Research Article
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Relationship Between Serum IgE Level and Anxiety, Depression, Somatization and Quality of Life in Pediatric Asthma

Year 2019, Volume: 11 Number: Supplement 1 (Research Issue), 276 - 292, 29.12.2019
https://doi.org/10.18863/pgy.628562

Abstract

The main purpose of the current study is to explore the potential relationship of asthma with depression, somatic predisposition, quality of life, manifest anxiety and Serum levels of IgE level. 141 participants between 6 and 12 years old were recruited and the following scales were used: Child Depression Inventory, Revised Version of Child Manifest Anxiety Scale, Pediatric Asthma Quality of Life Questionnaire and the Somatic Complaints Subscale of Child Behavior Check List. Based on asthma control level, severity of asthma was assessed by the specialists and the serum levels of IgE were assessed by using ELISA technique. Initially, correlation analysis conducted between expressed levels of anxiety, depression, quality of life, somatic complaints, asthma and serum levels of IgE. The results indicated that there was a highly correlated relationship between serum levels of IgE and manifest anxiety levels among uncontrolled asthma group. These results suggested that, since the strong correlational relationship between the serum levels of IgE and manifest anxiety would have an effect on asthma control, future research should focus on this relationship from the aspect of psychoneuroimmunology. 

References

  • Achenbach TM, Dumenci L, Rescorla LA (2002) Ten-Year Comparisons of Problems and Competencies for National Samples of Youth: Self, Parent, and Teacher Reports. J Emot Behav Disord, 10:194-203.
  • Ader N, Kohen N, Felten D (1995) Psychoneuroimmunology: Interactions between the Nervous System and the Immune System. Lancet, 345, 99-103.
  • Adeyeye OO, Adewumi TA, Adewuya AO (2017) Effect of psychological and other factors on quality of life amongst asthma outpatients in Lagos, Nigeria. Respir Med. Jan(122): 67-70.
  • Akcakaya N, Aydogan M, Hassanzadeh A, Camcioglu Y, Cokugras H (2003) Psychological Problems in Turkish Asthmatic Children and Their Families. Allergol Immunopathol, 31, 282-287.
  • Aktan ZD (2016). Reliability and Validity of Pediatric Asthma Quality of Life Questionnaire for 6 Children Aged 6 Years Old- PAQLQ (2006) 7th Symposium of Stay in Childhood, May 5-7 2016 Canakkale, Special Symposium Issue page 6.
  • Barnes PJ (1999) Novel approaches and targets for treatment of chronic obstructive pulmonary disease. Am J Respir Crit Care Med,160:72–79.
  • Barnett D, Walker B, Landay A, Denny TN (2008) CD4 immunophenotyping in HIV infection. Nat Rev Microbiol, 6(11):7–15.
  • Blaiss MS (2005) Asthma Disease Management: A Critical Analysis. Ann Allergy Asthma Immunol, 95(5Suppl1):10-6.
  • Boran P, Tokuç G, Pişgin B, Öktem S. (2008) Assessment of quality of life in asthmatic Turkish children. Turk J Pediatr, 50:18-22.
  • Borish L (2016) The immunology of asthma Asthma phenotypes and their implications for personalized treatment. Ann Allergy Asthma Immunol, 117:108-114
  • Bozo, Ö. (2007). Psikonöroimmünoloji. Kriz Dergisi, 15(3):21-30.
  • Çevik Ü (2011). The effect on the self-efficiacy and the prognosis of disease of the given training for the children and adolescents who have asthma. (PhD Thesis). Erzurum, Atatürk University.
  • Chrousos GP, Gold PW (1992) The Concepts of Stress and Stress System Disorders. Overview of Physical and Behavioural Homeostasis. JAMA, 267 (Mar 4), 1244-52.
  • Cohen S, Herbert TB (1996) Health Psychology: Psychological Factors and Physical Disease From the Perspective of Human Psychoneuroimmunology. Annual Review of Psy, 47, 113-42.
  • Cohen S, Herbert TB (1996) Health Psychology: Psychological Factors and Physical Disease From the Perspective of Human Psychoneuroimmunology. Annu Rev Psychol, 47:113-42.
  • Çölümlü GM (2014) The Psychometric Properties of the Revised Children’s Manifest Anxiety Scale. (MSc Dissertation). İstanbul, Bahçeşehir University.
  • Crepaz N, Passin WF, Herbst JH, Rama SM, Malow RM, Purcell DW et al (2008) HIV/AIDS Prevention Research Synthesis (PRS) Team; Meta-analysis of cognitive-behavioral interventions on HIV-positive persons' mental health and immune functioning. Health Psychology, 27(1):4-14.
  • Demirci E (2011). Astımlı Çocuklarda Yaşam Kalitesi Ve Etkileyen Bazı Faktörler. Cumhuriyet Üniversitesi Sağlık Bilimleri Enstitüsü, Yayınlanmamış Yüksek Lisans tezi, Sivas.
  • Di Marco F, Verga M, Santus P, Giovannelli F, Busatto P, Neri M, Girbino G, Bonini S, Centanni S (2010) Analysis of the Relation between Level of Asthma Control and Depression and Anxiety. Respir Med, 104(1):22-8.
  • Erol N, Şimşek Z (2010) The Turkish Version of Child Behaviour Check List Manual (CBCL, YSR, TRF). Ankara: Metis.
  • Gibson PG, Powell H, Coughlan J, Wilson AJ, Hensley MJ, Abramson M et al. (2001) Limited (Information Only) Patient Education Programs for Adults with Asthma. In: The Cochrane Library, Volume 4. Oxford.
  • Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2016. Available from: www.ginasthma.org
  • Goodwin, RD, Robinson M, Sly PD, McKeague IW, Susser ES, Zubrick SR, Stanley F et al. (2013) Severity and persistence of asthma and mental health: a birth cohort study. Psychol Med, 43(6).
  • Hossny E, Caraballo L, Casale T, El-Gamal Y, Rosenwasser L (2017) Severe asthma and quality of life. World Allergy Organ J, 10(1):28.
  • Ironson G, O'Cleirigh C, Fletcher MA, et al. (2005) Psychosocial factors predict CD4 and viral load change in men and women with human immunodeficiency virus in the era of highly active antiretroviral treatment. Psychosom Med, 67(6):1013–1021.
  • Juniper EF, Guyatt GH, Feeny DH, Ferrie PJ, Griffith LE, Townsend M (1996) Measuring Quality of Life in Children with Asthma. Qual Life Res, 5:35-46.
  • Kartaloğlu, Z (2011) Astım ve stres arasındaki ilişkiler. Gülhane Tıp Derg, 53:304-312
  • Klinnert MD, Kaugars AS, Strand M, Silveria L (2008) Family Psychological Factors in Relation to Children’s Asthma Status and Behaviour”. ProQuest Health and Medical Complete, 47:1.
  • Kotrotsiou E, Krommydas G, Papathanasiou I, Kotrotsiou S, Paralikas T, Lahana E, Kiparissi G (2011) Anxiety and Depression in Teenagers and Young Adults with Asthma, Health Science Journal, 5(3):229-236.
  • Kovacs M (1981) Rating Scales to Assess Depression in Schools Age Children. Acta Paedopsychiatria, 46:305-15.
  • Lama M, Chatterjee M, Chaudhuri TK (2013) Total serum immunoglobulin e in children with asthma. Indian J Clin Biochem,. 28(2):197–200.
  • Lambrecht BN, Hammad H (2015) The immunology of asthma. Nature immunology, 16(1):45-56
  • Lavoie KL, Cartier A, Labrecque M, Bacon SL, Lemière C, Malo JL, et.al. (2005) Are psychiatric disorders associated with worse asthma control and quality of life in asthma patients? Respir Med, 99:1249-57.
  • Leonard BE (2010) The concept of depression as a dysfunction of the immune system. Curr Immunol Rev, 6(3):205–212.
  • Lupinek C, Derfler K, Lee S, et al. Extracorporeal IgE Immunoadsorption in Allergic Asthma: Safety and Efficacy. EBioMedicine,17:119–133.
  • Mancuso CA, Rincon M, Mcculloch CE and Charlson ME (2001) Self-efficacy, Depressive Symptoms, and Patients’ Expectation Predict Outcomes In Asthma. Med Care, 39, 1326- 1338.
  • McDonald PG, O’Connell M, Lutgendorf SK (2013) Psychoneuroimmunology and cancer: A decade of discovery, paradigm shifts, and methodological innovations. Brain, Behavior, and Immunity, 30:1–9.
  • Murali R, Hanson MD, Chen E (2006) Psychological Stress and its Relationship to Cytokines and Inflammatory Diseases. In: Plotnikoff NP, Faith RE, Murgo AJ, and Good RA, editors. Cytokines: Stress and Immunity. Florida: CRC Press, p. 29-51.
  • Olff M (1999) Stress, Depression and Immunity: The Role of Defence and Coping Styles. Psychiatry Research, 85 (1), 7-15.
  • Opolski M, Wilson I (2005) Asthma and Depression: a Pragmatic Review of the Literature and Recommendations for Future Research. Clin Pract Epidemiol Ment Health, 1:18.
  • Öy B (1991). Child Depression Inventory: The Turkish Reliability and Validity Study. Turk J Psychiatry, 2(2):132-6.
  • Potoczek A, Nizankowska-Mogilnicka E, Bochenek G, Szczeklik A (2006) Links Between Panic Disorder, Depression, Defence Mechanisms, Coherence and Family Functioning in Patients Suffering From Severe Asthma. Psychiatry Research, 85, 7-15.
  • Revenson TA, and Hoyt MA (2016) Chronic Illness and Mental Health. In: Encyclopedia of Mental Health, 2nd ed. (Eds HS. Friedman):284-292. MA, Academic Press.
  • Reynolds CR, Richmond BO (1978) What I think and feel: A Revised Measure of Children’s Manifest Anxiety. J Abnorm Child Psychol, 6:271-80.
  • Rimington LD, Davies DH, Lowe D, Pearson MG (2001) Relationship Between Anxiety, Depression, and Morbidity in Adult Asthma Patients. Thorax, 56; 266-271.
  • Rogala B, Bozek A, Gluck J, Jarzab J (2015) Prevalence of IgE-mediated allergy and evaluation of Th1/Th2 cytokine profiles in patients with severe bronchial asthma. Postepy Dermatol Alergol, 32(4):274–280.
  • Rotsides DZ, Goldstein IF, Canfield SM, et al. (2010) Asthma, allergy, and IgE levels in NYC head start children. Respir Med, 104(3):345–355.
  • Saggini A, Maccauro G, Tripodi D, De Lutiis MA, Conti F, Felaco P, et al. (2011). Allergic inflammation: role of cytokines with special emphasis on IL-4. Int J Immunopathol Pharmacol, 24:305-11.
  • Segerstrom SC, Miller GE (2004) Psychological stress and the human immune system: a meta- analytic study of 30 years of inquiry. Psychol Bull, 130(4):601-30.
  • Steinke JW, Borish L. (2001) Th2 cytokines and asthma - Interleukin-4: its role in the pathogenesis of asthma, and targeting it for asthma treatment with interleukin-4 receptor antagonists. Respiratory Research, 2:66–70.
  • Thoren CT, Petermann F (2000) Reviewing Asthma And Anxiety, Respiratory Medicine, 94(5):409-415.
  • Thornton LM, Andersen BL (2006) Psychoneuroimmunology examined: The role of subjective stress. Cell Science Reviews Vol.2 No.4
  • Yüksel H, Yilmaz O, Kirmaz C, Eser E (2009) Validity and Reliability of the Turkish Translation of the Pediatric Asthma Quality of Life Questionnaire. Turk J Pediatr, 51(2):154-60.

Pediatrik Astımda Kaygı, Depresyon, Somatizasyon ve Yaşam Kalitesi ile Serum IgE Düzeyi İlişkisi

Year 2019, Volume: 11 Number: Supplement 1 (Research Issue), 276 - 292, 29.12.2019
https://doi.org/10.18863/pgy.628562

Abstract

Bu çalışmanın amacı çocuklarda astım şiddeti ile depresyon, açık kaygı, yaşam kalitesi, somatizasyon gibi değişkenleri ve astımda bağışıklık sistemi belirleyicilerinden olan IgE düzeyi arasındaki olası ilişkiyi analiz etmektir. Toplamda 141 katılımcının bulunduğu bu çalışmanın örneklemini 6-12 yaş arası astımlı çocuklar oluşturmaktadır. Katılımcıların ruh sağlığı belirtilerini değerlendirmek adına Çocuk Depresyon Ölçeği, Çocuklar İçin Açık Kaygı Ölçeği, Pediatrik Astımda Yaşam Kalitesi Ölçeği ve Davranış Değerlendirme Ölçeğinin Somatik Yakınmalar Alt Ölçeği kullanılmıştır. Astım şiddeti, astım kontrol düzeyi üzerinden uzman hekimlerce değerlendirilirken, Serum IgE düzeyleri ELISA tekniği kullanılarak elde edilmiştir. Katılımcıların astım düzeyleri ile anksiyete, depresyon, yaşam kalitesi, somatizasyon ve Serum IgE düzeyleri, arasındaki ilişkileri belirlemek amacıyla yapılan analizlerden elde edilen verilere göre, kontrolsüz astım grubunda bulunan katılımcıların açık kaygı puanlarıyla IgE düzeyleri arasında orta düzeyde anlamlı yüksek korelasyon olduğu görülmüştür. Araştırma verileri değerlendirildiğinde, ruh sağlığı değişkenlerinden açık kaygı ile astımda bağışıklık sistemi belirleyicilerinden olan IgE düzeyi arasındaki ilişkinin, astım hastalığının şiddeti üzerinde etkili olabileceği yönünde veriler elde edildiğinden, gelecek araştırmaların söz konusu ilişkiyi psikonöroimmunolojik açıdan derinlemesine incelemesi önerilmektedir.

References

  • Achenbach TM, Dumenci L, Rescorla LA (2002) Ten-Year Comparisons of Problems and Competencies for National Samples of Youth: Self, Parent, and Teacher Reports. J Emot Behav Disord, 10:194-203.
  • Ader N, Kohen N, Felten D (1995) Psychoneuroimmunology: Interactions between the Nervous System and the Immune System. Lancet, 345, 99-103.
  • Adeyeye OO, Adewumi TA, Adewuya AO (2017) Effect of psychological and other factors on quality of life amongst asthma outpatients in Lagos, Nigeria. Respir Med. Jan(122): 67-70.
  • Akcakaya N, Aydogan M, Hassanzadeh A, Camcioglu Y, Cokugras H (2003) Psychological Problems in Turkish Asthmatic Children and Their Families. Allergol Immunopathol, 31, 282-287.
  • Aktan ZD (2016). Reliability and Validity of Pediatric Asthma Quality of Life Questionnaire for 6 Children Aged 6 Years Old- PAQLQ (2006) 7th Symposium of Stay in Childhood, May 5-7 2016 Canakkale, Special Symposium Issue page 6.
  • Barnes PJ (1999) Novel approaches and targets for treatment of chronic obstructive pulmonary disease. Am J Respir Crit Care Med,160:72–79.
  • Barnett D, Walker B, Landay A, Denny TN (2008) CD4 immunophenotyping in HIV infection. Nat Rev Microbiol, 6(11):7–15.
  • Blaiss MS (2005) Asthma Disease Management: A Critical Analysis. Ann Allergy Asthma Immunol, 95(5Suppl1):10-6.
  • Boran P, Tokuç G, Pişgin B, Öktem S. (2008) Assessment of quality of life in asthmatic Turkish children. Turk J Pediatr, 50:18-22.
  • Borish L (2016) The immunology of asthma Asthma phenotypes and their implications for personalized treatment. Ann Allergy Asthma Immunol, 117:108-114
  • Bozo, Ö. (2007). Psikonöroimmünoloji. Kriz Dergisi, 15(3):21-30.
  • Çevik Ü (2011). The effect on the self-efficiacy and the prognosis of disease of the given training for the children and adolescents who have asthma. (PhD Thesis). Erzurum, Atatürk University.
  • Chrousos GP, Gold PW (1992) The Concepts of Stress and Stress System Disorders. Overview of Physical and Behavioural Homeostasis. JAMA, 267 (Mar 4), 1244-52.
  • Cohen S, Herbert TB (1996) Health Psychology: Psychological Factors and Physical Disease From the Perspective of Human Psychoneuroimmunology. Annual Review of Psy, 47, 113-42.
  • Cohen S, Herbert TB (1996) Health Psychology: Psychological Factors and Physical Disease From the Perspective of Human Psychoneuroimmunology. Annu Rev Psychol, 47:113-42.
  • Çölümlü GM (2014) The Psychometric Properties of the Revised Children’s Manifest Anxiety Scale. (MSc Dissertation). İstanbul, Bahçeşehir University.
  • Crepaz N, Passin WF, Herbst JH, Rama SM, Malow RM, Purcell DW et al (2008) HIV/AIDS Prevention Research Synthesis (PRS) Team; Meta-analysis of cognitive-behavioral interventions on HIV-positive persons' mental health and immune functioning. Health Psychology, 27(1):4-14.
  • Demirci E (2011). Astımlı Çocuklarda Yaşam Kalitesi Ve Etkileyen Bazı Faktörler. Cumhuriyet Üniversitesi Sağlık Bilimleri Enstitüsü, Yayınlanmamış Yüksek Lisans tezi, Sivas.
  • Di Marco F, Verga M, Santus P, Giovannelli F, Busatto P, Neri M, Girbino G, Bonini S, Centanni S (2010) Analysis of the Relation between Level of Asthma Control and Depression and Anxiety. Respir Med, 104(1):22-8.
  • Erol N, Şimşek Z (2010) The Turkish Version of Child Behaviour Check List Manual (CBCL, YSR, TRF). Ankara: Metis.
  • Gibson PG, Powell H, Coughlan J, Wilson AJ, Hensley MJ, Abramson M et al. (2001) Limited (Information Only) Patient Education Programs for Adults with Asthma. In: The Cochrane Library, Volume 4. Oxford.
  • Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2016. Available from: www.ginasthma.org
  • Goodwin, RD, Robinson M, Sly PD, McKeague IW, Susser ES, Zubrick SR, Stanley F et al. (2013) Severity and persistence of asthma and mental health: a birth cohort study. Psychol Med, 43(6).
  • Hossny E, Caraballo L, Casale T, El-Gamal Y, Rosenwasser L (2017) Severe asthma and quality of life. World Allergy Organ J, 10(1):28.
  • Ironson G, O'Cleirigh C, Fletcher MA, et al. (2005) Psychosocial factors predict CD4 and viral load change in men and women with human immunodeficiency virus in the era of highly active antiretroviral treatment. Psychosom Med, 67(6):1013–1021.
  • Juniper EF, Guyatt GH, Feeny DH, Ferrie PJ, Griffith LE, Townsend M (1996) Measuring Quality of Life in Children with Asthma. Qual Life Res, 5:35-46.
  • Kartaloğlu, Z (2011) Astım ve stres arasındaki ilişkiler. Gülhane Tıp Derg, 53:304-312
  • Klinnert MD, Kaugars AS, Strand M, Silveria L (2008) Family Psychological Factors in Relation to Children’s Asthma Status and Behaviour”. ProQuest Health and Medical Complete, 47:1.
  • Kotrotsiou E, Krommydas G, Papathanasiou I, Kotrotsiou S, Paralikas T, Lahana E, Kiparissi G (2011) Anxiety and Depression in Teenagers and Young Adults with Asthma, Health Science Journal, 5(3):229-236.
  • Kovacs M (1981) Rating Scales to Assess Depression in Schools Age Children. Acta Paedopsychiatria, 46:305-15.
  • Lama M, Chatterjee M, Chaudhuri TK (2013) Total serum immunoglobulin e in children with asthma. Indian J Clin Biochem,. 28(2):197–200.
  • Lambrecht BN, Hammad H (2015) The immunology of asthma. Nature immunology, 16(1):45-56
  • Lavoie KL, Cartier A, Labrecque M, Bacon SL, Lemière C, Malo JL, et.al. (2005) Are psychiatric disorders associated with worse asthma control and quality of life in asthma patients? Respir Med, 99:1249-57.
  • Leonard BE (2010) The concept of depression as a dysfunction of the immune system. Curr Immunol Rev, 6(3):205–212.
  • Lupinek C, Derfler K, Lee S, et al. Extracorporeal IgE Immunoadsorption in Allergic Asthma: Safety and Efficacy. EBioMedicine,17:119–133.
  • Mancuso CA, Rincon M, Mcculloch CE and Charlson ME (2001) Self-efficacy, Depressive Symptoms, and Patients’ Expectation Predict Outcomes In Asthma. Med Care, 39, 1326- 1338.
  • McDonald PG, O’Connell M, Lutgendorf SK (2013) Psychoneuroimmunology and cancer: A decade of discovery, paradigm shifts, and methodological innovations. Brain, Behavior, and Immunity, 30:1–9.
  • Murali R, Hanson MD, Chen E (2006) Psychological Stress and its Relationship to Cytokines and Inflammatory Diseases. In: Plotnikoff NP, Faith RE, Murgo AJ, and Good RA, editors. Cytokines: Stress and Immunity. Florida: CRC Press, p. 29-51.
  • Olff M (1999) Stress, Depression and Immunity: The Role of Defence and Coping Styles. Psychiatry Research, 85 (1), 7-15.
  • Opolski M, Wilson I (2005) Asthma and Depression: a Pragmatic Review of the Literature and Recommendations for Future Research. Clin Pract Epidemiol Ment Health, 1:18.
  • Öy B (1991). Child Depression Inventory: The Turkish Reliability and Validity Study. Turk J Psychiatry, 2(2):132-6.
  • Potoczek A, Nizankowska-Mogilnicka E, Bochenek G, Szczeklik A (2006) Links Between Panic Disorder, Depression, Defence Mechanisms, Coherence and Family Functioning in Patients Suffering From Severe Asthma. Psychiatry Research, 85, 7-15.
  • Revenson TA, and Hoyt MA (2016) Chronic Illness and Mental Health. In: Encyclopedia of Mental Health, 2nd ed. (Eds HS. Friedman):284-292. MA, Academic Press.
  • Reynolds CR, Richmond BO (1978) What I think and feel: A Revised Measure of Children’s Manifest Anxiety. J Abnorm Child Psychol, 6:271-80.
  • Rimington LD, Davies DH, Lowe D, Pearson MG (2001) Relationship Between Anxiety, Depression, and Morbidity in Adult Asthma Patients. Thorax, 56; 266-271.
  • Rogala B, Bozek A, Gluck J, Jarzab J (2015) Prevalence of IgE-mediated allergy and evaluation of Th1/Th2 cytokine profiles in patients with severe bronchial asthma. Postepy Dermatol Alergol, 32(4):274–280.
  • Rotsides DZ, Goldstein IF, Canfield SM, et al. (2010) Asthma, allergy, and IgE levels in NYC head start children. Respir Med, 104(3):345–355.
  • Saggini A, Maccauro G, Tripodi D, De Lutiis MA, Conti F, Felaco P, et al. (2011). Allergic inflammation: role of cytokines with special emphasis on IL-4. Int J Immunopathol Pharmacol, 24:305-11.
  • Segerstrom SC, Miller GE (2004) Psychological stress and the human immune system: a meta- analytic study of 30 years of inquiry. Psychol Bull, 130(4):601-30.
  • Steinke JW, Borish L. (2001) Th2 cytokines and asthma - Interleukin-4: its role in the pathogenesis of asthma, and targeting it for asthma treatment with interleukin-4 receptor antagonists. Respiratory Research, 2:66–70.
  • Thoren CT, Petermann F (2000) Reviewing Asthma And Anxiety, Respiratory Medicine, 94(5):409-415.
  • Thornton LM, Andersen BL (2006) Psychoneuroimmunology examined: The role of subjective stress. Cell Science Reviews Vol.2 No.4
  • Yüksel H, Yilmaz O, Kirmaz C, Eser E (2009) Validity and Reliability of the Turkish Translation of the Pediatric Asthma Quality of Life Questionnaire. Turk J Pediatr, 51(2):154-60.
There are 53 citations in total.

Details

Primary Language Turkish
Journal Section Research
Authors

Z. Deniz Aktan 0000-0003-1757-2024

H.özlem Sertel Berk 0000-0002-3045-3903

Fırat Erdogan 0000-0002-6299-7067

Sedat Öktem This is me 0000-0002-7950-2067

Publication Date December 29, 2019
Acceptance Date November 21, 2019
Published in Issue Year 2019 Volume: 11 Number: Supplement 1 (Research Issue)

Cite

AMA Aktan ZD, Berk HS, Erdogan F, Öktem S. Pediatrik Astımda Kaygı, Depresyon, Somatizasyon ve Yaşam Kalitesi ile Serum IgE Düzeyi İlişkisi. Psikiyatride Güncel Yaklaşımlar - Current Approaches in Psychiatry. December 2019;11:276-292. doi:10.18863/pgy.628562

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