New neurology guideline reframes care for functional seizures — and exposes big gaps in access

Clear guidance, real consequences: what changed and why it matters now

The American Academy of Neurology has issued its first formal guideline on functional seizures, a condition that looks like an epileptic attack but has a different origin. The new guidance pushes clinical teams to treat these episodes as a neurological problem that is best addressed with specific psychological therapies and integrated care — not only with anti-seizure drugs.

That shift matters because many people with functional seizures have been misdiagnosed or given medicines that do little to help and can cause harm. The guideline’s practical tone aims to change what happens in clinics, emergency rooms and primary care offices. It sets out which types of therapy have the best evidence, how clinicians should communicate the diagnosis, and where the limits of current knowledge lie.

Practically, patients and health systems can expect a stronger push toward combined neurology and mental health care — which is sensible but will be hard to deliver. The guideline highlights the clinical need, while also exposing a yawning gap: few places have the trained therapists and integrated teams needed to follow the advice. For patients, that means clearer routes to helpful treatment in some spots, and frustration and delays in others.

What the guideline recommends — psychological treatments take center stage

The guideline is focused and cautious. It does not claim a cure-all. But it does make two firm points: first, functional seizures should be diagnosed carefully using clinical judgment and available tests; second, psychological interventions are the front-line treatment where evidence exists.

On therapies, the AAN rates cognitive-behavioral therapy (CBT) and certain trauma-focused and psychotherapeutic approaches as “probably effective” for reducing seizure frequency and improving quality of life. The guideline also highlights that tailored programs combining education about the diagnosis with psychotherapy and rehabilitation components tend to work better than single-session advice.

At the same time, evidence for many commonly used options — broad use of anti-seizure medications, generic counseling without specific focus, and some physical therapies — is weak or mixed. The guideline warns against reflexive medication escalation when seizures are functional in origin. It recommends clinicians stop unnecessary drugs when the diagnosis is clear and monitor for harms if medications continue.

The panel grades its advice carefully and points out where the data are thin. Many recommendations are conditional: they suggest a reasonable course but acknowledge that higher-quality trials are still needed. That leaves clinicians with a clearer playbook, but not a perfect one.

Understanding functional seizures: what they are, what they were called, and why they’re hard to spot

Functional seizures are episodes that look like epileptic seizures — involuntary shaking, unresponsiveness, staring spells — but they are not caused by abnormal electrical activity in the brain. For years they were labeled with various terms, including psychogenic non-epileptic seizures, conversion disorder, or dissociative seizures. That mixed terminology contributed to stigma and confusion.

Prevalence is hard to pin down, but neurologists see functional seizures frequently in specialized clinics. Diagnosis can be difficult because the outward events mimic epilepsy, and standard tests like EEG can be normal. Often the diagnosis is only confirmed after careful observation, a review of the event, and sometimes video-EEG monitoring in specialized centers.

Mistakes happen: patients with functional seizures are sometimes treated for years with anti-seizure medicines they don’t need, or their symptoms are minimized as “all in your head.” The guideline stresses that functional seizures are genuine, disabling events rooted in brain-body processes linked to stress, past trauma, or other medical conditions. Calling them functional does not mean they are voluntary or imagined.

What patients and clinicians should expect — care pathways, access and real-world barriers

For patients, the guideline promises clearer communication and a treatment plan that often includes psychotherapy, education about the diagnosis, and rehabilitation. For clinicians, it urges early, explicit discussion of the diagnosis in plain language and a plan that addresses physical safety, mental health needs, and social supports.

But the gap between advice and reality is large. Many communities lack therapists trained in the specific psychotherapies recommended. Neurology clinics are not always integrated with mental health teams, and insurance coverage for the types of therapy that help can be spotty. Those shortfalls risk turning a welcome clinical shift into an uneven patchwork of care.

Another practical issue is medication management. The guideline advises stopping unnecessary anti-seizure drugs when appropriate, but that requires careful planning and monitoring — something busy clinics and overworked patients may struggle to coordinate.

Clinicians weigh in: support, caveats and where research must go next

Reaction from neurologists and psychologists is broadly favorable. Many clinicians welcome a guideline that treats functional seizures seriously and gives concrete options instead of vague suggestions. The emphasis on psychotherapy and multidisciplinary care is widely seen as a step forward.

Experts also raise cautions. The body of randomized, high-quality trials remains small. Many recommendations rest on moderate-quality evidence or expert consensus. That means the guideline helps standardize care, but it also flags numerous unanswered questions: which specific therapy works best for whom, how long treatment should last, and how to adapt programs for different age groups or coexisting medical conditions.

Finally, critics note the policy gap: without investments in training, integrated clinics and reimbursable care pathways, the guideline will change recommendations on paper more than outcomes in many places.

Where to read the guideline and how clinicians can start following it

The guideline is publicly released by the professional body and is intended for neurologists, psychiatrists, primary care doctors and allied therapists. Clinicians should begin by reviewing the diagnostic criteria the panel outlines and checking which recommended psychotherapies their local teams can deliver.

Practical next steps the guideline suggests include building referral links between neurology and mental health services, offering clear patient education materials that explain the diagnosis without blame, and setting up structured follow-up to safely taper unneeded medications. Training programs for therapists and short educational modules for neurologists are likely to be the most immediate, high-impact investments to make the guideline work on the ground.

In short: the guidance reframes functional seizures as a treatable condition that needs integrated care. It gives clinicians a clearer map. Turning that map into care for every patient will require time, money and focused training.