Preliminary communicationIowa gambling task performance in euthymic bipolar I disorder: A meta-analysis and empirical study
Introduction
Bipolar I disorder is a severe psychiatric condition defined by episodes of mania. The reward system has been a focus of psychological research on mania etiology (Johnson et al., 2012b). Over 20 years ago, Depue and Iacono (1989) argued that mania symptoms are consistent with an overactive pursuit of and response to reward and hypothesized that mania vulnerability involves elevated reward sensitivity—a tendency to show increased behavioral, affective, and cognitive responses to reward-relevant stimuli (Urosevic et al., 2008, Johnson et al., 2012b). Consistent with this, researchers have found that manic symptoms are more likely after life events involving goal attainment (Nusslock et al., 2007, Johnson et al., 2008). Self-reported sensitivity to reward, as measured by the Behavioral Activation System (BAS) scales (Carver and White, 1994), is elevated among people with bipolar disorder (Meyer et al., 2001) and is associated with a more severe course of mania (Meyer et al., 2001), the conversion of bipolar spectrum disorders to more severe forms of disorder (Alloy et al., 2012), and the onset of bipolar spectrum disorders (Alloy et al., 2008). Recent work has attempted to identify differences between those with and without bipolar disorder in responses to reward-relevant laboratory tasks (see Johnson et al., 2012b for review).
Recently, the National Institute of Mental Health (NIMH) RDoC workshop on Positive Valence Systems recommended the Iowa Gambling Task (IGT; Bechara et al., 1994) as a measure of approach motivation (NIMH, 2011). In the IGT, participants must choose cards from four decks. With each card selected, the participant gains money; for some cards, the participant gains money but also has to pay a penalty that may be larger than the amount gained. Two of the decks are “risky,” meaning that they provide larger payoffs but are more likely to lead to large losses, and two of the decks are “safe,” with smaller payoffs but smaller risks. In the long run, participants who play the risky decks will lose money, but participants who play the safe decks will gain money. Successful participants learn to choose cards from the safe decks over the course of the task. There are many ways to interpret IGT performance, but one interpretation is that those who select cards from risky decks are willing to hazard losses in the pursuit of larger rewards—a profile that may stem from greater reward sensitivity.
Several researchers have used the IGT with bipolar samples. Findings suggest that people experiencing acute mania and depression select more cards from risky decks than do control participants (Rubinsztein et al., 2006, Adida et al., 2011). However, reward models posit that people with bipolar disorder display elevated reward sensitivity even during remission. Some studies of IGT behavior among euthymic people with bipolar I disorder have found elevated risk taking among euthymic bipolar I participants (Adida et al., 2011, Malloy-Diniz et al., 2011), and others have found no differences in IGT behavior (Yechiam et al., 2008, Jogia et al., 2011, Martino et al., 2011). Given the mixed results, our first goal was to conduct a meta-analysis of relevant IGT findings.
Section snippets
Study 1
We identified published studies indexed in PubMed or PsycINFO with the key words (IGT or “Iowa Gambling”) and (mania, bipolar, or manic). Studies were excluded from analysis if they did not include a euthymic bipolar I group (Ibanez et al., 2012) and a control group (Christodoulou et al., 2006, Jollant et al., 2007).
Meta-analysis was performed in the metafor package for R (Viechtbauer, 2010) using a random-effects model with restricted maximum likelihood estimation. Fig. 1 shows the effect size
Study 1 discussion
Our meta-analysis raises two related questions. First, what is the source of the group difference? IGT performance rests on several cognitive processes, and analyses of overall IGT performance do not specify which processes underlie group differences. Second, the small effect size and relatively (though not significantly) heterogeneous pattern suggest that IGT performance varies among people with remitted bipolar disorder and that individual differences are important to consider. In study 2, we
Study 2
As noted, the IGT has been described as a measure of reward sensitivity (NIMH, 2011) and of real-life decision-making (Bechara et al., 1994), but IGT performance results from a complex of both “hot” and “cold” cognitive processes (Buelow and Suhr, 2009). Beyond reward sensitivity, potential explanations for poor performance include insensitivity to losses, difficulty learning or remembering the contingencies associated with each deck, random or inconsistent selections, or simple lack of
Participants
Participants were recruited through treatment centers, support groups, and community advertisements in the Miami and Palo Alto areas. Participants in the bipolar group (N=55) met criteria for bipolar I disorder as assessed by the Structured Clinical Interview for DSM-IV (SCID; First et al., 1997). Participants in the control group (N=39) did not meet current or lifetime criteria for any mood disorder, including bipolar I disorder, bipolar II disorder, cyclothymia, bipolar disorder NOS, major
Results
As shown in Table 1, bipolar and control groups did not differ on age, gender, years of education, or current manic or depressive symptoms. The bipolar group had higher rates of lifetime or current anxiety disorder and of lifetime substance-related disorder. The bipolar group reported a relatively severe illness history.
Discussion
Study 1 was a meta-analysis of five studies of IGT performance among euthymic persons with bipolar I disorder compared with control participants. Findings of the meta-analysis suggested an effect size of Hedges’ g=.35, which is relatively small compared with effect sizes associated with other cognitive tests in euthymic bipolar I disorder (Robinson et al., 2006, Bora et al., 2009). There was also marginal evidence of heterogeneity in the effect sizes across studies.
Study 2 examined IGT
Conflict of interest
All authors declare that they have no conflicts of interest.
Role of funding source
Data collection and manuscript preparation were supported by NIMH Grant RO1 076021 to Sheri Johnson. The NIMH was not otherwise involved in any phase of the research process, including study design, data collection, data analysis, manuscript preparation, or manuscript submission.
Acknowledgements
We thank Lori Eisner, Daniel Fulford, Ian Gotlib, Terence Ketter, Christopher Miller, Jennifer Nam, Bailey Smith, and Meggy Wang for their assistance in conducting this study. We thank Anthony Bishara for providing R code for fitting the Expectancy Valence Model.
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