English Papers

Iowa Gambling Task

as an Evaluating Method For
Cognitive Dysfunctions
in Drug Abuse and Other Brain
Diseases; a Review on Existing
Experiences and Future Research
Horizons
Payam Piray Mohammad Mehdi Keramati
Center of Excellence for Control and Intelligent Processing, Graduate School of Management and Economics, Sharif
Department of Electrical and Computer Engineering, Tehran University of Technology
University. Email: p.piray@gmail.com
Hamed Ekhtiari
Neurocognitive laboratory, Iranian National Center for Addiction
Amir Dezfuli Studies, Tehran University of Medical Sciences
Center of Excellence for Control and Intelligent Processing,
Department of Electrical and Computer Engineering, Tehran
University.

Abstract the deficit in decision-making. IGT immediate rewards on each selection

Of prime importance to the study
of neuro-cognitive aspects of human
decision making are cognitive
assessment tasks. Iowa Gambling
Task (IGT) designed by Bechara and
his colleagues ,1995, is one the most
successful ones simulating every day
risky decision-making circumstances.
The dysfunction of many brain
disorders is studied with the IGT until
now. In this article, we review studies
which utilize IGT to investigate
neural substrates of decision making
mechanisms especially those focusing
on neuro-cognitive malfunctions
induced by drug of abuse.
Then, we will review our experiences
with Persian version of IGT in Iran
for evaluation of cultural aspects of
risky decision making among normal
subjects, and decision making
DYSfunctions in substance abusers
and multiple sclerosis patients.
Finally we will present our
suggestions for future researches in
this field.
Introduction
Iowa Gambling Task (IGT), introduced
by Bechara and his colleagues, is one of
the most popular tasks in investigating
models a risky environment for decision-
making (Bechara, Damasio, Damasio
and Anderson, 1994). The task is
known as a strong evidence for the
influence of emotion in decision-making.
Several studies revealed that IGT is a
useful model in laboratory studies of
cognitive dysfunctions associated with
decision-making in risky and ambiguous
environments.
In the first section of this paper, IGT
and the primary studies using it are
reviewed. We review some studies
which have used IGT to investigate the
decision-making deficit of drug abusers
in the next section. The usefulness of IGT
to examine the schizophrenia and some
other brain disorders is reviewed briefly.
Finally we will present our experiences
with Persian version of IGT in Iran and
evaluate future research horizons and
priorities in this field.
Review of the IGT
In the IGT, participant selects from four
decks labeled as A, B, C and D. With
each selection, the card turns face up
to show reward or punishment amounts,
which vary within and between decks.
The cards of two decks have large
but larger punishments with some of
the cards (known as disadvantageous
decks). In contrast, the two other
decks have smaller immediate rewards
and smaller punishments (known as
advantageous decks). The number of
trials is not told to participants. There
are some variants of IGT used until
now. A famous variant task, known
as EFGH version, has two decks with
large immediate punishments in each
selection and larger rewards with some
of cards (known as advantageous
decks). In contrast, the two other decks
have smaller immediate punishments
and smaller rewards with some cards
(known as advantageous decks). It
means that in the EFGH version the
contingencies of reward and punishment
are reversed. The key point of the task in
both versions is that participants should
give up short-term benefit to obtain
long-term benefit (see Bechara, Tranel
and Damasio (2000) for details).
IGT has been introduced as an
evidence of Damasio’s Somatic
Markers Hypothesis (SMH). SMH
proposes that emotional markers,
arising in bio-regulatory processes,
bias some brain regions in particular
Ventromedial PreFrontal Cortex
(VMPFC), OrbitoFrontal Cortex (OFC)

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and amygdala (Damasio 1994). IGT has
remained as a useful model to evaluate
decision-making; However, the relation
between IGT and SMH is disputed by
some researchers (Dunn, Dalgleish and
Lawrence, 2006; Maia and McClelland,
2005; Tomb, Hauser, Deldin and
Caramazza, 2002).
The investigations of Iowa researchers
showed that patients with different
impaired brain regions have poorer
performance on the IGT than healthy
subjects. Bechara and colleagues
found that VMPFC patients, patients
with amygdala deficit and OFC patients
choose from disadvantageous decks
more than advantageous decks. In some
studies, Skin Conductance Response
(SCR) and the heart rating are recorded
as somatic signals. These patients with
VMPFC or OFC lesion did not develop
anticipatory SCRs but develop the
reward and punishment SCRs, while the
patients with amygdala lesion develop
none of them. In these studies, SCR was
supposed to be the marker of emotional
states based on SMH (Bechara, Tranel,
Damasio and Damasio, 1996; Bechara,
Damasio, Tranel and Damasio, 1997;
Bechara, Damasio, Damasio and Lee,
1999; Bechara, Damasio and Damasio,
2000).
Many reports which evaluate the
decision-making impairments using
IGT are recorded in detail until now.
These reports include the studies that
assess the performance of patients with
varying brain disorders, and studies that
investigate the impairment of decision-
making in the Substance-Dependent
Individuals (SDIs).
Drug abuse studies using IGT
Bechara and colleagues investigated
the decision-making deficit in addicts
using IGT (Bechara, Nader and van der
Kooy, 1998; Bechara, Dolan, Denburg,
Hindes, Anderson and Nathan, 2001;
Bechara and Damasio, 2002; Bechara,
Dolan and Hindes, 2002; Bechara, 2003;
Bechara and Martin, 2004; Bechara,
2005). Bechara emphasized on the role
of somatic signals and some sectors
of the brain especially VMPFC Based
on SMH. Bechara et al. evaluated the
decision-making of drug abusers using
the original version of IGT (ABCD)
(Bechara and Damasio H, 2002) and the
variant version (EFGH) (Bechara, Dolan
and Hindes, 2002). They found drug
abusers did not develop the anticipatory
SCRs. Based on it, they concluded the
somatic markers did not develop and
so the impaired decision-making in the
drug abusers is the result of emotional
mechanism deficit. Their studies showed
the poor performance in SDIs was due
to the hypersensitivity to reward in
some SDIs and myopia for the future
consequences in some other SDIs. They
Quarterly Journal of Addiction - Spring 2008
also found evidence that disputes the
usefulness of IGT to evaluate impaired
decision-making: A subgroup of drug
abusers had good performance on the
IGT and also developed the anticipatory
SCRs.
Clark et al. had a deep insight into the
Bechara and colleagues study. They
reviewed the results of Bechara’s study
in detail and criticized the methodology
of their study. Clark et al. argued that the
participants in the two Bechara’s studies
had been abstinent for at least 15 days,
while some neuro-imaging studies
showed the VMPFC modulation in the
withdrawal period of abstinent (Clark
and Robbins, 2002).
Grant et al. investigated the
performance of SDIs on the IGT and
Wisconsin Card Sorting Task (WCST)
(Grant, Contoreggi and London, 2000).
The WCST is a neuropsychological
test of set-shifting, the ability to display
flexibility in the face of changing
schedules of reinforcements (Spreen ,
Strauss, 1991). There is consensus that
poor performance of WCST is related
to deficit of frontal lobe in particular
dorsolateral prefrontal cortex and
parietal cortex (Anderson, Damasio H,
Jones, Tranel, 1991, Berman, Ostrem,
Randolph, Gold, Goldberg, Coppola,
Carson, Herscovitch, Weinberger,
1995). Bechara et al. found the IGT
is sensitive to ventromedial region of
PreFrontal Cortex (PFC) despite of
dorsolateral part of PFC (Bechara,
Damasio, Tranel, Anderson ,1998).
Grant et al. study showed the SDIs have
poorer performance on the IGT than
healthy subjects, but SDIs do not differ
from healthy subjects on the WCST.
They have concluded the IGT is a useful
model in laboratory studies of cognitive
dysfunctions associated with drug abuse
but WCST is not a useful model. Also
the study showed the impaired decision-
making of the SDIs is related to deficit of
VMPFC rather than dorsolateral PFC.
Ernst et al. used IGT as a risk-taking
task, which is sensitive to drug abuse,
to indicate regions of brain involved
in decision-making after controlling
for expectations of outcomes; also to
examine the brain regions that are
activated by the learned aspect of
decision-making using neuro-imaging
method (PET study) (Ernst, Bolla,
Mouratidis, Contorregi, Matochik,
Kurian, Cadet, Kimes and Londeon,
2002). They controlled the conditions
of healthy participants carefully. They
found the regions involved in decision-
making included OFC, dorsolateral PFC,
ventrolateral PFC, anterior cingulate
cortex, insula, parietal cortex, thalamus
and cerebellum. They also reported the
learned task activated the left amygdala,
the left middle PFC and the left posterior
parietal cortex compared with the
Q U A R T E R L Y J O U R N A L O F
unlearned task.
Bartzokis et al. compared some
recently abstinent with some non-
abstinent cocaine dependent subjects
using IGT, WCST and the California
Verbal Learning Task (CVLT). It is
agreed that CVLT evaluates verbal
learning and short-term memory
associated to the left medial temporal
cortex (Sullivan, Shear, Zipursky, Sagar,
Pfefferbaum, 1994). They found the
cocaine dependent subjects with four
or more days abstinence performed
better than subjects with fewer than four
days of abstinence. Also, they found
that cocaine abusers performance on
WCST and CVLT were not sensitive
to abstinence, so they suggested that
effect of cocaine mediated by VMPFC.
They suggested that IGT is a useful task
to evaluate the pharmacologic effects
on clinical variables (Bartzokis, Lu,
Beckson, Rapoport, Grant, Wiseman,
London, 2000).
Garavan et al. proposed a
neurobiological mechanism of addiction
using the result of SDIs on a modified
version of IGT (Garavan and Stout,
2005). They suggested drug abusers
are not able to modify their behavior in
response to feedback about negative
consequences. The most important
evidence of this suggestion was the
poorer performance of SDIs on the
modified version of IGT than the standard
version. In the modified version, when
the participant selects a deck, the top
cards of other decks are revealed in
addition to the top card of the chosen
deck. They proposed the inability to
behavior monitoring may be the result of
malfunction of Anterior Cingulate Cortex
(ACC) of the drug abusers.
In Table 1, we summarize some other
studies that used IGT to investigate the
behavior of SDIs.
Review some other varying
studies using IGT
The performance of the patients
with schizophrenia comparing with
healthy control has recorded in several
studies because of the prevalent idea
of emotional deficit in schizophrenia
(Trémeau, 2006). In Table 2, we
summarize some of these studies.
In addition to drug abuse and
schizophrenia, the performance of the
patients with various disorders and
individuals with specific properties has
studied on the IGT. Table 3 explains
some of these studies.
Our Experiences in Iran
In neurocognitive laboratory of Iranian
National Center for Addiction Studies,
Ekhtiari, H. and Behzadi, A. , 2000,
developed computerized Persian version
of IGT and added some new features to
its original version by making possible
Page 9
English Papers
to evaluate different temporal variables
during decision making in IGT. We used
this task on finger touch monitors in
different studies during these years.
1. Trans Cultural Differencos: Risky Ekhtiari et al , 2003, founded that Iranian
Decision making (RDM) as a part of normal subjects show lesser scores in
social cognition could be affected by IGT in comparison to other reported
cultural features of learning environment. performances of normal subjects from

Study Authors Description

Comparing the performance of methadone

MMPs show cognitive deficits
maintenance patients (MMP) and a matched Darke, Sims, Mcdonald et al, 2000
compared to matched controls.
sample of non-heroin-using control subjects

Evaluating performance of long-term abstinent

Fein, Klein and Finn, 2004 Impaired decision-making
alcoholics on the IGT

Comparing HIV-seropositive (HIV+) drug users

with HIV-seronegative (HIV−) drug abusers on
the IGT
To study opiate dependence, tobacco smoking, or
their combination accompanied performance on
the IGT
The HIV+ subjects performed
Martin, Pitrak, Weddington et al, 2004
significantly more poorly on the IGT
The impaired decision-making in
Rotheram-Fuller, Shoptaw, Berman et al, 2004
tobacco smokers

Examining the substance abusers patients during

Verdejo, de Arcos and Garca, 2004
the dishabituation phase

Studying long-term heavy marijuana users Whitlow, Liguori, Livengood, et al, 2004

Comparing the drug abusers decision-making

with healthy subjects using IGT and some other Fishbein, Hyde, Eldreth et al, 2005 Impaired decision-making
tasks
Comparing the performance of pathological
Goudriaan, Oosterlaan,
gambling patients, alcohol dependent individuals
de Beurs et al, 2005
and control subjects
Examining the respective contributions of
executive neuro-cognitive functions, sensation
Gonzalez, Vassileva, Bechara et al, 2005
seeking, and HIV serostatus in predicting risky
sexual practices among poly-substance users

Investigating the psychological processes that

Stout, Rock, Campbell et al, 2005
contribute to drug abuse

Studying 25-day-abstinent cocaine abusers show

alterations in normalized cerebral blood flow Bolla, Eldreth, Matochik et al, 2005
(rCBF) in the OFC using PET neuro-imaging
Comparing the decision-making ability of
Buprenorphine in contrast to
methadone- and buprenorphine-maintained
Pirastu, Fais, Messina et al, 2005 methadone improves decision-
individuals to non opiate-dependent drug free
making
controls.

Evaluating the performance of cigarette smokers No impairment of decision-making

Harmsen, Bischof, Brooks et al, 2006
on the IGT related to IGT

Comparing the performances of cocaine and

heroin polysubstance abusers (PSA) and healthy Verdejo-García, Perales and Perez-Garcia, 2007
controls

Investigating the relationship between cocaine Verdejo-García, Rivas-Perez, Vilar-Lopez et al,

and marijuana use and IGT learning 2007

Table 1. Some studies that evaluate decision-making of SDIs using IGT

Page 10

Study
Studying the role of orbitofrontal cortex in schizophrenia
Investigating schizophrenia patients treating with typical or
atypical anti-psychotics
Assessing patients with schizophrenia
Examining the performance of the patients with
schizophrenia and non-psychiatrically ill comparison subject
Investigating the decision-making deficit in the patients with
schizophrenia
Assessing performance of patients with catatonic
schizophrenia
Evaluating stabilized first-episode patients with
schizophrenia
Evaluating decision-making processes in adolescents with
early-onset schizophrenia
Assessing patients with schizophrenia
Evaluating schizophrenic patients and healthy controls using
some frontal tests
Evaluating patients with schizophrenia
Examining IGT performance, its three components, and their
grey matter volume (GMV) correlates in 75 stable patients
with schizophrenia
Table 2. Some studies that evaluate the decision-making of schizophrenia patients using IGT
US and Europe. They proposed that sensitive to frequency of punishment in
this weak performance could be due comparison to its amount.
to insensivity to punishment amount.
Iranian subjects usually are more 2. Conservative Behavior in Multiple
Study
Psychopathy
Severe acute mania
Huntington disease
Intermittent Explosive Disorder
Psychopathy
Q U A R T E R L Y J O U R N A L O F
Quarterly Journal of Addiction - Spring 2008
Authors Description
no differences in the performance of the
Wilder, Weinberger and Goldberg, 1998 patients with schizophrenia with healthy
participants
J.Beninger, Wasserman, Zanibbi et al, 2002
no difference between patients with
Cavallaro, Cavedini, Mistretta et al, 2003 schizophrenia and healthy subjects on
the IGT
Ritter, Meador-Woodru and Dalack, 2004
Impaired decision-making in the
Shurman, Horan and Nuechterlein, 2005
patients with schizophrenia
Bark, Dieckmann, Bogerts et al, 2005
Rodrguez-Snchez, Crespo-Facorro,
Perez-Iglesias et al, 2005
Kester, Sevy, Yechiam et al, 2006
Turnbull, Evans, Kemish et al, 2006 Used a modified version of IGT
Martino, Bucay, Butman et al, 2006
describe the schizophrenia based on
Sevy, Burdick, Visweswaraiah et al, 2007
somatic markers hypothesis
Poor memory, rather than less attention
to reward or impulsivity, contributes
Premkumer, Fannon, Kuipers et al, 2008
to IGT performance deficit, in
schizophrenia patients
Sclerosis Ekhtiari, et al, 2007, reported
that poor performance of MS patients
in IGT could be interpreted as a
conservative behavior that could be
Authors
Schmitt,
Brinkley and Newman, 1999
Clark, Iversen and Goodwin, 2001
Stout, Rodawalt and Siemers, 2001
Best, Williams and Coccaro, 2002
van Honk, Hermans, Putman et al, 2002
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English Papers
Obsessive-compulsive disorder (OCD) Nielen, Veltman, de Jong et al, 2002

Pathological gambling Cavedini, Riboldi, Keller et al, 2002

Attention deficit hyperactivity disorder Ernst, Kimes, London, et al, 2003

Obsessive-compulsive disorder Cavedini, Bassi, Zorzi et al, 2004

Anorexia Nervosa Cavedini, Bassi, Ubbiali et al, 2004

Role of body mass index on the IGT performance Davis, Levitan, Muglia et al, 2004

OCD and schizophrenia Whitney, Fastenau, Evans et al, 2004

Chronic pain Apkarian, Sosa, Krauss et al, 2004

Huntington disease Campbell, Stout and Finn, 2004

Multiple Sclerosis (MS) Kleeberg, Bruggimann, Annoni et al, 2004

Table 3. Varying studies using IGT

seen in other tasks of risky decision
making such as Balloon Analogue Risk
task (BART) and Time Perception Tasks
(TPT)
3. Risky Decision Making in Opioid
Abusers: Authors replicated the
published results about substance
abusers in Iranian subjects. They
also found that poor performances in
substance dependents could be due to
insensitivity to the amount of punishment
and greater amount of harm avoidance
especially in treatment seeker subjects
(Dezfuli , et al 2008)
Conclusion
As we see above, the impairment
of decision-making is evaluated using
IGT in several studies in particular to
evaluate the drug abusers and patients
with schizophrenia. The great literature
on the IGT helps researchers to compare
their findings with the results of varying
other studies. Also, some modified
versions of IGT are used in some studies
that help to evaluate impaired decision-
making under different conditions in
particular ambiguous situations and
risky environments.
There are several studies on IGT
in substance abuse and different
diseases. But there are some scientific
gaps for complete understanding of
different aspects of cognitive deficits
and features that are assessed by IGT.
First of all, we do not know much about
the time course of risky decision making
impairment. is it pre morbid to addiction,
co morbid or post morbid? Could it be
improved after different psychological or
pharmacological interventions?
The next under debate topic in
risky decision making is the extent of
universality of this process as we can
imagine, risky decision making as an
important part of social life could be
affected by social environment, culture,
moral beliefs and etc. so it could be
cultural bounded.
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