Two Forms of Non-Drug Therapy Helped Reduce Impulsive Aggression in Schizophrenia

Two Forms of Non-Drug Therapy Helped Reduce Impulsive Aggression in Schizophrenia

Posted: July 24, 2023
Two Forms of Non-Drug Therapy Helped Reduce Impulsive Aggression in Schizophrenia

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Two forms of cognitive remediation were found to “significantly reduce” impulsive aggression and significantly improve overall cognitive function in schizophrenia patients with a history of impulsive aggressive behavior. Overall cognition as well as emotion recognition improved more in patients who received both therapies in combination.


People with schizophrenia often show deficits in neurocognitive and social cognitive abilities. Neurocognitive abilities include processing speed, attention/vigilance, reasoning/problem solving, learning and memory, and working memory, a form of short-term memory for tasks immediately at hand. Social cognition refers to cognitive abilities specifically deployed in social interactions including perceiving and interpreting others’ emotions, intentions, and behaviors.

These deficits can contribute to difficulties that schizophrenia patients have in the social domain—being able to accurately assess facial and verbal expressions of other people, being able to verbally communicate, and being able to monitor their emotions and negotiate interpersonally stressful situations.

In contrast with “positive symptoms” of schizophrenia—phenomena such as unusual thoughts, hallucinations, and delusions, which can be controlled with antipsychotic medications—there are no drug therapies for cognitive and social cognition deficits. Cognitive remediation is a form of non-drug therapy that can help lessen the burden of cognitive dysfunction in many patients, when it is available.

A team of investigators led by 2015 BBRF Young Investigator Anthony O. Ahmed, Ph.D., of Weill Cornell Medical Center, recently published results of a study that Dr. Ahmed’s BBRF grant helped to support. Their focus was to compare two types of cognitive remediation therapies for chronic schizophrenia patients (and those with schizoaffective disorder) with a history of aggressive behavior, and specifically, impulsive aggression.

Most patients with psychotic disorders including schizophrenia do not manifest aggressive behaviors. But for those that do, such behaviors can contribute to adverse consequences, including involvement with the criminal justice system and frequent hospitalization in psychiatric and forensic facilities, as well as stigmatization.

“Few psychosocial treatment options are available for effective management of impulsive aggression in schizophrenia,” write Dr. Ahmed and colleagues, including Anzalee Kahn, Ph.D., who was first author of the team’s paper appearing in Schizophrenia Research. The researchers clarify that by impulsive aggression they mean limitations in an individual’s capacity to inhibit aggressive impulses, reflecting dysregulated emotion in social situations—for instance, when one becomes frustrated or feels provoked. Difficulties that patients have with social communication can sometimes generate such feelings. and in some patients, give rise to aggressive actions that are not premeditated but rather arise in response to the difficulty being experienced in the moment (hence, “impulsive”).

In prior research, Dr. Ahmed and colleagues demonstrated that after taking part in cognitive remediation training (CRT), violent offenders with schizophrenia “experienced decreased hostility and agitation” and fewer incidents of verbal and physical aggression. In Dr. Ahmed’s view, neurocognitive deficits experienced by patients are likely background risk factors for impulsive aggression, but “social cognitive deficits may be day-to-day contributors to aggression in patients with schizophrenia.”

In the clinical trial that they now report, Dr. Ahmed and colleagues compared CRT treatment for schizophrenia patients with a history of aggression with a combination treatment in which CRT was paired with what the team called “social cognition training” (SCT).

They recruited 130 chronic schizophrenia patients (average age 35; 84% male) with history of impulsive aggression, who were randomly assigned to two groups. One group received both CRT and SCT over 14 weeks; the other group received CRT plus a placebo version of SCT that served as a control. In the CRT + SCT group, 24 sessions of CRT were given over 14 weeks, along with 12 sessions of computer-delivered SCT training. In the CRT + placebo group, there were 24 CRT sessions over 14 weeks and 12 sessions of computer-delivered video games that involved no social cognitive training.

The CRT therapy used was called BrainHQ, a commercially available program that involves auditory and visual-based cognitive activities that allow patients to improve their auditory and visual information processing skills. Those who received SCT received it via both BrainHQ and MRIGE, an interactive computer program in which one practices recognition of hundreds of emotions and mental states in video presentations. Those who received the placebo version of SCT instead played computer games such as solitaire, checkers, and dominoes.

Both CRT and SCT were found to “significantly reduce” impulsive aggression, measured in several different ways. The combination of CRT and SCT therapies was not more effective than CRT + placebo in this regard.

Both interventions also enabled participants to significantly improve their overall cognitive functions, in all measured cognitive domains. But here, those who received the combined therapy of CRT and SCT did notably better. The combined intervention (but not CRT + placebo) was also associated with significant improvement in “general cognition”—measures of emotion recognition and mentalizing (the capacity to reflect on and interpret one's own behavior and that of others).

The particular advantages of CRT + SCT suggested to the team that there is a “close relationship” between neuro- and social cognition. Specifically, they noted, providing training in social cognition “imparted additional benefits to neurocognitive functioning.” When patients were trained to correctly recognize emotion expression in others, they likely had to draw upon cognitive skills such as processing speed, attention, and visual learning, the team said. At the same time, neurocognitive training may have improved patients’ ability to apply lessons learned in social cognitive training “via improved memory to recall strategies as well as enhanced executive function to apply skills flexibly.”

The team noted their trial involved chronic patients with considerable impairment (“moderate to marked”). For this reason, it is not known if the positive results of this trial will apply equally to higher-functioning patients with less pronounced cognitive deficits. This might be studied in future research, as well as the idea of supplying more intensive and more targeted social cognition training in combination with CRT.

The team also included Matthew J. Hoptman Ph.D., a 1999 BBRF Young Investigator.