What is the first line of treatment for patients with functional seizures?

First-Line Treatment for Functional Seizures

Psychotherapy is the first-line treatment for patients with functional seizures. 1

Understanding Functional Seizures

Functional seizures (also known as psychogenic non-epileptic seizures) are a form of functional neurological disorder that can mimic epileptic seizures but occur without epileptic discharges. They represent a significant diagnostic and therapeutic challenge, affecting approximately 20-25% of patients referred to specialist epilepsy clinics. 2, 3

Key characteristics:

• Not caused by abnormal electrical activity in the brain (unlike epileptic seizures)
• Result from complex biopsychosocial factors
• Associated with major disability, increased mortality, and frequent healthcare utilization
• Patients do not consciously fake their symptoms

Treatment Approach

First-Line Treatment: Psychotherapy

Psychotherapy has been demonstrated to be effective in treating functional seizures. 1 The treatment approach should follow these steps:

1. Clear communication of diagnosis

   • Explain the difference between functional and epileptic seizures
   • Emphasize that symptoms are real and not fabricated
   • Provide education about the biopsychosocial nature of the condition

2. Structured psychotherapeutic interventions

   • Cognitive Behavioral Therapy (CBT) focusing on:
     • Seizure management skills
     • Behavioral activation strategies
     • Lifestyle modifications
     • Stress management techniques

Evidence from recent research supports this approach. The Re-PROGRAM intervention, a brief structured psychotherapy program consisting of five 60-90 minute weekly sessions, demonstrated promising results with nearly all participants reporting reductions in seizure frequency, duration, and intensity. 2

Components of Effective Treatment Programs

Effective treatment programs for functional seizures should include:

• Seizure control strategies - Teaching patients techniques to manage and potentially abort seizures
• Assertive communication training - Helping patients express needs effectively
• Problem-solving skills - Developing strategies to address triggers and stressors
• Coping mechanisms - Building resilience to manage emotional distress
• Relationship improvement - Addressing interpersonal factors that may contribute to symptoms

Treatment Delivery Models

The most effective delivery model appears to be a stepped care approach: 3

1. Initial brief interventions - Like Re-PROGRAM, which can be delivered in outpatient settings
2. Progression to more intensive treatments - For patients with more complex presentations
3. Integrated interdisciplinary teams - Coordinating care between neurology, psychiatry, and psychology
4. Shared care with primary providers - Ensuring continuity of care

Common Pitfalls to Avoid

• Misdiagnosis as epilepsy - Leading to inappropriate antiepileptic medication use
• Failure to deliver a clear diagnosis - Creating confusion and distress for patients
• Focusing solely on medication - Antiepileptic drugs are not effective for functional seizures
• Neglecting psychological factors - Missing key therapeutic opportunities
• Fragmented care - Resulting in poor outcomes and increased healthcare utilization

Future Directions

While psychotherapy remains the first-line treatment, emerging research is exploring novel approaches. Recent studies are investigating psychedelic-assisted therapy (PAT) as a potential treatment option, though this remains experimental and requires further research. 4

The treatment gap for functional seizures remains significant compared to epilepsy, highlighting the need for improved clinical pathways and resources dedicated to this condition. 3