Sintomas somatoformes em Medicina Geral e Familiar

RESUMO: Os doentes que vão à consulta com sintomas físicos para os quais o médico não encontra uma causa orgânica, são frequentes na Medicina Geral e Familiar, embora não sejam específicos, e são o objecto de estudo do presente trabalho. Não deixar uma doença por diagnosticar (erro de tipo II) sem contudo rotular pessoas saudáveis como doentes (erro de tipo I) é um dos mais difíceis problemas da prática clínica diária e para o qual não existe uma orientação infalível e não é previsível que alguma vez venha a existir. Mas se o diagnóstico de doença ou não-doença é difícil, o tratamento dos que não tem doença, embora com sofrimento, também não é mais fácil, sobretudo, se estivermos conscientes do sofrimento que determina a medicalização e a iatrogenia. O presente trabalho está estruturado em 3 partes. Na primeira parte descrevemos a nossa visão integrada do que apreendemos da leitura da literatura publicada e à qual tivemos acesso. À semelhança do que se verifica na maioria das áreas da Medicina esta é também uma em que o conhecimento cresce a ritmo exponencial. No entanto, à falta de conceitos precisos e de definições consensuais sucede um conhecimento, por vezes, pouco consistente, tanto mais que estamos na fronteira entre a cultura leiga e a cultura erudita médica em que os significados devem, a todo o momento, ser validados. Fizemos uma revisão sobre as definições do que está em questão, sobre o que se sabe sobre a frequência dos sintomas físicos na população, quantos recorrem aos serviços de saúde e o que lhes é feito. Passámos por uma revisão da fisiologia destes sintomas e algumas explicações fisiopatológicas para terminarmos sobre o que os doentes pensam sobre os seus sintomas e os cuidados que recebem e o que os profissionais pensam sobre estes doentes. Esta parte termina com uma revisão das propostas de abordagem para este tipo de doentes. Na segunda parte, descrevemos os estudos empíricos focados no problema dos pacientes com sintomas físicos mas sem evidência de doença orgânica. Começa por uma apresentação dos aspectos processuais e metodológicos dos estudos realizados, mais especificamente, de dois estudos quantitativos e um qualitativo. No primeiro estudo pretendeu-se avaliar quais são os sintomas físicos e a sua frequência na população em geral e a frequência de pacientes que procuram (ou não) os serviços de saúde tendo como motivo este tipo de sintomas. O objectivo deste estudo é contribuir para a demonstração que este tipo de sintomas faz parte da vida do dia-a-dia e que, na maioria das vezes, só por si não significa doença, sem contudo negar que representa sofrimento, por vezes até maior do que quando há patologia orgânica. Se no primeiro estudo era demonstrar que os sintomas físicos são frequentes na população, no segundo estudo o objectivo é demonstrar que pacientes com este tipo de sintomas são igualmente frequentes e que o tipo de sintomas apresentados na consulta não difere dos referidos pela população em geral. Pretendia-se ainda saber o que é feito ou proposto pelo médico a estes doentes e se estes doentes traziam ou não, junto com os sintomas, ideias explicativas para os mesmos. Finalmente e não menos importante, é avaliar o grau de fidedignidade do diagnóstico de sintoma somatoforme, chamando assim ao sintoma físico que foi “levado” à consulta e que o médico diagnosticou como não tendo causa orgânica. O terceiro estudo parte do conhecimento adquirido que a Medicina tem muitas respostas para este problema, mas poucas que se possam considerar satisfatórias se usadas isoladamente. Que a maioria das soluções é procurada entre a cultura médica e num paradigma reducionista de separação mente-corpo. Contudo, se o sintoma é “construído” pelo doente, se o principal problema não está no sintoma mas na forma como o paciente o vê, então pareceu-nos lógico que a solução também tem que passar por integrarmos no plano de abordagem o que o doente entende ser melhor para si. Nesta sequência, entrevistaram-se alguns doentes cujo diagnóstico de sintomas somatoformes estava demonstrado pelo teste do tempo. Por isso, entrevistaram-se doentes que já tinham ido à consulta de MGF há mais de 6 meses por sintomas somatoformes e, na data da entrevista, o diagnóstico se mantinha inalterado, independentemente da sua evolução. As entrevistas visaram conhecer as ideias dos doentes sobre o que as motivou a procurarem a consulta, o que pensavam da forma como foram cuidados e que ideias tinham sobre o que os profissionais de saúde devem fazer para os ajudar a restabelecer o equilíbrio com o seu ambiente evitando a medicalização, a iatrogenia e a evolução para a cronicidade. Na terceira parte, discutem-se e integram-se os resultados encontrados no conhecimento previamente existente. Tenta-se teorizar, fazer doutrina sobre o tema e contribuir para abordagens terapêuticas mais personalizadas, abrangentes, variadas e multimodais, baseadas sempre no método clínico centrado no paciente, ou de modo menos correcto mas enfático, baseadas no método centrado na relação. Apresentam-se algumas hipóteses de trabalhos futuros sobre o tema e, sobretudo, esperamos ter contribuído para o reconhecimento da necessidade de a comunicação médico-doente ser uma aprendizagem transversal a todos os profissionais de saúde e ao longo da vida, com a ideia que é sempre possível fazer melhor, caso contrário tenderemos, inexoravelmente, a fazer cada vez pior.-----------ABSTRACT: Patients who go to consultation with physical symptoms, for which the doctor does not find an organic cause, are the subject of the present study. They are common in family medicine, although not specific. Do not let an undiagnosed disease (type II error), but without labeling healthy people as patients with disease (type I error) is one of the most difficult problems in clinical practice and for which doesn’t exist an infallible guide and it is unlikely that any since coming into existence. But, if the diagnosis of disease or non-disease is difficult, the treatment of those who do not have the disease, though suffering, it is not easy, especially if we are aware of the suffering that medicalization and iatrogenic determines. This work is structured in three parts. In the first part we describe our integrated view of what we grasp from reading the published literature and to which we had access. Similar to that found in most areas of medicine, this is also one in which knowledge grows exponentially. However, the absence of precise concepts and consensual definitions determines an inconsistent knowledge, especially because we're on the border between secular culture and medical culture where, at all times, the meaning must be validated. We did a review on the definitions of what is at issue, what is known about the frequency of physical symptoms in the population, how many use the services of health and what they receive as care. We went through a review of the physiology of these symptoms and some pathophysiological explanations, to finish on what patients think about their symptoms and how they perceived the care they received and, finally, what professionals think about these patients. This part ends with a review of the approaches proposed for such patients. In the second part, we describe the empirical studies focused on the problem of patients with physical symptoms but no evidence of organic disease. Begins with a presentation of the procedural and methodological aspects of studies, more specifically, two quantitative and one qualitative. The first study sought to assess which are the physical symptoms, their incidence in the general population and the frequency they seek (or not) health services on behalf of those symptoms. The aim behind this study was to contribute to the demonstration that this type of symptoms is part of life's day-to-day and that, in most cases, does not represent disease by itself, without denying that they represent suffering, sometimes even greater than when there are organic disease. The first study endeavor to demonstrate that the physical symptoms are common in the population. The second study aspires to demonstrate that patients with such symptoms are also common and that the type of symptoms presented in the consultation does not differ from those in the general population. The aim was also to know what is done or proposed by the physician for these patients and if these patients brought or not, along with the symptoms, explanatory ideas for them. Finally and not least, it would try to assess the degree of reliability of diagnosis of somatoform symptoms, thus drawing the physical symptom that patient presents in the consultation and that the doctor diagnosed as having no organic cause. The third study starts from the acquired knowledge that medicine has many answers to this problem, but few can be considered satisfactory if used in isolation. The most solutions are sought in the medical culture and based on a reductionist paradigm of mind-body. However, if the symptom is "built" by the patient, if the main problem is not the symptom but the way the patient sees it, then it seemed logical to us that the solution must integrate the approaches that patients believes are best for them. Subsequently, a few patients, whose diagnosis of somatoform symptoms was demonstrated by the test of time, were interviewed. Therefore, patients who were interviewed had gone to the consultation of family medicine more than 6 months before for somatoform symptoms and. at the moment of the interview, the diagnosis remained unchanged, regardless of their evolution. The interviews aimed to ascertain the patients' ideas about what motivated them to seek consultation, what they thought about the care they got and which ideas they have about what health professionals should do to help these patients to re-establish equilibrium with its environment avoiding medicalization, iatrogenic effects and the evolution to chronicity. In the third section, we discuss and integrate the results found in previously existing knowledge. Attempts to theorize on the subject and contribute to more personalized treatment, comprehensive, varied and multi-modal approaches, always based on patient-centered clinical method, with emphasis on the relationship. We presents some hypotheses for future work on the subject and,above all, defend the recognition of the importance of lifelong learning communication skills for all health professionals, with the idea that we can always do better, otherwise we tend inexorably to do worse.

Innovation and environmental policy: Clean vs. dirty technical change

We study a two sector endogenous growth model with environmental quality with two goods and two factors of production, one clean and one dirty. Technological change creates clean or dirty innovations. We compare the laissez-faire equilibrium and the social optimum and study first- and second-best policies. Optimal policy encourages research toward clean technologies. In a second-best world, we claim that a portfolio that includes a tax on the polluting good combined with optimal innovation subsidy policies is less costly than increasing the price of the polluting good alone. Moreover, a discriminating innovation subsidy policy is preferable to a non-discriminating one.

Real-time labview assessment on adsorption systems

Dissertação para obtenção do Grau de Mestre em Engenharia Química e Bioquímica

The politics of growth: Can lobbying raise growth and welfare?

This paper aims at analyzing the effects of lobbying over economic growth and primarily welfare. We model explicitly the interaction between policy-makers and firms in a setup where the latter undertakes political contributions to the former in exchange for more restrictive market regulations which induce exit and enhance the profitability of the market. In a sectorial equilibrium, despite stimulating growth, lobbying restricts the market structure and reduces welfare when compared to the free-entry outcome. However, once general equilibrium considerations are taken into account, we find that lobbying may improve welfare over a welfare maximizing free-entry equilibrium, by means of an expansion in aggregate demand. This introduces a new paradigm in the literature about the effects of lobbying over economic performance.

Oil price shocks and the Portuguese economy since the 1970s

This paper assesses empirically the effect of oil price shocks on Portuguese aggregate economic activity, industrial production and price level. We take the usual multivariate VAR methodology to investigate the magnitude and stability of this relationship. In doing so, we follow the approach presented in the recent literature and adopt different oil price specifications. We conclude that, as for most industrialized countries, the nature of this relationship changed in the mid-1980s. Furthermore, we show that the main Portuguese macroeconomic variables have become progressively less responsive to oil shocks and the adjustment towards equilibrium has become increasingly faster.

An existence result for discontinuous games

We introduce a notion of upper semicontinuity, weak upper semicontinuity, and show that it, together with a weak form of payoff security, is enough to guarantee the existence of Nash equilibria in compact, quasiconcave normal form games. We show that our result generalizes the pure strategy existence theorem of Dasgupta and Maskin (1986) and that it is neither implied nor does it imply the existence theorems of Baye, Tian, and Zhou (1993) and Reny (1999). Furthermore, we show that an equilibrium may fail to exist when, while maintaining weak payoff security, weak upper semicontinuity is weakened to reciprocal upper semicontinuity.

On the existence of pure-strategy equilibria in large games

Over the years, several formalizations and existence results for games with a continuum of players have been given. These include those of Schmeidler (1973), Rashid (1983), Mas-Colell (1984), Khan and Sun (1999) and Podczeck (2007a). The level of generality of each of these existence results is typically regarded as a criterion to evaluate how appropriate is the corresponding formalization of large games. In contrast, we argue that such evaluation is pointless. In fact, we show that, in a precise sense, all the above existence results are equivalent. Thus, all of them are equally strong and therefore cannot rank the different formalizations of large games.

Dual track sell-out: Signaling through IPO and Underpricing

A Work Project, presented as part of the requirements for the Award of a Masters Degree in Finance from the NOVA – School of Business and Economics

Reciprocity, inequity aversion, and oligopolistic competition

This paper studies how reciprocity and inequity aversion influence the behavior of firms in imperfectly competitive markets. The paper shows that if reciprocal firms compete à la Cournot, then they are able to sustain “collusive” outcomes under a positive reciprocity equilibrium. By contrast, Stackelberg warfare outcomes may emerge under a negative reciprocity equilibrium. The results for inequity aversion are similar. Cournot competition between inequity averse firms can be harmful to consumers if it leads to equilibria where firms feel compassion toward each other. However, in equilibria where inequity averse firms are envious of each other consumers are better off than if firms were selfish. The paper also shows that only under very restrictive conditions does reciprocity or inequity aversion have an impact on Bertrand competition. Finally, the paper shows that non-selfish preferences have a greater impact on equilibrium outcomes in markets with a small number of firms.

Inefficient commuting in a city with spillovers

A Masters Thesis, presented as part of the requirements for the award of a Research Masters Degree in Economics from NOVA – School of Business and Economics

Liquidity, business cycles and monetary policy: A simulation

A Masters Thesis, presented as part of the requirements for the award of a Research Masters Degree in Economics from NOVA – School of Business and Economics

Three essays on game theory and bargaining

A PhD Dissertation, presented as part of the requirements for the Degree of Doctor of Philosophy from the NOVA - School of Business and Economics

Transitional dynamics of an endogenous growth model with an erosion effect

The convergence features of an Endogenous Growth model with Physical capital, Human Capital and R&D have been studied. We add an erosion effect (supported by empirical evidence) to this model, and fully characterize its convergence properties. The dynamics is described by a fourth-order system of differential equations. We show that the model converges along a one-dimensional stable manifold and that its equilibrium is saddle-path stable. We also argue that one of the implications of considering this “erosion effect” is the increase in the adherence of the model to data.

Adsorption equilibria of flue gas components on activated carbon

Dissertação para obtenção do Grau de Mestre em Engenharia Química e Bioquímica

Isolation and encapsulation of a natural colourant using green technologies

The use of natural pigments instead of synthetic colourants is receiving growing interest in the food industry. In this field, cactus pears (Opuntia spp.) have been identified to be a promising betalainic crops covering a wide coloured spectrum. The aim of this work was to develop adequate clean and mild methodologies for the isolation and encapsulation of betacyanins, from cactus pear fruits (Opuntia spp.). Firstly, two different emerging technologies, namely PLE (Pressurized Liquid Extraction) and HPCDAE (High Pressure Carbon Dioxide-Assisted Extraction), were exploited to isolation of betacyanins form cactus pear fruits. Different process conditions were tested for the maximum recovery of betacyanins. Results showed that highest extraction yields were achieved for HPCDAE and mass ratio of pressurized carbon dioxide vs. acidified water was the parameter that most affected the betacyanins extraction. At optimum conditions of HPCDAE, Opuntia spp. extract presented a total betacyanin content of 211 ± 10 mg/100 g whereas extracts obtained using conventional extraction, PLE in static and in dynamic mode presented a total betacyanin content of 85 ± 3, 191 ± 2 and 153 ± 5 mg/100 g, respectively. HPCDAE has proven to be a successful technology to extract betacyanins from Opuntia spp. fruits. Afterward, Supercritical Fluid Technology was exploited to develop lipidic particles of betalain-rich extract. A betacyanin-rich conventional extract was encapsulated by PGSS® (Particles from Gas Saturated Solutions) technique. Different process conditions were tested in order to model the encapsulation of betacyanins. The pressure had a negative effect on betacyanin encapsulation. Lower pressures leads to an increase in the betacyanin encapsulation. This effect was more pronounced at higher temperatures and lower equilibrium time. At these conditions, Opuntia spp. particles presented 64.4 ± 4.5 mg/100 g and high antioxidant capacity. When compared with the Opuntia spp. dried extract, lipidic particles contributed to a better homogenization of the pink colour after incorporation in ice cream.