Asthenia

Asthenia or a progressive psychopathological disease, occurs against a background of many ailments, causing a violation of all body systems. Consider the causes of pathology, types, methods of diagnosis and treatment.

The disease is manifested by increased fatigue, decreased performance (physical, mental). Patients complain of problems with sleep, increased irritability, lethargy and other vegetative disorders. It is difficult to diagnose a disease, since its symptoms are similar to many ailments. Therefore, for its detection, special testing is used, according to the results of which the patient is selected a course of therapy.

[1], [2], [3], [4],

Epidemiology

The disease is one of the most common medical syndromes. It occurs with infectious diseases, somatic and psychopathological ailments. Post-traumatic, postpartum and post-traumatic periods are a perfect background for its development. Because of this, experts from different fields come across it. Since it can be a sign of a beginning illness or accompany it during a period of exacerbation.

[5], [6], [7], [8], [9], [10], [11], [12], [13]

Causes of the asthenia

Causes of ailment may be associated with increased mental or physical stress, various diseases that deplete the body. Wrong organization of work and rest, unhealthy diet, mental and nervous illnesses, also provoke it. In some cases, signs appear at the initial stage by lesions of internal organs or after an acute illness. In addition, asthenic syndrome refers to the clinical manifestations of electromagnetic radiation EMF microwave range.

But most often pathology is associated with depletion of higher nervous activity and prolonged overexertion. Deficiency of nutrients, the breakdown of metabolic processes, increased energy expenditure and any other factors that cause exhaustion of the body, provoke the disease. Even a change of place of work, changes in personal life, moving or quarreling with relatives, are risk factors and can cause the corresponding symptoms. People who abuse alcohol, smoking, and consuming a lot of tea and coffee are at risk.

[14]

Pathogenesis

The development of asthenic syndrome is directly related to pathophysiology. The main link is the violation of the RAS - the reticular activating system. This system is a neural network, responsible for managing all the energy resources of the body. It controls the coordination of voluntary movements, endocrine and autonomic regulation, memorization, sensory perception.

Since PAC is responsible for a large number of neurophysiological connections, it is important in modulating psychological attitudes, intellectual functions and physical activity. Psychopathological dysfunction forms a signal that leads to an overload of RAS due to disturbances in the management of energy resources. On the patient it is reflected as increased anxiety, the extinction of physical and mental activity.

Another important factor affecting the development of asthenia is the failure of biological rhythms. The system regulates the secretion of hormones (somatoliberin, tiroliberin, cortico-liberin), controls blood pressure, temperature, wakefulness, affects performance and appetite. The functioning of this system is intensively violated in the elderly, with flights over long distances and with shift work. Normal functioning of the biological clock prevents the development of the disease.

Mechanisms of development

The main mechanism of asthenic syndrome is associated with a reset of the activating reticular formation. The mechanism is responsible for synchronizing all aspects of human behavior and managing energy resources.

In clinical practice, most often there are such variants of psychopathological disease:

• Asthenia as a sign of a certain disease (somatic, infectious, mental, endocrine and others).
• The temporary state that arose from the impact of provoking factors. It can be various diseases, mental and physical overload, taking medications or surgical interventions. Typically, this indicates a reactive or secondary form. When eliminating provoking factors, unfavorable symptoms go away.
• The syndrome of chronic fatigue is not only one of the leading symptoms of pathology, but also a provoking factor. Constant weakness, fatigue and irritability lead to social and physical disadaptation.

Patients with this discomfort suffer from regular mood swings, loss of self-control, tearfulness, self-doubt. On the physical side, this is manifested as: pain in the heart, tachycardia, unstable pressure, problems with the gastrointestinal tract. In addition, there are possible: increased sweating, intolerance to bright light, temperature changes and loud sounds.

[15], [16], [17], [18], [19], [20]

Symptoms of the asthenia

Symptoms include three essential components:

1. Own clinical manifestations.
2. Disturbances based on the pathological state of the disease that caused the disorder.
3. The symptomatology that arises from the psychological reaction to malaise.

Manifestations of asthenic syndrome increase during the day, in the morning the symptom complex is weakly expressed or absent. But in the evening, the pathology reaches its maximum extent. Consider the main signs of the disease:

• Fatigue

This symptom is found in all forms of the disease. Full sleep and rest do not relieve fatigue. With physical labor there is general weakness and reluctance to do the work. With intellectual work, difficulties arise when trying to concentrate, memory, wit and care are deteriorating. The patient experiences difficulties in verbal expression of his own thoughts. It is difficult to concentrate on one problem, to choose words for the expression of ideas or emotions, absentmindedness and inhibition are observed. We have to take breaks and break the tasks into stages. All this leads to the fact that the work does not bring the desired results, fatigue increases, causing anxiety, self-doubt and self-reliance.

• Vegetative disorders

Psychopathological disease is always accompanied by dysfunction of the autonomic nervous system. Patients suffer from tachycardia, blood pressure changes, constipation, pulse lability, pain in the intestine, chilliness, heat and sweating. In addition, the appetite decreases, there are headaches and possibly a decrease in libido.

• Sleep Disorders

Regardless of the form of asthenia, there are different in nature problems with sleep. These can be difficulties with falling asleep, frequent night awakenings, intense and restless dreams, a feeling of fatigue and weakness after sleep. In particularly difficult cases, patients feel that they do not sleep at night, but in reality it is not. The illness is accompanied by daytime drowsiness, problems with falling asleep and poor quality of sleep.

• Psycho-emotional defects

This symptom arises from a decrease in productivity and increased patient focus on this issue. Patients become quick-tempered, irritable, tense, lose self-control. There is a state of depression, sharp mood swings, unreasonable optimism or pessimism. Acceleration of such symptoms leads to neurasthenia, hypochondriac or depressive neurosis.

Temperature for asthenia

Subfebrile temperature in anxiety states and psychological ailments indicates a vegetative instability of the nervous system. This is due to the fact that psychogenic factors disrupt thermoregulation. Regular daily fluctuations in body temperature indicate neurotic and pseudo-neurotic states. Such signs complicate the process of diagnosis, as they can be a sign of focal infection and other injuries of the body. In this case, antibiotic therapy, only aggravates the asthenic state and somatic symptoms.

If the subfebrile temperature is accompanied by a poor state of health, which manifests itself in the form of weakness, rhythmic hyperthermia, mood changes, this indicates the disruption of internal circadian rhythms. In addition to problems with thermoregulation, asthenic syndrome causes other pathologies, for example, perspiration in the throat, limb tremor and others.

Treatment depends on the true cause of the pathology. If the temperature jumps are due to a psychopathological illness against a background of chronic diseases, then the treatment of the underlying cause is required. To do this, patients are prescribed antibiotics, antihistamines and antidepressants, but only after a comprehensive examination of the body.

[21], [22], [23],

Headache with asthenia

Headaches with neurasthenic diseases are one of the most unpleasant and persistent symptoms. It is this manifestation of the illness that makes one seek medical help. In medical practice, special diagnostic criteria are used that allow you to determine the degree of headaches and stress:

• As a rule, episodic pain lasts from 30 minutes to 7 days. If the discomfort is chronic, then the pain is uninterrupted.
• The pain has a compressive, squeezing and tightening character. It is localized on both sides of the head, but one side can hurt more.
• Everyday physical activity does not increase discomfort, but everyday and professional activities exacerbate the situation.
• With the intensification of unpleasant sensations, there are such signs as: photophobia, phonophobia, nausea, pain in the digestive tract, anorexia, migraine.

At the heart of the pathology is chronic emotional stress, which is formed under the influence of many factors (the transferred diseases, physical and emotional overloads). If the pain is chronic, then along with the asthenic syndrome, migraine and neurosis develop. This symptom entails various violations: problems with sleep, poor appetite, irritability, nervousness, reduced attention. Proceeding from this, it can be concluded that the headaches in asthenia are included in the psychovegetative complex.

Asthenia in children

Asthenic syndrome in childhood is a psychological condition that causes a number of deviations in behavior. The child becomes capricious, whiny, frequent mood swings, inability to concentrate, increased lability. The disease is difficult to recognize, because the child is already emotionally unstable because of his age. But if your child suddenly became sluggish, behavior changed significantly for the worse, there was tearfulness, frequent whims and other unfavorable signs, this indicates asthenia.

Symptoms in children are not very prominent, unlike adults. As a rule, these are experiences, overwork, emotional instability. Asthenia can appear on the background of other diseases, but sometimes its symptoms are confused with age-related changes. If the above characteristics are ignored, they will begin to progress and cause a number of complications.

Treatment of pathology in childhood begins with the definition of the true cause of the disease. Since sometimes adverse symptoms indicate a latent disease. If the diagnosis did not reveal anything, then it is recommended to visit a psychologist. In addition, it is necessary to adjust the regime of the baby's day, organize proper nutrition and spend more time with the child.

[24], [25], [26], [27], [28],

Asthenia in adolescents

Psychopathological disorder in adolescence is associated with hormonal changes in the body and formation in society. At this age, any, even a minor event can cause a trauma. Heavy loads and obligations contribute to the development of pathology.

Signs of the disease:

• Increased fatigue
• Irritability
• Inability to concentrate
• Headaches without physiological prerequisites
• Painful sensations in the heart, digestive tract, dizziness
• Insecurity in themselves and their own strengths.
• Complexity in performing simple tasks, problems with study

If you leave the above symptoms without attention, then they will progress. As a result, the teenager closes in himself, begins to avoid peers and relatives. Treatment begins with a comprehensive examination of the body. Since in some cases, the disease occurs due to hidden diseases. Obligatory is the help of a therapist, drug therapy and the use of restorative drugs. The help of the patient's parents is of great importance. They must support the child and adjust to a positive result of treatment.

[29], [30], [31], [32], [33]

Asthenia in Pregnancy

During pregnancy, a woman has to face many problems, including those with psychopathology. Most often, with this ailment encounter in the I and III trimesters. Asthenia requires a comprehensive medical and midwifery survey.

• I trimester - nausea, headaches, sleep disorders, gastrointestinal problems and constipation are caused by symptoms characteristic of vegetative disorders, which disappear after a full rest. Perhaps a feeling of constant fatigue, which indicates the intense nature of the disease. In this case, there is a deterioration in the general condition, weight loss, various biological disorders. This condition requires hospitalization and medical supervision.
• II trimester - at this time, increased fatigue and weakness is due to an increase in the volume of the fetal egg and the body weight of the woman. Asthenic symptoms are manifested along with functional abnormalities of the digestive tract, pruritus of the skin, pain in the bones and muscles, insomnia. As a rule, a full rest eliminates the above-described ailments, and regular sports activities prevent their appearance. But in some cases there are severe forms of the syndrome. The woman has constant headaches, high blood pressure, weakness, iron deficiency anemia. Similar symptoms occur with polyhydramnios, nephropathy, and benign recurrent cholestatic jaundice.
• III trimester - the disease has a pronounced character, accompanied by high blood pressure, anxiety, respiratory distress, abdominal and lumbar pains, disability. These symptoms can result from a viral infection, malformations in the fetus, diabetes mellitus, or Rh-immunization.

Expressed autonomic disorders are observed in multiple pregnancies. A similar condition is diagnosed in 15% of pregnant women. Very often the cause of malaise is a low level of hemoglobin, improper nutrition, stress, lack of rest and lack of sleep. Without proper nutrition, symptomatic treatment and hygiene recommendations, pathology can lead to serious complications.

[34], [35], [36], [37]

Postpartum asthenia

Asthenic illness in the postpartum period is not uncommon, which is caused by a variety of factors. First of all, it is hormonal and physiological restoration of the body. After delivery, the endocrine system is reconstructed, since the body needs to produce milk. During this period, fever, sweating and weakness are possible. Another factor of the disease is anemia, that is anemia. It occurs after cesarean section, with bleeding or blood loss during labor. A significant decrease in hemoglobin leads to oxygen starvation, weakness, dizziness and fainting.

Unpleasant symptoms appear due to a restart of the cardiovascular system. The thing is that during the period of gestation the blood volume increases by 1.5 times, which affects the arterial pressure and the work of the heart. After giving birth, the data of the system abruptly return to normal, which causes discomfort. Asthenia can be caused by postpartum depression. In this case, a woman feels depressed, spells of blues, weakness and irritability. Do not forget about the adaptation period, because the appearance of the child requires psychological adaptation.

Main features:

• Weakness
• Irritability
• Fast fatiguability
• Mood swings, tearfulness
• Headache and muscle pain
• Intolerance to bright light, sharp odors and loud sounds
• Sleep Disorders

When the above signs appear, it is necessary to understand that if they are not caused by a specific disease, they are temporary. The disease can be masked for serious damage to the body. So, if weakness and unreasonable fatigue occur along with sharp pains in the lower abdomen, edema of the legs, blood in the urine, pain during urination, chills and fever, then urgent medical attention is required. In all other cases it is recommended to spend more time outdoors, do not give up the help of relatives, eat fully, get enough sleep and avoid stress.

The scale of asthenia

Based on the MMRI questionnaire (the Minnesota multidimensional personality list), a scale of asthenic condition was developed. This system is needed to determine the extent of the ailment. It was developed taking into account the data obtained in the treatment of patients with different forms of the disease.

The scale is used to quickly determine the severity of the disease. There are points for assessing the nervous excitability, working capacity and aggressiveness of the patient. Some questions give information about the quality of sleep and the state of the system of reproduction.

Subjective scale of asthenia evaluation (MFI-2O)

No.	Suggestions	Answers
1	I feel healthy	Yes, it's true 1 2 3 4 5 no, it's not true
2	Physically, I'm capable of a little	Yes, it's true 5 4 3 2 1 no, this is not true
3	I feel active	Yes, it's true 1 2 3 4 5 no, it's not true
4	Everything I do makes me happy	Yes, it's true 1 2 3 4 5 no, it's not true
5	I feel tired	Yes, it's true 5 4 3 2 1 no, this is not true
6th	I think I have a lot of work in a day	Yes, it's true 1 2 3 4 5 no, it's not true
7th	When I do something, I can concentrate on this	Yes. It's true 1 2 3 4 5 no, it's not true
8	Physically I am capable of much	Yes, it's true 1 2 3 4 5 no, it's not true
9	I'm afraid of the things that I need to do	Yes, it's true 5 4 3 2 1 no, this is not true
10	I think that for a day I do very little work	Yes, it's true 5 4 3 2 1 no, this is not true
Eleven	I can concentrate well	Yes, it's true 1 2 3 4 5 no, it's not true
12	I feel rested	Yes, it's true 1 2 3 4 5 no, it's not true
13	I need a lot of effort to concentrate	Yes, it's true 5 4 3 2 1 no, this is not true
14	Physically I feel badly	Yes, it's true 5 4 3 2 1 no, this is not true
15	I have many plans	Yes, it's true 1 2 3 4 5 no, it's not true
16	I quickly get tired	Yes, it's true 5 4 3 2 1 no, this is not true
17th	I have very little time to do	Yes, it's true 5 4 3 2 1 no, this is not true
18	It seems to me that I do not do anything	Yes, it's true 5 4 3 2 1 no, this is not true
19	My thoughts easily dissipate	Yes, it's true 5 4 3 2 1 no, this is not true
20	Physically I feel fine	Yes, it's true 1 2 3 4 5 no, it's not true

Key to the scale:

Form disorder	Your questions
Mental Health	7,11,13,19
Physical	2, 8, 14, 20
General information	1, 5, 12, 16
Reduced activity	3, 6, 10, 17
Decreased motivation	4, 9, 15, 18

If after answering all the questions the patient gets 30-50 points, then there is no disorder. From 51-75 - a weak form of asthenia, 76-100 - a moderate form, 101-120 - expressed.

Asthenia syndrome

Asthenic syndrome is a condition of the body that is characterized by increased fatigue, exhaustion of vital forces and energy resources.

The main symptoms are:

• Irritability
• Weakness
• Increased excitability
• Frequent mood swings
• Tearfulness
• Sleep Disorders
• Intolerance to bright light, sharp smells and sounds
• Violations of the autonomic nervous system

The above characteristics increase gradually. At the initial stage, fatigue and fatigue appear, later irritability, impatience, mood swings.

The manifestation of the syndrome largely depends on the causes that caused it. If the malaise has appeared after acute illnesses, then, as a rule, takes the form of emotional weakness, tension and hypersensitivity. After craniocerebral trauma, the disease is characterized by severe headaches and problems with the vegetative system. The early stages of hypertension and atherosclerosis are accompanied by severe fatigue, weakness and mood swings.

The syndrome can arise as a result of prolonged emotional or intellectual overstrain. Infectious and non-infectious diseases, intoxication, this is another reason for asthenia. The risk category includes people with an unbalanced or weak type of higher nervous activity.

[38], [39], [40], [41], [42],

Forms

Mkb 10 defines a progressive psychopathological disorder with such a value - systematic complaints of general weakness, increased fatigue regardless of load, decreased performance, muscle and headaches, sleep disorders, inability to relax and irritability.

Мкб 10, that is the international classification of diseases of the 10th revision, relates asthenia to several classes simultaneously:

V Mental and behavioral disorders

F00-F09 Organic, including symptomatic, mental disorders

• F40-F48 Neurotic, stress-related, and somatoform disorders

F48 Other neurotic disorders

F48.0 Neurasthenia

• F50-F59 Behavioral syndromes associated with physiological disorders and physical factors

XVIII Symptoms, signs and abnormalities detected in clinical and laboratory studies, not elsewhere classified.

R50-R69 Common Symptoms and Signs

• R53 Miscommunication and fatigue

F48.0 Neurasthenia.

The fact that the disease enters into several categories is explained by the fact that it manifests itself in many diseases and has many symptoms. If there is a need to identify the primary disease, then additional coding is used.

[43], [44]

Complications and consequences

In the absence of treatment, asthenic syndrome can lead to serious consequences. First of all, it is neurasthenia, depression, hysteria and even schizophrenia. If the disease is chronic, it causes a lack of focus, absent-mindedness, memory problems. If the disease occurs as a result of infectious or viral diseases, it can lead to secondary damage to the body. In this case, the work of the immune system and the body as a whole worsens.

The vegetative syndrome does not cause irreversible changes, but in severe forms, hospitalization in special clinics is indicated. In addition, the patient is assigned a limited degree of work capacity. Timely address to the doctor, correct diagnosis, the course of drug therapy and physiotherapy, allow you to quickly return to the usual life.

[45], [46]

Diagnostics of the asthenia

Diagnosis of asthenia is a differential study, the main purpose of which is to identify the true symptoms of the disease and not confuse them with the syndrome of chronic fatigue. Different methods are used for this, but rely more on evaluation scales and tests, with which you can establish the type of ailment and limit it from other diseases.

Comparative characteristics of signs of asthenia and fatigue:

Fatigue	Asthenia
Physiological phenomenon	Pathological process
Reduced excitability of the body and functional activity due to overexertion (after rest and sleep)	Reduced excitability and functional activity of the body, which do not disappear after rest and sleep
Comes after intense or prolonged exertion	The tension is permanent
Passes after rest	Does not pass after rest
Does not require medical consultation	Requires medical attention, as it is chronic, irrational and badly reversible

The disease occurs due to violations of the use of energy resources, and fatigue due to their exhaustion.

In addition, additional research is also being used. For example, magnetic resonance imaging, positron emission tomography and computed tomography can exclude tumors, cysts and progressive diffuse brain lesions. In this case, the pathology is symptomatic, not pathological. In each case, the doctor appoints a number of laboratory studies, electroencephalography, ultrasound, ECG and other diagnostic procedures.

Test for asthenia

Various tests for the diagnosis of asthenic condition can differentiate asthenia from other lesions of the body. The advantage of this method is its simplicity and quick result.

The simplest is a test questionnaire. The proposed assumptions must be carefully read and evaluated, in relation to their state at a moment's time. In the test, several options are used: no, wrong, perhaps, so, truly, absolutely true.

Test

1. I work with a lot of stress
2. It's hard for me to focus on anything
3. My sex life does not satisfy me
4. Waiting makes me nervous
5. I have muscle weakness
6. I do not feel like going to the cinema or to the theater
7. I'm forgetful
8. I feel tired
9. My eyes get tired with prolonged reading
10. My hands are shaking
11. I have a bad appetite
12. It's hard for me to be at a party or in a noisy company
13. I no longer understand reading so well
14. My hands and feet are cold
15. I'm easy to hurt
16. I have a headache
17. I wake up in the morning tired and not rested
18. I have dizziness
19. I have muscle twitching
20. My ears are buzzing
21. I am concerned about sex
22. I feel heavy in my head
23. I have a general weakness
24. I have pain in my head
25. Life for me is connected with stress
26. My head is wrapped like a hoop
27. I easily wake up from the noise
28. I'm tired of people
29. When I'm worried, I get covered up later
30. I do not give restless thoughts to sleep

For each answer points are calculated according to this scheme:

• 1 - no, it's wrong
• 2 - perhaps, so
• 3 - true
• 4 - quite right

For the test, you can score from 30-120 points.

• 30-50 points - absence of asthenia
• 51-75 points weak
• 76 -100 points - moderate
• 101-120 points - expressed.

There is one more questionnaire, which was developed by G.V. Zalevsky and consists of 141 question-statements. Each item reflects situations in which the subject needs to change the already existing elements of his behavior. The questionnaire consists of 7 scales, each of which is assessed by the parameters of mental rigidity.

The SMIL questionnaire is another test that presents a shortened version of MMPI and consists of 11 scales. The first three are estimated, because they measure the reliability of the answers, the sincerity of the respondent and the correction due to caution. The remaining scales assess personality properties and are basic. The results of the test are interpreted in the form of a graphical personality profile.

[47], [48], [49], [50]

Differential diagnosis

Another feature of the ailment is that it must be differentiated from ordinary fatigue, which occurs after a mental or psychological strain. Pathological impotence develops gradually and persists for a long period of time (months, years), does not go away after a full sleep and rest, so it requires medical care.

Treatment of the asthenia

Treatment of asthenic syndrome depends on pathological signs and on the revealed provoking ailment. At the initial stage, the patient undergoes a complex examination of the body and therapy of the revealed disorders. This helps prevent a destructive effect on the psychoemotional state.

The main stages of treatment:

1. Day regimen - all patients need to establish a schedule of life, that is, to allocate time for proper rest and sleep, time for work, sports and other things important for the normal state of health and nervous system.
2. Nutrition - a healthy diet is the key to recovery. For patients useful products containing protein, tryptophan, amino acids and vitamins - turkey, cheese, bananas, eggs, bread with bran, fresh berries, fruits, vegetables and cereals.
3. Medicamental therapy - prescribe a course of antidepressants or homeopathic remedies. Most often used adaptogens, that is, preparations of natural origin. Alternative treatment methods, for example, calming herbs, various physiotherapy procedures and sanatorium treatment can also be used.

All of the above steps are included in the course of recovery of the body, as it allows to normalize well-being without side effects. To prevent recurrence, preventive measures are recommended, which minimize stress and its destructive effect on the body.

Prevention

Preventative measures for vegetative disorders are aimed at preventing psychopathological symptoms that oppress the central system and the entire body.

Preventive measures:

• Timely and comprehensive treatment of any diseases and their further prevention.
• Complete rest and sleep.
• Rational, healthy food.
• Minimizing stressful situations, nervous disorders.
• Regular physical activity.
• Frequent walks in the fresh air.
• The use of pharmacological drugs that reduce fatigue (glucose, vitamin C, ginseng, eleutherococcus) and enhance the protective properties of the immune system.

Compliance with the above recommendations will prevent the development of asthenic syndrome and protects the body from the negative influence of external stimuli.

[51], [52], [53], [54], [55],

Forecast

The prognosis of the asthenic syndrome completely depends on the form of the disease, the individual characteristics of the patient's organism and on the effectiveness of the treatment. So, if the malaise is of a postinfectious nature, then the prognosis is favorable, since a variety of therapies allow the body to fully recover without any complications.

Under the condition of correct treatment, a favorable prognosis has psychological, cerebral, neurotic and functional forms. In the case of prolonged course, the disease causes serious complications, in some cases irreversible, transforming into neuroses, schizophrenia and chronic depression.

[56], [57], [58]

Asthenia and the army

The presence of symptoms of asthenic disease can be the reason for refusal of the commission for those wishing to join the army. As a rule, this applies to psychopathological disorders of neglected type, accompanied by serious disorders of the psyche and the functioning of the body.

Particular attention is paid to neurocirculatory asthenia, as it is characterized by persistent and pronounced vegetative-vascular disorders. If the malaise is accompanied by hypertensive reactions, persistent cardia, lability of blood pressure and pronounced symptoms that can not be cured, the appeal may be refused or recognized as temporarily unsuitable for military service.

Asthenia is rightfully considered a disease of the present, as frequent stresses, nervous experiences and negative influence of the external environment cause its pathological symptoms. In order to overcome weakness and increased fatigue, it is necessary to strengthen the body, relax, eat fully and lead a healthy lifestyle with a minimum of stress and anxiety.

[59], [60], [61], [62], [63], [64], [65], [66], [67], [68]