Decision-making ability limitations and brain neural activity changes in healthcare workers after mild COVID-19

Studies have demonstrated that the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) extensively affects brain function. Although cognitive dysfunction is considered a common manifestation in COVID-19 patients during the recovery period, the potential changes in decision-making ability, are not yet clear. Decision-making functions are essential to the work of healthcare workers. However, there is a lack of a multidimensional assessment of its functioning in COVID-19 cases. Here, we used tests combined with the resting-state functional magnetic resonance imaging (rs-fMRI) stabilization feature amplitude of low-frequency fluctuations (ALFF) to explore decision-making behavior and brain neural activity changes in healthcare workers after mild COVID-19. Participants were divided into the SARS-CoV-2 infected group (SI, n = 41) and healthy controls (HC, n = 42). All participants underwent a series of neuropsychological tests. They performed the Iowa Gambling Task (IGT) and the Game of Dice Task (GDT), followed by fMRI (n = 20) to assess their decision-making ability under ambiguous and risky conditions and changes in brain neural activity. The SI group performed worse in verbal memory than the HC group. Furthermore, the SI group performed worse in the IGT, whereas no significant difference was observed in the GDT. In addition, rs-fMRI showed enhanced spontaneous neural activity in the postcentral gyrus and inferior parietal lobe in the SI group compared to the HC group.

Cognitive Functions in Patients with Moderate-to-Severe Obstructive Sleep Apnea Syndrome with Emphasis on Executive Functions and Decision-Making

BACKGROUND

Patients with obstructive sleep apnea syndrome (OSAS) have cognitive dysfunction in many aspects, however, these patients' decision-making function remains unclear. In this study, the Game of Dice Task (GDT) was used to investigate the function of decision making in patients with OSAS.

METHODS

30 participants with moderate to severe OSAS and 27 participants with no or mild OSAS diagnosed by sleep breathing monitor were selected from June 2021 to March 2022. Risky decision making was tested through the GDT with known risk probability. General demographic information and background cognitive functions, such as the overall cognitive functioning and executive functioning, were tested to establish baseline data.

RESULTS

There were no significant differences in gender, age, and years of education between the two groups. During the GDT, the moderate to severe OSAS group opted for the safety option at a statistically significant lower rate when compared to the no or mild OSAS group (7.53 ± 4.43 vs. 10.26 ± 4.26, p = 0.022). The moderate to severe OSAS group utilized the higher risk option than the group with no or mild OSAS (10.47 ± 4.43 vs. 7.74 ± 4.26, p = 0.022). The utilization rate of negative feedback in the moderate and severe OSAS group was lower than that in the no or mild OSAS group (7.50, 52.50 vs. 28.57, 100.00, p = 0.001). At the end of the GDT, the moderate and severe OSAS group was more likely to have negative total assets than the patients with no or mild OSAS (-1846.67 ± 2587.20 vs. 300.00 ± 1509.97, p < 0.001). Multiple linear regression analysis shows that there is a negative correlation between the selection of risk options and negative feedback utilization in the GDT.

CONCLUSION

Patients with moderate and severe OSAS displayed impaired decision-making throughout the study. Impaired decision-making is related to executive processes and may be caused by diminished prefrontal cortex functioning. However, the functions of memory, attention, language, abstraction, and orientation are relatively retained.

The impact of mild cognitive impairment on decision-making under explicit risk conditions: Evidence from the Personality and Total Health (PATH) Through Life longitudinal study

OBJECTIVE

Previous research has indicated that cognition and executive function are associated with decision-making, however the impact of mild cognitive impairment (MCI) on decision-making under explicit risk conditions is unclear. This cross-sectional study examined the impact of MCI, and MCI subtypes, on decision-making on the Game of Dice Task (GDT), among a cohort of older adults.

METHOD

Data from 245 older adult participants (aged 72-78 years) from the fourth assessment of the Personality and Total Health Through Life study were analyzed. A diagnostic algorithm identified 103 participants with MCI, with subtypes of single-domain amnestic MCI (aMCI-single; n = 38), multi-domain amnestic MCI (aMCI-multi; n = 31), and non-amnestic MCI (n = 33), who were compared with an age-, sex-, education-, and income-matched sample of 142 cognitively unimpaired older adults. Decision-making scores on the GDT (net score, single number choices, and strategy changes) were compared between groups using nonparametric tests.

RESULTS

Participants with MCI showed impaired performance on the GDT, with higher frequencies of single number choices and strategy changes. Analyses comparing MCI subtypes indicated that the aMCI-multi subtype showed increased frequency of single number choices compared to cognitively unimpaired participants. Across the sample of participants, decision-making scores were associated with measures of executive function (cognitive flexibility and set shifting).

CONCLUSION

MCI is associated with impaired decision-making performance under explicit risk conditions. Participants with impairments in multiple domains of cognition showed the clearest impairments. The GDT may have utility in discriminating between MCI subtypes.

Executive Functions in Decision Making under Ambiguity and Risk in Healthy Adults: A Scoping Review Adopting the Hot and Cold Executive Functions Perspective

Decision making (DM) has a pivotal role in supporting individual autonomy and well-being. It is considered a complex ability exploiting many cognitive functions, among which executive functions (EFs) are crucial. Few studies analyzed the role played by EFs in DM in healthy adults under ambiguity and risk, which are common conditions for most decisions in daily life. This scoping review aims to analyze the relationships between two individual tasks widely used to assess DM under these conditions (Iowa Gambling Task and Game of Dice Task) and EFs. According to the organizing principle that conceptualizes hot and cold EFs, DM under such conditions mainly implies hot EFs, but the relationship with cold EFs is still unclear. Using such an approach, a comprehensive framework is provided, highlighting main findings and identifying possible gaps in the literature. The results suggest different roles played by cold EFs in DM under ambiguity and risk, according to the characteristics of the tasks. The findings can offer guidance to further studies and to design interventions to support DM in healthy adults.

Are correlations among behavioral decision making tasks moderated by simulated cognitive impairment?

Behavioral decision making tasks are common in research settings, with only the Iowa Gambling Task available for clinical assessments. However, correlations among these tasks are low, indicating each may assess a distinct component of decision making. In addition, it is unclear whether these tasks are sensitive to invalid performance or even simulated impairment. The present study examined relationships among decision making tasks and whether simulated impairment moderates the relationships among them. Across two studies (Study 1: n = 166, Study 2: n = 130), undergraduate student participants were asked to try their best or to simulate a specific diagnosis (Attention-Deficit/Hyperactivity Disorder; Study 1), decision making impairment (Study 2), or general cognitive impairment (Study 2). They then completed a battery of tests including embedded and standalone performance validity tests (PVTs) and three behavioral decision making tasks. Across studies, participants simulating impairment were not distinguishable from controls on any of the behavioral tasks. Few significant correlations emerged among tasks across studies and the pattern of relationships between tasks did not differ on the basis of simulator or PVT failure status. Collectively, our findings suggest that these tasks may not be vulnerable to simulated cognitive impairment, and that the tasks measure largely non-overlapping aspects of decision making.

Decision-making, cognitive functions, impulsivity, and media multitasking expectancies in high versus low media multitaskers

In several studies, individuals who reported to frequently multitask with different media displayed reduced cognitive performance, for example in fluid intelligence and executive functioning. These cognitive functions are relevant for making advantageous decisions under both objective risk (requiring reflection and strategical planning) and ambiguous risk (requiring learning from feedback). Thus, compared to low media multitaskers (LMMs), high media multitaskers (HMMs) may perform worse in both types of decision situations. The current study investigated HMMs and LMMs in a laboratory setting with the Game of Dice Task (GDT; objective risk), the Iowa Gambling Task (IGT; ambiguous risk), various tests quantifying cognitive functions (logical reasoning, working memory, information processing, general executive functions), and self-report measures of impulsivity, media multitasking expectancies, and problematic Internet use. From 182 participants, 25 HMMs and 19 LMMs were identified using the Media Multitasking Index. Results show that HMMs compared to LMMs performed weaker on the IGT but not on the GDT. Furthermore, HMMs had slightly decreased performance in tests of logical reasoning and working memory capacity. HMMs tended to increased information processing speed but this difference was not significant. Furthermore, HMMs have more positive expectancies regarding media multitasking and reported higher tendencies toward problematic Internet use. HMMs and LMMs did not differ significantly with respect to impulsivity and executive functions. The results give a first hint that HMMs may have difficulties in decision-making under ambiguous but not under objective risk. HMMs may be more prone to errors in tasks that require feedback processing. However, HMMs appear not to be impaired in aspects of long-term strategic decision-making.

The role of cognition and reinforcement sensitivity in older adult decision-making under explicit risk conditions

Introduction: Previous research has suggested that individual differences in executive functions, memory and reinforcement sensitivity are associated with performance on behavioral decision-making tasks. Decision-making performance may also decline with age, however there is a lack of research on the interplay of cognitive and affective processes, and their impact on older adult decision-making. This study examined associations between executive functions, memory and reinforcement sensitivity on the Game of Dice Task (a measure of decision-making under explicit risk) among older adults.Method: One thousand and two older adults without cognitive impairment (aged 72-78 years) participated as part of an Australian longitudinal cohort study (the Personality and Total Health Through Life study). Decision-making sub-types were identified through cluster analysis and multinomial logistic regression was used to assess associations with measures of cognition and reinforcement sensitivity.Results: Cluster analysis identified three decision-making sub-types, which we label "advantageous," "disadvantageous" and "switching." Multivariate analyses found that relative to the mid-performing "switching" sub-type, advantageous decision-makers were more likely to be younger, male and have higher scores on a test of verbal learning. Disadvantageous decision-makers were more likely to have poorer scores on some components of executive function (set shifting, but not working memory or inhibitory control), although this effect was partly attenuated by a measure of reinforcement sensitivity (reward responsiveness).Conclusion: These results indicate that specific components of learning and executive functions are influential in decision-making under explicit risk among a sample of older adults.

Better modulation for risk decision-making after optimized magnetic stimulation

Traditional repetitive transcranial magnetic stimulation can only produce a significant but weak effect on the cortex while theta burst stimulation (TBS), a patterned accelerated form of stimulation, can produce a stronger poststimulation effect, which may improve decision-making abilities. We designed a comparative assessment of the effect of intermittent TBS (iTBS), 20 Hz, in two risk decision-making tasks on healthy controls. Participants were randomized and assigned to the iTBS (n = 29), 20 Hz (n = 29), or sham (n = 29) groups. The effects of the different methods of left dorsolateral prefrontal cortex stimulation on risk decision-making functions were compared based on subjects' performance in the Game of Dice Task (GDT) and Risky Gains Task (RGT). The main indicators were positive and negative feedback utilization rates of GDT and RGT. Both iTBS and 20 Hz stimulation resulted in significant improvements upon negative feedback in the GDT, with increases in safe options and reductions in risky options; iTBS stimulation increased subjects' use of positive feedback in the GDT and RGT (all p < 0.05). Furthermore, the iTBS group had a stronger feedback risk reduction effect than the 20 Hz or sham group following RGT negative feedback (p < 0.05). Individuals would integrate positive and negative information more efficiently, leading to them making rational choices after excitatory transcranial magnetic stimulation. Moreover, iTBS has a stronger risk reduction effect following negative feedback than the 20Hz stimulation did. In summary, iTBS might have clinical value in decision promotion.

Impaired decision-making under risk in patients with functional dyspepsia

INTRODUCTION

The cognitive processing in patients with functional dyspepsia (FD) has not been well established. Decision-making is an important component of cognitive function. Most brain regions involved in decision-making are abnormal in FD patients. This study aimed to investigate the decision-making under ambiguity and risk in FD patients.

METHODS

We recruited 40 FD patients meeting Rome III criteria and 40 healthy controls (HCs) matched for age, sex, marital status, and education level. The Hamilton Anxiety Scale (HAMA) and the 17-item Hamilton Depression Scale (HAMD-17) were used to evaluate their anxiety and depression emotions. The Iowa Gambling Task (IGT) and Game of Dice Task (GDT) were used to evaluate decision-making under ambiguity and risk, respectively. Helicobacter pylori status, disease duration, dyspeptic symptom score, and the Nepean Dyspepsia Life Quality Index (NDLQI) were obtained from all patients.

RESULTS

In IGT, FD patients had a lower total net score, chose more adverse choices, and showed a slower response to change their behavior than HCs. However, there was no significant difference in the net score of the first 2 blocks between the two groups. In GDT, FD patients had a lower total net score, higher risk score, and lower use of negative feedback than HCs. In addition, FD patients showed better GDT performance than those without early satiation.

CONCLUSIONS

FD patients showed impaired decision-making under risk. The deficiency might be related to dyspeptic symptoms of FD patients.

The Effectiveness of the Game of Dice Task in Predicting At-Risk and Problem Gambling Among Adolescents: The Contribution of the Neural Networks

The Game of Dice Task (GDT; Brand et al. in Neuropsychology 19:267-277, 2005a; Psychiatry Res 133:91-99, 2005b) measures decision-making under objective risk conditions. Although disadvantageous decision-making has been shown in individuals with substance dependency, such as pathological dependency, any studies have been conducted with adolescents by using the GDT to investigate the relationship between the performance on the task and gambling behavior. Moreover, all the previous studies have considered only the GDT net score and not the single choices. In the current study, focusing on adolescents, we wanted to investigate the relationship between the sequence of the choices at the GDT and gambling behavior, measured with the SOGS-RA. To analyze the predictive power of the sequence of choices made in the GDT and problem gambling and gambling frequency, we used the Neural Networks (NNs), which are often used to find relationships between a series of input actions and the correspondent empirical outputs in order to discover behavioral patterns that may be predictive of at-risk behaviors. Results showed that neither a linear or a non-linear relationship could be detected between the GDT performance and the SOGS-RA classification both in terms of gambling problem severity and gambling frequency. Indeed, different training algorithms produced different performances of the NN on the training sets, but all of them showed a very low prediction capability on new samples. Thus, the performance at the GDT did not discriminate between adolescent gamblers with different and progressive levels of problematic gambling behavior and gambling frequency. Limitations and future studies are discussed.

Decision support in patients with mild Alzheimer's disease

INTRODUCTION

Making advantageous decisions is a key competence of individuals of all ages. However, previous studies reported a reduction of this competence in patients with neurodegenerative diseases such as Alzheimer's disease, which is explained by impairments of executive functions such as cognitive flexibility or working memory. While previous findings from healthy participants with reduced executive functions showed that support can improve decision making under risk, the study at hand aimed to investigate this effect in patients with mild Alzheimer's disease (mAD).

METHOD

A group of elderly individuals diagnosed with mAD (n = 14; mean Mini-Mental State Examination, MMSE = 24.14, SD = 3.18) and a group of healthy age-matched controls (n = 14; mean MMSE = 29.29, SD = 1.98) performed the Game of Dice Task (GDT) three times (t₀, t_1, t₂) with intervals of five to nine days between each: The standard GDT plus other neurocognitive tasks (t₀), the GDT with decision support (t₁), and again the standard GDT (t₂).

RESULTS

At any time, mAD patients made more disadvantageous decisions than controls. However, the decision-making performance of mAD patients improved significantly with decision support. Interestingly, when the standard GDT was played again (t₂), mAD patients' performance remained similar to the performance in the GDT with decision support (t₁). GDT performance correlated consistently with executive function measures in the control group, but only at t₀ in the mAD group.

CONCLUSIONS

The findings indicate that supportive information about the riskiness of options can compensate for mAD-related deficits in decision making under risk. Thus, decision support can improve the quality of mAD patients' decisions. Further, it may prevent mAD patients from making highly risky decisions in similar situations in the future. The persistence of decision support should be further investigated as it has relevant implications for everyday decisions that include risks.

Psychopathy and Decision-Making: Antisocial Factor Associated With Risky Decision-Making in Offenders

Psychopathy is a personality development disorder increasing the risk of antisocial behavior. Studies on the relationship between psychopathy and decision-making have received limited attention and the result of studies is mixed. A present study examines whether or not the different factors of psychopathy are related to decision-making under risk and ambiguity in offenders and how they are related. Also, the study investigates whether general intelligence is associated with decision-making or moderates the relationship between psychopathy and decision-making. The results showed that only antisocial factor of psychopathy significantly correlates with Game of Dice Task (GDT) risky selections, but there no general relation between psychopathy and Iowa Gambling Task (IGT) performance. Lastly, general intelligence neither is related to decision-making under risk and ambiguity nor moderates the relationship between decision-making and psychopathy. The study results show that antisocial factor of psychopathy was associated with decision-making under risk rather than ambiguity. Our results also suggest that the antisocial factor of psychopathy was more related to executive dysfunction in offenders.

Decision making under risk and under ambiguity in depressed suicide attempters, depressed non-attempters and healthy controls

BACKGROUND

A number of neuropsychological alterations have been found in patients who have attempted suicide. Most studies investigating decision making (DM) abilities in suicide attempters so far have used one single DM task and included patients with a lifetime history of suicide attempts. These studies have yielded conflicting results.

METHOD

In this study, currently depressed in-patients who had a recent suicide attempt (within the last six months) (n = 21), depressed in-patients without a lifetime history of suicide attempts (n = 31) and a healthy control group (n = 26) were assessed with two tasks for the assessment of DM. The Game of Dice Task (GDT) measures DM under risk and the Iowa Gambling Task (IGT) DM under ambiguity. Further, depression severity, impulsiveness and suicidal intent of the current suicide attempt were assessed.

RESULTS

Both depressed groups differed from controls with respect to marital and partnership status, smoking, impulsiveness and psychiatric family history. In terms of DM, IGT scores did not differ significantly between groups. However, suicide attempters made significantly more risky decisions as assessed with the GDT than both control groups (p < 0.05 for pairwise comparisons, p = 0.065 for overall comparison of the 3 groups).

LIMITATIONS

The available tasks assess DM under laboratory conditions which may not reflect the emotional status of suicidal individuals. No general cognitive assessment was included.

CONCLUSIONS

Depressed suicide attempters differed with regard to DM under risk but not DM under ambiguity. When studying DM it appears crucial to take varying aspects of DM into account.

Impaired decision making under risky conditions in the acute phase of Graves' thyroitoxicosis

The patients with Graves' thyroitoxicosis often complain that they have neuropsychiatric symptoms and impaired cognitive function. Decision making is important and complex process involving the interaction and integration of a series of cognitive components. In the 31 newly diagnosed patients with Graves' thyroitoxicosis and 30 healthy controls, we used the Hamilton Anxiety Rating Scale (HAMD), Hamilton Depression Rating Scale (HAMD) and The Game of Dice Task (GDT) to assess the emotion and decision making under risky conditions. The patients with Graves' disease had higher score on HAMA and HAMD, and had poorer performance in GDT than healthy controls. A negative correlation was found between utilization of negative feedback and score of HAMA in the patients with Graves' disease. Our findings in Graves' disease might be association with the extensive brain disorders including prefrontal cortex and the limbic system, and dopamine dysfunction.

Similarities and Differences in Decision-Making Impairments between Autism Spectrum Disorder and Schizophrenia

Although individuals with autism spectrum disorders (ASD) and schizophrenia (SCH) share overlapping characteristics and may perform similarly on many cognitive tasks, cognitive dysfunctions common to both disorders do not necessarily share the same underlying mechanisms. Decision-making is currently a major research interest for both ASD and SCH. The aim of the present study was to make direct comparisons of decision-making and disorder-specific underlying neuropsychological mechanisms between the two disorders. Thirty-seven participants with ASD, 46 patients with SCH, and 80 healthy controls (HC) were assessed with the Iowa Gambling Task (IGT), which measures decision-making under ambiguity, and the Game of Dice Task (GDT), which measures decision-making under risk. The results revealed that both the ASD and SCH groups had deficits for both the IGT and the GDT compared with the HC. More importantly, in the IGT, participants with ASD displayed a preference for deck A, indicating that they had more sensitivity to the magnitude of loss than to the frequency of loss, whereas patients with SCH displayed a preference for deck B, indicating that they showed more sensitivity to the frequency of loss than to the magnitude of loss. In the GDT, the impaired performance might be due to the deficits in executive functions in patients with SCH, whereas the impaired performance might be due to the deficits in feedback processing in participants with ASD. These findings demonstrate that there are similar impairments in decision-making tasks between ASD and SCH; however, these two disorders may have different impairment mechanisms.

Decision making under explicit risk is impaired in individuals with human immunodeficiency virus (HIV)

INTRODUCTION

Human immunodeficiency virus (HIV) can affect the frontal-striatal brain regions, which are known to subserve decision-making functions. Previous studies have reported impaired decision making among HIV+ individuals using the Iowa Gambling Task, a task that assesses decision making under ambiguity. Previous study populations often had significant comorbidities such as past or present substance use disorders and/or hepatitis C virus coinfection, complicating conclusions about the unique contributions of HIV-infection to decision making. Decision making under explicit risk has very rarely been examined in HIV+ individuals and was tested here using the Game of Dice Task (GDT).

METHOD

We examined decision making under explicit risk in the GDT in 20 HIV+ individuals without substance use disorder or HCV coinfection, including a demographically matched healthy control group (n = 20). Groups were characterized on a standard neuropsychological test battery. For the HIV+ group, several disease-related parameters (viral load, current and nadir CD4 T-cell count) were included. Analyses focused on the GDT and spanned between-group (t-tests; analysis of covariance, ANCOVA) as well as within-group comparisons (Pearson/Spearman correlations).

RESULTS

HIV+ individuals were impaired in the GDT, compared to healthy controls (p = .02). Their decision-making impairments were characterized by less advantageous choices and more random choice strategies, especially towards the end of the task. Deficits in the GDT in the HIV+ group were related to executive dysfunctions, slowed processing/motor speed, and current immune system status (CD4+ T-cell levels, ps < .05).

CONCLUSIONS

Decision making under explicit risk in the GDT can occur in HIV-infected individuals without comorbidities. The correlational patterns may point to underlying fronto-subcortical dysfunctions in HIV+ individuals. The GDT provides a useful measure to assess risky decision making in this population and should be tested in larger studies.

Dissociation of decision making under ambiguity and decision making under risk: a neurocognitive endophenotype candidate for obsessive-compulsive disorder

Evidence in the literature suggests that executive dysfunction is regarded as an endophenotype candidate for obsessive-compulsive disorder (OCD). Decision making is an important domain of executive function. However, few studies that have investigated whether decision making is a potential endophenotype for OCD have produced inconsistent results. Differences in the findings across these studies may be attributed to several factors: different study materials, comorbidity, medication, etc. There are at least two types of decision making that differ mainly in the degree of uncertainty and how much useful information about consequences and their probabilities are provided to the decision maker: decision making under ambiguity and decision making under risk. The aim of the present study was to simultaneously examine decision making under ambiguity as assessed by the Iowa Gambling Task (IGT) and decision making under risk as measured by the Game of Dice Task (GDT) in OCD patients and their unaffected first-degree relative (UFDR) for the first time. The study analyzed 55 medication-naïve, non-depressed OCD patient probands, 55 UFDRs of the OCD patients and 55 healthy matched comparison subjects (CS) without a family history of OCD with the IGT, the GDT and a neuropsychological test battery. While the OCD patients and the UFDRs performed worse than the CS on the IGT, they were unimpaired on the GDT. Our study supports the claim that decision making under ambiguity differs from decision making under risk and suggests that dissociation of decision making under ambiguity and decision making under risk may qualify to be a neurocognitive endophenotypes for OCD.

Monitoring supports performance in a dual-task paradigm involving a risky decision-making task and a working memory task

Performing two cognitively demanding tasks at the same time is known to decrease performance. The current study investigates the underlying executive functions of a dual-tasking situation involving the simultaneous performance of decision making under explicit risk and a working memory task. It is suggested that making a decision and performing a working memory task at the same time should particularly require monitoring—an executive control process supervising behavior and the state of processing on two tasks. To test the role of a supervisory/monitoring function in such a dual-tasking situation we investigated 122 participants with the Game of Dice Task plus 2-back task (GDT plus 2-back task). This dual task requires participants to make decisions under risk and to perform a 2-back working memory task at the same time. Furthermore, a task measuring a set of several executive functions gathered in the term concept formation (Modified Card Sorting Test, MCST) and the newly developed Balanced Switching Task (BST), measuring monitoring in particular, were used. The results demonstrate that concept formation and monitoring are involved in the simultaneous performance of decision making under risk and a working memory task. In particular, the mediation analysis revealed that BST performance partially mediates the influence of MCST performance on the GDT plus 2-back task. These findings suggest that monitoring is one important subfunction for superior performance in a dual-tasking situation including decision making under risk and a working memory task.

Cognitive correlates of under-ambiguity and under-risk decision making in high-functioning patients with relapsing remitting multiple sclerosis

INTRODUCTION

Impairment of decision making in relapsing remitting multiple sclerosis is still controversial, and its neuropsychological correlates have never been explored thoroughly, especially in patients with minimal physical and cognitive deficits. In the present study we investigated the cognitive underpinnings of decision making under ambiguous and explicit conditions in patients with very mild relapsing remitting multiple sclerosis, using a dice and a card gambling game.

METHOD

The study sample included 60 patients and 35 healthy subjects. In the Game of Dice Task, winning and losing probabilities are obvious to the subject, while in the Iowa Gambling Task they are initially ambiguous and have to be gradually identified. Performance at the two tasks was correlated with scores obtained at tests investigating cognitive processing speed, memory, language and executive functions.

RESULTS

Patients' performance did not differ from that of controls at either gambling task. There was only a trend for them to be significantly slower than healthy subjects in progressively recognizing advantageous decks in the Iowa Gambling Task. While the Game of Dice was unrelated to neuropsychological tests, predictors of performance at the Iowa task were Letter Fluency and the Symbol Digit Modalities Test for the initial, under-ambiguity, trials and the Wisconsin Card Sorting Test for the last, purely under-risk, trials.

CONCLUSIONS

Our results suggest that high-functioning patients with relapsing remitting multiple sclerosis are substantially capable of making advantageous decisions, even if they may be slower in processing options and shifting strategy when selection criteria are not explicit.

Among three different executive functions, general executive control ability is a key predictor of decision making under objective risk

Executive functioning is supposed to have an important role in decision making under risk. Several studies reported that more advantageous decision-making behavior was accompanied by better performance in tests of executive functioning and that the decision-making process was accompanied by activations in prefrontal and subcortical brain regions associated with executive functioning. However, to what extent different components of executive functions contribute to decision making is still unclear. We tested direct and indirect effects of three executive functions on decision-making performance in a laboratory gambling task, the Game of Dice Task (GDT). Using Brand's model of decisions under risk (2006) we tested seven structural equation models with three latent variables that represent executive functions supposed to be involved in decision making. The latent variables were general control (represented by the general ability to exert attentional and behavioral self-control that is in accordance with task goals despite interfering information), concept formation (represented by categorization, rule detection, and set maintenance), and monitoring (represented by supervision of cognition and behavior). The seven models indicated that only the latent dimension general control had a direct effect on decision making under risk. Concept formation and monitoring only contributed in terms of indirect effects, when mediated by general control. Thus, several components of executive functioning seem to be involved in decision making under risk. However, general control functions seem to have a key role. They may be important for implementing the calculative and cognitively controlled processes involved in advantageous decision making under risk.

Failure to utilize feedback causes decision-making deficits among excessive Internet gamers

Internet gaming addiction (IGA) is an increasing mental health issue worldwide. Previous studies have revealed decision-making impairments in excessive Internet gamers (EIGs) with high symptoms of IGA. However, the role of feedback processing in decision-making deficits among EIGs remains unknown. The present study aimed to investigate the effect of feedback processing on decision-making deficits under risk among EIGs, using the Game of Dice Task (GDT) and a modified version of the GDT in which no feedback was provided. Twenty-six EIGs and 26 matched occasional Internet gamers (OIGs) were recruited. The results showed: (a) OIGs performed better on the original GDT than on the modified GDT (no feedback condition); however, EIGs performed similarly on both tasks; (b) EIGs and OIGs performed equally on the modified GDT; however, EIGs chose more disadvantageous options than OIGs on the original GDT; (c) EIGs utilized feedback less frequently on the original GDT relative to OIGs. These results suggest that EIGs are not able to utilize feedback to optimize their decisions, which could underlie their poor decision-making under risk.

A versatile task for assessing decision-making abilities: the truck dispatcher framework

In neuropsychological decision-making research, several different tasks are used to measure decision-making competences in patients and healthy study participants. Unfortunately, the existing tasks are often inflexible for modification, use different scenarios, and include several gambling cues. Therefore, comparisons between participants' performances in different tasks are difficult. We developed the Truck Dispatcher Framework (TDF), in which different decision-making tasks can be designed within one unitary, flexible, and real-world-oriented story line. To test the story line, TDF analogues of three standard decision-making tasks (Game of Dice Task, Probability-Associated Gambling task, Iowa Gambling Task) were developed. In three studies with brain-healthy participants, the behavior in standard decision-making tasks and the TDF analogues of those tasks were compared. Similar behaviors indicate that the TDF tasks measure decision making appropriately. Thus, the TDF is recommended for experimental and clinical research because it allows for examining decision-making competences in tasks with different demands that take place within one unitary story line.

Decision-making impairment in patients with multiple sclerosis: a case-control study

OBJECTIVES

To assess decision-making under explicit risk conditions in relapsing-remitting multiple sclerosis patients and its relationship to decisions made under conditions of ambiguity. To assess cognitive functions related to decision-making performance in patients with multiple sclerosis (MS).

SETTING

MS center in Buenos Aires, Argentina.

PARTICIPANTS

27 patients with relapsing-remitting multiple sclerosis and 27 sex-matched, age-matched and education-matched healthy controls.

INTERVENTION

Neuropsychological assessment and decision-making evaluation using the Game of Dice Task and the Iowa Gambling Task.

OUTCOMES

Game of Dice Task and the Iowa Gambling Task scores.

RESULTS

Patients with MS showed significantly poorer performance on the Game of Dice Task, choosing disadvantageous dice more often (p=0.019), as well as significantly lower overall scores in the Iowa Gambling Task (p=0.007). Block analysis showed that patients with MS and controls had scores that were comparable for blocks 1 and 2 (p=0.15 and p=0.24, respectively). Conversely, patients with MS scored poorly on blocks 4 (p=0.003) and 5 (p=0.023), the last two of the test, corresponding to decision-making under conditions of risk. Finally, the Game of Dice Task performance together with the last three blocks of the Iowa Gambling Task were correlated with visuospatial learning, processing speed and working memory but not with executive functioning.

CONCLUSIONS

Patients with MS showed deficits in decision-making under risk conditions, which might be related to deficits in visuospatial learning, processing speed and working memory.

Developmental changes in decision making under risk: The role of executive functions and reasoning abilities in 8- to 19-year-old decision makers

Previous studies have shown that children and adolescents often tend toward risky decisions despite explicit knowledge about the potential negative consequences. This phenomenon has been suggested to be associated with the immaturity of brain areas involved in cognitive control functions. Particularly, "frontal lobe functions," such as executive functions and reasoning, mature until young adulthood and are thought to be involved in age-related changes in decision making under explicit risk conditions. We investigated 112 participants, aged 8-19 years, with a frequently used task assessing decisions under risk, the Game of Dice Task (GDT). Additionally, we administered the Modified Card Sorting Test assessing executive functioning (categorization, cognitive flexibility, and strategy maintenance) as well as the Ravens Progressive Matrices assessing reasoning. The results showed that risk taking in the GDT decreased with increasing age and this effect was not moderated by reasoning but by executive functions: Particularly, young persons with weak executive functioning showed very risky decision making. Thus, the individual maturation of executive functions, associated with areas in the prefrontal cortex, seems to be an important factor in young peoples' behavior in risky decision-making situations.

Decision-making impairments in breast cancer patients treated with tamoxifen

The selective estrogen receptor modulator tamoxifen (TAM) is most commonly prescribed for patients with hormone-sensitive breast cancer. Although TAM can bind to estrogen receptors in the nervous system, it is unknown whether it acts as an estrogen agonist or antagonist in the human brain. Several studies have reported the negative effects of TAM on cognitive function; however, its effects on decision-making function have not been previously explored. The present study aimed to investigate the decision-making function under ambiguity and risk in breast cancer patients treated with TAM. Participants included breast cancer patients taking TAM (TAM, n=47) and breast cancer patients not taking TAM (non-TAM, n=45) as well as their matched healthy controls (HC, n=50). All participants were given the Iowa Gambling Task (IGT) to assess their decision-making under conditions involving ambiguity, the Game of Dice Task (GDT) to assess their decision-making under conditions involving risk, and a battery of neuropsychological tests. Our results indicated that patients in the TAM group were significantly impaired as assessed by both the IGT and GDT and performed significantly worse on some aspects of various tasks involving memory and information processing. Furthermore, we found that decreased performance on verbal memory testing significantly correlated with IGT performance, and executive dysfunction was associated with poor GDT performance in breast cancer patients undergoing TAM treatment. This study demonstrates that breast cancer patients taking TAM have several decision-making impairments. These findings may support the idea that TAM resulting in cognitive changes plays an antagonistic role in the areas of the brain where estrogen receptors are present, including the prefrontal cortex, hippocampus and amygdala.

Decision-making, reward-seeking behaviors and dopamine agonist therapy in restless legs syndrome

STUDY OBJECTIVES

To assess whether the frequency of impulse control disorders (ICDs), addictive behaviors, impulsivity, and impairment of decision-making task performance under ambiguous and risky conditions were present in patients with restless legs syndrome (RLS) and whether changes could be related to dopaminergic medications.

DESIGN

Case-control prospective study.

SETTING

Academic Sleep Disorders Center.

PARTICIPANTS

Of the 149 participants, there were 39 who were drug free with primary RLS, 50 who were taking dopamine agonists (DA), and 60 control subjects. Participants were assessed with a clinical interview screening for ICDs, augmentation syndrome, impulsivity, depression, and addictive behaviors. All participants completed two decision-making tasks, one under an ambiguous condition (Iowa Gambling Task) and the other under a risky condition (Game of Dice Task). Drug-free patients with RLS underwent 1 night of polysomnography recording.

MEASUREMENTS AND RESULTS

Seventy percent of patients were treated with pramipexole (median dose, 0.36 mg), and 30% with ropinirole (median dose, 0.75 mg). Median duration of DA intake was 11 mo (range, 1-72 mo). No differences were found on impulsivity scores, ICDs, and substance addiction between drug-free patients or those taking DA, or control subjects. Patients with RLS reported more depressive symptoms than control subjects, but without differences between patients taking or not taking DA. Drug-free and treated patients demonstrated reduced performances on the Iowa Gambling Task but not on the Game of Dice Task compared to control subjects, with no differences between patients taking medications and those who were not. No association was found between decision-making task performances, or polysomnographic and clinical variables.

CONCLUSION

Impulse control disorders, impulsivity, and substance addiction were infrequent in drug-free patients with restless legs syndrome or those treated with a low dose of dopamine agonists. However, patients with restless legs syndrome, either drug free or taking dopamine agonists, had preferences toward risky choices on the Iowa Gambling Task, which led to negative consequences in the long run, a condition potentially leading to further development of impulse control disorders.

Effect of psychostimulants on impulsivity and risk taking in narcolepsy with cataplexy

OBJECTIVE

To investigate the effect of psychostimulants on impulsivity, depressive symptoms, addiction, pathological gambling, and risk-taking using objective sensitivity tests in narcolepsy with cataplexy (NC). Drug-free patients with NC present alterations in reward processing, but changes with psychostimulants remain unknown.

DESIGN

Prospective case-control study.

SETTING

Academic sleep disorders center.

PARTICIPANTS

There were 120 participants: 41 drug-free patients with NC, 37 patients with NC taking psychostimulants, and 42 matched healthy controls.

INTERVENTIONS

All participants underwent a semistructured clinical interview for impulse control and addictive behaviors and completed questionnaires for depression and impulsivity. Risk taking was analyzed through performance on a decision-making task under ambiguity (Iowa Gambling Task [IGT]) and under risk (Game of Dice Task [GDT]). All patients with NC underwent 1 night of polysomnography followed by a multiple sleep latency test for drug-free patients and a maintenance wakefulness test for treated patients.

RESULTS

Depressive symptoms were higher in drug-free patients than in treated patients and controls, with no difference between controls and treated patients. No between-group differences were found for impulsivity, substance addiction, or pathological gambling. Drug-free and treated patients showed selective reduced performance on the IGT and normal performance on the GDT compared with controls, with no differences between patients taking medication and those who did not. No clinical or polysomnographic characteristics or medication type was associated with IGT scores.

CONCLUSIONS

Our results demonstrated that, whether taking psychostimulants or not, patients with narcolepsy with cataplexy preferred risky choices on a decision-making task under ambiguity. However, the lack of association with impulsivity, pathological gambling, or substance addiction remains of major clinical interest in narcolepsy with cataplexy.

Decision making in narcolepsy with cataplexy

OBJECTIVES

To investigate decision-making and addictive behaviors in narcolepsy-cataplexy (NC). NC is caused by the loss of hypothalamic neurons that produce hypocretins. The hypocretin system plays a crucial role in sleep, wakefulness, and energy homeostasis, and is also involved in emotion regulation, reward processing, and addiction.

SETTING

Academic sleep center.

PATIENTS

23 subject with NC and 23 matched healthy controls.

DESIGN

We used the Iowa Gambling Task (IGT) to assess decision making under ambiguity condition based on emotional feedback processing and the Game of Dice Task (GDT) to assess decision making under risk condition. All participants underwent a semi-structured psychiatric interview and completed the Beck Depression Inventory-II and the UPPS Impulsive Behavior Scale. Patients underwent one night of polysomnography followed by an MSLT, with neuropsychological evaluation performed between MSLT sessions.

MEASUREMENTS AND RESULTS

NC patients had higher depressive symptoms and showed a significant lack of perseverance. One NC patient had a past history of drug dependence. NC patients also exhibited selective reduced IGT performance and normal performance on the GDT. No clinical or polysomnographic characteristics were associated with increased sensitivity to reward and/or decreased sensitivity to punishment. However, lack of perseverance in NC patients was associated with disadvantageous decision making on the IGT.

CONCLUSION

We demonstrated a lack of perseverance and a selective reduced performance on decision making under ambiguity in NC in contrast to normal decision making under explicit conditions. Patients with narcolepsy-cataplexy may opt for choices with higher immediate emotional valence, regardless of higher future punishment, to compensate for their reduced reactivity to emotional stimuli.