The American Academy of Neurology (AAN) has released its first guideline for the management of functional seizures, providing clinicians with timely recommendations on treating the commonly misunderstood condition.

Formerly known as psychogenic nonepileptic seizures or nonepileptic attack disorder functional seizures, are often misdiagnosed and managed as epilepsy, prompting the new guidance.

“This guideline is urgently needed because there is a growing body of evidence showing that psychological interventions can be effective in treating functional seizures,” Benjamin Tolchin, MD, MS, director of the Center for Clinical Ethics at Yale New Haven Health and associate professor of neurology at Yale School of Medicine in New Haven, Connecticut, told Medscape Medical News.

Many patients with functional seizures do not receive evidence-based treatment or receive no treatment at all, Tolchin said.

“Our hope is that this guideline will increase access to evidence-based treatment, increase awareness of the disorder and of effective treatment options, and decrease stigma relating to functional seizures,” he added.

He also noted that the name of the disorder was changed because surveys showed that patients and families find the term “psychogenic” to be stigmatizing and the term “functional seizure” connects the disorder to the broader category of functional neurological disorder.

The guidelines were published online on December 10 in Neurology.

Why Now?

Functional seizures — episodes that mimic epileptic seizures but stem from dissociative or other cognitive-affective mechanisms — are frequently misdiagnosed and managed as epilepsy. The current prevalence is estimated at 2-33 cases per 100,000 people. Previous studies have shown that patients with functional seizures experience diagnostic delays of roughly 7 years, largely due to misclassification as epilepsy.

Stigma and the lack of knowledge surrounding the disorder can affect diagnosis. “Another contributing factor may be that some clinicians incorrectly believe that patients with functional seizures are ‘faking’ or simulating their symptoms,” Tolchin said.

He noted that functional seizures are much more common than factitious disorder or malingering, and that these patients do not intentionally produce their symptoms. Psychotherapy can reduce seizure frequency and improve quality of life. However, the authors noted that many patients never receive treatment because of stigma, limited clinician familiarity, and poor access to mental health treatment.

These gaps, coupled with the risks of receiving unnecessary antiseizure medications was the impetus behind the development of the guideline.

To that end, the AAN convened a multidisciplinary expert panel that conducted a systematic review of 12 Class II-III studies and integrated the evidence with clinicians’ real-world experience.

Each study was independently rated using AAN therapeutic classification criteria, and conclusions were developed with a modified GRADE approach. The panel then used a modified Delphi process to translate the evidence and clinical expertise into practice recommendations.

Based on this process the experts developed key clinical practice recommendations. They include avoiding antiseizure medications for the treatment of functional seizures and informing patients about the benefits and risks of psychological interventions.

To determine whether a patient is experiencing functional seizures, epileptic seizures, or both, clinicians should start with a careful review of the patient’s history and seizure semiology, the guideline recommends. Videos of events or accounts from witnesses can further aid diagnosis.

Key Recommendations

EEG can help rule out co-occurring epilepsy. During a functional seizure, the brain’s electrical activity is typically normal, whereas epileptic seizures are marked by abnormal activity, or epileptiform discharges on EEG.

If still unclear, video-EEG can confirm the diagnosis with the greatest possible level of clinical certainty, the guideline states.

To differentiate between syncope and functional seizures, clinicians should assess blood pressure and cardiac rhythm during episodes.

The guideline also recommends clinicians avoid stigmatizing behavior, diagnose with clarity and empathy, involve the patient in treatment decisions, and assess the impact of disorder on their professional and social life.

Functional seizures frequently co-occur with psychiatric disorders such as mood or anxiety disorders. A previous study led by Tolchin showed that psychotherapy is linked to reduced functional seizure frequency and improved quality of life.

The guideline recommends clinicians assess patients with functional seizures for co-occurring psychiatric disorders and if present, refer the patient to a mental health specialist for treatment.

The systematic review also showed that psychological interventions may be effective in reducing seizure frequency, improving quality of life, and reducing anxiety among patients with functional seizures.

Compared with standard care, functional seizure-specific cognitive behavioral therapy might increase the chance of patients achieving freedom from functional seizures. Other interventions with evidence of efficacy for functional seizures are neuro-behavioral therapy, retraining and control therapy, and motivational interviewing.

Need for Head-to-Head Trials

However, there are currently no head-to-head comparisons of psychological interventions, so it’s not possible to say one intervention is better than another, Tolchin said.

“If psychological interventions for functional seizures are available, neurologists can discuss with patients and mental health clinicians whether those specialized interventions can be introduced into their current psychotherapy regimen, provided in parallel, or provided in series,” he said.

The guideline recommends that clinicians also provide information about the benefits and risks of psychological interventions, and with patient permission, involve family or other caregivers in treatment decisions.

Patients with functional seizures who do not have co-occurring epilepsy or another clear indication for antiseizure medication should not be prescribed these drugs, and those already taking them should taper off. The guideline authors also noted that there is insufficient evidence that benzodiazepines are effective for functional seizures, a point clinicians should clearly communicate to patients.

Tolchin pointed to a 2024 nationwide administrative claims database study that showed 15% of patients with functional seizures received benzodiazepines in the month prior to diagnosis and 18% received benzodiazepines in the month following diagnosis.

However, the authors noted that epilepsy can co-occur in up to 20% of patients with functional seizures and, in this case, antiseizure drugs should be prescribed.

While the guideline highlighted the latest evidence of potential beneficial treatments for functional seizures, the authors noted that much more research is needed.

Predictive machine learning or artificial intelligence could advance diagnostic tools for functional seizures. Studies investigating the disorder’s pathophysiology could also inform future treatments and research.

The most important next steps for patient care, Tolchin said, will be to conduct studies that directly compare psychological interventions and evaluate their long-term outcomes.

“We hope that the guideline will raise awareness of functional seizures among clinicians, policymakers, and the general public, improve access to diagnosis and treatment, and strengthen shared decision-making,” he said.

Tolchin reported that his institution received research funding from the US Department of Veterans Affairs and the C.G. Swebilius Foundation.