Differential Thinking in Sexual Health Assessment · Clinical Exercise

Four Hypotheses, One Discriminator

One presentation, two tasks. Decide which hypotheses are worth holding, then decide what evidence would actually test each one. The second task is the one that matters, because a hypothesis you cannot name a discriminator for is not doing any work.

What this exercise practises

Generating a differential from this client's data rather than from base rates, distinguishing evidence that would move a hypothesis from evidence that is merely consistent with it, and holding a leading hypothesis without closing on it.

Three of the eight hypotheses on offer should not be on your list, and each of the three fails in a different way.

Estimated time to complete this exercise: 25 minutes

1The list
2The discriminators
3Closing too early
4Close

Before you begin

How this one works

One presentation and two tasks. First, decide which hypotheses are worth holding. Then, for each hypothesis, decide what evidence would actually test it.
The second task is the one that matters. Generating hypotheses is the easy half, and a hypothesis you cannot name a discriminator for is not doing any work.
Three of the eight hypotheses on offer should not be on your list, and each of the three is there for a different reason.
Part 3 is what you do once one hypothesis is clearly leading.
Nothing is graded and nothing is recorded. Reloading starts it again.

The test of a hypothesis is not its plausibility but its explanatory power: does it account for all the clinical evidence. If a working hypothesis cannot explain why the concern is situational rather than generalised, or why it began when it did, it is incomplete regardless of how reasonable it sounds.

References

  1. Croskerry, P. (2003). The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine, 78(8), 775–780. https://doi.org/10.1097/00001888-200308000-00003
  2. Eells, T. D. (Ed.). (2007). Handbook of psychotherapy case formulation (2nd ed.). Guilford Press.
  3. Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x
  4. Persons, J. B. (2008). The case formulation approach to cognitive-behavior therapy. Guilford Press.