Fracasso crônico no tratamento da dor crônica? A influência silenciosa da personalidade e seus transtornos
DOI:
https://doi.org/10.5935/0104-7795.20140020Palavras-chave:
Dor Crônica, Transtornos da Personalidade, Transtorno da Personalidade Borderline, NarcisismoResumo
Transtornos psiquiátricos são comuns entre pacientes com dor crônica não oncológica. Em uma amostra de pacientes que foram encaminhados para avaliação psiquiátrica, transtornos de personalidade foram encontrados mais frequentemente que qualquer outro diagnóstico psiquiátrico, incluindo-se depressão maior. Os transtornos de personalidade borderline e narcisista foram os mais prevalentes. O presente artigo discute tais achados à luz de uma revisão de literatura em que os termos chronic pain, borderline personality disorder, narcissistic personality disorder foram adequadamente combinados como descritores. Além dos critérios diagnósticos para cada um dos transtornos, discutem-se alguns “sinais sutis” que podem orientar na identificação de traços de cada um deles, e duas vinhetas clínicas são apresentadas para ilustrar os transtornos de personalidade em discussão. Ao final, dão-se recomendações que podem facilitar o seguimento destes pacientes em equipes multiprofissionais de dor crônica.
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Referências
Merskey H. Psychiatric patients with persistent pain. J Psychosom Res. 1965;9(3):299-309. DOI: http://dx.doi.org/10.1016/0022-3999(65)90055-3
Bond MR. Psychological and psychiatric aspects of pain. Anaesthesia. 1978;33(4):355-61. DOI: http://dx.doi.org/10.1111/j.1365-2044.1978.tb12418.x
Crown S. Psychological aspects of low back pain. Rheumatol Rehabil. 1978;17(2):114-24. DOI: http://dx.doi.org/10.1093/rheumatology/17.2.114
Weisberg JN. Personality and personality disorders in chronic pain. Curr Rev Pain. 2000;4(1):60-70. DOI: http://dx.doi.org/10.1007/s11916-000-0011-9
Tragesser SL, Bruns D, Disorbio JM. Borderline personality disorder features and pain: the mediating role of negative affect in a pain patient sample. Clin J Pain. 2010;26(4):348-53. DOI: http://dx.doi.org/10.1097/AJP.0b013e3181cd1710
Dersh J, Polatin PB, Gatchel RJ. Chronic pain and psychopathology: research findings and theoretical considerations. Psychosom Med. 2002;64(5):773-86.
Knoplich J, Tosi SD. Dores crônicas na coluna e depressäo. Rev Bras Reumatol. 1989;29(6):214-8.
APA. Manual diagnóstico e estatístico de transtornos mentais. 4 ed. Porto Alegre: ArtMed; 1994.
APA. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5 ed. Washington: American Psychiatric Association; 2013.
Kalira V, Treisman GJ, Clark MR. Borderline personality disorder and chronic pain: a practical approach to evaluation and treatment. Curr Pain Headache Rep. 2013;17(8):350. DOI: http://dx.doi.org/10.1007/s11916-013-0350-y
McWilliams LA, Higgins KS. Associations between pain conditions and borderline personality disorder symptoms: findings from the National Comorbidity Survey Replication. Clin J Pain. 2013;29(6):527-32. DOI: http://dx.doi.org/10.1097/AJP.0b013e31826ab5d0
Keuroghlian AS, Frankenburg FR, Zanarini MC. The relationship of chronic medical illnesses, poor health-related lifestyle choices, and health care utilization to recovery status in borderline patients over a decade of prospective follow-up. J Psychiatr Res. 2013;47(10):1499-506. DOI: http://dx.doi.org/10.1016/j.jpsychires.2013.06.012
Frankenburg FR, Zanarini MC. The association between borderline personality disorder and chronic medical illnesses, poor health-related lifestyle choices, and costly forms of health care utilization. J Clin Psychiatry. 2004;65(12):1660-5. DOI: http://dx.doi.org/10.4088/JCP.v65n1211
Sansone RA, Whitecar P, Meier BP, Murry A. The prevalence of borderline personality among primary care patients with chronic pain. Gen Hosp Psychiatry. 2001;23(4):193-7. DOI: http://dx.doi.org/10.1016/S0163-8343(01)00148-7
Mason P, Kreger R. Stop walking on eggshells: taking your life back when someone you care about has borderline personality disorder. Oakland: New Harbinger; 1998.
Kreger R. The essential family guide to borderline personality disorder. Center City: Hazelden; 2008.
Kreisman J, Straus H. I hate you - don't leave me: understanding the borderline personality. New York: AvonBooks; 1989.
Sansone RA, Sansone LA. Borderline personality and the pain paradox. Psychiatry (Edgmont). 2007;4(4):40-6.
Sansone RA, Sansone LA. Chronic pain syndromes and borderline personality. Innov Clin Neurosci. 2012;9(1):10-4.
Hopwood CJ, Thomas KM, Zanarini MC. Hyperbolic temperament and borderline personality disorder. Personal Ment Health. 2012;6(1):22-32. DOI: http://dx.doi.org/10.1002/pmh.158
Hopwood CJ, Donnellan MB, Zanarini MC. Temperamental and acute symptoms of borderline personality disorder: associations with normal personality traits and dynamic relations over time. Psychol Med. 2010;40(11):1871-8. DOI: http://dx.doi.org/10.1017/S0033291709992108
Kerns RD, Sellinger J, Goodin BR. Psychological treatment of chronic pain. Annu Rev Clin Psychol. 2011;7:411-34. DOI: http://dx.doi.org/10.1146/annurev-clinpsy-090310-120430
Edwards RR, Cahalan C, Calahan C, Mensing G, Smith M, Haythornthwaite JA. Pain, catastrophizing, and depression in the rheumatic diseases. Nat Rev Rheumatol. 2011;7(4):216-24. DOI: http://dx.doi.org/10.1038/nrrheum.2011.2
Turk DC, Wilson HD. Fear of pain as a prognostic factor in chronic pain: conceptual models, assessment, and treatment implications. Curr Pain Headache Rep. 2010;14(2):88-95. DOI: http://dx.doi.org/10.1007/s11916-010-0094-x
Kehlet H, Dahl JB. Assessment of postoperative pain-need for action! Pain. 2011;152(8):1699-700.
Karpman S. Fairy tales and script drama analysis. Transactional Analysis Bulletin. 1968;7(26):39-43.
Levy K, Reynoso J, Wasserman R, Clarkin J. Transtorno de personalidade narcisista. In: O'Donohue W, Fowler K, Lilienfeld S. Transtornos de personalidade: em direção ao DSM-V. São Paulo: Roca; 2010.
Kernberg O. Transtorno da personalidade narcisista. In: Clarkin J, Fonagy P, Gabbard GO. Psicoterapia psicodinâmica para transtornos da personalidade. Porto Alegre: ArtMed; 2013.
Westen D, Shedler J. Revising and assessing axis II, Part II: toward an empirically based and clinically useful classification of personality disorders. Am J Psychiatry. 1999;156(2):273-85.
Gabbard GO. Two subtypes of narcissistic personality disorder. Bull Menninger Clin. 1989;53(6):527-32.
Wink P. Two faces of narcissism. J Pers Soc Psychol. 1991;61(4):590-7. DOI: http://dx.doi.org/10.1037/0022-3514.61.4.590
Conrad R, Wegener I, Geiser F, Kleiman A. Temperament, character, and personality disorders in chronic pain. Curr Pain Headache Rep. 2013;17(3):318. DOI: http://dx.doi.org/10.1007/s11916-012-0318-3
Kernberg OF, Yeomans FE. Borderline personality disorder, bipolar disorder, depression, attention deficit/hyperactivity disorder, and narcissistic personality disorder: practical differential diagnosis. Bull Menninger Clin. 2013;77(1):1-22. DOI: http://dx.doi.org/10.1521/bumc.2013.77.1.1
Dersh J, Gatchel RJ, Mayer T, Polatin P, Temple OR. Prevalence of psychiatric disorders in patients with chronic disabling occupational spinal disorders. Spine (Phila Pa 1976). 2006;31(10):1156-62. DOI: http://dx.doi.org/10.1097/01.brs.0000216441.83135.6f
Powers AD, Oltmanns TF. Personality disorders and physical health: a longitudinal examination of physical functioning, healthcare utilization, and health-related behaviors in middle-aged adults. J Pers Disord. 2012;26(4):524-38. DOI: http://dx.doi.org/10.1521/pedi.2012.26.4.524
Lieb K, Zanarini MC, Schmahl C, Linehan MM, Bohus M. Borderline personality disorder. Lancet. 2004;364(9432):453-61. DOI: http://dx.doi.org/10.1016/S0140-6736(04)16770-6
Clarkin J, Yeomans F, Kernberg O. Psychotherapy for Borderline Personality. Arlington: American Psychiatric; 2006.
Turk DC, Wilson HD, Cahana A. Treatment of chronic non-cancer pain. Lancet. 2011;377(9784):2226-35. DOI: http://dx.doi.org/10.1016/S0140-6736(11)60402-9
Turk DC, Okifuji A. Detecting depression in chronic pain patients - adequacy of self-reports. Behav Res Ther. 1994;32(1):9-16. DOI: http://dx.doi.org/10.1016/0005-7967(94)90078-7
Weisberg MB, Clavel AL. Why is chronic pain so difficult to treat? Psychological considerations from simple to complex care. Postgrad Med. 1999;106(6):141-8.
Fischer-Kern M, Kapusta ND, Doering S, Hörz S, Mikutta C, Aigner M. The relationship between personality organization and psychiatric classification in chronic pain patients. Psychopathology. 2011;44(1):21-6. DOI: http://dx.doi.org/10.1159/000317271
Caligor E, Clarkin J. Um modelo de personalidade e patologia da personalidade baseado na teoria das relações objetais. In: Clarkin J, Fonagy P, Gabbard G. Psicoterapia psicodinâmica para transtornos de personalidade. Porto Alegre: ArtMed; 2013.
Engel GL. Psychogenic pain and pain-prone patient. Am J Med. 1959;26(6):899-918. DOI: http://dx.doi.org/10.1016/0002-9343(59)90212-8
Zanarini MC, Frankenburg FR, DeLuca CJ, Hennen J, Khera GS, Gunderson JG. The pain of being borderline: dysphoric states specific to borderline personality disorder. Harv Rev Psychiatry. 1998;6(4):201-7. DOI: http://dx.doi.org/10.3109/10673229809000330
Oliveira JT. Behavioral aspects of chronic pain syndromes. Arq Neuropsiquiatr. 2000;58(2A):360-5.
Main CJ, Spanswick CC. 'Functional overlay', and illness behaviour in chronic pain: distress or malingering? Conceptual difficulties in medico-legal assessment of personal injury claims. J Psychosom Res. 1995;39(6):737-53. DOI: http://dx.doi.org/10.1016/0022-3999(95)00040-P
Tyrer SP. Learned pain behaviour. Br Med J (Clin Res Ed). 1986;292(6512):1-2. DOI: http://dx.doi.org/10.1136/bmj.292.6512.1
Pawl R. When the pain won't wane, it's mainly in the brain. Surg Neurol Int. 2013;4(Suppl 5):S330-3.
DOI: http://dx.doi.org/10.4103/2152-7806.113442
Gomez J, Dally P. Psychologically mediated abdominal pain in surgical and medical outpatients clinics. Br Med J. 1977;1(6074):1451-3. DOI: http://dx.doi.org/10.1136/bmj.1.6074.1451
Merskey H. The characteristics of persistent pain in psychological illness. J Psychosom Res. 1965;9(3):291-8. DOI: http://dx.doi.org/10.1016/0022-3999(65)90054-1
Ramírez-Maestre C, Esteve R. Disposition and adjustment to chronic pain. Curr Pain Headache Rep. 2013;17(3):312. DOI: http://dx.doi.org/10.1007/s11916-012-0312-9
Wasan AD, Wootton J, Jamison RN. Dealing with difficult patients in your pain practice. Reg Anesth Pain Med. 2005;30(2):184-92. DOI: http://dx.doi.org/10.1097/00115550-200503000-00009
Saper JR, Lake AE. Borderline personality disorder and the chronic headache patient: review and management recommendations. Headache. 2002;42(7):663-74. DOI: http://dx.doi.org/10.1046/j.1526-4610.2002.02156.x
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