aspecte psihosociale ale durerii ibi
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Aspecte psihosocialeale durerii
Prof. Dr. I. B. Iamandescu
Catedra de Psihologie Medicala si Psihosomatica UMF Carol Davila
FMD
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Definitie
Experienta aversiva senzoriala, cognitiva, afectiva.
Generata de leziuni tisulare (inclusiv SNC) Modulata de factori psihoindividuali si socioculturali Caracter adaptativ: Semnal de avertizare
Caracter parazitarDurere acutaDurere cronica
DezorganizatorInclusa in personalitatea individului (≠ bucuria de viata)
Durere cronica
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Fenomen multi-dimensional
Morfofiziologic Biochimic Senzorial, cognitiv, afectiv Comportamental
ExistentialSocio-cultural
Durerea
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Rezultanta personala (cf. “gate-theory”)
Fact. psiho-sociali modulat. (preexistenti / coexistenti) restanti
Impulsuri morfo-fiziologice Confruntarea (la niv. c. post. ale MS)
Impuls descendent(cortex + subcortex)
Durerea
Factori psihosociali modulatori
Impuls ascendent(fb. A si C)
Nociceptori
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Caracteristici clinico-evolutive
Durerea
Durata Aspect Ψ Progn. terap.
Cauza
Durere acuta (predominant organica)
<ore /minuteLocalizata
Variabila pasagera
Anxietate ↑↑Iritabilitate ↑↑Insomnie ↑↑
Bun disparitie
Evidenta sursa ++reductibila
Durere cronica (partial organica /sine-materia)
DifuzaBoli cronice
Variabila progresiva
Anxietate ↑Iritabilitate ↑Insomnie ↑Depresie ↑↑
Slab atenuare -psihotrope + psihoterapie ↑↑
IntuitaSursa ±Partial reductibila
Durere continua
antialgiceDur. metast. (ex. osos)
Permanenta (adesea opioide)
Anxietate ↑↑↑Depresie ↑↑↑
Rezervat Sursa ++
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Evaluare
Istoric rel. temporala (exacerbare, biografie) Caracterele (tipul (diferit de tulb.somatof.)* si evolutia
durerii (fluctuanta) Implic. bio-psiho-soc. afectarea profesiei Raspunsul la tratam. anterior
*O parte sunt incluse in tulb. somatoforme
Durerea
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Caractere descriptive
Localizata punct “pumnal” (± iradiere) intepatura zona “ghiara” banda redoare Difuza pulsatila (± iradiere) arsura lancinanta (paroxistica) Intensitate: “surda”
Durerea
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Comportamentul pacientului
Acuze de tip durere acuta(chiar daca se sectioneaza caile durerii, persista durerea)
Durerea
Personalul medical aplica abord. durerii cronice ca pe una acuta
Pentru ca pacientul “se vaita” ca la o durere acuta (desi se pot uita la TV, râde, etc.)
Tentatia pt. placebo ( succes “pacientul are o tulburare functionala”)
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Factori psihologici de atenuare (Wise si Rendell) Analgezia de stres Inhibitia endogena a durerii Factori psihosociali (suport social, etc.)
Durerea
Natura organica sau psihogena
Diagnostic diferential cu tulburarile somatoforme dureroase S. dosarului Localizari multiple “aparate” diferite (g-i, genit., ± neurol.)
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Allodynia - orice stimul non-dureros (ex: lumina) Nociceptiv / central* Hypo/hiper-algezie Hiperestezie (sensibilitate ↓ la durere) Disestezie (neplacut) Hipoestezia (orice stimul) Algezie (doar stimuli dur) Nociceptiv (sursa clara, nn.specifici, localizare
buna pielea sau slaba viscere)
*Durere centrala – vezi paragraful respectiv
Terminologie
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Factorul psihologic poate fi incriminat Exclusiv (tulburari somatoforme) Major (benef. sec.) Inconstant asociat (durerea are un substrat real)
Coeficient crescut de “psihizare” Daca are un substrat real + esecuri terapeutice repetate Apar simptome psih. de “rezonanta” la durere
Comportament modificat Fara disabilitati secundare durerii In caz de diabilitati secundare
Conotatii psihosociale ale durerii cronice
Obtin beneficii secundare intarire
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Depresie majora, tulb. distimica >30%, neaga durerea
Tulb. somatizare Tb.somatiz., pain disorder, hypoc., conv.disorders
Anxietatea generalizataDependenta de subst./droguri si
sevrajul subst.psihoactive“Pain-prone” patientsPsihoticiManipularea anturajului
(tb.pers.antisociale)
Comorbiditati psihiatrice la pacientii cu durere cronica sine materia
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1. Substrat organic absent/ redus, amplificare vs. instalare psih. (ritmare)
2. Asociata adesea cu factori psih. Refl. condition. – apar Distres – se intensifica Mai accentuata la anxiosi si depresivi
3. Localizare: Tipica – “montata”= imitata (ex. Anginoasa) Atipica ± mai multe sedii
4. “Capricioasa”: mobilitate / aparitie5. Ameliorare /disparitie
De catre eustres-uri Medicatie psihotropa
Durerea psihogena
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Amplificarea durerii Tipurile D, Ms, My (“triada nevrotica”) Anxiosi Pain-prone personality (Engle)
Inlusa deseori in tabloul clinic al: Depresiei mascate Tulb. somatoforme
Terenul psihologic receptiv pentru durere
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Pentru pacient ↓ QOL ↑ anxietatea, ↑ depresia ↑ iritabilitatea
Pentru anturaj Revendicari afective Beneficii secundare Manipulare
Reculul somatopsihic al durerii
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Indicatori clinici Pozitii antalgice, mimica, examen anamnestic,
palpatorScale de autoevaluare
VAS (scala analoga vizuala), reduc durerea semnificativ (33-66% - scoruri medii, >67% - scor crescut)
Desene despre durere Personale: desenul analog, “testul tabloului” Facies Pain Scale for Adults and Children
Indici psihofiziologici EEG, EMG, ECG, RGC
Evaluarea durerii
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Chestionare de personalitate
A. Chestionare specifice pentru durere
Multidimensional Pain Inventory (Kerns, Turk, Rudy)• Scale: efectul durerii, reactiile celorlalti, angajare in activitate
McGill Pain Questionaire (MPQ)• Scale: durerea senzoriala, durerea afectiva, durerea
evaluativa
*Forma scurta: durerea senzoriala si afectiva + scale de intensitate a durerii si indice analog vizual
Evaluarea durerii
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Chestionare de personalitate
B. Chestionare nespecifice pentru durere
MMPI-2 – itemi despre durere Beck Depression Inventory – depresie HAD pentru – depresie asociate – anxietate durerii Spielberger Anxiety Inventory – anxietate
Evaluarea durerii
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Antialgice
Psihotrope Simptome psihiatrice comorbide (insomnie)
Psihoterapie Factori psih. ce amplifica durerea (anxietate, depresie) Ca terapie adjuvanta (in recul somatopsihic)
Placebo Neindicat ca alternativa la medicatie (nu inlatura med.
pt. etilogie, distruge relatia medic – pacient) Indicat ca amplificator/potenţator al efectelor medicaţiei
Terapia durerii
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Abordare holistica echipa terapeutica (modalitati practice)A. Centrata pe simptome
• Medicatie (analgetica, psihotropa, altele)• Kinetoterapie, acupunctura, etc.• “aport endorfine”
B. Cognitiv-comportamentala• Cognitiv: - semnificatia durerii ↓ - reducerea distresului (surse ↓, coping ↑) - motivatie ↑ pentru recuperarea profesionala si sociala - comutarea atentiei catre alte interese≠ pain behavior*
• Comportamental: - activitati “acaparante” - miscare (≠ IM, fracturi, etc.), mobilitate, ≠ poz.antalgice - muzica, hobby-uri
*pain behavior: - comportament evitant: - miscare (pozitii antalgice vicioase), - activitate (profesionala, sociala)
- Comunicare redusa (izolare, depresie, suport social↓) - Beneficii secundare/ manipulare anturaj
Principii de abordare psihologica a pacientilor cu durere cronica
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Abordare diferita• Durere acuta
– Centrare pe medicament– Distragerea (comutarea) atentiei
• Durere cronica– Centrare pe comportament– Accentuarea pe psihoterapie (cognitiv-comportamentala, relaxare)
Consolarea pacientului: Durerea = o problema de acceptat si de integrat
Accent pe independenta fizica si psihica; function.psiho-soc.
Principii de abordare psihologica a pacientilor cu durere cronica
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Combaterea fact. psih. de intretinere (distresuri elective, anxietate excesiva, depresie)
Evaluarea afectarii QOL solutii adecvate
Reducerea dozelor de medicatie ≠ dependenta terapie fizica si comportamentala
Se vor evita:• Abuz de tactici defensive (ex: repaus exagerat)• Dr. Shopping• Centrare excesiva pe durere alternare coping: centr.pe
probl., emotii; plan de actiune
Principii de abordare psihologica a pacientilor cu durere cronica
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