A clínica da dor crônica como ninho de pacientes difíceis

o papel da identificação projetiva

Autores

  • João Paulo Consentino Solano Centro Universitário São Camilo

DOI:

https://doi.org/10.5935/0104-7795.20150010

Palavras-chave:

Dor Crônica, Dor Intratável, Projeção, Identificação (Psicologia), Transtornos da Personalidade

Resumo

Pacientes difíceis - ou de personalidade difícil - são frequentemente encontrados na clínica da dor crônica não-oncológica, impondo à relação médico-paciente sobrecargas que vão além das complexidades da doença e do tratamento. Esta revisão/relato de experiência discute o papel que o processo psicológico e comunicacional da identificação projetiva exerce sobre as relações entre pacientes e médicos (e outros profissionais) nas equipes de dor crônica. São revisados os conceitos de identificação projetiva, na sua forma benigna e maligna. Duas vinhetas clínicas são dadas como exemplos de cada uma. São apresentadas situações no cenário da comunicação médico-paciente em que a identificação projetiva opera complicando a relação terapêutica. Ao final, recomendações são dadas sobre o manejo do paciente difícil que se comunica maciçamente por identificação projetiva, assim como às equipes multiprofissionais que lidam com estes pacientes. Os pacientes difíceis de nossa clínica de dor crônica têm em comum o fato de se comunicarem pela forma maligna de identificação projetiva e terem organizações imaturas de personalidade. Nas equipes de dor crônica, as relações entre pacientes e profissionais (assim como as relações entre os profissionais), podem ser otimizadas se a equipe for capaz de identificar precocemente o fenômeno da identificação projetiva e manejá-lo de forma terapêutica. Para o paciente, a psicoterapia de longo prazo é o tratamento de eleição.

Downloads

Não há dados estatísticos.

Biografia do Autor

João Paulo Consentino Solano, Centro Universitário São Camilo

Psiquiatra da Equipe de Controle da Dor do Hospital das Clínicas da FMUSP, Professor Centro Universitário São Camilo

Referências

Jackson JL, Kroenke K. Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomes. Arch Intern Med. 1999;159(10):1069-75. DOI: http://dx.doi.org/10.1001/archinte.159.10.1069

Hahn SR, Thompson KS, Wills TA, Stern V, Budner NS. The difficult doctor-patient relationship: somatization, personality and psychopathology. J Clin Epidemiol. 1994;47(6):647-57. DOI: http://dx.doi.org/10.1016/0895-4356(94)90212-7

Hahn SR, Kroenke K, Spitzer RL, Brody D, Williams JB, Linzer M, et al. The difficult patient: prevalence, psychopathology, and functional impairment. J Gen Intern Med. 1996;11(1):1-8. DOI: http://dx.doi.org/10.1007/BF02603477

Hahn SR. Physical symptoms and physician-experienced difficulty in the physician-patient relationship. Ann Intern Med. 2001;134(9):897-904. DOI: http://dx.doi.org/10.7326/0003-4819-134-9_Part_2-200105011-00014

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

Gabbard GO. Patients who hate. Psychiatry. 1989;52(1):96-106.

Groves JE. Taking care of the hateful patient. N Engl J Med. 1978;298(16):883-7. DOI: http://dx.doi.org/10.1056/NEJM197804202981605

Klein M. Inveja e gratidao e outros trabalhos (1946-1963). Rio de Janeiro: Imago; 1946.

Aguayo J. On understanding projective identification in the treatment of psychotic states of mind: the publishing cohort of H. Rosenfeld, H. Segal and W. Bion (1946-1957). Int J Psychoanal. 2009;90(1):69-92. DOI: http://dx.doi.org/10.1111/j.1745-8315.2008.00115.x

Bion WR. Estudos psicanalíticos revisados (second thoughts). Rio de Janeiro: Imago; 1994.

Segal H. A Obra de Hanna Segal. Rio de Janeiro: Imago; 1982.

Rosenfeld H. Impasse e interpretaçao. Rio de Janeiro: Imago; 1987.

Goretti GR. Projective identification: a theoretical investigation of the concept starting from notes on some schizoid mechanisms. Int J Psychoanal. 2007;88(2):387-405.

Laplanche J. Vocabulário da psicanálise/Laplanche e Pontalis. 3 ed. Sao Paulo: Martins Fontes; 1998.

Goldstein WN. Clarification of projective identification. Am J Psychiatry. 1991;148(2):153-61.

Böhmer MW. "Communication by impact" and other forms of non-verbal communication: a review of transference, countertransference and projective identification. Afr J Psychiatry (Johannesbg). 2010;13(3):179-83.

Ramchandani D. The concept of projective identification and its clinical relevance. Am J Psychother. 1989;43(2):238-47.

Kernberg OF. Projection and projective identification: developmental and clinical aspects. J Am Psychoanal Assoc. 1987;35(4):795-819. DOI: http://dx.doi.org/10.1177/000306518703500401

Clarke S. Projective Identification: From Attack to Empathy? [text on the Internet]. London: Kleinian Studies Ejournal [cited 2014 July 7] Available form: http://www.psychoanalysis-andtherapy.com/human_nature/ksej/clarkeempathy.html

Ogden TH. On projective identification. Int J Psychoanal. 1979;60(3):357-73.

Gabbard GO. Splitting in hospital treatment. Am J Psychiatry. 1989;146(4):444-51. DOI: http://dx.doi.org/10.1176/ajp.146.4.444

Forward S. Emotional blackmail. New York: Harper; 1997.

Waska RT. Projective identification, countertransference, and the struggle for understanding over acting out. J Psychother Pract Res. 1999;8(2):155-61.

Solano JPC. Fracasso crônico no tratamento da dor crônica? A influência silenciosa da personalidade e seus transtornos. Acta Fisiatr. 2014;21(2):93-100.

Weisberg MB, Clavel AL. Why is chronic pain so difficult to treat? Psychological considerations from simple to complex care. Postgrad Med. 1999;106(6):141-2.

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.

Poppe C, Crombez G, Devulder J, Hanoulle I, Vogelaers D, Petrovic M. Personality traits in chronic pain patients are associated with low acceptance and catastrophizing about pain. Acta Clin Belg. 2011;66(3):209-15.

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

McShea M. The failure to contain: How persecutory anxieties contribute to noncompliance in adult patients with congenital chronic pain conditions. Psychoanalytic Social Work. 2008;15(2):132-57. DOI: http://dx.doi.org/10.1080/15228870802086975

Segal H. Introduçao à obra de Melanie Klein. Rio de Janeiro: Imago; 1975.

Ogden T. Os sujeitos da psicanálise. Sao Paulo: Casa do Psicólogo; 1996.

Clarkin J, Yeomans F, Kernberg O. Psychotherapy for borderline personality. Arlington: American Psychiatric; 2006.

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

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

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

Sansone RA, Sansone LA. Chronic pain syndromes and borderline personality. Innov Clin Neurosci. 2012;9(1):10-4.

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

Sansone RA, Sansone LA. Borderline personality and the pain paradox. Psychiatry (Edgmont). 2007;4(4):40-6.

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

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 JF, Levy KN, Lenzenweger MF, Kernberg OF. Evaluating three treatments for borderline personality disorder: a multiwave study. Am J Psychiatry. 2007;164(6):922-8.

Newman A. As idéias de D.W. Winnicott: um guia. Rio de Janeiro: Imago; 2003.

Gabbard GO. On 'doing nothing' in the psychoanalytic treatment of the refractory borderline patient. Int J Psychoanal. 1989;70(Pt 3):527-34.

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

Publicado

2015-03-09

Edição

Seção

Tendências e Reflexões