Cognitive biases and prazosin study

Cognitive biases and prazosin study

by Laura Compton -

   I enjoyed this session’s article, as it challenged our prior assumptions about prazosin and its efficacy in PTSD-related nightmares, and seems to have really made us think about how and why we make our treatment decisions. I’ve also been under the impression that prazosin was the gold standard for PTSD-related nightmares, and I’ve had many patients on it with a variety of responses. (Perhaps prazosin remains the gold standard because we have so few effective ways of treating PTSD-related nightmares. Despite rosy reports of how EMDR and other psychotherapeutic modalities fix PTSD, there are many patients who have minimal improvement even after really intensive treatment. As with prazosin, research doesn’t always reflect what we see in practice.)

   It’s interesting to see each of us go through the processes of questioning our knowledge and then either discarding or modifying previous practices or, in some cases, doubling down despite this research. This made me think about how we make our treatment decisions - while we all would like to think we are completely rational, using evidence- and science-based treatment choices, in reality our decision-making processes as providers are subject to a lot of cognitive biases that can lead us astray. Cognitive biases affect our clinical reasoning processes, and can lead to errors in diagnosis and treatment, which in turn lead to poorer outcomes, higher healthcare costs, and decreased patient satisfaction. A systematic review of research on cognitive biases in physicians (Saposnic et al., 2016) identified some of the most common cognitive biases:

  • Tolerance to risk or ambiguity - more a personality trait than a bias, lower tolerance to risk or ambiguity is associated with more diagnostic errors
  • Overconfidence - a universal tendency to believe we know more than we do. Overconfidence reflects a tendency to act on incomplete information, intuitions, or hunches. Too much faith is placed in opinion instead of carefully gathered evidence.
  • Framing effects - how diagnosticians see things may be strongly influenced by the way in which the problem is framed, e.g., physicians’ perceptions of risk to the patient may be strongly influenced by whether the outcome is expressed in terms of the possibility that the patient might die or might live. In terms of diagnosis, physicians should be aware of how patients, nurses, and other physicians frame potential outcomes and contingencies of the clinical problem to them
  • Availability bias - the disposition to judge things as being more likely, or frequently occurring, if they readily come to mind. Thus, recent experience with a disease may inflate the likelihood of its being diagnosed. Conversely, if a disease has not been seen for a long time (is less available), it may be underdiagnosed
  • Anchoring bias - the tendency to perceptually lock onto salient features in the patient’s initial presentation too early in the diagnostic process, and failing to adjust this initial impression in the light of later information. This may be severely compounded by the confirmation bias
  • Confirmation bias - the tendency to look for confirming evidence to support a diagnosis rather than look for disconfirming evidence to refute it, despite the latter often being more persuasive and definitive
  • Premature closure - a powerful bias accounting for a high proportion of missed diagnoses. It is the tendency to apply premature closure to the decision-making process, accepting a diagnosis before it has been fully verified. The consequences of the bias are reflected in the maxim: ‘‘When the diagnosis is made, the thinking stops.’’ (definitions of each bias taken from Croskerry, 2003)

   Confirmation bias and overconfidence definitely play a role in the way many of us have used prazosin - we’ve just ‘known’ that it was the correct and best treatment for PTSD-related nightmares! And many of us (myself included) seem to be struggling with how to synthesize this contrary finding and integrate it into our practice. Thankfully there are ways we can identify and address our cognitive biases, and be more mindful of when they are likely. Rather than regurgitate the whole Croskerry article, I highly recommend reading over it (it’s only 3 pages long, and very concisely written - it’s a great breakdown!)

References

Croskerry, P. (2003). The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine, 78(8), 775-780. Retrieved from https://insights-ovid-com.ucsf.idm.oclc.org/pubmed?pmid=12915363

Saposnik, G., Redelmeier, D., Ruf, C. C., & Tobler, P. N. (2016). Cognitive biases associated with medical decisions: A systematic review. BMC Medical Informatics & Decision Making, 16, 138. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5093937/ 

Re: Cognitive biases and prazosin study

by Sareen -

Laura,

Thanks for your post (and response to my post) that touches upon cognitive biases. I agree that when I read journal articles, I am often at fault for falling into confirmation bias--finding evidence that already supports what I believe to be true. I think this was some of the discomfort of reading the results of this article on Prazosin. You bring up a really good point that we think we are rational and follow evidence based research when in practice, but we are constantly at risk of cognitive biases. I was reading through the different biases, though, and was realizing that a lot of them are opposites of another. For example, the commission bias (the tendency toward action rather than inaction) directly contradicts the omission bias (the tendency toward inaction over action) (Croskerry, 2003). Sometimes I get so overwhelmed trying to navigate all the different biases I could have that I have a hard time maintaining that balance and struggle with confidence of my diagnosis. But bringing it back to reading journal articles with as little bias as possible, I do believe that with more experience objectively critiquing articles, we are more likely to read them with sober eyes. Additionally, I think it's equally to consult with colleagues if we believe we are starting to sense our own biases creeping in (not just in reading articles, but in caring for our patients). Thanks for good food for thought!


Croskerry, P. (2003). The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine, 78(8): 775-780. Retrieved from:  https://insights-ovid-com.ucsf.idm.oclc.org/pubmed?pmid=12915363

Re: Cognitive biases and prazosin study

by Abigail -

Laura, thank you for breaking down all of the biases that influence our approach to patient care and treatment decisions. I find myself struggling with confirmation bias in clinical practice and when reviewing literature and agree that is plays a part in the use of prazosin for PTSD-related nightmares. 

Just prior to reading the article for this journal club session, I had a discussion with my supervising psychiatrist about prazosin. We see a lot of TAY with PTSD and some patients do experience regular trauma-related nightmares, which contribute to poor sleep and subsequent worsening of PTSD symptoms. The psychiatrist is not convinced of prazosin's efficacy based on anecdotal experience and lack of strong evidence to support it. He believes it is considered the gold standard by so many providers, as you mentioned, because it serves as a way to "do something" when it seems like treatment options are so limited and to help build a therapeutic alliance. 

So far, I find PTSD to be one of the most challenging diagnoses to address as a soon-to-be provider. I would love to have more tools in my toolbox to help treat trauma-related symptoms and I can definitely understand why providers lean heavily toward prazosin, hoping it can alleviate nightmares and, in turn, help them feel they are contributing to patients' recovery when the overall process feels so daunting. 

Re: Cognitive biases and prazosin study

by Mousumi Mukerji -

Dear Abby (no relation to the advice columnist),

I loved hearing your supervising psychiatrist's thoughts on prazosin. I just spoke to my preceptor about a patient who has been on prazosin for a couple of years, who is very difficult to work with (seems to have a personality disorder in the making) though a diagnosis of PTSD for her is dubious. I suspect prazosin was prescribed for her for the very reasons your psychiatrist mentioned. 

My own personal bias is that trauma is best addressed through psychotherapeutic modalities, many of which we learned about in our trauma class this quarter. Somatic psychotherapies in particular (Somatic Experiencing, Sensorimotor Psychotherapy) and yoga are particularly promising in targeting unconscious processes and sympathetic arousal; however because the data on these modalities is limited we have not been exposed to them with the exception of EMDR. Now, I may be exhibiting the biases of overconfidence and premature closure on this; I suppose my future forays into training in somatic psychotherapy will tell. Nevertheless, pharmacotherapy has its place in healing from trauma, but must be used judiciously of course and its need and effectiveness evaluated on an ongoing basis.