Diagnostic Judgments Research Articles

Are you as smart as a 4th grader? Why the prototypesimilarity approach to diagnosis is a step backward for a scientific psychiatry

Are you as smart as a 4th grader? Why the prototypesimilarity approach to diagnosis is a step backward for a scientific psychiatry

A Quantum Probability Model of Causal Reasoning

People can often outperform statistical methods and machine learning algorithms in situations that involve making inferences about the relationship between causes and effects. While people are remarkably good at causal reasoning in many situations, there are several instances where they deviate from expected responses. This paper examines three situations where judgments related to causal inference problems produce unexpected results and describes a quantum inference model based on the axiomatic principles of quantum probability theory that can explain these effects. Two of the three phenomena arise from the comparison of predictive judgments (i.e., the conditional probability of an effect given a cause) with diagnostic judgments (i.e., the conditional probability of a cause given an effect). The third phenomenon is a new finding examining order effects in predictive causal judgments. The quantum inference model uses the notion of incompatibility among different causes to account for all three phenomena. Psychologically, the model assumes that individuals adopt different points of view when thinking about different causes. The model provides good fits to the data and offers a coherent account for all three causal reasoning effects thus proving to be a viable new candidate for modeling human judgment.

O-23 - Diagnostic and biological characteristics of depression in pregnancy and postpartum

Background The physiological changes in peripartum may affect symptoms of depression and impact diagnostic judgments in the peripartum. The sharp fall in cortisol and CRH after childbirth suggests that the HPA axis characteristics of postpartum depression are different from melancholic depression, the latter being characterized by high cortisol levels. Methods A modified version of the SCID was used to assess symptoms of depression and melancholic and atypical subtypes in pregnancy and the postpartum period. Secondly, we investigated the diurnal output of saliva cortisol in women with and without symptoms of depression at 7.5 weeks postpartum, and non perinatal controls. Results The antenatal symptom pattern (n = 892 women) was different from the postnatal. The sensitivity of the symptoms ranged from 0.7% to 51.6%, and specificity from 61.3% to 99.1%. The best discriminating symptoms were motor retardation/agitation and concentration antenatally, and motor retardation/agitation, concentration and fatigue postnatally. In a subgroup of this sample (n = 449) 17% of the cohort met SCID criteria for a depression at least once in pregnancy: melancholic depression (2.4%), atypical depression (4.4%), and non specified depression (10.2%). Mood reactivity, distinct quality of mood and sleep pattern discriminated between the two groups. There was no increase in cortisol over the day, however a significant difference in diurnal pattern of cortisol between postnatally depressed and non-depressed women. Discussion These findings suggest that perinatal depression has different associated symptoms from depression at other times. The cortisol pattern in the postnatally depressed women is similar to that reported for PTSD and atypical depression.

P-919 - Sensory gating deficits assessed by the P50 event-related potential - source localisation. case report of patient with diagnosis of schizotypal personality disorder, preliminary report

There is a minimal information about neurophysiological investigation of schizotypal persons also its diagnostic position differs in ICD10 and DSM IV and some people believe that it is a part of the schizophrenia spectrum disorder or insidious schizophrenia or personality disorder. Perhaps neurophysiological investigation will make us more able to make a final diagnostic judgment of this clinical term, we found only one publication which is partly close to our investigation. Cadenhead and all. (2000) reports the results of their investigation concerning subjects with schizotypal personality disorder may have trait-linked. Sensory gating deficits similar to those in patients with schizophrenia and their relatives. Because these subjects may manifest sensory gating deficits without overt psychotic symptoms, it is likely that these deficits represent a core cognitive dysfunction of the schizophrenia spectrum. (Am J Psychiatry 2000; 157:55–59) We have under the many years lasting observation female Patient with diagnosis of schizotypal personality and with specific features of this type of personality, It was confirmed by the results of schizotypal scales (Schizotypal Ambivalence Scale) Our neurophysiological investigation is as follows - we want to present the source localization of P 50 in a female patient with schizotypal personality.

Influence of Race and Symptom Expression on Clinicians’ Depressive Disorder Identification in African American Men

Studies show that depressed African Americans are more likely to be misdiagnosed than are depressed Caucasians. A randomized sample of 239 California licensed clinical social workers and licensed marriage and family therapists were shown experimentally designed clinical videos and asked to make diagnostic judgments. Clinicians were randomly assigned to view 1 of 4 videos of 2 young adult male actors, 1 African American and 1 Caucasian, playing the part of a depressed client engaging in a first-time therapy session. Each actor played 2 roles: a depressed man with classic symptoms of a major depressive disorder (MDD) and a depressed man displaying symptoms that meet the MDD criteria described in the literature as African American cultural expressions of depression. Results indicate statistically significant differences in the identification of mood disorder; licensed clinicians under diagnosed unipolar mood disorder more frequently when clients of either race presented with culturally expressed depression symptoms. Implications for clinical social work and mental health practice with African American males are discussed.

Adult norms of the perceptual threshold of touch (PTT) in the hands and feet in relation to age, gender, and right and left side using transcutaneous electrical nerve stimulation

There is a lack of standardized and quantifiable measures of touch function, for clinical work. Furthermore, it is not possible to make accurate diagnostic judgments of touch function before normative values are estimated. The objectives of this study were to establish adult norms of the perceptual threshold of touch (PTT) for the hands and feet according to age and gender and to determine the effect of right/left side, handedness, height, weight, and body mass index (BMI) on the PTT. The PTT was assessed by using a high-frequency transcutaneous electrical nerve stimulator (Hf/TENS) with self-adhesive skin electrodes in 346 adults. The PTT was identified as the level registered in mA at which the participants perceived a tingling sensation. The PTT for all participants was a median of 3.75 mA (range 2.50–7.25) in the hands and a median of 10.00 (range 5.00–30.00) in the feet. With increasing age an increase of the PTT was found. Men reported higher PTT than women. The right hand had higher PTT than the left. Handedness, height, weight, and BMI did not affect the PTT. Adult norms of the PTT in the hands for age, gender, and right/left side are presented for four age groups. The present study's estimate of the PTT in the hands could be used as adult norms. Adult norms for the feet could not be estimated because the PTT values in the feet showed a great variance.

Understanding the prehospital physician controversy. Step 1

In many European countries prehospital care by emergency medical services (EMS) is supplemented by physician-staffed services. There is ongoing controversy on the benefits of a prehospital physician. Possible advantages are additional competencies of the physician. Similarities and differences in competencies of EMS providers and physicians have however never been studied. This study aims to compare competencies of ambulance nurses and helicopter EMS physicians in the Netherlands to gain better insight into the controversy of the prehospital physician. In this descriptive study, a quantitative inventory was made of the diagnostic, therapeutic, and clinical judgment competencies of the ambulance nurse and physician, based on analysis of protocols, registration, equipment, and personal interviews. We identified 438 mutual competencies of the ambulance nurse and physician and 62 physician-specific competencies. The ambulance nurse masters 278 diagnostic, 131 therapeutic, and 29 clinical judgment competencies. The physician masters 285 diagnostic, 175 therapeutic, and 40 clinical judgment competencies. Seventy-one percent of the physician-specific competencies are therapeutic and related to advanced life support. The ambulance nurse and physician have various mutual competencies. In addition, the physician can provide specific competencies on the scene. Knowing the exact overlap and differences in competencies is the first step to understand the prehospital physician controversy. Our results can be used as a tool for the next step in research on prehospital care by EMS providers and physicians and to improve prehospital care.

Cognitively demanding learning materials with texts and instructional pictures: teachers’ diagnostic skills, pedagogical beliefs and motivation

Learning materials incorporating written texts as well as instructional pictures are the basis for learning in many subjects. However, text–picture integration makes high cognitive demands of learners, and it seems plausible that the development of this competence is influenced by teachers’ instructional skills. The present studies investigated first the differential role of learning materials integrating text with pictures in geography and biology classes compared to German language arts instruction, and the accuracy of teachers’ diagnostic judgments concerning materials and student competencies from teachers who majored in different subjects. Second, we examined whether teachers with different majors systematically differ in their pedagogical beliefs and motivation to use text–picture materials, and if these differences predict both the quantity as well as the quality of instruction using both text and pictures. We present teacher questionnaires and test data from two independent studies, including N = 108 teachers with biology/geography or German major with in total over 1,000 students from grades 5 through 8 of all school tracks in study I, and N = 107 teachers with their students in study II. Descriptive statistics, t tests, and SEM are reported. The results indicate that teachers currently do not sufficiently manage to judge these learning materials, and that for the most part, variation between teachers was not systematically attributable to their subject major. At the same time, the differences observed between teachers in pedagogical beliefs and motivation had important consequences for both the quantity and quality of instruction using both text and pictures. Implications are discussed in regard to further research and educational practice.

History and structures of telecommunication in pathology, focusing on open access platforms

BackgroundTelecommunication has matured to a broadly applied tool in diagnostic pathology.Technology and SystemsContemporary with the development of fast electronic communication lines (Integrated digital network services (ISDN), broad band connections, and fibre optics, as well as the digital imaging technology (digital camera), telecommunication in tissue - based diagnosis (telepathology) has matured. Open access (internet) and server - based communication have induced the development of specific medical information platforms, such as iPATH, UICC-TPCC (telepathology consultation centre of the Union International against Cancer), or the Armed Forces Institute of Pathology (AFIP) teleconsultation system. They have been closed, and are subject to be replaced by specific open access forums (Medical Electronic Expert Communication System (MECES) with embedded virtual slide (VS) technology). MECES uses php language, data base driven mySqL architecture, X/L-AMPP infrastructure, and browser friendly W3C conform standards.ExperiencesThe server - based medical communication systems (AFIP, iPATH, UICC-TPCC) have been reported to be a useful and easy to handle tool for expert consultation. Correct sampling and evaluation of transmitted still images by experts reported revealed no or only minor differences to the original images and good practice of the involved experts. β tests with the new generation medical expert consultation systems (MECES) revealed superior results in terms of performance, still image viewing, and system handling, especially as this is closely related to the use of so - called social forums (facebook, youtube, etc.).Benefits and ExpectationsIn addition to the acknowledged advantages of the former established systems (assistance of pathologists working in developing countries, diagnosis confirmation, international information exchange, etc.), the new generation offers additional benefits such as acoustic information transfer, assistance in image screening, VS technology, and teaching in diagnostic sampling, judgement, and verification.

How do practising clinicians and students apply newly learned causal information about mental disorders?

New causal theories explaining the aetiology of psychiatric disorders continuously appear in the literature. How might such new information directly impact clinical practice, to the degree that clinicians are aware of it and accept it? We investigated whether expert clinical psychologists and students use new causal information about psychiatric disorders according to rationalist norms in their diagnostic reasoning. Specifically, philosophical and Bayesian analyses suggest that it is rational to draw stronger inferences about the presence of a disorder when a client's presenting symptoms are from disparate locations in a causal theory of the disorder than when they are from proximal locations. In a controlled experiment, we presented experienced clinical psychologists and students with recently published causal theories for different disorders; specifically, these theories proposed how the symptoms of each disorder stem from a root cause. Participants viewed hypothetical clients with presenting proximal or diverse symptoms, and indicated either the likelihood that the client has the disorder, or what additional information they would seek out to help inform a diagnostic decision. Clinicians and students alike showed a strong preference for diverse evidence, over proximal evidence, in making diagnostic judgments and in seeking additional information. They did not show this preference in the control condition, in which they gave their own opinions prior to learning the causal information. These findings suggest that experienced clinical psychologists and students are likely to use newly learned causal knowledge in a normative, rational way in diagnostic reasoning.

The Effect of Changing Diagnostic Algorithms on Acute Myocardial Infarction Rates

Population rates of acute myocardial infarction (AMI) are changing. Consistent case definitions to evaluate these trends and make comparisons are essential. The World Health Organization (WHO) AMI diagnostic algorithm and clinical judgments were the standards for classification. However, in recent years, five new algorithms, to include diagnostic advances, are advocated by professional organizations. This study compares AMI rates derived from six algorithms and the impact of troponins on those rates. The authors use the population-based Minnesota Heart Survey hospital data in 1995 and 2001 to compare six published diagnostic algorithms and the impact of troponins. In 1995 differences in AMI rates between algorithms ranged from 281/100,000 to 440/100,000 for men and 98/100,000 to 139/100,000 for women. The use of troponin, a more sensitive biomarker, adds to the differences by increasing eligible cases. Using 2001 data in patients where creatine kinase and troponin were simultaneously measured, a 64% and 95% increase in AMI rates among men and women, respectively, was observed. Accurate and consistent AMI definitions are crucial for clinical trials, epidemiology and public health research. Demonstrated here is the sensitivity of AMI rates to changing case definitions and the biomarker troponin.

Study on the state of implementation of HER2 testing and positive ratios in patients with breast cancer in the Kyushu-Okinawa region of Japan

The development of molecular-targeted agents has improved the recovery rate for cancer. In Japan, trastuzumab has been approved as an adjuvant treatment for human epidermal growth factor receptor-2 (HER2)-positive breast cancer; therefore, accurate management of HER2 testing has become more important. In addition, proper patient selection is required from the viewpoint of health care economics. The current situation of HER2 testing in patients with infiltrating breast cancer from April 2008 to March 2009 was evaluated in 49 institutions (50 departments) treating breast cancer in the Kyushu-Okinawa region. In a total of 5286 samples, HER2-positive ratio was 14.2%, which may reasonably reflect the current state of HER2 testing for breast cancer in the Kyushu-Okinawa region. There was a moderate discrepancy in HER2-positive ratio between institutions. Immunohistochemistry (IHC) analysis was outsourced in 15 institutions, and fluorescence in situ hybridization (FISH) analysis was outsourced in 23 institutions. The ratio of retesting by FISH analysis for samples judged as 2+ on IHC was 86.1%. There was no correlation between HER2-positive ratio and the number of HER2 tests at the institution. However, a high percentage of HER2 IHC 0-1+ results and a low percentage of HER2 2+ and 3+ results at the institution were significantly correlated with a high percentage of HER2 FISH-positive results for HER2 IHC 2+ cases. There is a moderate discrepancy in HER2-positive ratio between institutions. Institutions with a high percentage of HER2 IHC 0-1+ and a low percentage of HER2 2+ and 3+ may have more false negative cases. These institutions should perform internal accuracy evaluations in order to maintain proper diagnostic judgment.

Asymmetries in predictive and diagnostic reasoning.

In this article, we address the apparent discrepancy between causal Bayes net theories of cognition, which posit that judgments of uncertainty are generated from causal beliefs in a way that respects the norms of probability, and evidence that probability judgments based on causal beliefs are systematically in error. One purported source of bias is the ease of reasoning forward from cause to effect (predictive reasoning) versus backward from effect to cause (diagnostic reasoning). Using causal Bayes nets, we developed a normative formulation of how predictive and diagnostic probability judgments should vary with the strength of alternative causes, causal power, and prior probability. This model was tested through two experiments that elicited predictive and diagnostic judgments as well as judgments of the causal parameters for a variety of scenarios that were designed to differ in strength of alternatives. Model predictions fit the diagnostic judgments closely, but predictive judgments displayed systematic neglect of alternative causes, yielding a relatively poor fit. Three additional experiments provided more evidence of the neglect of alternative causes in predictive reasoning and ruled out pragmatic explanations. We conclude that people use causal structure to generate probability judgments in a sophisticated but not entirely veridical way.

Mononeuritis múltiple en un paciente con síndrome de Churg-Strauss. Pseudobloqueos como expresión electroclínica temprana

Multiple mononeuritis is one of the most frequent manifestations of Churg-Strauss syndrome. We describe a case of acute sensory-motor multiple mononeuritis in all four limbs of a 53-year-old male with Churg-Strauss syndrome. Electrodiagnosis performed within the first seven days revealed conduction blocks in several nerves. Follow-up studies showed diffuse bilateral sensory-motor axonal polyneuropathy with symmetries, but without blocks. Electrophysiological and histological analyses, together with experimental studies, showed it to be an axonopathy secondary to acute ischaemia. In only a few cases, such as this one and in a small number of incipient studies, have there been reports of conduction blocks that, owing to the fact that they are commonly related with demyelination, give rise to confusion when it comes to diagnoses and prognoses. The condition usually displays axonopathy due to Wallerian degeneration. It therefore seems recommendable in these cases to proceed with caution and to perform neurophysiological studies in the following weeks in order to prevent inappropriate diagnostic and prognostic judgements from being formed.

Bringing morphometrics into the Fetal Alcohol Report: Statistical Language for the Forensic Neurologist or Psychiatrist

The components of a diagnosis in the fetal alcohol spectrum consider, among other domains, evidence of prenatal alcohol exposure, facial features, neurological or neuropsychological deficits, and neuroanatomical form. Most of these assessments are based on traditional sorts of quantifications (e.g., length measures, IQ scores, quantity of alcohol drunk by the mother), but for one of the domains, the morphometric assessment of neuroanatomical form as abnormal in a way suggesting fetal alcohol damage, the associated quantifications are relatively recent. For purposes of a forensic report, this morphometric component of the diagnostic judgment would seem to go best in the form of one classic statistical quantity, the likelihood ratio (odds ratio) of two hypotheses as they both attempt to explain the form of a particular structure within the defendant's brain (in our approach, the midcurve of the corpus callosum). On one hypothesis, the subject is presumed to be from a normal population; on the other, he is from a group all characterized by diagnosable fetal alcohol damage. Our article explains in simple terms how the forensic physician might wish to couch that component of the FASD diagnostic system for the purpose of aiding those in the courtroom who have the task of determining guilt or culpability.

Arrhythmia discrimination by physician and defibrillator: Importance of atrial channel

BackgroundMany ICD carriers experience inappropriate shocks, but the relative merits of dual- /single-chamber devices for arrhythmia discrimination still remain unclear. We explored possible advantages of the atrial data provided by dual-chamber implantable defibrillators (ICD) for discrimination of real-life supraventricular/ventricular tachyarrhythmias (SVT/VT). Methods100 dual-chamber traces from 24 ICD were blindly reviewed in dual-chamber and simulated single-chamber (with/without discriminator data) reading modes by five electrophysiologists who determined chamber of origin and provided Likert-scale “confidence” ratings. We assessed 1) intra/interobserver concordance; 2) diagnostic accuracy, using expert diagnoses as a reference standard; 3) ROC curves of sensitivity/specificity of “likelihood perception” scores, generated by combining chamber-of-origin diagnostic judgments with Likert-scale “confidence” ratings. We also assessed diagnostic accuracy of automated discrimination by all possible dual-/single-chamber algorithm configurations. ResultsInterobserver concordance was “substantial” (modified Cohen kappa-test values for dual-/single-chamber, 0.79/0.68); intraobserver concordance “almost complete” (kappa≥0.89). Dual-chamber mode provided best diagnostic sensitivity/specificity (99%/92%) and highest reader confidence (p<0.001). Area under ROC curves of sensitivity/specificity values for the “likelihood perception” score (representing electrophysiologists' perceptions of the likelihood that an episode was of ventricular origin) was highest in dual-chamber mode (0.98 vs. 0.93 for both single-chamber modes; p<0.001). Regarding automated discrimination, all four dual-chamber configurations conferred 100% sensitivity (specificity values ranged 39%–88%), whereas single-chamber configurations appeared inferior (best sensitivity/specificity combination, 89%/64%). ConclusionsAvailability of the atrial channel helps in reducing inappropriate ICD therapies by providing relevant advantages in terms of both appropriate cardiologist's post-hoc discrimination of SVT/VT (improving program tailoring) and automated arrhythmia discrimination.

Primary Care Gains Popularity as MH Screening Site

Primary Care Gains Popularity as MH Screening Site

Neglect of Alternative Causes in Predictive but Not Diagnostic Reasoning

People are renowned for their failure to consider alternative hypotheses. We compare neglect of alternative causes when people make predictive versus diagnostic probability judgments. One study with medical professionals reasoning about psychopathology and two with undergraduates reasoning about goals and actions or about causal transmission yielded the same results: neglect of alternative causes when reasoning from cause to effect but not when reasoning from effect to cause. The findings suggest that framing a problem as a diagnostic-likelihood judgment can reduce bias.

Evidence-based practices in outpatient treatment for eating disorders.

Eating disorders remain a significant concern in a culture where thinness is unduly emphasized, and where anorexia nervosa is disorder with highest premature fatality rate of any mental illness (Sullivan, 1995). Four out of five women in United States are dissatisfied with their appearance (Smolak, 1996), and forty percent of Americans have experienced an eating disorder or know someone who has (NEDA, 2005). Eating disorders often go unrecognized and undiagnosed due to lack of education and awareness about signs and symptoms of eating disorders in general public, an absence of societal sanctions for maintaining an unhealthy weight, and minimizing or denial of symptoms among people with eating disorders and their loved ones. In current economic climate, many individuals are finding cost of treatment to be an additional, significant obstacle. As mental health professionals, it is becoming more important than ever to make available effective treatment options that yield promising results in a relatively short time period. This study examines current issues related to implementing evidence-based practice in psychology for people with eating disorders, and examined effectiveness of a day treatment program for people with eating disorders. Evidence-Based Practice According to APA Presidential Task Force on Evidence-Based Practice (2006), field of psychology is fundamentally committed to evidence-based practices. The APA Task Force defined evidence-based practice in psychology (EBPP) as the integration of best available research with clinical expertise in context of patient characteristics, culture, and preferences (2006, p.273). Thus, evidence-based practices are derived from three components, which are all relevant to good outcomes in psychotherapy: 1) research, 2) clinical expertise, and 3) individual patient characteristics. Therefore, when treating patients with eating disorders, it is best to keep in mind all three components. First, a thorough knowledge of outcome research is critical in deciding which interventions to use with eating disorder patients, and research offers a way to keep common human errors in judgment (e.g., confirmatory bias, self-enhancement bias, availability heuristic) in check. Yet, while one typically thinks of high-quality research as foundation for identifying true evidence-based interventions, clinical expertise is also essential for identifying and integrating best research evidence with clinical data, which is obtained through a relationship with patient over course of treatment (APA Task Force, 2006). Evidence-based treatments for eating disorders include cognitive-behavioral therapy for bulimia nervosa (Fairburn, 1985) and binge eating disorder (Wilson, Grilo, & Vitousek, 2007), and Maudsley approach to family-based treatment for adolescents with anorexia nervosa (Lock et al., 2001; Wilson, Grilo, & Vitousek, 2007). The second component, clinical expertise, is a less quantifiable, but equally important component that may include informal analysis, clinical experience, clinical observations, psychological theory, and consultation with colleagues (Shapiro, Friedberg, & Bardenstein, 2006). Though both research and clinical expertise have susceptibility to error, they can be integrated in such a way so as to maximize our overall understanding of both internal and external validity of a particular treatment intervention for people with eating disorders. In addition, research and practice share a commitment to providing best knowledge about psychological methods and treatment in order to improve patient care (Kazdin, 2008). According to APA Task Force, clinical expertise includes components such as a) assessment, diagnostic judgment, systematic case formulation, and treatment planning, b) clinical decision making, treatment implementation, and monitoring of patient progress, c) interpersonal expertise, d) continual self-reflection and acquisition of skills, e) evaluation and use of research evidence, f) understanding influence of individual, cultural, and contextual differences on treatment, g) seeking available resources as needed through consultation or alternative services, and h) a cogent rationale for clinical strategies. …

Experimental Design and Data Analysis in Receiver Operating Characteristic Studies: Lessons Learned from Reports inRadiologyfrom 1997 to 2006

To provide a broad perspective concerning the recent use of receiver operating characteristic (ROC) analysis in medical imaging by reviewing ROC studies published in Radiology between 1997 and 2006 for experimental design, imaging modality, medical condition, and ROC paradigm. Two hundred ninety-five studies were obtained by conducting a literature search with PubMed with two criteria: publication in Radiology between 1997 and 2006 and occurrence of the phrase "receiver operating characteristic." Studies returned by the query that were not diagnostic imaging procedure performance evaluations were excluded. Characteristics of the remaining studies were tabulated. Two hundred thirty-three (79.0%) of the 295 studies reported findings based on observers' diagnostic judgments or objective measurements. Forty-three (14.6%) did not include human observers, with most of these reporting an evaluation of a computer-aided diagnosis system or functional data obtained with computed tomography (CT) or magnetic resonance (MR) imaging. The remaining 19 (6.4%) studies were classified as reviews or meta-analyses and were excluded from our subsequent analysis. Among the various imaging modalities, MR imaging (46.0%) and CT (25.7%) were investigated most frequently. Approximately 60% (144 of 233) of ROC studies with human observers published in Radiology included three or fewer observers. ROC analysis is widely used in radiologic research, confirming its fundamental role in assessing diagnostic performance. However, the ROC studies reported in Radiology were not always adequate to support clear and clinically relevant conclusions.