Made available in DSpace on 2017-06-01T18:08:45Z (GMT). No. of bitstreams: 1 carolina_cavalcanti_henriques.pdf: 339372 bytes, checksum: 35ac31ce1aa15f2bcacce66bd22f3ada (MD5) Previous issue date: 2013-10-11 / In contemporary practice, we have been faced with new expressions of suffering, in which the body gets featured. Among the recurring phenomena found chronic pain and fibromialgia. Studies on these subjects feature distinct positions: some consider such pain as hysterical phenomena, others as a manifestation of the body down. We intend to verify the specifics of chronic pain, since the possibility of a hysterical demonstration or depressed, but advancing the hypothesis that they may be manifestations of melancholic framework. Take the theory of Freud as the main source of our studies on the melancholy and cotejaremos also latest authors dealing with the phenomenon of pain, particularly the psychoanalytic literature. Patients who mobilized us to undertake such studies were those that were curious traits: low fluidity pulsional, dismay, pain in various parts of the body, psychosomatic symptoms, anxiety quite expressive and usually marked by a lack of sense, connoting, on the other hand, melancholic traits and somatic symptoms. In melancholy, a loss in pulsional life while suffering from a normal grief, that doesn't happen; libido peels back the object, due to a position occupied by this lost object, in which there was a double job to him directed, of love and hate, so liable to be drafted in the conscious level. In this same text, it shows that in the pathological mourning, the missing object remains invested, libidinalmente, resulting in an attachment to him, without it can be elaborated, causing therefore a shadow of the object about the subject's ego itself. That means there's a hyper narcissistic investment in object, in which the subject is fixed by pasting it. In a world facing individualism, for narcissism and without ideals is likely to stimulate more this encapsulation, preventing the subject from link. In contemporary clinical symptoms are more of this nature: are primary, narcissistic character, in which the subject finds himself wrapped in a world empty and without meaning. In this context, we think it's more conducive to speak of melancholy subjects, distinct from the depressed, because these make a libidinal investment withdrawal, but maintains a relationship with object. / Na clínica contemporânea, temos nos defrontado com novas expressões de sofrimento, nas quais o corpo ganha destaque. Entre os fenômenos recorrentes encontramos a dor crônica e as fibromialgias. Os estudos sobre esses assuntos apresentam posições distintas: uns consideram tais dores como fenômenos histéricos, outros, como uma manifestação do corpo deprimido. Pretendemos verificar as especificidades das dores crônicas, desde a possibilidade de uma manifestação histérica ou depressiva, mas avançando na hipótese de que elas possam ser manifestações do quadro melancólico. Tomaremos a teoria de Freud como principal fonte dos nossos estudos sobre a melancolia e cotejaremos também autores mais recentes que tratam do fenômeno da dor, particularmente os da psicossomática psicanalítica. Os pacientes que nos mobilizaram a empreender tais estudos foram aqueles que apresentavam traços curiosos: pouca fluidez pulsional, desânimo, dores em vários pontos do corpo, sintomas psicossomáticos, ansiedade bastante expressiva e, geralmente, marcados por uma falta de sentido, conotando, de um lado, traços melancólicos e, de outro, sintomas somáticos. Na melancolia, trata-se de uma perda na vida pulsional enquanto que no sofrimento decorrente de um luto normal, isso não acontece; a libido se desprende do objeto, devido a uma posição ocupada por esse objeto perdido, em que havia um duplo trabalho a ele dirigido, de amor e ódio, portanto passível de ser elaborado, no nível consciente. Nesse mesmo texto, ele mostra que no luto patológico, o objeto perdido mantém-se investido, libidinalmente, tendo como consequência um apego a ele, sem que ele possa ser elaborado, causando, portanto, uma sombra do objeto sobre o próprio ego do sujeito. Isso significa que há um hiper investimento narcísico no objeto, no qual o sujeito se fixa colando nele. Num mundo voltado para o individualismo, para o narcisismo e sem ideais é provável que se estimule mais esse encapsulamento, impedindo o sujeito de se vincular. Na clínica contemporânea os sintomas são mais dessa natureza: são primários, de caráter narcísico, no qual o sujeito se vê encapsulado num mundo vazio e sem significação. Nesse contexto, pensamos ser mais propício falar de sujeitos melancólicos, distinto dos deprimidos, pois estes fazem uma retirada do investimento libidinal, mas mantém uma relação com objeto.

Indiana University-Purdue University Indianapolis (IUPUI) / The presence of a chronic pain condition can have a profound impact on one’s self-concept. Some individuals may have had to make major lifestyle changes. As a result, some people may start to define themselves in terms of their pain, such that their self-schema and pain-schemas become intertwined in a process termed schema-enmeshment. It is thought that schema-enmeshment is related to psychological distress making it a prime target for intervention. Little research has been conducted on interventions to reduce schema-enmeshment. Acceptance-based interventions may be especially appropriate in reducing schema-enmeshment or the connection between self and illness symptoms as these interventions tend to emphasize learning to live with pain and other symptoms and to work toward important life goals rather than continually fighting against the condition and allowing it to control their life. This study is a randomized trial comparing Acceptance and Commitment Therapy (ACT) to education about pain management in a sample of women with Fibromyalgia Syndrome (FMS). The primary aim of this study was to assess the efficacy of ACT in reducing schema-enmeshment between self and pain, as well as enmeshment between self and other symptoms and FMS as a whole. In addition, this study also explored the role of pain acceptance, specifically activity engagement as a mediator of the relationship between treatment group membership and changes in schema-enmeshment. The data was analyzed as an intent-to-treat analysis using the “last measure carried forward” method. Results indicated that the ACT group reported statistically significant differences in self schema-enmeshment with FMS, fatigue, and cognitive symptoms, but not with pain, following the intervention, compared to the educational control group. In each of these cases, the ACT group experienced greater reductions in schema-enmeshment compared to the education group. Interestingly, no statistically significant differences were observed for schema-enmeshment with pain. Statistically significant group differences were also observed for acceptance of pain following the intervention. Finally, a mediational model in which changes in activity engagement (a form of pain acceptance) served as the mediator of the relationship between treatment group and changes in schema-enmeshment with FMS was tested. The model was tested using a bootstrapping method, and results revealed a trend toward a significant indirect effect of changes in activity engagement leading to changes in schema-enmeshment with FMS. Taken together, the results of this study indicate that ACT may be a promising intervention for targeting maladaptive beliefs about the self in relation to illness, especially schema-enmeshment of self with illness and illness symptoms. Additionally, there is evidence that ACT may target key constructs such as activity engagement, which may be related to other cognitive and behavioral changes. Future directions for research and clinical practice related to ACT as an intervention for FMS are discussed in depth.

Indiana University-Purdue University Indianapolis (IUPUI) / While the majority of chronic pain patients report receiving inadequate care, there is evidence that female and Black patients receive less analgesic medications and treatment for their chronic pain compared to male and White patients, respectively. While treatment disparities have been evidenced in the literature, there is little understanding of provider-factors, such as their decision-making awareness and attitudes, which may contribute to the differences in treatment. This investigation employed quantitative and qualitative procedures to examine the relationship between patient demographics and chronic pain treatment variability, providers’ awareness of these non-medical influences on their decisions, and the extent to which providers’ gender and racial attitudes associate with their treatment decisions. Twenty healthcare trainees made pain treatment decisions (opioid, antidepressant, physical therapy, pain specialty referral) for 16 computer-simulated patients presenting with chronic low back pain; patient sex and race were manipulated across vignettes. Participants then selected among 9 factors, including patient demographics, to indicate which factors influenced their treatment decisions for the simulated patients and completed gender and racial attitude measures. After online study completion, follow-up semi-structured interviews were conducted to discuss the medical/non-medical factors that influence trainees’ clinical treatment decisions. Quantitative analysis indicated that 5%-25% of trainees were actually influenced (p<0.10) by patient sex and race in their treatments, and on the whole, trainees gave higher antidepressant ratings to White than Black patients (p<.05). Fifty-five percent demonstrated concordance, or awareness, between their actual and reported use of patient demographics. Follow-up McNemar’s test indicated trainees were generally aware of the influence of demographics on their decisions. Overall, gender and racial attitudes did not associate with trainees’ treatment decisions, except trainees’ complementary stereotypes about Black individuals were positively associated with their opioid decisions for White patients. During qualitative interviews, aware and unaware trainees discussed similar themes related to sex and racial/ethnic differences in pain presentation and tailoring treatments. We found that (1) a subset of trainees were influenced by patient sex and race when making chronic pain treatment decisions, (2) trainees were generally aware of the influence of patient demographics, and (3) trainees discussed differences in pain presentation based on patients’ sex and ethnic origin. These findings suggest trainees’ are influenced by patient demographics and hold stereotypes about patient populations, which may play a role in their decision-making.