Clinical Considerations for Pharmacologic Approaches to Functional Seizures: Benjamin Tolchin, MD, FAAN

WATCH TIME: 3 minutes

“At this time, there is no evidence to support the use of antiseizure medications or benzodiazepines to treat functional seizures themselves. In fact, continued use of these agents without another clear indication can complicate care and expose patients to unnecessary risk.”

Pharmacologic management remains one of the most challenging and frequently misunderstood aspects of functional seizure care. In clinical practice, patients with functional seizures are often prescribed antiseizure medications or benzodiazepines, sometimes reflexively, particularly when diagnostic uncertainty exists or when symptoms appear acutely responsive to anxiolytic effects. However, the long-term risks of these approaches, combined with limited evidence of sustained benefit, have raised concerns about overuse and potential harm.

The recently published American Academy of Neurology (AAN) guidelines on functional seizures directly address this issue, synthesizing available evidence on psychopharmacologic interventions and clarifying when medications may or may not have a role. These recommendations aim to help neurologists distinguish between treating functional seizures themselves versus appropriately managing coexisting psychiatric or neurologic conditions that may warrant pharmacologic therapy.

Following the publication, study author Benjamin Tolchin, MD, FAAN, Director of the Center for Clinical Ethics at Yale New Haven Health, discussed the limited evidence supporting pharmacologic treatment of functional seizures. He explains why antiseizure medications and benzodiazepines should not be initiated specifically for functional seizures, outlines the risks associated with long-term benzodiazepine use, and emphasized the importance of deprescribing when no other clinical indication exists. Furthermore, Tolchin clarified how clinicians should counsel patients who are already receiving these medications and differentiate treatment of functional seizures from management of coexisting epilepsy or psychiatric disorders.

REFERENCE
1. Tolchin B, Goldstein LH, Reuber M, et al. Management of Functional Seizures Practice Guideline Executive Summary: Report of the AAN Guidelines Subcommittee. Neurology. 2026;106(1):e214466. doi:10.1212/WNL.0000000000214466