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    Clinical Trial Effecst of Writing

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    Đức Nguyên
    skill

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    © All Rights Reserved
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    iim PRELIMINARY Effects of Writing About Stressful Experiences on Symptom Reduction in Patients With Asthma or Rheumatoid Arthritis A Randomized Trial Joshua M. Arthur A. Sto Alan Kaell, MD ‘GROWING AMOUNT OF LITERA- ture suggests that addressing palients| psychological needs produces both psychological and physical health benelits."> Expres- sive writing is one such technique that has been used successfully in several con- trolled studies.*© A brief written emo- ional expression exercise developed by Pennebaker and Beall’ has been tested in studies of health benefits in healthy per- sons. ILcalls or partiipating subjects to write an essay, typically during a 3-day period, expressing their thoughts and feelings about a traumatic experience. Differences have been found between control subjects (Who write about in- rnocuous topics) and experimental sub- jects in frequency of subsequent health L-being, and immune function." A recent mela center visits, subjective w analysis of this written emotional ex pression exercise concluded that the procedure reliably improved health out- Prior studies have not addressed the clinical relevance of these findings, in part because thetr samples were physi cally healthy people. Itis not clear that the effects extend to individuals with medical conditions. Prior studies were For edi comment see p 13 404 JAMA, Ap L4, 1992 Vol 201, No. 14 Downloaded From: http:/jamanetwork.com/ on 12/28/2016 Context Nongharmacologcal treatments white patent costorricare sey rent tophamacolhaapy fhe earn’ of pats th cronies Resear has emontated hat wing out emotonaly traumatic expeenceshasssurpisngh ber= tfeilefecton symptom reports, wel-aeng, and hea cre sein hea naa Objective To determine if wring about stressful life experiences affects deease Statusin patients wth asthma orheumated arts Using standardized quanttstive outcome measures Design Randomized controled isl conducted between October 1996 and Decem- bor tio7 Setting Cutpten community residents awn from private and isto practice. Patients. Volunteer sample of 112 patient wit asthma (n= 61) or rheumatoid a- fh (0251) receved the nterenton 107 completed the study, 38 nthe asta roup and 49 inthe eumatod ans provp. Intervention Patients were assigned to wre ether abou the mos stressful event oftherives(n=7'- 29 asthma, 38 heumatld atts) orabout emotional neu topics (ne; 22 asthma, 19 rheumatold arth) (he conta intervention, Main Outcome Measures Asthma patents were evaluated with spromety and ‘heumatois arnt patients wee cnkly examined by 2 heumatologet Ase tents were conducted at baseline and at 2 weeke and 2 months and 4 month afer Urting and were done Bnd to expenmentaleonaiton. Results Of evaluable patents & months after treatment, asthma patient in the ex- Permental group stowed improvements in lung functon (the mean percentage of predicted forced expiratory woume in second [FEV] improved from 629% at sse- fine to 78.3% atthe month follow-up, Pe O01, wheres contol group patents shoved nochange Rheumatoid artis patients nthe expermental group showed improvement in overall sesse acy (a mean reduction disease seventy fom ‘eb to 119 28%] ona sale of [asymptomate] to [very severe the month follow-up: P=.003), wherens contol rou patient didnot change. Combining al completing patents, 33 (27 1%) of 70 experimental patents had inkl eevant Improvement, whereas 9(24 3%) of37 contol patients had improvement = 001) Conclusion Patients wth mid to moderately severe asthma or rheumatoid artis iho wrote about stressful fe experences had ial relevant changesin hela tusat'4 month compared with tose inthe contol goup. These gins were beyond those atrbutable tthe standard medical care tat partpants were receiving remain unknown whether these health mproverments wl pers beyond 4 months orwhether ths exercse wil prove effective nth other dees dana onaer nee a Fate aos eid eco sa” Sah AD Depo oe wa al fee Noftn Dakota State Universiy, Ftgo, ND 53105 CCrtesponding Author and Reprints: Joshua M5075 emai srytndprae nok ed). (©1909 American Medical Association, All rights reserved, also limited to indirect measures of dis- cease (eg, iver enzyme function, health center Visits) oF to self-reported assess- ments." While important outcomes in their own right, self-reported symp- toms are susceptible to many biases.” Therefore, we used outcomes more closely related to disease status. This study examined whether writ- ing about stressful experiences affects objective measures of disease status in patients with chronic asthma or theu- rmatoid arthritis (RA). We chose these 2 diseases because they are common, cause substantial personal and eco- nomic burden, and are chronte cond) tions affecting daily life. As writing pro- duces health benefits in healthy people, we hypothesized that patients as- signed tothe experimental group would show improvements in outcomes 4 months alter writing compared with a control group. We also hypothesized that health changes would be of clini- cally significant magnitudes METHODS: Study Population Participants wer {rom local communities who had asthma oF RA. Diagnoses were confirmed in the RA group by a board-certified rheuma- ‘ologist and all participants met Ameri can College of Rheumatology criteria, Asthma was diagnosed by a history of asthma confirmed by a physician; pa tients were also required to provide a documented reduction in expiratory function (either in physician records or when evaluated by study staf). Adver- Lisements were posted in local newspa pers and at nearby hospitals and medh cal practices, seeking individuals with asthma or RA to “participate in a study of your daily experience of illness.” In- terested participants were screened by telephone to determine eligibility and to collect demographic and other data used (o characterize participants vs nonpar- Licipants, Exclusion criteria included the following: (1) ongoing psychotherapy or hhavinga defined psychiatric disorder, (2) using medication that could interfere with symptom report (eg, mood- altering medications) or king more volunteers recruited (©1909 American Medical Association. All Downloaded From: http:/jamanetwork.com/ on 12/28/2016 ‘WRITING ABOUT STRESSFUL EXPERIENCES than 10 mg of prednisone daily, (3) be- ing deemed unable to comply with the protocol (either self-selected or by in- dicating during screening that he or she could not attend sessions or complete all requested tasks), and (4) being un- able to write for a duration of 20 min- utes. Participants received $50 for com- pleting the entire protocol, which was conducted between October 1996 and December 1997, Procedures Approval was obtained from both the Slate University of New York at Stony Brook and the University Hospital hu- man subjects review boards. Informed consent was obtained from interested and eligible patients for random) tion and for medical examinations at the first visit to our laboratory. Consent- ing patients completed baseline ques- tlonnaires, which included demo- graphic information, measures of disease severity and quality of life" and a variety of psychological ques- lionnaires to be used in future exami nations of individual differences in re- sponse to this intervention, Intervention Participants were asked to write for 20 minutes on 3 consecutive days a week after completing baseline assessments, Writing took place in private rooms lo- cated in our laboratory to ensure con- fidentiality. All participants were given writing tablet containing an insert with ‘writing instructions. Participants in the experimental group (39 asthma, 32 RA) ‘were assigned to write about the most stressful experience that they had ever undergone, while the participantsin the control group were asked to describe their plans for the day. Expectancy dif- ferences were minimized by informing both groups that we were interested in their experience of stress. Experimen- tal participants were explicitly writing about stressful life experiences, while control group writing was framed as a lime-management exercise to reduce stress, Participants were asked to write continuously, without regard for spell- ing or stylistic concerns, and were sig- sights reserved naled to stop after 20 minutes, Partict- pants could write about a topic for 3 sessions, of move from one topic to an- other (they were asked to repeat a pre vious topic, ifnecessary, rather than stop carly). All essays were anonymous and were returned by dropping the writing tablet intoa sealed box. Participants did not discuss their writing with project stall, and participants were ne tact with one anotheras par of the study (eg, ina waiting room) ‘Sample-Size Determination A recent meta-analysis! suggests that the elfect size of this exercise in healthy samples isd =0.47, although effect sizes for the measures tsed in this study are likely to be closer to d=0.68. Power computations for an unbalanced de- sign indicate that an overall total of 120 should be sufficient to achieve 80% power with 2ailed tests and a =.05. Outcome Measures Disease activity outcomes were evalu- ated at baseline, 2 weeks, 2 months, and + months after writing. (Self- assessments of the psychosocial envi ronment were also collected by partici pants for L week prior to and 2 weeks following the writing exercise, but these results are not presented herein.) The pulmonary function of patients with asthma was assessed in the laboratory by spirometry (Renaissance, Nelleor Pu- ritan Bennett, Mallinckrodt, St Louis, Mo), following the guidelines put forth by the American Thoracic Society. The primary outcome measure was forced expiratory volume in 1 second (FEV,). Evaluations of RA patients were made with a structured interview com- pleted by the treating rheumatologist 114s a modification of that used by AE. fleck and colleagues.** and reflects the recent shift away from entirely quali- tative to more quantitative, standard- ized methods.” The interview re- quires the physician to rate diagnostic symptoms, a global assessment of dis- case activity, symptom severity, disti- bution of pain, tenderness, and swell- ing throughout the affected joints, presence and severity of deformities, JAMA, Api 14, 1999—Vol 201, No 6 1305 WRITING ABOUT STRESSFUL EXPERIENCES assessment of daily living capacity, and general psychosocial functioning. The primary outcome measure for this study was the physician’s global assessment of patients’ current clinical status, which has been recommended for use in RA clinical trials.” Each RA patient had 4 clinical examinations completed by the same physician, Several physi- cians conducted evaluations for the study. These measures not only repre Figure 1. Tal Proc Hl sent the core symptoms of the 2 dis- ceases but also represent contrast approaches to illness evaluation (1 bio- mechanical, 1 clinical interview). All raters were unaware of experimental condition. Statistical Analysis In addition to overall intervention, {group comparisons from baseline to f- nal follow-up, analyses examining the clinical relevance of observed changes and the time-course of changes were planned in advance. Group differ cences were evaluated with analysis of covariance, testing the effect of group (control vs experimental) at 4 months following writing, statistically control- ling for baseline levels. Clinical rel- cevance was tested by examining the dis- tribution of patients who met our criteria for clinically relevant improve- ment in each group, using x? analyses, Finally, the time course of changes was examined using repeated measures analysis of covariance including terms representing the effect of group, time, and the interaction of group and time, Random Assignment and Masking An unbalanced design with greater numbers of participants assigned to the ‘Table 1, Sample Characteristics by Disease Group™ Characteristics Fg TERA SDIY Feral Te at onion ean BO) FEacaton, mean (50), gad Werking tuFtine Working pari Partin, mean SDF Fay eee, mea Foguer medieaton use Foguir erie Shoes Aas atime 29) (n=58) ich wz g 959) a0, 3a a0, 7 a0, TT a0, 7 Ta ay Tart) ao aE Ta Bo Boa EH) a a5 1306 JANA, apn 14, 1999—Val Downloaded From: http:/jamanetwork.com/ on 12/28/2016 experimental than the control condi tion (35:21 for RA, 48:22 for asthma, respectively) was used to enhance later exploration of the experimental group (4 patients dropped out of the study before receiving the intervention). After entering the study and completing base- lineassessments, participants were ran- domized into the control or experimen- tal group using a computer-generated random assignment scheme, which assigned 2 of every 3 patients (within disease group) tothe experimental con- dition. This strategy also provided com- parable seasonal effects for control and experimental groups. Assignments were kept in sealed opaque envelopes until participants were scheduled to com- plete the writing interves point the research coordinator pre- pared intervention instructions spe cille to group assignment, These instrutc- dons were then handed to patients who were instructed to open them in pri- vacy. Neither patients nor physicians were informed ofthe assignment. There was no indication that either patients oF physicians attempted to compro- mise blinding procedures. Statistical analyses were conducted primarily by the first author, who was aware of group assignment on, atwhich RESULTS Participants We received 405 telephone calls ex- pressing interest in the study, 222 from, asthma patients and 243 from RA pa tients. Among the asthma patients, 31 callers (14.0%) were interested but not eligible, 73 32.0%) were eligible but said they were not interested in participat- ing because of the time commitment, 32 (4.496) were not interested and did not provide eligibility information, and project stall were notable to contact the remaining 16 (7-2). Among the RA pa- 35 callers (14.4%) were inter- ested but not eligible, 49 (20.2%) were eligible but not interested because ofthe 7 (35.89) were not interested and did not provide eligibil- ity information, and project staff were not able to contact the remaining 16 (6.6%). This resulted in 126 eigibleand (©1909 American Medical Association, All rights reserved, terested callers who initisted partict- pation in the study. These subjects did not differ on any demographic mea- sures (age, sex, number of children, edu- cation, employment status, income; all P values >.10) from individuals ineli- gible or not interested. After beginning the study, 14 participants (11%) dropped out before completing the written dis- closure exercise—9 from the asthma group and 5 from the RA group. All par- Uicipants exiting the study were de- briefed. Four participants cited current life events (divorce, the development of ancurological disorder, death of a close fiend, and being recently unemployed and constantly interviewing for new jobs). One participant was unable to par- Uicipate duc to work constraints. The re- maining 9 participants indicated that they were too busy with personal is- sues. This information is summarized in a tral profile (FIGURE 1), Baseline sample characteristics for each disease group are shown in TABLE 1. The sample represents the \ypical distribution ofthese diseases and {s representative of the geographic area from which it was drawn. Baseline Equivalence Control and experimental groups did not differ (using an @ of P<.20) at base- line on demographic measures (age, sex, number of children, education, em- ployment status, income), health be- haviors (regular medication use, exer- cise, smoking), or psychological measures (alexithymia, intrusive and avoidant thoughts, coping strategies, or anxiety). Baseline disease severity did not der between control and experi mental groups for asthma outcomes (FEV, FEV /forced vital capacity [EVCI, quality of life) or RA out comes (overall disease activity, RA symptoms, joint pain, joint swelling) Outcomes The first hypothesis was that the ex- perimental group, relative to the con- ‘gol group and controlling for baseline levels of disease, would show improve- ‘ments in objective health indicators 4 months after writing. In patients with (©1909 American Medical Association. All Downloaded From: http:/jamanetwork.com/ on 12/28/2016 ‘WRITING ABOUT STRESSFUL EXPERIENCES asthmas, writing about emotionally lraumatic events was related to signifi- cantly greater improvement in FEV,, compared with controls (F,3s= 15.11, P<.001; FIGURE 2). The same elfect was found for overall rheumatic disease ac- Livity, for which writing was related to significant reductions in disease activ- ity (F,49= 11.48, P=.001; Figure 2). These results confirm the hypothesis that writing about emotionally tras matic experiences reduced symptoms in individuals with chronic illness. These primary analyses were repli- cated using nonparametric statistics, which require many fewer assump- tions about the distribution ofthe data, to ensure that the findings were ro- bust. For both RA and asthma groups, no control vs experimental difference was observed at baseline (Wilcoxon rmatched-pairs signed-rank test <= 0.07, P>.20; z= -0.61, P>.20, respec. tively), but a strong difference was found at the 4-month follow-up (Wil- ccoxon matched-pairs signed-rank test 41, P<.001; z= -2.42, P= 016). The second hypothesis concerned the clinical significance of observed differ- cences. To quantify patient change over 4 months, we defined 3 categories of change, which include the following: im- provement, no significant change, and worsening (defined by baseline to 4 month follow-up change). For patients ‘with asthma, improvements of 15% or seater in FEV, over pretreatment val- utes were defined as improvement, whereas worsening was 15% oF greater decline from pretreatment values, The ‘overall rating of disease activity used for RA patients was categorical (asymptom- atic, mild, moderate, severe, very vere), so we followed published guide lines that a shift in 1 category to another Ss aclinically significant change.” A shift of 1 oF more categories toward asymp- tomatic defined improvement, and a worsening condition was by moving 1 lor more categories toward very severe. (No participants shifted more than 2eat- egories in either direction over the course of the study.) Experimental group participants showed greater rates of improvement and lesser rates of worsening than the control group across both diseases Figure 2 eect of structured Writng By Disease: Acta or Rheumatoid Arthrtis ac L i Be 2 : a i é Followup by Bxpermental Group Assignment” 2. Percentage of Patents With Clinically Relevant Changes From Baseline to 4-Month Tio, (of Paonte With Ghanga mn Disease Satue Wore Patan comping oy ancl act Erpararial in =70 Tes Conott = 63 ane) Experian = EI] ‘No Change Improve 20 SEB, ara 25 605) 9/209) TT EB) wang) sights reserved JAMA, Api 14, 1999—Vol 201, No 6 1307 WRITING ABOUT STRESSFUL EXPERIENCES (x= 10.42, P=.005; Fisher exact low-up (Table 3). Means (and SEs) for writing exercise." Ibis possible that P<006; TABLE2). Acrossall groups,33 cach time point, by group assignment, such affective or physiological re experimental patients (47.1%) im- are shown in Table 3. sponses can explain our results. Alter- proved according to these criteria, ———________________ naively, participants’ cognitive and Whereas 9 of control patients (24.3%) COMMENT memory representation of past traumas Improved. Adopting a more conserva- Thisisthe first study todemonstratethat may be altered by this writing exercise, tive intent-to-treat approach, we repli- writing about stressful life experiences perhaps facilitating improvements in cated these results by including all pa- improves physician ratings of disease se- coping with stressful events" The most tients who had not completed thestudy verity and objectiveindices ofdiseasese- common topics patients wrote about in the “no change” group (x':=10.38, verity in chronically ill patients. These were the death of a loved oni (006; Fisher exact P<.007; Table2). findings extend our knowledge about problems ofa close other, problems in These results support our second hy- this writing exercise romself-reported relationships, and, on rare occasions, see- pothesis, that observed changesin health symptom and health use outcomes ob- ing or being in a major disaster such as status are clinically significant served in healthy individuals. Not only atrainor car wreck. Alterations of health, Wewerealso interested inunderstand- were these effects reliably observed + behaviors (eg, medication compliance, Ing how outcomes changed over time, months following the structured writ- smoking, and alcohol consumption) in andadded the 2-week and 2-month data ing, they appear clinically meaningful. response to the exercise could also im- to theanalysis. Forasthma patients, the Approximately 47% ofexperimental pa- prove health, although there is cur- effect of group remained significant ents vs 24% of control patientsmetcri- rently litle support for this explans- (F,;=31.37, P=.003), indicating im- teria for clinically relevant improve-tion."! These speculations require provement in the experimental group ment. Thus, both ofthestudy's primary examination in the context of studies in across all 3 follow-up evaluations. The hypotheses were confirmed. Although which physiological and behavioral fac- effects of time (P,,,o= 154,P>20) and it may be difficult to believe thata brief _torsare explicitly tested as mediators of group Xtime(P. .P=.13) were writing exercise can meaningfully af- illness outcomes. not significant, indicating that the ob- fect health, this study replicates in a The time course of change in the pri- served improvement was consistent over chronically ill sample what a burgeon- mary outcomes (a secondary analysis) time (TABLE 3). For RA patients, I of ing literature indicates in healthy indi- showed that asthmatic patients in the whom did not have data at ime 2, the viduals. Mechanisms underlying these experimental group improved within main elfecisof group (F,,5=0.13,P>.70) effects have not been established, al- 2 weeks, whereas change for the RA and time (Fsy=2.17, P=.12) were not though several have been proposed. patients was not evident until the significant, The effect of group X time Observation of participants in simi- 4-month assessment, We did not pre- (Ey 6.13,P<.01) wassignificant. We lar writing conditions show that they re- diet this pattern of response and there- examined this interaction by testing the port considerable emotional upset dur- fore view it cautiously. Nevertheless, the elfect of group at each point for RA pa- ing the writing sessions; concomitant finding implies that mechanisms under- tients. Itwasnot significant at time 2 or _alterationsin psychophysiological mea-_ lying improvements, possibly immune 3 (Pvalues >. 30), but was significant at sures (eg, heart rate, blood pressure) are response, may differ in the 2 diseases time 4 (F, 4,=8.32, P=.004), indicating also observed." Additionally, several Despite thestudy’sexperimental de- the RA experimental and control groups studies have shown alterations in func-signand the robust results, we havesev- did not differ until the 4-month fol- onal immune measures following the eralconcerns about translating these re- sults into supplemental treatments for sic iscsses First although our ‘Table 3, Outcomes for Each Tie Paint fr Patients With Artima or Rheurataie Athile by Beperimental Group Assignment month follow-up data demonstrate the Importance of the effects, itis unclear effects will persist beyond this period. 16Weeks Second, patients with only 2 diseases, asthma and RA, were examined in this Foeederinioy oli study, and the results may not general- enrol geup = 19) 64.080 56829 658102 653/94) _izetootheracute orchronic conditions. Eipermenial pop H=ST__ SIGH TATRA TAT EA 783;2q Third, it is clear from the clinical im- Patients Wis arsed Ati? provementanalyses that approximately Overal isese actity, mean (SE) half of the patientsin both control and “Ceri goup n= 17 471/025 1.76029 185/029 1.710017) experimental groupsdid not respond to Expert oop n= 750.19 190016 181/009 T1903) the exercise, and additional research Terran amtecrc ans OniaiSaanpioran Maa noaa seaman wevanee should explore the characteristics ofre- Seopa wn mura ae not hae at ponders Fourth, untlthemechanlsra 1308 JAMA apn 14, 1999—Val Nels (©1909 American Medical Association, All rights reserved, Downloaded From: http:/jamanetwork.com/ on 12/28/2016 underlying the findingsis identified, we cannot say how the exercise will inter actwithother treatments for thediseases. Since Engels classic article introduuc- ing the biopsychosocial model,” the medical community has come to recog nize the importance of psychological and social factors in preventing and treating illness. This research shows that a psy- chological exercise—writing bout emo- Lionally stressful experiences—ean r duce symptoms of 2 chronic diseases. These provocative yet preliminary results ‘WRITING ABOUT STRESSFUL EXPERIENCES lead us to endorse further research on structured writing and illness, ‘Author Afliations: Department of Psychistiy (rs Syn and Stone) an Bustos of Pulmonary Mec Gia (Or Hurewt) ana Rreumataogy (rae, Sate Univers fen Yorat Stony rk schol of ed Cine, Stony rook r Smyth snow a he Depart. ‘nent of Poyehology Norn Datoa ate niet, Fre. ‘Author Contibutions: Or smyth was espensblefor| {he study design, supervision ofthe study ara td atid preparation. Dr Stone was aso respon ‘Slefor he stay design and was cowiter ofthe a fide. Dr Hirewrts was esponsbie forte develop rent of te asthma-specti aspects of the stay, {Sthma patent regutment and waning er spec try tecmican. Dr Kael wae cesponsbe forthe evelopment ofthe Rasp aspects of testy, FA patient rerutment andthe cca amination ofthe maj of patients De Hurewit and Dr Kae So contd to the ail. Funding/Spport. Ts work wasundedbytheFetzr Insitute Kalmar, eh, Previous resentation Porionsf his wok erepre Senta a the 1998 Anal esting ote Ameen Pjchosomatc Society, March 11-14, Clearwater enh Fn td tne 999 Annual Meeting ofthe Ame ‘an Pychsomati Scie, March 17-20, 1958, Van ‘ouverts Columb ‘Acknowledgment: We thank the Rheumatology ‘Associates f Long lan, NY for asastance ih ‘inal examinations for patients win Rx, Eca Shertae for her work and Geeton to the study Steven Grossman, MS and Joe Schwartz, PRD, or ststel soe TRE 4. Fawry FeuzyN yun eta. Magnan mea roma effec ofan ea srucuredpsyenabe et ‘Vertion coping. and affecive stale on ecuene ar Survival yen ater. Arch Gen Paychity. 199330 ares 2. Mamior E, Selsinge Hl), Glass GV. Reducing imekal costs through mental eatnWeakment re {earch prblens and recommendations. osc ‘Mare, Budman SH ede Linking Heath and ‘etal Heth Bevery Has, Cal. Sage: 1985257 co 5. SpieglD, Bloom i, Kisrer H, Cotta tects ‘Si pajebonoitestment on vial of patent th meat ese cancer. Lance, 19892 888-291 4 Donnelly DA, Murry E. Cogntive and em: ‘onal changes wntten esaye ana therapy ner. wes. 1 So Clin Psycho. 19910334350, Sr Vabate L. Boye J Rus 0, Brac. Propammed ‘ing wo folon-aps and oneapliton wih ‘aout patents. Contam Paycodamics. noes. {6 Muray€Sega)D.Emotons pocesng noc Shaun expen offesing bout traumatic princes.) Tura Sues. 1998,7391-405, ‘Peonebater I, Beal SK. Confronting tau mae even ova an undestndng of bon an (SseseJ Abnorm Pcl. 198698274281, 1 Greenberg MA, Stone AA. Emotional dose Shout traunst ands elton taht ects of pe ‘out deosure nd aun seve 1 Pr Soc Py. (ho 1975 3 Penebaker IW, Colder M, Sharp LK. Ace Inge copng proces J es Soc Pychol. 198038: sues 40. Pennebaker, Kicolt-Glcr Glaser R ‘Ses of traumas and wrmune funciona Batons for paychotherapy.J Consul Psycho. owe 029.045, 41. Sth IM. Witten emotional expression: eet Ss elcome ype, and medeating vata J Ca Sut ln Psyena 1998 66°174-188 42, Cohen S, Witaon GM. Set and infectious seas nhs. schol Bull 1991108524 4. Meenan Rr: Mason, Angason I, Cuccione AK ‘as LE AIMS the content and properties of re ‘teed and expanded atts pet measurement “aes hath slats questonare. Artis Rheum. ‘95225410 14. lanpar,Guyatt Fei, Gift. Meas ingqualty often ahs Am ev Respir De 1993 tres a8, 15, Spe ger CD, Coruch RL, Lshene RE Manual forthe Sate-ait Arty inventory Pao Alto, Ce It Conuting Paycholognte Pres 1870. 16, Bec AT Depression: Causes and Treatment. Phiadephi Univers of Pensyvana Press. 1867 4s Pretano ME. Holes K Mesures of perceived Saal supper rom hasan em ayes val Aston ses A) Communty yc. 1983 ts 48, CarverC Scie M Weintraub. Asesing cop Ing sites: a therecaly based approach J Pes Sc Pye 1989 56267-283, 48, Chun, Kamae, Merman RA glbal nes Sure of peeved Stes. J Healt Soc Beha 1383 24385. 256. 20. Bagby, Parker J Taye G. The twentyitem “ojos alesthyma sce tem seeebon ad cose. ‘alton of he factor suture. J Psychosom Re. sssn3809-22, 21. Marlowe ©, Crowne DP. Soci dest and Fespanse to prcevedstusinal demands. Ca Sul Poyera 196125: 108-118. 22. Greenberg MA, Stone AA Wotan CB Heath ind psychologic efes of emotioal dsdsure: 2 {est ofthe ohbion-

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