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1.
Salud ment ; 45(2): 61-69, Mar.-Apr. 2022. tab
Article in English | LILACS-Express | LILACS | ID: biblio-1377300

ABSTRACT

Abstract Introduction Adverse childhood experiences (ACEs) are potentially traumatic events that people may experience during early life, including physical, psychological, and sexual abuse; neglect; and household dysfunction. Objective To evaluate the frequency of ACEs and their relationship with the mental and physical health of Mexican adults. Method 389 people between 18 and 65 years old were included in a cross-sectional study with an incidental sample and voluntary participation. Subjects responded to the ACEs questionnaire, the PHQ-9, the GAD-7, and the PHQ-15. Logistic regression models were used to evaluate the association between ACEs and adult health conditions. Results 75% reported at least one type of adversity, and 31.4% reported three or more. Reporting three or more ACEs was associated with an increased odds ratio for depression (OR = 5.04, 95% CI [2.38, 10.68]), anxiety (OR = 3.33, 95% CI [1.09, 6.99]), psychosomatic severity (OR = 4.58, 95% CI [2.53, 8.29]), obesity (OR = 2.08, 95% CI [1.21, 3.59]), and limitations due to physical or emotional discomfort (OR = 5.90, 95% CI [2.88, 12.09]). Higher anxiety was associated with sexual abuse (OR = 2.12 95% CI [.92, 4.85]) and witnessing violence (OR = 5.09, 95% CI [1.04, 24.77]). The probability of psychosomatic severity was higher if reported sexual abuse increased (OR = 1.94 95% CI [.06, 3.54]) and emotional neglect (OR = 1.84, 95% CI [1.02, 3.32]). Discussion and conclusion ACEs are associated to mental health difficulties and psychosomatic symptoms. The relationship between different types of adversity and health is confirmed.


Resumen Introducción Las experiencias adversas en la infancia (EAI) se refieren a la exposición durante la niñez a sucesos potencialmente perjudiciales para la salud. Estos incluyen: maltrato físico, psicológico, sexual y negligencia, así como algunas formas de disfunción familiar. Objetivo Examinar la frecuencia de las EAI y su relación con la salud mental y física de adultos en Ciudad Juárez. Método 389 personas de entre 18 y 65 años, en un estudio transversal con muestra incidental y participación voluntaria. Los instrumentos empleados fueron: PHQ-9 para depresión, GAD-7 para ansiedad y PHQ-15 para síntomas psicosomáticos. Resultados El 75% reportó al menos un tipo de adversidad y el 31.4% tres o más. Reportar 3+ EAI estuvo asociado con un incremento en Odds Ratio para depresión (OR = 5.04, 95% IC [2.38, 10.68]), ansiedad (OR = 3.33, 95% IC [1.09, 6.99]), severidad psicosomática (OR = 4.58, 95% IC [2.53, 8.29]), obesidad (OR = 2.08, 95% IC [1.21, 3.59]) y limitaciones por malestares físicos o emocionales (OR = 5.90, 95% IC [2.88, 12.09]). Una mayor ansiedad se asoció con abuso sexual (OR = 2.12 95% IC [.92, 4.85]) y haber sido testigo de violencia (OR = 5.09, 95% IC [1.04, 24.77]). Mayor riesgo de severidad psicosomática se presentó si se reportaba abuso sexual (OR = 1.94 95% IC [1.06, 3.54]) y negligencia (OR = 1.84, 95% IC = [1.02, .32]). Discusión y conclusión Las EAI están asociadas con dificultades de salud mental y psicosomatización. Se confirma relación entre los distintos tipos de adversidad y la salud.

2.
Article | IMSEAR | ID: sea-205424

ABSTRACT

Background: Medical residents are exposed to numerous stressors during their post-graduate training which affects them both physically and emotionally. This stress can have a profound impact on the resident’s ability to work and perform activities of daily living. Objectives: The goals of this study are to (1) estimate the psychological stress in medical post-graduate doctors and (2) study the sociodemographic factors associated with stress in post-graduate doctors. Materials and Methods: This was a cross-sectional study of resident doctors in a tertiary care hospital in Central India. A total of 130 medical residents at a tertiary hospital in Central India were surveyed anonymously using the Kessler psychological distress reporting scale questionnaire (K10) + self-reporting measure. Descriptive statistics as well as Pearson’s Chi-square test (χ2) and odds ratios were used to quantify the associations between categorical variables using SPSS v24.0 software. P < 0.05 was considered statistically significant. Results: A total of 131 (of 138, with a response rate of 95%) medical post-graduate residents were participated in this study. The mean age of study participants was 27 years. The results showed that there was no statistical gender difference when it came to reports of stress among the residents. Moderate amounts of stress were reported by the residents, with some of this stress requiring time off from the residency and/or medical care. Conclusions: This study has shown that postgraduate medical residents at a tertiary care hospital in Central India experience increased amounts of stress during their residency training.

3.
Environmental Health and Preventive Medicine ; : 61-61, 2019.
Article in English | WPRIM | ID: wpr-777580

ABSTRACT

BACKGROUND@#Chemical intolerance (CI) is a chronic condition characterized by recurring and severe symptoms triggered by exposure to low levels of odorous or pungent substances. The etiology of CI has been a controversial subject for a long time. The aim of this review is to summarize findings on the neurological processing of sensory information during and after exposure to low levels of odorous or pungent substances in individuals with CI, focusing on the brain function and networks.@*METHODS@#Scientific studies on CI published between 2000 and 2019 in academic peer-reviewed journals were systematically searched using medical and scientific literature databases. Only peer-reviewed articles reporting original research from experimental human studies directly associated with CI, and involving related neurological responses or brain imaging after exposure to odorous or pungent substances (i.e., in chemical provocation tests), were considered.@*RESULTS@#Forty-seven studies were found to be eligible for a full-text review. Twenty-three studies met the selection criteria and were included in this review. Evidence indicated that differences between subjects with CI and healthy controls were observed by brain imaging during and after exposure to odorous or pungent substances. Differences in brain imaging were also observed between initial exposure and after exposure to these substances. Neurological processing of sensory information after exposure to extrinsic stimuli in the limbic system and related cortices were altered in subjects with CI. A previous documentable exposure event was likely to be involved in this alteration.@*CONCLUSIONS@#This review documents consistent evidence for the altered neurological processing of sensory information in individuals with CI. Further neurophysiological research exploring the processing of extrinsic stimuli and cognition of sensation through the limbic system and related cortices in CI, and the appearance of symptoms in individuals with CI, are required.

4.
Chinese Journal of Behavioral Medicine and Brain Science ; (12): 439-443, 2018.
Article in Chinese | WPRIM | ID: wpr-704113

ABSTRACT

Objective To confirm the mediation effect of trait coping styles between childhood a-buse and psychosomatic symptoms among college students. Methods 262 medical students were investiga-ted by Psychosomatic Health Questionnaire( PHQ) ,Personal Report of Childhood Abuse( PRCA) ,Trait Cop-ing Styles Questionnaire(TCSQ),Self-rating Anxiety Scale(SAS),Suicide Ideation Scale(SIS) and Beck Depression Inventory(BDI).Structural equation models were established by Amos 7.0. Results The positive coping scores of medical students were (34.70±4.50),and (27.48±5.68) for negative coping,(7.79±5.58) for depression,(29.40±6.22) for self rating anxiety,(1.33±1.75) for suicidal ideation,(1.26±0.51) for mental symptoms,(1.27±0.52) for somatic symptoms and (3.17±4.26) for behavioral problems.Abuse total score was positively correlated with negative coping style, depression, self rating anxiety, suicidal ideation, mental symptoms and behavioral problems ( r=0.148-0.417,P<0.05) ,and negatively correlated with positive coping style(r=-0.148,P<0.05).Negative coping style was positively correlated with Beck depression,self rating anxiety,suicidal ideation,mental symptoms and somatic symptoms( r=0.252-0.350,P<0.01) ,and neg-atively correlated with positive coping style(r=-0.309,P<0.01).Positive coping style was negatively correla-ted with Beck depression,self rating anxiety,suicidal ideation,mental symptoms and somatic symptoms ( r=-0.208--0.271,P<0.01).Structural equation modeling showed that childhood abuse had an direct effect on psychosomatic symptoms( B=0.290,P<0.01) ,positive coping styles( B=-0.129,P<0.05) and negative cop-ing styles(B=0.243,P<0.01) among medical students.Positive coping styles and negative coping styles had direct effect on psychosomatic symptoms(B=-0.194,P<0.01;B=0.263,P<0.01).The model fit indexes were χ2/df=1.576,PGFI=0.585,PCFI=0.689,PNFI=0.645,RMSEA=0.047,GFI=0.951,AGFI=0.920, NFI=0.900,RFI=0.858,IFI=0.960,TLI=0.943,CFI=0.959. Conclusion The results indicate that trait coping styles as a mediator mediating the relationship between childhood abuse and psychosomatic symptoms in medical students.

5.
Rev. chil. neuro-psiquiatr ; 53(1): 24-34, mar. 2015. tab
Article in Spanish | LILACS | ID: lil-745585

ABSTRACT

Background: Several researches have demonstrated the relationship between alexithymia and depression. Some authors support the hypothesis that alexithymia measured by TAS-20 and BVAQ may be a personality trait and others point out that it would be a confrontation mechanism against stressful life events. Objective: To describe the concept of alexithymia, the evidence on its relationship with depression and its correlates within the context of various biopsychosocial aspects. Method: Medline/Pubmed and SciELO databases were used to look for evidence on alexithymia and depression. Results: The higher level of alexithymia, the higher severity of anxiety and depressive symptoms and a worse response to antidepressant treatment. Alexithymia is a risk factor for the development of psychopathological disorders (panic, eating disorders, substance abuse). In the acute phase of a major depressive disorder, alexithymia rates reached 46% and its prevalence was eight times higher in depressive patients than in a general population. Obssesive personality traits were significant predictors of alexithymia and in turn, a triggering and/or perpetuating factor and a prognosis index of psychosomatic illness in the development and maintenance of pain, mainly within a context of a negative affective state like depression. Conclusions: Alexithymia is significantly associated to depression. Future longitudinal studies are required to determine if both conditions are different phenomena or affective and cognitive variants of a unique psychopathological disorder.


Antecedentes: Numerosas investigaciones han demostrado la relación entre alexitimia y depresión. Algunos autores apoyan la hipótesis de que la alexitimia, evaluada por la TAS-20 y el BVAQ, puede ser un rasgo de personalidad y otros señalan que sería un mecanismo de afrontamiento ante eventos vitales estresantes. Objetivo: Describir el concepto de alexitimia y la evidencia de su relación con la depresión y su correlación con diversos aspectos biopsicosociales. Método: Se realizó una búsqueda bibliográfica de evidencia sobre alexitimia y depresión mediante las bases de datos Medline/PubMed, SciELO y textos especializados. Resultados: A mayor nivel de alexitimia, mayor severidad de síntomas ansiosos y depresivos y peor respuesta a antidepresivos. La alexitimia es un factor de riesgo para el desarrollo de trastornos psicopatológicos (pánico, conducta alimentaria, abuso de sustancias). En la fase aguda de un trastorno depresivo mayor, la tasa de alexitimia alcanzó un 46%, siendo su prevalencia ocho veces superior entre depresivos que en la población general. Los rasgos obsesivos de personalidad fueron predictores significativos de alexitimia, siendo ésta además un factor desencadenante y/o perpetuante e índice pronóstico de enfermedades psicosomáticas, favoreciendo el desarrollo y mantención del dolor, principalmente en el contexto de un afecto negativo como la depresión. Conclusiones: La alexitimia se encuentra significativamente asociada a la depresión. Se requieren futuros estudios longitudinales para determinar si ambas condiciones corresponden a fenómenos distintos o a variantes afectivas y cognitivas de un mismo desorden psicopatológico.


Subject(s)
Humans , Adaptation, Psychological , Affective Symptoms , Depression
6.
Korean Journal of Psychosomatic Medicine ; : 79-86, 2014.
Article in Korean | WPRIM | ID: wpr-69507

ABSTRACT

OBJECTIVES: Shift work disorder occurs when you have difficulties adjusting to a work schedule that takes place during a time which most people sleep. Some people may have diverse psychosomatic symptoms, such as sleep problems, depression, anxiety, and headaches even after the shift work schedule ends. The aims of this study are to compare difference of psychosomatic symptoms between rotating shift and daytime working nurse groups. METHODS: Volunteer nurses working in a general hospital were recruited in a general hospital. We collected sociodemographic data. We used questionnaires for headache type, headache frequency, and VAS(Visual Analog Scale) for headache intensity, BDI(Beck depression Inventory) and GSAQ(Global Sleep Assessment Questionnaire). We used Mann-Whitney test and Chi-square test for hypothesis testing. RESULTS: Data collected from 84 women nurses. Rotating shift(N=37) working nurses showed younger, more unmarried, and shorter work periods than daytime working nurses (N=47). Also rotating shift group showed more problems of headache, insomnia, excessive daytime sleepiness, depression and anxiety than daytime group. The above results were statistically significant. CONCLUSIONS: The rotating shift work women nurses produced more headache, insomnia, excessive daytime sleepiness, depression, and anxiety than daytime working ones.


Subject(s)
Female , Humans , Anxiety , Appointments and Schedules , Depression , Headache , Hospitals, General , Surveys and Questionnaires , Single Person , Sleep Initiation and Maintenance Disorders , Volunteers
7.
Journal of Korean Academy of Nursing ; : 888-895, 2005.
Article in Korean | WPRIM | ID: wpr-88710

ABSTRACT

PURPOSE: This cross-sectional study was designed to identify anger-expression types in late school-age children and investigate the relation between the identified anger-expression types and their health status. METHOD: One thousand twenty seven children in elementary school fifth and sixth grades were recruited from November to December, 2004. Data was analyzed using descriptive statistics, cluster analysis, 2-test, ANOVA, Duncan's multiple comparison test, and Wilcoxon rank sum test. RESULTS: Three anger-expression types in late school-age children were found; Anger-out/in, Anger-control, and Low anger-expression types. Children frequently using the anger-out/in type among the three types and with a higher state anger reported higher psychosomatic symptoms and depression. Children from a divorced or separated family reported higher state anger. CONCLUSION: This study suggests that a specific anger management program needs to be developed for late school-age children with high state anger and frequently using the anger out/in expression type. For understanding the anger level and the anger expression types of Korean school-age children, further research needs to be done with large samples using a randomized sampling method.


Subject(s)
Male , Humans , Female , Child , Psychophysiologic Disorders/psychology , Korea , Health Status , Family Characteristics , Depression , Cross-Sectional Studies , Psychology, Child , Anger
8.
Environmental Health and Preventive Medicine ; : 95-102, 2004.
Article in English | WPRIM | ID: wpr-332062

ABSTRACT

<p><b>OBJECTIVES</b>To examine the relationship between lifestyles and psychosomatic symptoms in children, we conducted a self-administered questionnaire survey of elementary school students and junior high school students in Japan.</p><p><b>METHODS</b>We designed an original questionnaire to investigate the lifestyles and psychosomatic symptoms of children. In 1997, responses to the questionnaires were elicited from public elementary school fourth grade students (then aged 9-10) and public junior high school seventh grade students (then aged 12-13). The survey was repeated annually for three years as the students advanced through school.</p><p><b>RESULTS</b>For both boys and girls, each cross-sectional analysis revealed a strong relationship between lifestyle behaviors and psychosomatic symptoms. Psychosomatic, symptoms scores varied according to daily hours of sleep, eating of breakfast, having strong likes and dislikes of food, bowel habits, and daily hours of television watching. Both boys and girls with "good" lifestyle, behaviors evaluated by the HPI (Health Practice Index) showed lower scores for psychosomatic symptoms.</p><p><b>CONCLUSIONS</b>These findings show that the lifestyle behaviors of children are significantly associated with psychosomatic symptoms and suggest that poor lifestyle behaviors are likely to increase physical and psychological health risks.</p>

9.
Environmental Health and Preventive Medicine ; : 95-102, 2004.
Article in Japanese | WPRIM | ID: wpr-361448

ABSTRACT

Objectives: To examine the relationship between lifestyles and psychosomatic symptoms in children, we conducted a self-administered questionnaire survey of elementary school students and junior high school students in Japan. Methods: We designed an original questionnaire to investigate the lifestyles and psychosomatic symptoms of children. In 1997, responses to the questionnaires were elicited from public elementary school fourth grade students (then aged 9–10) and public junior high school seventh grade students (then aged 12–13). The survey was repeated annually for three years as the students advanced through school. Results: For both boys and girls, each cross-sectional analysis revealed a strong relationship between lifestyle behaviors and psychosomatic symptoms. Psychosomatic symptoms scores varied according to daily hours of sleep, eating of breakfast, having strong likes and dislikes of food, bowel habits, and daily hours of television watching. Both boys and girls with “good” lifestyle behaviors evaluated by the HPI (Health Practice Index) showed lower scores for psychosomatic symptoms. Conclusions: These findings show that the lifestyle behaviors of children are significantly associated with psychosomatic symptoms and suggest that poor lifestyle behaviors are likely to increase physical and psychological health risks.


Subject(s)
Child , Life Style
10.
Journal of Korean Neuropsychiatric Association ; : 387-395, 2003.
Article in Korean | WPRIM | ID: wpr-70433

ABSTRACT

OBJECTIVES: Our objectives were to examine the differences of coping strategies, sexual abuse, physical abuse, and psychosomatic symptoms between student adolescents and delinquent adolescents and to explore the extent of influence of psychosomatic symptoms and coping strategies to delinquent behavior among Korean adolescents. METHODS: The research design of this study was cross-sectional nation-wide survey using Mental Health Questionnaire for Korean Adolescents(MHQKA). Subjects serving for this study were consisted of 2,086 including 1,230 student adolescents and 856 delinquents adolescents, using the proportional stratified random sampling method. Their age range was from 12 to 18. Data were analysed by IBM computer using SAS program. Statistical methods employed for this study were Cronbach's Alpha for reliability, chi2, t-test and path analysis etc. RESULTS: The results of this study were as follows : (1) Delinquent adolescents showed the more sexual abuse, physical abuse, psychosomatic symptom I, II, III and IV than student adolescents. (2) Delinquent adolescents showed the more negative coping strategies such as cognitive avoidance, behavioral avoidance, and consequently higher delinquent behavior than student adolescents. (3) The most powerful contributing variables on delinquent behavior among Korean adolescents were sexual abuse, psychosomatic symptom I, physical abuse, behavioral avoidance coping strategies, cognitive avoidance coping strategies in this order named. CONCLUSION: The results of the present study confirmed the relationship between psychosomatic symptoms and coping strategies and delinquent behavior. However, in view of the cross-sectional study character of the present study one needs to be cautious in interpretation on the relationship between psychosomatic symptoms and coping strategies and delinquent behavior. Several potential processes may underlie the relationship among these variables.


Subject(s)
Adolescent , Humans , Cross-Sectional Studies , Mental Health , Surveys and Questionnaires , Research Design , Sex Offenses
11.
Chinese Mental Health Journal ; (12)2002.
Article in Chinese | WPRIM | ID: wpr-684750

ABSTRACT

Objective:To study the relationship between psychosomatic symptoms and psychosocial factors of nursing students in military school.Methods:469 nursing students of a military medical school were investigated by SCL-90,EPQ,PSSS,Coping style inventory and self-esteem scale and so on.Results:Nursing students had lower SCL-90 score than the norm of Chinese female and that of military medical students.Their SCL-90 score correlated with EPQ-E、EPQ-L negatively and EPQ-N、EPQ-P positively.It also correlated with passive coping style positively; with positive coping style,self-esteem negatively.Conclusion:Nursing students of military school have less psychosomatic symptoms than medical students.The influential factors are similar to other populations.

12.
Chinese Mental Health Journal ; (12)2002.
Article in Chinese | WPRIM | ID: wpr-587475

ABSTRACT

Objective: To study the effect of childhood abuse on students mental health and alexithymia, and to analyze the relationship between psychosomatic symptoms and alexithymia. Methods: 90 abused Technical Secondary School Students and 90 no-abused Technical Secondary School Students from Xuzhou were investigated by applying Symptom Checklist 90 ( SCL - 90 ) , Toronto alexithymia Scale ( TAS) . Results: Compared with no-abused students, the students who had been abused in childhood showed significantly higher psychiatric symptoms of somatization (1. 8?0. 6) , interpersonal relationship (2.0?0.7) , depression (1.9?0.6) , anxiety (1. 8?0. 5 ) , hostility (1. 8?0. 6) , paranoia (1. 9?0. 6) , psychoticism (1. 8?0. 6) , obsessive (2. 0?0. 6) , phobia (1. 7?0. 6) than control (1.4?0.5, 1.7?0.6, 1.6?0.6, 1.6?0.5, 1.5?0.5, 1.6?0.5, 1.6?0.5, 1.8?0.6, 1.5?0.5, P

13.
Chinese Journal of Clinical Psychology ; (6)2001.
Article in Chinese | WPRIM | ID: wpr-540006

ABSTRACT

Objective:To investigate the Psychosomatic symptoms and coping styles and their influences on quality of life in chronic Hepatitis B.Methods:The Chronic Hepatitis Disease Questionnair(CLDQ),Symptoms Checklist(SCL-90) and Medical Coping Modes Questionnair(MCMQ) were administered to 152 Chronic Hepatitis B.Results:The scores of SCL-90 of the patients were found to be different from the norm and the normal controls and negatively correlated with scores of CLDQ for all domains.The patients had a lower Confronce score and higher Avoidance and Acceptance-Resignation scores compared with the norm,and there was negative correlation between the scores of negative coping styles and the quality of life.Conclusion:The psychosomatic symptoms and the negative coping styles of chronic Hepatitis B can influence their quality of life.

14.
Kampo Medicine ; : 225-232, 1997.
Article in Japanese | WPRIM | ID: wpr-368226

ABSTRACT

The authors investigated the clinical effects of Shishi-zai for neurosis with chest disturbance. There were 19 subjects in the study, 9 of which reported improvement with Shishi-zai. Three of the cases in particular showed marked improvement and will be discussed here.<br>The first case was 68-year-old female who had been suffering from pharyngolaryngial neurosis. She came to our clinic in March of 1994. Shishi-kanzoshi-to was given for a burning sensation in the throat. She reported relief after administration. The second case was 57-year-old female who had previously suffered from ethylene oxicide poisoning. She complained of chest discomfort and sleeplessness. Shishi-kanzoshi-to was administered and her complaint was improved. The third case was 25-year-old female who had been suffering from atopic dermatitis. She had a relapse when her relationship with her husband was strained, and was also experiencing headaches and anxiety when she came to our clinic in September of 1994. Her condition was reliened by administration of Shishi-kankyo-to.<br>The results suggest that Shishi formulas are effective for neurosis with chest discomfort when the indicators of sleeplessness, heat sensations, restlessness and flaccidity of the epigastrium are present.

15.
Arq. bras. cardiol ; 60(4): 269-272, abr. 1993. tab
Article in Portuguese | LILACS | ID: lil-127036

ABSTRACT

Objetivo - Avaliar a eficácia e a segurança do cloridato de buspirona em pacientes de clínica cardiológica com manifestaçöes de ansiedade generalizada. Métodos - Cinquenta pacientes ambulatoriais de clínica cardiológica com sintomas psicossomáticos cardiovasculares foram tratados com cloridato de buspirona na dose inicial de 5mg 3 vezes ao dia, por 6 semanas. Resultado - Os resultados obtidos foram considerados bons em 76//, regulares em 18// e ineficazes em 6// dos casos. Treze pacientes (26//) relatarm pelo menos uma reaçäo adversa, os efeitos colaterais relatados foram sonolência, cefaléia, flatulência, zumbido, congestäo nasal e boca seca. Näo houve necessidade de interrupçäo do tratamento. Conclusäao - O cloridato de buspirona é uma alternativa válida no tratamento da ansiedade patológica em pacientes onde o estado de vigilância e habilidade psicomotora devem ser preservados


Purpose - To evaluate the efficacy of buspirone hydrochloride in patients of the cardiologic clinic with generalized anxiety. Méthods - Fifty out-patients with psychossomatic cardiovascular symptons in cardialogy were treated for six weeks with initial dose of 5mg of baspirone hydrochloride t.i.d. Results - The results obtained were good in 76% of the patients, foir in 18% and ineffective in 6% of the cases. Thirteen patients (26%) reported at least one adverse event, the side effects reported were: somnolence, headache, flatulence, tinnitus, nasal congestion and dry mouth. No interruption of the treatment was needed. Conclusion - Buspirone hydrochloride is a valid alternative for treating pathological anxiety in patients in which the state of alertness and good psychomotor skills must be preserved


Subject(s)
Humans , Male , Female , Anxiety/drug therapy , Buspirone/therapeutic use , Cardiovascular Diseases/psychology , Psychophysiologic Disorders/drug therapy , Buspirone/administration & dosage , Treatment Outcome , Ambulatory Care
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