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Castagna PJ, Edgar EV, Delpech R, Topel S, Kortink ED, van der Molen MJW, Crowley MJ. Computational modeling of social evaluative decision-making elucidates individual differences in adolescent anxiety. JOURNAL OF RESEARCH ON ADOLESCENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR RESEARCH ON ADOLESCENCE 2024. [PMID: 38961725 DOI: 10.1111/jora.12999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 06/26/2024] [Indexed: 07/05/2024]
Abstract
Adolescents experience significant developmental changes during a time of heightened sensitivity to social cues, particularly rejection by peers, which can be especially overwhelming for those with elevated levels of social anxiety. Social evaluative decision-making tasks have been useful in uncovering the neural correlates of information processing biases; however, linking youths' task-based performance to individual differences in psychopathology (e.g., anxiety symptoms) has proven more elusive. Here, we address this weakness with drift diffusion modeling to decompose youths' performance on the social judgment paradigm (SJP) to determine if this approach is useful in discovering individual differences in anxiety symptoms, as well as puberty, age, and sex. A sample of 103 adolescents (55 males, Mage = 14.49, SD = 1.69) completed the SJP and self-report measures of anxiety, as well as self- and parent-reported measures of puberty. The decision threshold parameter, reflecting the amount of evidence needed to make a social evaluative decision, predicted youth self-reported anxiety, above and beyond typical metrics of SJP performance. Our results highlight the potential advantage of parsing task performance according to the underlying cognitive processes. Future research would likely benefit from applying computational modeling approaches to social judgment tasks when attempting to uncover performance-based individual differences in psychopathology.
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Affiliation(s)
- Peter J Castagna
- Department of Psychology, The University of Alabama, Tuscaloosa, Alabama, USA
| | - Elizabeth V Edgar
- Yale School of Medicine, Yale Child Study Center, New Haven, Connecticut, USA
| | - Raphaëlle Delpech
- Yale School of Medicine, Yale Child Study Center, New Haven, Connecticut, USA
| | - Selin Topel
- Clinical Psychology, Institute of Psychology, Leiden University, Leiden, The Netherlands
| | - Elise D Kortink
- Developmental and Educational Psychology, Institute of Psychology, Leiden University, Leiden, The Netherlands
| | - Melle J W van der Molen
- Developmental and Educational Psychology, Institute of Psychology, Leiden University, Leiden, The Netherlands
| | - Michael J Crowley
- Yale School of Medicine, Yale Child Study Center, New Haven, Connecticut, USA
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2
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Wang C, Xie R, Chen L, Yang X, Yan C. Psychometric evaluation of the Social Touch Questionnaire in Chinese adolescents. Psych J 2024. [PMID: 38965783 DOI: 10.1002/pchj.789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 06/14/2024] [Indexed: 07/06/2024]
Abstract
Social touch promotes psychological well-being through inducing positive effects on social affiliation and stress alleviation, especially in adolescence. However, there is a scarcity of instruments available for evaluating adolescents' attitude toward social touch in China. The present study aimed to investigate the validity and reliability of the Social Touch Questionnaire (STQ) in Chinese adolescents. A total of 2839 high school students were enrolled, ranging in age from 11 to 19 years. The dimensions of the scale were conducted by exploratory factor analysis, and validated by confirmatory factor analysis. A three-factor model showed the best fit and consisted of the following subgroups: liking of informal social touch, liking of general social touch, and dislike of social touch. Furthermore, positive associations were found between social touch and interaction anxiety, fear of negative evaluation, depressive and anxiety symptoms, and sleep quality. Short-term prediction of dislike of social touch in anxiety symptoms was determined, while no significant predictor of depressive symptoms was found. The STQ demonstrates reliability and validity as a self-report questionnaire designed to assess behaviors and attitudes toward social touch. It effectively adapts to the nuances of the Chinese context among adolescents.
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Affiliation(s)
- Chenglei Wang
- Shanghai Changning Mental Health Centre, Shanghai, China
| | - Ruyun Xie
- Shanghai Changning Mental Health Centre, Shanghai, China
| | | | - Xinhua Yang
- Shanghai Changning Mental Health Centre, Shanghai, China
| | - Chao Yan
- Key Laboratory of Brain Functional Genomics (MOE&STCSM), Affiliated Mental Health Center (ECNU), School of Psychology and Cognitive Science, East China Normal University, Shanghai, China
- Key Laboratory of Philosophy and Social Science of Anhui Province on Adolescent, Mental Health and Crisis Intelligence Intervention, Hefei, China
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3
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Ginat-Frolich R, Gilboa-Schechtman E, Huppert JD, Aderka IM, Alden LE, Bar-Haim Y, Becker ES, Bernstein A, Geva R, Heimberg RG, Hofmann SG, Kashdan TB, Koster EHW, Lipsitz J, Maner JK, Moscovitch DA, Philippot P, Rapee RM, Roelofs K, Rodebaugh TL, Schneier FR, Schultheiss OC, Shahar B, Stangier U, Stein MB, Stopa L, Taylor CT, Weeks JW, Wieser MJ. Vulnerabilities in social anxiety: Integrating intra- and interpersonal perspectives. Clin Psychol Rev 2024; 109:102415. [PMID: 38493675 DOI: 10.1016/j.cpr.2024.102415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 02/28/2024] [Accepted: 03/08/2024] [Indexed: 03/19/2024]
Abstract
What are the major vulnerabilities in people with social anxiety? What are the most promising directions for translational research pertaining to this condition? The present paper provides an integrative summary of basic and applied translational research on social anxiety, emphasizing vulnerability factors. It is divided into two subsections: intrapersonal and interpersonal. The intrapersonal section synthesizes research relating to (a) self-representations and self-referential processes; (b) emotions and their regulation; and (c) cognitive biases: attention, interpretation and judgment, and memory. The interpersonal section summarizes findings regarding the systems of (a) approach and avoidance, (b) affiliation and social rank, and their implications for interpersonal impairments. Our review suggests that the science of social anxiety and, more generally, psychopathology may be advanced by examining processes and their underlying content within broad psychological systems. Increased interaction between basic and applied researchers to diversify and elaborate different perspectives on social anxiety is necessary for progress.
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Affiliation(s)
| | | | | | - Idan M Aderka
- School of Psychological Sciences, University of Haifa, Israel
| | - Lynn E Alden
- Department of Psychology, University of British Columbia, Canada
| | - Yair Bar-Haim
- School of Psychological Sciences and Sagol School of Neuroscience, Tel Aviv University, Israel
| | - Eni S Becker
- Behavioural Science Institute, Radboud University Nijmegen, Netherlands
| | - Amit Bernstein
- School of Psychological Sciences, University of Haifa, Israel
| | - Ronny Geva
- Department of Psychology, Bar Ilan University, Israel
| | - Richard G Heimberg
- Department of Psychology, Temple University, Philadelphia, United States of America
| | - Stefan G Hofmann
- Department of Clinical Psychology, Philipps-University Marburg, Marburg, Germany; Department of Psychological and Brain Sciences, Boston University, Boston, United States of America
| | - Todd B Kashdan
- Department of Psychology, George Mason University, Virginia, United States of America
| | - Ernst H W Koster
- Department of Experimental Clinical and Health Psychology, Ghent University, Belgium
| | | | - Jon K Maner
- Department of Psychology, Florida State University, Florida, United States of America
| | - David A Moscovitch
- Department of Psychology and Centre for Mental Health Research & Treatment, University of Waterloo, Canada
| | - Pierre Philippot
- Department of Psychology, Université Catholique de Louvain, Belgium
| | - Ronald M Rapee
- Centre for Emotional Health and School of Psychological Sciences, Macquarie University, Australia
| | - Karin Roelofs
- Behavioural Science Institute, Radboud University Nijmegen, Netherlands; Donders Institute, Radboud University Nijmegen, Netherlands
| | - Thomas L Rodebaugh
- Department of Psychological and Brain Sciences, Washington University in St. Louis, Missouri, United States of America
| | - Franklin R Schneier
- New York State Psychiatric Institute, Columbia University Irving Medical Center, New York, United States of America
| | | | - Ben Shahar
- The Paul Baerwald School of Social Work and Social Welfare, Hebrew University, Jerusalem, Israel
| | - Ulrich Stangier
- Department of Psychology, Goethe University Frankfurt, Germany
| | - Murray B Stein
- Department of Psychiatry and School of Public Health, University of California San Diego, United States of America
| | - Lusia Stopa
- Department of Psychology, University of Southampton, United Kingdom
| | - Charles T Taylor
- Department of Psychiatry and School of Public Health, University of California San Diego, United States of America
| | - Justin W Weeks
- Department of Psychology, Nebraska Medicine, Omaha, Nebraska, United States of America; Department of Psychiatry, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Matthias J Wieser
- Department of Psychology, Education, and Child Studies, Erasmus University Rotterdam, Netherlands
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Bulbena A, Rosado S, Cabaleiro M, Martinez M, Baeza-Velasco C, Martin LM, Batlle S, Bulbena-Cabré A. Validation of the neuroconnective endophenotype questionnaire (NEQ): a new clinical tool for medicine and psychiatry resulting from the contribution of Ehlers-Danlos syndrome. Front Med (Lausanne) 2023; 10:1039223. [PMID: 37234249 PMCID: PMC10206165 DOI: 10.3389/fmed.2023.1039223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 03/22/2023] [Indexed: 05/27/2023] Open
Abstract
Introduction The link between anxiety disorders and joint hypermobility syndrome (now under hypermobility spectrum disorders, which include hypermobile Ehlers-Danlos syndrome) has been widely replicated over the past 30 years and has grown beyond the initial nosological limits. To integrate clinical and research progress in this field, a new neuroconnective endophenotype (NE) and its corresponding instrument, the Neuroconnective Endophenotype Questionnaire (NEQ), have been developed. This new clinical construct, created with the active participation of patients, includes both somatic and psychological dimensions and symptoms and resilience items. Methods The NE includes five dimensions: (1) sensorial sensitivity, (2) body signs and symptoms, (3) somatic conditions, (4) polar behavioral strategies, and (5) psychological and psychopathological dimensions. The NEQ information is collected through four self-administered questionnaires (sensorial sensitivity, body signs and symptoms, polar behavioral strategies, and psychological characteristics) and a structured diagnostic part that should be completed by a trained observer. This hetero-administered part incorporates (a) psychiatric diagnoses (using structured criteria, e.g., MINI), (b) somatic disorders diagnosis, using structured criteria, and (c) assessment of joint hypermobility criteria. Results In a sample of 36 anxiety cases with 36 matched controls, the NEQ obtained high scores for test-retest, inter-rater reliability, and internal consistency. As for predictive validity, cases and controls significantly differed in all five dimensions and hypermobility measurements. Discussion We can conclude that the NEQ has achieved acceptable reliability and validity values and, therefore, is ready to be used and tested in different samples. This original and consistent construct including somatic and mental items may improve clinical specificity, the search for more comprehensive therapies, and their genetic and neuroimaging bases.
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Affiliation(s)
- Antonio Bulbena
- Department of Psychiatry and Forensic Medicine, Universitat Autonoma Barcelona, Barcelona, Spain
- Anxiety Unit, Hospital del Mar, Institute Neuropsychiatry and Addictions (INAD) CIBERSAM, Barcelona, Spain
| | - Silvia Rosado
- Anxiety Unit, Hospital del Mar, Institute Neuropsychiatry and Addictions (INAD) CIBERSAM, Barcelona, Spain
- Doctorate Program in Psychiatry, Department of Psychiatry and Forensic Medicine, Universitat Autonoma Barcelona, Barcelona, Spain
| | - Marina Cabaleiro
- Department of Psychiatry and Forensic Medicine, Universitat Autonoma Barcelona, Barcelona, Spain
- Anxiety Unit, Hospital del Mar, Institute Neuropsychiatry and Addictions (INAD) CIBERSAM, Barcelona, Spain
| | - María Martinez
- Department of Psychiatry and Forensic Medicine, Universitat Autonoma Barcelona, Barcelona, Spain
- Anxiety Unit, Hospital del Mar, Institute Neuropsychiatry and Addictions (INAD) CIBERSAM, Barcelona, Spain
| | - Carolina Baeza-Velasco
- Laboratoire de Psychopathologie et Processus de Santé, Université Paris Cité, Paris, France
- Department of Emergency Psychiatry and Acute Care, CHU Montpellier, Montpellier, France
- Institute of Functional Genomics, University of Montpellier, CNRS, INSERM, Montpellier, France
| | - Luis-Miguel Martin
- Anxiety Unit, Hospital del Mar, Institute Neuropsychiatry and Addictions (INAD) CIBERSAM, Barcelona, Spain
| | - Santiago Batlle
- Anxiety Unit, Hospital del Mar, Institute Neuropsychiatry and Addictions (INAD) CIBERSAM, Barcelona, Spain
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Zhang Y, Chen J, Gao W, Chen W, Xiao Z, Qi Y, Turel O, He Q. From fears of evaluation to social anxiety: The longitudinal relationships and neural basis in healthy young adults. Int J Clin Health Psychol 2023; 23:100345. [PMID: 36381587 PMCID: PMC9630624 DOI: 10.1016/j.ijchp.2022.100345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 10/01/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Social anxiety disorder (SAD) is a common mental health problem, and its core cognitive manifestation is the persistent fear of being evaluated, including both negatively (FNE) and positively (FPE). This study aimed to examine the longitudinal relationships of FNE, FPE and SAD and explore their neural basis. METHODS Three samples were retrieved in this study. First, the data of 649 college students who completed a survey and fMRI scan were used to explore the neural basis of FNE, FPE, and SAD symptoms. Next, the data of 450 participants who completed the same survey twice were used to examine the longitudinal relationships of the variables. Finally, the overlapping of the two samples (N = 288) who completed two surveys and the fMRI scan were used to establish a brain-behavior model. RESULTS Both FNE and FPE predicted SAD, and SAD also predicted FPE. The neural signals of subregions in prefrontal cortex were correlated with the scores of FNE, FPE and SAD. Abnormal prefrontal signals influenced SAD symptoms via fears of evaluation. CONCLUSIONS Our findings explain the behavioral and neural underpinnings of social anxiety from a fear of evaluation angle. This contributes to a better theorical understanding of SAD and clinical practice.
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Affiliation(s)
- Yifei Zhang
- Faculty of Psychology, MOE Key Laboratory of Cognition and Personality, Southwest University, Chongqing, China
| | - Junwen Chen
- Research School of Psychology, College of Health & Medicine, The Australia National University, Canberra, Australia
| | - Wei Gao
- Faculty of Psychology, MOE Key Laboratory of Cognition and Personality, Southwest University, Chongqing, China
| | - Wanting Chen
- Faculty of Psychology, MOE Key Laboratory of Cognition and Personality, Southwest University, Chongqing, China
| | - Zhibing Xiao
- Faculty of Psychology, MOE Key Laboratory of Cognition and Personality, Southwest University, Chongqing, China
| | - Yawei Qi
- Faculty of Psychology, MOE Key Laboratory of Cognition and Personality, Southwest University, Chongqing, China
| | - Ofir Turel
- School of Computing and Information Systems, The University of Melbourne, Parkville, VIC, Australia
| | - Qinghua He
- Faculty of Psychology, MOE Key Laboratory of Cognition and Personality, Southwest University, Chongqing, China,Southwest University Branch, Collaborative Innovation Center of Assessment toward Basic Education Quality, Chongqing, China,Corresponding author at: Faculty of Psychology, Southwest University, 2 Tiansheng Rd, Chongqing, 400715 China.
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6
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Zhang Y, Li Y, Mai X. Fear of negative evaluation modulates the processing of social evaluative feedback with different valence and contexts. Cereb Cortex 2022; 33:4927-4938. [PMID: 36190437 DOI: 10.1093/cercor/bhac390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 09/06/2022] [Accepted: 09/07/2022] [Indexed: 11/13/2022] Open
Abstract
Fear of negative evaluation (FNE) is a susceptible and maintaining factor of social anxiety disorders. However, the question, how people process negative evaluation is influenced by individual differences in FNE, is poorly understood. To clarify the habitual processing characteristics of individuals with different levels of FNE, electroencephalography was recorded when two groups of participants with high FNE (hFNE) and low FNE (lFNE) performed a social evaluation perception task in which the feedback context/source (human vs. a computer) and valence (thumb-up/like vs. thumb-down/dislike) were manipulated. We found effects of feedback source and valence on N1, P2, and P3, which reflect early attention, integrated perception, and elaborative processing, respectively, as well as general reward effects on reward positivity (RewP) across contexts. Importantly, compared to the lFNE group, the hFNE group showed larger midfrontal N1 and theta oscillation in response to negative feedback indicating dislike (vs. like), and also showed larger P3. These findings suggest that individuals with hFNE are more attentional vigilance to negative (vs. positive) social feedback, implying that individuals with different levels of FNE assign different implicit threat values to social-evaluation threat stimuli.
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Affiliation(s)
- Yinling Zhang
- Department of Psychology, Renmin University of China, Beijing 100872, China
| | - Yanju Li
- Department of Psychology, Renmin University of China, Beijing 100872, China
| | - Xiaoqin Mai
- Department of Psychology, Renmin University of China, Beijing 100872, China.,Laboratory of Department of Psychology, Renmin University of China, Beijing 100872, China.,Interdisciplinary Platform of Philosophy and Cognitive Science, Renmin University of China, Beijing 100872, China
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7
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Zeng R, Zhu D. Fear of Evaluation and Online Self-Disclosure on WeChat: Moderating Effects of Protective Face Orientation. Front Psychol 2021; 12:530722. [PMID: 34512427 PMCID: PMC8424039 DOI: 10.3389/fpsyg.2021.530722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 07/27/2021] [Indexed: 11/13/2022] Open
Abstract
Fear of evaluation is a key factor that affects how social media users present themselves to others, but little is known about the effects and mechanisms involved, especially on the relationship between fear of positive evaluation and online self-disclosure. This study explores how fear of evaluation affects online self-disclosure and examines how this relationship is moderated by protective face orientation in the Chinese context. A total of 750 Chinese WeChat users constituted the sample for a questionnaire-based analysis and regression analysis. The results showed that both fear of positive evaluation and fear of negative evaluation had a significant negative effect on the amount of online self-disclosure and a significant positive effect on the depth of online self-disclosure. Protective face orientation had a moderating effect on the relationship between fear of evaluation and online self-disclosure for both the amount and depth of online self-disclosure. Our findings suggest that social network site (SNS) users' fear of evaluation can be attributed to their cognitive attitude toward the external environment, and the loss of face in the Chinese context can be included in the social context.
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Affiliation(s)
- Runxi Zeng
- School of Journalism and Communication, Chongqing University, Chongqing, China
| | - Di Zhu
- School of Journalism and Communication, Chongqing University, Chongqing, China
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Murray RJ, Apazoglou K, Celen Z, Dayer A, Aubry JM, Ville DVD, Vuilleumier P, Piguet C. Maladaptive emotion regulation traits predict altered corticolimbic recovery from psychosocial stress. J Affect Disord 2021; 280:54-63. [PMID: 33202338 DOI: 10.1016/j.jad.2020.09.122] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/14/2020] [Accepted: 09/28/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Adaptive recovery from stress promotes healthy cognitive affective functioning, whereas maladaptive recovery is linked to poor psychological outcomes. Neural regions, like the anterior cingulate and hippocampus, play critical roles in psychosocial stress responding and serve as hubs in the corticolimbic neural system. To date, however, it is unknown how cognitive emotion regulation traits (cER), adaptive and maladaptive, influence corticolimbic stress recovery. Here, we examined acute psychosocial stress neural recovery, accounting for cER. METHODS Functional neuroimaging data were collected while forty-seven healthy participants performed blocks of challenging, time-sensitive, mental calculations. Participants immediately received performance feedback (positive/negative/neutral) and their ranking, relative to fictitious peers. Participants rested for 90 seconds after each feedback, allowing for a neural stress recovery period. Collected before scanning, cER scores were correlated with neural activity during each recovery condition. RESULTS Negative feedback recovery yielded increased activity within the dorsomedial prefrontal cortex and amygdala, but this effect was ultimately explained by maladaptive cER (M-cER), like rumination. Isolating positive after-effects (i.e. positive > negative recovery) yielded a significant positive correlation between M-cER and the anterior cingulate, anterior insula, hippocampus, and striatum. CONCLUSIONS We provide first evidence of M-cER to predict altered neural recovery from positive stress within corticolimbic regions. Positive feedback may be potentially threatening to individuals with poor stress regulation. Identifying positive stress-induced activation patterns in corticolimbic neural networks linked to M-cER creates the possibility to identify these neural responses as risk factors for social-emotional dysregulation subsequent to rewarding social information, often witnessed in affective disorders, like depression.
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Affiliation(s)
- Ryan J Murray
- Psychiatry Department, Faculty of Medicine, University of Geneva, Campus Biotech, 1202 Geneva, Switzerland.
| | - Kalliopi Apazoglou
- Psychiatry Department, Faculty of Medicine, University of Geneva, Campus Biotech, 1202 Geneva, Switzerland; Neuroscience Department, Laboratory for Behavioral Neurology and Imaging of Cognition, Campus Biotech, 1202 Geneva, Switzerland
| | - Zeynep Celen
- Psychiatry Department, Faculty of Medicine, University of Geneva, Campus Biotech, 1202 Geneva, Switzerland
| | - Alexandre Dayer
- Psychiatry Department, Faculty of Medicine, University of Geneva, Campus Biotech, 1202 Geneva, Switzerland; Mood Disorder Unit, Psychiatric Specialties Service, Geneva University Hospital, 1201 Geneva, Switzerland
| | - Jean-Michel Aubry
- Psychiatry Department, Faculty of Medicine, University of Geneva, Campus Biotech, 1202 Geneva, Switzerland; Mood Disorder Unit, Psychiatric Specialties Service, Geneva University Hospital, 1201 Geneva, Switzerland
| | - Dimitri Van De Ville
- Medical Image Processing Laboratory, Center for Neuroprosthetics, Institute of Bioengineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), Campus Biotech, 1202 Geneva, Switzerland; Department of Radiology and Medical Informatics, University of Geneva, 1211 Geneva, Switzerland
| | - Patrik Vuilleumier
- Neuroscience Department, Laboratory for Behavioral Neurology and Imaging of Cognition, Campus Biotech, 1202 Geneva, Switzerland
| | - Camille Piguet
- Psychiatry Department, Faculty of Medicine, University of Geneva, Campus Biotech, 1202 Geneva, Switzerland; Mood Disorder Unit, Psychiatric Specialties Service, Geneva University Hospital, 1201 Geneva, Switzerland
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