Anxiety And Low White Blood Cell Count - BloodHealthAdvice.com (2023)

And What Factors Affect White Blood Cell Count

How Stress Affects Your White Blood Cells (WBCs) and Immune System

  • Frequently Asked Questions

White blood cells are the immune cells in your body. They circulate in your bloodstream and work as guardians to help protect you from viruses, bacteria, and other infectious organisms.

Maintaining a normal level of healthy white blood cells can help reduce the risk of infection and is a key component of overall health. If you have a low WBC count, called leukopenia, you may be at an increased risk of developing infections.

Importantly, you don’t want extremely high levels of white blood cells. Increased WBC levelsknown as leukocytosisare a sign the body is responding to a stressor. Stressors that increase WBC levels can be physical, such as an infection, cancer, or an autoimmune disorder, or emotional.

This article discusses the function of white blood cells, the causes of increased and decreased white blood cell counts, and the medications and habits needed to maintain a healthy white blood cell count.

SEBASTIAN KAULITZKI / Getty Images

What Are Symptoms Of Low White Blood Cells

If you have a low white blood cell count, you may:

  • Have repeated fevers and infections.
  • Get bladder infections that may make it painful to pass urine, or make you urinate more often.
  • Get lung infections that cause coughing and difficulty breathing.
  • Get mouth sores.
  • Get sinus infections and a stuffy nose.

How Can Doctors Tell If My White Blood Cell Count Is Low

Doctors can tell you have a low white blood cell count by doing a routine complete blood count . If you’re getting treatments or have a disease that can lower your white blood cell count, doctors check your CBC often.

Sometimes, the cause is obvious, such as if youre getting chemotherapy or radiation therapy for cancer.

If the cause isn’t clear, doctors may do:

  • Blood, urine, and imaging tests looking for infection

  • Bone marrow biopsy

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What Foods Increase White Blood Cells

Vitamin C increases WBC production, which is key to fighting infections. Almost every citrus fruits are high in vitamin C. With such a variety to choose from, its easy to add a few squeezes of this vitamin to any meal.

Also, you should eat foods high in protein, such as:

  • Is Broccoli Good For You?

Most of you dont know how to boost white blood cells. So I have shared a few tips in the upcoming section.

Iron pills help the body absorb iron while maintaining a healthy immune system and keeping the nerve and blood cells healthy recommended iron pills are the best source of iron. Buy now..

When Should I See A Doctor About A Possible Low White Blood Cell Count

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Ask your doctor if he or she is concerned about your white blood cell count and if you will need additional tests. If your white blood cell count is low, and you feel like you have an infection, contact your healthcare provider right away.

Last reviewed by a Cleveland Clinic medical professional on 01/12/2018.

References

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Does Anxiety Cause Anemia

An interesting question though is whether or not anxiety can actually cause anemia. It’s unlikely that anxiety can lead to dangerous levels of anemia, but it may be possible for anxiety to contribute to the development of mild anemia.

Studies have rarely looked at the effects of anxiety on vitamin metabolism. But there are reasons to believe that stress does have an effect. For example, as many as 25% of the country is already magnesium deficient. During times of severe stress, the body actually uses up magnesium in the body. Thus those with anxiety may already have low magnesium, and then be using up what they do have when they’re experiencing anxiety attacks. It’s possible this leads to the development of mild anemia.

Hyperventilation also uses up magnesium. Since many people with anxiety hyperventilate, a large number may be contributing to a magnesium deficiency and ultimately anemia.

Anxiety can also affect the immune system, which may have an effect on anemia. It can also cause poor eating habits these too may cause you to become more anemic.

These are all unexplored, but absolutely possible links between anxiety and anemia.

The Effects Of Stress On White Blood Cells

Stress can be a positive or negative event. Getting married or buying a new home can be just as stressful as financial or health problems. Stress becomes a problem when it occurs on a regular basis with no break and creates feelings of being out of control or overwhelmed. Even a low level of stress can have negative effects if it becomes chronic. Stress can alter many systems of the body, including the immune system 3. To help prevent complications it is important to understand the role stress plays on the activity of the white blood cells.

If you are experiencing serious medical symptoms, seek emergency treatment immediately.

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What Happens During A White Blood Count

A health care professional will take a blood sample from a vein in your arm, using a small needle. After the needle is inserted, a small amount of blood will be collected into a test tube or vial. You may feel a little sting when the needle goes in or out.

To test children, a health care provider will take a sample from the heel or the fingertip . The provider will clean the heel or fingertip with alcohol and poke the site with a small needle. The provider will collect a few drops of blood and put a bandage on the site.

Types Of Wbcs And Their Functions

My white blood count is low: Should I Worry?

Several types of white blood cells are found in your body, and each has specialized functions. The major WBC types are:

  • Neutrophils: These cells make up the majority of the white blood cell population. Neutrophils are the primary cells responsible for responding to bacterial infections.
  • Lymphocytes: Lymphocytes are the second most common white blood cell subtype. The lymphocytes include T cells and B cells, which help support the immune system’s response to infections, cancers, and other stresses.
  • Eosinophils: These white blood cells are primarily responsible for allergies and responding to parasitic infections.
  • Monocytes: These WBCs are the first to respond to an infection. These blood cells include macrophages and dendritic cells and can be elevated in autoimmune disorders and chronic infections.

WBCs fight infection and are also an integral part of the bodys ability to fend off cancer. Since cancer cells are foreign to the body, white blood cells such as lymphocytes can help eliminate cancer cells.

Some cancers can evade detection by the immune system, but medical advances have created new therapies and treatments that use white blood cells to detect and target cancer, such as checkpoint inhibitors and cell therapies.

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Study Links Depression Scores White Blood Cell Count

Researchers across four health care systems, including Vanderbilt University Medical Center, have found that increased depression polygenic scores are associated with increased white blood cell count, highlighting the importance of the immune system in the etiology of depression.

Despite a wide understanding of depression as a psychiatric disorder, depressions underlying biological effects are still poorly understood, says Lea Davis, PhD, associate professor of Medicine, investigator in the Vanderbilt Genetics Institute and an author of the JAMA Psychiatry paper.

We know that theres a strong relationship between depression and several chronic health conditions, and we also know theres a relationship between depression and inflammation, Davis said.

What we dont know is exactly how theyre connected, which condition causes the other or if theres something underlying that causes both.

To answer that question, Davis and the research team, which consisted of researchers from VUMC, the Icahn School of Medicine at Mount Sinai, Mass General Brigham and the Million Veteran Program, studied two groups people who had depression and people who did not, but were at a high genetic risk for developing depression.

The team found a strong connection between depression polygenic scores and white blood cell count.

Cross-institutional collaboration is a necessity when it comes to understanding things like depression, Davis says.

Database And Study Sample

The healthy aging in neighborhoods of diversity across the lifespan study is an ongoing prospective cohort study initiated in 2004 that recruited a representative sample of African Americans and whites aged 3064 years old and living in Baltimore, MD, USA. The HANDLS design consisted of an area probability sample of 13 neighborhoods , with a first phase at baseline that screened and recruited participants and administered a household interview. At phase II, in-depth examinations in mobile medical research vehicles were conducted. Written informed consent was obtained after access to a protocol booklet in layman’s terms along with a video describing all the procedures and future re-contacts. The MedStar Institutional Review Board approved all the materials. Longitudinal data from baseline and the first follow-up examination were used in this study.

In addition, for Hypothesis 2, the final sample size consisted of participants with complete WBC variables at either wave and complete data on CES-D total score at wave 1 , with similar selectivity patterns as for Sample 2A.

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Are There Any Risks To The Test

After a blood test, you may have slight pain or bruising at the spot where the needle was put in, but most symptoms go away quickly.

There is very little risk to your baby or child with a needle stick test. Your child may feel a little pinch when the site is poked, and a small bruise may form at the site. This should go away quickly.

Foods That Increase Wbc Counts

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If your white blood cell level is low, there are changes you can make to try to increase it. Always consult with a healthcare professional before starting any new treatments, including diets, that may disrupt your WBC count. Very low WBCs are medical emergencies that require prompt treatment.

A healthy diet, rich in vegetables, and protein is a good way to maintain a healthy immune system.

A Mediterranean diet, which consists of whole grains fruits and vegetables beans, nuts, and seeds healthy fats moderate amounts of fish and poultry and limited amounts of red meat, has been shown to help boost white blood cell levels. Foods such as blueberries, strawberries, and leafy green vegetables can help reduce the risk of developing certain immune disorders. These whole foods are a good source of antioxidants, which can help support the function of a healthy immune system.

As much as possible, look to get your nutrients and antioxidants from foods. You should consult with a healthcare professional before starting any supplements.

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Causes Of Increased White Blood Cell Counts

There are many causes of elevated WBC counts. WBC levels can rise due to the following:

  • Bone marrow failure
  • Autoimmune disorders

If you have a low white blood cell count, you should ask your healthcare provider to determine the cause and the best course of treatment. In some cases, a very low white blood cell count can increase your risk of developing serious infections.

Causes Of A Low White Blood Cell Count

Common causes of a low white blood cell count are:

  • Medications and cancer treatments, such as some antibiotics, chemotherapy, and radiation therapy
  • Bone marrow cancers and bone marrow disorders, including aplastic anemia and multiple myeloma
  • Infectious diseases, including human immunodeficiency virus and severe infections

White blood cells are made in the bone marrow and circulate throughout the body. Diseases, toxins, medications, or medical treatments that harm the bone marrow can prevent enough white blood cells from being produced. Some medical conditions can also cause the destruction of white blood cells.

Usually, having low white blood cells is a sign of chronic disease. But sometimes medications or infections can temporarily cause this problem due to the destruction of white blood cells. This should resolve once the infection clears up or the medication is discontinued.

Benign ethnic neutropenia is a cause of inherited chronic neutropenia . It is seen mostly in people of African, Middle Eastern, and West Indian descent worldwide. It does not increase a person’s risk of infection.

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Why Do Doctors Check Your Wbc Count

The WBC count is usually included in a test that measures your complete blood count . A low white blood cell count or a high blood cell count may indicate an infection or an undiagnosed condition such as a blood disorder, an autoimmune diseases or an immune deficiency. The WBC count can help doctors detect and provide treatment for these potential conditions as well as help monitor the effectiveness of radiation treatment or chemotherapy for cancer patients.

How Can You Better Manage Your Stress Levels

Is low white blood cells a sign of cancer?

Stress reduction strategies not only give your mind a break, but they can also relieve the pressure on your immune system. You can take steps to reduce short-term and long-term stress, Dr. Calabrese says. Two tactics are most effective:

  • Meditation : Meditate for 10 minutes to 15 minutes three or four times weekly to lower your stress. It reduces your cortisol levels and reduces inflammation. Research also shows it helps prevent the breakdown of your chromosomes that leads to cancer and premature aging.
  • Yoga: Practicing yoga also lowers stress hormone levels and calms your nervous system to reduce inflammation. Deep breathing helps boost your resistance to infection. Inverted poses in yoga help circulate fluid through your lymphatic system, filtering out toxins.
  • Stress in acute situations, however, can be healthful and protective, so its not all bad for us. Remember: its chronic stress that we seek to control.

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    Is There Anything Else I Need To Know About A White Blood Count

    White blood count results are often compared with results of other blood tests, including a blood differential. A blood differential test shows the amount of each type of white blood cell, such as neutrophils or lymphocytes. Neutrophils mostly target bacterial infections. Lymphocytes mostly target viral infections.

    • A higher than normal amount of neutrophils is known as neutrophilia.
    • A lower than normal amount is known as neutropenia.
    • A higher than normal amount of lymphocytes is known as lymphocytosis.
    • A lower normal amount is known as lymphopenia.

    Similar Symptoms For Different Diseases

    Many people convince themselves they have anemia because it’s hard for them to believe that their symptoms could be caused by anxiety. Anemia is not that uncommon either, affecting roughly 5 to 10% of the population.

    But many of those are pregnant women and those born with red blood cell diseases.

    The symptoms of anxiety especially panic attacks and anemia are very similar, so it is no wonder that so many of those living with anxiety convince themselves anemia must be the cause. Both anxiety and anemia cause:

    • Shortness of breath

    However, while anemia may cause these symptoms, it also often leads to other, more serious problems that cause hospitalization. Similarly, the symptoms above are also caused by an issue that is far more common hyperventilation. As many as 50% of those with panic attacks or more hyperventilate, along with millions of people with anxiety.

    So while it’s possible to be anemic, it’s also very likely that you simply have symptoms of panic attacks and hyperventilation, both of which are more common and more likely to lead to these issues especially if you have a healthy diet.

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    Symptoms Of Low White Blood Cells

    You wouldnt expect to have direct symptoms of low white blood cells. But when these cells are low, it causes the immune system to be weak. With a weak immune system, medical problems can arise and these problems will often cause symptoms.

    Infections are the most common effect of a low number of white blood cells. The infections can be more frequent and more severe than what you would experience if you had a healthy immune system. Lacking white blood cells can also make it difficult for you to heal from injuries or recover from illnesses.

    Symptoms that you may experience from complications of having a low white count include:

    • Painful urination, blood in the urine, urinary frequency
    • Skin sores that dont heal
    • Mouth sores, mouth pain

    The symptoms that accompany a low white blood cell count can vary and depend on what’s causing the low count. For example, a bladder infection can cause urinary symptoms, and a stomach infection can cause nausea and vomiting.

    Sometimes a lack of white blood cells leads to opportunistic infections, which are infections that wouldnt normally develop in a person with a healthy immune system.

    Cancer is another potentially serious effect of low white blood cells. These immune cells normally recognize and destroy abnormal cancer cells, and a white blood cell deficiency can allow cancer cells to multiply and spread in the body.

    How Is Anxiety Treated

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    After a mental health professional or doctor has diagnosed you with anxiety, there are different treatment options available to help with symptoms. These options include:

    • Psychotherapy. This is therapy thats done with a psychotherapist. Talking to a therapist can help identify root causes of anxiety and any triggers that you may have. According to the American Psychiatry Association , nearly 75 percent of people who try talk therapy find it beneficial.
    • Medication. There are several different types of medication that you can take that may help reduce your symptoms of anxiety.

    Finding help for anxiety

    If youre experiencing symptoms of anxiety that interfere with your daily life, help is available here:

    If youre having thoughts of harming yourself, talk with your doctor, call 911, or go to the nearest emergency room right away.

    In addition to these treatment options, there are many things you can do to help reduce and manage your anxiety. These include:

    • avoiding alcohol and caffeine

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    FAQs

    Can stress and anxiety cause low white blood cell count? ›

    In addition, stress decreases the body's lymphocytes — the white blood cells that help fight off infection. The lower your lymphocyte level, the more at risk you are for viruses, including the common cold and cold sores.

    Can anxiety affect white blood cell count? ›

    Most of the time, leukocytosis is a normal immune response caused by infection or inflammation. Sometimes, it's associated with stress, anxiety or pregnancy. In some cases, however, a high white blood cell count could mean something more serious. That's why it's important to talk to your healthcare provider.

    Can stress affect white blood cells? ›

    Stress levels increase white blood cell count

    This indicates a connection between elevated stress levels and the body's production of what are known as inflammatory leukocytes, a particular variety of white blood cell. Normally, inflammatory leukocytes are the body's defense system against infection and disease.

    What are 2 signs or symptoms associated with low white blood cells? ›

    What are leukopenia symptoms?
    • Fever and chills.
    • Swelling and redness.
    • Mouth sores.
    • Red or white patches in your mouth.
    • Sore throat.
    • Severe cough or shortness of breath.
    • Painful urination or pee that smells bad.
    • Diarrhea.
    Oct 27, 2022

    Can stress and lack of sleep cause low white blood cell count? ›

    Some animal and human studies have shown that lack of sleep appears to lower white blood cell count, which is an indication of decreased immune function. This means you may be more susceptible to illnesses when you are sleep deprived.

    How much does stress affect WBC? ›

    Any infection or acute stress will result in an increased production of WBCs. This usually entails increased numbers of cells and an increase in the percentage of immature cells (mainly band zcells) in the blood. This change is referred to as a "shift to the left".

    Can stress and anxiety cause neutropenia? ›

    Conclusion: It can be concluded that stress is correlated with neutropenia, and stress management in patients with leukemia will be accompanied by better recovery outcomes and reduced risk of infectious disease.

    Why would your white blood cells be low? ›

    Low WBC counts are often linked to bone marrow problems. Being around certain chemicals, like benzene and pesticides, as well as some types of cancer and cancer treatments including chemotherapy and radiation, can hurt your bone marrow's ability to make WBCs.

    Can you have a low white blood cell count and be healthy? ›

    It's possible for some people to have white blood cell counts that are lower than what's usually expected and still be healthy.

    Can fatigue cause low WBC? ›

    If you have low WBC and are increasingly feeling fatigued, both are likely symptoms of an underlying issue. This could be a range of issues, from over-exercise or overtraining, low folate or B12 levels, autoimmune diseases, viral infections, and certainly cancers.

    Can anxiety weaken your immune system? ›

    Stress and anxiety have a tremendous impact on our immune system," said David Tolin, PhD, director of the Anxiety Disorders Center at Hartford Hospital's Institute of Living. "We know excess levels of stress produce hormonal changes that lower the body's resistance to colds and other infections.” Dr.

    What supplements increase white blood cells? ›

    If your diet is poor, or you're having trouble eating, you can take a multivitamin or supplement with vitamin B12 and folate. The body uses vitamin B12 and folate to make WBCs.

    Should I worry if my white blood count is low? ›

    The main risk of an abnormally low white blood cell count is how vulnerable it may make a person to infection. Without an adequate white blood cell response available to fight infection, the body is at greater risk that any infection (including those usually regarded as minor) may cause serious illness or death.

    How do you feel when WBC is low? ›

    The common symptoms of a low WBC, also known as leukopenia, include body aches, chills, fever and headaches. If you have these symptoms, please schedule an appointment with your doctor and he/she may recommend a WBC count.

    What do doctors do if your white blood cells are low? ›

    Doctors treat a low white blood cell count using:
    1. Antibiotics to treat any infections.
    2. Medicines to push your body to make more white blood cells.
    3. Treatment for any diseases that may be causing the count to be low.

    Does rest help increase white blood cells? ›

    Highlights. Young adults with irregular sleep patterns have higher total white blood cell count. Sleep irregularity is also associated with neutrophils, lymphocytes, and monocytes.

    Does vitamin B12 increase white blood cells? ›

    Your body needs vitamin B12 to make healthy red blood cells, white blood cells, and platelets.

    What foods to avoid if you have low white blood cells? ›

    Order only fully cooked foods and well-done meats. Avoid all raw fruits and vegetables. Don't eat foods that contain raw fish, such as sushi. Some dressings and sauces may be made with raw egg yolks, like caesar salad dressing and carbonara sauce.

    What is an alarming WBC count? ›

    In general, for adults a count of more than 11,000 white blood cells in a microliter of blood is considered high.

    How long does it take for white blood cells to increase? ›

    Based on the nature of the infection, it takes the body up to 5 to 25 days for the white blood cell count to return to normal.

    How much can WBC fluctuate in a day? ›

    Fluctuation of WBC count during the 4-hour interval is linked to changes in neutrophils and lymphocytes. Neutrophil count increases from 1h after meal and peaks at 11% after 4 hours. Lymphocyte count decreases from 1h after meal, falls at 19% after 2 hours, and returns to baseline values after 4 hours.

    Can depression affect white blood cell count? ›

    Conclusions and Relevance This genetic association study found that increased depression polygenic scores were associated with increased white blood cell count, and suggests that this association may be bidirectional.

    What are 3 causes of neutropenia? ›

    Infections: Viral, bacterial and parasitic infections can cause neutropenia. Common causes include HIV, hepatitis, tuberculosis, sepsis, and Lyme disease, among other infections.

    Can anxiety lower neutrophils? ›

    Psychological stress or life events might significantly decrease neutrophil function in elderly individuals and lead to infectious diseases.

    Can lack of vitamin D cause low white blood cell count? ›

    To date, there appear to be no studies that confirm vitamin D is a cause of low WBC count.

    Can dehydration affect white blood count? ›

    Yes, dehydration may cause homoconcentration which can double the white blood cells in healthy people.

    What vitamin deficiency causes low WBC? ›

    Reduction in the number of white blood cells and platelets also can occur, especially when people have had vitamin deficiency anemia for a long time. The blood levels of vitamin B12 and folate are measured, and other tests may be done to determine the cause of the vitamin B12 deficiency.

    Do all cancers have low white blood cell count? ›

    Cancer can lead to a high or low WBC count, depending on the type of cancer, which type of white blood cell is affected, and where the cancer is in your body.

    Can anxiety bring on autoimmune disease? ›

    But it's theorized that persistent stress (such as worry about finances, mental or physical health, or interpersonal relationships) could lead to chronic disease such as high blood pressure or autoimmune disease. What causes stress for a person is highly individual. A common example is having to speak in public.

    Is anxiety linked to autoimmune disease? ›

    While stress-related disorders are more severe than stress, stress is still often related to autoimmunity. Studies have shown that up to 80% of patients experienced heightened emotional stress ahead of autoimmune diagnosis. Plus, stress-related hormones are believed to lead to dysregulation within the immune system.

    What autoimmune disorders cause anxiety? ›

    Systemic Lupus Erythematosus (SLE) is another autoimmune disease known to have a high degree of neuropsychiatric problems, such as depression and anxiety, occurring in between 21 and 95% of patients (41).

    Does vitamin D help white blood cells? ›

    The reason: Vitamin D instructs your white blood cells to manufacture a protein that kills infections. Specifically, a 30 to 50 percent lower chance of breast cancer, and a 50 percent lower chance of colon cancer.

    Can zinc increase white blood cells? ›

    Zinc helps your immune system by aiding in the production of immune cells, like T-cells and white blood cells, that help your body fight off diseases.

    What herbal increases white blood cells? ›

    Ginger contains compounds that increase the number of white blood cells in the body, which kills foreign bacteria and virus. You can increase the amount of garlic in your food to uplift your immune system.

    How long does it take to recover from low WBC count? ›

    Once the WBC count drops, it remains low for 7–10 days. The lowest level that blood cell counts reach is called the nadir. During nadir, the body's resistance to infection is weakest.

    Does emotional stress cause a low blood count? ›

    This happens because stress causes us to decrease the amount of stomach acid in our system, which can lead to poor nutrient absorption. Some of these nutrients are vital for iron absorption, which can also cause the number of red blood cells we have at any given time.

    Is a slightly low white blood count serious? ›

    A white blood cell count that is just slightly below the cutoff for the established normal range may actually still be normal and not require further evaluation. In addition, what would be considered a low white blood cell count for some people may be a normal finding for others.

    What lowers white blood cell count? ›

    Low WBC counts are often linked to bone marrow problems. Being around certain chemicals, like benzene and pesticides, as well as some types of cancer and cancer treatments including chemotherapy and radiation, can hurt your bone marrow's ability to make WBCs.

    What blood tests are affected by stress? ›

    A cortisol blood test is one of the most commonly used blood tests. Cortisol is a hormone that is released by the adrenal glands when one is under stress. Higher levels of cortisol would indicate higher levels of stress.

    How concerning is low white blood cell count? ›

    A low white blood cell count usually means your body is not making enough white blood cells. It can increase your risk of getting infections.

    Why would white blood cells be low for no reason? ›

    ANSWER: A low white blood cell count almost always is related to a decrease in a type of infection-fighting white blood cell called neutrophils. When you have a low level of neutrophils, the condition is known as neutropenia. There are many causes of neutropenia, and some medications can lead to this problem.

    Why would a healthy person have a low white blood cell count? ›

    White blood cells are made in bone marrow — the spongy tissue inside some of the larger bones. Conditions that affect the bone marrow are the usual causes of low white blood cell count. Some of these conditions are present at birth, also known as congenital.

    Can you have low white blood cell count without symptoms? ›

    A low white blood cell count has no specific symptoms. You get symptoms because you develop frequent infections. Sometimes the infections are unusual ones that most people don't get.

    Can vitamin D deficiency cause low white blood count? ›

    However, all these studies observed low vitamin D with low WBC count in already clinically ill subjects, and correlation does not mean causation. To date, there appear to be no studies that confirm vitamin D is a cause of low WBC count.

    How can I get my white blood cell count back up? ›

    Lean meats, such as fish, eggs seafood, and skinless poultry contain high quantities of protein. Great plant based sources include lentils, beans and soy. Zinc is one of the best foods to increase white blood cells you can consume as it can help the body produce more WBCs and makes existing WBCs more aggressive.

    What cancers cause low WBC? ›

    Low Blood Counts From Cancer
    • Leukemia.
    • Lymphoma.
    • Myeloma.
    Jun 14, 2022

    What vitamin deficiency causes low white blood cells? ›

    Reduction in the number of white blood cells and platelets also can occur, especially when people have had vitamin deficiency anemia for a long time. The blood levels of vitamin B12 and folate are measured, and other tests may be done to determine the cause of the vitamin B12 deficiency.

    References

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