1
|
Haim-Nachum S, Lazarov A, Zabag R, Martin A, Bergman M, Neria Y, Amsalem D. Self-stigma mediates the relationships between childhood maltreatment and symptom levels of PTSD, depression, and anxiety. Eur J Psychotraumatol 2024; 15:2370174. [PMID: 38985020 PMCID: PMC11238652 DOI: 10.1080/20008066.2024.2370174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 06/07/2024] [Indexed: 07/11/2024] Open
Abstract
Background: Childhood maltreatment is a risk factor for developing multiple forms of psychopathology, including depression, posttraumatic stress disorder (PTSD), and anxiety. Yet, the mechanisms linking childhood maltreatment and these psychopathologies remain less clear.Objective: Here we examined whether self-stigma, the internalization of negative stereotypes about one's experiences, mediates the relationship between childhood maltreatment and symptom severity of depression, PTSD, and anxiety.Methods: Childhood trauma survivors (N = 685, Mage = 36.8) were assessed for childhood maltreatment, self-stigma, and symptoms of depression, PTSD, and anxiety. We used mediation analyses with childhood maltreatment as the independent variable. We then repeated these mediation models separately for childhood abuse and neglect, as well as the different subtypes of childhood maltreatment.Results: Self-stigma significantly mediated the relationship between childhood maltreatment and depression, PTSD, and anxiety symptoms. For sexual abuse - but not physical or emotional abuse - a significant mediation effect of self-stigma emerged on all symptom types. For childhood neglect, self-stigma significantly mediated the relationship between both emotional and physical neglect and all symptom types.Conclusion: Our cross-sectional study suggests that different types of childhood maltreatment experiences may relate to distinct mental health problems, potentially linked to increased self-stigma. Self-stigma may serve as an important treatment target for survivors of childhood abuse and neglect.
Collapse
Affiliation(s)
- Shilat Haim-Nachum
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
- New York State Psychiatric Institute, New York, NY, USA
- School of Social Work, Tel Aviv University, Tel Aviv, Israel
| | - Amit Lazarov
- School of Psychological Sciences, Tel-Aviv University, Tel Aviv, Israel
| | - Reut Zabag
- Department of Psychology, Yale University, New Haven, CT, USA
| | - Andrés Martin
- Yale Child Study Center, Yale School of Medicine, New Haven, CT, USA
| | - Maja Bergman
- New York State Psychiatric Institute, New York, NY, USA
| | - Yuval Neria
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
- New York State Psychiatric Institute, New York, NY, USA
- Department of Epidemiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Doron Amsalem
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
- New York State Psychiatric Institute, New York, NY, USA
| |
Collapse
|
2
|
Vidales CA, Smolenski DJ, Skopp NA, Vogel D, Wade N, Sheppard S, Speed K, Hood K, Cartwright P. Assessing the dimensionality and construct validity of the military stigma scale across current service members. MILITARY PSYCHOLOGY 2024; 36:49-57. [PMID: 38193877 PMCID: PMC10790807 DOI: 10.1080/08995605.2021.1997501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 10/21/2021] [Indexed: 10/19/2022]
Abstract
US service members are at elevated risk for distress and suicidal behavior, compared to the general US population. However, despite the availability of evidence-based treatments, only 40% of Service members in need of mental health care seek help. One potential reason for the lower use of services is that service members experience stigma or concerns that the act of seeking mental health care from a mental health provider carries a mark of disgrace. The Military Stigma Scale (MSS) was designed to assess two theoretical dimensions of help-seeking stigma (public and self), specifically among service members. The goal of the current study was to further examine the validity of the MSS among 347 active duty service members. Examination of unidimensional, two-factor, and bifactor models revealed that a bifactor model, with a general (overall stigma), two specific factors (public and self-stigma), and one method factor (accounting for negatively worded items) provided the best fit to the data. Ancillary reliability analyses also supported the MSS measuring a broad stigma factor associated with seeking mental health care in the military. Subsequent model analyses showed that the MSS was associated with other stigma-related constructs. Overall, findings suggest that the MSS is a reliable and validated scale that can be used to assess military help-seeking stigma and to evaluate results of programs designed to reduce stigma.
Collapse
Affiliation(s)
| | - Derek J. Smolenski
- Psychological Health Center of Excellence (PHCoE), Silver Spring, Maryland, USA
| | - Nancy A. Skopp
- Psychological Health Center of Excellence (PHCoE), Silver Spring, Maryland, USA
| | - David Vogel
- Department of Psychology, Iowa State University, Ames, Iowa, USA
| | - Nathaniel Wade
- Department of Psychology, Iowa State University, Ames, Iowa, USA
| | - Sean Sheppard
- Uniformed Services University of the Health Sciences (USUHS), Madigan Army Medical Center, Bethesda, Maryland, USA
| | - Katrina Speed
- Department of Psychology, Mississippi State University (MSU), Tacoma, Washington, USA
| | - Kristina Hood
- Department of Psychology, Mississippi State University (MSU), Tacoma, Washington, USA
| | - Patricia Cartwright
- Department of Psychology, Mississippi State University (MSU), Tacoma, Washington, USA
| |
Collapse
|
3
|
Fowler K. Generalized Anxiety Disorder in Canadian Adults: to what Extent Might Social Support Subdomains and Negative Social Interactions Predict Psychological Distress? Psychiatr Q 2023; 94:655-673. [PMID: 37768501 DOI: 10.1007/s11126-023-10055-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2023] [Indexed: 09/29/2023]
Abstract
Generalized anxiety disorder (GAD) may involve persistent and unwarranted anxiety, fear, and rumination, combined with various somatic symptoms (e.g., fatigue, dizziness, muscle tension, and nausea) which may compel many to withdraw socially. While studies report an inverse relationship between social support and psychological distress among adults with GAD, those that assess the distinct influence of negative social relations, particularly by sex are limited. The primary aims of this study were to (a) assess and compare respondents with a lifetime of GAD in terms of levels of perceived social support (using the Social Provisions Scale - 10 Items (SPS-10) Scale), negative social interactions (using the Negative Social Interaction (NSI) Scale) and psychological distress (using the Kessler Psychological Distress Scale (K10)), and (b) determine whether SPS-10 subdomains and NSIs predict psychological distress. Compared with a matched sample without GAD, respondents with GAD were more likely to be single, divorced, and have lower incomes. Respondents with GAD also had lower overall SPS-10 scores, and lower scores for each subdomain (i.e., 'guidance', 'reliable alliance', 'reassurance of worth', 'attachment', and 'social integration'), and higher NSI and K10 scores. Although no difference in psychological distress was observed between men and women with GAD, men had lower SPS-10 scores (overall and for each subdomain), while women had higher NSIs scores. A subsequent hierarchical regression for respondents with GAD revealed that 'social integration' and 'reassurance of worth' predicted lower psychological distress, while higher NSI scores predicted higher psychological distress. Finding implications and future research are discussed.
Collapse
Affiliation(s)
- Ken Fowler
- Student Wellness and Counselling Centre, Memorial University of Newfoundland, St. John's, NL, Canada.
| |
Collapse
|
4
|
Chan KKS, Tsui JKC. Longitudinal impact of experienced discrimination on mental health among people with mental disorders. Psychiatry Res 2023; 322:115099. [PMID: 36848709 DOI: 10.1016/j.psychres.2023.115099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/29/2023] [Accepted: 02/05/2023] [Indexed: 02/09/2023]
Abstract
The present study examined the longitudinal impact of stigma on mental health among people with mental disorders. Specifically, this study tested whether higher levels of experienced discrimination would be longitudinally associated with lower levels of symptomatic remission, functional restoration, well-being, and life satisfaction and whether these associations would be mediated by higher levels of self-stigma content and process. A total of 202 people with mental disorders completed questionnaires at three time points (i.e., T1, T2, and T3) over two years. Path analyses showed that experienced discrimination at T1 was positively associated with self-stigma content and process at T2, which were, in turn, negatively associated with symptomatic remission, functional restoration, well-being, and life satisfaction at T3. Bootstrap analyses further revealed that experienced discrimination at T1 had indirect effects on symptomatic remission, functional restoration, well-being, and life satisfaction at T3 through self-stigma content and process at T2. This study shows that experienced discrimination may exacerbate self-stigma content and process and, in turn, impede recovery and wellness among people with mental disorders. Our findings highlight the importance of designing and implementing stigma and self-stigma reduction programs in order to enable people with mental disorders to attain mental illness recovery and positive mental health.
Collapse
Affiliation(s)
- Kevin Ka Shing Chan
- Department of Psychology, The Education University of Hong Kong, Hong Kong; Centre for Psychosocial Health, The Education University of Hong Kong, Hong Kong.
| | - Jack Ka Chun Tsui
- Department of Psychology, The Education University of Hong Kong, Hong Kong
| |
Collapse
|
5
|
Fung HW, Černis E, Shum MHY. Self-stigma predicts post-traumatic and depressive symptoms in traumatized individuals seeking interventions for dissociative symptoms: a preliminary investigation. Eur J Psychotraumatol 2023; 14:2251778. [PMID: 37682581 PMCID: PMC10494730 DOI: 10.1080/20008066.2023.2251778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/23/2023] [Accepted: 07/31/2023] [Indexed: 09/09/2023] Open
Abstract
Background: Previous studies showed that self-stigma is associated with poor clinical outcomes in people with serious mental illness, and is associated with post-traumatic stress disorder (PTSD). However, less is known about self-stigma in people with dissociative symptoms, which are often related to psychological trauma. This study examined whether baseline self-stigma would be associated with dissociative, PTSD and depressive symptoms at post-intervention, after controlling for treatment usage and baseline symptom severity, in a sample of traumatized Chinese adults undertaking a psychoeducation intervention for dissociative symptoms.Methods: We conducted a secondary analysis of data from a 60-day web-based psychoeducation programme. A total of 58 participants who provided data before and after the intervention were included for analysis. Hierarchical regression analyses were conducted.Results: In this highly traumatized, dissociative, and symptomatic help-seeking sample, baseline self-stigma was associated with PTSD (β = .203, p = .032) and depressive (β = .264, p = .025) symptoms at post-intervention, even after controlling for baseline symptom severity, age, location, number of sessions attended in the web-based psychoeducation programme, and use of psychological treatments for PTSD/dissociative symptoms. However, self-stigma was not associated with dissociative symptoms (p = .108).Conclusions: This is the first study showing that self-stigma is a significant predictor of comorbid symptoms (i.e. PTSD and depressive symptoms) in people seeking interventions for dissociative symptoms. The findings that post-traumatic and dissociative symptoms have different relationships to self-stigma also highlight the possibility dissociation might be an independent psychological construct closely associated with trauma, but not merely a PTSD symptom, although further studies are necessary. The preliminary findings call for more efforts to understand, prevent, and address self-stigma in people with trauma-related mental health issues such as dissociative symptoms.
Collapse
Affiliation(s)
- Hong Wang Fung
- Department of Social Work, Hong Kong Baptist University, Kowloon Tong, Hong Kong
| | - Emma Černis
- School of Psychology, University of Birmingham, Birmingham, UK
| | | |
Collapse
|
6
|
Ge R, Feng C, Cao X, Li X. Self-Management and Its Influential Factors Among Individuals With Anxiety Disorders: A Cross-Sectional Study. J Psychosoc Nurs Ment Health Serv 2022; 61:27-35. [PMID: 36198120 DOI: 10.3928/02793695-20220929-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Self-management has been proposed as a crucial pathway to recovery from mental disorders. The aim of the current study was to explore self-management and its influential factors among individuals with anxiety disorders. Data were from a cross-sectional survey of 180 individuals diagnosed with anxiety disorders. Sociodemographic characteristics, anxiety, self-management, and social support were investigated and analyzed. Participants' mean self-management score was 79.04, with a score rate of 63%. Economic burden, number of relapses, and anxiety severity significantly influenced self-management among participants. Increased social support was correlated with greater self-management. Mental health nursing services should be directed toward individuals with anxiety disorders. [Journal of Psychosocial Nursing and Mental Health Services, 61(4), 27-35.].
Collapse
|
7
|
Pyszkowska A, Stojek MM. Early Maladaptive Schemas and Self-Stigma in People with Physical Disabilities: The Role of Self-Compassion and Psychological Flexibility. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10854. [PMID: 36078568 PMCID: PMC9518149 DOI: 10.3390/ijerph191710854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 08/25/2022] [Accepted: 08/26/2022] [Indexed: 06/15/2023]
Abstract
Self-stigmatizing thoughts may be rooted in one's core beliefs, and in turn be associated with early maladaptive schemas (EMS). Psychological flexibility, an ability to distance and accept one's thoughts, is reported to diminish EMS's effect on well-being, while self-compassion, a mindful attitude towards one's suffering, often reduces self-stigma. The objective of this study was to examine associations between EMS, self-stigma, psychological flexibility and self-compassion in individuals with disabilities, as they are at higher risk of experiencing self-stigma. Participants were 238 persons with disabilities. The Self-Stigma Scale, Young's Schemas Questionnaire, the Self-Compassion Scale Short and the Acceptance and Action-II Questionnaire were used. Hierarchical regression and mediation analysis were used to establish (1) predictors and (2) potential mediators of self-stigma in people with disabilities. Hierarchical regression showed that EMS alone accounted for 39% of the variance explained by self-stigma, and with the addition of psychological flexibility-an additional 2% was explained. Parallel mediation analyses indicated that psychological flexibility partially mediated the relationship between EMS domains and self-stigma. It appears that psychological rigidity is related to self-stigma and should be addressed in treatment through evidence-based approaches such as Schema Therapy and Acceptance and Commitment Therapy to enhance individuals' healthy life patterns, flexibility and self-compassion.
Collapse
Affiliation(s)
- Anna Pyszkowska
- Department of Social Sciences, University of Silesia in Katowice, 40-007 Katowice, Poland
| | - Monika M. Stojek
- Department of Social Sciences, University of Silesia in Katowice, 40-007 Katowice, Poland
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA 30322, USA
| |
Collapse
|
8
|
Ociskova M, Prasko J, Vanek J, Holubova M, Hodny F, Latalova K, Kantor K, Nesnidal V. Self-Stigma and Treatment Effectiveness in Patients with SSRI Non-Responsive Obsessive-Compulsive Disorder. Psychol Res Behav Manag 2021; 14:85-97. [PMID: 33574718 PMCID: PMC7873032 DOI: 10.2147/prbm.s287419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 01/04/2021] [Indexed: 12/16/2022] Open
Abstract
Purpose Obsessive compulsive disorder (OCD) is a debilitating mental disorder that often takes a chronic course. One of the factors influencing the treatment effectiveness in anxiety and depressive disorders is the self-stigma. This study focused on the relationship between the self-stigma, symptomatology, and therapeutic outcomes in patients with OCD. Patients and Methods Ninety-four inpatients with OCD, who did not sufficiently respond to at least one selective serotonin reuptake inhibitor trial, participated in the study. They attended a six-week therapeutic program consisting of exposure and response prevention, transdiagnostic group cognitive behavioral therapy, individual sessions, mental imagery, relaxation, sport, and ergotherapy. The participants completed several scales: the Internalized Stigma of Mental Illness Scale (ISMI), the self-report Yale-Brown Obsessive Compulsive Scale (Y-BOCS-SR), Beck Anxiety Scale (BAI), Beck Depression Scale-II (BDI-II), and Dissociative Experiences Scale (DES). A senior psychiatrist filled in the Clinical Global Impression (CGI-S). Results The average scales' scores considerably declined in all measurements except for DES. The self-stigma positively correlated with all psychopathology scales. It was also higher in patients with a comorbid personality disorder (PD). The higher self-stigma predicted a lower change in compulsion, anxiety, and depressive symptoms but not the change of obsessions or the overall psychopathology. Conclusion The self-stigma presents an important factor connected to higher severity of OCD. It is also a minor predictor of a lower change in symptomatology after combined treatment.
Collapse
Affiliation(s)
- Marie Ociskova
- Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University in Olomouc, University Hospital in Olomouc, Olomouc, The Czech Republic
| | - Jan Prasko
- Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University in Olomouc, University Hospital in Olomouc, Olomouc, The Czech Republic.,Department of Psychology Sciences, Faculty of Social Science and Health Care, Constantine the Philosopher University in Nitra, Nitra, The Slovak Republic.,Institute for Postgraduate Education in Health Care, Prague, The Czech Republic
| | - Jakub Vanek
- Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University in Olomouc, University Hospital in Olomouc, Olomouc, The Czech Republic
| | - Michaela Holubova
- Department of Psychiatry, Hospital Liberec, Prague, The Czech Republic
| | - Frantisek Hodny
- Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University in Olomouc, University Hospital in Olomouc, Olomouc, The Czech Republic
| | - Klara Latalova
- Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University in Olomouc, University Hospital in Olomouc, Olomouc, The Czech Republic
| | - Krystof Kantor
- Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University in Olomouc, University Hospital in Olomouc, Olomouc, The Czech Republic
| | - Vlastimil Nesnidal
- Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University in Olomouc, University Hospital in Olomouc, Olomouc, The Czech Republic
| |
Collapse
|
9
|
Gomes DRAS, Zanetti ACG, Miasso AI, Castro FFS, Vedana KGG. Internalized Stigma in People With Mood Disorders: Predictors and Associated Factors. J Nerv Ment Dis 2021; 209:54-58. [PMID: 33093358 DOI: 10.1097/nmd.0000000000001257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To analyze the predictors of internalized stigma among people with mood disorders, we conducted an analytical observational cross-sectional study with 108 people with mood disorders in a public service setting in Sao Paulo, Brazil. We applied a sociodemographic and clinical questionnaire, the Internalized Stigma of Mental Illness Scale, the Medication Adherence Scale, the Brief Psychiatric Rating Scale-Anchored, and the Herth Hope Index. We analyzed the data using descriptive statistics, average comparison tests, a correlation test, and multiple linear regression. Internalized stigma was associated with symptomatology, history of aggressive behavior, psychiatric hospitalizations, suicide attempts, hopelessness, nonadherence to psychotropic medications, and unemployment. The predictors of internalized stigma were unemployment, more psychiatric symptoms, history of previous suicide attempts, and less hope. Clinical interventions and investigations for stigma reduction and psychosocial rehabilitation should incorporate the factors associated with self-stigma (aggressive behavior, history of psychiatric hospitalizations, suicide attempts, hopelessness, nonadherence to medication, and unemployment).
Collapse
|
10
|
Deres AT, Bürkner PC, Klauke B, Buhlmann U. The role of stigma during the course of inpatient psychotherapeutic treatment in a German sample. Clin Psychol Psychother 2020; 27:239-248. [PMID: 31910308 DOI: 10.1002/cpp.2423] [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: 08/12/2019] [Revised: 12/17/2019] [Accepted: 12/17/2019] [Indexed: 11/11/2022]
Abstract
The current study intends to investigate whether the therapeutic process is impeded by stigma and how stigma develops over the course of cognitive behavioural psychotherapy treatment. Sixty German psychotherapy inpatients were asked on a weekly basis about two facets of stigma: self-stigma and perceived public stigma. That information was linked to additional process as well as outcome variables (therapeutic engagement, working alliance, depressive, and general psychological symptoms). Both facets of stigma decreased over the course of psychotherapy, but only the decrease in self-stigma was significant. In a weekly interval, low (high) self-stigma predicted high (low) levels of working alliance and therapeutic engagement and vice versa. The current study shows that self-stigma is especially subject to change during the course of an inpatient psychotherapeutic treatment. In addition, our results point to the interrelation between self-stigma and other process variables contributing to the effectiveness and success of psychotherapy.
Collapse
Affiliation(s)
- Anna Tabea Deres
- Institute of Psychology, Clinical Psychology and Psychotherapy, Westfälische Wilhelms-Universität Münster, Münster, Germany
| | - Paul-Christian Bürkner
- Institute of Psychology, Clinical Psychology and Psychotherapy, Westfälische Wilhelms-Universität Münster, Münster, Germany
| | | | - Ulrike Buhlmann
- Institute of Psychology, Clinical Psychology and Psychotherapy, Westfälische Wilhelms-Universität Münster, Münster, Germany
| |
Collapse
|
11
|
Sarafim-Silva BAM, Duarte GD, Sundefeld MLMM, Biasoli ÉR, Miyahara GI, Bernabé DG. Childhood trauma is predictive for clinical staging, alcohol consumption, and emotional symptoms in patients with head and neck cancer. Cancer 2018; 124:3684-3692. [DOI: 10.1002/cncr.31597] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 05/18/2018] [Accepted: 05/22/2018] [Indexed: 12/21/2022]
Affiliation(s)
- Bruna Amélia M. Sarafim-Silva
- Psychosomatic Research Center, Oral Oncology Center, School of Dentistry; São Paulo State University - UNESP; Araçatuba São Paulo Brazil
| | - Gabrielle D. Duarte
- Psychosomatic Research Center, Oral Oncology Center, School of Dentistry; São Paulo State University - UNESP; Araçatuba São Paulo Brazil
| | - Maria Lúcia M. M. Sundefeld
- Psychosomatic Research Center, Oral Oncology Center, School of Dentistry; São Paulo State University - UNESP; Araçatuba São Paulo Brazil
| | - Éder Ricardo Biasoli
- Psychosomatic Research Center, Oral Oncology Center, School of Dentistry; São Paulo State University - UNESP; Araçatuba São Paulo Brazil
| | - Glauco I. Miyahara
- Psychosomatic Research Center, Oral Oncology Center, School of Dentistry; São Paulo State University - UNESP; Araçatuba São Paulo Brazil
| | - Daniel Galera Bernabé
- Psychosomatic Research Center, Oral Oncology Center, School of Dentistry; São Paulo State University - UNESP; Araçatuba São Paulo Brazil
| |
Collapse
|