Psychological interventions are associated with improved seizure-related outcomes in patients with functional seizures, according to a new clinical practice guideline from the American Academy of Neurology (AAN).
The guideline, published in Neurology, was developed by a multidisciplinary panel that conducted a systematic review and integrated findings with clinical experience to create evidence-based recommendations for diagnosing and managing functional seizures.
Based on 7 Class III studies, psychological interventions were associated with a higher probability of achieving seizure freedom compared with standard medical care, routine clinical care, nondirective supportive therapy, informational interviews, diazepam, or no therapy, with a pooled risk ratio of 1.87. Use of psychological interventions also corresponded with lower functional seizure frequency, with a pooled standardized mean difference of −0.81. Studies indicated that psychological interventions may improve health-related quality of life and psychosocial functioning, whereas evidence was insufficient to determine effects on depression and seizure symptom burden.
"Psychological interventions...possibly increase the probability of achieving freedom from functional seizures during the follow-up period," wrote lead study author Benjamin Tolchin, MD, of the Department of Neurology at Yale School of Medicine, and colleagues. The researchers rated their confidence in these estimates as low, anchored by the class of studies.
In developing the guideline, the panel followed a National Academy of Medicine–compliant process and conducted a systematic review of peer-reviewed literature published through February 25, 2025. Searches of MEDLINE, Embase, PsycINFO, and CINAHL identified 12 eligible Class II and Class III studies. Each study was independently rated by two panel members using AAN criteria for therapeutic studies, and evidence synthesis used a modified Grading of Recommendations Assessment, Development, and Evaluation framework.
Psychological interventions evaluated across studies included functional seizure–specific cognitive behavioral therapy (CBT), neurobehavioral therapy, Retraining and Control Therapy, behavioral therapy, motivational interviewing, group psychoeducation, body-focused group therapy, and psychotherapy with protocolized review of videotaped functional seizures. Interventions typically ran for 3 to 12 sessions. Long-term outcome data were not available beyond 1 year of follow-up.
Because psychological approaches varied across studies, the panel conducted additional analyses restricted to studies evaluating functional seizure–specific CBT. In these analyses, the pooled risk ratio for seizure freedom was 1.76, appearing to favor CBT over standard medical care.
Evidence supporting pharmacologic interventions was limited. Studies evaluating sertraline and diazepam did not demonstrate consistent benefit, and confidence in these estimates was reported as very low.
The guideline includes the following key recommendations:
When evaluating patients with seizure-like episodes, clinicians should seek historical and semiological information from both patients and witnesses and may obtain video-EEG of all typical seizure-like episodes where feasible. Clinicians should evaluate patients diagnosed with functional seizures for co-occurring psychiatric disorders and co-occurring epilepsy. Clinicians should adhere to universal standards of care for patients, including speaking respectfully, refraining from unnecessary harm, and avoiding stigmatizing behavior. Clinicians should provide a specific diagnostic label and rationale for the diagnosis, engage in shared decision-making regarding the treatment plan, and provide continuity of care to patients diagnosed with functional seizures.
When psychological interventions for functional seizures are indicated, clinicians should counsel patients regarding the potential benefits and risks and should refer interested and appropriate patients to these interventions. Clinicians should involve family, caregivers, or others in the social support network in the psychological treatment of patients with functional seizures.
Clinicians should not prescribe benzodiazepines or antiseizure medications for patients with functional seizures without co-occurring epilepsy or another indication for these medications. Clinicians should counsel patients regarding the potential risks and lack of evidence of benefit for using these medications for functional seizures. Clinicians should taper off antiseizure medications for patients with functional seizures and without another indication for these medications.
For full disclosure of the authors of the report, visit neurology.org.
Source: Neurology