The role of cognitive control in the positive symptoms of psychosis

Background: Positive symptoms of psychosis (e.g., hallucinations) often limit everyday functioning and can persist despite adequate antipsychotic treatment. We investigated whether poor cognitive control is a mechanism underlying these symptoms.Methods: 97 patients with early psychosis (30 with high positive symptoms (HS) and 67 with low positive symptoms (LS)) and 40 healthy controls (HC) underwent fMRI whilst performing a reward learning task with two conditions; low cognitive demand (choosing between neutral faces) and high cognitive demand (choosing be-tween angry and happy faces - shown to induce an emotional bias). Decision and feedback phases were examined.Results: Both patient groups showed suboptimal learning behaviour compared to HC and altered activity within a core reward network including occipital/lingual gyrus (decision), rostral Anterior Cingulate Cortex, left pre-central gyrus and Supplementary Motor Cortex (feedback). In the low cognitive demand condition, HS group showed significantly reduced activity in Supplementary Motor Area (SMA)/pre-SMA during the decision phase whilst activity was increased in LS group compared to HC. Recruitment of this region suggests a top-down compensatory mechanism important for control of positive symptoms. With additional cognitive demand (emotional vs. neutral contrast), HS patients showed further alterations within a subcortical network (increased left amygdala activity during decisions and reduced left pallidum and thalamus activity during feedback) compared to LS patients.Conclusions: The findings suggest a core reward system deficit may be present in both patient groups, but persistent positive symptoms are associated with a specific dysfunction within a network needed to integrate social-emotional information with reward feedback.