[Integration of the Insured Person's Perspective in the Quality Assessment of Medical Evaluations]. / Integration der Versichertenperspektive in die Qualitätsbewertung der Begutachtung.

Integration of the Insured Person's Perspective in the Quality Assessment of Medical Evaluations Abstract. In the current practice of medical work disability evaluations and other pension assessments, insured persons in Switzerland lack the possibility to routinely provide feedback on the extent to which they felt treated with dignity and respect by medical experts, which, according to occasional complaints, does not always seem to be the case. In order to be able to systematically capture such aspects of interactive fairness, we developed a questionnaire, the Basel Fairness Questionnaire (BFQ). The BFQ contains 30 statements such as «The reviewer listened to me.¼, which the insured person can agree to on four levels (from «I do not agree at all.¼ to «I fully agree.¼). For validating the questionnaire, 305 claimants for disability pensions completed the BFQ after their medical work disability evaluation. A factor analysis conducted on the answered questions confirmed our assumption that the BFQ questions covered the areas of 1) respect and trust, 2) participation, 3) case familiarity of the expert, and 4) transparency of the evaluation process. Furthermore, our study demonstrated divergent and convergent validity of the BFQ with other questionnaire instruments. The BFF opens up the possibility to capture the abstract concept of fairness by means of assessments of concrete expert behavior. We expect that the questionnaire can thus contribute to quality assurance in this sensitive area.

The assessment of capacity limitations in psychiatric work disability evaluations by the social functioning scale Mini-ICF-APP.

OBJECTIVE: Insurers frequently commission medical experts to estimate the degree of the remaining work capacity (RWC) in claimants for disability benefits. The social functioning scale Mini-ICF-APP allows for a rating of activity and participation limitations in thirteen capacity domains, considered as particularly relevant for work ability. The current study sought to evaluate the role of the Mini-ICF-APP ratings in psychiatric work disability evaluations, by examining how the capacity limitation ratings varied with the claimants' primary psychiatric diagnoses and how the ratings were related to RWC estimates. METHODS: Medical experts estimated the RWC of 946 claimants with mental disorders and rated their activity and participation limitations using the Mini-ICF-APP, with higher ratings reflecting more severe limitations. The ratings were compared between claimants with different psychiatric diagnoses by analyses of variance. The mean Mini-ICF-APP rating across all capacity domains as well as all capacity-specific ratings were entered in simple or multiple regression models to predict the RWC in an alternative job. RESULTS: The Mini-ICF-APP capacity limitation ratings in all domains but mobility were higher for claimants with personality and behavior disorders as compared to those with mood disorders or with neurotic, stress-related and somatoform disorders. The largest differences were observed in social capacities (e.g. group integration: F 2, 847 = 78.300, P < 0.001). In claimants with depression, all ratings increased with the severity of the diagnosis (all Fs 2, 203 > 16.393, all Ps < 0.001). In the overall sample, the mean Mini-ICF-APP rating showed a strong negative correlation with the estimated RWC (r = -.720, P < 0.001). Adding the capacity-specific ratings to the prediction model improved this prediction only marginally. DISCUSSION: The Mini-ICF-APP allows for documenting claimants' activity and participation limitations, which is likely to increase the transparency of medical experts' RWC estimates and enables them to check the plausibility of such estimates. However, our study showed that despite the strong association between RWC and Mini-ICF-APP ratings, half of the RWC variance was unrelated to the capacity limitations documented in the Mini-ICF-APP.

Indirect and Neuropsychological Indicators of Pedophilia.

The present study aimed to differentiate pedophilic child sex offenders (CSOs) from nonoffending controls (CTLs), as well as contact from noncontact CSOs. For this purpose, we investigated 21 contact CSOs, 20 noncontact CSOs (child pornography offenders), as well as 21 CTLs on neuropsychological test measures and indirect test measures of sexual interest. Multiple logistic regression models showed that three parameters of indirect tests and two neuropsychological test parameters allowed the differentiation of CSOs from CTLs with a maximum accuracy of 87%. The profile of contact and noncontact CSOs was remarkably similar and the optimal model for this group differentiation had a maximum accuracy of 66%, with slightly increased levels of risk-taking behavior and greater susceptibility for perceptual interference in contact CSOs than in noncontact CSOs. The findings suggest that standardized, objective methods can support the assessment of sexual offenders against children in forensic psychiatry and legal psychology.

The effect of shared distinctiveness on source memory: An event-related potential study.

An illusory correlation (IC) is the erroneous perception that two actually uncorrelated categories are correlated. The Shared Distinctiveness Approach (SDA) explains ICs with heightened accessibility of distinctive category combinations in episodic memory. However, empirical evidence for this approach is heterogeneous. In the present event-related potential (ERP) study, we exploited the fact that more distinctive items elicit larger P300 responses than less distinctive items, which potentially predict subsequent memory performance differences for such items. Distinctiveness at encoding was created by presenting words that differed from frequently presented, positive words in valence, font color, or both. We hypothesized that shared distinctiveness (deviation in both color and valence) would lead to an enhanced P300 subsequent memory effect (SME), better source memory performance, and an overestimation of the frequency of shared distinctive items. Behavioral results indicated the presence of shared distinctiveness effects on source memory and frequency estimation. Unexpectedly, memory also was enhanced for positive items in the frequent color. This pattern also was reflected in the P300 for highly positive and negative items. However, shared distinctiveness did not modulate the P300 SME, indicating that the processing of distinctive features might only indirectly contribute to better encoding. This study shows that shared distinctiveness indeed is associated with better source memory and ICs. Because effects were observed for the most frequent and the least frequent category combination, our results imply that the processing of distinctiveness might involve attention allocation to diametrical category combinations, thereby accentuating the differences between the categories.

Psychopathy, Neuroticism, and Abusive Behavior in Low Risk Child Sex Offenders.

Personality traits are considered as an important aspect in the assessment of child sex offenders (CSOs). The current study sought to elucidate the association between neuroticism, psychopathy, and abusive behavior in low risk CSOs. 43 pedophilic CSOs and 21 controls (CTLs) completed the NEO-Personality Inventory-Revised (NEO-PI-R), Psychopathy Checklist: Screening Version (PCL:SV), and Multiphasic Sex Inventory (MSI). Our results revealed small differences in PCL scores between CSOs and CTLs, with comparatively low levels of psychopathy in both groups. Higher levels of neuroticism were associated with higher PCL scores, in both CSOs and CTLs. However, higher PCL scores in CSOs did not correlate with higher MSI total scores on the subscale child molest. These findings suggest an ambiguous role of psychopathy in CSOs: higher levels of psychopathy co-occur with higher levels of neuroticism, but psychopathy does apparently not modulate abusive behavior, at least not in low risk offenders, as currently investigated.

Resting-state functional connectivity remains unaffected by preceding exposure to aversive visual stimuli.

While much is known about immediate brain activity changes induced by the confrontation with emotional stimuli, the subsequent temporal unfolding of emotions has yet to be explored. To investigate whether exposure to emotionally aversive pictures affects subsequent resting-state networks differently from exposure to neutral pictures, a resting-state fMRI study implementing a two-group repeated-measures design in healthy young adults (N = 34) was conducted. We focused on investigating (i) patterns of amygdala whole-brain and hippocampus connectivity in both a seed-to-voxel and seed-to-seed approach, (ii) whole-brain resting-state networks with an independent component analysis coupled with dual regression, and (iii) the amygdala's fractional amplitude of low frequency fluctuations, all while EEG recording potential fluctuations in vigilance. In spite of the successful emotion induction, as demonstrated by stimuli rating and a memory-facilitating effect of negative emotionality, none of the resting-state measures was differentially affected by picture valence. In conclusion, resting-state networks connectivity as well as the amygdala's low frequency oscillations appear to be unaffected by preceding exposure to widely used emotionally aversive visual stimuli in healthy young adults.

The event-related potential component P3a is diminished by identical deviance repetition, but not by non-identical repetitions.

Mismatch negativity (MMN) represents an event-related potential (ERP) component which is elicited by deviant sound events in an otherwise regular, repetitive stimulation. The MMN amplitude typically decreases when two identical deviants are presented in direct succession, but it remains stable when the two deviants vary from the standard in different features. Less is known about such repetition effects on another ERP component, the P3a, which usually follows the MMN. In the current study, we investigated how the P3a was affected by identical and non-identical repetitions of sound deviants. The ERP analysis revealed that the P3a amplitudes were strongly diminished when the repeated deviants were identical, but the P3a remained stable when the repeated deviants varied. The findings suggest that not only the deviance detection system, as reflected in the MMN, but also subsequent attention switch systems, as reflected in the P3a, operate independently across different sound features.

Illusory correlations despite equated category frequencies: A test of the information loss account.

Illusory correlations (IC) are the perception of covariation, where none exists. For example, people associate majorities with frequent behavior and minorities with infrequent behavior even in the absence of such an association. According to the information loss account, ICs result from greater fading of infrequent group-behavior combinations in memory. We conducted computer simulations based on this account which showed that ICs are expected under standard conditions with skewed category frequencies (i.e. 2:1 ratio for positive and negative descriptions), but not under conditions with equated category frequencies (i.e. 1:1 ratio for positive and negative descriptions). Contrary to these simulations, our behavioral experiments revealed an IC under both conditions, which did not decrease over time. Thus, information loss alone is not sufficient as an explanation for the formation of ICs. These results imply that negative items contribute to ICs not only due to their infrequency, but also due to their emotional salience.

The role of retrieval mode and retrieval orientation in retrieval practice: insights from comparing recognition memory testing formats and restudying.

The effectiveness of retrieval practice for aiding long-term memory, referred to as the testing effect, has been widely demonstrated. However, the specific neurocognitive mechanisms underlying this phenomenon remain unclear. In the present study, we sought to explore the role of pre-retrieval processes at initial testing on later recognition performance by using event-related potentials (ERPs). Subjects studied two lists of words (Chinese characters) and then performed a recognition task or a source memory task, or restudied the word lists. At the end of the experiment, subjects received a final recognition test based on the remember-know paradigm. Behaviorally, initial testing (active retrieval) enhanced memory retention relative to restudying (passive retrieval). The retrieval mode at initial testing was indexed by more positive-going ERPs for unstudied items in the active-retrieval tasks than in passive retrieval from 300 to 900 ms. Follow-up analyses showed that the magnitude of the early ERP retrieval mode effect (300-500 ms) was predictive of the behavioral testing effect later on. In addition, the ERPs for correctly rejected new items during initial testing differed between the two active-retrieval tasks from 500 to 900 ms, and this ERP retrieval orientation effect predicted differential behavioral testing gains between the two active-retrieval conditions. Our findings confirm that initial testing promotes later retrieval relative to restudying, and they further suggest that adopting pre-retrieval processing in the forms of retrieval mode and retrieval orientation might contribute to these memory enhancements.

Functional Somatic Syndromes: Skin Temperatures and Activity Measurements Under Ambulatory Conditions.

Functional somatic syndromes are mostly associated with pain and emotional distress. As one marker for the autonomic stress response, the distal skin temperature decreases during psychological stress. In patients with functional somatic syndromes, the distal skin temperature under baseline conditions (without stress induction) is usually lower than in healthy subjects, which could be due to the sustained presence of pain-related stress in such patients. The aim of our study was to investigate whether patients with functional somatic syndromes show altered skin temperatures also under everyday life conditions. 14 patients with functional somatic syndromes and 14 matched healthy control subjects were investigated under ambulatory conditions over six consecutive days. During this time, distal and proximal skin temperatures were continuously recorded and sleep-wake cycles were monitored by actimetry and sleep-wake diaries. Unexpectedly, the patients showed higher distal skin temperatures than control subjects in the afternoon. The objective temperature data did not match the patients' subjective experience: ratings of thermal comfort did not vary between the two groups. Moreover, similar levels of daytime activity were recorded in the two samples, even though patients reported more tiredness and more body tension than controls. We interpret the observed dissociation between objective skin temperature measurements and subjective ratings of the bodily thermal comfort as support for the notion of an alexisomia account (reduced bodily awareness) for functional somatic syndromes. Moreover, findings indicate that subjective complaints of tiredness and tension do not necessarily result in physical avoidance behaviour.

How does testing affect retrieval-related processes? An event-related potential (ERP) study on the short-term effects of repeated retrieval.

The testing effect is conceptualized as the benefit for remembering items that were studied and tested rather than just studied. Thus far, little is known about the underlying neurocognitive mechanisms. In an event-related potential (ERP) study, we investigated the immediate consequences of testing on recollection processes. During an initial study phase, participants encountered object names together with pictures of the denoted objects ("perceived items") or with the instruction to mentally visualize them ("imagined items"). Directly afterward, they had to differentiate between perceived, imagined, and new items, in two consecutive source memory tests. Half of the studied items were presented in the first run, and all items in the second. Behaviorally, repeated testing led to improved item and source memory, as well as faster reaction times, relative to items that had been tested once. In accordance with these behavioral changes, the left parietal old-new effect (500-900 ms) as the putative correlate of recollection was strongly enhanced by previous testing. An enhancement after testing was also observed for the early portion of the late right frontal old-new effect (700-900 ms). In contrast, old-new effects after 900 ms were not modulated by previous testing. The finding of a stronger left parietal old-new effect for previously tested items suggests that testing leads to an elaboration of memory traces, whereas the faster reaction times are more likely explained in terms of transfer-appropriate processing. The combination of more elaborated memory traces and transfer-appropriate processing provides a tentative explanation for the effectiveness of testing in enhancing retrieval performance.

Retrieving self-vocalized information: An event-related potential (ERP) study on the effect of retrieval orientation.

Retrieval orientation refers to a pre-retrieval process and conceptualizes the specific form of processing that is applied to a retrieval cue. In the current event-related potential (ERP) study, we sought to find evidence for an involvement of the auditory cortex when subjects attempt to retrieve vocalized information, and hypothesized that adopting retrieval orientation would be beneficial for retrieval accuracy. During study, participants saw object words that they subsequently vocalized or visually imagined. At test, participants had to identify object names of one study condition as targets and to reject object names of the second condition together with new items. Target category switched after half of the test trials. Behaviorally, participants responded less accurately and more slowly to targets of the vocalize condition than to targets of the imagine condition. ERPs to new items varied at a single left electrode (T7) between 500 and 800ms, indicating a moderate retrieval orientation effect in the subject group as a whole. However, whereas the effect was strongly pronounced in participants with high retrieval accuracy, it was absent in participants with low retrieval accuracy. A current source density (CSD) mapping of the retrieval orientation effect indicated a source over left temporal regions. Independently from retrieval accuracy, the ERP retrieval orientation effect was surprisingly also modulated by test order. Findings are suggestive for an involvement of the auditory cortex in retrieval attempts of vocalized information and confirm that adopting retrieval orientation is potentially beneficial for retrieval accuracy. The effects of test order on retrieval-related processes might reflect a stronger focus on the newness of items in the more difficult test condition when participants started with this condition.

Patient-centeredness in psychiatric work disability evaluations and the reproducibility of work capacity estimates.

OBJECTIVES: To evaluate the extent of patient-centeredness in psychiatric work disability evaluations and its association with the reproducibility of work capacity (WC) estimates. METHODS: In our mixed methods study, 29 video-taped interviews conducted in psychiatric work disability evaluations were coded with the Roter Interaction Analysis System (RIAS) and different measures of patient-centeredness were derived from these codings, including a summary patient-centred communication ratio. Four experts each estimated a claimant's WC on a scale from 0% to 100%. RESULTS: Patient-centred communication ratios were always >1, suggesting a preponderance of psychosocial information exchange. In contrast, utterances reflecting empathy were rare e.g., the expert did not address the claimant's emotions in 25 of 29 interviews. None of the derived patient-centeredness measures showed a significant association with WC reproducibility. CONCLUSIONS: Many of the experts' questions addressed the claimant's lifestyle and psychosocial situation. However, this likely reflected factual requirements for the expert opinion, rather than patient-centeredness. Indeed, the experts rarely showed empathy, which is a hallmark characteristic of patient-centeredness. The reproducibility of work capacity estimates was not modulated by patient-centeredness, irrespective of its quantification. PRACTICE IMPLICATIONS: Patient-centeredness in work disability evaluations should find its entry in continuing education of experts.

Effects of nature-adapted lighting solutions ("Virtual Sky") on subjective and objective correlates of sleepiness, well-being, visual and cognitive performance at the workplace.

Exposure to natural daylight benefits human well-being, alertness, circadian rhythms and sleep. Many workplaces have limited or no access to daylight. Thus, we implemented a light-panel ("Virtual Sky"), which reproduced nature-adapted light scenarios. In a laboratory office environment, three lighting scenarios were presented during the day: two lighting conditions with nature-adapted spectral light distributions, one with static and one with dynamic clouds, and a standard office lighting condition. We compared the impact of the three lighting scenarios on subjective and objective measures of alertness, cognitive performance, wellbeing, visual comfort, contrast sensitivity, and cortisol levels in 18 healthy young male volunteers in a within-participant cross-over study design. We found no evidence that an 8-h lighting scenario with static or dynamic clouds during the waking day (9am-5pm) was associated with any significant effect on objective and/or subjective alertness, cognitive performance and morning cortisol concentrations compared to standard workplace lighting. However, the dynamic light scenario was accompanied with lower levels of perceived tensionafter completing cognitive tasks and less effort to concentrate compared to the static lighting scenarios. Our findings suggest that apart from smaller effects on tension and concentration effort, nature-adapted lighting conditions did not improve daytime alertness and cognitive performance in healthy well-rested young participants, as compared to standard office lighting.

Digitally Assisted Standard Diagnostics in Insurance Medicine (DASDIM): psychometric data in psychiatric work disability evaluations.

PURPOSE: Insurers often commission psychiatric experts to evaluate the eligibility of workers with mental disorders for disability benefits, by estimating their residual work capacity (RWC). We investigated the validity of a standardized, computer-based battery of established diagnostic instruments, for evaluating the personality, cognition, performance, symptom burden, and symptom validity of claimants. METHODS: One hundred and fifty-three claimants for benefits were assessed by the assembled test battery, which was applied in addition to a conventional clinical work disability evaluation. RESULTS: A principal component analysis of the test and questionnaire battery data revealed six factors (Negative Affectivity, Self-Perceived Work Ability, Behavioral Dysfunction, Working Memory, Cognitive Processing Speed, and Excessive Work Commitment). Claimants with low, medium, and high RWC exclusively varied in the factor Negative Affectivity. Importantly, this factor also showed a strong association to psychiatric ratings of capacity limitations in psychosocial functioning. CONCLUSIONS: The findings demonstrate that the used test battery allows a substantiation of RWC estimates and of psychiatric ratings by objective and standardized data. If routinely incorporated in work disability evaluations, the test battery could increase their transparency for all stakeholders (insurers, claimants, medical experts, expert case-coordinators, and legal practitioners) and would open new avenues for research in the field of insurance medicine.Implications for rehabilitationThe residual work capacity (RWC) estimation by medical experts is internationally good practice, but plagued by a relatively low interrater agreement.The current study shows that psychiatric RWC estimates and capacity limitation ratings can be substantiated by data from objective, standardized psychometric instruments.Systematically using such instruments might help to improve the poor interrater agreement for RWC estimates in work disability evaluations.Such data could also be used for adopting vocational trainings and return-to-work programs to the individual needs of workers with mental health problems.

No evidence for auditory N1 dishabituation in healthy adults after presentation of rare novel distractors.

Previous studies were not able to show that presentation of change stimuli leads to dishabituation of the auditory evoked potential (AEP) component N1 for repeated stimuli. However, these change stimuli were usually themselves repeatedly presented. Here, we tested whether the presentation of non-repeating distractor stimuli ('novels') would lead to N1 dishabituation. The study sample consisted of 18 healthy participants who had to identify auditory target stimuli (´targets´) among repeated standard stimuli and rare novels. AEPs to standards were separately averaged, depending on the preceding stimulus (standards after standards, standards after targets, and standards after novels) and were compared by F statistics and Bayesian t-test. Moreover, N1 repetition effects within recording blocks were analyzed in single trial analyses. The analyses showed that targets elicited significantly larger N1 amplitudes than standards and standards elicited larger N1 amplitudes than novels. In contrast, the N1 amplitude to standards did not vary with the preceding stimulus. The single trial analyses revealed significant, but similar N1 amplitude decreases within the recording blocks for all standards. The current study revealed no evidence for N1 dishabituation, as the N1 amplitude for standards after novels was not increased as compared to the N1 for standards after standards. Thus, stimulus variation had no impact on the N1 of repeated standards, as also suggested by the single trial analyses. The lack of N1 dishabituation is at odds with the assumption that the N1 amplitude decrease after repeated stimulation results from habituation.

Electrophysiological correlates of retrieval orientation in reality monitoring.

Retrieval orientation describes the modulation in the processing of retrieval cues by the nature of the targeted material in memory. Retrieval orientation is usually investigated by analyzing the cortical responses to new (unstudied) material when different memory contents are targeted. This approach avoids confounding effects of retrieval success. We investigated the neural correlates of retrieval orientation in reality monitoring with event-related potentials (ERPs) and assessed the impact of retrieval accuracy on obtained ERP measures. Thirty-two subjects studied visually presented object names that were followed either by a picture of that object (perceived condition) or by the instruction to mentally generate such a picture (imagine condition). Subsequently, subjects had to identify object names of one study condition and reject object names of the second study condition together with newly presented object names. The data analysis showed that object names were more accurately identified when they had been presented in the perceived condition. Two topographically distinct ERP effects of retrieval orientation were revealed: From 600 to 1100 ms after stimulus representation, ERPs were more positive at frontal electrode sites when object names from the imagine condition were targeted. The analysis of response-locked ERP data revealed an additional effect at posterior electrode sites, with more negative ERPs shortly after response onset when items from the imagine condition were targeted. The ERP effect at frontal electrode sites, but not at posterior electrode sites was modulated by relative memory accuracy, with stronger effects in subjects who had lower memory accuracy for items of the imagine condition. The findings are suggestive for a contribution of frontal brain areas to retrieval orientation processes in reality monitoring and indicate that neural correlates of retrieval orientation can be modulated by retrieval effort, with stronger activation of these correlates with increasing task demands.

When the brain decides: a familiarity-based approach to the recognition heuristic as evidenced by event-related brain potentials.

Humans can make fast and highly efficient decisions by using simple heuristics that are assumed to exploit basic cognitive functions. In the study reported here, we used event-related potentials (ERPs) to disclose the psychological mechanisms underlying one of the most frugal decision rules, namely, the recognition heuristic. According to this heuristic, whenever two objects have to be ranked by a specific criterion and only one object is recognized, the recognized object is ranked higher than the unrecognized object. Using a standard recognition-heuristic paradigm, we predicted participants' decisions by analyzing an ERP correlate of familiarity-based recognition occurring 300 to 450 ms after stimulus onset. The measure remained a significant predictor even when later ERP correlates were taken into account. These findings are evidence for the thesis that simple heuristics exploit basic cognitive processes. Specifically, the findings show that familiarity--that is, recognition in the absence of recollection--contributes to decisions made on the basis of such heuristics.

The reduced auditory evoked potential component N1 after repeated stimulation: Refractoriness hypothesis vs. habituation account.

Similar to other event-related potential (ERP) components, the amplitude of the auditory evoked N1 depends on the interstimulus interval (ISI). At ISIs > 0.4 s, the amplitude of the N1 increases with longer ISIs, until it saturates at ISIs around 10 s. This amplitude increase with increasing ISI has been conceptualized as a function of N1 recovery or N1 refractoriness. Habituation (as a simple form of learning) represents an elaborated, opposing account for such stimulus repetition effects. For passive oddball experiments (stimulation protocols with frequent standards and rare deviants), the two accounts make different predictions. According to the habituation account, the presentation of small deviants should lead to an increased N1 for subsequent standards (= dishabituation); according to the N1 refractoriness account, there should be no or just minor effects on the N1. In the current study, we tested these predictions and compared the ERPs to standards after small deviants and to standards preceded by other standards. We observed that the ERPs to standards after small deviants were characterized by a small mismatch negativity with an onset latency > 150 ms, but the N1 to standards after deviants did not differ from the N1 to standards preceded by other standards. This negative finding is in line with other previous studies that were also not able to reveal evidence for N1 dishabituation. Aside from this repeated lack of evidence for dishabituation, the N1 habituation account is challenged by the finding that the N1 decrease is stronger for more intense stimuli. Overall, the current and previous findings are more compatible with the N1 refractoriness account, although the mechanisms underlying N1 refractoriness remain to be elucidated. Knowledge about these mechanisms would also help to understand why N1 deficits in schizophrenia are more pronounced at longer ISIs.