close

Вход

Забыли?

вход по аккаунту

?

Psychological factors associated with primary fibromyalgia syndrome.

код для вставкиСкачать
1101
--
PSYCHOLOGICAL FACTORS ASSOCIATED WITH
PRIMARY FIBROMYALGIA SYNDROME
TIM A. AHLES, MUHAMMAD B. YUNUS, SUE D. RILEY,
JOHN M. BRADLEY, and ALFONSE T. MAS1
Forty-five ambulatory patients with primary fibromyalgia syndrome (PFS), 30 with rheumatoid arthritis, and 32 normal controls were administered 3 psychological tests: the Minnesota Multiphasic Personality
Inventory (MMPI), the Life Events Inventory, and the
Assertiveness-Aggressiveness Inventory. The PFS patients scored significantly higher on 8 MMPI scales
when compared with the normal control group and on 4
MMPI scales when compared with the rheumatoid
arthritis group. Further subgrouping of PFS patients
according to MMPI scores showed that only 31% were
“psychologically disturbed,” 33% had a typical chronic
pain profile, and 36% were within the normal range.
The PFS patients scored higher than the rheumatoid
arthritis and normal control groups on the Life Events
Inventory but not the Assertiveness-Aggressiveness Inventory.
Fibromyalgia or “fibrositis” is a form of nonarticular rheumatism characterized by diffuse musculo-
From the Departments of Psychiatry and Behavioral Medicine and Medicine, Division of Rheumatology, University of Illinois
College of Medicine at Peoria.
Tim A. Ahles, PhD: Assistant Professor of Psychiatry
(Psychology); Muhammad B. Yunus, MD: Assistant Professor of
Medicine, Division of Rheumatology; Sue D. Riley, MA: Associate
in Psychology; John M. Bradley, PhD: Clinical Assistant Professor
of Psychiatry (Psychology); Alfonse T. Masi. MD, DrPH: Professor
and Head, Department of Medicine, University of Illinois College of
Medicine at Peoria.
Address reprint requests to Muhammad B. Yunus, MD,
Division of Rheumatology, Department of Medicine, University of
Illinois College of Medicine at Peoria, P.O. Box 1649, Peoria, IL
61656.
Submitted for publication December 29, 1983; accepted in
revised form May 25, 1984.
Arthritis and Rheumatism, Vol. 27, No. 10 (October 1984)
skeletal aches and pains accompanied by exaggerated
tenderness at specific areas (1-4). The condition is
considered primary when no known underlying cause
is evident and usual laboratory test results are normal
(1-3). Since no evidence of inflammation exists ( 3 3
and various non-musculoskeletal symptoms are present, we prefer the term primary fibromyalgia syndrome (PFS), which we have previously described as a
recognizable clinical entity (3). This syndrome is one
of the most common disorders encountered in ambulatory patients seen by generalists or rheumatology
physicians (3,6,7), and is especially common in younger women.
Although psychological factors have been implicated in this syndrome, few systematic studies have
been conducted. Using the Minnesota Multiphasic
Personality Inventory (MMPI), Payne et a1 (8) compared 30 hospitalized PFS patients with 30 rheumatoid
arthritis (RA) patients and found significantly elevated
scores in the PFS group on the Frequency (F), Hypochondriasis (Hs), Hysteria (Hy), Psychopathic Deviancy (Pd), Psychasthenia (Pt), Schizophrenia (Sc), and
Mania (Ma) scales. Based on these results, they concluded that PFS patients are psychologically disturbed.
The results of the study by Payne et a1 (8) are
interesting; however, questions remain concerning the
relevance of psychological factors in PFS. First, as
they observed, there is a large variability in the MMPI
responses of the PFS patients, implying that they may
range from a subgroup of patients demonstrating no
evidence of psychological disturbance to one showing
extreme disturbance. These results suggest that an
examination of subgroups of PFS patients is indicated.
Second, personality measures such as the
AHLES ET AL
1102
MMPI are only one means of assessing psychological
factors which may be related to medical disorders.
Other authors have proposed that stress associated
with traumatic life events (9) and low levels of social
skills (10) is implicated in the development of many
medical disorders. Therefore, instruments assessing
these variables should also be used in evaluating the
psychological status of PFS patients.
Third, the study by Payne et a1 is based upon a
comparison of hospitalized PFS patients and RA patients, whereas PFS is almost entirely diagnosed and
managed in an ambulatory setting. Thus, an ambulatory population should be studied t o avoid a possible
bias of greater psychological disturbance in a hospitalized group.
Finally, the inclusion of a normal comparison
group is important to ensure that differences found
between PFS and RA patients are due to elevated
scores of the PFS patients and not depressed scores of
the RA group.
Therefore, the purpose of this study was t o
extend the work of Payne et a1 (8). The design differs in
that we studied ambulatory PFS patients and included
a normal comparison group. Additionally, we sought
to examine the presence of subpopulations of PFS
patients based upon responses to the MMPI, as well as
to assess the association of stressful life events and
social skills in PFS.
PATIENTS AND METHODS
Forty-five consecutive, ambulatory PFS patients fulfilling our previously described criteria (3) were recruited for
the study. All PFS patients had chronic, diffuse aches and
pains and multiple tender points, but none had an underlying
or associated condition such as osteoarthritis or a history of
trauma. Roentgenograms showed minor osteophytes in 4
patients, but in none could any symptom be attributed to
these findings. Results of laboratory tests including complete
blood count, Westergren erythrocyte sedimentation rate, a
blood chemistry profile including muscle enzymes, rheumatoid factor, and antinuclear antibodies were normal or negative. Forty-three of the PFS patients were female with ages
ranging from 17-54 years (mean 34) and with a mean
symptom duration of 7 years.
Thirty ambulatory RA patients (28 female, 2 male,
aged 16-55 years, mean 37) who satisfied the American
Rheumatism Association criteria for classic or definite rheumatoid arthritis (1 1) agreed to participate in the study. The
mean symptom duration of the RA patients was 6.5 years.
Chronicity of pain, in terms of duration, was thus similar in
RA and PFS groups. Finally, 32 age-matched (?2 years)
normal female controls (NC) (aged 17-53, mean 35) with no
significant illnesses, aches, or pains were recruited for the
study. The normal controls were usually selected from
friends, neighbors, or relatives of PFS patients, thus minimizing differences in social status. All subjects signed an
informed consent form prior to participation.
The following psychological inventories were completed during one appointment: Minnesota Multiphasic Personality Inventory (12), Holmes-Rahe Life Events Inventory
(LEI) (9), and the Bakker Assertiveness-Aggressiveness
Scale (AAS) as a measure of social skills (13). Each inventory was scored using the standard methods described by its
authors, without knowledge of the participant's diagnostic
category.
Additionally, the MMPI results were used to divide
patients into subgroups using criteria similar to those of
Bradley et al(14). Those investigators found that female low
back pain patients could be divided into 4 groups based on
MMPI responses: 1) all T-scores <70 (normal profile) (12); 2)
T-score elevations (>70) on Hs and Hy scales only; 3) Tscore elevations on Hs, Depression (D), and Hy scales; and
4) T-score elevations on Hs, D, Hy, Pt, and Sc scales.
Profiles 2 and 3 are typically found in pain patients (15),
whereas profile 4 is indicative of more severe psychological
disturbance (14).
For this analysis, groups 2 and 3 were combined
since they demonstrated the same pattern except for a
moderate elevation of the Depression scale in group 3.
Therefore, all PFS and control subjects were divided into 3
groups based upon the following criteria: group 1 had no
MMPI scale score greater than 70; group 2 had T-score
elevations on Hs, D, and/or Hy; and group 3 had T-score
elevations greater than 70 on 4 or more scales.
Using this procedure, 89% of the subjects fell within
these 3 categories. The remaining subjects had fewer than 4
elevations, but at least 1 was on a scale other than Hs, D, or
Hy. These subjects included 2 PFS patients (with elevation
on Hs, Pd, Ma; and on Pd, Paranoia [Pa], respectively); 8
RA patients (with elevated scores on Male/Female [Mfl; Hs,
Pd, Sc; Pa, Pt; D, Pa; D, Social Introversion [Si]; Hs, D, Si;
Si; and Hs, Hy, Pa, respectively); and 3 NC subjects (with
elevation on Ma; Pa; and Pd, Ma, respectively). For purposes of the present analysis, these subjects were placed in
group 2.
Single-factor multivariate analysis of variance
(MANOVA) was initially used to examine the main effect of
diagnostic group. One-way univariate analyses of variance
(ANOVAs) were then used to analyze the main effect of
diagnostic category on the individual MMPI scales, the LEI,
and the AAS. The Neuman-Keul's multiple range test (16)
was used to make post hoc comparisons between pairs of
means. Chi-square analysis was used to compare the percentage of patients who fell within the 3 subgroups based on
the MMPI data.
RESULTS
The single-factor MANOVA revealed a significant difference among the 3 groups (P < 0.001) in the
responses on the MMPI scales observed simultaneously. Table 1 displays the means, standard deviations,
and 95% confidence intervals for each group as well as
the multiple R for each comparison, which is provided
1103
PSYCHOLOGICAL FACTORS IN PFS
Table 1.
Minnesota Multiphasic Personality Inventory mean, standard deviation (SD), and 95%
confidence interval (CI) for the primary fibromyalgia syndrome (PFS), rheumatoid arthritis (RA), and
normal control (NC) groups
PFS
(n = 45)
Scale
Mean
SD
Lie
Frequency t
K-correction$
Hypochondriasis9
Depression7
Hysteria#
Psychopathic devianc:y
Male/female
Paranoia
Psychasthenia**
Schizophreniatt
Mania
Social isolation$$
50.00
54.40
54.44
69.89
65.33
69.71
59.44
44.02
59.27
61.44
60.73
56.91
55.91
5.9
8.5
8.9
11.4
13.7
11.2
11.6
11.1
11.6
10.4
10.5
10.4
10.9
(n
NC
RA
= 30)
(n = 32)
Mean
SD
CI
Multiple
R*
(21.7) 49.77
6.2 (22.2) 49.72
(22.5) 51.53
5.3 (51.9) 50.06
(22.6) 55.00 9.4 ('-3.3) 59.72
(23.3) 62.47 10.3 (23.7) 50.66
(24.0) 61.43 10.6 ('-3.8) 49.16
(23.3) 64.07 8.8 (23.1) 56.19
(23.4) 53.67 8.7 (23.1) 55.88
( t 3 . 3 ) 45.70 9.8 (23.5) 48.63
55.34
(t3.4) 57.23 8.4 ('3.0)
(23.0) 55.40 9.5 ('-3.4) 52.97
( k 3 . l ) 56.23 8.1 (22.9) 52.53
(23.0) 51.83 10.9 (23.9) 54.91
(23.2) 53.47 13.0 (24.6) 48.13
6.6
6.9
8.3
8.9
10.9
8.8
9.5
7.4
8.4
9.6
6.9
10.0
9.1
(22.3)
(22.4)
(22.9)
(23.1)
(k3.6)
(23.0)
(23.3)
(22.5)
(22.9)
(23.3)
(22.4)
(23.4)
(23.1)
0.00
0.24
0.26
0.62
0.50
0.48
0.24
0.20
0.17
0.35
0.37
0.20
0.26
CI
Mean
SD
CI
* Provided as an indication of the strength of the relationship between diagnoses and MMPI scaled
scores.
t Significant difference (P< 0.05) PFS versus NC.
$ Significant difference (P < 0.05) PFS versus NC; RA versus NC.
5 Significant difference (P < 0.01) PFS versus RA; PFS versus NC; RA versus NC.
1 Significant difference (P < 0.01) PFS versus NC; RA versus NC.
# Significant difference (P< 0.05) PFS versus RA; (P< 0.01) RA versus NC; PFS versus NC.
** Significant difference (P < 0.05) PFS versus RA; (P< 0.01) PFS versus NC.
tt Significant difference (P < 0.05) PFS versus RA; ( P < 0.01) PFS versus NC.
$$ Significant difference (P< 0.05) PFS versus NC.
as an indicator of the strength of the relationship
correlation between diagnosis and MMPI scores (17).
One-way ANOVAs on the individual MMPI scales
revealed significant ( P < 0.05) differences among the
groups on 8 of 13 scales (F, K-correction, Hs, D, Hy,
Pt, Sc, Si). Post hoc analyses revealed that the PFS
804
I
group scored significantly higher than the NC group on
all 8 scales and significantly higher than the RA
patients on 4 of them (Hs, Hy, Pt, and Sc). The RA
patients scored significantly higher than the NC group
on the Hs, D, and Hy scales (all P < 0.05). No
differences among the groups were found on the Pd,
Mf, Pa, or Ma scales. Figure I displays the means for
each group.
Approximately equal numbers of PFS patients
fell within each of the 3 MMPI subgroups (Table 2),
whereas all but 2 RA patients were placed in groups 1
Table 2. Percentages of participants within the Minnesota
Multiphasic Personality Inventory (MMPI) subgroups*
MMPI subgroupt
L F K HsD HyWMfPaPtScMaSi
Figure 1. Minnesota Multiphasic Personality Inventory mean T-
score profiles for the primary fibromyalgia syndrome (u),
rheumatoid arthritis (M),
and normal control (W)
groups. See
Patients and Methods for definitions of abbreviations.
Group 1 (normal), %
Group 2 (typical
chronic pain), %
Group 3 (psychological
disturbance), %
PFS
(n = 45)
(n
RA
= 30)
NC
(n
=
32)
35.6
33.3
44.8
48.3
87.5
9.4
31.1
6.9
3.1
* PFS = Primary fibromyalgia syndrome; RA = rheumatoid arthritis; NC = normal controls.
t More PFS patients were in group 3 as compared with the RA
group (P< 0.01) and NC group (P< 0.001); more RA patients were
in group 2 as compared with WC subjects (P < 0.01).
1104
AHLES ET AL
Table 3. Mean and standard deviation of the Minnesota Multiphasic Personality Inventory scales for
primary fibromyalgia syndrome subgroups*
Lie
Frequency
K-correction
H ypochondriasis
Depression
Hysteria
Psychopathic deviancy
Male/female
Paranoia
Psychasthenia
Schizophrenia
Mania
Social isolation
Group 1
Group 2
Group 3
50.8 t 5.5 (81)
50.3 t 5.1 (88)
56.5 t 8.7 (81)
59.8 f 6.3 (69)
55.2 t 9.5 (75)
59.2 t 8.0 (81)
51.8 2 7.4 (69)
44.6 t 11.3 (63)
53.8 f 9.9 (63)
54.5 f 6.9 (81)
55.5 f 6.3 (75)
55.8 t 7.5 (81)
50.6 2 8.5 (81)
50.5 f 5.9 (75)
53.3 5.4 (73)
57.0 f 7.3 (67)
73.5 12.3 (73)
63.3 f 9.8 (60)
73.3 ? 8.3 (75)
59.3 ? 8.0 (67)
47.6 f 11.2 (73)
55.1 f 9.9 (67)
58.4 f 7.6 (67)
57.1 f 7.3 (67)
57.5 ? 12.5 (75)
5 1.2 9.9 (73)
48.6 ? 6.4 (64)
60.4 ? 11. I (71)
49.4 f 8.9 (71)
77.8 f 5.0 (86)
79.1 f 9.7 (71)
77.9 f 7.2 (71)
68.4 ? 12.7 (93)
39.5 9.7 (71)
70.0 2 7.6 (71)
72.6 f 6.7 (86)
70.6 2 10.8 (71)
57.5 f 11.4 (71)
65.1 f 8.2 (71)
*
*
*
*
* The numbers in parentheses indicate the percentage of patients who fall within the range of the
standard deviation on each scale. Group 1
psychological disturbance.
=
and 2, and the great majority of NC subjects (87.5%)
were in group 1 (P < 0.001). Significantly more PFS
patients were placed in group 3 (i.e., the “psychological disturbance” group) than RA patients (P < 0.01) or
NC subjects (P < 0,001). Finally, significantly more
RA patients (P < 0.01) were placed in group 2 compared with the NC subjects. Table 3 displays the
means and standard deviations for each subgroup as
well as the percentage of patients who fell within the
mean and standard deviation on each scale (17).
Data from the Life Events Inventory (Table 4),
analyzed by one-way ANOVA, revealed a significant
difference among the diagnostic groups ( P < 0.05).
Post hoc analyses showed that the PFS patients scored
significantly higher (P < 0.05) (mean 228.3) than either
the RA (mean 153.6) or the NC (mean 160.0) subjects.
The latter 2 groups did not differ from each other.
Analysis of the LEI responses for the 3 PFS subgroups
revealed significant differences (P < 0.05). Subgroups
1 (mean 177.9) and 2 (mean 203.0) each differed
significantly (P < 0.05) from subgroup 3 (mean 334.1)
but did not differ from each other.
Table 4. Mean scores on the Life Events Inventory for the
primary fibromyalgia syndrome (PFS), rheumatoid arthritis (RA),
and normal control (NC) groups*
PFS
(n = 38)
All groups
Group 1 (n
Group 2 (n
Group 3 (n
=
=
=
14)
14)
10)
228.3 f
177.9 t
203.0 f
334.1 f
154
RA
(n = 29)
NC
(n = 31)
153.6 5 82
160.0 2 115
113
142
180
* PFS significantly different from RA and NC groups (P < 0.05).
PFS group 3 significantly different from groups I and 2 (P < 0.05).
Group I = normal; group 2 = typical chronic pain; group 3 =
psychological disturbance.
normal; group 2
=
typical chronic pain; group 3 =
Finally, the analyses using the AssertivenessAggressiveness Inventory (Table 5) produced no significant differences among diagnostic groups or within
the 3 subgroups of PFS patients.
DISCUSSION
Our results are similar to those of Payne et al(8)
except that fewer significant differences were found
between PFS and RA patients, i.e., no differences
were found on the Pd, Pa, or Ma scales. Two potential
explanations can be offered for these differences: 1)
ambulatory patients, in general, display a lower level
of psychological distufbance than hospitalized patients, and 2) the inclusion of the NC group reveals
that some of the differences between PFS and RA
patients found in the Payne study may be explainable
by a depression of the RA scale means rather than an
elevation of PFS means (particularly with the Pd ahd
Ma scales, where the NC mean fell between those of
the PFS and RA groups).
Table 5. Mean Assertivendss and Aggressiveness scores for the
primary fibromyalgia syndrome (PFS), rheumatoid arthritis (RA),
and normal control (NC) groups*
Patient group
Assertiveness
Aggressiveness
PFS
All groups (n = 40)
Group 1 (n = 15)
Group 2 (n = 15)
Group 3 (n = 10)
RA (n = 29)
NC (n = 30)
56.4 t 10
58.9 t 10
55.1 2 6
52.4 t 13
56.3 f 7
55.7 f 8
56.2 10
56.8 8
59.3 2 10
50.6 f 10
54.8 f 10
55.8 f 8
*
*
* No significant difference among PFS, RA, and NC groups, or
among PFS subgroups. Group 1 = normal; group 2 = typical chronic
pain; group 3 = psychological disturbance.
1105
PSYCHOLOGICAL FACTORS IN PFS
Our data reveal that the differences observed
between the PFS and RA patients may be due to the
presence of a subgroup of PFS patients with marked
psychological disturbance. In the present sample, a
significantly greater proportion of PFS patients
(31.1%) fell into a “psychologically disturbed” group
compared with the RA (6.9%) and NC (3.1%) groups.
However, of equal importance, 35.6% of the PFS
patients were within the normal psychological profile,
and 33.3% had profiles which are typically seen in
patients with other pain-related disorders, including
those with a definite organic etiology, e.g., spinal
injuries (15). This latter profile is considered by some
to be a reaction to living with chronic pain since the
score elevations tend to disappear with effective treatment (18). Therefore, although these data support the
relevance of psychological factors in PFS, they also
demonstrate that severe disturbance may be present in
only a minority subset of such patients. Further,
subgrouping of PFS patients may have practical implications in the management and prognosis of these
patients, since response to treatment may decline with
increasing levels of psychopathology (15).
Although the relative level of psychopathology
within PFS groups 2 and 3 can be determined using the
MMPI, diagnostic categories cannot be specified (e.g.,
an elevation on the Hysteria or Schizophrenia scale
does not necessarily mean that the patient has somatization disorder or schizophrenia). An important area
for future investigation will be to identify the psychiatric diagnoses found with these subgroups of PFS
patients based upon the Diagnostic and Statistical
Manual of Mental Disorders (DSM 111) criteria (19).
In addition to the above relationships, we examined the role of stressful life events and social skills
(e.g., assertiveness and aggressiveness) in PFS. These
data support an association of PFS with stressful life
events, especially within the psychologically disturbed
subgroup, but not with assertiveness or aggressiveness
skills. We used the LEI of Holmes and Rahe (9) since
it has been used extensively in studying the relationship between stressful life events and physical disease.
However, the underlying assumptions of the scale, as
well as the cqnstruction of the scale have been criticized (20). A newer scale, the Daily Hassles Scale (21),
which measures the sources of daily frustration and
stress may be more appropriate for the study of
stressful life events in this population. Further investigation in this area is warranted.
Together, these data support the hypothesis
that psychological factors are associated with PFS,
particularly in the subgroup of patients demonstrating
evidence of the presence of psychological disturbance.
However, these results must be interpreted within the
context of the limitations of static group design. Multiple factors which may influence the results, other than
diagnosis, may vary among the groups. We controlled
for the major demographic variables, e.g., age and sex.
Additionally, socioeconomic status was roughly
matched in that the normal controls were recruited
from friends, neighbors, and relatives of the patients.
We also controlled for major medical variables such as
presence and duration of pain; thus, both RA and PFS
groups had a chronic condition. Therefore, although
other unmeasured variables may influence the pattern
of results, we believe that this study controls for the
major, potentially confounding variables.
Finally, it should be noted that the association
of psychological factors in a medical condition is not
unique to PFS. Psychological factors have been implicated in disorders as different from PFS as cancerrelated pain (22) and as similar as irritable bowel
syndrome (3,23). Indeed, the similarity between PFS
and irritable bowel syndrome is striking (3,23-25).
These data do not remove PFS from the realm of
medical disorders and restrict it to the psychological
arena but, rather, describe another dimension of a
common and complex disorder of unknown etiology
and pathogenesis.
ACKNOWLEDGMENT
We are grateful to Dr. Joseph M. Couri for referring
several patients for this study.
REFERENCES
1 . Trout EF: Fibrositis. J Am Geriatr SOC16331-538, 1968
2. Smythe HA: Non-articular rheumatism and fibrositis
syndrome, Arthritis and Allied Conditions. Edited by J L
Hollander, DJ McCarty. Philadelphia, Lea and Febiger,
1972, pp 874-884
3. Yunus MB, Masi AT, Calabro JJ, Miller KA, Feigenbaum SL: Primary fibromyalgia (fibrositis): clinical
study of 50 patients with matched normal controls.
Semin Arthritis Rheum 11:151-171, 1981
4. Campbell SM, Clark S, Tindall EA, Forehand ME,
Bennett RM: Clinical characteristics of fibrositis: a
“blinded,” controlled study of symptoms and tender
points. Arthritis Rheum 26:817-824, 1983
5. Yunus MB, Kalyanaraman UP, Kalyanaraman K, Masi
AT, Berg BC: Microscopic and radioactive bone scan
studies in primary fibromyalgia (abstract). Arthritis
Rheum (suppl) 25:S146, 1982
AHLES ET AL
1106
6. Mazanec DJ: First year of a rheumatologist in private
practice (letter). Arthritis Rheum 25:718-719, 1982
7. Alarcon-Segovia D: One thousand private rheumatology
patients in Mexico City (letter). Arthritis Rheum 26:688689, 1983
8. Payne TC, Leavitt F, Garron DC, Katz RS, Golden HE,
Glickman PB, Vanderplate C: Fibrositis and psychological disturbance. Arthritis Rheum 25:213-217, 1982
9. Holmes TH, Rahe RH: The social readjustment rating
scale. J Psychosom Res 4:189-194, 1967
10. Keane TM, Martin JE, Berler ES, Wooten LS, Fleece
EL, Williams JG: Are hypertensives less assertive? A
controlled evaluation. J Consult Clin Psychol 50:499508, 1982
1 1 . Ropes MW, Bennett GA, Cobb S , Jacox R, Jessar RA:
1958 revision of diagnostic criteria for rheumatoid arthritis. Bull Rheum Dis 9: 175-176, 1958
12. Dahlstrom WG, Welsh GS, Dahlstrom LE: An MMPI
Handbook. Vol. 1 . Minneapolis, University of Minnesota Press, 1972
13. Bakker CB, Bakker-Rabdau MK, Breit S: The measurement of assertiveness and aggressiveness. J Pers Assess
42:277-284, 1978
14. Bradley LA, Prokop CK, Margolis R, Gentry WD:
Multivariate analysis of MMPI profiles of low back pain
patients. J Behav Med 1:253-272, 1978
15. Sternbach RA: Pain Patients: Traits and Treatment.
New York, Academic Press, 1974
16. Bruning JL, Kintz BL: Computational Handbook of
17.
18.
19.
20.
21.
22.
23.
24.
25.
Statistics. Glenview, Illinois, Scott, F o r e m a n and Company, 1977
Butcher JN, Tellegen A: Common methodological problems in MMPI research. J Consult CIin Psychol 46:620628, 1978
Sternbach RA, Timmermans G: Personality changes
associated with reduction of pain. Pain 1:177-181, 1975
Diagnostic and Statistical Manual of Mental Disorders
(DSM 111). Washington, DC, American Psychiatric Association, 1980
Mechanic D: Discussion of research programs on relations between stressful life events and episodes of
physical illness, Stressful Life Events: Their Nature and
Effects. Edited by BS Dohrenwend, BP Dohrenwend.
New York, Wiley, 1974, pp 87-97
Kanner AD, Coyne JC, Schaefer C, Lazarus RS: Comparison of two modes of stress measurement: daily
hassles and uplifts versus major life events. J Behav
Med 4: 1-39, 1981
Ahles TA, Blanchard EB, Ruckdeschel JC: The multidimensional nature of cancer-related pain. Pain I7:277288, 1983
Whitehead WE, Bosmajian LS: Behavioral medicine
approaches to gastrointestinal disorders. J Consult Clin
Psychol 50:972-983, 1982
Kirsner JB: The irritable bowel syndrome. Arch Intern
Med 141:635-639, 1981
Yunus MB: Fibromyalgia syndrome: a need for uniform
classification (editorial). J Rheumatol 10:841-844, 1983
Документ
Категория
Без категории
Просмотров
2
Размер файла
525 Кб
Теги
factors, fibromyalgia, associates, psychological, syndrome, primary
1/--страниц
Пожаловаться на содержимое документа