Dissociable mechanisms underpinning effort-cost decision-making across the psychosis spectrum

Recent theoretical models propose that abnormal effort-cost decision-making (ECDM) likely has divergent underpinnings across mood and psychotic disorders. However, whether this same model applies to individuals across the psychosis spectrum, including individuals with affective psychosis, remains unclear. This study aimed to empirically test whether two component processes - working memory and reward learning - contribute to ECDM impairment across the psychosis spectrum. ECDM was assessed using the Effort Expenditure for Rewards Task in individuals with psychotic disorders (n = 190) and healthy controls (n = 52). Working memory was assessed using a Digit Sequencing Task and reward learning was assessed using a Probabilistic Reward Task. Relative to the control group, the psychosis group showed reduced willingness to expend effort for higher probability, higher value rewards. This effect was most pronounced in individuals with schizophrenia and schizoaffective disorder relative to individuals with psychotic bipolar disorder. Across the whole sample, better working memory but not reward learning predicted greater willingness to expend effort for higher probability rewards. However, the link between working memory and ECDM differed as a function of patient symptom profile. Specifically, working memory was only predictive of ECDM for individuals with less severe negative symptoms and minimal depressive symptoms. For individuals with more severe negative symptoms, poorer ECDM was instead predicted by deficits in reward learning. Although these findings reiterate the important link between working memory and ECDM in individuals with psychotic disorders, they also show that this link varies in accordance with the presence of prominent negative and depressive symptoms.