Neurobiological Aspects in Affective and Social Decision Making and Influence of Stress: Potential Implications in Clinical Decision Making
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Decision-making is influenced by various factors that many times are not conscious. This article summarizes some neurobiological correlates on affective and social components for decision-making, including the impact of acute and chronic stress and cognitive perspective of heuristics and the biases in clinical practice. At an affective level, the hypothesis of somatic markers has correlated peripheral body response with central nervous structures in the decisions setting; intervening structures such as the orbitofrontal cortex and the hippocampus. Social decision making involve reward/motivation dimensions. In this type of decisions, the ability to mentalize others and integrate their perspective into decision-making is crucial. This function has been correlated with the posterior superior temporal sulcus, the temporoparietal junction, the anterior cingulate cortex and the medial prefontal cortex. However, social decision making also includes compliance of socially accepted rules. Acute/chronic stress may positive/negatively affect decision-making. These processes have involved the hypothalamic-pituitary-adrenal axis along with cortical striatal/prefrontal/amygdaline/hippocampal pathways. In clinical decision-making, there is a blend of prerreflexive/emotional/social/cognitive factors directly influencing conducts adopted with patients. We recommend to emphasize research in this area and to boost its research in order to learn about them properly.
Keywords: neurosciences, emotions, clinical medicine, heuristics, biases
People make decisions based on various levels of consciousness, reflection and certainty, influenced by their own and/or external experiences. This process involves various levels of deliberation and cognitive effort. Even though the neurobiological point of view represents a level within many others, it is a spot for synthesis and convergence of various stances aimed to analyze decision making (DM), understanding that this is the result of an integrative process involving various sensorial/affective/contextual afferences, as well as cognitive/motivational and mnemic processes(1). We understand this from a theoretical approach of the reward system. For instance, DM before dilemmas is conceptualized as a set of cognitive-affective states and actions when people make changes aimed to move to states related with a higher reward, but always in a context of social significance(2).
Some theoretical perspectives state that in a clinical scenario DM is characterized by being a hypothetical-deductive process allowing to choose an action by means of clinical reasoning. In this way a diagnosis must be made and the conduct to be followed, based on the patient and on scientific evidence, but also on the clinician´s experiences(3). The study is based on technical/cognitive reasoning models that have removed the affective aspects of DM. However, sanitary professionals must often make decisions in emotionally demanding/complex contexts, dealing with their own experience and emotional skills, in order to reach this goal. From that point of view, DM does not seem to exclusively obey a “rational” and “conscious” logic, as there are various subjective/affective/contextual/social factors influencing it. Even though the study of interacting neurobiological factors of DM in a clinical context is very rare, this review is aimed to summarize the literature available on affective/social influence and on the stress of this process, thus describing some of its neurobiological bases and finally discussing its potential implications in the sanitary context.
A narrative review was developed in order to describe the evidence available regarding neurobiological aspects studied in affective/social DM, and influence of stress. A systematic research of the literature available in PubMed/Medline, SciELO, PsycInfo and Cochrane Library was made. As search terms of the controlled language we have used “neurosciences”, “neurobiology”, “emotions”, “clinical medicine”, “heuristics” and “bias”. Terms of non-controlled language, such as “decision-making”, “social decision-making”, “stress”, “affective decision-making” and “emotional decision-making” were used. All primary articles (any methodological design) and secondary articles (narrative and systematic reviews with or with no meta-analysis) including in the title and/or abstract neurobiological DM aspects in the areas of interest. The references of the articles included were reviewed, as a second method of inclusion. Articles in Spanish, English, French and German were reviewed.
Next, a narrative synthesis of the main results found is described.
Emotions and Affections in Decision Making
Damásio in 1994(4) stated the hypothesis of the somatic marker. He explained that reasoning is influenced by sign biases coming out from neural mechanisms underlying emotions(5). According to Dunn et al(6), the sign (somatic marker) represents the emotional reaction before a potential response. For each response option, a somatic state is generated, including visceral sensations of the milieu intérieur/musculoskeletal/smooth muscles. These somatic markers are deemed as a value indicator of representations and impact on further working memory and attention. Specially, under complex/uncertain situations, this sign helps to reduce the problem into a manageable amount of response options with an emotionalsign. Only those options that are marked as promissory are fully cognitive processed. In this way, the brain can make up an anticipated model of changes executed in the body, thus allowing it to respond more quickly to outer stimuli, not expecting that the activity comes out from the periphery. These signals may work either consciously or unconsciously. The structure is believed to be in charge of codifying the correlation between secondary inductors (situations already experienced and marked) and the bio regulatory state linked to the experience related to such situation from the past (considering bodily aspects of the emotional response), it is the ventromedial prefrontal cortex. This is not done directly, but is done by reactivating the experience by means of other brain areas, such as the hypothalamus, autonomic centers, periaqueductal grey matter (associated to body changes), somatosensory cortex, insula, cingulate, basal nuclei and brainstem sensory nuclei (related to body changes representation). The amygdala has a similar function than the ventromedial prefrontal cortex, but focused on primary inductors, i.e. s first-time experiences. The influence of somatic states on the response selection is regulated by the dopaminergic/ serotoninergic/noradrenergic/cholinergic pathway in the brainstem(6).
Beyond Dual Systems: the Modulating Role of Emotions on Decision Making
Usually, two systems being part of DM have been described: System 1. It operates faster and automatically, with little effort and a feeling of voluntary control. System 2. It has a subjective component of agency, choice and concentration(7). The first deals with a hotter emotional, spontaneous and automatic, system, functioning, according to similarity/continuity principles which influence behavior by means of affective impulses (related with limbic system. This is deemed as phylogenetically older or more primitive) and another one cold, with a cognitive control, related with the deliberative process, with efforts, functioning according to logical formal rules (related with the neocortex). The system 2 is in charge of the control inhibitory, i.e. a mechanism aimed to block affective impulses and allow deliberative decision making, even in situations with an affective burden(8). However, current scientific evidence states that this view might be obsolete: for instance, the orbitofrontal cortex linked to rational thinking is also relevant for emotional processing, while the hippocampus, is a key component of the limbic system, therefore of emotional processing, and it is crucial in memory. There is no clear boundaries splitting brain regions underlying emotions and cognition. We could say that a decision is already an affective process by itself, as it involves the evaluation of a preference, motivation or subjective value assigned to the options(9). The two systems act together, not as separate entities. The confirmation bias is a good example of how both systems may be affected by biases. The information supporting our prior beliefs may be easily remembered (one activity of the system 1), and there is motivation as well, for analyzing new information supporting our prior beliefs (one activity of the system 2)(10). Next, we will further describe the topic of cognitive biases.
Heuristics and Cognitive Biases
In cognitive sciences and in behavioral economics, as well as in some theoretical guidelines on clinical practice, many cognitive biases and heuristics affecting judgment and DM have been identified. When human beings make decisions or make judgments, usually heuristic strategies are used (also named as shortcuts) simplifying the complex tasks to evaluate probabilities and predict values on simple judgment operations. Usually, heuristics use to be very useful, but sometimes it may lead to systematic mistakes(11,12). These biases come from the violation of several principles of rationality; the three main are: Principle of dominance. It suggests the individual should choose the option that is never worse than the other and it may have a better result than the other options; Principle of invariance. It suggests the information must be understood and considered in the same way, regardless of how it is described; Principle of sunken costs. It suggests that as decisions affect the future, these should be taken into account considering future consequences, not results, and conducts happened in the past(12). Some biases related to these principles are: tendency to believe that losses weigh more que relevant earnings (aversion to risk)(13), evaluate the probability of an event based on the possibility to remember it more than the actual probabilities (availability bias)(11) and let time, money or efforts invested influence current/future decisions (bias of sunken cost). Other systematic mistakes are the tendency to remember and be more influenced by the options or facts presented at the beginning and at the end (bias of serial position, primacy and recency); choosing what other choose (effect of dragging), tend to choose the default option (default effect); see the damages resulting from an action as worse than those resulting from an omission (omission bias) and the inaccuracy to estimate future emotional states (impact bias)(13). An example of heuristics impact and cognitive biases on clinical contexts is the following: an elderly physician has some unspecific abdominal pain, associated to discomfort, for several days. After an evaluation, his diagnosis was chronic appendicitis. He was subject to abdominal surgery and his pain and discomfort disappeared. After this experience, he diagnosed chronic appendicitis in many of his elderly patients who had recent unspecific abdominal pain and decided to take them to surgery. The memory of his own experience led him to believe this diagnosis was somewhat common in elderly patients with abdominal discomfort. This is an example of availability bias(14). In another study made with psychiatrists and forensic psychologists, an evaluation of violent conducts risks and the decision to keep or not hospitalization for patients, according to the estimated risk was required. 41% of them did not agree to discharge a patient if he/she had a risk to have violent conducts 20 out of 100. While only 21% did not agree to discharge the patient, in case a risk of violent conducts could arise in 20%. This is an example of framework effect. It means if the information was presented as frequency, it had a different influence than if presented as probability(15).
Social Decision Making
Interaction among human beings provide the essence of the social aspect regarding a decision(16): we decide regarding others, for others and with others(17). A theory has been stated that there are visual areas specialized in perceiving faces, while the dorsomedial prefrontal cortex and the temporoparietal junction are specifically involved in representing intentions, emotions and other people´s actions(17). Although research, in Social DM, has included -to a lesser degree- the motivational component, Social DM has many components similar to those of the motivational systems, such as reward and aversion components(2,18). Social decisions are characterized, because the value associated to the judgment the person makes depends on the impact it has on actions and mental states of others. Decisions must fit within the mental state of a third party(2), whose perception (or capacity to mentalize others) has been a function referred to the posterior superior temporal sulcus, the temporoparietal junction, the anterior cingulate cortex and the medial prefontal cortex(19). On the other hand, the idea of a specific framework of social valuation, framed within the hypothesis of social brain, proposes that reward and social values are processed by a neural circuit that evolved, in order to incorporate the information coming from interacting with others, in order to allow social cohesion and cooperation among peers. Ruff and Fehr(17) describe three scenarios where the circuit gets involved in Social DM: (I) situations when social evaluation involves a reward or a punishment for himself/herself and it comes from a third party, (II) when the subject decides the impact it may have on a third party and (III) when the decision involves compliance of social rules. Under these scenarios, the structures generally linked to positive valuation responses are the orbitofrontal cortex, prefrontal ventromedial and the ventral striatum, while in case of responses associated to punishment have been linked to the anterior cingulate cortex and to the insula. Regarding this, valuation of punishment to negative valuation responses such as, for instance, unfair treatment or non-compliance of social rules, has been linked with activation of the prefrontal ventrolateral cortex. Finally, trust is a primordial phenomenon in Social DM. Its regulation is linked to the activation of the amygdala(16,18). Oxytocin seems to be a main mediator, as it could suppress amygdala activity, thus decreasing anxiety and increasing trust behavioral expression(2,16,20,21).
Influence of Acute and Chronic Stress on Decision Making
Some affective/cognitive/social aspects involved in DM have been stated. All of them affect Clinical DM. However, another significant contextual factor is stress. DM process may be stressing by itself, thus creating a reciprocal correlation where stress may affect the quality of decisions and, at the same time, it may be evoked by the need to make it. This correlation between stress and DM has some neural correlates tested by the affectation of the cognitive function in cases of acute/chronic stress(2224). Neurobiological mechanism through which stress may affect DM depends on the sympathetic nervous system, by means of the hypothalamohypophysial and sympathetic adrenomedullary pathways(25). Activation of the latter happens ipso facto when facing a stressing agent and it involves an increasing heart rate and increasing artery pressure. At the same time, metabolic changes in various brain areas have been detected: an increasing activity of the dorsolateral prefrontal cortex, the anterior cingulate cortex, the basal nuclei and the anterior corpus striatum. A decrease in the activity of the orbitofrontal/hypothalamic/hippocampal cortex(23) has also been observed. On its part, the hypothalamohypophysial pathway has a higher temporary latency in its functioning, thus releasing cortisol from the adrenal cortex , which has receptors of glucocorticoids in the prefrontal cortex , hippocampus and amygdala(23,25). The impact on DM, when activating these pathways will be an advantage or a problem, according to the task and the specific situation the subject is involved in(23). On the one hand, acute moderate stress has been proved to improve DM in cases of uncertainty where the subject learn strategies aimed to prioritize rewards in the long term, instead of immediate earnings(25,26); but, on the other hand, stress hinders executive functions, thus reducing control on cognitive processes(23). Stress has been determined to cause changes from an analytical reasoning to more intuitive processes, thus causing more spontaneous responses(27). Chronic stress would have a deep brain impact, involving cognition and behavior(28), due to modulation of neural circuits, as it releases corticosteroids. This would cause a dendritic/ synaptic reorganization in the hippocampus and medial prefontal cortex, thus inhibiting cognitive control(28,29). In
Even though DM is based on cognitive/rational processes, it encompasses various “prerreflexive” processes associated to affections and relationships with others, and it is modulated by stress scenarios. Somatic interoceptive manifestations relieved in the somatic marker hypothesis have a role in DM, as they are encoded by certain brain structures, in order to allow a quick future response. From a theoretical point of view, DM has been divided into affective/cognitive/social dimensions. However, decision is a complex phenomenon where all of them interact. The same happens from a neurobiological point of view as, no structures and/or circuits only managing affective/cognitive/social aspects of DM have been found.
When sanitary professionals manage cases bringing memories associated to highly affective components (for instance, himself/herself or a close person suffered something similar), probably they will make different clinical decisions than those they would make with an unrelated case, from their own emotional experience, that is to say, they could offer more attention and devotion to the case or even getting “overinvolved”. Contrariwise, if a patient unleashes negative/aversive emotions, it is possible that clinical decisions will not reflect the best possible attention. This has been proven by Tentler et al(30), who performed a qualitative study aimed to evaluate prescription of antidepressants made by 22 primary care physicians. Patients´ requirements unleashed affective/cognitive decision processes, according to their personal characteristics, contextual factors, the professional´s assumptions and his/her self-consciousness. Responses led by affective factors, such as discomfort or empathy, assumptions based on previous experiences and decisions led by deliberation processes were described.
From a referential standing point, offered by the somatic marker hypothesis, a rather experienced physician probably has “recorded” in his/her nervous system the “consequences” of his/her prior decisions, by virtue of the positive/ negative impact, both in patients as well as in the environment, with their relevant somatic markers. Later, when the clinician faces new decisions in similar contexts, the analysis associated to DM will be faster, as he/she will be capable to “feel” what he/she “must do”. That is the unconscious somatic emotional impact on clinical decisions. This phenomenon is quite relevant in building up clinical experience, by making differences with those professional who make clinical decisions mainly based on rather theoretical knowledge.
In history, teaching medicine has emphasized more on knowledge content, rather than in the process leading to this clinical DM, using this knowledge. Cognitive/affective biases are deemed as a regular exercise of mental functioning; therefore, the possibility to recognize them is a significant component of the critical thought in clinical reasoning. Its development, along with other cognitive skills, is fundamental for education and training of clinician regarding DM. In this line, research on psychological processes underlying DM in a clinical context must be enhanced, in order to detect and minimize the impact of cognitive biases in a practical sense. It is also advisable to think about clinical DM during training of sanitary professionals.
DM in a health scenario is not a merely individual process, as many times work is performed in teams. That is why, decisions will depend on professional/personal experiences of all those who participate in those decisions. There are collected decisions made affecting others, according to the knowledge acquired during our professional performance, individual experiences, usual/generalized clinical practice, the opinions of the team and what is stated by social rules. All these scenarios account for the three plans stated by Ruff and Fehr regarding social DM, which are combined with the aforementioned emotional component(17), thus making this phenomenon more complex. Apart from that, anxiety and stress involved in making quick decisions in a clinical scenario, or whose result represents a huge consequence for patients and their environment, activate the neuroendocrine pathway of stress, involving structures, such as the hypothalamic-pituitary-adrenal axis, corticocerebral regions, basal nuclei and limbic system (Figure 1). All these structures are involved in imbricated cognitive/affective/motor processing, which summarizes the DM complexity. In turn, this could explain the huge heterogeneity observed in Clinical DM in health areas.
There is wide evidence that DM is a composed process, influenced by emotional, affective and social aspects, going beyond logical/conscious reasoning. Regarding clinical decisions, there is little research linking processes, structures and/or specific neurobiological circuits with DM, i.e. an analysis at this level requires extrapolation of findings made in areas other than clinical areas. We recommend supporting research in this area and improving teaching and recognition of the processes involved in clinical DM, as we are not fully conscious about it, specifically what impacts on clinical performance.
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