Review
Decision making and neuropsychiatry

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Abstract

Abnormal decision making is a central feature of neuropsychiatric disorders. Recent investigations of the neural substrates underlying decision making have involved qualitative assessment of the cognition of decision making in clinical lesion studies (in patients with frontal lobe dementia) and neuropsychiatric disorders such as mania, substance abuse and personality disorders. A neural network involving the orbitofrontal cortex, ventral striatum and modulatory ascending neurotransmitter systems has been identified as having a fundamental role in decision making and in the neural basis of neuropsychiatric diseases. This network accounts for the dissociations among decision-making deficits in different clinical populations. Ultimately, a more refined and sophisticated characterization of such deficits might guide the early diagnosis and cognitive and therapeutic rehabilitation of these patients.

Section snippets

Somatic markers

To explain the dissociation between personal decision-making ability and other aspects of cognition, markers or biasing factors in humans have been postulated to act in normal cognition to enhance decision making 10. For the brain to compute expected utilities accurately (as a computer might) would take a finite time; it is better to make an imperfect decision quickly than eventually to make what would have been the perfect decision. Damasio has argued that ‘somatic markers’ provide a way of

Decision making in substance abusers

Examining the decision-making behaviour of substance abusers provides a useful starting point, because drug abuse could reflect a breakdown of the ability to evaluate potential reward against harm from drug self-administration. Activity in the OFC and its connections have now been found to play a role in several components of the maladaptive behaviour of substance abuse, including expectancy, craving and impaired decision making 22.

The importance of the ventral striatum and the amygdala in

Frontotemporal dementia

In a rather different clinical condition – frontal-variant frontotemporal dementia (fvFTD) – PFC neurodegeneration is the principal cause for a circumscribed behavioural syndrome in which the majority of patients are brought to the clinic unaware of major pervasive changes in their personality, behaviour and social conduct, as observed by informants 26. Patients can appear apathetic or withdrawn, or alternatively they can become socially disinhibited with facetiousness and inappropriate

Decision making and the regulation of impulsive behaviour

Tasks such as ours can help to clarify the relationship between impulsive responding and risk taking. Impulsivity is multifaceted 36 but includes aspects of sensation seeking, inappropriately short decision times and lack of persistence. In our task, early bets would suggest consistent impulsive, or disinhibited, responding but large bets would indicate risk seeking. As described earlier, using this measure it appears that patients with fvFTD are not consistently impulsive. However, the poor

Unipolar and bipolar depression

The relevance of examining decision making in unipolar and bipolar (‘manic’) depression is clear from the DSM-IV classification, which states that individuals currently experiencing major depressive episodes often have difficulty making decisions. Likewise, manic individuals tend to display excessive involvement in pleasurable activities carrying a high potential for painful consequences. Despite markedly different clinical presentations, few studies have reported differences between

Conclusion

This review has examined our understanding of the neuroscientific basis of decision making and its relevance to several pertinent neuropsychiatric conditions. Results from studies using several different approaches, including lesion studies, functional neuroimaging and neurophysiology, converge upon the notion that the neural substrates underlying decision making include the OFC, striatum, amygdala, somatosensory cortices and the chemically defined neuromodulatory projections of the

Questions for future research

  • What are the relative contributions of the amygdala and the OFC to decision making?

  • How can methodologies such as ‘efferent connectivity’ be used to determine how structures within the decision-making neural system interact 56?

  • To what extent are somatic markers absent or abnormal in neuropsychiatric disorders such as anxiety and depression?

  • To what extent are the neural mechanisms governing decision making lateralized in the brain?

Acknowledgements

This research was funded by a Programme Grant from the Wellcome Trust to T.W.R., B.J. Everitt, B.J.S. and A.C. Roberts, and was completed within the Medical Research Council Cooperative Group in Brain, Behaviour and Neuropsychiatry. S.R. and R.N.C. were supported by the Medical Research Council and the University of Cambridge School of Clinical Medicine. We would like to thank the participating subjects, doctors and nursing staff involved in the studies included in this review.

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