Causal Reasoning during Reading of Clinical Reports

in Clinicians

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Pedro L. CobosAmanda FloresEstrella González-Martín Francisco J. López &Antonio GodoyFacultad de PsicologíaUniversidad de Málaga

Causal Reasoning During Reading of Clinical Reports in cliniciansIntroduction

The main question

How are causal reasoning processes involved in diagnosing DSM-IV disorders?

Kim & Ahn’s (2002) study:

The Causal Status Effect

Causal Reasoning During Reading of Clinical Reports in clinicians

Kim & Ahn’s (2002) study

Depression

Sadness

Fatigue

Suicide thoughts

Weight alterations

Motor activity problems

Low pleasure in daily activities

Worthlessness and blame feelings

Sleep problems

Lack of concentration

Introduction

Previous work

Causal Reasoning During Reading of Clinical Reports in clinicians

Kim & Ahn (2002)’ study

1. Sadness

2. Worthlessness and blame feelings

3. Low pleasure in daily activities

4. Sleep problems

5. Lack of concentration

6. Motor activity problems

7. Fatigue

8. Suicide thoughts

9. Weight alterations

Depression

+ peripheral

+ central

Introduction

Previous work

Causal Reasoning During Reading of Clinical Reports in clinicians

Kim & Ahn (2002)’ study

Clinical judgements modulated by causal reasoning

More central diagnostic criteria are …

… more important to diagnosis

… better remembered

Introduction

Previous work

Causal Reasoning During Reading of Clinical Reports in clinicians

To extend Kim and Ahn’s results by using on-line measures to detect causal reasoning processes during reading of clinical reports.

Introduction

Our main goal

Causal Reasoning During Reading of Clinical Reports in clinicians

If causal theories play an important role in clinicians’ reasoning, one would expect:

On-line measures during reading of clinical reports allows to study these processes.

• Rapid and efficient access to causal theories to …

• relate new data with previous information …• in an on-line and semi-automatic manner …• in more natural conditions …• without inducing the use of causal theories.

Introduction

Our main goal

Why using on-line measures during reading of clinical reports?

Causal Reasoning During Reading of Clinical Reports in clinicians

Introduction to the experimental strategy:

From text comprehension studies

Good readers search for local and global coherence in texts

Causal theories are fundamental in this search for coherence

Solving coherence problems takes time and resources

Assumptions and empirical findings behind the logic

Causal Reasoning During Reading of Clinical Reports in clinicians

INCONSISTENT TEXT

Preliminary information

Filler information

Final sentence

Target sentence

John is diagnosed with the avoidant personality disorder by a clinician.

He lives in a populated area in the centre of the town and works as an IT teacher. He spends a lot of hours at work.

He views himself as socially skilled and personally appealing.

Once the session had been finished a new appointment was arranged.

Introduction to the experimental strategy:

The inconsistency paradigm (Albrecht & O´Brien, 1993)

Causal Reasoning During Reading of Clinical Reports in clinicians

CONTROL TEXT

Preliminary information

Filler information

Final sentence

Target sentence

John is diagnosed with the sleepwalking disorder by a clinician.

He lives in a populated area in the centre of the town and works as an IT teacher. He spends a lot of hours at work.

He views himself as socially skilled and personally appealing.

Once the session had been finished a new appointment was arranged.

Introduction to the experimental strategy:

The inconsistency paradigm (Albrecht & O´Brien, 1993)

Causal Reasoning During Reading of Clinical Reports in clinicians

INCONSISTENT CLINICAL REPORT

• Diagnosis and symptoms

• Filler information

• Final sentence

Target sentence:

Absent criterion: Central / Peripheral

Introduction to the experimental method:

The inconsistency paradigm (Albrecht & O´Brien, 1993)

Causal Reasoning During Reading of Clinical Reports in clinicians

INCONSISTENT CENTRAL

John is diagnosed with the avoidant personality disorder by a clinician.

He lives in a populated area in the centre of the town and works as an IT teacher. He spends a lot of hours at work.

He views himself as socially skilled and personally appealing.

Once the session had been finished a new appointment was arranged.

Introduction to the experimental strategy:

The inconsistency paradigm (Albrecht & O´Brien, 1993)

Causal Reasoning During Reading of Clinical Reports in clinicians

INCONSISTENT PERIPHERAL

John is diagnosed with the avoidant personality disorder by a clinician.

He lives in a populated area in the centre of the town and works as an IT teacher. He spends a lot of hours at work.

He gets easily involved in new activities.

Once the session had been finished a new appointment was arranged.

Introduction to the experimental strategy:

The inconsistency paradigm (Albrecht & O´Brien, 1993)

Causal Reasoning During Reading of Clinical Reports in clinicians

Experimental strategy

Inconsistency

Paradigm

Manipulation of causal status of DSM-IV

diagnostic criteria

Processes measured:- Comprehension- On-line access- On-line inferences- On-line integration

Causal Reasoning During Reading of Clinical Reports in clinicians

Experimental strategy

Additionally,

For each clinical report, participants in our experiments rated the degree of agreement with the diagnosis stated in the preliminary information.

Causal Reasoning During Reading of Clinical Reports in clinicians

  InconsistencyControl

(No inconsistency)

CentralReading timeJudgement

Reading timeJudgement

PeripheralReading timeJudgement

Reading timeJudgement

IV 2CausalStatus

IV 1 Degree of inconsistency

Experimental strategy

Design

Causal Reasoning During Reading of Clinical Reports in clinicians

Hypothesis

Clinicians were expected to efficiently access and use their causal theories in a clinical report

reading task

Longer reading times in the inconsistency than

in the control condition

Lower agreement judgements in the

inconsistency than in the

control condition

Greater inconsistency effect in the central than in

the peripheral condition.

Greater inconsistency effect in the central

than in the peripheral condition.

Causal Reasoning During Reading of Clinical Reports in cliniciansExperiment 1

Method: participants

Years of practice averaged 17

Most of them cognitive-behavioural

17 clinicians

Causal Reasoning During Reading of Clinical Reports in clinicians

Target + Post-target Reading times

Experiment 1

Results

00

1.900

2.300

2.700

3.100

3.500

Inconsist Control Inconsist Control

CENTRAL PERIPHERAL

Mseg

Deg. Incons. F(1,16)=10.70, p=.005Caus. St. x Deg. Incons. F(1,16)=9.59, p=.007

Deg. Incons.F(1,16)=11.39, p=.004 Deg. Incons.

F(1,16)=4.46, p=.051

Causal Reasoning During Reading of Clinical Reports in cliniciansExperiment 1

Results

Judgements (0-100 Agreement)

0102030405060708090

100

Inconsist Control Inconsist Control

CENTRAL PERIPHERAL

Judgem

ent

s

Deg. Incons. F(1,16)=51.40, p<.001Caus. St. x Deg. Incons. F(1,16)=4.76, p=.044

Deg. Incons.F(1,16)=31.44, p<.001 Deg. Incons.

F(1,16)=43.23, p<.001

Causal Reasoning During Reading of Clinical Reports in cliniciansExperiment 1

Results

Clinicians

Inconsistency affected by causal status

Affected by inconsistency

Tiempos de lectura y juicios en la misma líneaClinicians rely on causal theories in on-line reasoning during reading of clinical

reports

Causal Reasoning During Reading of Clinical Reports in clinicians

Discussion

The achieved goals

Replication of Kim & Ahn’s (2002) resultsCausal status effect in diagnostic judgements

ExtensionWe have provided evidence of on-line causal reasoning in

clinicians …in a natural and ecologically valid task (reading clinical

reports) …without inducing the use of causal theories …and taking behavioural measures in a non-intrusive way

Causal Reasoning During Reading of Clinical Reports in clinicians

Discussion

The achieved goals

MethodologicalWe have shown the usefulness of reading comprehension

techniques to study on-line clinical reasoning processes

BUT

Causal Reasoning During Reading of Clinical Reports in clinicians

Discussion

The causal status effect found may be a conceptual centrality effect or a statistical effect.

Causal Reasoning During Reading of Clinical Reports in clinicians

We have created inconsistencies to obtain the inconsistency effect by manipulating the temporal order of symptom appearance.

We have selected common disorders that are explained by well known theories according to which symptoms can be causally linked.

We have added new tasks:

The reading task.

The memory task.

The diagnostic judgement task.

The treatment task.

Experiment 2 (almost ready to be run)

Strategy

Causal Reasoning During Reading of Clinical Reports in cliniciansExperiment 2 (almost ready to be run)

Strategy

Body sensations

Emotions

Fear of gaining weight

Cognitive distortions

Altered self-perception of size, weight, and

silhouette

Diet Vomiting Laxative abuse

Weight loss

Amenorrhea

Yellow buttons include DSM-IV diagnostic criteria Toro y Vilardell

(1989)

An example based on anorexia nervosa

Causal Reasoning During Reading of Clinical Reports in cliniciansExperiment 2 (almost ready to be run)

Strategy

Fear of gaining weight

Altered self-perception of size, weight, and

silhouette

Weight loss

Amenorrhea

Yellow buttons include DSM-IV diagnostic criteria Toro y Vilardell

(1989)

An example based on anorexia nervosa

Tem

pora

l ord

er

Causal Reasoning During Reading of Clinical Reports in clinicians

CONSISTENT CLINICAL REPORT

A. realizes that she needs help for a problem and, eventually, decided to request the aid of a clinical psychologist.

The last appearing symptom was amenorrhea.

Filler sentence 1.

Before, she had been suffering from altered self-perception of weight.

Filler sentence 2.

The first appearing symptom was an intense fear of becoming fat.

Filler sentences 3-6.

After the assessment process, A. received the diagnosis of anorexia nervosa.

The clinical psychologist encouraged A. to start with the treatment process as soon as possible.

Experiment 2 (almost ready to be run)

Strategy: The reading task

An example based on anorexia nervosa

Target sentence

Causal Reasoning During Reading of Clinical Reports in clinicians

INCONSISTENT CLINICAL REPORT

A. realizes that she needs help for a problem and, eventually, decided to request the aid of a clinical psychologist.

The first appearing symptom was amenorrhea.

Filler sentence 1.

Later on, she started to suffer from altered self-perception of weight.

Filler sentence 2.

The last appearing symptom was an intense fear of becoming fat.

Filler sentences 3-6.

After the assessment process, A. received the diagnosis of anorexia nervosa.

The clinical psychologist encouraged A. to start with the treatment process as soon as possible.

Experiment 2 (almost ready to be run)

Strategy: The reading task

An example based on anorexia nervosa

Target sentence

Causal Reasoning During Reading of Clinical Reports in clinicians

We expect to find longer reading times for the target sentence in the inconsistent than in the consistent clinical report.

Experiment 2 (almost ready to be run)

Strategy: The reading task

Hypothesis

Causal Reasoning During Reading of Clinical Reports in clinicians

Please, indicate the order in which symptoms appeared in the client:

Experiment 2 (almost ready to be run)

Strategy: The memory task

Altered self-perception of weight

Fear of becoming fat

Amenorrhea

A B C

First

Middle

Last

An example based on anorexia nervosa

Causal Reasoning During Reading of Clinical Reports in clinicians

¿To what extent do you agree with the diagnosis of anorexia nervosa?

Experiment 2 (almost ready to be run)

Strategy: The diagnostic judgement task

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0

OK

An example based on anorexia nervosa

Causal Reasoning During Reading of Clinical Reports in clinicians

We expect to find higher ratings of agreement in the consistent than in the inconsistent clinical report.

Experiment 2 (almost ready to be run)

Strategy: The reading task

Hypothesis

Causal Reasoning During Reading of Clinical Reports in clinicians

¿To what extent do you think that an hormone treatment based on progesterone will eliminate the following clients’ symptoms?

Altered self-perception of weight

Fear of becoming fat

Amenorrhea

Experiment 2 (almost ready to be run)

Strategy: The treatment decision-making task

An example based on anorexia nervosa

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0

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0

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0

Causal Reasoning During Reading of Clinical Reports in clinicians

¿To what extent do you think that a treatment based on the comparison between the self-perception of the body and its actual size, silhouette and weight will eliminate the following clients’ symptoms?

Altered self-perception of weight

Fear of becoming fat

Amenorrhea

Experiment 2 (almost ready to be run)

Strategy: The treatment decision-making task

An example based on anorexia nervosa

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0

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0

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0

Causal Reasoning During Reading of Clinical Reports in clinicians

¿To what extent do you think that a treatment in which the client is faced to the possibility of gaining weight and learn how to cope with its consequences will eliminate the following clients’ symptoms?

Altered self-perception of weight

Fear of becoming fat

Amenorrhea

Experiment 2 (almost ready to be run)

Strategy: The treatment decision-making task

An example based on anorexia nervosa

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0

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0

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Causal Reasoning During Reading of Clinical Reports in clinicians

The treatment that operates directly on the symptom with the highest causal status in the disorder will receive, in general, higher ratings of efficacy in the consistent than in the inconsistent clinical report.

Experiment 2 (almost ready to be run)

Strategy: The reading task

Hypothesis

Causal Reasoning During Reading of Clinical Reports in clinicians

If you had to choose one treatment among the three just mentioned to eliminate the maximum number of symptoms, which one would you prefer?

Experiment 2 (almost ready to be run)

Strategy: The treatment decision-making task

An example based on anorexia nervosa

Thank you very much

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