Mette degaard Nielsen, Egill Rostrup, Sanne Wulff, Nikolaj Bak, Henrik Lublin, Shitij Kapur, and Birte Glenthj Background: Various schizophrenic symptoms aresuggestedtobelinkedtoa dysfunctionof thebrainrewardsystem. Several studies have found alterations in the reward processing in patients with schizophrenia; however, most previous ndings might be confounded by medication effects. Methods: Thirty-one antipsychotic-nave schizophrenia patients and 31 age- and gender-matched healthy control subjects were exam- ined with functional magnetic resonance imaging while playing a variant of the monetary incentive delay task. The task variant made it possible to separate overall salience (dened as arousing events) into behavioral salience (events where a predicted reward requires performance) andvalence anticipation(the anticipationof a monetarily signicant outcome). Furthermore, the evaluationof monetary gain and loss was assessed. Results: During reward anticipation, patients had a signicant attenuation of the activation in ventral tegmentum, ventral striatum, and anterior cingulate cortex during presentation of salient cues. This signal attenuation in ventral striatum was correlated with the degree of positivesymptoms. Signal attenuationwas most pronouncedfor behavioral salienceandnonsignicant for valueanticipation. Furthermore, patients showed a changed activation pattern during outcome evaluation in right prefrontal cortex. Conclusion: Our results suggest that changes during reward anticipation in schizophrenia are present from the beginning of the disease. This supports a possible involvement of rewarddisturbances in the pathophysiology of schizophrenia. The most pronouncedchanges were seen in relation to overall salience. In ventral striatum these changes were associated with the degree of positive symptoms. Key Words: Functional magnetic resonance imaging, negative symptoms, positive symptoms, reward, schizophrenia, ventral striatum B rainrewardcircuits are involvedinmultiple processingsteps, with regard to biologically important stimuli: an outcome must be allocated positive or negative value, a relationship to a conditioning cue must be learned, and the need for a behav- ioral response must be indicated (1). In this process, dopaminergic neurons projecting from ventral tegmental area (VTA) to ventral striatum (VS) are essential for signaling salience, dened as stimuli beingarousingandtowhichattentional or behavioral resources are preferentially redirected (26). Medial prefrontal cortex (MPFC) plays an important role in value representation and pleasure expe- rience (7,8), whereas dorsolateral prefrontal cortex (DLPFC) is be- lieved to be central in translating the achieved value into future goal-directed behavior (9,10). Schizophrenia patients are thought to have a disruption of striato-cortico-thalamic macro circuits and frontal microcircuits in- volving disturbances in several transmitter systems, including the glutamatergic, serotonergic, -aminobutyric acid-ergic, cholin- ergic, noradrenergic, and dopaminergic systems (1114). Irrespec- tive of the primary abnormality in individual patients, increased dopaminergic turnover in striatum has been hypothesized as the nal common pathway leading to positive psychotic symptoms (15). Several studies have demonstrated an increased synthesis of dopamine (1619) and a heightened striatal dopamine release in response to an impulse (2022) in patients with schizophrenia dur- ing psychotic episodes. Likewise, a well-established relationship exists between the dopamine-type 2 receptor blockade in striatum and the resolution of positive symptoms (23,24). Literature also points to a decisive role for frontal dopaminergic activity and schizophrenic symptomatology (12,14) and to a relationship be- tween cortical and subcortical dopamine activity (25). Studies havedemonstrateda central roleof dopamineinreward processing (3,26,27), and in functional magnetic resonance imag- ing(fMRI), the event-relatedsignal in VS duringrewardanticipation is most likely caused by dopamine activity (2830). In medication- free schizophrenia patients an attenuated signal in VS for reward predicting cues has been found (31,32). This attenuation correlated with the degree of negative symptoms and at a trend level with the degree of positive symptoms (31). InPFC, a decreaseddistinctionof the signal during processing of unexpected and expected out- comes has been found (32), but no fMRI studies have looked at changes in relation to processing of valence in PFC in medication- free patients. Studies using positron emission tomography (PET) have reported reduced pleasure-related activation in PFC and lim- bic areas in unmedicated patients (33,34). Functional MRI studies in medicatedpatients have describeda negative correlation between pleasure-related activity in PFC and the degree of negative symp- toms (3537). Increased dopaminergic tone in VS has been suggested to result in attenuated event-related blood oxygen leveldepen- dent (BOLD) response (38). Thus we expect antipsychotic-nave rst-episode schizophrenia patients to have an attenuated BOLD response during anticipation, and we expect this change to corre- late with the degree of positive symptoms. During outcome evalu- ation, we expect patients to have an attenuated pleasure-related BOLDresponse in PFC when receiving a reward, and we expect this Fromthe Center for Clinical Intervention and Neuropsychiatric Schizophre- nia Research, Center for Neuropsychiatric Schizophrenia Research (MN, SW, NB, HL, BG); Functional Imaging Unit (ER), Copenhagen Uni- versity Hospital, Glostrup, Denmark; and the Institute of Psychiatry (SK), Kings College London, United Kingdom. Address correspondence to Mette degaard Nielsen, M.D., Ph.D. student, Copenhagen University Hospital, Center for Neuropsychiatric Schizo- phrenia Research, CNSR, Psychiatric Center Glostrup, Nordre Ringvej 29-67, 2600 Glostrup, Denmark; E-mail: mette@cnsr.dk. Received Aug 4, 2011; revised and accepted Feb 3, 2012. BIOL PSYCHIATRY 2012;71:898905 0006-3223/$36.00 doi:10.1016/j.biopsych.2012.02.007 2012 Society of Biological Psychiatry attenuationtocorrelate withthe degree of negative symptoms. We used an fMRI paradigm that enabled distinction between behav- ioral salience (dened as events, where the positive or negative outcomes were performance-contingent) and valence anticipation (anticipation of a monetarily signicant outcome). Because cues indicating behavioral salience and positive valence have been foundtoactivate VS (39), we expect attenuatedresponse tobothof these in patients. Methods and Materials Conducted in accordance with the declaration of Helsinki II, the project was approved by the Danish National Committee on Bio- medical Research Ethics (H-D-2008-088). All participants approved participation by signed informed consent. Participants As part of a large rst-episode project, 36 antipsychotic-nave schizophrenia patients 18-45 years of age were recruited frompsy- chiatric hospitals and outpatient psychiatric centers in the Capital Region of Denmark. The ICD-10 1 diagnoses of schizophrenia or schizoaffective psychoses were based on a structured diagnostic interview(Schedule of Clinical Assessment in Neuropsychiatry, ver- sion 2.1). Patients with a current diagnosis of drug dependency accordingtoICD-10 were excluded, but previous diagnoses of drug dependency or current occasional use of drugs were accepted. Current drug status was measured by urine test (Rapid Response, Jepsen HealthCare, Tune, Denmark). None of the patients had ever received any antipsychotic medication or Ritalin. Treatment with antidepressants within the last month was also an exclusion crite- rion. Patients were allowed to receive benzodiazepines or sleeping medication but not later than 12 hours before scans (see Table 1 for details on drugs and benzodiazepines). Healthy control subjects were recruited from the community and were matched on age, gender, and parental socioeconomic status. They underwent a Schedule of Clinical Assessment in Neuropsychiatry interview to ensure they had no former or present psychiatric illness, drug- abuse, or any rst-degree relatives with psychiatric diagnoses. Both patients and healthy control subjects were required to have a nor- mal physical and neurological examination and no history of major head injury. Clinical Measures Psychopathology of the patients was measured with the Posi- tive and Negative Syndrome Scale (PANSS) (40) and Global Assess- ment of Functioning (GAF). Edinburg Handedness Inventory (EHI) (41) was used to assess participant handedness. Experimental Design and Task We used a modied variant of monetary incentive delay task described by Knutson (7,42) and modied by Cooper and Knutson (39) to elicit VS activation in response to cues indicating monetary gain and loss (Figure S1 in Supplement 1). In each trial, participants were presented initially with a cue indicating the trial condition. After a short delay, a visual target appeared briey on the screen, and participants were instructed to press a button while the target was on screen. After another delay, participants receivedfeedback onthe outcome of the trial andhow much money they had earned in total. Initial target duration for all participants and trial conditions was 300 msec, but an automated adaptive timing algorithm adjusted target time to maintain a hit rate of approximately 66% over the experiment. After the scan, participants were paid the amount of money they won, typically 4585 for each session. There were six different trial conditions representing two levels of uncertainty (certain and uncertain), crossed with three levels of value expectation (gain, neutral, and loss). In uncertain gain and loss conditions, the outcome dependedonwhether the buttonwas pressed in time. In uncertain-gain trials, a participant could make 7 on a hit but earn nothing on a miss. In uncertain-loss trials, a participant could make 0 on a hit but would lose 7 on a miss. In the two certain conditions, outcome was pre-determined and non- contingent on the response, and a participant would gain or lose 7 regardless of pressing the button in time. In the two neutral trials, participants knewthe outcome would be 0. After each trial, the recent and total amount won or lost was displayed on the screen. Participants were instructed to respond rapidly on all trials, regardless of whether they involved uncertain, certain, or neutral outcomes. Before scans, participants were instructed about the meaning of each cue. They performed a 10-min training version of the task. Participants were not told about the adaptive timing algo- rithm. Duration of one trial was 15 sec. Each of the six trial conditions was presented in a block-wise, randomized order 12 times in each of the two runs. Total task time was 36 min (18 min/run). Presenta- 1 In ICD-10 and DSM-IV the major difference in the diagnostic criteria for schizophrenia is the duration of symptoms. In ICD-10 it is 1 month, whereas in DSM-IV it is 6 months. A few of the patients in this rst- episode study did not meet the duration criteria in DSM-IV when they were included in the study. Table 1. Participant Demographic Data Schizophrenia Patients (n 31) Healthy Control Subjects (n 31) Age, Years: Mean (SD) 25.9 (6.4) 25.7 (5.8) Gender: Male/Female 22/9 22/9 Handedness: Mean EHI-Score (SD) 61 (61) 54 (77) Education, Years 11.9 (2.3) 15.7 (2.7) a Parental Socioeconomic Status b 4/17/10 6/17/8 Smokers (Cigarettes/Day) 21 (16.1) 8 (12.2) a PANSS Total, Mean (SD) 86 (15) PANSS Positive 21 (4.4) PANSS Negative 22 (6.9) PANSS General 43 (8.0) GAF Score 42 (10) Duration of Untreated Illness, Weeks 77 (72) Diagnosis Subtype, n (%) Paranoid 17 (55) Undifferentiated 10 (32) Hebephrenic 1 (3) Simplex 1 (3) Schizoaffective c 2 (7) Lifetime Abuse 13 Cannabis/alcohol/amphetamine 12/2/3 Current Abuse (Last Month) 7 Cannabis/alcohol/amphetamine 6/1/0 Urine test positive 6 (5 THC, 1 benzo) Benzodiazepines Last Week (Range) d 5 (530 mg/day) Sleeping Medication Last Week d 2 (7.5 mg/day) Benzo, benzodiazepines; EHI, Edinburg Handedness Inventory; GAF, Global Assessment of Functioning; PANSS, Positive andNegative Syndrome Scale; THC, tetrahydrocannabinol. a Signicant group difference, p .01. b High/moderate/low. c One was in a neutral mood, and one was in a sub-manic mood with rst-rank psychotic symptoms. d Mean daily doses of oxazepam and zopiclone during the last week. M.. Nielsen et al. BIOL PSYCHIATRY 2012;71:898905 899 www.sobp.org/journal tionof thetask andrecordingof thebehavioral dataweredonewith Presentation software (Neurobehavioral Systems, Albany, Califor- nia). Imaging Functional and structural MRIs were performed with a Philips Achieva 3.0T whole body MRI scanner (Philips Healthcare, Best, The Netherlands) with an 8-channel SENSE Head Coil (Invivo, Orlando, Florida). For each participant, we acquired 1080 (540/run) whole- brain functional echo-planar images (38 slices, thickness 2.4 mm, voxel size 2.4 2.9 2.9 mm, ipangle 75, repetitiontime 2 sec, echo time 25 msec), and whole-brain three-dimensional (3D) high-resolution T1-weighted structural images were acquired for anatomical reference (repetition time 10 msec, echo time 4.6 msec, ip angle 8, voxel size .79 .79 .80 mm). Data Analysis Analyses were performed with BrainVoyager 2.20 (Brain Innova- tion B.V., Maastricht, The Netherlands). Images were corrected for slice-timing effects, and 3D motion correction was performed with trilinear interpolation. Spatial smoothing was performed with a 4-mm full-width at half maximal Gaussian kernel, and a high pass lter (200 sec) was applied to reduce low frequency noise. Func- tional images were then coregistered to the 3D anatomical images and transformed into Talairach space. General Linear Model A general linear model was constructed for statistical analysis. For anticipation to act, the six different cues were modeled as separate predictors: uncertaingain(ug); certaingain(cg); uncertain loss (ul); certain loss (cl); uncertain neutral (un); and certain neutral (cn). Target onset and the delay to outcome was modeled with two different predictors not included in any contrast (one for uncertain events, andonefor certainandneutral events). Theoutcomeperiod was modeled with seven predictors, one for each of the possible outcomes. There were two situations for winning: certain win (cw), and uncertain win (uw). Similarly, there were two situations for losing: certain lose (ocl), and uncertain lose (oul). There were three economically neutral but emotionally different outcomes: zero miss (zm), when failing to win in uncertain trial; zero hit (zh), when avoiding to lose in uncertain trials; and zero neutral (zn), which was the outcome of neutral trials. All explanatory variables were con- volved with the hemodynamic response function, and six realign- ment parameters were included. Due to the repetitive nature of the stimulation, considerable oscillations were observed at the para- digm frequency (1/15 Hz). To reduce any trivial effects of the main frequency of the stimulation paradigm, we further included sine and cosine regressors at this frequency (1/15 Hz). Contrasts During reward anticipation, we were interested in the overall effect of salience (the joined effect of uncertainty and value expectation) modeled by uncertain cues versus neutral cues [ugulcnun]. To highlight the motivational component and eliminate the value component, we constructed a behavioral sa- lience contrast by contrasting uncertain versus certain cues [ugulcgcl] (43,44). Finally, the effect of valence anticipation was dened as a contrast between cues indicating gain versus those indicating loss [cgugclul] (39). During the outcome phase we dened two contrasts of interest: 1) winning modeled by all money-receiving outcomes versus zero neutral [cwuwzn]; and 2) losing modeled by all money-losing outcomes versus zero neutral [ocloulzn]. Statistics We analyzedthe imagingdata witha randomeffects model. The statistical threshold for all voxel-wise analyses was dened as whole-brain false discovery rate (FDR) q .05. All contrasts were analyzed with a one-way analysis of variance (ANOVA), with group as between factor. All analyses were performed with and without three covariates: age, gender, and smoking status (smoker or non- smoker). Behavioral data of the monetary incentive delay task, demo- graphic data, and the psychopathological ratings were analyzed with SPSS (version 11.0, SPSS, Chicago, Illinois). Simple group com- parisons were performed with two-sample t tests, whereas more complex comparisons of behavioral data were performed with re- peated measures ANOVA. Regions of Interest Alongwiththe whole-brainanalyses, we performedgroupcom- parisons of the average effect size (regression coefcient, ) in six predened regions of interest (ROIs). We dened regions in VTA/ substantia nigra, right and left VS, and anterior cingulate cortex (ACC)known to be active during reward anticipationand re- gions in MPFC and right DLPFCknown to be active during out- comeevaluation(7,42,44,45). Withintheseregions weselectedvox- els that were functionally dened by being active in the relevant contrast (overall salience contrast during anticipation and winning during outcome evaluation). Thus the nal ROI denition was the intersectionof theanatomically andfunctionally denedareas (Fig- ure S3 and Table S2 in Supplement 1). Results Initially, 36 antipsychotic-nave schizophrenia patients and 32 healthy control subjects were recruited. Five patients were ex- cluded (three patients experienced symptom exacerbation during the examination period and started medication urgently; one pa- tient had a minor, structural brain lesion; and in one patient func- tional scanning was lost due to technical problems). One healthy control subject was excluded due to incidental nding of structural brain lesion, leaving us with 31 patients (22 men) and 31 age- and gender-matched healthy control subjects (Table 1). Behavioral Data A two-sample t test showed no signicant differences between the groups with regard to the total amount won (patients vs. con- trol subjects: 61 21 vs. 64 15/run). The rest of the behavioral data was analyzed with 2 3 2 ANOVA, with group as between factor and valence (gain, loss, neutral) and certainty (certain, uncer- tain) as within factors. 2 With regard to the hit rate, there was a main effect of certainty [F(1,60) 33, p .001] and valence [F(1,60) 24, p .001] but no effect of group. There was no group certainty valence interac- tion, but we found a certainty valence [F(1,60) 9.3, p .003] anda groupvalence interaction[F(1,60) 13.8, p .001]. The hit rate was highest in uncertain trials in both groups. In healthy con- trol subjects, the lowest hit rate was seen in neutral trials; however, inpatients thelowest hit-ratewas seenincertaingainandloss trials. With regard to reaction times, we found a main effect of cer- tainty [F(1,59) 14.1, p .001], valence [F(1,59) 6.1, p .02], and 2 In a few cases (1 patient and 1 control subject) there were no or very few responses in the certain gain condition, so that response times for that condition could not be reliably measured. Performing all analysis (be- havioral and fMRI) with or without these subjects did not alter the results, but this explains why degree of freedom is 59 in analyses of reaction time. 900 BIOL PSYCHIATRY 2012;71:898905 M.. Nielsen et al. www.sobp.org/journal group [F(1,59) 5.1, p .03]. There were no signicant interac- tions, although there was a group valence interaction at a trend level (p.06). Responses were generally faster on uncertain trials compared with certain trials and on gain and loss trials com- pared with neutral trials. Patients were slower overall than healthy control subjects. The trend-wise interaction was caused by an increased reaction time to neutral trials in healthy control subjects (HC), which was not found in patients (Figure S2 and Table S1 in Supplement 1). fMRI Data Initially, we performed voxel-wise analyses for the entire group. During anticipation to act, the overall salience contra- sts [ugulcnun] and the behavioral salience contrasts [ugulcgcl] showed activation of very large, conuent brain areas at the statistical level of FDR q .05. To reveal the most relevant clusters for these contrasts, we increased the threshold to whole-brain FDR q .001. At this threshold, there were several active clusters in both contrasts, including VS bilaterally, ACC, and an area in VTA in the overall salience contrast but only left VS in the behavioral salience contrast (Figure S4 and Tables S3 and S4 in Supplement 1). Thevalenceanticipationcontrast [ugcgulcl] showedthreesmall clusters surviving FDR q .05. Two of these clusters were in the most ventral part of striatum(FigureS5andTableS5inSupplement 1). During outcome evaluation, the main effect of winning money revealed 12 active clusters surviving FDR q .05. Several of them were located in the frontal area, Brodmann area (BA) 910, whereas there was no activation in VS (Figure S6 and Table S6 in Supplement 1). The main effect of losing money revealed two signicant clus- ters at FDRq.05, a negative cluster inBA10, anda positive cluster in BA 18 (Figure S6 and Table S7 in Supplement 1). Whole-Brain Group Comparison A voxel-wise group comparison was conducted for each con- trast of interest. There was signicant groupdifferences inthe over- all salience contrast [ugulcnun] at FDR q .05. The patients showed an attenuated activation in several areas, including ACC, the midbrain, thalamus, cerebellum, and striatum bilaterally. This was not altered after correction for smoking, gender, and age (Fig- ure 1 and Table S8 in Supplement 1). Voxel-wise group comparison of the behavioral salience con- trast and the valence anticipation contrast revealed no group dif- Figure 1. (A) The voxel-wise group comparison of the overall salience contrast [ugulcnun] corrected for whole-brain false discovery rate (FDR), q .05. Widespread group differences exist; all of them are caused by attenuated activation in the schizophrenia patients. Lower panels: the activation map for each of the groups: (B) healthy control subjects, and (C) antipsychotic-na- ve schizophrenia patients. For the healthy control subjects, the FDR level was lowered to q .001 to emphasize the most relevant areas. A, anterior; Bonf, Bonferroni; cn, certain neutral; COR, coronal; L, left; P, posterior; R, right; SAG, sagital; TRA, transversal; ug, uncertaingain; ul, uncertain loss; un, uncertain neutral. Figure 2. Response to different cues during reward antic- ipation in predened regions of interest divided by groups. In all of the regions the healthy control subjects showedalarger bloodoxygenleveldependent signal on uncertain trials relative to certain and neutral trials. The blood oxygen leveldependent signal in patients was re- duced under all conditions, but the most pronounced difference was seen on trials with cues to uncertain out- comes. Error-bars indicate standard error. ACC, anterior cingulate cortex; cg, certain gain; cl, certain loss; cn, cer- tain neutral; ug, uncertain gain; ul, uncertain loss; un, un- certain neutral; VTA, ventral tegmental area. M.. Nielsen et al. BIOL PSYCHIATRY 2012;71:898905 901 www.sobp.org/journal ferences. Similarly, we found no group differences during outcome evaluation. This was unchanged after including the covariates. Anticipation Phase: ROI Analyses, VS, VTA, and CG Because we found signicant group differences in or very close to our predened ROIs with the voxel-wise approach, we did not nd it necessary to perform a ROI-wise group comparison of the overall salience contrast. However, we wanted to examine possible group differences for behavioral salience and anticipated valence on the ROI level. In the behavioral salience contrast, we found signicant groupdifferences inleft VS [F(1,60) 8.9, p.004], right VS [F(1,60) 4.9, p .031], and VTA[F(1,60) 4.1, p .046]. There were no signicant group differences in ACC in the behavioral salience contrast or in any of the regions in the valence contrast. There were no signicant effects of the covariates. Finally, to understand the changes of the activation pattern in the patients, we plotted the mean ROI parameter estimates for all cues during anticipation by group (Figure 2). Patients generally showed an attenuated activation for all cues, although this was most pronounced for cues indicating uncertain gain and loss. Outcome Phase: ROI Analyses, MPFC, and DLPFC Because the outcome-relevant ROIs were dened by being ac- tive during winning, we only analyzed the winning contrast. There werenosignicant groupdifferences inMPFC, but patients showed a trend toward attenuated response in DLPFC (p .06). There were no signicant effects of the covariates. When we extracted the parameter estimates for the individual regressors in DLPFC, one of the healthy control subjects was an extreme outlier ( values in all predictors 3 SDbelowmean). The mean values were plotted with and without the outlier. We found a changed activation pattern with an increased BOLD response in the neutral condition in pa- tients (Figure 3). Correlation with Psychopathology We found a negative correlation between PANSS positive score andthe average signal change of the overall salience contrast inthe right andleft VS ROI (r .41, p .02 andr .36, p .04) (Figure 4). There was no correlation between the VS, MPFC, or DLPFC acti- vation and PANSS negative symptoms score. Analyses of Substance Abuse Additional analyses were performed comparing healthy control subjects with patients with and without previous or ongoing sub- stance abuse. Voxel-wise comparison of the overall salience con- trast showed similar signal attenuation in the two groups of pa- tients. Comparison of the two subgroups of patients showed one area in ACC with an attenuated signal in the abusing patients. The ROIs showed no difference in activation in the two subgroups of patients in any contrasts (Figures S7 and S8 in Supplement 1). Discussion This is the rst study to use a voxel-wise approach to look at alterations of the brain reward system in a large group of schizo- Figure 3. Response todifferent outcomes inpredenedregions of interest dividedby groups. There was nodifference inthe medial prefrontal cortex (MPFC). Indorsolateral prefrontal cortex (DLPFC), patients showedelevatedsignals inresponsetoneutral outcome, whichwas not seeninthehealthycontrol subjects. For DLPFC the means are shown with (corner) and without the extreme outlier found in the healthy control subjects. Error bars indicate standard error. cl, certain loss; cw, certain win; ul, uncertain loss; uw, uncertain win; zh, zero hit; zm, zero miss; zn, zero neutral. Figure 4. There was a negative correlation between the degree of positive symptoms andthe signal change inthe right and left striatum during anticipation of uncertain outcomes relative to neutral outcomes. The highest pos- itive score on the Positive and Negative Syndrome Scale (PANSS) was found in the patients with the least (most abnormal) signal change in the contrasts between the conditions. cn, certain neutral; ug, uncertain gain; ul, un- certain loss; un, uncertain neutral; VS, ventral striatum. 902 BIOL PSYCHIATRY 2012;71:898905 M.. Nielsen et al. www.sobp.org/journal phrenia patients who have never received antipsychotic medica- tion. Patients showed attenuated activation in multiple brain areas during reward anticipation as compared with control subjects, and in VS this correlated with the degree of positive symptoms. There were nogroupdifferences duringoutcome evaluationwitha voxel- wise approach, but we observed a changed activation pattern in right DLPFC during outcome evaluation. Behavioral Level On the behavioral level, there was a generally slower mean reaction time in patients, as described in a previous study on un- medicated patients (32). There was a trend-wise group valence interaction, withhealthy control subjects showingalonger reaction time in neutral events compared with positive and negative certain and uncertain events. This discrimination was not seen in patients who seemed to have a relatively accelerated reaction time in neu- tral trials. This has previously been reported and interpreted as aberrant assignment of motivation (46). Furthermore, the group valence interaction in the hit-rate indicated that healthy control subjects were better at improving accuracy in gain and loss com- pared with neutral events. Nevertheless, uncertainty had a signi- cant inuence on reaction time and hit-rate in both groups. This indicates that all participants understood the behavioral impor- tance of the uncertain trials, but it might introduce a slightly differ- ent motor-activation between the trials. fMRI Similar to previous fMRI studies, we found an attenuated BOLD response in VS during reward anticipation (31,32). Positron emis- siontomography studies report anincreaseddopaminergic activity in schizophrenia (17,4749), and the increased dopaminergic tone has been suggested to result in an elevated baseline in fMRI. Thus, the event-related BOLD responses are often smaller, because pha- sic-dopamine responses might not sufciently differentiate them- selves from tonic dopamine levels (38). Knutson et al. (28) demon- strated this in healthy control subjects by increasing the dopaminergic tone with amphetamine, which resulted in a de- creased event-related BOLD response in VS. Furthermore, Taylor et al. (50) found an elevated tonic activity but a reduced immediate response to salient pictures in VS in unmedicated schizophrenia patients. Phasic dopamine release in VS has been suggested to mediate the incentive salience of cues indicating a possible reward or pun- ishment (4,51). This understanding of dopaminergic function was used by Heinz (52) and Kapur (53) to link dopaminergic hyperactiv- ityinstriatumtothedevelopment of psychotic symptoms inschizo- phrenia. The salience hypotheses suggest that increased dopami- nergic activity in striatum leads to an aberrant assignment of salience tootherwise irrelevant stimuli, resultingindevelopment of psychotic symptoms. In our patients, we found that attenuated activation in relation to salience in VS was correlated with the de- gree of positive symptoms, with the most attenuated BOLD re- sponse in the most psychotic patients. If a decreased event-related BOLD response is a consequence of an increased dopaminergic tone, this correlation supports the link between an increased dopa- minergic tone and the development of psychotic symptoms, as suggested by Heinz and Kapur. In our study the contrast showing the effect of overall salience revealed signicant group differences in several brain areas. When we divided salience into components of motivation (behavioral salience) and value expectation, there were no signicant group differences in the voxel-wise analyses. This indicates that the atten- uated response in schizophrenia patients during presentation of salient cues is a combination of changes in value expectation and motivation. Although changes related to motivation account for the majority of the difference (being marginally signicant in the ROI analyses), an additional difference might be added by the an- ticipated gain or loss, although it is too small to be detected on its own, even in a study with a moderate sample size (36). This nding is consistent with schizophrenia patients reporting decreasedplea- sure anticipation (54). During outcome evaluation, we found an intact BOLD response in patients in relation to winning money in MPFC, which is in line with previous results in medicated patients (35,55). In medicated patients, a correlation between PFC activation during reward out- come evaluation and negative symptoms has been reported (35 37,56). However, inour study, where negative symptoms cannot be caused by present or previous treatment, this relation was not found. It would be interesting to relate the brain response to moti- vation and pleasure experienced during the game, but these as- pects were not assessed. We observed a trend toward decreased activation in patients in relation to winning money in right DLPFC. This seemed to be caused, lookingat the activation-pattern in the ROI (Figure 3), by an increased BOLD-response in relation to neutral events in patients. This might indicate primary disturbances incortical processingdur- ing rewardoutcome evaluation andis in line with previous ndings on unmedicated patients (32), where a decreased difference in activity during evaluation of successful and unsuccessful outcomes in MPFC was related to the development of delusional beliefs (32,57). Thevoxel-wiseapproachadditionally revealedsignicant group differences in thalamus, large areas of cerebellum, and occipital lobe in the overall salience contrast. These areas are known to be active during reward processing of particularly motivating events (44). As reviewed by Picard et al. (58), networks involving these areas have shown alterations during fMRI in different cognitive tasks. The reward task used in our study is not cognitively demand- ing, but it requires payingspecial attentiontouncertainevents. Our results suggest that schizophrenia patients havedecits infocusing attention on these specic events. Study Limitations A large group of schizophrenia patients have a previous or on- going use of drugs. To increase external validity of our ndings and to be able to collect a large group of patients, we allowed previous or current sporadic drug abuse in patients, although drug abuse is known to affect reward-related activation (59,60). We examined this confounder and found an overall identical group difference between healthy control subjects and the two sub-groups of pa- tients. Nonetheless, the nding of a region in ACC with a decreased activation in the abusing patients supports that inclusion of abus- ing patients represents a limitation of the study (see Supplement 1 for a discussion of this topic). Another limitation of our study is that the control groupwas not matched on smoking. Even though smoking was limited 1 hour before the scans, smoking status might have affected the BOLD response (61,62). However, there was no signicant effect from smoking as a covariate. This strongly supports the contention that the alterations in schizophrenia patients reported here are not ex- plained by group differences in smoking or drug abuse habits. This study was supported by the Danish Medical Research Council, the Lundbeck Foundation, and the Mental Health ServicesCapital Region of Denmark. We would like to thank the various departments for helping us recruit patients and the patients for their participation. M.. Nielsen et al. BIOL PSYCHIATRY 2012;71:898905 903 www.sobp.org/journal We are grateful to the Radiological Department, Glostrup Hospital, for clinical evaluation of the obtained images. Shitij Kapur has received grant support from AstraZeneca and Glaxo Smith Kline and has served as consultant and/or speaker for AstraZeneca, Bioline, Bristol-Myers Squibb, Otsuka, Eli Lilly, Janssen (JohnsonandJohnson), Lundbeck, NeuroSearch, Pzer, Roche, Servier, and Solvay Wyeth. Henrik Lublinhas servedas aspeaker or chairmanfor AstraZeneca, H. Lundbeck, Bristol-Myers Squibb, and Eli Lilly; and has re- ceived research grants from H. Lundbeck. All other authors reported no biomedical nancial interests or potential conicts of interest Supplementary material cited in this article is available online. 1. Berridge KC, Robinson TE, Aldridge JW (2009): Dissecting components of reward: liking, wanting, andlearning. Curr Opin Pharmacol 9:6573. 2. Redgrave P, Prescott TJ, Gurney K (1999): Is the short-latency dopamine response too short to signal reward error? Trends Neurosci 22:146151. 3. Schultz W, Dayan P, Montague PR (1997): A neural substrate of predic- tion and reward. Science 275:15931599. 4. BerridgeKC(2007): Thedebateover dopamines roleinreward: Thecase for incentive salience. Psychopharmacology (Berl) 191:391431. 5. Zink CF, Pagnoni G, Martin-Skurski ME, Chappelow JC, Berns GS (2004): Humanstriatal responses to monetary rewarddependonsaliency. Neu- ron 42:509517. 6. Horvitz JC (2000): Mesolimbocortical and nigrostriatal dopamine re- sponses to salient non-reward events. Neuroscience 96:651656. 7. Knutson B, Fong GW, Adams CM, Varner JL, Hommer D (2001): Dissoci- ationof rewardanticipationandoutcome withevent-relatedfMRI. Neu- roreport 12:36833687. 8. Costa VD, Lang PJ, Sabatinelli D, Versace F, Bradley MM (2010): Emo- tional imagery: Assessing pleasure and arousal in the brains reward circuitry. HumBrain Mapp 31:14461457. 9. Wallis JD (2007): Orbitofrontal cortex and its contribution to decision- making. Annu Rev Neurosci 30:3156. 10. BarchDM, DowdEC(2010): Goal representations andmotivational drive in schizophrenia: The role of prefrontal-striatal interactions. Schizophr Bull 36:919934. 11. Carlsson A (2006): The neurochemical circuitry of schizophrenia. Phar- macopsychiatry 39(suppl 1):S10S14. 12. Seamans JK, Yang CR (2004): The principal features and mechanisms of dopamine modulation in the prefrontal cortex. Prog Neurobiol 74:158. 13. RasmussenH, ErritzoeD, AndersenR, EbdrupBH, Aggernaes B, OranjeB, et al. (2010): Decreased frontal serotonin2A receptor binding in antip- sychotic-naive patients with rst-episode schizophrenia. Arch Gen Psy- chiatry 67:916. 14. Glenthoj BY, Mackeprang T, Svarer C, Rasmussen H, Pinborg LH, Friberg L, et al. (2006): Frontal dopamine D(2/3) receptor binding in drug-naive rst-episode schizophrenic patients correlates with positive psychotic symptoms and gender. Biol Psychiatry 60:621629. 15. Howes OD, Kapur S (2009): The dopamine hypothesis of schizophrenia: Version IIIthe nal common pathway. Schizophr Bull 35:549562. 16. Reith J, Benkelfat C, Sherwin A, Yasuhara Y, Kuwabara H, Andermann F, et al. (1994): Elevated dopa decarboxylase activity in living brain of patients with psychosis. Proc Natl Acad Sci U S A 91:1165111654. 17. Hietala J, Syvalahti E, VuorioK, RakkolainenV, BergmanJ, Haaparanta M, et al. (1995): Presynaptic dopamine function in striatumof neuroleptic- naive schizophrenic patients. Lancet 346:11301131. 18. Dao-Castellana MH, Paillere-Martinot ML, Hantraye P, Attar-Levy D, Remy P, Crouzel C, et al. (1997): Presynaptic dopaminergic function in the striatum of schizophrenic patients. Schizophr Res 23:167174. 19. LindstromLH, Gefvert O, Hagberg G, Lundberg T, BergstromM, Hartvig P, et al. (1999): Increased dopamine synthesis rate in medial prefrontal cortex and striatum in schizophrenia indicated by L-(beta-11C) DOPA and PET. Biol Psychiatry 46:681688. 20. Laruelle M, Abi-DarghamA, vanDyck CH, Gil R, DSouza CD, Erdos J, et al. (1996): Single photon emission computerized tomography imaging of amphetamine-induced dopamine release in drug-free schizophrenic subjects. Proc Natl Acad Sci U S A 93:92359240. 21. Abi-Dargham A, Gil R, Krystal J, Baldwin RM, Seibyl JP, Bowers M, et al. (1998): Increased striatal dopamine transmission in schizophrenia: Con- rmation in a second cohort. Am J Psychiatry 155:761767. 22. Breier A, SuTP, Saunders R, CarsonRE, KolachanaBS, deBartolomeis A, et al. (1997): Schizophrenia is associated with elevated amphetamine-induced synaptic dopamine concentrations: Evidence from a novel positron emis- siontomography method. Proc Natl AcadSci US A94:25692574. 23. AgidO, MamoD, Ginovart N, VitcuI, WilsonAA, Zipursky RB, et al. (2007): Striatal vs extrastriatal dopamine D2 receptors in antipsychotic re- sponsea double-blind PET study in schizophrenia. Neuropsychophar- macology 32:12091215. 24. Zipursky RB, Christensen BK, Daskalakis Z, Epstein I, Roy P, Furimsky I, et al. (2005): Treatment response to olanzapine and haloperidol and its association with dopamine D receptor occupancy in rst-episode psy- chosis. Can J Psychiatry 50:462469. 25. Meyer-LindenbergA, Miletich RS, Kohn PD, Esposito G, Carson RE, Quaran- telli M, et al. (2002): Reducedprefrontal activitypredictsexaggeratedstriatal dopaminergic function in schizophrenia. Nat Neurosci 5:267271. 26. Waelti P, Dickinson A, Schultz W (2001): Dopamine responses comply with basic assumptions of formal learning theory. Nature 412:4348. 27. Berridge KC, Robinson TE (2003): Parsing reward. Trends Neurosci 26: 507513. 28. Knutson B, Bjork JM, Fong GW, Hommer D, Mattay VS, Weinberger DR (2004): Amphetamine modulates human incentive processing. Neuron 43:261269. 29. Dreher JC, Meyer-Lindenberg A, Kohn P, Berman KF (2008): Age-related changes in midbrain dopaminergic regulation of the human reward system. Proc Natl Acad Sci U S A 105:1510615111. 30. da Silva AF, Schmitz N, Figee M, AbelingN, Hasler G, vander Meer J, et al. (2011): Dopaminergic modulation of the human reward system: A pla- cebo-controlled dopamine depletion fMRI study. J Psychopharmacol 25:538549. 31. Juckel G, Schlagenhauf F, Koslowski M, WustenbergT, Villringer A, Knut- son B, et al. (2006): Dysfunction of ventral striatal reward prediction in schizophrenia. Neuroimage 29:409416. 32. Schlagenhauf F, Sterzer P, SchmackK, Ballmaier M, RappM, WraseJ, et al. (2009): Reward feedback alterations in unmedicated schizophrenia pa- tients: Relevance for delusions. Biol Psychiatry 65:10321039. 33. Paradiso S, Andreasen NC, Crespo-Facorro B, OLeary DS, Watkins GL, Boles Ponto LL, et al. (2003): Emotions in unmedicated patients with schizophrenia during evaluation with positron emission tomography. AmJ Psychiatry 160:17751783. 34. Plailly J, dAmato T, Saoud M, Royet JP (2006): Left temporo-limbic and orbital dysfunction in schizophrenia during odor familiarity and hedo- nicity judgments. Neuroimage 29:302313. 35. Simon JJ, Biller A, Walther S, Roesch-Ely D, Stippich C, Weisbrod M, et al. (2010): Neural correlates of reward processing in schizophreniarela- tionship to apathy and depression. Schizophr Res 118:154161. 36. Waltz JA, Schweitzer JB, Ross TJ, Kurup PK, Salmeron BJ, Rose EJ, et al. (2010): Abnormal responses to monetary outcomes in cortex, but not in the basal ganglia, in schizophrenia. Neuropsychopharmacology 35: 24272439. 37. Harvey PO, Armony J, Malla A, Lepage M (2010): Functional neural substrates of self-reported physical anhedonia in non-clinical individu- als and in patients with schizophrenia. J Psychiatr Res 44:707716. 38. Heinz A, Schlagenhauf F (2010): Dopaminergic dysfunction in schizo- phrenia: Salience attribution revisited. Schizophr Bull 36:472485. 39. Cooper JC, KnutsonB(2008): Valenceandsaliencecontributetonucleus accumbens activation. Neuroimage 39:538547. 40. Kay SR, FiszbeinA, Opler LA(1987): The positive andnegative syndrome scale (PANSS) for schizophrenia. Schizophr Bull 13:261276. 41. Oldeld RC (1971): The assessment and analysis of handedness: The Edinburgh inventory. Neuropsychologia 9:97113. 42. Knutson B, Adams CM, Fong GW, Hommer D (2001): Anticipation of increasing monetary reward selectively recruits nucleus accumbens. J Neurosci 21:RC159. 43. Dreher JC, KohnP, BermanKF (2006): Neural codingof distinct statistical properties of reward information in humans. Cereb Cortex 16:561573. 44. Kirsch P, Schienle A, Stark R, Sammer G, Blecker C, Walter B, et al. (2003): Anticipation of reward in a nonaversive differential conditioning para- digmand the brain reward system: An event-related fMRI study. Neuro- image 20:10861095. 45. Walter H, Kammerer H, Frasch K, Spitzer M, Abler B (2009): Altered reward functions in patients on atypical antipsychotic medication in line with the revised dopamine hypothesis of schizophrenia. Psychop- harmacology (Berl) 206:121132. 904 BIOL PSYCHIATRY 2012;71:898905 M.. Nielsen et al. www.sobp.org/journal 46. Murray GK, Corlett PR, Clark L, Pessiglione M, Blackwell AD, Honey G, et al. (2008): Substantia nigra/ventral tegmental reward prediction error disruption in psychosis. Mol Psychiatry 13:239, 267276. 47. Abi-DarghamA, Rodenhiser J, Printz D, Zea-Ponce Y, Gil R, Kegeles LS, et al. (2000): Increased baseline occupancy of D2 receptors by dopamine in schizophrenia. Proc Natl Acad Sci U S A 97:81048109. 48. Kegeles LS, Abi-DarghamA, Frankle WG, Gil R, Cooper TB, Slifstein M, et al. (2010): Increased synaptic dopamine function in associative regions of the striatumin schizophrenia. Arch Gen Psychiatry 67:231239. 49. Howes OD, Egerton A, Allan V, McGuire P, Stokes P, Kapur S (2009): Mechanisms underlying psychosis and antipsychotic treatment re- sponse in schizophrenia: Insights from PET and SPECT imaging. Curr PharmDes 15:25502559. 50. Taylor SF, Phan KL, Britton JC, Liberzon I (2005): Neural response to emo- tional salience in schizophrenia. Neuropsychopharmacology 30:984995. 51. Robinson TE, Berridge KC (1993): The neural basis of drug craving: An incentive-sensitization theory of addiction. Brain Res Brain Res Rev 18: 247291. 52. Heinz A (2002): Dopaminergic dysfunction in alcoholism and schizo- phreniapsychopathological and behavioral correlates. Eur Psychiatry 17:916. 53. Kapur S (2003): Psychosis as a state of aberrant salience: A framework linking biology, phenomenology, and pharmacology in schizophrenia. AmJ Psychiatry 160:1323. 54. Gard DE, Kring AM, Gard MG, Horan WP, Green MF (2007): Anhedonia in schizophrenia: Distinctions between anticipatory and consummatory pleasure. Schizophr Res 93:253260. 55. Dowd EC, Barch DM (2010): Anhedonia and emotional experience in schizophrenia: Neural and behavioral indicators. Biol Psychiatry 67: 902911. 56. Ursu S, Kring AM, Gard MG, Minzenberg MJ, Yoon JH, Ragland JD, et al. (2011): Prefrontal cortical decits and impaired cognition-emotion in- teractions in schizophrenia. Am J Psychiatry 168:276285. 57. Corlett PR, Murray GK, Honey GD, Aitken MR, Shanks DR, Robbins TW, et al. (2007): Disrupted prediction-error signal in psychosis: Evidence for an associative account of delusions. Brain 130:23872400. 58. Picard H, Amado I, Mouchet-Mages S, Olie JP, Krebs MO(2008): The role of the cerebellumin schizophrenia: An update of clinical, cognitive, and functional evidences. Schizophr Bull 34:155172. 59. van Hell HH, Vink M, Ossewaarde L, Jager G, Kahn RS, Ramsey NF (2010): Chronic effects of cannabis use on the human reward system: An fMRI study. Eur Neuropsychopharmacol 20:153163. 60. Nestor L, Hester R, Garavan H (2010): Increased ventral striatal BOLD activity during non-drug reward anticipation in cannabis users. Neuro- image 49:11331143. 61. Kozink RV, Kollins SH, McClernon FJ (2010): Smoking withdrawal modu- lates right inferior frontal cortex but not presupplementary motor area activation during inhibitory control. Neuropsychopharmacology 35: 26002606. 62. Friedman L, Turner JA, Stern H, Mathalon DH, Trondsen LC, Potkin SG (2008): Chronic smoking and the BOLD response to a visual activation task and a breath hold task in patients with schizophrenia and healthy controls. Neuroimage 40:11811194. M.. Nielsen et al. BIOL PSYCHIATRY 2012;71:898905 905 www.sobp.org/journal