So yes, side effects are an issue, but in medicine sometimes we have the thing where the risk of the untreated condition if present, outweighs the harm of intervention in the face of no pathology.
I'm not a neurologist. Here's my thoughts anyway.
It was also explained to me, not sure how true and no I don't have a citation, that there can be this overlap between folks who have both pseudoseizures and real seizures. That it is easier to determine someone HAS pseudoseizures than it is to prove they DON'T have some type of epilepsy. Not all events are frequent or caught on diagnostics as pointed out. I'm not saying all the folks with pseudoseizures have real seizures. But some do. I think it was suggested even to me, that there might be a link between the two phenomenon.
Another analogy might be the migraine frequent flier always worried it's a stroke, and some number of them will go on to have a stroke. So that can't always get treated like that's all it is, a migraine. The consequences of the missed diagnosis is too profound.
This could get way into the woo woo about "pseudoseizures" and "real" seizures. I fell down this rabbit hole on rotation because functional movement disorders fascinate me (the so-called psychogenic stuff). If there's a neurologist who wants to talk a lot about it I would be fascinated. That's a digression I might pick up later after a review.
I've heard it said that some of the terminology, "pseudoseizures" vs "real seizure" may be too simplistic.
So the issue with untreated seizures is that, untreated seizures tend to get worse over time if untreated and even one untreated seizure can be devastating on the same level as a STEMI or asthma attack. One time incident, one time death, one time without enough oxygen for brain damage. If they're driving, a whole busload of kids. So do we want to be sure we let someone have undiagnosed seizures until they become bad enough to be obvious? We can't leave people on EEG 24/7. What's more, the lab might never recreate whatever stimulus that could be something that is actually triggering something real, in someone who may also have pseudoseizures.
Maybe the rare neurotic person who will never quit, really has something wrong. May benefit from meds. Maybe that's why they won't quit. Even if they have pseudoseizures... they might be right they have real ones. The point about oh well, some folks aren't going to quit until they get meds, so here's meds... I don't take to mean, oh, let's give meds to anyone who wants them. I think it's more a statement, if all there is to gain is potentially missing the person who maybe has real seizures, because we want to be a hardass about these other folks ending up where they're headed (some kind of meds) regardless, maybe that isn't worth it.
Sometimes in medicine we worry so much about the person who doesn't need treatment, that we might miss the person who *really* does. The more serious that consequence, the better tolerated the drug, on the balance it might be better to give it. It's all a balance. But that kind of thinking happens all the time, both ways (we miss things, we overtreat).
I hope that makes sense. If I'm not going to make a difference with those people, I may as well hedge my bets with the folks that might benefit from the intervention.
I dunno man. I leave this to the neurologists. If they put the person on the sz med, I don't really care what the diagnosis is. It's not for me to decide. Not my wheelhouse.
There's a perception that "validating" the neurotic person with treatment will make them worse and make other fanciful claims... yes, and no.
I also think there are other ways we treat these folks, not in terms of meds or interventions, that creates some of the behaviors we don't want to see.
Going back to functional movement disorders, I think there are a lot of things in medicine we thought were "psychological" and turned out to have some basis where the issue isn't, the symptomology would be completely resolved with "good living" and counseling. That there is a somatic process not under the person's direct or subconscious control, and would benefit from a biomolecular approach. Other things are entrenched in the brain in a way that dealing with the circuit behind the behavior is going to take more than a will to do it, and we don't know how.
Even the folks where psychiatric therapy is all there is do to for them, certain approaches are more likely to get them there. Sometimes you have to play along until they realize, the issue isn't that no one believes them or that there is a therapy that hasn't been tried. We have a hard enough time convincing people with 100% somatic disease that we have nothing more to offer without it coming off like abandonment. People are in distress, and they want to be fixed. It's human. So the issue is trying to lead someone where they need to go, and if it's the psychiatrist, it's not a result of not being taken seriously.
I've seen this with functional movement disorders. Plenty of well meaning individuals and after a diagnosis of exclusion determines the neurologist and meds have limited utility, and they go to psychiatry. Some get better, some don't. The true malingerer is rare.
I mean so we're talking about neurology and psychiatry, and the process I'm talking about, is this major journey on the order of years for some of the thing EM docs or other specialties find frustrating. It's fine, it's not what you do and you see it as needlessly making your life harder. Because yes, it doesn't belong with you. But what others are doing with it, just because it makes your life harder, doesn't mean it's being done wrong.
I think it takes a different beast entirely for psych/neuro.
