> Cognitive-behavioral approach in medicine Mgr. Barbora Kóša Podzim 2020 ÚPP LF MU Affective heuristic •Occurence: Open-ended questions, no intense attention is needed •Current mood: highly affects reasoning •Affective heuristic: relying on emotion concerning object in fast judgement •H: People concentrate their attention less on losess than gains when they are in a good mood •Quick emotional reactions (concern or safety?) can serve as relevant information (affect as information mechanism). • • Slovic, P., Finucane, M., Peters, E., & MacGregor, D. G. (2002). The affect heuristic. In T. Gilovich, D. Griffin, & D. Kahneman (Eds.), Heuristics and biases: The psychology of intuitive judgment (pp. 397-420). New York: Cambridge University Press. Heuristics •problem-solving method à shortcuts to produce good-enough solutions •quick decisions, particularly when working with complex data •derived from previous experiences with similar problems •using readily accessible, though loosely applicable, information problem solving •For example, pattern recognition: seeing a patient with grandiose delusions and pressured speech leading to a rapid differential with the most-likely diagnosis being bipolar disorder. • •+ Advantage •Reduce cognitive load: time and effort to make reasonably good judgments and decisions. • •- Disadvantage: •Potential to lead to systematic cognitive errors called biases. • Acad Med. 2011 Mar;86(3):307-13. •Factors influencing which system is employed •Task complexity •S1 – typical signs and symptoms •S2 – atypical symptoms, complex cases •Expertise •S2 – novices, students •accuracy of systems 2 thinking depends on knowledge base, expertise.. • Dual processes theory Experiential system (intuitive 1) Analytic system (2) Holistic Effortful Emotional: Pleasure – Pain Logical: resoning oriented (what is rational?) Associative connections Logical connections Behavior is influenced by previous emotions Behavior is influenced by rational judgement of events Reality is encoded in images, metaphores and narratives Reality is encoded in abstract symbols, words and numbers Fast processing: focues on immediate action Slow processing: focused on postponed action Valid for own person: „experiencing is believing“ Demands support wit logic and evidence Heuristic or Bias Medical Example Non-medical example Anchoring is the tendency to lock onto salient features in the patient’s initial presentation and failing to adjust this initial impression in the light of later information. A patient is admitted from the emergency department with a diagnosis of heart failure. The hospitalists who are taking care of the patient do not pay adequate attention to new findings that suggest another diagnosis. We buy a new car based on excellent reviews and tend to ignore or downplay negative features that are noticed. Affective bias refers to the various ways that our emotions, feelings, and biases affect judgment. New complaints from patients known to be “frequent flyers” in the emergency department are not taken seriously. We may have the belief that people who are poorly dressed are not articulate or intelligent. Availability bias refers to our tendency to more easily recall things that we have seen recently or things that are common or that impressed us. A clinician who just recently read an article on the pain from aortic aneurysm dissection may tend toward diagnosing it in the next few patients he sees who present with nonspecific abdominal pain, even though aortic dissections are rare. Because of a recent news story on a tourist kidnapping in Country “A,” we change the destination we have chosen for our vacation to Country “B.” Heuristic or Bias Medical Example Non-medical example Context errors reflect instances where we misinterpret the situation, leading to an erroneous conclusion. We tend to interpret that a patient presenting with abdominal pain has a problem involving the gastrointestinal tract, when it may be something else entirely: for example, an endocrine, neurologic or vascular problem. We see a work colleague picking up two kids from an elementary school and assume he or she has children, when they are instead picking up someone else’s children. Search satisficing, also known as premature closure, is the tendency to accept the first answer that comes along that explains the facts at hand, without considering whether there might be a different or better solution. The emergency department clinician seeing a patient with recent onset of low back pain immediately settles on a diagnosis of lumbar disc disease without considering other possibilities in the differential diagnosis. We want a plane ticket that costs no more than $1,000 and has no more than one connection. We perform an online search and purchase the first ticket that meets these criteria without looking to see if there is a cheaper flight or one with no connections. Obrázok, na ktorom je jedlo, ovocie, stôl, vnútri Automaticky generovaný popis Obrázok, na ktorom je sladké, koláč, jedlo, stôl Automaticky generovaný popis Working memory and affective heuristic •You hold in memory 7 digit number and need to write it down in different room • •On the corridor, someone from your family stops you and asks: •Are you going to have chocolate or fruit? • •You need to rememer the numbers but are hungry too. What are you going to choose? • • • • Working memory and affective heuristic • •63% chose chocolate cake when holding in memory 7 digits •41% chose chocolate cake when holding in memory 2 digits • • •Fast judgement of object according to emotion. •Capacity of working memory can influence you capacity for reasoning and consider rational arguments. • Adobe Systems Forgas, J. P., & Koch, A. S. (2013). 11 Historical background of learning theories ̶affective nature of human beings has long been considered secondary and inferior to the study of rational thinking, “nonscientific“ ̶cognitive shift (1960s) – psychology was directed even more • on cold, afectless mental processes ̶since 1980s – mood plays central role in how information about world is represented and affect determines cognitive representation of social experiences Adobe Systems 12 Early evidence linking Mood and Cognition ̶Classical conditioning: if neutral stimulus associates with negative stimulus: child encounters live rabbit + noise à negative evaluation of neutral stimulus à avoidance of neutral: the child avoids the rabbit (Watson, 1929) https://www.youtube.com/watch?v=V09FuazW8bc ̶People evaluated sociopolitical messages more favorably when in good rather than in a bad mood, induced either by a free lunch (!) or aversive smells, respectively (Razran, 1940) ̶Electric shocks induced negative affect in subjects. Fearful subjects‘ evaluations of another person were more negative than neutral subjects‘ and even greater when subjects were trying to suppress their fear (Wegner, 1994). ̶“suppression of fear facilitates the tendency to project fear onto another social object” (p. 286) Learning: Operant conditioning •Operant conditioning, is a method of learning that employs rewards and punishments for behavior. Through operant conditioning, an association is made between a behavior and a consequence •P, of behavior to repeat depends on consequences • • •stimulus reaction consequence Cofnitive factors in learning •Not stimulus provokes behavior, but the meaning it has for a person •Behavior can be predicted and understood based on cognitive processes • • • •Eye contact with attracitve man à Organism: THOUGTHS: I look silly! EMOTION: anxiety BODY: redness in face à Reaction: turning away eye contact à Consequence: relief from anxiety •Eye contact with attracitve man à Organism: T: I like him, I want to look good! E: excitement T: pupil enlargement à Reaction: smile, long eye contact à Consequence: pleasant arousal • stimulus organism reaction consequence Cognitive factors when response is formed •ABC – Albert Ellis • • • • • Situation Cognition Consequence: emotion, behavior page46image3105346464 page46image3105024096 page46image3121491408 Experience of patient •Part of human psychology in awareness: •emotion, cognition a behavior • • •Thoughts – hypotheses which can be confirmed or not, not facts •Emotion – validate that there are no good or bad feelings, labeling helps to deal and act in constructive ways •Behavior – strengthen: valued behavior condition with positive consequences Cognitive behavioral interview •When too ambiguos or technical à “What exactly do you mean?“ •Reflective feedback: to make sure you understand •Don‘t use suggestive questions („You were probably scared, right?“ better: „How did you feel in that situation?“) •Open ended à more specific questions •Avoid starting with „Why...“ (asking for explanation), better: “Who?“, “Where?“, „How often?“ (asking for description) •Assure the patient that his problems are common •Strong emotion – be patient, curious, compassionate (What does it mean for the patient? Why is he/she so upset?) Problem description •Subjective description of symptoms, their evolution, triggers, consequences, related problems ... •Looking for mechanisms that maintain problem behavior •Predisposing factors •Precipital factors – internal / external • Microanalysis of problematic behavior Situation Cognition Emotion Behavior Bodily signals Consequence Modifying factors Microanalysis of problematic behavior SYMPTOMS Eg. Increased heart rate palpitations (Mis)interpretation „It mus be a heart attack“ Emotion Increased anxiety Increased symptoms Consequences •Relationships, work, reputation, health.... •Short-term positive / negative •Long-term positive / negative Goal setting to motivate the patient •What do you want to happen at the end of your treatment? •S: specific •M: measurable •A: attainable •R: relevant •T: timely Myšlienky •How to know patients thouths •What do you think? What is going to happen? What if you will never change how you think? What is the worst case scenario? •Hot – + emotion / Cold – descriptive • Scenár návštevy Horúce myšlienky človeku len tak nevyvrátite, ale môžete ich zjemniť Cognitive distortions Obrázok, na ktorom je stôl Automaticky generovaný popis Useful CBT techniques Cognitive restructuring 1.Situation When? Where? Who? What? 2. Emotion Intesity 1-10 3. Automatic thought Persuasiveness 0 – 100% 4. Evidence proving thought 5. Evidence against thought 6. Alternative thought Persuasiveness 0-100% 7. Emotion now Intensity 1-10 Thank you for attention Suggested study materials: Croskerry P. (2002). Achieving quality in clinical decision making: cognitive strategies and detection of bias. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 9(11), 1184–1204. Howard, J. (2018). Cognitive Errors and Diagnostic Mistakes. Springer Berlin Heidelberg. Mandatory study materials: Chapters from Psychology in medicine