Context-dependent goal-directed control in psychosis: Prioritizing loss avoidance over reward pursuit

While individuals with psychosis struggle to pursue rewards, their ability to avoid negative outcomes appears relatively intact. The neural mechanisms of this dissociation and its relation to negative symptoms remain poorly understood. We hypothesized that in early psychosis, cognitive resources are preferentially directed toward avoiding losses rather than pursuing rewards, potentially limiting reward processing and contributing to negative symptoms. Fifty medicated and stable individuals with early psychosis and 48 healthy controls completed a two-step sequential decision task, which distinguishes between goal-directed and habitual strategies, under reward and loss conditions during functional magnetic resonance imaging (fMRI). Compared to the loss context, healthy participants showed more goal-directed (model-based) control in the reward setting. In contrast, individuals with early psychosis showed the opposite pattern, engaging model-based control more strongly in the loss context. These behavioral shifts were reflected in the prefrontal cognitive network. In the anterior cingulate, orbitofrontal, and dorsolateral prefrontal cortex, individuals with early psychosis showed increased activation during model-based learning specifically in the loss condition. Within this group, loss-related activation in the anterior cingulate was associated with anhedonia, but no other consistent links to negative symptom domains were found. Our findings suggest that early psychosis is associated with a reallocation of cognitive resources from reward pursuit towards loss avoidance. Loss-focused processing in the anterior cingulate may help explain the reduced capacity for pleasure seen in early psychosis.