Cognitive Remediation: What Is the Impact of Peer Interaction?

Cognitive deficits, across a range of domains—including IQ, executive function, and verbal learning and recall—are a defining characteristic of schizophrenia. These deficits remain stable across the lifespan of an individual with schizophrenia and correlate with functional outcomes. That is, the degree to which an individual achieves success in social settings and interpersonal relationships is negatively correlated to the degree of cognitive dysfunction. Fewer cognitive deficits, better functional outcomes.

Pharmacologic and other interventions have demonstrated efficacy in remediating cognitive deficits in individuals with schizophrenia. Their goal is to improve functional outcomes as a result.

One such intervention is computer-based neurocognitive training (CBNT), which is designed to improve individuals’ attention, working memory, processing speed, and verbal memory and learning. It sometimes takes place in one-on-one settings, in which the individual interacts only with a single clinician and the computer. And it sometimes it takes place in small-group settings requiring some peer interaction.

Does the Presence of Others Affect the Effect of Cognitive Training?

So a group of researchers, led by Luis R. Sandoval, of Harvard Medical School, decided to look at whether such social interaction influenced the effectiveness of the cognitive remediation achieved after CBNT. For the purposes of their work, they defined social interaction as individuals responding to one another in a way that shows they are taking others’ actions and feelings into account.

In “Effects of Peer Social Interaction on Performance During Computerized Cognitive Remediation Therapy in Patients with Early Course Schizophrenia: A Pilot Study,” published in the journal Schizophrenia Research (June 2017), the researchers describe enrolling 16 people in the study, which is part of a larger study called Brain Imaging, Cognitive Enhancement and Early Schizophrenia (BICEPS). The aim of BICEPS is to measure the impact of cognitive enhancement therapy on individuals with early-course schizophrenia, but here the focus is on the pilot study about peer interaction.

All 16 study participants were younger adults, ages 18–35, who met DSM-IV-TR diagnostic criteria for schizophrenia or schizoaffective disorder, received treatment with antipsychotic medicine, and satisfied several other enrollment requirements as to IQ, reading level, linguistic abilities, and degree of social and cognitive disability. All were early in disease course.

Excluded were those with substance use disorder or those who exhibited tendencies to harm self or others, as were individuals with disorders that cause significant cognitive impairments, such as seizure disorders or brain injury.

At baseline, participants underwent a battery of tests to assess cognitive function, among them:

  • MATRICS, to assess cognition
  • WAS-II, for memory recall and IQ
  • WRAT, to assess premorbid intellectual functioning

Trained clinicians ascertained each individual’s cognitive style via semi-structured interviews, then used the information gleaned to pair participants for the study.

Computer-Based Neurocognitive Training (CBNT)

The study employed the Orientation Remedial Module, or ORM, a computer-based program of exercises intended to gradually increase cognitive functions, such as attention, alertness, perseverance, concentration, and processing speed. Specifically, the study employed three ORM modules:

  • Attention Reaction Conditioner (ARC)
  • Zeroing Accuracy Conditioner (ZAC)
  • Time Estimation (TE)

Social Conditions

Participants performed the CBNT in the presence of a clinician. The participants were either alone or partnered with a peer, with 75% experiencing both conditions during the course of the study. After paired participants finished a phase of the training, they were given a rest period together in which they were prompted to discuss a topic of their choosing, without the involvement of the clinician. (If the conversation veered into potentially distressing topics, the clinician intervened to suggest a new subject to discuss.)

The participants who did the exercises alone were also given a rest period, which they spent alone.

What the Results Showed

The study’s authors conclude that peer social interaction positively affected participants’ performance on ARC, but not on the other tests. ARC’s exercises home in on alertness, processing speed, and reaction time. Even after controlling for clinicians, the peer social interaction clearly improved performance on the ARC module of the ORM: adjusted mean of performance accuracy of 65.4% vs. 58.01% (p=0.009, 95% CI = –12.97 to –1.81).

The study’s results suggest that social interaction with a peer increases the effectiveness of cognitive remediation facilitated by computer-based neurocognitive training (CBNT), specifically in those qualities targeted by ARC. The authors note that one of them, processing speed, seems to affect other cognitive domains. In other words, improving processing speed may in turn improve other cognitive functions.

Limitations of this study include the fact that social interaction was not a controlled variable, but rather it was determined by the number of participants who showed up on any specific occasion.

In sum, the study is encouraging in its finding that social interaction, paired with computer-based neurocognitive training, can facilitate remediation in specific cognitive domains for individuals with early-course schizophrenia.

Reference
Effects of Peer Social Interaction on Performance During Computerized Cognitive Remediation Therapy in Patients with Early Course Schizophrenia: A Pilot Study. Sandoval, Luis R., et al. Schizophr Res. 2019 Jan;203:17-23.

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