Reward processing in psychosis: adding meanings to the findings

Much of our daily behavior is driven by rewards. The ability to learn to pursue rewarding experiences is, in fact, an essential metric of mental health. Conversely, reduced capacity to engage in adaptive goal-oriented behavior is the hallmark of apathy, and present in the psychotic disorder. The search for its underlying mechanisms has resulted in findings of profound impairments in learning from rewards and the associated blunted activation in key reward areas of the brain of patients with psychosis. An emerging research field has been relying on digital phenotyping tools and ecological momentary assessments (EMA) that map patients’ current mood, behavior and context in the flow of their daily lives. Using these tools, we have started to see a different picture of apathy, one that is exquisitely driven by the environment. For one, reward sensitivity appears to be blunted by stressors, and exposure to undue chronic stress in the daily life may result in apathy in those predisposed to psychosis. Secondly, even patients with psychosis who exhibit clinically elevated levels of apathy are perfectly capable of seeking out and enjoying social interactions in their daily life, if their environment allows them to do so. The use of digital phenotyping tools in combination with neuroimaging of apathy not only allows us to add meanings to the neurobiological findings, but could also help design rational interventions.