In 2020, epileptologist Selim R. Benbadis published a short but pointed letter to the editor in Epilepsy & Behavior: “Functional seizures? ‘So I still have seizures, right?
The piece was in response to the growing enthusiasm for replacing “psychogenic nonepileptic seizures” (PNES) with the term “functional seizures” (or FS).
Benbadis pushed back against this rebranding; he was concerned that the new label risked creating patient confusion and conceptual murkiness.
What Benbadis Actually Said
Benbadis highlighted a predictable real-world reaction from patients. When a neurologist carefully explains that the events are “functional seizures” — emphasizing that they are not epileptic, not caused by abnormal electrical discharges, and rooted in brain network dysfunction, (carefully avoiding any mention of psychological factors) many patients respond with understandable confusion: “So… I still have seizures, right?”
This question cuts to the heart of the terminology debate. The word “seizure” carries powerful connotations for patients and families: it implies a sudden, neurological event, often serious, often requiring anticonvulsants, and often carrying restrictions (driving, work, etc.). Pairing it with the vague, sanitized adjective “functional” doesn’t erase those associations and instead, can actually further confuse patients and other professionals.
His 2020 letter was skeptical of the “functional” movement. Although he acknowledged that older terms like “pseudoseizures” feel dismissive to patients and some patients may be opposed to psychogenic,” he warned that “functional seizures” might create new problems:
- First of all, FS keeps the loaded noun “seizures,” potentially reinforcing the idea that these events are fundamentally the same as epileptic ones.
- FS downplays or obscures the psychological mechanisms (dissociation, trauma, etc.) that are central to understanding and treating PNES.
- FS risks leaving patients unclear about why psychotherapy is being recommended instead of more anti-seizure medications or neurological interventions. If psychogenesis is completely avoided, it’s increasingly unlikely that patients will make the effort to search out evidence-based psychological treatments (since they are rarely provided with actual referrals, patients are required to be proactive in finding proper treatment).
Why This Matters in the Bigger “De-Psychiatrizing” Trend
Benbadis’s letter was timely because he wrote it at the cusp of a shift in the FND/PNES field, when papers were being published making the case for “functional seizures” as a more acceptable, brain-based-sounding label (e.g., Asadi-Pooya et al., 2020). The stated goal of these papers was destigmatization: to make the diagnosis feel more “legitimate” and neurological, less “all in your head.”
However, Benbadis identified the same logical tension I commented on regarding the 2026 DeDominicis and Lidstone article in Seminars in Neurology. When experts try to “neurologize” the explanation while still relying on psychotherapy as the primary effective treatment for PNES, patients end up receiving mixed messages and rather than being helped, end up misguided:
The message doctors are giving them is
- “This is a real brain network problem.”
- “But the best treatment is psychotherapy that addresses trauma, anxiety, dissociation, and maladaptive behavioral patterns.”
Benbadis’s patient question — “So I still have seizures, right?” — perfectly illustrates the potential for confusion. If the diagnosis sounds neurological, why isn’t the treatment neurological? Why would a patient comply with psychology/psychiatry referrals (if even provided) when the nondescript “functional” explanation is chosen over the “offensive psychogenic” term.
The Evidence Doesn’t Support Sanitizing Away the Psychological Core
As I’ve noted previously, the strongest outcome data for PNES points to tailored psychologically informed treatments:
- Meta-analyses show tailored psychotherapy leading to seizure freedom in ~47% and ≥50% reduction in ~82% of completers.
- RCTs support both Cognitive Behavioral therapy (CBT) and Prolonged Exposure (PE) therapy (the latter especially when psychological trauma symptoms are present).
- Mindfulness-based approaches have also shown promise.
Comorbid psychiatric conditions (anxiety, depression, PTSD, trauma histories) are extremely common. Downplaying these in the explanatory model doesn’t make them disappear — it just risks delaying access to care that actually works.
Benbadis wasn’t arguing against multidisciplinary care or against trying to reduce stigma. He was cautioning that terminology changes have real downstream effects on how patients understand their condition and subsequently, how they reach the appropriate treatment.
A Better Way Forward
Terminology matters, but clarity and honesty matter more. We should strive for language that doesn’t shame or dismiss patients. But we shouldn’t pretend that renaming something erases historical stigma, nor should we suppress its psychological underpinnings because we prefer to avoid an uncomfortable conversation with a patient.
When the label creates immediate confusion (“So I still have seizures, right?”), does it really help the patients? Furthermore, I would say that confusion is also spreading within the medical field in that there is a growing push to suppress any mention of anything “psychological” in FND and PNES but the only empirically validated treatments for this condition are tailored psychotherapies!
Interested in this topic, please see my previous post on “De-Psychiatrizing” FND: Why it isn’t as straightforward as hoped— especially when including psychogenic nonepileptic seizures (PNES) – Non Epileptic Seizures – Blog