Unplanned admissions after day-case surgery in an Italian third-level pediatric hospital: a retrospective study.

BACKGROUND: Increasing procedures in day-case surgery can mitigate the costs of health service, without reducing safety and quality standards. The Ospedale Pediatrico Bambino Gesù has adopted an educational program for healthcare personnel and patients' families to increase the number of day-case surgery procedures performed without reducing the level of safety. The unplanned admission rate after day-case surgery can be a quality benchmark for pediatric day-case surgery, and in literature, there are no Italian data. METHODS: We made a retrospective analysis of the hospital database and focused on children requiring unplanned admission to the central venue of the hospital for the night. The audit covered the period from September 2012 to April 2018. RESULTS: We performed general anesthesia for 8826 procedures (urology 33.60%, plastic surgery 30.87%, general surgery 17.44%, dermatology 11.66%, dentistry 3.16%, orthopedics 1.64%, digestive endoscopy 1.63%). Unplanned admission for anesthetic reasons resulted in two cases: one case of syncope and one case of vomit (0.023% rate). No one major complication. CONCLUSIONS: Good quality of patient selection, the safety of the structure, family education, and an efficient organizational model combined with an educational program for anesthesiologists can improve the safety of anesthesia for day-case surgery.

Exploring Guilt Differences in Grandiose Narcissism, Vulnerable Narcissism, and Malignant Self-Regard.

Narcissistic personality disorder is a heterogeneous and complex pathology which manifests itself very differently in individuals. The aim of the present study was to analyze differences and similarities in morality and sensitivity to feelings of guilt among grandiose narcissism (GN), vulnerable narcissism (VN), and malignant self-regard (MSR). We expected that MSR and VN would be most sensitive to deontological and altruistic guilt, and that MSR and VN would have higher levels of moral standards than GN. A nonclinical sample of 752 participants was evaluated. Results showed a significant association among MSR, VN, and GN. According to our hypothesis, GN turned out to be the one with the lowest association values to guilt measures. Our results demonstrated that MSR is strongly associated with all types of guilt, GN is associated with a substantial lack of guilt, and VN is associated with deontological guilt and self-hate, but not altruistic guilt. Results confirm the relevance of considering and understanding guilt when differentiating GN, VN, and MSR.

Preliminary Development and Psychometric Evaluation of the Metacognition Brief Rating Scale: An Informant form of the Metacognition Self-Assessment Scale.

Objective: Metacognition has been conceptualized as the ability to reflect on self and others' mental states and representations, including affects, beliefs, and intentions. The Metacognition Self-Assessment Scale (MSAS) was developed to assess various aspects of metacognition, aiming to leverage its potential applications in fields like clinical psychology and psychotherapy. However, a concern associated with MSAS is whether individuals can accurately self-report difficulties in identifying and describing mental states, both their own and others', when they lack these abilities. In response to this challenge, we aimed to develop and validate an alternative reporting tool, the Metacognition Brief Rating Scale (MBRS), which serves as an informant form of MSAS. Method: The MBRS was administered to 384 individuals randomly recruited from the general population. We employed a methodological strategy based on three successive steps. In the preliminary step, items from the MSAS were rewritten into a third-person version by the authors. In the second step, we examined whether the four-factor structure was congruent between the informant-report (MBRS) and the self-report (MSAS) using exploratory and confirmatory factor analysis. In the last step, we examined and compared the psychometric properties of the MBRS and MSAS items, including item characteristics and internal reliability analyses. Results: The psychometric properties (items and scales) of both versions were found to be adequate, and the four-factor structure of the MBRS was supported. The correlation between the two versions was statistically significant, and the factor structures were similar. Conclusions: The results support the psychometric properties of the MBRS. However, further research is needed, especially in larger non-clinical and clinical samples, to replicate and extend these findings.

Analysis on Burnout, Job Conditions, Alexithymia, and Other Psychological Symptoms in a Sample of Italian Anesthesiologists and Intensivists, Assessed Just before the COVID-19 Pandemic: An AAROI-EMAC Study.

Background. It was previously reported that health care professionals working in the fields of anesthesiology and emergency are at higher risk of burnout. However, the correlations between burnout, alexithymia, and other psychological symptoms are poorly investigated. Furthermore, there is a lack of evidence on which risk factors, specific to the work of anesthetists and intensivists, can increase the risk of burnout, and which are useful for developing remedial health policies. Methods. This cross-sectional study was conducted in 2020 on a sample of 300 professionals recruited from AAROI-EMAC subscribers in Italy. Data collection instruments were a questionnaire on demographic, education, job characteristics and well-being, the Maslach Burnout Inventory Tool, the Toronto Alexithymia Scale, the Symptom Checklist-90-R, and the Rosenberg Self-Esteem Scale administered during refresher courses in anesthesiology. Correlations between burnout and physical and psychological symptoms were searched. Results. With respect to burnout, 29% of individuals scored at high risk on emotional exhaustion, followed by 36% at moderate-high risk. Depersonalization high and moderate-high risk were scored by 18.7% and 34.3% of individuals, respectively. Burnout personal accomplishment was scored by 34.7% of respondents. The highest mean scores of burnout dimensions were related to dissatisfaction with one's career, conflicting relationships with surgeons, and, finally, difficulty in explaining one's work to patients. Conclusions. Burnout rates in Italian anesthesiologists and intensivists have been worrying since before the COVID-19 pandemic. Anesthesiologists with higher levels of alexithymia are more at risk for burnout. It is therefore necessary to take urgent health policy measures..

Metacognition Mediates the Relationship Between Maladaptive Personality Traits and Levels of Personality Functioning: A General Investigation on a Nonclinical Sample.

ABSTRACT: The impaired ability to reflect on one's own state of mind and that of others (called metacognition or mentalization) is a central feature of personality disorders (PDs). Metacognition involves different specific abilities, which can be selectively impaired with different PDs and personality maladaptive traits. Moreover, research in the field of PDs has indicated that personality features and metacognitive abilities are associated with the severity of personality pathologies. In this study, we tested a mediation model of the interactions between these variables on predicting levels of personality functioning in a sample of adults taken from the general population (N = 775). Results showed that the relationship between personality traits and personality functioning is partially mediated by metacognitive abilities. These findings support the hypothesis that metacognition plays a significant role in predicting the levels of impairment in personality functioning. These findings have several clinical implications.

Metacognition as a Predictor of Improvements in Personality Disorders.

Personality Disorders (PDs) are particularly hard to treat and treatment drop-out rates are high. Several authors have agreed that psychotherapy is more successful when it focuses on the core of personality pathology. For this reason, therapists dealing with PDs need to understand the psychopathological variables that characterize this pathology and exactly what contributes to maintaining psychopathological processes. Moreover, several authors have noted that one key problem that characterizes all PDs is an impairment in understanding mental states - here termed metacognition - which could also be responsible for therapy failures. Unfortunately, a limited number of studies have investigated the role of mentalization in the process of change during psychotherapy. In this paper, we assume that poor metacognition corresponds to a core element of the general pathology of personality, impacts a series of clinical variables, generates symptoms and interpersonal problems, and causes treatment to be slower and less effective. We explored whether changes in metacognition predicted an improvement among different psychopathological variables characterizing PDs; 193 outpatients were treated at the Third Center of Cognitive Psychotherapy in Rome, Italy, and followed a structured path tailored for the different psychopathological variables that emerged from a comprehensive psychodiagnostic assessment that considered patients' symptoms, metacognitive abilities, interpersonal relationships, personality psychopathology, and global functioning. The measurements were repeated after a year of treatment. The results showed that changes in metacognitive abilities predicted improvements in the analyzed variables.

Expanding the validity of the malignant self-regard construct in an Italian general population sample.

Malignant self-regard (MSR) was proposed as a particular type of self-structure that may account for similarities among a set of clinically relevant Personality Disorders (PDs) such as masochistic/self-defeating and depressive PDs that yet have failed to be adequately represented in the diagnostic manuals. The investigation on the MSR may provide a better framework upon which to understand the nature of these personality types and their discrimination from related constructs. The present study examines the psychometric properties of the Italian adaptation of the Malignant Self-Regard Questionnaire (MSRQ). Reliability and validity indicators are determined in a large sample of adults from general population (n = 2574). The measure was found to be reliable and valid, given its correlations with measures of depressive personality, negative affectivity, self-defeating, and vulnerably narcissistic personalities. MSR also can be meaningfully differentiated from a nomological network of related constructs, including sadness rumination, depression, neuroticism, extraversion, and grandiose narcissism. These findings suggest that MSR may be a personality component which includes a negativistic self-representation, vulnerability and hypersensitivity to judgment, sometimes compensated by perfectionistic tendencies. As a whole, results seem to support the reliability and the validity of the Italian adaptation of the MSRQ as a measure of the MSR.

Symptom severity and mindreading in narcissistic personality disorder.

BACKGROUND: Grandiose narcissism has been associated with poor ability to understand one's own mental states and the mental states of others. In particular, two manifestations of Narcissistic Personality Disorder (NPD) can be explained by poor mindreading abilities: absence of symptomatic subjective distress and lack of empathy. METHODS: We conducted two studies to investigate the relationships between mindreading capacity, symptomatic subjective distress and narcissistic personality. In the first study (N = 246), we compared mindreading capacities and symptomatic distress in three outpatient samples: narcissistic patients (NPD); patients with other Personality Disorders (PD); patients without PD. In the second study (N = 1357), we explored the relationships between symptomatic distress, mindreading and specific NPD criteria. RESULTS: In the first study, the NPD patients showed poorer mindreading than the patients without PD and comparable to patients with other PDs. Symptomatic subjective distress in the narcissistic group was less severe than in the other PDs group and comparable to the group without PDs. However, no relationship emerged between mindreading and symptomatic subjective distress. In the second study, taking the clinical sample as a whole, symptomatic distress appeared negatively linked to grandiosity traits, while mindreading scores were negatively linked to empathy. CONCLUSIONS: NPD showed specific mindreading impairments. However, mindreading capacity did not appear to be directly connected with subjective distress, but did appear to be connected with specific aspects of narcissistic pathology.

Cooperation in psychotherapy increases metacognitive abilities: a single-case study.

INTRODUCTION: Both clinical observations and empirical data suggest that the ability to think about the mental states of themselves and others (i.e., metacognition) is a crucial factor strongly associated to the outcome of individual psychotherapies. Although it has been hypothesized that the activation of cooperation between patient and psychotherapist within psychotherapy sessions may increase metacognitive abilities, few data is still available to support this hypothesis. METHODS: We explore the association between cooperation of patient and psychotherapist and the modifications of metacognition abilities along five sessions of a patient with a personality disorder using the Assessing Interpersonal Motivations in Transcripts method (AIMIT) and the Metacognition Assessment Scale (MAS). RESULTS: Our data showed that the activation of cooperation was positively associated with both the MAS total scores and all MAS sub-scales. DISCUSSION AND CONCLUSION: Our results demonstrate that the activation of the cooperation within therapeutic relationship can increase patient's metacognition and its subsystem (e.g. self-monitoring).

Avoidant personality disorder and social phobia: Does mindreading make the difference?

OBJECTIVE: Avoidant personality disorder (AvPD) is closely related to and partially overlaps with social phobia (SP). There is an ongoing debate as to whether AvPD and SP can be classified as separate and distinct disorders or whether these diagnoses rather reflect different degrees of severity of social anxiety. The hypothesis of this study is that in patients with AvPD and in those with AvPD and comorbid SP both interpersonal functioning and metacognitive abilities (the ability to understand mental states) are more severely impaired than they are in patients with SP only. We also hypothesise that the interpersonal and metacognitive functioning of these patients (both AvPD and AvPD+SP) is comparable to that of patients with other PD diagnoses. METHODS: To test this hypothesis, we compared four groups (22 patients with SP, 32 patients with AvPD, 43 patients with both AvPD and SP and 50 patients with other personality disorders without SP and AvPD criteria) on metacognitive abilities, interpersonal functioning and global symptomatic distress. RESULTS: Metacognitive ability showed significant variation among the four groups, with the lowest score observed in the AvPD group. As far as the interpersonal functioning is concerned, the lack of sociability was more severe in the AvPD group compared with the SP group. These differences were maintained even after controlling for global symptomatic distress. CONCLUSION: Results are in line with the alternative model of PD, proposed in the DSM-5, as dysfunction of the self and relationships. They suggest that specific impairments in critical areas of self domains and interpersonal domains of personality functioning may serve as markers distinguishing AvPD from SP.

Mindreading Dysfunction in Avoidant Personality Disorder Compared With Other Personality Disorders.

The ability to reflect on one's own states of mind and those of others (metacognition or mindreading) is strongly implicated in personality disorders (PDs). Metacognition involves different abilities, and there is evidence that specific abilities can be selectively impaired in different PDs. The purposes of this study were to compare metacognitive competence in avoidant PD (AvPD) with that in other PDs and to investigate whether there is a specific profile for AvPD. Sixty-three patients with AvPD and 224 patients with other PDs were assessed using the Metacognitive Assessment Interview. AvPD patients showed difficulties with two metacognitive functions: monitoring and decentration, even when the severity of psychopathology was controlled for. These results support the hypothesis of specific profiles of metacognitive dysfunction in different PDs and highlight a close link between impaired monitoring and decentration functions and the inhibited and withdrawn personality style typical of AvPD.

Perfectionism and Personality Disorders as Predictors of Symptoms and Interpersonal Problems.

Maladaptive perfectionism is a common factor in many disorders and is correlated with some personality dysfunctions. Less clear is how dimensions, such as concern over mistakes, doubts about actions, and parental criticism, are linked to overall suffering. Additionally, correlations between perfectionism and personality disorders are poorly explored in clinical samples. In this study we compared a treatment seeking individuals (n=93) and a community sample (n=100) on dimensions of maladaptive perfectionism, personality disorders, symptoms, and interpersonal problems. Results in both samples revealed maladaptive perfectionism was strongly associated with general suffering, interpersonal problems, and a broad range of personality disordered traits. Excessive concern over one's errors, and to some extent doubts about actions, predicted unique additional variance beyond the presence of personality pathology in explaining symptoms and interpersonal problems.

Personality Disorders and Mindreading: Specific Impairments in Patients With Borderline Personality Disorder Compared to Other PDs.

The capacity of understanding mental states is a complex function which involves several components. Single components can be selectively impaired in specific clinical populations. It has been suggested that impairments in mindreading are central for borderline personality disorder (BPD). However, empirical findings are inconsistent, and it is debatable whether BPD presents a specific profile of mindreading impairments. The aim of this study is to compare BPD and other PDs in mindreading. Seventy-two patients with BPD and 125 patients with other PD diagnoses were assessed using the Metacognition Assessment Interview. BPD showed difficulties in two mindreading functions, differentiation and integration, even when the severity of psychopathology was controlled. These results suggest a specific mindreading impairment in BPD and a strong relationship between these impairments and the severity of psychopathology.

Italian normative data for the Battery for Visuospatial Abilities (TERADIC).

Battery for Visuospatial Abilities (BVA, known in Italy as TeRaDiC) has been developed to analyse putative basic skills involved in drawing and to plan and monitor outcomes after rehabilitation of visuoconstructional disorders. It encompasses eight tasks assessing both simple "perceptual" abilities, such as line length and line orientation judgments and complex "representational" abilities, such as mental rotation. The aim of present study was to provide normative values for BVA collected in a wide sample of healthy Italian subjects. Three hundred seventeen healthy Italian subjects (173 women and 144 men) of different age classes (age range, 40-95 years) and education level (from primary to university), with a normal score on Mini Mental State Examination, completed BVA/TeRaDiC. Multiple linear regression analysis revealed that age and education significantly influenced performance on most tests of the BVA/TeRaDiC; only line length judgment was not affected by educational level. Gender significantly affected line orientation judgment and mental rotation, with an advantage for males in both tests. From the derived linear equations, a correction grid for adjusting BVA/TeRaDiC raw scores was built. Using a non-parametric technique, inferential cut-off scores were determined and equivalent scores computed. The present study provided Italian normative data for the BVA/TeRaDiC useful for both clinical and research purposes.

Normative data for the Montreal Cognitive Assessment in an Italian population sample.

The Montreal Cognitive Assessment (MoCA) is a rapid screening battery, also including subtests to assess frontal functions such as set-shifting, abstraction and cognitive flexibility. MoCA seems to be useful to identify non-amnestic mild cognitive impairment (MCI) and subcortical dementia; it has high sensitivity and specificity in distinguishing MCI from mild Alzheimer's Disease. Previous studies revealed that certain items of MoCA may be culturally biased and highlighted the need for population-based norms for the MoCA. The aim of present study was to collect normative values in a sample of Italian healthy subjects. Four hundred and fifteen Italian healthy subjects (252 women and 163 men) of different ages (age range 21-95 years) and educational level (from primary to university) underwent MoCA and Mini Mental State Examination (MMSE). Multiple linear regression analysis revealed that age and education significantly influenced performance on MoCA. No significant effect of gender was found. From the derived linear equation, a correction grid for MoCA raw scores was built. Inferential cut-off score, estimated using a non-parametric technique, is 15.5 and equivalent scores were computed. Correlation analysis showed a significant but weak correlation between MoCA adjusted scores with MMSE adjusted scores (r = 0.43, p < 0.001). The present study provided normative data for the MoCA in an Italian population useful for both clinical and research purposes.

Metacognitive dysfunctions in personality disorders: correlations with disorder severity and personality styles.

Metacognitive impairment is crucial to explaining difficulties in life tasks of patients with personality disorders (PDs). However, several issues remain open. There is a lack of evidence that metacognitive impairments are more severe in patients with PDs. The relationship between severity of PD pathology and the extent of metacognitive impairment has not been explored, and there has not been any finding to support the linking of different PDs with specific metacognitive profiles. The authors administered the Metacognitive Assessment Interview to 198 outpatients with PDs and 108 outpatients with no PDs, differentiating overall severity from stylistic elements of personality pathology. Results showed that metacognitive impairments were more severe in the group with PDs than in the control group, and that metacognitive dysfunctions and the severity of the PD were highly associated. Positive correlations were found between specific metacognitive dysfunctions and specific personality styles. Results suggest that metacognitive impairments could be considered a common pathogenic factor for PDs.

Differences between axes depend on where you set the bar: associations among symptoms, interpersonal relationship and alexithymia with number of personality disorder criteria.

Personality disorders are better understood as entities that vary according to severity along specific domains rather than a phenomenon separate from and unrelated to Axis I disorders. This study explores whether patients who were rated as having greater numbers of personality disorder traits reported greater levels of interpersonal problems, psychiatric symptoms, and alexithymia. The sample was composed of 506 consecutive patients assessed in a private outpatient center who were administered the SCID-II Symptom-Checklist (SCL-90-R), Inventory of Interpersonal Problems (IIP-47), and Toronto Alexithymia-Scale (TAS-.20). Based upon the number of personality disorder traits identified in the SCID, participants were classified into five groups: 0-4, 5-9, 10-14, 15-19, and 20 or more personality disorder traits met. Comparisons between groups revealed that symptom severity and levels of interpersonal problems increased between groups as the number of personality disorder traits increased. After covarying for symptom severity, there were no significant between-groups differences for levels of alexithymia. Findings are consistent with the claims that the simple Axis I-Axis II distinction is not an optimal strategy to understand personality pathology. It instead may be more fruitful to consider group differences in terms of numbers of personality disorder traits met.

The development of the Metacognition Assessment interview: instrument description, factor structure and reliability in a non-clinical sample.

BACKGROUND: Metacognition is a multi-facet psychological construct; deficits in metacognitive abilities are associated to low social functioning, low quality of life, psychopathology, and symptoms. The aim of this study was to describe and develop a valid and reliable interview for assessing metacognition. METHODS: The semi-structured interview, based on the author's theory model of the metacognition construct, is described. The Metacognition Assessment Interview (MAI) is an adaptation of the Metacognition Assessment Scale (MAS) and evaluates how the subject is interviewed used metacognition during his own real life experiences elicited by the interviewer. A user manual was developed to assist the interview and scoring procedure. RESULTS: Exploratory factor analysis and confirmatory factor analysis revealed preliminary evidence of a two factor-hierarchical structure, with two lower-order scales, representing the two main theoretical domains of the metacognitive function, "the Self" and "the Other", and one single higher-order scale that we labelled metacognition. Contrary to the authors' prediction the existence of the four distinct dimensions under the two domains was not confirmed. The MAI and its two domains demonstrated acceptable levels of inter-rater reliability and internal consistency. CONCLUSIONS: The MAI appears to be a promising instrument for assessing metacognition. Future psychometric validation steps and clinical directions are discussed.

Metacognitive mastery dysfunctions in personality disorder psychotherapy.

Individuals with personality disorders (PDs) have difficulties in modulating mental states and in coping with interpersonal problems according to a mentalistic formulation of the problem. In this article we analyzed the first 16 psychotherapy sessions of 14 PD patients in order to explore whether their abilities to master distress and interpersonal problems were actually impaired and how they changed during the early therapy phase. We used the Mastery Section of the Metacognition Assessment Scale, which assesses the use of mentalistic knowledge to solve problems and promote adaptation. We explored the hypotheses that a) PD patients had problems in using their mentalistic knowledge to master distress and solve social problems; b) the impairments were partially stable and only a minimal improvement could be observed during the analyzed period; c) patients' mastery preferences differed from one another; d) at the beginning of treatment the more effective strategies were those involving minimal knowledge about mental states. Results seemed to support the hypotheses; the patients examined had significant difficulties in mastery abilities, and these difficulties persisted after 16 sessions. Moreover, the attitudes towards problem-solving were not homogenous across the patients. Lastly, we discuss implications for assessment and treatment of metacognitive disorders in psychotherapy.