Orientador: Heloisa André Pontes / Tese (doutorado) - Universidade Estadual de Campinas, Instituto de Filosofia e Ciências Humanas / Made available in DSpace on 2018-08-17T13:04:35Z (GMT). No. of bitstreams: 1 Silva_DanielaFerreiraAraujo_D.pdf: 3618993 bytes, checksum: 6b462d863f9f233f3a22b46cd7419a9b (MD5) Previous issue date: 2011 / Resumo: Esta tese surgiu do interesse em pesquisar em maior profundidade alguns aspectos da intrincada relação entre corporificação, gênero e assujeitamento, através da análise do conjunto de perturbações denominadas "transtornos alimentares". No contexto contemporâneo em que o corpo torna-se alvo privilegiado de investimento e intervenção, assumindo centralidade nos processos de construção identitária, uma investigação antropológica destas perturbações permite pensar como a constituição de sujeitos corporificados é perpassada por múltiplas normatividades de gênero, classe, regionalidade, raça e etnicidade, presentes na socialidade cotidiana e nas práticas e discursos biomédicos. Tomando como eixo central a composição de três histórias de vida, em colaboração com mulheres que tiveram experiências pessoais com transtornos alimentares, é possível ter acesso ao processo através do qual pessoas vivenciam formas particulares de assujeitamento, compostas por distintas articulações entre múltiplas dimensões de poder, deforma inseparável, constituindo-se, assim, como sujeitos de ação em meio a conformações e resistências. Ainda que o fio condutor da tese encontre-se nas histórias de vida, escritas ao longo de quatro anos em colaboração com três interlocutoras voluntárias, sua trama é composta pelos diversos percursos teóricos e empíricos de uma etnografia multi-situada (HANNERZ, 2003), que transitou pelo universo de comunidades virtuais brasileiras sobre transtornos alimentares, um serviço ambulatorial de um hospital universitário, congressos de psiquiatria, uma vasta bibliografia e uma agência feminista de base comunitária para tratamento, educação e prevenção de transtornos alimentares na Nova Zelândia. / Abstract The aim of this thesis is to investigate in greater depth some aspects of the intricate relation between embodiment, gender and subjectification, through the analysis of the group of perturbations named "eating disorders". In the contemporary context, in which the body becomes the privileged target of investment and intervention, assuming a central role in the processes of identity construction, an anthropological investigation of these perturbations allows us to evaluate how the constitution of embodied subjects is fraught with multiple normativities of gender, class, regionality, race and ethnicity, present in daily sociality and in biomedical practices and discourses. Taking as a central axis the composition of three life-histories, in collaboration with women who had personal experiences with eating disorders, it is possible to gain access to the process by means which persons live particular forms of subjectification, composed by distinct inseparable articulations of multiple dimensions of power, becoming, thus, subjects of agency amidst conformation and resistance. If the connecting thread of the thesis is found in the life histories, written with the voluntary research collaborators along four years, its warp is the woven out of the different theoretical and empirical paths of a multi-sited ethnography (HANNERZ, 2003), along the universe of Brazilian virtual communities about eating disorders, an outpatient treatment unit at an University hospital, Psychiatry congresses, a wide bibliography and a feminist community based service for the education, prevention and counseling for eating difficulties in New Zealand. / Doutorado / Estudos de Gênero / Doutor em Ciências Sociais

Transtornos Alimentares (TA) são transtornos mentais considerados graves. Dentre eles, Anorexia Nervosa e Bulimia Nervosa compartilham sintomas e características psicopatológicas como hábitos desregulados de alimentação, métodos extremos para controle do peso, e preocupações exageradas com a forma e o peso corporal. Os TA compartilham ainda sintomas comuns em outros transtornos psiquiátricos, como Depressão e Ansiedade. Pesquisas sobre o tema devem levar em conta este amplo espectro de sintomas. A meditação é uma prática que tem recebido crescente atenção de pesquisadores de diversas áreas de saúde. Dentro da área de Psiquiatria, a meditação mindfulness tem sido estudada como terapia complementar para diversos transtornos, sendo os mais pesquisados os transtornos de ansiedade, a depressão e a dependência química. Alguns programas baseados em mindfulness já demonstraram resultados positivos em pacientes com Compulsão Alimentar e Bulimia Nervosa. Este é um projeto que teve a intenção de desenvolver e mensurar os efeitos de uma nova intervenção baseada em meditação mindfulness para pacientes internados na Enfermaria de Comportamentos Alimentares (ECAL) do Instituto de Psiquiatria do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. A hipótese primária foi que o treinamento em mindfulness diminuiria sintomas de ansiedade e depressão, em comparação com os pacientes que seguiram o tratamento usual da enfermaria. O projeto todo teve duração de três anos, sendo dividido em fase piloto, fase grupo controle e fase grupo intervenção. Cada fase aconteceu em diferentes períodos de tempo, para que um número adequado de indivíduos fosse alcançado para fins de pesquisa. Avaliações foram feitas sempre nos mesmos períodos para os três grupos: durante a primeira semana de internação e após 8 semanas, ou antes, se o paciente recebesse alta. Os resultados do grupo piloto foram positivos e ajudaram a delinear os exercícios que compuseram o programa aplicado na intervenção. A comparação dos resultados do grupo controle com o grupo intervenção apresentou significativa diferença para os índices de ansiedade (p < 0,01), depressão (p < 0,03), capacidade de agir com atenção (p < 0,01) e atitudes alimentares relacionadas a dietas (p < 0,04). Como previsto e em linha com outras pesquisas utilizando mindfulness para indivíduos com TA menos grave, este protocolo de oito sessões demonstrou efeito positivo e significativo apesar dos desafios de trabalhar com esta população neste contexto. Estes resultados dão suporte a novas pesquisas que poderão testá-los e compreender melhor a duração dos efeitos terapêuticos deste treinamento. Também, devem ser considerados aprimoramentos necessários, como refinamento dos exercícios, capacitação de outros terapeutas no protocolo e treinamento em mindfulness para outros profissionais envolvidos / Eating disorders (ED) are considered severe mental disorders. Anorexia Nervosa and Bulimia Nervosa are disorders that share symptoms and psychopathological characteristics such as deregulated feeding habits, extreme methods for weight control and exaggerated concerns about shape and weight. Eating Disorders also share common symptoms with other psychiatric disorders such as depression and anxiety. Research on eating disorders should take into account this wide spectrum of symptoms. Meditation is a practice that has received increasing attention from researchers in various areas of healthcare. Within the area of Psychiatry, mindfulness meditation has been studied as a complementary therapy for many disorders, and the most researched are anxiety, depression and addiction. Some mindfulness-based programs have already shown promising results in patients with Binge Eating Disorder and Bulimia Nervosa. This research project aimed to measure the effects of a mindfulness meditation intervention delivered to patients admitted to the Eating Disorders Ward at the Institute of Psychiatry in the Clinical Hospital for the Medical School, University of São Paulo. The primary hypothesis was that mindfulness training would lower symptoms measuring anxiety and depression compared to inpatients that received treatment as usual. The entire project was conducted during three years, with a pilot group phase, a control group phase and an intervention group phase. Each phase happened in different periods of time so the study could recruit a suitable number of participants. Assessments were made for all groups during the first week of admission and at eight weeks (or earlier if the patient were to be discharged). Pilot results were positive and helped delineate exercises that would be part of the main study intervention protocol. The final analysis comparing control and intervention group showed significant differences for measures in anxiety (p < 0.01), depression (p < 0.03), acting with awareness (p < 0.01) and dieting attitudes (p < 0.04). As hypothesized and in line with previous research with less severe eating disorders samples, this novel eight week program showed a positive and significant effect despite the challenges of working with this population and in this setting. These findings will inform future research which will need to replicate the findings, understand more about the durability of the effects and consider the resource allocation (eg staff training) needed to offer this promising intervention in this setting

Introduction Poor adherence is a common challenge in self-directed mental health interventions. Research findings indicate that telephone prompts may be useful to increase adherence. Method Due to poor adherence in a randomized controlled trial evaluating an Internet-based aftercare program for women with bulimia nervosa we implemented regular short telephone prompts into the study protocol halfway through the trial period. Of the 126 women in the intervention group, the first 63 women were not prompted by telephone (unprompted group) and compared with 63 women who subsequently enrolled into the study and were attempted to prompt bimonthly by a research assistant (telephone prompt group). Completed telephone calls took less than 5 min and did not include any symptom-related counseling. Results Most of the women in the telephone prompt group (67%) were reached only once or twice during the intervention period. However, overall adherence in the telephone prompt group was significantly higher than in the unprompted group (T = − 3.015, df = 124, p = 0.003). Conclusion Our findings from this secondary analysis suggest that telephone prompts can positively affect adherence to an Internet-based aftercare intervention directed at patients with bulimia nervosa.

Facing poor long-term outcome and high relapse rates in the treatment of bulimia nervosa, we developed an Internet-based aftercare program for women with severe and chronic bulimia nervosa following inpatient treatment based on previous experiences with self-directed targeted prevention and early intervention programs delivered online. The aim of the present study was to examine adherence to the program in detail, to explore potential variables that predict adherence and to analyze whether adherence affects outcomes. We analyzed data from 126 women in the intervention group of a randomized controlled trial. 107 women (85%) logged on to the program platform at least once. These women opened on average 42.8% (SD=31.9%) of all assigned program pages. Adherence declined during the course of the intervention. Adherence was not associated with the number of outpatient treatment sessions received during the intervention period. Adherence was not related to overall illness severity or duration at baseline. However, excessive exercise at hospital discharge (which may be a sign of insufficient motivation to change eating disorder related behaviors) seems to play some small role in adherence. Adherence did not affect intervention outcomes. Based on our findings, we would like to advocate further research on online aftercare interventions for women with severe and chronic bulimia nervosa.

Die vorliegende Literatursichtung belegt, gerade im Lichte neuen Störungswissens und für neue diagnostische Kategorien, die Notwendigkeit, die Wirksamkeit bestehender Therapieformen zu erhöhen und/oder neue Behandlungen für Essstörungen, speziell für Bulimia Nervosa und Binge Eating-Störung, zu entwickeln. Ein wesentlicher Erkenntnisgewinn wird zudem von einer systematischen Analyse des therapeutischen Prozesses sowie von Moderatoren und Mediatoren erwartet. Darüber hinaus stellen die Dissemination evidenzbasierter Therapiemethoden in die Praxis und eine Überprüfung gestufter Behandlungsmodelle wichtige Aufgaben zukünftiger Forschung dar. / The consideration of existing literature, especially in light of new knowledge of eating disorders and new diagnostic categories, highlights the necessity to increase the efficacy of current forms of therapy, and to develop novel therapies for eating disorders. This pertains, in particular, to bulimia nervosa and binge eating disorder. A considerable gain in knowledge is to be expected from a systematic analysis of the therapeutic process as well as the moderators and mediators. Furthermore, dissemination of evidence-based treatment methods in practical settings and an examination of stepped care models are important avenues of future research.

Essstörungen sind prävalente psychische Störungen mit schwerwiegenden, oftmals langfristigen Auswirkungen auf die psychische und körperliche Gesundheit. Eine zunehmende Anzahl von klinischen Studien dokumentiert die Wirksamkeit verschiedener psychotherapeutischer Ansätze für spezifische Essstörungen. Im vorliegenden Themenheft 5 werden die Wirksamkeit von neuen Ansätzen zur Einzeltherapie und zur internet-basierten Rückfallprophylaxe, die Patientensicht auf die Therapie sowie die Relevanz von Faktoren des therapeutischen Prozesses bei verschiedenen Essstörungen beleuchtet. Weiterer Forschungsbedarf besteht insbesondere hinsichtlich des Prozesses und der Dissemination evidenzbasierter Psychotherapie für Essstörungen. / Eating disorders are prevalent psychiatric disorders with severe and longstanding 15 implications for mental and physical health. An increasing number of clinical studies documents the efficacy of certain psychotherapeutic approaches for specific eating disorders. This special issue addresses the efficacy of novel approaches in face-to-face individual therapy and Internet-based relapse prevention, patient views of treatment, and the relevance of therapeutic process factors for diverse eating disorders. Further research is particularly 20 warranted regarding the process and dissemination of evidence-based psychotherapy for eating disorders.

Während Leitlinien „Gold-Standards“ für die Psychotherapie bei bulimischen Essstörungen (Bulimia Nervosa und Binge-Eating-Störung) empfehlen, ist über psychotherapeutische Prozessfaktoren bei Essstörungen wenig bekannt. Ziel war es, mit Hilfe des etablierten Generic Model of Psychotherapy zur Systematisierung psychotherapeutischer Prozessfaktoren die aktuelle Literatur zum Einfluss dieser Faktoren auf den Therapieerfolg, operationalisiert als Symptomreduktion oder -remission, auf Basis einer systematischen Datenbanksuche zu sichten. Während der Einfluss des therapeutischen Settings nach bisheriger Forschungslage kaum Schlüsse hinsichtlich des Therapieerfolgs zulässt, konnte dieser durch spezifische Interventionen, frühe Symptomreduktionen und eine gute therapeutische Beziehung vorhergesagt werden. Weitere Forschung zu Prozessfaktoren bei bulimischen Essstörungen erscheint notwendig, um die praktische psychotherapeutische Arbeit zu unterstützen und Behandlungen effektiver gestalten zu können. / While guidelines recommend gold standards for psychotherapy in bulimic eating disorders (bulimia nervosa and binge eating disorder), less is known about psychotherapeutic process aspects. We aimed to summarize the current literature on the impact of process aspects on significant symptom reductions and/or abstinence as treatment outcome using the Generic Model of Psychotherapy. A systematic literature search was conducted. While effects of treatment settings can not yet be estimated, specific interventions, rapid response, and the therapeutic bond repeatedly predicted outcome. Process-outcome research in bulimic eating disorders will be necessary to support clinical practice and to enhance treatment efficacy.

Objective: For eating disorders, a vast number of investigations have demonstrated the efficacy of psychological treatments. However, evidence supporting the impact of therapeutic process aspects on outcome (i.e., process-outcome research) has not been disentangled. Method: Using the Generic Model of Psychotherapy (GMP) to organize various process aspects, a systematic literature search was conducted on psychological treatment studies for anorexia nervosa, bulimia nervosa, binge-eating disorder, and eating disorders not otherwise specified. Results: Improved outcomes resulted for family-based treatment compared to individual treatment, for individual compared to group treatment, booster sessions, and positive patient expectations (GMP contract aspect); for nutritional counseling and exercising but not exposure with response prevention as adjunct interventions (therapeutic operations); for highly motivated patients and, to a lesser extent, for therapeutic alliance (therapeutic bond); as well as for rapid response and longer overall treatment duration (temporal patterns). Regarding other GMP aspects, studies on self-relatedness were completely lacking and in-session impacts were rarely investigated. Discussion: As most studies assessed only a limited number of process aspects, the ability to draw conclusions about their overall impact regarding outcome is rather limited. Therefore, future process-outcome research is needed beyond investigations of treatment efficacy for eating disorders.

Maladaptive interpersonal functioning is considered typical of eating disorders. The present thesis aimed to add to existing knowledge of interpersonal functioning in the eating disorders in terms of both symptomatology and treatment. In Study 1, relationships were found between eating disorder attitudes and several types of poor interpersonal functioning. These associations were present when controlling for depression and anxiety. Study 2 found that generalised interpersonal problems were more likely to be reported by women with bulimic disorders than comparison women, apart from problems with being too open, which were more likely to be reported by comparison women. In Study 3, individuals with self identified eating disorders were found to have poorer problem solving skills in specific interpersonal situations than healthy controls, generating less means to solve the problem, with these means being significantly less effective and less specific than those generated by healthy controls. In Study 4, the experience of an invalidating childhood environment was explored as a potential predictor of adult interpersonal problems in the eating disorders. Viewing the expression of emotions as a sign of weakness was a mediator of the relationship between having a more invalidating mother and adult eating concern in a nonclinical population. In Study 5, the interpersonal experiences of patients with bulimic disorders are explored using qualitative methodology. They report a range of problems characterised by social avoidance, social anxiety, non-assertiveness, and a difficulty with being genuine in relationships. In Study 6, patients reported their experiences of interpersonal psychotherapy for bulimic disorders. In general, they experienced the therapy as positive and beneficial. They express that it helped them address a range of interpersonal problems, and reduced but did not cure their eating disordered behaviours. Patients liked that therapy focused on both interpersonal relationships and eating. In Study 7, interpersonal psychotherapists discussed their perceptions of the modified therapy. They identified several factors as being related to outcome, such as the existence or willingness to build a support network, motivation to change, a clear interpersonal problem identified in the patient, level of depression, duration of the eating disorder and keeping therapy focused on the interpersonal. Results of these studies suggest that those with higher levels of eating disorder related attitudes and behaviours often have significant problems with interpersonal functioning. This thesis supports the use of interpersonal psychotherapy as a viable treatment approach to the eating disorders. It also supports the use of the modified version of the therapy, which addresses eating as well as interpersonal functioning.

Este estudo tem por objetivos identificar as representações sociais da equipe de enfermagem acerca da anorexia e bulimia nervosa e dos indivíduos portadores desses transtornos, bem como correlacionar essas representações com as intervenções realizadas no cotidiano do trabalho desses profissionais em um hospital psiquiátrico. Para realizá-lo, foram feitas entrevistas semi-estruturadas, individuais, junto a 12 componentes da equipe de enfermagem de um hospital universitário. A teoria moscoviciana de representação social foi adotada como referencial teórico-metodológico e os dados submetidos à análise de conteúdo segundo Bardin. Dessa análise emergiram temas como sintomas físicos e psíquicos além dos fatores psicossociais, que constituíram a categoria “A Construção do conhecimento". A construção desse conhecimento mostrou-se ancorada essencialmente em um discurso médico – científico veiculado na instituição, numa interface com o conhecimento prático que a vivência cotidiana possibilita. Já a outra categoria delineou-se a partir do “Campo das Ações/ Sentimentos", constituída por temas como controle/limite, onde o sofrimento psíquico do trabalhador é mais evidente, principalmente na iminência do suicídio. Por outro lado, é por meio de temas como a escuta, o vínculo de confiança e o cuidar individualizado que os profissionais conseguem expressar o prazer no trabalho / This study intends to identify the social representations of nursing staff about anorexia and bulimia nervosa and about carries of these eating disorders as long as to correlate these representations with the interventions made in the se professionals daily life, inside of a psychiatric hospital. Semi-structured, and individuals interviews were made with twelve members of the nursing staff of a university hospital. The moscovician theory of social representation was adopted as referential-methodological referential and the data were submitted for content analysis in Bardin’ s point of view. From this analysis emerged themes as physical and psychic symptoms, besides psychosocial factors, which constituted the category “knowledge Construction". The construction of knowledge seemed to be anchored essentially on a medical-scientific lecture diffused in the institution, in a interface with the pratic knowledge which the daily life provides. On the other side, the other category was outlined from “Actions / Feelings Field", constituted by themes as control / limit, where the worker’ s psychic suffering is more evident, mostly in imminence of suicide. By other way, is by themes as the listening, confidence link and individually care that professionals care express their pleasure on work