Emotion Regulation Mechanisms of Cognitive Improvement in a Multi-Site Trial of Cognitive Enhancement Therapy for Schizophrenia

Background and Purpose: Cognitive Enhancement Therapy (CET), a comprehensive social and non-social cognitive remediation approach, has been shown to improve cognitive and functional recovery among individuals with early course and long-term schizophrenia. Using data from a randomized clinical trial of CET, this study incorporated a measure of emotional dysregulation to examine whether CET improves emotional regulation and how changes affect improvements in social and non-social cognitive domains. Because cognitive and affective symptoms of schizophrenia have been shown to be interconnected in various studies employing neurocognitive and psychosocial approaches, CET researchers and clinicians benefit from understanding the degree to which improved emotion regulation abilities serve as mechanisms of cognitive improvement during treatment.

Methods: Individuals in the early course of schizophrenia (N = 100) participated in an 18-month randomized clinical trial of CET. A comprehensive battery of cognitive assessments and the General Emotion Dysregulation Measure (GEDM) were administered at baseline, 9 months, and 18 months. Composite indexes were calculated for neurocognitive and social cognitive outcomes. Linear mixed effects models were used to examine improvements in GEDM scores during the trial, as well as how changes in the GEDM contributed to neurocognitive and social cognitive improvements. Individual subdomains of cognition were also analyzed using exploratory linear mixed effect models.

Results: Models indicated that participants receiving both CET and the supportive therapy comparison intervention demonstrated general improvements in GEDM scores. In a subsequent model including GEDM as a time-varying covariate predicting cognitive improvement, GEDM predicted improvements in social cognition (β = -0.24, SE = 0.07, 95% CI [-0.38, -0.11], t(104) = -3.65, p < .01) but not neurocognition (β = -0.02, SE = 0.04, 95% CI [-0.09, -0.05], t(100) = -0.56, p = 0.58). Exploratory analyses of the individual measures within social cognition revealed specific domains in which GEDM was a significant contributor for each individual model. Emotion regulation changes proved to be most predictive of social cognition changes in social-cognitive behaviors and emotion processing and management. That is, as emotion regulation increased, social cognition in these sub-domains improved for participants. No significant relationship was found between GEDM and any of the other social-cognitive subdomains.

Conclusions and Implications: Improvements in emotional regulation contributed to improvements in social cognition, but not neurocognition. When examining the individual measures within the social cognitive composite score, social cognition measures of emotion processing appeared to be significantly affected by improvements in emotional regulation, but not factors that may fall into the theory of mind subdomain. Psychosocial interventions for schizophrenia could potentially benefit from additional emotion regulation skill building in areas such as reappraisal, acceptance, distress tolerance, and mindfulness which are traditionally used to reduce emotion dysregulation across transdiagnostic groups.