Effects of diagnostic classification systems on clinical hypothesis-generation

In this study it was determined whether (a) classification as opposed to absence of classification has an effect on the quality of clinical hypotheses (b) the DSM-III-R and the CBCL have a different effect on the quality of clinical hypotheses, and (c) the potential difference between the DSM-III-R and the CBCL is moderated by the different number of syndromes identified by these systems. To investigate these questions, an experiment was conducted in which 86 clinicians generated hypotheses for six cases. The clinicians were divided into a DSM-III-R, a CBCL, and a control group. Of the six cases, two were classified by both classification systems as one syndrome, two were classified as one syndrome by the DSM-III-R but as two syndromes by the CBCL, and two were classified as two syndromes by the DSM-III-R but as one syndrome by the CBCL. The quality of the hypotheses was determined by means of four dependent variables selected from an overview of qualitative criteria: explanatory value, redundancy, possibility of operationalization, and specificity. No differences between the CBCL and the control groups were found. The DSM group performed better than the control group regarding explanatory value and redundancy. The DSM-III-R group also scored better than the CBCL group regarding explanatory value, particularly when the number of identified syndromes was two for the CBCL and one for the DSM-III-R.     

Are explanatory trials ethical? Shifting the burden of justification in clinical trial design

Most phase III clinical trials today are explanatory. Because explanatory, or efficacy, trials test hypotheses under “ideal” conditions, they are not well suited to providing guidance on decisions made in most clinical care contexts. Pragmatic trials, which test hypotheses under “usual” conditions, are often better suited to this task. Yet, pragmatic, or effectiveness, trials are infrequently carried out. This mismatch between the design of clinical trials and the needs of health care professionals is frustrating for everyone involved, and explains some of the challenges inherent in attempts to enhance knowledge translation and encourage evidence-based practice. The situation is more than simply frustrating, however; it is potentially unethical. Clinical trials must be socially valuable in order to (1) warrant the risks they impose on human research subjects and (2) fairly and efficiently assess new clinical interventions. Most bioethicists would agree that trials that have no social value, for instance, because their results do not have the potential to advance clinical care, should not be performed. What is less widely appreciated is that given limited research resources, trials that are more socially valuable should be preferred to trials that are less socially valuable when all else is equal. With respect to clinical trial design, I argue that while explanatory trials often have some social value, many have less social value than their pragmatic counterparts. On the basis of this general ethical assessment, I provide a preliminary defense of the position that clinical researchers should aim to conduct pragmatic trials, that is, that researchers face a burden of justification related to any idealizing elements added to trial designs.     

Stability,breadth and guidance

Much recent work on explanation in the interventionist tradition emphasizes the explanatory value of stable causal generalizations—i.e., causal generalizations that remain true in a wide range of background circumstances. We argue that two separate explanatory virtues are lumped together under the heading of `stability’. We call these two virtues breadth and guidance respectively. In our view, these two virtues are importantly distinct, but this fact is neglected or at least under-appreciated in the literature on stability. We argue that an adequate theory of explanatory goodness should recognize breadth and guidance as distinct virtues, as breadth and guidance track different ideals of explanation, satisfy different cognitive and pragmatic ends, and play different theoretical roles in (for example) helping us understand the explanatory value of mechanisms. Thus keeping track of the distinction between these two forms of stability yields a more accurate and perspicuous picture of the role that stability considerations play in explanation.     

The Effects of Sentence‐Level Context,Prior Word Knowledge,and Need for Cognition on Information Processing of Technical Language in Print Ads

An experiment was conducted to examine the effects of sentence‐level context, prior word knowledge, and need for cognition on responses to print ads for technical products. Words and phrases that help readers understand technical language in context increased the supportive arguments generated in response to ads, whereas prior word knowledge and need for cognition primarily influenced neutral thoughts. Only explanatory language facilitated the comprehension of product information. Explanatory language led to an increase in attitudes and purchase intent. Need for cognition had a positive influence on attitude formation when the context language was ambiguous, but decreased attitude formation when the context language was explanatory. Results are consistent with predictions guided by a comprehension elaboration model of persuasion.     

Idiopathic physical symptoms: a common manifestation of psychiatric disorders in primary care

Worldwide, patients with common mental disorders, such as depression and anxiety, have a tendency to present first to primary care exhibiting idiopathic physical symptoms. Typically, these symptoms consist of pain and other physical complaints that remain medically unexplained. While in the past, traditional psychopathology emphasized the relevance of somatic presentations for disorders, such as depression, in the last few decades, the "somatic component" has been neglected in the assessment and treatment of psychiatric patients. Medical specialties have come up with a variety of "fashionable" labels to characterize these patients and the new psychiatric nomenclatures, such as the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, attempt to classify these patients into a separate "somatoform disorders" category. These efforts fall short, and revisionists are asking altogether for the elimination of "somatoform disorders" from future nomenclatures. This review emphasizes the importance of idiopathic physical symptoms to the clinical phenomenology of many psychiatric disorders, offers suggestions to the diagnostic conundrum, and provides some hints for the proper assessment and management of patients with these common syndromes.     

Conducting a Pragmatic Trial in Integrated Primary Care: Key Decision Points and Considerations

Pragmatic trials testing the effectiveness of interventions under “real world” conditions help bridge the research-to-practice gap. Such trial designs are optimal for studying the impact of implementation efforts, such as the effectiveness of integrated behavioral health clinicians in primary care settings. Formal pragmatic trials conducted in integrated primary care settings are uncommon, making it difficult for researchers to anticipate the potential pitfalls associated with balancing scientific rigor with the demands of routine clinical practice. This paper is based on our experience conducting the first phase of a large, multisite, pragmatic clinical trial evaluating the implementation and effectiveness of behavioral health consultants treating patients with chronic pain using a manualized intervention, brief cognitive behavioral therapy for chronic pain (BCBT-CP). The paper highlights key choice points using the PRagmatic-Explanatory Continuum Indicator Summary (PRECIS-2) tool. We discuss the dilemmas of pragmatic research that we faced and offer recommendations for aspiring integrated primary care pragmatic trialists.

     

Explanatory Effort and Structure as Contributors to the Good Life Among University Students

Ample theory and case evidence suggest the salutary role of making sense or explaining social reality for people's well-being. However, empirical evidence in support of the proposition is slim. To examine this proposition in a testable way, the present study employed a longitudinal panel design to assess associations between earlier reasoning on later well-being among a sample of 151 university students in Hong Kong. At the first wave, it measured reasoning in terms of explanatory consolidation and explanatory effort. Explanatory consolidation referred to a student's consistent agreement or disagreement with propositions of sociological theories that explain social problems, protest, and crime. Explanatory effort concerned the student's tendency to explain social problems. At the second wave, the study measured five good-life indicators to represent well-being. Results showed that explanatory consolidation and effort have significant relations with good life characteristics that are consistent with Chinese culture. These findings support social constructionist claims about the contribution of reasoning in the educational setting.     

The Holte Sleeping Technique: An experimental study

The Holte Sleeping Technique is an alternative to medication to facilitate sleep onset in situations of normal stress. The technique is based on a combination of conditioning within the theory of learning, simulation of natural bodily processes, and manipulation of naturally available sleep-releasing stimuli. The author describes the technique and reports on experimental testing of its efficacy. Fifty-six female subjects were selected according to criteria based on questionnaires and sleep logs. The subjects were randomly assigned to a treatment group, a placebo group, and a no-treatment group. A pre-test-post-test design was used. The author questions the generalizability of findings from modern electronic sleep laboratories to the bedrooms of everyday life. In order to optimize the combination of normal stress, objective criteria and generalizability, sleep onset was measured by behavioural criteria based on the "fog-horn procedure" developed by the author. At post-test 67% of the treatment group fell asleep, while only 17% of the placebo group and 25% of the no-treatment group fell asleep. The differences were significant. It is concluded that the Holte Sleeping Technique is highly effective. In a discussion of placebo trials the author argues that traditional medical trials do not take into consideration the differentiating psychological attribution effects occurring by giving the same experimental instruction under different experimental conditions. As a consequence the active treatment is given better conditions than the placebo in traditional clinical trials.     

A Normative Pragmatic Perspective on Appealing to Emotions in Argumentation

Is appealing to emotions in argumentation ever legitimate and, if so, what is the best way to analyze and evaluate such appeals? After overviewing a normative pragmatic perspective on appealing to emotions in argumentation, I present answers to these questions from pragma-dialectical, informal logical, and rhetorical perspectives, and note positions shared and supplemented by a normative pragmatic perspective. A normative pragmatic perspective holds that appealing to emotions in argumentation may be relevant and non-manipulative; and that emotional appeals may be analyzed as strategies that create pragmatic reasons and assessed by the standard of formal propriety or reasonability under the circumstances. I illustrate the explanatory power of the perspective by analyzing and evaluating some argumentation from Frederick Douglass’s “What to the Slave is the Fourth of July.” I conclude that a normative pragmatic perspective offers a more complete account of appealing to emotions in argumentation than a pragma-dialectial, informal logical, or rhetorical perspective alone, identifies a range of norms available to arguers, and explains why appealing to emotions may be legitimate in particular cases of argumentation.     

Emotional and Behavioral Problems Among Impoverished Kenyan Youth: Factor Structure and Sex-Differences

Data on youth emotional and behavioral problems from societies in Sub-Saharan Africa are lacking. This may be due to the fact that few youth mental health assessments have been tested for construct validity of syndrome structure across multicultural societies that include developing countries, and almost none have been tested in Sub-Saharan Africa. The Youth Self-Report (YSR), for example, has shown great consistency of its syndrome structure across many cultures, yet data from only one developing country in Sub-Saharan Africa have been included. In this study, we test the factor structure of YSR syndromes among Kenyan youth ages 11–18 years from an informal settlement in Nairobi, Kenya and examine sex-differences in levels of emotional and behavioral problems. We find the eight syndrome structure of the YSR to fit these data well (Root Mean Square Error of Approximation = 0.049). While Kenyan girls have significantly higher internalizing (Anxious/Depressed, Withdrawn/Depressed, Somatic) problem scores than boys, these differences are of similar magnitude to published multicultural findings. The results support the generalizability of the YSR syndrome structure to Kenyan youth and are in line with multicultural findings supporting the YSR as an assessment of emotional and behavioral problems in diverse societies.     

Relation of irrational thinking and the Pessimistic Explanatory Style

This study investigated the possible relationship between Ellis's construct of irrational thinking and Seligman's construct of explanatory style, with a view toward possibly strengthening the personality theory underlying Rational Emotive Behavior Therapy in particular and cognitive-behavior therapies more generally. In this investigation 180 college students were administered the Survey of Personal Beliefs and the Attributional Style Questionnaire to measure irrational thinking and explanatory style, respectively. Students who scored higher on Pessimistic Explanatory Style also scored higher on Overall Irrational Thinking and on Low Frustration Tolerance than did those who were categorized as having an Optimistic Explanatory Style. This indicates support for Ellis's developing personality theory, especially his theoretical account of depression.     

Narratives of Treatment Outcome

This article is based on the findings of an interview study that explored the discourses clinicians draw on in their narratives in relation to self-injury. More specifically, the study focused on the clinicians’ discourses of responsibility for treatment outcome, and how they construct concepts of success, failure, and partial failure. Eight mental health clinicians from various disciplines who employed a range of treatment modalities were selected using purposive sampling. An in-depth conversational-style interviewing approach was used. The findings of the study highlight the complexities and difficulties the clinicians encountered with regard to the evaluation of their clinical practice with self-injuring patients. It appears that clinicians have little or no systematic way of thinking or conceptualizing “progress” with regard to self-injury. In relation to who is responsible for treatment outcome, the clinicians occupied various discursive positions. These findings have implications for the education and training of clinicians in developing systematic indicators of progress with respect to self-injury and in creating spaces in which they can speak about and reflect on their clinical effectiveness and failures.     

Behavioral equipoise: a way to resolve ethical stalemates in clinical research

Randomized trials depend on clinicians feeling that they are morally justified in allowing their patients to be randomized across treatment arms. Typically such justification rides on what has been called "clinical equipoise"--when there is disagreement of opinion among the community of experts about whether one treatment is better than another, then physicians can ethically enter their patients into a clinical trial, even if individual physicians are not at equipoise. Recent debates over prominent studies, however, illustrate that controversy can be easily created rather than dispelled by trials, with many clinicians choosing not to use the proven therapy until they receive more convincing evidence of its superiority. In such situations, we propose that a new standard of equipoise be used to guide decisions about the ethical justifications for research trials--a standard of behavioral equipoise. Under behavioral equipoise, a trial is potentially justifiable if it addresses behavioral resistance to prior scientific evidence.     

Cancer-related fatigue: a systematic and meta-analytic review of non-pharmacological therapies for cancer patients

Cancer-related fatigue (CRF) is a significant clinical problem for more than 10 million adults diagnosed with cancer each year worldwide. No "gold standard" treatment presently exists for CRF. To provide a guide for future research to improve the treatment of CRF, the authors conducted the most comprehensive combined systematic and meta-analytic review of the literature to date on non-pharmacological (psychosocial and exercise) interventions to ameliorate CRF and associated symptoms (vigor/vitality) in adults with cancer, based on 119 randomized controlled trials (RCTs) and non-RCT studies. Meta-analyses conducted on 57 RCTs indicated that exercise and psychological interventions provided reductions in CRF, with no significant differences between these 2 major types of interventions considered as a whole. Specifically, multimodal exercise and walking programs, restorative approaches, supportive-expressive, and cognitive-behavioral psychosocial interventions show promising potential for ameliorating CRF. The results also suggest that vigor and vitality are distinct phenomena from CRF with regard to responsiveness to intervention. With improved methodological approaches, further research in this area may soon provide clinicians with effective strategies for reducing CRF and enhancing the lives of millions of cancer patients and survivors.     

Frameworks for understanding emotions and their development: functionalist and dynamic systems approaches

In recent years, both functionalist and dynamic systems approaches have assumed increasing prominence in the study of emotion and its development, but the similarities and differences between these perspectives remain largely unexplored and open to more systematic examination. In this article, the authors argue that both approaches share a systems view of emotion and regard emotion in relational, process terms. However, each approach adopts a distinct level of analysis and distinct types of explanation for emotion and its development. Whereas the functionalist approach appeals to formal and final causes to explain patterning in emotion at the level of organism-environment relations, the dynamic systems approach appeals to efficient and material causes to explain emotion at the specific content level of behavior in context. Whether these approaches complement or conflict with one another depends on the extent to which the dynamic systems approach admits abstraction into its explanatory framework. A. Fogel's social process theory and M. D. Lewis' approach to emotion self-organization are discussed in this regard.     

Gender differences in the development of depression

The present study attempted to examine possible gender differences in the vulnerability to depression, specifically with regard to eliciting factors, marital status, age of onset, season of hospitalization, and type of treatment. The records of all patients (67 women and 34 men), treated during 1991 for major depression, dysthymia, or depression NOS at a psychiatric hospital in Southeastern Sweden were examined, and placed in empirically derived categories regarding eliciting factors.
The results indicated significant gender differences with regard to eliciting factors, marital status, and age. The eliciting factor in female depression was most commonly "threat to social bonds" whereas in male depression it was "threat to self esteem" or "threat to self respect". Married women were more prone to depression than were married men, as were men living alone compared to women living alone. Women above 60 years of age were significantly more prone to depression than were men of this age group. The results were discussed from two theoretical perspectives: gender role theory and gender-specific developmental theory.     

Adversarial Problem Solving: Modeling an Opponent Using Explanatory Coherence

In adversarial problem solving (APS), one must anticipate, understand and counteract the actions of an opponent. Military strategy, business, and game playing all require an agent to construct a model of an opponent that includes the opponent's model of the agent. The cognitive mechanisms required for such modeling include deduction, analogy, inductive generalization, and the formation and evaluation of explanatory hypotheses. Explanatory coherence theory captures part of what is involved in APS, particularly in cases involving deception.     

A Puzzle about Consent in Research and in Practice

In this paper, I will examine a puzzling discrepancy between the way clinicians are allowed to treat their patients and the way researchers are allowed to treat their subjects: in certain cases, researchers are legally required to disclose quite a bit more information when obtaining consent from prospective subjects than clinicians are when obtaining consent from prospective patients. I will argue that the proper resolution of this puzzling discrepancy must appeal to a pragmatic criterion of disclosure for informed consent: that what needs to be disclosed in order for consent to be valid depends on what the patient/subject needs to know in order to make a decision. I will then use this pragmatic criterion of disclosure to argue that when obtaining consent researchers should be permitted to omit the same information clinicians are, given certain qualifications. I will also examine how this puzzle forces us to confront some perhaps surprising truths about valid consent. My broader aim in this paper is to examine, not so much the puzzle itself, but rather what this particular puzzle can teach us about more theoretical issues surrounding informed consent.