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Antoine Bechara highlights that real-life decision-making is impaired after a ventromedial prefrontal brain injury, despite otherwise intact intellectual functions.

Image courtesy of interviewee. February 2, 2024

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This video video discusses a pivotal neurological case from 1868 involving a man named Phineas Gage, who survived an accident in which an iron tamping bar penetrated his skull and front brain. Remarkably, he did not experience any neurological deficits post-accident but exhibited significant changes in personality, becoming impulsive and demonstrating poor judgment. This video video case led to the study of the ventromedial prefrontal cortex's role in decision-making and the development of the Iowa Gambling Task (IGT) in the 1990s.

The Iowa Gambling Task was created to assess decision-making deficits, particularly in patients with prefrontal cortex damage, as traditional cognitive tests failed to detect such issues. The IGT simulates real-life decision-making by presenting participants with four decks of cards associated with various rewards and penalties. Two decks provide immediate but ultimately poor long-term returns, while the other two offer safer, more beneficial outcomes over time. Normal participants learn to choose advantageous decks, while those with damage to the prefrontal cortex struggle to do so.

The speaker explains the importance of incorporating emotional elements (rewards and punishments) into psychological testing, a novel approach at the time. They also highlight the connection between cognitive functions and emotional responses within the brain, specifically how the prefrontal cortex integrates these aspects into decision-making—a concept supported by the Somatic Marker Hypothesis. Damage to this brain area disconnects cognitive reasoning from emotional feedback, leading to impaired decision-making, which is observed in various psychiatric conditions, including substance abuse disorders and psychopathy.

The speaker concludes by noting the relevance of this line of research to understanding more contemporary behavioral issues, including debates around the addictive nature of excessive internet use compared to traditional substance abuse. Overall, the text underscores the complexity of decision-making processes and the critical role of the prefrontal cortex in facilitating effective judgments and emotional responses.

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X-TIMESTAMP-MAP:LOCAL=00:00:00.000,MPEGTS=900000

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This is actually a classic, paper,

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and it goes back in history to a very, very old case

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in 1868.

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Uh, pH g I dunno if you've heard that name,

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but this is a well known, neurological case

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where actually, this is someone who had an accident

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where an explosion happened

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and an iron temping bar went through the front of his head.

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It's like a bullet, but, but,

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but it was, it was, an an iron temping bar.

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So the, remarkable thing about it is

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that not only he survived the accident,

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because remember in those days, there were no antibiotics

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and, and nothing, of this sort.

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Uh, he didn't have any neurological deficits at all.

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So, so that was

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what was puzzling about that case.

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And then of course, all the work that happened since

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that time, patients who, get damage in

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that particular part of the brain,

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and, you know, it doesn't damage other surrounding area.

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You know, the ventral medial prefrontal cortex,

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usually they don't have any neurological deficits,

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so they don't have memory impairments,

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no language impairments, no paralysis, nothing of this sort.

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But there is a big change in their, personality.

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They become impo impulsive.

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And one of the main, defects that one begins

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to observe, and mostly, usually it's the people

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around the person, is that they have poor judgment

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and poor decision making.

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So they tend, they begin to make choices,

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that is, shortsighted.

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You know, that is, you know,

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if it has immediate con consequences

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and some long term negative consequences, they tend to focus

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on the, on the immediate for, so for this longest time

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until the 1990s,

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because that paper was published in 1994,

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there were no clinical tests that could capture

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that deficit in patients who suffer from that problem.

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So they come to the clinic,

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they don't have any neurological deficits,

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they don't have any cognitive deficits,

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so the reasoning ability is intact.

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Uh, their memory, their language, everything seems

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to be, normal.

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So there was no instrument that can capture that deficit.

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And that was the, the basis for that study

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and the development of that task that you see in that study

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that is now widely known as the Iowa Gambling Task

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or the IIGT.

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So, so the idea was to create sort

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of a, a laboratory model that

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that would capture the deficit in, in those patients.

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And, and, and the, the modeling of the real life,

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decision making is basically setting up a situation

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where you have choices that have some immediate reward

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or immediate punishment,

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but there are consequences that you could lose

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or you could, you could win in, in making decisions based on

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that, for example, how do you, how do you

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elicit reward in punishment in humans,

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in animal paradigms is very easy.

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You know, you can get, give them a food palate or,

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or a sweet taste or something of that sort.

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Uh, but in humans, what would drive a human, you know,

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for reward and for a punishment, and the answer is money.

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And we didn't have to use real money.

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We just used points and, and fake fake money.

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And, and it's a big motivator.

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So, so, so this is what the task is all about, is

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that, you know, you have choices between four decks

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of cards, and if you picked from any deck,

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you could win a, a certain amount, of money,

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but every once in a while,

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and it's unpredictable, you could stand

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to lose a certain amount of money.

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So each, each deck then is associated with a conflict.

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You could win money and you could lose money,

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but, the loss sometimes is bigger than the gain

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and, and vice versa.

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So that's, that's the, the setup.

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And, and,

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and of course, so there are four decks of cards.

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So two of the decks, we consider them advantageous

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because in the short term, they give you a lot of money.

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In the long term, you tend to lose a lot of money,

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whereas there are two other choices

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that they are safer choices.

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So in the short term, a term, you

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win less money in the long term, you win more money.

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Normal people, learn to,

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to choose from the good decks or the advantageous decks.

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Patients who have damage to the prefrontal cortex,

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they can never do that.

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So they keep choosing, from the decks that lead

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to long term, consequences.

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This task is the first of its kind,

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because all the neuropsychological testing up to

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that point was a very cognitive in nature.

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Uh, the idea Of introducing

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Reward And, and punishment,

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Uh, It was unheard of, you know, so,

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So There is no such a neuropsychological

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Task where basically you

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Exchange money gains in, in money losses.

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So it started with Me sitting

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With The patients

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With, With, you know, with

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Actual, not actual decks of cards,

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because here's, here's the, here's the trick.

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So there were a lot of little subtle

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Things that went on before The, the

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Task came about.

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If you, if we used a real decks

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of cards, what people

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Start to make wrong associations

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Was with, You know,

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If you have jacks or queens.

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So in other words, they, They associate

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Whatever they know about card games, which has nothing to

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Do with the task.

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The task is all about what you see in that

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Paper. You know, this

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is the original manual,

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Uh, task.

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You know, you see boxes, empty boxes,

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it means you are winning money.

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Those boxes that have negative number, it means

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That's a, A fixed amount of money that you

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Will use. So

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it, you will lose. So it,

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It's not gambling at all.

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It's a very, fixed schedule of

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Reward in, in, in punishment. So

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I really Sat down with the patients, and it's a matter

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Of, error In trial.

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You know, find the balance

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Of,

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How often you need to punish the person, how,

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how often you need to make the person win so

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that it's not very obvious.

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So the task, the way it is, it's very, very, subtle.

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So it's very hard to figure out that,

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You know, some decks are winners

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and by how much you are winning, and some decks are

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Losers. So it's,

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the,

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Uh, the amounts of gains and losses

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Are, are very, very subtle.

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So to avoid that,

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Uh, misconception about Associating

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Jacks and queens and kings with the game,

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we made the cards

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Discolor You, you know, red colors

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Or, or, black colors. Uh, people

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Ask me, Why did you have four decks

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Instead of Two decks, for example?

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Why not two choices, one good in one bad?

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Again, it's, it's the complexity. If you make it

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Two decks, It becomes so simple,

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Everybody will, will, will figure it out.

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So it's,

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It's it just error

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and trial kind of thing to find the right balance.

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And, and that's how the task came about.

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We started with a manual version, as you see in

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that particular paper,

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but now it's computerized, you know, the task is used

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worldwide and, and, and it comes on a computer.

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This was the very, very first test ever that

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captured that decision making deficit in this,

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in these particular, patients,

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because as, as we said, these patients will come

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to the clinic and they do well on the majority

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of cognitive tests that were available, at the time.

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So, so this was the, the very first test

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that allowed us to, capture

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that deficit in the laboratory.

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And this actually allowed us

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to study the underlying mechanisms.

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That is what goes wrong in, in, you know,

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or what is the underlying function

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of the ventromedial prefrontal, cortex.

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And, and then of course, the task,

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became not only specific to patients

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who have vented prefrontal cortex damage,

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but it's used now, widely, in a lot

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of psychs patients, patients who are thought to have

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frontal lobe dysfunction.

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So they don't necessarily have an injury,

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but there are a lot of disorders, you know, like,

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bipolar disorders, you know,

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those, those kind of conditions where, where actually,

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you know, substance abuse disorders, you know,

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those kind of disorders, there,

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there is impaired decision making,

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and these can be detected by this kind of task.

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You know, my previous mentor, Antonio DiMaggio, he was,

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he was the one who, developed

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that theory called the Somatic Marker Hypothesis.

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And, and the idea is that that part of the brain,

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the way it it function is that it couples

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two things, on, every decision,

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every complex decision in life,

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it has a cognitive component.

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So, you know, you have a se scenario, you have an image,

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you have, strategies, you have,

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thoughts in your mind,

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but there is also an emotional component.

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There is a marker. You know, there is something you learn

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throughout your life, you know, prior experiences

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with reward in punishment, your brain tends to

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register or, or, or record all those instances

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of reward in punishment.

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So basically the prefrontal cortex kind of couple,

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you know, that cognitive scenario to, you know,

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to that marker, which can be positive

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or a negative experience.

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And it's on that basis, you know, you make the decision

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or you bias your, your decision in one way.

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And that marker, in, in, in general language,

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people probably refer to it to a gut feeling or,

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or, or intuition.

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But in a way, the somatic marker, hypothesis

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was pretty much an evidence.

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It was a neuroscientific evidence that really

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describes an anatomical pathways in physi physiological

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pathways that are consistent with what people in general

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refer to gut feeling.

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So basically, the prefrontal cortex kind of,

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ties your cognitive thinking, you know, to a marker

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that can be positive or negative, which is a gut feeling.

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When you damage the prefrontal cortex, you,

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you disconnect the two.

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So, so the patient is still able

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to be cognitively con, intact.

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They could be geniuses, they could think everything,

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but they don't have that gut feeling

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that tells them not to do it.

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Like, let's say, trying to accept a bribe, you know,

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you know, that can be a very, very

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cognitively sophisticated thing,

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or let's say robbing a bank.

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And I'm not saying there is a different story about,

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you know, why, why neurological

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patients don't do those behaviors.

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This is a little bit of an extreme, but,

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but developmental people, you know, psychopathy,

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which is known to impact that part of the,

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brain, they do that.

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So why, for example, robbing a bank, you know,

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it can be very cognitively complex,

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but you don't have that marker, that negative marker,

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you know, that tells you don't do it.

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So the disconnect between the cognitive

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mechanisms and that emotional component that,

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puts a tag or,

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or puts a value on that cognitive scenario, in a way I kind

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of mentioned, mentioned this, is that, understanding

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the function of, of the prefrontal cortex, led

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to studies for understanding a lot of other neuropsych,

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neuropsychiatric disorders that are known

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to impact prefrontal cortex, function.

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Uh, I mentioned few, I mentioned substance abuse disorders.

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They are known to impact decision making functions.

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Psychology, are, are, are known

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to impact decision making, functions.

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And at least in, in, in my case, you know, beside

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studying neurological patients, you know, with brain damage,

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I led, many a career with many years of studying

15:20.205 --> 15:24.525
substance use, disorders, starting with,

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you know, patients who take hard drugs like heroin and,

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and cocaine to, modern day addictions.

15:34.365 --> 15:38.045
I call them. Uh, you know, there are, debates now,

15:38.045 --> 15:42.365
whether, for example, excessive internet use is, is a,

15:42.585 --> 15:44.405
is a form of an addiction.

15:44.665 --> 15:47.565
And, and whether this is really related

15:47.785 --> 15:50.845
to prefrontal cortex dysfunction or, or not,

15:50.985 --> 15:54.205
and at least, even though this is not related to this, I,

15:54.405 --> 15:55.885
I wanna assure everybody,

15:56.445 --> 16:01.125
although excessive internet, used,

16:02.345 --> 16:05.205
can be sometimes described as an addiction,

16:05.505 --> 16:06.725
but it's not identical.

16:06.995 --> 16:10.965
It's not the same pathology as someone who's addicted

16:11.465 --> 16:12.085
to heroin.

Neurological Insights from a Historic Case

00:00:00 - This is actually a classic, paper, and it goes back in history to a very, very old case in 1868. pH g I dunno if you've heard that name, but this is a well known, neurological case where actually, this is someone who had an accident where an explosion happened and an iron temping bar went through the front of his head.
00:00:32 - but it was, it was, an an iron temping bar. So the, remarkable thing about it is that not only he survived the accident, because remember in those days, there were no antibiotics and, and nothing, of this sort. he didn't have any neurological deficits at all. So, so that was what was puzzling about that case. And then of course, all the work that happened since
00:01:06 - that particular part of the brain, and, you know, it doesn't damage other surrounding area. You know, the ventral medial prefrontal cortex, usually they don't have any neurological deficits, so they don't have memory impairments, no language impairments, no paralysis, nothing of this sort. But there is a big change in their, personality. They become impo impulsive. And one of the main, defects that one begins
00:01:36 - around the person, is that they have poor judgment and poor decision making. So they tend, they begin to make choices, that is, shortsighted. You know, that is, you know, if it has immediate con consequences and some long term negative consequences, they tend to focus on the, on the immediate for, so for this longest time until the 1990s,
00:02:09 - there were no clinical tests that could capture that deficit in patients who suffer from that problem. So they come to the clinic, they don't have any neurological deficits, they don't have any cognitive deficits, so the reasoning ability is intact. their memory, their language, everything seems to be, normal.
00:02:39 - And that was the, the basis for that study and the development of that task that you see in that study that is now widely known as the Iowa Gambling Task or the IIGT. So, so the idea was to create sort of a, a laboratory model that that would capture the deficit in, in those patients.

Iowa Gambling Task: Decision Making and Rewards

00:03:12 - decision making is basically setting up a situation where you have choices that have some immediate reward or immediate punishment, but there are consequences that you could lose or you could, you could win in, in making decisions based on that, for example, how do you, how do you elicit reward in punishment in humans,
00:03:42 - You know, you can get, give them a food palate or, or a sweet taste or something of that sort. but in humans, what would drive a human, you know, for reward and for a punishment, and the answer is money. And we didn't have to use real money. We just used points and, and fake fake money. And, and it's a big motivator. So, so, so this is what the task is all about, is
00:04:17 - of cards, and if you picked from any deck, you could win a, a certain amount, of money, but every once in a while, and it's unpredictable, you could stand to lose a certain amount of money. So each, each deck then is associated with a conflict. You could win money and you could lose money, but, the loss sometimes is bigger than the gain
00:04:49 - So that's, that's the, the setup. And, and, and of course, so there are four decks of cards. So two of the decks, we consider them advantageous because in the short term, they give you a lot of money. In the long term, you tend to lose a lot of money, whereas there are two other choices that they are safer choices. So in the short term, a term, you
00:05:23 - Normal people, learn to, to choose from the good decks or the advantageous decks. Patients who have damage to the prefrontal cortex, they can never do that. So they keep choosing, from the decks that lead to long term, consequences. This task is the first of its kind,
00:05:54 - that point was a very cognitive in nature. the idea Of introducing Reward And, and punishment, It was unheard of, you know, so, So There is no such a neuropsychological Task where basically you Exchange money gains in, in money losses. So it started with Me sitting

Understanding the Iowa Gambling Task Design

00:06:21 - With, With, you know, with Actual, not actual decks of cards, because here's, here's the, here's the trick. So there were a lot of little subtle Things that went on before The, the Task came about. If you, if we used a real decks of cards, what people Start to make wrong associations Was with, You know, If you have jacks or queens.
00:06:55 - Whatever they know about card games, which has nothing to Do with the task. The task is all about what you see in that Paper. You know, this is the original manual, task. You know, you see boxes, empty boxes, it means you are winning money. Those boxes that have negative number, it means That's a, A fixed amount of money that you Will use. So it, you will lose. So it,
00:07:23 - It's a very, fixed schedule of Reward in, in, in punishment. So I really Sat down with the patients, and it's a matter Of, error In trial. You know, find the balance Of, How often you need to punish the person, how, how often you need to make the person win so that it's not very obvious. So the task, the way it is, it's very, very, subtle.
00:07:59 - You know, some decks are winners and by how much you are winning, and some decks are Losers. So it's, the, the amounts of gains and losses Are, are very, very subtle. So to avoid that, misconception about Associating Jacks and queens and kings with the game, we made the cards Discolor You, you know, red colors
00:08:32 - Ask me, Why did you have four decks Instead of Two decks, for example? Why not two choices, one good in one bad? Again, it's, it's the complexity. If you make it Two decks, It becomes so simple, Everybody will, will, will figure it out. So it's, It's it just error and trial kind of thing to find the right balance.
00:09:03 - We started with a manual version, as you see in that particular paper, but now it's computerized, you know, the task is used worldwide and, and, and it comes on a computer. This was the very, very first test ever that captured that decision making deficit in this, in these particular, patients, because as, as we said, these patients will come

Understanding Decision Making Through the Brain

00:09:36 - of cognitive tests that were available, at the time. So, so this was the, the very first test that allowed us to, capture that deficit in the laboratory. And this actually allowed us to study the underlying mechanisms. That is what goes wrong in, in, you know, or what is the underlying function of the ventromedial prefrontal, cortex.
00:10:09 - became not only specific to patients who have vented prefrontal cortex damage, but it's used now, widely, in a lot of psychs patients, patients who are thought to have frontal lobe dysfunction. So they don't necessarily have an injury, but there are a lot of disorders, you know, like, bipolar disorders, you know,
00:10:43 - you know, substance abuse disorders, you know, those kind of disorders, there, there is impaired decision making, and these can be detected by this kind of task. You know, my previous mentor, Antonio DiMaggio, he was, he was the one who, developed that theory called the Somatic Marker Hypothesis. And, and the idea is that that part of the brain,
00:11:14 - two things, on, every decision, every complex decision in life, it has a cognitive component. So, you know, you have a se scenario, you have an image, you have, strategies, you have, thoughts in your mind, but there is also an emotional component. There is a marker. You know, there is something you learn throughout your life, you know, prior experiences
00:11:48 - register or, or, or record all those instances of reward in punishment. So basically the prefrontal cortex kind of couple, you know, that cognitive scenario to, you know, to that marker, which can be positive or a negative experience. And it's on that basis, you know, you make the decision
00:12:16 - And that marker, in, in, in general language, people probably refer to it to a gut feeling or, or, or intuition. But in a way, the somatic marker, hypothesis was pretty much an evidence. It was a neuroscientific evidence that really describes an anatomical pathways in physi physiological pathways that are consistent with what people in general

Prefrontal Cortex and Decision-Making Disconnect

00:12:49 - So basically, the prefrontal cortex kind of, ties your cognitive thinking, you know, to a marker that can be positive or negative, which is a gut feeling. When you damage the prefrontal cortex, you, you disconnect the two. So, so the patient is still able to be cognitively con, intact. They could be geniuses, they could think everything,
00:13:22 - that tells them not to do it. Like, let's say, trying to accept a bribe, you know, you know, that can be a very, very cognitively sophisticated thing, or let's say robbing a bank. And I'm not saying there is a different story about, you know, why, why neurological patients don't do those behaviors. This is a little bit of an extreme, but,
00:13:53 - which is known to impact that part of the, brain, they do that. So why, for example, robbing a bank, you know, it can be very cognitively complex, but you don't have that marker, that negative marker, you know, that tells you don't do it. So the disconnect between the cognitive mechanisms and that emotional component that, puts a tag or,
00:14:26 - of mentioned, mentioned this, is that, understanding the function of, of the prefrontal cortex, led to studies for understanding a lot of other neuropsych, neuropsychiatric disorders that are known to impact prefrontal cortex, function. I mentioned few, I mentioned substance abuse disorders.
00:14:57 - Psychology, are, are, are known to impact decision making, functions. And at least in, in, in my case, you know, beside studying neurological patients, you know, with brain damage, I led, many a career with many years of studying substance use, disorders, starting with,
00:15:29 - and cocaine to, modern day addictions. I call them. you know, there are, debates now, whether, for example, excessive internet use is, is a, is a form of an addiction. And, and whether this is really related to prefrontal cortex dysfunction or, or not, and at least, even though this is not related to this, I, I wanna assure everybody,

Understanding Addiction: A Nuanced Perspective

00:16:11 - can be sometimes described as an addiction, but it's not identical. It's not the same pathology as someone who's addicted to heroin.

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