Does working memory training affect decision making ? : a neuroeconomic study

We all make decisions of varying levels of importance every day. Because making a decision implies that there are alternative choices to be considered, almost all decision involves some conflicts or dissatisfaction. Traditional economic models esteem that a person must weight the positive and negative outcomes of each option, and based on all these inferences, determines which option is the best for that particular situation. However, individuals rather act as irrational agents and tend to deviate from these rational choices. They somewhat evaluate the outcomes' subjective value, namely, when they face a risky choice leading to losses, people are inclined to have some preference for risk over certainty, while when facing a risky choice leading to gains, people often avoid to take risks and choose the most certain option. Yet, it is assumed that decision making is balanced between deliberative and emotional components. Distinct neural regions underpin these factors: the deliberative pathway that corresponds to executive functions, implies the activation of the prefrontal cortex, while the emotional pathway tends to activate the limbic system. These circuits appear to be altered in individuals with ADHD, and result, amongst others, in impaired decision making capacities. Their impulsive and inattentive behaviors are likely to be the cause of their irrational attitude towards risk taking. Still, a possible solution is to administrate these individuals a drug treatment, with the knowledge that it might have several side effects. However, an alternative treatment that relies on cognitive rehabilitation might be appropriate. This project was therefore aimed at investigate whether an intensive working memory training could have a spillover effect on decision making in adults with ADHD and in age-matched healthy controls. We designed a decision making task where the participants had to select an amount to gamble with the chance of 1/3 to win four times the chosen amount, while in the other cases they could loose their investment. Their performances were recorded using electroencephalography prior and after a one-month Dual N-Back training and the possible near and far transfer effects were investigated. Overall, we found that the performance during the gambling task was modulated by personality factors and by the importance of the symptoms at the pretest session. At posttest, we found that all individuals demonstrated an improvement on the Dual N-Back and on similar untrained dimensions. In addition, we discovered that not only the adults with ADHD showed a stable decrease of the symptomatology, as evaluated by the CAARS inventory, but this reduction was also detected in the control samples. In addition, Event-Related Potential (ERP) data are in favor of an change within prefrontal and parietal cortices. These results suggest that cognitive remediation can be effective in adults with ADHD, and in healthy controls. An important complement of this work would be the examination of the data in regard to the attentional networks, which could empower the fact that complex programs covering the remediation of several executive functions' dimensions is not required, a unique working memory training can be sufficient. -- Nous prenons tous chaque jour des décisions ayant des niveaux d'importance variables. Toutes les décisions ont une composante conflictuelle et d'insatisfaction, car prendre une décision implique qu'il y ait des choix alternatifs à considérer. Les modèles économiques traditionnels estiment qu'une personne doit peser les conséquences positives et négatives de chaque option et en se basant sur ces inférences, détermine quelle option est la meilleure dans une situation particulière. Cependant, les individus peuvent dévier de ces choix rationnels. Ils évaluent plutôt les valeur subjective des résultats, c'est-à-dire que lorsqu'ils sont face à un choix risqué pouvant les mener à des pertes, les gens ont tendance à avoir des préférences pour le risque à la place de la certitude, tandis que lorsqu'ils sont face à un choix risqué pouvant les conduire à un gain, ils évitent de prendre des risques et choisissent l'option la plus su^re. De nos jours, il est considéré que la prise de décision est balancée entre des composantes délibératives et émotionnelles. Ces facteurs sont sous-tendus par des régions neurales distinctes: le chemin délibératif, correspondant aux fonctions exécutives, implique l'activation du cortex préfrontal, tandis que le chemin émotionnel active le système limbique. Ces circuits semblent être dysfonctionnels chez les individus ayant un TDAH, et résulte, entre autres, en des capacités de prise de décision altérées. Leurs comportements impulsifs et inattentifs sont probablement la cause de ces attitudes irrationnelles face au risque. Cependant, une solution possible est de leur administrer un traitement médicamenteux, en prenant en compte les potentiels effets secondaires. Un traitement alternatif se reposant sur une réhabilitation cognitive pourrait être appropriée. Le but de ce projet est donc de déterminer si un entrainement intensif de la mémoire de travail peut avoir un effet sur la prise de décision chez des adultes ayant un TDAH et chez des contrôles sains du même âge. Nous avons conçu une tâche de prise de décision dans laquelle les participants devaient sélectionner un montant à jouer en ayant une chance sur trois de gagner quatre fois le montant choisi, alors que dans l'autre cas, ils pouvaient perdre leur investissement. Leurs performances ont été enregistrées en utilisant l'électroencéphalographie avant et après un entrainement d'un mois au Dual N-Back, et nous avons étudié les possibles effets de transfert. Dans l'ensemble, nous avons trouvé au pré-test que les performances au cours du jeu d'argent étaient modulées par les facteurs de personnalité, et par le degré des sympt^omes. Au post-test, nous avons non seulement trouvé que les adultes ayant un TDAH montraient une diminutions stable des symptômes, qui étaient évalués par le questionnaire du CAARS, mais que cette réduction était également perçue dans l'échantillon des contrôles. Les rsultats expérimentaux mesurés à l'aide de l'éléctroencéphalographie suggèrent un changement dans les cortex préfrontaux et pariétaux. Ces résultats suggèrent que la remédiation cognitive est efficace chez les adultes ayant un TDAH, mais produit aussi un effet chez les contrôles sains. Un complément important de ce travail pourrait examiner les données sur l'attention, qui pourraient renforcer l'idée qu'il n'est pas nécessaire d'utiliser des programmes complexes englobant la remédiation de plusieurs dimensions des fonctions exécutives, un simple entraiment de la mémoire de travail devrait suffire.

Effective continuing professional development for translating shared decision making in primary care: A study protocol.

Background: Shared decision making (SDM) is a process by which a healthcare choice is made jointly by the healthcare professional and the patient. SDM is the essential element of patient-centered care, a core concept of primary care. However, SDM is seldom translated into primary practice. Continuing professional development (CPD) is the principal means by which healthcare professionals continue to gain, improve, and broaden the knowledge and skills required for patient-centered care. Our international collaboration seeks to improve the knowledge base of CPD that targets translating SDM into the clinical practice of primary care in diverse healthcare systems. Methods: Funded by the Canadian Institutes of Health Research (CIHR), our project is to form an international, interdisciplinary research team composed of health services researchers, physicians, nurses, psychologists, dietitians, CPD decision makers and others who will study how CPD causes SDM to be practiced in primary care. We will perform an environmental scan to create an inventory of CPD programs and related activities for translating SDM into clinical practice. These programs will be critically assessed and compared according to their strengths and limitations. We will use the empirical data that results from the environmental scan and the critical appraisal to identify knowledge gaps and generate a research agenda during a two-day workshop to be held in Quebec City. We will ask CPD stakeholders to validate these knowledge gaps and the research agenda. Discussion: This project will analyse existing CPD programs and related activities for translating SDM into the practice of primary care. Because this international collaboration will develop and identify various factors influencing SDM, the project could shed new light on how SDM is implemented in primary care.

How can continuing professional development better promote shared decision-making? Perspectives from an international collaboration.

ABSTRACT: BACKGROUND: Shared decision-making is not widely implemented in healthcare. We aimed to set a research agenda about promoting shared decision-making through continuing professional development. METHODS: Thirty-six participants met for two days. RESULTS: Participants suggested ways to improve an environmental scan that had inventoried 53 shared decision-making training programs from 14 countries. Their proposed research agenda included reaching an international consensus on shared decision-making competencies and creating a framework for accrediting continuing professional development initiatives in shared decision-making. CONCLUSIONS: Variability in shared decision-making training programs showcases the need for quality assurance frameworks.

How family caregivers' medical and moral assumptions influence decision making for patients in the vegetative state: a qualitative interview study.

Background Decisions on limiting life-sustaining treatment for patients in the vegetative state (VS) are emotionally and morally challenging. In Germany, doctors have to discuss, together with the legal surrogate (often a family member), whether the proposed treatment is in accordance with the patient's will. However, it is unknown whether family members of the patient in the VS actually base their decisions on the patient's wishes. Objective To examine the role of advance directives, orally expressed wishes, or the presumed will of patients in a VS for family caregivers' decisions on life-sustaining treatment. Methods and sample A qualitative interview study with 14 next of kin of patients in a VS in a long-term care setting was conducted; 13 participants were the patient's legal surrogates. Interviews were analysed according to qualitative content analysis. Results The majority of family caregivers said that they were aware of aforementioned wishes of the patient that could be applied to the VS condition, but did not base their decisions primarily on these wishes. They gave three reasons for this: (a) the expectation of clinical improvement, (b) the caregivers' definition of life-sustaining treatments and (c) the moral obligation not to harm the patient. If the patient's wishes were not known or not revealed, the caregivers interpreted a will to live into the patient's survival and non-verbal behaviour. Conclusions Whether or not prior treatment wishes of patients in a VS are respected depends on their applicability, and also on the medical assumptions and moral attitudes of the surrogates. We recommend repeated communication, support for the caregivers and advance care planning.

Effects of anxiety on visuospatial pattern discrimination and decision-making processes: what can we learn from brain dynamics ?

Detection and discrimination of visuospatial input involve at least extracting, selecting and encoding relevant information and decision-making processes allowing selecting a response. These two operations are altered, respectively, by attentional mechanisms that change discrimination capacities, and by beliefs concerning the likelihood of uncertain events. Information processing is tuned by the attentional level that acts like a filter on perception, while decision-making processes are weighed by subjective probability of risk. In addition, it has been shown that anxiety could affect the detection of unexpected events through the modification of the level of arousal. Consequently, purpose of this study concerns whether and how decision-making and brain dynamics are affected by anxiety. To investigate these questions, the performance of women with either a high (12) or a low (12) STAI-T (State-Trait Anxiety Inventory, Spielberger, 1983) was examined in a decision-making visuospatial task where subjects have to recognize a target visual pattern from non-target patterns. The target pattern was a schematic image of furniture arranged in such a way as to give the impression of a living room. Non-target patterns were created by either the compression or the dilatation of the distances between objects. Target and non-target patterns were always presented in the same configuration. Preliminary behavioral results show no group difference in reaction time. In addition, visuo-spatial abilities were analyzed trough the signal detection theory for quantifying perceptual decisions in the presence of uncertainty (Green and Swets, 1966). This theory treats detection of a stimulus as a decision-making process determined by the nature of the stimulus and cognitive factors. Astonishingly, no difference in d' (corresponding to the distance between means of the distributions) and c (corresponds to the likelihood ratio) indexes was observed. Comparison of Event-related potentials (ERP) reveals that brain dynamics differ according to anxiety. It shows differences in component latencies, particularly a delay in anxious subjects over posterior electrode sites. However, these differences are compensated during later components by shorter latencies in anxious subjects compared to non-anxious one. These inverted effects seem indicate that the absence of difference in reaction time rely on a compensation of attentional level that tunes cortical activation in anxious subjects, but they have to hammer away to maintain performance.

Public particiation and the legitimacy of intergovernmental decision-making : a focus on the World Trade Organization

The legitimacy of the WTO's decision-making process has always been questioned, and many have advocated public participation mechanisms as a remedy. The present study considers the limits and potential of these mechanisms by advancing a conceptual framework, which distinguishes the four 'implementation parameters' of public participation: the goal, the object, the modalities, and the actors. It addresses the issue of legitimacy by considering to what extent, and by virtue of which legal developments, one can see implementing the democratic principle as a goal for public participation in the context of the WTO. By analyzing the institutional structure of the WTO and its different types of decisions, it then outlines how this goal should influence the object and modalities of public participation, which decision-making procedures should be opened to public participation, and how the mechanisms should be implemented in practice. Finally, it suggests speciflrc amendments to existing WTO affangements on public participation

Evolution of decision-making and learning under fluctuating social environments

The capacity to learn to associate sensory perceptions with appropriate motor actions underlies the success of many animal species, from insects to humans. The evolutionary significance of learning has long been a subject of interest for evolutionary biologists who emphasize the bene¬fit yielded by learning under changing environmental conditions, where it is required to flexibly switch from one behavior to another. However, two unsolved questions are particularly impor¬tant for improving our knowledge of the evolutionary advantages provided by learning, and are addressed in the present work. First, because it is possible to learn the wrong behavior when a task is too complex, the learning rules and their underlying psychological characteristics that generate truly adaptive behavior must be identified with greater precision, and must be linked to the specific ecological problems faced by each species. A framework for predicting behavior from the definition of a learning rule is developed here. Learning rules capture cognitive features such as the tendency to explore, or the ability to infer rewards associated to unchosen actions. It is shown that these features interact in a non-intuitive way to generate adaptive behavior in social interactions where individuals affect each other's fitness. Such behavioral predictions are used in an evolutionary model to demonstrate that, surprisingly, simple trial-and-error learn¬ing is not always outcompeted by more computationally demanding inference-based learning, when population members interact in pairwise social interactions. A second question in the evolution of learning is its link with and relative advantage compared to other simpler forms of phenotypic plasticity. After providing a conceptual clarification on the distinction between genetically determined vs. learned responses to environmental stimuli, a new factor in the evo¬lution of learning is proposed: environmental complexity. A simple mathematical model shows that a measure of environmental complexity, the number of possible stimuli in one's environ¬ment, is critical for the evolution of learning. In conclusion, this work opens roads for modeling interactions between evolving species and their environment in order to predict how natural se¬lection shapes animals' cognitive abilities. - La capacité d'apprendre à associer des sensations perceptives à des actions motrices appropriées est sous-jacente au succès évolutif de nombreuses espèces, depuis les insectes jusqu'aux êtres hu¬mains. L'importance évolutive de l'apprentissage est depuis longtemps un sujet d'intérêt pour les biologistes de l'évolution, et ces derniers mettent l'accent sur le bénéfice de l'apprentissage lorsque les conditions environnementales sont changeantes, car dans ce cas il est nécessaire de passer de manière flexible d'un comportement à l'autre. Cependant, deux questions non résolues sont importantes afin d'améliorer notre savoir quant aux avantages évolutifs procurés par l'apprentissage. Premièrement, puisqu'il est possible d'apprendre un comportement incorrect quand une tâche est trop complexe, les règles d'apprentissage qui permettent d'atteindre un com¬portement réellement adaptatif doivent être identifiées avec une plus grande précision, et doivent être mises en relation avec les problèmes écologiques spécifiques rencontrés par chaque espèce. Un cadre théorique ayant pour but de prédire le comportement à partir de la définition d'une règle d'apprentissage est développé ici. Il est démontré que les caractéristiques cognitives, telles que la tendance à explorer ou la capacité d'inférer les récompenses liées à des actions non ex¬périmentées, interagissent de manière non-intuitive dans les interactions sociales pour produire des comportements adaptatifs. Ces prédictions comportementales sont utilisées dans un modèle évolutif afin de démontrer que, de manière surprenante, l'apprentissage simple par essai-et-erreur n'est pas toujours battu par l'apprentissage basé sur l'inférence qui est pourtant plus exigeant en puissance de calcul, lorsque les membres d'une population interagissent socialement par pair. Une deuxième question quant à l'évolution de l'apprentissage concerne son lien et son avantage relatif vis-à-vis d'autres formes plus simples de plasticité phénotypique. Après avoir clarifié la distinction entre réponses aux stimuli génétiquement déterminées ou apprises, un nouveau fac¬teur favorisant l'évolution de l'apprentissage est proposé : la complexité environnementale. Un modèle mathématique permet de montrer qu'une mesure de la complexité environnementale - le nombre de stimuli rencontrés dans l'environnement - a un rôle fondamental pour l'évolution de l'apprentissage. En conclusion, ce travail ouvre de nombreuses perspectives quant à la mo¬délisation des interactions entre les espèces en évolution et leur environnement, dans le but de comprendre comment la sélection naturelle façonne les capacités cognitives des animaux.

Role of disease activity for decision making ability in early multiple sclerosis

Background and purpose: Decision making (DM) has been defined as the process through which a person forms preferences, selects and executes actions, and evaluates the outcome related to a selected choice. This ability represents an important factor for adequate behaviour in everyday life. DM impairment in multiple sclerosis (MS) has been previously reported. The purpose of the present study was to assess DM in patients with MS at the earliest clinically detectable time point of the disease. Methods: Patients with definite (n=109) or possible (clinically isolated syndrome, CIS; n=56) MS, a short disease duration (mean 2.3 years) and a minor neurological disability (mean EDSS 1.8) were compared to 50 healthy controls aged 18 to 60 years (mean age 32.2) using the Iowa Gambling Task (IGT). Subjects had to select a card from any of 4 decks (A/B [disadvantageous]; C/D [advantageous]). The game consisted of 100 trials then grouped in blocks of 20 cards for data analysis. Skill in DM was assessed by means of a learning index (LI) defined as the difference between the averaged last three block indexes and first two block indexes (LI=[(BI-3+BI-4+BI-5)/3-(BI-1+B2)/2]). Non parametric tests were used for statistical analysis. Results: LI was higher in the control group (0.24, SD 0.44) than in the MS group (0.21, SD 0.38), however without reaching statistical significance (p=0.7). Interesting differences were detected when MS patients were grouped according to phenotype. A trend to a difference between MS subgroups and controls was observed for LI (p=0.06), which became significant between MS subgroups (p=0.03). CIS patients who confirmed MS diagnosis by presenting a second relapse after study entry showed a dysfunction in the IGT in comparison to the other CIS (p=0.01) and definite MS (p=0.04) patients. In the opposite, CIS patients characterised by not entirely fulfilled McDonald criteria at inclusion and absence of relapse during the study showed an normal learning pattern on the IGT. Finally, comparing MS patients who developed relapses after study entry, those who remained clinically stable and controls, we observed impaired performances only in relapsing patients in comparison to stable patients (p=0.008) and controls (p=0.03). Discussion: These results raise the assumption of a sustained role for both MS relapsing activity and disease heterogeneity (i.e. infra-clinical severity or activity of MS) in the impaired process of decision making.

Playing Second Fiddle: Expert Advice and Decision-Making in Switzerland

This thesis concerns the role of scientific expertise in the decision-making process at the Swiss federal level of government. It aims to understand how institutional and issue-specific factors influence three things: the distribution of access to scientific expertise, its valuation by participants in policy for- mulation, and the consequence(s) its mobilization has on policy politics and design. The theoretical framework developed builds on the assumption that scientific expertise is a strategic resource. In order to effectively mobilize this resource, actors require financial and organizational resources, as well as the conviction that it can advance their instrumental interests within a particular action situation. Institutions of the political system allocate these financial and organizational resources, influence the supply of scientific expertise, and help shape the venue of its deployment. Issue structures, in turn, condition both interaction configurations and the way in which these are anticipated by actors. This affects the perceived utility of expertise mobilization, mediating its consequences. The findings of this study show that the ability to access and control scientific expertise is strongly concentrated in the hands of the federal administration. Civil society actors have weak capacities to mobilize it, and the autonomy of institutionalized advisory bodies is limited. Moreover, the production of scientific expertise is undergoing a process of professionalization which strengthens the position of the federal administration as the (main) mandating agent. Despite increased political polarization and less inclu- sive decision-making, scientific expertise remains anchored in the policy subsystem, rather than being used to legitimate policy through appeals to the wider population. Finally, the structure of a policy problem matters both for expertise mobilization and for the latter's impact on the policy process, be- cause it conditions conflict structures and their anticipation. Structured problems result in a greater overlap between the principal of expertise mobilization and its intended audience, thereby increasing the chance that expertise shapes policy design. Conversely, less structured problems, especially those that involve conflicts about values and goals, reduce the impact of expertise.

Preserved decision making ability in early multiple sclerosis.

BACKGROUND: The purpose of this study was to assess decision making in patients with multiple sclerosis (MS) at the earliest clinically detectable time point of the disease. METHODS: Patients with definite MS (n = 109) or with clinically isolated syndrome (CIS, n = 56), a disease duration of 3 months to 5 years, and no or only minor neurological impairment (Expanded Disability Status Scale [EDSS] score 0-2.5) were compared to 50 healthy controls using the Iowa Gambling Task (IGT). RESULTS: The performance of definite MS, CIS patients, and controls was comparable for the two main outcomes of the IGT (learning index: p = 0.7; total score: p = 0.6). The IGT learning index was influenced by the educational level and the co-occurrence of minor depression. CIS and MS patients developing a relapse during an observation period of 15 months dated from IGT testing demonstrated a lower learning index in the IGT than patients who had no exacerbation (p = 0.02). When controlling for age, gender and education, the difference between relapsing and non-relapsing patients was at the limit of significance (p = 0.06). CONCLUSION: Decision making in a task mimicking real life decisions is generally preserved in early MS patients as compared to controls. A possible consequence of MS relapsing activity in the impairment of decision making ability is also suspected in the early phase of MS.

Progressive decline of decision-making performances during multiple sclerosis.

The purpose of this study was to evaluate longitudinally, using the Iowa Gambling Task (IGT), the dynamics of decision-making capacity at a two-year interval (median: 2.1 years) in a group of patients with multiple sclerosis (MS) (n = 70) and minor neurological disability [Expanded Disability Status Scale (EDSS) < or = 2.5 at baseline]. Cognition (memory, executive functions, attention), behavior, handicap, and perceived health status were also investigated. Standardized change scores [(score at retest-score at baseline)/standard deviation of baseline score] were computed. Results showed that IGT performances decreased from baseline to retest (from 0.3, SD = 0.4 to 0.1, SD = 0.3, p = .005). MS patients who worsened in the IGT were more likely to show a decreased perceived health status and emotional well-being (SEP-59; p = .05 for both). Relapsing rate, disability progression, cognitive, and behavioral changes were not associated with decreased IGT performances. In conclusion, decline in decision making can appear as an isolated deficit in MS.

'Doctor, what would you do in my position?' Health professionals and the decision-making process in pregnancy monitoring.

OBJECTIVE: Routine prenatal screening for Down syndrome challenges professional non-directiveness and patient autonomy in daily clinical practices. This paper aims to describe how professionals negotiate their role when a pregnant woman asks them to become involved in the decision-making process implied by screening. METHODS: Forty-one semi-structured interviews were conducted with gynaecologists-obstetricians (n=26) and midwives (n=15) in a large Swiss city. RESULTS: Three professional profiles were constructed along a continuum that defines the relative distance or proximity towards patients' demands for professional involvement in the decision-making process. The first profile insists on enforcing patient responsibility, wherein the healthcare provider avoids any form of professional participation. A second profile defends the idea of a shared decision making between patients and professionals. The third highlights the intervening factors that justify professionals' involvement in decisions. CONCLUSIONS: These results illustrate various applications of the principle of autonomy and highlight the complexity of the doctor-patient relationship amidst medical decisions today.