From service design thinking to the third generation of activity theory: a new model for designing AI-based decision-support systems

Introduction

The rise of Artificial Intelligence (AI), particularly machine learning, has brought a significant transformation in decision-making (DM) processes within organizations, with AI gradually assuming responsibilities that were traditionally performed by humans. However, as shown by recent findings, the acceptance of AI-based solutions in DM remains a concern as individuals still strongly prefer human intervention. This resistance can be attributed to psychological factors and other trust-related issues. To address these challenges, recent studies show that practical guidelines for user-centered design of AI are needed to promote justified trust in AI-based systems.

Methods and results

To this aim, our study bridges Service Design Thinking and the third generation of Activity Theory to create a model which serves as a set of practical guidelines for the user centered design of Multi-Actor AI-based DSS. This model is created through the qualitative study of human activity as a unit of analysis. Nevertheless, it holds the potential for further enhancement through the application of quantitative methods to explore its diverse dimensions more extensively. As an illustrative example, we used a case study in the field of human capital investments, with a particular focus on organizational development, which involves managers, professionals, coaches and other significant actors. As a result, the qualitative methodology employed in our study can be characterized as a "pre-quantitative" investigation.

Discussion

This framework aims at locating the contribution of AI in complex human activity and identifying the potential role of quantitative data in it.

Enhancing organizational processes for service innovation: strategic organizational counseling and organizational network analysis

Previous studies have primarily focused on product innovation, overlooking the examination of organizational processes. This limited perspective poses a theoretical and practical gap as it primarily considers the external aspects of innovation. On the contrary, organizational processes play a crucial role in improving and creating internal operations necessary for product/service innovation success. To this aim, this paper presents a novel approach to enhancing service innovation within complex organizations by integrating Strategic Organizational Counseling (SOC) and Organizational Network Analysis (ONA) methodologies. More specifically, SOC supports organizations in understanding and defining the professional families that need to be triggered in the service ideation, delivery and commercialization process, especially in the case of complex organizations with multiple departments. Secondly, ONA enables the identification of the intra-organizational nodes within the professional families that, due to their social position and other personal characteristics, can be actively engaged as Ambassadors for the promotion of innovation practices. By focusing on intra-organizational processes, understanding role-related needs, and selecting influential organizational actors, this approach provides a new perspective on the service innovation process, assuming both a micro and macro viewpoint. The paper also highlights the importance of cyclically monitoring the proposed workflow to adapt to the dynamic nature of innovation.

Natives with a need for cognitive closure can approve of immigrants' economic effect when they trust pro-immigrant epistemic authorities

Previous research on the need for cognitive closure (NFC), or the desire for epistemic certainty, has consistently found that it is associated with negative attitudes toward immigrants, among other outgroups, potentially because they represent agents of change and/or due to a general preference for perceived stability and certainty associated with right-wing politics. However, as individuals with this need theoretically prefer stable and certain knowledge, independent of the specific content, it is also possible that these individuals could have positive attitudes toward immigrants when they are provided with a positive source of information to which they can metaphorically "close" upon. In two studies (n = 397), controlling for participants' political orientation, we found that individuals with an NFC were more likely to accept immigrants when their positive effect was endorsed by an epistemic authority (Study 1), but only when they trusted this source (Study 2).

The contribution of activity theory to modeling multi-actor decision-making: A focus on human capital investments

Making investment decisions is usually considered a challenging task for investors because it is a process based on risky, complex, and consequential choices (Shanmuganathan, 2020). When it comes to Investments in human capital (IHC), such as startups fundings, the aspect of decision-making (DM) becomes even more critical since the outcome of the DM process is not completely predictable. Indeed, it has to take into consideration the will, goals, and motivations of each human actor involved: those who invest as well as those who seek investments. We define this specific DM process as multi-actor DM (MADM) since not a group is making decisions but different actors, or groups of different actors, who – starting from non-coinciding objectives – need to reach a mutual agreement and converge toward a common goal for the success of the investment. This review aims to give insights on psychological contributions to the study of complex DM processes that deal with IHC to provide scholars and practitioners with a theoretical framework and a tool for describing the complex socio-ecological systems involved in the DM processes. For this purpose, we discuss in the paper how the third generation of activity theory (Leont’ev, 1974, 1978;Engeström, 1987, 2001) could be used as an appropriate model to explain the specificities of MADM construct, focusing on the particular case of startup funding. Design thinking techniques will be proposed as a methodology to create a bridge between different activity systems.

The multifaceted nature of the response to adversity in an Italian sample of refugee community leaders

The end of the last decade saw record numbers of refugee arrivals to Italy, straining the existing reception and integration systems. Although significant research attention has focused on the prevalence of posttraumatic stress disorder (PTSD), depression, and suicidal ideation in refugee populations, there are increasing calls to study the interactions between distress, resilience, and positive outcomes of adversity. To fully understand the complexity of the refugee experience, these voices must be heard in dialogue. Studies must be framed within a more nuanced view of refugees, characterizing them not exclusively as victims but also as advocates for their own well-being and the well-being of their communities. This exploratory study performed a thematic analysis of 15 interviews conducted with refugee community leaders in Italy, each a founder or leader of a community association and actively engaged in civil society. In keeping with Papadopoulos' (2007) construct of adversity-activated development, an inductive analysis identified three distinct patterns of positive adversity response: meaning, motivation, and mobilization. A deductive analysis identified the most appropriate theories of resilience to describe the sample, which included resilience as a dynamic positive adaptation and resilience as resistance to change in moral codes and personal value systems. The resulting image of refugee community leaders in Italy is that of individuals who are exposed to adversity and experiences of suffering and distress but safeguard their core values while positively adapting to a new country.

A Multilevel Analysis of the Impact of Unit Tightness vs. Looseness Culture on Attitudes and Behaviors in the Workplace

This study examines the impact of work unit-level perceived Tightness vs. Looseness (T-L) culture on individual-level perceived stress, intention to leave, organizational deviance, job satisfaction, effort investment, and organizational commitment. Using quantitative cross-sectional data (N=417) collected from preexisting work units (N=57) in different organizations in Italy, multilevel analysis results revealed that a perceived cultural tightness at the unit level was significantly and positively related to individual-level job satisfaction, effort investment, and organizational commitment and significantly and negatively related to individual-level stress, intention to leave, and organizational deviance. The findings suggest that organizations should promote a culture of tightness to positively influence employee attitudes and behaviors. Limitations and recommendations for future research are discussed.

Defining Adjustment to Address the Missing Link between Refugees and Their Resettlement Communities

Background: data from the United Nations High Commissioner for Refugees (UNHCR) show that, in 2020, among 82.4 million refugees, only 251,000 returned to their home countries, indicating the desire for refugees to stay, for the long-term, in their new homelands. The paper contributes to the scientific–psychological debate on the social representation of refugee populations, by studying this population, not simply as “foreigners”, traumatized and resourceless people, but rather focusing on the factors that lead to their positive adjustments within local communities. Method: a scoping review was carried out to explore the phenomenon of adjustment (RQ1) and to identify the factors that foster adjustment among refugees and their resettlement communities (RQ2). A research protocol and eligibility criteria were defined prior to conducting the literature research through the Scopus database. Afterwards, data charting and items were conducted to organize the results. Results: a process of data mapping outlined three dimensions of adjustment—psychological, social, and scholastic. In addition, six macro factors emerged that ease refugee adjustments—context characteristics, time, social integration markers, acculturation, social support, and psychological capital. Results show that adjustment is the result of the inter-relations among sociological and psychological factors. Conclusions: the lack of studies addressing the inner resources of refugees and community participation confirms that research in this field needs a change of paradigm, to identify the resources that refugees use to adjust to their new communities and promote their development.

The Emergency Department's management of a severe acute psychomotor agitation: a rare case of an adult presentation of Rasmussen's Syndrome?

We report a severe acute psychomotor agitation treated in the Emergency Department. We hypothesized to be a rare case of an adult presentation of Rasmussen's Syndrome.

"The Flow in the Funnel": Modeling Organizational and Individual Decision-Making for Designing Financial AI-Based Systems

Nowadays, the current application of artificial intelligence (AI) to financial context is opening a new field of study, named financial intelligence, in which the implementation of AI-based solutions as "financial brain" aims at assisting in complex decision-making (DM) processes as wealth and risk management, financial security, financial consulting, and blockchain. For venture capitalist organizations (VCOs), this aspect becomes even more critical, since different actors (shareholders, bondholders, management, suppliers, customers) with different DM behaviors are involved. One last layer of complexity is the potential variation of behaviors performed by managers even in presence of fixed organizational goals. The aim of this study is twofold: a general analysis of the debate on implementing AI in DM processes is introduced, and a proposal for modeling financial AI-based services is presented. A set of qualitative methods based on the application of cultural psychology is presented for modeling financial DM processes of all actors involved in the process, machines as well as individuals and organizations. The integration of some design thinking techniques with strategic organizational counseling supports the modeling of a hierarchy of selective criteria of fund-seekers and the creation of an innovative value proposition accordingly with goals of VCOs to be represented and supported in AI-based systems. Implications suggest that human/AI integration in the field can be implemented by developing systems where AI can be conceived in two distinct functions: (a) automation: treating Big Data from the market defined by management of VCO; and (b) support: creating alert systems that are coherent with ordered weighted decisional criteria of VCO.

The mediating role of narcissism in the effects of regulatory mode on positivity

Positivity (i.e., the individual tendency to positively approach life experiences) has proven to be an effective construct applied in positive psychology. However, individuals’ self-regulation may have contrasting effects on positivity. We specifically examined whether positivity could be partially explained through two aspects of motivation concerned with self-regulation: locomotion (i.e., a motivational orientation concerned with movement) and assessment (i.e., a motivational orientation concerned with comparison and evaluation). Furthermore, based on previous literature that found a link between these aspects and narcissism, we examined whether “adaptive” and “maladaptive” dimensions of narcissism could mediate the effects of locomotion and assessment on increased or decreased positivity. Narcissism was defined by previous research as adaptive or maladaptive insofar as it leads or does not lead to increased psychological well-being. We estimated a mediation model with multiple independent variables and multiple mediators in a cross-sectional study with self-reported data from 190 university students. We found that both locomotion and assessment were associated with adaptive narcissism, which in turn was positively associated with positivity. However, assessment was also associated with maladaptive narcissism, which in turn was negatively associated with positivity. Relationships between aspects of self-regulation, narcissism, and positivity can have significant implications which will be discussed.

Social and Psychological Capital for the Start-Up of Social Enterprises With a Migratory Background

The highest number of forcibly displaced people has been currently recorded due to war, poverty, and climate change. Recently, a process that recognizes refugees as reliable interlocutors for the improvement of reception policies has started. Refugees are therefore encouraged to start up social enterprises aimed at fostering newcomers’ social integration to participate to such a phenomenon. Positive Psychology, with its focus on human strengths, allows to identify the resources that pushed refugees to turn the difficulties they faced during the journey and the resettlement process into resources for themselves and for the resettlement community. The following paper explores in particular the interplay between social and psychological capital that is at the base of a similar social entrepreneurship project through a case study. A qualitative research has been carried out within a social enterprise with a migratory background to analyze the internal and relational resources that brought founders to start up the venture. Results show that while social and psychological capital were independently activated to start from scratch in the resettlement community, they occurred in interrelation in a subsequent phase when participants transformed their direct experiences related to migration into the human capital of their enterprise.

Diagnostic and therapeutic challenges in neuroleptic malignant syndrome: a severe medical case

Neuroleptic malignant syndrome (NMS) is a rare, idiosyncratic medical emergency usually associated with the use of dopamine antagonists, commonly typical antipsychotic drugs. However, it has been observed that it can occur with atypical antipsychotics as well. NMS is characterized by altered consciousness, fever, rigidity, autonomic instability and high creatine phosphokinase (CPK) blood levels. Here, we report a case of a 44-year-old female patient with history of a treatment-resistant bipolar disorder. She was admitted to our psychiatric ward for severe psychomotor agitation and treated with a therapy based on typical and atypical antipsychotics. During the course of the hospitalization she developed NMS. In this case, the diagnosis was delayed due to the slow and insidious symptom presentation, therefore requiring a differential diagnosis. Autoimmune NMDA receptor encephalitis, catatonic syndrome and malignant catatonia have been excluded. The patient met all the DSM-5 criteria for NMS: exposure to dopamine-blocking agent, severe muscle rigidity, fever, diaphoresis, dysphagia, altered level of consciousness, mutism, tremors, tachycardia, high or labile blood pressure, leukocytosis, high creatine phosphokinase. Since robust evidence-based protocols are lacking, here we discuss the relevance of this case in order to highlight the hurdles of a prompt diagnosis, clinical management of associated complications and treatment possibilities for such emergency.

Vitamin D and N-Acetyl Cysteine Supplementation in Treatment-Resistant Depressive Disorder Patients: A General Review

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Major Depressive Disorder (MDD) is often a lifetime disabling mental illness as individuals with MDD might not benefit from standard-therapy, including both pharmacological and psychosocial interventions. Novel therapies are, therefore, required.

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It was shown by recent preclinical and clinical studies that the dysfunction of glutamatergic neurotransmission might be involved in the pathophysiology of MDD. Furthermore, neuroimmune alterations could have a significant role in the pathogenesis of MDD.

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Vitamin D is a neurosteroid hormone essential for several metabolic processes, immune responses, and for regulating neurotrophic-neuroprotective processes, neurotransmission and synaptic plasticity. Recent studies have also shown Vitamin D deficiency in patients with severe psychiatric disorders, including MDD.

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Lately, clinical studies have shown the neuroprotective action of N-acetyl cysteine (NAC) through the modulation of inflammatory pathways and via the modulation of synaptic release of glutamate in cortico-subcortical brain regions; the cysteine-glutamate antiporter.

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This paper reviews the therapeutic use of Vitamin D and NAC and among individuals with refractory MDD to the first- line pharmacological interventions, reviewing the clinical studies published in the last decade.

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A detailed summary of the current evidence in this area aims to better inform psychiatrists and general practitioners on the potential benefits of Vitamin D and NAC supplementation for this disorder.

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Nutraceutical supplementation with Vitamin D and NAC in treatment-resistant MDD patients may be important not only for improving depressive clinical manifestations but also for their safety and tolerability profile. This is of great interest, especially considering the need for treating special populations affected by MDD, such as youngsters and elders. Finally, the nutraceutical approach represents a good choice, considering its better compliance by the patients compared to traditional psychopharmacological treatment.

The Influence of Vitamin D on Neurodegeneration and Neurological Disorders: A Rationale for its Physio-pathological Actions

Vitamin D is a steroid hormone implicated in the regulation of neuronal integrity and many brain functions. Its influence, as a nutrient and a hormone, on the physiopathology of the most common neurodegenerative diseases is continuously emphasized by new studies. This review addresses what is currently known about the action of vitamin D on the nervous system and neurodegenerative diseases such as Multiple Sclerosis, Alzheimer's disease, Parkinson's disease and Amyotrophic Lateral Sclerosis. Further vitamin D research is necessary to understand how the action of this "neuroactive" steroid can help to optimize the prevention and treatment of several neurological diseases.

N-Acetyl Cysteine and Vitamin D Supplementation in Treatment Resistant Obsessive-compulsive Disorder Patients: A General Review

OBJECTIVE

Obsessive-compulsive Disorder (OCD) is a disabling mental illness for which pharmacological and psychosocial interventions are all too often inadequate. This demonstrates the need for more targeted therapeutics. Recent preclinical and clinical studies have implicated the dysfunction of glutamatergic neurotransmission in the pathophysiology of OCD. Moreover, there are studies suggesting that neuroimmune abnormalities may play an important role in the pathogenesis of OCD. N-acetyl cysteine (NAC) is a safe and readily available agent that would modify the synaptic release of glutamate in subcortical brain regions via modulation of the cysteine-glutamate antiporter. The modulation of inflammatory pathways may also play a role in the benefits seen following NAC treatment. Therefore NAC can be considered a neuroprotective agent.

METHODS

This paper explores the role of NAC in the treatment of OCD conditions refractory to first-line pharmacological interventions, reviewing the clinical studies published in the last decade.

RESULTS

The possible benefit mechanisms of NAC for this disorder will be discussed, as well as the role of vitamin D supplementation, given its specific property of stimulating the formation of glutathione in the brain.

CONCLUSION

Nutraceutical supplementation in treatment resistance OCD may be important not only for improving obsessive-compulsive symptomatology, but also from a psychological perspective, given its better acceptance by the patients compared to pharmacological treatment.

Bridging Museum Mission to Visitors' Experience: Activity, Meanings, Interactions, Technology

In recent years, the contribution of various disciplines and professionals (i.e., from marketing, computer science, psychology, and pedagogy) to museum management has encouraged the development of a new conception of museology. Specifically, psychology has affected the overall conception of museum and the visitors toward a more holistic vision of the museum experience as a complexity of memory, personal drives, group identity, meaning-making process, as well as leisure preferences. In this regard, psychological research contributes to advance the scientific knowledge about psychological and social phenomena related to the visitor experience, as well as to design innovative technologies and future tourism services. The present contribution discusses the Socio-Cultural Activity Theory (AT) as a theoretical framework to conceptualize the museum visit as an activity mediated by the technology, and to better identify the factors shaping the interaction between the visitors and the technologies. To do so, a case study is presented: a qualitative research performed at the Ara Pacis Museum in Rome (Italy) to analyze the visitor experience of a tour that integrates augmented and virtual reality. Information derived from applying AT on visitors’ experience highlight the value of technology as mediating tool between the museum mission and the visitor experience, considering the interaction between visitors’ characteristics, museum environmental dimensions, and technology’s features.

Cutaneous features of Zika virus infection: a clinicopathological overview

Zika virus (ZIKV) is an emerging mosquito-borne flavivirus transmitted mainly by Aedes species of mosquitos. Although the infection is usually mild and self-limiting, it is emerging as a public health challenge in tropical and subtropical countries owing to its unprecedented pathogenicity and increased risk for fetal malformations and neurological symptoms. Cutaneous manifestations as for other mosquito-borne viruses remain a hallmark of the disease. This article provides a detailed overview on ZIKV infection, including its varied cutaneous clinical manifestations and diagnostic aspects, and also provides detailed insights into its pathogenesis in human skin.

Team performance in the Italian NHS: the role of reflexivity

Purpose The purpose of this paper is twofold: first, to investigate the goodness of the input-process-output (IPO) model in order to evaluate work team performance within the Italian National Health Care System (NHS); and second, to test the mediating role of reflexivity as an overarching process factor between input and output. Design/methodology/approach The Italian version of the Aston Team Performance Inventory was administered to 351 employees working in teams in the Italian NHS. Mediation analyses with latent variables were performed via structural equation modeling (SEM); the significance of total, direct, and indirect effect was tested via bootstrapping. Findings Underpinned by the IPO framework, the results of SEM supported mediational hypotheses. First, the application of the IPO model in the Italian NHS showed adequate fit indices, showing that the process mediates the relationship between input and output factors. Second, reflexivity mediated the relationship between input and output, influencing some aspects of team performance. Practical implications The results provide useful information for HRM policies improving process dimensions of the IPO model via the mediating role of reflexivity as a key role in team performance. Originality/value This study is one of a limited number of studies that applied the IPO model in the Italian NHS. Moreover, no study has yet examined the role of reflexivity as a mediator between input and output factors in the IPO model.

Occupations at Risk and Organizational Well-Being: An Empirical Test of a Job Insecurity Integrated Model

One of the more visible effects of the societal changes is the increased feelings of uncertainty in the workforce. In fact, job insecurity represents a crucial occupational risk factor and a major job stressor that has negative consequences on both organizational well-being and individual health. Many studies have focused on the consequences about the fear and the perception of losing the job as a whole (called quantitative job insecurity), while more recently research has begun to examine more extensively the worries and the perceptions of losing valued job features (called qualitative job insecurity). The vast majority of the studies, however, have investigated the effects of quantitative and qualitative job insecurity separately. In this paper, we proposed the Job Insecurity Integrated Model aimed to examine the effects of quantitative job insecurity and qualitative job insecurity on their short-term and long-term outcomes. This model was empirically tested in two independent studies, hypothesizing that qualitative job insecurity mediated the effects of quantitative job insecurity on different outcomes, such as work engagement and organizational identification (Study 1), and job satisfaction, commitment, psychological stress and turnover intention (Study 2). Study 1 was conducted on 329 employees in private firms, while Study 2 on 278 employees in both public sector and private firms. Results robustly showed that qualitative job insecurity totally mediated the effects of quantitative on all the considered outcomes. By showing that the effects of quantitative job insecurity on its outcomes passed through qualitative job insecurity, the Job Insecurity Integrated Model contributes to clarifying previous findings in job insecurity research and puts forward a framework that could profitably produce new investigations with important theoretical and practical implications.

The Impact of Qualitative Job Insecurity on Identification with the Organization

Abstract. The detrimental effects of job insecurity are well recognized in the scientific literature. In this paper, we investigate the impact of qualitative job insecurity on an outcome that has been somewhat neglected to date: organizational identification. In addition, we test the moderating role of organizational justice in the relationship between qualitative job insecurity and organizational identification. A group of 170 workers completed a questionnaire assessing qualitative job insecurity, overall organizational justice, and identification with the organization. We found that qualitative job insecurity was negatively related to organizational identification as well as to organizational justice. Organizational justice buffered the negative impact of qualitative job insecurity on organizational identification. When organizational justice was low, qualitative job insecurity was significantly negatively related to organizational identification. However, when organizational justice was high, qualitative job insecurity and organizational identification were unrelated.

The role of locally-designed organizational artifacts in supporting nurses’ work: an ethnographic study on the wards

INTRODUCTION

This paper aims to describe how nurses' planning and coordination work is performed through the use of locally designed tools (i.e., diaries, planners, reminders, and organizers). These tools are investigated as the materialization of organizational work, thus offering a complementary perspective on nursing practice to that proposed by the professional mandate and supported by official artifacts in use.

METHOD

Ethnographic study.

RESULTS

By analyzing locally designed artifacts, the rationale that enables nurses to make the flow of activities work is highlighted and explained. Evidence is provided by a description of how nurses' tacit knowledge is reified and embedded into objects produced by the nurses themselves. Implications for the design of digital systems supporting nursing practice are discussed.

CONCLUSION

The analysis of these artifacts has allowed an understanding of practices used by the nurses to manage the workflow in the wards.

An Organizational Perspective to the Creation of the Research Field

The aim of the paper is to contribute to the definition and analysis of the "access to the field" (Feldman et al. 2003) through an inter-organizational perspective. The paper discusses a case study on the access of a researcher to a hospital department where both organizations and actors are shown as actively constructing the research site. Both researcher and participants are described in terms of work organizations originally engaged in parallel systems of activity. Dynamics of negotiation "tied" the different actors' activities in a new activity system where researcher and participants concur to the effectiveness of both organizations (i.e., the research and the hospital ward). An Activity Theory perspective (Leont'ev 1978) is used with the aim of focusing the analysis on the activities in charge to the different actors. The approach adopted introduces the idea that, from the outset, research is made possible by a process of co-construction that works through the development of a completely new and shared work space arising around the encounter between researchers and participants. It is the balance between improvised actions and the co-creation of "boundary objects" (Star and Griesemer 1989), which makes interlacement possible between the two activity systems. The concept of "knotworking" (Engeström 2007a) is adopted to interpret specific actions by both organizations and actors intended to build a knot of activities whereby the new research system takes place.

Metabolic syndrome in psychiatrically hospitalized patients treated with antipsychotics and other psychotropics

OBJECTIVE

We evaluated prevalence and risk factors for metabolic syndrome in inpatients treated with antipsychotics, with or without other psychotropic drugs. Although the literature on metabolic syndrome in psychiatry has expanded in recent years, we seek to elucidate some of the remaining gaps by examining a severely and chronically ill population heavily treated with pharmacological agents.

METHODS

With data from medical records of 589 adults hospitalized at McLean Hospital in 2010 and 2011, we used standard statistical analyses to characterize risks and covariates of metabolic syndrome.

RESULTS

With prior antipsychotic treatment, prevalence of metabolic syndrome was 29.5%. The syndrome was strongly associated with being overweight (≥25 kg/m(2) in 60.1% of subjects), older age, longer treatment-exposure, schizoaffective diagnosis (39.8%), more illness-episodes or hospitalizations, polytherapy, and higher total daily chlorpromazine-equivalent doses, but not sex. Notably, metabolic syndrome risk was greater among young, antipsychotic treated patients (15.5-fold at age ≤25 years).

CONCLUSIONS

The findings extend information on the association of metabolic syndrome with antipsychotic treatment. Metabolic syndrome was found in 30% of antipsychotic-exposed inpatients. Risk was surprisingly high in young persons and after brief treatment-exposure, and psychotropic polytherapy increased risk.

Insight and awareness as related to psychopathology and cognition

BACKGROUND

Insight affects adherence and treatment outcome and relates to cognitive impairment and psychopathology. We investigated the relationship of insight with cognition in patients with major depression, schizophrenia and bipolar disorder in acute psychiatric care, long-term inpatient, and outpatient settings.

METHODS

Eighty-one patients (women, 59.5%; age, 45.9 ± 13.5 years; 27 in each setting group; 33.3% with DSM-IV bipolar disorder, 39.5% with unipolar major depression, and 27.2% with schizophrenia) underwent the Wisconsin Card Sorting Test (WCST) to test flexibility, clinician-rated Scale to Assess Unawareness of Mental Disorder (SUMD), and self-rated Insight Scale (IS) to assess insight/awareness.

RESULTS

Poor performance on the WCST correlated with higher SUMD scores such as current psychiatric illness unawareness, impaired symptom attribution, unawareness of medication effect, or of social consequences, but not with IS scores. The latter correlated with days on continuous treatment. Patients receiving psycho-education showed greater symptom awareness compared to patients treated with drugs alone. Cognitive flexibility and diagnostic category did not correlate. Poor insight corresponded with severe mental illness, particularly acute psychosis.

CONCLUSIONS

Treatment setting specificity reflects psychopathology and severity. Insight is inversely proportional to illness severity and cognitive flexibility, which is also affected by psychopathology. Limitations comprise group heterogeneity, cross-sectional design, and limited sample size.

The tension between dialogicality and interobjectivity in cooperative activities

The context of a vocational e-learning project is used to explore the relation between dialogicality, intersubjectivity, and interobjectivity. By means of narrative analysis, we show that human mediation is sometimes directed outwards (interobjectivity) and sometimes directed inwards (intersubjectivity). Some interactions are closer to the intersubjectivity polarity because participants focus on a shared understanding of the world, whereas others are oriented to the interobjectivity polarity because subjects direct their efforts to what is shared ‘‘out there in the world.’’ We claim that this positioning between the two polarities influences the type of interaction occurring between the subjects. Whenever subjects engage in dialogical interactions, where the other’s collaboration is sought to redefine a shared understanding of the present state of the activity, the intersubjective polarity is put in place. In contrast, when the other’s position takes on an instrumental function, the interobjectivity polarity is chosen.

Folie à deux: double case-report of shared delusions with a fatal outcome

BACKGROUND

Treatment of shared delusional disorder (folie à deux) often involves separation and use of antipsychotic medication, with uncertain outcomes and potential risks.

METHODS

We report on two highly interdependent and chronically psychotic sisters with shared systematic delusion, followed by psychiatrists over several years.

RESULTS

The dominant patient was diagnosed with schizoaffective disorder and her non-dominant sister with paranoid schizophrenia. Both received antipsychotics and supportive therapy as outpatients and allowed to continue conjoint therapy with individual psychiatrists-therapists. They returned for follow-up visits for 20 months, when the dominant decided to continue treatment alone, as her sister gradually improved symptomatically and functionally. After separation, the dominant became increasingly anxious. She impulsively ingested an overdose of the non-dominant sister's medicines and died of cardiac arrest, despite her sister's efforts to seek medical assistance. The surviving non-dominant sister developed anxiety and increasing agitation requiring psychiatric hospitalization and increased pharmacotherapy. She improved gradually, but continued to be dysfunctional and required placement in a psychiatric inpatient unit for several months, eventually doing better in a community-based rehabilitative program with regular psychiatric follow-up.

CONCLUSIONS

Combined treatment of patients with folie à deux may encourage continuous pathological interactions, but separation may increase risk of adverse outcomes.

Suicide attempters in the emergency department before hospitalization in a psychiatric ward

PURPOSE

The study aims to compare the current suicidal risk of mood disorder patients who had just attempted suicide, as compared with those who had not attempted suicide, admitted to an emergency department (ED), and then hospitalized in a psychiatric unit.

METHOD

One hundred sixty-one mood disorder patients admitted to the ED were studied. A total of 22.4% of the participants were admitted for a suicide attempt. Patients were assessed for psychopathology and diagnosis.

FINDINGS

Suicide attempters were nearly 12 times more likely to report ongoing suicidal ideation during the psychiatric evaluation in the ED than nonattempters. Men and women did not differ for current and previous suicide attempts or for ongoing suicidal ideation.

PRACTICAL IMPLICATIONS

It is important to conduct a suicide risk assessment when individuals are admitted to an ED.

Is season of birth related to developmental dyslexia?

Different moderators/mediators of risk are involved in developmental dyslexia (DD), but data are inconsistent. We explored the prevalence of season of birth and its association with gender and age of school entry in an Italian sample of dyslexic children compared to an Italian normal control group. The clinical sample included 498 children (345 boys, mean age 10.3 ± 2.1 years) with DD, the control sample 1,276 children (658 boys, mean age 10.8 ± 2.2 years) from four elementary schools from the same urban area, and with the same socio-economic status level. A prevalence of birth in autumn was found among children with DD compared to controls (34% versus 24%, p < 0.0001). Children with DD were more frequently males (p < 0.0001) and had a lower mean age of school entry (p < 0.0001). Regarding the distribution of ages, 11.4% of children with DD, but none of the subjects in the control group, started school before 5.7 years. Therefore, greater risk of DD was related to age of school entry (OR = 2.72), gender (OR = 2.16), and season of birth (OR = 1.21). Significant interactions between boys with DD born in autumn, and correct school of entry (OR = 2.56) were joint predictors of higher risk of DD. The association between birth in autumn and DD may be explained by the earlier age of school entry, which may be a critical element in the youngest children with DD or at risk to DD. Whether Italian school policy is oriented to anticipate the school entry, a closer detection of early learning disorders and associated risk factors (familial load, specific language disorders, and attention deficit hyperactivity disorder) should be warranted.

Characteristics and clinical changes during hospitalization in bipolar and psychotic disorder patients with versus without substance-use disorders

BACKGROUND

Co-morbid substance-use disorders (SUDs) are prevalent among patients with severe psychiatric disorders, but the characteristics of such patients remain incompletely defined, and their current treatments and responses, poorly documented.

METHODS

We evaluated the records of 481 consecutive inpatients diagnosed with DSM-IV bipolar or schizoaffective disorders, or schizophrenia, admitted to McLean Hospital in 2004 or 2009. Demographic and clinical characteristics, and treatments, were extracted from hospital and pharmacy records for bivariate and multivariate analyses.

RESULTS

SUD prevalence increased 1.84-times from 2004 (31.3%) to 2009 (57.6%). Patients with (n=204) versus without co-morbid SUDs (n=277) were similar in many respects, but in multivariate modeling, the following factors were more likely with SUD, in rank-order: co-morbid anxiety disorders > men more than women > greater prevalence in 2009 vs. 2004 > younger age > greater doses of mood-stabilizers > shorter hospitalization.

CONCLUSIONS

Hospitalized patients with severe primary psychiatric disorders, and comorbid SUD were more likely to be young and have anxiety disorders, to receive more combinations and higher doses of mood-stabilizers, and show more improvement in impulsivity and hostility, but otherwise differed little in treatment-responses. Prevalence of SUD rose substantially in the past five years, with increased but largely unproved use of mood-stabilizers.

Changes in medication practices for hospitalized psychiatric patients: 2009 versus 2004

BACKGROUND

We tested the hypothesis that combinations and total daily doses of psychotropics for hospitalized patients diagnosed with major psychiatric disorders are rising.

METHODS

We evaluated McLean Hospital records of 481 consecutive inpatients with DSM-IV schizophrenia, schizoaffective, or bipolar disorders in 2004 (n = 278) or 2009 (n = 203) to compare characteristics and treatments.

RESULTS

In 2009, Clinical Global Impression (CGI)-severity scores were 6% lower at intake and improved 1.7 times more than in 2004, as hospitalization-length decreased by 12%. Polytherapy (> or = 2 psychotropics) increased in 2009 (affective or schizoaffective disorders > schizophrenia). Total psychotropics/patient (3.1-3.2) remained stable but mood-stabilizers/patient increased markedly and antipsychotics/patient decreased somewhat in 2009. Antipsychotic-choice (2009) ranked: quetiapine, aripiprazole, risperidone, and others; mood-stabilizers ranked: lamotrigine, valproate, lithium, and others (1/4 off-label). In 2009, final total antipsychotic doses (mg/day) increased by 97%, and mood-stabilizers by 75%. Adverse-effect rates fell by half. Factors differing independently for 2009 versus 2004 ranked: (a) more CGI improvement, (b) more mood-stabilizers/patient, (c) lower admission CGI scores, and (c) higher total antipsychotic dose.

COMMENT

Combinations and doses of antipsychotic and mood-stabilizing drugs for inpatients increased markedly (2004 vs. 2009) without consistent correspondence of agents/person and doses, without apparent increase in major adverse effects, and with possibly superior clinical improvement.

Burnout, hopelessness and suicide risk in medical doctors

OBJECTIVES

The aim of the present study was to investigate the association between burnout and hopelessness in medical doctors.

MATERIALS AND METHODS

We conducted an investigation of 133 medical doctors working either in a hospital setting or in general practice to explore the relationship between the level of burnout and hopelessness, a psychometric marker for suicide risk. The participants were administered the Oldenburg Burnout Inventory (OBI) and Beck's Hopelessness Scale (BHS).

RESULTS

Burnout is an important issue in mediating the level of hopelessness. Doctors with high hopelessness had higher scores on the disengagement factor (2.61±0.47 vs 2.14±0.41; t131=-4.37; p<0.001; Cohen D=1.07), and on the exhaustion factor (2.68±0.65 vs 2.19±0.54; t131=-3.39; p<0.001; Cohen D=0.82) than doctors with low hopelessness. A multivariate regression analysis confirmed that disengagement and exhaustion are significant predictors of the BHS scores.

CONCLUSIONS

People in charge of workers' health should pay particular attention to the level of burnout in doctors, intervene with changes in the work environment and evaluate the impact of such procedures.

The long-term effects of extreme war-related trauma on the second generation of Holocaust survivors

The psychological consequences of intergenerational trauma on the second generation of Holocaust survivors were studied in a sample of 40 nonimmigrant Italian Jews and compared to a control group. Differences between offspring of Holocaust survivors (HSO) and a comparison group were assessed by the Adjective Check List, Anxiety Questionnaire Scale, Defence Mechanism Inventory, and Family Environment Scale. Although the HSO displayed no serious psychological consequences, they had higher anxiety levels than controls, low self-esteem, inhibition of aggression, and relational ambivalence. These data partially confirm previous research on the topic, although the level of psychological distress seems to be lower in the Italian sample than in other samples of second-generation Holocaust survivors.

Comparison of mania patients suitable for treatment trials versus clinical treatment

It remains uncertain whether bipolar disorder (BPD) patients in randomized-controlled trials (RCTs) are sufficiently representative of clinically encountered patients as to guide clinical-therapeutic practice. We complied inclusion/exclusion criteria by frequency from reports of 21 RCTs for mania, and applied them in a pilot study of patients hospitalized for DSM-IV BPD manic/mixed states to compare characteristics and clinical responses of patients who did versus did not meet exclusion criteria. From 27 initially identified inclusion/exclusion criteria ranked by citation frequency, we derived six inclusion, and 10 non-redundant-exclusion factors. Of 67 consecutive patients meeting inclusion criteria, 15 (22.4%) potential "research subjects" met all 10 exclusion criteria. The remaining 52 "clinical patients" differed markedly on exclusion criteria, including more psychiatric co-morbidity, substance abuse, involuntary hospitalization, and suicide attempts or violence, but were otherwise similar. In both groups responses to clinically determined inpatient treatments were similar, including improvement in mania ratings. Based on applying reported inclusion/exclusion criteria for RCTs to a pilot sample of hospitalized-manic patients, those likely to be included in modern RCTs were similar to patients who would be excluded, most notably in short-term antimanic-treatment responses. The findings encourage further comparisons of subjects included/excluded from RCTs to test potential clinical generalizability of research findings. The pilot study is limited in numbers and exposure times with which to test for the minor differences between "research subjects" and "clinical patients."

Personality and psychopathological profiles in individuals exposed to mobbing

Increasingly, mental health and medical professionals have been asked to assess claims of psychological harm arising from harassment at the workplace, or "mobbing." This study assessed the personality and psychopathological profiles of 146 individuals exposed to mobbing using validity, clinical, and content scales of the Minnesota Multiphasic Personality Inventory 2. Profiles and factor analyses were obtained. Two major dimensions emerged among those exposed to mobbing: (a) depressed mood, difficulty in making decisions, change-related anguish, and passive-aggressive traits (b) somatic symptoms, and need for attention and affection. This cross-sectional pilot study provides evidence that personality profiles of mobbing victims and psychological damage resulting from mobbing may be evaluated using standardized assessments, though a longitudinal study is needed to delineate cause-and-effect relationships.

Comorbid substance-use in schizophrenia: relation to positive and negative symptoms

As substance use disorders (SUD) are common in schizophrenia patients, we tested the hypothesis that comorbid patients (SUD[+]) have more positive vs. negative symptoms than non-comorbid (SUD[-]) patients. From reports identified by literature-searching we compared Positive and Negative Syndrome Scale (PANSS) ratings in schizophrenia patients with and without SUD using meta-analytic methods. Among 9 comparisons (N=725 subjects), SUD[+] patients were more often men, and abused alcohol>cannabis>cocaine. SUD[+] patients had very significantly higher PANSS-positive, and lower PANSS-negative scores. Comorbid SUD in schizophrenia patients was associated with male sex and higher PANSS positive to lower negative scores. Cause-effect relationships remain to be clarified.

Use of combinations of antipsychotics: McLean Hospital inpatients, 2002

BACKGROUND

The empirical use of combinations of antipsychotic agents appears to be increasing with little research support for the relative efficacy, safety or cost-effectiveness of this practice. Such treatment was evaluated in hospitalized psychiatric patients.

METHODS

Samples of consecutive inpatients treated with > or = 2 ('polytherapy') vs 1 antipsychotic ('monotherapy') were matched on age, sex, diagnosis and admission clinical ratings, and these groups were compared on total daily chlorpromazine-equivalent doses, days in hospital, and changes in clinical ratings between admission and discharge.

RESULTS

The study sample included 69 polytherapy and 115 well-matched monotherapy subjects. Despite matching for initial CGI and GAF ratings, polytherapy was associated with high PANSS subscale scores of positive symptoms among affective psychosis, and relatively greater PANSS subscale ratings of excitement-agitation among patients diagnosed with schizophrenia. Estimated clinical improvement during hospitalization was similar among poly- and monotherapy patients, but total daily CPZ-eq doses at discharge averaged twice-greater with polytherapy, and hospitalization lasted 1.5 times longer.

CONCLUSIONS

Antipsychotic polytherapy as well as the types of agents combined may reflect clinician responses to particular symptom patterns. The value of specific combinations of antipsychotic agents and their comparison with monotherapies requires specific, prospective, randomized and well-controlled trials that consider matching on clinical characteristics and truly comparable doses across regimens.

Strategic identities in cyberspace

This paper aims at describing, according to the recent advances in social psychology and Computer Mediated Communication, how identities are perceived and constructed in cyberspace. All interactions analyzed in this study were performed within "Euroland," a collaborative virtual environment. The interacting community was composed of students, teachers, and researchers working on a transnational educational project. Practices and dialogues within Euroland are analyzed using an ethnographic and conversational method. A sample of discourses and actions that occurred during 8 months of time, selected according to the research aims, was analyzed. During online connections, users were personified by an "Avatar." Avatars are able to walk, fly, and look around the virtual world. They are also able to build and manipulate three-dimensional objects, perform virtual actions, and chat with other connected users. Results showed that "Eurolanders" showed and constructed their identities using strategic "positioning" depending on the interactive situation. Identities are thus dynamic and strongly related to the context, created and constantly recreated by the users. It is concluded that specific features offered by the Euroland environment are exploited by the users as resources to play with, while moving from one strategic positioning to another. Cyber identities involve resources given by specific technological tools and by community. The cyber-identity construction process seems to be highly congruent to the advances in the dialogical perspective in psychology, where identities are considered in their conceptualizations as multiple, "multivoiced," "positioned," and context-dependent.