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The purpose of the present study was to investigate the effect of perceived time pressure on a learning-based task called the Iowa Gambling Task (IGT). One hundred and sixty-three participants were randomly assigned to one of two groups. The experimental group was informed that the time allotted was typically insufficient to learn and successfully complete the task. The control group was informed that the time allotted was typically sufficient to learn and successfully complete the task. Both groups completed the IGT and performance was recorded. The major finding was that participants who were advised that the amount of time allotted was typically insufficient to complete the task performed significantly worse than those who were advised that time was typically sufficient to complete the task.
Judgment and Decision Making, Vol. 3, No. 8, December 2008, pp. 636–640
Perceived time pressure and the Iowa Gambling Task
Michael A. DeDonnoand Heath A. Demaree
Department of Psychology
Case Western Reserve University
The purpose of the present study was to investigate the effect of perceived time pressure on a learning-based task called
the Iowa Gambling Task (IGT). One hundred and sixty-three participants were randomly assigned to one of two groups.
The experimental group was informed that the time allotted was typically insufficient to learn and successfully complete
the task. The control group was informed that the time allotted was typically sufficient to learn and successfully complete
the task. Both groups completed the IGT and performance was recorded. The major finding was that participants who
were advised that the amount of time allotted was typically insufficient to complete the task performed significantly
worse than those who were advised that time was typically sufficient to complete the task.
Keywords: Iowa Gambling Task; decision making; time pressure.
1 Introduction
Research shows that real time constraints adversely influ-
ence IGT performance (Cella, Dymond, Cooper, & Turn-
bull, 2007). There remains a need, however, to deter-
mine how perceived time pressure affects IGT decision-
making. In essence, is IGT performance impaired by real
time constraints or simply the perception of time con-
straints? The present research was designed to deter-
mine how perceived time pressure influences IGT perfor-
1.1 The Iowa Gambling Task and the So-
matic Marker Hypothesis
The IGT is a well-established assessment tool, and its use
by researchers has helped reveal the value emotions play
in at least some forms of decision making (Evans, Kem-
ish, & Turnbull, 2004). Because the IGT involves uncer-
tainty, reward, and punishment, it is thought to simulate
real-world decision-making (Bechara, Damasio, Dama-
sio, & Lee, 1999). In the IGT, participants choose from
among fours decks of cards with the goal of making as
much money as possible. For each card selected, the par-
ticipant receives a reward (i.e., s/he wins money). On
some trials, however, an additional punishment is expe-
rienced (i.e., s/he loses money). Two decks — A and B
— have high gains but larger relative losses; that is, the
decks have negative utility (they are “bad decks”). The
Address: Department of Psychology, Case Western Reserve Uni-
versity, Cleveland, Ohio 44106. Email:
two remaining decks — C and D — have smaller rewards
than decks A and B, but the wins outweigh the losses; that
is, the decks have positive utility (they are “good decks”).
The goal of the task is to maximize profit on a loan of play
In one study using the IGT, Bechara et al. (1999) tested
three groups of people: healthy controls, people with le-
sions in the brain’s ventromedial prefrontal cortex, and
people with lesions in the amygdala of the brain. All par-
ticipants performed the IGT while their skin conductance
responses were measured. The healthy participants gen-
erated skin conductance responses at two different points
throughout the task. First, presumably because they were
having emotional responses to the rewards and punish-
ments received, participants generated skin conductance
responses after selecting each card. Second, within the
selection of the first twenty cards, normal participants be-
gan generating skin conductance responses prior to the
selection of cards, and these “anticipatory” skin conduc-
tance responses were most pronounced when selecting
cards from one of the two bad decks. Conversely, peo-
ple with ventromedial prefrontal cortex or amygdala le-
sions failed to generate anticipatory skin conductance re-
sponses before selecting bad cards and continued to se-
lect from the bad decks throughout the 100 card selec-
tions (Bechara et al., 1999). This observation, as well
as data from other studies (e.g., Bechara, Tranel, Dama-
sio, & Damasio, 1996; Bechara & Damasio, 2005: Ernst,
Bolla, Mouratidis, Contoreggi, Matochik, Kurian, Cadet,
Kimes, & London, 2002; but see Maia & McClelland,
2004), support the Somatic Marker Hypothesis (SMH;
Damasio, 1994).
Judgment and Decision Making, Vol. 3, No. 8, December 2008 Perceived time pressure and the IGT
The SMH postulates that decision making is influenced
by emotion-based biasing signals (somatic markers) that
occur during the consideration of options in the decision
making process (Bechara & Damasio, 2005). For every
decision option available, a somatic state is generated ei-
ther by physiological changes within the body proper (the
“body loop”) or the brain’s mental representation of the
anticipated physiological responses that would take place
in the body (the “as if body loop”) (Dunn, Dalgleish, &
Lawrence, 2006). These somatic states are thought to
aid in rapid choice selection under time pressure (Pfis-
ter & Bohm, 2008). When making decisions, impairment
of these emotional signals can adversely affect speed of
deliberation and cause people to make sub-optimal deci-
sions (Bechara & Damasio, 2005). For example, Manes
and colleagues (2002) found that patients with emotional
processing deficits resulting from orbitofrontal lesions in
the brain evidenced prolonged deliberation and impaired
IGT performance.
1.2 IGT in the real-world
Although research involving the IGT has frequently fo-
cused on clinical populations (e.g., Bechara et al., 1999;
Levine, Black, Cheung, Campbell, O’Toole, & Schwartz,
2005; Best, Williams, & Coccaro, 2002), researchers
have also uncovered daily life factors that affect IGT per-
formance in healthy individuals. Cella and colleagues
(2007), for example, found that people who were given
less time to select a card performed worse relative to
those who were given more time to select a card. de
Vries, Holland, and Witteman (2008) found that, com-
pared to people in negative mood states, people in posi-
tive mood states selected more cards from the good decks
during the second block (i.e., cards 21–40) of the game.
These studies provide evidence that time pressure and
mood can affect IGT performance.
A question then arises as to the potential effect of
perceived time pressure on IGT performance. Although
most studies have treated time-pressure as a task charac-
teristic, researchers have also found that the mere percep-
tion of time pressure may affect cognitive performance
(e.g., Maule & Maillet-Hausswrith, 1995). One model
linking perceived time pressure to task performance, the
Variable State Activation Theory, suggests that impaired
decision making performance can occur when the indi-
vidual feels time is insufficient to successfully perform
the task at hand (Maule & Hockey, 1993). One reason for
this is that people change the strategies they use to make
decisions when they feel time pressure. For example, the
sequential comparison approach posits that people con-
sider fewer variables when they feel a need to make faster
decisions (Aschenbrener, Albert, & Schmalhofer, 1984;
Busemeyer, 1985).
Because perceived time pressure may affect both
strategies employed and emotional experiences while
people make real-life decisions, it is important to as-
sess how perceived time pressure affects performance
on a realistic decision-making task such as the IGT. In-
terestingly, opposite results are possible. When time is
perceived as insufficient, participants’ IGT performances
may be improved if they rely more heavily on emotional
processes, which are thought to be integral to good IGT
performance (e.g., Bechara et al., 1999). Conversely, be-
cause IGT performance is also based on cognitive pro-
cesses (e.g., Maia & McClelland; 2004; Yechiam, Good-
night, Bates, Busemeyer, Dodge, Pettit, & Newman,
2006), the perception of time pressure may impair IGT
performance because people might reduce the number of
variables they consider when selecting cards.
1.3 The present study
The purpose of the present study, then, was to explore the
effect of perceived time pressure on IGT performance.
The experimental group was informed that the time al-
lotted was typically insufficient to successfully complete
the task while the control group was informed that the
time allotted was typically sufficient to complete the task.
Although Cella and colleagues (2007) found that actual
time limits impaired IGT performance, the present study
explored how the perception of time pressure affects IGT
performance. The differences between these two stud-
ies are as follows: First, Cella and colleagues (2007) did
not provide any information to their participants regard-
ing whether the time allotted was sufficient or insuffi-
cient. Rather, they instructed their participants by say-
ing, “Your task is to select one card at a time as fast as
you can. . . (Cella et al., 2007). Second, in Cella et al.’s
(2007) study, the message “Too slow!” was displayed on
the screen whenever a participant failed to make a card
selection within the specified time limit. Finally, card se-
lections were not recorded on trials that the participant
was too slow; this resulted in fewer than 100 trials per
participant (Cella et al., 2007). In the present study, the
only instructions involving the perception of time pres-
sure were provided at the start of the task and all 100
trials for every participant were used in the analysis. As a
result of these differences in experimental design, the fo-
cus in the present study shifted from exploring how actual
time pressure affects IGT performance to how perceived
pressure affects it1
1The present study also manipulated the amount of time each sub-
ject had to make decisions on each trial of the IGT. However, because
the effectiveness of the manipulation was questionable and because the
manipulation did not significantly influence IGT performance, these re-
sults are not discussed.
Judgment and Decision Making, Vol. 3, No. 8, December 2008 Perceived time pressure and the IGT
2 Methods
2.1 Subjects
Participants were undergraduate students attending a pri-
vate Midwest university enrolled in an introductory psy-
chology course. A total of one hundred and sixty-three
participants completed the study.
2.2 Apparatus and Materials
The present study included three standard personal com-
puters running Windows 98. Additional software in-
cluded the IGT application. Each computer was placed in
a separate room with a door to minimize external noise.
Standard 15-inch monitors were used and placed about
15 inches from the participant.
In the IGT, participants were presented four decks of
cards on a computer screen. The decks were labeled A, B,
C, and D. Using a mouse, the participant was allowed to
select a card from any of the four decks. The participant
selected one card at a time from any of the four decks
and was free to switch from one deck to another at any
time. After selecting a card, a message was displayed
indicating the amount of play money won (reward). On
some cards, the win message was followed by a message
indicating the amount of play money lost (punishment).
At the top of the screen was a green bar that changed
according to the amount of money won or lost. Below the
green bar was a red bar that showed the amount of money
borrowed; this amount was $2,000.00 at the beginning of
the game. The difference between the two bars was the
total amount of play money won or lost. The goal of the
task was to maximize profit on a loan of play money.
The sample in the present study was randomly divided
into two groups. Both groups were instructed to select a
card within two seconds of seeing “pick a card” on the
computer screen. Perception of time was manipulated by
informing the experimental group that the time allotted
was typically insufficient to learn and successfully com-
plete the task while the control group was informed that
the time allotted was typically sufficient to learn and suc-
cessfully complete the task.
2.3 Procedure
After each participant signed a consent form, the exper-
imenter gave written instructions for the IGT, informed
the participant that s/he had 2 seconds to select each card
and that the time provided was either sufficient (con-
trol group) or insufficient (experimental group) to learn
and successfully complete the task. The gambling task
instructions used for both groups were the standard in-
structions used in other IGT experiments (e.g., Bechara,
1 2 3 4 5
IGT Performance ( [C+D] - [A+B] )
Insufficient Sufficient
Figure 1: IGT performance as a function of perceived
time pressure and block.
Tranel & Damasio, 2000; Bechara & Damasio, 2005).
Once the participant indicated s/he understood the in-
structions, s/he was allowed to start the IGT.
3 Results
The dependent variable for data analyses was the number
of selections from good decks C and C minus the num-
ber of selections from bad decks A and B (i.e., [C+D]–
[A+B]). If a participant selected more bad relative to good
decks, s/he would have a negative score. As is typical in
research involving the IGT (e.g., Bechara et al., 2000),
the 100 card selections were separated into five blocks of
twenty cards (i.e., Block 1 = Trials 1–20, Block 2 = Tri-
als, 21–40 . . . Block 5 = Trials 81–100). This allowed
for the tracking of changes in performance as the partici-
pants played the game.
Figure 1 shows the results. A 2 (Sufficiency: Insuffi-
cient, Sufficient) x 5 (Block: 1–20, 21–40, 41–60, 61–80,
81–100) ANOVA found that main effect for the between-
subjects factor of Sufficiency was significant F(1,161) =
8.404, p= .004. Collapsing across Blocks, the Sufficient
group (M = 22.49, SD = 30.53) selected more cards from
the good decks than the Insufficient group (M = 9.14,
SD = 27.90). The Block by Sufficiency interaction was
not statistically significant, F(4,644) = 1.877, p= .113.
In addition, the within-subjects factor of Block was sig-
nificant F(4,644) = 73.810, p= .000. As can be seen
in Figure 1, collapsing across both groups, participants
increasingly sampled from good decks as the game pro-
gressed. Post-hoc analyses using the least significant dif-
ference (LSD) test revealed significant differences (p<
Judgment and Decision Making, Vol. 3, No. 8, December 2008 Perceived time pressure and the IGT
.05) in performance between each individual block and
all other blocks.
4 Discussion
The present study was the first to investigate the rela-
tionship between perceived time pressure and IGT per-
formance. Participants who were advised that the time
allotted was insufficient performed worse than those who
were advised that time was sufficient. This finding further
supports the Variable State Activation Theory by demon-
strating that perceived time pressure impairs performance
on a real-life decision-making task.
It is worth noting that the perception of time pressure
impaired IGT performance over an extended period of
time. Other manipulations have been found to cause tran-
sient changes in IGT performance. For example, de Vries
et al. (2008) found that negative mood was associated
with fewer good card selections during Block 2 of the
IGT only. In the present study, the perception of time in-
sufficiency did not interact with block thereby suggesting
that the mere perception of time pressure may be a more
robust factor in IGT performance than mood. It is also no-
table that, compared to the Cella et al. (2007) study which
reminded participants throughout the task that they were
under real time pressure, the present study informed par-
ticipants only once (prior to IGT administration) that the
time allotted was either sufficient or insufficient. It ap-
pears that the communication of time insufficiency – even
when announced only once — can have a long-lasting ef-
fect on real-life decision-making.
There are specific real-world benefits to understand-
ing the effects of perceived time pressure on decision
making performance. For example, research has found
that members of project teams who perceived a high de-
gree of time pressure had lower job satisfaction and felt
that overall project objectives were less often attained
(Nordqvist, Hovmark & Zika-Viktorsson, 2004). This
finding, taken together with the present research, sug-
gests that employee performance and overall project suc-
cess may benefit from building a sense of adequacy in a
project’s time-line.
Perhaps nowhere can the impact of increased time
pressure be seen than in the practice of medicine. The
advent of Health Maintenance Organizations (HMOs) ap-
pears to have reduced the amount of time physicians
spend with patients. In fact, one study found that HMO
physicians were allotted significantly less time for new
patients (31 minutes) than those practicing either solo
(39 minutes) or in academic settings (43 minutes), and
83% of HMO family physicians felt their allotted time
was insufficient to provide appropriate diagnosis (Linzer,
Konrad, Douglas, McMurray, Pathman Williams, et al.,
2000). Not surprisingly, Tamblyn and colleagues (1997)
found that physicians tend to prescribe inappropriate
medications during shorter office visits. Although more
time may be needed to optimize diagnostic accuracy, it
may also be beneficial for managers of HMO’s to work
more closely with their physicians in instilling a sense of
sufficiency in current time allotments.
To conclude, we believe perceived time pressure can
affect the quality of real-life decisions. The present study
demonstrated that a belief of time being insufficient can
impair IGT performance throughout the task. It remains
to be determined why this happened.
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Impaired decision-making leads to the inability to distinguish between advantageous and disadvantageous choices. The impairment of a person’s decision-making is a common goal of gambling games. Given the recent trend of gambling using immersive Virtual Reality it is crucial to investigate the effects of both immersion and the virtual environment (VE) on decision-making. In a novel user study, we measured decision-making using three virtual versions of the Iowa Gambling Task (IGT). The versions differed with regard to the degree of immersion and design of the virtual environment. While emotions affect decision-making, we further measured the positive and negative affect of participants. A higher visual angle on a stimulus leads to an increased emotional response. Thus, we kept the visual angle on the Iowa Gambling Task the same between our conditions. Our results revealed no significant impact of immersion or the VE on the IGT. We further found no significant difference between the conditions with regard to positive and negative affect. This suggests that neither the medium used nor the design of the VE causes an impairment of decision-making. However, in combination with a recent study, we provide first evidence that a higher visual angle on the IGT leads to an effect of impairment.
Using a video game platform, we examined how vision-based decision making was affected by a concurrent, potentially conflicting auditory stimulus. Electroencephalographic responses showed that by 150 milliseconds of stimulus onset, the brain had detected the conflict between visual and auditory stimuli. Systematically reducing the intertrial interval (ITI), which subjects described as stressful, undermined decision making. Subjects’ arterial pulse variance decreased along with ITI, signaling increased parasympathetic influence on the heart. When successive trials required a shift in processing mode, short ITIs significantly boosted one trial’s influence on the next, suggesting that stress reduces cognitive flexibility. Finally, our study demonstrates the heart’s and the brain’s important influence on decision making.
Prior research has found that variation in the length of deadlines, or their presence, can affect risky choice. We study whether such results are affected if subject experience and some form of self-selection are allowed. We find that choices of experienced and self-selected subjects are immune to temporal aspects, while immunity fails if experienced subjects are not allowed self-selection opportunities. Additionally, we find that experience and self-selection jointly promote safer choice and increased task completion. Our overall evidence indicates that experience as well as self-selection may be issues of importance, particularly in conjunction.
Social media users today are becoming ever more aggressive in their posting behaviour, pausing as a fourth party assessment agency of many sectors, most importantly hotel services. The moderating effect of the personal competencies of these social media end-users in the relationship between hotel satisfaction and emotional stability on one side and their posting behaviour on the other warrants a closer look. Using standard statistical analysis with SPSS, as well as Structured Equation Modelling through AMOS, the results clearly show that end-user efficacy is playing a role in this respect. The paper’s contribution in highlighting an important aspect of today’s hotel clientele whose effectiveness in using social media exceeds plays an important role while their personal emotional stability seems to be less effective.
Research investigating the effects of time pressure on judgment and decision making has tended to conceptualize the effects of time constraints in one of two ways. One approach has considered the imposition of a deadline as a stressor, emphasizing the mediating role of changes in affective state in influencing cognition (Maule & Mackie, 1990; Svenson & dland, 1989). The second approach has assumed that time constraints are one among a number of task and environmental factors that are included in a cost/benefit determination of cognitive strategy (Payne, Bettman & Johnson, 1988; Payne, Johnson, Bettman, & Coupey, 1990). The aim of the present chapter is to critically evaluate these approaches and to consider them in the light of recent research on the effects of stress on cognition. To meet these aims, the chapter is structured in the following way. First, there is a brief discussion of a number of key methodological issues. This is followed by a brief and selective review of major approaches investigating the effects of time constraints on judgment and decision making Finally, there is a review of Variable State Activation Theory (VSAT) (Hockey, 1986; Hockey, Briner, Tattersall, & Wiethoff, 1989; Hockey & Hamilton, 1983) and an analysis of how it may provide a unifying approach to develop our understanding of the effects of time constraints on judgment and decision making.
This study addresses the issue of perceived time pressure in project teams. The first purpose was to investigate how time pressure relates to job satisfaction and estimated goal achievement. A second purpose was to investigate how team processes [team support for the goal, cooperation and collective ability] affect the potential effect of time pressure. The study includes members [n=110] of 12 projects [six construction projects, five product development projects and one organizational development project] from four Swedish companies. Data was collected by means of a questionnaire and the response rate was 76%. Time pressure was negatively related, although slightly, to both estimated goal fulfillment and job satisfaction. The negative effect of time pressure was moderated by team support for the goal and collective ability in such a way that the negative effect disappeared. The findings remained after controlling for task complexity.
OBJECTIVE: To assess the association between HMO practice, time pressure, and physician job satisfaction. DESIGN: National random stratified sample of 5,704 primary care and specialty physicians in the United States. Surveys contained 150 items reflecting 10 facets (components) of satisfaction in addition to global satisfaction with current job, one’s career and one’s specialty. Linear regression-modeled satisfaction (on 1–5 scale) as a function of specialty, practice setting (solo, small group, large group, academic, or HMO), gender, ethnicity, full-time versus part-time status, and time pressure during office visits. “HMO physicians” (9% of total) were those in group or staff model HMOs with >50% of patients capitated or in managed care. RESULTS: Of the 2,326 respondents, 735 (32%) were female, 607 (26%) were minority (adjusted response rate 52%). HMO physicians reported significantly higher satisfaction with autonomy and administrative issues when compared with other practice types (moderate to large effect sizes). However, physicians in many other practice settings averaged higher satisfaction than HMO physicians with resources and relationships with staff and community (small to moderate effect sizes). Small and large group practice and academic physicians had higher global job satisfaction scores than HMO physicians (P<.05), and private practice physicians had quarter to half the odds of HMO physicians of intending to leave their current practice within 2 years (P<.05). Time pressure detracted from satisfaction in 7 of 10 satisfaction facets (P<.05) and from job, career, and specialty satisfaction (P<.01). Time allotted for new patients in HMOs (31 min) was less than that allotted in solo (39 min) and academic practices (44 min), while 83% of family physicians in HMOs felt they needed more time than allotted for new patients versus 54% of family physicians in small group practices (P<.05 after Bonferroni’s correction). CONCLUSIONS: HMO physicians are generally less satisfied with their jobs and more likely to intend to leave their practices than physicians in many other practice settings. Our data suggest that HMO physicians’ satisfaction with staff, community, resources, and the duration of new patients visits should be assessed and optimized. Whether providing more time for patient encounters would improve job satisfaction in HMOs or other practice settings remains to be determined.
Modern economic theory ignores the influence of emotions on decision-making. Emerging neuroscience evidence suggests that sound and rational decision making, in fact, depends on prior accurate emotional processing. The somatic marker hypothesis provides a systems-level neuroanatomical and cognitive framework for decision-making and its influence by emotion. The key idea of this hypothesis is that decision-making is a process that is influenced by marker signals that arise in bioregulatory processes, including those that express themselves in emotions and feelings. This influence can occur at multiple levels of operation, some of which occur consciously, and some of which occur non-consciously. Here we review studies that confirm various predictions from the hypothesis, and propose a neural model for economic decision, in which emotions are a major factor in the interaction between environmental conditions and human decision processes, with these emotional systems providing valuable implicit or explicit knowledge for making fast and advantageous decisions.
A class of stochastic model is presented which assume that binary choice among multidimensional alternatives is accomplished by sequential accumulation of dimensional value differences until enough evidence is accumulated. The models purpose not only to predict individual choices or choice probabilities from dimensional evaluations of the alternatives but also to map the cognitive processes taking place. The latter conjecture is tested by an analysis of choice latencies. Within the model class competing assumptions are made about the source of fluctuations in choice behavior (fluctuations in values versus fluctuations in the selection of dimensions) and about the dimensional comparison process (cardinal versus ordinal). The models are tested with individual choice probabilities and latencies from eight subjects making many choices between alternatives in four topic fields. The models do better when alternatives are described on a number of dimensions than for alternatives presented only by name. Further, the results suggest that fluctuations in the selection of dimensions must be seriously considered as an alternative to fluctuations in values for explaining choice variability.
The purpose of this article is to investigate the learning and memory processes involved in decision making under uncertainty. In two different experiments, subjects were given a choice between a certain alternative that produced a single known payoff and an uncertain alternative that produced a normal distribution of payoffs. Initially this distribution was unknown, and in the first experiment it was learned through feedback from past decisions, whereas in the second experiment it was learned by observing sample outcomes. In the first experiment, a response deadline was used to limit the amount of time available for making a decision. In the second experiment, an observation cost was used to limit the number of samples that could be purchased. The mean and variance of the uncertain alternative and the value of the certain alternative were factorially manipulated to study their joint effects on choice probability, choice response time (Experiment 1), and number of observations purchased (Experiment 2). Algebraic-deterministic theories developed for decision making with simple gambles fail to explain the present results. Two new models are developed and tested--fixed- and sequential-sampling models--that attempt to describe the learning and memory processes involved in decision making under uncertainty.
Following damage to specific sectors of the prefrontal cortex, humans develop a defect in real-life decision making, in spite of otherwise normal intellectual performance. The patients so affected may even realize the consequences of their actions but fail to act accordingly, thus appearing oblivious to the future. The neural basis of this defect has resisted explanation. Here we identify a physiological correlate for the defect and discuss its possible significance. We measured the skin conductance responses (SCRs) of 7 patients with prefrontal damage, and 12 normal controls, during the performance of a novel task, a card game that simulates real-life decision making in the way it factors uncertainty, rewards, and penalties. Both patients and controls generated SCRs after selecting cards that were followed by penalties or by reward. However, after a number of trials, controls also began to generate SCRs prior to their selection of a card, while they pondered from which deck to choose, but no patients showed such anticipatory SCRs. The absence of anticipatory SCRs in patients with prefrontal damage is a correlate of their insensitivity to future outcomes. It is compatible with the idea that these patients fail to activate biasing signals that would serve as value markers in the distinction between choices with good or bad future outcomes; that these signals also participate in the enhancement of attention and working memory relative to representations pertinent to the decision process; and that the signals hail from the bioregulatory machinery that sustains somatic homeostasis and can be expressed in emotion and feeling.
Use of nonsteroidal anti-inflammatory drugs (NSAIDs) increases the risk for hospitalization and death from gastrointestinal bleeding and perforation. To 1) estimate the extent to which NSAIDs are prescribed unnecessarily and NSAID-related side effects are inaccurately diagnosed and inappropriately managed and 2) identify the physician and visit characteristics associated with suboptimal use of NSAIDs. Prospective cohort study. Montreal, Canada. 112 physicians representing academically affilliated general practitioners, community-based general practitioners, and residents in family medicine and internal medicine. Blinded, office-based assessment of the management of two clinical cases (chronic hip pain due to early osteoarthritis and NSAID-related gastropathy) using elderly standardized patients. Quality of drug management and potential predictors of suboptimal drug management. Unnecessary prescriptions for NSAIDs or other drugs were written during 41.7% of visits. Gastropathy related to NSAID use was correctly diagnosed in 93.4% of visits and was acceptably managed in 77.4% of visits. The risk for an unnecessary NSAID prescription was greater when the contraindications to NSAID therapy were incompletely assessed (odds ratio, 2.3 [95% CI, 1.0 to 5.2]) and when the case was managed by residents in internal medicine (odds ratio, 4.1 [CI, 1.2 to 14.7]). The risk for suboptimal management of NSAID-related side effects was increased by incorrect diagnosis (odds ratio, 16.6 [CI, 3.6 to 76.5]) and shorter visits. Unnecessary NSAID prescribing and suboptimal management of NSAID-related side effects were sufficiently common to raise questions about the appropriateness of NSAID use in the general population. If these results reflect current practice, prescribing patterns may contribute to avoidable gastrointestinal morbidity in elderly persons.