research article anxiety, automatic negative thoughts, and...

Research ArticleAnxiety, Automatic Negative Thoughts, and UnconditionalSelf-Acceptance in Rheumatoid Arthritis: A Preliminary Study

Ramona Palos,1 and Loredana Vîs,cu2

1 Department of Psychology, West University of Timisoara, V. Parvan Street, No. 4, 300323 Timis,oara, Romania2 Social Work Department, University “Eftimie Murgu” of Res,it,a, Train Vuia Square, No. 1-4, 320085 Res,it,a, Romania

Correspondence should be addressed to Ramona Palos,; ramona [email protected]

Received 8 November 2013; Accepted 27 January 2014; Published 20 March 2014

Academic Editors: C. Chizzolini and R. Marks

Copyright © 2014 R. Palos, and L. Vıs,cu.This is an open access article distributed under theCreativeCommonsAttribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objectives.This research was carried out in two stages: the objectives of the first stage were (1) to identify the existing relationshipsbetween the level of anxiety, the frequency of automatic negative thoughts, and unconditional self-acceptance and (2) to capturethe existing differences regarding these variables between people diagnosed with rheumatoid arthritis and those with no suchmedical history. Methods. The sample made up of 50 subjects filled out the following three questionnaires: the Hamilton AnxietyScale, theAutomaticThoughtsQuestionnaire, and theUnconditional Self-AcceptanceQuestionnaire.Results.Psychological anxietyis positively correlated with automatic negative thoughts, while unconditional self-acceptance is negatively correlated with bothpsychological anxiety and somatic anxiety as well as with automatic negative thoughts. All studied variables were significantlydifferent in rheumatoid arthritis as compared to the control population. Conclusions. The results showed the presence to agreater extent of anxiety and automatic negative thoughts, along with reduced unconditional self-acceptance among people withrheumatoid arthritis. Intervention on these variables through support and counseling can lead to reducing anxiety and depression,to altering the coping styles, and, implicitly, to improving the patients’ quality of life.

1. Introduction

Rheumatoid arthritis (RA) is one of the main and mostcommon inflammatory rheumatic diseases that affect thejoints, causing chronic pain and disability [1]. Although inarthritis disability has been associated with damaging effecton the joints, gradually, the predictive nature of psychologicaland social factors has also been acknowledged in increasingdisability over time (e.g., attitude towards the disease, copingstyles, anxiety, automatic negative thoughts, or depression).This can determine significant influences in carrying out one’sroles, in one’s quality of life andmental health [2]. Fortunately,as the disease progresses, patients can learn how to adapt toit and its consequences, so as to maintain a normal level ofdistress [3].

The literature explaining rheumatoid arthritis highlightsthe role played by psychological factors in health-seekingbehaviors and in using medical services [4] or in developingcounseling and support programs. The self-regulation modelsuggests the fact that the emotional and cognitive aspects of

perceiving the disease guide the response to this illness anddetermine the efficiency of the copingmechanisms developedby patients. Coping—seen as a general concept employedto describe cognitive, emotional and behavioral reactions tostressful events and situations—and perception of the diseaseappear as the most significant variables in the relationshipbetween physical and psychological factors in RA [5]. Thisis explained by the fact that in the process of coping one cantrace three dimensions: (1) one related to the set of cognitionsconcerning the significance that a person attributes to astressful event; (2) a second dimension related to the set ofcognitions that a person has with regard to resources forcoping with a stressful event; (3) and a third dimensionreferring to avoidance-oriented coping [5, page 204]. In thecase of people diagnosed with RA, research studies focusedparticularly on finding answers to two questions: how thesepeople use coping mechanisms in this disease and why, whenfaced with the same stressful events, people cope differently.With these patients, psychotherapeutic approaches focusedon behavioral therapy, on cognitive therapy, on education for

Hindawi Publishing CorporationISRN RheumatologyVolume 2014, Article ID 317259, 5 pageshttp://dx.doi.org/10.1155/2014/317259

2 ISRN Rheumatology

arthritis, on stress management, or on supportive counseling[6].

The biopsychosocial approach to arthritis also acknowl-edged the impact of psychological and social factors on theevolution of arthritis [7]. Among the most important factorsthat influence copingmechanisms are stress, depression, self-efficacy, lack of hope, and social relationships. A large numberof research studies suggest the existence of a link between psy-chological factors and those that influence pain and disability[8, 9]. Stress and depression can be both considered as con-sequences of arthritis, but they can also exacerbate arthritisactivity [8–10]. Also, anxiety and depression influence painin different ways and call for different means of intervention[11]. Anxiety, for example, is linked to the perseverativecognition, amaladaptive process ofmaintaining the cognitiverepresentation of a stressor in the absence of implementingan adaptive behavior of coping [12]. Moreover, automaticnegative thoughts, simultaneously occurring with a stressfulsituation, lead to depression [13, 14]. Although automaticthoughts are an element of both normal and abnormalcognitions, the presence of a consistent pattern of automaticnegative thoughts leads to one’s reduced ability to functionand adequately adapt to the environment [15]. The origin ofthese thoughts lies in the pessimistic beliefs about oneself,about one’s future and relationships with others, and theyconsist of negative statements about oneself. Certain studiescorrelate automatic negative thoughtswith depression, aswellas with one’s coping styles, with the problem solving process[16]. Also, another factor that determines personal adaptationand well-being is unconditional self-acceptance [17], seen asan adaptive acceptance of oneself regardless of the approval,respect, or love received from others [18]. Research studiescarried out by Chamberlain and Haaga [19] highlight thefact that low unconditional self-acceptance is associated withdepression and anxiety, as well as with low levels of self-esteem, happiness, and life satisfaction.

Knowing all these factors can help clinical psychologistscontribute to the improvement of the quality of life of patientswith RA. Starting from this premise, the pilot research wascarried out in two stages. For the first stage, the objectiveswere (1) to identify the relationships that exist between thelevel of anxiety developed by patients, the frequency of auto-matic negative thoughts, and unconditional self-acceptanceand (2) to capture the differences regarding these variablesbetween people diagnosed with rheumatoid arthritis andpeople with no such medical history. In the second stage,based on the results obtained, a pilot strategy was devisedto create a support and psychological counseling group forpeople diagnosed with rheumatoid arthritis, followed by anew evaluation of the studied variables after a period of sixmonths.

2. Methods

2.1. Participants. The first stage of the study was carriedout during year 2012 within the County Hospital locatedin Resita, on the psychologist’s initiative, approved by thechief of the hospital’s psychology department. The sample of

the research included 50 participants: one sample made upof 25 people diagnosed with rheumatoid arthritis (RA) forat least 5 years, frequently hospitalized and registered at theCounty Hospital (with an average age of 49.43), and a witnesssample made up of 25 in-good-health people with no suchmedical history or other chronic diseases (with an average ageof 51.71).

2.2. Procedure. The participation in the study was voluntary;the subjects were given instructions regarding the study, itspurpose, and benefits, followed by their verbal agreement.They were asked to fill out three licensed questionnaires,part of a battery of questionnaires adapted to the Romanianpopulation [20]. A semistructured interview was also neces-sary in order to gather information about disease history andpatients’ quality of life. People within the sample diagnosedwith rheumatoid arthritis for at least 5 years (11 man and14 women) were hospitalized for two weeks. Participants inthe witness sample (10 man and 15 women) were selectedrandomly, with the main condition being the absence of thisdisease in their medical history.

2.3. Measures. The three questionnaires used in the first stageof this pilot research are part of a battery of questionnairesadapted to the Romanian population and distributed underlicense [20]. (1) The Hamilton Anxiety Scale, developed byHamilton (2007) [21], is used to evaluate the severity ofanxiety symptoms in children and adults. The scale includes14 items for evaluating cognitive, emotional, and, mainly,somatic components (physical complaints related to anxi-ety), an evaluation based on the patients’ current state ofhealth and following a semistructured interview that includesquestions regarding the presence of anxiety symptoms; theanswers are given on a 5-step scale (0: no anxiety, 4:severe anxiety); (2) the Automatic Thoughts Questionnaire,developed by Hollon and Kendal (2006) [22], is made upof 15 items that measure the frequency of dysfunctionaland irrational automatic negative thoughts about oneself; theanswers are given on a 5-step Likert scale (1: never, 5: almostalways), according to the frequency of these thoughts duringthe last four weeks; (3) the Unconditional Self-AcceptanceQuestionnaire, developed by Chamberlain and Haaga (2007)[23], includes 20 items that measure unconditional self-acceptance, regardless of behavior, achievement, approval,respect, or love from others; the answers are given on a 7-step Likert scale (1: almost always false, 7: almost alwaystrue), according to the subjects approval or disapproval ofthe given statements. Individual semistructured interviewswere also carried out in order to gather information aboutthe rheumatoid arthritis-related medical history and theparticipants’ quality of life.

2.4. Analysis. The data obtained by applying the question-naires was statistically processed using the SPSS version16 program. In order to achieve the objectives set for thefirst stage of the research, correlations were calculated usingthe Bravais-Pearson coefficient; as data distribution was notnormal, and the samples sizes were less than 30 participants,

ISRN Rheumatology 3

for establishing the differences, the nonparametric Mann-Whitney 𝑈 test was used for comparing two independentsamples [24].

3. Results

For the first stage, the first objective of the pilot study wasto (1) identify the relationships between the level of anxietydeveloped by patients, the frequency of automatic negativethoughts, and unconditional self-acceptance. Table 1 showsthe positive correlations obtained between psychologicalanxiety and automatic negative thoughts, highlighting thefact that an increase in psychological anxiety is linkedto a higher frequency of automatic negative thoughts; thenegative correlations obtained between psychological anxietyand somatic anxiety, respectively, and unconditional self-acceptance, indicating that higher psychological and somaticanxiety are tightly related to lower self-acceptance; and anegative relationship between automatic negative thoughtsand unconditional self-acceptance, indicating that higherfrequency of automatic negative thoughts is linked to lowerunconditional self-acceptance.

The second objective aimed at highlighting the differ-ences between the level of anxiety, the frequency of auto-matic negative thoughts, and unconditional self-acceptancein the case of people diagnosed with rheumatoid arthritis ascompared to people not suffering from this disease, in orderto develop counseling and support programs—in the secondstage of the study. Table 2 shows the existing differencesbetween the two samples in terms of psychological andsomatic anxiety—indicating a higher level of psychologicaland somatic anxiety in the case of subjects diagnosed withRA; a higher frequency of automatic negative thoughts inthe case of subjects diagnosed with RA; and a higher level ofunconditional self-acceptance in the case of subjects withoutRA.

4. Discussion

The results obtained in this preliminary study are in confor-mity with the biopsychosocial model of the RA. Apart fromanxiety and depression, associated with chronic sufferingand intensified pain [11], relationships with two other typesof psychological variables were also captured: automaticnegative thoughts and unconditional self-acceptance.

According to the cognitive approach to depression, one’semotions and behaviors are determined by the way in whichone interprets events, interpretation based on the circum-stances in which the event occurs, on one’s disposition, andon other past events that are part of one’s personal experience[20]. The theory of automatic negative cognitions stressesthe importance of structures that represent past experiencesthat influence the processing and organizing of currentinformation [25], structures that were named automaticnegative cognitions.These are cognitive products in the formof reasoning and prediction made by the individual aboutoneself, the world, and the future. Automatic negative cogni-tions are repetitive and escape immediate control [25]. They

Table 1: Correlation coefficients between psychological and somaticanxiety, automatic negative thoughts and unconditional self-acceptance.

Variables 1 2 3 4(1) Psychological anxiety 1.00(2) Somatic anxiety — 1.00(3) Automatic negativethoughts .530∗∗ — 1.00

(4) Unconditionalself-acceptance −.404∗∗ −.397∗∗ −.594∗∗ 1.00

Note: N = 50; ∗∗correlation coefficient significant at p < .01.

are activated quickly, allow the individual to save resources,and determine a quick categorization of new stimuli fromthe environment, favoring the update of complex scenarios[13]. The dysfunctional cognitive schemes can also be thesource of cognitive distortions; they can favor a faulty or apreferential encoding of certain stimuli, omissions or errors,and inadequate behaviors [14]. Once activated, these negativeautomatic thoughts determine emotional and behavioralresponse to a stimulus or situation and allow biased informa-tion processing. Thus, dysfunctional patterns are reinforced,whereas adaptive but inconsistent patterns are suppressed[26]. The prevalence of automatic thoughts, that is, thosedysfunctional cognitions that affect both the perception ofoneself and external perception, has been associated withdepression [26]. In a study carried out by Flett et al. [17], theauthors also highlighted the existence of a link between lowunconditional self-acceptance and symptoms of depression.At the same time, low unconditional self-acceptance is tightlycorrelated with low self-esteem and elevated levels of self-esteem liability and proneness to depression [27]. Self-esteemis part of those factors that are associated with mental health.A low self-esteem as a consequence of problems that arosein the past is associated with the presence of symptomsspecific of depression [28]. Although there is a link betweenunconditional self-acceptance and global self-esteem, the twoconcepts do not overlap [27].

In the case of the study sample, one can notice thefact that an enhancement of psychological anxiety (mentalnervousness and psychological distress) and somatic anxiety(physical complaints related to anxiety) is closely connectedto a decrease in the patients’ self-acceptance, and an increasein the frequency of automatic negative thoughts is followedby a decrease in unconditional self-acceptance. In terms ofdifferences regarding these variables between people withRA and people without RA, results indicate the presence ofpsychological and somatic anxiety and a higher frequency ofautomatic negative thoughts in the case of patients diagnosedwith RA and a higher level of unconditional self-acceptancefor patients without RA.

Based on the analysis of these results a pilot strategywas developed in order to create a support and psycholog-ical counseling group for people taking part in this study.The interventions focused on the action on psychologicaland somatic anxiety, on automatic thoughts associated with

4 ISRN Rheumatology

Table 2: Differences between psychological and somatic anxiety, automatic negative thoughts, and unconditional self-acceptance.

Variables Participants Mean rank Mann-Whitney U Z p

Psychological anxiety Sample with RA 34.28 93.000 −4.277 .000Sample without RA 16.72

Somatic anxiety Sample with RA 35.14 71.500 −4.692 .000Sample without RA 15.86

Automatic negative thoughts Sample with RA 29.88 203.000 −2.128 .033Sample without RA 21.12

Unconditional self-acceptance Sample with RA 19.50 162.500 −2.913 .004Sample without RA 31.50

Note: N = 50 (25 participants with RA and 25 participants without RA).

depression, and on unconditional self-acceptance. The strat-egy followed a general plan as well as an individualizedone. Thus, for (1) the intervention on automatic thoughtsassociated with depression, the starting point was usingtechniques that would allow their identification, followed byapplying techniques for altering automatic thoughts; for (2)the intervention on anxiety, on a general level the focus wason learning how to relax through the Schultz autogenoustraining, followed by the development of individualizedplans for reducing anxiety where this measure was neededto a greater extent. All these activities aimed at changingmaladaptive thought and behavioral patterns, offering thepatients the opportunity to acquire tools for adapting tothe situation and the disease [29]. Moreover, studies showthat therapeutic interventionsmust firstly focus on automaticnegative thoughts because these are the closest to consciousawareness [16]. After identifying, evaluating, and alteringthese thoughts, one can notice a decrease in depression asthese thoughts are associated not only with depression, butalso with coping styles [26]. After carrying out an evaluationof the subsequent progress that followed these programs, anew testing and adaptation of the support and psychologicalcounseling strategy are intended, depending on the resultsobtained.

This undertaking was chosen due to the increasinginterest in the patients’ perspective on their own illness.Along with the traditional clinical approach interested in thepresence and severity of joint inflammation and the end-organ damage, the evaluation of a third domain, that of thequality of life, carried out by the patients themselves, becomesvery important [30].

5. Conclusion and Implication forFurther Research

Although the current study is in line with the results ofother research studies, a series of limitations must be noted.Firstly, one must note the small number of participants thatwere included in the study. Despite this fact, a numberof differences were noticeable between the two samples,regarding the variables investigated. Although many clinicalresearch studies aim at identifying the presence of depressionsymptoms in such situations, the current study did notemploy a questionnaire that would allow this. The three

psychological variables investigated—anxiety, automatic neg-ative thoughts, and unconditional self-acceptance—were,however, explained by referring to their relationship withdepression-specific symptoms. However, the portfolio ofquestionnaires focused on other variables as well, such asdecision making ability or the subjects’ attitudes and generalbeliefs. Although differences between the two samples wereobtained, these were not analyzed in this stage of the research,with the main concern being the creation of a support andpsychological counseling group for people with RA. Despitethese limitations, the study also bears potentially importantclinical implications. The results highlight the presence to agreater extent of anxiety and automatic negative thoughts,along with reduced unconditional self-acceptance amongpeople with RA. The intervention on these variables throughsupport and counseling can lead to reducing anxiety anddepression, to altering the coping styles, and, implicitly, toimproving the patients’ quality of life. Also, developing suchprograms that allow the patients’ education, from providinginformation and learning common nursing techniques tousing cognitive-behavioral strategies within these programs,can become an important component of active managementprograms for RA [31].

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

References

[1] R. Puchner, J. Sautner, D. Loisl, and U. Puchner, “Doesa special relationship between personality and rheumatoidarthritis exist? Experiences with an Austrian PsychologicalQuestionnaire,” Clinical Rheumatology, vol. 28, no. 10, pp. 1147–1152, 2009.

[2] J. E. Broderick, A. A. Stone, J. M. Smyth, and A. T. Kaell,“The feasibility and effectiveness of an expressive writing inter-vention for rheumatoid arthritis via home-based videotapedinstructions,” Annals of Behavioral Medicine, vol. 27, no. 1, pp.50–59, 2004.

[3] R. K. Dissanayake and J. V. Bertouch, “Psychosocial interven-tions as adjunct therapy for patients with rheumatoid arthritis: asystematic review,” International Journal of Rheumatic Diseases,vol. 13, no. 4, pp. 324–334, 2010.

ISRN Rheumatology 5

[4] T. Covic, G. Tyson, D. Spencer, and G. Howe, “Depressionin rheumatoid arthritis patients: demographic, clinical, andpsychological predictors,” Journal of Psychosomatic Research,vol. 60, no. 5, pp. 469–476, 2006.

[5] Y. Zyrianova, B. D. Kelly, J. Sheehan, C. McCarthy, and T. G.Dinan, “The psychological impact of arthritis: the effects ofillness perception and coping,” Irish Journal of Medical Science,vol. 180, no. 1, pp. 203–210, 2011.

[6] L. Sharpe, “Arthritis: behavioral treatment,” in Encyclopedia ofHealth & Behavior, N. B. Anderson, Ed., Sage Publications,Thousand Oaks, Calif, USA, 2004.

[7] F. J. Keefe, S. J. Smith, A. L. H. Buffington, J. Gibson, J. L. Studts,and D. S. Caldwell, “Recent advances and future directionsin the biopsychosocial assessment and treatment of arthritis,”Journal of Consulting and Clinical Psychology, vol. 70, no. 3, pp.640–655, 2002.

[8] A. J. Zautra and B.W. Smith, “Depression and reactivity to stressin older women with rheumatoid arthritis and osteoarthritis,”Psychosomatic Medicine, vol. 63, no. 4, pp. 687–696, 2001.

[9] B. W. Smith and A. J. Zautra, “The role of personality inexposure and reactivity to interpersonal stress in relation toarthritis disease activity and negative affect in women,” HealthPsychology, vol. 21, no. 1, pp. 81–88, 2002.

[10] B. W. Smith and A. J. Zautra, “The role of purpose in life inrecovery from knee surgery,” International Journal of BehavioralMedicine, vol. 11, no. 4, pp. 197–202, 2004.

[11] B. W. Smith and A. J. Zautra, “The effects of anxiety anddepression on weekly pain in women with arthritis,” Pain, vol.138, no. 2, pp. 354–361, 2008.

[12] J. F. Brosschot, W. Gerin, and J. F. Thayer, “The perseverativecognition hypothesis: a review of worry, prolonged stress-related physiological activation, and health,” Journal of Psycho-somatic Research, vol. 60, no. 2, pp. 113–124, 2006.

[13] J. S. Beck, Cognitive Therapy: Basics and Beyond, Guilford, NewYork, NY, USA, 1995.

[14] J. W. Kanter, R. J. Kohlenberg, and E. F. Loftus, “Experimentaland psychotherapeutic demand characteristics and the cogni-tive therapy rationale: an analogue study,”CognitiveTherapy andResearch, vol. 28, no. 2, pp. 229–239, 2004.

[15] C.A.Arpin-Cribbie andR.A. Cribbie, “Psychological correlatesof fatigue: examining depression, perfectionism, and automaticnegative thoughts,” Personality and Individual Differences, vol.43, no. 6, pp. 1310–1320, 2007.

[16] D. Clarke and T. Goosen, “The mediating effects of cop-ing strategies in the relationship between automatic negativethoughts and depression in a clinical sample of diabetespatients,” Personality and Individual Differences, vol. 46, no. 4,pp. 460–464, 2009.

[17] G. L. Flett, A. Besser, R. A. Davis, and P. L. Hewitt, “Dimensionsof perfectionism, unconditional self-acceptance, and depres-sion,” Journal of Rational, vol. 21, no. 2, pp. 119–138, 2003.

[18] L.-G. Lundh, “Perfectionism and acceptance,” Journal of Ratio-nal: Emotive and Cognitive-Behavior Therapy, vol. 22, no. 4, pp.255–269, 2004.

[19] J. M. Chamberlain and D. A. F. Haaga, “Unconditional self-acceptance and psychological health,” Journal of Rational-Emotive and Cognitive-Behavior Therapy, vol. 19, no. 3, pp. 163–176, 2001.

[20] D. David, Ed., Sistem de Evaluare Clinica, Editura RTS, Cluj-Napoca, Romania, 2007.

[21] M. Hamilton, “Scala de anxietate Hamilton, (adaptat deMacavei, B),” in Sistem de Evaluare Clinica, D. David, Ed.,Editura RTS, Cluj-Napoca, Romania, 2007.

[22] S. D. Hollon and P. C. Kendall, “Chestionarul gandurilorautomate” (adaptat de Moldovan, R.),” in Sistemul de EvaluareClinica, D. David, Ed., Editura RTS, Cluj-Napoca, Romania,2006.

[23] J. M. Chamberlain and D. A. F. Haaga, “Chestionarul deacceptare neconditionata a propriei persoane” (adaptat deMacavei B),” in Sistem de Evaluare Clinica, D. David, Ed.,Editura RTS, Cluj-Napoca, Romania, 2007.

[24] M. Popa, Statistica Pentru Psihologie. Teories,iaplicat,ii SPSS,Editura Polirom, Ias,i, Romania, 2008.

[25] A. T. Beck, “Cognitive models of depression,” Journal of Cogni-tive Psychotherapy: An International Quarterly, vol. 1, pp. 5–57,1987.

[26] E. L. Garland, B. Fredrickson, A. M. Kring, D. P. Johnson,P. S. Meyer, and D. L. Penn, “Upward spirals of positiveemotions counter downward spirals of negativity: insights fromthe broaden-and-build theory and affective neuroscience onthe treatment of emotion dysfunctions and deficits in psy-chopathology,” Clinical Psychology Review, vol. 30, no. 7, pp.849–864, 2010.

[27] J. M. Chamberlain and D. A. F. Haaga, “Unconditional self-acceptance and responses to negative feedback,” Journal ofRational-Emotive and Cognitive-Behavior Therapy, vol. 19, no.3, pp. 177–189, 2001.

[28] A. Ellis, Reason and Emotion in Psychotherapy, Birch Lane,Secaucus, NJ, USA, 1994.

[29] D. David, Ed., Tratat de Psihoterapii Cognitive Si Comportamen-tale, Editura Polirom, Ias,i, Romania, 2006.

[30] G. Kingsley, I. C. Scott, and D. L. Scott, “Quality of life and theoutcome of established rheumatoid arthritis,” Best Practice andResearchClinical Rheumatology, vol. 25, no. 4, pp. 585–606, 2011.

[31] M. G. Albano, J.-S. Giraudet-Le Quintrec, C. Crozet, and J.-F. d’Ivernois, “Characteristics and development of therapeuticpatient education in rheumatoid arthritis: analysis of the 2003–2008 literature,” Joint Bone Spine, vol. 77, no. 5, pp. 405–410,2010.

Submit your manuscripts athttp://www.hindawi.com

Stem CellsInternational

Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014


MEDIATORSINFLAMMATION

of


Behavioural Neurology

EndocrinologyInternational Journal of



Disease Markers


BioMed Research International

OncologyJournal of



Oxidative Medicine and Cellular Longevity


PPAR Research

The Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014

Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014

Journal of

ObesityJournal of



Computational and Mathematical Methods in Medicine

OphthalmologyJournal of


Diabetes ResearchJournal of



Research and TreatmentAIDS


Gastroenterology Research and Practice


Parkinson’s Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

research article anxiety, automatic negative thoughts, and...

Documents