Influence of Threat/Control-Override symptoms on emotion recognition, emotional attribution, and aggression in schizophrenia

Threat/control-override (TCO) delusional experiences have been linked to aggression in schizophrenia and may also shape threat-related social-cognitive processing. We compared facial emotion recognition and stimulus-based emotional attribution in patients with schizophrenia and healthy controls, and tested whether TCO symptoms were associated with task performance, aggression, and insight. Thirty male inpatients meeting DSM-5 criteria for schizophrenia and fifteen healthy controls completed a computerized task assessing recognition of five facial expressions (happiness, anger, disgust, fear, neutral) and attribution of the identified emotion’s likely cause (forced choice between a neutral vs emotion-congruent context picture). TCO symptoms were assessed with the Threat/Control-Override Questionnaire (TCOQ), aggression with the Buss-Perry Aggression Questionnaire (BPAQ), and insight with the Birchwood Insight Scale (BIS). Compared with controls, patients showed reduced accuracy in both emotion recognition and causal attribution, with the largest deficits for anger recognition and anger attribution. Within the patient sample, higher TCO symptom levels were associated with higher self-reported aggression, primarily anger and hostility, and with poorer insight driven by reduced perceived need for treatment. In exploratory subgroup analyses (low vs high TCO), both patient subgroups showed impaired anger recognition, while additional differences emerged for fear and neutral attribution in low TCO group. TCO symptom severity was associated with heightened aggressive affect and reduced treatment-related insight and may selectively modulate threat-relevant social-cognitive processes. In this sample, higher TCO levels were linked to differences in fear-related processing without further exacerbating anger recognition deficits, suggesting a specific association with threat vigilance rather than generalized social-cognitive impairment. • Aggression in schizophrenia relates to symptom patterns, not diagnosis alone. • Threat and control-override (TCO) delusions are are linked to higher anger and hostility. • We compared patients with high or low TCO on emotional recognition and attribution. • Patients show deficits in emotion recognition and contextual attribution • Anger and fear processing are most impaired, with limited impact of TCO level. • High-TCO patients report higher aggression and poorer treatment-need insight.