Functional neurological disorder — structured clinical viva

Diagnosis language. Prefer functional seizures / dissociative seizures / FND with attacks over pejorative “pseudoseizures” and never “attention-seeking” as a clinical diagnosis. Video-EEG without ictal epileptiform correlate during a typical event supports functional seizures; dual epilepsy remains possible if other event types exist — clarify with history and monitoring records.[3][4][6]

Acute management. Protect from injury, time events, reduce crowd and panic, avoid automatic high-dose benzodiazepine/ICU pathways once the pattern is known, but still escalate if airway risk or diagnostic uncertainty.[4]

AED plan. With secure functional seizures alone, plan supervised taper of unnecessary AEDs with neurology collaboration; leaving dual high-dose therapy “just in case” undermines the diagnosis and adds harm. Document driving advice per local law based on event control and diagnosis.[4][6]

Psychological evidence. LaFrance pilot RCT supports CBT-informed psychotherapy for PNES. CODES is the large pragmatic RCT of seizure-specific CBT plus standardised medical care versus standardised medical care — discuss primary and secondary outcomes honestly rather than claiming universal seizure cure.[1][2]

Comorbidity and prognosis. Treat depression actively; prognosis without treatment is often guarded with persistent attacks and disability in many series — early engagement and MDT care improve prospects relative to nihilism.[5][4]

Ethics of language. Repair iatrogenic harm from pejorative labels; restore therapeutic alliance; involve partner with consent.[3]