AAN Publishes First-Ever Guideline for Functional Seizure Care Management

In recent news, the American Academy of Neurology (AAN) has released a new practice guideline outlining evidence-based approaches to the diagnosis and management of functional seizures, a condition marked by seizure-like episodes that are not due to epilepsy. The document aims to address persistent gaps in care, including delayed diagnosis, inconsistent treatment practices, and ongoing stigma, while guiding clinicians toward more standardized, patient-centered care.

“Over the 2010s into 2020 there was a completion of multiple randomized trials of different psychological interventions. That buildup of higher quality evidence over the course of 5-7 years made it clear that it was time for a guideline,” study author Benjamin Tolchin, MD, FAAN, told NeurologyLive®. “At the same time, there was a lot of interest from clinicians, patients, families, and advocates for greater guidance, because there’s so much variability in diagnosis and treatment (of functional seizures).”

Informed by a systematic review of available studies through early 2025 and the expertise of a multidisciplinary panel, the guideline places strong emphasis on semiology-based diagnosis, assessment of psychiatric comorbidities and co-occurring epilepsy, and the use of psychological interventions as a central treatment approach. It also cautions against the routine use of antiseizure medications and benzodiazepines in the absence of another indication, while highlighting the importance of clear communication, shared decision making, and continuity of care. Below is a breakdown of the key sections and clinical recommendations.

Practice Recommendations

Diagnosis of Functional Seizures

Here, study authors tackle the longstanding issue of delayed diagnosis in functional seizures, historically averaging 7–8 years after symptom onset. The guideline stresses that functional seizures should be considered early in the differential of seizure-like and syncope-like episodes to avoid misdiagnosis, unnecessary antiseizure treatment, and iatrogenic harm. Diagnosis is framed as a positive, semiology-driven process, grounded in detailed clinical history, witness accounts, and ictal observation when possible.

Although video-EEG capture of a typical event remains the gold standard for a definite diagnosis, the guideline recognizes real-world access limitations and supports a graded diagnostic approach. When VEEG is not feasible, clinicians may rely on combinations of history, semiology, interictal or ambulatory EEG, and smartphone-recorded events. Cardiac evaluation is emphasized when syncope is a consideration, and clinicians are reminded to screen for co-occurring functional neurologic symptoms and refer to specialists when diagnostic confidence or expertise is limited.

Tolchin, director of the Center for Clinical Ethics at Yale New Haven Health, added, “The diagnosis begins with the history and semiology, meaning how the patient’s events have developed and what the seizure episodes look and feel like. We highlight the importance of getting as much information as possible by interviewing the patient, eyewitnesses, family, or friends, and by obtaining smartphone videos of typical episodes. Getting a video, even before video EEG, can be very helpful in informing the diagnostic workup.”

Psychiatric Comorbidities and Co-occurring Epilepsy

This section emphasizes that functional seizures commonly coexist with psychiatric disorders, including mood and anxiety disorders, PTSD, personality disorders, substance use, and significant trauma histories. These comorbidities influence treatment engagement and outcomes, as greater psychiatric burden is linked to lower adherence to psychotherapy, which is associated with better seizure control and quality of life. The guideline therefore positions routine psychiatric screening and referral for evidence-based mental health treatment as a central part of functional seizure care.

“Evaluating co occurring disorders is a really important part of the initial workup,” Tolchin continued. “Studies show that up to 90% of patients with functional neurologic disorders may have co occurring psychiatric disorders, including depression, anxiety, PTSD, or bipolar disorder. Active untreated psychiatric comorbidities can make the treatment of functional seizures much more complex and much more difficult.”

The guideline also highlights the frequent overlap between functional seizures and epilepsy, requiring careful differentiation of event types. Clinicians should use history, semiology, and VEEG when feasible to distinguish seizures, treat epileptic events with appropriate antiseizure medications, and counsel patients that these therapies do not address functional seizures.

General Principles of Management

Care for functional seizures includes psychological therapies as a key component of evidence informed treatment. Several approaches, including functional seizure specific CBT, ReACT, neurobehavioral therapy, paradoxical therapy, psychoeducation, behavioral interventions, and motivational interviewing combined with psychotherapy, are linked to reductions in seizure frequency, greater likelihood of seizure freedom, and improvements in anxiety, quality of life, and psychosocial functioning. CBT based therapies and ReACT show some of the most consistent benefit across multiple outcomes.

These interventions are generally safe and well tolerated, but success depends on patient engagement, understanding of treatment goals, and social support. The guideline highlights the importance of discussing potential benefits and treatment demands with patients, referring to trained clinicians when needed, and involving family or caregivers in care, particularly for children and, when appropriate, for adults to support better outcomes.

Psychological Interventions

Care for functional seizures includes psychological therapies as a key component of evidence informed treatment. Several approaches, including functional seizure specific CBT, ReACT, neurobehavioral therapy, paradoxical therapy, psychoeducation, behavioral interventions, and motivational interviewing combined with psychotherapy, are linked to reductions in seizure frequency, greater likelihood of seizure freedom, and improvements in anxiety, quality of life, and psychosocial functioning. CBT based therapies and ReACT show some of the most consistent benefit across multiple outcomes.

Tolchin added, “One of the really key findings from the systematic review is that psychological interventions can be effective in achieving freedom from functional seizures, reducing seizure frequency, improving quality of life, and decreasing anxiety. That was shown across multiple randomized trials.”

These interventions are generally safe and well tolerated, but success depends on patient engagement, understanding of treatment goals, and social support. The guideline highlights the importance of discussing potential benefits and treatment demands with patients, referring to trained clinicians when needed, and involving family or caregivers in care, particularly for children and, when appropriate, for adults to support better outcomes.

Pharmacologic Interventions

Medication use in functional seizures is often a legacy of initial misdiagnosis. Many patients are started on antiseizure medications or benzodiazepines before the correct diagnosis is made, and these drugs are frequently continued despite a lack of evidence that they treat functional seizures themselves. While antiseizure medications remain appropriate for co-occurring epilepsy and psychopharmacologic agents for psychiatric disorders, the guideline makes clear that neither class has demonstrated efficacy for the direct treatment of functional seizures.

The risks of medication overuse are emphasized. Benzodiazepines carry risks of dependence, cognitive effects, motor vehicle accidents, and iatrogenic harm in emergency settings, including intubation. Antiseizure medications also have a broad adverse effect profile, ranging from fatigue and dizziness to rare but life-threatening complications. For patients with functional seizures without another clear indication, the guideline supports counseling about lack of benefit and tapering off unnecessary antiseizure medications to improve outcomes and reduce harm.

“There really is not evidence of benefit in the treatment of functional seizures with these medications… and at this point the evidence is sufficient to recommend that antiseizure medications, including benzodiazepines, should not be initiated for the treatment of functional seizures unless there is another clear indication,” Tolchin concluded.

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