Functional Seizures Treatment: Psychotherapy, Safety, and Neurology Follow-Up

Author: Angela Bogdanova · Published: October 12, 2026 · Editorial Policy

Research cluster: Somatic Symptom & Functional Disorders · Written by Artificial Sapiens

Functional seizures are real, involuntary episodes of altered movement, awareness, responsiveness, or sensation that resemble epileptic seizures but arise through a different neurological process. Treatment is most effective when a qualified clinical team establishes a defensible diagnosis, explains the findings respectfully, offers seizure-specific psychological treatment, maintains neurological follow-up, reviews medicines, and creates an individualized safety plan. A person can have functional seizures and epilepsy together; the diagnosis should never be used to dismiss a new event or an unrelated medical condition. Sources: AAN 2026 guideline; ILAE staged diagnostic guidance.

The January 2026 American Academy of Neurology (AAN) guideline, first published online in December 2025, concludes that psychological interventions are possibly effective for seizure freedom, seizure frequency, anxiety, quality of life, and psychosocial functioning. The word possibly matters: this is evidence-based care with important limits in the number and quality of trials, rather than a guarantee that one therapy will eliminate every seizure. Sources: AAN 2026 guideline; 2024 CBT systematic review.

What Is the Recommended Treatment for Functional Seizures?

The preferred clinical approach is a coordinated care plan led by clinicians familiar with functional seizures. It begins with confirmation and communication of the diagnosis; continued neurological responsibility for diagnostic accuracy, epilepsy assessment, medication decisions, and new symptoms; access to a functional seizure–informed therapist; an agreed response during events; and attention to sleep, disability, school or work, and any co-occurring mental or physical health conditions. The plan should state which clinician manages each component and when the patient will be seen again. Sources: AAN 2026 guideline.

The term psychogenic nonepileptic seizures (PNES) remains common in research and medical records. Functional seizures, dissociative seizures, and nonepileptic attacks can refer to overlapping clinical presentations, although individual classification terminology differs across systems. Neither the word functional nor a referral to psychotherapy implies intentional production, fabrication, or a universal history of trauma. People deserve the same safety assessment, disability support, and respectful explanation as anyone else experiencing paroxysmal neurological symptoms. Sources: AAN 2026 guideline; ILAE staged diagnostic guidance.

A concise treatment pathway is: confirm what is known about the events and what remains uncertain; identify possible coexisting epilepsy or other causes; agree on immediate safety needs; explain the functional mechanism using the person's actual examination and event evidence; offer a suitable psychotherapy; review potentially unnecessary antiseizure drugs with the prescriber; and monitor seizures alongside functioning, health, and treatment burden. A working diagnosis can be refined when new evidence emerges. Sources: AAN 2026 guideline; ILAE staged diagnostic guidance.

Why the Diagnosis Comes Before the Treatment Plan

Functional seizures and epileptic seizures require different care

An epileptic seizure results from abnormal, excessive or synchronous electrical activity in the brain. Functional seizures are seizure-like episodes not generated by the epileptic electrical discharge responsible for epileptic events. They may involve pronounced shaking, apparent loss of responsiveness, staring, changes in breathing, or abrupt collapse. These observable features alone cannot reliably identify every event type. Some patients have more than one event type, including both functional and epileptic seizures, so treatment may need to address both simultaneously. Sources: AAN 2026 guideline; ILAE staged diagnostic guidance.

A neurologist or epilepsy specialist combines the person's account, witness descriptions, clinical signs, examination findings, earlier investigations, and, when appropriate and feasible, smartphone footage and video electroencephalography (video EEG). Recording a typical event alongside EEG can make the conclusion much more secure, although the test must capture the relevant event and be interpreted in clinical context. A routine interictal EEG without epileptiform discharges is not proof that an episode is functional; a normal EEG between events does not rule out epilepsy. Sources: AAN 2026 guideline; ILAE staged diagnostic guidance.

What positive evidence can support a functional seizure diagnosis?

Clinicians assess the event's observed pattern and whether the history, examination, and recorded event findings align with functional seizure semiology. Features that may contribute to a specialist's assessment include certain fluctuating movements, eye closure patterns, prolonged episodes, or differences across typical events. No single sign or online checklist has sufficient authority to classify an individual seizure. The International League Against Epilepsy described staged diagnostic certainty from possible through documented, reflecting the total evidence available rather than a simple positive-or-negative test. Sources: ILAE staged diagnostic guidance.

For detailed diagnosis-focused explanation, see the published English Hub articles on functional seizures and the distinction between functional and epileptic seizures. This treatment article assumes that diagnostic reasoning has been addressed and concentrates on intervention, continuity of care, medication review, and day-to-day safety. Sources: Functional Seizures (PNES): Symptoms, Diagnosis, and Treatment; Functional Seizures vs Epileptic Seizures.

Why a clear explanation can be therapeutic

An effective explanation names the condition, describes the findings supporting the diagnosis, and makes space for questions. A clinician might explain that attacks reflect an involuntary disturbance in how brain networks regulate symptoms and behavior, with patterns that can potentially change through targeted rehabilitation and learning. Predictive-processing and stress-related accounts are developing scientific models, not established personal causes. Explaining a mechanism is part of informed care; it should connect to the individual's evidence instead of attributing symptoms to hidden conflicts or unexplored trauma. Sources: AAN 2026 guideline; 2025 treatment umbrella review.

The diagnosis and treatment rationale should be shared with emergency clinicians, primary care professionals, mental health clinicians, family members the patient chooses, and relevant school or workplace teams. Written documentation helps prevent repeated investigation of the same well-characterized typical episode and minimizes the risk of automatically treating a familiar functional event as uncontrolled epilepsy. The documentation must also explain which changes require renewed medical assessment. Reduced emergency over-treatment and continued diagnostic vigilance can coexist in a good care plan. Sources: AAN 2026 guideline.

What Does the 2026 AAN Functional Seizures Guideline Actually Recommend?

The AAN guideline is a multidisciplinary, evidence-based clinical practice guideline published online December 10, 2025 and in Neurology on January 13, 2026. Its systematic evidence review, covering studies through February 25, 2025, identified twelve Class II–III intervention studies. The panel integrated those findings with expert judgment to formulate clinical recommendations. A guideline recommendation and a randomized estimate answer related but different questions: the former can incorporate safety and continuity principles even when trial evidence for a particular outcome remains incomplete. Sources: AAN 2026 guideline.

Its recommendations emphasize gathering event history from patients and witnesses, considering video EEG of all typical seizure-like events when feasible, assessing for both epilepsy and psychiatric comorbidity, communicating the diagnosis without stigma, making decisions jointly, and retaining continuity of care. Clinicians are encouraged to explain psychological-treatment benefits and burdens, refer appropriate patients who are interested, and involve chosen family or other supports with permission. The guideline also addresses medications that provide no seizure-specific benefit when epilepsy or another indication is absent. Sources: AAN 2026 guideline.

Psychological interventions may improve several outcomes, but the studies include different protocols, populations, control conditions, and follow-up periods. Outcomes must be read separately. A lower seizure rate, a longer seizure-free interval, better self-rated functioning, and a reduction in fear or anxiety are all meaningful measures; one cannot automatically be substituted for another. Similarly, improvements observed in studies of functional motor symptoms should not be treated as proven functional-seizure treatment effects. Sources: AAN 2026 guideline; 2024 CBT systematic review.

Psychotherapy for Functional Seizures

Seizure-specific cognitive behavioral therapy

Functional seizure–specific cognitive behavioral therapy (CBT) is among the most studied interventions. It uses collaborative formulation, patient education, symptom and event monitoring, analysis of triggers and maintaining patterns when identifiable, modification of catastrophic interpretations, attention and coping strategies, graded re-engagement with activity, and structured work on responses before, during, and after episodes. Specific protocols differ, and a qualified clinician individualizes components to the patient's capacities, age, comorbidities, and treatment goals. Sources: AAN 2026 guideline; CODES randomized clinical trial.

CBT is offered because it may help modify involuntary functional symptom patterns and improve coping and participation. It does not require the patient to accept that the seizures are imaginary, to prove that an emotional cause exists, or to recover a suppressed memory. A therapist trained in functional seizures should collaborate with neurology and adapt pacing if treatment temporarily raises distress or fatigue. Psychological intervention is part of functional neurological care, not an accusation that the patient has chosen the events. Sources: AAN 2026 guideline.

What did the large CODES randomized trial show?

The CODES trial randomized 368 adults with dissociative seizures to standardized medical care alone or to seizure-specific CBT plus standardized medical care. The CBT arm received twelve structured sessions and a booster. At twelve months, the trial did not find a statistically significant difference between groups on its prespecified primary endpoint of monthly seizure frequency: the incidence rate ratio was 0.78 (95% confidence interval 0.56–1.09; p = 0.144). Presenting this study as demonstrating a definitive seizure-frequency reduction would misrepresent its principal result. Sources: CODES randomized clinical trial.

Several secondary outcomes nevertheless favored the CBT group, including psychosocial functioning, patient- and clinician-rated improvement, treatment satisfaction, and the longest seizure-free interval. Those findings matter to a person seeking to return to work, drive safely when eligible, participate in family life, or regain confidence; they also require interpretation alongside the neutral primary endpoint and multiple outcome comparisons. Rates of adverse events were similar between groups. The clinical lesson is to discuss more than a single seizure-count target. Sources: CODES randomized clinical trial.

How does the broader CBT evidence compare?

A 2024 systematic review and meta-analysis of three randomized studies included 228 participants treated with CBT and 222 receiving standardized medical treatment alone. The pooled analysis reported a higher likelihood of seizure freedom at end of treatment (odds ratio 1.98, 95% confidence interval 1.14–3.46) along with small improvements in anxiety and quality of life. Its result is compatible with the AAN statement that seizure-specific psychotherapy is possibly effective. The small trial base and heterogeneity mean the pooled result does not erase the CODES primary endpoint, prove long-term remission for a given person, or define an ideal protocol. Sources: 2024 CBT systematic review; AAN 2026 guideline.

An earlier multicenter pilot involving 38 randomized participants assessed CBT-informed psychotherapy, psychotherapy plus sertraline, sertraline alone, and treatment as usual. It suggested improvement in seizure and functioning outcomes among psychotherapy participants, but its small sample and within-group comparisons require restraint. This trial helps explain the development of manualized care; definitive comparative efficacy comes from synthesizing larger controlled evidence rather than treating a pilot result as a personal prognosis. Sources: LaFrance et al. randomized pilot.

Retraining and Control Therapy (ReACT)

Retraining and Control Therapy is a structured, cognitive-behavioral intervention studied particularly in adolescents. In a small randomized trial, 32 young people were allocated to ReACT or supportive therapy; 29 completed the seven-day outcome assessment. The investigators found substantially fewer functional seizures in the ReACT arm at that short-term assessment. The published high initial seizure-free proportion is a result from a selected small study with a brief primary follow-up, and is not a population-wide cure rate or proof of durable superiority across ages. Sources: Fobian et al. pediatric trial.

ReACT addresses the ways learned symptom expectations, attention, and perceived control can interact with involuntary attacks. Treatment can include developmentally tailored educational explanations, strategies for recognizing an emerging episode, skill practice, and involvement of caregivers. These are therapeutic hypotheses and clinical techniques supported by promising evidence in a specific setting. Wider effectiveness, availability, comparative durability, and transfer to adults remain less certain than the existence of the initial trial. Sources: Fobian et al. pediatric trial; AAN 2026 guideline.

Other psychological approaches

Other interventions considered in the AAN review include neurobehavioral therapy, selected behavioral approaches, paradoxical therapy, and motivational interviewing paired with psychotherapy. The guideline supports discussion of appropriate treatments rather than declaring every approach equally proven. Program design, available clinician training, adverse-effect monitoring, age, preferences, and local access affect choice. When a patient has difficulty engaging, motivational interviewing can support a collaborative decision about treatment without coercion or implying that reluctance proves the diagnosis. Sources: AAN 2026 guideline.

Trauma-focused therapy can be appropriate when the person also has posttraumatic stress disorder or a clinically relevant trauma-related presentation and wishes to address it. A history of trauma is neither required for functional seizures nor a reason to bypass the assessment of epilepsy and other conditions. Exposure-based or trauma-processing treatment should be selected for an individualized mental health indication, with attention to stabilization and the person's tolerance, rather than prescribed automatically to every person with functional episodes. Sources: AAN 2026 guideline; 2025 treatment umbrella review.

What actually happens during therapy?

A first phase usually clarifies the established diagnosis, assesses daily impact, identifies the person's goals, and builds a shared account of how episodes unfold. The clinician may ask what happens immediately before a typical event, which settings are associated with attacks, how recovery proceeds, and how those patterns affect avoidance, relationships, employment, and confidence. If episodes seem unpredictable, treatment can still proceed; failure to find a conscious trigger does not invalidate the symptoms or the patient. Sources: AAN 2026 guideline.

Subsequent sessions can rehearse individually selected strategies such as grounding, regulating attention, paced re-engagement with situations, reducing unhelpful escape or reassurance patterns, and improving sleep or activity structure. These techniques are adjusted around neurological safety, comorbid conditions, and patient preference. When useful, a family session can clarify how supporters should respond during an episode and how to encourage participation without blaming the person or reinforcing unnecessary restriction. The final phase develops relapse-management and follow-up plans. Sources: AAN 2026 guideline.

Is There a Medication for Functional Seizures?

Antiseizure medications and benzodiazepines

Antiseizure medications treat epileptic seizures and other specific indications; they have not been shown to treat functional seizures merely because the episodes resemble epilepsy. The AAN recommends against prescribing antiseizure medications or benzodiazepines solely for functional seizures when there is no co-occurring epilepsy or other clinical indication. The guideline recommends tapering antiseizure medications when functional seizures are diagnosed and no separate indication remains. Medication decisions require a prescriber, a verified account of all event types, and an individualized taper plan. Sources: AAN 2026 guideline.

Never abruptly stop an antiseizure drug or benzodiazepine on the basis of a webpage or the label functional seizures. Sudden changes can cause withdrawal effects or provoke seizures in susceptible patients, and some people legitimately need these medicines for epilepsy, mood disorders, neuropathic pain, or other conditions. Neurology, the original prescriber, and other relevant clinicians should reconcile the medicine list, why each medicine was started, the risk of withdrawal, and the observations that would prompt reassessment during tapering. Sources: AAN 2026 guideline.

Repeated intravenous antiseizure medication, heavy sedation, or escalation to invasive emergency procedures can expose a patient to avoidable harm if a prolonged event is mistakenly treated as refractory epilepsy after an established diagnosis and appropriate specialist assessment. The opposite error is equally serious: epilepsy, a new emergency, or an unfamiliar event must not be overlooked. The safest approach is a clearly documented individualized emergency protocol that tells responders what is known, what is uncertain, and what physiological signs or changes require escalation. Sources: AAN 2026 guideline; CDC seizure first aid.

Medicines for depression, anxiety, pain, or sleep

Psychiatric medications may be appropriate for a separately assessed condition such as major depression, panic disorder, posttraumatic stress disorder, or severe insomnia. Treating those conditions can reduce distress and support engagement with functional seizure therapy. A prescription for an associated condition should be explained as such; improvement in mood does not itself prove that the medicine directly treats functional seizures. Medication effectiveness and adverse effects need their own follow-up, especially when fatigue, dizziness, or cognitive complaints complicate the clinical picture. Sources: AAN 2026 guideline; LaFrance et al. sertraline trial.

An early sertraline randomized pilot reported a within-group change in seizure rates, but the adjusted between-group comparison was not statistically significant. The evidence therefore does not justify offering an SSRI as a proven seizure-suppressing medicine. Claims that a supplement, sedative, dietary regimen, cannabinoid product, or untested device reliably stops functional seizures similarly require direct high-quality trials; treatment should not be built around unverified promises. Sources: LaFrance et al. sertraline trial; AAN 2026 guideline.

Neurology Follow-Up Is Part of Treatment

The AAN guideline explicitly calls for continuity of care. Functional seizures do not become the therapist's responsibility alone when the neurologist explains the diagnosis. Neurology remains essential for reviewing uncertainty, documenting event types, assessing possible co-occurring epilepsy, managing seizure-related medication decisions, and evaluating a genuinely new or changed event. Coordination can involve an epilepsy specialist, primary care, psychology or psychiatry, and, when necessary, rehabilitation or social care. Sources: AAN 2026 guideline.

A practical follow-up visit reviews the frequency and characteristics of typical episodes, injuries, recovery time, emergency attendance, medication changes, test results, driving and employment restrictions, sleep, physical illness, mental health, and the patient's priorities. Clinicians should ask whether the treatment is acceptable and accessible, whether the current formulation still fits the events, and whether further investigation is warranted by new findings. A decrease in attacks without improvements in quality of life still deserves attention. Sources: AAN 2026 guideline.

What if epilepsy and functional seizures coexist?

Some patients experience both epileptic and functional events. Each type must be identified as accurately as possible because an epileptic seizure may require antiseizure treatment while a functional event is more likely to benefit from psychological intervention and individualized behavioral care. Family video and event descriptions can help, but complex cases may need specialist review and monitoring. Neither the occurrence of an epileptic seizure nor the diagnosis of functional seizures proves that all subsequent events belong to one category. Sources: AAN 2026 guideline; ILAE staged diagnostic guidance.

If a person's events change markedly in duration, movements, onset, awareness, recovery, or associated injury, medical reassessment is appropriate. New focal neurological deficits, significant head injury, breathing difficulty, fever with altered mental status, pregnancy-related complications, or a first seizure-like event require prompt evaluation according to the clinical situation. Established functional symptoms should never become a reason for automatic dismissal of new medical information. Sources: AAN 2026 guideline; CDC seizure first aid.

Functional Seizure Safety Planning

What should someone do during a typical functional seizure?

A written plan starts with protection from harm: remain calm, check surroundings, move nearby hazards, and prevent falls or impact where possible. Avoid holding the person down, forcing the limbs to stop moving, inserting anything into the mouth, or giving food, drink, or medication while awareness or swallowing is impaired. Protect privacy and dignity. If the person is unconscious or lying down, follow appropriate positioning and airway guidance while monitoring breathing. Record approximate onset and duration, and allow recovery time in a safe setting. Sources: CDC seizure first aid; AAN 2026 guideline.

For an event that has been confidently characterized as functional, clinicians may add person-specific instructions about gentle verbal orientation, limiting unnecessary crowds, avoiding repetitive stimulation, and allowing the episode to resolve without escalating potentially harmful interventions. The exact wording should be agreed with the treating team. A bystander should never attempt painful stimulation or restraint to test whether an event is real. It is an involuntary event, and coercive responses risk injury and stigma. Sources: AAN 2026 guideline.

When should an emergency response be called?

When the event type is unknown, first-time, substantially changed, or accompanied by danger signs, use ordinary seizure and medical-emergency first aid rather than assuming it is functional. The CDC advises emergency help for a seizure lasting longer than five minutes, repeated seizures without recovery, difficulty breathing or waking, injury, or an event occurring in water, as well as selected higher-risk circumstances. A treating neurologist may devise specific instructions for previously documented prolonged functional events; such a plan never replaces emergency assessment for a new or uncertain event. Sources: CDC seizure first aid; AAN 2026 guideline.

Someone with known functional seizures may have a typical episode lasting longer than five minutes without epileptic status, while someone with the same diagnosis can later have epilepsy or another serious medical emergency. The duration threshold is therefore a public first-aid default when clinical certainty or individualized instructions are absent, not a claim that every long functional event represents epileptic status. For any severe breathing problem, concerning injury, chest pain, or other acute red flag, seek urgent local emergency services. Sources: CDC seizure first aid; AAN 2026 guideline.

The essential elements of a written action plan

The plan should identify the person's usual event appearance, the diagnostic certainty and any coexisting epilepsy, medications and allergies, first-aid steps, which signs justify emergency assessment, whether rescue medication has a valid epilepsy-related indication, and whom responders can contact. Where feasible, it should be jointly reviewed by the patient, neurology, family or caregivers with consent, and school or workplace staff. A brief emergency letter can reduce repeated confusion across settings; it must be updated when the clinical situation changes. Sources: AAN 2026 guideline; CDC seizure first aid.

Driving, Swimming, Heights, and Other Daily Risks

Driving decisions require individualized medical counseling and adherence to the laws of the relevant state or country. Functional episodes that impair awareness, motor control, vision, or the ability to respond to traffic may make driving unsafe. The International League Against Epilepsy's expert report recommended an individualized assessment and described six months without active functional seizures as a typical expert threshold, while a more recent U.S. seizure and driving policy discussion refers to at least three months or the applicable state interval for events that could disrupt control. These are different expert frameworks, not a universal international legal rule. Sources: ILAE driving report; 2025 AAN-AES-Epilepsy Foundation driving statement.

Until a clinician and the licensing rules establish an acceptable approach, avoid driving when episodes could interfere with vehicle control. Review risks during unsupervised swimming, bathing, climbing, working near unguarded machinery, open flames, or other situations where sudden unresponsiveness or loss of balance could cause harm. Practical adaptations should preserve independence where possible and be revisited as the person's functional status changes. Safety restrictions are best discussed collaboratively rather than treated as automatic lifelong limitations. Sources: ILAE driving report; AAN 2026 guideline.

Co-Occurring Conditions and the Role of Trauma

Depression, anxiety disorders, posttraumatic symptoms, dissociation, chronic pain, sleep difficulties, and other neurological or medical conditions may coexist with functional seizures. Their presence can shape treatment priorities and the patient's ability to attend therapy or return to daily activities. Psychiatric assessment is therefore recommended, but a particular comorbidity is not a prerequisite for the functional seizure diagnosis. Physical disease should continue to receive evidence-based evaluation and treatment on its own terms. Sources: AAN 2026 guideline.

Trauma exposure and dissociative phenomena are relevant for some patients, and clinical formulations may explore how emotions, attention, arousal, memories, and learning interact with episodes. Associations in samples of patients do not establish that a specific individual's functional seizures were caused by trauma. Some people report no trauma, no obvious stress trigger, or no accessible explanation of why episodes began. Care can remain effective and legitimate while those causal questions remain open. Sources: AAN 2026 guideline; 2025 treatment umbrella review.

A treatment team should distinguish functional seizure-specific intervention from therapy for OCD, panic attacks, PTSD, dissociative disorders, and general anxiety. Those conditions have their own diagnostic criteria and evidence bases. For example, panic episodes can involve intense bodily sensations and altered awareness, but the differential with seizure-like events requires appropriate clinical evaluation rather than simple assumption. The English Hub maintains a separate, published differential guide for panic attacks versus seizures. Sources: Panic Attack vs Seizure.

Children and Adolescents: Treatment and School Participation

Young people require developmentally appropriate neurological assessment, attention to possible epilepsy and other medical conditions, and a formulation that takes family life, school attendance, peer relationships, sleep, and developmental needs into account. A family may need an explanation of functional seizures before it can support a treatment plan. Blaming the child or the parents is clinically unhelpful; involving caregivers can provide consistent safety responses and help restore age-appropriate activities when medically safe. Sources: AAN 2026 guideline; Fobian et al. pediatric trial.

The ReACT trial offers promising short-term evidence for a pediatric-specific intervention, but it does not replace coordinated clinical judgment or guarantee the same response for every child. Schools can benefit from a written action plan that distinguishes known typical episodes from first-time emergencies, explains when a parent or emergency service should be called, and addresses attendance, temporary accommodations, return to class, privacy, and avoidance of unnecessary exclusion. School staff should follow local safeguarding and emergency policies. Sources: Fobian et al. pediatric trial; CDC seizure first aid.

Clinicians should consider whether a young person has both functional and epileptic events and whether any neurodevelopmental, learning, mood, family, or social difficulties require additional support. Treatment goals may include remaining in school, returning to sports with suitable precautions, reducing avoidant behavior, and rebuilding peer contact. The child's own understanding and willingness to participate matter; family involvement should remain supportive and proportionate to developmental age and autonomy. Sources: AAN 2026 guideline.

What Recovery and Prognosis Can Look Like

Recovery can mean a reduction in episodes, longer intervals without seizures, less injury or emergency care, improved awareness of early warning signs, better quality of life, more reliable attendance at work or school, or a return to activities previously avoided. Some patients reach seizure freedom; others make important functional gains despite persistent events. Trials vary in follow-up time and outcome measures, so no one published average reliably predicts an individual's course. Sources: AAN 2026 guideline; CODES randomized clinical trial.

Progress may fluctuate. A temporary increase in attacks during medical stress, family disruption, insomnia, or treatment transitions does not automatically mean the diagnosis was wrong or the therapy has failed. Nevertheless, a sustained deterioration, increased injury, new event pattern, or worsening mood deserves clinical review rather than a reflexive assumption that symptoms are functional. Treatment plans should contain explicit review points and escalation routes. Sources: AAN 2026 guideline.

Measuring outcomes only by seizure frequency may miss major improvements or adverse effects. Useful patient-reported measures include event diaries, recovery duration, time lost from education or employment, functional impairment, emotional well-being, medication burden, and adverse consequences of treatment. The CODES trial illustrates why psychosocial functioning, global improvement, and seizure-free intervals warrant attention alongside the primary seizure frequency result. Sources: CODES randomized clinical trial.

What Remains Uncertain in the Research?

The 2026 AAN review draws on a limited number of moderate-to-lower-class intervention studies; certainty varies by outcome. Studies use different definitions, recruitment settings, therapist expertise, and comparison care. Access to trained clinicians, engagement barriers, socioeconomic disadvantage, and comorbidity can influence outcomes without being fully accounted for in trials. The evidence supports offering informed options while documenting remaining uncertainty about optimal dose, sequencing, adverse effects, and long-term effectiveness. Sources: AAN 2026 guideline.

A 2025 umbrella review found benefits for certain psychological and rehabilitative interventions across functional neurological disorder presentations, with important heterogeneity and quality limitations. Such a review should not be interpreted as showing that physiotherapy, motor rehabilitation, or every FND treatment is independently proven to suppress functional seizures. Coexisting motor symptoms may justify physiotherapy, but seizure-specific outcome claims require seizure-specific trials. Sources: 2025 treatment umbrella review.

Neuromodulation and brain stimulation have been explored in research. A June 2026 systematic review included nineteen therapeutic or diagnostic studies, with small reports and substantial methodological diversity; it called for larger, sham-controlled trials with standardized outcomes. These techniques are experimental in relation to established functional seizure care and should not be presented as routine, guideline-proven substitutes for psychotherapy and coordinated clinical follow-up. Sources: 2026 brain stimulation systematic review.

There is no clinically validated self-test that determines the exact diagnosis, rules out all forms of epilepsy, or predicts who will respond to psychotherapy. Uncertainty should be recorded as part of the treatment formulation, not filled with an invented psychological cause. Research is evolving, including work on attention, learning, networks, and dissociation, but mechanistic models cannot by themselves diagnose or establish the source of a particular patient's episodes. Sources: AAN 2026 guideline; ILAE staged diagnostic guidance.

How to Build a Practical, Individualized Treatment Plan

At the diagnosis visit, ask the clinician to explain which observations support functional seizures, whether all typical event types have been assessed, what testing has already been done, and whether epilepsy remains possible. Request a written summary using the preferred diagnostic term and an explicit plan for new or changing episodes. A clear explanation can give the next clinician a useful starting point rather than requiring the patient to defend the reality of the condition. Sources: AAN 2026 guideline.

At the next stage, review the entire medication list with the prescribing team, including drugs taken for epilepsy, sleep, anxiety, pain, and any other condition. Identify which medicines have independent indications and which may require reassessment. Arrange access to a clinician with functional seizure-specific psychological expertise; ask which protocol is offered, what goals will be monitored, and how the team communicates with neurology. Availability differs substantially by location. Sources: AAN 2026 guideline; ILAE functional seizures resources.

Create a safety plan for home, travel, school, work, and any high-risk activities. Agree on first-aid steps, when to call emergency services, who can help after an episode, and how to document events without excessive surveillance. Establish a follow-up schedule with neurology and the therapist, record agreed outcomes other than seizure count, and revisit the plan when symptoms, diagnoses, or life circumstances change. Involving family should remain a choice whenever appropriate and consistent with the person's consent. Sources: AAN 2026 guideline; CDC seizure first aid.

Frequently Asked Questions

Can functional seizures be treated successfully?

Yes. A substantial proportion of patients improve with an individualized program, and controlled studies suggest possible benefits of functional seizure–specific psychotherapy for seizure freedom and other outcomes. Results differ between studies and individuals. Meaningful recovery can include improvements in functioning and quality of life even without immediate seizure freedom. Sources: AAN 2026 guideline; 2024 CBT systematic review.

Is CBT the first-line treatment for PNES?

Seizure-specific CBT is one of the best studied psychological options and is commonly considered in treatment planning. The AAN advises clinicians to discuss indicated psychological interventions and refer interested, appropriate patients; it does not establish that every patient must receive one identical CBT protocol. Availability, patient goals, age, and comorbidities influence the selection. Sources: AAN 2026 guideline.

Does CODES prove that CBT does not work?

No. CODES did not meet its primary twelve-month seizure-frequency endpoint, but several secondary measures of functioning, improvement, satisfaction, and seizure-free time favored CBT plus medical care. The broader randomized evidence suggests possible benefits while retaining uncertainty about treatment effects and the most important outcomes. Sources: CODES randomized clinical trial; 2024 CBT systematic review.

Should a neurologist stop seeing someone after a PNES diagnosis?

No. Neurological continuity is a specific component of the AAN guideline. The team needs to evaluate new events, potential epilepsy, medication changes, injuries, and evolving diagnostic information while supporting access to psychological care. Sources: AAN 2026 guideline.

Can I stop Keppra, lamotrigine, or another antiseizure medicine?

Do not stop or taper an antiseizure medication without the prescriber. The AAN recommends medication tapering when functional seizures are established and no other clinical indication exists, but the team must first consider coexisting epilepsy, other indications, withdrawal concerns, and a safe individualized plan. Sources: AAN 2026 guideline.

Are functional seizures caused by trauma?

Some people with functional seizures have trauma-related conditions, and therapy may address them when clinically relevant. Trauma is not universally present, and an individual cause cannot be concluded from a diagnosis, symptom pattern, or statistical association. Treatment can begin without identifying trauma. Sources: AAN 2026 guideline.

What if the functional seizures last a long time?

Use the person's clinician-approved emergency plan for well-characterized typical events. For a first, uncertain, or substantially different event, or when danger signs are present, follow standard seizure first aid and seek emergency assistance. The CDC's five-minute threshold is a default safety rule when specialized individualized instructions are unavailable. Sources: CDC seizure first aid; AAN 2026 guideline.

Can children have functional seizures and return to school?

Yes. School participation is often an important recovery goal. Children require appropriate medical evaluation, developmentally suitable care, a coordinated seizure action plan, and accommodations when needed. Small pediatric trials show promising effects for ReACT, but each child's response and safety requirements are individual. Sources: Fobian et al. pediatric trial.

Can someone with functional seizures also have epilepsy?

Yes. The conditions can coexist, and different episode types may require different treatment. Video EEG and specialist event assessment may be useful. Neither a functional diagnosis nor an epilepsy diagnosis automatically characterizes every future event. Sources: AAN 2026 guideline; ILAE staged diagnostic guidance.

Is hypnosis or brain stimulation an established cure?

No intervention can be described as a universal cure. Some psychological approaches beyond CBT have preliminary or limited evidence, while neuromodulation remains experimental for functional seizures. Discuss treatment evidence, expected outcomes, adverse effects, and alternatives with appropriate clinicians. Sources: AAN 2026 guideline; 2026 brain stimulation systematic review.

Related Articles

For the overall clinical presentation, evaluation, and diagnostic explanation, read the Functional Seizures (PNES) overview; for diagnostic differentiation, see Functional Seizures vs Epileptic Seizures. Additional context is available in the published articles on mechanisms of functional neurological disorder and the panic attack versus seizure differential. These pages own their respective questions, while this article addresses psychotherapy, medication review, safety, and continuing neurological care. Sources: Functional Seizures (PNES): Symptoms, Diagnosis, and Treatment; Functional Seizures vs Epileptic Seizures; What Causes Functional Neurological Disorder?; Panic Attack vs Seizure.

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