NCGS covers a wide range of syncope disorders. Many patients have high vagal tone and faint easily. There are multiple triggers for this, including pain and changes in posture. Other “triggers” are various neuroses. It seems that quite a few neurotic patients carry this diagnosis now.

To avoid lumping these patients with those who have a significant physiologic cause, possibly another name would be more useful. Syncope neuroticus comes to mind. Choosing a proper name would help to direct therapy toward treatment of the anxiety rather than its symptom.

I’m sure there are patients with fibromyalgia who do not have accompanying psychiatric disease. I don’t see them in my practice, but they must be out there. It seems that fibromyalgia is mainly a physical manifestation of depression. I don’t doubt that these patients are uncomfortable. I do doubt the need for a term that does not acknowledge this relationship.

That there are different types of pain is well known. Ketorolac is great for renal colic but terrible for a fractured femur. Opiates are great for a fractured femur but only marginally effective for herpetic neuralgia. Gabapentin works well for herpetic neuralgia but not renal colic.

If the root of fibromyalgia is related to depression, it makes sense to treat it with an SSRI and leave the opiates for ailments and conditions such as crush injuries.

Are we doing anyone a favor by labeling them with a term that suggests they have a problem not related to its root cause?

I think not.

Physical manifestations of psychiatric illness are well known, so why hide behind vague terminology? Just tell the patient that multiple tests are normal and that you believe the symptoms are related to depression, anxiety, or addiction.

Now let’s treat that.

These diagnoses have their proponents who make sound arguments regarding these conditions. Unfortunately, these diagnoses have become the wastebasket for a population of patients who are mostly anxious, opiate addicted, or depressed.

This puts us in a conundrum in the emergency department. These diagnoses are not easily proved or disproved. Once a patient has been labeled with one of these, there is no politically correct or Press Ganey–friendly method of changing that.

I don’t have this discussion with patients because it is a swim upstream in a cold and rapid river. Instead, I’m content to watch the river flow and use my prescriptive authority sparingly.

Be happy.