A self-guided online programme cut functional seizures in a small trial

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A brief, self-guided online programme reduced the frequency of functional seizures compared with usual care in a small Australian randomised trial published in JAMA Neurology [s1]. The finding matters because effective treatment for this condition is scarce and hard to reach — but the trial is small, and its most striking result is one the authors did not predict.

Functional seizures — episodes that look like epileptic seizures but arise from how the brain processes and controls movement and awareness, not from the abnormal electrical discharges of epilepsy — are common in neurology clinics and genuinely disabling. They are also chronically undertreated: the psychological therapies that help are concentrated in a few specialist centres, leaving most patients without access. A scalable, internet-delivered option could narrow that gap, which is what this trial set out to test [s1].

What the trial did

This was a three-arm, parallel randomised trial conducted between February 2022 and April 2024 at a specialist outpatient clinic in Melbourne, with follow-up to 12 months, registered as ACTRN12622000262707 [s1][s2]. It enrolled adults with functional seizures confirmed by video EEG monitoring and at least four seizures a month, excluding people with active epilepsy [s1]. Participants were randomly assigned 1:1:1 to one of three options: a self-guided internet programme plus standard care, a therapist-guided version of the same programme plus standard care, or standard care alone [s1]. The programme, called Re-PROGRAM, is five structured sessions drawing on cognitive behavioural, acceptance and commitment, and dialectical behaviour therapy, plus seizure-management and lifestyle elements [s1]. The primary outcome was monthly seizure frequency at 6 weeks, 6 months and 12 months, from a daily seizure diary [s1].

Of 220 people screened, 107 were randomised (mean age 36, 83% women), and 96 contributed to the full analysis [s1]. These are small numbers, which is the first thing to hold in mind. Functional seizures have historically been under-researched relative to their burden — long stranded between neurology, which can rule out epilepsy but has little to offer afterwards, and psychiatry, which many patients are reluctant to be referred to. A trial that puts a concrete, deliverable treatment to the test at all is therefore notable, even before its numbers are weighed.

What it found

The self-guided arm cut seizures substantially. Compared with standard care, it produced an overall rate ratio of 0.35 (95% CI 0.18–0.69; p=0.006) — roughly two-thirds fewer seizures — with the effect sustained at 6 weeks (0.37), 6 months (0.31) and 12 months (0.35), all statistically significant [s1]. It also improved anxiety at every timepoint and helped depression and mental quality of life at some points [s1]. No adverse events were reported in any arm [s1].

The therapist-guided arm is where the result turns counterintuitive. It improved anxiety at 6 months but its reduction in seizure frequency did not reach statistical significance, and a direct comparison between the two active arms found no significant difference between them (rate ratio 0.67, 95% CI 0.33–1.36) [s1]. In other words, adding a therapist did not clearly beat the self-guided version — and on the primary measure the self-guided arm was the one that separated from usual care.

How to read it

The mismatch between arms is the part to read carefully. A self-guided programme outperforming a therapist-guided one runs against intuition and, with only about 30 people per arm, is exactly the kind of pattern that small trials can throw up by chance. The wide confidence interval on the direct comparison (0.33–1.36, spanning no difference) means the trial cannot actually distinguish the two approaches; it is underpowered for that question [s1]. The trial was also single-centre, open to the usual expectation effects when a diary is the outcome and participants know their assignment, and it measured seizures rather than return to work, independence or other life outcomes.

What it means

The useful, defensible takeaway is modest and real: a short internet-based programme, deliverable without a specialist therapist's time, was associated with fewer functional seizures sustained to a year in this trial [s1]. That is promising for a condition where access is the central problem. Whether the self-guided version is truly as good as — or better than — therapist support, and whether the effect holds in larger, multi-centre populations, are questions this trial raises rather than answers.