Elizabeth Goldfarb

Memory-Guided Attention: Independent Contributions of the Hippocampus and Striatum

Memory can strongly influence how attention is deployed in future encounters. Though memory dependent on the medial temporal lobes has been shown to drive attention, how other memory systems could concurrently and comparably enhance attention is less clear. Here, we demonstrate that both reinforcement learning and context memory facilitate attention in a visual search task. Using functional magnetic resonance imaging, we dissociate the mechanisms by which these memories guide attention: trial by trial, the hippocampus (not the striatum) predicted attention benefits from context memory, while the striatum (not the hippocampus) predicted facilitation from rewarded stimulus-response associations. Responses in these regions were also distinctly correlated with individual differences in each type of memory-guided attention. This study provides novel evidence for the role of the striatum in guiding attention, dissociable from hippocampus-dependent context memory.

Enhancing informed consent best practices: gaining patient, family and provider perspectives using reverse simulation

Background Obtaining informed consent in the clinical setting is an important yet challenging aspect of providing safe and collaborative care to patients. While the medical profession has defined best practices for obtaining informed consent, it is unclear whether these standards meet the expressed needs of patients, their families as well as healthcare providers. The authors sought to address this gap by comparing the responses of these three groups with a standardised informed consent paradigm. Methods Piloting a web-based ‘reverse’ simulation paradigm, participants viewed a video showing a standardised doctor engaging in an informed consent discussion. The scenario depicted a simulated patient with psychotic symptoms who is prescribed an atypical antipsychotic medication. 107 participants accessed the simulation online and completed a web-based debriefing survey. Results Survey responses from patients, family members and healthcare providers indicated disparities in information retention, perception of the doctors performance and priorities for required elements of the consent process. Conclusions To enhance existing informed consent best practices, steps should be taken to improve patient retention of critical information. Adverse events should be described in the short-term and long-term along with preventative measures, and alternative psychosocial and pharmacological treatment options should be reviewed. Information about treatment should include when the medication takes therapeutic effect and how to safely maintain the treatment. The reverse simulation design is a model that can discern gaps in clinical practice, which can be used to improve patient care.

Low lifetime stress exposure is associated with reduced stimulus–response memory

Exposure to stress throughout life can cumulatively influence later health, even among young adults. The negative effects of high cumulative stress exposure are well-known, and a shift from episodic to stimulus-response memory has been proposed to underlie forms of psychopathology that are related to high lifetime stress. At the other extreme, effects of very low stress exposure are mixed, with some studies reporting that low stress leads to better outcomes, while others demonstrate that low stress is associated with diminished resilience and negative outcomes. However, the influence of very low lifetime stress exposure on episodic and stimulus-response memory is unknown. Here we use a lifetime stress assessment system (STRAIN) to assess cumulative lifetime stress exposure and measure memory performance in young adults reporting very low and moderate levels of lifetime stress exposure. Relative to moderate levels of stress, very low levels of lifetime stress were associated with reduced use and retention (24 h later) of stimulus-response (SR) associations, and a higher likelihood of using context memory. Further, computational modeling revealed that participants with low levels of stress exhibited worse expression of memory for SR associations than those with moderate stress. These results demonstrate that very low levels of stress exposure can have negative effects on cognition.

Simulation in Psychiatry

Simulation is used increasingly in psychiatry and mental health as a tool for clinician education, patient care, and research. Requiring realistic and evocative interpersonal interactions, as well as presentations of complex psychological symptom profiles for clinician training or emotionally salient stimuli for patient treatment, psychiatry pushes the boundaries of simulation design. Varying modalities, from simple audio tracks to immersive and interactive virtual environments, have been used to accomplish these goals. This chapter reviews current and future uses of simulation in psychiatry, focusing on the nuances of educational and therapeutic objectives as well as challenges inherent in using different simulation modalities.

Gaps in preparedness of clergy and healthcare providers to address mental health needs of returning service members.

To elucidate gaps in the preparedness of clergy and healthcare providers to care for service members (SM) with deployment-related mental health needs. Participants identified clinically relevant symptoms in a standardized video role play of a veteran with deployment-related mental health needs and discussed their preparedness to deal with SM. Clergy members identified suicide and depression most often, while providers identified difficulty sleeping, low energy, nightmares and irritability. Neither clergy nor providers felt prepared to minister to or treat SM with traumatic brain injury. Through a mixed methods approach, we identified gaps in preparedness of clergy and healthcare providers in dealing with the mental health needs of SM.

Simulation-based ongoing professional practice evaluation in psychiatry: a novel tool for performance assessment.

BACKGROUND Ongoing professional practice evaluation (OPPE) activities consist of a quantitative, competency-based evaluation of clinical performance. Hospitals must design assessments that measure clinical competencies, are scalable, and minimize impact on the clinicians daily routines. A psychiatry department at a large academic medical center designed and implemented an interactive Web-based psychiatric simulation focusing on violence risk assessment as a tool for a departmentwide OPPE. METHODS Of 412 invited clinicians in a large psychiatry department, 410 completed an online simulation in April-May 2012. Participants received scheduled e-mail reminders with instructions describing how to access the simulation. Using the Computer Simulation Assessment Tool, participants viewed an introductory video and were then asked to conduct a risk assessment, acting as a clinician in the encounter by selecting actions from a series of drop-down menus. Each action was paired with a corresponding video segment of a clinical encounter with a standardized patient. Participants were scored on the basis of their actions within the simulation (Measure 1) and by their responses to the open-ended questions in which they were asked to integrate the information from the simulation in a summative manner (Measure 2). RESULTS Of the 410 clinicians, 381 (92.9%) passed Measure 1,359 (87.6%) passed Measure 2, and 5 (1.2%) failed both measures. Seventy-five (18.3%) participants were referred for focused professional practice evaluation (FPPE) after failing either Measure 1, Measure 2, or both. CONCLUSIONS Overall, Web-based simulation and e-mail engagement tools were a scalable and efficient way to assess a large number of clinicians in OPPE and to identify those who required FPPE.

Acute Stress Time-dependently Modulates Multiple Memory Systems

Acute stress has been shown to modulate the engagement of different memory systems, leading to preferential expression of stimulus–response (SR) rather than episodic context memory when both types of memory can be used. However, questions remain regarding the cognitive mechanism that underlies this bias in humans—specifically, how each form of memory is individually influenced by stress in order for SR memory to be dominant. Here we separately measured context and SR memory and investigated how each was influenced by acute stress after learning (Experiment 1) and before retrieval (Experiment 2). We found that postlearning stress, in tandem with increased adrenergic activity during learning, impaired consolidation of context memory and led to preferential expression of SR rather than context memory. Preretrieval stress also impaired context memory, albeit transiently. Neither postlearning nor preretrieval stress changed the expression of SR memory. However, individual differences in cortisol reactivity immediately after learning were associated with variability in initial SR learning. These results reveal novel cognitive mechanisms by which stress can modulate multiple memory systems.

Autonomic Arousal and Learning in Web-Based Simulation: A Feasibility Study

Introduction: Autonomic arousal is an important component of understanding learning as it is related to cognitive effort, attention, and emotional arousal. Currently, however, little is known about its relationship to online education. We conducted a study to determine the feasibility of measuring autonomic arousal and engagement in online continuing medical education (CME). Method: Using the Computer Simulation Assessment Tool (CSAT) platform, health care providers were randomly assigned to either high‐ or low‐valence versions of a Web‐based simulation on risk assessment for a returning veteran. Data were collected on participants’ actions within the simulation, self‐reported cognitive engagement, knowledge retention, and autonomic arousal measured using galvanic skin response (GSR). Results: Participants in the high‐valence condition (n = 7) chose a lower percentage of critical actions (M = 79.2, SD = 4.2) than participants in the low valence (n = 8) condition (M = 83.9, SD = 3.6, t(1,14) = 2.44, p = .03). While not statistically significant, high‐valence participants reported higher cognitive engagement. Participants in the high‐valence condition showed a larger increase in physiologic arousal when comparing mean tonic GSR during the orientation simulation to the study simulation (high‐valence mean difference = 4.21 &mgr;S, SD = 1.23 vs low‐valence mean difference = 1.64 &mgr;S, SD = 2.32, t(1,13) = ‐2.62, p = .01). Discussion: In addition to being consistent with previous engagement research, this experiment functioned as a feasibility study for measuring autonomic arousal in online CME. The current study provides a framework for future studies, which may use neurophysiology to identify the critical autonomic and engagement components associated with effective online learning.

Acute Stress Throughout the Memory Cycle: Diverging Effects on Associative and Item Memory

Acute stress can modulate memory for individual parts of an event (items), but whether it similarly influences memory for associations between items remains unclear. We used a within-subjects design to explore the influence of acute stress on item and associative memory in humans. Participants associated negative words with neutral objects, rated their subjective arousal for each pair, and completed delayed item and paired associative recognition tasks. We found strikingly different patterns of acute stress effects on item and associative memory: for high-arousal pairs, preencoding stress enhanced associative memory, whereas postencoding stress enhanced item memory. Preretrieval stress consistently impaired both forms of memory. We found that the influence of stress-induced cortisol also varied, with a linear relationship between cortisol and item memory but a quadratic relationship between cortisol and associative memory. These findings reveal key differences in how stress, throughout the memory cycle, shapes our memories for items and associations.

Classifying emotion regulation strategies

In their recent article (The neural bases of emotion regulation. Nat. Rev. Neurosci. 16, 693–700 (2015))1, Etkin, Büchel and Gross proposed testing emotion regulation using computational approaches that are anchored in reinforcement learning. Their framework classifies emotion regulation strategies as model-based (MB; computationally sophisticated, prospective processes that consider environmental structure) or model-free (MF; computationally efficient, reflexive processes relying on past reinforcement)2. Although linking emotion regulation to computational decision making is valuable, here we argue that the MB versus MF classification may be inadequate to capture the complexity of emotion regulation. The authors use extinction as a key example of a MF regulation strategy. During extinction, conditioned responses diminish as a conditioned stimulus (CS) is no longer reinforced by an unconditioned stimulus (US). Extinction could be perceived as a MF strategy because it uses prediction error signals that emerge from recent reinforcement (that is, a CS no longer predicts an US). However, a standard observation is that after extinction learning, conditioned responses tend to re-emerge over time (a process known as spontaneous recovery)3,4. As MF reinforcement learning theories describe extinction as the process of ‘unlearning’ the CS–US association5, they cannot account for spontaneous recovery. Rather, extinction learning across species has been shown to have MB features6,7. Specifically, a MB perception of the ‘state’ in which extinction learning occurs predicts the magnitude of spontaneous recovery. Further, modelling conditioned responses in humans using a MF learning strategy alone fits the data more poorly than a Bayesian ‘latent cause’ model that incorporates MB features7. Thus, extinction appears to reflect a complex interaction of MF learning with MB state representations8. Since even simple extinction learning cannot be described as purely MF, it is unlikely that a MB–MF distinction will usefully distinguish between emotion regulation strategies9. The limitations of the MB–MF distinction are further highlighted by recent work on decision making demonstrating the predictive power of hybrid MB–MF models and identifying complex relationships between these strategies. Such conceptualizations can include hierarchical organization of goals and sub-goals, in which MB–MF processes exist within each other (for example, a goal is selected in a MF sense, but implemented using MB strategies10). We propose that this account may provide a better framework to understand emotion regulation. Take the example of avoidance, which is a behavioural strategy prevalent in anxiety disorders11. The initial choice to avoid something aversive may be a MF process: it need not require a prospective model given its strong history of negative reinforcement (alleviated fear). However, once this goal has been selected, the steps to carry out avoidance may require a ‘nested’ MB process. An individual with a height phobia may reflexively avoid crossing bridges on their way home (MF), but may use a number of flexible, complex strategies (MB) to achieve this goal, such as taking a novel, circuitous route. Using these nuanced classifications can provide a path forward. We propose that emotion regulation strategies should be classified on the basis of the degree to which they involve MB elements (for example, prospection12) and MF elements (for example, linking action and reinforcement), and the hierarchical relationships between them. This class ification will enable us to predict the utility of these strategies across individuals12,13 (for example, in healthy versus clinical populations) and contexts (for example, under stress14 or cognitive load15).