NeuroVoices: Benjamin Tolchin, MD, FAAN, on First-Ever AAN Guidelines for Functional Seizures

Functional seizures remain one of the most common and challenging conditions encountered in epilepsy and general neurology clinics, yet approaches to diagnosis and treatment have historically varied widely across practices. Over the past decade, growing recognition of functional neurologic disorders, coupled with an expanding body of randomized clinical trial data, has underscored the need for clearer, evidence-based guidance to support clinicians managing these patients. As awareness has increased among neurologists, patients, and advocates alike, so too has demand for standardized recommendations that reflect both diagnostic rigor and evolving therapeutic strategies.

In response to this need, the American Academy of Neurology (AAN) recently published its first clinical practice guidelines focused specifically on functional seizures. Benjamin Tolchin, MD, FAAN, Director of the Center for Clinical Ethics at Yale New Haven Health and Associate Professor of Neurology at Yale School of Medicine, served as a study author on the guideline development panel. In a new iteration of NeuroVoices, Tolchin discussed the evidence base that prompted the guidelines, key recommendations related to diagnosis and treatment, and the most pressing gaps that remain in research and clinical care for patients with functional seizures.

NeurologyLive: What prompted the development of these guidelines, and how did the evidence reach a point where formal recommendations were needed?

Benjamin Tolchin, MD, FAAN: There has been increasing awareness among clinicians that functional seizures and other functional neurologic disorders are common and often underdiagnosed or variably managed. At the same time, there has been a steady accumulation of evidence about what is effective in treating functional seizures, particularly psychological interventions.

We had been discussing the possibility of guidelines as far back as 2014 or 2015, but at that time there were only a small number of randomized trials. When you are developing a guideline, you want to see a body of evidence, not just one or two isolated studies. Over the latter half of the 2010s and into the early 2020s, multiple randomized trials of psychological treatments were completed. That growth in higher quality evidence made it clear that the field had reached a point where guidance was both feasible and necessary. There was also increasing interest from clinicians, patients, and families who were looking for consistency in diagnosis and management.

From a diagnostic standpoint, what are the most important principles clinicians should follow when evaluating possible functional seizures?

Diagnosis begins with careful attention to history and semiology. Understanding how events developed over time, whether there are co-occurring psychiatric or medical issues, and what the seizures look and feel like is essential. Whenever possible, clinicians should gather information not only from the patient but also from eyewitnesses such as family members or friends.

We also strongly recommend the use of smartphone videos when available. Reviewing recordings of typical events can be extremely helpful, even before formal EEG monitoring, particularly when reviewed by a neurologist experienced in seizure diagnosis. To reach the highest level of diagnostic certainty, additional testing is often needed, including interictal EEG and, when appropriate, prolonged video EEG monitoring to capture typical events. This clarity is important not only for diagnosis but also for building confidence among patients, families, and clinicians as treatment moves forward.

How should clinicians approach assessment of psychiatric comorbidities and possible coexisting epilepsy in this population?

Evaluating comorbid conditions is a critical part of the workup. Studies suggest that a large majority of patients with functional neurologic disorders have co-occurring psychiatric conditions, most commonly depression and anxiety, but sometimes more severe illnesses such as post-traumatic stress disorder or bipolar disorder. At a minimum, patients should be screened for psychiatric comorbidities, and when possible, referred for formal psychiatric evaluation.

This is important because untreated psychiatric conditions can complicate psychotherapy for functional seizures. Addressing depression or anxiety often makes functional seizure treatment more effective. At the same time, clinicians must carefully assess for coexisting epilepsy. Systematic reviews indicate that roughly 20 to 22 percent of patients with functional seizures also have epileptic seizures. Distinguishing between these event types is essential for appropriate treatment decisions, including whether antiseizure medications are indicated.

What did the guideline conclude about psychological interventions, and how should clinicians think about referring patients for these therapies?

One of the most important findings from our systematic review is that psychological interventions can be effective in reducing seizure frequency, achieving seizure freedom, improving quality of life, and decreasing anxiety. These benefits were observed across multiple randomized trials.

Importantly, the interventions studied were not generic psychotherapy but treatments specifically tailored to functional seizures. These included cognitive behavioral therapy protocols designed for functional seizures, neurobehavioral therapy, motivational interviewing, and React for pediatric patients. When available, referral to providers trained in these condition-specific approaches is recommended. The publication of standardized treatment manuals is encouraging and should help expand access over time.

What does the evidence show regarding pharmacologic treatments for functional seizures?

Unfortunately, there is very limited evidence supporting pharmacologic treatment of functional seizures themselves. Available data do not demonstrate benefit from antiseizure medications, benzodiazepines, or antidepressants when used specifically to treat functional seizures. Based on this evidence, the guideline recommends against initiating these medications solely for functional seizures.

If a patient is already taking these medications without another clear indication, clinicians should discuss the lack of evidence and potential risks and consider tapering them. Benzodiazepines are a particular concern because while they may appear helpful in the short term, long-term use is associated with tolerance, cognitive effects, and withdrawal risks. That said, these medications may still be appropriate when used for other valid indications such as coexisting epilepsy or psychiatric disorders.

What are the biggest barriers to advancing research and treatment for functional seizures moving forward?

A major challenge is our limited understanding of the underlying pathophysiology. Functional seizures may represent a heterogeneous group of conditions rather than a single entity, and better neurobiological understanding could help refine diagnosis and guide treatment development.

We also need comparative studies between different psychological interventions, data on long-term outcomes, and guidance on second- or third-line treatments for patients who do not respond initially. Additionally, emerging modalities such as teletherapy and technology-assisted interventions require rigorous evaluation. These guidelines represent an important first step, but they are not the final word. Continued research will be essential to refine and expand care for patients with functional seizures.

Transcript was edited for clarity. Click here for more iterations of NeuroVoices.

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