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Impairments in effort-cost decision-making have been consistently observed in people with schizophrenia (SZ) and may be an important mechanism of negative symptoms. However, the processes that give rise to impairments in effort-cost decision-making are unclear, leading to limited progress in identifying the most relevant treatment targets. Drawing from cognitive models of negative symptoms and goal-directed behavior, this study aimed to examine how and under what type of task conditions defeatist performance beliefs contribute to these decision-making processes. Outpatients with SZ (n = 30) and healthy controls (CN; n = 28) completed a cognitive effort allocation task, the Cognitive Effort-Discounting (COGED) task, which assesses participants' willingness to exert cognitive effort for monetary rewards based on parametrically varied working memory demands (completing N-back levels). Results showed that although participants with SZ demonstrated reduced willingness to work for rewards across N-back levels compared to CN participants, they showed less choice modulation across different N-back conditions. However, among SZ participants with greater defeatist performance beliefs, there was a reduced willingness to choose the high effort option at higher N-back levels (N-back levels 3, 4, and 5 versus 2-back). Results suggest that compared to CN, the SZ group's subjective willingness to expend effort largely did not dynamically adjust as cognitive load increased. However, defeatist beliefs may undermine willingness to expend cognitive effort, especially when cognitive task demands are high. These beliefs may be a viable treatment target to improve effort-cost decision-making impairments in people with SZ., Competing Interests: Declaration of competing interest Dr. Gregory Strauss is one of the original developers of the Brief Negative Symptom Scale (BNSS) and receives royalties and consultation fees from Medavante-ProPhase LLC in connection with commercial use of the BNSS and other professional activities; these fees are donated to the Brain and Behavior Research Foundation. Dr. Strauss has received honoraria and travel support from Medavante-ProPhase LLC for training pharmaceutical company raters on the BNSS. In the past 2 years, Dr. Strauss has consulted for and/or been on the speaker bureau for Minerva Neurosciences, Acadia, Lundbeck, Sunovion, Boehringer Ingelheim, and Otsuka pharmaceutical companies. All other authors have no relevant disclosures to report., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Abnormal effort-based decision-making represents a potential mechanism underlying motivational deficits (amotivation) in psychotic disorders. Previous research identified effort allocation impairment in chronic schizophrenia and focused mostly on physical effort modality. No study has investigated cognitive effort allocation in first-episode psychosis (FEP)., Method: Cognitive effort allocation was examined in 40 FEP patients and 44 demographically-matched healthy controls, using Cognitive Effort-Discounting (COGED) paradigm which quantified participants' willingness to expend cognitive effort in terms of explicit, continuous discounting of monetary rewards based on parametrically-varied cognitive demands (levels N of N-back task). Relationship between reward-discounting and amotivation was investigated. Group differences in reward-magnitude and effort-cost sensitivity, and differential associations of these sensitivity indices with amotivation were explored., Results: Patients displayed significantly greater reward-discounting than controls. In particular, such discounting was most pronounced in patients with high levels of amotivation even when N-back performance and reward base amount were taken into consideration. Moreover, patients exhibited reduced reward-benefit sensitivity and effort-cost sensitivity relative to controls, and that decreased sensitivity to reward-benefit but not effort-cost was correlated with diminished motivation. Reward-discounting and sensitivity indices were generally unrelated to other symptom dimensions, antipsychotic dose and cognitive deficits., Conclusion: This study provides the first evidence of cognitive effort-based decision-making impairment in FEP, and indicates that decreased effort expenditure is associated with amotivation. Our findings further suggest that abnormal effort allocation and amotivation might primarily be related to blunted reward valuation. Prospective research is required to clarify the utility of effort-based measures in predicting amotivation and functional outcome in FEP.

Background: Better understanding of interplay among symptoms, cognition and functioning in first-episode psychosis (FEP) is crucial to promoting functional recovery. Network analysis is a promising data-driven approach to elucidating complex interactions among psychopathological variables in psychosis, but has not been applied in FEP., Method: This study employed network analysis to examine inter-relationships among a wide array of variables encompassing psychopathology, premorbid and onset characteristics, cognition, subjective quality-of-life and psychosocial functioning in 323 adult FEP patients in Hong Kong. Graphical Least Absolute Shrinkage and Selection Operator (LASSO) combined with extended Bayesian information criterion (BIC) model selection was used for network construction. Importance of individual nodes in a generated network was quantified by centrality analyses., Results: Our results showed that amotivation played the most central role and had the strongest associations with other variables in the network, as indexed by node strength. Amotivation and diminished expression displayed differential relationships with other nodes, supporting the validity of two-factor negative symptom structure. Psychosocial functioning was most strongly connected with amotivation and was weakly linked to several other variables. Within cognitive domain, digit span demonstrated the highest centrality and was connected with most of the other cognitive variables. Exploratory analysis revealed no significant gender differences in network structure and global strength., Conclusion: Our results suggest the pivotal role of amotivation in psychopathology network of FEP and indicate its critical association with psychosocial functioning. Further research is required to verify the clinical significance of diminished motivation on functional outcome in the early course of psychotic illness.

Background: Cognitive impairment is a core feature of schizophrenia and has been observed in both familial (FHR) and clinical high-risk (CHR) samples. Nonetheless, there is a paucity of research directly contrasting cognitive profiles in these two high-risk states and first-episode schizophrenia. This study aimed to compare cognitive functions in patients with first-episode schizophrenia-spectrum disorder (FES), their unaffected siblings (FHR), CHR individuals and healthy controls., Method: A standardized battery of cognitive assessments was administered to 69 FES patients, 71 help-seeking CHR individuals without family history of psychotic disorder, 50 FHR participants and 68 controls. FES and CHR participants were recruited from territory-wide early intervention service for psychosis in Hong Kong. CHR status was ascertained using Comprehensive Assessment of At-Risk Mental State., Results: Among four groups, FES patients displayed the largest global cognitive impairment and had medium-to-large deficits across all cognitive tests relative to controls. CHR and FHR participants significantly underperformed in most cognitive tests than controls. Among various cognitive tests, digit symbol coding demonstrated the greatest magnitude of impairment in FES and CHR groups compared with controls. No significant difference between two high-risk groups was observed in global cognition and all individual cognitive tests except digit symbol coding which showed greater deficits in CHR than in FHR participants., Conclusion: Clinical and familial risk groups experienced largely comparable cognitive impairment that was intermediate between FES and controls. Digit symbol coding may have the greatest discriminant capacity in distinguishing FES and CHR from healthy controls, and between two high-risk samples.

Effort-based decision-making has recently been proposed as a potential mechanism contributing to motivational deficits (amotivation) in psychotic disorder. Previous research has identified altered effort allocation in chronic schizophrenia, but produced mixed results regarding its relationship with amotivation. No study has investigated effort allocation in first-episode psychosis (FEP). We examined effort-based decision-making in 45 clinically-stabilized FEP patients and 45 demographically-matched controls, using Effort-Expenditure for Reward Task (EEfRT) which measures allocation of physical effort for monetary reward at varying magnitude and probability levels. Our results showed that FEP patients did not demonstrate overall reduction in effort expenditure but displayed reduced willingness to expend effort for high-value/high-probability reward as compared to controls. In particular, such selective effort-related impairment was most pronounced in patients with high levels of amotivation. Furthermore, reduced allocation of greater effort for higher probability reward was related to poorer psychosocial functioning. Decreased effort exertion was generally unrelated to other symptom dimensions, self-report anhedonia, antipsychotic dose and cognitive deficits. This study thus provides the first evidence of effort-based decision-making impairment in FEP, and indicates that first-episode patients were not generally effort-averse but exhibited inefficient effort allocation by failing to make high-effort choices to maximize reward receipt. Our findings affirm the critical role of amotivation on aberrant effort allocation, and support the link between laboratory-based effort-cost measures and real-world psychosocial functioning in medicated FEP. Further longitudinal research is required to clarify trajectory of suboptimal effort allocation and its potential utility in predicting amotivation and functional outcomes in the early course of illness., (Copyright © 2019 Elsevier B.V. and ECNP. All rights reserved.)

Background: Functional impairment is prevalent in patients with first-episode psychosis (FEP). Longitudinal course of functioning in the early stage of psychotic illness is under-studied. In this report, we aimed to investigate the patterns and baseline predictors of social-occupational functional trajectories over 3 years, utilizing growth mixture modeling (GMM) analysis, in a large representative Chinese young FEP cohort in Hong Kong., Method: Six hundred seventeen consecutive patients aged 15-25 years presenting with first-episode non-affective psychosis to a specialized early intervention service were studied. Data on demographic, pre-treatment and baseline clinical characteristics were collected. Individual class membership of functioning derived from GMM was based on ratings on Social and Occupational Functioning Scale (SOFAS) measured at five different time-points (baseline, 6, 12, 24 and 36 months) across 3-year follow-up., Results: Four distinct functional trajectories were identified including persistently poor (48.1%, n = 320), early improved (31.3%, n = 203), gradually improved (14.8%, n = 69) and improved-deteriorated (5.8%, n = 25) trajectories. Multinomial regression analysis revealed that male gender, lower educational attainment, a diagnosis of schizophrenia-spectrum disorder and a receipt of inpatient treatment upon initial presentation independently predicted persistently poor trajectory membership., Conclusion: The current study reveals a heterogeneous course of social-occupational functioning in FEP. Our finding that approximately half of the patients displaying persistently poor trajectory over 3 years indicates functional impairment as an unmet therapeutic need in early illness phase. Further research applying individual-based trajectory analysis in FEP is warranted to facilitate better characterization of longitudinal patterns of functioning and development of targeted intervention to promote early recovery., (Copyright © 2018 Elsevier B.V. All rights reserved.)