Durerea este .com



Buletinul Clubului Rom?n din ChattanoogaNum?rul 85 (optzeci ?i cinci) Noiembrie 2018romclub.Tema lunii:DurereaToate sunt m?rginite, durerea nu... Mihai EminescuDefini?ia durerilorDurerea este o senza?ie nepl?cut?, sau o experien?? emo?ional? negativ? asociate cu modific?ri tisulare, reale sau poten?iale, sau descrierea lor ?n termenii unor astfel de modific?ri. (Defini?ie dat? de IASP - Asocia?ia Interna?ional? pentru Studiul Durerii - ?n anul 1994; asocia?ia a fost ?nfiin?at? ?n anul 1973).Ca ?i opusul ei, pl?cerea, deasemeni ca g?ndurile, amintirile ?i ideile, durerea este ?n ?ntregime subiectiv?. Ea nu poate fi examinat?, m?surat? sau cunoscut? altfel dec?t prin relat?rile celor care o tr?iesc.Cum pragul de durere, intensitatea ei ?i felul ?n care este perceput? variaz? de la un individ la altul, inexactitatea ?n aprecierea durerilor apare de neevitat.Cel mai frecvent simptom al bolnavilor este durerea, ?n sutele ei de manifest?ri ?i localiz?ri. Medicii sunt lipsi?i de informa?ii legate de durere la bolnavii cu psihicul sau starea de con?tiin?? alterate.Studiul durerii a identificat mai multe tipuri distincte:Allodynia: durerea provocat? de un stimul care deobicei nu este asociat cu durerea (atingerea, lumina, cald-rece, etc);Causalgia: dureri asociate cu tulbur?ri vasomotorii, de sudora?ie ?i de sensibilitate ?n teritoriul unui nerv lezat; Nevralgia: durere prelungit? ?i recidivant? ?n teritoriul de distribu?ie al unui nervAnestezia dureroas?: dureri ?ntr-o zon? care este lipsit? de sensibilitate;Disestezia: "senza?ia anormal?" , cum ar fi durerea, arsura, senza?ia de ud, amor?eala, ?n?ep?turile ?n zone anatomic intacte, mai ales pielea corpului, sclapul, limba, extremit??ile. A fost legat? de boli neurologice (Guillain Barre, neuropatii, scleroza multipl?), de diabet, sau de alcoolsim.Hiperestezia, Hiperpatia, Hiperalgia: durere de intensitate mult crescut? fa?? de cea indus? de un stimul dureros minim. Se deosebe?te de allodynia ?n care senza?ia de durere este produs? de un stimul nedureros (atingere, temperatur?).Peresteziile: senza?ii de arsur?, m?nc?rime, durere, ?n?ep?turi localizat? mai ales la extremit??i. A fost asociat? cu bolile vasculare periferice, deficitul de vitamine, traumatismele nervoasee.Durerea neuropatic?: produs? de lezarea sistemul de fibre senzitive. Poate fi asociat? cu allodynia, hiperstezia, parestezia.Nocicep?ia: stimularea receptorului (termina?iilor senzitive pentru durere) de stimuli care pot fi nocivi, sau nu. Analizatorul durerii poate fi activat prin mai multe forme de energie – mecanica?, chimica?, termica?, electrica?, electromagnetica?. Stimulul, ce prezinta? pericol de leziune este numit nociceptiv sau noxic. Daca? stimulul nociceptiv provoaca? o percept?ie, calificata? de ca?tre individ ca durere, atunci el este numit algogen. Daca? stimulul algogen nu provoaca? leziune tisulara?, el este numit nenociv. Un stimul va fi sau nu nociv i?n funct?ie de intensitatea s?i/sau durata aplica?rii. Nociceptorii sunt terminat?ii nervoase libere, nemielinizate, ale fibrelor Aδ s?i C. Se disting mecanonociceptori, chemonociceptori, termonociceptori, nociceptori polimodali s?i nociceptori silent?ios?i. Dupa? localizare, se i?mpart i?n superficiali (derm, hipoderm s?i fascia superficiala?), profunzi (mus?chi, tendoane, fascii, periost, pericondru, capsule articulare) s?i viscerali (subseros, subepitelial, intra-adventit?ial, corial s?i i?n tunica medie a vaselor). Nu au nociceptori t?esuturile hepatic, splenic, renal, osos s?i cortexul cerebral. Sensibilitatea nociceptiva? a acestor organe este asigurata? de ca?tre nociceptorii capsulelor sau meningelui. Mediatorii noxici provin din 4 surse principale: celulele lezate, celulele implicate i?n inflamat?ie (leucocite, trombocite, endoteliocite, celule gliale), fibrele nervoase senzoriale s?i simpatice s?i circuitul sistemic (substant?ele acumulate i?n timpul ischemiei-reperfuziei t?esuturilor). ?Amestecul” de substant?e biologic active din micromediul nociceptorilor poarta? denumirea de ?supa? periferica?”Din fiziologia dureriiComponentele durerii: perceperea durerii (fenomen neurologic) ?ireac?ia la durere (fenomen psihic, vegetativ, somatic).Pragurile durerii: pragul perceperii durerii = cea mai mica intensitate a unui stimul recunoscut ca durere; pragul reactiei la durere = intensitatea senza?iei dureroase care antreneaz? reac?ii psihice (anxietate, agita?ie), vegetative (tulburari de puls, hipertensiune arterial?, transpira?ie), somatice (contrac?ia unor mu?chi faciali, pleoape) .Variabilitatea interindividuala este relativ redus? pentru pragul perceperii durerii dar este mare pentru pragul reac?iei la durere.Factorii care influen?eaz? pragurile durerii sunt numero?i (zgomot, presiune, diferen?e personale, stoicism, anxietate, situa?ii, euforia efortului, excita?ia din zonele de lupt?, etc.).?Tipurile de durere:?n func?ie de locul leziunii dureroase ?i a durerii primare: somatic? (la nivelul aparatului locomotor); visceral? (la nivelul unui organ intern; central? (leziuni medulare sau cerebrale); psihic? (cauze psihogene).?n func?ie de evolu?ie: acut? (simptom in cadrul unei boli, care dispare dup? vindecarea bolii, nu las? sechele fizice sau psihice ?i r?spunde la o terapie antalgic? obi?nuit?); cronic? (boal? ?n sine, care persist? 1-6 luni, ?n func?ie de timpul de vindecare a leziunii dureroase ?i este rezistent? la terapia antalgic? obi?nuit?). Durerea cronic? poate continua dup? vindecarea leziunii dureroase primare, prin migrarea durerii din periferie, central "r?m?n?nd astfel ?n capul pacientului", acest fenomen c?p?t?nd denumirea de "somatizarea durerii".Durerea cronica este ?nso?it? de insomnie; reac?ii senzitivo-senzoriale ?i somato-vegetative exagerate, acestea creind un cerc vicios de??ntre?inere a durerii cronicizate; stare depresiv? care poate fi mascat? (?n cca. 50% din cazuri); pragurile durerii sunt sc?zute; nivelurile de neuromediatori antalgici (endorfine ,NA ,5-HT ,DA) sunt sc?zute.?Importan?a durerii:Durerea acuta?este un sistem de alarm? important pentru protec?ia organismului (?ndep?rtarea agentului nociv; stabilirea diagnosticului);Sunt nocive : durerea acuta foarte intens?, care declan?eaz? starea de ?oc (reac?ie de ap?rare, manifestat? prin eliberarea masiv? de opioizi endogeni); durerea acut? prelungit?, care antreneaz? tulbur?ri func?ionale (atrofii musculare, tulburari articulare ?i nervoase); durerea cronic?, care antreneaz? diverse tulbur?ri psihice (insomnie ,depresie).Rolul esent?ial al sistemelor aferente este de a informa scoart?a cerebrala? despre mediul extern s?i intern al organismului. Analizatorul durerii este cel care semnalizeaza? existent?a unor condit?ii anormale, cu potent?ial lezional, sau despre prezenent?a leziunii. El este conectat cu toate structurile SNC, aferente s?i eferente s?i integrat, i?n final, i?n comportamentul uman, modelat de experient?a cotidiana? individuala?. Analizatorul durerii are o organizare principiala? identica? celorlalt?i analizatori: consta? din segmentul de recept?ie, ca?ile de conducere s?i segmentul central, cortical. Este compus din doua? sisteme antagoniste: nociceptiv s?i antinociceptiv. Perceperea durerii este o funct?ie corticala?, care nu i?ntotdeauna depinde de evenimentele petrecute i?n segmentul de recept?ie sau conducere, adica? de sistemul nociceptiv s?i antinociceptiv.?n funct?ie de mediatorul principal al ret?elei, deosebim mai multe sisteme de modulare descendenta? a traficului nociceptor. ??Sistemul opioid endogen. Endomorfinele (Endorfinele). I?n prezent sunt cunoscut?i peste 50 de opioizi endogeni, ce apart?in la 3 familii, i?n funct?ie de precursori: proopiomelanocortina (POMC), proenkefalina s?i prodynorfina. Sistemul opioizilor endogeni joaca? un rol fiziologic foarte divers. Pe la?nga? modularea traficului nociceptiv, el este implicat i?n controlul funct?iilor respiratorii, cardiovasculare, gastro- intestinale, motorii, de secret?ie hormonala?, comportament. Analgezicele opioide (morfina, fentanilul, sufentanilul, remifentanilul, alfentanilul s?.a.) au formule similare cu endorfinele. Sistemul adrenergic. Modularea este realizata? prin intermediul familiei receptorilor s?i a noradrenalinei la nivelul SNC (cornul medular dorsal, locus coeruleus, nucleii noradrenergici A5 s?i A7 ai trunchiuluicerebral). Sistemul GABA-ergic. Acidul ?-aminobutiric interact?ioneaza? cu receptorii GABA s1i GABA s?i este cel mai ra?spa?ndit mediator inhibitor. Circuite GABA-ergice se proiecteaza? prin fascicule bulbospinale i?n laminele I, II, IV, V ale cornului medular dorsal .?Sistemul serotoninergic. Neuronii serotoninergici proiecteaza? axonii prin funiculul dorsolateral, predominant i?n laminele I, II, IV, V ale cornului dorsal. La periferie serotonina are efect pro-nociceptiv, pe ci?nd la nivel central – antinociceptiv. Sistemul canabinoid. I?n anii ’90 ai sec. XX au fost descoperit?i canabinoizii endogeni s?i receptorii lor. Sunt larg ra?spa?ndit?i i?n SNC s?i periferic (fibrele C, ganglionii spinali). Sinteza lor decurge “la solicitare” (nu exista? rezerve) din fosfolipidele membranei postsinaptice. Cca 50% dintre persoanele traumate i?n urma unui accident rutier, de exemplu, nu acuza? durere, cu toate ca? traficul nociceptiv este deosebit de intens. Acest fenomen este numit ?analgezie de stress? s?i se explica? prin eliberarea de opioizi endogeni, activarea celorlalte circuite inhibitorii. Un rol important i?l are s?i focalizarea atent?iei, care nu este i?ndreptata? atunci asupra durerii. Anestezia medical?Medicina dureriiFigura 6. Palierele OMS de analgezie Debutul analgeziei postoperatorii i?ncepe, de regula?, de la palierul III. Orientativ, o durere calificata? de pacient SVN ≥7= palierul III; SVN 5-6 = palierul II; SVN 4= palierul I; SVN ≤ 3 nu necesita? analgezie. Fiecare palier superior i?nclude, automat, s?i cont?inutul celor inerioare. Fiecare palier permite asocierea adjuvant?ilor (ex: ketamina?, gabapentina?, xilocaina? sistemic). Se va utiliza principiul ?deescalada?rii”. Un consum nictimeral de ≤7 mg de morfina? permite trecerea la palierul II. Pentru realizarea analgeziei postoperatorii, administrarea medicamentelor se face pe 2 ca?i: intravnenoasa? sau perorala?. Se trece la administrarea analgezicelor per os imediat ce s-a restabilit tranzitul intestinal. Administrarea intramusculara? a medicamentelor pentru realizarea analgeziei postoperatorii i?n ziua de azi este i?n contradict?ie cu buna practica? practica? medicala?. 5. Administrarea analgezicelor i?nainte de debutul durerii. Componentul de sensitizare centrala? este obligator prezent i?n durerea postoperatorie. Cca 10% din pacient?i sufera? i?n postoperatoriu de durere intensa?, rezistenta? la administrarea de analgezice opioide. Sensitizarea centrala? se manifesta? prin hiperalgezie, care, i?n urma unor anumite intervent?ii 9 chirurgicale, pot conduce la cronicizarea durerii pa?na? la 50% din cazuri. Durerea cronica? este invalidata?, costisitoare i?n tratament s?i, practic, incurabla?. Minimizarea acestui fenomen se face prin administrarea unor substant?e cu act?iune analgezica?, dar s?i antihiperalgezica? (ketamina, nefopamul, gabapentina, xilocaina, adenozina, dextrometorfanul), i?nainte de i?nceperea durerii (as?a-numita analgezie preemptiva?). I?n practica?, principiul se realizeza? foarte simplu: dupa? induct?ia anesteziei, pacientului i se perfuzeaza? i.v., de exemplu, 1g de paracetamol, asociat cu 20 mg de nefopam sau 15-25 mg de ketamina?. Obstacolele unei analgezii postoperatorii eficiente sunt preponderent de ordin organizat?ional s?i logistic (adica?, cauze administrative) s?i nu de ordin s?tiint?ific sau tehnic. Des?i exista? de peste un deceniu recomanda?ri clare pentru tratamentul durerii acute perioperatorii, iar numeroase studii au demonstrat eficient?a s?i beneficiul acestor recomanda?ri, durerea ra?mi?ne, s?i la ora actuala?, insuficient tratata? i?n toata? lumea. Au fost, i?n consecint?a?, identificate trei ?nivele de rezistent?a?” i?n combaterea durerii: 1. Nivelul administrativ, ce impune o legislat?ie restrictiva? i?n privint?a utiliza?rii analgezicelor opioide; sprijinul insuficient al autorita?t?ilor sanitare pentru programele de evaluare s?i combatere ale sindromului algic; nerecunoas?terea beneficiului unei analgezii calitative de ca?tre autorita?t?ile financiare (companiile de asigurare), reticent?a administrat?iei spitaliere fat?a? de introducerea, respectarea s?i promovarea principiilor de management al durerii. 2. Nivelul personalului medical, prega?tit insuficient i?n domeniul evalua?rii s?i combaterii durerii, ci?t s?i conservatismul lui i?n acceptarea tehnicilor s?i protocoalelor noi de analgezie. I?n consecint?a?, Societa?t?ile Nat?ionale de Durere militeaza? pentru implementarea sau realizeza? programe de formare s?i, implicit, de reactualizare a cunos?tint?elor din domeniu. 3. Nivelul pacient?ilor, care nu declara? prezent?a durerii din motive de educat?ie, religie, convingere, necunos?tint?a? de cauza? sau motive obiective. Astfel, educarea pacientului i?n acest domeniu este un lucru esent?ial, care depinde, i?n cea mai mare ma?sura?, de personalul medical. VII. Rolul analgezicelor non-opioide i?n tratamentul durerii postoperatorii Utilizarea analgezicelor non-opioide este capitala? pentru tratamentul durerii acute. Ele pot fi administrate fie i?n monoterapie, fie combinate i?ntre ele sau cu analgezicele opioide. I?n aceasta? sect?iune vom aborda paracetamolul, antiinflamatoarele non-steroide, nefopamul s?i tramadolul. ??Paracetamolul. Poseda? act?iune centrala?, mediata? prin intermediul receptorilor serotoninici 5HT3 s?i celor pentru PGE2. Act?iunea periferica? este nesemnificativa?. Debutul efectului: 1 ora?, efect maximal – i?n 4 ore. Interact?iunea cu AINS s?i morfina este aditiva? (adica?, 1+1=2). E utilizat la 70-100% de pacient?i i?n postoperatoriu (Europa Occidentala?). Paracetamolul reduce intensitatea durerii cu 50% la fiecare al patrulea pacient (NNT≈4, ?number need to treat”). Scopul principal al prescrierii paracetamolului i?n postoperatoriu este reducerea necesarului de analgezice opioide. Economia astfel realizata? este de 38% i?n cazul durerii de intensitate medie s?i de 18% - i?n cazul durerii puternice. Paracetamolul nu are nicio influent?a? asupra durerii dinamice (la mis?care). Doza toxica? e de >10g la adult sau de >100mg/kg la copil. Doza terapeutica? este de 1g × 4 ori i?n 24 ore la adult sau 15 mg/kg × 4 ori i?n 24 ore la copil s?i are un efect ?on-off”, adica? ?totul sau nimic”. ??AINS. Toate AINS blocheaza? ciclooxigenaza (COX1, COX2), i?nsa? prin mecanism diferit (de exemplu: aspirina – prin acetilare, ibuprofenul – competitiv cu PGE2, indometacina – prin carboxilare etc). Variabilitatea i?ntre diferite AINS i?n sensul potent?ialului analgezic i?n postoperatoriu este destul de mica?, inclusiv s?i pentru preparatele de ultima? generat?ie. Realizeaza? o economie de morfina? de 20-40% i?n postoperator. Fiecare 10mg de morfina? economisite reduce incident?a gret?urilor cu 10% s?i a vomei cu 5%. Niciodata? nu trebuie de aceptat ?economisirea” morfinei i?n scopul reducerii react?iilor ei adverse i?n detrimentul calita?t?ii analgeziei. Eficient?a clinica? este mai mare pentru durerea acuta? de origine somatica? (ex: chirurgia ortopedica?, herniile, chirurgia toracica?). Pentru unele tipuri de intervent?ii 10 (ORL, neurochirurgie, oftalmologie), utilizarea AINS pentru analgezie este contraindicata? din cauza cres?terii riscului de sa?ngerare, estimat la 1 caz suplimentar la fiecae 30 pacient?i. Din cauza riscurilor unor react?ii adverse frecvente s?i severe, durata utiliza?rii AINS i?n postoperatoriu i?n administrare i.v. este limitata? la maxim 2 zile, iar peroral – la 5 zile (sau 3 zile, daca? anterior a fost utilizata? calea i.v.). Cel mai sigur AINS i?n sensul complicat?iilor postoperatorii este ketoprofenul (100 mg × 2 i?n 24 ore). ??Nefopamul. Act?ioneaza? la nivel medular s?i cerebral prin inhibit?ia recapta?rii noradrenalinei s?i serotoninei. Nu interact?ioneaza? cu sistemul opioidergic. Are s?i un efect antihiperalgezic (foarte util, de altfel), mediat prin intermediul receptorului NMDA. Combate eficient frisonul (majoritatea absoluta? a pacient?ilor sunt hipotermi ca?tre sfa?rs?itul operat?iei, iar normalizarea temperaturii, fiziologic, se face prin frison – foarte nedorit i?n postoperatoriu). Asocierea cu AINS este sinergica? (adica?, 1+1=3), iar cu morfina – infraaditiva? (1+1=1,5). I?nsa? efectul antihiperalgezic permite o reducere a necesarului de morfina? i?n postoperatoriu cu 35-50%. Nu are act?iune asupra sistemului respirator s?i hemostazei, e lipsit de fenomene de sevraj sau adict?ie. Doza terapeutica?: 20 mg bolus, urmat de o perfuzie i.v. continua? cu seringa electrica? de 2 mg/ora?. Doze echianalgezice: 20 mg nefopam = 7 mg morfina? = 50 mg petidina? = 75 mg diclofenac. Doza de nefopam maxima? admisibila? i?n 24 ore s?i aparit?ia efectului-plafon este de cca 60 mg. ??Tramadolul. Este un analgezic central, cu act?iune preponderent monoaminergica?. Are s?i un efect opioidergic, care este, i?nsa?, de 6000 (s?ase mii) ori mai mic deca?t cel al morfinei. Metabolitul lui, O-demetil-tramadolul (M1) are act?iune analgezica? majora?. ?Es?ecul” analgeziei cu tramadol este datorat lipsei enzimei CYP2D6 din citocromul P450 (nu se produce metabolictul M1), care are o prevalent?a? de 7% la caucazieni. I?n insuficient?a renala? sau hepatica?, dozele uzuale de tramadol se i?njuma?ta?t?esc. Doza perorala? de tramadol este identica? cu cea i.v., deoarece biodisponibilitatea dupa? primele prize este de cca 100%. Are act?iune sinergica? cu paracetamolul s?i AINS. Nu are act?iune asupra centrului respirator, i?n schimb frecvent?a gret?urilor, vertijurilor s?i va?rsa?turilor poate atinge 40%, ceea ce i?i limiteaza? utilizarea. Ondansetronul (antiemetic) nu este eficient i?n tratamentul gret?urilor provocate de tramadol. Doza ?clasica?” este de 50-100 mg tramadol per os la fiecare 4-6 ore. Este contraindicat la pacient?ii epileptici s?i la cei care se afla? sub tratament cu antidepresive triciclice sau IMAO (scade pragul de convulsii). VIII. Rolul analgezicelor opioide i?n tratamentul durerii postoperatorii Pentru combaterea durerii postoperatorii sunt utilizate 2 clase de analgezice opioide: agonis?tii puri (morfina) s?i agonis?tii-antagonis?ti. Farmacologia analgezicelor opioide este bine redata? i?n manualul de farmacologie; prezenta sect?iune se va referi doar la aspectele ce se refera? la analgezia postoperatorie. ??Agonis?tii opioizi. Morfina este considerata? ?standard de aur” i?n tratamentul durerii. Morfina este metabolizata? preponderent prin glucuron-conjugare (M3G, M6G, M3,6G), sulfo-conjugare s?i N-demetilare. Metabolitul M3D nu are act?iune analgezica?, dar stimuleaza? receptorii NMDA, ce provoaca? fenomenul de hiperalgezie. Metabolitul M6G este de 13 ori mai puternic deca?t morfina. Eficient?a analgezica? dupa? administrarea subcutanata? sau intramusculara? de morfina? are o variabilitate interindividuala? foarte mare, deci, utilizarea acestor ca?i nu este recomandata?; este recomandata? administrarea ei i.v. sau perorala?. Combinat?ia paracetamol + AINS sau nefopam + morfina? titrata? i.v., urmata? i?n PCA s?i respectarea principiilor descrise mai sus, asigura? o analgezie calitativa? pentru 95% din pacient?i. Principiul titra?rii i.v. a morfinei este urma?torul (exemplu):a. Pacientului X, internat postoperator i?n sala de trezire i s-a administrat deja intraoperator 1g de paracetamol (reduce necesarul de morfina?), 20mg nefopam (analgezie preemptiva?) s?i 20mg ketamina? (i?n scopul profilaxiei fenomenului de hiperalgezie);b. Se apreciaza? intensitatea durerii cu unul din scoruri s?i nivelul de sedare. Daca? SVA≥4, atunci se i?ncepe titrarea nemijlocita? a morfinei: 2mg i.v., dupa? care se as?teapta? 5 min. Se 11 reevalueaza? intensitatea durerii. Daca? SVA≥4, se mai administreaza? i?nca? 2 mg de morfina? i.v. Procedeul se repeta?, pa?na? ca?nd SVA ≤3. De obicei, o doza? de 4-8 mg este suficienta? pentru majoritatea pacient?ilor. Daca? necesarul depa?s?es?te 12 mg pentru procedura de titrare, atunci se va ca?uta o complicat?ie, cel mai probabil de origine chirurgicala?. Apoi, dupa? procedura de titrare, se instaleza? pompa PCA (vezi sect?iunea 9). Astfel, analgezia pacientului se afla? ?i?n ma?inile lui”. Pompa PCA se ment?ine pa?na? i?n momentul ca?nd: consumul nictimeral de morfina? ≤7 mg (atunci opioizii se exclud din schema de analgezie), fie pa?na? ca?nd calea enterala? devine disponibila? (adica?, dupa? ce pacientul bea apa? sau ma?na?nca? ceva us?or nu are great?a? sau vomita?). Din acest moment, analgezia i.v se trece i?n totalitate pe calea perorala?, inclusiv morfina. La momentul edita?rii manualului, forma orala? de morfina? i?n Republica Moldova este indisponibila?. ??Agonis?tii-antagonis?ti opioizi se caracterizeaza? prin efecte agoniste fat?a? de receptorii κ (kappa) s?i antagoniste fat?a? de μ (miu). Au o doza?-plafon, depa?s?irea ca?reia cres?te numai probabilitatea s?i severitatea react?iilor adverse. Antagonizeaza? analgezia produsa? de agonitii opioizi. Pe durata act?iunii lor, face ineficienta?, deci, inutilizabila? act?iunea agonis?tilor. Potent?ialul de sedare este mai puternic comparativ cu cel al agonis?tilor. Tot?i agonis?tii- antagonis?ti opioizi au un potent?ial de depresie respiratorie identic morfinei. Depresia respiratorie produsa? de agonis?tii-antagonis?ti opioizi (cu except?ia nalbufinei) nu este antagonizata? de ca?tre naloxona?! Pentazocina (Fortalul) a fost scoasa? din arsenalul de medicamente din cauza efectelor psihoafective, hemodinamice s?i coronare ra?u tolerate de pacient?i. Buprenorfina (agonist part?ial) confera? o stare de analgezie i?n doze de 4-6 μg/kg. Efectul se manifesta? i?n 30-60 minute s?i t?ine pa?na? la 6-8 ore. Nalbufina un preparat ce se administreaza? exclusiv parenteral (biodisponibilitatea extrem de mica? o face inutilizabila? per os). Analgezia apare i?n 2-3 minute dupa? administrarea i.v., dureaza? cca 4 ore. Dozarea: 0,20–max. 0,40 mg/kg la fiecare 4-6 ore. ??Formele medicamentoase noi nu sunt deca?t molecule ?vechi”, condit?ionate i?n matrit?e medicamentoase ultramoderne: Actiq? este fentanilul formulat i?n comprimate bucale, care se plaseaza? i?nre obraz s?i gingie (fa?ra? a le suge sau a le sfa?ra?ma, pentru a evita pasajul hepatic al medicamentului). Astfel, o doza? de 200-1600 μg este eliberata? s?i absorbita? i?n 15 minute (800 μg Actiq? = 10 mg morfina? i.v.). Debutul analgeziei – 5 minute, durata efectului – 3 ore. Sophidona? LP este hidromorfona condit?ionata? i?n forma de gelula? cu liberare prelungita?. E de doua? ori mai puternica? deca?t morfina. Debutul act?iunii – 1 ora?, maximumul – 6 ore, durata efectului – 12 ore. Durogesic? este o forma? de administrare transcutanata? continua? a fentanilului i?n doze de 25-100 μg/ora?. Un patch asigura? o analgezie de buna? alitate timp de 72 ore. Ionsis? este o forma? medicamentoasa? originala?, scoasa? pe piat?a? i?n 2008. Molecula activa? (fentanilul) este administrata? transcutanat prin mecanism iontoforetic la cererea pacientului (apa?sarea pe buton). Dispozitivul este minuscul (15×35 mm), se lipes?te pe deltoid sau antebrat? s?i asigura? analgezia timp de 72 ore. Pentru combaterea react?iilor adverse la nivelul tractului gastro-intestinal (constipat?ia s?i spasmul oddian), cura?nd va fi pus pe piat?a? preparatul Adolor? (almivopanul, antagonist μ opioid, ce nu trece bariera hemato-encefalica?) s?i metilnaltrexona. ??React?iile adverse. Amintim doar cele mai frecvente react?ii adverse, cauzate de analgezicele opioide, i?nta?lnite i?n cadrul analgeziei postoperatorii: gret?uri (pa?na? la 40%), voma?, constipat?ie, prurit, mioza?, disforie, retent?ie urinara?. React?ii rar i?nta?lnite: colica hepatica? (spasm al sfincterului Odii, <3% cazuri), depresie respiratorie (0,1-0,5%). React?iile adverse sunt indisociabile de efectele farmacologice. Hipercapnia (un PaCO2 >45 mmHg) este un efect farmacologic comun pentru opioizi, ce apare la doze infraclinice. Un PaCO2 pa?na la 50 mmHg este ceva normal pentru un pacient care primes?te 12 morfinomimetice. Hipercapnia nu i?nseamna? depresie respiratorie. De fapt, riscul de depresie respiratorie este minim (<0,5%) i?n cadrul utiliza?rii corecte a analgezicelor opioide. Cu toate acestea, luarea ma?surilor de precaut?ie este obligatorie: administrarea de O2 pe masca? sau ochelari nazali pe toata? durata administra?rii i.v. a morfinei (sau altui opioid), monitorizarea respirat?iei s?i gradului de sedare a pacientului (Figura 7), disponibilitatea imediata? a naloxonei i?n scop de antagonizare a efectelor (depresie respiratorie, glob vezical, colica? hepatica?). Supravegherea de rutina? Evaluat?i nivelul de sedare Supravegherea de rutina? Figura 7. Algoritm de monitorizare a analgeziei cu analgezice opioide i?n postoperatoriu. De asemenea, i?n cazul rahianalgeziei cu analgezice opioide (fentanil sau morfina?), din cauza riscului de depresie respiratorie tardiva? (<0,2%), pacientul va fi monitorizat i?n sect?ia de reanimare timp de 24 ore postoperator, indiferent daca? funct?iile vitale sunt stabile. Rahianalgezia cu analgezice opioide este indicata?, i?n special, i?n chirurgia toracica? sau cardiaca?, care sunt foarte dureroase postoperator. Cu toate react?iile adverse ment?ionate mai sus, beneficiul utiliza?rii analgezicelor opioizide pentru asigurarea analgeziei este indiscutabil mai mare deca?t inconvenientele. IX. Utilizarea analgezicelor opioide i?n tratamentul durerii: o problema? globala? Analgezicele opioide reprezinta? una din clasele de medicamente ce necesita? un regim special de securitate, evident?a?, prescriere s?i asigurare a trasabilita?t?ii. Aceste aspecte sunt reglementate prin convent?ii internat?ionale (de ex, Convent?ia Unica? cu privire la medicamentele stupefiante din 1961 cu Amendamentul din 1977, ) s?i cadrele legale nat?ionale. I?n Republica Moldova, acest regim e reglementat de: Legea Nr. 382-XIV din 06.10.1999 ?Cu privire la circulatia substantelor narcotice, psihotrope s?i a precursorilor”, Hota?ra?rile de Guvern HG nr. 1088 din 05.10.2004 ?Cu privire la aprobarea tabelelor s?i listelor substant?elor narcotice, psihotrope s?i precursorilor acestora, supuse controlului”, HG nr. 79 din 23.01.2006 ?Privind aprobarea Listei substant?elor narcotice, psihotrope s?i a plantelor care cont?in astfel de substant?e depistate i?n trafic ilicit, precum s?i cantita?t?ile acestora”, HG nr. 128 06.02.2006 ?Cu privire la aprobarea Cerint?elor tehnice fat?a? de i?nca?perile s?i obiectivele i?n care se pa?streaza? substant?e narcotice, psihotrope s?i/sau precursori”, HG nr. 216 din 27.02.2006: ?Privind tranzitul pe teritoriul Republicii Moldova al substant?elor narcotice, psihotrope s?i precursorilor”, ordinele Ministerului Sa?na?ta?t?ii (nr. 71 din 03.03.1999, “Cu privire la pa?strarea, evident?a s?i eliberarea produselor s?i substantelor stupefiante, toxice si psihotrope” + anexe; nr. 434 din 28.11.2007, “Cu privire la modul de prescriere si livrare a medicamentelor” +anexe) s?.a. Problema utiliza?rii insuficiente a analgezicelor opioide pentru tratamentul durerii este una globala?. Conform raportului din 2007 a Comitetului International pentru Controlul Drogurilor, i?n 2006 consumul de analgezice opioide a statelor vest-europene, i?mpreuna? cu Canada s?i SUA a R0 Respirat?ie normala? (R≥10 rpm, Vt>5 mL/kg R1-R2 Respirat?ie anormala? sau FR<10 rpm R3 Respirat?ie obstructiva?, pauze respiratorii sau apnee S0-S1 Cons?tiint?a? normala? S2 Somnolent?a? intermediara? (pacientul poate fi trezit) S3 Somnolent?a? profunda? (pacient trezit cu dificultate) Supraveghere apropiata? la fiecare 15 min. Reducet?i doza bolusului urma?tor. Oprit?i administrarea de morfina? sau pompa PCA. Stimulat?i pacientul. Administrat?i O2. Administrat?i naloxona? (1 fiola? de 0,4 mg i.v.). Chemat?i ajutor. S1 Pacientul se trezes?te us?or S2-S3 Pacient trezit cu dificultate 13 constituit 89% din cel global; 80% din populat?ia Terrei consuma? mai put?in de 6% de analgezicele opioide, iar i?n 50 de state ale lumii ceta?t?enii nu au niciun acces la aceste preparate. I?n Republica Moldova, consumul de analgezice opioide a fost de 3234g dintr-un necesar minim estimat de 9500g (de 20 ori mai put?in deca?t media europeana?), cu predilect?ie pentru asigurarea anesteziei (Figura 8). 160 140 120 Media globala, 5.9847 mg Austria 153,51 Canada 61,01 SUA 57,88 Georgia 1,82 Jamaica 1,13 Moldova 1,09 Armenia 0,82 Kenya 0,13 Nepal 0,035 154 State ale lumiis 100 Danemarca 55,71 Australia 52,28 80 France 43,45 60 40 20 0 Norvegia 31,54 Figura 8. Consumul mondial de analgezice opioide i?n scopul tratamentului durerii (mg/locuitor/an). Cauzele unui consum ata?t de deficitar sunt (studiu OMS din 1995, efectuat i?n 65 state): ???teama exprimata? de guverne i?n provocarea adict?iei s?i favorizare a narcomaniei (72% state); ???lipsa instruirii personalului medical s?i administrativ; ???legi excesiv de severe s?i restrictive (59% de state); ???teama medicilor de sanct?iuni, daca? fac prescript?ii de analgezice opioide; ???indisponibilitatea opioizilor (adica?, nu se importa? i?n t?ara? fie cantitatea necesara?, fie formele medicamentoase necesare, i?n special morfina orala? – solut?ie sau comprimate); ???Costul opioizilor s?i lipsa de resurse a sistemelor de sa?na?tate; ???Lipsa de politici s?i recomanda?ri nat?ionale i?n domeniu. I?n realitate, fenomenul de adict?ie fat?a? de analgezicele opioide, care sunt utilizate i?n scopul combaterii durerii sunt cu totul s?i cu totul except?ionale (1 caz la ca?teva mii pacient?i, i?n cazul prezent?ei unor factori de risc preexistent?i). Niciun caz de deces nu a fost i?nregistrat i?n cadrul utiliza?rii corecte a analgezicelor opioide i?n scopul combaterii durerii. Pentru comparare, numai AINS au provocat 16000 de decese i?n 2004 i?n Statele Unite. Este foarte important de a face distinct?ie dintre definit?iile utilizate i?n acest sens. Termenul ?adict?ie fat?a? de droguri” a fost supus la numeroase modifica?ri de-a lungul anilor s?i nu-s?i are locul i?n cadrul utiliza?rii i?n scopuri medicale a analgezicelor opioide. Ultima modificare (OMS, 1996) utilizeaza? termenul de ?sindrom de dependent?a?”, care este un cluster de fenomene fiziologice, comportamentale s?i cognitive de intensitate variabila?, i?n care utilizarea unui sau unor medicamente psihoactive ocupa? o prioritate i?nalta?. Este foarte important de specificat caracterul preocupant, dorit, de a obt?ine s?i a utiliza drogul s?i prezent?a unui comportament de ca?utare. Pentru stabilirea diagnosticului de ?sindrom de dependent?a?”, este necesara? aparit?ia a 3 criterii din lista de mai jos i?n anul precedent: 1) Dorint?a?puternica?dealuamedicamentul(substant?a);2) Dificulta?t?ii?ncontrolulutiliza?rii;3) Caracterulnociv,da?una?toralutiliza?riisubstant?ei;4) Ignorareapla?ceriis?iacordareadincei?ncemaimulttimppentruobt?inereasubstant?ei; 5) Instalareafenomenuluidetolerant?a?; 6) Instalareafenomenuluidesevrajfizic7) Utilizareasubstant?einuconducelaameliorareacalita?t?iiviet?ii; 8) Utilizatorulneaga?utilizareasubstant?ei. 14 Pacientul care utilizeaza? analgezice opioide i?n scopul combaterii durerii nu cade sub incident?a acestor criterii. Tolerant?a s?i dependent?a fizica? sunt consecint?e normale a tratamentului prelungit cu analgezice opioide s?i nu este echivalenta? cu ?adict?ia” sau ?sindromul de dependent?a?”. Ca urmare a acestor schimba?ri de mentalitate s?i politici, ata?t la nivel internat?ional, ca?t s?i la cel nat?ional, un s?ir de t?a?ri s?i-au ajustat cadrul reglementar, care asigura? 2 condit?ii fundamentale: a) accesibilitatea s?i disponibilitatea analgezicelor opioide pentru tratamentul durerii s?i b) prevenirea abuzului s?i traficului de substant?e (Tabelul 1). Tabelul 1. Exemple de modifica?ri legislative, care au condus la ameliorarea accesibilita?t?ii s?i disponibilita?t?ii analgezicelor opioide pentru tratamentul durerii Statul Legea veche Legea noua? (durata s?i doza maxima? i?n prescript?ie) 30 zileDurata? nelimitata?30 zile30 zile4000 mg pe o ret?eta?30 zile, la discret?ia medicului, fa?ra? doza? limita? s?i pa?na? la 3 opioizi (s. forme) per ret?eta?. ? (durata s?i doza maxima? i?n prescript?ie)Frant?a 7 zile 28 zile Columbia Germania Israel Italia Polonia Roma?nia Republica Moldova 10 zile1zi10 zile8 zile100 mg pe o ret?eta?3 zile, 3 diagnoze, 60mg/zi, 1 medicament sau forma? medicamentoasa? per ret?eta?. 7 zile (pentru pacient?ii cu cancer – 14 zile), doar forma injectabila?, doza maxima? – 10 fiole/14 zile, procedura? laborioasa?. Conform OMS (2006), cheia succesului i?n managementul durerii este respectarea celor 2 principii (?triunghiul” OMS): politici nat?ionale pentru un management adecvat al durerii, disponibilitatea s?i accesibilitatea formelor medicamentoase orale de analgezice opioide, instruirea pacient?ilor, medicilor s?i administratorilor. X. Tehnici analgezice particulare, utilizate i?n combaterea durerii postoperatorii 1. Infiltrat?ia pla?gii operatorii cu anestezic local I?n acest scop se utilizeaza? ropivacaina, 0,75%, doza maximala? admisibila? 3 mg/kg. Lidoicaina are utilizare limitata? din cauza duratei scurte de act?iune s?i efectelor neurotoxice, iar bupivacaina – din cauza potent?ialului cardiotoxic. Pentru articulat?ii, pot fi asociate: morfina 1mg, AINS sau corticoizii. La i?nchiderea pla?gii, chirurgul infiltreaza? plaga cu ropivacaina?, ce asigura? o analgezie timp de 6-8 ore. Necesita?, totus?i, combinare cu analgezia sistemica?. Metoda reduce necesarul postoperator de morfina? cu 40-60%. Lista nonexhaustiva? a siturilor de infiltrare a anestezicelor locale i?n scop de analgezie postoperatorie este prezentata? i?n Tabelul 2. Lista nonexhaustiva? a siturilor de infiltrare a anestezicelor locale ??infiltrareadupa?curahernieiinghinale??infiltrareintra-articulara?dupa?chirurgiauma?ruluis?iagenunchiului??infiltrareazoneidechirurgieplastica???infiltrarepentruchirurgiaproctologica???infiltrareapereteluipla?giidupa?laparotomie,chirurgieortopedica?saupetiroida? ??infiltrareintraperitoneala?dupa?intervent?iicelioscopice??infiltrareatrompeloruterines?imezosalpinxului??infiltrareascalpuluii?nneurochirurgie??infiltrareaintrapleurala?i?nuneleindicat?iii?nchirurgitoracica?s?iabdominala? 2. Analgezia controlata? de pacient (PCA s?i PCEA) Tabelul 2. Analgezia autocontrolata? de pacient (PCA, patient controlled analgesia) este standardul de aur i?n managementul durerii. Pompa PCA (Figura 9) permite administrarea automata? a dozei prescrise de analgezic prin apa?sarea unui buton i?n momentul dorit de pacient, i?n limitele de securitate, stabilite de medic. Accesul direct la seringa cu morfina? este imposibil pentru pacient, 15 la fel s?i pentru seta?rile aparatului (e necesara? fie o cheie electronica?, fie un pin-cod). Exemplu de prescript?ie PCA: Morfina? bolus 2 mg, perioada refractara? – 7 min, doza maximala? pe 4 ore – 20 mg. Aparatul afis?eaza? urma?torii parametri: doza totala? consumata?, ultima administrare, raportul doze cerute/doze administrate. O varianta? a PCA este PCEA, care, prin acelas?i principiu, administreaza? anestezic local i?n spat?iul peridural. Figura 9. Pompa PCA s?i pompa elastomerica?. 3. Rahianalgezia Rahianalgezia este o metoda? foarte eficienta? de control al durerii postoperatorii, i?n special dupa? cezariana? s?i chirurgia cardiaca?. Nu s?i-a demonstrat utilitatea i?n intervent?iile pe abdomen. I?n chirurgia ortopedica? a membrului inferior necesita? combinaea cu analgezia perineurala?. Drept analgezic este utilizata?, practic i?n exclusivitate, morfina. Tehnica este identica? unei punct?ii lombare, cu administrarea unei doze unice de 0,1mg de morfina? (1 fiola?=10mg – 1mL. Fiola se dizolva? i?n 9mL ser fiziologic =1mg/mL; de aici se ia 1 mL de solut?ie, care se dizolva? pa?na? la 10 mL. Din solut?ia obt?inuta? (0,1 mg/mL) se administreaza? rahidian 1 mL. Se poate asocia cu 300μg clonidina?. Difuzia morfinei se face odata? cu mis?carea LCR, ce explica? onset-ul tardiv al analgeziei. Din acest motiv, metoda data? de analgezie realizeaza? i?nainte de induct?ia i?n anestezie, i?n sala de operat?ii. Durata efectului – 24 ore (de aici s?i necesitatea monitoriza?rii pacientului timp de 24 ore i?n sect?ia de reanimare din cauza riscului de depresie respiratorie tardiva?, care este o complicat?ie rara?). 4. Analgezia peridurala? Analgezia peridurala? este o tehnica? remarcabila?, i?nsa?, din pa?cate, i?nca? put?in utilizata?. Este, practic, indispensabila? i?n analgezia nas?terii, i?n postoperatoriu dupa? intervent?ii majore intraabdominale, pe membrele inferioare, i?n pancreatita acuta?. Motivul subutiliza?rii acestei metode este specificul cultural (al personalului medical, i?n special). Este singura tehnica? analgezica? care desinesta?ta?tor reduce complicat?iile trombembolice postoperatorii, accelereaza? repriza tranzitului intestinal s?i scurteaza? durata de spitalizare. Ropivacaina 2% a substituit, practic, definitiv, celelalte anestezice locale ata?t i?n realizarea anesteziei, ca?t s?i analgeziei peridurale. Ada?ugarea la ropivacaina? a morfinei, sufentanilului sau fentanilului cres?te calitatea analgeziei. Utilizarea numai a analgezicelor opioide pe cale peridurala? nu are niciun interes. Drept adjuvant?i, mai pot fi utilizate: clonidina (risc de hipotensiune), adrenalina (reduce de 2 ori necesarul de anestezic local pentru aceeas?i calitate a analgeziei). De exemplu, amestecul de ropivacaina? 0,1%, fentanil 2μg/mL s?i adrenalina? 2μg/mL, administrata? i?n perfuzie continua? cu o viteza? de 5-8 mL/ora? realizeaza? o analgezie remarcabila?. React?iile adverse sunt rare s?i se manifesta? i?n primele 24 ore: prurit (14%), gret?uri (11%), hipotensiune (3%). 5. Analgezia perineurala?Utilizata? fie i?n continuarea anesteziei perineurale, fie independent de ea. Siturie de punct?ie, tehnica realiza?rii este identica? anesteziei perineurale. Deosebirea o face doar concentrat?ia utilizata? de anestezic local (ropivacaina?). Metoda permite deambularea a 90% din pacient?ii operat?i peste 24 ore (contra unui maxim de 50% pentru anestezia sistemica? cu opioizi). 16 Administrarea continua? de anestezic local, inclusiv i?n condit?ii de domiciliu este asigurata? fie de un perfuzor electric, fie, mai nou, de ca?tre pompe elastomerice (Figura 9). Pompa elastomerica? consta? dintr-un rezervor elastic, cu un colum de 200mL. O diafragma? speciala? asigura? o curgere stabila? de anestezic local cu viteze cuprinse i?ntre 5, 7 sau 10 mL/ora?. Pacientul poate opri/porni desinesta?ta?tor pompa elastomerica?, i?n funct?ie de necesita?t?i, prin simpla clampare a tubului. 6. Electroanalgezia (tehnica TENS) Electroanalgezia (stimulare electrica? nervoasa? transcutanata?, TENS) utilizeaza? principiul ?bruierii” impulsului nervos nociceptiv prin emiterea unor impulsuri cu o intensitate, forma? s?i frecvent?a? prestabilita? (Figura 10). Figura 10. Model de aparat de stimulare electrica? nervoasa? transcutanata? Se presupune ca? interfereaza? cu mecanismele port?ii de control medular s?i segmentele suprasegmentare de control a traficului nociceptiv. Cres?te eliberarea opioizilor endogeni. Electrozii se plaseaza? i?n jurul pla?gii operatorii sau deasupra, respecta?nd dermatoamele. Se include curentul electric, iar intensitatea lui se cres?te de ca?tre pacient pa?na? la aparit?ia senzat?iei de furnica?turi. Efectul apare i?n cca 30 min. Eficient la cca 40% de pacient?i. Necesita? asocierea analgeziei perorale. Tehnica are o ra?spa?ndire limitata?, se afla?i?nca? i?n faza? de evaluare. Un istoric al medicinei dureriiin Articol, Istorie 22 Dec 2017?nc? de la apari?ia sa ?n antichitate, conceptul de durere a r?mas un subiect de larg? dezbatere. Primele ?ncerc?ri de a defini durerea sunt anterioare anului 1800 ?i se reg?sesc, at?t ?n Orient, c?t ?i ?n Occident. De?i teoriile momentului referitoare la durere erau potrivite pentru interpretarea unor aspecte, ele nu sunt ?nc? exhaustive. Parte din explica?ie vine din aceea c? istoria durerii este la fel de lung? ca cea a omenirii, ?n?elegerea mecanismelor sale fiind departe de a fi complet?. Ea poate fi abordat?, de exemplu, pornind de la dezvoltarea teoriilor durerii ?i a descoperirilor fundamentale din acest domeniu.O ?ntrebare care vine natural ar putea fi – de ce s? ne preocupe istoria durerii? Cum ar putea aceast? informa?ie s? ajute un cititor obi?nuit, un pacient sau un medic?HYPERLINK ""????????Sursa foto: este ?nfrico??toare ?i genereaz? fric?. Pacien?ii care se tem de durere sunt ?n situa?ia cea mai dificil?. Ei simt c? nu au niciun control asupra corpului lor, iar aceasta amplific? frica. ?n astfel de situa?ii, cunoa?terea poate s? ajute.O istorie a durerii, dincolo de valen?ele informa?ionale, ?i poate ajuta pe pacien?ii care se tem de durere s? dep??easc? emo?ia negativ? generat? de fric? ?i s? ?n?eleag? natura durerii ?i modul ?n care produc?torii de medicamente ?i cercet?torii au ajuns la gama actual? de op?iuni de tratament.Practicile cele mai documentate sunt cele din perioada secolelor XVII ?i XVIII.René Descartes (1596-1650) a fost cel a c?rui cercetare a influen?at g?ndirea referitoare la durere, chiar ?i ?n secolele care au urmat.??n plus, contribu?iile sale ?n ?tiin?? ?i medicin? au fost at?t de semnificative ?nc?t sunt ?nc? valide ?n practica medical? occidental? de ast?zi. ?n anul 1644 au fost publicate Principiile filosofiei Descartes, ?n care apare tema legat? de durerea ?n membrele lips?.?Din observa?iile sale, el a dedus c? durerea este sim?it? ?n creier, nu ?n membrul amputat.?El a definit conceptul de suflet al durerii care e localizat ?n glanda pineal? ?i a sus?inut c? agita?ia persistent? a nervilor membrului amputat produce senza?ii ca ?i c?nd acesta este ?nc? intact.?Pentru c? g?ndirea Bisericii la acel moment considera durerea ca fiind str?ns legat? de p?catul original, iar Biserica avea o mare influen?? asupra g?ndirii ?tiin?ifice a perioadei, Descartes a preferat s? nu ri?te ?i a introdus conceptul de suflet ?n explica?ia sa. Ast?zi este bine cunoscut modelul s?u al durerii resim?it? de un b?iat care-?i apropie piciorul de fl?c?ri. Pe m?sur? ce focul se apropie de picior, ?ntre stimulul dureros ?i creier se genereaz? o leg?tur? rapid? (indicat? de el printr-un fir cu traseu scurt)HYPERLINK ""????????????Sursa foto: lui Descartes al durerii sugereaz? c? aceasta este ?n primul r?nd un fenomen senzorial care este separat de influen?ele de ordin superior (neocortex). ?n plus, natura dualist? a durerii lui Descartes presupune c? durerea este fie fizic?, fie de origine psihic?, deci ele se exclud reciproc.Cercet?rile din prezent au ?nceput din ce ?n ce mai mult s? indice eroarea teoriei dualiste a lui Descartes ?i s? demonstreze importan?a dimensiunii psihice a durerii asociate diverselor afect?ri fizice.Cu toate acestea, g?ndirea lui Descartes aduce o real? valoare prin aceea c? el a deschis calea cercet?rii ulterioare privind localizarea func?iilor cerebrale. Tot el are meritul de a fi ?ncercat s? ?nl?ture confuzia dintre durere ?i triste?e. El sim?ea c? triste?ea urma ?ntotdeauna durerii, deoarece sufletul recuno?tea astfel sl?biciunea trupului ?i incapacitatea lui de a rezista leziunilor care l-au afectat. Cercetarea sa era revolu?ionar? pentru perioada ?n care a tr?it, mai ales dac? avem ?n vedere nivelul tehnologic precar al acesteia.Secolul al XVIII, cunoscut mai ales ca perioada iluminist?, va aduce progrese, favorizate ?i de descre?terea influen?ei Bisericii. ?n plus, g?ndirea ?i sentimentele aveau s? se schimbe, ?n ceea ce prive?te percep?ia ?i definirea durerii.?n lucrarea Istoria durerii, Roselyne Rey avea s? observe c? ?n secolul al XVIII-lea au existat trei filozofii medicale diferite:? ?coala mecanic? de g?ndire – erau cei care voiau s? se ?ntoarc? la ideea corpului uman care func?ioneaz? ca o ma?in? simpl?, model care era popular p?n? ?n mijlocul secolului al XVIII-lea.? ?coala de g?ndire vitalist?, care a fost mai dominant? spre sf?r?itul secolului. Erau lideri care au adoptat conceptul de sensibilitate, care includea simultan conceptele de fiziologie ?i psihologie.? ?coala minoritar? de g?ndire (animism) considera c? natura este mai pasiv?. Ace?ti credincio?i acceptau explica?ii mecanice ?i considerau c? sufletul este direct responsabil pentru toate func?iile organice. Mai mult, ei au crezut c? durerea era un semn important al bolii ca urmare a conflictelor interne.Primul mare contributor la aceast? schimbare ?n modul de g?ndire a fost Albrecht von Haller (1708-1777). El a f?cut distinc?ia dintre iritabilitatea fibrei musculare (pe care a numit-o contractibilitate) ?i excitabilitatea fibrelor nervoase (pe care a numit-o sensibilitate). Von Haller va insista pe dihotomia strict? ?ntre sensibilitate, care este asociat? cu con?tiin?a, ?i iritabilitate, care este independent? de con?tiin??. El a fost prima persoan? care a descoperit c? numai nervii produc senza?ii ?i numai acele p?r?i ale corpului conectate la sistemul nervos pot suferi o senza?ie.C?tre mijlocul secolului XVIII, Pierre Jean George Cabanis (1757-1808) va propune o abordare psihofiziologic? a durerii, care a inclus componenta emo?ional?. Pentru el, sensibilitatea nu a putut fi definit? ?n afara domeniului pl?cerii ?i durerii, deoarece ceea ce ne afecteaz? nu ne poate fi niciodat? indiferent. ?n opinia sa, durerea este util? deoarece aduce stabilitate ?i echilibrul nervilor ?i sistemelor musculare. Ideea utilit??ii durerii a condus la tehnicile terapeutice de tip ?oc electric ?i de stimulare. El a introdus ?i conceptul de ipohondrie ?i durere: durerea nu este o reac?ie fiziologic? pur? la un stimul, ci necesit? activitatea mental? a pacientului.?ntreb?rile sale despre condi?iile psiho-fiziologice necesare pentru ca durerea s? ajung? la con?tiin?? l-au f?cut s? considere percep?ia durerii ca fiind un proces complex ?i cronologic. ?n timpul acestui proces, orice senza?ie, la un moment dat, ar putea fi absorbit? de o alt? senza?ie. El a propus un model competitiv ?ntre sentimentele interne ?i externe, unde cele mai slabe senza?ii au fost absorbite de cele mai puternice.Cel care a venit cu alte contribu?ii semnificative pe finalul secolului XVIII avea s? fie Xavier Bichat (1771-1802). El a studiat separat sistemul nervos simpatic ?i parasimpatic, pe care le vedea distincte, fiecare av?nd dou? centre principale: unul ?n creier ?i cel?lalt ?n ganglioni. ?n plus, durerea venit? din ganglioni era foarte diferit? de durerea din nervii spinali. Contribu?ia lui Bichat la medicina durerii a fost descoperirea importan?ei sistemului nervos simpatic. Descoperirile sale au condus, de asemenea, la cre?terea utiliz?rii opiului ca op?iune de tratament.Lucr?rile lui Cabanis ?i Bichat au reprezentat ?nceputul unei tendin?e importante ?n tratamentul durerii: abordarea holistic? ?i multidisciplinar?.Secolele XIX ?i XX aduc noi dezvolt?ri ale domeniului. Livingston este cel care vorbe?te despre ciclul vicios al durerii (causalgia). El afirm? c? o leziune organic? la periferie care implic? un nerv senzorial poate fi sursa irit?rii constante. Mai mult, impulsurile aferente de la “punctul de declan?are” genereaz? o stare anormal? de activitate ?n centrele neuronilor de leg?tur? ai materiei cenu?ii din m?duva spin?rii. Aceast? perturbare se reflect? apoi ?ntr-un r?spuns motor anormal, at?t din coarnele laterale, c?t ?i din cele anterioare. Acest spasm muscular, modific?rile vasomotorii ?i alte efecte pe care le produce perturbarea central? a func?iilor ?n ?esuturile periferice pot contribui la noi surse de durere ?i noi reflexe. Este creat un ciclu vicios de activitate. Dac? acestui proces i se permite s? continue, el se r?sp?nde?te ?n zone noi ?i va fi din ce ?n ce mai greu de ?nvins.Teoria por?ii de control a durerii, care a fost lansat? sub influen?a lui Livingston, reprezint? un model care este contrar ?colii dualismului ?i teoriei specificit??ii durerii, ?nc? predate ?n multe ?coli medicale din SUA. ?n 1965, Ron Melzack (1929-prezent) ?i Patrick Wall (1925-2001) au propus aceast? teorie, care sugereaz? c? mecanismele neuronale din cornul dorsal al m?duvei spin?rii ar putea ac?iona ca o poart?, cresc?nd sau sc?z?nd fluxul de impulsuri nervoase de la fibrele periferice c?tre celulele m?duvei spin?rii ?i apoi c?tre creier. Cu alte cuvinte, poarta m?duvei spin?rii blocheaz? semnalele de durere sau le permite acestora s? treac? c?tre creier.Cei doi cercet?tori au afirmat c? intrarea somatic? este supus? influen?ei modulatoare a por?ii, ?nainte de a evoca percep?ia ?i r?spunsul durerii. Aceast? teorie sugereaz? c? intr?rile, cum ar fi frecarea sau vibra?ia u?oar?, ?nchid poarta, ?n timp ce o stimulare intens? deschide, ?n general, poarta, care este influen?at? de controalele descendente din creier. Au mai precizat c? intrarea senzorial? este modulat? de sinapsele succesive de la m?duva spin?rii c?tre creier. Durerea apare atunci c?nd num?rul impulsurilor nervoase care ajung ?n aceste zone dep??e?te un anumit nivel critic (Figura 1)HYPERLINK ""??????????Sursa foto: Melzack, ?mpreun? cu colegul s?u Kenneth Casey, au extins, ?n 1968, teoria por?ii de control pentru a include componenta motiva?ional? a durerii. ?n acest model, exist? trei componente descrise ca fiind sistemul senzorial, sistemul motiva?ional / afectiv ?i sistemul cognitiv / evaluativ (figura 2).HYPERLINK ""??????????????Sursa foto: Melzack ?i Casey au presupus c? toate cele trei componente interac?ioneaz? una cu cealalt? pentru a furniza informa?ii perceptuale care influen?eaz? ?n cele din urm? mecanismele motrice ale durerii.Ast?zi, teoria por?ii de control continu? s? evolueze, ?n ciuda controverselor considerabile. Conceptul de poart? este mai puternic dec?t oric?nd. Tehnologia stimul?rii m?duvei spin?rii se bazeaz? ?i ea pe teoria por?ii de control.De ce sunt importante toate aceste lucruri? Durerea este o problem? major? ?n Europa. De?i durerea acut? poate fi ?n mod rezonabil considerat? un simptom al bolii sau al r?nirii, durerea cronic? ?i recurent? este o problem? specific? de s?n?tate, o boal? ?n sine.Durerea acut?, cum ar fi cea care rezult? din traume sau interven?ii chirurgicale, constituie un semnal pentru un creier con?tient de prezen?a unor stimuli nocivi ?i / sau a afect?rii ?esuturilor. Acest semnal de durere acut? este util ?i adaptabil, avertiz?nd persoana de pericol ?i indic?nd nevoia de a sc?pa sau de a c?uta ajutor. Durerea acut? este un rezultat direct al evenimentului nociv ?i este, ?n mod rezonabil, clasificat? ca un simptom al afect?rii sau bolii. Cu toate acestea, la mul?i pacien?i durerea persist? mult timp dup? ce utilitatea sa a dip?rut ?i, adesea, mult timp dup? vindecarea leziunilor tisulare. Durerea cronic? la ace?ti pacien?i nu este (probabil) ?n mod direct legat? de leziunea sau boala ini?iale, ci mai degrab? de modific?rile secundare, inclusiv cele care apar ?n sistemul de detectare a durerii.Pe l?ng? faptul c? se datoreaz? unor mecanisme fiziologice diferite dec?t durerea acut?, durerea cronic? creeaz? adesea condi?iile pentru apari?ia unui set complex de modific?ri fizice ?i psihosociale, care fac parte integrant? din problematica durerii cronice ?i care adaug? foarte multe alte poveri pacientului. Acestea includ depresia, anxietatea, probleme legate de somn, dependen?a de medica?ie, activitatea ?i func?ia fizic? redus?, am?r?ciune, frustrare ?i g?nduri suicidale.La costul semnificativ al durerii cronice pentru individ, surse care reprezint? autorit??i ?n domeniu plaseaz? costurile financiare globale pentru societate ale durerii cronice ?n aceea?i zon? cu cancerul ?i bolile cardiovasculare.Mirela Musta??, Redactor Executiv E-Asistent?-Durerea mea de Tudor ArgheziDurerea mea de vineri duminica-i mai dulce.O gust mai mult c?nd sun? un clopot dintr-o turl?.De ziua s?pt?m?nii mi-e mil? ?i mi-e sil?.Anu-i opac ?i vremea s-a-ngro?at,M? cheam? ora din trecutul ispr?vit?i nu e loc s? ies din cea de-acum,Prin funingini ?i scrum.Timpul mi-este ?nsa scump,C?ci mi se pare c?-i al meu,?n vitejie ?i-n ?nfrico?are.E?ti un erou? E?ti un fugar?Omule, purtat ca o manta t?r??.Din ?apte nasturi mai at?rn? cinci.Doi s-au pierdut,Unul a ramas pe munte,Altul a c?zut ?n r?p?.Auzi-l! Cade ?n eternitate.Citate despre durereNoi ne-am n?scut ?n timp ce mamele noastre r?cneau de durere - Nichita St?nescuLimita fiec?rei dureri este o durere ?i mai mare. - Emil Cioran ?n durere omul cuget? prin sim?uri. Acest paradox vrea s? arate c?, prizonier ?n obsesiunile durerii, omul nu mai poate desf??ura opera?iunile inutile de combinare a ideilor, ci las? sim?urilor libertatea de a proiecta ceea ce se petrece ?n fr?m?ntarea lor. Aici este explica?ia faptului pentru ce toate crea?iunile izvor?te din suferin?? sunt de o sinceritate perfect?. - Emil CioranPoate c? omul ar suporta cu un curaj ne?nfr?nt durerile, dac? n-ar fi singur?t??ile care le ?nso?esc. - Emil CioranS? nu ?tie nimeni ce r?ni te dor - Octavian GogaNu durerile violente las? urme ?n noi, ci durerile ?n?bu?ite st?ruitoare, suportabile care fac parte din rutina noastr? cotidian? ?i care ne macin? la fel de con?tiincios ca ?i timpul. - Emil CioranDurerile nu se uit?, chiar fiindc? sunt legate, ?ntr-un mod nem?surat?demare,?de?con?tiin??. De aceea, singurii oameni?care?au mult?de?uitat sunt aceia?care?au suferit mult. Numai oamenii normali n-au ce uita. - Emil CioranTot ce nu are un accent de durere- o privire, o vorb?, o carte sau o voce- m? plictise?te de moarte. - Emil CioranLa un om adev?rat, durerea nu conteaz? - Ernest HemingwayVia?a e durere, a?a c? tr?ie?te-o c?t po?i - Ernest Hemingway Cel mai dureros lucru este s? te pierzi cu totul iubind pe cineva prea mult ?i s? ui?i c? ?i tu e?ti o fiin?? special? - Ernest Hemingway?n alegerea ?ntre experien?a dureroas? ?i nimic, eu aleg durerea - William FaulknerDurerea este ca un nou n?scut pl?ng?nd: nu poate spune ce vrea - Philip Roth Gradul de sensibilitate la durere cre?te proportional cu sim?irea ?i inteligen?a .- Arthur SchopenhauerDorin?a ?nso?e?te suferin?a, se dezvolt? perpetuu ajung?nd subiect de tragedie sau comedie . - Arthur SchopenhauerTot ce nu are un accent de durere- o privire, o vorb?, o carte sau o voce- m? plictise?te de moarte. - Emil CioranTrebuie sa scriu un text despre durere. ?tiu foarte bine ce am de spus -dar ce sa spun ? De ce n-am suferi ?n t?cere, ca animalele? - Emil CioranPrin forma?ia sa, "dor" are ?n el ceva de prototip: este o alc?tuire nealc?tuit?, un ?ntreg f?r? p?r?i, ca multe alte cuvinte rom?ne?ti cu ?n?eles ad?nc ?i specific. Reprezint? o contopire ?i nu o compunere. S-a contopit ?n el durerea, de unde vine cuv?ntul, cu pl?cerea, crescut? din durere, nici nu pricepi bine cum. - Constantin NoicaMuzica?este tovar??a rom?nului ?n singur?tatea mun?ilor ?i c?mpiilor; ea ?i lini?te?te spaimele, ?l ajut? s?-?i spun? dorul, nostalgia ?i durerea. Muzica rom?neasc? este n?scut? din suferin?ele poporului nostru prigonit. De aceea ea este dureroas? ?i nobil?. Ea este una din comorile cu care se poate m?ndri Rom?nia”.- George EnescuVoi cinsti ?ntotdeauna pe Dumnezeu cu toate cele potrivnice pe care le ?ng?duie s? mi se ?nt?mple.?Durerea, pentru mine, este medicamentul m?ntuirii. - Sf?ntul Grigore Teologul?Despre durere ?i suferin??Prima durere din istoria lumii1.?arpele ?ns? era cel mai ?iret dintre toate fiarele de pe p?m?nt, pe care le f?cuse Domnul Dumnezeu. ?i a zis ?arpele c?tre femeie: "Dumnezeu a zis El, oare, s? nu m?nca?i roade din orice pom din rai?"2.Iar femeia a zis c?tre ?arpe: "Roade din pomii raiului putem s? m?nc?m;3.Numai din rodul pomului celui din mijlocul raiului ne-a zis Dumnezeu: "S? nu m?nca?i din el, nici s? v? atinge?i de el, ca s? nu muri?i!"4.Atunci ?arpele a zis c?tre femeie: "Nu, nu ve?i muri!5.Dar Dumnezeu ?tie c? ?n ziua ?n care ve?i m?nca din el vi se vor deschide ochii ?i ve?i fi ca Dumnezeu, cunosc?nd binele ?i r?ul".6.De aceea femeia, socotind c? rodul pomului este bun de m?ncat ?i pl?cut ochilor la vedere ?i vrednic de dorit, pentru c? d? ?tiin??, a luat din el ?i a m?ncat ?i a dat b?rbatului s?u ?i a m?ncat ?i el.7.Atunci li s-au deschis ochii la am?ndoi ?i au cunoscut c? erau goi, ?i au cusut frunze de smochin ?i ?i-au f?cut acoper?minte.8.Iar c?nd au auzit glasul Domnului Dumnezeu, Care umbla prin rai, ?n r?coarea serii, s-au ascuns Adam ?i femeia lui de fa?a Domnului Dumnezeu printre pomii raiului.9.?i a strigat Domnul Dumnezeu pe Adam ?i i-a zis: "Adame, unde e?ti?"10.R?spuns-a acesta: "Am auzit glasul T?u ?n rai ?i m-am temut, c?ci sunt gol, ?i m-am ascuns".11.?i i-a zis Dumnezeu: "Cine ti-a spus c? e?ti gol? Nu cumva ai m?ncat din pomul din care ti-am poruncit s? nu m?n?nci?"12.Zis-a Adam: "Femeia care mi-ai dat-o s? fie cu mine, aceea mi-a dat din pom ?i am m?ncat".13.?i a zis Domnul Dumnezeu c?tre femeie: "Pentru ce ai f?cut aceasta?" Iar femeia a zis: "?arpele m-a am?git ?i eu am m?ncat".14.Zis-a Domnul Dumnezeu c?tre ?arpe: "Pentru c? ai f?cut aceasta, blestemat s? fii ?ntre toate animalele ?i ?ntre toate fiarele c?mpului; pe p?ntecele t?u s? te t?r??ti ?i ??r?n? s? m?n?nci ?n toate zilele vie?ii tale!15.Du?m?nie voi pune ?ntre tine ?i ?ntre femeie, ?ntre s?m?n?a ta ?i s?m?n?a ei; aceasta ??i va zdrobi capul, iar tu ?i vei ?n?epa c?lc?iul".16.Iar femeii i-a zis: "Voi ?nmul?i mereu necazurile tale, mai ales ?n vremea sarcinii tale; ?n dureri vei na?te copii; atras? vei fi c?tre b?rbatul t?u ?i el te va st?p?ni".17.Iar lui Adam i-a zis: "Pentru c? ai ascultat vorba femeii tale ?i ai m?ncat din pomul din care ?i-am poruncit: "S? nu m?n?nci", blestemat va fi p?m?ntul pentru tine! Cu osteneal? s? te hr?ne?ti din el ?n toate zilele vie?ii tale!18.Spini ?i p?l?mid? ??i va rodi el ?i te vei hr?ni cu iarba c?mpului!19.?n sudoarea fetei tale ??i vei m?nca p?inea ta, p?n? te vei ?ntoarce ?n p?m?ntul din care e?ti luat; c?ci p?m?nt e?ti ?i ?n p?m?nt te vei ?ntoarce".20.?i a pus Adam femeii sale numele Eva, adic? via??, pentru c? ea era s? fie mama tuturor celor vii.21.Apoi a f?cut Domnul Dumnezeu lui Adam ?i femeii lui ?mbr?c?minte de piele ?i i-a ?mbr?cat.22.?i a zis Domnul Dumnezeu: "Iat? Adam s-a f?cut ca unul dintre Noi, cunosc?nd binele ?i r?ul. ?i acum nu cumva s?-?i ?ntind? m?na ?i s? ia roade din pomul vie?ii, s? m?n?nce ?i s? tr?iasc? ?n veci!..."23.De aceea l-a scos Domnul Dumnezeu din gr?dina cea din Eden, ca s? lucreze p?m?ntul, din care fusese luat.24.?i izgonind pe Adam, l-a a?ezat ?n preajma gr?dinii celei din Eden ?i a pus heruvimi ?i sabie de flac?r? v?lv?itoare, s? p?zeasc? drumul c?tre pomul vie?ii. (Vechiul Testament. Geneza)Nichita St?nescu: ?din volumul "Fiziologia poeziei"; III. Contemplarea lumii din afara eiI. Durerea poate fi ?ntruchiparea vital? a erorii.Ea st? la r?d?cina cunoa?terii ?i a revela?iei: na?anele noastre de sim? sunt balan?e delicate ale durerii. Culorile, albastrul de pild?, ro?ul de pild?, sunt stinse ?i suave dureri ale vederii.Nu recept?m realul prin sim?uri, ci durerea lui. ?n acest sens, bunul sim? este obi?nuin?a ?i practica durerilor conven?ionale. El poate fi considerat ca o reac?ie melodic? a organelor, iar nu ca o posesiune de informa?ii reale.Durerile suave pot p?rea adev?ruri obiective, dar ele nu sunt dec?t ?mpliniri nespectaculare ale erorii. ?n existen??, epica este organul colectiv al durerii. ?ndep?rtare de legi, ea constituie un real al obi?nuirii su neobi?nuirii cu realul, iar nu un real al realului.II. ?n cazul durerii fizice ne apare mai distinct? interdependen?a dintre eroare ?i durere. Un os rupt, adic? un os ?n afara legilor de os, adic? ?n eroare, provoac? restului organismului din care se compune durere p?na la urlet.Legea este cea care resimte eroarea. Am putea afirma c? legea este ce care resimte durerea, legea ?n diferitele ei ?ncorpor?ri.Durerea abstract?, mai pu?in sesizabil?, se manifest? prin angoas?, prin nelini?te calm?.Epica poate fi carecterizat? prin nelini?te calm?, iar ?n coresponden?? literar?, eposul ?i culmina?ia sa, mitul, prin actul ?nt?mpl?rii, consider?nd ?nt?mplarea o ?ndep?rtare de lege, adic? o eroare, se ?ntruchipeaz? vital prin durere.Subiectul eposului este eroarea.III. ?n?eleg?nd durerea ca pe o form? a erorii; eroarea ca pe o ?ndep?rtare de lege; legea ca pe un fiind al lui este; sim?im durerea ca pe o ?ndep?rtare de este; ca pe o ?ndep?rtare fie ?n imaginar, ?n nefiind, fie ?n obiecte, ?n murind.Ne reprezent?m durerea ca pe un orice alt num?r ?n afara lui unu.Cartea lui Iov din Vechiul Testament:V?z?nd Dumnezeu r?bdarea lui Iov, dup? ce-au plecat cei trei prieteni, a ap?rut Dumnezeu ?n nori ?i ?n vifor deasupra lui. Iov z?cea acolo de ?apte ani jum?tate, numai oasele ?i inima r?m?sese - c?ci carnea lui era m?ncat? de viermi. ?i c?nd a venit Ziditorul cerului ?i al p?m?ntului, Iov era acum r?nit ?i de prietenii lui, oc?r?t ?i def?imat ?i de so?ia lui ?i de to?i. Deodat? aude glasul lui Dumnezeu din nori: "Iov, scoal?-te ca un b?rbat, ia ve?m?ntul t?u - c? i-a trimis un ve?m?nt din cel mai alb ca z?pada -, ?ncinge-te ?i s? st?m de vorb? am?ndoi!"S-a sculat Iov, s?n?tos ca la 30 de ani ?i frumos ?i vesel, s-a ?mbr?cat cu ve?m?ntul dat de Dumnezeu. ?i a spus Dumnezeu c?tre el: "Iov, unde erai tu c?nd am ?ntemeiat p?m?ntul? Spune-mi Mie care-i l??imea cea de sub cer? ?n ce loc locuie?te ?ntunericul ?i ce loc are lumina? Unde erai tu c?nd am m?surat Eu mun?ii cu a?ez?m?ntul cuno?tin?ei, v?ile cu cump?na ?i dealurile; c?nd am pus m?rii hotar nisipul ?i am ?ngr?dit marea cu nisip ?i I-am spus: "P?n? aici s? stai ?i ?ntru tine s? se sf?r?me valurile tale"? Eu am ?ntins criv??ul pe uscat. Eu am f?cut cuv?nt?tori pe p?m?nt. Eu am m?surat greutatea v?nturilor. Eu am ?nsemnat calea fulgerilor sub cer. Eu am r?nduit na?terile fiarelor din codri, na?terea dobitoacelor p?m?ntului ?i a oamenilor. Eu am f?cut orionul ?i rari?a cea de miaz?noapte ?i am ?mpodobit cerul cu stele, cu soare ?i lun?, ?i lumin? am d?ruit zidirii Mele. Spune-Mi, unde erai tu atunci? Iov, Eu pe tine Te-am turnat ca laptele ?n p?ntecele maicii tale, Te-am ?nchegat ca br?nza, Te-am ?esut ca p?nza, ?i-am f?cut inim? ?i oase ?i te-am f?cut f?ptura Mea ?n p?ntecele maicii tale ?i Eu am zidit inima ta ?i am ?tiut c? nu-?i vei pierde r?bdarea. Eu am ?ntemeiat inima ta ?ntru tine ?i credin?a ?i r?bdarea ta.?i acum, Iov, fiindc? ai a?teptat cu r?bdare venirea Mea ?i n-ai zis vreun cuv?nt r?u ?n at?tea sc?rbe ?i necazuri ?i boale, iat?, Eu ??i d?ruiesc ?ie de acum ?nainte ?nc? 140 de ani de via??; ?i vor fi averile tale ?ndoite. ?i vei ajunge s? tr?ie?ti p?n? la al cincilea str?nepot ?i vei adormi plin de zile ?i vei veni la Mine s? te vesele?ti cu Mine ?n veci".CS Lewis: Problema durerii (1940)If God were good, He would wish to make His creatures perfectly happy, and if God were almighty He would be able to do what He wished. But the creatures are not happy. Therefore God lacks either goodness, or power, or both.” This is the problem of pain, in its simplest form. the possibility of answering it depends on showing that the terms “good” and “almighty”; and perhaps also the term “happy” are equivocal: for it must he admitted from the outset that if the popular meanings attached to these words are the best, or the only possible meanings, then the argument is unanswerable.The relation between Creator and creature is, of course, unique, and cannot be paralleled by any relations between one creature and another. God is both further from us, and nearer to us, than any other being. He is further from us because the sheer difference between that which has its principle of being in itself and that to which being is communicated, is one compared with which the difference between an archangel and a worm is quite insignificant. He makes, we are made: He is original, we derivative. But at the same time, and for the same reason, the intimacy between God and even the meanest creature is closer than any that creatures can attain with one another. Our life is, at every moment, supplied by Him: our tiny, miraculous power of free will only operates on bodies which His continual energy keeps in existence — our very power to think is His power communicated to us. Such a unique relation can be apprehended only by analogies: from the various types of love known among creatures we reach an inadequate, but useful, conception of God’s love for man. Yet perhaps even this view falls short of the truth. It is not simply that God has arbitrarily made us such that He is our only good. rather God is the only good of all creatures: and by necessity, each must find its good in that kind and degree of the fruition of God which is proper to its nature. The kind and degree may vary with the creature’s nature: but that there ever could be any other good, is an atheistic dream. George Macdonald, in a passage I cannot now find, represents God as saying to men “you must be strong with my strength and blessed with my blessedness, for I have no other to give you.” That is the conclusion of the whole matter. God gives what He has, not what He has not: He gives the happiness that there is, not the happiness that is not. To be God — to be like God and to share His goodness in creaturely response — to be miserable — these are the only three alternatives. If we will not learn to eat the only food that the universe grows — the only food that any possible universe ever can grow — then we must starve eternally. I have tried to show in a previous chapter that the possibility of pain is inherent in the very existence of a world where souls can meet. When souls become wicked they will certainly use this possibility to hurt one another; and this, perhaps, accounts for four-fifths of the sufferings of men. It is men, not God, who have produced racks, whips, prisons, slavery, guns, bayonets, and bombs; it is by human avarice or human stupidity, not by the churlishness of nature, that we have poverty and overwork. But there remains, none the less, much suffering which cannot thus be traced to ourselves. But the truth is that the word Pain has two senses which must now be distinguished. A. a particular kind of sensation, probably conveyed by specialised nerve fibres, and recognisable by the patient as that kind of sensation whether he dislikes it or not (e.g., the faint ache in my limbs would be recog- nised as an ache even if i didn’t object to it). B. any experience, whether physical or mental, which the patient dislikes. It will be noticed that all Pains in sense a become Pains in sense b if they are raised above a certain very low level of intensity, but that Pains in the b sense need not be Pains in the a sense. Pain in the b sense, in fact, is synonymous with “suffering”, “anguish”, “tribulation”, “adversity”, or “trouble”, and it is about it that the problem of pain arises.Pain is a common and definite event which can easily be recognised: but the observation of character or behaviour is less easy, less complete, and less exact, especially in the transient, if intimate, relation of doctor and patient. In spite of this difficulty certain impressions gradually take form in the course of medical practice which are confirmed as experience grows. a short attack of severe physical pain is overwhelming while it lasts. the sufferer is not usually loud in his complaints. He will beg for relief but does not waste his breath on elaborating his trou- bles. it is unusual for him to lose self control and to become wild and irrational. it is rare for the severest physical pain to become in this sense unbearable. When short, severe, physical pain pass- es it leaves no obvious alteration in behaviour. Long continued pain has more noticeable effects. it is often accepted with little or no complaint and great strength and resignation are developed. Pride is humbled or, at times, results in a determination to con- ceal suffering. Women with rheumatoid arthritis show a cheerful- ness which is so characteristic that it can be compared to the spes phthisica of the consumptive: and is perhaps due more to a slight intoxication of the patient by the infection than to an increased strength of character. Some victims of chronic pain deteriorate. they become querulous and exploit their privileged position’ as invalids to practise domestic tyranny. but the wonder is that the failures are so few and the heroes so many; there is a challenge in physical pain which most can recognise and answer. On the other hand, a long illness, even without pain, exhausts the mind as well as the body. the invalid gives up the struggle and drifts helplessly and plaintively into a self-pitying despair. even so, some, in a similar physical state, will preserve their serenity and selflessness to the end. to see it is a rare but moving experience. Mental pain is less dramatic than physical pain, but it is more common and also more hard to bear. the frequent attempt to conceal mental pain increases the burden: it is easier to say “my tooth is aching” than to say “my heart is broken”. yet if the cause is accepted and faced, the conflict will strengthen and purify the character and in time the pain will usually pass. Sometimes, how- ever, it persists and the effect is devastating; if the cause is not faced or not recognised, it produces the dreary state of the chronic neurotic. but some by heroism overcome even chronic mental pain. they often produce brilliant work and strengthen, harden, and sharpen their characters till they become like tempered steel. In actual insanity the picture is darker. in the whole realm of medicine there is nothing so terrible to contemplate as a man with chronic melancholia. but most of the insane are not unhappy or, indeed, conscious of their condition. in either case, if they re- cover, they are surprisingly little changed. Often they remember nothing of their illness. Pain provides an opportunity for heroism; the opportunity is seized with surprising frequency. Noul Testament: 2 Corintieni 12:7 Durerea trimis? de Diavol, pe care Dumnezeu nu o vindec?, pentru a consolida credin?a?...mi-a fost pus un ?epu? ?n carne,?un sol al Satanei, ca s? m? p?lmuiasc? ?i s? m? ?mpiedice s? m? ?ng?mf.”?Al cui sol era ??epu?ul din carne”??Cel care a cauzat suferin?a lui Pavel, nu era Dumnezeu, ci Satan.?C?nd analiz?m cu c?t? putere slujea Pavel, ?i ce mult r?u a cauzat ?mp?r??iei ?ntunericului, nu ne mai mir?m c? diavolul a desemnat pe unul din demonii s?i, ca s?-i fac? r?u.Cuv?ntul folosit de Pavel, ?n limba original?, greac? pentru ?p?lmuiasc?” , este ?kolaphizó”, care ?nseamn? a lovi pe cineva cu pumnul cu violen??, cu cruditate. (conform ?Strong's Concordance”). Iar ?n ? HELPS Word-studies”, defini?ia este mai ampl?:?a lovi cu pumnul str?ns, ca s? r?m?n? urme ?i s? zdrobeasc?.??n 2 Corinteni 12:7, semnifica?ia este de ?a lovi cu ceva ascu?it care s? p?trund? ?n carne ?i s? r?m?n? acolo.” Ambele explica?ii arat? clar c? Pavel se referea la persecu?ii dure care r?neau ?i nicidecum la o boal? fizic?.Deci ??epu?ul” avea rolul s?-l chinuie pe Pavel l?s?nd r?ni ad?nci ?i s?-l ?mpiedice s? fie m?ndru. Niciodat? nu a fost o m?ndrie s? ajungi dup? gratiile ?nchisorii. La fel era ?i ?n vremea lui Pavel. ?i el a ajuns ?nchis de multe ori, pe perioade diferite de timp. Din cei 32 de ani de slujire (din anul 36 d.Hr. c?nd s-a ?ntors la Cristos ?i p?n? ?n 68 d.Hr. c?nd a fost decapitat la ordinele ?mp?ratului roman, Nero), Pavel a petrecut aproape 6 ani ?n ?nchisoare. De la perioade de o noapte la aproximativ 2 ani (?n Iudea ?i apoi ?n Roma).Pavel a fost r?sf??at din plin cu ?daruri cere?ti”, dar a ?i pl?tit scump. Demonul trimis s?-l chinuie ?i-a f?cut bine treaba. A st?rnit autorit??ile aproape ?n fiecare cetate unde Pavel predica Evanghelia, ?i punea bazele unei noi biserici. Scopul era foarte clar. Pentru c? du?manul nu-i putea strecura ?ndoiala ?n inim? (Pavel a primit prea multe revela?ii divine ca dovezi de necontestat despre cine este Dumnezeu Tat?l, Fiul ?i Duhul Sf?nt ca s? se mai lase min?it) ?i nici nu-i putea lua puterea ungerii Duhului Sf?nt care era peste via?a lui, alternativa era s?-i fac? pe cei care auzeau Vestea Bun?, s? se team? s-o primeasc?, ca nu cumva s? ajung? ?i ei la ?nchisoare, b?tu?i cu nuiele sau prigoni?i, a?a cum era cel care ?i evangheliza. Dar nu func?iona, odat? ce vedeau minunile f?cute prin Pavel ?i Duhul Sf?nt ?i convingea de adev?rul pe care ?l auzeau prin el, oamenii se ?ntorceau al Cristos indiferent de repercursiuni.Domnul Isus a spus:?...Cui i s-a dat mult, i se?va cere mult; ?i cui i s-a ?ncredin?at mult, i se va cere mai mult.”?(Luca 12:48b)?Pavel a fost unul dintre ace?tia ?i s-a achitat cu prisosin?? de tot ce i s-a cerut.?De asemenea Isus le spunea ucenicilor c? ?vor bea paharul” pe care urma El s?-l bea. Se referea la suferin?e, torturi, persecu?ii. Jertfa Lui Isus la cruce, ne-a r?scump?rat din blestemul legii, dar nu ne-a privat de persecu?ii. Primii care au testat acest adev?r, au fost chiar cei care au fost cei mai apropia?i de Domnul ?n anii slujirii Sale pe P?m?nt.2 Corinteni 12:8??De trei ori am rugat pe Domnul s? mi-l ia. ?i El mi-a zis:??Harul Meu ??i este de ajuns, c?ci puterea Mea ?n?sl?biciune?este f?cut? des?v?r?it?.”...”Dumnezeu nu i-a r?spuns primelor dou? rug?ciuni ?n care a cerut s? fie eliberat, iar la a treia ?i spune de ce. Dac? acest r?spuns era referitor la o boal? fizic?, s-ar fi contrazis cu versetele ?n care Dumnezeu spune c? prin r?nile lui Isus am fost deja vindeca?i (Isaia 53:5,?1 Petru 2:24). Fiul Lui Dumnezeu a f?cut deja tot ce trebuia f?cut pentru vindecarea noastr?. Ca s? intr?m ?n posesia ei, ?ine de noi. Dar dac? ??epu?ul” reprezint? persecu?iile ?i prigonirea, atunci r?spunsul este valabil ?i pentru noi. Doar ?n ?ncerc?ri ni se formeaz? caracterul. Doar c?nd nu ne putem baza pe noi ?n?ine, dovedim c? ne baz?m pe Dumnezeu ?i pe promisiunile Scripturii. Dumnezeu ne ?ine pe acest P?m?nt, ca s? ne preg?teasc? pentru cer.?Ne dore?te cu El, pentru eternitate ?i pentru a ajunge acolo, trecem prin teste ?n fiecare zi.?Pavel era obi?nuit s? primeasc? r?spuns la rug?ciunile sale, de la primul enun?.?Nu citim c? ar fi fost nevoie s? cear? ceva de mai multe ori, cu excep?ia ?ndep?rt?rii ?epu?ului. Credin?a lui Pavel era ferm? ?i neclintit? ?i dup? ce a ?n?eles c? trebuie s? treac? prin persecu?ii n-a mai l?sat nimic s?-l tulbure. Timpul petrecut ?n ?nchisoare, l-a privit ca pe o oportunitate de a predica Evanghelia ?i a ajuta al?i de?inu?i s? se fie m?ntui?i. C?nd era ?nchis pe perioade mai lungi, a folosit acel timp pentru a se concentra pe scrierea epistolelor , sub conducerea Duhului Sf?nt. Scrierile lui continu? s? ?nve?e cre?tinii de genera?ii cum s? tr?iasc? pentru Cristos.?n a doua parte a versetului 8, spune c?: ?...Deci m? voi l?uda mult mai bucuros cu?sl?biciunile?mele, pentru ca puterea lui Hristos s? r?m?n? ?n mine.” Lacrime ?i lacrime de Veronica Micle?nceteaz? de-a mai pl?nge?Inim? f?r' de noroc?C?ci prin lacrime de s?nge?Nu s-alin?, nu se stinge?Al durerii mele foc.?Foc ce arde ?n t?cere??i-i ascuns ?n pieptul meu,?Unde jalnica durere?Picur?nd amar? fiere?A?ezat-a jugul greu.?Ah! ?i-?i ad? tu aminte?C-acest chin de foc nestins?Prin duioase jur?minte?Tot o lacrim? fierbinte?De iubire, l-a aprins.Proz? scurt?: Cea dint?i durere - de Emil G?rleanuAm crescut pe uli?a boiereasc? a Ia?ului, pe Podul-Verde, cum i se zicea odat?, ?n fa?a gr?dinii lui Mihai-vod? Sturza ?i-n coasta p?durii Copoului. Am crescut pe uli?a din cap?tul c?reia privirea p?trundea p?n? departe, spre ?esul ?ntins, ?n fundul c?ruia Cet??uia se ridica deodat?, ca ?n?l?at? de ni?te bra?e uria?e, m?ndre c? pot sc?lda ?n razele soarelui un asemenea giuvaier. Am mai apucat ?nc? pe cei de pe urm? boieri, ?mbr?ca?i totdeauna ?n hain? neagr?, cu p?l?rii ?nalte, r?t?cind pe sub aleile de tei, cu ochii pierdu?i ?n urm?rirea unui vis ce nu se poate ?ndeplini. ?mi aduc aminte cum ascultam, toat? ziua, tr?mbi?ele, al c?ror glas r?zboinic f?cea s? r?sune caz?rmile ce ne ?nconjurau casa. Toat? lumea milit?reasc? era t?b?ruit? l?ng? noi, la deal. Nu o dat? am r?mas uimit, ?n poart?, c?nd regimentul de linie pornea la parad?, cu tamburul-major ?n frunte, un ?igan c?t un munte, purt?nd ?n cap o c?ciul? de urs, c?t o bani?? de mare, haine numai aur, ?i-n m?n? un buzdugan pe care ?l azv?rlea ?n aer de se rotea de dou? ori, apoi ?l prindea ?n palm? ?i-l ?inea o clip? sus, p?n? ce clocotea glasul de tunet al tobei celei mari. Din poarta ogr?zii duceam m?na la p?l?rie, s? salut milit?re?te pe tata, care mergea c?lare ?n fruntea batalionului. Tata, parc?-l v?d, se uita de sus, pleca sabia spre g?tul calului, ca s?-mi r?spund?, iar eu m? credeam un soldat stra?nic.Multe am v?zut ?n uli?a aceasta, ?n multe ?nt?mpl?ri am fost ?i eu amestecat, ?i multe lucruri de pe acea vreme sunt ?nchise ?n sufletul meu. De unele nu-mi aduc aminte, ?s ascunse bine colea, ?i cine ?tie dac? vreodat? farmecul sau durerea lor vor r?s?ri iar??i ?n mintea mea, cum r?sar, ?n unele nop?i, d?rele luminoase ale f?r?miturilor de stele. Cine ?tie! Dar unele din aceste ?nt?mpl?ri mi-au r?mas s?pate ?n amintire cu o at?t de mare putere, ?nc?t oric?nd le pot vedea, le pot povesti, cum a? putea spune cea dint?i rug?ciune pe care mama m-a ?nv??at s-o ?n?ir: cu m?inile ?mpreunate ?i-n genunchi, ?n fa?a icoanei de deasupra p?ti?orului meu...De multe ori m-am g?ndit la cea dint?i durere ce-am sim?it-o ?n inima mea de copil. O pot povesti a?a cum a? fi v?zut-o asear?, cu ?n?elegerea mea de acum, cu ochii ?i inima mea de atuncea....Poate s? fi avut vreo cinci-?ase ani. ?ntr-o sear? m? jucam ?n gr?dinu?a din fa??. Cum f?ceam gr?mezi de nisip, deodat? clocoti strig?tul grabnic ?i dezn?d?jduit al tr?mbi?ei de foc. ?i ?ntr-o clip? n?v?li, ?n goana nebun? a cailor, ?irul ?ntreg de care cu solda?i, ale c?ror c??ti galbene t?iar? repede o dung? luminoas? ?n ?nseratul zilei. Apoi a fost un ?nv?lm??ag de tr?suri, de c?l?re?i, de ofi?eri, de solda?i alerg?nd mai mul?i, sub comanda cuiva, sau singuri, ?n g?f?iala fugii. Se opreau unii pe al?ii, se ?ntrebau, sau ??i strigau vorbe de-abia spuse, apoi se aruncau ?n aceea?i goan? grozav?. Un soldat sosi cu un plic; dup? c?teva clipe am v?zut ?i pe tata, cu chipul ?ngrijat, trec?nd pe l?ng? mine f?r? s? m? vad?. M? rezemasem de parmacl?c, ?n col?ul gr?dinu?ei, ?i priveam cu pl?cere la neobi?nuita mi?care a uli?ei.Peste pu?in veni ?n fug? slujnica noastr?, m?tu?a Smaranda. Am v?zut-o ie?ind p?n? ?n mijlocul str?zii, ?ip?nd speriat?: Vai de mine, arde t?rgul! Atunci m-am strecurat printre dou? jaluzele desprinse, ?i b?tr?na s-a trezit cu mine l?ng? d?nsa. M-am uitat ?i eu: ?n fund, cerul se rumenise, unde de fum negru se ridicau ?n v?zduh ?i, uneori, c?te un smoc de sc?ntei sc?p?ra ca ni?te m?rgele ?mpr??tiate. Ne-am ?ntors l?ng? poart?. Un c?l?re? trecu ?n goan?; nu mult dup? aceea, alte p?lcuri de solda?i se perindar?, ca ni?te vedenii. Seara se a?ezase u?oar?; odat? cu r?coarea ei, veni un miros acru ?i ?nec?cios; rumeneala cuprinse tot cerul, iar v?rfurile copacilor din gr?dina lui vod? se aurir?; mi?cate de v?nt, p?reau ni?te fl?c?ri ce ardeau leg?n?ndu-se. Peste tot se ?ntinsese o lumin? dulce, de vis. M?tu?a Smaranda ?ntreb? pe un trec?tor: M? rog dumitale, ce arde? Acesta ?i r?spunse din treac?t: Uli?a Mare. B?tr?na ??i rosti numele, cum obi?nuia s? fac? la orice ?nt?mplare ce-i rede?tepta mila sau m?hnirea: Sm?r?ndi??, Sm?r?ndi??! ?i iar se f?cu t?cere. Numai de departe venea vuietul n?bu?it al unui zbucium. M? cuprinsese o fric? ne?n?eleas?. Deodat?, g?ndul mi se opri la mama, care plecase ?n t?rg. Dar mama? ?ntrebai ?ngrijat. B?tr?na m? trase mai l?ng? d?nsa ?i-mi r?spunse: O s? vie, cona?ule, n-ai mata team?.Nu ?tiu c?t vom fi stat ?n aceast? a?teptare ?ncordat?. Mama nu mai venea, nici tata, care pornise pe urm?. Deodat? r?sunar? ni?te pa?i tr?g?na?i. Privir?m ?n lungul uli?ei. ?n cur?nd putur?m deslu?i pe cei ce veneau: erau doi solda?i care duceau o n?s?lie. ?n dreptul por?ii d?n?ii se oprir?: de sub p?tura ce acoperea n?s?lia ie?ea un horc?it r?gu?it, care se stingea cu totul o clip?, apoi izbucnea din nou. Am auzit bine ?i mi-a r?mas s?pat ?n ad?ncul min?ii fiecare cuv?nt din convorbirea celor doi solda?i. Cel dint?i se ?ntoarse ?i spuse, cu glas plin de spaim?: Moare, m?i. Da, moare, ?i r?spunse celalt. ?nt?iul urm?: S?-l punem ici, ?n dosul por?ii, s?-?i deie sufletul ?n lini?te. S?-l punem. C?nd z?rir? pe m?tu?a Smaranda, o trimiser? repede: F?-?i poman? ?i adu o lum?nare.B?tr?na se z?p?ci, alerg? numaidec?t, ?i pe mine m? l?s? singurel l?ng? st?lpul por?ii. Solda?ii nici nu m? v?zur? poate. A?ezar? n?s?lia ?n ograd?, chiar l?ng? parmacl?cul gr?dinu?ei, ?i unul dintre ei ridic? p?tura. Lumina felinarului din fa?? se ?ntindea p?n? acolo. Horc?itul se auzi deslu?it, aerul serii parc?-i dase putere; cel ce sta ?ntins, un pompier, ?nghi?ea ?n g?lg?iri ad?nci, parc? ar fi b?ut, ?nsetat, ap?. O grij? de ceva ce nu ?n?elegeam m? f?cuse ?i mai mititel ?i m? ?intuise locului. Pieptul pompierului se ridica des, ca ni?te foi. Scoate-i casca, spuse unul dintre solda?i. Celalt ?i lu? bini?or casca.Atunci se petrecu ceva groaznic. Pompierul scoase un strig?t de durere, un strig?t a?a de ad?nc, c? mi s-a p?rut c? ie?ise din fundul unei hrube, de sub picioarele mele. Apoi, cu cea din urm? putere, vroi s? se scoale, se pr?v?li pe o coast? ?i se r?sturn? jos, tr?ntind pe soldatul ce se plecase peste d?nsul. Casca se rostogoli p?n? l?ng? mine. R?nitul r?mase pe p?m?nt, zb?t?ndu-se, iar fa?a i se acoperi ca de un v?l negru, ce se ?ntindea cu ?ncetul ?i pe jos: ?i izvora s?ngele din cap.Toate acestea s-au petrecut c?t ai clipi. Nici n-am avut vreme s? m? ?nsp?im?nt. Aproape ?n aceea?i vreme putusem auzi, la spate, glasul mamei: Ce-i aici? Apoi acel al tatei, ?ntreb?nd pe solda?i: Ce e, ce face?i? C?nd mama se apropie ?i ?n?elese ce se petrecea, ?i c?nd, ?ntorc?ndu-se, m? z?ri pe mine, se azv?rli, cu un ?ip?t, s? m? ieie ?n bra?e: Pentru numele lui Dumnezeu, ce cau?i tu aici? M? ridic?, apoi ?mi ?ntoarse capul cu m?na ?i mi-l sprijini de um?rul ei.?n aceast? vreme veni ?i m?tu?a Smaranda. Am auzit scr??netul chibritului ce aprindea lum?narea, am auzit cele c?teva cuvinte, ?ntret?iate, ale soldatului ce povestea tatei: Un zid d?r?mat... da, peste d?nsul... scos de sub d?r?m?turile unei bol?i... Apoi o clip? de lini?te, ?i pe urm? un suspin, un suspin lung, de u?urare, ca al unui om care se a?az? s? se odihneasc? dup? un drum lung. Sim?ii tremurul mamei. Tata o lu? de bra?: Hai, ce stai ?i tu; hai, drag?. ?n urm?, glasul b?tr?nei t?nguia: Sm?r?ndi??, Sm?r?ndi??!?n noaptea aceea n-am putut dormi. ?ntr-un r?stimp mi se p?ru c? lumina candelei se ?nal??, se sub?iaz? ?i se toarce mereu din caierul luminat al paharului, apoi se ?ntinde de se str?nge ghem ?mprejurul unei c??ti mari ce sp?nzura deasupra patului meu. Am ?ipat, a alergat mama l?ng? mine, ?i toat? noaptea mi-am sim?it m?na ?ntr-a ei.A doua zi m-am jucat, ca de obicei. Tot ce privisem cu o sear? mai ?nainte se ?tersese ca un vis. La ?nt?mplarea din seara trecut? nu mai g?ndeam, cum nu mai g?ndeam la zg?riiturile care m? usturaser? numai ?n clipa c?nd mi le f?cusem.Dar a treia zi, r?nduri-r?nduri, solda?i treceau ?n pas domol, cu to?i ofi?erii lor, cu drapelul ?i cu goarnele ce sunau, duios, o rug?ciune. E o parad?, ?mi spuse mama, care m? ?inea ?n bra?e, o parad?, ?tii, ca atunci c?nd a venit generalul. Eu n-am crezut; c?ci de la fereastr? am v?zut sicriul purtat pe un tun, iar deasupra sicriului, casca. ?i atunci, din nou mi-a r?s?rit ?n minte seara aceea.Din nou am v?zut pompierul ?ntins jos, v?rs?ndu-?i chinul ?n suspinul ad?nc ce mi se p?ruse c? ie?ise de sub p?m?nt. Mi-am dat seama c? acum ?l duceau undeva, departe, c?-l luau de l?ng? to?i ai lui, s?racul! ?i-am avut acea presim?ire nedeslu?it? a desp?r?irii ce c?ndva nu se poate ?nl?tura, presim?ire care se na?te odat? cu noi. Nu pricepusem tot, dar ?n?elesesem destul. ?i, ca ?i c?nd cineva ar fi vrut s? m? despart? ?i pe mine de mama, am cuprins-o de g?t cu am?ndou? m?inile ?i-am pl?ns, zguduitor, cea dint?i durere a mea.?n limba ta - de Grigore Vieru?n aceea?i limb?Toata lumea pl?nge,??n aceea?i limb?R?de un p?m?nt.Ci doar ?n limba taDurerea po?i s-o m?ng?i,?Iar bucuriaS-o preschimbi ?n c?nt.?n limba ta?i-e dor de mama,??i vinul e mai vin,??i pr?nzul e mai pr?nz.?i doar ?n limba taPo?i r?de singur,??i doar ?n limba taTe po?i opri din pl?ns.Iar cand nu po?iNici pl?nge ?i nici r?de,?C?nd nu po?i m?ng?ia?i nici c?nta,?Cu-al t?u p?m?nt,?Cu cerul t?u ?n fa??,?Tu taci atunceaTot ?n limba ta.?The Psychology of Pain de GR Hartzler ?i Jon Stretzler Emerg Med Clin N Am 23 (2005) 339–348 The perception of pain involves far more than mere sensation. The affective and evaluative components of pain are often as important as the production and transmission of the pain signal. These emotional aspects are most prominent in chronic pain patients, but knowledge of the psychology of pain can greatly improve the treatment of acute pain as well. Pain and its perception The limbic system, where emotions are processed, modulates the amount of pain experienced for a given noxious stimulus. It has been shown in cancer patients [1] that the affective component of pain can be completely blocked by frontal lobectomy. Lobectomized patients still register severe pain, but it doesn’t ‘‘bother’’ them. Pain can thus be viewed as merely a ‘‘signal’’ that something is wrong somewhere in the body, until it reaches the emotional brain, where this signal becomes what we feel as pain. The emotional response to pain involves the anterior cingulate gyrus and the right ventral prefrontal cortex. These centers are also activated by social rejection. Serotonin and norepinephrine circuits are also involved in the modulation of sensory stimuli, which probably influence how depression and antidepressant medications affect the perception of pain [2]. Context The perception of even acute pain is highly dependent on the context in which it occurs [3]. It has been found that the pain perceived in battle wounds bears little relationship to the extent of the wounds [4]. There are reports of soldiers in battle who suffer a compound fracture, and report only twinges of pain [5]. In laboratory studies of experimental pain in which context, fear, and anxiety are controlled, the placebo effect and opioids are much less effective. This occurs because the reduction of both the fear and anxiety is a large part of the placebo effect and of the function of opioids [6]. Attention Focusing one’s attention on pain makes the pain worse [1]. Patients who have somatic preoccupation or hypochondriasis are overvigilant about bodily sensations. It has been found that by attending to these sensations, they amplify them to the point of feeling painful [7]. Conversely, distracting patients is highly effective in reducing their pain. Burn patients undergoing treatments or physical therapy experience excruciating pain, even after they have been given opioids. It has been shown that these patients report only a fraction of this pain if they are distracted with a virtual-reality type of video game during the procedure [8]. Anxiety Anxiety, fear, and a sense of loss of control contribute to patient suffering. Treating anxiety and providing psychological support has been shown to improve pain and reduce analgesic use. Improving patients’ sense of control and allowing them to participate in their care is also helpful [9]. Physicians should try to create an environment that is nonthreatening. For procedures, prepare needles and other equipment out of sight from the patient. In addition to assuring that procedures are performed in the least painful way possible, use nonthreatening terms such as ‘‘mild discomfort’’ instead of ‘‘pain.’’ It is also helpful to distract patients with conversation about subjects that interest them, such as their hobbies or family [10]. Memory Patients who have low levels of pain remember it as being worse than they originally reported, which tends to worsen with time. Almost all patients report relief with treatment, even when true measured changes in pain scale are not significant, and sometimes when measured pain is worse [11]. Learned pain Pain can be a learned response, rather than a purely physical problem. Just as cancer patients can develop nausea as a learned response to treatment and experience it even before chemotherapy is administered, patients can learn to have pain even in the absence of a physical stimulus [12]. In some cases, pain can be entirely ‘‘in the mind,’’ as in the case of a butcher who slipped and caught his arm on a meat hook, and was reported to be suffering in great agony. When he learned that the hook had merely caught on his sleeve and his arm was uninjured, his pain resolved [13]. Patients can learn to feel different amounts of pain just by viewing other people. When laboratory subjects were shown models demonstrating high pain tolerance, they required 3.48 times greater stimulus before they rated it as painful, compared with those subjects who observed models who showed poor tolerance. Nonaversive shock, usually described as ‘‘tingling,’’ was rated as painful by only 3% of those who had viewed a tolerant model, compared with 77% of the subjects who viewed models who showed poor tolerance [14]. Expectations Patients’ expectations of how much pain they should have also influence how much pain they feel, their response to treatment [15], and whether or not the condition becomes chronic and disabling. The results of minor whiplash injuries have been shown to be highly variable in different regions. This has been attributed to the local cultures and expectations. Any mes- sages that communicate to patients that they have a serious or debilitating injury may contribute to deconditioning and maladaptive postures that worsen their pain. Prescribing medications can contribute to the problem. Patients who are not given sick leave and are told to ‘‘act as usual’’ have much better outcomes [7]. The placebo effect is also influenced by patients’ and physicians’ expectations [15]. It can be assumed that the ‘‘nocebo’’ effect (ie, the perception of harm resulting from a patient’s beliefs) can also result from messages that inadvertently increase the patient’s anxiety and expectations of pain. Beliefs and coping Other psychosocial issues, such as what patients believe about their pain [16,17], their coping skills [18–21], their tendency to ‘‘catastrophize’’ [17,18,20], self-efficacy [17], locus or control [22], and their involvement in the ‘‘sick role’’ [13], all have an impact on how much pain patients feel, and how it affects them. In successfully getting low back pain patients back to work, the most important factor identified has been a reduction in subjective feelings of disability [23]. Patients diagnosed with fibromyalgia have to stop catastrophizing to improve, and they must be persuaded that they have the capacity to be more functional [24]. Consequently, physicians should focus on improved function and long-term management. Patients should be led to understand that they themselves have an important role in distracting themselves, and that they can minimize the interference that pain has in their lives. Chronic pain Chronic pain patients commonly have problems with the psychological and emotional aspects of pain [25]. Preexisting psychological factors have been shown to be very important in the development of chronic pain after surgery [26,27] and in complex regional pain syndrome (CRPS) [28,29], tension-type headaches [30], and fibromyalgia [24]. The National Institutes of Health Technology Assessment Conference Statement [31] identified six factors that correlated with treatment failures of low back pain—all were psychosocial. Even chronic, episodic, low back pain may have a vital com- ponent of socioeconomic and psychological influences [32]. There is a vicious cycle in which pain causes disability and stress, which in turn worsens the perception of pain [21]. An unhealthy lifestyle, lack of social support, depressive illness, and substance abuse are predisposing factors to chronic pain [33]. Chronic pain has been referred to as ‘‘complex’’ when there are interactions of legal, psychological, medication, and family issues [34]. Behavior Immobility may be a factor in adult ‘‘reflex sympathetic dystrophy,’’ which some feel is overdiagnosed [35]. A study of reflex neurovascular dystrophy in children revealed that prominent swelling, skin changes, and decreased skin temperature were caused by maintaining the extremity in an immobile, dependent position. The prolonged immobility also caused chronic fibrosis of subcutaneous tissues and contractures of tendons and ligaments. This was effectively relieved with physical treatments, which included vigorous sensory stimulation and use of the affected extremity [36]. Inactivity is a serious impediment to improvement in chronic pain, and can produce concurrent myofascial pain [37]. Many fibromyalgia patients have been found to have a vicious cycle of maladaptive pain behavior, resulting in further deconditioning, social dysfunction, and subsequent worsening pain [24]. Obesity is also a problem in chronic pain. A review of patients at a rehabilitation clinic found that among those who could not be returned to gainful employment or function, 78% were grossly overweight [38]. Many low back pain patients have been found to be in the lowest quartile for aerobic capacity [39]. Pain behavior, such as guarding, bracing, rubbing, grimacing, and sighing, has been shown to be strongly influenced by psychological factors [40]. Some chronic pain patients demonstrate pain behavior only around staff [41], or decrease this behavior when they think no one is watching [42]. Reinforcing this behavior can cause some patients to perceive that they have more pain. Eliminating the behavior leads to improved pain [40]. It has been noted that if neuropathic pain patients are allowed to develop guarding and behavioral dysfunction, then drugs are not effective, and the patients require multidisciplinary pain treatment [37]. Pain can be a conditioned response similar to conditioned nausea associated with chemotherapy. The behavior begins purely in response to the presence of injury. It is then reinforced and becomes a conditioned response, an iatrogenic complication of treatment [12], particularly when rewards are made contingent on the expression of pain behavior [21]. The effect of reinforcement is illustrated by the case of a 10-year-old girl who had chronic daily abdominal pain for which no medical condition could be found. During episodes, her mother allowed her to rest in bed with her toys and watch television, and brought her food and drinks. After an hour or so, she would go back to play. After the mother stopped reinforcing the patient’s pain behavior, the episodes rapidly diminished, as well as her use of belladonna and phenobarbital elixir [43]. Pain can result from conditioned fear reactions that persist even after the resolution of pain [42], phobic reactions to pain and to nonpainful activities [44], and posttraumatic stress disorder [45]. Some patients have had good improvement of their pain or function with desensitization therapy [46]. Psychiatric disease Overall, some psychiatric morbidity is present in up to 67% of chronic pain patients [47]. Personality disorders have been found in 31% to 59% of chronic pain patients [48]. Among low back pain patients admitted to an inpatient multidisciplinary pain center, 70% were found to have a hysterical conversion disorder, and 8% had a sociopathic personality disorder [49]. Somatoform pain disorders Somatoform disorders are conditions in which the presence of physical symptoms suggests a general medical condition, but cannot be explained by any such condition. Among the somatoform disorders, ‘‘pain disorder associated with psychological factors’’ is specified in the Diagnostic and Statistical Manual of Mental disorders, fourth edition (DSMIV) [50] as a clinical condition in which pain is the focus and in which psychological factors have the major role in the onset, severity, maintenance, or exacerbation The epidemiology of this condition is not known, but unexplained chronic pain that causes disability is common in general practice and is frequently seen in emergency rooms. Pain disorder associated with psychological factors was found in 88% of referrals to a pain clinic serving an indigent population [51]. Most somatoform patients had pain that spread to new areas from the site of injury, whereas this did not occur in the patients who had objective signs of injury. Compared with patients who had serious injuries involving long-term pain, mildly injured somatoform pain patients are more than five times as likely to use daily opioids [52]. Moreover, one program found a 30% incidence of abuse of opioids among those patients who had somatoform pain disorder, many times higher than that of the other patients [53]. Hypochondriasis, another kind of somatoform disorder that involves fear of having a disease when there is none, has also been identified in chronic pain patients [54]. It has been found to be worsened by the chronic medical use of morphine [55], and by its abuse [56]. Mood disorders In a study of chronic pain patients on opioids, 61% were found to have major depression [57]. It appears that the pain causes depression at least as often as depression causes pain [58,59]. Nonetheless, depression is known to make the patient’s pain feel worse [48]. In postsurgical pain after cholecys- tectomy, patients who had even subclinical depressive symptoms reported higher pain [60]. Treating depression can improve, and in some cases eliminate, chronic pain [6]. Whether depression is considered to be a cause or an effect of chronic pain, it should be considered at least a comorbid condition that requires concurrent treatment [61]. An anxiety disorder was found in 10.6% of chronic work-related musculoskeletal pain patients [62]. The lifetime risk of a major anxiety disorder in men who have chronic low back pain is 30.9%, compared with 14.3% in men who do not have low back pain [59]. It is likely that some ‘‘chronic pain’’ patients are actually using opioid medications to self-treat anxiety or depression, instead of relying on more effective anxiolytic or antidepressant agents [57]. These patients are not only using the wrong drug for their condition, but what little subjective benefit they initially feel is rapidly lost with tolerance, and replaced with dependence. Evaluation Because of the influence of psychological factors on chronic pain, at least brief screening should be done on initial evaluation. It is very useful to examine for Waddell signs or nonphysiological findings, which can be done quickly during the physical [63]. A particularly good test is the application of pressure on the top of the head when the patient is standing, to put stress on the spine. The low back pain patient who has a somatoform pain disorder will often complain of increased pain. If the pain were purely of spinal origin, this maneuver would not increase it. Whenever psychiatric comorbidity is present or suspected, more comprehensive screening should include tests such as the Multidimensional Pain Inventory (MPI) and the Minnesota Multiphasic Personality Inventory 2 (MMPI-2) [21]. Such comprehensive testing is usually impractical in the emergency setting, and ideally should be done by a psychiatric consultant familiar with chronic pain [48]. Although acute care physicians are not likely to be doing this evaluation themselves, they should insure that it has already been completed, or that it will be done as soon as possible. Failing to address psychological issues in chronic pain patients may result in prolonged disability in a substantial number of patients [25]. The psychology of opioid dependence The subject of opioid dependence in patients complaining of pain is controversial, and is discussed in further detail in the article by Hansen elsewhere in this issue on the drug-seeking patient. It should be noted that chronic opioid use, particularly in high doses, can produce a condition of enhanced pain sensitivity [64]. Patients dependent on daily doses feel worse when the medication wears off, and closer to baseline levels of pain temporarily when they take it, even though the overall pain condition fails to improve [65]. These patients may see opioids as necessary for survival. It may become difficult to control the use of opioids, and they visit the emergency room when they run out. They complain of increased pain from conditions that would not typically call for opioids. The patient who escalates demands for opioids when these are not forthcoming is typically opioid-dependent, and may have issues of problematic use. The psychology of the physician also influences the use of opioids for chronic pain, and the interpretation of their effectiveness. Some patients are insistent that certain medications must be prescribed. They will exaggerate the benefits and deny adverse effects. Some physicians have difficulty setting limits. It is faster and easier to give in to the patient’s demands than to institute an alternate course. The physician may realize that the prescription is in excess of normal practice, but rationalizes that for this particular patient, nothing else works. The emergency physician can anticipate these issues, and plan, with consultation if desired, how to deal with them. Summary Emotional and evaluative issues are very important in the evaluation and treatment of pain. Treating the physical pain alone can leave these issues unresolved, and possibly exacerbate them through reinforcement. Understanding the impact of fear, expectations, and attention can help physicians deal more effectively with acute pain. Psychological issues are particularly prominent in chronic pain. Though acute care physicians my not be treating these psychological conditions, they can help by referring patients to the appropriate psychological or multidisciplinary setting. De rerum natura - de Lucian BlagaA c?zut pe lucruri rou?sau e numai o p?rere?Poate c? le pl?nge fa?ade-o l?untric? durere.Bate-o inim? ?n lucruri?Preajma ocup?nd-o-n p?lcurin-au ?i ele g?nduri, patimi?F?r? ochi se uit?-n lumepurt?toarele de t?lcuri,n?sc?toarele de lacrimi.PARIS PENDANT LA GUERRE - de Paul EluardLes bêtes qui descendent des faubourgs en feu,Les oiseaux qui secouent leurs plumes meurtrières,Les terribles ciels jaunes, les nuages tout nusOnt, en toute saison, fêté cette statue.Elle est belle, statue vivante de l’amour.O neige de midi, soleil sur tous les ventres,O flamme du sommeil sur un visage d’angeEt sur toutes les nuits et sur tous les visages.Silence. Le silence éclatant de ses rêvesCaresse l’horizon. Ses rêves sont les n?tresEt les mains de désir qu’elle impose à son glaiveEnivrent d’ouragans le monde délivré.(din Volumul Capitala Durerii 1926)Durerea ca parte a vie?iiCa ?i fericirea ?i nefericirea, ca ?i suferin?a, iubirea, dezam?girea, extazul su moartea, durerea este o parte a vie?ii. S? negi durerea nu este altceva dec?t s? negi via?a. 5 Reasons You Have to Accept Pain If You Want to Be Happy1. Pain helps you recognize (and savor) pleasure.Posted Nov 14, 2015HYPERLINK ""SHAREHYPERLINK ""TWEETHYPERLINK "mailto:?subject=Psychology%20Today:%205%20Reasons%20You%20Have%20to%20Accept%20Pain%20If%20You%20Want%20to%20Be%20Happy&body=Hi,%0D%0A%0D%0AI%20thought%20you%27d%20be%20interested%20in%20this%20article%20on%20Psychology%20Today:%0D%0A%0D%0A5%20Reasons%20You%20Have%20to%20Accept%20Pain%20If%20You%20Want%20to%20Be%20Happy%0D%0A"EMAILHYPERLINK ""MOREThe struggle to find happiness is a common reason people seek therapy. Clients often enter my office saying, "I've tried everything, but I don't feel happier."While some struggled with mental health concerns like?depression, many others just weren't finding their pursuits of happiness to be fruitful. Much to their frustration, their efforts to become happier people did not yield?the desired results. Many had read countless articles and books on how to be happier, yet they weren't becoming the extraordinarily happy people they hoped to be. Who could blame them, then, for their frustration? The benefits of happiness are undeniable. It can help you live a longer, healthier life. But the truth is, many people have no idea how to become happier. In fact, some people's pursuits of happiness backfire, causing them to end up more miserable than ever.The Biggest Happiness MisconceptionEating an extra helping of food to avoid feeling hungry, treating yourself to concert tickets so you don't miss out on time with friends, or skipping your workout because you just don't feel like exercising may seem like opportunities to temporarily boost your mood. But this way of thinking could actually be getting in the way of living a happier life—because the biggest misconception about happiness is that the path to achieving involves avoiding pain.But pain is actually a necessary part of happiness, and research?shows that it can lead to pleasure in several ways:1. Pain helps you recognize pleasure.?If you felt happy all the time, you wouldn't recognize it as happiness. You need to experience the opposite end of the spectrum sometimes to be able to truly recognize and appreciate happiness.2. Relief from pain boosts pleasure.?Pain isn't pleasurable, but relief from pain is. Studies show that when pain goes away, you experience increased happiness, above and beyond the level of happiness you'd experience if you'd never had any pain at all.3. Pain forms social bonds.?It's likely that you relate to other people more easily when you've both endured similar painful events in your life because pain promotes empathy, which is essential to social connection. The bonding caused by pain even increases cooperation among people. Volunteers often come together to clean up after a natural disaster because they experienced pain and witnessed suffering together. Remember the ice bucket challenge?4. Pain gives you permission to reward yourself.?There's a reason a cold beer tastes better after you've mow the lawn or a hot chocolate tastes better after you?shovel the driveway: Enduring pain actually makes you enjoy your rewards more. When you have worked out, or completed some other difficult task, you are more likely to give yourself permission to enjoy a reward. Not only will you then feel less guilt over splurging, but your senses will be heightened and you'll actually appreciate the reward more.article continues after advertisement5. Pain captures your attention.?Pain makes you aware of what is going on right now. Whether you're dealing with a bad headache or experiencing emotional pain, you'll be focused on what is going on in the moment. And while that may not seem like a good thing on the surface, being in the moment is a skill people try hard to gain through meditation, mindfulness, and yoga. Being in the moment means you'll be less likely to ruminate about what happened yesterday or worry about what could happen tomorrow. Learning how to stay in the moment—even when you're not in pain—can help you live a happier life.Don't Fear PainThere's a lot of truth to the saying, "Pain is inevitable. Suffering is optional." Happiness isn't the absence of pain. Instead, the secret to living a happier life involves believing you have enough?mental strength?to embrace your pain and learn from it.Durerea mea ...- de Nicolae Labi?Durerea mea ?n nave cosmice alearg?Neistovit? de pustietatea larg?Durerea mea e ?nc?lcit? ?i confuz?Durerea labirintului de straziAmar? ca soda strivit? pe buz?Sinistr? ca apa temutei otr?viCu miros de lut ?i uraniuAp?s?toare pe suflet ?i craniuDoamne, e proprie plaga ?i ulcer!Nu mi-o po?i rupe! Nu mi-o pot smulge!Oglinzi cojite ale ochilor stin?i.Durerile suflete?tiDurerile desp?r?iriiDurerile de doliuDurerile iubirii ne?mp?rt??ite: Psihologul Andra T?n?sescu sus?ine c? atunci c?nd iubirea ?nceteaz? s? se mai manifeste,?c?nd scade ?n intensitate, dispare sau nu este ?mp?rt??it?, sentimentele celui care este r?nit se transform? ?n ur?, furie sau triste?e. V?rsta la care oamenii sunt predispu?i la o criz? existen?ial?...(adev?rul.ro 23 noiembrie 2017).Suferin?a psihic? produs? de o dragoste ne?mp?rt??it? nu duce ?ntotodeauna la sentimente negative, dar poate declan?a ?i ?ntre?inei modific?ri majore de comportament (retragere, lips? de interes pentru via??, munc?, ceilal?i) sau poate induce o deprimare grav?, merg?nd p?n? la idei de sinucidere ?i chiar punerea lor ?n aplicare.Nu m? ?n?elegi - de Mihai Eminescude Mihai Eminescu?n ochii mei acuma nimic nu are pre?Ca taina ce ascunde a tale frumuse?i;C?ci pentru care alt? minune dec?t tineMi-a? risipi o via?? de cuget?ri seninePe basme ?i nimicuri, cuvinte cump?nind,Cu pieritorul sunet al lor s? te cuprind,?n lan?uri de imagini duiosul vis s?-l ferec,S?-mpiedec umbra-i dulce de-a merge-n ?ntunerec.—?i azi c?nd a mea minte, a farmecului roab?,Din ori?ice durere ??i face o podoab?,?i c?nd r?sai nainte-mi ca marmura de clar?,C?nd ochiul t?u cel m?ndru str?luce ?n afar?,?ntunec?nd privirea-mi, de nu pot s? v?d ?nc?Ce-ad?nc trecut de g?nduri e-n noaptea lui ad?nc?,Azi c?nd a mea iubire e-at?ta de curat?Ca farmecul de care tu e?ti ?mpresurat?,Ca setea cea etern? ce-o au dup?olalt?Lumina de-ntunerec ?i marmura de dalt?,C?nd dorul meu e-at?ta de-ad?nc ?i-at?t de sf?ntCum nu mai e nimica ?n cer ?i pe p?m?nt,C?nd e o-namorare de tot ce e al t?u,De-un z?mbet, de-un cutremur, de bine ?i de r?u,C?nd e?ti enigma ?ns??i a vie?ii mele-ntregi…Azi v?d din a ta vorb? c? nu m? ?n?elegi!Durerea amintirilor:Durerea vinov??iei:CulpableBlameworthy;?involving?the?commission?of?a?fault?or?the?breach?of?a?duty?imposed?by?law.Culpability?generally?implies?that?an?act?performed?is?wrong?but?does?not?involve?any?evil?intent?by?the?wrongdoer.?Theconnotation?of?the?term?is?fault?rather?than?malice?or?a?guilty?purpose.?It?has?limited?significance?in?Criminal?Law?except?incases?of?reckless?Homicide?in?which?a?person?acts?negligently?or?demonstrates?a?reckless?disregard?for?life,?which?results?inanother?person's?death.?In?general,?however,?culpability?has?milder?connotations.?It?is?used?to?mean?reprehensible?rather?thanwantonly?or?grossly?negligent?behavior.?Culpable?conduct?may?be?wrong?but?it?is?not?necessarily?criminal.Culpable?ignorance?is?the?lack?of?knowledge?or?understanding?that?results?from?the?omission?of?ordinary?care?to?acquire?suchknowledge?or?understanding.West's Encyclopedia of American Law, edition 2. Copyright 2008 The Gale Group, Inc. All rights reserved.culpableadj.?sufficiently?responsible?for?criminal?acts?or?negligence?to?be?at?fault?and?liable?for?the?conduct.?Sometimes?culpabilityrests?on?whether?the?person?realized?the?wrongful?nature?of?his/her?actions?and?thus?should?take?the?plexul de vinovatieYou are here:HomeBoli psihice19 decembrie 2011Leave a commentBoli psihiceBy?Camelia StavaracheRevista Somatoterapia Nr. 28 /2007Complexul de vinovatieAutor: psiholog, master Analiza Jung-iana MIHAELA NECULA?O serie de autori abordeaza o data cu complexul de vinovatie si pe cele denumite ‘‘nevoia de pedepsire’’, ‘‘autopedepsire’’ sau complexul esecului.Expresiile direct manifestate ale complexului de vinovatie – in cadrul interviurilor sau confidentelor cu persoanele care au acest complex atrage atentia, in primul rand, vigilenta acestora in privinta constiintei morale. Foarte repede insa se observa ca individul este incapabil de a face distinctia intre ceea ce este moral si imoral, el fiind incapabil sa-si asume o responsabilitate personala reala.In evaluarea unei greseli se remarca inversunarea persoanei de a se autopedepsi. Este vorba de o autocondamnare implacabila si permanenta.Frica de responsabilitate in privinta a ceea ce ar putea sa se intample in urma unui act spontan al vietii cotidiene sau a unei vorbe negandite, antreneaza, pe fondul unei anxietati continue, o inhibitie mai mult sau mai putin completa a spontaneitatii, o frica de cea mai mica responsabilitate acceptata si grija constanta de a medita, de a prevedea totul, de a calcula totul pentru a evita eroarea si consecintele neprevazute ale acesteia.Destinderea si repaosul sunt rare iar atunci cand exista, sunt culpabilizate. Subiectul nu are dreptul de a fi linistit si de a lasa lucrurile sa mearga de la sine datorita simtului exagerat al datoriei, asa cum il concepe constiinta sa legata de supra-Eu. Puterea interdictiilor loveste dinainte orice libertate a Eului, orice aspiratie la fericirea personala. Toate incercarile directe pentru a relativiza o greseala se folosesc de zidul implacabil al supra-Eului care a sufocat complet si a inlocuit constiinta morala normala.Orice prezenta sociala, orice privire mai insistenta apar in ochii ‘‘culpabilizatului’’ ca un fel de judecatori care ‘‘stiu’’ sau ‘‘ghicesc’’ chair gandurile cele mai secrete. Individul traieste permanent ca si cum ar fi in fata unui tribunal. Orice nenorocire care se intampla o considera ca venind din partea unei justitii imanente si traita ca o pedeapsa a destinului sau a lui Dumnezeu. Indiferent de nivelul de inteligenta a subiectului, rationamentul in privinta valorii personale este intotdeauna mascat, neclar.Autopedepsirea se manifesta in toate planurile vietii si persoana se condamna la esec. Se dezvolta astfel complexul de esec, caracterizat prin sase fenomene:1. minimalizarea si desconsiderarea oricarui succes sau oricarui eveniment fericit care priveste individul;2. intensificarea si dramatizarea oricarui esec personal;3. abordarea oricarei situatii de incercare cu un sentiment de angoasa si de certitudine a esecului – esecul este de neinlocuit;4. acuzarea de sine, dorinta de a se pedepsi se finalizeaza cu autofrustrari, autopersecutii, chair automutilari;5. conduite constiente organizate in jurul sentimentului datoriei si a rascumpararii personale;6. provocarea unei sanctiuni ‘‘exterioare’’ si bucuria sau usurarea paradoxala datorate pedepsei primite.Varsta la care apare acest complex – in conceptia clasica a lui Freud complexul de culpabiliate este legat de cel oedipian. Vinovatia se datoreaza sexualitatii. Angoasa datorata vinovatiei este accentuata de teama castrarii.Studiile clinice au pus in evidenta si alte origini: culpabilizarea parentala ca metoda de educatie (un astfel de climat educativ care foloseste rusinea si, mai ales, santajul afectiv asupra unui copil constituie mijloace pedagogice care cultiva vinovatia); culpabilizarea masiva a primelor interese sexuale si debutul vietii sexuale in preadolescenta; dramatizarea traumatica a greselilor mici comise de copil scenarizate de parinti pentru a impresiona un copil si a-l face sa creada ca ajunge la inchisoare, sau sanctionarea reala a copilului cu privatiuni mai lungi sau mai scurte; impregnarea precoce cu angoasa pacatului si culpabilizarea gandurilor, obligatia de a spune totul, urmate de represiuni si pedepsiri ale parintilor mai mult sau mai putin sadici; traumatismul precoce datorat unei greseli morale la care a fost agent sau victima, dar considerat in ambele ipoteze vinovat; autoacuzarea si autopedepsirile incepand cu pulsiunile sexuale ale pubertatii insotite de dezvoltarea rusinii de sine, efortul infructuos catre un ideal de ascentism sau de puritate morala; coincidenta fatala intre o initiativa, idee sau angajament personal al subiectului si o nenorocire, accident sau catastrofe care au urmat, aducand subiectul in situatia de a-si impune plexele posibile care il insotesc pe cel de vinovatie sunt urmatoarele: de abandon, de insecuritate, de castrare, de inferioritate.Durerea - de Vasile Voiculescu20MART.Oprit? s? se urce ?n Ceruri vreodat?,Durerea?n-are aripi, s?-?i fac? v?nt,Ci calc?, peste lespezi ?ncovoiat?,?nger pururi ?nc?tu?at de p?m?nt.Ad?ncu-i glas n-ajunge la stele…Bra?ele-i v?ntur? cenu?? ?i lut,Pres?r?ndu-le peste r?ni grele.Dar Domnul a ales-o de la ?nceput.?n ochii ei luce?te, ?nc? ne?n?eleas?,Lumina, semnul Lui izb?vitor,?i a pus-o mai presus, cr?ias?,?i pild?, ?ngerilor tuturor.Ea nu ?tie…Dar c?nd somnul o doboar?,?n miezul nop?ii ?i-al t?cerii,Marii ?ngeri pe p?m?nt coboar??i se pleac? de s?rut? picioarele?durerii.Durere pur? - de Marin SorescuNu mi-e r?u ca s?-mi fie bineMi-e r?u ca s?-mi fie ?i mai r?u.Ca marea cu valuri verzi ?n?el?toareNici durerii nu-i po?i ghici fundul.Faci scufund?ri ?n durerea pur?.Esen?? de ?ipat ?i disperare -?i m? ?ntorc la suprafa?? v?n?tCa un scafandru care ?i-a pierdutBalonul de oxigen.M? rog de ?mparatul pe?tilorS?-mi trimit? un rechin de treab?S?-mi taie calea.Durerile false: exagerate, ?nchipuite, manipulate?Factitious DisordersIN THIS ARTICLETypes of Factitious DisordersWhat Are the Symptoms of Factitious Disorders?What Causes Factitious Disorders?How Common Are Factitious Disorders?How Are Factitious Disorders Diagnosed?How Are Factitious Disorders Treated?What Is the Outlook for People With Factitious Disorders?Can Factitious Disorders Be Prevented?Factitious disorders are conditions in which a person deliberately and consciously acts as if he or she has a physical or?mental illness?when he or she is not really sick. Factitious disorder by proxy is when a person acts as if a person in their care has an illness when they do not.People with factitious disorders deliberately create or exaggerate symptoms of an illness in several ways. They may lie about or fake symptoms, hurt themselves to bring on symptoms, or alter tests (such as contaminating a urine sample) to make it look like they or the person in their care are sick.People with factitious disorders behave this way because of an inner need to be seen as ill or injured, not to achieve a clear benefit, such as financial gain. People with factitious disorders are even willing and sometimes eager to undergo painful or risky tests and operations in order to obtain the sympathy and special attention given to people who are truly ill or have a loved one who is ill. Factitious disorders are considered mental illnesses because they are associated with severe emotional difficulties.Many people with factitious disorders also suffer from other mental conditions, particularly personality disorders. People with personality disorders have long-standing patterns of thinking and acting that differ from what society considers usual or normal. These people generally also have poor coping skills and problems forming healthy?relationships.Factitious disorders are similar to another group of mental disorders called?somatoform disorders, which also involve the presence of symptoms that are not due to actual physical illness or another mental illness. The main difference between the two groups of disorders is that people with?somatoform disorders?do not fake symptoms or mislead others about their symptoms on purpose.ADVERTISEMENTTypes of Factitious DisordersThere are four main types of factitious disorders, including:Factitious disorder with mostly psychological symptoms: As the description implies, people with this disorder mimic behavior that is typical of a mental illness, such as?schizophrenia. They may appear confused, make absurd statements and report?hallucinations, the experience of sensing things that are not there; for example, hearing voices.?Ganser syndrome, sometimes called prison?psychosis, is a factitious disorder that was first observed in prisoners. People with Ganser syndrome have short-term episodes of bizarre behavior similar to that shown by people with serious mental illnesses.Factitious disorder with mostly physical symptoms: People with this disorder claim to have symptoms related to a physical illness, such as symptoms of?chest pain,?stomach problems, or fever. This disorder is sometimes referred to as?Munchausen syndrome, named for Baron von Munchausen, an 18th century German officer who was known for embellishing the stories of his life and experiences.Factitious disorder with both psychological and physical symptoms: People with this disorder produce symptoms of both physical and mental illness.Factitious disorder not otherwise specified: This type includes a disorder called factitious disorder by proxy (also called?Munchausen syndrome by proxy). People with this disorder produce or fabricate symptoms of illness in another person under their care. It most often occurs in mothers (although it can occur in fathers) who intentionally harm their children in order to receive attention.What Are the Symptoms of Factitious Disorders?Possible warning signs of factitious disorders include:Dramatic but inconsistent medical historyUnclear symptoms that are not controllable and that become more severe or change once treatment has begunPredictable relapses following improvement in the conditionExtensive knowledge of hospitals and/or medical terminology, as well as the textbook descriptions of illnessPresence of many surgical scarsAppearance of new or additional symptoms following negative test resultsPresence of symptoms only when the patient is with others or being observedWillingness or eagerness to have medical tests, operations, or other proceduresHistory of seeking treatment at many hospitals, clinics, and doctors offices, possibly even in different citiesReluctance by the patient to allow?health care?professionals to meet with or talk to family members, friends, and prior doctorsWhat Causes Factitious Disorders?The exact cause of factitious disorders is not known, but researchers are looking at the roles of biological and psychological factors in the development of these disorders. Some theories suggest that a history of abuse or neglect as a child, or a history of frequent illnesses that required hospitalization, might be factors in the development of the disorder.How Common Are Factitious Disorders?There are no reliable statistics regarding the number of people in the U.S. who suffer from factitious disorders. Obtaining accurate statistics is difficult because dishonesty is common with this condition. In addition, people with factitious disorders tend to seek treatment at many different?health carefacilities, which can lead to statistics that are misleading.In general, factitious disorders are more common in men than in women. However,?factitious disorder by proxy?tends to be more common in women than in men.How Are Factitious Disorders Diagnosed?Diagnosing factitious disorders is very difficult because of, again, the dishonesty that is involved. Doctors must rule out other possible physical and mental illnesses before a diagnosis of factitious disorder can be considered.If the doctor finds no physical reason for the symptoms, or suspects that symptoms or abnormal laboratory results may be self-induced, he or she may refer the person to a psychiatrist or?psychologist, mental health professionals who are specially trained to diagnose and treat mental illnesses. Psychiatrists and psychologists use specially designed interview and assessment tools to evaluate a person for a factitious disorder. The doctor bases his or her diagnosis on the exclusion of actual physical or mental illness, and his or her observation of the person's attitude and behavior.How Are Factitious Disorders Treated?The first goal of treatment for a factitious disorder is to modify the person's behavior and reduce his or her misuse or overuse of medical resources. In the case of factitious disorder by proxy, the main goal is to ensure the safety and protection of any real or potential victims. Once the initial goal is met, treatment aims to work out any underlying psychological issues that may be causing the person's behavior.The primary treatment for factitious disorders is?psychotherapy?(a type of counseling). Treatment likely will focus on trying to change?the thinking and behavior of the individual with the disorder (cognitive-behavioral therapy). Family therapy may also be helpful in teaching family members not to reward or reinforce the behavior of the person with the disorder.There are no?medications?to treat factitious disorders themselves. Medication may be used, however, to treat any related disorder -- such as?depressionoranxiety. The use of medications must be carefully monitored in people with factitious disorders due to the risk that the drugs may be misused in a harmful way.What Is the Outlook for People With Factitious Disorders?People with factitious disorders are at risk for health problems (or even death) associated with hurting themselves or otherwise causing symptoms. In addition, they may suffer from reactions or health problems related to multiple tests, procedures, and treatments; and are at high risk for?substance abuse?and attempts at?suicide. A complication of factitious disorder by proxy is the abuse and potential death of the victims.Because many people with factitious disorders deny they are faking symptoms and will not seek or follow treatment, recovery is dependent on a doctor or loved one identifying or suspecting the condition in the person and encouraging them to receive proper medical care for their disorder and stick with it.Some people with factitious disorders suffer one or two brief episodes of symptoms and then get better. In most cases, however, the factitious disorder is a chronic, or long-term, condition that can be very difficult to treat.Can Factitious Disorders Be Prevented?There is no known way to prevent factitious disorders.Request an AppointmentPatient Care & Health InformationDiseases & ConditionsFactitious disorderSymptoms & causesDiagnosis & treatmentDoctors & departmentsPrintOverviewFactitious disorder is a serious mental disorder in which someone deceives others by appearing sick, by purposely getting sick or by self-injury. Factitious disorder also can happen when family members or caregivers falsely present others, such as children, as being ill, injured or impaired.Factitious disorder symptoms can range from mild (slight exaggeration of symptoms) to severe (previously called Munchausen syndrome). The person may make up symptoms or even tamper with medical tests to convince others that treatment, such as high-risk surgery, is needed.Factitious disorder is not the same as inventing medical problems for practical benefit, such as getting out of work or winning a lawsuit. Although people with factitious disorder know they are causing their symptoms or illnesses, they may not understand the reasons for their behaviors or recognize themselves as having a problem.Factitious disorder is challenging to identify and hard to treat. However, medical and psychiatric help are critical for preventing serious injury and even death caused by the self-harm typical of this disorder.SymptomsFactitious disorder symptoms involve mimicking or producing illness or injury or exaggerating symptoms or impairment to deceive others. People with the disorder go to great lengths to hide their deception, so it may be difficult to realize that their symptoms are actually part of a serious mental health disorder. They continue with the deception, even without receiving any visible benefit or reward or when faced with objective evidence that doesn't support their claims.Factitious disorder signs and symptoms may include:Clever and convincing medical or psychological problemsExtensive knowledge of medical terms and diseasesVague or inconsistent symptomsConditions that get worse for no apparent reasonConditions that don't respond as expected to standard therapiesSeeking treatment from many different doctors or hospitals, which may include using a fake nameReluctance to allow doctors to talk to family or friends or to other health care professionalsFrequent stays in the hospitalEagerness to have frequent testing or risky operationsMany surgical scars or evidence of numerous proceduresHaving few visitors when hospitalizedArguing with doctors and staffFactious disorder imposed on anotherFactitious disorder imposed on another (previously called Munchausen syndrome by proxy) is when someone falsely claims that another person has physical or psychological signs or symptoms of illness, or causes injury or disease in another person with the intention of deceiving others.People with this disorder present another person as sick, injured or having problems functioning, claiming that medical attention is needed. Usually this involves a parent harming a child. This form of abuse can put a child in serious danger of injury or unnecessary medical care.How those with factitious disorder fake illnessBecause people with factitious disorder become experts at faking symptoms and diseases or inflicting real injuries upon themselves, it may be hard for health care professionals and loved ones to know if illnesses are real or not.People with factitious disorder make up symptoms or cause illnesses in several ways, such as:Exaggerating existing symptoms.?Even when an actual medical or psychological condition exists, they may exaggerate symptoms to appear sicker or more impaired than is true.Making up histories.?They may give loved ones, health care professionals or support groups a false medical history, such as claiming to have had cancer or AIDS. Or they may falsify medical records to indicate an illness.Faking symptoms.?They may fake symptoms, such as stomach pain, seizures or passing out.Causing self-harm.?They may make themselves sick, for example, by injecting themselves with bacteria, milk, gasoline or feces. They may injure, cut or burn themselves. They may take medications, such as blood thinners or drugs for diabetes, to mimic diseases. They may also interfere with wound healing, such as reopening or infecting cuts.Tampering.?They may manipulate medical instruments to skew results, such as heating up thermometers. Or they may tamper with lab tests, such as contaminating their urine samples with blood or other substances.When to see a doctorPeople with factitious disorder may be well aware of the risk of injury or even death as a result of self-harm or the treatment they seek, but they can't control their behaviors and they're unlikely to seek help. Even when confronted with objective proof — such as a videotape — that they're causing their illness, they often deny it and refuse psychiatric help.If you think a loved one may be exaggerating or faking health problems, it may help to attempt a gentle conversation about your concerns. Try to avoid anger, judgment or confrontation. Also try to reinforce and encourage more healthy, productive activities rather than focusing on dysfunctional beliefs and behaviors. Offer support and caring and, if possible, help in finding treatment.If your loved one causes self-inflicted injury or attempts suicide, call 911 or emergency medical help or, if you can safely do so, take him or her to an emergency room immediately.Request an Appointment at Mayo ClinicCausesThe cause of factitious disorder is unknown. However, the disorder may be caused by a combination of psychological factors and stressful life experiences.Risk factorsSeveral factors may increase the risk of developing factitious disorder, including:Childhood trauma, such as emotional, physical or sexual abuseA serious illness during childhoodLoss of a loved one through death, illness or abandonmentPast experiences during a time of sickness and the attention it broughtA poor sense of identity or self-esteemPersonality disordersDepressionDesire to be associated with doctors or medical centersWork in the health care fieldFactitious disorder is considered rare, but it's not known how many people have the disorder. Some people use fake names to avoid detection, some visit many different hospitals and doctors, and some are never identified — all of which make it difficult to get a reliable plicationsPeople with factitious disorder are willing to risk their lives to be seen as sick. They frequently have other mental health disorders as well. As a result, they face many possible complications, including:Injury or death from self-inflicted medical conditionsSevere health problems from infections or unnecessary surgery or other proceduresLoss of organs or limbs from unnecessary surgeryAlcohol or other substance abuseSignificant problems in daily life, relationships and workAbuse when the behavior is inflicted on anotherPreventionBecause the cause of factitious disorder is unknown, there's currently no known way to prevent it. Early recognition and treatment of factitious disorder may help avoid unnecessary and potentially dangerous tests and treatment.Medicina dureriiFrica de durere R?bdarea durerii - stoicismul Provocarea durerii - sadismulmasochismul, tortura, automutilareaDrinkology: Moartea durerii (Painkiller cocktail)0000Prin anii '70, a fost lansat ?n Caraibe cocktailul Moartea durerii, cu 50 de mL de rom, 50 cc de suc de ananas, 25 cc de crem? de cocos, 25 cc de suc de portocale ?i ghia??.Rubrica gastronomic?: PRAJITURA DURERE - de Corina Ureche (corinaureche.ro)60 g faina250 g unt la temperatura camerei2 linguri lapte1 lingurita otet1 lingurita cafea ness3 linguri Nutella sau crema preferata de alune cu ciocolataCiocolata amaruie razuita pentru decorMod de preparare Pornim cuptorul la 180 grade si punem hartie de copt intr-o tava. Eu am folosit o tava cu dimensiunea de 28×24 cm.Separam ouale.Pentru blat vom pune albusurile intr-un bol mare si le mixam pana se formeaza spuma, apoi adaugam treptat 180 g zahar. Batem albusurile cu zaharul pana obtinem o spuma ferma si lucioasa. Adaugam otetul si amestecam.Amestecam miezul de nuca cu 40 g faina cernuta. Amestecul il turnam peste spuma de albusuri si amestecam cu grija pana acesta este inglobat.Impartim aluatul pentru blat in doua si il turnam in tava. Eu am copt blaturile unul dupa celalalt. Nu va faceti probleme, pana se coace un blat spuma nu se va lasa.Coacem fiecare blat 20 de minute. Cum le scoatem din cuptor le rasturnam pe blatul de lucru si indepartam hartia de copt. Lasam blaturile sa se raceasca.Like629 people like this. Sign Up to see what your friends like. ................
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