Schizophrenia Research 136 (2012) 122–127

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Schizophrenia Research
journal homepage: www.elsevier.com/locate/schres

Schizophrenia and risk-taking: Impaired reward but preserved

punishment processing
Gordon L.F. Cheng a, b, Joey C.Y. Tang a, c, Frendi W.S. Li d, Esther Y.Y. Lau a, d, Tatia M.C. Lee a, b, d, e,⁎
a
Laboratory of Neuropsychology, The University of Hong Kong, Hong Kong, China
b
Laboratory of Cognitive Affective Neuroscience, The University of Hong Kong, Hong Kong, China
c
Number Laboratory, The University of Hong Kong, Hong Kong, China
d
Department of Psychology, The University of Hong Kong, Hong Kong, China
e
The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong, China

a r t i c l e i n f o a b s t r a c t

Article history: Risky decision-making is subserved by the frontostriatal system, which includes a network of interconnected
Received 17 September 2011 brain regions known to be dysfunctional in patients with schizophrenia. This study aimed to investigate
Received in revised form 14 December 2011 whether and to what extent patients with schizophrenia display a different pattern of risk-taking behavior
Accepted 4 January 2012
relative to matched healthy controls. The Balloon Analogue Risk Task (BART) and the Risky-Gains Task
Available online 27 January 2012
were used as naturalistic measures of risk-taking behavior in 25 patients with schizophrenia and 25 controls.
Keywords:
Results of the BART revealed that patients behaved more conservatively, and this in turn led to suboptimal risky
Balloon Analogue Risk Task decision-making. Consistently, patients behaved more conservatively in the Risky-Gains Task. Interestingly,
Risky-Gains Task however, they adjusted the pattern of risk-taking following a punished trial similar to controls. These findings
Psychosis indicate that patients have impaired reward but preserved punishment processing. This study complements pre-
Frontostriatal system vious studies on decision-making in schizophrenia and suggests specific rather than widespread abnormalities
along the frontostriatal system in schizophrenia.
© 2012 Elsevier B.V. All rights reserved.

1. Introduction
Schizophrenia is a form of psychopathology that implicates abnor-
mal functioning in the frontostriatal system (e.g. Abi-Dargham, 2003;
Kim et al., 2003; see Barch and Dowd, 2010). One of the higher cognitive
processes that are known to involve the frontostriatal system is risky
decision-making, which is a form of behavior that entails striking a
balance between options with different likelihoods of reward and
punishment. Processing of reward and punishment is subserved by
interconnected brain regions including the prefrontal cortex (PFC),
anterior cingulate cortex (ACC), insula, and subcortical areas such as
the striatum (e.g. Knutson et al., 2000; O'Doherty et al., 2001; Elliott et
al., 2003; FitzGerald et al., 2009).
Owing to the significance of the frontostriatal system in risky
decision-making, the present study aimed to investigate the perfor-
mance of patients with schizophrenia on naturalistic risk-taking tasks
that are known to involve this brain system. These risk-taking tasks
include the Balloon Analogue Risk Task (BART; Lejuez et al., 2002) and
Risky-Gains Task (Paulus et al., 2003), both known to involve brain
regions along the frontostriatal system in response to choosing a risky
over a safe option (Paulus et al., 2003; Lee et al., 2008a, 2008b; Rao et
⁎ Corresponding author at: K610, The University of Hong Kong, Pokfulam Road,
Hong Kong, China. Tel.: + 852 2857 8394; fax: + 852 2819 0978.
E-mail address: tmclee@hku.hk (T.M.C. Lee).
al., 2008; Lee et al., 2009). Several studies have examined the extent
of suboptimal decision-making in patients with schizophrenia using
the Iowa Gambling Task (IGT), which was originally believed to rely
on the ventromedial PFC (Bechara et al., 1994, 2000) and now known
to involve the frontostriatal network (Li et al., 2010). These studies
either reported no difference in IGT performance between patients
with schizophrenia and healthy controls (e.g. Wilder et al., 1998;
Cavallaro et al., 2003; Evans et al., 2005; Rodríguez-Sánchez et al.,
2005; Turnbull et al., 2006) or that patients selected more disadvantaged
options which led to lower returns (Ritter et al., 2004; Shurman et al.,
2005; Kester et al., 2006; Sevy et al., 2007; Yip et al., 2009). Despite the
conflicting findings, these studies provided important insight that at
least in some patients with schizophrenia, there seems to be difficulty
in making optimal decisions. Employing the BART and Risky-Gains
Task in patients with schizophrenia will add to our knowledge of the
specific characteristics of risk-taking behavior in this clinical population
as the designs of such tasks allow for a direct assessment of the tendency
to engage in risky versus conservative options. This knowledge can
supplement existing findings from IGT studies, some of which indicate
a very different pattern of risky decision-making between patients
with schizophrenia and the healthy population. To our knowledge this
is the first reported study that investigated schizophrenia using the
BART and Risky-Gains tasks. We chose these well-established computer-
ized tasks as risk-taking measures for reasons of ecological validity.
The Risky-Gains Task and BART are with and without time pressure

0920-9964/$ – see front matter © 2012 Elsevier B.V. All rights reserved.
doi:10.1016/j.schres.2012.01.002
 G.L.F. Cheng et al. / Schizophrenia Research 136 (2012) 122–127 123

respectively. Therefore, using both tasks maximizes the ability to gener- Table 1
alize findings to real life situations where risky decision-making can be Background scores for patient and control groups.

made in both contexts of deliberation and haste. Patients Controls Statistics

Our prediction was formulated based on a recent report that (N = 25) (N = 25)
patients with schizophrenia have a preserved capacity to process Mean (SD) Mean (SD) t p
immediate reward but are unable to utilize this information in making
Age 38.2 (7.5) 41.0 (9.0) 1.21 ns
long-term decisions (Heerey et al., 2008). This behavioral temporal Years of education 10.5 (3.2) 11.2 (3.1) 0.81 ns
myopia is reminiscent of findings from some previous studies that C-BDI-II 10.7 (9.7) 9.4 (8.5) − 0.53 ns
investigated schizophrenia using the IGT. Patients tended to select Estimated IQ (RPM) 34.8 (11.5) 50.3 (6.7) 5.83 b.001
cards from more disadvantaged decks that contained large reward Age of onset 26.1 (7.9) – –
Duration of illness (years) 12.8 (9.0) – –
but at times even larger penalties, which led to lower returns in the No. of admissions 4.0 (5.2) – –
long run (Ritter et al., 2004; Shurman et al., 2005; Kester et al., 2006; PANSS positive 10.3 (4.0) – –
Sevy et al., 2007; Yip et al., 2009). Both the BART and Risky-Gains PANSS negative 12.8 (5.1) – –
tasks require making risky decisions over a time window, i.e. risk- PANSS general 21.6 (4.2) – –
taking is measured as a tendency to withhold until larger rewards Note. C-BDI-II = Second Chinese version of Beck Depression Inventory (Chinese Behavioral
are presented. Based on such a temporally accumulated design, it Sciences Society, 2000); RPM = Raven's Progressive Matrices (Raven, 2008); PANSS =
was hypothesized that patients with schizophrenia would fail to Positive and Negative Syndrome Scale (Kay et al., 1987); Patients = adults diagnosed
with schizophrenia; Controls = healthy adults matched to patients in terms of age and
utilize reward information to guide long-term decision-making, and sex; SD = standard deviations; t = t-values from independent groups t-tests; p = associ-
this would manifest as lower scores in the BART and different rates ated p-values; ns = non-significant difference between patients and controls.
of choosing safe and/or risky options relative to controls in the
Risky-Gains Task. 1 We also aimed to further characterize risk-taking
behavior by investigating: (1) the reaction time for choosing each explosion. Alternatively, participants could decide to collect points,
option; and (2) correlations between risk-taking measures and which prevent the balloon from exploding and saving points to a
patients' clinical profiles. permanent repository. Three dependent measures were derived
from BART. First, the adjusted score was calculated by averaging the
2. Method number of pumps for each unexploded balloon. Exploded balloons
were not included since in these trials participants stopped pumping
2.1. Participants without a choice. The adjusted score serves as a measure of decision-
making quality (i.e. a higher score indicates a more optimal decision).
Twenty-five Chinese patients with schizophrenia (in- and out- To complement the adjusted score as a measure of risk-taking, analyses
patients) were recruited from the Castle Peak Hospital or Tuen Mun were also carried out on the rate of exploded balloons and average time
Mental Health Centre, Hong Kong. Diagnoses were made according spent on each balloon.
to DSM-IV-TR (APA, 2000). Patients were either receiving typical
(n = 6) or atypical antipsychotic (n = 18) drugs (medication record 2.2.2. Risky-Gains Task
for one patient failed to be retrieved). Twenty-five Chinese healthy In this task participants decided whether to take the current smaller
control participants were recruited. Exclusion criteria for both the reward, or wait for a larger reward with the potential to lose in a hasty
patient and control groups were history of neurological disorder, context. Specifically, participants were asked to select 20, 40, or 80
substance abuse, head injury with loss of consciousness, and also points with the risk of losing points as they proceeded with their
history of psychiatric disorder for the control group. All participants judgments. Selecting 20 was always the safe option that guarantees a
were right-handed and each group consisted of 9 males. See Table 1 (small) reward, while waiting for and selecting 40 or 80 were risky
for comparison of demographics between patients and controls, and since it has the potential of either a (larger) reward or punishment.
also patients' clinical details. The rates of choosing safe (+20) and risky (+/−40, +/−80) options
This study was approved by the local ethics committee, consented were calculated as the primary dependent measure of risk-taking
by all participants, and carried out according to the Declaration of behavior. In order to reveal sensitivity to punishment, we tested the
Helsinki. rates of choosing either options (safe and risky) following each of the
two outcomes in the preceding trial (rewarded and punished), in
2.2. Experimental tasks accordance with Leland and Paulus (2005) and Paulus et al. (2003).
Risk-taking was further characterized by investigating reaction times
After completion of background measures including IQ (Raven's (RTs), i.e. the time used to select an option, which could be either safe
Progressive Matrices; Raven, 2008), mood rating (2nd Chinese (+20) or risky (+40, +80).
version of Beck Depression Inventory; Chinese Behavioral Science
Corporation, 2000), and in addition for patients the Positive and 2.3. Data analysis
Negative Syndrome Scale (PANSS; Kay et al., 1987), participants carried
out two computerized risk-taking tasks: the Balloon Analogue Risk Task Univariate analyses of variance (ANOVAs) were conducted to test
and Risky-Gains Task. Below are brief descriptions of the risk-taking for the effect of group (patients, controls) in the three BART measures
tasks. See Fig. 1 for detailed task procedures. (adjusted score, explosion rate, and time spent on balloon). For the
Risky-Gains Task, a 2 × 2 × 2 ANOVA on response rates was conducted
2.2.1. Balloon Analogue Risk Task (BART) with group (patients, controls) as between-subjects factor, response
This task simulates the pumping of a balloon, which inflates by a (safe, risky) and outcome (rewarded or punished in the preceding
small degree with each pump. The willingness to inflate balloons is trial) as within-subjects factors. In addition, RTs were investigated
indicative of deliberative risky behavior since each pump leads to using a 2 × 2 ANOVA with group and response as between-subjects
either an extra point gained in the temporary repository or balloon and within-subjects factors, respectively. Follow-up t-tests were
conducted when there was a significant interaction between factors.
1
Final scores in the Risky-Gains Task were not investigated since this task was
In order to investigate whether different profiles of schizophrenia
designed such that there is no inherent advantage in choosing the safe option over have an effect on risk-taking behavior, correlation analyses on all of
risky options, and vice versa. the risk-taking measures with PANSS scores and illness duration
124 G.L.F. Cheng et al. / Schizophrenia Research 136 (2012) 122–127

Fig. 1. Experimental tasks. (A) The Balloon Analogue Risk Task (BART). The BART employed was adapted based on Lejuez et al.'s (2002) original version. For each trial participants
had to decide either to pump the displayed balloon (for one point to the temporary repository) or collect the points accumulated in that trial by pressing the corresponding buttons
on the keyboard. Each pump (or point) represented risk-taking behavior since the balloon could explode at each pump and consequently all points in the temporary repository would
be lost. Deciding to collect the points instead of pumping means that the points are transferred from the temporary repository to the permanent repository (where accumulated
points are safe from future balloon explosions). The explosion point of each balloon was between the 1st and 128th pump, set randomly by the computer (this information was
not known to the participants). Taking the current points (before balloon explosion) and balloon explosion both signifies the end of a trial and beginning of the next. It was made
clear to the participants that there were twenty trials (i.e. twenty balloons). They were simply asked to accumulate as many points as possible in the permanent repository. At
the bottom of the screen are Chinese translations of: accumulated score, number of pumps, and balloon (already played). (B) Risky-Gains Task. The Chinese version of the original
task (Paulus et al., 2003) was used in this study and also in some of our previous experiments (Lee et al., 2008a, 2008b, 2009). Participants were first shown ‘20’ on the screen with the
option to take these points by pressing a button, or wait (for 1 s) for the 40 points that follows it. Similarly, when ‘40’ was shown they could decide to take 40 points or wait for ‘80’.
However, for ‘40’ and ‘80’ there were risks of losing the points, in which case the numbers were shown with a minus sign and the corresponding points (40 or 80) deducted from the
total score. There were 96 trials: 54 nonpunished (i.e. potential of gaining up to 80 points), 24 punished for ‘40’ (i.e. losing 40 points if the safe ‘20’ option was not taken), and 18
punished for ‘80’ (i.e. losing 80 points if both ‘20’ and ‘40’ were not taken). These trials were constructed so that there was no advantage in choosing the safe over risky option,
and vice versa (Paulus et al., 2003). Participants were asked to achieve as high as possible on the accumulated score, which was displayed on the screen throughout the task. A practice
session was carried out prior to the proper experiment to ensure accurate understanding of task instructions. Illustrated is a ‘punished for 80’ trial, in which punishment was
presented if either the ‘20’ or ‘40’ points were not taken. Top of the screen shows the ‘score’. Chinese characters for ‘you win’ or ‘you lose’ were shown in accordance to the outcome
of a trial.

were conducted. Unless otherwise specified, all statistical tests were
carried out and reported with significance level at p b .05 (two-tailed).
3. Results
Summary data for both patients and controls are presented in
Table 2.
significant group-by-response [F(1,46) = 4.56, p b .05] and response-
by-outcome [F(1,46) = 4.25, p b .05] interactions. Further t-tests
revealed that regardless of outcome the control group showed a
preference toward choosing risky over safe options [t(24) = − 3.17,
p b .01], but for patients there was no difference between rates of
choosing risky and safe options [t(24) = .98, p > .05]. This finding is

Table 2
3.1. Group differences in risk-taking behavior
Means and standard deviations for risk rates (A) and time (B) in both BART and Risky-
Gains tasks.
Three dependent measures were derived from the BART: adjusted
score, explosion rate, and time spent on balloon. There was a significant A BART Risky-Gains Task

group effect for the adjusted score [F(1,48) = 8.77, p = .005] such that Adjusted Explosion Risk rate after Risk rate
patients obtained a lower score than controls. Similarly, the explosion score rate punishment after reward

rate was lower in patients relative to controls [F(1,48) = 4.36, p b .05]. Patients M 27.3 .28 .43 .46
These results are indicative that patients with schizophrenia performed (SD) (14.4) (.14) (.31) (.36)
Controls M 40.5 .37 .60 .68
this task at a suboptimal level, possibly due to an abnormal tendency to
(SD) (17.1) (.16) (.31) (.27)
engage in safe over risky actions. Analysis on the average time spent on
each balloon revealed significantly longer time in the patient group B BART Risky-Gains Task
relative to controls [F(1,48) = 18.1, p b .001]. Time spent on balloon (s) Safe RT (ms) Risk RT (ms)
For the Risky-Gains Task response rates (safe or risky options)
Patients M 18.4 487 383
were measured as a function of outcome in the preceding trial (SD) (11.7) (95) (90)
(rewarded or punished). Analysis revealed no main effects of Controls M 7.50 495 371
response [F(1,46) = 1.45, p > .05], outcome [F(1,46) = 1.09, p > .05], (SD) (5.26) (116) (84)
or group [F(1,46) = 1.09, p > .05]. The group-by-outcome interaction Note. BART = Balloon Analogue Risk Task (Lejuez et al., 2002); M = means; SD =
was not significant [F(1,46) = 1.09, p > .05]. There were, however, standard deviations; s = seconds; ms = milliseconds; RT = reaction time.
 G.L.F. Cheng et al. / Schizophrenia Research 136 (2012) 122–127 125

again suggestive that patients are less willing to take risks relative to trial, suggesting intact punishment sensitivity; and (3) none of the
controls. In addition, regardless of group there were lower rates of risk-taking measures correlated with patients' clinical profiles. Since
risky response [t(47) = − 2.09, p b .05] and higher rates of safe an ecological sample of patients with schizophrenia was investigated,
response [t(47)= 2.10, p b .05] following a punished trial. Interestingly, their IQ scores were significantly lower than the control group. Correla-
the 3-way-interaction was not significant [F(1,46) = .052, p > .05]. This tion analyses, however, revealed that IQ did not relate to any risk-taking
finding suggests that, similar to controls, patients adjusted risk-taking measures in both patients and controls, suggesting that observed group
following a punished trial and is indicative of intact punishment differences were not driven by intelligence.
sensitivity among patients (Leland and Paulus, 2005). In terms of RTs, The present finding that patients with schizophrenia behaved
both the main effects of group [F(1,43) = .33, p > .05] and group-by- suboptimally in risky decision-making is consistent with the a-priori
response interaction [F(1,43) = .039, p > .05] were not significant. prediction, based on their inability to utilize reward information in
However, there was a main effect of response such that selecting risky long-term decision-making (Heerey et al., 2008). Specifically, our data
options was faster than selecting the safe option [F(1,43) = 42.6, suggest that patients with schizophrenia behaved more conservatively
p b .001], consistent with our previous study that also investigated RTs in both tasks. This could be explained in terms of the ‘temporal myopia’
in the Risky-Gains Task (Lee et al., 2008b). (Bechara et al., 1994) that the patients suffer, since both tasks involve
increasingly large reward through a temporally accumulated design.
3.2. Correlations between risk measures and clinical profiles The inability to delay immediate but smaller rewards despite availability
of larger rewards in the future, therefore, manifested as conservative
Correlation analyses were conducted on risk-taking measures behavior in both the BART and Risky-Gains tasks. It is however impor-
with PANSS scores and illness duration of patients with schizophrenia tant to note that conservative decision-making, although detrimental
in order to investigate whether the suboptimal risk-taking observed to the BART as it leads to lower overall scores in this task, may not be
could in part be explained by patients' clinical profiles. As evident in harmful in other contexts (Lighthall et al., 2009). There are instances
Table 3, none of the PANSS scores or illness duration correlated with that may benefit from conservative behavior or that neither benefits
any of the risk-taking measures. These results are suggestive of a from risky or conservative behavior, such as in the Risky-Gains Task.
homogenous pattern of suboptimal risk-taking behavior in patients The Risky-Gains Task is therefore limiting in that it does not tell whether
with schizophrenia. conservative risk-taking in patients may be translated as maladaptive
behavior.
3.3. Supplementary analyses: effect of IQ The present finding that patients with schizophrenia lack the ability
to delay immediate gratification is in line with previous studies that
Since IQ scores between patients and controls were statistically employed the Iowa Gambling Task (IGT). These studies demonstrated
different (with controls having higher scores as a group), we followed that patients preferred disadvantaged decks that contain large reward
a previous procedure (e.g. Morise et al., 2011) of correlating task but also at times even larger punishment (Ritter et al., 2004; Shurman
performance with IQ to see if intelligence might have any relation et al., 2005; Kester et al., 2006; Sevy et al., 2007; Yip et al., 2009).
to risk-taking behavior. Analyses revealed that IQ did not correlate However, a novel and important finding of the present study is that in
with any of the risk-taking measures for either patients or controls the Risky-Gains Task all participants responded more conservatively
(all p > .05, uncorrected). This suggests that the group differences in following a punishment than when they were following a reward. In
risk-taking behavior were not driven by the difference in IQ, consistent other words, both patients and controls adjusted their decisions accord-
with previous studies that also reported no correlations between ing to the outcome of the preceding trial. The finding that healthy adults
risk-taking and intelligence (Lejuez et al., 2002; Deakin et al., 2004). behaved more conservatively following punishment is not new (Paulus
et al., 2003; Leland and Paulus, 2005). However, it is intriguing that
4. Discussion patients with schizophrenia also followed the same response pattern,
despite clear indication of their overall deviant risk-taking behavior
This study aimed to investigate risk-taking decisions in patients with relative to controls. This finding suggests both an intact sensitivity and
schizophrenia using the BART (Lejuez et al., 2002) and Risky-Gains Task utilization of punishment information in patients with schizophrenia
(Paulus et al., 2003). Three main results emerged: (1) patients behaved (Leland and Paulus, 2005). Processing of reward and punishment is
more conservatively relative to controls, leading to suboptimal risky reported to subserve separable neural resources among the healthy
decision-making; (2) in the Risky-Gains Task patients adjusted risk- population. For instance, both the striatum (Delgado et al., 2000;
taking similarly to controls following punishment in the preceding Knutson et al., 2001; Yacubian et al., 2006) and OFC (O'Doherty et al.,
2001) are differentially involved in reward and punishment. The
present finding that patients with schizophrenia are impaired in reward
Table 3 processes but with preserved punishment processes therefore suggests
Pearson correlation coefficients of risk-taking measures with PANSS and illness
specific abnormalities along the frontostriatal network in this clinical
duration.
population. Whether the levels of frontostriatal activations can differen-
Schizophrenia PANSS PANSS PANSS Illness tiate between patients and healthy controls in relation to risky decision-
patients (N = 25) positivea negativea generala durationa
making remains to be confirmed in future imaging studies.
BART Adjusted score .18 .20 .38 −.08 Although our hypothesis was formed in relation to a previous
Explosion score −.18 .20 .11 −.21 finding that patients with schizophrenia lack the ability to use reward
Time spent on balloon −.19 −.18 −.38 .08
Risky-Gains Risk rate after reward .23 .30 .28 .16
information to guide long-term decision-making (Heerey et al.,
Task Risk rate after .21 .18 .21 .26 2008), there are two other possible explanations for the patient's
punishment conservative behavior in both the BART and Risky-Gains tasks. First,
Safe rate after reward −.21 −.18 −.21 −.16 patients may have a depleted sensitivity to reward, such that they
Safe rate after −.23 −.30 −.28 −.26
did not appreciate a difference between the smaller and larger reward
punishment
Safe RT −.08 .12 .02 .44 options. The design of this study did not allow exclusion of this possi-
Risk RT .17 −.16 .08 .08 bility, but in our opinion this was unlikely the case since Heerey et al.
Note. PANSS = Positive and Negative Syndrome Scale (Kay et al., 1987); BART =
(2008) demonstrated intact reward sensitivity in patients with
Balloon Analogue Risk Task (Lejuez et al., 2002); RT = reaction time. schizophrenia using a signal detection procedure. Second, patients
a
All correlations are non-significant at corrected p b .001 level. may have a lack of impulse control, which may be related to the
126 G.L.F. Cheng et al. / Schizophrenia Research 136 (2012) 122–127
tendency to select anything that is available in the present context
without regard to future consequences, even if these future conse-
quences imply large rewards that lead to higher overall returns. This
interpretation may seem compatible with the present findings that
patients behaved more conservatively in both the BART and Risky-
Gains tasks, since both tasks measure risk-taking as the tendency to
withhold until larger rewards are presented. Experimentally, risk-
taking and impulse control are dissociable (e.g. Clark et al., 2008). It
is a limitation that the present study was not designed to differentiate
them. However, there was no group difference in reaction time for the
Risky-Gains Task. In fact, the average time spent on each balloon in the
BART was significantly longer for patients relative to controls. These
findings may suggest that patients' conservative behavior was not
due to their impulsive urge since one would expect a shorter reaction
time in those that are highly impulsive. Furthermore, without a
complete neuropsychological assessment it is difficult to discern the
mechanisms underlying the behavioral difference between patients
and controls. For instance, patients' conservative behavior in the
BART could be due to impaired vigilance, working memory, attention,
or a combination of these factors. The cognitive deficits underlying
patients' suboptimal decision-making therefore remains to be tested
in future studies. Likewise, in future studies it would be important to
explore whether differences in personality may explain tendencies
to engage in risky/safe decisions. Particularly interesting are impulsivity
(Barratt, 1994) and antisocial traits (Loranger et al., 1994), which are
aspects of personality that implicate the control of inhibition subserved
by the prefrontal cortex.
Patients in the present study showed similar risky-taking behavior
such that none of their clinical profiles correlated with risk-taking
measures. This is in line with some (Cavallaro et al., 2003; Ritter et
al., 2004; Evans et al., 2005; Rodríguez-Sánchez et al., 2005; Kester
et al., 2006; Yip et al., 2009), but not all previous studies (Hutton et
al., 2002; Shurman et al., 2005; Turnbull et al., 2006). Such inconsis-
tencies may be related to sample selection or medication effects. It is
reasonable to suspect that in the present study, patients' homoge-
neous pattern of risky decision-making is associated with the fact
that they were all undergoing medication treatment. To the best of
our knowledge, there is no risky decision-making study that com-
pared schizophrenia patients who are undergoing medication to
those that are medication-naïve. This is an important issue that awaits
careful investigation.
In summary, patients with schizophrenia displayed a very different
pattern of risk-taking relative to healthy controls. Specifically, patients
behaved more conservatively in both contexts of deliberation (i.e.
BART) and haste (i.e. Risky-Gains Task), possibly due to the inability
to utilize reward information in guiding risky decision-making. In
order to build a thorough theoretical framework of risky decision-
making in schizophrenia and other clinical disorders implicating a
reward/punishment deficit in general, future studies would benefit
from including large samples of patients that allow elucidating the
relationship between clinical profiles (including types of treatment)
and risky decision-making, and to employ neuroimaging to characterize
the specific neural circuits that differentiate between patients and
healthy controls.
Role of funding source
Sponsors of the work reported in this manuscript did not play any roles in the
research design and data management (data collection, analysis and interpretation)
of the study. They did not participate in the writing of the report nor participated in
the decision making of paper submission for publication.
Contributors
TMCL conceptualized the research idea. All authors designed the study. JCYT,
FWSL, and EYYL helped with measure selection. TMCL collected the clinical data.
GLFC and JCYT analyzed the data and wrote the first draft of the manuscript. TMC
supervised the research project and critically revised the manuscript. All authors
contributed to and have approved the final manuscript.
Conflict of interest
All authors report no conflicts of interest relevant to the subject of this article.
Acknowledgment
This study was supported by the May Endowed Professorship and the Research
and Conference Grant (#10401362) of The University of Hong Kong, and the Research
Grant Council Collaborative Research Fund (PolyU9/CRF/09).
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