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Bruti G, Foggetti P. Insecure Attachment, Oxytocinergic System and C-Tactile Fibers: An Integrative and Translational Pathophysiological Model of Fibromyalgia and Central Sensitivity Syndromes. Biomedicines 2024; 12:1744. [PMID: 39200209 PMCID: PMC11351601 DOI: 10.3390/biomedicines12081744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 07/16/2024] [Accepted: 07/27/2024] [Indexed: 09/02/2024] Open
Abstract
Although the pathophysiology of fibromyalgia syndrome has been better understood in recent decades, a unified model of its pathogenesis and an effective therapeutic approach are still far from being realized. The main aim of this article will be to delve into the fundamental mechanisms of the pathophysiology of fibromyalgia conceptualized as stress intolerance syndrome. Using the biopsychosocial model of chronic pain syndromes, we will describe the potential role of the attachment system, C-tactile fibers, and oxytocinergic system dysfunction in the pathophysiology of fibromyalgia syndrome and other central sensitivity syndromes. At the end of the article, the therapeutic implications of this new global and translational pathophysiological model will be briefly discussed.
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Affiliation(s)
- Gianluca Bruti
- Eurekacademy, Center for International Studies of Cognitive Neurosciences and Integrated Medicine, Antonio Bertoloni 26/C, 00197 Rome, Italy
| | - Paola Foggetti
- Eurekacademy, Center for International Studies of Cognitive Neurosciences and Integrated Medicine, Antonio Bertoloni 26/C, 00197 Rome, Italy
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2
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Dent E, Davinson N, Wilkie S. The impact of gastrointestinal conditions on psychosocial factors associated with the biopsychosocial model of health: A scoping review. Appl Psychol Health Well Being 2021; 14:626-644. [PMID: 34866337 DOI: 10.1111/aphw.12323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 11/04/2021] [Indexed: 11/28/2022]
Abstract
The increase in the prevalence of gastrointestinal (GI) conditions is an emerging global health concern. Studies of the impact on the lives of individuals living with GI conditions such as irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD) typically focus on biological elements, such as symptomology and treatment efficacy. Comparatively fewer studies have explored the psychological and social aspects of GI conditions, which could provide key information needed to better understand the impact of GI conditions on people and their lived experiences. In this review, existing literature concerning the psychosocial factors and well-being outcomes associated with GI conditions was reviewed using a scoping methodology. Sixty-eight studies were selected for inclusion. Of these studies, the well-being outcomes most frequently addressed, for both IBS and IBD, were quality of life and health-related quality of life, and the most frequently addressed psychosocial factors were social support and coping. These outcomes are largely consistent with those identified for other medical conditions explored using the biopsychosocial model of health, with some exploration of the lived experiences of those with a GI condition.
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Affiliation(s)
- Elizabeth Dent
- School of Psychology, Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK
| | - Nicola Davinson
- School of Psychology, Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK
| | - Stephanie Wilkie
- School of Psychology, Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK
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3
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Lee SY, Hwang HR, Yi YH, Kim JM, Kim YJ, Lee JG, Cho YH, Tak YJ, Lee SH, Park EJ, Lee Y. Association between Irritable Bowel Syndrome and Risk of Osteoporosis in Korean Premenopausal Women. Med Princ Pract 2021; 30:527-534. [PMID: 34148043 PMCID: PMC8738912 DOI: 10.1159/000517909] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 06/17/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The objective of this study is to evaluate irritable bowel syndrome (IBS) as a risk factor for osteoporosis and osteoporotic fracture in Korean women after controlling for basic confounding factors and considering detailed demographic and clinical information. SUBJECTS AND METHODS We performed a nationwide population-based retrospective cohort analysis and matched every IBS case with a non-IBS case at a 1:4 frequency ratio based on age. The population consisted of female patients with data in the Health Insurance Review and Assessment (HIRA) database from 2002 to 2010. To determine the risk of osteoporosis and osteoporotic fracture in IBS and non-IBS patients, hazard ratios (HRs) with 95% confidence intervals (CI) were estimated using Cox proportional hazards regression models, adjusting for confounding variables, such as the area of residence, health insurance type, and economic status. RESULTS We identified 1,017,468 patients in the HIRA database with data from 2002 to 2010 who could potentially be included in the cohort. Among these, we identified 1,545 (11.4%) women (age >19 years) with newly diagnosed IBS (IBS group). Additionally, 6,180 patients without IBS and age-matched to the IBS group were selected. Cox modeling revealed that the crude HRs for osteoporosis and osteoporotic fractures in patients with IBS were 1.476 (95% CI, 1.241-1.754) and 1.427 (95% CI, 1.086-1.876), respectively. CONCLUSION Our data showed an increased incidence of osteoporosis and osteoporotic fractures in women with IBS compared with age-matched controls.
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Affiliation(s)
- Sang-Yeoup Lee
- Family Medicine Clinic, Obesity, Metabolism and Nutrition Center, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
- Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Hye-Rim Hwang
- Department of Family Medicine, Medical Research Institute and Busan Tobacco Control Center, Pusan National University Hospital, Busan, Republic of Korea
| | - Yu-Hyeon Yi
- Pusan National University School of Medicine, Yangsan, Republic of Korea
- Department of Family Medicine, Medical Research Institute and Busan Tobacco Control Center, Pusan National University Hospital, Busan, Republic of Korea
- *Yu-Hyeon Yi,
| | - Jin-Mi Kim
- Department of Biostatistics, Clinical Trial Center, Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Yun-Jin Kim
- Pusan National University School of Medicine, Yangsan, Republic of Korea
- Department of Family Medicine, Medical Research Institute and Busan Tobacco Control Center, Pusan National University Hospital, Busan, Republic of Korea
| | - Jeong-Gyu Lee
- Pusan National University School of Medicine, Yangsan, Republic of Korea
- Department of Family Medicine, Medical Research Institute and Busan Tobacco Control Center, Pusan National University Hospital, Busan, Republic of Korea
| | - Young-Hye Cho
- Family Medicine Clinic, Obesity, Metabolism and Nutrition Center, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
- Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Young-Jin Tak
- Pusan National University School of Medicine, Yangsan, Republic of Korea
- Department of Family Medicine, Medical Research Institute and Busan Tobacco Control Center, Pusan National University Hospital, Busan, Republic of Korea
| | - Seung Hun Lee
- Pusan National University School of Medicine, Yangsan, Republic of Korea
- Department of Family Medicine, Medical Research Institute and Busan Tobacco Control Center, Pusan National University Hospital, Busan, Republic of Korea
| | - Eun Ju Park
- Family Medicine Clinic, Obesity, Metabolism and Nutrition Center, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
- Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Youngin Lee
- Family Medicine Clinic, Obesity, Metabolism and Nutrition Center, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
- Pusan National University School of Medicine, Yangsan, Republic of Korea
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Opheim R, Moum B, Grimstad BT, Jahnsen J, Prytz Berset I, Hovde Ø, Huppertz-Hauss G, Bernklev T, Jelsness-Jørgensen LP. Self-esteem in patients with inflammatory bowel disease. Qual Life Res 2020; 29:1839-1846. [PMID: 32144613 PMCID: PMC7295843 DOI: 10.1007/s11136-020-02467-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2020] [Indexed: 01/19/2023]
Abstract
Purpose The purpose of this study was to explore self-esteem and associations between self-esteem and sociodemographic, clinical, and psychological factors in patients with inflammatory bowel disease (IBD), a disease of chronic relapsing inflammation of the gastrointestinal tract. IBD symptoms, including pain, fatigue, and diarrhea, as well as potential life-long medical treatment and surgery, may be demanding, cause significant challenges, and influence self-esteem. Methods In this cross-sectional multicenter study, participants were recruited from nine hospitals in the southeastern and western regions of Norway from March 2013 to April 2014. Data were collected using self-report questionnaires. Self-esteem was assessed by the Rosenberg Self-Esteem Scale, fatigue was assessed by the Fatigue Questionnaire, self-efficacy was assessed by the General Self-Efficacy Scale, and disease activity was assessed by the Simple Clinical Colitis Activity Index for ulcerative colitis (UC) and Harvey Bradshaw Index for Crohn’s disease (CD). Multiple linear regression analysis was applied to examine associations between self-esteem and sociodemographic, clinical, and psychological factors. Results In total, 411 of 452 (91%) patients had evaluable data and were included in this study. The mean scores on self-esteem, self-efficacy, total fatigue, anxiety, and depression were similar between UC patients and CD patients. Male gender, being employed, and higher self-efficacy were independently associated with higher self-esteem, whereas anxiety and depression were independently associated with lower self-esteem. Neither disease activity nor fatigue were associated with self-esteem in the final multiple regression analyses. Conclusion Patient-centered interventions that improve self-esteem and reduce anxiety and depression seem to be important to optimize IBD management.
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Affiliation(s)
- Randi Opheim
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway. .,Department of Nursing Science, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Bjørn Moum
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Bjørn Tore Grimstad
- Department of Internal Medicine, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Jørgen Jahnsen
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
| | - Ingrid Prytz Berset
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Medicine, Aalesund Hospital Trust, Aalesund, Norway
| | - Øistein Hovde
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Internal Medicine, Innlandet Hospital Trust, Gjøvik, Norway
| | | | - Tomm Bernklev
- Department of Research and Development, Vestfold Hospital Trust, Tønsberg, Norway
| | - Lars-Petter Jelsness-Jørgensen
- Department of Gastroenterology, Østfold Hospital Trust, Grålum, Norway.,Department of Health Sciences, Østfold University College, Fredrikstad, Norway
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Berens S, Schaefert R, Baumeister D, Gauss A, Eich W, Tesarz J. Does symptom activity explain psychological differences in patients with irritable bowel syndrome and inflammatory bowel disease? Results from a multi-center cross-sectional study. J Psychosom Res 2019; 126:109836. [PMID: 31627144 DOI: 10.1016/j.jpsychores.2019.109836] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 09/11/2019] [Accepted: 09/12/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Irritable bowel syndrome (IBS) and inflammatory bowel diseases (IBD) have similar symptoms and are affected by psychological factors via gut-brain-interactions. However, previous studies on IBS and IBD showed inconsistent results regarding psychological factors, potentially because they failed to consider the impact of symptom activity. The aim of this study was 1) to compare psychological distress and psychological risk factors among patients with IBS, IBD and healthy controls (HC), and 2) to assess the impact of symptom activity. METHODS A controlled cross-sectional study was conducted. Patients with IBS and IBD were recruited in several primary, secondary, and tertiary medical care units between 02 and 12/2017 in Germany. Overall, 381 matched participants (127/group, 63% female) were included. For the second analyses, patients with IBD were distinguished in patients with active (n = 93) and non-active (n = 34) symptoms. Psychological distress (somatization, depression, anxiety, and illness anxiety) and risk factors (adverse childhood experiences, attachment style, and mentalizing capacity) were measured. RESULTS Patients with IBS showed higher psychological distress and more psychological risk factors than patients with IBD and HC. However, patients with IBD and active symptoms showed similar psychological distress than patients with IBS, except for lower illness anxiety (p < .001, η2 = 0.069). CONCLUSION With the exception of higher illness anxiety in IBS patients, differences in psychological factors between patients with IBS and IBD were more strongly associated with symptom activity than with the underlying diagnosis. Therefore, this study challenges previous concepts of distinguishing functional and organic gastrointestinal diseases, but highlights the role of symptom activity and illness anxiety. TRIAL REGISTRATION DRKS00011685.
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Affiliation(s)
- Sabrina Berens
- Institute of Psychology, Heidelberg University, Hauptstraße 47-51, D-69117 Heidelberg, Germany; Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany.
| | - Rainer Schaefert
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany; Department of Psychosomatic Medicine, Division of Internal Medicine, University Hospital Basel, Hebelstrasse 2, CH-4031 Basel, Switzerland; Faculty of Medicine, University of Basel, Klingelbergstrasse 61, CH-4056 Basel, Switzerland.
| | - David Baumeister
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany.
| | - Annika Gauss
- Department of Gastroenterology and Hepatology, University Hospital Heidelberg, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany.
| | - Wolfgang Eich
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany.
| | - Jonas Tesarz
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany.
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Sahan HE, Yildirim EA, Soylu A, Tabakci AS, Cakmak S, Erkoc SN. Comparison of functional dyspepsia with organic dyspepsia in terms of attachment patterns. Compr Psychiatry 2018; 83:12-18. [PMID: 29501961 DOI: 10.1016/j.comppsych.2018.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 01/28/2018] [Accepted: 02/14/2018] [Indexed: 12/18/2022] Open
Abstract
AIM Functional dyspepsia, originates from gastroduodenal region, is described as resistant and recurring dyspeptic symptoms with unknown etiology. Although there is some evidence in support of a relationship between functional dyspepsia and psychopathology, attachment patterns of functional dyspepsia patients have not been studied yet. In our study, we aimed to compare attachment patterns of functional dyspepsia patients with organic dyspepsia patients and healthy volunteers. METHOD 43 patients diagnosed with functional dyspepsia, 38 patients with organic dyspepsia and 42 healthy volunteers matched in terms of age, sex and education were included in the study. All participants were evaluated using a socio-demographic and clinical data questionnaire, the State and Trait Anxiety Inventory, the Experiences in Close Relationships Questionnaire and the Adult Attachment Scale. RESULTS There was no difference in sociodemographic features among the three groups. Functional dyspepsia group exhibited significantly higher Trait Anxiety scores compared to organic dyspepsia and control groups. Control group showed significantly higher secure attachment styles compared to functional dyspepsia and organic dyspepsia groups, there was no difference between groups in non-secure attachment styles according to triple attachment model. Dimensionally, functional dyspepsia group showed more avoidant attachment patterns than organic dyspepsia groups and organic dyspepsia group showed more avoidant attachment patterns than control group. CONCLUSION According to our findings, Functional dyspepsia patients are more anxious than organic dyspepsia patients and healthy volunteers. Non-secure attachment patterns were seen generally in all dyspeptic patients while avoidant attachment patterns are more prominent in functional dyspepsia patients.
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Affiliation(s)
- Halide E Sahan
- Van Training And Research Hospital Department Of Psychiatry, 65300 Edremit, Van, Turkey
| | - Ejder A Yildirim
- Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Psychotherapy Outpatient Clinic Bakirkoy, 34147 Istanbul, Turkey.
| | - Aliye Soylu
- Bakırköy Dr. Sadi Konuk Training and Research Hospital Department of Gastroenterology, Tevfik Sağlam Cad. No: 11, Zuhuratbaba Mah., 34147 Istanbul, Turkey
| | - Abdulkadir S Tabakci
- Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Psychotherapy Outpatient Clinic Bakirkoy, 34147 Istanbul, Turkey
| | - Serdal Cakmak
- Bakırköy Dr. Sadi Konuk Training and Research Hospital Department of Gastroenterology, Tevfik Sağlam Cad. No: 11, Zuhuratbaba Mah., 34147 Istanbul, Turkey
| | - Sahap N Erkoc
- Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Bakirkoy, 34147, Istanbul, Turkey
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7
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Carrozzino D, Porcelli P. Alexithymia in Gastroenterology and Hepatology: A Systematic Review. Front Psychol 2018; 9:470. [PMID: 29681874 PMCID: PMC5897673 DOI: 10.3389/fpsyg.2018.00470] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 03/21/2018] [Indexed: 12/18/2022] Open
Abstract
Background: Alexithymia is a multifaceted personality construct that represents a deficit in the cognitive processing of emotions and is currently understood to be related to a variety of medical and psychiatric conditions. The present review aims to investigate the relationship of alexithymia with gastrointestinal (GI) disorders as functional gastrointestinal disorders (FGID, as irritable bowel syndrome (IBS) and functional dyspepsia) and inflammatory bowel disease (IBD) [ulcerative colitis (UC) and Crohn's disease (CD)] and liver diseases as chronic hepatitis C (CHC), cirrhosis, and liver transplantation. Methods: The articles were selected from the main electronic databases (PsycInfo, Medline, PubMed, Web of Science, Scopus, Cochrane, and ScienceDirect) using multiple combinations of relevant search terms (defined GI and liver diseases, articles in English, use of the Toronto scales [TAS] for alexithymia). The TAS was selected as inclusion criterion because it is the most widely used measure, thus allowing comparisons across studies. Results: Forty-eight studies met the inclusion criteria, of which 38 focused on GI disorders (27 on FGID and 11 on IBD) and 10 on liver diseases. Most studies (n = 30, 62%) were cross-sectional. The prevalence of alexithymia was higher in FGID (two third or more) than IBD and liver diseases (from one third to 50% of patients, consistent with other chronic non-GI diseases) than general population (10-15%). In functional disorders, alexithymia may be viewed as a primary driver for higher visceral perception, symptom reporting, health care use, symptom persistence, and negative treatment outcomes. Also, it has been found associated with psychological distress and specific GI-related forms of anxiety in predicting symptom severity as well as post-treatment outcomes and is associated with several psychological factors increasing the burden of disease and impairing levels of quality of life. A number of critical issues (small sample sizes, patients referred to secondary and tertiary care centers, cross-sectional study design, use of one single scale for alexithymia) constitutes a limitation to the generalization of findings. Conclusions: Alexithymia showed to play different roles in gastroenterology according to the clinical characteristics and the psychological burden of the various disorders, with main relevance in increasing subjective symptom perception and affecting negatively post-treatment outcomes.
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Affiliation(s)
- Danilo Carrozzino
- Department of Psychological, Health and Territorial Sciences, University “G.d'Annunzio” of Chieti-Pescara, Chieti, Italy
- Psychiatric Research Unit, Psychiatric Centre North Zealand, Copenhagen University Hospital, Hillerød, Denmark
| | - Piero Porcelli
- Department of Psychological, Health and Territorial Sciences, University “G.d'Annunzio” of Chieti-Pescara, Chieti, Italy
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8
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Mohebbi Z, Sharif F, Peyrovi H, Rakhshan M, Naini MA, Zarshenas L. Self-Perception of Iranian Patients during their life with Irritable Bowel Syndrome: A Qualitative Study. Electron Physician 2017; 9:5885-5893. [PMID: 29560138 PMCID: PMC5843412 DOI: 10.19082/5885] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 07/04/2017] [Indexed: 12/12/2022] Open
Abstract
Background Irritable bowel syndrome (IBS), as a chronic digestive disorder, impacts extensively on the quality of life, emotional well-being and self-identity. Chronic illness disrupts taken-for-granted notions about self. No qualitative study was found regarding patients’ experience of life with irritable bowel syndrome (IBS) in Iran. Objective To explore the self-perception of lived experience of IBS patients. Methods A qualitative study with hermeneutic phenomenological approach was conducted on 12 IBS patients who had been referred to three central clinics (2 governmental and 1 private) affiliated to Shiraz University of Medical Sciences. The data were collected through in-depth semi-structured interviews from July 2015 to September 2016 by purposeful sampling. Thematic analysis was carried out using Van Manen’s six-step methodological framework as a guide. In addition, MAXQDA software was used for data management. Results In this study, two main themes “the threatened self” and “deep self-knowledge”, emerged during the life of patients with IBS, indicating the meaning of self-perception of such patients. The theme of “the threatened self” consisted of two subthemes of “fear from stigmatization” and “bad sense of self”. The subthemes of “body knowledge”, “self-acceptance” and “personal growth” were related to deep self-knowledge. Conclusion The results of the present study could be applied in designing and implementation effective and holistic care of IBS patients.
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Affiliation(s)
- Zinat Mohebbi
- Ph.D. Candidate of Nursing, Faculty Member, Student Research Committee, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Farkhondeh Sharif
- Ph.D. of Psychiatric Nursing, Professor, Community Based Psychiatric Care Research Center, Shiraz Geriatric Research Center, Department of Mental Health and Psychiatric Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamid Peyrovi
- Ph.D. of Nursing, Professor, Nursing Care Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mahnaz Rakhshan
- Ph.D. of Nursing, Assistant Professor, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahvash Alizade Naini
- Gastroenterologist, Associate Professor, Gastroenterology and Hepatology Research Center, Department of Gastroenterology and Hepatology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ladan Zarshenas
- Ph.D. of Nursing, Assistant Professor, Community Based Psychiatric Care Research Center, Department of Mental Health and Psychiatric Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
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9
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Abautret-Daly Á, Dempsey E, Riestra S, de Francisco-García R, Parra-Blanco A, Rodrigo L, Medina C, Connor TJ, Harkin A. Association between psychological measures with inflammatory anddisease-related markers of inflammatory bowel disease. Int J Psychiatry Clin Pract 2017; 21:221-230. [PMID: 28353360 DOI: 10.1080/13651501.2017.1306081] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE This study aimed at investigating the associations between inflammatory mediators, symptoms and psychological disturbances in inflammatory bowel disease (IBD) patients. METHODS IBD patients and patient controls were examined during a single visit to a gastroenterology clinic. Disease activity was assessed using the Mayo index for ulcerative colitis (UC), inflammatory bowel disease questionnaire (IBDQ), Crohn's disease activity index (CDAI) and Crohn's disease endoscopic index of severity (CDEIS). Gene expression of inflammatory mediators were measured in intestinal biopsies and whole blood samples along with circulating concentrations of interleukin (IL)-6, interferon (IFN)γ, C-reactive protein (CRP), kynurenine and tryptophan. Validated depression, anxiety and quality of life scores were used to assess psychological well-being. RESULTS Patients who were symptomatic had the highest depression and anxiety scores, together with increased intestinal expression of IL-1β, IL-6 and matrix metalloproteinase-9, increased circulating IL-6 and CRP, and an increased circulating kynurenine:tryptophan ratio. Increased Hamilton depression (HAM-D) scores in IBD patients were observed independent of the psychological impact of acute symptoms. CONCLUSIONS Active IBD is associated with symptoms of depression and anxiety and with a raised circulating inflammatory mediator profile. Patients with active IBD exhibiting psychological symptoms should undergo psychological evaluation to ensure the psychological aspects of the condition are considered and addressed.
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Affiliation(s)
- Áine Abautret-Daly
- a Neuropsychopharmacology Research Group, Trinity College Institute of Neuroscience, Trinity College , Dublin 2 , Ireland.,b School of Pharmacy and Pharmaceutical Sciences, Trinity College , Dublin 2 , Ireland
| | - Elaine Dempsey
- a Neuropsychopharmacology Research Group, Trinity College Institute of Neuroscience, Trinity College , Dublin 2 , Ireland.,b School of Pharmacy and Pharmaceutical Sciences, Trinity College , Dublin 2 , Ireland
| | - Sabino Riestra
- c Department of Gastroenterology , Hospital Central de Asturias , Oviedo , Spain
| | | | - Adolfo Parra-Blanco
- c Department of Gastroenterology , Hospital Central de Asturias , Oviedo , Spain
| | - Luis Rodrigo
- c Department of Gastroenterology , Hospital Central de Asturias , Oviedo , Spain
| | - Carlos Medina
- b School of Pharmacy and Pharmaceutical Sciences, Trinity College , Dublin 2 , Ireland.,d Trinity Biomedical Sciences Institute, Trinity College , Dublin 2 , Ireland
| | - Thomas J Connor
- e Neuroimmunology Research Group, School of Medicine and Trinity College Institute of Neuroscience, Trinity College , Dublin 2 , Ireland
| | - Andrew Harkin
- a Neuropsychopharmacology Research Group, Trinity College Institute of Neuroscience, Trinity College , Dublin 2 , Ireland.,b School of Pharmacy and Pharmaceutical Sciences, Trinity College , Dublin 2 , Ireland
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10
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Zhou XP, Sha J, Huang L, Li TN, Zhang RR, Tang MD, Lin L, Li XL. Nesfatin-1/NUCB2 in the amygdala influences visceral sensitivity via glucocorticoid and mineralocorticoid receptors in male maternal separation rats. Neurogastroenterol Motil 2016; 28:1545-53. [PMID: 27380730 DOI: 10.1111/nmo.12853] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 04/17/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Nesfatin-1, a recently identified satiety molecule derived from nucleobindin 2 (NUCB2), is associated with visceral hypersensitivity in rats and is expressed in the amygdala. We tested the hypothesis that nesfatin-1 expression in the amygdala is involved in the pathogenesis of irritable bowel syndrome (IBS) visceral hypersensitivity. METHODS An animal model of IBS-like visceral hypersensitivity was established using maternal separation (MS) during postnatal days 2-16. The role of nesfatin-1 in the amygdala on visceral sensitivity was evaluated. KEY RESULTS Rats subjected to MS showed a significantly increased mean abdominal withdrawal reflex (AWR) score and electromyographic (EMG) activity at 40, 60, and 80 mmHg colorectal distension. Plasma concentrations of nesfatin-1 and corticosterone were significantly higher than in non-handled (NH) rats. mRNA and protein expression of nesfatin-1/NUCB2 in the amygdala were increased in MS rats, but not in NH rats. In MS rats, AWR scores and EMG activity were significantly decreased after anti-nesfatin-1/NUCB2 injection. In normal rats, mean AWR score, EMG activity, and corticosterone expression were significantly increased after nesfatin-1 injection into the amygdala. Nesfatin-1-induced visceral hypersensitivity was abolished following application of glucocorticoid receptor (GR) and mineralocorticoid receptor (MR) antagonists. CONCLUSIONS & INFERENCES Elevated expression of nesfatin-1/NUCB2 in the amygdala in MS rats suggests a potential role in the pathogenesis of visceral hypersensitivity, which could potentially take place via activation of GR and MR signaling pathways.
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Affiliation(s)
- X-P Zhou
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Third People's Hospital of Zigong, Zigong, Sichuan, China
| | - J Sha
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - L Huang
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - T-N Li
- Department of PET/CT, First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
| | - R-R Zhang
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - M-D Tang
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - L Lin
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - X-L Li
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
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11
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Model and Processes of Acceptance and Commitment Therapy (ACT) for Chronic Pain Including a Closer Look at the Self. Curr Pain Headache Rep 2016; 20:12. [PMID: 26803836 DOI: 10.1007/s11916-016-0541-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Acceptance and commitment therapy (ACT) is one of the so called "third-wave" cognitive behavioral therapies. It has been increasingly applied to chronic pain, and there is accumulating evidence to support its effectiveness. ACT is based on a model of general human functioning called the psychological flexibility (PF) model. Most facets of the PF model have been examined in chronic pain. However, a potential key facet related to "self" appears underappreciated. Indeed, a positive or healthy sense of self seems essential to our well-being, and there have been numerous studies of the self in chronic pain. At the same time, these studies are not currently well organized or easy to summarize. This lack of clarity and integration creates barriers to progress in this area of research. PF with its explicit inclusion of self-related therapeutic processes within a broad, integrative, theoretical model may help. The current review summarizes the PF model in the context of chronic pain with a specific emphasis on the parts of the model that address self-related processes.
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Mak GZ, Lucchetti AR, Drossos T, Fitzsimmons-Craft EE, Accurso EC, Stiles-Shields C, Newman EA, Skelly CL. Pediatric Chronic Abdominal Pain and Median Arcuate Ligament Syndrome: A Review and Psychosocial Comparison. Pediatr Ann 2016; 45:e257-64. [PMID: 27403674 DOI: 10.3928/00904481-20160613-01] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Chronic abdominal pain (CAP) occurs in children and adolescents with a reported prevalence of 4% to 41% with significant direct and indirect costs to the child, family, and society. Median arcuate ligament syndrome (MALS) is a vascular compression syndrome of the celiac artery that may cause symptoms of epigastric pain and weight loss and is a frequently overlooked cause of CAP in the pediatric population. We have observed that the psychosocial presentation of patients with MALS is notable for various psychiatric comorbidities. In this article, we review MALS as well as our study results of the psychosocial profile of 30 MALS patients. Our data suggest that children and adolescents with MALS have similar psychosocial profiles to children with other gastrointestinal disorders resulting in CAP. The overlap of physical and psychosocial symptoms of patients who have MALS with other CAP disorders leads us to recommend that patients with CAP should be evaluated for MALS. [Pediatr Ann. 2016;45(7):e257-e264.].
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13
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Molavi R, Alavi M, Keshvari M. Relationship between general health of older health service users and their self-esteem in Isfahan in 2014. IRANIAN JOURNAL OF NURSING AND MIDWIFERY RESEARCH 2016; 20:717-22. [PMID: 26793259 PMCID: PMC4700693 DOI: 10.4103/1735-9066.170009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background: Self-esteem is known to be one of the most important markers of successful aging. Older people's self-esteem is influenced by several factors that particularly may be health related. Therefore, this study aimed to explore some important general health-related predictors of the older people's self-esteem. Materials and Methods: In this study, 200 people, aged 65 years and older, who referred to health care centers were selected through stratified random sampling method. Data were collected by using Rosenberg's self-esteem scale and the 28-item Goldberg's general health questionnaire. Data were analyzed by Pearson's coefficient tests and multiple regression analysis. Results: Findings showed that the entered predictor variables accounted for 49% of the total variance (R2) of self-esteem in the model (P < 0.001, F4,195 = 46.717). Three out of the four predictor variables including somatic signs, anxiety/insomnia, and depression, significantly predicted the self-esteem. The results emphasized on the determinant role of both physical (somatic signs) and mental (anxiety/insomnia and depression) aspects of health in older patients’ self-esteem. Conclusions: The significant general health-related predictors found in the present study emphasize on some of the significant points that should be considered in planning for improving older patients’ self-esteem.
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Affiliation(s)
- Razieh Molavi
- Department of Community Health Nursing, Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mousa Alavi
- Department of Psychiatric Nursing, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mahrokh Keshvari
- Department of Community Health Nursing, Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
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In search of the person in pain: A systematic review of conceptualization, assessment methods, and evidence for self and identity in chronic pain. JOURNAL OF CONTEXTUAL BEHAVIORAL SCIENCE 2015. [DOI: 10.1016/j.jcbs.2015.10.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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15
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Freitas TH, Andreoulakis E, Alves GS, Miranda HLL, Braga LLBC, Hyphantis T, Carvalho AF. Associations of sense of coherence with psychological distress and quality of life in inflammatory bowel disease. World J Gastroenterol 2015; 21:6713-6727. [PMID: 26074710 PMCID: PMC4458782 DOI: 10.3748/wjg.v21.i21.6713] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 01/12/2015] [Accepted: 02/05/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the relationship between sense of coherence, psychological distress and health related quality of life in inflammatory bowel disease (IBD).
METHODS: This cross-sectional study enrolled a consecutive sample of 147 IBD (aged 45.1 ± 14.1 years; 57.1% female) patients recruited from a tertiary gastroenterology service. Sixty-four participants met diagnostic criteria for Crohn’s disease, while eighty-three patients had ulcerative colitis. Socio-demographic data (education, age, race, gender, gross monthly income and marital status), disease-related variables (illness activity, relapse rate in past 2 years, history of surgery and time since diagnosis), sense of coherence (Antonovsky’s SOC scale), psychological distress symptoms (Hospital Anxiety and Depression Scale) and health-related quality of life (HRQoL; WHOQOL-Bref) were assessed. Hierarchical multiple regression analyses were performed to identify factors that are independently associated with psychological distress and HRQoL in patients with IBD and to provide indications for possible moderating or mediating effects. In addition, formal moderation and mediation analyses (Sobel tests) were performed to confirm potential moderators/mediators of the relationship between SOC, psychological distress symptoms and HRQoL.
RESULTS: Lower SOC scores (std beta= -0.504; P < 0.001), female gender (std beta = 0.176; P = 0.021) and White race (std beta = 0.164; P = 0.033) were independently associated with higher levels of depressive symptoms, while lower levels of SOC (std beta = -0.438; P < 0.001) and higher relapse rate (std beta = 0.161; P = 0.033) were independently associated with more severe anxiety symptoms. A significant interaction between time since diagnosis and SOC was found with regard to the severity of depressive or anxiety symptoms, as the interaction term (time since diagnosis X SOC) had beta coefficients of -0.191 (P = 0.009) and -0.172 (P = 0.026), respectively. Lower levels of anxiety symptoms (std beta = -0.369; P < 0.001), higher levels of SOC (std beta = 0.231; P = 0.016) and non-White race (std beta = -0.229; P = 0.006), i.e., mixed-race, which represented the reference category, were independently associated with higher levels of overall HRQoL. Anxiety symptoms were the most potent independent correlate of most aspects of HRQoL. In addition, anxiety mediated the association between SOC and satisfaction with health, as well as its relationship with physical, mental, and social relations HRQoL. Depressive symptoms also mediated the association between SOC and mental HRQoL.
CONCLUSION: Our data indicated that SOC is an important construct, as it influences psychological distress and has significant albeit indirect effects on several HRQoL domains in IBD.
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More negative self-esteem and inferior coping strategies among patients diagnosed with IBS compared with patients without IBS--a case-control study in primary care. BMC FAMILY PRACTICE 2015; 16:6. [PMID: 25626450 PMCID: PMC4316793 DOI: 10.1186/s12875-015-0225-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 01/15/2015] [Indexed: 12/14/2022]
Abstract
Background Irritable Bowel Syndrome (IBS) is a chronic, relapsing gastrointestinal disorder, that affects approximately 10% of the general population and the majority are diagnosed in primary care. IBS has been reported to be associated with altered psychological and cognitive functioning such as mood disturbances, somatization, catastrophizing or altered visceral interoception by negative emotions and stress. The aim was to investigate the psychosocial constructs of self-esteem and sense of coherence among IBS patients compared to non-IBS patients in primary care. Methods A case–control study in primary care setting among IBS patients meeting the ROME III criteria (n = 140) compared to controls i.e. non-IBS patients (n = 213) without any present or previous gastrointestinal complaints. The data were collected through self-reported questionnaires of psychosocial factors. Results IBS-patients reported significantly more negative self-esteem (p < 0.001), lower scores for positive self-esteem (p < 0.001), and lower sense of coherence (p < 0.001) than the controls. The IBS-cases were also less likely to report ‘good’ health status (p < 0.001) and less likely to report a positive belief in the future (p < 0.001). After controlling for relevant confounding factors in multiple regressions, the elevation in negative self-esteem among IBS patients remained statistically significant (p = 0.02), as did the lower scores for sense of coherence among IBS cases (p = 0.04). Conclusions The more frequently reported negative self-esteem and inferior coping strategies among IBS patients found in this study suggest the possibility that psychological therapies might be helpful for these patients. However these data do not indicate the causal direction of the observed associations. More research is therefore warranted to determine whether these psychosocial constructs are more frequent in IBS patients.
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17
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Opheim R, Fagermoen MS, Jelsness-Jørgensen LP, Bernklev T, Moum B. Sense of coherence in patients with inflammatory bowel disease. Gastroenterol Res Pract 2014; 2014:989038. [PMID: 24527028 PMCID: PMC3910263 DOI: 10.1155/2014/989038] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 11/29/2013] [Indexed: 12/21/2022] Open
Abstract
Background and Aim. Sense of coherence (SOC) is a health-promoting concept reflecting a person's view of life and response to stressful situations and may be of importance in coping with chronic illness. The aim of this study was to explore associations between SOC and sociodemographic, disease-related, and personal characteristics in a sample of patients with inflammatory bowel disease (IBD). Methods. Measures included sociodemographic and disease-related data, the Sense of Coherence Scale, General Self-Efficacy Scale (GSE), and Fatigue Severity Scale (FSS-5). Results. In total, 428 IBD patients had evaluable questionnaires (response rate 93%). The overall mean SOC total score was 66.25 (SD 11.47) and with no statistically significant difference between patients with ulcerative colitis (UC) and patients with Crohn's disease (CD). In the multivariate analyses, higher GSE scores were significantly associated with higher SOC scores and higher FSS-5 scores were significantly associated with lower SOC scores in both UC and CD. Conclusion. GSE and FSS-5 contributed more to the variance in SOC than sociodemographic and disease-related variables. Longitudinal studies are warranted to investigate the value of SOC as a predictor of disability, medication adherence, coping behavior, and health-related quality of life.
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Affiliation(s)
- Randi Opheim
- Department of Gastroenterology, Division of Medicine, Oslo University Hospital, P.O. Box 4956, Nydalen, 0424 Oslo, Norway
- The Institute of Clinical Medicine, University of Oslo, P.O. Box 1171, Blindern, 0318 Oslo, Norway
| | - May Solveig Fagermoen
- Department of Gastroenterology, Division of Medicine, Oslo University Hospital, P.O. Box 4956, Nydalen, 0424 Oslo, Norway
- Department of Nursing Science, Institute of Health and Society, University of Oslo, P.O. Box 1130, Blindern, 0318 Oslo, Norway
| | - Lars-Petter Jelsness-Jørgensen
- Østfold University College, K.G. Meldahlsvei 9, 1671 Fredrikstad, Norway
- Department of Gastroenterology, Østfold Hospital Trust, 1603 Fredrikstad, Norway
| | - Tomm Bernklev
- Research and Development Department, Telemark Hospital Trust, 3710 Skien, Norway
| | - Bjørn Moum
- Department of Gastroenterology, Division of Medicine, Oslo University Hospital, P.O. Box 4956, Nydalen, 0424 Oslo, Norway
- The Institute of Clinical Medicine, University of Oslo, P.O. Box 1171, Blindern, 0318 Oslo, Norway
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Yen CM, Muo CH, Lin MC, Chang SN, Chang YJ, Kao CH. A nationwide population cohort study: irritable bowel syndrome is a risk factor of osteoporosis. Eur J Intern Med 2014; 25:87-91. [PMID: 24183216 DOI: 10.1016/j.ejim.2013.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 10/14/2013] [Accepted: 10/17/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND The goal of the study is to determine the relationship between irritable bowel syndrome (IBS) and osteoporosis in Taiwan. MATERIALS AND METHODS We collected data from the National Health Insurance (NHI) program in Taiwan. The sample in this study consisted of 31,892 patients enrolled from 2000 to 2009 and diagnosed by the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). We divided the sample into 2 cohorts based on whether they had IBS, and formed subgroups based on age, sex, enrolment year, and enrolment month. RESULTS Age and gender did not differ statistically among the 2 cohorts. Results show that IBS is more correlated with urbanization and the occupation of business. The IBS cohort had a higher incidence of osteoporosis than the non-IBS cohort (6.90 vs 4.15 per 1000 person-years; HR=1.65, 955 CI=1.54-1.77). Female patients aged 40-59years had the highest risk of developing osteoporosis (HR=4.42, 95% CI=3.37-5.79 in the IBS cohort; HR=4.41, 95% CI=3.67-5.29 in the non-IBS cohort, respectively). In IBS patients less than 40years of age, female patients had a significant 2.18-fold greater risk of developing osteoporosis than male patients (HR=2.18, 95% CI=1.09-4.38). CONCLUSIONS IBS is a risk factor for osteoporosis in Taiwan.
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Affiliation(s)
- Chia-Ming Yen
- Department of Anesthesiology, Buddhist Tzu Chi General Hospital, Taichung Branch, Taichung, Taiwan
| | - Chih-Hsin Muo
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Ming-Chia Lin
- Department of Nuclear Medicine, E-DA Hospital, Kaohsiung, Taiwan
| | - Shih-Ni Chang
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Yen-Jung Chang
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan; Department of Health Promotion and Health Education, National Taiwan Normal University, Taipei, Taiwan
| | - Chia-Hung Kao
- Department of Nuclear Medicine PET Center, China Medical University Hospital, Taichung, Taiwan; Graduate Institute of Clinical Medicine Science and School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan.
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Bengtsson M, Ohlsson B. The brief Visual Analogue Scale for Irritable Bowel Syndrome questionnaire can be used to evaluate psychological well-being in patients with irritable bowel syndrome. Eur J Intern Med 2013; 24:e82-3. [PMID: 23773543 DOI: 10.1016/j.ejim.2013.05.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Revised: 05/19/2013] [Accepted: 05/20/2013] [Indexed: 12/29/2022]
Affiliation(s)
- Mariette Bengtsson
- Faculty of Health and Society, Institution of Care Science, Malmö University, Sweden.
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