Executive function and decision-making in Colombian patients with paranoid schizophrenia

JE Acosta-Lopez; M L Cervantes-Henriquez; S Téllez-Bustillo; Mostapha Ahmad; Manuel Sanchez-Rojas; C N Paredes-Manrique; J A Zegarra-Valdivia

doi:10.12688/f1000research.143978.2

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Research Article

Revised

Executive function and decision-making in Colombian patients with paranoid schizophrenia

[version 2; peer review: 2 approved with reservations]

JE Acosta-Lopez ¹, M L Cervantes-Henriquez¹, S Téllez-Bustillo², [...] Mostapha Ahmad³, Manuel Sanchez-Rojas⁴⁺, C N Paredes-Manrique⁵, J A Zegarra-Valdivia⁶

JE Acosta-Lopez ¹, M L Cervantes-Henriquez¹, [...] S Téllez-Bustillo², Mostapha Ahmad³, Manuel Sanchez-Rojas⁴⁺, C N Paredes-Manrique⁵, J A Zegarra-Valdivia⁶

⁺ Deceased author

PUBLISHED 22 May 2025

Author details Author details

¹ Faculty of Juridical and Social Sciences, Center for Research in Life Sciences, Universidad Simón Bolívar, Barranquilla, Colombia
² Hospital Universitario CARI-ESE, Barranquilla, Colombia
³ Faculty of Health Sciences, Center for Research in Life Sciences, Universidad Simón Bolívar, Barranquilla, Colombia
⁴ Universidad Simón Bolívar, Barranquilla, Colombia
⁵ Universidad Tecnológica del Perú, Lima, Peru
⁶ Universidad Senor de Sipan, Chiclayo, Peru

JE Acosta-Lopez
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

M L Cervantes-Henriquez
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing

S Téllez-Bustillo
Roles: Formal Analysis, Investigation, Methodology, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing

Mostapha Ahmad
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology

Manuel Sanchez-Rojas
Roles: Conceptualization, Writing – Original Draft Preparation

C N Paredes-Manrique
Roles: Supervision, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

J A Zegarra-Valdivia
Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Supervision, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

This article is included in the Social Psychology gateway.

Abstract

Background

Schizophrenia (SCZD) is a mental disorder characterized by cognitive dysfunction, impaired decision-making abilities, abnormalities in brain functioning, and specific genetic markers. Ethnic and racial factors influence the development and presentation of schizophrenia, with different groups experiencing different levels of risk and exhibiting different patterns of mental disorders.

Objective

We sought to investigate the executive function and decision-making profile of Schizophrenia participants from Barranquilla, Colombia, which have a high genetic mixture and significant ethnic and racial diversity.

Methods

The sample consists of 40 individuals, 20 diagnosed with paranoid schizophrenia and 20 controls. We use the BANFE neuropsychological battery and the Iowa Gambling task to measure executive function and decision-making processes.

Results

The study found differences in cognitive performance, measured by the Neuropsychological Battery of Executive Functions and Frontal Lobes, in the medial orbit, anterior prefrontal, dorsolateral, and total executive function measures. In decision-making, as measured by the Iowa Gambling Test, there were also differences between the two groups, with those with schizophrenia performing worse and showing a preference for disadvantageous options. The study also found that there were no significant differences in socio-demographic characteristics between the two groups but that there were differences in terms of socio-economic status and educational level.

Conclusion

This study found that individuals with paranoid schizophrenia had significant differences in their prefrontal cortex compared to those without the condition, specifically in the dorsolateral and orbital-prefrontal cortex. These differences may be linked to difficulties adjusting to their environment and processing reinforcement, leading to impaired learning and arousal disturbances.

Keywords

Schizophrenia, Colombia, neuropsychological assessment, executive function, decision-making.

Corresponding author: JE Acosta-Lopez

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2025 Acosta-Lopez J et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Acosta-Lopez J, Cervantes-Henriquez ML, Téllez-Bustillo S et al. Executive function and decision-making in Colombian patients with paranoid schizophrenia [version 2; peer review: 2 approved with reservations]. F1000Research 2025, 13:189 (https://doi.org/10.12688/f1000research.143978.2) First published: 11 Mar 2024, 13:189 (https://doi.org/10.12688/f1000research.143978.1) Latest published: 22 May 2025, 13:189 (https://doi.org/10.12688/f1000research.143978.2)

Revised Amendments from Version 1

This version of the article includes specific changes in response to the reviewer’s comments. The theoretical framework was strengthened with recent literature, particularly in the discussion and methodology sections, to better contextualize the findings. The research objectives were reformulated for greater clarity, and details were added regarding sample selection criteria and analytical instruments.
In the results section, the data were reorganized, and new tables and figures were included as requested. The discussion was expanded, establishing a more direct connection between the findings and previous studies, and enhancing their interpretation. The conclusion was rewritten to more accurately reflect the study’s contributions and implications.
Finally, formal and stylistic revisions were made to improve clarity, coherence, and alignment with the journal’s academic standards.

To read any peer review reports and author responses for this article, follow the "read" links in the Open Peer Review table.

Introduction

Schizophrenia (SCZD) is a severe mental disorder that affects approximately 0.5-15 of the general population, occupying 0.9-3.8 cases per 1000 inhabitants.² This disorder is associated with lasting effects on health, generating an impact on quality of life,³ presenting high costs for medical care, representing 1.1% of the total amount of national spending on health care⁴^,⁵ in countries such as the United States (Charrier et al., 2013) China,⁴^,⁶ Malaysia,⁷ India, England⁸^,⁹ France,⁵ Germany,¹⁰ Switzerland¹¹ and the rest of Europe.¹² In Colombia,¹³ there is a significant variation in the interventions¹⁴ and the direct and indirect costs¹⁵ (i.e., employment rates, gender, salary, age, number of hospitalizations, pharmaceutical products, rehabilitation processes and monitoring of patients) compared to other countries.¹⁶

Neurophysiology studies of schizophrenia report abnormalities in N200 and P300, functional connectivity measures¹⁷^,¹⁸ electroencephalography EEG¹⁹ Quantitative association between the volume of gray matter and ventromedial prefrontal cortex (VMPFC),²⁰ have evidenced alterations in the integration routes related to symptoms and cognitive dysfunction; as a fundamental characteristic of schizophrenia with substantial proportions of inheritability (h2 = 0.33-0. 85),²¹^–²⁵ which makes it possible to elucidate the mechanisms that lead from genes to psychopathology; therefore, genes such as Brain-derived neurotrophic factor (BDNF), Neurotrophic tyrosine kinase receptor 2 NTRK2,²⁶^–²⁹ Cholinergic receptor nicotinic alpha 4 subunit (CHRNA4), cholinergic receptor nicotinic beta 2 subunit (CHRNB2), Brain-derived neurotrophic factor (BDNF), neurotrophic receptor tyrosine kinase 2 (NTRK2),³⁰ Gamma-Aminobutyric Acid (GABA),²⁸ Antagonists of receptors 5-hydroxitriptamine type 3 (5-HT3A),³¹ AKT serine/threonine kinase 1(AKT1),³² Neurogranin (NRGN)³³; considered polygenic vulnerability markers³⁴ with minor effects.³⁵ Identifying these biomarkers could contribute to the diagnosis and treatment of schizophrenia.³⁶ associated with neurocognitive deficits,³⁷ inhibitory control, intellectual disability,³⁸^,³⁹ working memory,⁴⁰ visual and verbal memory, speed processing, attention,³²^,⁴¹^–⁴⁵ visual construction,⁴⁶ social cognition,⁴⁶ theory of mind,⁴⁷^–⁴⁹ sensory processing, facial recognition deficits,⁵⁰ and decision making.⁴⁹^,⁵¹ The identification of these markers could contribute to the diagnosis and treatment of schizophrenia.³⁶

Regarding decision-making in patients with schizophrenia, most studies showed deficiencies in the Iowa Gambling Test (IGT), which suggests a preference for disadvantageous cards,⁵² which poses a reduced sensitivity to punishments, being unable to regulate their decision-making to implement practical strategies, even when the probabilities of winning or losing are explicitly revealed.⁵³^,⁵⁴ In selecting and initiating action, through the integration of sensorimotor, cognitive, and motivational/emotional information.⁵⁵

This work is of particular interest because Colombia is an ethnically diverse country presenting the highest levels in Latin America⁵⁶^,⁵⁷ of mixtures by three groups (Indigenous/Amerindians, Spaniards, and Africans).⁵⁸ The miscegenation process was selective to the point of having regions of African descent⁵⁹^–⁶² predominantly Caucasian or indigenous.⁶³^,⁶⁴ Other prominent minority populations are concentrated on the Caribbean Coast.⁵⁸^,⁶⁵ For example, the city of Barranquilla is the result of a mixture between the Afro-descendant population, white Europeans from Andalusia, Spain, Syrian Lebanese, Sephardic Jews, Germans, Italians and English.⁶⁶^–⁶⁹ Colombia has one of the highest levels of genetic admixture of the three groups.⁷⁰^–⁷²

Significant interactions have been found between race/ethnicity⁷³^,⁷⁴ sociocultural traditions, education, linguistically different populations, developmentally presupposed behavioral stereotypes, typical patterns, and mental disorders⁷³ in minority groups (i.e., Asian, Black, African American, White, Hispanic) who are at low risk for mental disorders, but not evenly across racial/ethnic groups or disorders.⁷⁵

This study aims to characterize the executive function, specifically the decision-making of the people affected by the schizophrenia of a sample with these characteristics related to the demographic location.

Methods

Subjects

We recruited 40 participants for this study (20 controls and 20 Schizophrenia). Participants were selected according to the following The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) criteria guidelines for paranoid schizophrenia. The control participants were recruited from the Health Services of Primary Attention and university students from Barranquilla City. The mean age of the sample was 33.80 ± 4.66 years old. 67.5% of the participants were females. Further details are provided in Table 1.

Table 1. Demographic characteristics of the participants included in this study.

Variables	Controls	SCZD Group	Statistic	p	Cohen’s d
Variables	N = 20	N = 20	Statistic	p	Cohen’s d
	Mean (SD)	Mean (SD)	U Mann-Whitney
Age	30,50 (10,17)	37,10 (8,11)	117,000	0.025	0.74
Educational Level	9,70 (2,59)	9,35 (3,04)	18<0.001	0.568	0.13
Socio-economic Status	1 (0,00)	1(0,00)	20<0.001	1.000	-
Gender			χ²
Males	5	8	0,125	0.727	-
Females	15	12	0,125	0.727	-

Forty participants were recruited for this study (20 controls and 20 schizophrenics). Participants were selected according to the following Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria guidelines for paranoid schizophrenia, who were diagnosed by professionals in the field, with clinical stability of symptoms of three months, school-aged and in the age range of 18 to 65 years. Subjects with additional psychiatric comorbidities, severe neurological illnesses (dementia, brain lesions) and who were taking medications other than antipsychotics that may alter cognition were excluded from the study. Control participants were recruited from primary care health services and university students in the city of Barranquilla. Participants between 18 and 65 years of age with no history of psychiatric or neurological disorders, schooled, were included. Exclusion criteria for this group were personal or family history of schizophrenia or other psychoses, active consumption of psychoactive substances, and use of medications that could alter cognitive function. The mean age of the sample was 33.80 ± 4.66 years. 67.5% of the participants were women. Further details are given in Table 1.

Design and procedure

Retrospective ex post facto study with two groups.⁷⁶ Sampling was non-probabilistic and intentional. For the sample selection, we proceeded to request the respective permits in the hospital. Subsequently, informed consent was obtained from each participant. Controls were recruitment from Health Services of Primary Attention and the university. After approval, the participants were selected considering the following inclusion/exclusion points: a) the presence of any medical illness that prevents the evaluation; b) uncorrected sensory alteration (visual problems) that prevented the correct execution of the neuropsychological test; c) management and understanding of the tests instructions in the Spanish language; d) presence of psychiatric symptoms or severe cognitive alteration that prevented the evaluation, e) signed consent.

Ethical statement

This study adhered to the ethical considerations for clinical trials, ensuring that all methods were conducted in accordance with the relevant guidelines and regulations of the Declaration of Helsinki. Participants were fully informed about the aims and potential risks of the study, and gave written consent. Ethical approval for the research was obtained from the Ethics Committee of the Universidad Simón Bolívar, created under internal regulation N° 00001 on 11/05/06 in Barranquilla, Colombia, which granted this research with the code CIE-USB-0075. Following approval by the ethics committee, participants were informed of the purposes of the study and their written consent was obtained.

Crucially, all data collected during the research were stored anonymously in a database, ensuring the confidentiality and privacy of participants’ information. This additional measure reflects an ongoing commitment to the ethical principles outlined in the Declaration of Helsinki and safeguards the integrity of the research.

Clinical assessment

Brief Psychiatric Rating Scale (BPRS): The Brief Psychiatric Rating Scale (BPRS) was created by Overall and Gorham⁷⁷^,⁷⁸ and assesses symptomatologic changes in psychiatric patients. There is a validated Spanish version.⁷⁹ It is currently used as a measure of severity and subtyping in schizophrenia. This assessment scale is probably the most widely used in psychiatry. This test initially consisted of 16 items, although there is also an expanded version with 24 items. It is carried out in the context of a semi-structured interview. It provides an overall score and scores in two sections: positive symptoms and negative symptoms. The Likert scale’s cut-off points offer three possibilities: absence of disorder, mild disorder or probable case, and severe disorder or specific case.

Neuropsychological assessment

The Neuropsychological Battery of Executive Functions and Frontal Lobes (BANFE).⁸⁰ The Battery of Executive Functions employed in this study, commonly known as BANFE (The Neuropsychological Battery of Executive Functions and Frontal Lobes), is indeed an instrument used in this research, acquired in compliance with ethical and legal considerations, along with the necessary licenses for its use. The required authorizations and licensing details have been secured by the psychometrics department of the institution, which is responsible for procuring materials and supplies while adhering to intellectual property regulations related to the use of the instrument.

This battery represents a detailed and appropriate neuropsychological assessment proposal for both children and adults; it evaluates the development of Executive Functions through high reliability and validity tests for assessing cognitive processes that depend on which are grouped into three specific areas: Orbit medial, Anterior Prefrontal, and Dorsolateral. The battery allows for obtaining not only a global performance index in the battery but also an index of the functioning of the three areas evaluated. It also has a performance profile in which a summary of the normalized scores corresponds to each subtest.⁸¹

As described somewhere else,⁸² the subtest includes the following a) prefrontal-dorsal-lateral (working memory verbal, ordering, Card Sorting Test (mental flexibility, Mazes (visuospatial planning), Tower of Hanoi (sequential planning), Consecutive Subtraction (reverse sequencing), Verb Generation (verbal fluency), b) Orbito-medial prefrontal (Stroop (inhibitory control), “Iowa” card test (processing risk-benefit), and mazes (following rules), and c) Anterior prefrontal (Generation of classifications semantics (productivity), comprehension and selection of proverbs (understanding the figurative meaning), the curve of meta-memory (metacognitive control, judgment, and monitoring). BANFE is a set of widely used neuropsychological tests applied to subjects with brain damage or neuropsychiatric diseases. These tests are supported by functional neuroimaging studies and are considered to have convergent and clinical validity in neuropsychology.

Iowa Gambling Task (IGT).⁸³^,⁸⁴ It measures decision-making by risk-benefit election⁸⁵ Participants were presented with four virtual decks of cards on a computer screen. They are told that each deck has cards that reward or penalize them using in-game money. The object of the game is to earn as much money as possible. The decks differ in the balance of reward vs. penalty cards. Therefore, some decks are “bad decks,” and other decks are “good decks” because some decks tend to reward the player more often than others decks.⁸⁶

Statistical analysis

Measures of location and dispersion were employed to summarize continuous variables. Frequencies and proportions were estimated for categorical variables. Categorical variables were compared using a χ² test. Variables meeting the assumptions of normality and homogeneity of variance were contrasted using the t-test for two independent samples or the nonparametric Mann–Whitney U test. Normality and homogeneity of variance were tested with the Shapiro–Wilks and the Bartlett tests, respectively. Uncorrected Cohen’s d was calculated to measure the effect size for all variables.⁸⁷^,⁸⁸ To avoid the effect of potential confounding variables such as age, gender, and education, p-values were corrected using analysis of covariance (ANCOVA) and (MANOVA).

In particular, an ANCOVA was applied to examine the effect of clinical diagnosis on performance on the Iowa Gambling Task (IGT), controlling for the aforementioned covariates. This analysis also allowed estimating the observed statistical power (post hoc) for each predictor of the model, calculated from the partial eta squared effect size (η²), the sample size, the degrees of freedom and a prespecified alpha level of 0.05 (see Supplementary table).

A Two-Way ANOVA analysis followed by Sidak’s multiple comparisons tests was also performed. Statistical analysis was performed with Statistical Package for the Social Sciences version 24 (SPSS, Chicago, IL, USA) and Graph Path (version 9.5.0, San Diego, California, USA). Significant results are indicated with * p<0.05 and ** p<0.01.

Results

Sample description

The sample comprises 40 subjects residing in Barranquilla and its metropolitan area ( Table 1). The subjects were organized into two groups made up of 20 adults diagnosed with paranoid schizophrenia (50.0%), of the diagnosed subjects (8[40%] male, 12 [60%] female). As expected, the distribution of diagnosis did not differ by gender (95% CI: 1.15-1.45). Subjects were under medication at the time of evaluation. While the control group with 20 subjects (50.0%), of which (5 [25%] were male and 15 [75%] were female). The mean age in the entire sample was 34.85±9.792 (range 18-50); As expected, the distribution by age found statistically significant differences (p<0.025) according to the SCZD status (affected 37.10±8.11, unaffected 30.50±10.17) regarding schooling, no statistically significant differences were found in the groups (SCZD 9.35±3.04, unaffected 9.70±2.59, p=0.568), regarding the stratum no significant differences were found.

Executive function

Table 2 presents the analysis results to determine the differences between individuals affected and not affected by SCZD in the sample of 40 subjects. Differences were found in the average performance registered by cases and controls in the medial orbit (p≤0.001; d=3.15), the Anterior Prefrontal (p≤0.001; d=1.99), Dorsolateral (p≤0.001) areas; d=3.02) and in Total Executive Functions (p≤0.001; d=3.39).

Table 2. Performance in the Neuropsychological Battery of Executive Functions and Frontal Lobes BANFE.

Neuropsychological Battery Executive Functions	Controls	SCZD Group	U Mann-Whitney	p	Cohen’s d
Neuropsychological Battery Executive Functions	N=20	N=20	U Mann-Whitney	p	Cohen’s d
Orbit medial	101,90 (12,84)	52,30 (18,96)	7,000	<0.001	3.15
Anterior Prefrontal	109,15 (13,31)	77,50 (18,84)	30,500	<0.001	1.99
Dorsolateral	92,80 (15,53)	52,10 (11,07)	9,000	<0.001	3.02
Total Executive Function	95,75 (14,70)	51,50 (11,92)	5,000	<0.001	3.39

Decision-making

The analyzed results are presented to determine the differences ( Table 3) between affected and unaffected individuals. After correcting for confounding variables, differences were found in the average performance recorded by cases and controls on the Iowa Gambling test (IGT) (p<0.012; d=0.96) with a medium effect size.

Table 3. Decision-making in Schizophrenia participants.

TEST	Controls	SCZD group	U Mann-Whitney	p	Cohen’s d
TEST	N=26 (DE)	N=20 (DE)	U Mann-Whitney	p	Cohen’s d
Iowa Gambling Test	1607,5 (685,4)	2422,5 (1020,1)	107,000	0.012	0.96

Figure 1 shows the differences between the total amount obtained (cumulative earnings) by the control group vs. SCZD. Discrepancies in performance were found; even the SCZD group showed a more significant presence of economic losses, obtained by the absence of a pattern of adaptive responses or future myopia (t-test, Welch correction, p=0.0010**). The effect size through Cohen’s d is 1.032, which is considered a good effect. To avoid potential cofounders in this comparison, we use ANCOVA, including IGT total score as an independent variable, diagnostic as independent, and age, gender, and education years as covariables (see Supplementary Table 1). No effects were found for age (p=0.67), gender (p=0.402), and education years (p=0.405). The impact of diagnosis (control vs. patients) was still high (p<0.001, η²=0.243).

Figure 1. Total IGT score between participants.

Figure 2 shows the scores in groups of 20 stimuli through the different trials. Significant statistical differences are observed (Two-Way ANOVA, p≤0.0011 for the group, and p=0.03 for the interaction effect). From the second trial, it is observed that the learning pattern, guided by the positive/negative reinforcements in the choice of cards, shows that the SCZD group presents a poor performance, which is maintained throughout the trials, while the control group shows a straightforward learning process. Through multiple comparisons (Sidak’s test), the following differences were found trial 1 (p=0.0816), trial 2 (p=0.0050*), trial 3 (p=0.0053*), trial 4 (p≤0.0011**), and trial 5 (p≤0.0011**). To avoid potential cofounders in this comparison, we use MANCOVA, including IGT1 to IGT5 scores as dependent variables, diagnostic as independent, and age, gender, and education years as covariables (see Supplementary Table 2). No effects were found for age, gender, and education years. The impact of diagnosis (control vs. patients) was still high for each IGT score (IGT2: p=0.002, η²=0.206, IGT3: p=0.012, η²=0.146, IGT4: p=0.002, η²=0.203, and IGT5: p<0.001, η²=0.297) except for first trial block (IGT 1: p=0.1140, η²=0.060).

Figure 2. Response Pattern in IGT in Persons Affected with Paranoid Schizophrenia.

Discussion

The studies of schizophrenia related to cognitive deficits have gained great interest and have currently allowed us to identify and evaluate the altered cognitive dimensions in people with schizophrenia including executive functions; Especially, decision making. This study threw two aspects regarding the dimensions of the executive functions; The first aspect is a). The functions evaluated with the neuropsychological battery of executive functions and frontal lobes (BANFE) have solid evidence that support the presence of significant differences in areas belonging to the prefrontal cortex between affected and not affected by paranoid schizophrenia ( Table 2) consisting of an altered activation To generate exploratory behaviors in uncertain reward environments affected with this disorder⁸⁹^,⁹⁰ the sample belonging to the study presented poor performance in areas of the dorsolateral prefrontal cortex (DLPFC) particularly when the damage is in the right hemisphere and there are also difficulties In the working memory,⁹¹ in this sense there has been a marked deficit in decision making in patients with lesions in the orbitofrontal (COF) and ventromedial (CPFVM) regions of the prefrontal cortex (CPF) that is related to changes in the predictions of future and rewarding events; as well as, direct the behavior to the achievement of a goal, carry out adequate learning of the task and transfer the solution to similar tasks.⁹² Together, these findings can be unraveled through maladjustment and frequent outdated strategy.⁹³^–⁹⁵

On the other hand and by the results, a continuous interpretation deficit was found based on its incentive value; The brain areas that underlie these processes have been identified as the medial and orbitofrontal,⁹⁶ prefrontal regions, also related to functions such as the planning and anticipation of temporary signals, inhibition of erroneous behaviors, effectiveness in the solution of the task which It allows the constant update of the information regarding the time used to act, in addition to the processing of information, the regulation of the affective states, the control of the behavior and the decision making based on the estimate (risk-benefit), In uncertain, nonspecific or unpredictable situations, aspects present in patients with paranoid schizophrenia.

This result supports the tendency of those affected with the disorder to immediate gain, increasing the probability of remaining in the election due to the failure in the processing of the reward and the loss of avoidance⁹¹^,⁹⁶^,⁹⁷ presenting the association with the processing of the reinforcement of the reinforcement, Ability to transfer solutions to analogous situations could constitute the basis of learning deficits and their associated arousal alterations. Patients with schizophrenia have difficulties using feedback to guide future choices, generating a lower capacity to conceive alternatives in procedures, strategies, and responses to the same situations and preventing learning (risk-benefit) due to failures in value representations, The attribution of the importance of stimuli,⁹⁸ evidencing an “emotional learning” that guides decision making. In addition, the probability-magnitude integration deficits were explicitly due to a failure in the representation of the magnitude of the reward.⁹⁹ Therefore, those affected cannot avoid their preference for “bad” decks in the IGT (or, due to the “win-shed frequency” effect),⁹⁷ which can explain myopic behaviors due to failed predictions of the consequences. Thus, as of inductive processes, the establishment of temporary connections between actions and their consequences, making it difficult to learn experiences, not being able to properly identify the advantageous and disadvantageous letters and their adjustment in real life because of their ability to Learning from reinforcement is affected,¹⁰⁰ preventing the generation of behaviors that can organize prospectively.¹⁰¹ Consequently, a deficit in decision-making in paranoid schizophrenia can be assumed with an inability to move from initial preferences, that is, high risk, to a more profitable or low-risk strategy, with an initial selection of cards Without greater analysis. Again, this decision-making deficit seems to be specifically related to the paranoid schizophrenia subtype.⁹¹

The Iowa game task is an excellent method to evaluate ecological decision-making, since it mainly implies the anticipation of events, with rewards and losses. Neuroimaging studies in subjects who carry out the IGT demonstrate the importance of the dopaminergic system and wide areas of the orbit-medial prefrontal cortex and reward roads.¹⁰² In the case of subjects with schizophrenia, different studies have shown difficulties in decision-making based on the reward.¹⁰³ This diminished response is likely because patients with schizophrenia cannot incorporate the experience obtained in successive past choices in the betting task,¹⁰⁴ preventing an emotional-expensive categorization in similar situations, tasks, or circumstances. In its successive choices, this problem would be reflected in the lack of learning of negative decks (which imply more significant economic losses). It is interesting to think that the Iowa game task implies a “hot” cognitive reasoning task, distancing itself from “colder” executive function processes.¹⁰⁵ It is possible that involving processes of effective anticipation of differential learning object/context/individual is more related to tasks of social cognition or theory of the mind.¹⁰⁶

Although these concepts have been traditionally linked to social interaction, many basic cognitive processes of social cognition imply the correct anticipation of events based on the experience and learning of contingencies related to a specific social context and the clear differentiation of objects and subjects. An especially striking characteristic of patients with schizophrenia is that show difficulties in these processes.¹⁰⁶ On the other hand, studies that involve the analysis of Valencia Models of Perspective (PVL) highlight that the decision-making task would be linked to this model and the parameters of success/gain, actuality, and coherence. These parameters would reflect the degree of consistency in the choice of cards associated with low rewards in the SCZD.¹⁰⁴

The findings of the present study are in line with previous research showing significant deficits in executive functions and decision making in this population. In particular,¹⁰⁷ report consistent impairments in cognitive flexibility, response inhibition and planning. Likewise,¹⁰⁶ found a pattern of maladaptive decisions in schizophrenic patients when using IGT, suggesting dysfunction in prefrontal circuits involved in risk and reward assessment. However, not all studies agree¹⁰⁸ found that not all patients with schizophrenia have impaired decision-making when controlling for variables such as educational level and negative symptomatology. The universal validity of the IGT has also been questioned due to the influence of cultural factors on performance,¹⁰⁵ highlighting the need to contextualize the findings.

These discrepancies underline the importance of considering individual and sociocultural factors, as well as the need for personalized neuropsychological assessments. Interpretation of the results must be made in light of the complexity of variables that interact in the expression of cognitive deficits in schizophrenia.

Data availability

Simon Bolivar University: EXECUTIVE FUNCTION AND DECISION-MAKING IN COLOMBIAN PATIENTS WITH PARANOID SCHIZOPHRENIA, https://doi.org/10.17632/hsz66phhmf.1.¹⁰⁹

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Acknowledgments

We would like to thank all the institutions and participants involved in this study. The authors used OpenAI’s ChatGPT (version 4, May 2024) to assist with improving the clarity and language of the manuscript. All content was critically reviewed and approved by the authors, who take full responsibility for the final version.

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