Assessing the Personality Profile of Patients with Fibromyalgia Syndrome: A Rorschach Study
Abstract
Background: The role that psychological factors and personality traits play in the pathogenesis of Fibromyalgia Syndrome (FMS) is currently controversial. Most of the studies on FMS used self-report measures, and to date only a doctoral dissertation was conducted to compare the Rorschach responses of patients with FMS to the normative sample.
Aim and Method: By using the Rorschach Performance Assessment System (R-PAS), we compared the scores of 35 women with FMS with those of 35 women with rheumatoid arthritis (RA). R-PAS is a performance-based task able to provide information on psychological processes occurring in the context outside and beyond the test. Furthermore, we chose RA patients as a contrast group because they both share the same medical picture in terms of pain experiences.
Results: Compared to the RA group, the FMS group seemed to experience considerable implicit distress (YTVC’) associated with a sense of helplessness and despair (Y) that interferes with coping and adaptive mechanisms. Moreover, we found that these patients showed a cognitive processing focused mostly on the straightforward components of the environment (SI and Sy), but the interpretation of the environment was more unconventional (FQo%). Finally, we observed that almost half of the FMS group exhibited an excessive worry on the body (An).
Conclusions: Our study has two implications for practicing psychologists. First, by using a performance-based test such as the R-PAS, we were able to provide a different clinical picture than self-reports (e.g., we did not find alexithymia features in the FMS protocols) and to identify the problematic features even at different levels of Complexity. Second, the increased levels of implicit stress found in the FMS group require psychological interventions focused on empowering these patients with self-management, active coping strategies when dealing with stressors and pain, so to defy their sense of helplessness.
Keywords
Full Text:
PDFReferences
Aaron, R. V., Fisher, E. A., De La Vega, R., Lumley, M. A., & Palermo, T. M. (2019). Alexithymia in individuals with chronic pain and its relation to pain intensity, physical interference, depression, and anxiety: a systematic review and meta-analysis. Pain, 160(5), 994–1006. http://dx.doi.org/10.1097/j.pain.0000000000001487
Ablin, J. N., Buskila, D., Van Houdenhove, B., Luyten, P., Atzeni, F., & Sarzi-Puttini, P. (2012). Is fibromyalgia a discrete entity? Autoimmunity reviews, 11(8), 585-588. http://dx.doi.org/10.1016/j.autrev.2011.10.018
Anderberg, U. M., Forsgren, T., Ekselius, L., Marteinsdottir, I., & Hallman, J. (1999). Personality traits on the basis of the Temperament and Character Inventory in female fibromyalgia syndrome patients. Nordic Journal of Psychiatry, 53(5), 353-359. https://doi.org/10.1080/080394899427827
Andò, A., Salatino, A., Giromini, L., Ricci, R., Pignolo, C., Cristofanelli, S., Ferro, L., Viglione, D. J., & Zennaro, A. (2015). Embodied simulation and ambiguous stimuli: The role of the mirror neuron system. Brain Research, 1629, 135-142. http://dx.doi.org/10.1016/j.brainres.2015.10.025
Arnold, L. M., Bennett, R. M., Crofford, L. J., Dean, L. E., Clauw, D. J., Goldenberg, D. L., ... & Buskila, D. (2019). AAPT diagnostic criteria for fibromyalgia. The Journal of Pain, 20(6), 611-628. http://dx.doi.org/10.1016/j.jpain.2018.10.008
Arroita, A., Barreiro, A., Ugarte, K., Losada, N., Rico, P., Touzon, R., & Lopez, M. D. M. (2009). P01-221 Psychiatric comorbidity in fibromyalgia. European Psychiatry, 24, S609. https://doi.org/10.1016/S0924-9338(09)70842-9
Axelsson, E., Hedman-Lagerlöf, M., Hedman-Lagerlöf, E., Ljótsson, B., & Andersson, E. (2020). Symptom Preoccupation in Fibromyalgia: Prevalence and Correlates of Somatic Symptom Disorder in a Self-Recruited Sample. Psychosomatics, 61(3), 268-276. https://doi.org/10.1016/j.psym.2020.01.012
Baastrup. S, Schultz, R., Brødsgaard, I., Moore, R., Jensen, T.S., Vase Toft, L., Bach, F.W., Rosenberg R, & Gormsen, L. (2016). A comparison of coping strategies in patients with fibromyalgia, chronic neuropathic pain, and pain-free controls. Scandinavian Journal of Psychology, 57(6), 516–522. http://dx.doi.org/10.1111/sjop.12325
Bagby, R. M., Taylor, G. J., Parker, J. D. & Dickens, S. E. (2006). The development of the Toronto Structured Interview for Alexithymia: item selection, factor structure, reliability and concurrent validity. Psychotherapy and Psychosomatics, 75, 25–39. http://dx.doi.org/10.1159/000089224
Baumstark, K. E., Buckelew, S. P., Sher, K. J., Beck, N., Buescher, K. L., Hewett, J., & Crews, T. M. (1993). Pain behavior predictors among fibromyalgia patients. Pain, 5(3), 339-346. http://dx.doi.org/10.1016/0304-3959(93)90009-E
Benjamini, Y., & Hochberg, Y. (1995). Controlling the false discovery rate: A practical and powerful approach to multiple testing. Journal of the Royal Statistical Society: Series B (Methodological), 57(1), 289–300. http://dx.doi.org/10.1111/j.2517-6161.1995.tb02031.x
Blom, D., Thomas, S., Kool, M. B., Middendorp, H. V., Lumley, M. A., Bijlsma, J. W. J., & Greene, R. (2012). A combination of illness invalidation from the work environment and help- lessness is associated with embitterment in patients with FM. Rheumatology, 51(2), 347-353. https://doi.org/10.1093/rheumatology/ker342
Boisset‐Pioro, M. H., Esdaile, J. M., & Fitzcharles, M. A. (1995). Sexual and physical abuse in women with fibromyalgia syndrome. Arthritis & Rheumatism: Official Journal of the American College of Rheumatology, 38(2), 235-241. http://dx.doi.org/10.1002/art.1780380212
Borg-Stein, J., & Stein, J. (1996). Trigger points and tender points: one and the same? Does injection treatment help?. Rheumatic Disease Clinics, 22(2), 305-322. https://doi.org/10.1016/S0889-857X(05)70274-X
Castelli, L., Tesio, V., Colonna, F., Molinaro, S., Leombruni, P., Bruzzone, M., Fusaro, E., Sarazi-Puttin, P., & Torta, R. (2012). Alexithymia and psychological distress in fibromyalgia: prevalence and relation with quality of life. Clinical and Experimental Rheumatology, 30(6 Suppl 74), 70-77.
Celikel, F. C., & Saatcioglu, O. (2006). Alexithymia and anxiety in female chronic pain patients. Annals of General Psychiatry, 5(1), 13. http://dx.doi.org/10.1186/1744-859X-5-13
Cohen, H., Neumann, L., Haiman, Y., Matar, M. A., Press, J., & Buskila, D. (2002). Prevalence of post-traumatic stress disorder in fibromyalgia patients: overlapping syndromes or post-traumatic fibromyalgia syndrome?. Seminars in arthritis and rheumatism, 32(1), 38-50. http://dx.doi.org/10.1053/sarh.2002.33719
Conversano, C., Marchi, L., Ciacchini, R., Carmassi, C., Contena, B., Bazzichi, L. M., & Gemignani, A. (2018). Personality traits in fibromyalgia (FM): does FM personality exists? A systematic review. Clinical practice and epidemiology in mental health, 14, 223-232. http://dx.doi.org/10.2174/1745017901814010223
Cronan, T. A, Serber, E. R., Walen, H. R., & Jaffe, M. (2002). The influence of age on fibromyalgia symptoms. Aging Health, 14(3), 370-84. http://dx.doi.org/10.1177/08964302014003004
Davis, M. C., Zautra, A. J., & Reich, J. W. (2001). Vulnerability to Stress Among Women in Chronic Pain From Fibromyalgia and Osteoarthritis. Annals of Behavioral Medicine, 23(3), 215-226. http://dx.doi.org/10.1207/S15324796ABM2303_9
Di Tella, M., & Castelli, L. (2016). Alexithymia in chronic pain disorders. Current Rheumatology Reports, 18(7), 41. http://dx.doi.org/10.1007/s11926-016-0592-x
Di Tella, M., Ghiggia, A., Tesio, V., Romeo, A., Colonna, F., Fusaro, E., . Torta, R.,& Castelli, L. (2017). Pain experience in Fibromyalgia Syndrome: The role of alexithymia and psychological distress. Journal of affective disorders, 208, 87-93. http://dx.doi.org/10.1016/j.jad.2016.08.080
Di Tella, M., Enrici, I., Castelli, L., Colonna, F., Fusaro, E., Ghiggia, A., ... & Adenzato, M. (2018). Alexithymia, not fibromyalgia, predicts the attribution of pain to anger-related facial expressions. Journal of Affective Disorders, 227, 272-279. http://dx.doi.org/10.1016/j.jad.2017.10.048
Di Tella, M., Tesio, V., Ghiggia, A., Romeo, A., Colonna, F., Fusaro, E., Geminiani G.C., Bruzzone M., Torta, R., & Castelli, L. (2018). Coping strategies and perceived social support in fibromyalgia syndrome: relationship with alexithymia. Scandinavian Journal of Psychology, 59(2), 167–176. http://dx.doi.org/10.1111/sjop.12405
Donges, U.-S., Kersting, A., & Suslow, T. (2014). Alexithymia and perception of emotional information: A review of experimental psychological findings. Universitas Psychologica, 13(2), 745–756. https://doi.org/10.11144/Javeriana.UPSY13-2.apei
Eisenstat, A. P. (1997). Somatization and the fibromyalgia syndrome. Dissertation Abstracts International: Section B: The Sciences and Engineering, 57(12-B), 7722.
Epstein, S. A., Kay, G., Clauw, D., Heaton, R., Klein, D., Krupp, L., Kuck, J., Leslie V., Masur, D., Wagner, W., Waid, R., & Zisok, S. (1999). Psychiatric disorders in patients with fibromyalgia: a multicenter investigation. Psychosomatics, 40(1), 57-63. https://doi.org/10.1016/S0033-3182(99)71272-7
Exner, J. E. (1993). The Rorschach: A Comprehensive System: Vol. 1. Basic foundations (3rd ed.). New York, NY: Wiley.
Finan, P. H., Zautra, A. J, & Davis, M. C. (2009). Daily affect relations in fibromyalgia patients reveal positive affective disturbance. Psychosomatic Medicine. 71(4), 474–482. https://doi.org/10.1097/PSY.0b013e31819e0a8b
Ghiggia, A., Torta, R., Tesio, V., Di Tella, M., Romeo, A., Colonna, F., Geminiani, G.C, Fusaro, E., Batticciotto, A. & Castelli, L. (2017). Psychosomatic syndromes in fibromyalgia. Clinical and Experimental Rheumatology, 35(3), 106-111.
Giromini, L., Ando’, A., Morese, R., Salatino, A., Di Girolamo, M., Viglione, D. J., & Zennaro, A. (2016). Rorschach Performance Assessment System (R-PAS) and vulnerability to stress: A preliminary study on electrodermal activity during stress. Psychiatry Research, 246, 166-172. http://dx.doi.org/10.1016/j.psychres.2016.09.036
Häuser, W., Kosseva, M., Üceyler, N., Klose, P., & Sommer, C. (2011). Emotional, physical, and sexual abuse in fibromyalgia syndrome: A systematic review with meta-analysis. Arthritis care & research, 63(6), 808-820. http://dx.doi.org/10.1002/acr.20328
Huber, A., Suman, A. L., Biasi, G., & Carli, G. (2009). Alexithymia in fibromyalgia syndrome: associations with ongoing pain, experimental pain sensitivity and illness behavior. Journal of psychosomatic research, 66(5), 425-433. http://dx.doi.org/10.1016/j.jpsychores.2008.11.009
Jackson, J. L., O'Malley, P. G., & Kroenke, K. (2006). Antidepressants and cognitive-behavioral therapy for symptom syndromes. CNS spectrums, 11(3), 212-222. https://doi.org/10.1017/S1092852900014383
Jakobsson, U., & Hallberg, I. R. (2002). Pain and quality of life among older people with rheumatoid arthritis and/or osteoarthritis: a literature review. Journal of Clinical Nursing, 11(4), 430-443. https://doi.org/10.1046/j.1365-2702.2002.00624.x
Jensen, K. B., Petzke, F., Carville, S., Fransson, P., Marcus, H., Williams, S. C., Choy, E., Mainguy, Y., R Gracely, R., Ingvar, M., & Kosek, E. (2010). Anxiety and depressive symptoms in fibromyalgia are related to poor perception of health but not to pain sensitivity or cerebral processing of pain. Arthritis & Rheumatology, 62(11), 3488-3495. https://doi.org/10.1002/art.27649
Johannsson, V. (1993). Does a fibromyalgia personality exist? Journal of Musculoskeletal Pain, 1(3–4), 245–252. http://dx.doi.org/10.1300/J094v01n03_26
Katon, W. J., & Walker, E. A. (1998). Medically unexplained symptoms in primary care. The Journal of clinical psychiatry, 59(Suppl 20), 15-21.
Kivisalu, T. M., Lewey, J. H., Shaffer, T. W., & Canfield, M. L. (2016). An investigation of interrater reliability for the Rorschach Performance Assessment System (R–PAS) in a nonpatient U.S. sample. Journal of Personality Assessment, 98, 382-390. http://dx.doi.org/10.1080/00223891.2015.1118380
Kivisalu, T. M., Lewey, J. H., Shaffer, T. W., & Canfield, M. L. (2017). Correction to: An investigation of interrater reliability for the Rorschach Performance Assessment System (R–PAS) in a nonpatient U.S. sample. Journal of Personality Assessment, 99, 558-560. http://dx.doi.org/10.1080/00223891.2017.1325244
Krag, N. J., Nørregaard, J., Hindberg, I., Larsen, J. K., & Danneskiold-Samsøe, B. (1995). Psychopathology measured by established self-rating scales and correlated to serotonin measures in patients with fibromyalgia. European psychiatry, 10(8), 404-409. http://dx.doi.org/10.1016/0924-9338(96)80346-4
Langley, P. C. (2011). The prevalence, correlates, and treatment of pain in the European Union. Current Medical Research and Opinion, 27, 463–480. http://dx.doi.org/10.1185/03007995.2010.542136
Lieb, A. M. (2008). Fibromyalgia and the Rorschach Inkblot Test [Doctoral dissertation, Pacific University].
Malt, E. A., Olafsson, S., Lund, A., & Ursin, H. (2002). Factors explaining variance in perceived pain in women with fibromyalgia. BMC Musculoskeletal Disorders, 3(1), 12. http://dx.doi.org/10.1186/1471-2474-3-12
Marques, A. P., do Espírito Santo, A. D. S., Berssaneti, A. A., Matsutani, L. A., & Yuan, S. L. K. (2017). Prevalence of fibromyalgia: literature review update. Revista Brasileira de Reumatologia (English Edition), 57(4), 356-363. http://dx.doi.org/10.1016/j.rbre.2017.01.005
Mcallister, M. J. (2000). The unvanquished: Prevalence of moral masochistic personality characteristics in persons with fibromyalgia. Dissertation Abstracts International Section B: The Sciences and Engineering, 61, 540.
Meyer, G. J., Viglione, D. J., Mihura, J. L., Erard, R. E., & Erdberg, P. (2011). Rorschach performance assessment system: Administration, coding, interpretation, and technical manual. Toledo, OH: Rorschach Performance Assessment System, LLC.
Mihura, J. L., Meyer, G. J., Dumitrascu, N., & Bombel, G. (2013). The validity of individual Rorschach variables: Systematic reviews and meta-analyses of the comprehensive system. Psychological bulletin, 139(3), 548. https://doi.org/10.1037/a0029406
Mishel, M. H., & Clayton, M. F. (2008). Theories of uncertainty. In M. J. Smith & P. R. Liehr (Eds.), Middle range theory for nursing (2nd ed., pp. 55-78). Springer.
Molton, I. R., & Terrill, A. L. (2014). Overview of persistent pain in older adults. American Psychologist, 69(2), 197-207. https://doi.org/10.1037/a0035794
Nicassio, P. M., Radojevic, V., Schoenfeld-Smith, K., & Dwyer, K. (1995). The contribution of family cohesion and the pain-coping process to depressive symptoms in fibromyalgia. Annals of Behavioral Medicine, 17(4), 349-356. https://doi.org/10.1007/BF02888600
Nicassio, P. M., Schuman, C., Radojevic, V., & Weisman, M. H. (1999). Helplessness as a mediator of health status in fibromyalgia. Cognitive Therapy and Research, 23(2), 181-196.
Palomino, R. A., Nicassio, P. M., Greenberg, M. A., & Medina Jr, E. P. (2007). Helplessness and loss as mediators between pain and depressive symptoms in fibromyalgia. Pain, 129(1-2), 185-194. https://doi.org/10.1016/j.pain.2006.12.026
Paras, M. L., Murad, M. H., Chen, L. P., Goranson, E. N., Sattler, A. L., Colbenson, K. M., Elamin, M.B, Seime, R.S., Prokop, L.J., & Zirakzadeh, A. (2009). Sexual abuse and lifetime diagnosis of somatic disorders: a systematic review and meta-analysis. Jama, 302(5), 550-561. https://doi.org/10.1001/jama.2009.1091
Pignatti, P. F. (2003). Malattie genetiche multifattoriali. Rivista di Medicina di Laboratorio, 4(S1), 32-34.
Pignolo, C., Giromini, L., Ando', A., Ghirardello, D., Di Girolamo, M., Ales, F., & Zennaro, A. (2017). An interrater reliability study of Rorschach Performance Assessment System (R–PAS) raw and complexity-adjusted scores. Journal of personality assessment, 99(6), 619-625. https://doi.org/10.1080/00223891.2017.1296844
Porcelli, P., & Mihura, J. L. (2010). Assessment of alexithymia with the Rorschach comprehensive system: The Rorschach Alexithymia Scale (RAS). Journal of personality assessment, 92(2), 128-136. https://doi.org/10.1080/00223890903508146
Reibel, M. D., & Hutti, M. H. (2020). The Role of Helplessness in the Appraisal of Illness Uncertainty in Women With Fibromyalgia. Nursing Science Quarterly, 33(4), 346-352. https://doi.org/10.1177/0894318420943151
Sifneos, P. E. (1973). The prevalence of “alexithymic” characteristics in psychosomatic patients. Psychotherapy and Psychosomatics, 22, 255–262. https://doi.org/10.1159/000286529
Smythe, H. A., & Moldofsky, H. (1977). Two contributions to an understanding of the “fibrositis” syndrome. Bulletin on the Rheumatic Diseases, 28(1), 928-931.
Steinweg, D. L., Dallas, A. P., & Rea, W. S. (2011). Fibromyalgia: unspeakable suffering, a prevalence study of alexithymia. Psychosomatics, 52(3), 255–262. https://doi.org/10.1016/j.psym.2010.12.022
Stisi, S., Venditti, C., & Saracco, I. (2008). Distress influence in fibromyalgia. Reumatismo, 60(4), 274-281. https://doi.org/10.4081/reumatismo.2008.274
Su, W. S., Viglione, D. J., Green, E. E., Tam, W. C., Su, J. A., & Chang, Y. T. (2015). Cultural and linguistic adaptability of the Rorschach Performance Assessment System as a measure of psychotic characteristics and severity of mental disturbance in Taiwan. Psychological Assessment, 27, 1273-1285. https://doi.org/10.1037/pas0000144
Taskin, E. O., Tikiz, C., Yuksel, E. G., Firat, A., Tuzun, C., & Aydemir, O. (2007). Prevalence of depressive disorders among patients with fibromyalgia seeking help for the first time, and its relationship with alexithymia. Anatolian Journal of Psychiatry, 8, 248–255.
Taylor, G. J. (2000). Recent developments in alexithymia theory and research. Canadian Journal of Psychiatry, 45(2), 134–142. https://doi.org/10.1177/070674370004500203
Taylor, G. J., Bagby, R. M., & Parker, J. D. (1999). Disorders of Affect Regulation: Alexithymia in Medical and Psychiatric Illness. Cambridge: Cambridge University Press.
Tesio, V., Di Tella, M., Ghiggia, A., Romeo, A., Colonna, F., Fusaro, E., Geminiani, G. C., & Castelli, L. (2018). Alexithymia and Depression Affect Quality of Life in Patients With Chronic Pain: A Study on 205 Patients With Fibromyalgia. Frontiers in Psychology, 9, 442. http://dx.doi.org/10.3389/fpsyg.2018.00442
Tesio, V., Ghiggia, A., Di Tella, M., & Castelli, L. (2019). Utility of the Diagnostic Criteria for Psychosomatic Research in assessing psychological disorders in fibromyalgia patients. Journal of Affective Disorders, 256, 219-220. http://dx.doi.org/10.1016/j.jad.2019.06.013
Tibon, S., Weinberger, Y., Handelzalts, J. E., & Porcelli, P. (2005). Construct validation of the Rorschach Reality-Fantasy Scale in alexithymia. Psychoanalytic Psychology, 22(4), 508. http://dx.doi.org/10.1037/0736-9735.22.4.508
Vallejo, M. A., Vallejo-Slocker, L., Offenbaecher, M., Hirsch, J. K., Toussaint, L. L., Kohls, N., ... & Rivera, J. (2021). Psychological Flexibility Is Key for Reducing the Severity and Impact of Fibromyalgia. International Journal of Environmental Research and Public Health, 18(14), 7300. https://doi.org/10.3390/ijerph18147300
Van Houdenhove, B., & Egle, U. T. (2004). Fibromyalgia: A stress disorder?. Psychotherapy and psychosomatics, 73(5), 267-275. https://doi.org/10.1159/000078843
Van Houdenhove, B., Egle U., & Luyten P. (2005). The role of life stress in fibro-myalgia. Current Rheumatology Reports, 7(5), 365–370. http://dx.doi.org/10.1007/s11926-005-0021-z
Van Middendorp, H., Lumley, M. A., Jacobs, J. W., van Doornen L. J., Bijlsma, J. W, & Geenen, R. (2008). Emotions and emotional approach and avoidance strategies in fibromyalgia. Journal of Psychosomatic Research, 64(2), 159–167. http://dx.doi.org/10.1016/j.jpsychores.2007.08.009
Viglione, D. J., Blume-Marcovici, A. C., Miller, H. L., Giromini, L., & Meyer, G. (2012). An inter-rater reliability study for the Rorschach Performance Assessment. Journal of Personality Assessment, 94, 607-612. http://dx.doi.org/10.1080/00223891.2012.684118
Vlaeyen, J. W., & Linton, S. J. (2012). Fear-avoidance model of chronic musculoskeletal pain: 12 years on. Pain, 153, 1144– 1147. http://dx.doi.org/10.1016/j.pain.2011.12.009
Walker, E., Keegan, D., Gardner, G., Sullivan, M., Bernstein, D., & Katon, W. J. (1997). Psychosocial factors in fibromyalgia compared with rheumatoid arthritis: II. Sexual, physical, and emotional abuse and neglect. Psychosomatic medicine, 59(6), 572-577. http://dx.doi.org/10.1097/00006842-199711000-00003
Wolfe, F., & Hawley, D. J. (1999). Evidence of disordered symptom appraisal in fibromyalgia: increased rates of reported comorbidity and comorbidity severity. Clinical and experimental rheumatology, 17, 297-304.
Wolfe, F., Clauw, D. J., Fitzcharles, M. A., Goldenberg, D. L., Häuser, W., Katz, R. L., Mease, P. J., Russel, A. S., Russel, I.J., & Walitt, B. (2016). 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Seminars in arthritis and rheumatism, 46(3), 319-329. https://doi.org/10.1016/j.semarthrit.2016.08.012
Wolfe, F., Clauw, D. J., Fitzcharles, M. A., Goldenberg, D. L., Katz, R. S., Mease, P., Russell, A.S., Russell, I. J., Winfield, J.B., & Yunus, M. B. (2010). The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis care & research, 62(5), 600-610. https://doi.org/10.1002/acr.20140
Wolfe, F., Smythe, H. A., Yunus, M. B., Bennett, R. M., Bombardier, C., Goldenberg, D. L., Tugwell, P., Campbell, S.M., Abeles, M., Clark, P., Fam, A.G, Farber, S.J., Fiechtner, J., J., Franklin, C. M., Gatter, R.A., Hamaty, D., Lessard, J., Lichtbroun, A., S., Masi, A.T., … & Sheon, R.P. (1990). The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis & Rheumatism, 33(2), 160-172. https://doi.org/10.1002/art.1780330203
DOI: https://doi.org/10.13129/2282-1619/mjcp-3140
Refbacks
- There are currently no refbacks.