Neural basis of attentional deployment in affective forecasting of hypothetical medication outcome trade-offs

Predicting the emotional impact of future events, known as affective forecasting, is central to decision-making. When outcomes are emotionally bivalent (i.e. contain mixed-valence elements), such as medical treatments involving both remission and adverse side effects, forecasts are often inaccurate. We used functional magnetic resonance imaging (fMRI) to investigate the neural basis of affective forecasting in medical treatment trade-offs and how it is shaped by attentional deployment, an emotion regulation strategy that directs attention toward or away from aspects of an outcome. Participants imagined undergoing a treatment providing pain relief but causing side effects, and forecasted their emotions while focusing on remission or side effects. Univariate analyses showed that attentional deployment modulated neural activity during forecasting: the side-effect-focus condition recruited the insula and frontal pole, whereas remission-focus trials recruited the superior frontal gyrus and frontal pole. Multivariate analyses revealed a broad and distributed network that differentially represented positive and negative forecasting. We conclude that attentional deployment modulates which brain regions are recruited for affective forecasting. We identify the frontal pole as a hub for sustaining emotion-regulation goals during prospective thought. Together, these findings advance models of affective forecasting and highlight potential mechanisms, such as attentional deployment, which may bias emotional predictions in medical trade-off scenarios.