Levels Of Fear Research Articles

Nonlinear dynamics in a fear‐driven predator–prey system: Bistability, bifurcations, hydra effect, and optimal harvesting

The impact of predator‐driven fear on ecosystems is significant and can encompass both trophic (direct) and nontrophic (indirect) effects. Previous studies have shown that nontrophic fear effects have an important role in predator–prey dynamics. This study investigates the nontrophic fear effect on prey caused by generalist predators and explores optimal harvesting. We assume that the reproduction rate of prey is reduced due to the fear effect, and generalist predator follows Holling type II foraging strategy for predation. Additionally, we assume that predators are commercially valuable and harvested proportionately to their density. We demonstrate the existence of equilibrium points, their local and global stability, and bifurcation analysis. We observe that the model system undergoes a sequence of codimension one and codimension two bifurcations. Our results show that in the absence of predator harvesting, increasing levels of fear destabilize the predator–prey system, and controlled harvesting is beneficial for the coexistence of both populations. Also, the harvesting of predators may produce hydra and multiple hydra effects. We identify different types of bistability phenomena, which emphasize the importance of initial population size. Further, an optimal harvesting policy is also explored by formulating an optimal control problem (OCP). The harvesting cost‐functional is designed by incorporating the bionomic equilibrium state. We use Pontryagin's maximum principle and solve the OCP numerically. It is observed that implementing optimal harvesting not only contributes to the ecological benefits by maintaining a sustainable balance of predator–prey evolution but also plays a significant role in maximizing the economic benefits.

The effect of dental treatment using conscious sedation therapy on patient satisfaction

Objectives: This study aimed to investigate the effects of conscious sedation on patient satisfaction with dental treatment. Methods: The survey included questions on the patients’ general characteristics, dental treatment fear, anxiety, and satisfaction, and patient evaluation by an observer. Statistical analyses were performed using SPSS 20.0 ver. and data were analyzed using frequency analysis, independent t-test, Pearson’s correlation coefficient, and multilinear regression analysis. Results: Patients who received conscious sedation therapy showed significantly lower levels of dental fear and anxiety, whereas their dental treatment satisfaction was significantly higher than that of patients who received regular dental treatment (p<0.05). Dental treatment fear, anxiety, satisfaction, and conscious sedation depth were significantly correlated in patients who received conscious sedation therapy (p<0.05). Factors influencing dental treatment satisfaction included age, weight, use of medication, smoking habits, use of conscious sedation therapy, dental treatment fear and anxiety, and conscious sedation depth (p<0.05). Conclusions: Conscious sedation therapy can be an effective method to reduce dental treatment fear and anxiety and improve patient satisfaction.

The level of dental fear and anxiety is higher in children with both severe Molar-Incisor Hypomineralisation and active dental caries lesions compared to children without these conditions

PurposeTo assess levels of dental fear and anxiety (DFA) in children with and without Molar-Incisor Hypomineralisation (MIH) and dental caries lesions.MethodsIn this cross-sectional observational study, 159 children between 8 and 12 years of age were included. For the evaluation of DFA, children responded to the validated version of the Children’s Fear Survey Schedule-Dental Subscale. MIH was assessed using the MIH Index. To evaluate the activity of dental caries lesions and dental caries experience, the Nyvad criterion and the dmft/DMFT index were used, respectively. Dental hypersensitivity was evaluated using air stimulation and a Visual Analogue Scale. The association between MIH and dental caries with DFA was assessed using the generalised linear model with Poisson family, identity link function and robust variance estimation. The significance level was set at 5%.ResultsThe mean DFA score was 28.3 (SD = 13.4) with scores ranging from 15 to 64. Amongst children presenting both MIH and dental caries, the perception of DFA was notably higher compared to those with either MIH or dental caries alone. The activity of caries lesion in patients with MIH also influenced DFA levels (diff: 18.6; 95% CI: 12.0–25.2; p < 0.001). Dental caries experience in the primary dentition also demonstrated statistical significance concerning DFA (95% CI: 0.8–13.3; p value = 0.027).ConclusionChildren with MIH exhibit higher levels of DFA than children without MIH. The experience of dental caries and the activity of caries lesions significantly influence the perception of DFA in children with MIH.

Investigating the Effect of Social and Cultural Capital on the Level of Fear of COVID-19 among Retired Employees in Iran

Investigating the Effect of Social and Cultural Capital on the Level of Fear of COVID-19 among Retired Employees in Iran

Reasons for fear of cancer recurrence after endoscopic treatment of T1 esophageal adenocarcinoma. A semi-structured interview study.

Prior research has shown that patients with early Barrett's neoplasia treated endoscopically report at least the same level of fear for cancer recurrence as patients treated surgically for a more advanced disease stage. The aim of this qualitative study was to gain insight into the reasons why endoscopically treated patients fear or not fear cancer recurrence. Patients treated endoscopically for T1 esophageal adenocarcinoma participated in a semi-structured interview. Patients were asked open questions about their fear of cancer recurrence and presented an a priori list of possible reasons for experiencing or not experiencing fear of cancer recurrence. Data saturation was reached with 12 patients who added 7 new reasons. Reasons that induced fear of cancer recurrence were related to physical symptoms, if cancer was diagnosed as an accidental finding and experiences with cancer in close relations. Endoscopic surveillance was mentioned as a reason for not experiencing fear of cancer recurrence. Patients reduced their fear of cancer recurrence by talking to close relations and seeking distraction. Caregivers reduced patients fear of cancer recurrence by giving adequate information and by showing photo of the treatment and the results of the treatment. According to patients with early Barrett's neoplasia, receiving comprehensible information about the risk of recurrence and potential symptoms that may or may not be indicative of cancer recurrence, and continuing endoscopic surveillance, reduced fear of cancer recurrence. We recommend that healthcare providers discuss fear of cancer recurrence with their patients to enable tailoring information provision to their needs.

The effects of fear appeals on reactance in climate change communication

Addressing the existential threat posed by climate change requires urgent actions, both on an individual level and on a policy level. In the present research, we applied an emotion-based persuasion appeal model to climate change mitigation to test the effect of climate mitigation appeals formulated with different levels of threat (high vs. low) and appealing to different types of climate change solutions (individual vs. policy) in eliciting psychological reactance, motivating support for climate change mitigation, and influencing willingness to discuss the issue with others. Through an online between-subjects experiment, we found that appealing to individuals (as opposed to policy) increased individuals' perceived threat to freedom, and psychological reactance. Our threat manipulation increased levels of fear, but the interaction between level of threat and type of appeal was not statistically significant on any of our dependent variables. Results are discussed in light of the active debate regarding the effectiveness of fear appeals in the climate change communication context.

Patient-reported physical activity, pain, and fear of movement after cardiac surgery: a descriptive cross-sectional study

Objectives After cardiac surgery, there may be barriers to being physically active. Patients are encouraged to gradually increase physical activity, but limited knowledge exists regarding postoperative physical activity levels. This study aimed to assess patient-reported physical activity six months after cardiac surgery, determine adherence to WHO's physical activity recommendations, and explore potential relationships between pain, dyspnea, fear of movement, and activity levels. Methods The study design was a cross-sectional study at Örebro University Hospital, Sweden. Preoperative and surgical data were retrieved from medical records and questionnaires concerning physical activity (Frändin-Grimby Activity Scale, the Physical activity Likert-scale Haskell, Patient-Specific Functional Scale, and Exercise Self-efficacy Scale) were completed six months after surgery. Data were collected on pain, dyspnea, general health status and kinesiophobia i.e. fear of movement, using the Tampa Scale of Kinesiophobia Heart. Results In total, 71 patients (68 ± 11 years, males 82%) participated in this study. Most patients (76%) reported a light to moderate activity level (Frändin-Grimby levels 3-4) six months after cardiac surgery. In total, 42% of the patients adhered to the WHO’s physical activity recommendations (150 min/week). Pain and dyspnea were low. Patients with lower activity levels exhibited significantly higher levels of fear of movement (p =.025). Conclusions The majority of patients reported engaging in light to moderate activity levels six months after cardiac surgery. Despite this, less than half of the patients met the WHO's physical activity recommendations. Potential barriers to physical activity such as pain, dyspnea and fear of movement were reported to be low.

Psychometric Properties and Factorial Structure of General Mattering Scale, Anti-Mattering Scale, and Fear of Not Mattering Inventory Within the Palestinian Context

The current study examined the psychometric properties and correlates of three measures assessing individual differences in mattering among people from Palestine assessed in January, 2024. This study uniquely considers mattering as a resource and feelings of not mattering as a risk factor among people experiencing traumatizing life circumstances. Our sample consisted of 950 Palestinian adults (305 men and 645 women). They completed the General Mattering Scale, the Anti-Mattering Scale, the Fear of Not Mattering Inventory, and the Depression Anxiety Stress Scales-21 (DASS-21). Extensive psychometric tests supported these measures as each having one factor with adequate reliability and validity. Examination of means indicated significantly elevated levels of fear of not mattering, anxiety, depression, and stress. Regression analyses further established that each measure predicted significant unique variance in anxiety, depression, and stress. The findings attest to the further use of these measures and how feelings of mattering can be vital resource as the need for resilience and adaptability escalates due to traumatizing events.

Examination of the COVID-19 fear levels of nurses and their compliance to isolation.

It is very important for healthcare professionals to know the isolation precautions and apply the isolation rules correctly in COVID-19 process. This study was conducted to determine the COVID-19 fear levels and isolation compliance levels of nurses. This descriptive, cross-sectional, and correlational study was conducted between December 2020-February 2021 with 217 nurses working in a public hospital in Istanbul/Turkey. Data were collected using the Sociodemographic-Form, the COVID-19 Fear Scale, and the Compliance with Isolation Measures Scale. Statistically significant difference was found between the level of compliance with the isolation measures and the education level of the nurses (p = .011), as well as their professional position (p = .026) (p < .05). A positive, low-level significant relationship was determined between the COVID-19 fear of nurses and their compliance with isolation measures (r = 0.168; p = .015). It was determined that nurses' compliance with Isolation Precautions and their level of fear were high during the COVID-19 pandemic. It was observed that nurses' fear levels and isolation adaptation levels were related.

The Importance of Mind-Body in Pilates Method in Patients with Chronic Non-Specific Low Back Pain-A Randomized Controlled Trial.

Background/Objectives: Chronic non-specific low back pain (CNSLBP) is a prevalent condition causing significant distress and healthcare costs globally. Despite various treatments, effective management remains challenging. Pilates, recognized for its focus on core strength and postural alignment, has emerged as a promising intervention. This study investigates the impact of mind-body in Pilates for directing participants on CNSLBP outcomes. Methods: A randomized controlled trial was conducted with 67 participants, aged 18 to 65 years, suffering from CNSLBP. They were allocated into two groups: Pilates with mind-body cueing (n = 34) and Pilates without cueing (n = 33). Both groups underwent 60 min sessions twice weekly for 8 weeks. Outcome measures included pain intensity (Visual Analogue Scale), functional disability (Roland Morris Disability Questionnaire), fear of movement (Tampa Scale of Kinesiophobia), and adherence (percentage of sessions attended). Statistical significance was determined through repeated measures ANOVA. Results: Both groups showed significant improvement in pain reduction, functional ability, and kinesiophobia. However, the mind-body group demonstrated a statistically significant reduction in kinesiophobia compared to the non-cueing group (p = 0.048), indicating the potential additional benefit of mind-body cueing in managing movement-related fear in CNSLBP. Conclusions: This study underscores the effectiveness of an 8-week Pilates intervention in managing CNSLBP, highlighting the added value of mind-body cueing in reducing fear of movement. These findings suggest incorporating mind-body cueing in Pilates could enhance the therapeutic benefits, particularly for patients with high levels of movement-related fear, potentially improving long-term adherence to physical activity and rehabilitation outcomes.

An Integrative Review on Cross-Cultural Psychometric Studies of the Fear of COVID-19 Scale.

Background and Purpose: The rapid spread of coronavirus disease 2019 (COVID-19) worldwide prompted global fear and panic among all populations. The Fear of COVID-19 Scale was developed to assess the degree of fear. This review summarizes and synthesizes the revised cross-cultural validation studies of the Revised Fear of COVID-19 Scale to explore the properties of the scale and fear characteristics among different populations. Methods: A systematic literature search was conducted on the electronic databases of PubMed and Scopus. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis framework. Results: The review demonstrated that the Revised Fear of COVID-19 Scale has robust psychometric properties and fear impacts mental health across all study populations. The characteristics of the fear of COVID-19 are associated with specific variables. Conclusion: The Revised Fear of COVID-19 Scale can be used as a screening tool to assess levels of COVID-19 fear among different populations globally.

Differences in Fear and Negativity Levels Between Formal and Informal Health-Related Websites: Analysis of Sentiments and Emotions.

Searching for web-based health-related information is frequently performed by the public and may affect public behavior regarding health decision-making. Particularly, it may result in anxiety, erroneous, and harmful self-diagnosis. Most searched health-related topics are cancer, cardiovascular diseases, and infectious diseases. A health-related web-based search may result in either formal or informal medical website, both of which may evoke feelings of fear and negativity. Our study aimed to assess whether there is a difference in fear and negativity levels between information appearing on formal and informal health-related websites. A web search was performed to retrieve the contents of websites containing symptoms of selected diseases, using selected common symptoms. Retrieved websites were classified into formal and informal websites. Fear and negativity of each content were evaluated using 3 transformer models. A fourth transformer model was fine-tuned using an existing emotion data set obtained from a web-based health community. For formal and informal websites, fear and negativity levels were aggregated. t tests were conducted to evaluate the differences in fear and negativity levels between formal and informal websites. In this study, unique websites (N=1448) were collected, of which 534 were considered formal and 914 were considered informal. There were 1820 result pages from formal websites and 1494 result pages from informal websites. According to our findings, fear levels were statistically higher (t2753=3.331; P<.001) on formal websites (mean 0.388, SD 0.177) than on informal websites (mean 0.366, SD 0.168). The results also show that the level of negativity was statistically higher (t2753=2.726; P=.006) on formal websites (mean 0.657, SD 0.211) than on informal websites (mean 0.636, SD 0.201). Positive texts may increase the credibility of formal health websites and increase their usage by the general public and the public's compliance to the recommendations. Increasing the usage of natural language processing tools before publishing health-related information to achieve a more positive and less stressful text to be disseminated to the public is recommended.

Ecosystem Barriers and Facilitators Linked to the Fear of Cancer Recurrence: An Umbrella Review.

The fear of cancer recurrence is an important topic in the healthcare field. In general, approximately 40% of survivors experience high levels of fear of recurrence. This study aims to fill this gap by synthesizing the findings of systematic reviews studies investigating ecosystems, correlates or predictors, and barriers and facilitators of fear of cancer recurrence among cancer survivors. An umbrella meta-synthesis was conducted using the following databases: MEDLINE, PsycINFO, PsycARTICLES, CINAHL, Business source premier, and SOCindex, ending in April 2024 with PRISMA methods. A total of 24 systematic reviews, representing 729 articles, were included in the study. In total, six ecosystems were identified, including family, work, friends, the healthcare system, caregivers, and religion. As part of this umbrella review, 55 specific ecosystemic factors were identified that may contribute to fear of cancer recurrence. Furthermore, the umbrella review identified 12 facilitators and 12 barriers related to fear of cancer recurrence. This umbrella meta-synthesis contributed significantly to our review's strength in synthesizing the main ecosystem and its influence on fears of cancer recurrence. Understanding the interdependence of ecosystems should enable future research on intervention effectiveness or the development of interventions that could reduce the fear of cancer recurrence.

The Effect of Simulation Education on Nursing Students' Perception and Fear of COVID-19: A Randomized Controlled Trial

Aim: This study aims to determine the effect of simulation education on nursing students’ perception and fear of the COVID-19 disease. Method: This study was conducted in a randomized controlled trials with 86 nursing students from a university between November 10 and December 10, 2021. Data were collected using a personal information form and the Approach to COVID-19 Patient Form, which were designed by the researchers, the COVID-19 Disease Perception Scale, and the Fear of COVID-19 Scale. Results: While the COVID-19 Fear Scale mean score of the intervention and control groups was high before the training, it decreased after the training. After the training of the intervention and control group, the mean score of the COVID-19 Disease Perception Scale increased. It was found that the simulation education given to the intervention group increased the level of correct implementation of the interventions related to approaching patients after the education. Conclusion: It was found that the simulation education given to students provided positive improvements in the approach to patients with COVID-19 and disease perception and fear levels.

The effect of virtual reality versus standard-of-care treatment on pain perception during paediatric vaccination: Study protocol for a randomised controlled trial.

To study the effects of virtual reality (VR) on pain perception among a paediatric population while being vaccinated. We will also investigate the effects of VR on the fear experienced by children during the vaccination procedure, as well as parental satisfaction levels. Many studies, for example, in the fields of oncology, dermatology or plastic surgery, have described the benefits of using VR to reduce the perception of pain among paediatric populations. These results are encouraging, but their main limitations were the small sample sizes they included or their methodological design. This will be a randomised clinical trial. SPIRIT guidelines were followed to report this protocol, and we will use the CONSORT and CONSORT-EHEALTH guidelines to report the randomised clinical trial. The sample will comprise 148 children aged 3-14 years who will come for vaccination at the Tres Forques Health Center. The participants will be randomly allocated into intervention group (VR; n = 74) or (the control group standard-of-care; n = 74) at a 1:1 ratio. The intervention group will view experiences with a VR headset as a distraction measure. The study variables will be the level of pain and fear perceived by the child during vaccination, parental satisfaction with the vaccination procedure, and sociodemographic and vaccination variables. The start of the study is planned for September 2020, and the results will be expected in September 2021. This study aims to identify what measures reduce pain and fear in children during vaccination, which in turn, can help to improve the degree of parental satisfaction with these procedures. Vaccination is an independent function of the nursing profession. Identifying which distraction measures reduce the perception of pain and fear in the paediatric population will not only improve children's experiences but will also improve the satisfaction of both parents and children, thus increasing the degree of compliance with the vaccination schedule.

The language of belonging: The role of symbolic language in shaping social identity and public perceptions of police gender targets

AbstractGender‐targeted recruitment in policing has elicited varied public responses. This study explores public sentiment toward policing gender targets using a symbolic interactionist and social identity approach. A sentiment analysis was conducted on 5447 comments extracted from a Facebook recruitment campaign targeting women. The study revealed a nearly equal distribution of positive and negative language in the comments, with high levels of trust and fear, and notable expressions of anger and sadness. Positive sentiments utilised terms like “equality” and “merit” indicating support for gender targets as a means to promote gender equality and career opportunities for women. Conversely, negative sentiments centred on discrimination. Findings underscore how individuals construct meaning around gender and interpret gender‐target initiatives in policing through the sentiments expressed in online interactions. This research contributes to a nuanced understanding of public discourse surrounding gender targets, highlighting the importance of tailored recruitment and educational campaigns to promote inclusivity and effective gender‐targeted initiatives.

Evaluation of The Role of Music and Bach Flower Remedies in The Management of Anxious Pediatric Dental Patients: A Randomised Clinical Trial

Objective: Dental fear and anxiety describe negative feelings towards the dental environment, particularly significant in pediatric dentistry due to their cognitive, behavioral, and physical impacts on children. Managing this anxiety through positive dentist-child relationships and behavioral guidance techniques is crucial. This study aims to evaluate the effectiveness of passive distraction using music and Bach flower remedy in reducing dental fear and anxiety in children aged 6-8 years. Methods: This randomized controlled clinical study included 12 children (n=4 for each group) aged 6-8 years, randomly assigned to Group 1 (control), Group 2 (Bach flower remedy), or Group 3 (passive distraction with music) for treating superficial dentin caries in primary teeth without local anesthesia. Dental fear and anxiety levels were assessed using objective (heart rate, oxygen saturation, systolic and diastolic blood pressure) and subjective (Facial Image Scale and Venham’s Picture Test) measures before and after treatment. Results: The study included 12 children (6 female, 6 male) with a mean age of 7.3±0.8 years. In Group 2, heart rate significantly decreased after treatment (97.8 ± 10.1 to 90.5 ± 8.8, p.05). Conclusion: In this study, although passive distraction with music and Bach flowers did not have a significant effect on physiological and projective measurement tools in children with dental fear and anxiety, a decrease in heart rate was observed in children exposed to Bach flowers.

Leveraging independence and mental fitness - keys to reducing in-hospital mortality among geriatric COVID-19 patients in the intensive care unit: A cross-sectional study in Poland.

Coronavirus disease 2019 (COVID-19) quickly reached the pandemic status, with 765.22 million confirmed cases of COVID-19 and 6.92 million COVID-19 deaths reported worldwide by May 2023. Due to its sudden and global nature, the COVID-19 pandemic has had a significant impact on the emotional and mental health of many people. A group of COVID-19 patients who frequently require intensive care are geriatric patients. The cognitive performance of these patients and their independence in instrumental activities of daily living (IADL) may be crucial to their prognosis and risk of in-hospital death. The present study aimed to assess the level of independence in activities of daily living (ADL), mental fitness, the level of fear of COVID-19, and cognitive functions to determine their impact on in-hospital mortality in geriatric COVID-19 patients. A total of 300 intensive care unit (ICU) patients with COVID-19 were included in the cross-sectional study, using the following questionnaires: the Lawton IADL scale, the Katz ADL index of independence, the fear of COVID-19 scale (FCV-19S), the abbreviated mental test score (AMTS), and the 15-item geriatric depression scale (GDS15). Patients aged 64 or below reported significantly greater independence on the IADL scale and the basic ADL scale, and showed a significantly higher level of mental fitness (Mann-Whitney U test; p = 0.001). Patient survival and in-hospital mortality were influenced by independence in basic and complex ADL. The level of independence is an important prognostic indicator for in-hospital mortality in geriatric COVID-19 patients. The higher the level of mental fitness, the higher the level of independence in basic and instrumental activities of daily living. Patients aged ≥65 years are less independent in basic and instrumental activities of daily living. Moreover, they show a significantly lower level of cognitive functions.

Soothing venipuncture: Bubble blowing and ball squeezing in reducing anxiety, fear, and pain in children.

The objective of this study was to investigate the impact of bubble-blowing and ball-squeezing interventions on children's levels of anxiety, fear, and pain during venipuncture procedures. This study was designed as a randomized controlled trial. Out of 108 children aged 5-10 years, 72 were allocated to the two experimental groups, while 36 were assigned to the control group. The levels of anxiety, fear, and pain experienced by the children were assessed using the "Wong-Baker FACES® Pain Rating Scale," "Child Anxiety Scale-State," and "Child Fear Scale," respectively. Intergroup comparisons were analyzed using one-way ANOVA, while intragroup comparisons were conducted using Wilks' Lambda analysis. It was observed that 50% of the children in the control group, 47.2% in the bubble-blowing group, and 47.2% in the ball-queezing group did not receive information about the painful procedure. Anxiety, fear, and pain scores of all groups were statistically similar in the initial measurement without any intervention. Children in the bubble-blowing and ball-squeezing groups experienced lower anxiety, fear, and pain during and at the end of the painful procedures. The study discovered that interventions involving bubble blowing and ball squeezing significantly decreased children's levels of anxiety, fear, and pain both during and after intravenous procedures. Information on procedures, alongside interactive techniques like bubble blowing and ball squeezing, helps pediatric nurses calm children, easing anxiety, fear, and pain. Implementing these strategies enhances treatment experiences and confidence in healthcare.

Impact of the COVID-19 Pandemic on Saudi Parents' Perceptions Toward Their Children's Oral Health: A Cross-Sectional Study.

Background The coronavirus disease 2019 (COVID-19) markedly affected all aspects of life. Pediatric dentistry and oral health of children faced a challenging situation during the pandemic. Aim This study aimedto assess the attitude of Saudi parents toward their children's oral health and dental treatment during the COVID-19 pandemic. Methods This online-based cross-sectional study was conducted using a structured questionnaire adopted from previous studies with some modifications. It was distributed among 385 Saudi parentsrecruited through social media. It included questions regarding demographic data, parents' attitudes toward their children's dental care and dental visits during the COVID-19 pandemic, their fear level and willingness to take their children to dental appointments, and the parent's perception of dental clinics with regard to the COVID-19 spread. Descriptive statistics and the chi-squaretest were used; statistical significance was set at a p-value < 0.05. Results Different levels of fear of the pandemic were expressed by Saudi parents, with 42 (10.9%) showing maximum fear while 36 (9.3%) reported no fear. Although about half of the parentsstated that their children experienced dental pain during the pandemic, only 97 (25.1%) looked for dental care and were assisted. There was a significant association (p < 0.05) between the fear level with the family income and parents' willingness to take their children to dental appointments. Conclusions COVID-19 has hada great impact on parents' attitudes towards their children's oral health. A high percentage of Saudi parents' stated that they would take their children to dental clinics during the pandemic only for urgent treatment and severe pain.