Somatic Medicine

UAB School of Nursing

NPN 622
Spring 2019
Chronic Fatigue Syndrome
• 6 months “severe unexplained” fatigue
• Unrelieved by rest, distinct onset, impairing
• 4 or more of the following:
• Headaches Myalgias Arthralgias
• Trouble with memory/ concentration
• Unrefreshing sleep Post exertional malaise
• Sore throat/ tender lymph nodes
• Unremarkable physical exam/ lab values
• Less genetic loading for psychiatric d/o
• Comorbid IBS, fibromyalgia
• Comorbid depressive disorders
• Women 2x > men
Somatic Symptom Disorder
• Shift in DSM 5 focus away from “medically unexplained
symptoms” toward the patient’s affect, cognition, and behavior
related to the expressed Sx.
• Focus is on the person’s response to the Sx
• This view diagnosed patients based on ability of medical
assessment to identify a cause
• Physical expression of psychiatric Sx?
• Alexithymia
• Often have mood, anx, PD
• Pts will present for repeated evaluation in medical settings
• Family pattern of bx
Somatic Symptom Disorder
• A: One or more somatic symptoms that are distressing or disrupt daily life
• B: Excessive thoughts, feelings, Bx related to symptoms
• 1) “disproportionate and persistent” thoughts about
• 2) persistently high anxiety related to the Sx
• 3) Excessive time and energy devoted to the Sx
• SPECIFIER: “with predominant pain” if pain is the focus of clinical attention
• ** Somatic Symptom Disorder, with predominant pain = Pain Disorder
• C: 6 months
• Psychological factors related to onset, severity, exacerbation, maintenance
• Not malingering
• Not due to medical condition
Additional psychosomatic disorders
• Functional Neurological Symptom D/O
• Formerly “Conversion Disorder”
• W>M, late teens/ 20s, trauma Hx
• Blindness, paralysis, mutism
• Comorbid with MDD, anxiety, SCZ
• Factitious Disorder
• Formerly “Munchausen syndrome”
• Fictional presentation of Sx to obtain medical attention and warrant medical
intervention
• Estimated M>W, no definitive tests
SSD, with predominant pain
• Frequent comorbid MDD or dysthymia
• Pain may be posttraumatic, iatrogenic, or idiopathic
• Unaware of psychological contribution
• Pain is unaffected by intervention
• Options:
• CBT
• SSRI/ SNRI/ TCA
• Analgesics often ineffective
Jerry
• Jerry is a 55 y.o. male presenting for follow up after
inpatient medical hospitalization
• He was treated for colitis flare and discharged with 2 PO
antibiotics
• He is diagnosed with Unspecified Depressive
Disorder
• He lives with his adult son who cares for him
Jerry, cont.
• Jerry talks at length about his treatments in the
hospital, nebulizers, blood draws, IV medications,
allergic reactions
• He discussed additional concerns about Rt hip pain
since being discharged, plans to seek help from an
orthopaedist and physical therapy
• He endorses low energy and difficulty concentrating
Jerry, cont.
• Dx: HTN, GERD, fibromyalgia, migraines, low back
pain, radiculopathy, colon polyps

• Jerry is prescribed pregabalin 100mg TID, norco

10/325mg TID, lisinopril/HCTZ 10/12.5mg, naproxen
500mg daily, and venlafaxine XR 225mg daily for
mood.
Planning for Jerry
• What else do you want to know?
• Severity of depression currently
• Rule outs

• Medication recommendations?
• pregabalin 100mg TID
• norco 10/325mg TID
• lisinopril/HCTZ 10/12.5mg
• naproxen 500mg daily
• venlafaxine XR 225mg daily for mood

• Other recommendations
• Stage of change