Annals of Behavioral Medicine

, Volume 51, Issue 2, pp 189–198 | Cite as

Attachment Orientations, Respiratory Sinus Arrhythmia, and Stress Are Important for Understanding the Link Between Childhood Socioeconomic Status and Adult Self-Reported Health

Original Article

Abstract

Background

Low childhood socioeconomic status (SES) is reliably associated with poor adult health. Social environments early in life and physiological stress responses are theorized to underlie this link; however, the role of attachment orientations is relatively unknown.

Purpose

In this study, we examined whether attachment orientations (i.e., attachment anxiety and attachment avoidance) and self-reported stress were mediators of the association between childhood SES and self-reported health in adulthood. Furthermore, we examined whether parasympathetic nervous system functioning was a moderator of associations between attachment orientations and self-reported stress.

Methods

Participants (N = 213) provided self-reports of childhood SES, attachment orientations, general stress, and self-rated health. Respiratory sinus arrhythmia (RSA) was measured at rest, as well as during an acute social stressor.

Results

Low childhood SES was associated with poor self-reported health via the serial pathway from attachment anxiety to general stress. Moreover, attachment avoidance was associated with self-reported health via general stress, but only among those with high stress-induced RSA. Findings were independent of participant age, sex, race, body mass index, baseline RSA, and adult SES.

Conclusions

Attachment theory is useful for understanding why those from low SES backgrounds are at greater risk of negative health outcomes in adulthood. Findings extend our knowledge of how interpersonal relationships in childhood can shape emotional and physical health outcomes in adulthood.

Keywords

Attachment theory Respiratory sinus arrhythmia Stress Self-rated health Child development 

References

  1. 1.
    Aber, JL, Bennett, NG, Conley, DC, Li J. The effects of poverty on child health and development. Annu Rev Publ Health. 1997;18:463–483.CrossRefGoogle Scholar
  2. 2.
    Cohen S, Doyle WJ, Turner RB, Alper C, Skoner DP. Childhood socioeconomic status and host resistance to infection illness in adulthood. Psychosom Med. 2004;66(4):553–558.CrossRefPubMedGoogle Scholar
  3. 3.
    Cohen S, Janicki-Deverts D, Chen E, Matthews KA. Childhood socioeconomic status and adult health. Ann N Y Acad Sci. 2010;1186:37–55.CrossRefPubMedGoogle Scholar
  4. 4.
    Fagundes CP, Way B. Early-life stress and adult inflammation. Curr Dir Psychol Sci. 2014;23(4):277–283.CrossRefGoogle Scholar
  5. 5.
    Braveman PA, Cubbin C, Egerter S, Williams DR, Pamuk E. Socioeconomic disparities in health in the United States: What the patterns tell us. Am J Public Health. 2010;100(1):186–196.CrossRefGoogle Scholar
  6. 6.
    National Center for Health Statistics. Health statistics: Measuring our nation’s health. Hyattsville, MD; 2015.Google Scholar
  7. 7.
    Steptoe A, Feldman, PJ, Kunz S, Owen N, Willemsen G, Marmot M. Stress responsivity and socioeconomic status: A mechanism for increased cardiovascular risk? Eur Heart J. 2002; 23:1757–1763.CrossRefPubMedGoogle Scholar
  8. 8.
    Conger RD, Ge X, Elder GH, Lorenz FO, Simons RL. Economic stress, coercive family process, and developmental problems of adolescents. Child Dev. 1994;65(2):541–561.CrossRefPubMedGoogle Scholar
  9. 9.
    Repetti RL, Taylor SE, Seeman TE. Risky families: Family social environments and the mental and physical health of offspring. Psychol Bull. 2002;128(2):330–366.CrossRefPubMedGoogle Scholar
  10. 10.
    Wickrama KAS, Conger RD, Lorenz FO, Jung T. Family antecedents and consequences of trajectories of depressive symptoms from adolescence to young adulthood: A life course investigation. J Health Soc Behav. 2008;49(4):468–483.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Conger RD, Conger KJ, Martin MJ. Socioeconomic status, family processes, and individual development. J Marriage Fam. 2010;72(3):685–704.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Hoff E, Laursen B, Tardif T. Socioeconomic status and parenting. In Bornstein, MH, ed. Handbook of parenting Volume 2: Biology and ecology of parenting. Mahwah, New Jersey; Lawrence Erlbaum Associates, Publishers; 2002:231–52.Google Scholar
  13. 13.
    Vaughn BE, Bost KK. Attachment and temperament: Redundant, independent, or interacting influences on interpersonal adaptation and personality development? In Cassidy J, Shaver PR, eds. Handbook of attachment: Theory, research, and clinical applications. New York, New York: Guilford Press; 1999:198–225.Google Scholar
  14. 14.
    Valenzuela M. Maternal sensitivity in developing society: The context of urban poverty and infant chronic undernutrition. Dev Psychol. 1997;33(5):845–855.CrossRefPubMedGoogle Scholar
  15. 15.
    Lovejoy MC, Graczyk PA, O’Hare E, Neuman G. Maternal depression and parenting behavior: A meta-analytic review. Clin Psychol Rev. 2000;20(5):561–592.CrossRefPubMedGoogle Scholar
  16. 16.
    Wilson, AL. Poverty and children’s health. Child Youth Fam Serv Q. 1993;16:14–16.Google Scholar
  17. 17.
    Mazzeschi C, Pazzagli C, Laghezza L, Radi G, Battistini D, De Feo P. The role of both parents’ attachment pattern in understanding childhood obesity. Front Psychol. 2014;5:791CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Ahrens KR, Ciechanowski P, Katon W. Associations between adult attachment style and health risk behaviors in an adult female primary care population. J Psychosom Res. 2012;72(5):364–370.CrossRefPubMedGoogle Scholar
  19. 19.
    Ainsworth, MS, Blehar, MC, Waters, E, Wall, S. Patterns of attachment: A psychological study of the Strange Situation. Hillsdale, NJ: Lawrence Erlbaum Associates, Inc.; 1978.Google Scholar
  20. 20.
    Bowlby J. Attachment and loss. 3rd edition. New York, New York: Basic books; 1980.Google Scholar
  21. 21.
    Hazan C, Shaver PR. Romantic love conceptualized as an attachment process. J Pers Soc Psychol. 1987;59:511–524.CrossRefGoogle Scholar
  22. 22.
    Fraley, RC, Waller NG, Brennan KA. An item-response theory analysis of self-report measures of adult attachment. J Pers Soc Psychol. 2000;78:350–365.CrossRefPubMedGoogle Scholar
  23. 23.
    Fagundes CP, Diamond LM, Allen KP. Adolescent attachment insecurity and parasympathetic functioning predict future loss adjustment. Pers Soc Psychol Bull. 2012;38(6):821–832.CrossRefPubMedGoogle Scholar
  24. 24.
    Murray SL, Holmes JG, Griffin DW. Self-esteem and the quest for felt security: How perceived regard regulates attachment processes. J Pers Soc Psychol. 2000;78(3):478–498.CrossRefPubMedGoogle Scholar
  25. 25.
    Karreman, A, Vingerhoets JJM. Attachment and well-being: The mediating role of emotion regulation and resilience. Pers Individ Dif. 2012;53:821–826.CrossRefGoogle Scholar
  26. 26.
    Mikulincer M, Shaver PR. Adult attachment and affect regulation. In Caddidy J, Shaver PR, eds. Handbook of attachment: Theory, research, and clinical applications, second edition. New York, New York: Guilford Press; 2008:503–531.Google Scholar
  27. 27.
    Glaser R, Kiecolt-Glaser JK. Stress-induced immune dysfunction: Implications for health. Nat Rev Immunol. 2005;5(3):243–251.CrossRefPubMedGoogle Scholar
  28. 28.
    Jaremka LM, Glaser R, Loving TJ, Malarkey WB, Stowell JR, Kiecolt-Glaser JK. Attachment anxiety is linked to alterations in cortisol production and cellular immunity. Psychol Sci. 2013;24(3):272–279.CrossRefPubMedGoogle Scholar
  29. 29.
    McWilliams LA, Bailey SJ. Associations between adult attachment ratings and health conditions: Evidence from the National Comorbidity Survey Replication. Health Psychol. 2010;29(4):446–453.CrossRefPubMedGoogle Scholar
  30. 30.
    Puig J, Englund MM, Simpson JA, Collins WA. Predicting adult physical illness from infant attachment: A prospective longitudinal study. Health Psychol. 2013;32(4):409–417.CrossRefPubMedGoogle Scholar
  31. 31.
    Brooks, K. P., Robles, T. F., & Schetter, C. D. (2011). Adult attachment and cortisol responses to discussions with a romantic partner. Personal Relationships, 18(2), 302–320.CrossRefGoogle Scholar
  32. 32.
    Carpenter, E. M., & Kirkpatrick, L. A. (1996). Attachment style and presence of a romantic partner as moderators of psychophysiological responses to a stressful laboratory situation. Personal Relationships, 3(4), 351–367.CrossRefGoogle Scholar
  33. 33.
    Maunder RG, Lancee WJ, Nolan RP, Hunter JJ, Tannenbaum DW. The relationship of attachment insecurity to subjective stress and autonomic function during standardized acute stress in healthy adults. J Psychosom Res. 2006;60:283–290.CrossRefPubMedGoogle Scholar
  34. 34.
    Fagundes CP, Jaremka LM, Glaser R, Alfano CM, Povoski SP, Lipari AM, Agnese DM, Yee LD, Carson WE, Farrar WB, Malarkey WB, Chen M, Kiecolt-Glaser JK. Attachment anxiety is related to Epstein-Barr virus latency. Brain Behav Immun. 2014;41:232–238.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Dewitte M, De Houwer J, Goubert L, Buysse A. A multi-modal approach to the study of attachment related distress. Biol Psychiatry. 2010;85(1):149–162.CrossRefGoogle Scholar
  36. 36.
    Gouin JP, Glaser R, Loving TJ, Malarkey WB, Stowell J, Houts C, Kiecolt-Glaser JK. Attachment avoidance predicts inflammatory responses to marital conflict. Brain Behav Immun. 2009;23(7):898–904.CrossRefPubMedGoogle Scholar
  37. 37.
    Konstantinos K, Sideridis GD. Attachment, social support and well-being in young and older adults. J Health Psychol. 2006;11:863–876.CrossRefGoogle Scholar
  38. 38.
    Merz EM, Consedine NS. Attachment security moderates the links between emotional and instrumental family support and wellbeing in later life. Attach Hum Dev. 2009;11:203–221.CrossRefPubMedGoogle Scholar
  39. 39.
    Mikulincer M, Shaver PR, Pereg D. Attachment theory and affect regulation: The dynamics, development, and cognitive consequences of attachment-related strategies. Motiv Emotion. 2003;27(2):77–102.Google Scholar
  40. 40.
    Mikulincer M, Dolev T, Shaver PR. Attachment-related strategies during thought suppression: Ironic rebounds and vulnerable self-representations. J Pers Soc Psychol. 2004;87(6):940–956.CrossRefPubMedGoogle Scholar
  41. 41.
    Sweller J. Cognitive load theory, learning difficulty, and instructional design. Learn Instr. 1994;4(4):295–312.CrossRefGoogle Scholar
  42. 42.
    Brennan KA, Clark CL, Shaver PR. Self-reported measurement of adult attachment: An integrative overview. In: Simpson, J. A., Rholes, W. S. (Eds.), Attachment Theory and Close Relationships. Guilford Press, New York; 1998: 46–76.Google Scholar
  43. 43.
    Diamond LM, Fagundes CP. Psychobiological research on attachment. J Soc Pers Relat. 2010;27(2):218–225.CrossRefGoogle Scholar
  44. 44.
    Vögele C, Jarvis A, Cheeseman K. Anger suppression, reactivity, and hypertension risk: Gender makes a difference. Ann Behav Med. 1997;19(1):61–69.CrossRefPubMedGoogle Scholar
  45. 45.
    Appleton AA, Buka SL, Loucks EB, Gilman SE, Kubzansky LD. Divergent associations of adaptive and maladaptive emotion regulation strategies with inflammation. Health Psychol. 2013;32(7): 748–756.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Diamond LM, Fagundes CP, Cribbett MR. Individual differences in adolescents’ sympathetic and parasympathetic functioning moderate associations between family environment and psychosocial adjustment. Dev Psychol. 2012;48(4):918–931.CrossRefPubMedGoogle Scholar
  47. 47.
    Fagundes CP, Jaremka LM, Malarkey WB, Kiecolt-Glaser JK. Attachment style and respiratory sinus arrhythmia predict post-treatment quality of life in breast cancer survivors. Psychooncology. 2014;23:820–826.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Sbarra DA, Borelli JL. Heart rate variability moderates the association between attachment avoidance and self-concept reorganization following marital separation. Int J Psychophysiol. 2013;88(3):253–260.CrossRefPubMedGoogle Scholar
  49. 49.
    Hayano J, Yasuma F, Okada A, Mukai S, Fujinami T. Respiratory sinus arrhythmia: A phenomenon improving pulmonary gas exchange and circulatory efficiency. Circulation. 1996;94:842–847.CrossRefPubMedGoogle Scholar
  50. 50.
    Segerstrom, SC, Nes, LS. Heart rate variability reflects self-regulatory strength, effort, and fatigue. Psych Sci. 2007;18(3):275–281.CrossRefGoogle Scholar
  51. 51.
    Beauchaine TP. Vagal tone, development, and Gray’s motivational theory: Toward an integrated model of autonomic nervous system functioning in psychopathology. Dev Psychopathol. 2001;13:183–214.CrossRefPubMedGoogle Scholar
  52. 52.
    Gentzler AL, Santucci AK, Kovacs M, Fox NA. Respiratory sinus arrhythmia reactivity predicts emotion regulation and depressive symptoms in at-risk and control children. Biol Psychol. 2009;82(2):156–163.CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Rottenberg J, Salomon K, Gross JJ, Gotlib IH. Vagal withdrawal to a sad film predicts subsequent recovery from depression. Psychophysiology. 2005;42:277–281.CrossRefPubMedGoogle Scholar
  54. 54.
    Porges SW. The polyvagal theory: Phylogenetic substrates of a social nervous system. Int J Psychophysiol. 2001;42(2):123–146.CrossRefPubMedGoogle Scholar
  55. 55.
    Thayer JF, Lane RD. A model of neurovisceral integration in emotion regulation and dysregulation. J Affect Disord. 2000;61(3):201–216.CrossRefPubMedGoogle Scholar
  56. 56.
    Cohen S, Janicki-Deverts D, Turner RB, Casselbrant ML, Li-Korotky HS, Epel ES, Doyle WJ. Association between telomere length and experimentally induced upper respiratory viral infection in healthy adults. JAMA. 2013;309(7):699–705.CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Janicki-Deverts D, Cohen S, Doyle WJ, Marsland AL, Bosch J. Childhood environments and cytomegalovirus serostatus and reactivation in adults. Brain Behav Immun. 2014;40:174–181.CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Kirschbaum C, Pirke K, Hellhammer DH. The ‘Trier Social Stress Test’: A tool for investigating psychobiological stress responses in a laboratory setting. Neuropsychobiology. 1993;28(1–2):76–81.PubMedGoogle Scholar
  59. 59.
    Adler NE, Epel ES, Castellazzo G, Ickovics JR. Relationship of subjective and objective social status with psychological and physiological functioning: Preliminary data in healthy white women. Health Psychol. 2000; 19(6):586–592.CrossRefPubMedGoogle Scholar
  60. 60.
    Operario D, Adler NE, Williams DR. Subjective social status: Reliability and predictive utility for global health. Psychol Health. 2004; 19(2):237–246.CrossRefGoogle Scholar
  61. 61.
    Goodman, E, Adler NE, Kawachi I, Frazier AL, Huang B, Colditz GA. Adolescents’ perceptions of social status: Development and evaluation of a new indicator. Pediatrics. 2001; 108:1–8.CrossRefGoogle Scholar
  62. 62.
    Wei M, Russell, DW, Mallinckrodt B, Vogel, DL. The experiences in Close Relationship Scale (ECR)-Short Form: Reliability, validity, and factor structure. J Person Assess. 2007;88:187–204.CrossRefGoogle Scholar
  63. 63.
    Malik M. Heart rate variability: Standards of measurement, physiological interpretation and clinical use. Task force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Circulation. 1996;93(5):1043–1065.CrossRefGoogle Scholar
  64. 64.
    Duhamel P, Vetterli M. Fast Fourier transforms: A tutorial review and state of the art. Signal Process. 1990;19:259–299.CrossRefGoogle Scholar
  65. 65.
    Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24:385–396.CrossRefPubMedGoogle Scholar
  66. 66.
    Ware JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30(6):473–483.CrossRefPubMedGoogle Scholar
  67. 67.
    Schafer JL, Olsen MK. Multiple imputation for multivariate missing-data problems: A data analyst’s perspective. Multivar Behav Res. 1998;33(4):545–571.CrossRefGoogle Scholar
  68. 68.
    Cacioppo JT, Uchino BN, Berntson GG. Individual differences in the autonomic origins of heart rate reactivity: The psychometrics of respiratory sinus arrhythmia and preejection period. Psychophysiology. 2007;31(4):412–419.CrossRefGoogle Scholar
  69. 69.
    Bentler, PM. EQS (Version 6.1). Encino, CA: Multivariate Software; 2004.Google Scholar
  70. 70.
    Hayes AF. Beyond Baron and Kenny: Statistical mediation analysis in the new millennium. Commun Monogr. 2009;76(4):408–420.CrossRefGoogle Scholar
  71. 71.
    Johnson PO, Fay LC. The Johnson-Neyman Technique, its theory and application. Psychometrika. 1950;15(4):349–367.CrossRefPubMedGoogle Scholar
  72. 72.
    Larsson D, Hemmingsson T, Allebeck P, Lundberg I. Self-rated health and mortality among young men: What is the relation and how may it be explained? Scand J Public Health. 2002;30(4):259–266.CrossRefPubMedGoogle Scholar
  73. 73.
    Nybo H, Petersen, HC, Gaist D, Jeune B, Andersen K, McGue M, Vaupel, JW, Christensen K. Predictors of mortality in 2,249 nonagenarians—the Danish 1905-cohort survey. J Am Geriatric Soc. 2003;51(10):1365–1373.CrossRefGoogle Scholar
  74. 74.
    Nielsen AB, Siersma V, Hiort LC, Drivsholm T, Kreiner S, Hollnagel H. Self-rated general health among 40-year-old Danes and its association with all-cause mortality at 10-, 20-, and 29 years’ follow-up. Scand J Public Health. 2008;36(1):3–11.CrossRefPubMedGoogle Scholar
  75. 75.
    Yu, ES, Kean YM, Slymen DJ, Liu WT, Zhang M, Katzman R. Self-perceived health and 5-year mortality risks among the elderly in Shanghai, China. Am J Epidemiol. 1998;147(9):880–890.CrossRefPubMedGoogle Scholar
  76. 76.
    Bosworth HB, Siegler IC, Brummett BH, Barefoot JC, Williams RB, Clapp-Channing NE, Mark DB. The association between self-rated health and mortality in a well-characterized sample of coronary artery disease patients. Med Care. 1999;37(12):1226–1236.CrossRefPubMedGoogle Scholar
  77. 77.
    Jylhä M. What is self-rated health and why does it predict mortality? Towards a unified conceptual model. Soc Sci Med. 2009;69(3):307–316.CrossRefPubMedGoogle Scholar
  78. 78.
    Kaplan GA, Camacho T. Perceived health and mortality: A nine-year follow-up of the Human Population Laboratory Cohort. Am J Epidemiol. 1983;117(3):292–304.CrossRefPubMedGoogle Scholar
  79. 79.
    Schneiderman N, Ironson G, Siegel SD. Stress and health: Psychological, behavioral, and biological determinants. Annu Rev Clin Psychol. 2005;1:607–628.CrossRefPubMedPubMedCentralGoogle Scholar
  80. 80.
    Dickerson SS, Gable SL, Irwin MR, Aziz N, Kemeny ME. Social-evaluative threat and proinflammatory cytokine regulation: An experimental laboratory investigation. Psychol Sci. 2009;20(10):1237–1244.CrossRefPubMedPubMedCentralGoogle Scholar
  81. 81.
    Dickerson SS, Kemeny ME. Acute stressors and cortisol responses: A theoretical integration and synthesis of laboratory research. Psychol Bull. 2004;130(3):355–391.CrossRefPubMedGoogle Scholar
  82. 82.
    Wagner DD, Heatherton TF. Emotion and self-regulation failure. In J. J. Gross (Ed.) Handbook of Emotion Regulation, Second Edition. New York, New York: The Guilford Press; 2014:613–628Google Scholar
  83. 83.
    Schubert C, Lambertz M, Nelesen RA, Bardwell W, Choi JB, Dimsdale JE. Effects of stress on heart rate complexity: A comparison between short-term and chronic stress. Biol Psychol. 2009;80(3):325–332.CrossRefPubMedGoogle Scholar
  84. 84.
    Chen E, Miller GE, Kobor MS, Cole SW. Maternal warmth buffers the effects of low early-life socioeconomic status on pro-inflammatory signaling in adulthood. Mol Psychiatry. 2011;16(7):729–737.CrossRefPubMedGoogle Scholar
  85. 85.
    Miller GE, Lachman ME, Chen E, Gruenewald TL, Karlamangla AS, Seeman TE. Pathways to resilience: Maternal nurturance as a buffer against the effects of childhood poverty on metabolic syndrome at midlife. Psychol Sci. 2011;22(12):1591–1599.CrossRefPubMedPubMedCentralGoogle Scholar
  86. 86.
    John-Henderson, NA, Stellar, JE, Mendoza-Denton, R, Francis, DD. Socioeconomic status and social support: Social support reduces inflammatory reactivity for individuals whose early-life socioeconomic status was low. Psychol Sci. Advance online publication.Google Scholar
  87. 87.
    Fiori K, Consedine NS, Merz EM. Attachment, social network size, and patterns of social exchange in later life. Res Aging. 2011;33:465–493.CrossRefGoogle Scholar
  88. 88.
    Merz EM, Consedine NS. The association of family support and wellbeing in later life depends on adult attachment. Attach Hum Dev. 2009;11:203–221.CrossRefPubMedGoogle Scholar
  89. 89.
    Saxena S, Eliahoo J, Majeed A.. Socioeconomic and ethnic group differences in self reported health status and use of health services by children and young people in England: Cross sectional study. BMJ. 2002;325(7363):520–523.CrossRefPubMedPubMedCentralGoogle Scholar
  90. 90.
    Pietromonaco PR, Uchino B, Schetter CD. Close relationship processes and health: Implications of attachment theory for health and disease. Health Psychol. 2013;32(5):499–153.CrossRefPubMedPubMedCentralGoogle Scholar
  91. 91.
    Podsakoff PM, MacKenzie SB, Podsakoff NP. Sources of method bias in social science research and recommendations on how to control it. Annu Rev Psychol. 2012;63:539–569.CrossRefPubMedGoogle Scholar
  92. 92.
    Murdock KW, Fagundes CP, Peek MK, Vohra V, Stowe RP. The effect of self-reported health on latent herpesvirus reactivation and inflammation in an ethnically diverse sample. Psychoneuroendocrinology. 2016;72:113–118.CrossRefPubMedGoogle Scholar
  93. 93.
    DeSalvo, KB, Muntner P. Discordance between physician and patient self-rated health and all-cause mortality. Ochsner J. 2011;11:232–240.PubMedPubMedCentralGoogle Scholar
  94. 94.
    Fraley RC, Shaver PR. Adult romantic attachment: Theoretical developments, emerging controversies, and unanswered questions. Rev Gen Psychol. 2000;4(2):132–154.CrossRefGoogle Scholar

Copyright information

© The Society of Behavioral Medicine 2016

Authors and Affiliations

  1. 1.Department of PsychologyRice UniversityHoustonUSA
  2. 2.Department of Symptom ResearchThe University of Texas MD Anderson Cancer CenterHoustonUSA
  3. 3.Department of PsychiatryBaylor College of MedicineHoustonUSA

Personalised recommendations