How distinct functional insular subdivisions mediate interacting neurocognitive systems.

Recent neurocognitive models propose that the insula serves as a hub of interoceptive awareness system, modulating 2 interplaying neurocognitive systems: The posterior insula (PI) receives and integrates various interoceptive signals; these signals are then transmitted to the anterior insula for processing higher-order representations into awareness, where the dorsal anterior insula (dAI) modulates the prefrontal self-control system and the ventral anterior insula (vAI) modulates the amygdala (AMG)-striatal reward-seeking circuit. We sought to test this view using a multimodal approach. We first used a resting-state functional magnetic resonance imaging (fMRI) approach with a sample of 120 undergraduate students. Then, we unpacked the neuro-cognitive association between insular connectivity and cognitive performance during an Iowa gambling fMRI task. Lastly, an independent Open Southwest University Longitudinal Imaging Multimodal dataset was used to validate the results. Findings suggested that the dAI was predominantly connected to the prefrontal regions; the vAI was primarily connected to the AMG-ventral-striatum system; and the PI was mainly connected to the visceral-sensorimotor system. Moreover, cognitive scores were positively correlated with FC between dAI and the self-control process of ventrolateral prefrontal cortex and were negatively correlated with FC between vAI and the reward-seeking process of orbitofrontal cortex and subgenual anterior cingulate cortex. The findings highlight the roles of our theorized subinsular functionality in the overall operation of the neural cognitive systems.

Pathological Gambling in Parkinson's disease: Autonomic measures supporting impaired decision-making.

According to the somatic marker hypothesis, autonomic measures and arousal modulation can reveal a difference in subgroups of patients developing impaired decision-making because of addictions. Previously, pathological gambling (PG) and Parkinson's disease (PD) have been associated with differential arousal levels during gambling behavior. However, no research considered the specific autonomic responses of Parkinson's disease patients with pathological gambling and with a previous history of gambling. Thus, this study investigated skin conductance responses (SCRs), skin conductance level (SCL) and heart rate (HR) during the Iowa Gambling Task (IGT) in two groups of PD patients with gambling disorder, active (PD Gamblers; n = 14) or remitted (PD Non-Gamblers; n = 13) and a control group of patients with Parkinson's disease only (n = 13). Anticipatory autonomic responses to disadvantageous decks and advantageous decks during the Iowa Gambling Task were measured for each participant. The PD Gamblers group performed worse than the PD Non-Gamblers and the control groups at the IGT task and exhibited lower SCRs, SCL, and HR during the decision-making processing of cards belonging to disadvantageous decks. The role of autonomic and behavioral measures was considered.

Missed losses loom larger than missed gains: Electrodermal reactivity to decision choices and outcomes in a gambling task.

Loss aversion is a defining characteristic of prospect theory, whereby responses are stronger to losses than to equivalently sized gains (Kahneman & Tversky Econometrica, 47, 263-291, 1979). By monitoring electrodermal activity (EDA) during a gambling task, in this study we examined physiological activity during risky decisions, as well as to both obtained (e.g., gains and losses) and counterfactual (e.g., narrowly missed gains and losses) outcomes. During the bet selection phase, EDA increased linearly with bet size, highlighting the role of somatic signals in decision-making under uncertainty in a task without any learning requirement. Outcome-related EDA scaled with the magnitudes of monetary wins and losses, and losses had a stronger impact on EDA than did equivalently sized wins. Narrowly missed wins (i.e., near-wins) and narrowly missed losses (i.e., near-losses) also evoked EDA responses, and the change of EDA as a function of the size of the missed outcome was modestly greater for near-losses than for near-wins, suggesting that near-losses have more impact on subjective value than do near-wins. Across individuals, the slope for choice-related EDA (as a function of bet size) correlated with the slope for outcome-related EDA as a function of both the obtained and counterfactual outcome magnitudes, and these correlations were stronger for loss and near-loss conditions than for win and near-win conditions. Taken together, these asymmetrical EDA patterns to objective wins and losses, as well as to near-wins and near-losses, provide a psychophysiological instantiation of the value function curve in prospect theory, which is steeper in the negative than in the positive domain.

Decision-making deficit of a patient with axonal damage after traumatic brain injury.

Patients with traumatic brain injury (TBI) were reported to have difficulty making advantageous decisions, but the underlying deficits of the network of brain areas involved in this process were not directly examined. We report a patient with TBI who demonstrated problematic behavior in situations of risk and complexity after cerebral injury from a traffic accident. The Iowa gambling task (IGT) was used to reveal his deficits in the decision-making process. To examine underlying deficits of the network of brain areas, we examined T1-weighted structural MRI, diffusion tensor imaging (DTI) and Tc-ECD SPECT in this patient. The patient showed abnormality in IGT. DTI-MRI results showed a significant decrease in fractional anisotropy (FA) in the fasciculus between the brain stem and cortical regions via the thalamus. He showed significant decrease in gray matter volumes in the bilateral insular cortex, hypothalamus, and posterior cingulate cortex, possibly reflecting Wallerian degeneration secondary to the fasciculus abnormalities. SPECT showed significant blood flow decrease in the broad cortical areas including the ventromedial prefrontal cortex (VM). Our study showed that the patient had dysfunctional decision-making process. Microstructural abnormality in the fasciculus, likely from the traffic accident, caused reduced afferent feedback to the brain, resulting in less efficient decision-making. Our findings support the somatic-marker hypothesis (SMH), where somatic feedback to the brain influences the decision-making process.

Conscious knowledge influences decision-making differently in substance abusers with and without co-morbid antisocial personality disorder.

Decision-making impairment, as measured by the Iowa Gambling Task (IGT), is a consistent finding among individuals with substance use disorder (SUD). We studied how this impairment is influenced by co-morbid antisocial personality disorder (ASPD) and conscious knowledge of the task. Three groups were investigated: SUD individuals without co-morbid ASPD (n = 30), SUD individuals with co-morbid ASPD (n = 16), and healthy controls (n = 17). Both SUD and SUD+ASPD participants had poor overall IGT performance. A block-by-block analysis revealed that SUD participants exhibited slow but steady improvement across the IGT, whereas SUD+ASPD participants exhibited initial normal improvement, but dropped off during the last 40 trials. Conscious knowledge of the task was significantly correlated to performance for controls and SUD participants, but not for SUD+ASPD participants. Our findings suggest that decision-making proceeds differently in SUD and SUD+ASPD individuals due to differences in acquisition and application of conscious knowledge.

Bittersweet memories and somatic marker hypothesis: adaptive control in emotional recall facilitates long-term decision-making in the Iowa Gambling Task.

The somatic marker hypothesis states that emotional recall and its somatic influence guide long-term decision-making. However, the mechanism through which decision-making benefits from emotional recall is unclear; whether emotional recall and the induced affect increase the regulatory demand or amplify the affect state that requires inhibition. It is unclear if controlling the automatic flow of emotion in recall improves adaptive decision-making. Two studies examine the hypothesis that affect control in emotional recall facilitates inhibitory control and benefits long-term decision-making. In Experiment 1 (n = 137), affect control was assessed in emotional recall to examine if switching of affect in recall of positive and negative valence (order: positive-negative memory recall vs. negative-positive memory recall) is linked with long-term decision-making. Results for long-term decision-making showed that negative-positive recall sequence was associated with higher long-term decision-making, whereas automatic frequency-based decision-making remained unaffected by the recall sequence. In experiment 2 (n = 71, all male), emotional recall (positive vs. negative), recall specificity (i.e., specific vs. overgeneralized recall), and post-recall mood regulation (post-recall positive mood regulation vs. no regulation) was expected to facilitate long-term decision-making. Results showed that emotional recall and post-recall mood regulation (i.e., negative recall - positive mood and positive recall - negative mood) were associated with higher long-term decision-making (decks C' and D'). Results of frequency decision-making showed that positive emotional recall, and poor recall specificity led to infrequent punishment deck choices (decks B' and D'). Hierarchical regression indicated that emotional recall increased infrequent deck choices and accounted for 10% of choices made, recall specificity increased the explanatory power to 19%, and higher recall specificity was associated with fewer infrequent punishment deck choices. Affect control engaged via negative emotional recall, post-recall mood regulation, and recall specificity might be a potential mechanism through which affect control in emotional recall might facilitate long-term decision-making.

Interoceptive accuracy is associated with benefits in decision making in children.

Introduction: Decision making results not only from logical analyses, but seems to be further guided by the ability to perceive somatic information (interoceptive accuracy). Relations between interoceptive accuracy and decision making have been exclusively studied in adults and with regard to complex, uncertain situations (as measured by the Iowa Gambling Task, IGT). Methods: In the present study, 1454 children (6-11 years) were examined at two time points (approximately 1 year apart) using an IGT as well as a delay-of-gratification task for sweets-items and toy-items. Interoceptive accuracy was measured using a child-adapted version of the Heartbeat Perception Task. Results: The present results revealed that children with higher, as compared to lower, interoceptive accuracy showed more advantageous choices in the IGT and delayed more sweets-items, but not toy-items, in a delay-of-gratification task at time point 2 but not at time point 1. However, no longitudinal relation between interoceptive accuracy and decision making 1 year later could be shown. Discussion: Results indicate that interoceptive accuracy relates to decision-making abilities in situations of varying complexity already in middle childhood, and that this link might consolidate across the examined 1-year period. Furthermore, the association of interoceptive accuracy and the delay of sweets-items might have implications for the regulation of body weight at a later age.

Decision-making in uncertain contexts: The role of autonomic markers in resolving indecision.

Although impulsivity is associated with an increased willingness to make risky decisions, uncertainty intolerance may also contribute to maladaptive decision-making behavior, where individuals neglect to pursue potential rewards even when probabilities for success are in their favor. Several theories have sought to explain the neural systems that guide decision-making in this context, with evidence supporting a role for increased sympathetic activation. However, it remains unclear whether the sympathetic system is associated with greater apprehension in response to uncertain outcomes, or whether it serves to guide behavioral decisions in the context of this uncertainty. Furthermore, although postulated as a within-person process, most research has examined the association between decision behavior and sympathetic activation at the between-person level. We hypothesize that in the context of uncertainty between-person differences in skin conductance will be associated with longer deliberation times; whereas within-person trial-level increases in skin conductance will be associated with a tendency to reject uncertain options. Data were collected from n = 56 children aged 7-11 years, using a computerized card game in which children chose to accept or reject cards of varying point value at varying levels of probability. Skin conductance level (SCL) was recorded throughout the task. No significant between-person associations emerged. However, within-person analyses indicated that momentary deliberation time moderated the association between momentary skin-conductance and decision outcome. This moderation was such that for trials during which the individual deliberated longer (i.e., was more indecisive), a concurrent increase in skin conductance was associated with a significantly higher likelihood of rejecting the card. The within-person nature of these results suggests that skin conductance may help in resolving indecision in the context of uncertainty.

Brain Neural Underpinnings of Interoception and Decision-Making in Alzheimer's Disease: A Narrative Review.

This study reviews recent literature on interoception directing decision-making in Alzheimer's disease (AD). According to the somatic marker hypothesis, signals from the internal body direct decision-making and involve the ventromedial prefrontal cortex (vmPFC). After reviewing relevant studies, we summarize the brain areas related to interoception and decision-making (e.g., vmPFC, hippocampus, amygdala, hypothalamus, anterior cingulate cortex, and insular cortex) and their roles in and relationships with AD pathology. Moreover, we outline the relationship among interoception, the autonomic nervous system, endocrine system, and AD pathology. We discuss that impaired interoception leads to decreased decision-making ability in people with AD from the perspective of brain neural underpinning. Additionally, we emphasize that anosognosia or reduced self-awareness and metacognition in AD are remarkably congruent with the malfunction of the autonomic nervous system regulating the interoceptive network. Furthermore, we propose that impaired interoception may contribute to a loss in the decision-making ability of patients with AD. However, there still exist empirical challenges in confirming this proposal. First, there has been no standardization for measuring or improving interoception to enhance decision-making ability in patients with AD. Future studies are required to better understand how AD pathology induces impairments in interoception and decision-making.

The comparison of decision-making in ambiguous situations and galvanic skin responses as somatic markers in patients with posterior cortex epilepsy and mesial temporal lobe epilepsy with hippocampal sclerosis.

INTRODUCTION: Decision-making behaviors of patients with mesial temporal lobe epilepsy (MTLE) is a subject that has been studied frequently. However, determining the neuropsychological profiles of patients with different types of epilepsy is also important. Our main purpose was to examine the decision-making behaviors of patients with posterior cortex epilepsy (PCE) through the assumptions of somatic marker hypothesis (SMH) and to compare their performances with those of a MTLE group and a control group. METHOD: Participants comprised of 13 patients with PCE (mean age 30.92 ± 9.99 years); 14 patients with MTLE with hippocampal sclerosis (MTLE-HS) (mean age 25.53 ± 7.40 years) and 15 controls (mean age 24.60 ± 8.45 years). Decision-making performances were assessed with the Iowa gambling test (IGT) and anticipatory skin responses before each choice were recorded. A comprehensive neuropsychological test battery was also given to all participants in order to examine the relationship of decision-making with other cognitive functions. RESULTS: Anticipatory responses before choosing from disadvantageous decks were significantly larger than choosing from advantageous decks in the PCE group (p = 0.00). No significant difference was found between the PCE and control group's total net scores. IGT total net scores was significantly correlated with Stroop test interference time (p = 0.03). CONCLUSION: The study reveals that cognitive impairments of patients with PCE are not limited to brain's posterior areas' functions, and provides evidence for the current paradigm which understands epilepsy as a network disorder.

Reanalyzing the Maia and McClelland (2004) Empirical Data: How Do Participants Really Behave in the Iowa Gambling Task?

Background: Since 2007, the Iowa Gambling Task (IGT) has been a standardized clinical assessment tool for assessing decision behavior in 13 psychiatric/neurological conditions. After the publication of Maia and McClelland's (1) article, there were two responses in 2005 from Bechara et al. and Maia and McClelland, respectively, discussing whether implicit emotion or explicit knowledge influences the development of foresighted decision strategies under uncertain circumstances (e.g., as simulated in the IGT). Methods and Results: We reanalyze and verify the data obtained by Maia and McClelland (1) in their study "What participants really know in the Iowa Gambling Task" and find that decision-makers were lured into shortsighted decisions by the prospect of immediate gains and losses. Conclusion: Although the findings of this reanalysis cannot support any arguments concerning the effect of either implicit emotion or explicit knowledge, we find evidence that, based on the gain-loss frequency in the IGT, participants behave myopically. This is consistent with most IGT-related articles (58 out of 86) in Lee et al.'s (2) cross-cultural review. Alternatively, under uncertain circumstances, there is probably no such thing as foresighted decision strategy irrespective of the proposed mechanisms of implicit emotion or explicit knowledge.

Normatively Irrelevant Affective Cues Affect Risk-Taking under Uncertainty: Insights from the Iowa Gambling Task (IGT), Skin Conductance Response, and Heart Rate Variability.

Being able to distinguish between safe and risky options is paramount in making functional choices. However, deliberate manipulation of decision-makers emotions can lead to risky behaviors. This study aims at understanding how affective reactions driven by normatively irrelevant affective cues can interfere with risk-taking. Good and Bad decks of the Iowa Gambling Task have been manipulated to make them unpleasant through a negative auditory manipulation. Anticipatory skin conductance response (SCR) and heart rate variability (HRV) have been investigated in line with the somatic marker hypothesis. Results showed fewer selections from Good decks when they were negatively manipulated (i.e., Incongruent condition). No effect of the manipulation was detected when Bad decks were negatively manipulated (i.e., Congruent condition). Higher anticipatory SCR was associated with Bad decks in Congruent condition. Slower heart rate was found before selections from Good decks in Control and Congruent condition and from Bad decks in Incongruent condition. Differences in heart rate between Bad and Good decks were also detected in Congruent condition. Results shed light on how normatively irrelevant affective cues can interfere with risk-taking.

Somatic Marker Production Deficits do not Explain the Relationship between Psychopathic Traits and Utilitarian Moral Decision Making.

In moral dilemma tasks, high levels of psychopathic traits often predict increased utilitarian responding-specifically, endorsing sacrificing one person to save many. Research suggests that increased arousal (i.e., somatic marker production) underlies lower rates of utilitarian responding during moral dilemmas. Though deficient somatic marker production is characteristic of psychopathy, how this deficit affects the psychopathy-utilitarian connection remains unknown. We assessed psychopathic traits in undergraduates, as well as behavioral performance and skin conductance level reactivity (SCL-R; a measure of somatic marker production) during a moral dilemma task. High psychopathic traits and low SCL-R were associated with increased utilitarian decisions in dilemmas involving direct personal harm. Psychopathic traits were unrelated to SCL-R, nor did SCL-R mediate the relationship between psychopathy and utilitarianism. The present study did not find evidence that somatic marker production explains the connection between utilitarianism and psychopathy in a college population. Further research is necessary to identify the neural mechanisms relating psychopathy and moral decision-making in nonclinical samples.

Bridging Ecological Rationality, Embodied Emotion, and Neuroeconomics: Insights From the Somatic Marker Hypothesis.

The somatic marker hypothesis (SMH) has been utilized to demonstrate the role of emotion and somatic state in decision-making under uncertainty over the past two decades. Despite some debate, the SMH has provided not only a neurobiological framework for understanding emotion and decision-making but also a good empirical support for ecological rationality and embodied emotion. Unlike the traditional maximizing rationality and bounded satisficing rationality, the ecological rationality stresses that emotions should be brought to the decision-making process. The embodied emotion furthermore emphasizes that emotions are embodied in the body and the brain. On the other hand, behavioral decision-making has spawned many new interdisciplines, including neuroeconomics. In this case, the SMH could act as a bridge to translate the ecological rationality and the embodied emotion into emerging neuroeconomics. Thus, this mini-review article aims to propose an integrated framework for introducing ecological rationality and embodied emotion into the field of neuroeconomics by virtue of insights from the SMH.

The Agony of Choice? Preserved Affective Decision Making in Early Multiple Sclerosis.

Background: Cognitive impairment (CI) is an early and frequent symptom of multiple sclerosis (MS). Likewise, affective symptoms (e.g., depression and anxiety) and alterations in the processing of emotional stimuli have been frequently reported. Thus, abilities that integrate affective and cognitive processes such as decision making (DM) based on affective feedback are potentially valuable early diagnostic markers for MS. The available research on this topic, however, is still inconclusive and suffers from methodological issues. Methods: We compared DM ability in a clinically homogeneous cohort of 24 patients with early relapsing-remitting MS (RRMS) and 59 age-matched healthy controls (HCs). A modified version of the Iowa gambling task (IGT) allowed us to control for individual differences in search strategies during the risk exploration phase. Besides standard IGT measures (netscore, obtained play money, and learning index), we also examined reaction times and post-error slowing (PES) patterns as a proxy for abnormalities in the processing of affective feedback. Results: The performance of patients did not significantly deviate from HCs in any standard parameter of the modified IGT. Furthermore, although RRMS patients reacted significantly slower than HCs overall, we found similar patterns of PES in both groups, suggesting similarly efficient processing of affective feedback. Conclusion: We conclude that there is no specific deficit in affective feedback processing in early RRMS. Previous findings of IGT impairments in this patient group may thus not represent a genuine deficit in affective DM but rather be related to sample characteristics, general CI, and/or differences in individual search strategies. Future research should explore the potential influence of lesion volumes and locations on DM ability by employing brain imaging techniques.

Electrophysiological Measurement of Emotion and Somatic State Affecting Ambiguity Decision: Evidences From SCRs, ERPs, and HR.

Twenty-three years ago, the Somatic Marker Hypothesis (SMH) proposed by Damasio was introduced to explain the role of emotion in decision-making, and provided a unique neuroanatomical framework for decision-making and its influence by emotion. The core idea of the SMH is that decision-making is a process that is affected by somatic state signals, including those that express themselves in emotion and feeling. In order to verify the SMH, the Iowa Gambling Task (IGT) was originally designed by Bechara et al. and the skin conductance responses (SCRs) was recorded during the IGT. The initial confirmatory results showed that normal subjects would generate anticipatory SCRs when they received reward or punishment, but patients of the VMPFC lesion entirely failed to generate anticipatory SCRs prior to their selection of a card. With the further development of the SMH-related researches, other electrophysiological methods of measuring somatic state was gradually used to test the SMH, including event-related potentials (ERPs), and heart rate (HR). In this mini review article, we summarize the extant electrophysiological research on the SMH and decision-making under ambiguity, propose an integrative perspective for employing different electrophysiological measurement methods, and indicate the application of electrophysiological measurement based on the SMH in daily social decision-making.

Cerebellum, Basal Ganglia, and Cortex Mediate Performance of an Aerial Pursuit Task.

The affordance competition hypothesis is an ethologically inspired theory from cognitive neuroscience that provides an integrative neural account of continuous, real-time behavior, and will likely become increasingly relevant to the growing field of neuroergonomics. In the spirit of neuroergonomics in aviation, we designed a three-dimensional, first-person, continuous, and real-time fMRI task during which human subjects maneuvered a simulated airplane in pursuit of a target airplane along constantly changing headings. We introduce a pseudo-event-related, parametric fMRI analysis approach to begin testing the affordance competition hypothesis in neuroergonomic contexts, and attempt to identify regions of the brain that exhibit a linear metabolic relationship with the continuous variables of task performance and distance-from-target. In line with the affordance competition hypothesis, our results implicate the cooperation of the cerebellum, basal ganglia, and cortex in such a task, with greater involvement of the basal ganglia during good performance, and greater involvement of cortex and cerebellum during poor performance and when distance-from-target closes. We briefly review the somatic marker and dysmetria of thought hypotheses, in addition to the affordance competition hypothesis, to speculate on the intricacies of the cooperation of these brain regions in a task such as ours. In doing so, we demonstrate how the affordance competition hypothesis and other cognitive neuroscience theories are ready for testing in continuous, real-time tasks such as ours, and in other neuroergonomic settings more generally.

The Altered Somatic Brain Network in State Anxiety.

Highly anxious individuals often show excessive emotional arousal, somatic arousal, and characteristics of mental illness. Previous researches have extensively investigated the emotional and cognitive biases of individuals with high anxiety, but overlooked the spontaneous brain activity and functional connections associated with somatic arousal. In this study, we investigated the relationship between state anxiety and the spontaneous brain activity of the somatosensory cortex in a non-clinical healthy population with state anxiety. Furthermore, we also explored the functional connections of the somatosensory cortex. We found that state anxiety was positively correlated with the amplitude of low-frequency fluctuations (ALFFs) of somatic related brain regions, including the right postcentral gyrus (somatosensory cortex) and the right precentral gyrus (somatic motor cortex). Furthermore, we found that state anxiety was positively correlated with the connections between the postcentral gyrus and the left cerebellum gyrus, whereas state anxiety was negatively correlated with the connectivity between the postcentral gyrus and brain regions including the left inferior frontal cortex and left medial superior frontal cortex. These results revealed the association between the anxious individuals' body-loop and state anxiety in a healthy population, which revealed the importance of somatic brain regions in anxiety symptoms and provided a new perspective on anxiety for further study.

Improved decision-making and psychophysiological responses in mesial temporal lobe epilepsy after anterior temporal lobectomy.

The somatic marker hypothesis is an influential model of human decision-making postulating that somatic feedback to the brain enhances decision-making in ambiguous circumstances, i.e. when the probabilities of various outcomes are unknown. The somatic feedback can be measured as autonomic responses, which are regulated by the amygdala. The failure to evoke this somatic feedback, which occurs in patients with amygdala lesions, impairs decision-making. The purpose of this study was to investigate the decision-making behaviour of mesial temporal lobe epilepsy patients with pre- and post-epilepsy surgery to ascertain whether the decision-making abilities of groups can be explained by means of the generation of somatic feedback responses. The preoperative group comprised 32 patients with mesial temporal lobe epilepsy due to hippocampal sclerosis, while the postoperative group comprised 23 patients who had undergone anterior temporal lobectomy. The age and gender-matched control group consisted of 30 healthy participants. Decision-making performances were assessed and skin resistance responses were measured simultaneously. The findings of this study reveal that the decision-making performance of preoperative patients with unilateral mesial temporal lobe epilepsy was impaired under conditions of ambiguity, i.e. they did not generate somatic feedback responses before making decisions around ambiguous outcomes, and produced significantly poor scores overall based on a decision-making task. In addition, the resection of epileptogenic limbic structures positively affected the generation of somatic feedback responses, as demonstrated by the significant difference between the magnitudes of autonomic responses of the pre- and post-operative groups. The findings of the study validate the contribution of mesial temporal lobe structures to decision-making behaviour, and also point to the importance of examining the connectivity patterns between the neural structures involved in the decision-making network.

Performance Under Stress: An Eye-Tracking Investigation of the Iowa Gambling Task (IGT).

Stress pervades everyday life and impedes risky decision making. The following experiment is the first to examine effects of stress on risky decision making in the Iowa Gambling Task (IGT), while measuring inspection time and conscious awareness of deck contingencies. This was original as it allowed a fine grained rigorous analysis of the way that stress impedes awareness of, and attention to maladaptive financial choices. The extended Cognitive Reflection Task (CRT) further afforded examination of the impact of impaired reflective thinking on risky decision making. Stressed participants were slower to avoid the disadvantageous decks and performed worse overall. They inspected disadvantageous decks for longer than the control condition and were slower in developing awareness of their poor deck quality compared to the control condition. Conversely, in the control condition greater inspection times for advantageous decks were observed earlier in the task, and better awareness of the deck contingencies was shown as early as the second block of trials than the stress condition. Path analysis suggested that stress reduced IGT performance by impeding reflective thinking and conscious awareness. Explicit cognitive processes, moreover, were important during the preliminary phase of IGT performance-a finding that has significant implications for the use of the IGT as a clinical diagnostic tool. It was concluded that stress impedes reflective thinking, attentional disengagement from poorer decks, and the development of conscious knowledge about choice quality that interferes with performance on the IGT. These data demonstrate that stress impairs risky decision making performance, by impeding attention to, and awareness of task characteristics in risky decision making.