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Current Psychology

, Volume 38, Issue 1, pp 66–74 | Cite as

Perceived Stress as a Mediator of the Relationship between Neuroticism and Depression and Anxiety Symptoms

  • Angela J. Pereira-Morales
  • Ana Adan
  • Diego A. ForeroEmail author
Article

Abstract

Although major depressive disorder (MDD) is one of the main causes of global disease burden, there is little evidence about the association between personality traits and depressive symptoms in Latin America. The aim of this study was to examine the possibility that perceived stress might be a mediator of the association between neuroticism and depressive and anxious symptoms. Two hundred seventy four Colombian subjects (mean age 21.3 years) were evaluated with the short version of the Big Five Inventory (BFI-S), the Center for Epidemiologic Studies Depression Scale (CES-D), the Hospital Anxiety and Depression Scale (HADS), the Zung Self-Rating Anxiety Scale (ZSAS) and the Perceived Stress Scale-10. Both neuroticism and perceived stress were significantly correlated with higher scores in depressive and anxious symptoms (p < 0.01). Perceived stress was a significant mediator of the relationship between neurotic trait and depressive and anxious symptoms. Our results are one of the first descriptions of the role of perceived stress as a mediator of the association between neuroticism and psychological distress. These findings are of particular importance, in the context of the need for more evidence about the psychosocial risk factors for MDD in Latin America.

Keywords

Personality Depression Anxiety Perceived stress Latin America 

Notes

Acknowledgements

This study was supported by a research grant from Colciencias (grant # 823-2015). AA is supported by a research grant from the Spanish Ministry of Economy and Competitiveness (PSI2015-65026, MINECO/FEDER/UE). The authors thank Rodrigo González-Reyes, MD, PhD, Andrés Camargo, RN, MSc, Karen Jiménez, BSc and Juliana Villada, whom helped with recruitment of subjects.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

“All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.”

Informed Consent

“Informed consent was obtained from all individual participants included in the study.”

Supplementary material

12144_2017_9587_MOESM1_ESM.docx (15 kb)
Table S1 (DOCX 14 kb)

References

  1. Aalto-Setala, T., Marttunen, M., Tuulio-Henriksson, A., Poikolainen, K., & Lonnqvist, J. (2001). One-month prevalence of depression and other DSM-IV disorders among young adults. Psychological Medicine, 31(5), 791–801.CrossRefGoogle Scholar
  2. Abbasi, I. S. (2016). The role of neuroticism in the maintenance of chronic baseline stress perception and negative affect. The Spanish Journal of Psychology, 19, E9. doi: 10.1017/sjp.2016.7.CrossRefPubMedGoogle Scholar
  3. Adan, A., Navarro, J. F., & Forero, D. A. (2016). Personality profile of binge drinking in university students is modulated by sex. A study using the alternative five factor model. Drug and Alcohol Dependence, 165, 120–125. doi: 10.1016/j.drugalcdep.2016.05.015.CrossRefPubMedGoogle Scholar
  4. Arrivillaga Quintero, M., Cortés García, C., Goicochea Jiménez, V. L., & Lozano Ortíz, T. M. (2004). Caracterización de la depresión en jóvenes universitarios. Universitas Psychologica, 3(1), 17–25.Google Scholar
  5. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). Arlington: American Psychiatric Association.CrossRefGoogle Scholar
  6. Barnhofer, T., & Chittka, T. (2010). Cognitive reactivity mediates the relationship between neuroticism and depression. Behaviour Research and Therapy, 48(4), 275–281. doi: 10.1016/j.brat.2009.12.005.CrossRefPubMedPubMedCentralGoogle Scholar
  7. Bergdahl, J., & Bergdahl, M. (2002). Perceived stress in adults: prevalence and association of depression, anxiety and medication in a Swedish population. Stress and Health, 18(5), 235–241.CrossRefGoogle Scholar
  8. Bovier, P. A., Chamot, E., & Perneger, T. V. (2004). Perceived stress, internal resources, and social support as determinants of mental health among young adults. Quality of Life Research, 13(1), 161–170.CrossRefGoogle Scholar
  9. Bromet, E., Andrade, L. H., Hwang, I., Sampson, N. A., Alonso, J., de Girolamo, G., et al. (2011). Cross-national epidemiology of DSM-IV major depressive episode. BMC Medicine, 9, 90. doi: 10.1186/1741-7015-9-90.CrossRefPubMedPubMedCentralGoogle Scholar
  10. Campo-Arias, A., Díaz-Martínez, L. A., Rueda-Jaimes, G. E., Cadena-Afanador, L. d. P., & Hernández, N. L. (2007). Psychometric properties of the CES-D scale among Colombian adults from the general population. Revista Colombiana de Psiquiatría, 36(4), 664–674.Google Scholar
  11. Campo-Arias, A., Oviedo, H. C., & Herazo, E. (2014). Escala de Estrés Percibido-10: Desempeño psicométrico en estudiantes de medicina de Bucaramanga, Colombia. Revista de la Facultad de Medicina, 62(3), 1–24.Google Scholar
  12. Chamorro-Premuzic, T., Gomà-i-Freixanet, M., Furnham, A., & Muro, A. (2009). Personality, self-estimated intelligence, and uses of music: a Spanish replication and extension using structural equation modeling. Psychology of Aesthetics, Creativity, and the Arts, 3(3), 149.CrossRefGoogle Scholar
  13. Cohen, J. (1992). A power primer. Psychological Bulletin, 112(1), 155–159.CrossRefGoogle Scholar
  14. Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24(4), 385–396.CrossRefGoogle Scholar
  15. Conard, M. A., & Matthews, R. A. (2008). Modeling the stress process: personality eclipses dysfunctional cognitions and workload in predicting stress. Personality and Individual Differences, 44(1), 171–181.CrossRefGoogle Scholar
  16. Costa Jr., P. T., & McCrae, R. R. (1980). Influence of extraversion and neuroticism on subjective well-being: happy and unhappy people. Journal of Personality and Social Psychology, 38(4), 668–678.CrossRefGoogle Scholar
  17. De La Ossa, S., Martinez, Y., Herazo, E., & Campo, A. (2009). Study of internal consistency and factor structure of three versions of the Zung's rating instrument for anxiety disorders. Colombia Médica, 40(1), 71–77.Google Scholar
  18. Demyttenaere, K., Bruffaerts, R., Posada-Villa, J., Gasquet, I., Kovess, V., Lepine, J. P., et al. (2004). Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization world mental health surveys. JAMA, 291(21), 2581–2590. doi: 10.1001/jama.291.21.2581.CrossRefPubMedGoogle Scholar
  19. Diehr, P. H., Derleth, A. M., McKenna, S. P., Martin, M. L., Bushnell, D. M., Simon, G., et al. (2006). Synchrony of change in depressive symptoms, health status, and quality of life in persons with clinical depression. Health and Quality of Life Outcomes, 4, 27. doi: 10.1186/1477-7525-4-27.CrossRefPubMedPubMedCentralGoogle Scholar
  20. Ebstrup, J. F., Eplov, L. F., Pisinger, C., & Jorgensen, T. (2011). Association between the five factor personality traits and perceived stress: is the effect mediated by general self-efficacy? Anxiety, Stress, and Coping, 24(4), 407–419. doi: 10.1080/10615806.2010.540012.CrossRefPubMedGoogle Scholar
  21. Ferrari, A. J., Charlson, F. J., Norman, R. E., Patten, S. B., Freedman, G., Murray, C. J., et al. (2013). Burden of depressive disorders by country, sex, age, and year: findings from the global burden of disease study 2010. PLoS Medicine, 10(11), e1001547. doi: 10.1371/journal.pmed.1001547.CrossRefPubMedPubMedCentralGoogle Scholar
  22. Galvez, J. M., Forero, D. A., Fonseca, D. J., Mateus, H. E., Talero-Gutierrez, C., & Velez-van-Meerbeke, A. (2014). Evidence of association between SNAP25 gene and attention deficit hyperactivity disorder in a Latin American sample. Attention Deficit and Hyperactivity Disorders, 6(1), 19–23. doi: 10.1007/s12402-013-0123-9.CrossRefPubMedGoogle Scholar
  23. Garcia-Alvarez, R. (1986). Epidemiology of depression in Latin America. Psychopathology, 19(Suppl. 2), 22–25.CrossRefGoogle Scholar
  24. Gonzalez-Giraldo, Y., Camargo, A., Lopez-Leon, S., & Forero, D. A. (2015). No association of BDNF, COMT, MAOA, SLC6A3, and SLC6A4 genes and depressive symptoms in a sample of healthy Colombian subjects. Depression Research and Treatment, 2015, 145483. doi: 10.1155/2015/145483.CrossRefPubMedPubMedCentralGoogle Scholar
  25. Goodwin, R. D., & Gotlib, I. H. (2004). Gender differences in depression: the role of personality factors. Psychiatry Research, 126(2), 135–142. doi: 10.1016/j.psychres.2003.12.024.CrossRefPubMedGoogle Scholar
  26. Griffith, J. W., Zinbarg, R. E., Craske, M. G., Mineka, S., Rose, R. D., Waters, A. M., et al. (2010). Neuroticism as a common dimension in the internalizing disorders. Psychological Medicine, 40(7), 1125–1136. doi: 10.1017/S0033291709991449.CrossRefPubMedGoogle Scholar
  27. Hakulinen, C., Elovainio, M., Pulkki-Raback, L., Virtanen, M., Kivimaki, M., & Jokela, M. (2015). Personality and depressive symptoms: individual participant meta-analysis of 10 cohort studies. Depression and Anxiety, 32(7), 461–470. doi: 10.1002/da.22376.CrossRefPubMedPubMedCentralGoogle Scholar
  28. Hamad, R., Fernald, L. C., Karlan, D. S., & Zinman, J. (2008). Social and economic correlates of depressive symptoms and perceived stress in south African adults. Journal of Epidemiology and Community Health, 62(6), 538–544. doi: 10.1136/jech.2007.066191.CrossRefPubMedGoogle Scholar
  29. Harenski, C. L., Kim, S. H., & Hamann, S. (2009). Neuroticism and psychopathy predict brain activation during moral and nonmoral emotion regulation. Cognitive, Affective, & Behavioral Neuroscience, 9(1), 1–15. doi: 10.3758/cabn.9.1.1.CrossRefGoogle Scholar
  30. Hayes, A. F. (2013). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. New York: Guilford Press.Google Scholar
  31. Henrich, J., Heine, S. J., & Norenzayan, A. (2010). The weirdest people in the world? The Behavioral and Brain Sciences, 33(2–3), 61–83 discussion 83-135. doi: 10.1017/S0140525X0999152X.CrossRefPubMedGoogle Scholar
  32. Hernandez, H. G., Mahecha, M. F., Mejia, A., Arboleda, H., & Forero, D. A. (2014). Global long interspersed nuclear element 1 DNA methylation in a Colombian sample of patients with late-onset Alzheimer's disease. American Journal of Alzheimer's Disease and Other Dementias, 29(1), 50–53. doi: 10.1177/1533317513505132.CrossRefPubMedGoogle Scholar
  33. Hernández-Pozo, M., Macías, D., Calleja, N., Cerezo, S., & del Valle Chauvet, C. (2008). Propiedades psicométricas del Inventario Zung del Estado de Ansiedad con mexicanos. Psychologia. Avances de la disciplina, 2(2), 19–46.Google Scholar
  34. Herrero, M. J., Blanch, J., Peri, J. M., De Pablo, J., Pintor, L., & Bulbena, A. (2003). A validation study of the hospital anxiety and depression scale (HADS) in a Spanish population. General Hospital Psychiatry, 25(4), 277–283.CrossRefGoogle Scholar
  35. Hewitt, P. L., Flett, G. L., & Mosher, S. W. (1992). The perceived stress scale: factor structure and relation to depression symptoms in a psychiatric sample. Journal of Psychopathology and Behavioral Assessment, 14(3), 247–257.CrossRefGoogle Scholar
  36. Hinz, A., Finck, C., Gomez, Y., Daig, I., Glaesmer, H., & Singer, S. (2014). Anxiety and depression in the general population in Colombia: reference values of the hospital Anxiety and depression scale (HADS). Social Psychiatry and Psychiatric Epidemiology, 49(1), 41–49. doi: 10.1007/s00127-013-0714-y.CrossRefPubMedGoogle Scholar
  37. Ibrahim, A. K., Kelly, S. J., Adams, C. E., & Glazebrook, C. (2013). A systematic review of studies of depression prevalence in university students. Journal of Psychiatric Research, 47(3), 391–400. doi: 10.1016/j.jpsychires.2012.11.015.CrossRefPubMedGoogle Scholar
  38. Kendler, K. S., Kessler, R. C., Walters, E. E., MacLean, C., Neale, M. C., Heath, A. C., et al. (1995). Stressful life events, genetic liability, and onset of an episode of major depression in women. The American Journal of Psychiatry, 152(6), 833–842. doi: 10.1176/ajp.152.6.833.CrossRefPubMedGoogle Scholar
  39. Kendler, K. S., Kuhn, J., & Prescott, C. A. (2004). The interrelationship of neuroticism, sex, and stressful life events in the prediction of episodes of major depression. The American Journal of Psychiatry, 161(4), 631–636. doi: 10.1176/appi.ajp.161.4.631.CrossRefPubMedGoogle Scholar
  40. Kessler, R. C., Matthias, A., Anthony, J. C., De Graaf, R., Demyttenaere, K., Gasquet, I., et al. (2007). Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization’s world mental health survey initiative. World Psychiatry, 6(3), 168–176.Google Scholar
  41. Kim, H. Y. (2013). Statistical notes for clinical researchers: assessing normal distribution (2) using skewness and kurtosis. Restorative Dentistry & Endodontics, 38(1), 52–54. doi: 10.5395/rde.2013.38.1.52.CrossRefGoogle Scholar
  42. Kim, H. J., & Abraham, I. (2016). Psychometric comparison of single-item, short, and comprehensive depression screening measures in Korean young adults. International Journal of Nursing Studies, 56, 71–80. doi: 10.1016/j.ijnurstu.2015.12.003.CrossRefPubMedGoogle Scholar
  43. Kim, S. E., Kim, H. N., Cho, J., Kwon, M. J., Chang, Y., Ryu, S., et al. (2016). Direct and indirect effects of five factor personality and gender on depressive symptoms mediated by perceived stress. PloS One, 11(4), e0154140. doi: 10.1371/journal.pone.0154140.CrossRefPubMedPubMedCentralGoogle Scholar
  44. Kotov, R., Gamez, W., Schmidt, F., & Watson, D. (2010). Linking “big” personality traits to anxiety, depressive, and substance use disorders: a meta-analysis. Psychological Bulletin, 136(5), 768–821. doi: 10.1037/a0020327.CrossRefPubMedGoogle Scholar
  45. Kupfer, D. J., Frank, E., & Phillips, M. L. (2012). Major depressive disorder: new clinical, neurobiological, and treatment perspectives. Lancet, 379(9820), 1045–1055. doi: 10.1016/S0140-6736(11)60602-8.CrossRefPubMedGoogle Scholar
  46. Lahey, B. B. (2009). Public health significance of neuroticism. The American Psychologist, 64(4), 241–256. doi: 10.1037/a0015309.CrossRefPubMedPubMedCentralGoogle Scholar
  47. Lang, F. R., John, D., Ludtke, O., Schupp, J., & Wagner, G. G. (2011). Short assessment of the big five: robust across survey methods except telephone interviewing. Behavior Research Methods, 43(2), 548–567. doi: 10.3758/s13428-011-0066-z.CrossRefPubMedPubMedCentralGoogle Scholar
  48. Leach, L. S., Christensen, H., Mackinnon, A. J., Windsor, T. D., & Butterworth, P. (2008). Gender differences in depression and anxiety across the adult lifespan: the role of psychosocial mediators. Social Psychiatry and Psychiatric Epidemiology, 43(12), 983–998. doi: 10.1007/s00127-008-0388-z.CrossRefPubMedGoogle Scholar
  49. Lee, E. H. (2012). Review of the psychometric evidence of the perceived stress scale. Asian Nursing Research, 6(4), 121–127. doi: 10.1016/j.anr.2012.08.004.CrossRefPubMedGoogle Scholar
  50. Mohamadi Hasel, K., Besharat, M. A., Abdolhoseini, A., Alaei Nasab, S., & Niknam, S. (2013). Relationships of personality factors to perceived stress, depression, and oral lichen planus severity. International Journal of Behavioral Medicine, 20(2), 286–292. doi: 10.1007/s12529-012-9226-5.CrossRefPubMedGoogle Scholar
  51. Morgan-Lopez, A. A., & MacKinnon, D. P. (2006). Demonstration and evaluation of a method for assessing mediated moderation. Behavior Research Methods, 38(1), 77–87.CrossRefGoogle Scholar
  52. Muñoz, R. A., McBride, M. E., Brnabic, A. J., López, C. J., Hetem, L. A. B., Secin, R., et al. (2005). Major depressive disorder in Latin America: the relationship between depression severity, painful somatic symptoms, and quality of life. Journal of Affective Disorders, 86(1), 93–98.CrossRefGoogle Scholar
  53. Newton-Howes, G., Tyrer, P., Johnson, T., Mulder, R., Kool, S., Dekker, J., et al. (2014). Influence of personality on the outcome of treatment in depression: systematic review and meta-analysis. Journal of Personality Disorders, 28(4), 577–593. doi: 10.1521/pedi_2013_27_070.CrossRefPubMedGoogle Scholar
  54. O’Connor, D. B., & Shimizu, M. (2002). Sense of personal control, stress and coping style: a cross-cultural study. Stress and Health, 18(4), 173–183.CrossRefGoogle Scholar
  55. Ormel, J., Oldehinkel, A. J., & Brilman, E. I. (2001). The interplay and etiological continuity of neuroticism, difficulties, and life events in the etiology of major and subsyndromal, first and recurrent depressive episodes in later life. American Journal of Psychiatry, 158(6), 885–891.CrossRefGoogle Scholar
  56. Ormel, J., Bastiaansen, A., Riese, H., Bos, E. H., Servaas, M., Ellenbogen, M., et al. (2013). The biological and psychological basis of neuroticism: current status and future directions. Neuroscience and Biobehavioral Reviews, 37(1), 59–72. doi: 10.1016/j.neubiorev.2012.09.004.CrossRefPubMedGoogle Scholar
  57. Parker, G., Cheah, Y.-C., & Roy, K. (2001). Do the Chinese somatize depression? A cross-cultural study. Social Psychiatry and Psychiatric Epidemiology, 36(6), 287–293.CrossRefGoogle Scholar
  58. Perea, C. S., Paternina, A. C., Gomez, Y., & Lattig, M. C. (2012). Negative affectivity moderated by BDNF and stress response. Journal of Affective Disorders, 136(3), 767–774. doi: 10.1016/j.jad.2011.09.043.CrossRefPubMedGoogle Scholar
  59. Preacher, K. J., & Kelley, K. (2011). Effect size measures for mediation models: quantitative strategies for communicating indirect effects. Psychological Methods, 16(2), 93–115. doi: 10.1037/a0022658.CrossRefPubMedGoogle Scholar
  60. Quilty, L. C., Van Ameringen, M., Mancini, C., Oakman, J., & Farvolden, P. (2003). Quality of life and the anxiety disorders. Journal of Anxiety Disorders, 17(4), 405–426.CrossRefGoogle Scholar
  61. Radloff, L. S. (1977). The CES-D scale a self-report depression scale for research in the general population. Applied Psychological Measurement, 1(3), 385–401.CrossRefGoogle Scholar
  62. Rammstedt, B., Goldberg, L. R., & Borg, I. (2010). The measurement equivalence of big five factor markers for persons with different levels of education. Journal of Research in Personality, 44(4), 53–61. doi: 10.1016/j.jrp.2009.10.005.CrossRefPubMedPubMedCentralGoogle Scholar
  63. Remor, E. (2006). Psychometric properties of a European Spanish version of the perceived stress scale (PSS). The Spanish Journal of Psychology, 9(1), 86–93.CrossRefGoogle Scholar
  64. Renau, V., Oberst, U., Gosling, S. D., Rusiñol, J., & Lusar, A. C. (2013). Translation and validation of the ten-item-personality inventory into Spanish and Catalan. Aloma: revista de psicologia, ciències de l’educació i de l’esport Blanquerna, 31(2), 85–97.Google Scholar
  65. Richards, D. (2011). Prevalence and clinical course of depression: a review. Clinical Psychology Review, 31(7), 1117–1125.CrossRefGoogle Scholar
  66. Richards, D., & Sanabria, A. S. (2014). Point-prevalence of depression and associated risk factors. The Journal of Psychology, 148(3), 305–326. doi: 10.1080/00223980.2013.800831.CrossRefPubMedGoogle Scholar
  67. Roohafza, H., Feizi, A., Afshar, H., Mazaheri, M., Behnamfar, O., Hassanzadeh-Keshteli, A., et al. (2016). Path analysis of relationship among personality, perceived stress, coping, social support, and psychological outcomes. World Journal of Psychiatry, 6(2), 248–256. doi: 10.5498/wjp.v6.i2.248.CrossRefPubMedPubMedCentralGoogle Scholar
  68. Suls, J., & Martin, R. (2005). The daily life of the garden-variety neurotic: reactivity, stressor exposure, mood spillover, and maladaptive coping. Journal of Personality, 73(6), 1485–1509. doi: 10.1111/j.1467-6494.2005.00356.x.CrossRefPubMedGoogle Scholar
  69. Tellegen, A., Lykken, D. T., Bouchard, T. J., Wilcox, K. J., Segal, N. L., & Rich, S. (1988). Personality similarity in twins reared apart and together. Journal of Personality and Social Psychology, 54(6), 1031.CrossRefGoogle Scholar
  70. Vazquez, F. L., Blanco, V., & Lopez, M. (2007). An adaptation of the Center for Epidemiologic Studies Depression Scale for use in non-psychiatric Spanish populations. Psychiatry Research, 149(1–3), 247–252. doi: 10.1016/j.psychres.2006.03.004.CrossRefPubMedGoogle Scholar
  71. Versluis, A., Verkuil, B., Spinhoven, P., van der Ploeg, M. M., & Brosschot, J. F. (2016). Changing mental health and positive psychological well-being using ecological momentary interventions: a systematic review and meta-analysis. Journal of Medical Internet Research, 18(6), e152. doi: 10.2196/jmir.5642.CrossRefPubMedPubMedCentralGoogle Scholar
  72. Vos, T., Flaxman, A. D., Naghavi, M., Lozano, R., Michaud, C., Ezzati, M., et al. (2012). Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the global Burden of disease study 2010. Lancet, 380(9859), 2163–2196. doi: 10.1016/S0140-6736(12)61729-2.CrossRefPubMedPubMedCentralGoogle Scholar
  73. Wongpakaran, N., & Wongpakaran, T. (2010). The Thai version of the PSS-10: An investigation of its psychometric properties. BioPsychoSocial Medicine, 4, 6. doi: 10.1186/1751-0759-4-6.CrossRefPubMedPubMedCentralGoogle Scholar
  74. Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67(6), 361–370.CrossRefGoogle Scholar
  75. Zung, W. W. (1971). A rating instrument for anxiety disorders. Psychosomatics, 12(6), 371–379. doi: 10.1016/S0033-3182(71)71479-0.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  • Angela J. Pereira-Morales
    • 1
  • Ana Adan
    • 2
    • 3
  • Diego A. Forero
    • 1
    Email author
  1. 1.Laboratory of Neuropsychiatric Genetics, Biomedical Sciences Research Group, School of MedicineUniversidad Antonio NariñoBogotáColombia
  2. 2.Department of Clinical Psychology and Psychobiology, School of PsychologyUniversity of BarcelonaBarcelonaSpain
  3. 3.Institute of NeurosciencesUniversity of BarcelonaBarcelonaSpain

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