Treating functional seizures: Psychological care may lead as medication benefit remains unclear
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Most people with functional seizures do not receive evidence-based treatment, and many have poor health-related quality of life—high levels of disability, low socioeconomic status, elevated caregiver burden, and high healthcare resource utilization and high healthcare cost.
—Benjamin D. Tolchin, MD, MS, FAAN
On the first day of the AAN 2026 Annual Meeting, experts discussed new guidelines in epilepsy and functional seizure treatment.
During the session, Benjamin D. Tolchin, MD, MS, FAAN, spoke on new guidelines regarding psychotherapeutic and psychopharmacological interventions in the management of functional seizures.[]
He explained that functional seizures—transient episodes of altered consciousness or involuntary movements resembling epileptic seizures or syncope—are thought to be driven by episodic dissociation and other cognitive-affective mechanisms.
“It has high levels of biopsychosocial complexity,” he said, with most patients experiencing concurrent psychiatric conditions and adverse life experiences.
For this reason, Dr. Tolchin said there’s a growing body of evidence that psychological treatments may be effective in treating functional seizures. The problem? Patients aren’t getting that care.
Psychological interventions may be better
“Most people with functional seizures do not receive evidence-based treatment, and many have poor health-related quality of life—high levels of disability, low socioeconomic status, elevated caregiver burden, and high healthcare resource utilization and high healthcare cost,” Dr. Tolchin said.
For kids, functional seizures mean worse quality of school and social life.
There are reasons for the lack of proper treatment, he added: Stigmatization, limited collaboration between neurologists and mental health care providers, lack of familiarity with the disorder, and limited access to healthcare, period.
Guidelines for treating functional seizures
When it comes to pharmacological interventions, he says, the AAN Guidelines Subcommittee found that “There is insufficient evidence to determine whether or not psychopharmacologic interventions change the probability of achieving seizure freedom, change the seizure frequency, health-related quality of life, or psychosocial functioning.”[]
Dr. Tolchin says clinicians need to seek historical and semiological information (including smartphone videos) from patients and witnesses and also evaluate patients for co-occurring psychiatric disorders and epilepsy. At the same time, mental healthcare providers shouldn’t just refer patients to a neurologist.
“Neurologists and mental health clinicians should collaborate in assessment and treatment,” Dr. Tolchin stresses. “Clinicians should adhere to universal standards of care for patients, including speaking respectfully, refraining from unnecessary harm, and avoiding stigmatizing behavior.”
More so, he says, clinicians should provide a diagnostic label and rationalize for the diagnosis, while engaging in shared decision making with the patient.
As for pharmacologic interventions, Dr. Tolchin emphasizes the importance of counseling patients—without co-occurring epilepsy or another indication for benzodiazepines or anti-seizure medications—on the potential risks and lack of evidence of benefit, and should not prescribe these medications in such cases.
Patients with functional seizures who do not have an indication for ASMs (like epilepsy) should be tapered off of ASMs.