients can often respond appropriately to complicated stimuli during focal impaired awareness seizures but have no memory of their actions afterward. Nevertheless, diagnostic information is often obtained by an experienced observer witnessing a typical seizure.

In lieu of inpatient video-EEG monitoring for this purpose, suggestion has been used as a provocative test for functional seizures (52), but this approach can lead to misdiagnosis when a concurrent EEG is not obtained and has been challenged as unethical by some because of the potential impact on trust for the physician. Other provocative tests, such as hyperventilation and photic stimulation (22) and hypnosis (14), are reported to be useful. In the context of video-EEG monitoring with provocative techniques, patients with epileptic seizures may experience functional seizures with atypical semiology compared to their typical events due to a conscious or unconscious pressure to perform. Consequently, definitive demonstration of an epileptic seizure or a functional seizure does not rule out the possibility that both seizure types exist unless all seizure types have been recorded. A careful history of each of the different seizure types experienced by the patient is essential because patients may have both functional seizures and epileptic seizures.

In addition to clearly diagnosing functional seizures, clinicians also must consider either mimics or co-occurring conditions. The most common co-occurring condition was epileptic seizures. In 2025, a structured criterion for the evidence of co-occurring epilepsy was developed to be analogous to the diagnostic certainty criteria for functional seizures (67). Patients should be classified based on the highest level of evidence in any category.

Table 2. Levels of Evidence for Co-occurring Epilepsy in Functional Seizures

Diagnostic level	History	Event witness	EEG findings	Neuroimaging
Unlikely	No concerning factors	No concerning factors	Normal or non-specific	Normal or nonspecific
Possible	Concerning for epilepsy	Non-clinician
Probable		Nonseizure specialist clinician (eg, emergency)	Epileptiform findings on interictal EEG	Epilepsy-associated findings
Clinically established	Concerning for epilepsy syndrome (eg, juvenile myoclonic epilepsy)	Seizure-experienced clinician reviewed video or in-person clinician observation (no EEG)	Scalp EEG negative epileptic seizure observed on EEG during a typical event
Documented		Video-EEG with typical seizure and seizure-experienced clinician	Electrographic or electroclinical seizure observed on EEG.
Adapted with permission from (67).

Other co-occurring conditions or mimics include migraine with aura (previously called complex migraine), syncope, cardiac arrhythmias, dysautonomia, pain disorders, primary movement disorders (Tourette syndrome), and primary psychiatric disorders. Aspects of these conditions can mimic functional seizures, and each does not have an EEG correlate; when patients have no EEG correlate to their events that phenomenologically resemble these mimics, additional personalized evaluation may be necessary to evaluate for those mimics. Alternatively, these conditions can represent biopsychosocial stressors that contribute to superimposed functional seizures. For example, a portion of patients experience functional seizures exclusively in the context of migraine. If adequate treatment of headache can be initiated, then the functional seizures may also abate.

Management

Effective management of functional seizures requires that the physician, family, and patients recognize that the events are involuntary, legitimately disabling, not epilepsy, and treatable (62). Appropriate treatments for functional seizures include neurobehavioral therapy, group psychotherapy, ReACT, behavioral modifications, stress reduction, reassurance, and, at times, antidepressant or antipsychotic medication to treat comorbid psychiatric disease (54; 129; 94; 57; 59; 103; 98; 149). Neurobehavioral therapy has also been called cognitive behavioral-informed therapy. Although it has been established that neurobehavioral targeting of events is superior to treatment as usual, there is no clear evidence that one particular type of psychotherapy is superior to another. This broad approach differs from standardized tests for clinicians, which often focus on cognitive behavioral therapy. However, many patients benefit from perspectives different from CBT.

There is an overlap between pain attacks and functional seizures. One of the analogies for functional seizures is “panic without panic,” where the body experiences a state of physical panic, but the functional neurologic disorder with alexithymia “protects” the patient from feeling the panic. The analogy of “protection” is understood as similar to an overprotective loved one, where the overprotective nature can be harmful. Over the course of treatment for functional seizures, improvements in alexithymia can transition functional seizures from panic without panic to panic with panic. That transition can be very distressing for patients because the insight into their panic is a demand for action to address their distress. For that reason, neurobehavioral treatment often develops coping strategies to address that distress prior to addressing the alexithymia. In treatment for functional seizures, we describe learning coping strategies outside the context of seizures or panic as “easy mode.” In contrast, “hard mode” is evaluating if those coping strategies are effective when implemented in the pre-seizure state or during seizure or panic.

In 2026, the American Academy of Neurology published a guideline for the treatment of functional seizures (149). When patients have only one seizure type, and it is functional, antiseizure medication can be safely tapered and discontinued, ideally during the diagnostic video-EEG admission. Additionally, this guideline clearly states that benzodiazepines are not recommended as rescue or acute treatment for functional seizures, due to lack of effectiveness and potential for harm.

When patients have several seizure types, and one or more may be epileptic, antiseizure medication therapy must be continued with counseling that the medication therapy only addresses the epileptic seizures. We also recognize that refractory or breakthrough epileptic seizures are biological stressors that add to the other contributors to functional seizures within a biopsychosocial model. The patient, as well as family and friends, should be made aware of which ictal events are functional, which are definitely epileptic, and which may be epileptic so that seizure logs can record them independently. It is then necessary to see which seizures respond to antiseizure medication. The specific neurobehavioral therapy for functional seizures was modified based on neurobehavioral therapy to address biopsychosocial factors that can worsen epileptic seizures; therefore, response to medication or therapy does not perfectly indicate that the seizures were epileptic or functional. An open-label study demonstrated that neurobehavioral therapy designed for functional seizures was associated with improvement in epileptic seizures without co-occurring functional seizures (153); therefore, even though the study did not include people with co-occurring seizures, neurobehavioral therapy should be offered to all people with functional seizures, irrespective of the evidence for co-occurring epilepsy.

The question as to whether patients with functional seizures should be permitted to drive has not been adequately answered (21).

The interdisciplinary functional seizure clinics that have been established are a collaboration between psychiatry, psychology, social work, and neurology (17). Although all these providers can be trained in psychotherapy for seizures, the bulk of the psychotherapy can be accomplished with psychologists, whereas psychiatry manages the psychiatric medications and neurology manages seizure medications, if indicated, and evaluates any new or changing characteristics of the seizures or other functional neurologic disorders (98). In the absence of an interdisciplinary clinic, we highly encourage keeping the door open for follow-up with neurology, if only for continued reassurance, clarification of the diagnosis, evaluation of new, possibly functional symptoms, and coordination of psychological services. When patients are discharged from neurologic practice, there are fears that the 80% of patients who are not seizure-free after neurobehavioral therapy will seek out neurologists or other healthcare providers for re-evaluation, leading to redundancies in healthcare utilization.

Both the patient-driven charity Functional Neurological Disorders Hope (FND Hope) and the following website have a list of psychotherapy providers for functional seizures: nonepilepticseizures.com. The website, neurosymptoms.org, also provides substantial patient-facing information to help educate patients and the people around them. However, providing a website without other interventions is not sufficient for the treatment of functional seizures.

Outcomes

Simply establishing and delivering the diagnosis in a sensitive manner can have a profound impact on health care utilization as well as the direct and indirect costs of illness (156; 100; 18; 02; 99). In particular, motivational interviewing may improve outcomes (148; 147). In addition to improvements in seizure frequency and rates of seizure freedom, these improvements are made through education regarding the utilization of emergency services, the reduction of costs associated with further diagnostic assessment, the costs of medications, and improvements in the quality of life of patients.

Of patients who complete treatment as described above, the prognosis for control of seizures is modest. Some patients do extremely well, but many continue to either have seizures or other forms of psychiatric disability despite appropriate therapy (102; 86; 48; 49; 133). Seizure freedom has occurred in 16% to 35% of study populations with follow-up periods ranging from 6 to 67 months (156; 49; 69; 111; 59).

However, as few as 60% of patients attend the first psychiatric follow-up visit, and 15% to 25% of patients complete the full recommended course of therapies described above. This adherence varies substantially across studies; therefore, identification of barriers to care and facilitation of follow-up is an active area of research and policy (64; 98; 148; 147). Telepsychiatry has been effective for improving adherence and delivery of therapy both prior to the COVID19 pandemic and during the pandemic (93; 146).

Special considerations

Pregnancy

Functional seizures can occur during pregnancy and may first develop during pregnancy. Prompt definitive diagnosis, ideally with video-EEG monitoring, should be performed because treatment with antiseizure medications may be teratogenic (35). Additionally, pregnancy can represent a biopsychosocial stressor due to both the physical burden of pregnancy and the increased occurrence of domestic violence during pregnancy. Small studies of people with functional seizures in pregnancy have demonstrated individualized changes, including some individuals who markedly worsen, others who markedly improve, and still others with no change in seizure frequency (27). There are also data regarding an increased rate of seizures during delivery, which may be associated with an increased rate of delivery by cesarean section (60%) as compared to others with medication-resistant epilepsy (30%) and non-seizure comparison patients (22%) (45; 50; 27).

Anesthesia

Although there are limited peer-reviewed publications on the topic, our clinical experience is that functional seizures can be precipitated by anesthesia and are observed in the post-anesthesia recovery area. In the biopsychosocial model of functional seizures, anesthesia likely represents a biological stressor. We have cared for multiple patients who have a history of seizures only after general anesthesia, who were demonstrated to be functional with concurrent extracranial surgery and video-EEG monitoring that was started before surgery and continued in the post-anesthesia care unit. In these cases, we provided reassurance that these functional seizures were not physically dangerous and did not reflect acute neurologic injury from the surgery. We counseled that these seizures may occur after other episodes of general anesthesia and likely warranted time-sensitive neurologic reevaluation before aggressive treatment with benzodiazepines that have a risk of iatrogenic harm. Functional seizures are not treated by antiseizure medications, so pre- or post-operative prophylactic antiseizure medications were not recommended. Anecdotally, we have also cared for a patient with medication-resistant epilepsy who had functional seizures during the first few days of stereo-EEG monitoring but has not experienced functional seizures at other times.

Media

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Contributors

All contributors' financial relationships have been reviewed and mitigated to ensure that this and every other article is free from commercial bias.

Author

Wesley T Kerr MD PhD

Dr. Kerr of University of Pittsburgh School of Medicine received consulting fees from Biohaven Pharmaceuticals and SK Lifesciences.
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Editor

John M Stern MD

Dr. Stern, Director of the Epilepsy Clinical Program at the University of California in Los Angeles, received honorariums from Ceribell, Jazz, LivaNova, Neurelis, SK Life Sciences, and UCB Pharma, and Xenon as advisor and/or lecturer.
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Former Authors

Jerome Engel Jr MD PhD

Patient Profile

Age range of presentation: 6 to 65+ years
Sex preponderance: Female>male, 3:1
Heredity: None
Population groups selectively affected: None selectively affected. Patients with functional seizures have been reported in all cultures with the manifestation of seizures somewhat varying across cultures (Asadi-Pooya et al 2020; Sawchuk et al 2020).
Occupation groups selectively affected: None selectively affected.

ICD & OMIM codes

ICD-10: Other and unspecified convulsions: R56.8

Functional neurological disorders with attacks or seizures: F44.5
ICD-11: Dissociative neurological symptom disorder: 6B60

Dissociative neurological symptom disorder, with non-epileptic seizures: 6B60.4

Type of seizure, unspecified: 8A68.Z

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Functional/dissociative seizures

Associated Disorders

Anxiety disorders
Asthma
Chronic pain
Epilepsy
Fibromyalgia
- Major depressive disorder
- Migraine
- Pain
- Posttraumatic stress disorder

Differential Diagnosis

epileptic seizures
frontal lobe seizures
complex partial seizures
secondarily generalized seizures
convulsive syncope
- confusion episodes in dementia
- systemic illness causing seizure-like behavior
- psychogenic epileptic seizures
- Munchausen syndrome
- factitious seizures by proxy

Also Relevant

Epilepsy
Frontal lobe seizures
Functional movement disorders
Functional neurologic disorders and related disorders
Neurologic disorders associated with behavioral symptoms

Functional/dissociative seizures

Cite this article

Introduction

Overview

Key points

Historical note and terminology

Clinical manifestations

Presentation and course

Prognosis and complications

Clinical vignette

Biological basis

Etiology and pathogenesis

Epidemiology

Prevention

Differential diagnosis

Confusing conditions

Associated or underlying disorders

Diagnostic workup

Table 1. Diagnostic Levels of Certainty for Functional Seizures Reproduced from LaFrance and Colleagues with permission

Table 2. Levels of Evidence for Co-occurring Epilepsy in Functional Seizures

Management

Outcomes

Special considerations

Pregnancy

Anesthesia

Media

References

Contributors

Author

Editor

Former Authors

Patient Profile

ICD & OMIM codes

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Questions or Comment?

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