Crisis Support Scale Research Articles

Coping, Social Support and Loneliness during the COVID-19 Pandemic and Their Effect on Depression and Anxiety: Patients' Experiences in Community Mental Health Centers in Norway.

Background: Little is known about psychiatric patients’ experiences during the COVID-19 pandemic. The purpose of this study was to investigate associations of coping strategies, social support and loneliness with mental health symptoms among these patients. Methods: We recruited 164 patients from Community Mental Health Centers in June–July 2020. Participants responded to an online questionnaire on corona-related questions, Brief Coping Orientation to Problems Experience, Crisis Support Scale, a 3-item Loneliness Scale, and Hopkins Symptom Checklist-25. We used linear regression models to investigate associations between these and symptoms of depression and anxiety. Results: Almost 51% were aged 31–50 years and 77% were females. Forty-six (28%) participants reported worsened overall mental health due to the pandemic. The reported rates of clinical depression and anxiety were 84% and 76%, respectively. Maladaptive coping was independently associated with both depression and anxiety symptoms. Loneliness was independently associated with depression symptoms. Conclusions: Patients in Community Mental Health Centers in Norway reported high rates of depression and anxiety symptoms. Many of them reported worsening of their mental health due to the pandemic, even at a time when COVID-19 infections and restrictive measures were relatively low. Maladaptive coping strategies and loneliness may be possible explanations for more distress.

Factors Affecting Secondary Traumatic Stress Disorder among Search and Rescue Team in Makassar

Introduction: Disaster is an unwanted event and usually occur suddenly and is accompanied by many victims. Disasters can have many impacts, both physical and psychological. The psychological impact that can arise on disaster victims is called Post Traumatic Stress Disorder (PTSD). Not only on the victim, the person who served as a helper also can have psychological disorders. Psychological disorders in these helpers are called Secondary Traumatic Stress Disorder (STSD). This study was aimed to identify factors that influence the incidence STSD the Search and Rescue (SAR) teams in universities and BASARNAS Makassar. Method: This research is a quantitative study with a cross-sectional approach using total sampling techniques the samples in this study were all sar and basrnas member (n=60) who agreed to be the respondent and have involved in rescue activity on one last year. Data is collected by distributing questionnaires. Questionnaires used were Secondary Traumatic Stress Scale and Crisis Support Scale. The statistical test used Chi square test, Mann-Whitney U test and logistic regression analysis. Result: The study showed that there was a relationship between the frequency of exposure, social support, and the length of work (p<0,05) and the incidence of STSD. However, the type of exposure has no significant relationship with the incidence of STSD. Conclusion: Social support is the most significant factor compared to the frequency of exposure, the type of disaster and length of work / joining. This research is expected to provide additional information on STSD risk factors. For future researchers, in order to examine other variables which is trauma history and coping mechanism the SAR team to experience symptoms of STSD

Social support and household disaster evacuation readiness in a flood-affected rural village in Tamil Nadu, South India

OBJECTIVE: To assess the social support and household disaster evacuation readiness among flood-affected households in a rural village of Tamil Nadu. METHODS: We conducted this cross-sectional analytical study in the flood-affected Koonimedu village of Villupuram District, Tamil Nadu, 8 months after the flood. One adult member (age >18 years) from each of the flood-affected households was included and interviewed face to face at his/her house. Information on sociodemographic details, loss of property, and household evacuation readiness plan was obtained using a semistructured pretested questionnaire. Social support was measured using the Crisis Support Scale (CSS). RESULTS: Nearly 60% of the households were still waiting for government assistance for house repair. Less than a quarter of households reported adequate social support. Availability of people to listen to them, able to discuss their thoughts and feelings, and contact with people in similar situations showed improvement after 8 months of flood. CSS score on feeling letdown showed a significant increase 8 months after the flood. Although all the households were ready to evacuate if flood recurs, none have undergone training on disaster preparedness. Majority of the households reported to secure ration card first during evacuation. CONCLUSION: The level of adequate social support during flood as well as 8 months after the flood was low among the study population. Although all households have their own disaster evacuation plan, none have been given information and training on disaster preparedness.

Mental health status of flood-affected adults in rural Tamil Nadu: A cross-sectional study

Objectives: The objective is to study the mental health status (in terms of posttraumatic stress disorder [PTSD]) of flood-affected adults aged 18 years and above residing in a rural village of Tamil Nadu affected by flood in December 2015. Methods: The study adopted a cross-sectional descriptive design. One adult member (age >18 years) preferably, head from each of the flood-affected households of Koonimedu village, Tamil Nadu, was included in the study. Participants were interviewed face to face 8 months after the occurrence of flood, and information on sociodemographic details and immediate effect of flood on health and property was obtained using semi-structured pretested questionnaire. Mental health and social support were assessed using the Impact of Event Scale-Revised (IES-R) and Crisis Support Scale, respectively. Mental health was expressed in terms of PTSD based on IES-R screening. Data analysis was done using statistical software. Results: The prevalence of PTSD as screened by IES-R among adults was found to be 51.3%. PTSD was found to be higher among females (56.7%) than males (43.3%). The elderly reported highest PTSD (63%). PTSD was found to be higher among participants who had received adequate social support. Conclusions: Even after 8 months of flood, the prevalence of screened PTSD was found to be very high and crisis social support low among individuals aged 18 years or above. Hence, mental health-care services including counseling support during and after the flood should be given priority by policy-maker.

Social support and complicated grief: A longitudinal study on bereaved parents after the Utøya terror attack in Norway

On the 22nd of July 2011, Norway experienced its most extreme act of terror in recent times. The terror attacks at the Government Quarters and Utoya, claiming the lives of 77 people, left a nation in shock and numerous people grieving. Such traumatic bereavement is associated with an increased risk of chronically elevated grief symptoms, and identifying protective factors is important. The purpose of this study was to investigate the effect of social support on complicated grief over time among bereaved parents after the terror attack on Utoya. Our sample consisted of 86 bereaved parents ( M age = 51.6 years, 52.3% women), who completed the Crisis Support Scale (CSS) and the Inventory of Complicated Grief (ICG) 18, 28, and 40 months after the loss of their child. The results showed a decrease in levels of complicated grief with time. Men had lower levels of complicated grief than women. Findings did not, however, show that parents with higher levels of social support had significantly lower levels of complicated grief compared to parents with less social support. Furthermore, our results did not suggest an accelerated recovery directly due to these factors of social support and gender. Implications and suggestions for further research are discussed. «/><meta name=

Psychological morbidity and return to work after injury: multicentre cohort study.

The benefits of work for physical, psychological, and financial wellbeing are well documented. Return to work (RTW) after unintentional injury is often delayed, and psychological morbidity may contribute to this delay. The impact of psychological morbidity on RTW after a wide range of unintentional injuries in the UK has not been adequately quantified. To quantify the role of psychological factors, including anxiety, depression, and post-traumatic distress, on RTW following unintentional injuries. A longitudinal multicentre prospective study was undertaken in Nottingham, Bristol, Leicester, and Guildford, UK. Participants (n = 273) were 16-69-year-olds admitted to hospital following unintentional injury, who were in paid employment prior to injury. They were surveyed at baseline, then at 1, 2, 4, and 12 months following injury; demographic data were collected along with injury characteristics, psychological morbidity, and RTW status. Associations between demographic, injury and psychological factors, and RTW between 2 and 12 months after injury were quantified using random effects logistic regression. The odds of RTW between 2 and 12 months after injury reduced as depression scores early in the recovery period (1 month after injury) increased (odds ratio [OR] 0.87, 95% confidence interval [CI] = 0.79 to 0.95) and as length of hospital stay increased (OR 0.91, 95% CI] = 0.86 to 0.96). For those experiencing threatening life events following injury (OR 0.27, 95% CI = 0.10 to 0.72) and with higher scores on the Crisis Support Scale (OR 0.93, 95% CI] = 0.88 to 0.99), the odds of RTW between 2 and 12 months after injury were lower. Multiple imputation analysis found similar results, but those relating to crisis support did not remain statistically significant. Primary care professionals can identify patients at risk of delayed RTW who may benefit from management of psychological morbidity and support to RTW.

Treatment of trauma-affected refugees with venlafaxine versus sertraline combined with psychotherapy - a randomised study.

BackgroundThe prevalence of trauma-related psychiatric disorders is high among refugees. Despite this, little is known about the effect of pharmacological treatment for this patient group. The objective of the present study was therefore to examine differences in the effects of venlafaxine and sertraline on Post-Traumatic Stress Disorder (PTSD), depression and functional impairment in trauma-affected refugees.MethodsThe study was a randomised pragmatic trial comparing venlafaxine and sertraline in combination with psychotherapy and social counselling. PTSD symptoms were measured on the Harvard Trauma Questionnaire – part IV, which was the primary outcome measure. Other outcome measures included: Hopkins Symptom Check List-25 (depression and anxiety), Social Adjustment Scale – short version (social functioning), WHO-5 Well-being Index (quality of life), Crisis Support Scale (support from social network), Sheehan Disability Scale (disability in three areas of functioning), Hamilton Depression and Anxiety scale, the somatisation items of the Symptoms Checklist-90, Global Assessment of Functioning scales and the summarised score of pain in four body areas rated on visual analogue scales.ResultsTwo hundred seven adult refugee patients were included in the trial (98 in the venlafaxine and 109 in the sertraline group). Of these, 195 patients were eligible for intention-to-treat analyses. Small but significant pre-treatment to post-treatment differences were found on the Harvard Trauma Questionnaire and a number of other ratings in both groups. On the primary outcome measure, no difference was found in treatment effect between the sertraline and venlafaxine group. A significant group difference was found in favour of sertraline on the Sheehan Disability Scale.ConclusionSertraline had a slightly better outcome than venlafaxine on some of the secondary outcome measures, but not on the primary outcome measure. Furthermore, a higher percentage of dropouts was found in the venlafaxine group compared to the sertraline group. Although this could indicate that sertraline was better tolerated, which is supported by other studies, a final conclusion on tolerability cannot be drawn from the current study due to lack of systematic reporting of side effects.Trial RegistrationClinicalTrials.gov NCT01569685. Registration date: 28/2/12Electronic supplementary materialThe online version of this article (doi:10.1186/s12888-016-1081-5) contains supplementary material, which is available to authorized users.

Risk factors for suicide attempts in the total population of Faroese eighth graders

Abstract Objectives: Suicide is still one of the leading causes of youth mortality, and amongst others previous suicide attempts have been found to be one of the strongest risk factors for suicide. The objective of this study is to examine risk factors of suicide attempts in a total population of Faroese adolescents. It is expected that anxious attachment, high scores on negative affectivity and low scores on past and present social support were correlated to an increased risk of life-time suicide attempts in both female and male adolescents. Method: Analyses were conducted based on data from The Faroese Adolescent Trauma Study, a self-report questionnaire survey including a total population of Faroese eighth graders (N = 687; 85 % response rate, mean age 14.2 years, SD = 2.1). The questionnaire included The Revised Adult Attachment Scale (RAAS), The Trauma Symptom Checklist (TSC), and The Crisis Support Scale (CSS). Results: In the total population 9.9 % (N = 68) of the participants reported life-time suicide attempt; of those 28 % were boys and 72 % were girls. In line with the expectations, the initial comparison showed that adolescents reporting life-time suicide attempt had significantly higher scores on attachment anxiety and negative affectivity, and had significantly lower scores on attachment closeness, and both past and present social support. Further analyses stratified on gender, however, revealed unexpected results, as a high score on negative affectivity only was a significant risk factor for life-time suicide attempt among the girls, and high score on attachment closeness only was a significant protective factor of life-time suicide attempt among the boys. Conclusions: This study provides important data about the role of attachment, negative affectivity, and social support in suicide attempts in a total population of Faroese adolescents. Moreover the results show the necessity of taking gender into account in research of risk and protective factors of suicide attempts, and when establishing arrangements to prevent and treat suicide attempts in adolescents.

Parents bereaved by infant death: PTSD symptoms up to 18 years after the loss

ObjectiveLosing an infant or fetus late in pregnancy, during birth or in the first year of life is a potentially traumatic event for parents. However, little is known about the factors contributing to chronic posttraumatic stress reactions in this population. The present study examined chronic posttraumatic stress disorder (PTSD) symptoms and potential correlates in 634 mothers and fathers up to 18 years (M=3.4 years) after the death of their infant. MethodsMembers of a private national support organization for parents bereaved by infant death were contacted and asked to participate in the study. Participants filled out a questionnaire package including measures of PTSD (the Harvard Trauma Questionnaire), coping (the Coping Style Questionnaire), perceived social support (the Crisis Support Scale) and attachment (the Revised Adult Attachment Scale). Associations between variables were examined through the use of analyses of variance, correlation analyses and a regression analysis. ResultsWe found an estimated PTSD prevalence of 12.3%. Type of loss (pre-, peri- or postnatal) did not have any effect on PTSD severity, but lower gestational age was associated with more symptoms. Time since the loss, female sex, attachment avoidance, attachment anxiety, emotion-focused coping, rational coping, feeling let down and social support satisfaction accounted for 42% of the variance in PTSD severity. ConclusionsThe study highlights the long-term impact of infant loss and points to attachment, coping and social support as important contributors to the development and maintenance of posttraumatic stress symptoms.

Can Demographic and Exposure Characteristics Predict Levels of Social Support in Survivors from a Natural Disaster?

ObjectiveLack of social support is a strong predictor for poor mental health after disasters. Psychosocial post-disaster interventions may benefit from targeting survivors at risk of low support, yet it is unknown whether demographic and disaster exposure characteristics are associated with social support. This study assessed if age, gender, educational status, cohabitation, and disaster exposure severity predicted aspects of informal social support in a cohort of Swedish survivors from the 2004 Southeast Asian tsunami.MethodsThe participants were 3,536 disaster survivors who responded to a mail survey 14 months after the disaster (49% response rate). Their perceptions of present emotional support, contact with others, tangible support, negative support and overall satisfaction with informal support were assessed with the Crisis Support Scale and analysed in five separate ordinal regressions.ResultsDemographic factors and exposure severity explained variation in social supports although the effect size and predictive efficiency were modest. Cohabitation and female gender were associated with both more positive and more negative support. Single-household men were at risk for low emotional support and younger women were more likely to perceive negative support. Higher education was associated with more positive support, whereas no clear pattern was found regarding age as a predictor. Disaster exposure severity was associated with more negative support and less overall support satisfaction.ConclusionsAfter a disaster that entailed little disruptions to the community the associations between demographic characteristics and social support concur with findings in the general population. The findings suggest that psychosocial disaster interventions may benefit from targeting specific groups of survivors.

Post-traumatic stress disorder in partners of people with epilepsy

AimsThe objectives of the present study were to examine whether living with an individual who suffered from epilepsy was a potentially traumatizing event and to identify predictive risk factors in developing post-traumatic stress disorder (PTSD). MethodsSix hundred fourteen respondents completed the Harvard Trauma Questionnaire, the Crisis Support Scale, the Hopkins Symptom Checklist—25, and the Dyadic Adjustment Scale. In addition, demographic variables were included in order to identify factors that might predict PTSD. ResultsThe percentage of the participants that fulfilled the symptom criteria of PTSD was 7.7%, and an additional 43.9% reported a subclinical level of PTSD. Clinical and subclinical anxiety was unveiled in 9.3% of the respondents. ConclusionPartners were at risk of PTSD when living with a patient with epilepsy. Identified variables that explained PTSD were frequency and types of seizures medication, side effects, and objective and subjective epilepsy severity, anxiety, and depression. High level of social support decreased the level of traumatic stress.

The psychological reactions after witnessing a killing in public in a Danish high school

BackgroundSchool killings attract immense media and public attention but psychological studies surrounding these events are rare.ObjectiveTo examine the prevalence of posttraumatic stress disorder (PTSD) and possible risk factors of PTSD in 320 Danish high school students (mean age 18 years) 7 months after witnessing a young man killing his former girlfriend in front of a large audience.MethodThe students answered the Harvard Trauma Questionnaire (HTQ), the Crisis Support Scale (CSS), and the Trauma Symptom Checklist (TSC).ResultsPrevalence of PTSD 7 months after the incident was 9.5%. Furthermore, 25% had PTSD at a subclinical level. Intimacy with the deceased girl; feeling fear, helplessness, or horror during the killing; lack of expressive ability; feeling let down by others; negative affectivity; and dissociation predicted 78% of the variance of the HTQ total scores.ConclusionIt is possible to identify students who are most likely to suffer from PTSD. This knowledge could be used to intervene early on to reduce adversities.

Social Support Moderates Posttraumatic Stress and General Distress After Disaster

Social support buffers the negative impact of stressful events. Less, however, is known about the characteristics of this association in the context of disaster and findings have been discrepant regarding direct and buffering effects. This study tested whether the protective effects of social support differed across levels of exposure severity (i.e., buffered distress) and assessed whether the buffering effect differed between event-specific and general distress. Participants were 4,600 adult Swedish tourists (44% of invited; 55% women) repatriated within 3 weeks after the 2004 Indian Ocean tsunami. A survey 14 months after the disaster included the Crisis Support Scale, the Impact of Event Scale-Revised (IES-R), and the General Health Questionnaire (GHQ-12). Social support buffered the negative impact of exposure on both outcomes. The support and distress association ranged from very small in participants with low exposure to moderate in those with high exposure (η(p)(2) = .004 to .053). The buffering effect was not found to differ between the IES-R and GHQ-12, F(2, 4589) = 0.87, p = .42. The findings suggest that social support moderates the stressor-distress relationship after disasters. This study might help explain discrepant findings and point to refinements of postdisaster interventions.

Posttraumatic Stress Disorder After Bereavement: Early Psychological Sequelae of Losing a Close Relative Due to Terminal Cancer

Very few studies have investigated posttraumatic stress disorder (PTSD) as a consequence of bereavement from terminal illness. Therefore, knowledge on the traumatizing effects of bereavement and risk factors for traumatization from bereavement is rather sparse. This study investigated prevalence and predictors of PTSD in a group of people who had recently lost a close relative due to incurable cancer. The participants were 132 persons who were assessed with the Harvard Trauma Questionnaire, the Trauma Symptom Checklist, and the Crisis Support Scale. One month after the loss, 29.5% of the subjects had clinical PTSD and an additional 26.2% reached a subclinical PTSD level. Negative affectivity, social support, and locus of control in relation to the loss predicted 57% of the variance in PTSD severity. A focus on these risk factors in early assessment after bereavement will help identify subjects at risk for developing PTSD as a result of bereavement.

Support, opinion of support and psychological health among survivors of a natural disaster

Although formal intervention after disasters is recommended, the evidence base for this is weak. Satisfaction with support after disasters is seldom investigated and the relation to psychological symptoms is unknown. To investigate whether dissatisfaction with social and formalized support are associated with post-disaster psychological symptoms. A total of 1,505 Swedish survivors of the 2004 Indian Ocean tsunami responded to a questionnaire 14 months after the disaster, including the General Health Questionnaire-12, the Impact of Events Scale - Revised, the Crisis Support Scale, and questions concerning the reception and appraisal of social and formalized support from health care, psychological services and insurance agencies. Disaster exposure and background factors were controlled for in the analyses. Reception of formalized support, but not social support, was associated with both psychological distress and post-traumatic stress. Dissatisfaction with social but not formalized support, with the exception of support from insurance agencies, was associated with psychological distress. Social support and formalized support should be differentiated in future studies in order to improve preventive intervention efforts after disasters. The reporting of dissatisfaction with social support merits special attention, since this may indicate increased risk for psychological symptoms.

Adversarial growth in telephone counsellors: psychological and environmental influences

The aims of this study were to investigate the level of adversarial growth among telephone counsellors, and to examine the influence of psychological and environmental factors on growth. In particular, the effect of compassion fatigue, empathy, environmental support and calls per shift on posttraumatic growth was assessed. Sixty-four telephone counsellors completed five self-report measures: a demographic questionnaire, the Posttraumatic Growth Inventory, the Professional Quality of Life Scale, the Jefferson Scale of Physician Empathy, and the Crisis Support Scale. Although relatively low, levels of posttraumatic growth were in evidence. As predicted, compassion fatigue was significantly related to posttraumatic growth. In addition, calls per shift were associated with growth, although this was a negative relationship whereby the more calls that were taken, the lower the level of growth. Contrary to expectation, neither empathy nor crisis support were significant predictors of growth. In conclusion, adversarial growth was observed in the current sample of telephone counsellors. However, there appears to be a threshold of adversity, beyond which there is less likelihood of continued growth. This was evident in those telephone counsellors who, having taken a relatively high number of calls in a shift, were less likely to experience growth.

A longitudinal study of PTSD in the elderly bereaved: Prevalence and predictors

Complicated grief reactions are relatively common following spousal bereavement. Old-age spousal loss qualifies as a possible traumatic stressor; however, posttraumatic stress disorder (PTSD) as a possible complication of the loss has rarely been explored in this population. This study aimed to investigate the frequency of PTSD in elderly bereaved people across the first 18 months of bereavement. Additionally, risk factors for the prediction of bereavement outcome in relation to four domains of the bereavement process were investigated. Data were collected via self-report questionnaires measuring traumatic stress (Harvard Trauma Questionnaire (HTQ)), coping style (Coping Style Questionnaire (CSQ)), crisis support (Crisis Support Scale (CSS)), and personality (e.g., NEO-five factor inventory (NEO-FFI)). Elderly bereaved people (N = 296, Mean = 73 years) participated at 2, 6, 13, and 18 months post loss. The comparison group consisted of married elderly people who had experienced at least one significant loss (N = 276, mean = 70 years). The frequency of PTSD within the spousal bereaved group was high (16%) compared to the comparison group (4%) and remained stable across time. Each individual domain included in the current analysis was a predictor of PTSD 18 months post loss. Most predictors remained stable across time. A hierarchical regression analysis of the four domains predicted 49% of the variance, indicating a considerable overlap between the domains. Only one predictor, early posttraumatic distress, remained significant. The results confirm that loss of a spouse in old age is traumatic for some and that the effects of the loss remain over the first 18 months post loss. The results therefore underline the importance of further investigation into PTSD in the elderly bereaved.

Attachment styles, traumatic events, and PTSD: a cross-sectional investigation of adult attachment and trauma

The aim of the present study was to examine the association between post-traumatic stress disorder (PTSD) and adult attachment in a young adult population. A sample of 328 Danish students (mean age 29.2 years) from four different schools of intermediate education level were studied by the Harvard Trauma Questionnaire (HTQ), the Revised Adult Attachment Scale (RAAS), the Trauma Symptom Checklist (TSC), the Crisis Support Scale (CSS), the Coping Style Questionnaire (CSQ), and the World Assumption Scale (WAS). Attachment styles were associated with number of PTSD symptoms, negative affectivity, somatization, emotional coping, attributions, and social support. The distribution of attachment styles in relation to PTSD symptoms could be conceived as uni-dimensional.

PTSD and psychological distress in Icelandic parents of chronically ill children: Does social support have an effect on parental distress?

The purpose of the study was to investigate psychological distress and the prevalence of PTSD among Icelandic parents of chronically ill children, and the potential effects of social support on distress, at two points in time. The Impact on Family scale (IFS), the Trauma Symptom Checklist (TSC), the Harvard Trauma Questionnaire (HTQ) and the Crisis Support Scale (CSS) were completed by 105 parents of children with various diseases (69 mothers and 36 fathers). Despite the heterogeneity of the sample in terms of disease type, PTSD was present in 13.2% of the parents and an additional 28.6% had subclinical PTSD. Time since diagnosis, length of hospitalizations and disease-related daily care predicted 40% of the HTQ total score.

Post-traumatic Stress Reactions in Children after two large Earthquakes in Iceland

Bödvarsdóttir, Í., Elklit, A. & Gudmundsdottir, D.B. Post-traumatic Stress Reactions in Children after two large Earthquakes in Iceland. Nordic Psychology, 58, 91–107. The aim of the study was to explore the psychological consequences of two earthquakes in Iceland in two probability samples of children aged 10–15 years (67 exposed and 73 non- exposed). Three months after the earthquakes, children answered demographic questions, stressor questions, and completed the Child Posttraumatic Stress Reaction Index (CPTS-RI), the Trauma Symptom Checklist (TSC) and the Crisis Support Scale (CSS). Thirty-three percent of the exposed group and 6% of the control group fulfilled the diagnostic criteria for PTSD. Experiences of great horror during the earthquake and thoughts about future earthquakes explained 49% of the variance in PTSD. Wish for relocation, arousal, and avoidance symptoms predicted psychological distress, as measured by the TSC total score, explaining 65% of the variance. The exposed children reported more emotional support than controls immediately after the earthquake, but not at three months post earthquake. Exposed children who did not receive crisis intervention but reported that they would have wanted it had significantly more PTSD symptoms than all other groups, suggesting that all exposed children should be offered crisis intervention and receive continuous attention from adults even after a moderate disaster. Key words: Earthquake, posttraumatic stress disorder, psychological symptoms, social support.