Anxiety and depression in patients infected with Borrelia burgdorferi

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Using MEmind to compare clinical assessment with self-assessment in patients with depression and anxiety diagnosis" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "158" "paginaFinal" => "164" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2816 "Ancho" => 1583 "Tamanyo" => 265362 ] ] "descripcion" => array:1 [ "en" => "MEmind Health Record View (P100)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Gómez-Carrillo, M.L. Barrigón, A. Leon-Velasco, C. Gonzalez-Garrido, M. Ruiz-Gomez, R.M. Molina-Madueño, S. López-González, F. Aroca, I. Barahona, J. Lopez-Castroman, S. Berrouiguet, P. Courtet, E. Baca-García" "autores" => array:14 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Gómez-Carrillo" ] 1 => array:2 [ "nombre" => "M.L." "apellidos" => "Barrigón" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Leon-Velasco" ] 3 => array:2 [ "nombre" => "C." "apellidos" => "Gonzalez-Garrido" ] 4 => array:2 [ "nombre" => "M." "apellidos" => "Ruiz-Gomez" ] 5 => array:2 [ "nombre" => "R.M." "apellidos" => "Molina-Madueño" ] 6 => array:2 [ "nombre" => "S." "apellidos" => "López-González" ] 7 => array:2 [ "nombre" => "F." "apellidos" => "Aroca" ] 8 => array:2 [ "nombre" => "I." "apellidos" => "Barahona" ] 9 => array:2 [ "nombre" => "J." "apellidos" => "Lopez-Castroman" ] 10 => array:2 [ "nombre" => "S." "apellidos" => "Berrouiguet" ] 11 => array:2 [ "nombre" => "P." "apellidos" => "Courtet" ] 12 => array:2 [ "nombre" => "E." "apellidos" => "Baca-García" ] 13 => array:1 [ "colaborador" => "MEmind Study Group" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213616317300514?idApp=UINPBA00004N" "url" => "/02136163/0000003100000004/v1_201711170436/S0213616317300514/v1_201711170436/en/main.assets" ] "en" => array:17 [ "idiomaDefecto" => true "cabecera" => "Original article" "titulo" => "Anxiety and depression in patients infected with Borrelia burgdorferi" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "165" "paginaFinal" => "171" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M. Makara-Studzińska, R. Rolla-Szczepańska, A. Urbańska, K. Nowakowska-Domagała, P. Stecz" "autores" => array:5 [ 0 => array:3 [ "nombre" => "M." "apellidos" => "Makara-Studzińska" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "R." "apellidos" => "Rolla-Szczepańska" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Urbańska" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "K." "apellidos" => "Nowakowska-Domagała" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 4 => array:4 [ "nombre" => "P." "apellidos" => "Stecz" "email" => array:1 [ 0 => "patryk.stecz@uni.lodz.pl" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Department of Health Psychology, Faculty of Health Sciences, Jagiellonian University Medical College, Cracow, Poland" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Chair and Department of Infectious Diseases, I Faculty of Medicine, Medical University of Lublin, Poland" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "II Department of Psychiatry and Psychiatry Rehabilitation, Chair of Psychiatry, I Faculty of Medicine, Medical University of Lublin, Poland" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Department of Preventive and Addiction Psychology, Institute of Psychology, Faculty of Educational Sciences, University of Lodz, Poland, Poland" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "textoCompleto" => "IntroductionLyme borreliosis is a multisystem inflammatory anthropozoonosis caused by a complex interaction between the spirochete Borrelia burgdorferi sensu lato (B. burgdorferi s.l.) and the immune system of the infected individual at the site of infection.<a class="elsevierStyleCrossRef" href="#bib0170">1</a>Annually, more than 25,000 new cases of Lyme disease are diagnosed in the USA (incidence 7.9/100,000), and around 85,000 in Europe.<a class="elsevierStyleCrossRef" href="#bib0175">2</a> The NIZP-PZH, the Polish National Institute of Public Health-National Department of Hygiene, reports that the incidence of B. burgdorferi infection in Poland increased by almost 50% in the period 2011–2014.<a class="elsevierStyleCrossRef" href="#bib0180">3</a> Although in Poland, the incidence varies according to province, it was found to be 39.7/100,000 for the whole of Lublin province in 2014.<a class="elsevierStyleCrossRef" href="#bib0185">4</a>The epidemiology of tick-born disease depends on a number of factors, including the specificity of natural resources and type of employment in the region, with Eastern Poland being one of the more exposed regions in the European Union.<a class="elsevierStyleCrossRef" href="#bib0185">4</a>The symptomatology of the B. burgorferi sensu lato complex varies according to the species of Borrelia present. Eighteen species have been diagnosed, with individual types characterized by different tissular affinity: i.e. neural system or dermal, generalized or particular; a high level of pathogenicity has been found in three species.<a class="elsevierStyleCrossRef" href="#bib0190">5</a> All types can cause the occurrence of a primary lesion known as erythema migrans. A diagnosis of borreliosis must take into account the epidemiological aspect, the tick bite, the clinical aspect and the serological aspect, with a two-step diagnostic procedure based on an immune enzymatic test and Western blotting.<a class="elsevierStyleCrossRef" href="#bib0195">6</a> The disease is characterized by a multiorgan symptomatology and differentiated clinical picture, which can be attributed to, among other things, its considerable adaptability to the human organism.<a class="elsevierStyleCrossRef" href="#bib0190">5</a>Asbrinkn and Hovmark<a class="elsevierStyleCrossRef" href="#bib0200">7</a> define three clinical pictures of infection: early local type, early disseminated type and late type. The early local type is present in half the patients as erythema migrans between three and 30 days following infection. The early disseminated type can develop several days or months following the bite: some symptoms from central nervous system can appear, sometimes without signs of erythema migrans. Late treatment of early types can result in numerous consequences: changes in the osteoarticular system in 60% of cases, neurological symptoms (i.e. mildly declined executive cognitive functions) in 10–40%, and cardiological complications in 5%,<a class="elsevierStyleCrossRefs" href="#bib0205">8,9</a> which can lead to a prolonged decline in the health-related quality of life.<a class="elsevierStyleCrossRef" href="#bib0215">10</a>An important potential comorbidity observed in patients with borrelia is fibromyalgia: a conditions manifested by widespread pain and which known to intensify mood and sleep disturbances.<a class="elsevierStyleCrossRef" href="#bib0220">11</a> Fibromyalgia could be considered an additional burden triggered by Lyme borreliosis which affects psychological function.<a class="elsevierStyleCrossRef" href="#bib0225">12</a> Chronic Lyme disease is another irrelevant and controversial term used to diagnose a broad spectrum of diverse, medically unexplained symptoms.<a class="elsevierStyleCrossRef" href="#bib0230">13</a> From a methodological perspective, evidence-based studies should refer to B. burgdorferi infection rather than CLD, and recognize the existence of early Lyme Borreliosis as a condition instead of using it as a basis for the diagnosis of Chronic Lyme disease.<a class="elsevierStyleCrossRef" href="#bib0235">14</a>Most of the mental disorders experienced during early Lyme disease are considered to be the direct consequences of an inflammatory state in neural tissue and the psychological consequence of chronic illness. Mental symptoms are not specific for neuroborreliosis, although they have been observed during various stages of the infection.<a class="elsevierStyleCrossRef" href="#bib0240">15</a> Several ill-conceived studies suggest that the early stage of borreliosis can present symptoms typical for fibromyalgia and mild depression, while the late stage may manifest Lyme encephalopathy characterized by symptoms of memory deficits, fatigue, spatial disorientation and mood disturbances.<a class="elsevierStyleCrossRef" href="#bib0245">16</a>The co-occurrence of fibromyalgia and B. burgdorferi infection can also be problematic in determining whether the presentations of these illnesses are associated with depression or anxiety symptoms. The nonspecific chronic syndromes observed in some patients seem to have an unknown medical explanation. Many complaints remain subjective and resistant to medical treatment.<a class="elsevierStyleCrossRef" href="#bib0250">17</a> Generally, the adjustment to chronic disease itself is regarded as a dynamic process which is challenging enough to a sick person, and one which depends on the individual characteristics of the patient and the quality of healthcare, including accurate diagnosis and treatment.<a class="elsevierStyleCrossRef" href="#bib0255">18</a> It is argued that some patients with recognized Lyme disease are incorrectly diagnosed due to comorbidities and the atypical presentation of symptoms.<a class="elsevierStyleCrossRef" href="#bib0260">19</a> A further point of controversy is whether patients diagnosed with Lyme disease also suffered from mental disorders before the diagnosis.The aim of this research was to learn how the factors accompanying B. burgdorferi infection such as fibromyalgia or erythema migrans were associated with self-reported anxiety and depression comprising the majority of affective disorders. Additionally, the objective was to investigate whether Western-blot tests might predict the level of anxiety and depression symptoms in B. burgdorferi infection. It was hypothesized that:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.Patients diagnosed with B. burgdorferi infection associated with fibromyalgia would report a higher level of anxiety and depression than patients without fibromyalgia.</li><li class="elsevierStyleListItem" id="lsti0010">2.Patients diagnosed with B. burgdorferi infection associated with erythema migrans would report a higher level of anxiety and depression than patients without erythema migrans.</li><li class="elsevierStyleListItem" id="lsti0015">3.There would be a relationship between Western blot IgM/IgG (immunoglobulin M/immunoglobulin G) test results and the level of anxiety and depression in patients with B. burgdorferi.</li></ul>MaterialsPatients diagnosed and treated for B. burgdorferi infection were recruited at the Outpatient Clinic, Department of Infectious Diseases, Medical University of Lublin. In total, 87 participants (43 females and 44 males) completed the study, including psychological diagnosis, medical record analysis, medical interview with demographic questions and additional medical tests. The overall response rate of 87% was achieved by encouragement from academics and keeping the questionnaires brief. All patients were ethnically white European. B. burgdorferi was diagnosed according to criteria proposed by the British Infection Association and the Polish Association of Epidemiologists and Infectious Disease Specialists<a class="elsevierStyleCrossRef" href="#bib0265">20</a>:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020">1.A clinical image of the infected joints (Lyme arthritis), defined as migrating joint pain or recurrent pain in the large joints, particularly the knees or shoulder, and less commonly, ankle and wrist pain limiting active and passive mobility, accompanied by stiffness in the morning.</li><li class="elsevierStyleListItem" id="lsti0025">2.The presence of erythema migrans noted in interviews, and/or risk factors such as being in contact with ticks, working in a forest, farming, working in the garden or picking forest fruits.</li><li class="elsevierStyleListItem" id="lsti0030">3.Positive serological tests performer according to a two-step procedure: ELISA test for IgM and IgG verified by Western blot, identifying a serological profile of IgM(+) IgG(−) for borreliosis lasting less than four weeks; or IgM(+), IgG(+) or IgM(−) IgG(+) for borreliosis lasting longer than four weeks (four to ten weeks).</li></ul>In the analyzed group, 27 people, (nine men and 18 women, including four women infected professionally) presented a serological profile of IgM (+) IgG(−), 12 people presented IgM (+) IgG(+), and 43 presented IgM(−) IgG(+).The exclusion criteria ruled out those with a positive test for rheumatic agents, acute-phase C-reactive protein, or anti-CCP, and those diagnosed with rheumatoid arthritis or lupus systematicus.The additional inclusion criteria comprised patient age between 18 and 88, and no diagnosis of psychotic illness or severe cognitive impairment which may result in symptom overlap or measurement bias. The study was approved by the Medical University of Lublin Ethical Board. Informed consent was obtained from the participating subjects.MethodsThe participants completed a demographic survey including data on gender, age, residence area and marital status (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Administered immunological test results were within normal ranges for all subjects (rheumatoid factor – RF, cyclic citrullinated peptide antibodies – anti-CCP, acute-phase proteins – CRP and erythrocyte sedimentation rate – ESR). Fibromyalgia was primarily diagnosed using the Criteria for the Classification of fibromyalgia of The America College of Rheumatology (excerpt)<a class="elsevierStyleCrossRef" href="#bib0270">21</a>:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035">1.The history of widespread pain – recorded using the pain points protocol with a questionnaire definition, where pain is considered widespread when all of the following are present: pain in the left side of the body, pain in the right side of the body, pain above the waist, and pain below the waist. In addition, axial skeletal pain (cervical spine or anterior chest or thoracic spine or low back) must be present. In this definition, shoulder and buttock pain is considered as pain for each involved side. “Lower back” pain is considered lower segment pain.</li><li class="elsevierStyleListItem" id="lsti0040">2.Pain found to be present on digital palpation in at least 11 of the following 18 sites: Occiput (bilateral), Low cervical (bilateral), Trapezius (bilateral), Supraspinatus (bilateral), Second rib (bilateral), Lateral epicondyle (bilateral), Gluteal (bilateral), Greater trochanter (bilateral), Knee (bilateral).</li></ul><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Digital palpation should be performed with an approximate force of 4kg. For a tender point to be considered “positive”, the subject must state that the palpation was painful. Tender is not considered “painful”. Fibromyalgia is recorded as present if both criteria are satisfied. Widespread pain must have been present for at least three months.Additionally, the psychological characteristics of the subjects toward Lyme borrelia were assessed with psychometric tests in an interview performed by a psychologist.AnxietyThe State Trait Anxiety Inventory (STAI), developed by Spielberger, Gorsuch and Lushene, is a 40-item questionnaire indicating dispositional (20 items) and situational (20 items) feelings of worry and tension. A greater score is associated with higher levels of anxiety. The scale is reported to have good internal reliability coefficients (alpha-Cronbach values varying from 0.84 to 0.94) and is used internationally in clinical settings.<a class="elsevierStyleCrossRef" href="#bib0275">22</a>DepressionThe self-reporting 21-item revised Beck's Depression Inventory (BDI) was used to determine the occurrence and intensity of depressive symptoms such as feelings of being punished and guilt, worries, sadness, fatigue, suicidal thoughts, changes in sleep, appetite or decrease of interests in sexual behavior. The original version is reported to have good psychometric properties in clinical and non-clinical populations. The alpha-Cronbach value for the revised version was 0.86.<a class="elsevierStyleCrossRef" href="#bib0280">23</a> It has been widely used in psychological and medical research. The total score ranges from 0 to 63 points, with a higher scores representing more common and stronger symptoms of depression disorder.Statistical methodsThe analyses were conducted using SPSS Statistics. All variables except the depression scale (K–S=1.55; p=0.016) were found to have a normal distribution. The chi-square test was used to compare the relationship between erythema migrans and fibromyalgia. The Student's t-test for independent samples was used to compare anxiety level between patients with and without fibromyalgia. Similarly, the Mann–Whitney test was performed for determining depression levels. One-way ANOVA for independent groups followed by post hoc tests were conducted to compare the differences in anxiety and depression results among subjects with positive and negative IgM and IgG results. p-Values lower than 0.05 were determined to be significant, while p-values ranging from 0.05 to 0.09 were interpreted as suggesting a statistical tendency. A number of effect size measures was used, including phi φ for chi-square test, r for U Mann–Whitney test, Cohen's d for t-test.ResultsThe severity of anxiety as a state (depending on the current situation) and anxiety as a trait (acquired behavioral disposition) was evaluated in Lyme borrelia patients who also presented with symptoms of fibromyalgia, and in whom physical examination had confirmed the presence of at least 11 of 18 tender points as described above. The findings were compared with those recorded in another group of patients without algetic symptoms, or those with algetic symptoms but with a negative result for the physical examination.The data concerning exposure to bite, recognized tick-bite by patient and presence of erythema migrans did not significantly differentiate the studied groups with regard to the level of anxiety and depression. However, the presence of fibromyalgia was significantly different with regard to the appearance of erythema in the patient history (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).The Student's t-test revealed a significantly higher level of state anxiety in patients with algetic symptoms specific for fibromyalgia; while trait anxiety was similar in both groups (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The results of the Mann–Whitney test indicate that the patients with fibromyalgia reported a higher level of depression symptoms (M=22.88, SD=9.84) than subjects without fibromyalgia (M=12.72, SD=8.28). However, the effect size was moderate (Z=−3.903; p<0.001; r=0.426).Although the Western blot IgM test results did not differentiate patient anxiety, the IgM+ subjects were observed in general to have more severe depression symptoms (M=16.89; SD=9.88) than the IgM− subjects (M=12.13; SD=7.96), t(83)=−2.417; p=0.018. A univariate analysis of variances for independent traits was performed to examine whether statistically significant differences were present with regard to depression, trait anxiety or state anxiety, depending on both IgM and IgG content (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). The result revealed statistically significant differences with respect to the level of depression F(2; 79)=3.478; p<0.05, but no differences regarding state anxiety, F(2; 80)=0.854; p=0.429, or trait anxiety, F(2; 80)=0.626; p=0.537. Post hoc NIR tests found the only significant difference in the severity of depression to be between IgM(+)/IgG(−) and IgM(−)/IgG(+) (p<0.05): no such difference was found between these two and the two others. A higher level of depression was found in the IgM(+)/IgG(−) group than the IgM(−)/IgG(+) group. As the depression variable was not normally distributed, the non-parametric Kruskal–Wallis was used for further examination. The result of which confirmed the result of the ANOVA.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>DiscussionThe present study assesses the level of anxiety and depression in patients infected with B. burgdorferi to determine whether additional disorders and conditions, such as fibromyalgia, positive B. burgdorferi tests, types of Western-blot patterns (IgM and IgG) or recognition of tick bite exposure by the patient, were associated with different intensities of psychological symptoms.The results suggest that a relationship may exist between the results of IgM and IgG tests, which allow relatively early infections to be differentiated from later ones, and the severity of depression, state anxiety and trait anxiety. Significantly higher levels of depression symptoms and higher levels of state anxiety, although not significant, were observed in the IgM+/IgG- group, including patients with early infection. These patients had no time to psychologically elaborate their diagnosis, to assess its meaning and consequences, and were not able to suffer any damage, such as neurological changes, due to the prolonged activity of B. burgdorferi.The symptoms of depression are probably correlated with experiences of anxiety in the early stage of the disease, and are a typical defensive reaction before growth is observed.<a class="elsevierStyleCrossRef" href="#bib0255">18</a> The increased level of anxiety mobilizes the individual to experience improvement and cope, while the presence of depressive symptoms may indicate a weak adaptation to new circumstances and feelings of apprehensiveness concerning loss of health, control or safety. Previous studies have also suggested the presence of mild depressive symptoms during the early stage of borreliosis.<a class="elsevierStyleCrossRef" href="#bib0245">16</a>Patients whose serological test results indicated past infection demonstrated lower anxiety and depression scores, although they also demonstrated higher levels of state anxiety than patients with early infection. This could be the result of struggling with diagnosis and distress related to misconception of the illness, manifested as an increasing tendency toward anxiety and worry. Low indexes for mood disorders among patients with a longer duration of illness may also suggest that borrelia is not associated with psychological symptoms determined by changes in the central nervous system.Our results suggest that neurological symptoms and changes in mental activities are non-specific, as no strong differentiation was found between groups: The only significant difference concerned depression. The sample size of this study can be a limiting factor in making generalizations, especially because epidemiological data from large populations indicates that IgG antibody level does not differ between healthy and infected people with regard to depression symptoms; however, these studies are not always based on an assessment of the clinical symptoms of depression.<a class="elsevierStyleCrossRef" href="#bib0285">24</a> The results of other works suggest that the prevalence of depression in Lyme disease is low and does not differ much from that of the general population. For instance, one study reported the prevalence of clinical depression to be 4% among a group of Lyme disease patients, with increased depression scores measured by BDI questionnaire in 40% of the same sample.<a class="elsevierStyleCrossRef" href="#bib0290">25</a> Similarly, Dersch et al.<a class="elsevierStyleCrossRef" href="#bib0295">26</a> report no significant differences in depression levels between patients with residual symptoms and healthy controls.The participants of our study with fibromyalgia demonstrated higher levels of state and trait anxiety, which suggests they might be slightly more exposed to mental problems. An additional burden faced by a considerable number of patients with Lyme Neuroborreliosis is chronic fatigue syndrome.<a class="elsevierStyleCrossRef" href="#bib0300">27</a> Our study confirms that fibromyalgia is associated with self-reported erythema migrans in the medical history.Over the course of time, persistent somatic symptoms can affect the presence and maintenance of depressive symptoms in patients with borrelia. These include constant pain such as muscular and articular pains or headaches, prolonged complaints and physical restrictions,<a class="elsevierStyleCrossRef" href="#bib0305">28</a> as well as other consequences correlated with organ damage and inflammation of connective tissue.<a class="elsevierStyleCrossRef" href="#bib0310">29</a> Furthermore, the inflammatory processes in Borrelia infection may activate the response manifested by sickness behavior. Sickness behavior is considered to be an adaptive response that may have similar symptomatology to depression (i.e. anxiety, melancholic states). However, it serves a role in enhancing recovery by conserving energy.<a class="elsevierStyleCrossRef" href="#bib0315">30</a> The symptoms measured by BDI and STAI could be triggered both by depression and sickness behavior. Thus, the caution is needed when interpreting the results of this study.The experience of chronic symptoms is related to perception of negative social impact of disease.<a class="elsevierStyleCrossRef" href="#bib0320">31</a> Therapeutic interventions for depressive patients with borreliosis should take into account many factors, such as persistent physical complaints and environmental variables, and their negative influence should be reduced as far as possible. It cannot be ruled out that depression and anxiety symptoms may ameliorate as the disease progresses. Solomon<a class="elsevierStyleCrossRef" href="#bib0325">32</a> reports that patients who experienced strong stress before infection with B. burgdorferi, had more chronic psychological complaints during the disease. A suggestion for future study could be identifying a group without preceding depression or anxiety in high risk population (exposure to tick bite) who may develop B. burgdorferi infection and following this cohort forward.As well as occasional mood disturbances, borreliosis is believed to be sometimes accompanied by impairments in attention, memory or reduced speed of complex cognitive processes, whose presence and severity might be expected to be controlled by early diagnosis and health education.<a class="elsevierStyleCrossRef" href="#bib0330">33</a>The species of spirochetes present in examined region may have a great influence on the degree of depression, and anxiety may result as a mood disturbance based on disease duration. While the most common species is B. burgdorferi sensu stricto, Borrelia garinii is also frequently observed; both are responsible for neuroborreliosis and articular-type symptoms. Species with less pathogenicity, such as Borrelia spielmani, are also found in the examined area, further complicating the already unclear picture of Lyme borreliosis and making diagnosis more difficult.<a class="elsevierStyleCrossRef" href="#bib0245">16</a>Conclusions<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0045">1.A significantly higher level of depression and state anxiety is observed in early diagnosed B. burgdorferi patients with fibromyalgia than in those without.</li><li class="elsevierStyleListItem" id="lsti0050">2.B. burgdorferi patients characterized by IgM− and IgG+, suggesting far advanced infection in months, demonstrated the lowest levels of depression and anxiety.</li><li class="elsevierStyleListItem" id="lsti0055">3.A longitudinal study on depression and anxiety among patients with recent infections appears necessary to support the assumption that individuals treated medically for B. burgdorferi generally do not develop high levels of depression and anxiety in a long-term perspective.</li></ul>Conflict of interestThe authors have no conflict of interest to declare.FundingThere was no funding for this work." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres940654" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec914011" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials" ] 4 => array:3 [ "identificador" => "sec0015" "titulo" => "Methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Anxiety" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Depression" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical methods" ] ] ] 5 => array:2 [ "identificador" => "sec0035" "titulo" => "Results" ] 6 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interest" ] 9 => array:2 [ "identificador" => "sec0055" "titulo" => "Funding" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-03-13" "fechaAceptado" => "2017-09-26" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec914011" "palabras" => array:4 [ 0 => "Psychological adaptation" 1 => "Affective disorders" 2 => "Borrelia burgdorferi" 3 => "Fibromyalgia depression and anxiety in patients with Borrelia burgdorferi" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "Background and objectivesThe aim of the study was to evaluate the symptoms of depression and anxiety associated with fibromyalgia and erythema migrans in Borrelia burgdorferi infection. MethodsA group of 87 patients with clinically and serologically diagnosed B. burgdorferi (mean age 53.37) was formed. They were examined using the State-Trait Anxiety Inventory, Beck's Depression Inventory and various immunological tests, as well as for fibromyalgia. A demographic survey with additional questions was also administered. ResultsOur results confirm that fibromyalgia is associated with higher anxiety and depression symptoms. It is possible that serological markers of infection could act as indicators of depression level in patients with B. burgdorferi. The examined patients with B. burgdorferi infection reported a low prevalence of anxiety and depression symptoms. ConclusionsThe studied population is not very likely to experience neurologically-determined mood disorders, taking into consideration the above-mentioned results." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">N \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Erythema migrans</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No ECM \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ECM \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Females \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43 (49.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fibromyalgia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Males \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44 (50.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="3" align="left" valign="top">χ2=4.610 p=0.032 phi=0.233</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rural residence<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">38 (43.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Urban residence<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">47 (54.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">85<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Unknown residence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (2.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Occupational exposure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 (27.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1591800.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">M \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mdn \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SD \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Min \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Max \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">88.00 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">State anxiety \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43.18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70.00 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Trait anxiety \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46.28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">78.00 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Depression \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47.00 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1591799.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Missing data reported in 2 cases, ECM, erythema migrans; Mdn, median; SD, standard deviation; Min, minimum value; Max, maximum value; phi φ, measure of effect size for chi-square test." ] ] ] "descripcion" => array:1 [ "en" => "Patient characteristics." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "M, mean; SD, standard deviation; CI, confidence interval, LL, lower limit, UL, upper limit; d Cohen, measure of effect size for the independent samples t-test." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Fibromyalgia (n=16)</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">No fibromyalgia (n=69)</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">95% CI</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">M \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SD \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">M \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SD \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">t \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LL \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">UL \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">d Cohen \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">State Anxiety \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47.44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42.26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.816 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.073 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.494 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.847 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.504 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Trait Anxiety \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49.56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45.54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.243 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.217 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−2.418 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.471 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.345 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1591802.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Anxiety in subjects with and without fibromyalgia." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "M, mean; SD, standard deviation; IgM, immunoglobulin; IgG, immunoglobulin G. Note: averages not sharing a literal index differ at the level p<0.05. Multiple comparisons: post hoc LSD (Fisher's least significant difference)." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">IgM(+)/IgG(−) n=27</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">IgM(+)/IgG(+) n=12</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">IgM(−)/IgG(+) n=43</th><th class="td" title="table-head " align="left" valign="top" scope="col">F \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">p \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">M \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SD \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">M \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SD \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">M \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SD \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Depression \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17.93a \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.91 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.28b \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.478 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.036 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">State anxiety \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44.93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.02 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.06 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42.84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.854 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.429 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Trait anxiety \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44.30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48.67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46.50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.02 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.626 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.537 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1591801.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Depression and anxiety according to negative and positive Western blot tests." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:33 [ 0 => array:3 [ "identificador" => "bib0170" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lyme disease: a review of aspects of its immunology and immunopathogenesis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "L.H. 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M. Makara-Studzińskaa, R. Rolla-Szczepańskab, A. Urbańskac, K. Nowakowska-Domagaład, P. Steczd,

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patryk.stecz@uni.lodz.pl

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a Department of Health Psychology, Faculty of Health Sciences, Jagiellonian University Medical College, Cracow, Poland

b Chair and Department of Infectious Diseases, I Faculty of Medicine, Medical University of Lublin, Poland

c II Department of Psychiatry and Psychiatry Rehabilitation, Chair of Psychiatry, I Faculty of Medicine, Medical University of Lublin, Poland

d Department of Preventive and Addiction Psychology, Institute of Psychology, Faculty of Educational Sciences, University of Lodz, Poland, Poland

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Lyme borreliosis is a multisystem inflammatory anthropozoonosis caused by a complex interaction between the spirochete <span class="elsevierStyleItalic">Borrelia burgdorferi sensu lato</span> &#40;<span class="elsevierStyleItalic">B&#46; burgdorferi</span> s&#46;l&#46;&#41; and the immune system of the infected individual at the site of infection&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Annually&#44; more than 25&#44;000 new cases of Lyme disease are diagnosed in the USA &#40;incidence 7&#46;9&#47;100&#44;000&#41;&#44; and around 85&#44;000 in Europe&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">2</span></a> The NIZP-PZH&#44; the Polish National Institute of Public Health-National Department of Hygiene&#44; reports that the incidence of <span class="elsevierStyleItalic">B&#46; burgdorferi</span> infection in Poland increased by almost 50&#37; in the period 2011&#8211;2014&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">3</span></a> Although in Poland&#44; the incidence varies according to province&#44; it was found to be 39&#46;7&#47;100&#44;000 for the whole of Lublin province in 2014&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The epidemiology of tick-born disease depends on a number of factors&#44; including the specificity of natural resources and type of employment in the region&#44; with Eastern Poland being one of the more exposed regions in the European Union&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The symptomatology of the <span class="elsevierStyleItalic">B&#46; burgorferi sensu lato</span> complex varies according to the species of <span class="elsevierStyleItalic">Borrelia</span> present&#46; Eighteen species have been diagnosed&#44; with individual types characterized by different tissular affinity&#58; i&#46;e&#46; neural system or dermal&#44; generalized or particular&#59; a high level of pathogenicity has been found in three species&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">5</span></a> All types can cause the occurrence of a primary lesion known as <span class="elsevierStyleItalic">erythema migrans&#46;</span> A diagnosis of borreliosis must take into account the epidemiological aspect&#44; the tick bite&#44; the clinical aspect and the serological aspect&#44; with a two-step diagnostic procedure based on an immune enzymatic test and Western blotting&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">6</span></a> The disease is characterized by a multiorgan symptomatology and differentiated clinical picture&#44; which can be attributed to&#44; among other things&#44; its considerable adaptability to the human organism&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Asbrinkn and Hovmark<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">7</span></a> define three clinical pictures of infection&#58; early local type&#44; early disseminated type and late type&#46; The early local type is present in half the patients as <span class="elsevierStyleItalic">erythema migrans</span> between three and 30 days following infection&#46; The early disseminated type can develop several days or months following the bite&#58; some symptoms from central nervous system can appear&#44; sometimes without signs of <span class="elsevierStyleItalic">erythema migrans</span>&#46; Late treatment of early types can result in numerous consequences&#58; changes in the osteoarticular system in 60&#37; of cases&#44; neurological symptoms &#40;i&#46;e&#46; mildly declined executive cognitive functions&#41; in 10&#8211;40&#37;&#44; and cardiological complications in 5&#37;&#44;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">8&#44;9</span></a> which can lead to a prolonged decline in the health-related quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">An important potential comorbidity observed in patients with borrelia is fibromyalgia&#58; a conditions manifested by widespread pain and which known to intensify mood and sleep disturbances&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">11</span></a> Fibromyalgia could be considered an additional burden triggered by Lyme borreliosis which affects psychological function&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">12</span></a> Chronic Lyme disease is another irrelevant and controversial term used to diagnose a broad spectrum of diverse&#44; medically unexplained symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">13</span></a> From a methodological perspective&#44; evidence-based studies should refer to <span class="elsevierStyleItalic">B&#46; burgdorferi</span> infection rather than CLD&#44; and recognize the existence of early Lyme Borreliosis as a condition instead of using it as a basis for the diagnosis of Chronic Lyme disease&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">14</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Most of the mental disorders experienced during early Lyme disease are considered to be the direct consequences of an inflammatory state in neural tissue and the psychological consequence of chronic illness&#46; Mental symptoms are not specific for neuroborreliosis&#44; although they have been observed during various stages of the infection&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">15</span></a> Several ill-conceived studies suggest that the early stage of borreliosis can present symptoms typical for fibromyalgia and mild depression&#44; while the late stage may manifest Lyme encephalopathy characterized by symptoms of memory deficits&#44; fatigue&#44; spatial disorientation and mood disturbances&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">16</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The co-occurrence of fibromyalgia and <span class="elsevierStyleItalic">B&#46; burgdorferi</span> infection can also be problematic in determining whether the presentations of these illnesses are associated with depression or anxiety symptoms&#46; The nonspecific chronic syndromes observed in some patients seem to have an unknown medical explanation&#46; Many complaints remain subjective and resistant to medical treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">17</span></a> Generally&#44; the adjustment to chronic disease itself is regarded as a dynamic process which is challenging enough to a sick person&#44; and one which depends on the individual characteristics of the patient and the quality of healthcare&#44; including accurate diagnosis and treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">18</span></a> It is argued that some patients with recognized Lyme disease are incorrectly diagnosed due to comorbidities and the atypical presentation of symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">19</span></a> A further point of controversy is whether patients diagnosed with Lyme disease also suffered from mental disorders before the diagnosis&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The aim of this research was to learn how the factors accompanying <span class="elsevierStyleItalic">B&#46; burgdorferi</span> infection such as fibromyalgia or <span class="elsevierStyleItalic">erythema migrans</span> were associated with self-reported anxiety and depression comprising the majority of affective disorders&#46; Additionally&#44; the objective was to investigate whether Western-blot tests might predict the level of anxiety and depression symptoms in <span class="elsevierStyleItalic">B&#46; burgdorferi</span> infection&#46; It was hypothesized that&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Patients diagnosed with <span class="elsevierStyleItalic">B&#46; burgdorferi</span> infection associated with fibromyalgia would report a higher level of anxiety and depression than patients without fibromyalgia&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Patients diagnosed with <span class="elsevierStyleItalic">B&#46; burgdorferi</span> infection associated with <span class="elsevierStyleItalic">erythema migrans</span> would report a higher level of anxiety and depression than patients without <span class="elsevierStyleItalic">erythema migrans</span>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0060" class="elsevierStylePara elsevierViewall">There would be a relationship between Western blot IgM&#47;IgG &#40;immunoglobulin M&#47;immunoglobulin G&#41; test results and the level of anxiety and depression in patients with <span class="elsevierStyleItalic">B&#46; burgdorferi</span>&#46;</p></li></ul></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materials</span><p id="par0065" class="elsevierStylePara elsevierViewall">Patients diagnosed and treated for <span class="elsevierStyleItalic">B&#46; burgdorferi</span> infection were recruited at the Outpatient Clinic&#44; Department of Infectious Diseases&#44; Medical University of Lublin&#46; In total&#44; 87 participants &#40;43 females and 44 males&#41; completed the study&#44; including psychological diagnosis&#44; medical record analysis&#44; medical interview with demographic questions and additional medical tests&#46; The overall response rate of 87&#37; was achieved by encouragement from academics and keeping the questionnaires brief&#46; All patients were ethnically white European&#46; <span class="elsevierStyleItalic">B&#46; burgdorferi</span> was diagnosed according to criteria proposed by the British Infection Association and the Polish Association of Epidemiologists and Infectious Disease Specialists<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">20</span></a>&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">1&#46;</span><p id="par0070" class="elsevierStylePara elsevierViewall">A clinical image of the infected joints &#40;Lyme arthritis&#41;&#44; defined as migrating joint pain or recurrent pain in the large joints&#44; particularly the knees or shoulder&#44; and less commonly&#44; ankle and wrist pain limiting active and passive mobility&#44; accompanied by stiffness in the morning&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">2&#46;</span><p id="par0075" class="elsevierStylePara elsevierViewall">The presence of erythema migrans noted in interviews&#44; and&#47;or risk factors such as being in contact with ticks&#44; working in a forest&#44; farming&#44; working in the garden or picking forest fruits&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">3&#46;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Positive serological tests performer according to a two-step procedure&#58; ELISA test for IgM and IgG verified by Western blot&#44; identifying a serological profile of IgM&#40;&#43;&#41; IgG&#40;&#8722;&#41; for borreliosis lasting less than four weeks&#59; or IgM&#40;&#43;&#41;&#44; IgG&#40;&#43;&#41; or IgM&#40;&#8722;&#41; IgG&#40;&#43;&#41; for borreliosis lasting longer than four weeks &#40;four to ten weeks&#41;&#46;</p></li></ul></p><p id="par0085" class="elsevierStylePara elsevierViewall">In the analyzed group&#44; 27 people&#44; &#40;nine men and 18 women&#44; including four women infected professionally&#41; presented a serological profile of IgM &#40;&#43;&#41; IgG&#40;&#8722;&#41;&#44; 12 people presented IgM &#40;&#43;&#41; IgG&#40;&#43;&#41;&#44; and 43 presented IgM&#40;&#8722;&#41; IgG&#40;&#43;&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The exclusion criteria ruled out those with a positive test for rheumatic agents&#44; acute-phase C-reactive protein&#44; or anti-CCP&#44; and those diagnosed with rheumatoid arthritis or lupus systematicus&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The additional inclusion criteria comprised patient age between 18 and 88&#44; and no diagnosis of psychotic illness or severe cognitive impairment which may result in symptom overlap or measurement bias&#46; The study was approved by the Medical University of Lublin Ethical Board&#46; Informed consent was obtained from the participating subjects&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Methods</span><p id="par0100" class="elsevierStylePara elsevierViewall">The participants completed a demographic survey including data on gender&#44; 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pain in the left side of the body&#44; pain in the right side of the body&#44; pain above the waist&#44; and pain below the waist&#46; In addition&#44; axial skeletal pain &#40;cervical spine or anterior chest or thoracic spine or low back&#41; must be present&#46; In this definition&#44; shoulder and buttock pain is considered as pain for each involved side&#46; &#8220;Lower back&#8221; pain is considered lower segment pain&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">2&#46;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Pain found to be present on digital palpation in at least 11 of the following 18 sites&#58; Occiput &#40;bilateral&#41;&#44; Low cervical &#40;bilateral&#41;&#44; Trapezius &#40;bilateral&#41;&#44; Supraspinatus &#40;bilateral&#41;&#44; Second rib &#40;bilateral&#41;&#44; Lateral epicondyle &#40;bilateral&#41;&#44; Gluteal &#40;bilateral&#41;&#44; Greater trochanter &#40;bilateral&#41;&#44; Knee &#40;bilateral&#41;&#46;</p></li></ul></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Digital palpation should be performed with an approximate force of 4<span class="elsevierStyleHsp" style=""></span>kg&#46; For a tender point to be considered &#8220;positive&#8221;&#44; the subject must state that the palpation was painful&#46; Tender is not considered &#8220;painful&#8221;&#46; Fibromyalgia is recorded as present if both criteria are satisfied&#46; Widespread pain must have been present for at least three months&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Additionally&#44; the psychological characteristics of the subjects toward Lyme borrelia were assessed with psychometric tests in an interview performed by a psychologist&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Anxiety</span><p id="par0125" class="elsevierStylePara elsevierViewall">The State Trait Anxiety Inventory &#40;STAI&#41;&#44; developed by Spielberger&#44; Gorsuch and Lushene&#44; is a 40-item questionnaire indicating dispositional &#40;20 items&#41; and situational &#40;20 items&#41; feelings of worry and tension&#46; A greater score is associated with higher levels of anxiety&#46; The scale is reported to have good internal reliability coefficients &#40;alpha-Cronbach values varying from 0&#46;84 to 0&#46;94&#41; and is used internationally in clinical settings&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Depression</span><p id="par0130" class="elsevierStylePara elsevierViewall">The self-reporting 21-item revised Beck&#39;s Depression Inventory &#40;BDI&#41; was used to determine the occurrence and intensity of depressive symptoms such as feelings of being punished and guilt&#44; worries&#44; sadness&#44; fatigue&#44; suicidal thoughts&#44; changes in sleep&#44; appetite or decrease of interests in sexual behavior&#46; The original version is reported to have good psychometric properties in clinical and non-clinical populations&#46; The alpha-Cronbach value for the revised version was 0&#46;86&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">23</span></a> It has been widely used in psychological and medical research&#46; The total score ranges from 0 to 63 points&#44; with a higher scores representing more common and stronger symptoms of depression disorder&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Statistical methods</span><p id="par0135" class="elsevierStylePara elsevierViewall">The analyses were conducted using SPSS Statistics&#46; All variables except the depression scale &#40;K&#8211;S<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;55&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;016&#41; were found to have a normal distribution&#46; The chi-square test was used to compare the relationship between <span class="elsevierStyleItalic">erythema migrans</span> and fibromyalgia&#46; The Student&#39;s <span class="elsevierStyleItalic">t</span>-test for independent samples was used to compare anxiety level between patients with and without fibromyalgia&#46; Similarly&#44; the Mann&#8211;Whitney test was performed for determining depression levels&#46; One-way ANOVA for independent groups followed by post hoc tests were conducted to compare the differences in anxiety and depression results among subjects with positive and negative IgM and IgG results&#46; <span class="elsevierStyleItalic">p</span>-Values lower than 0&#46;05 were determined to be significant&#44; while <span class="elsevierStyleItalic">p</span>-values ranging from 0&#46;05 to 0&#46;09 were interpreted as suggesting a statistical tendency&#46; A number of effect size measures was used&#44; including phi <span class="elsevierStyleItalic">&#966;</span> for chi-square test&#44; <span class="elsevierStyleItalic">r</span> for <span class="elsevierStyleItalic">U</span> Mann&#8211;Whitney test&#44; Cohen&#39;s <span class="elsevierStyleItalic">d</span> for <span class="elsevierStyleItalic">t</span>-test&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Results</span><p id="par0140" class="elsevierStylePara elsevierViewall">The severity of anxiety as a state &#40;depending on the current situation&#41; and anxiety as a trait &#40;acquired behavioral disposition&#41; was evaluated in Lyme borrelia patients who also presented with symptoms of fibromyalgia&#44; and in whom physical examination had confirmed the presence of at least 11 of 18 tender points as described above&#46; The findings were compared with those recorded in another group of patients without algetic symptoms&#44; or those with algetic symptoms but with a negative result for the physical examination&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The data concerning exposure to bite&#44; recognized tick-bite by patient and presence of <span class="elsevierStyleItalic">erythema migrans</span> did not significantly differentiate the studied groups with regard to the level of anxiety and depression&#46; However&#44; the presence of fibromyalgia was significantly different with regard to the appearance of erythema in the patient history &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The Student&#39;s <span class="elsevierStyleItalic">t</span>-test revealed a significantly higher level of state anxiety in patients with algetic symptoms specific for fibromyalgia&#59; while trait anxiety was similar in both groups &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">The results of the Mann&#8211;Whitney test indicate that the patients with fibromyalgia reported a higher level of depression symptoms &#40;<span class="elsevierStyleItalic">M</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#46;88&#44; SD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#46;84&#41; than subjects without fibromyalgia &#40;<span class="elsevierStyleItalic">M</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>12&#46;72&#44; SD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#46;28&#41;&#46; However&#44; the effect size was moderate &#40;<span class="elsevierStyleItalic">Z</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;3&#46;903&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#59; <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;426&#41;&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Although the Western blot IgM test results did not differentiate patient anxiety&#44; the IgM&#43; subjects were observed in general to have more severe depression symptoms &#40;<span class="elsevierStyleItalic">M</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>16&#46;89&#59; SD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#46;88&#41; than the IgM&#8722; subjects &#40;<span class="elsevierStyleItalic">M</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>12&#46;13&#59; SD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#46;96&#41;&#44; <span class="elsevierStyleItalic">t</span>&#40;83&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;2&#46;417&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;018&#46; A univariate analysis of variances for independent traits was performed to examine whether statistically significant differences were present with regard to depression&#44; trait anxiety or state anxiety&#44; depending on both IgM and IgG content &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; The result revealed statistically significant differences with respect to the level of depression <span class="elsevierStyleItalic">F</span>&#40;2&#59; 79&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;478&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#44; but no differences regarding state anxiety&#44; <span class="elsevierStyleItalic">F</span>&#40;2&#59; 80&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;854&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;429&#44; or trait anxiety&#44; <span class="elsevierStyleItalic">F</span>&#40;2&#59; 80&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;626&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;537&#46; Post hoc NIR tests found the only significant difference in the severity of depression to be between IgM&#40;&#43;&#41;&#47;IgG&#40;&#8722;&#41; and IgM&#40;&#8722;&#41;&#47;IgG&#40;&#43;&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#58; no such difference was found between these two and the two others&#46; A higher level of depression was found in the IgM&#40;&#43;&#41;&#47;IgG&#40;&#8722;&#41; group than the IgM&#40;&#8722;&#41;&#47;IgG&#40;&#43;&#41; group&#46; As the depression variable was not normally distributed&#44; the non-parametric Kruskal&#8211;Wallis was used for further examination&#46; The result of which confirmed the result of the ANOVA&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Discussion</span><p id="par0165" class="elsevierStylePara elsevierViewall">The present study assesses the level of anxiety and depression in patients infected with <span class="elsevierStyleItalic">B&#46; burgdorferi</span> to determine whether additional disorders and conditions&#44; such as fibromyalgia&#44; positive <span class="elsevierStyleItalic">B&#46; burgdorferi</span> tests&#44; types of Western-blot patterns &#40;IgM and IgG&#41; or recognition of tick bite exposure by the patient&#44; were associated with different intensities of psychological symptoms&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">The results suggest that a relationship may exist between the results of IgM and IgG tests&#44; which allow relatively early infections to be differentiated from later ones&#44; and the severity of depression&#44; state anxiety and trait anxiety&#46; Significantly higher levels of depression symptoms and higher levels of state anxiety&#44; although not significant&#44; were observed in the IgM&#43;&#47;IgG- group&#44; including patients with early infection&#46; These patients had no time to psychologically elaborate their diagnosis&#44; to assess its meaning and consequences&#44; and were not able to suffer any damage&#44; such as neurological changes&#44; due to the prolonged activity of <span class="elsevierStyleItalic">B&#46; burgdorferi</span>&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">The symptoms of depression are probably correlated with experiences of anxiety in the early stage of the disease&#44; and are a typical defensive reaction before growth is observed&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">18</span></a> The increased level of anxiety mobilizes the individual to experience improvement and cope&#44; while the presence of depressive symptoms may indicate a weak adaptation to new circumstances and feelings of apprehensiveness concerning loss of health&#44; control or safety&#46; Previous studies have also suggested the presence of mild depressive symptoms during the early stage of borreliosis&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">16</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Patients whose serological test results indicated past infection demonstrated lower anxiety and depression scores&#44; although they also demonstrated higher levels of state anxiety than patients with early infection&#46; This could be the result of struggling with diagnosis and distress related to misconception of the illness&#44; manifested as an increasing tendency toward anxiety and worry&#46; Low indexes for mood disorders among patients with a longer duration of illness may also suggest that borrelia is not associated with psychological symptoms determined by changes in the central nervous system&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Our results suggest that neurological symptoms and changes in mental activities are non-specific&#44; as no strong differentiation was found between groups&#58; The only significant difference concerned depression&#46; The sample size of this study can be a limiting factor in making generalizations&#44; especially because epidemiological data from large populations indicates that IgG antibody level does not differ between healthy and infected people with regard to depression symptoms&#59; however&#44; these studies are not always based on an assessment of the clinical symptoms of depression&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">24</span></a> The results of other works suggest that the prevalence of depression in Lyme disease is low and does not differ much from that of the general population&#46; For instance&#44; one study reported the prevalence of clinical depression to be 4&#37; among a group of Lyme disease patients&#44; with increased depression scores measured by BDI questionnaire in 40&#37; of the same sample&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">25</span></a> Similarly&#44; Dersch et al&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">26</span></a> report no significant differences in depression levels between patients with residual symptoms and healthy controls&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">The participants of our study with fibromyalgia demonstrated higher levels of state and trait anxiety&#44; which suggests they might be slightly more exposed to mental problems&#46; An additional burden faced by a considerable number of patients with Lyme Neuroborreliosis is chronic fatigue syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">27</span></a> Our study confirms that fibromyalgia is associated with self-reported <span class="elsevierStyleItalic">erythema migrans</span> in the medical history&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Over the course of time&#44; persistent somatic symptoms can affect the presence and maintenance of depressive symptoms in patients with borrelia&#46; These include constant pain such as muscular and articular pains or headaches&#44; prolonged complaints and physical restrictions&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">28</span></a> as well as other consequences correlated with organ damage and inflammation of connective tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">29</span></a> Furthermore&#44; the inflammatory processes in Borrelia infection may activate the response manifested by sickness behavior&#46; Sickness behavior is considered to be an adaptive response that may have similar symptomatology to depression &#40;i&#46;e&#46; anxiety&#44; melancholic states&#41;&#46; However&#44; it serves a role in enhancing recovery by conserving energy&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">30</span></a> The symptoms measured by BDI and STAI could be triggered both by depression and sickness behavior&#46; Thus&#44; the caution is needed when interpreting the results of this study&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">The experience of chronic symptoms is related to perception of negative social impact of disease&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">31</span></a> Therapeutic interventions for depressive patients with borreliosis should take into account many factors&#44; such as persistent physical complaints and environmental variables&#44; and their negative influence should be reduced as far as possible&#46; It cannot be ruled out that depression and anxiety symptoms may ameliorate as the disease progresses&#46; Solomon<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">32</span></a> reports that patients who experienced strong stress before infection with <span class="elsevierStyleItalic">B&#46; burgdorferi</span>&#44; had more chronic psychological complaints during the disease&#46; A suggestion for future study could be identifying a group without preceding depression or anxiety in high risk population &#40;exposure to tick bite&#41; who may develop <span class="elsevierStyleItalic">B&#46; burgdorferi</span> infection and following this cohort forward&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">As well as occasional mood disturbances&#44; borreliosis is believed to be sometimes accompanied by impairments in attention&#44; memory or reduced speed of complex cognitive processes&#44; whose presence and severity might be expected to be controlled by early diagnosis and health education&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">33</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">The species of spirochetes present in examined region may have a great influence on the degree of depression&#44; and anxiety may result as a mood disturbance based on disease duration&#46; While the most common species is <span class="elsevierStyleItalic">B&#46; burgdorferi sensu stricto</span>&#44; <span class="elsevierStyleItalic">Borrelia garinii</span> is also frequently observed&#59; both are responsible for neuroborreliosis and articular-type symptoms&#46; Species with less pathogenicity&#44; such as <span class="elsevierStyleItalic">Borrelia spielmani</span>&#44; are also found in the examined area&#44; further complicating the already unclear picture of Lyme borreliosis and making diagnosis more difficult&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">16</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conclusions</span><p id="par0215" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">1&#46;</span><p id="par0220" class="elsevierStylePara elsevierViewall">A significantly higher level of depression and state anxiety is observed in early diagnosed <span class="elsevierStyleItalic">B&#46; burgdorferi</span> patients with fibromyalgia than in those without&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">2&#46;</span><p id="par0225" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">B&#46; burgdorferi</span> patients characterized by IgM&#8722; and IgG&#43;&#44; suggesting far advanced infection in months&#44; demonstrated the lowest levels of depression and anxiety&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">3&#46;</span><p id="par0230" class="elsevierStylePara elsevierViewall">A longitudinal study on depression and anxiety among patients with recent infections appears necessary to support the assumption that individuals treated medically for <span class="elsevierStyleItalic">B&#46; burgdorferi</span> generally do not develop high levels of depression and anxiety in a long-term perspective&#46;</p></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflict of interest</span><p id="par0235" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Funding</span><p id="par0240" class="elsevierStylePara elsevierViewall">There was no funding for this work&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The aim of the study was to evaluate the symptoms of depression and anxiety associated with fibromyalgia and <span class="elsevierStyleItalic">erythema migrans</span> in <span class="elsevierStyleItalic">Borrelia burgdorferi</span> infection&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A group of 87 patients with clinically and serologically diagnosed <span class="elsevierStyleItalic">B&#46; burgdorferi</span> &#40;mean age 53&#46;37&#41; was formed&#46; They were examined using the State-Trait Anxiety Inventory&#44; Beck&#39;s Depression Inventory and various immunological tests&#44; as well as for fibromyalgia&#46; A demographic survey with additional questions was also administered&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Our results confirm that fibromyalgia is associated with higher anxiety and depression symptoms&#46; It is possible that serological markers of infection could act as indicators of depression level in patients with <span class="elsevierStyleItalic">B&#46; burgdorferi&#46;</span> The examined patients with <span class="elsevierStyleItalic">B&#46; burgdorferi</span> infection reported a low prevalence of anxiety and depression symptoms&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The studied population is not very likely to experience neurologically-determined mood disorders&#44; taking into consideration the above-mentioned results&#46;</p></span>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">Erythema migrans</span></th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No ECM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ECM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Females&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">43<br>&#40;49&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fibromyalgia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Males&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44<br>&#40;50&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="3" align="left" valign="top"><span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#46;610<br><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;032<br>phi<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;233</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rural residence<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38<br>&#40;43&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Urban residence<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">47<br>&#40;54&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">85<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Unknown residence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2<br>&#40;2&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Occupational exposure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24<br>&#40;27&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab1591800.png"
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            1 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">M</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mdn&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Max&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">88&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">State anxiety&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Trait anxiety&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&#46;28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">78&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Depression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#46;56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "identificador" => "tblfn0005"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Missing data reported in 2 cases&#44; ECM&#44; erythema migrans&#59; Mdn&#44; median&#59; SD&#44; standard deviation&#59; <span class="elsevierStyleItalic">Min</span>&#44; <span class="elsevierStyleItalic">minimum value</span>&#59; <span class="elsevierStyleItalic">Max</span>&#44; <span class="elsevierStyleItalic">maximum value</span>&#59; phi <span class="elsevierStyleItalic">&#966;</span>&#44; measure of effect size for chi-square test&#46;</p>"
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">M</span>&#44; mean&#59; SD&#44; standard deviation&#59; CI&#44; confidence interval&#44; LL&#44; lower limit&#44; UL&#44; upper limit&#59; <span class="elsevierStyleItalic">d</span> Cohen&#44; measure of effect size for the independent samples <span class="elsevierStyleItalic">t</span>-test&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Fibromyalgia &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>16&#41;</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">No fibromyalgia &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>69&#41;</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">95&#37; CI</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">M</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">M</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">t</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">UL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">d</span> Cohen&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">State Anxiety&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47&#46;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&#46;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;816&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;073&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;494&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;847&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;504&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Trait Anxiety&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49&#46;56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&#46;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;243&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;217&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;2&#46;418&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;471&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 02136163
Original language: English

DOI:10.1016/j.ejpsy.2017.09.003

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 October	8	1	9
2024 September	19	3	22
2024 August	23	3	26
2024 July	32	5	37
2024 June	25	4	29
2024 May	35	6	41
2024 April	28	11	39
2024 March	49	9	58
2024 February	42	5	47
2024 January	22	5	27
2023 December	29	2	31
2023 November	30	3	33
2023 October	21	4	25
2023 September	19	0	19
2023 August	27	0	27
2023 July	14	7	21
2023 June	17	0	17
2023 May	42	5	47
2023 April	44	4	48
2023 March	30	2	32
2023 February	22	1	23
2023 January	28	3	31
2022 December	32	9	41
2022 November	58	14	72
2022 October	81	12	93
2022 September	36	12	48
2022 August	37	7	44
2022 July	14	8	22
2022 June	21	11	32
2022 May	33	8	41
2022 April	19	11	30
2022 March	21	9	30
2022 February	14	6	20
2022 January	59	13	72
2021 December	33	12	45
2021 November	24	8	32
2021 October	41	11	52
2021 September	16	13	29
2021 August	41	8	49
2021 July	32	8	40
2021 June	14	5	19
2021 May	24	9	33
2021 April	55	21	76
2021 March	38	8	46
2021 February	23	5	28
2021 January	16	9	25
2020 December	18	8	26
2020 November	16	10	26
2020 October	15	10	25
2020 September	11	6	17
2020 August	16	7	23
2020 July	12	5	17
2020 June	16	7	23
2020 May	11	6	17
2020 April	9	5	14
2020 March	17	8	25
2020 February	28	4	32
2020 January	17	4	21
2019 December	14	6	20
2019 November	7	10	17
2019 October	14	12	26
2019 September	8	4	12
2019 August	4	2	6
2019 July	12	15	27
2019 June	30	13	43
2019 May	81	1	82
2019 April	33	16	49
2019 March	3	2	5
2019 February	9	3	12
2019 January	6	2	8
2018 December	4	6	10
2018 November	1	0	1
2018 October	5	3	8
2018 May	1	0	1

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