A review of risky decision-making in psychosis-spectrum disorders

Highlights

• Explicit, ambiguous, and uncertain risk-taking were reviewed in psychosis.

• Risk imperception, rather than risk-seeking, is implicated in explicit risk-taking.

• Risk aversion is implicated in uncertain risk-taking, though not exclusively.

• Risk imperception may be secondary to, or associated with, cognitive deficits.

• Symptoms are not consistently associated with risky decision-making behavior.

Abstract

The investigation of risky decision-making has a prominent place in clinical science, with sundry behavioral tasks aimed at empirically quantifying the psychological construct of risk-taking. However, use of differing behavioral tasks has resulted in lack of agreement on risky decision-making within psychosis-spectrum disorders, as findings fail to converge upon the typical, binary conceptualization of increased risk-seeking or risk-aversion. The current review synthesizes the behavioral, risky decision-making literature to elucidate how specific task parameters may contribute to differences in task performance, and their associations with psychosis symptomatology and cognitive functioning. A paring of the literature suggests that: 1) Explicit risk-taking may be characterized by risk imperception, evidenced by less discrimination between choices of varying degrees of risk, potentially secondary to cognitive deficits. 2) Ambiguous risk-taking findings are inconclusive with few published studies. 3) Uncertain risk-taking findings, consistently interpreted as more risk-averse, have not parsed risk attitudes from confounding processes that may impact decision-making (e.g. risk imperception, reward processing, motivation). Thus, overgeneralized interpretations of task-specific risk-seeking/aversion should be curtailed, as they may fail to appropriately characterize decision-making phenomena. Future research in psychosis-spectrum disorders would benefit from empirically isolating contributions of specific processes during risky decision-making, including the newly hypothesized risk imperception.

Introduction

“…taking a risk is not the same as having poor judgement and impaired decision-making” - Bechara, Damasio, and Damasio (2000)

Psychotic disorders such as schizophrenia (SZ) and schizoaffective disorder (SZA) are often characterized by pervasive cognitive impairment, hallucinations, unusual beliefs, atypical affectivity, and decreased goal pursuit. Despite extensive literature investigating risky decision-making, there is no consensus as to whether psychotic disorders are associated with increased or decreased risk-taking on behavioral, laboratory tasks. This is particularly troublesome when conflicting interpretations are applied to understanding ecological phenomena or formulating recommendations for treatment. The present review synthesizes findings across three categories of risky decision-making tasks (explicit, ambiguous, and uncertain risk). It is posited that during explicit risk-taking psychotic disorders are not characterized by greater risk-averse nor risk-seeking attitudes, but rather risk imperception, defined as decreased ability to perceive and integrate risk-relevant information to properly discriminate between options and optimize decision-making. Risk imperception may also impact ambiguous or uncertain risky decision-making, but further investigation is necessary to identify specificity of potential deficits and rule out confounding processes. While the current review outlines descriptive support for risk imperception in psychosis by interpreting findings in the literature, the hypothesis warrants further, direct testing via targeted behavioral tasks.

During decision-making, evidence is accumulated from the environment and integrated with prior beliefs (Sterzer et al., 2018). Previous findings in psychosis have implicated a general deficit in this integration process, resulting in aberrant decision inferences that may not be well-adjusted by option values (Gold, Waltz, Prentice, Morris, & Heerey, 2008; Sterzer, Voss, Schlagenhauf, & Heinz, 2019). Poorer decision-making in psychosis has manifested as disrupted reinforcement learning, reduced effort allocation, indiscriminate probabilistic reversal learning, and jumping to conclusions, with many studies identifying an association between cognitive functioning and decision-making quality (Barch et al., 2017; Culbreth, Moran, & Barch, 2018; Reddy, Waltz, Green, Wynn, & Horan, 2016; Tripoli et al., 2020). Social, financial decision-making tasks in psychosis similarly reveal poorer choices in the forms of accepting unfair offers, rejecting fair offers, and other forms of maladjustment to a partner's performance (for review see Robson, Repetto, Gountouna, & Nicodemus, 2020). The present review suggests that this decision-making deficit, while not differential (i.e. not uniquely isolated to risky decision-making; MacDonald, 2014), extends into risk-taking tasks. Though the hypothesized risk imperception is likely secondary to a more general deficit (Fig. 1), it offers novel, process-oriented insight into evidence integration in psychosis, as many risky decision-making tasks do not rely on decision-outcome evaluation or learning. Thus, the current review is a departure from, and extension of, the extensive reinforcement and reward learning literature (Deserno, Schlagenhauf, & Heinz, 2016; Pratt et al., 2020).

Risk as a psychological experience can be conceptualized as the construal of future events with potentially undesirable consequences (Sjöberg, 2000). However, risk in behavioral tasks can be broken down into sub-components that differently influence decision-making (Fukunaga et al., 2018, Schonberg, Fox, & Poldrack, 2011). Behavioral tasks have investigated decision-making along various psychological and mathematical forms of risk, assessed in the laboratory using probabilistic gambles for gains, losses, or null outcomes. Such tasks have been purported to measure “risk attitude”, or the amount of risk one will endure for a potential benefit (Kahneman & Tversky, 2013). Risk attitude is typically described as risk seeking or risk averse, based on decisions relative to gamble parameters such as potential gain probability, gain amount, loss amount,¹ loss probability, variance, entropy, framing effects, and expected value (EV²; Herrnstein, 1970; Slovic & Lichtenstein, 1968). Differing methods of analyzing these parameters can determine the isolated or relative impact of specific forms or facets of risk on choice behavior^3,4

However, risk attitudes are importantly shaped by “risk perception”, or the initial cognitive processes by which information is integrated to formulate understanding of risk (Weber & Milliman, 1997). Rather than being driven primarily by gamble parameters, Sjöberg (2000) reflects that, “Risk perception is all about thoughts, beliefs and constructs”. Given the far-reaching cognitive dysfunction, atypical beliefs, and faulty information integration found in psychosis (Garety, Bebbington, Fowler, Freeman, & Kuipers, 2007; Lee & Park, 2005; Velthorst et al., 2021), it is vital to elucidate whether risky decision-making deficits may be better attributed to differences in risk perception (Fig. 2), rather than risk attitude.