Adult attachment, anxiety, and pain self-efficacy as predictors of pain intensity and disability

Pain self-efficacy and anxiety have each been shown to contribute substantially to pain intensity and pain-related disability. Although adult attachment theory has been related separately to chronic pain, anxiety, and self-efficacy, it has not before been investigated with either pain self-efficacy or anxiety in the context of chronic pain. This study investigated the interrelations between these aspects of the chronic pain experience and their relative contributions towards pain intensity and disability. A clinical sample of 152 chronic pain patients participated in this study, completing self-report measures of attachment, self-efficacy, pain intensity, and disability, prior to attending a multidisciplinary pain clinic. Results revealed that fearful and preoccupied (anxious) attachment categories were associated with low pain self-efficacy, while high scores on the attachment dimension of comfort with closeness were linked with high pain self-efficacy, particularly for males. Insecure attachment (whether defined in terms of categories or dimensions) was related to higher levels of anxiety. Pain self-efficacy proved a stronger predictor of pain intensity than did anxiety and was a stronger predictor of disability than pain intensity or anxiety. In addition, comfort with closeness moderated the associations between pain self-efficacy and disability, pain self-efficacy and pain intensity, and anxiety and disability. Together, these findings support the value of adopting an attachment theoretical approach in the context of chronic pain. Treatment considerations and future research directions are considered. (c) 2006 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

Evaluation of universal, indicated, and combined cognitive-behavioral approaches to the prevention of depression among adolescents

A cluster, stratified randomized design was used to evaluate the impact of universal, indicated, and combined universal plus indicated cognitive-behavioral approaches to the prevention of depression among 13- to 15-year-olds initially reporting elevated symptoms of depression. None of the intervention approaches differed significantly from a no-intervention condition or from each other on changes in depressive symptoms, anxiety, externalizing problems, coping skills, and social adjustment. All high-symptom students, irrespective of condition, showed a significant decline in depressive symptoms and improvement in emotional well-being over time although they still demonstrated elevated levels of psychopathology compared with the general population of peers at 12-month follow-up. There were also no significant intervention effects for the universal intervention in comparison with no intervention for the total sample of students in those conditions.

Brief motivational interviewing for depression and anxiety

Motivational interviewing (MI)can be applied as a brief, low intensity (LI) intervention of 1-4 individualised sessions (typically 45-60 minutes in duration), including screening, assessment feedback, and psycho-education. MI is a client-centred, directive therapeutic style that enhances readiness for change by helping clients explore and resolve ambivalence (Miller and Rollnick 2002). A summary of the key components of brief MI interventions is provided in Table 16.1. There is a well-established evidence base for MI in the treatment of substance misuse (particularly alcohol misuse; Moyer et al. 2002), as well as a growing evidence for the use of MI in the treatment of other mental disorders (e.g. depression, PTSD, OCD), as well as suicidality and physical health problems (Hettema et al. 2005). Brief MI intervention can be delivered as a standalone treatment or as a motivational prelude to pharmacological and/or other psychological treatments (Hettema et al. 2005). MI has been used as an accompaniment to cognitive behavioural therapy (CBT) in the treatment of both depression and anxiety for resolving ambivalence about change and developing strategies for responding to resistance (e.g. treatment attendance, homework/medication compliance; Arkowitz et al. 2008a, 2008b). This chapter will describe how to apply brief MI interventions to the treatment of depression and anxiety as applied to the case of Megan (see Box 16.1) along with some of the challenges and potential solutions to applying MI in practice.

Psychological interventions for alcohol misuse among people with co-occurring depression or anxiety disorders: A systematic review

Abstract OBJECTIVE: Depression, anxiety and alcohol misuse frequently co-occur. While there is an extensive literature reporting on the efficacy of psychological treatments that target depression, anxiety or alcohol misuse separately, less research has examined treatments that address these disorders when they co-occur. We conducted a systematic review to determine whether psychological interventions that target alcohol misuse among people with co-occurring depressive or anxiety disorders are effective. DATA SOURCES: We systematically searched the PubMed and PsychINFO databases from inception to March 2010. Individual searches in alcohol, depression and anxiety were conducted, and were limited to 'human' published 'randomized controlled trials' or 'sequential allocation' articles written in English. STUDY SELECTION: We identified randomized controlled trials that compared manual guided psychological interventions for alcohol misuse among individuals with depressive or anxiety disorders. Of 1540 articles identified, eight met inclusion criteria for the review. DATA EXTRACTION: From each study, we recorded alcohol and mental health outcomes, and other relevant clinical factors including age, gender ratio, follow-up length and drop-out rates. Quality of studies was also assessed. DATA SYNTHESIS: Motivational interviewing and cognitive-behavioral interventions were associated with significant reductions in alcohol consumption and depressive and/or anxiety symptoms. Although brief interventions were associated with significant improvements in both mental health and alcohol use variables, longer interventions produced even better outcomes. CONCLUSIONS: There is accumulating evidence for the effectiveness of motivational interviewing and cognitive behavior therapy for people with co-occurring alcohol and depressive or anxiety disorders.

A prospective study investigating the impact of school belonging factors on negative affect in adolescents

School belonging, measured as a unidimensional construct, is an important predictor of negative affective problems in adolescents, including depression and anxiety symptoms. A recent study found that one such measure, the Psychological Sense of School Membership (PSSM) scale, actually comprises three factors: Caring Relations, Acceptance, and Rejection. We explored the relations of these factors with negative affect in a sample of 504 Australian grade 7 and 8 students who completed the PSSM and Children’s Depression Inventory (CDI) at three time points. Each school belonging factor contributed to the prediction of negative affect in cross-sectional analyses. Scores on the Acceptance factor predicted subsequent negative affect for boys and girls, even controlling for prior negative affect. For girls, the Rejection factor was also significant in the prospective analysis. These findings have implications for the design of interventions and are further confirmation that school belonging should be considered a multidimensional construct.

The relationship between hip abductor muscle strength and magnitude of pelvic drop following a 3 week strengthening protocol in non-specific low back pain patients.

Purpose: To examine the relationship between hip abductor muscle (HABD) strength and the magnitude of pelvic drop (MPD) for patients with non-specific low back pain (NSLBP) and controls (CON) prior to and following a 3-week HABD strengthening protocol. At baseline, we hypothesized that NSLBP patients would exhibit reduced HABD strength and greater MPD compared to CON. Following the protocol, we hypothesized that strength would increase and MPD would decrease. Relevance: The Trendelenburg test (TT) is a common clinical test used to examine the ability of the HABD to maintain horizontal pelvic position during single limb stance. However, no study has specifically tested this theory. Moreover, no study has investigated the relationship between HABD strength and pelvic motion during walking or tested whether increased HABD strength would reduce the MPD. Methods: Quasi-experimental with 3-week exercise intervention. Fifteen NSLBP patients (32.5yrs,range 21-51yrs; VAS baseline: 5.3cm) and 10 CON (29.5yrs,range 22-47yrs) were recruited. Isometric HABD strength was measured using a force dynamometer and the average of three maximal voluntary contractions were normalized to body mass (N/kg). Two-dimensional MPD (degrees) was measured using a 60 Hz camera and was derived from two retroreflective-markers placed on the posterior superior iliac spines. MPD was measured while performing the static TT and while walking and averaged over 10 consecutive footfalls. NSLBP patients completed a 3-week HABD strengthening protocol consisting of 2 open-kinetic-chain exercises then all measures were repeated. Non-parametric analysis was used for group comparisons and correlation analysis. Results: At baseline, the NSLBP patients demonstrated 31% reduced HABD strength (mean=6.6 N/kg) compared to CON (mean=9.5 N/kg: p=0.03) and no significant differences in maximal pelvic frontal plane excursion while walking (NSLBP:mean=8.1°, CON:mean=7.1°: p=0.72). No significant correlations were measured between left HABD strength and right MPD (r=-0.37, p=0.11), or between right HABD strength and left MPD (r=-0.04, p=0.84) while performing the static TT. Following the 3-week strengthening protocol, NSLBP patients demonstrated a 12% improvement in strength (Post:mean=7.4 N/kg: p=0.02), a reduction in pain (VAS followup: 2.8cm), but no significant decreases in MPD while walking (p=0.92). Conclusions: NSLBP patients demonstrated reduced HABD strength at baseline and were able to increase strength and reduce pain in a 3-week period. However, despite increases in HABD strength, the NSLBP group exhibited similar MPD motion during the static TT and while walking compared to baseline and controls. Implications: The results suggest that the HABD alone may not be primarily responsible for controlling a horizontal pelvic position during static and dynamic conditions. Increasing the strength of the hip abductors resulted in a reduction of pain in NSLBP patients providing evidence for further research to identify specific musculature responsible for controlling pelvic motion.

Co-morbidity of depression and anxiety in common age-related eye diseases : a population-based study of 662 adults

This study examined the prevalence of co-morbid age-related eye disease and symptoms of depression and anxiety in late life, and the relative roles of visual function and disease in explaining symptoms of depression and anxiety. A community-based sample of 662 individuals aged over 70 years was recruited through the electoral roll. Vision was measured using a battery of tests including high and low contrast visual acuity, contrast sensitivity, motion sensitivity, stereoacuity, Useful Field of View, and visual fields. Depression and anxiety symptoms were measured using the Goldberg scales. The prevalence of self-reported eye disease [cataract, glaucoma, or age-related macular degeneration (AMD)] in the sample was 43.4%, with 7.7% reporting more than one form of ocular pathology. Of those with no eye disease, 3.7% had clinically significant depressive symptoms. This rate was 6.7% among cataract patients, 4.3% among those with glaucoma, and 10.5% for AMD. Generalized linear models adjusting for demographics, general health, treatment, and disability examined self-reported eye disease and visual function as correlates of depression and anxiety. Depressive symptoms were associated with cataract only, AMD, comorbid eye diseases and reduced low contrast visual acuity. Anxiety was significantly associated with self-reported cataract, and reduced low contrast visual acuity, motion sensitivity and contrast sensitivity. We found no evidence for elevated rates of depressive or anxiety symptoms associated with self-reported glaucoma. The results support previous findings of high rates of depression and anxiety in cataract and AMD, and in addition show that mood and anxiety are associated with objective measures of visual function independently of self-reported eye disease. The findings have implications for the assessment and treatment of mental health in the context of late-life visual impairment...

A smoking cessation intervention for people with chronic Hepatitis C : a randomised controlled trial

Purpose The purpose of this study was to examine the validity of current practice in smoking cessation for the general population i.e., a telephone counselling and nicotine replacement therapy (NRT) intervention and its applicability to people with chronic hepatitis-C. Methods A randomised controlled trial was conducted over twelve weeks. Following consent, ninety-two smokers (outpatients) with chronic hepatitis-C were recruited by the Nurse Practitioner hepatology, randomly assigned and stratified by number of cigarettes smoked (i.e., 15 and greater; <15) into the intervention group (telephone counselling and NRT) and control group (telephone counselling). Outcomes measured included socio-demographics, nicotine dependence, depression, anxiety and stress and quality of life (QOL). All statistical data were analysed using SPSS. Results After 12 weeks, the intervention group showed a sustained reduction of smoking i.e., 5.8(CI: 2.4,9.3) cigarettes less per day, whereas the control group showed 1.6(CI:-1.9,5.2) cigarette reduction. Although not statistically significantly different (F=2.9, p=0.090) the intervention group on average smoked 4.2 fewer cigarettes compared to the control group. After twelve weeks, seven patients in the intervention group and three patients in the control group reported quitting. Whilst not statistically significant (Fisher’s Exact, p=0.311) this was a clinically significant result. No differences were found for nicotine dependence or depression, anxiety and stress. The intervention group experienced no change in QOL (-0.1,CI:-0.9, 0.6), however, the environmental score for the control group decreased by 1.8(CI:1.0, 2.6,p= 0.001). This was statistically significant. Conclusion A telephone counselling and nicotine replacement therapy intervention from the nurse practitioner, hepatology reduced smoking in patients with chronic hepatitis-C. The intervention group showed a sustained reduction over the 12 weeks. A total of 10 patients quit smoking at the end of the study. QOL deteriorated in the environmental subscale for the control group. These results informed a nurse practitioner model of care for approaches to smoking cessation.

Factors associated with chronic pain in patients with bipolar depression: a cross-sectional study

Background: While pain is frequently associated with unipolar depression, few studies have investigated the link between pain and bipolar depression. In the present study we estimated the prevalence and characteristics of pain among patients with bipolar depression treated by psychiatrists in their regular clinical practice. The study was designed to identify factors associated with the manifestation of pain in these patients.- Methods:Patients diagnosed with bipolar disorder (n=121) were selected to participate in a cross-sectional study in which DSM-IV-TR criteria were employed to identify depressive episodes. The patients were asked to describe any pain experienced during the study, and in the 6 weeks beforehand, by means of a Visual Analogical Scale (VAS).- Results: Over half of the bipolar depressed patients (51.2%, 95% CI: 41.9%–60.6%), and 2/3 of the female experienced concomitant pain. The pain was of moderate to severe intensity and prolonged duration, and it occurred at multiple sites, significantly limiting the patient’s everyday activities. The most important factors associated with the presence of pain were older age, sleep disorders and delayed diagnosis of bipolar disorder.- Conclusions: Chronic pain is common in bipolar depressed patients, and it is related to sleep disorders and delayed diagnosis of their disorder. More attention should be paid to study the presence of pain in bipolar depressed patients, in order to achieve more accurate diagnoses and to provide better treatment options.

Vulnerability or resilience? Psycho-social factors associated with deliberate self-harm among adolescents

Background: Deliberate self-harm (DSH) is common among adolescents in Ireland and internationally. Psychological factors, negative life events and lifestyle factors have been found to be associated with self-harm in this group. However, large scale population-based studies of adolescent selfharm and its correlates have been lacking, and internationally a standardised methodology was needed to facilitate comparative studies. The focus on vulnerability which has been prevalent in this field has meant that research has failed to examine resilient adaptation among at-risk adolescents. Method: Data were obtained from a cross-sectional school-based study conducted in Ireland and in each of the six other centres which participated in the Child and Adolescent Self-harm in Europe (CASE) study. In Ireland, 3,881 adolescents in 39 schools in completing the anonymous questionnaire, while across all 7 centres, over 30,000 young people participated. Data were gathered on health and lifestyle, self-harm thoughts and behaviour, a wide range of life events, psychological characteristics (anxiety and depressive symptoms, self-esteem, impulsivity and coping style), and support available to young people. Results: This thesis reports the findings of the Irish CASE centre as well as one international study. The factors associated with DSH among Irish adolescents differed by gender, but among both genders drug use and knowing a friend who had engaged in self-harm were associated with DSH. Among Irish boys, strong associations were found between bullying and poor mental health and DSH. Among boys who had been bullied, psychological and school factors were associated with DSH, while family support was protective. Links between stressful life events, psychological characteristics and DSH within the international CASE sample were examined. Increased history of self-harm thoughts and acts was associated with greater depression, anxiety and impulsivity, lower self esteem and an increased prevalence of ten different negative life events, supporting the hypothesis of a “dose-response” relationship between these risk factors and the self-harm process. Associations between coping style, mental health factors (depressive symptoms, anxiety and self-esteem) and self-harm were examined among Irish adolescents. Emotion-oriented coping was strongly associated with poorer mental health and self-harm thoughts and acts. A mediating effect of emotion-oriented coping on associations between mental health factors and DSH was found for both genders and between problem-oriented coping and mental health factors for girls. Similar mediating effects of coping style were found when risk of self-harm thoughts was examined. Resilient adaptation among adolescents exposed to suicidal behaviour of others was examined. Self-harm thoughts were common in these adolescents. Among those exposed to suicidal behaviour of others, vulnerability factors were drug use and higher levels of anxiety among boys, while for girls drug use, bullying and abuse were vulnerability factors, while resilience was associated with higher self-esteem and use of problem-oriented coping. Conclusion: These findings can aid in the identification of young people at risk of self-harm in the school setting and highlight the importance of mental health, peer-related and lifestyle factors in the development of DSH. High-risk groups of young people such as bullying victims and those exposed to suicidal behaviour of others have distinctive profiles of risk factors which differ from those of their peers. Findings relating to the importance of positive coping skills can inform positive mental health programmes, many of which aim to enhance life skills and build resilience among young people. Knowledge of the factors associated with positive adaptation among at-risk adolescents can inform prevention efforts among this group.

Novel insights into the role of the GABAB receptor in depression and anxiety

The GABAB receptor is a functional heterodimer comprising the GABAB1 and GABAB2 subunits, with the GABAB1 subunit displaying two major isoforms, GABAB(1a) and GABAB(1b). Preclinical findings have strongly implicated the GABAB receptor in stress-related psychiatric disorders, however, the precise contribution of the GABAB receptor in depression and anxiety disorders remains unknown. Emerging data suggest that the interaction between adverse environmental conditions, such as early life stress, and a specific genetic composition can increase the risk to develop psychiatric disorders in adulthood. This thesis investigated the role of the GABAB receptor alone or in combination with early-life stress (maternal separation), in modulating antidepressant like and anxiety-related behaviours. Pharmacological blockade of the GABAB receptor with CGP52432 had antidepressant-like behavioural effects. Moreover, mice lacking the GABAB(1b) receptor subunit isoform exhibited antidepressant-like behaviours in adulthood but anxiety-like behaviour in early-life. In response to maternal separation, GABAB(1a)-/- mice exhibited early-life stress-induced anhedonia, a core symptom of depression, while GABAB(1b)-/- mice exhibited a more resilient phenotype. Moreover, when compared with wildtype or GABAB(1a)-/- mice, GABAB(1b)-/- mice that underwent maternal separation exhibited enhanced stressinduced neuronal activation in the hippocampus and in the nucleus accumbens (NAcc), a critical area for anhedonia thus suggesting that enhanced stress-induced neuronal activation in the hippocampus and NAcc in GABAB(1b)-/- mice may be important for their antidepressant-like phenotype and their resilience to stress-induced anhedonia. Pharmacological blockade of GABAB receptor and GABAB(1b) receptor subunit isoform loss of function increased adult hippocampal cell proliferation, thus suggesting that increased hippocampal neurogenesis could be a potential mechanism for the antidepressant-like effects of GABAB receptor antagonists and GABAB(1b) receptor subunit isoform disruption. Finally, this thesis investigated whether the expression of several genes involved in hippocampal neurogenesis or the antidepressant response were altered in the mouse hippocampus following chronic treatment with a GABAB receptor antagonist.

L'efficacité de l'imagerie guidée sur la douleur, l'anxiété, le coping et le retour aux activités d'adolescents ayant subi une chirurgie correctrice de scoliose

De nombreuses études ont démontré que les adolescents qui subissent une chirurgie correctrice de scoliose éprouvent des douleurs postopératoires intenses et cela pendant plusieurs jours après leur chirurgie. L’originalité de cette étude de type quasi-expérimental, consistait à réaliser un DVD sur une technique d’imagerie guidée et de relaxation combinée à une intervention éducative (gestion de la douleur) sur la douleur, l’anxiété, le coping et le retour aux activités d’adolescents ayant subi une chirurgie correctrice de scoliose. Prenant appui sur la théorie du portillon (Melzack & Casey, 1968) et sur la théorie transactionnelle du stress et coping (Lazarus & Folkman, 1984), quatre hypothèses ont été retenues en vue de vérifier l’effet de cette intervention. Trente et un adolescents, âgés entre 13 et 19 ans ont été répartis en deux groupes de façon aléatoire. Les participantes du groupe expérimental devaient visionner un DVD sur une technique d’imagerie guidée et de relaxation combinée à de l’information sur la gestion de la douleur en période préopératoire, au moment du congé de l’hôpital et ce, au moins trois fois par semaine sur une période d’un mois post congé. De plus, ce groupe continuait à recevoir les soins usuels. Les participants du groupe contrôle ne recevaient que les soins usuels. Les instruments de mesure utilisés furent le questionnaire concis de la douleur (QCD) (Larue F, Colleau, Brasseur, & Cleeland, 1995), l’inventaire d’anxiété situationnelle et de trait d’anxiété (IASTA-Y) (Gauthier & Bouchard, 1993) et l’inventaire du coping face à la douleur pédiatrique (Spicher, 2003). Quatre temps de mesure ont été planifiés, soit la journée avant la chirurgie, au congé de l’hôpital, au 14ième jour post congé et lors de la visite à la clinique d’orthopédie à un mois post congé. Les résultats montraient que les deux groupes étaient équivalents en ce qui concernait les caractéristiques sociodémographiques et les variables dépendantes. Les participants du groupe expérimental présentaient une douleur générale ressentie dans le dernier 24 heures plus basse au 14ième jour (p = 0,012) et un mois après leur congé de l’hôpital (p = 0,049). Certaines activités quotidiennes ont démontré une différence significative au 14ième jour soit : les activités scolaires ou de travail (p = 0,046), et les activités de soutien vital (manger, dormir) (p = 0,024), Par contre, nous n’avons pas observé de différence significative au niveau de l’anxiété situationnelle et des stratégies adaptatives de coping entre les deux groupes. L’auteur conclut que le niveau de douleur postopératoire des adolescents qui ont subi une chirurgie correctrice de scoliose peut être réduit par un visionnement d’un DVD sur une technique d’imagerie guidée et de relaxation combinée à une intervention éducative (information sur la douleur). De plus, ceci semble avoir un effet positif sur le retour plus rapide de certaines activités quotidiennes.

L’image corporelle chez les femmes atteintes de vestibulodynie provoquée primaire et secondaire : Une étude contrôlée

Essai doctoral présenté à la Faculté des études supérieures en vue de l’obtention du grade de Docteur en psychologie (D.Psy.) en psychologie option clinique

Feasibility and preliminary effectiveness of a novel cognitive-behavioral couple therapy for provoked vestibulodynia: a pilot study.

Introduction Provoked vestibulodynia (PVD), a recurrent, localized vulvovaginal pain problem, carries a significant psychosexual burden for afflicted women, who report impoverished sexual function and decreased frequency of sexual activity and pleasure. Interpersonal factors such as partner responses to pain, partner distress, and attachment style are associated with pain outcomes for women and with sexuality outcomes for both women and partners. Despite these findings, no treatment for PVD has systematically included the partner. Aims This study pilot‐tested the feasibility and potential efficacy of a novel cognitive–behavioral couple therapy (CBCT) for couples coping with PVD. Methods Couples (women and their partners) in which the woman was diagnosed with PVD (N = 9) took part in a 12‐session manualized CBCT intervention and completed outcome measures pre‐ and post‐treatment. Main Outcome Measures The primary outcome measure was women's pain intensity during intercourse as measured on a numerical rating scale. Secondary outcomes included sexual functioning and satisfaction for both partners. Exploratory outcomes included pain‐related cognitions; psychological outcomes; and treatment satisfaction, feasibility, and reliability. Results One couple separated before the end of therapy. Paired t‐test comparisons involving the remaining eight couples demonstrated significant improvements in women's pain and sexuality outcomes for both women and partners. Exploratory analyses indicated improvements in pain‐related cognitions, as well as anxiety and depression symptoms, for both members of the couple. Therapists' reported high treatment reliability and participating couples' high participation rates and reported treatment satisfaction indicate adequate feasibility. Conclusions Treatment outcomes, along with treatment satisfaction ratings, confirm the preliminary success of CBCT in reducing pain and psychosexual burden for women with PVD and their partners. Further large‐scale randomized controlled trials are necessary to examine the efficacy of CBCT compared with and in conjunction with first‐line biomedical interventions for PVD.

Calidad de vida en personas con hemofilia: una revisión de la literatura

Introducción: La hemofilia es una enfermedad poco frecuente; no obstante, los avances en los tratamientos de pacientes hemofílicos en las últimas décadas han generado cambios en su calidad de vida. Esto ha motivado el desarrollo de múltiples investigaciones al respecto. Objetivo: Revisar la literatura sobre la calidad de vida en el paciente hemofílico, producida en el periodo 2008-2012. Método: Se consultaron algunas bases de datos científicas utilizando como palabras clave “hemofilia” y “calidad de vida”. Se recopiló la información encontrada y se organizó según los objetivos propuestos en “factores negativos” y “factores protectores” de la calidad de vida a nivel fisiológico, psicosocial y cultural; “instrumentos para la evaluación de la calidad de vida” a nivel específico y general; y antecedentes empíricos de los últimos cinco años en los que se evaluara la calidad de vida o se realizara alguna intervención en la misma. Resultados: En general la información disponible sobre el comportamiento epidemiológico de la hemofilia es limitada. El interés por factores protectores y negativos es principalmente de tipo fisiológico, aunque se encontraron factores de tipo psicosocial y cultural, lo que indica la importancia de profundizar en esta temática. Existen pocos instrumentos especializados para la evaluación de la calidad de vida en hemofílicos. La evidencia empírica se centra en la evaluación. Conclusión: El estudio de la calidad de vida en pacientes hemofílicos amerita ser abordado de manera interdisciplinaria.