Accepted Manuscript

Title: Underlying decision making processes on Iowa

Gambling Task

Authors: Rajesh Kumar, Keshav Janakiprasad Kumar, Vivek

Benegal

PII: S1876-2018(18)30519-7
DOI: https://doi.org/10.1016/j.ajp.2018.12.006
Reference: AJP 1587

To appear in:

Received date: 6 June 2018

Revised date: 1 November 2018
Accepted date: 19 December 2018

Please cite this article as: Kumar R, Janakiprasad Kumar K, Benegal V, Underlying
decision making processes on Iowa Gambling Task, Asian Journal of Psychiatry (2018),
https://doi.org/10.1016/j.ajp.2018.12.006

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Title page

Underlying decision making processes on Iowa Gambling Task

Rajesh Kumara, Keshav Janakiprasad Kumarb and Vivek Benegalc

a
Clinical Psychologist, Department of Clinical Psychology, National Institute of Mental
Health and Neurosciences (NIMHANS), Bangalore-560029, India; Email:
bhurajes@gmail.com

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b
Professor, Department of Clinical Psychology, National Institute of Mental Health and

IP
Neurosciences (NIMHANS), Bangalore-560029, India; Email: keshavjkapp@gmail.com
c
Professor, Department of Psychiatry, National Institute of Mental Health and Neurosciences

R
(NIMHANS), Bangalore-560029, India; Email: vbenegal@gmail.com

SC
Corresponding author: Dr. Rajesh Kumar, Clinical Psychologist

U
Department of Clinical Psychology
Dr M V Govindaswamy building
N
NIMHANS
A
Hosur road, Bangalore-560029
M

Tel. 08026995180
Email: bhurajes@gmail.com
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PT

Highlights

 Supports the importance of frequency of reward/penalty schedule in deck preference

E

and decision making on IGT.

CC

 Supports the preference for disadvantageous infrequent penalty deck B in healthy

A

normal

 High/low frequency of reward/punishment is such a strong factor that it may lead to

disadvantageous decision making in healthy normal too.

 2

Abstract

Background: Iowa Gambling Task (IGT) assesses decision making in uncertain conditions.

Several studies have reported impaired performance on IGT in various clinical population

compared to healthy normal. However, some researchers have reported incongruent findings

from the basic assumptions of IGT in healthy normal. Our aim was to examine the possible

T
decision making processes on IGT.

IP
Methods: The IGT was administered on two groups: Healthy normal (n=34) and offspring at

R
high risk for alcoholism (n=34). Subjects were matched on age (+/–1 year), education (+/–1

SC
year) and gender. Other tools used were: Mini-international Neuropsychiatric Interview,

U
Family Interview for Genetic Studies, Socio-demographic Data Sheet, Annett’s Handedness
N
Questionnaire.
A
Results: Results showed a significant difference between two groups on selections made
M

from disadvantageous deck A but no significant difference on disadvantageous deck B,

ED

advantageous/safe decks C and D. Also, there was no significant difference between two

groups on IGT Net score [selections from decks (C + D) – decks (A + B)]. Further analysis
PT

showed that varying nature of reward and penalty schedules play an important role in

selecting the cards from four decks of IGT. Subjects may prefer infrequent penalty decks
E

without consideration of delayed loss/gain.

CC

Conclusion: Frequency and magnitude of reward/penalty in IGT may adversely impact

A

decision making. Deck B can induce myopia for delayed loss in the healthy normal too

because of having a high frequency of gains with high magnitude of reward. Hence, IGT

related studies should consider these factors while making an inference about decision

making ability.
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Keywords: Iowa Gambling Task, Decision Making, Reward/Penalty Schedules, Healthy

Normal

1. Introduction

Iowa Gambling Task (IGT) is one of the most popular tasks to assess decision making ability.

T
It assesses decision making in uncertain conditions involving risk and ambiguity (Bechara et

IP
al., 1994, Bechara et al., 2005). IGT is being used extensively for assessing affective

R
functions and decision making in adolescents and adults with several neurological and

SC
psychiatric conditions (Bowman et al., 2005, Ernst et al., 2003, Fishbein et al., 2005, Barry

and Petry, 2008, Kester et al., 2006, Nakamura et al., 2008, Blair et al., 2001, Cavedini et al.,

2002a, Cavedini et al., 2002b). U

N
A
In a computerized version of IGT (Bechara et al., 2000), the subject sees four decks of cards
M

named A, B, C and D equal in appearance and size with varying schedules of reward and

penalty. The subject is instructed that the game requires a long series of card selections, one
ED

card at a time, from any of the four decks until he/she is told to stop. However, the total

number of card selection is hundred. On clicking each card, the subject receives fictitious
PT

money (reward) and sometimes penalty along with reward according to a fixed schedule of
E

reward and penalty which is unknown to the subject. Deck A and C contain five gains and
CC

five losses while deck B and D contain nine gains and one loss in every ten consecutive trials

(Table 1). Deck A and B are known to be disadvantageous deck as both yield negative
A

outcome (loss) in long-term (i.e., delayed loss in every 10 consecutive selections). While,

deck C and D are known to be advantageous decks as both yield positive outcome (profit) in

long-term (i.e., delayed gain in every 10 consecutive selections).

 4

The subject is instructed before beginning the task 1. The goal of the task is to maximize

profit as much as possible, and, if he/she finds himself/herself unable to win, make sure avoid

losing money as much as possible. 2. He/she is free to switch one deck to another at any time,

and as often as he/she wishes, but 3. He/she is not told ahead of time that how many card

selections must be made. Also, in IGT with 100 trials, there is a restriction of 40 card

selections from a deck which is unknown to the subject (Bechara et al., 2000). The task is

T
stopped after a series of 100 card selections.

IP
The basic assumption of IGT for persons with clinical conditions (such as persons with

R
SC
psychiatric and neurological disorders) is that their behaviour will be guided by high

immediate reward gratification and they may fail to recognize the delayed loss they incur on

U
disadvantageous decks (deck A and deck B). Hence, persons with clinical conditions will opt
N
for more selections from disadvantageous decks than advantageous decks due to
A
hypersensitivity to reward and/or insensitivity to punishment (Bechara et al., 2000). On the
M

contrary, it is assumed that healthy normal can recognize the risk they incur on

disadvantageous decks as they encounter penalty and delayed losses. Once they recognize the
ED

risk on disadvantageous decks, they will shift to advantageous decks (deck C and D) for card

selections (Bechara et al., 1994). Hence, basic assumptions of IGT are stated as (a) there will
PT

be a significant difference between persons with clinical conditions and healthy normal on
E

the number of card selections from disadvantageous and advantageous decks. (b) there will
CC

be a significant difference between healthy normal and clinical population on a difference

score between the overall selections from advantageous and disadvantageous decks which
A

also known as net score [selections from advantageous decks (C+D) – selections from

disadvantageous decks (A+B)]. More selections from disadvantageous decks and poor net

score are the indicators of poor decision making.

 5

Several studies have reported findings consistent with basic assumptions of IGT that clinical

population as compared to healthy normal demonstrated more preference for disadvantageous

decks which yields immediate prospects but a loss in long-term. Whereas, healthy normal

could be learned to distinguish advantageous and disadvantageous decks as they encounter

penalties. Hence, as the task progressed they preferred more advantageous decks than

disadvantageous decks (Bechara et al., 1994, Bechara et al., 1999, Bechara et al., 1997).

T
IP
Empirical support for the good/bad performance on IGT is basically reported by the

presence/absence of anticipatory skin conductance responses (SCRs) (Bechara et al., 1994,

R
SC
Bechara et al., 1996). However, some researchers have reported incongruent findings from

the basic assumptions of IGT that some sub-sections of healthy normal subjects did not shift

U
from disadvantageous decks to advantageous decks as they progressed in the task. They
N
continued opting more selections from the disadvantageous decks, especially from deck B. In
A
other words, they did not avoid making selections from deck B in spite of encountering
M

delayed losses (Bechara and Damasio, 2002, Crone and van der Molen, 2004, Adinoff et al.,

2003). Hence, there was no overall reduction in selections from disadvantageous decks and a
ED

difference on the net score in persons with clinical conditions and healthy normal (Lehto and

Elorinne, 2003). Several studies have re-examined performance on IGT between healthy
PT

normal and clinical group with original IGT and/or using variants of IGT (i.e., by
E

manipulating the contingencies in IGT and with increasing/decreasing the delayed losses).
CC

Some of the studies have demonstrated more preference for disadvantageous deck B than

advantageous deck C or D in healthy normal (North and O'Carroll, 2001, Tomb et al., 2002,
A

Maia and McClelland, 2004, Lin et al., 2007a, Toplak et al., 2005).

Preliminary studies from the Iowa laboratory have reported that participants cannot be aware

of the reward/punishment schedule of IGT (Bechara et al., 1997), and reward and punishment

schedule is impenetrable (Bechara et al., 1994, Bechara et al., 1996). However, Turnbull et al.
 6

(2003) have reported that reward/punishment schedule can be comprehended consciously.

This could mean that cognitive expectancies could guide successful performance on IGT and

undermine the support of the somatic marker hypothesis. Maia and McClelland (2004) have

examined the evidence for somatic marker hypothesis and reported that reward/punishment

schedule is cognitively penetrable. They pointed out that several features in IGT may

facilitate explicit reasoning. For example, decision outcome is presented in the explicit

T
numerical form and there is little variation in the amount of the reward and punishment.

IP
Therefore, it is easy for an individual to track deck’s characteristics consciously. He/she

R
needs to pay attention only to the punishment delivered on each deck for performing well on

SC
this task. Several studies have used variants of IGT (i.e., by manipulation in the contingencies

U
or increasing/decreasing the penalties in IGT) to examine the effects of frequency of
N
reward/penalty in IGT performance. However, they did not use a comparable clinical group.
A
A comparable clinical group may help and provide better support for the impact of frequency
M

of reward/penalty in card selections. For example, preference for disadvantageous deck B in a

clinical group which has neurocognitive deficits and in healthy normal which has no
ED

neurocognitive deficits can provide the answer in a better way for underlying contributing

factors in card selections. Similarly, complexity of IGT itself can be a contributing factor for
PT

poor performance on IGT (Fernie et al., 2013) and that may make it difficult to dissociate

advantageous and disadvantageous decks. Some of the researchers have reported that
E
CC

immediate reward may directly influence decision making on IGT. Individuals make more

selections from decks which have high-frequency gains than those which have low-frequency
A

gains (Crone and van der Molen, 2004, Crone et al., 2005).

We have examined executive functions (such as working memory and planning), decision

making in an explicit condition (Game of Dice Task) and implicit condition (Iowa Gambling

Task), and impulsivity in offspring with familial alcoholism (also known as offspring at high
 7

risk for alcoholism) and healthy normal offspring without familial alcoholism (designated as

offspring at low risk for alcoholism). Results showed that there was a significant difference

between offspring at high risk for alcoholism and healthy normal on executive functions,

decision making and impulsivity (Kumar et al., 2018). However, on IGT, there was no

significant difference between two groups on selections made from disadvantageous deck B

as well as IGT Net score [selections from decks (C+D) – decks (A+B)], advantageous/safe

T
deck D and C. Hence, in the present study, we did deck analysis with frequency and

IP
magnitude of reward/penalty to examine its impact in card selections on IGT. The aim of

R
deck analysis was to examine whether card selections on IGT was influenced by the

SC
frequency of reward/penalty or long-term outcome (i.e., delayed gain/loss) on each deck.

U
Also, whether net score can be negatively impacted by the frequency of reward/penalty in
N
IGT. This study overcomes some of the limitations of the previous studies. For example, the
A
present study had two distinct groups that differ from each other (Kumar et al., 2018). The
M

complexity of IGT was reduced by a minor modification in order to make task cognitively

more penetrable.
ED

2. Material and Methods

The sample consisted of two groups, one group was designated as alcohol naïve offspring at
PT

high risk for alcoholism (n=34) while the second group was a healthy normal group (n=34).
E

Subjects were matched on age (+/–1 year), education (+/–1 year) and gender. All subjects
CC

were right handed.

Offspring with familial alcoholism were recruited from the Centre for Addiction Medicine,
A

National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru. We

followed established criteria for recruiting offspring at high risk for alcoholism (Andrews et

al., 2011, Cservenka and Nagel, 2012). To ensure the high risk for alcoholism, fathers of the

subjects at high risk for alcoholism were required to meet the following criteria: alcohol
 8

dependence according to ICD-10 research diagnostic criteria; two or more first degree

relatives with history of alcohol dependence; and an early onset of alcohol dependence (i.e.,

alcohol dependence before the age of 25 years). Subjects at high risk for alcoholism were

excluded from the study if (i) Father or first-degree family members had any major

psychiatric illnesses such as schizophrenia and mood disorders. (ii) History of other

substance abuse (except nicotine) such as cannabis abuse in the father or first-degree

T
relatives.

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The healthy normal subjects were recruited from schools and colleges. The Mini-

R
SC
International Neuropsychiatry Interview (MINI) questionnaires (MINI Screen, MINI- KID

and MINI plus-version 5.0) were used to screen and rule out alcohol and other substance

U
abuse, any major psychiatric illnesses such as schizophrenia and mood disorders. Family
N
interview for genetic studies (FIGS) (Maxwell, 1992) was used to screen and rule out other
A
substance abuse (except nicotine) and any major psychiatric disorders such as schizophrenia
M

and mood disorder in parents or first-degree family members.

ED

Written informed consent (from subjects above 18 years) and assent (from the parents of the

minors) was taken from each subject before recruiting for the study. Institute’s ethics
PT

guidelines and Helsinki’s ethical considerations were followed in the study. Subjects were
E

informed that they will not receive any monetary benefits for participating in this study.
CC

2.1 Measures
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Socio-demographic data sheet: This was prepared for the study to record socio-

demographic details such as age, gender, education, handedness, and socioeconomic status.

Mini-international Neuropsychiatric interview (MINI): This is a structured diagnostic

interview that was developed by (Sheehan et al., 1998) for DSM-IV and ICD-10 psychiatric
 9

disorder. This was used to screen out any major psychiatric illness. The Family Interview

for Genetic Studies (FIGS) (Maxwell, 1992): This was used to document family loading for

alcoholism and screen for other psychiatric disorders in the first degree relatives. Annett’s

handedness questionnaire (Annett, 1967): This was used to test for handedness and

laterality. Only right-handed subjects were included in the study. Iowa Gambling Task

(IGT): A software version of IGT was prepared based on original IGT used by Bechara et al.

T
(Bechara et al., 1994, Bechara et al., 2000). The frequency of reward/penalty and magnitude

IP
were kept same as used in the original IGT. However, a minor change was made in the IGT

R
used for this study. In the original IGT, participants receive the reward on each trial and

SC
sometimes they receive penalty along with reward. Table 1 shows the frequency and

U
magnitude of reward and penalty in each deck used in original IGT. We removed the reward
N
on trials which yield penalty. Thus, participants either received the reward without penalty or
A
vice versa (Table 2). This change was made in order to reduce the complexity of the task, to
M

make the reward/punishment schedule more explicit and to increase the penalty sensitivity.

This change in IGT increases the contrast between delayed gain and loss and increases
ED

participant’s sensitivity to the embedded rule of each deck (see Table 1 and 2 for

comparison). The programme schedules of reward and punishment are like this: selecting any
PT

card from deck A or deck B yield 100 rupees and selecting any card from deck C or deck D

yield 50 rupees. Penalty amounts are higher in the high-paying decks (A and B) and lower in
E
CC

the low-paying decks (C and D). In summary, decks A and B are “disadvantageous decks”

because they cost in the long run. Further, deck A is highest risky deck as it produces the
A

highest loss in long-term. The remaining two decks C and D are “advantageous/safe decks”

because they produce gain or no loss in the long-term.

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3. Results

Data were analysed using Statistical Package for Social Sciences version 15 (SPSS-15) for

Windows. Demographic analysis showed that participants were predominantly male [Male

(n=26; 76.5%), female (n=8; 23.5%)] and belonged to the middle socioeconomic status [High

risk group (88.2%); Healthy normal (79.4%)] in both the groups. The Chi- square analyses

revealed that there was no significant difference between the two groups in terms of their

T
socioeconomic status (p= 0.512). The average age of both groups was similar [ High risk

IP
group=17.32 ± 4.18 (SD) and healthy normal group=17.47 ± 4.27 (SD)]. The average years

R
of education of both groups was 10.88 ± 3.19 (SD) in high risk group and 11.09 ± 3.19 (SD)

SC
in healthy normal.

3.1 Cards selections on IGT in both the groups

U
N
Wilcoxon Signed Rank test was applied to see any significant differences on IGT between
A
two groups. Table 3, shows that there was a significant difference between two groups on
M

card selections from deck A. However, there was no significant difference between the two

groups on card selections from disadvantageous deck B and advantageous/safe deck D and C.
ED

Also, there was no significant difference between groups on IGT Net score

[adavantageous/safe decks (C+D) – disadvantageous decks (A+B)].

E PT

3.2 Deck wise analysis with frequency and magnitude of reward/penalty

CC

Further, Wilcoxon Signed Rank test was applied to determine the impact of infrequent and

frequent reward/penalty schedules and magnitude of immediate reward in card selections and
A

decision making. We compared between infrequent penalty decks and frequent penalty decks

with summated score [i.e., decks (B + D) vs. (A + C)] as well as single deck comparison

between infrequent penalty deck and frequent penalty deck with same magnitude of

immediate reward (i.e., deck B vs. deck A or deck D vs. deck C) and with different
 11

magnitude of immediate reward (i.e., deck B vs. deck C or deck D vs. deck A). Results

showed (Table 4) that there was a significant difference for card selections between

infrequent and frequent penalty deck in both the groups. Participants in both groups selected

more cards from infrequent penalty decks compared to frequent penalty decks irrespective of

whether the magnitude of reward was same or less. When we have compared card selections

between two infrequent penalty decks (i.e., deck B and D) or two frequent penalty deck (i.e.,

T
deck A and C), results showed that there was approximately an equal preference in both the

IP
groups and no significant difference in both the groups (Table 4).

R
SC
4. Discussion

4.1 Basic assumptions of IGT and incongruency

U
According to the basic assumptions of IGT, healthy normal subjects should prefer/switch
N
making more selections from advantageous/safe decks (deck C and D) than disadvantageous
A
decks (deck A and B) on consideration of long-term outcome (delayed loss). While clinical
M

population may prefer immediate prospect than long-term outcome due to certain

structural/functional brain abnormalities, hypersensitivity for reward and insensitivity to

ED

penalty such as persons with ventromedial prefrontal cortex lesion (Bechara, 2001, Bechara

et al., 1994, Bechara et al., 1999). They may fail to discriminate advantageous and
PT

disadvantageous decks and will continue choosing cards from disadvantageous decks. Hence,
E

basic assumptions of IGT are stated as (a) there will be a significant difference between
CC

persons with clinical conditions and healthy normal on the number of card selections from

disadvantageous and advantageous decks. (b) there will be a significant difference between
A

healthy normal and clinical population on a difference score between the overall selections

from advantageous and disadvantageous decks which is also known as net score [selections

from advantageous decks (C+D) – selections from disadvantageous decks (A+B)]. More
 12

selections from disadvantageous decks and poor net score are the indicators of a poor

decision making.

However, later many researchers have reported incongruent findings from the basic

assumptions of IGT in healthy normal too. Studies have reported that healthy normal subjects

may also prefer more disadvantageous deck B over other three decks (North and O'Carroll,

2001, Tomb et al., 2002, Maia and McClelland, 2004, Lin et al., 2007a, Toplak et al., 2005).

T
Due to this, summation score of advantageous and disadvantageous decks and IGT net score

IP
can be adversely affected. Hence, decision making deficits can also be demonstrated by

R
healthy normal. Few studies have attempted to explore reasons for preference for

SC
disadvantageous deck B. Researchers have used variants of IGT and reported that frequency

U
of reward/penalty may play an important role in card selections. Healthy normal subjects may
N
also prefer infrequent penalty deck B which produces delayed loss (Lin et al., 2007c, Lin et
A
al., 2007a, Lin et al., 2004, Lin et al., 2007b). However, these studies have some
M

methodological limitations that may limit the generalization of their findings. Several studies

have used variants of IGT to examine the effects of frequency of reward/penalty in IGT
ED

performance. However, they did not use a comparable or clinical group. Also, complexity of

IGT itself can be a contributing factor for poor performance on IGT and may make it difficult
PT

for the participants to dissociate advantageous and disadvantageous decks.

E

4.2 Clinical group (offspring at high risk for alcoholism) and healthy normal
CC

We have investigated executive functions (such as working memory and planning), decision

making in explicit condition (Game of Dice Task) and uncertain condition (modified Iowa
A

Gambling Task) and impulsivity in offspring with familial alcoholism (known as at high risk

for alcoholism) and without familial alcoholism (healthy normal offspring) (Kumar et al.,

2018). Results showed a significant difference between both groups on executive functions,

explicit decision making and impulsivity.

 13

On IGT, results showed a significant difference between two groups in card selections on

frequent penalty deck A which is a disadvantageous deck. However, there was no significant

difference between healthy normal and offspring at high risk for alcoholism on infrequent

penalty deck B (disadvantageous deck) and IGT Net score as well as deck C and D (Table 3).

Deck A produces the high magnitude of immediate reward but in long-term it produces the

highest negative outcome (delayed loss) in comparison of other decks. More preference for

T
deck A in high risk group and a significant difference with healthy normal supports the basic

IP
assumption of IGT. Studies have reported that offspring with familial alcoholism demonstrate

R
reward deficiency syndrome or in other words tendency of reward gratification. (Blum et al.,

SC
1996, Blum et al., 2000, Blum et al., 2008, Blum et al., 2012). Offspring at high risk for

U
alcoholism also demonstrates neurocognitive deficits (Corral et al., 2003, Gierski et al., 2013,
N
Tapert and Brown, 2000). Hence, more preference for deck A in participants with high risk
A
for alcoholism indicates that card selections could have been driven by immediate reward
M

gratification than considering long-term consequences. While less preference for deck A in

healthy normal indicates that they could identify the risk successfully and thus made fewer
ED

selections from deck A.

PT

4.3 Impact of frequency and magnitude of reward/penalty in deck preference

Table 3, shows that there was no significant difference between two groups in card selections
E
CC

from disadvantageous deck B. Both groups had the highest preference for deck B. This

finding is incongruent with the basic assumptions of IGT because healthy normal should
A

avoid making more selections from deck B. Hence, we examined whether card selections

were influenced by the frequency and magnitude of reward/penalty schedules. If decision

making could have influenced by the prediction of reward/penalty frequency, then

participants would have preferred both infrequent penalty decks (B and D) over both frequent
 14

penalty decks (A and C) in both the groups. Hence, there should be a significant difference in

card selections between an infrequent penalty deck and a frequent penalty deck (For e.g.,

comparing card selections between deck B and A). Similarly, the summated score of both

infrequent penalty decks (B + D) should significantly differ with the summated score of both

frequent penalty decks (A + C). We can also assume that participants should have roughly an

equal proportion of card selections from the same frequency of decks and there should be no

T
significant difference.

IP
We compared selections between frequent and infrequent penalty decks with the same

R
magnitude of immediate reward (i.e., between deck A and B or deck C and D) and with

SC
different magnitude of reward (i.e., between deck B and C or deck A and D) in both the

U
groups. Results showed that there was a significant difference in card selections between
N
infrequent and frequent penalty decks in both the groups. Participants preferred more card
A
selections from infrequent penalty decks irrespective of the magnitude of reward and/or long-
M

term outcomes. Further, the summated score of both infrequent penalty decks and frequent

penalty decks also showed a significant difference in both the groups (Table 4). These
ED

findings indicate that the frequency of reward/penalty is an important factor in decision

making. Participants may tend to prefer making more selections from infrequent penalty
PT

decks (B and D) than frequent penalty decks (A and C) without consideration of delayed

outcome. Several psychological factors may contribute to immediate reward seeking

E
CC

behaviours in infrequent penalty conditions despite having a negative outcome in long-term

(delayed loss). For example, learning (implicit and explicit knowledge and cognitive
A

processing with task or learned predictions about rewarding effects), affect or emotion

experienced by subjects with rewards (hedonic aspect of rewards), reward expectancy,

disconfirmation of reward expectancy and incentive motivation (Berridge and Robinson,

2003, Berridge and Kringelbach, 2015, Blum et al., 2012).

 15

When we compared card selections between two same frequency of decks [For e.g. deck B

and D (as both are infrequent penalty decks) or card selections between deck A and C (as

both are frequent penalty decks)], results showed that there was no significant difference in

both the groups. This indicates that participants had approximately an equal preference for

card selections from the same frequency of penalty decks and their decision was not guided

by long-term outcome.

T
Further, mean score (Table 3) shows that participants in both groups had the highest number

IP
of selection from deck B. In IGT, deck B and D are similar in terms of having a similar

R
frequency of reward/penalty (both yields nine rewards and one penalty in ten consecutive

SC
selections). However, deck B yields high magnitude of immediate reward (100 rupees) and

U
deck D yields low magnitude of immediate reward (50 rupees). When we compare the
N
magnitude of penalty on both decks then deck B produces a huge magnitude of penalty (1250
A
rupees) than deck D (250 rupees). Therefore, one should avoid preferring deck B after getting
M

a huge loss but results showed that in both groups there was more preference for deck B

compared to deck D. This means that card selections were guided by high magnitude of
ED

immediate reward in case of two infrequent penalty decks (B and D) without considering

long-term/delayed outcome in both the groups. These results are consistent with other studies
PT

that have reported more preference for deck B (also known as deck B phenomena) (North and

O'Carroll, 2001, Tomb et al., 2002, Maia and McClelland, 2004, Lin et al., 2007a, Toplak et
E
CC

al., 2005). In the beginning, the selection from deck B can appear most profitable as it

produces more profit compared to the other three decks (Maia and McClelland, 2004). It is
A

only the 10th trial which yields loss in huge amount. Hence, it is hypothesized that an

individual may prefer this deck over any other decks as it produces the frequent and high

magnitude of immediate reward. On the 10th trial, when he/she gets a huge penalty, he/she

may again tend to prefer this deck in order to compensate for the loss. Similarly, in the later
 16

phase also, an individual may tend to prefer this deck over other decks in order to compensate

or minimize the loss (Maia and McClelland, 2004).

More preference for deck B than any other decks in persons with clinical conditions and

healthy normal group may result in an increased proportion of disadvantageous selections in

both the groups. Thus, more preference for deck B in clinical population and healthy normal

may result in no significant difference between group on this disadvantageous deck as well as

T
it may adversely impact the IGT net score [summated selections of advantageous decks

IP
(C+D)–summated selections of disadvantageous decks (A+B)] and summation of

R
disadvantageous decks (A + B), as most of the IGT related studies also use summation of

SC
either advantageous or disadvantageous deck (Chiu and Lin, 2007). Due to summation score,

U
sometimes it may appear that there is no significant reduction from the disadvantageous
N
decks in healthy normal too. Hence, IGT related study should consider this factor while
A
interpreting the findings of advantageous and disadvantageous selections and making an
M

inference about decision making. Also, most of the studies use IGT with 100 trials and in

that, individuals can make 40 selections from a deck (Bechara et al., 2000). This raises
ED

confounding issues in card selections. For example, an individual may switch from

advantageous infrequent deck D to disadvantageous infrequent deck B or vice versa, once

PT

he/she finishes the cards from a particular deck. Hence, it may impact overall card selections

and net score. Thus, it may result in no significant differences between the healthy normal
E
CC

and clinical population.

5. Conclusion
A

Findings from this study are important and provide the answer for several hypotheses for

decision making on IGT. The high/low frequency of reward/punishment is such a strong

factor that it may impact adversely the overall card selections on IGT. The present study

strongly supports the importance of frequency and magnitude of reward and penalty in
 17

performance on IGT. Results showed that the healthy normal group too despite having better

executive functions and low impulsivity had more preference for disadvantageous deck B.

They were able to recognize risk on disadvantageous deck A. More preference for deck B due

to the task structure of reward and penalty may impact adversely the overall card selections

on IGT, summated score of disadvantageous decks and net score. Thus, it may lead to an

impression of decision making deficits in healthy normal too. Hence, it may limit the

T
applicability of IGT in examining and understanding decision making ability. The finding of

IP
the present study is certainly valuable but its limitation should also be considered in view of a

R
smaller sample size (n=34). It would be better to examine the findings of the present study

SC
with a large sample size. This will facilitate more generalization.

U
Future studies may examine performance on original IGT and modified IGT used in the
N
present study together in persons with clinical conditions (such as psychiatry disorders) and
A
healthy normal. This may provide a clearer understanding about underlying decision making
M

processes on IGT. Studies may also examine performance on IGT without having a

restriction of card selections in each deck. This may facilitate more understanding about
ED

impact of reward/penalty frequency in decision making because restriction of a particular

number of selections (such as 40/60 in IGT with 100 trials or 80 in IGT with 200 trials) from
PT

a deck may produce the confounding effect in card selections. For example, a person may
E

switch to the advantageous/disadvantageous deck because he/she has finished card selections
CC

from a particular deck and he/she has no choice rather to shift to other decks. It can be easily

assumed that probability of shifting from one infrequent penalty deck to another infrequent
A

penalty deck would be more than shifting to frequent penalty deck. Studies may also examine

and compare decision making processes on IGT with 100 trials and larger trials (for example

200 trials) to verify the impact of infrequent penalty deck B, beacuse understanding of the

delayed loss on infrequent penality deck may take more time compared to frequent penalty
 18

deck (Wetzels et al., 2010). Decision making is a complex process. Several psychological

factors may play an important role in decision making such as reward expectancy, incentive

motivation and emotion experience with reward/penalty. Role of these factors needs to be

examined in decision making.

Contributers: Rajesh Kumar conducted the study, analyzed the data and wrote the initial

T
draft of the manuscript. This study was supervised by Dr. Keshav Kumar J and co-supervised

IP
by Dr. Vivek Benegal. Both provided substantial edits and content to subsequent drafts. All

R
authors have approved the final manuscript.

SC
Financial Disclosure

U
This research did not receive any specific grant from funding agencies in the public,
N
commercial, or not-for-profit sectors.
A
M

Conflict of interest: The authors have no conflict of interest to declare.

ED
PT

Acknowledgement

NA
E
CC
A
 19

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 25

Tables

Table 1: The gain-loss structure and net value in each deck in the original IGT

IGT Card no. A B C D

1. +100 +100 +50 +50
2 +100 +100 +50 +50
3 +100, –150 +100 +50, –50 +50
4 +100 +100 +50 +50
5 +100, –300 +100 +50, –50 +50
6 +100 +100 +50 +50

T
7 +100, –200 +100 +50, –50 +50

IP
8 +100 +100 +50 +50
9 +100, –250 +100 +50, –50 +50
10 +100, –350 +100, –1250 +50, –50 +50, –250

R
Net value –250 –250 +250 +250
11 +100 +100 +50 +50

SC
12 +100, –350 +100 +50, –25 +50
13 +100 +100 +50, –75 +50
14 +100, –250 +100 +50 +50
+100, –200
15
16 +100
+100, –300
+100
+100
U+50
+50, –25
+50, –75
+50
+50
N
17 +100 +50
18 +100, –150 +100 +50 +50
19 +100 +100 +50, –50 +50
A
20 +100 +100, –1250 +50 +50, –250
Net value –250 –250 +250 +250
M

21 +100 +100 +50 +50

22 +100, –300 +100 +50 +50
23 +100 +100 +50, –50 +50
ED

24 +100, –350 +100 +50, –25 +50

25 +100 +100 +50, –50 +50
26 +100, –200 +100 +50 +50
27 +100, –250 +100 +50 +50
PT

28 +100, –150 +100 +50, –75 +50

29 +100 +100 +50, –50 +50
30 +100 +100, –1250 +50 +50, –250
E

Net value –250 –250 +250 +250

31 +100, –350 +100 +50 +50
CC

32 +100, –200 +100 +50 +50

33 +100, –250 +100 +50, –25 +50
34 +100 +100 +50, –25 +50
35 +100 +100 +50 +50
A

36 +100 +100 +50, –75 +50

37 +100, –150 +100 +50 +50
38 +100, –300 +100 +50, –50 +50
39 +100 +100 +50, –75 +50
40 +100 +100, –1250 +50 +50, –250
Net value –250 –250 +250 +250
 26

Table 2: The gain-loss structure and net value in each deck in the modified IGT

IGT Card no. A B C D

1. +100 +100 +50 +50
2 +100 +100 +50 +50
3 –150 +100 –50 +50
4 +100 +100 +50 +50
5 –500 +100 –50 +50
6 +100 +100 +50 +50
7 –200 +100 –50 +50
8 +100 +100 +50 +50

T
9 –250 +100 –50 +50
–1250 –50 –250

IP
10 +100
Net value –500 –350 00 +200
11 +100 +100 +50 +50

R
12 –350 +100 –25 +50
13 +100 +100 –75 +50

SC
14 –250 +100 +50 +50
15 –200 +100 +50 +50
16 +100 +100 –25 +50
17
18
–300
–150
+100
+100 U–75
+50
+50
+50
N
19 +100 +100 –50 +50
20 +100 –1250 +50 –250
A
Net value –750 –350 00 +200
21 +100 +100 +50 +50
M

22 –300 +100 +50 +50

23 +100 +100 –50 +50
24 –350 +100 –25 +50
ED

25 +100 +100 –50 +50

26 –200 +100 +50 +50
27 –250 +100 +50 +50
PT

28 –150 +100 –75 +50

29 +100 +100 –50 +50
30 +100 –1250 +50 –250
E

Net value –750 –350 00 +200

31 –350 +100 +50 +50
CC

32 –200 +100 +50 +50

33 –250 +100 –25 +50
34 +100 +100 –25 +50
A

35 +100 +100 +50 +50

36 +100 +100 –75 +50
37 –150 +100 +50 +50
38 –300 +100 –50 +50
39 +100 +100 –75 +50
40 +100 –1250 +50 –250
Net value –750 –350 00 +200
 27

Table 3: Comparison of two groups on IGT

Healthy normal group High risk group p value

Mean ± SD Mean ± SD

IGT A 19.44 ± 5.06 22.65 ± 6.09 0.033*

IGT B 31.32 ± 7.64 29.44 ± 7.30 0.290

T
IGT C 19.50 ± 6.97 20.85 ± 5.33 0.286

IP
IGT D 29.88 ± 7.50 27.06 ± 7.70 0.158

R
IGT Net score
–1.38 ± 18.96 – 4.18 ± 12.91 0.644

SC
[(C+D) – (A+B)]

*p < 0.05 (two-tailed)

U
N
A
M
ED
E PT
CC
A
 28

Table 4: Comparison of frequent and infrequent penalty decks in both the groups

High risk group p value Healthy normal group p value

Mean ± SD (Mean ± SD)
Infrequent penalty decks (B+D) 56.50 ± 6.92 0.001*** 61.21 ± 7.92 0.001***
Frequent penalty decks (A+C) 43.50 ± 6.92 38.94 ± 8.00
Infrequent penalty deck with 29.44 ± 7.30 0.004** 31.32 ± 7.64 0.001***
high immediate reward (B)

T
Frequent penalty deck with high 22.65 ± 6.09 19.44 ± 5.06

IP
immediate reward (A)
Infrequent penalty deck with 27.06 ± 7.70 0.008** 29.88 ± 7.50 0.001***

R
low immediate reward (D)

SC
Frequent penalty deck with low 20.85 ± 5.33 19.50 ± 6.97
immediate reward (C)
Infrequent penalty deck with 29.44 ± 7.30 0.304 31.32 ± 7.64 0.339
high immediate reward (B) U
N
Infrequent penalty deck with 27.06 ± 7.70 29.88 ± 7.50
A
low immediate reward (D)
M

Frequent penalty deck with high 22.65 ± 6.09 0.170 19.44 ± 5.06 0.613
immediate reward (A)
Frequent penalty deck with low 20.85 ± 5.33 19.50 ± 6.97
ED

immediate reward (C)

Infrequent penalty deck with 29.44 ± 7.30 0.001*** 31.32 ± 7.64 0.001***
PT

high immediate reward (B)

Frequent penalty deck with low 20.85 ± 5.33 19.50 ± 6.97
E

immediate reward (C)

CC

Frequent penalty deck with high 22.65 ± 6.09 0.013** 19.44 ± 5.06 0.001***
immediate reward (A)
Infrequent penalty deck with 27.06 ± 7.70 29.88 ± 7.50
A

low immediate reward (D)

***p < 0.001(two-tailed), **p < 0.01 (two-tailed)