SciELO - Scientific Electronic Library Online

 
vol.30 número3Narrativa escrita de escolares com e sem dificuldade de consciência sintáticaPunição física em casa e reprovação escolar relacionadas ao bullying índice de autoresíndice de assuntospesquisa de artigos
Home Pagelista alfabética de periódicos  

Journal of Human Growth and Development

versão impressa ISSN 0104-1282versão On-line ISSN 2175-3598

J. Hum. Growth Dev. vol.30 no.3 São Paulo set./dez. 2020

http://dx.doi.org/10.7322/jhgd.v30.11107 

ORIGINAL ARTICLE

 

Subjective aspects of body image in women with fibromyalgia

 

Aspectos subjetivos da imagem corporal em mulheres com fibromialgia

 

 

Rodrigo Sanches PeresI; Sofia de Freitas CostaII; Manoel Antônio dos SantosIII

IDoutor em Psicologia. Bolsista de Produtividade em Pesquisa do Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). Professor Associado do Instituto de Psicologia da Universidade Federal de Uberlândia (UFU) - Uberlândia - MG
IIPsicóloga pela Universidade Federal de Uberlândia (UFU) - Uberlândia - MG
IIIDoutor em Psicologia Clínica. Bolsista de Produtividade em Pesquisa do Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). Professor Titular da Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto da Universidade de São Paulo (USP) - Ribeirão Preto - SP

Correspondence

 

 


ABSTRACT

INTRODUCTION: Body image refers to the figuration of the body in the mind, has a strong experiential component, and is permeated by subjective aspects
OBJECTIVE: To analyze the subjective aspects of body image in women with fibromyalgia
METHODS: This was an observational cross-sectional study. Participants were 16 women with a confirmed diagnosis for at least six months. The instrument used was the Human Figure Drawing (HFD), a projective technique for the exclusive use of psychologists, following the procedures established in the specialized literature. The examination of the material was carried out independently by two expert evaluators, who used meaning attribution criteria established in classic publications in psychological evaluation
RESULTS: The following indicators in the participants' drawings were highlighted: medium thickness and continuous line, small size, location in the fourth quadrant, presence of reinforcements and representations of joints, figures with static body posture, and simplified facial features. These indicators were interpreted as signs suggestive of passivity, insecurity, inhibition, feeling of inferiority, conflicts regarding difficulties in contact, propensity to take refuge in fantasy, idealization, regression, and attempts at omnipotent control, psychic rigidity, and devitalization. Therefore, the body image of the participants seemed to be determined by mental representations that include the body, but are not restricted to their biological dimensions or the physical limitations resulting from the symptomatic manifestations of fibromyalgia
CONCLUSION: The participants' body image had an inherently negative value since it was subjectively shaped by internalized and unconscious unfavorable concepts about themselves

Keywords: body image, fibromyalgia, mental health, women's health.


RESUMO

INTRODUÇÃO: A imagem corporal se refere à figuração do corpo na mente, possui uma forte vertente experiencial e é perpassada por aspectos subjetivos
OBJETIVO: Analisar aspectos subjetivos da imagem corporal em mulheres com fibromialgia
MÉTODO: Trata-se de um estudo observacional de corte transversal. Participaram 16 mulheres com diagnóstico confirmado havia, no mínimo, seis meses. O instrumento empregado foi o Desenho da Figura Humana (DFH), técnica projetiva de uso exclusivo de psicólogos, seguindo os procedimentos estabelecidos na literatura especializada. O exame do material foi realizado de maneira independente por dois avaliadores especialistas, que utilizaram critérios de atribuição de significados estabelecidos em publicações clássicas da área de avaliação psicológica
RESULTADOS: Destacou-se a ocorrência dos seguintes indicadores nos desenhos das participantes: traço médio e contínuo, tamanho pequeno, localização no quarto quadrante, presença de reforços e representações de articulações, figuras com postura corporal estática e traços faciais simplificados. Esses indicadores foram interpretados como sinais sugestivos de passividade, insegurança, inibição, sentimento de inferioridade, conflitos relativos a dificuldades de contato, propensão ao refúgio na fantasia, à idealização, à regressão e a tentativas de controle onipotente, rigidez psíquica e desvitalização. Portanto, a imagem corporal das participantes parece ser determinada por representações mentais que incluem o corpo, mas não se restringem às suas dimensões biológicas ou às limitações físicas decorrentes das manifestações sintomáticas da fibromialgia
CONCLUSÃO: A imagem corporal das participantes apresenta uma valência essencialmente negativa, uma vez que é moldada subjetivamente por concepções internalizadas e inconscientes pouco favoráveis sobre si mesmas

Palavras-chave: imagem corporal, fibromialgia, saúde mental, saúde da mulher.


 

 

Authors summary

Why was this study done?

The psychodynamic comprehension of the body image of women with fibromyalgia tends to provide relevant elements for the planning of healthcare offered to this public; however, there are few studies on the subject.

What did the researchers do and find?

The body image of 16 women diagnosed with fibromyalgia was assessed using the Human Figure Drawing (HFD) instrument that allows the exploration of the internalized and unconscious concepts that each person has about themselves. Signs suggestive of psychic rigidity, passivity, insecurity, inhibition, inferiority, and contact difficulties were identified in the drawings.

What do these findings mean?

The participants' body image has an inherently negative valence, the intensity of which significantly exceeds that which would be expected if only the physical repercussions of fibromyalgia were objectively considered.

 

INTRODUCTION

In the 1930s, Schilder1 established the theoretical foundations that would come to support a significant portion of studies on body image, including those developed today. The author was innovative in defining this concept, basically, as the figuration of the body in the mind. He added that body image starts its construction at the beginning of life; however, it is continuously reconstructed as a result of a complex process guided by the subject's later bodily and psychic experiences. From this perspective, body image can be qualified as an interface phenomenon, as it is representation and experience, at the same time2.

These formulations emphasize that body image has a strong experiential component, which determines its dynamic character and is permeated by objective and subjective, conscious, and unconscious elements. In this line of reasoning, Schilder1 proposed that some natural vicissitudes of human existence, such as physical pain, tend to affect body image, although it would not be possible to determine a priori exactly how this would occur.

Fibromyalgia is a syndrome of multifactorial etiology, prevalent in middle-aged women, the clinical presentation of which is mainly characterized by the occurrence of chronic physical pain unrelated to bodily injuries and the presence of changes in mood, memory, and sleep3,4. Therefore, it can be assumed, from the theoretical developments proposed by Schilder1, that women with fibromyalgia will present a body image influenced by the way they relate to their body, experienced as a source of persistent pain and a vector of dissatisfaction and displeasure.

It is possible to postulate that the psychodynamic comprehension of body image in women with fibromyalgia tends to provide relevant elements for the healthcare offered to this public, which, according to the current guidelines, must be multidisciplinary and planned considering the specificities of each case5,6. Therefore, treatments must take into account the subjective aspects of the patients. The same applies, in a sense, to the diagnosis. After all, the confirmation of a case requires a clinical judgment concerning the complaints reported by the patients, as fibromyalgia does not cause physical deformities nor have objective markers resulting from medical examinations7.

However, studies aimed at exploring the subjective facets of fibromyalgia and, specifically, those that contemplate the assessment of patients' body image are still scarce. Within the scope of the international literature, two studies developed in the last decade8,9 are exceptions, with both finding that body image disorders are common in women affected by the syndrome. In the only Brazilian study carried out with this clinical population, published in the 1990s, it was also observed that the majority of the participants had a body image that was negatively affected by chronic physical pain10.

Although relevant, these studies do not exhaust the subject, since they emphasize components of the body image that are located, above all, at the conscious level. Therefore, the aim was to analyze the subjective aspects of body image in women diagnosed with fibromyalgia.

 

METHODS

This study has an observational cross-sectional design, an approach used mainly in initial research, to describe a phenomenon as it occurs spontaneously at a given moment11. In this way, the researcher obtains a "snapshot" of the variables of interest but does not evaluate evolutions and changes over time.

Participants were 16 women diagnosed with fibromyalgia, recruited from a specialized non-governmental organization, which constituted a convenience sample. Inclusion criteria were 18 years of age or older and a confirmed diagnosis of fibromyalgia for at least six months. The exclusion criteria were: presenting difficulties in understanding the instructions of the instrument or performing the proposed task, which could be perceived through the initial contact, and having comorbidity with physical diseases that pose a risk to the continuity of life.

The instrument used for data collection was the Human Figure Drawing (HFD), a projective technique originally systematized by Machover12 in the 1940s. Projective techniques are instruments for the exclusive use of psychologists under the terms of the current legislation in Brazil13 and are characterized by their presentation of stimuli with little structure, to which the subject can respond in different ways, with ample freedom of expression14. Precisely for this reason, these instruments demand a high degree of personal creation and elaboration and trigger mental operations in the subject that enable the circumscription of psychic contents that are not located at the conscious level15.

More precisely, HFD can be classified as a projective technique of graphic and oral production. The activity consists of: (1) asking the subject to produce the drawing of a human figure and then to produce the drawing of a human figure of the opposite sex in relation to the first and (2) applying an oral inquiry, through which the subject is invited to clarify specific characteristics of the drawings12. Although it supports the exploration of personality in a broader sense, HFD highlights the projection of subjective aspects of body image, as the proposed task refers to subjects' internalized and unconscious concepts of themselves16,17.

For this reason, this instrument was chosen for the present study. Besides, HFD is an established projective technique with advantages compared to questionnaires, inventories, and other instruments of a more objective nature aimed at assessing body image. One of its specificities lies in the fact that HFD emphasizes graphic communication, notably less susceptible to the action of defense mechanisms rationally controlled by the subject than verbal language, whether oral or written12,16. Another advantage concerns the excellent acceptance of the proposed task, since the theme of the human figure is universally familiar and, at the same time, not very specific17. Therefore, HFD has been widely used for decades in many countries, with different publics18-21.

Following the procedures recommended by Machover12, the instructions presented to the participants were as follows: (1) "Please draw a human figure"; (2) "Please now draw a human figure of the opposite sex to the one you just drew" and (3) "Now, please answer some questions." After this third instruction, we used the questions that refer most directly to body image, among those that constitute the oral inquiry prepared for the Brazilian population by van Kolck17, concerning the first human figure drawn.

These included the following questions: (1) "What is this person doing?"; (2) "How old is s/he?"; (3) "Whom does s/he live with?"; (4) "Does s/he work or study?"; (5) "What does s/he want?"; (6) "What is s/he thinking?"; (7) "What is s/he feeling?"; (8) "What is the best part of his/her body? Why?"; (9) "What is the worst part of his/her body? Why?"; (10) "What are his/her best qualities?"; (11) "What are his/her worst defects?"; (12) "Who does s/he look like"? and (13) "Would you like to be like him/her?". Also, when the sex of the first human figure was not distinct, a question was asked regarding this at the beginning of the oral inquiry.

The materials used to make the drawings were blank sheets of paper and a black, no 2, graphite pencil. With the consent of the participants, we used a digital recorder at the time of the application of the oral inquiry for the audio recording of the responses. The paper sheets were positioned vertically in front of the participants, and they made the drawings on a table that allowed the proposed task to be completed comfortably.

No refusals were observed about the instructions, and the initial resistance to carrying out of the tasks was minimal, always overcome after clarifying that no artistic skill would be necessary or evaluated. Data collection was conducted individually in a private room of the non-governmental organization to which the participants were linked, respecting the conditions of privacy and confidentiality.

Data analysis was carried out independently by two evaluators, psychologists specialized in HFD, and was based on two distinct, but complementary procedures. The first procedure, of a systematic nature, was divided into two stages: (a) the examination of the first drawings made by the participants, executed according to indicators concerning their general aspects, size and proportionality, which refer more directly to the body image22; and (b) the interpretation of the findings obtained with this expedient based on meaning attribution criteria established in classic publications in the area of psychological evaluation12,16,17,23-26.

The second procedure, of a non-systematic nature, consisted of examining the first drawings made by the participants according to the overall impression aroused by them. This examination depends directly on the evaluators' expertise; however, it is considered essential for capturing specific nuances of the drawings that could go unnoticed if only specific indicators were observed17. Occasional differences regarding the data analysis carried out independently by the evaluators were resolved after discussions to obtain validation by consensus between both.

The second drawings made by the participants were used to evaluate the differential treatment of the two figures produced. The transcripts of the responses presented by the participants at the time of the oral inquiry constituted complementary empirical material, as is common in research involving HFD. For the operationalization of the second analysis procedure, the evaluators assumed an attitude corresponding to that adopted by psychoanalysts in the clinical setting, guided by fluctuating attention27, to obtain support to freely associate, aiming at the demarcation of latent meanings from the drawings and the responses presented in the oral inquiry.

The present study was approved by the Research Ethics Committee (CAAE 50132215.8.0000.5152/Authorization 1.414.551) of the authors' institution, with all ethical principles followed.

 

RESULTS

As shown in Table 1, at the time of data collection, most of the participants were married, and less than half of them were active in their occupational situation. The participants' age varied between 41 and 60 years (M=53.50), the predominant level of education was incomplete elementary education, and the time of diagnosis ranged from 1 to 20 years. (M=7.37).

Tables 2 and 3 present the results derived from the first analysis procedure. Regarding the general aspects of the drawings, the use of medium thickness and continuous lines, and the fourth quadrant's location stood out, as shown in Figure 1. The presence of reinforcements and representations of joints was also recurrent, mainly through the execution of figures with large, straight shoulders, as shown in Figure 2.

 

 

 

 

Concerning size and proportionality, small human figures were predominant, with large heads and thin legs, as presented in Table 2. Many of them also had long, thin necks and waists delimited by a horizontal line, for example, in Figures 3 and 4. Regarding the second analysis procedure, based on the overall impression of the drawings, what most caught the attention of the evaluators was the static body posture and simplified facial features. Figures 3, 4, and 5 are emblematic of these characteristics.

 

 

 

 

 

 

DISCUSSION

The interpretation of specific indicators considering meaning attribution criteria established in classic publications in the area of psychological evaluation suggests that the location of the drawings, which were predominant in the fourth quadrant, reflects a tendency toward passivity, inhibition, and a propensity to take refuge in fantasy12,17. The same interpretation applies to the prevalence of small-sized drawings as a whole, in particular of the figure's chest, results that also denote a feeling of inferiority on the part of the participants, not only regarding their physical attributes.

The medium thickness and continuous line observed in the majority of the drawings substantiate the previous line of reasoning, as this was performed using reinforcements of the body limits of the figures, this being recognized as typical of insecure people24. Considering the proportionately large size of the head of the figures produced by some participants, following van Kolck17, this can indicate that they often unconsciously resort to idealization as a defense mechanism faced with insecurity and immaturity that characterize their personalities.

In other words, to protect themselves from a body image that does not provide them with the necessary support to relate to the world as they would like, some participants seem to seek comfort in the mental representation of a "perfect body," which they, however, end up feeling distant from, which results in psychological suffering. Besides, the fact that the majority of the participants drew young female figures denotes a tendency to fix on an earlier stage of emotional development, which was possibly promoted by a regressive movement motivated by marked difficulty in adjusting to the normal transitions and crises of the life cycle17.

This regressive movement is consistent with the propensity to take refuge in the fantasy suggested by the location of the drawings in the fourth quadrant, as well as by the relatively large size of the figures' heads25. The presence of representations of joints in most of the drawings suggests a motor rigidity that, for Levy25, correlates with a psychic rigidity to the handling of internal conflicts, which leads to compensatory attempts of omnipotent control.

This interpretation is in line with that advocated by van Kolck17 regarding the occurrence of figures with long, thin necks and waists marked with a horizontal line. It should be highlighted that the psychic conflicts experienced by the participants refer to the difficulty of contact, both with themselves and with other people, judging by the predominance of figures with thin legs and the absence of hands in a significant portion of them.

In short, the implementation of the two stages of the first analysis procedure indicated that signs suggestive of passivity, insecurity, inhibition, inferiority, and conflicts related to difficulties in contact emerged in the drawings. In this scenario, when exposed to stressful and frustrating situations, the participants tended to seek refuge in fantasy, resorting to regression, idealization, and attempts at omnipotent control. It should be emphasized that most of the psychological characteristics mentioned were not associated with women affected by the syndrome in previous studies.

Besides, this set of results reveals that the participants' body image is crossed by subjective aspects that give it an essentially negative valence. This valence, it seems, is determined by mental representations that include the body, but are not restricted to its biological dimensions or the physical limitations resulting from the symptomatic manifestations of fibromyalgia.

Consequently, it seems reasonable to think that the participants' body image, as an interface phenomenon, will have difficulty functioning as a safe "base of operations" for the establishment of healthy relationships with their bodies, with the other and with the surrounding world, which can lead to low adherence to treatments. Therefore, it is recommended that healthcare providers value the body image of women with fibromyalgia as one of the factors capable of influencing the healthcare provided to this public.

The findings from the overall impression of the drawings led to additional insights, as they highlighted the participants' apparent physical and psychic rigidity, as well as allowing of this attribute to be associated with a devitalization process. This interpretation is anchored in the free association raised by the fluctuating attention maintained by the evaluators during the examination of the material, which referred them to a work of the German painter Lucian Freud, grandson of the creator of Psychoanalysis, Sigmund Freud. The artist is considered to be one of the most influential contemporary masters of realism in the visual arts and, as Smee28 observed, was notable for portraying human bodies in a state of rest.

Lucian Freud also depicted animal bodies in a state of rest. It is one of these animal bodies at rest, as unusual as it may seem, that the evaluators remembered when examining the drawings of the participants without previously assigning particular importance to specific indicators. The animal body in question was depicted in the painting entitled Dead heron, which was produced during an early stage of the artist's career. A partially plucked bird in a state of rigor mortis can be seen on a bench. In this case, the physical rigidity is determined by extreme muscle contraction resulting from the way the bird was sacrificed.

It should be noted that, when killed, any living being tends to contract in a spasm that represents its last act of resistance in the face of inevitable death. In Dead heron, the artist seems to have sought to capture this farewell gesture, freezing its dramatic content and making this moment permanent to give full visibility to the last shine of the animal's eye before being subjected to annihilation.

Concerning the participants' drawings, it seems reasonable to conjecture that physical and psychic rigidity would result from the loss of vitality associated, in one way or another, with fibromyalgia and, in particular, with chronic physical pain that occupies a central place in the composition of their clinical presentation. This line of reasoning finds support in the formulations of Le Breton29, an author that, from an anthropological reading, stated that physical pain is equivalent to an incrustation of death in existence. In other words, both the participants' drawings and Lucian Freud's paintings would reveal, with certain specificities, shades of the mortal condition that surrounds living beings, inevitably doomed to organic deterioration and the outcome of finitude.

Deepening this line of reasoning, it is worth emphasizing that physical pain, especially when it becomes chronic and even if it is not associated with a fatal condition, as occurs in fibromyalgia, imprisons the individual in a kind of armor of a body that is still alive and pulsating, where their relationship with the totality of the world, however, is drastically devitalized. Therefore, the mortification of the body produced by physical pain would appear, according to Le Breton29, as a kind of corrosive and devouring possession.

The author proposed another comparison between physical pain and death by framing them as the most shared human experiences since no one can escape from either one or the other for life. Nevertheless, a clarification is necessary: the physical and psychic rigidity attributed to the participants does not seem to stem from supposed morbidity, understood as a psychic fixation on the theme of death, but, preferably, from a wide range of psychological characteristics that determine the negative valence with which these women invested the body image.

Because of the above, it can be seen that both the first and the second analysis procedures allow us to maintain that, in contrast to what a more superficial reading might indicate, it would not be the case to state that the participants presented a distorted body image. To do so would imply rejecting the role of subjective elements in the complex and dynamic process of creating and recreating the body image throughout the life cycle as if these vicissitudes could be based only on objective elements.

Furthermore, as Casetto3 proposed, when testing an extension of Schilder's1 formulations, perhaps body image is more than a figuration of the body in the mind. For the author, it would be reasonable, as an interface phenomenon, to consider body image as a kind of embodiment of the psyche. The results obtained in the present study provide an empirical substrate that reinforces this hypothesis; however, further research is necessary to corroborate this proposition.

Finally, consolidating the originality of the findings reported here, a comparison will be made between them and those from previous studies, specifically dedicated to the body image of women with fibromyalgia. In one of these studies, carried out in the Brazilian context, Mello and Marques10 reported the recurrence of body image disorders that they found derived from physical pain and postural changes. In the present study, on the other hand, the depreciative traits of the participants' body image seem to have psychic content, mainly unconscious, as their primary source.

It is noted that the instrument used by Mello and Marques10 was the Askevold Test. Thus, participants are asked to record, on a sheet of paper fixed on the wall, the location of a series of anatomical points as the researchers touched them. Accordingly, the sheet of paper should be considered to be a proprioceptive mirror. Therefore, this instrument seems more focused on the assessment of the perception of the body schema than the body image.

The present study also differs from the studies carried out by Boyington, Schoster, and Callahan8 in the United States and Akkaya et al.9 in Turkey, both of which had the participation of women with fibromyalgia. In the first study, the instrument used was a semi-structured interview conducted by telephone and directed toward perceptual elements of the body image. In the second, was used the Body Image Scale (BIS), a scale that favors the assessment of body satisfaction, considered an attitudinal aspect of body image.

Both Boyington, Schoster and Callahan8 and Akkaya et al.9 found that body image disturbances are frequent in this public and would be directly related to the impact of the syndrome, as estimated by parameters, especially physical ones can be assessed more objectively. The present study, on the other hand, focused on subjective aspects of the body image. This fact limits the scope of comparisons between referred studies and the present study in terms of their results.

The present study has some limitations. Due to the absence of a control group and, in particular, the use of a convenience sample, the results obtained are not suitable for statistical generalizations. Furthermore, as in any observational cross-sectional study, the findings portray the situation of a group of people regarding the variables of interest at a specific time. Nevertheless, from the present study, it is possible to extract the hypothesis, to be tested in future studies, that the body image of women with fibromyalgia does not correspond directly to the body sensations consciously stimulated by the syndrome.

The body images of the participants had a mainly negative valence since they were subjectively shaped by internalized and unconscious unfavorable concepts about themselves. In most cases, the intensity of this negative valence significantly exceeded that which would be expected if only the physical repercussions of fibromyalgia were objectively considered.

Acknowledgments

The authors thank Associação dos Reumáticos de Uberlândia e Região (ARUR), for the indispensable collaboration in carrying out this study.

Funding agencies

FAPEMIG (Process PPM-00290-18) and CNPq (Process 307100/2016-2).

 

REFERENCES

1.Schilder P. A imagem do corpo: as energias construtivas da psique. 3 ed. São Paulo: Martins Fontes, 2000.         [ Links ]

2.Casetto SJ. O corpo na psique, sua imagem consciente. In: Volich RM, Ranña W, Labaki MEP. Psicossoma V: integração, desintegração e limites. São Paulo: Casa do Psicólogo, 2015; p. 27-136.         [ Links ]

3.Clauw DJ. Fibromyalgia: a clinical review. JAMA. 2014;311(15):1547-55. DOI: https://doi.org/10.1001/jama.2014.3266        [ Links ]

4.Cohen H. Controversies and challenges in fibromyalgia: a review and a proposal.Ther Adv Musculoskelet Dis. 2017;9(5):115-27. DOI: https://doi.org/10.1177/1759720X17699199        [ Links ]

5.Macfarlane GJ, Kronisch C, Dean LE, Atzeni F, Häuser W, Fluß E, et al. EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis. 2017;76(2):318-28. DOI: https://doi.org/10.1136/annrheumdis-2016-209724        [ Links ]

6.Binkiewicz-Glińska A, Bakuła S, Tomczak H, Landowski J, Ruckemann-Dziurdzińska K, Zaborowska-Sapeta K, et al. Fibromyalgia syndrome: a multidisciplinary approach. Psychiatr Pol. 2015;49(4):801-10. DOI: https://doi.org/10.12740/psychiatriapolska.pl/online-first/4        [ Links ]

7.Gittins R, Howard M, Ghodke A, Ives TJ, Chelminski P. The accuracy of a fibromyalgia diagnosis in general practice. Pain Med. 2018;19(3):491-98. DOI: https://dx.doi.org/10.1093/pm/pnx155        [ Links ]

8.Boyington JEA, Schoster B, Callahan LF. Comparisons of body image perceptions of a sample of black and white women with rheumatoid arthritis and fibromyalgia in the US. Open Rheumatol J. 2015;9:1-7. DOI: https://doi.org/10.2174/1874312901409010001        [ Links ]

9.Akkaya N, Akkaya S, Atalay NS, Balci CS, Sahin F. Relationship between the body image and level of pain, functional status, severity of depression, and quality of life in patients with fibromyalgia syndrome. Clin Rheumatol. 2012;31(6):983-8. DOI: https://doi.org/10.1007/s10067-012-1965-9        [ Links ]

10.Mello M, Marques AP. A imagem corporal representada pelos fibromiálgicos: um estudo preliminar. Fisioter Pesqui. 1995;2(2):87-93. DOI: https://doi.org/10.1590/fpusp.v2i2.75430        [ Links ]

11.Zangirolami-Raimundo J, Echeimberg JO, Leone C. Research methodology topics: cross-sectional studies. J Hum Growth Dev. 2018;28(3):356-60. DOI: http://dx.doi.org/10.7322/jhgd.152198        [ Links ]

12.Machover K. Personality projection in the drawing of the human figure: a method of personality investigation. Springfield: Charles C Thomas Publisher. 1949;25. DOI: https://doi.org/10.1037/11147-000        [ Links ]

13.Conselho Federal de Psicologia (CFP). Resolução CFP 02/2003. [internet] 2003. [cited 2020 Jun 09] Available from: https://site.cfp.org.br/wp-content/uploads/2012/05/resoluxo022003.pdf.         [ Links ]

14.Piotrowski C, Keller JW, Ogawa T. Projective techniques: an international perspective. Psychol Rep. 1993;72(1):179-82. DOI: https://doi.org/10.2466/pr0.1993.72.1.179        [ Links ]

15.Chabert C. Psicanálise e métodos projetivos. São Paulo: Vetor, 2004.         [ Links ]

16.Portuondo J. La Figura Humana: test proyectivo de Karen Machover. 2 ed. Madrid: Biblioteca Nueva, 2007.         [ Links ]

17.van Kolck OL. Testes projetivos gráficos no diagnóstico psicológico. São Paulo: EPU; 1984.         [ Links ]

18.Dmitruk VM. Situational variables and performance on Machover's Figure-Drawing Test. Percept Mot Skills. 1972;35(2):489-90. DOI: https://doi.org/10.2466/pms.1972.35.2.489        [ Links ]

19.Opalić P. Human figure test in the research of psychopathological state of refugees and somatically traumatized. Srp Arh Celok Lek. 2005;133(1-2):21-8. DOI: https://doi.org/10.2298/sarh0502021o        [ Links ]

20.Skybo T, Ryan-Wenger N, Su YH. Human figure drawings as a measure of children's emotional status: critical review for practice. J Pediatr Nurs. 2007;22(1):15-28. DOI: https://doi.org/10.1016/j.pedn.2006.05.006        [ Links ]

21.D'Agata E, Rigo M, Pérez-Testor C, Puigví NC, Castellano-Tejedor C. Emotional indicators in young patients with idiopathic scoliosis: a study through the drawing of human figure. Scoliosis. 2014;9:24. DOI: https://doi.org/10.1186/s13013-014-0024-5        [ Links ]

22.Almeida GAN, Loureiro SR, Santos JE. A imagem corporal de mulheres morbidamente obesas avaliada através do desenho da figura humana. Psicol Reflex Crít. 2002;15(2):283-92. DOI: https://doi.org/10.1590/S0102-79722002000200006        [ Links ]

23.Piccolo EG. Os testes gráficos. In: Ocampo MLS, Arzeno MEG, Piccolo EG. O processo psicodiagnóstico e as técnicas projetivas. 6 ed. São Paulo: Martins Fontes, 1991; p. 203-311.         [ Links ]

24.Hammer EF. Aspectos expressivos dos desenhos projetivos. In: Hammer EF. Aplicações clínicas dos desenhos projetivos. 3 ed. São Paulo: Casa do Psicólogo, 2008; p. 42-60.         [ Links ]

25.Campos DMS. O teste do desenho como instrumento de diagnóstico da personalidade: validade, técnica de aplicação e normas de interpretação. 47 ed. Petrópolis: Vozes, 2014.         [ Links ]

26.Levy S. Desenho projetivo da figura humana. In: Hammer EF. Aplicações clínicas dos desenhos projetivos. 3 ed. São Paulo: Casa do Psicólogo, 2008; p. 61-85.         [ Links ]

27.Laplanche J, Pontalis JB. Vocabulário da psicanálise. 4 ed. São Paulo: Martins Fontes, 2016.         [ Links ]

28.Smee S. Lucian Freud. 2 ed. Cologne: Taschen, 2015.         [ Links ]

29.Le Breton D. Antropologia da dor. São Paulo: UNIFESP, 2013.         [ Links ]

 

 

Correspondence:
Rodrigo Sanches Peres
rodrigosanchesperes@yahoo.com.br

Received: March 2019
Revised: October 2019
Accepted: September 2020

Creative Commons License