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Assessment of anxiety, depression, social anxiety, anxiety sensitivity, and perceived stress in psoriasis patients: a controlled cross-sectional study. JOURNAL OF CONTEMPORARY MEDICINE 2021. [DOI: 10.16899/jcm.962932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Boullion GQ, Witcraft SM, Schadegg MJ, Perry MM, Dixon LJ. Emotion Regulation Difficulties and Depression Among Individuals With Dermatological and Body Dysmorphic Concerns. J Nerv Ment Dis 2021; 209:650-655. [PMID: 34009860 DOI: 10.1097/nmd.0000000000001355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Existing literature demonstrates strong links between emotion regulation (ER) difficulties and depression. Although high rates of depression are observed among individuals with body dysmorphic disorder and skin disease, little is known about these co-occurring syndromes. To advance our understanding of a vulnerable population, this study examined facets of ER difficulties in relation to depression among adults with skin disease symptoms and body dysmorphic concerns (N = 97). Participants were recruited online and completed self-report measures. The overall hierarchical regression model accounted for 61.6% of the variance in depression. After controlling for anxiety and stress, ER difficulties added 9.9% unique variance. In particular, limited access to ER strategies was the only ER dimension significantly associated with depression. This study integrates divergent literatures and suggests the important role of ER difficulties in depression in this unique sample, thereby highlighting directions for future investigation.
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Affiliation(s)
- Gina Q Boullion
- Department of Psychology, University of Mississippi, University, Mississippi
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Anxiety sensitivity and social anxiety in adults with psychodermatological symptoms. Arch Dermatol Res 2020; 313:531-537. [PMID: 32857186 DOI: 10.1007/s00403-020-02130-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/04/2020] [Accepted: 08/10/2020] [Indexed: 10/23/2022]
Abstract
Many dermatology patients experience social anxiety symptoms; however, few studies have investigated vulnerabilities contributing to this distress. Anxiety sensitivity (AS), or the fear of the consequences of anxiety, warrants consideration given its association with social anxiety and dermatological symptoms, respectively. The purpose of this investigation was to investigate the role of AS in social anxiety symptoms in two samples of adults with psychodermatological conditions. AS social, but not physical or cognitive, concerns were hypothesized to demonstrate unique associations with social anxiety symptoms after controlling for relevant variables. Participants completed self-report measures online (Study 1) or in-person (Study 2). Study 1 included 164 participants with active skin conditions (Mage = 31.88; 69.5% female; 83.5% White), and Study 2 included 63 dermatology outpatients (Mage = 51.49; 70.7% female; 65% White). Results revealed AS social concerns was a unique factor contributing to social anxiety symptoms in both samples. This study demonstrates replication, and the findings suggest heightened concerns about the negative consequences related to visible skin conditions may worsen social anxiety symptoms in individuals with psychodermatological conditions. Despite limitations, this study informs the conceptualization of co-occurring psychological and dermatological conditions and highlights the need to evaluate the efficacy of brief AS interventions among patients with psychodermatological conditions.
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Toth M, Jokić-Begić N. Psychological contribution to understanding the nature of dry eye disease: a cross-sectional study of anxiety sensitivity and dry eyes. Health Psychol Behav Med 2020; 8:202-219. [PMID: 34040868 PMCID: PMC8114394 DOI: 10.1080/21642850.2020.1770093] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 05/11/2020] [Indexed: 11/30/2022] Open
Abstract
Dry eye disease (DED) represents a common health problem in the general population. Previous studies have demonstrated that the subjective symptoms of dry eye are associated with several psychological factors, including depression, anxiety and post-traumatic stress disorder. However, there is a lack of empirical information about the mechanisms underlying the relationships between DED and various psychological symptoms. In light of emerging evidence of its trans-diagnostic nature, anxiety sensitivity (i.e. AS) represents one promising factor for further understanding DED. The present study aimed to explore whether anxiety sensitivity plays a role in the perception of DED symptoms in a community-based sample of adults aged 20-89 years (N = 381; M = 39.72, SD = 12.6). A dry ocular surface was reported by 22.8% of the participants. As expected, women more often reported symptoms of dry eye that could be categorized as moderate to severe. The findings demonstrated that AS, and the AS-psychological concerns dimension in particular, predict the intensity of dry eye symptoms above and beyond depressive and anxiety symptoms. These findings add to a growing body of work underscoring the relevance of AS in increasing the risk of chronic medical conditions.
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Affiliation(s)
- Marko Toth
- Department of Optometry, University of Applied Sciences Velika Gorica, Velika Gorica, Croatia
| | - Nataša Jokić-Begić
- Department of Psychology, Faculty of Humanities and Social Sciences, University of Zagreb, Zagreb, Croatia
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Lukaviciute L, Ganceviciene R, Navickas P, Navickas A, Grigaitiene J, Zouboulis CC. Anxiety, Depression, and Suicidal Ideation amongst Patients with Facial Dermatoses (Acne, Rosacea, Perioral Dermatitis, and Folliculitis) in Lithuania. Dermatology 2020; 236:314-322. [PMID: 32252051 DOI: 10.1159/000506627] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 02/19/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/OBJECTIVE Skin diseases, especially those with visible manifestation, are considered to cause a major influence on global mental health. Therefore, we determined the prevalence and severity of anxiety, depression, and suicidal ideation in a large sample of patients with facial dermatoses, namely acne, rosacea, folliculitis, and perioral dermatitis. METHODS The mental health of patients with facial dermatoses and respective controls was assessed using the Hospital Anxiety and Depression Scale and questions concerning suicidal ideation. RESULTS The study included 543 patients with facial dermatoses and 497 healthy individuals. Anxiety was present in 37.6% of the patients (14.9% of controls), depression in 21.7% (6.8%), and suicidal thoughts in 9.8% (3.2%) (p < 0.001). Acne patients demonstrated the highest anxiety and depression subscale scores (mean ± standard deviation: 7.1 ± 0.25, 95% confidence interval (CI): 6.58-7.56; controls: 5 ± 0.23, 95% CI: 4.57-5.49). In rosacea 30% of the patients had depression symptoms (adjusted odds ratio (OR): 7.216, 95% CI: 4.122-12.632, p < 0.001), while in folliculitis patients 15.4% (OR: 3.138, 95% CI: 1.241-7.936, p = 0.016) had suicidal thoughts. Patients with anxiety symptoms and suicidal thoughts were on average younger than those without (28.3 ± 0.76 vs. 31.2 ± 0.66 years, p = 0.001 and 25.3 ± 0.98 vs. 30.5 ± 0.55 years, p = 0.007, respectively). CONCLUSION Acne and rosacea are associated with anxiety, depression, and suicidal ideation in Lithuanian patients. Younger patients are more prone to report such symptoms than older ones.
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Affiliation(s)
| | - Ruta Ganceviciene
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Clinic of Infectious diseases, Centre of Dermatovenereology, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | | | - Alvydas Navickas
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Clinic of Psychiatry, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Jurate Grigaitiene
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Clinic of Infectious diseases, Centre of Dermatovenereology, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Christos C Zouboulis
- Departments of Dermatology, Venereology, Allergology, and Immunology, Dessau Medical Center, Brandenburg Medical School Theodor Fontane, Dessau, Germany,
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Hsu YM, Fang HY, Lin CL, Shieh SH. The Risk of Depression in Patients with Pemphigus: A Nationwide Cohort Study in Taiwan. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17061983. [PMID: 32192212 PMCID: PMC7142767 DOI: 10.3390/ijerph17061983] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/10/2020] [Indexed: 11/29/2022]
Abstract
Pemphigus is a chronic dermatological disorder caused by an autoimmune response and is associated with a high proportion of comorbidities and fatalities. The aim of this study was to investigate the risk of depression in patients with pemphigus. Data were derived from the National Health Insurance Research Database recorded during the period 2000–2010 in Taiwan. Multivariate Cox proportional hazards regression models were used to analyze the data and assess the effects of pemphigus on the risk of depression after adjusting for demographic characteristics and comorbidities. Patients with pemphigus were 1.98 times more likely to suffer from depression than the control group (pemphigus, adjusted HR: 1.99, 95% CI = 1.37–2.86). People aged ≥65 years were 1.69 times more likely to suffer from depression than those aged 20–49 years (≥65 years, adjusted HR: 1.42, 95% CI = 0.92–2.21). Female and male patients with pemphigus were respectively 2.02 and 1.91 times more likely to suffer from depression than the control group (female, adjusted HR: 2.09, 95% CI = 1.24–3.54; male, adjusted HR: 1.87, 95% CI = 0.97–3.60). People with HTN, hyperlipidemia, asthma/COPD, and chronic liver disease were respectively 1.73, 2.3, 2.2, and 1.69 times more likely to suffer from depression than those without these comorbidities (HTN, adjusted HR: 0.75, 95% CI = 0.41–1.42; hyperlipidemia, adjusted HR: 1.48, 95% CI = 0.78–2.82; asthma/COPD, adjusted HR: 1.4, 95% CI = 0.72–2.69; and chronic liver disease, adjusted HR: 1.61, 95% CI = 1.07–2.43). There was a significant association between pemphigus and increased risk of depression. Female patients had a higher incidence of depression.
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Affiliation(s)
- Yi-Min Hsu
- Department of Public Health, China Medical University, Taichung 40447, Taiwan;
- Department of Nursing, China Medical University Hospital, Taichung 40447, Taiwan
| | - Hsin-Yu Fang
- Department of dermatology, China Medical University Hospital, Taichung 40447, Taiwan
- Correspondence: (H.-Y.F.); (S.-H.S.); Tel.: +886-4-22052121 (ext. 4661) (H.-Y.F.); +886-4-22053366 (ext. 6631) (S.-H.S.)
| | - Cheng-Li Lin
- Management Office for Health Data, China Medical University Hospital, Taichung 40447, Taiwan;
| | - Shwn-Huey Shieh
- Department of Health Services Administration, China Medical University, Taichung 40447, Taiwan
- Department of Nursing, Asia University, Taichung 41354, Taiwan
- Correspondence: (H.-Y.F.); (S.-H.S.); Tel.: +886-4-22052121 (ext. 4661) (H.-Y.F.); +886-4-22053366 (ext. 6631) (S.-H.S.)
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Examining the cross-sectional and longitudinal effects of anxiety sensitivity on indicators of disease severity among patients with inflammatory arthritis. J Anxiety Disord 2019; 67:102117. [PMID: 31445391 DOI: 10.1016/j.janxdis.2019.102117] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 07/08/2019] [Accepted: 07/24/2019] [Indexed: 12/29/2022]
Abstract
Few studies have investigated anxiety sensitivity (AS) in the context of inflammatory arthritis (IA), despite evidence of a relationship between AS and pain. This study examined cross-sectional and longitudinal relationships between AS and indicators of IA severity in 148 participants with IA. AS and its factors (social, physical, cognitive) were self-reported. Arthritis severity was physician-assessed (disease activity scales) and self-reported (physical function; pain and fatigue). Cross-sectional correlations assessed the association between AS and arthritis severity outcomes. Longitudinal multivariable mixed-effect regressions assessed the association of AS total and AS factors at each visit with disease severity outcomes. All AS factors were significantly and positively correlated (at the same visit) with function, pain, and fatigue. AS total significantly predicted pain, fatigue, and function. Cognitive AS significantly predicted fatigue, and physical AS significantly predicted pain and fatigue. Social AS significantly predicted pain, fatigue, function and weighted joint count (articular burden). AS is associated with several indicators of disease severity among those with IA; unique findings emerged across factors with the broadest disease impact by social AS. The AS factors, especially social AS, may contribute to the development and severity of IA symptoms, which may have implications for interventions.
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Acer E, Altınoz AE, Erdogan HK, Agaoglu E, Yuksel Canakcı N, Saracoglu ZN. Anxiety Sensitivity and Quality of Life in Patients with Acne. Ann Dermatol 2019; 31:372-377. [PMID: 33911614 PMCID: PMC7992751 DOI: 10.5021/ad.2019.31.4.372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/27/2018] [Accepted: 12/08/2018] [Indexed: 12/13/2022] Open
Abstract
Background Anxiety sensitivity (AS) is a continuous fundamental fear and defined as extreme fear of anxiety sensations and symptoms. High AS can cause tendency to anxiety disorders. There are many studies evaluating the anxiety in patients with acne; however, AS has not been investigated. Objective We aimed to investigate AS in patients with acne. Methods Two hundred and fourteen acne patients and 117 healthy control subjects, aged older than 16 years were enrolled in the study. Severity of acne was evaluated by Global Acne Grading System. The acne patients and healthy controls were asked to complete the anxiety sensitivity index-3 (ASI-3), the Beck anxiety inventory (BAI) and the Turkish version of acne quality of life index. Results Anxiety and AS levels in acne patients were significantly higher than healthy controls (p<0.001). Quality of life was impaired in acne patients. Quality of life was negatively correlated with anxiety and AS levels in acne patients (p=0.014, p=0.019, respectively). There was no correlation between quality of life and disease severity (p=0.556) and also there was no correlation between psychiatric scale scores (ASI-3, BAI) and disease severity (p=0.147, p=0.871, respectively). Conclusion To our knowledge, our study is the first to report that AS is high in acne patients. Clinically, our results suggest that there might be a relationship between AS and acne. We conclude that further studies are needed in order to clarify the relationship between acne and AS and to investigate the efficacy of cognitive behavioral treatments in acne patients.
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Affiliation(s)
- Ersoy Acer
- Department of Dermatology, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - Ali Ercan Altınoz
- Department of Psychiatry, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - Hilal Kaya Erdogan
- Department of Dermatology, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - Esra Agaoglu
- Department of Dermatology, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - Nihan Yuksel Canakcı
- Department of Dermatology, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - Zeynep Nurhan Saracoglu
- Department of Dermatology, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
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Type D personality, anxiety sensitivity, social anxiety, and disability in patients with acne: a cross-sectional controlled study. Postepy Dermatol Alergol 2019; 36:51-57. [PMID: 30858779 PMCID: PMC6409878 DOI: 10.5114/ada.2019.82824] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 11/13/2017] [Indexed: 11/29/2022] Open
Abstract
Introduction Acne has long been associated with many psychiatric comorbidities. Aim To determine anxiety and depression levels, social phobia frequency, social anxiety level, subjective stress perception, anxiety sensitivity, disability, and the frequency of type D personality in patients with acne. Material and methods In total, 61 patients with acne aged > 16 years and 61 age, gender, and educationally matched healthy volunteers were included in the study. The patients and healthy controls were evaluated using the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 criteria for social anxiety disorder and completed the Liebowitz Social Anxiety Scale, Sheehan Disability Scale, Anxiety Sensitivity Index, Hospital Anxiety and Depression Scale, Perceived Stress Scale (PSS), and Type D Scale-14. Results Depression, anxiety, social anxiety, self-reported stress, anxiety sensitivity, and disability levels were significantly higher in patients with acne than in healthy controls (p < 0.05). Type D personality was more prevalent in patients with acne than in healthy controls (49% vs. 18%, p < 0.001). Conclusions To our knowledge, this study is the first reported in which type D personality and anxiety sensitivity, as well as social anxiety disorder according to the DSM-5 criteria, was evaluated in patients with acne compared with healthy controls. This study shows that patients with acne have higher levels of depression, anxiety, social anxiety, self-reported stress, anxiety sensitivity, and disability, and a greater prevalence of type D personality, than healthy controls. Psychiatric evaluation of patients with acne may aid the detection of mental disorders.
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Dixon LJ, Witcraft SM, Perry MM. How Does Anxiety Affect Adults with Skin Disease? Examining the Indirect Effect of Anxiety Symptoms on Impairment Through Anxiety Sensitivity. COGNITIVE THERAPY AND RESEARCH 2018. [DOI: 10.1007/s10608-018-9942-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Horenstein A, Potter CM, Heimberg RG. How does anxiety sensitivity increase risk of chronic medical conditions? CLINICAL PSYCHOLOGY-SCIENCE AND PRACTICE 2018. [DOI: 10.1111/cpsp.12248] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Arielle Horenstein
- Adult Anxiety Clinic of Temple; Department of Psychology; Temple University; Philadelphia Pennsylvania
| | - Carrie M. Potter
- Department of Psychiatry of Cambridge Health Alliance; Harvard Medical School; Boston Massachusetts
| | - Richard G. Heimberg
- Adult Anxiety Clinic of Temple; Department of Psychology; Temple University; Philadelphia Pennsylvania
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Dixon LJ, Witcraft SM, McCowan NK, Brodell RT. Stress and skin disease quality of life: the moderating role of anxiety sensitivity social concerns. Br J Dermatol 2018; 178:951-957. [PMID: 29078254 DOI: 10.1111/bjd.16082] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2017] [Indexed: 01/02/2023]
Abstract
BACKGROUND Stress is an important factor in the onset, exacerbation and reoccurrence of many skin diseases. Little is known about psychological risk factors that affect the association between stress and dermatological conditions. One relevant factor that may modulate this link is anxiety sensitivity (AS) social concerns - the propensity to respond fearfully to anxiety-related sensations (e.g. sweating, flushing) owing to perceived social consequences (e.g. rejection or humiliation). OBJECTIVES To gain insight into psychological factors affecting skin disease, we examined the moderating role of AS social concerns in the relationship between stress and skin disease quality of life (QoL). METHODS Participants [n = 237 (161 female), mean ± SD age 34·18 ± 9·57 years] with active skin disease symptoms were recruited online and completed questionnaires assessing stress, AS social concerns, skin disease QoL and global skin disease symptom severity. RESULTS AS social concerns moderated the association between stress and skin-related emotional and social functioning in adults with skin disease. Stress was a significant predictor of the impairment associated with skin disease. CONCLUSIONS Stress was linked to skin disease-related emotional and functional impairment associated with skin disease among individuals with high AS social concerns. These results highlight the potential for AS reduction interventions to break the vicious cycle of stress and skin disease symptoms and to improve psychosocial well-being in dermatology patients.
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Affiliation(s)
- L J Dixon
- Department of Psychology, University of Mississippi, P.O. Box 1848, MS, 38677, U.S.A.,Department of Dermatology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, U.S.A
| | - S M Witcraft
- Department of Psychology, University of Mississippi, P.O. Box 1848, MS, 38677, U.S.A
| | - N K McCowan
- Department of Dermatology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, U.S.A
| | - R T Brodell
- Department of Dermatology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, U.S.A
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Taylor JB, Stern TA. Meeting Its Mission: Does Psychosomatics Align With the Mission of Its Parent Organization, the Academy of Psychosomatic Medicine? PSYCHOSOMATICS 2017; 58:375-385. [PMID: 28449827 DOI: 10.1016/j.psym.2017.03.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 03/05/2017] [Accepted: 03/06/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND The vision and mission statements of the Academy of Psychosomatic Medicine (APM) indicate that the APM should promote excellence in clinical care for patients with comorbid psychiatric and general medical conditions by seeking to influence research, public policy, and interdisciplinary education. OBJECTIVE As the APM owns the journal, Psychosomatics, we sought to assess whether the APM's journal was fulfilling the vision and mission of its parent organization by reviewing the content of articles published in the journal to determine whether it sufficiently addresses the various clinical care knowledge areas it seeks to influence. METHODS We categorized content in all review articles, case reports, and original research articles published in Psychosomatics in 2015 and 2016. Each article was assigned to as many categories that it covered. RESULTS In the 163 articles reviewed, the most frequently covered fund of knowledge area was psychiatric morbidity in medical populations (44.2%); among psychiatric disorders, mood disorders (22.1%), psychiatric disorders due to a general medical condition or toxic substance (21.5%), anxiety disorders (14.7%), and delirium (13.5) were the most frequently covered. Of the medical and surgical topics, neurology (19.6%), coping with chronic illness/psychological response to illness (17.8%), toxicology (11.7%), outpatient medicine (10.4%), and cardiology (9.8%) appeared most often. CONCLUSIONS Psychosomatics appears to be successfully providing content relevant to the APM's vision and mission statements and to practitioners of psychosomatic medicine.
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Affiliation(s)
- John B Taylor
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA.
| | - Theodore A Stern
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
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