AAN Issues Evidence-Based Guideline for Management of Functional Seizures

• The American Academy of Neurology (AAN) has released an evidence-based guideline outlining diagnostic and therapeutic recommendations for managing functional seizures.
• A systematic review identified 12 Class II–III studies demonstrating that psychological interventions may reduce seizure frequency and improve quality of life.
• The guideline advises against benzodiazepines and antiseizure medications for patients without co-occurring epilepsy and emphasizes shared decision-making.

A new clinical practice guideline from the American Academy of Neurology (AAN), published in Neurology, provides comprehensive recommendations for diagnosing and managing functional seizures. Developed through a systematic review of evidence up to February 2025, the guideline integrates findings from 12 therapeutic studies along with expert consensus to address significant treatment gaps and improve patient outcomes.

The guideline panel conducted a National Academy of Medicine–compliant systematic review, identifying 12 Class II–III studies evaluating psychological and pharmacologic interventions. Psychological treatments included functional seizure–specific cognitive behavioral therapy (CBT), neurobehavioral therapy, Retraining and Control Therapy (ReACT), behavioral approaches, motivational interviewing, and group psychoeducation. Interventions typically ranged from 3 to 12 sessions, though long-term outcome data beyond 1 year remain unavailable.

Across 7 Class III studies, psychological interventions “possibly increase the probability of achieving freedom from functional seizures,” with a pooled risk ratio (RR) of 1.87 (95% CI 1.36–2.56). Three Class III studies showed a possible reduction in seizure frequency (standardized mean difference [SMD] –0.81). These interventions also possibly improve health-related quality of life (SMD 0.37) and psychosocial functioning (SMD –0.44).

The evidence for pharmacologic therapy remains insufficient. Two studies assessing sertraline and 1 evaluating diazepam did not demonstrate clear benefit for achieving seizure freedom, improving quality of life, or reducing psychiatric symptoms. The guideline therefore recommends against using benzodiazepines or antiseizure medications for functional seizures unless co-occurring epilepsy or another valid indication is present.

Diagnostic recommendations emphasize thorough history-taking, semiology assessment, and use of video-EEG when feasible. Smartphone videos reviewed by neurologists may assist diagnosis when formal monitoring is unavailable.

Functional seizures often involve substantial biopsychosocial complexity, and misdiagnosis can lead to inappropriate treatments, delays, and harm. The guideline highlights that obtaining historical details, eyewitness accounts, and semiological features—supported by video-EEG when possible—improves diagnostic accuracy and reduces unnecessary antiseizure medication exposure.

Psychological interventions form the core of evidence-supported treatment, offering potential benefits in seizure reduction, anxiety improvement, and quality-of-life gains. Clinicians are encouraged to provide clear diagnostic explanations, engage in shared decision-making, address co-occurring psychiatric conditions, and maintain continuity of care.

The guideline also underscores the importance of avoiding stigmatizing behavior, supporting patient self-management, and involving family or caregivers when appropriate to strengthen therapeutic engagement.

Lead author Benjamin Tolchin, MD, Department of Neurology, Yale School of Medicine, New Haven, CT, and co-authors note that “most people with functional seizures do not receive targeted and evidence-based treatment, contributing to ongoing functional seizures and disability.” This context underscores the critical need for standardized approaches to diagnosis, communication, and referral pathways.

The new AAN guideline provides clinicians with a structured, evidence-based framework to diagnose and manage functional seizures, prioritizing psychological interventions, careful diagnostic evaluation, and patient-centered communication. Implementation of these recommendations may reduce harm, improve outcomes, and guide future research priorities.

Reference:

Tolchin B, Goldstein LH, Reuber M, et al. Management of functional seizures practice guideline executive summary: report of the AAN guidelines subcommittee. Neurology. 2025;106(1):e214466. doi:10.1212/WNL.0000000000214466.