Emotions and Health Decision Making

shared_decision_making_smallThis post is based on a paper by Rebecca Ferrer, William Klein, Jennifer Lerner, Valerie Reyna, and Dacher Keltner: “Emotions and Health Decison-Making, Extending the Appraisal Tendency Framework to Improve Health and Healthcare,” in Behavioral Economics and Public Health, 2014. I note that Valerie Reyna is one of the authors of fuzzy trace theory (see post Fuzzy Trace Theory-Meaning, Memory, Development and subsequent posts.) which I find interesting.

The authors use the appraisal tendency framework (ATF) to predict how emotions may interact with situational factors to improve or degrade health-related decisions. The paper examines four categories of judgments and thought processes as related to health decisions: risk perception, valuation and reward-seeking, interpersonal attribution, and depth of information processing. They illustrate ways in which a better understanding of emotion can improve judgments and choices regarding health.

The ATF assumes that specific emotions give rise to corresponding cognitive and motivational processes that are related to the target of the emotion (i.e., the situation, person, or other stimulus that elicited the emotion). In contrast to theories that predict how broad mood states (positive or negative) may influence judgment and decision making, the ATF offers specific predictions for how discrete emotions will influence judgment and decision making (See Tables 1 and 2).



According to the ATF, patterns of cognitive appraisals along these dimensions provide a basis for comparing and contrasting discrete emotions. For example, certainty and control are the central dimensions that separate anger from fear. Anger is associated with appraisals of certainty about an event and individual control for negative events. Fear, by contrast, is associated with appraisals of uncertainty about what happened and situational control for negative events. Despite its positive valence, happiness, like anger, is associated with an elevated sense of certainty and individual control. Each emotion is also accompanied by a core appraisal theme, which is a mental schema associated with the emotion that summarize the specific harms or benefits associated with the target or elicitor of the emotion.  For example, sadness is accompanied by a core appraisal theme of loss; anger involves a core appraisal theme of being slighted or demeaned.

Decisions about Health Promotion and Disease Prevention Behaviors
Guided by the ATF, the effects of information content and depth-of-processing can be used to identify ways that emotion may systematically benefit or hinder choices about health promotion and disease prevention behaviors.
Risk Perception and Communication. Emotion influences risk perceptions for diseases that could be prevented through healthy behaviors. According to the ATF fearful individuals are more persuaded by loss-framed messages about the consequences of failing to eat fruits and vegetables (given that fear promotes loss averse behaviors), whereas angry individuals are more persuaded by gain-framed messages about the benefits of consumption (given that anger promotes approach behaviors and behavioral control).
Valuation and Reward-Seeking. Based on the ATF, sadness, associated with high valuation and reward-seeking, increases the consumption of hedonic foods, whereas disgust, associated with trading away or disposal, decreases consumption of these types of foods. Individuals induced to a sad emotional state also consume higher amounts of hedonic foods than those induced to feel happy.  It seems likely that sadness and disgust would influence health decisions like smoking, inactivity, and alcohol consumption, all involving intertemporal choice; sadness should increase willingness to risk later health outcomes in service of immediate gratification associated with negative health behaviors, whereas disgust may demotivate these behaviors. The effect of sadness may be increased in adolescents and young adults, where achieving immediate pleasure is a highly prioritized goal. The authors note that disgust has already been leveraged in smoking policy, in that many cigarette warning labels target disgust. Extending this hypothesis, sadness could increase smoking, which has potentially important implications, given that some antismoking advertisements may elicit sadness rather than fear by depicting a dying person.
Interpersonal Attribution. Ferrer et al suggest that individuals may be more motivated to engage in interpersonally relevant healthy behaviors if they are experiencing pride, an emotion involving attributions about the self in comparison to attributions about others. Research has demonstrated that pride increases perseverance on effortful and hedonically negative tasks. According to the authors, pride may reduce binge drinking, because it may reduce social normative influences. As such, pride seems an important emotion to leverage in interventions. Moreover, positioning interventions and communications in contexts where pride is facilitated by an outside source (e.g., sporting events or graduations) may increase their effectiveness.

Medical Decision-making
All patients make decisions about preventive care and screening. Patients with illness or disease also face decisions about diagnostic procedures and treatments, as well as later decisions about adherence to treatment.

Risk Perception and Communication. Because emotion influences perceptions related to disease risk, anger and happiness should decrease, and fear increase, perceived susceptibility to disease risk in the context of medical decision-making. Consistent with this prediction, basic research has demonstrated that mammography messages framed in terms of gains are more persuasive for happy, compared to sad, individuals.

In practice, risks in medical decision-making are relatively complex. Emotions relevant to risk perception may influence these types of decisions differently depending on which risks are salient (e.g., risk of cancer vs. risk of side effects). In situations in which choosing a risky option is advantageous, the ATF would predict that anger would facilitate risk taking, whereas fear would hinder it. In contrast, in situations where choosing a risky option is not recommended (e.g., a risky treatment when other effective treatment options are available) or the risk of disease is salient in the context of a screening decision, fear should facilitate decision-making, whereas anger should hinder it.
Valuation and Reward-Seeking. Emotions that influence choices involving valuation, such as sadness and disgust, are relevant. Sadness decreases susceptibility to the status quo bias, compared to anger. In decisions that involve choosing between types of treatment or screening, sadness may hinder decision-making when the status-quo is recommended, and optimize decision-making when there is not a status-quo option. Extending this research, disgust could bias decisions towards refusing any treatment; as such, disgust could be anticipated to hinder treatment decision-making.

Interpersonal Attribution . Emotions can systematically improve or degrade patient-provider interactions. Anger increases stereotyping (compared to sadness and fear).  Anger also decreases trust, whereas happiness and gratitude increase it (compared to sadness). Gratitude also increases advice-taking. Patients experiencing gratitude or happiness should be most poised to make the best decisions in situations where the course of action is fairly straight-forward, given high levels of trust and increased reliance on expertise, which could lead to adherence to physician recommendations. Conversely, sadness or fear would enhance decision-making when recommendations are ambiguous and depend on personal values and priorities.
Depth-of-Processing. Given the tendency to process information more heuristically (System 2) and less systematically (System 1) depending on emotional state, individuals in emotional states that predispose processing styles influence health-related information in a clinical encounter.  Indeed, Ferrer et al note that research shows that emotion can induce heuristic information processing, particularly among men.

There are some basic things here that might help make better health related decisions. As for the clinical setting, maybe the answer is to ask the same questions again later if a person is in a highly emotional state now.