Percepção do paciente portador de esclerose múltipla sobre o diagnóstico e tratamento / Perception of multiple sclerosis patients about diagnosis and treatment

O objetivo do presente artigo foi identificar o comportamento do paciente portador de esclerose múltipla após o recebimento do diagnóstico, com base em entrevista semi estruturada. A pesquisa foi realizada com estudo do discurso dez pacientes, buscando investigar as principais características presentes. Os relatos estudados indicam que os pacientes em geral têm dificuldades para aceitação do diagnóstico, devido à falta de informação sobre a origem da patologia e as características dos sintomas apresentados, os pacientes sentem insegurança, causadora de altos níveis de ansiedade. Embora a aceitação seja difícil isto não interfere diretamente na adesão ao tratamento. A família é o principal fator de apoio aos pacientes, que quanto mais próxima e estruturada é sua família melhor são seus resultados durante o tratamento. Embora a alteração no curso de vida destes pacientes seja significativa, alguns relatam condições de enfrentamento diante do quadro.

This article aimed at identifying the multiple sclerosis patients’ behavior after being diagnosed, based on a semi-structured interview. The research was carried out by studying the discourse of ten patients, seeking to investigate its main characteristics. The reports studied show that, in general, it is hard for patients to accept the diagnosis due to lack of information on the origin of the pathology and the characteristics of the symptoms experienced; the patients feel insecure, which causes high levels of anxiety. Although acceptance is difficult, it does not directly interfere with compliance with the treatment. Family is the key support to patients; the closer and the better structured the family, the better the treatment results. Even though changes in the course of life of these patients are significant, some of them report feeling able to face this challenge.

Cumplimiento e incumplimiento del tratamiento antihipertensivo desde la perspectiva del paciente / Compliance and non-compliance of antihypertensive treatment from a patient perspective

Los prestadores de servicios de salud, los pacientes, los familiares y la población en general elaboran hipótesis acerca de las causas que influyen en el cumplimiento o no de las prescripciones médicas. La literatura plantea un amplio grupo de factores influyentes en la conducta de cumplimiento o incumplimiento del tratamiento médico, involucrando componentes de naturaleza psicosocial, médica (características de la enfermedad y el tratamiento propiamente dicho) y de la relación médico-paciente. La OMS destacó la influencia de factores socioeconómicos y los relacionados con el sistema o el equipo que presta los servicios de salud. El presente trabajo tiene como finalidad indagar a través de una técnica de investigación de corte cualitativo cuáles son las causas que afectan o que contribuyen al cumplimiento del tratamiento antihipertensivo desde la perspectiva de las personas que padecen la enfermedad. Los resultados apuntan hacia cuestiones que tienen que ver con la organización de los servicios de salud, las configuraciones personológicas individuales del paciente, algunas características del tratamiento, los recursos económicos para realizar el tratamiento dietético y las redes de apoyo familiar necesarias para asumir el rol de enfermo. Para contribuir al control de la hipertensión arterial y lograr una atención médica de calidad, los aspectos relacionados con la organización de los servicios de salud deben ser atendidos de manera prioritaria.

Health service providers, patients, relatives and the general population work out their hypotheses about the causes influencing the compliance and non-compliance of medical prescriptions. The scientific literature presents a wide group of influencing factors in compliance or non-compliance of the medical treatment involving components of psychosocial, medical character and of the physician-patient relationship. The World Health Organization stressed the effect of socioeconomic factors and of those related to the system or equipment rendering health services. The present paper was aimed at ascertaining through a qualitative research technique the causes that affect or contribute to the compliance with the antihypertensive treatment from the perspective of the persons suffering this disease. The results pointed to questions that have to do with the organization of health services, the individual personality configurations of the patient, some characteristics of the treatment, the economic resources to carry out the dietary treatment and the networks of family backup necessary to assume the role of the patient. For contributing to blood hypertension control and to quality medical care, the aspects related to the health service organization should be addressed in a priority way.

Apego al tratamiento psicoterapéutico grupal en pacientes con Trastorno Límite de la Personalidad. Estudio piloto en pacientes de 18 a 24 años

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Abstract: The treatment of election for patients with Borderline Personality Disorder (BPD), consists on the combination of psychotherapy and pharmacotherapy. Concerning a psychoanalitic and individual focuse, there has been found, that in spite of the differences in orientations and the therapists experience, the manifestations of the disorder tend to decrease. First of all, a decrease in the impulsivity and an increase in the affective stability is seen, whether the identity alterations modify poorly with treatments of a duration of up to two years. Traditionally, patients with BPD have not been considered apt for group therapy, because their disruptive behavior interferes with the development of the groupal cohesion; however, this characteristics are the ones that can be rapidly treated in the group, when putting a slight pressure on the patient so he can modify this maladaptive behavior. The objectives of group therapy, are consistent with the ones in individual therapy. They include stability for patients, management of impulsivity and other symptoms, and management of the reactions in the transference and countertransference. The presence of other patients helps to establish limits between the participants and it also generates an altruistic interaction, in which they can consolídate their changes in the process of helping others. Group therapists suggest that individual therapy can be accelerated if the patient participates in the group in which the primitive fantasies are stimulated and where the group structure provides a support that helps personal growth. One of the most difficult tasks in any therapy is the desertion of the patients. Specially, the group is vulnerable to desertion, in its initial stage, since it has been recorded that there is a 13 to 63% of desertions. The purpose of the present study was to determine the psychological and psychopathological variables in patients with BPD, that influence the compliance in a group therapy. All the candidates in this investigation were patients with a probable diagnose of BPD, that had been sent to the Psychotherapy Department of National Institute of Psychiatry, aged between 18 to 24 years. This diagnose was corroborated with the SCID II. A descriptive study was made with the characteristics of the patients in some different areas: character and temperament, self esteem, quality of life, psychosocial functioning, interpersonal problems, ego strength, and psychiatric symptoms. A total of 24 weekly sessions with a duration of an hour and a half, were conducted under the direction of two psychotherapists and a non active observer. A Spearman correlation was used to correlate the psychological variables with the number of assisted sessions. We included 16 female patients, with an age mean of 20.43 years; the mean of assistance to the group was of 4.5 sessions. None of the subjects assisted to all the 24 sessions and 56% of the patients deserted the group as well as the pharmacological treatment. The findings of the correlations between the number of assisted sessions and the psychological variables, suggested first of all, a positive relation between the persistence scale of the ITC and a negative association with the subscales 1 (preoccupation vs optimism) and 4 (fatigability vs energy). Other findings suggested negative correlations between the psychosis scale of the SCL 90 and the evitative scale. The rest of the scales did not have a significative correlation with the number of assisted sessions. The items mentioned during the sessions by the patients consisted in the extreme dependency to the external criticism, that came from significative figures. The patients also talked about some of the common symptoms of BPD, like frustration, intolerance, suicide, lack of affective stability, self mutilations, rage, ambivalence, poor self concept, feelings of inferiority, and low self esteem. The percentage of desertion in this study was a lot higher than expected, assuming that in a regular group basis, there is 30% to 40% of desertion. It also came to our attention, that groupal phenomena, were not observed. Specially identifications and groupal cohesion, were not developed in this case. The patients collaborated exclusively with the therapists; they did not give any devolutions to other patients. They all waited for their turn, changing the theme, in a way that satisfied their own conflicts. The universality of the experience phenomenon was no seen, since the patients, did not feel that the others had the same problems, conflicts emotions or ideas, feeling supported or relieved by it. In conclusion, the patients with BPD, in our institution have a bad compliance in a group therapy, in which only personality disorders are admitted. These patients did not blend within the environment, because the groupal phenomena that produce the changes were not seen at all. This is probably associated with the intrinsic characteristics of the disorder, and this is why the probable changes in the patients should be evaluated and this technique questioned, as a reliable treatment method for personality disorders. A comparison of this technique with others, such as individual therapy and the combination of both, should be also considered. The Psychobiologic model of Cloninger, used in other investigations to predict the efficacy of pharmacotherapy, can be used to make a prediction of the compliance of BPD with groupal therapy. This data should be considered in the previous evaluation of the patients, with the goal of establishing different strategies, and an adequate treatment, for subjects with these characteristics.

Adesão ao tratamento da dor crônica: aspectos demográficos, terapêuticos e psicossocioculturais / Compliance with the chronic pain treatment: demographic, therapeutic and psycho-social-cultural

Os objetivos deste estudo foram identificar a prevalência de adesão plena, parcial e não adesão ao tratamento em doentes com dor crônica ao longo de seis meses; caracterizar os motivos da adesão e buscar relações entre adesão e variáveis demográficas, psicossocioculturais, de características de dor e do tratamento. Trinta docentes do Ambulatório de Dor do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo foram avaliados em cinco entrevistas ao longo de seis meses. Os instrumentos utilizados foram: identificação e caracterização da dor, descrição do tratamento medicamentoso, Escala de Locus de Controle da Saúde, Inventário de Depressão de Beck e Inventário de Atitudes frente à Dor-versão breve. Os doentes foram classificados quanto à adesão em plenamente aderentes (cumprimento total da prescrição medicamentosa), parcialmente aderentes (cumprimento parcial da prescrição medicamentosa) e não aderentes (não cumprimento da prescrição). Foram feitos testes estatísticos para verificar a presença de relações entre as variáveis e, em todos os testes, foi utilizado o nível de significância de 5%. O índice de não adesão e adesão parcial foi alto, entre 40,0% e 56,7%, e não houve variação significativa ao longo de seis meses. O Índice de Acerto de Ingestão Medicamentosa foi entre 57,2% e 69%, e também não houve variação. A principal razão para adesão plena foi "o remédio melhora a dor" (54,0% a 63,9%), para a adesão parcial foi "sente-se mal, tem efeitos colaterais" (55,6% a 66,6%), e para a não adesão foram "indisponibilidade na farmácia do hospital" (23,1% a 28,9%), "sente-se mal, tem efeitos colaterais" (25%) e "dinheiro insuficiente para a compra" (15,4% a 23,7%). A depressão e o locus de controle da saúde não variaram em seis meses. As atitudes frente à dor, com exceção do domínio cura médica, também não variaram ao longo de seis meses. Não se observaram relações estatisticamente ) significativas entre adesão e idade, estado civil, escolaridade, renda, características de dor, número de comprimidos, número de tomadas, uso de automedicação, presença de depressão, dimensões externalidade outros poderosos e acaso do locus de controle da saúde, e domínios controle, emoção, medicação e cura médica do Inventário de Atitudes frente à Dor. Observaram-se relações estatisticamente significativas entre adesão e presença de efeitos colaterais, dimensão internalidade e índice de Internalidade Total do locus de controle da saúde e domínios incapacidade, dano físico e solicitude do Inventário de Atitudes frente à Dor.

The aims of this study were identifying the prevalence of total compliance, partial compliance and non-compliance with the treatment of patients with chronic pain in the lenght of six months; characterising their reason for compliance and looking for relationship between compliance and demographic, psycho-social-cultural, characteristics of pain and treatment variables. Thirty out-patient in the Pain Clinic of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo were evaluated in five interviews in a period of six months. The instruments used were: identification and characterisation of pain, description of medical treatment, Multidimensional Health Locus of Control Scale, Beck Depression Inventory and Survey of Pain Attitudes-brief version. Patients were classified according to compliance as totally compliant (closely following the medical prescription), partially compliant (partially following the medical prescripton) and non-compliant (not following the medical prescription). Statistical tests were carried out to verify the presence of relationship among variables and, in every test, the significance level of 5% was used. The incidence of non-compliance and partial compliance was high, varying between 40,0% and 56,7%, and there was no significant variation during the six months. The Indexes of Right Ingestion of Medication was between 57,2% and 69% and, here too, there was not variation. The main reason for total compliance was "the medication eases the pain" (54,0% to 63,9%), for partial compliance was "felling bad, presence of side effects" (55,6% to 66,6%), and for non-compliance were "medicine unavailable in the hospital pharmacy" (23,1% to 28,9%)," feeling bad, having side effects" (25%) and "can not afford to buy the medicine prescribed" (15,4% to 23,7%). The depression and the health locus of control did not change in six months. Attitudes towards pain, with exception of cure dimension, did not change during six months. No significant statistic relationships were observed between compliance and age, marital status, education background, income group, characteristics of pain, number of pills taken, frequency of ingestion of medicine, use of self-medication, occurence of depression, powerful others and chance externality dimensions of health locus of control and control, emotion, medication and cure domains of the Survey of Pain Attitudes. Significant statistical relationships were observed between compliance and presence of side effects, internality dimension and total internal indexes of health locus of control besides disability, harm and solicitude domains in Survey of Pain Attitudes.