A Randomized Controlled Trial of Cognitive Control Training for Urgency in a Naturalistic Clinical Setting

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Project Summary/Abstract Impulsivity is a common and significant predictor of destructive, maladaptive behaviors among people with mental illness. Research shows that one specific type of impulsivity, known as urgency, is particularly problematic. This type of impulsivity refers to reflexive responses to strong emotions. As emotion dysregulation is a well-established transdiagnostic feature of mental illness, the construct of urgency represents a “perfect storm” of both reactivity to emotion and impulsive action. Elevations in this form of impulsivity predict serious negative outcomes including self-injury, suicide attempts, and poor response to treatment. Despite these dire consequences, there are no specific, targeted treatments for urgency. However, the mechanisms that might influence the expression of this trait are beginning to be understood. Urgency is related to several cognitive deficits, including difficulty stopping a planned behavior (response inhibition) as well as difficulty storing and manipulating information in mind for short periods of time (working memory). Recent findings suggest that people who completed computerized exercises involving response inhibition and working memory showed significantly reduced levels of urgency after two weeks of treatment. However, it is unknown if this improvement would be observable among individuals with serious mental illness, or whether this type of training actually produces changes in the putative underlying brain regions that support response inhibition and working memory. In this study, we will recruit adult patients reporting high levels of urgency who are receiving treatment for acute symptoms of mental illness in an intensive Partial Hospitalization Program. Patients will be randomly assigned to receive treatment as usual (TAU) or to receive TAU augmented with a two-week computerized cognitive training program targeting response inhibition and working memory. All participants will undergo electrophysiological recording of brain activity (EEG) at baseline and upon discharge from the program, in order to test changes in brain activity relevant to response inhibition and working memory. The goals of this project are to (1) confirm that the cognitive training intervention successfully engages underlying brain mechanisms; (2) test whether this training is associated with greater clinical improvements in depression, urges to self-injure, or urges to use substances; and (3) assess feasibility and acceptability to patients using this intervention in a naturalistic setting. If successful, this study may provide evidence that this new approach to treating impulsivity effectively engages underlying biological mechanisms, is clinically efficacious, and is applicable to real-world clinical settings. These goals are highly consistent with the NIMH's Third Strategic Aim, which states that “The challenge is to test…potential mechanisms rapidly to rule in or rule out the target as a mechanism of the illness. This requires that the intervention engage the target and test its efficacy for reducing symptoms.” The present study embraces this challenge to rapidly test a treatment targeting cognitive mechanism underlying a trait with serious consequences for mental health.