When coexisting epilepsy has been carefully excluded, gradual withdrawal of antiseizure medication is safe and is an important part of management. In a prospective study of 78 patients with non-epileptic seizures who met standardized criteria excluding epilepsy, withdrawal was accomplished without any serious adverse event; attack frequency fell in the group as a whole, a transient increase occurred in a minority, and only three patients developed a genuinely new event type. Withdrawal removes adverse effects and reinforces the diagnostic message that this is not epilepsy.
Two practical caveats govern the process. First, exclusion of epilepsy must be rigorous, because 5 to 20 percent of patients with dissociative attacks also have epilepsy; any account of a differing attack type, or independent electroencephalographic or imaging evidence, should prompt caution. Second, withdrawal should be tapered with follow-up rather than abrupt, since abrupt cessation of a benzodiazepine or of carbamazepine can provoke withdrawal symptoms and, in patients with any epileptic component, seizures. Withdrawal is best done after the diagnosis has been explained and accepted, not as a substitute for that explanation.
Every resident should know that antiseizure drugs do not treat dissociative attacks and that they can be stopped, so this item sits at the Core level of RITE content. Patients should also be advised about driving regulations and about avoiding emergency department attendance for typical attacks.
Incorrect Answers
- A. Indefinite continuation exposes her to adverse effects and undermines the diagnosis; status epilepticus is not a risk once epilepsy has been excluded.
- B. Abrupt cessation risks withdrawal phenomena and is unnecessary; a taper with follow-up is the recommended approach.
- C. Carbamazepine is equally unnecessary once epilepsy is excluded, and continuing it perpetuates the mistaken diagnostic label.
- D. Benzodiazepines do not terminate dissociative attacks, promote dependence, and risk harmful emergency treatment escalation.
Testing Pearls
- Antiseizure medication does not treat dissociative attacks and should be withdrawn.
- Withdrawal is safe when coexisting epilepsy has been rigorously excluded.
- Taper rather than stop abruptly, and arrange follow-up during withdrawal.
- A minority of patients have a transient increase in attack frequency during withdrawal.
- Reassess if a new or different attack semiology emerges during or after withdrawal.
References
- Jankovic J, Mazziotta JC, Newman NJ, Pomeroy SL, editors. Bradley and Daroff's Neurology in Clinical Practice. 8th ed. Philadelphia, PA: Elsevier; 2022. p. 2090.
- Oto M, Espie C, Pelosi A, Selkirk M, Duncan R. The safety of antiepileptic drug withdrawal in patients with non-epileptic seizures. J Neurol Neurosurg Psychiatry. 2005;76(12):1682-1685.
- LaFrance WC, Baker GA, Duncan R, Goldstein LH, Reuber M. Minimum requirements for the diagnosis of psychogenic nonepileptic seizures: a staged approach: a report from the International League Against Epilepsy Nonepileptic Seizures Task Force. Epilepsia. 2013;54(11):2005-2018.
