Emotional reactivity to daily life stress in psychosis and affective disorder: an experience sampling study

Negative affective responsivity to daily stressors in young adults: The influence of depressive symptom severity

BACKGROUND

Evidence suggests that adults with major depressive disorder appraise daily stressor events as more severe and report stronger stressor-related negative emotions than non-depressed adults. Despite the growing number of young adults (~18-25 yrs) experiencing depressive symptoms in the absence of a formal clinical diagnosis, limited studies have examined whether current depressive symptom severity influences affective responsivity to daily stressors in young men and women. We tested the hypotheses that greater depressive symptom severity would be related to greater negative stressor appraisal characteristics and greater affective responsivity to daily stressors but not to stressor exposure frequency. We further hypothesized that the relations between depressive symptom severity and daily stress processes would be sensitized in young females compared to males.

METHODS

Depressive symptom severity (Patient Health Questionnaire-9) and daily stress processes (8-day daily dairy) were assessed in 235 young adults (18-30 yrs.; 166 females).

RESULTS

Greater depressive symptom severity was related to greater likelihood of daily stressor exposure, intensity of feelings of anger and shame following a stressor event, and negative and positive affective responsivity to daily stressors. Self-reported biological sex moderated the association between depressive symptom severity and positive (but not negative) affective responsivity to daily stressors.

LIMITATIONS

Causality cannot be established from this daily diary study design.

CONCLUSIONS

These data demonstrate that daily stressors are more pervasively reported and worsen negative affect to a greater extent in young adults currently experiencing more severe symptoms of depression, which may contribute to an increased risk of developing future chronic disease.

Biased Information Routing Through the Basolateral Amygdala, Altered Valence Processing, and Impaired Affective States Associated With Psychiatric Illnesses

Accumulating evidence supports a role for altered circuit function in impaired valence processing and altered affective states as a core feature of psychiatric illnesses. We review the circuit mechanisms underlying normal valence processing and highlight evidence supporting altered function of the basolateral amygdala, valence processing, and affective states across psychiatric illnesses. The mechanisms controlling network activity that governs valence processing are reviewed in the context of potential pathophysiological mechanisms mediating circuit dysfunction and impaired valence processing in psychiatric illnesses. Finally, we review emerging data demonstrating experience-dependent, biased information routing through the basolateral amygdala promoting negative valence processing and discuss the potential relevance to impaired affective states and psychiatric illnesses.

Genetic Differences in Reactivity to the Environment Impact Psychotic-Like and Affective Reactivity in Daily Life

BACKGROUND AND HYPOTHESIS

Consistent with diathesis-stress models, psychosis research has focused on genetic moderation of adverse environmental exposures. In contrast, the Differential Susceptibility (DS) model suggests that the same genetic variants that increase risk-inducing effects of adverse experiences also enhance beneficial effects from positive experiences. This study examined whether individuals with high genetic susceptibility to the environment showed differential psychotic-like and affective reactivity in response to positive and negative events in daily life.

STUDY DESIGN

Experience sampling methodology assessed context (positive and stressful) and momentary levels of paranoia, psychotic-like experiences (PLE), and positive (PA) and negative affect (NA) in 217 non-clinical adults oversampled for schizotypy. Linear mixed models examined whether Polygenic Risk Scores of Environmental Sensitivity (PRS-ES) moderated the impact of current context on subsequent experiences.

STUDY RESULTS

PRS-ES moderated positive, but not stressful, context on subsequent levels of momentary paranoia, NA, and PA, but not PLE. Genetic and environmental (G × E) interactions indicated diathesis-stress at lower thresholds of PRS-ES, but a DS model at the highest threshold of the PRS-ES. Participants with elevated PRS-ES showed increased paranoia and NA and decreased PA in subsequent assessments when reporting low levels of positive situations, but also decreased paranoia and NA and increased PA when rating contexts as positive.

CONCLUSIONS

Findings support the influence of genetic sensitivity to the environment on psychotic-like and affective reactivity in daily life, particularly in response to positive contexts. This highlights the transdiagnostic protective role of positive experiences and informs ecological momentary interventions.

Optimizing differential diagnostics and identifying transdiagnostic treatment targets using virtual reality

Accurate diagnosis in psychiatry remains a significant challenge, often delaying appropriate treatment and resulting in poorer clinical outcomes. Identifying precise biomarkers for differential diagnosis is therefore crucial. This study aimed to identify distinct behavioral and psychophysiological markers of emotional reactivity in virtual reality (VR) settings among individuals with bipolar disorder (BD), borderline personality disorder (BPD), schizophrenia spectrum disorders (SSD), and healthy controls (HC). Participants (BD: n = 32, BPD: n = 21, SSD: n = 17, HC: n = 30) aged 19-60 were exposed to six immersive 360-degree social VR scenarios, ranging from neutral to highly emotional contexts (e.g., an elevator ride, a crying baby). Emotional responses were self-rated on a 1-5 scale, while galvanic skin response (GSR) was continuously recorded. Scenarios assessed feelings of unpleasantness, pleasantness, being observed, and the urge to comfort. Across diagnoses, individuals with mental health conditions reported more negative emotional responses (greater unpleasantness) across both neutral and negative scenarios (ps ≤ 0.02) despite similar GSR levels to HC. Specifically, in the elevator scenario, BPD and SSD experienced greater unpleasantness and feelings of being observed, coupled with stronger GSRs compared to BD (ps ≤ 0.03). SSD reported higher unpleasantness in the canteen scenario, less pleasantness in the happy baby scenario, and overall higher GSR than BD (ps ≤ 0.049). Negative emotional reactivity was consistent across BD, BPD, and SSD, with heightened emotional and physiological responses distinguishing SSD and BPD from BD in specific VR contexts. VR-based assessments of emotional and physiological markers show promise for improving differential diagnosis and identifying transdiagnostic treatment targets.

Cumulative effects of stress-sensitivity factors on depressive symptoms and suicide risk: A prospective study

BACKGROUND

Sensitivity to stress is essential in the onset, clinical symptoms, course, and prognosis of major depressive disorder (MDD). Meanwhile, it was unclear how variously classified but connected stress-sensitivity variables affect MDD. We hypothesize that high-level trait- and state-related stress-sensitivity factors may have different cumulative effects on the clinical symptoms and follow-up outcomes of MDD.

AIM

To investigate how stress-sensitivity factors added up and affected MDD clinical symptoms and follow-up results.

METHODS

In this prospective study, 281 MDD patients were enrolled from a tertiary care setting. High-level stress-sensitivity factors were classified as trait anxiety, state anxiety, perceived stress, and neuroticism, with a total score in the top quartile of the research cohort. The cumulative effects of stress-sensitivity factors on cognitive dysfunction, disability and functional impairment, suicide risk, and depressive and anxiety symptoms were examined using an analysis of variance with linear trend analysis. Correlations were investigated further using multiple regression analysis.

RESULTS

Regarding high-level stress-sensitivity factors, 53.40% of patients had at least one at baseline, and 29.61% had two or more. Four high-level stress-sensitivity components had significant cumulative impacts on MDD symptoms at baseline (all P < 0.001). Perceived stress predicted the greatest effect sizes of state-related factors on depressive symptoms (partial η 2 = 0.153; standardized β = 0.195; P < 0.05). The follow-up outcomes were significantly impacted only by the high-level trait-related components, mainly when it came to depressive symptoms and suicide risk, which were predicted by trait anxiety and neuroticism, respectively (partial η 2 = 0.204 and 0.156; standardized β = 0.247 and 0.392; P < 0.05).

CONCLUSION

To enhance outcomes of MDD and lower the suicide risk, screening for stress-sensitivity factors and considering multifaceted measures, mainly focusing on trait-related ones, should be addressed clinically.

Completion Rates of Smart Technology Ecological Momentary Assessment (EMA) in Populations With a Higher Likelihood of Cognitive Impairment: A Systematic Review and Meta-Analysis

Ecological Momentary Assessment using smartphone technology (smart EMA) has grown substantially over the last decade. However, little is known about the factors associated with completion rates in populations who have a higher likelihood of cognitive impairment. A systematic review of Smart EMA studies in populations who have a higher likelihood of cognitive impairment was carried out (PROSPERO; ref no CRD42022375829). Smartphone EMA studies in neurological, neurodevelopmental and neurogenetic conditions were included. Six databases were searched, and bias was assessed using Egger's test. Completion rates and moderators were analyzed using meta-regression. Fifty-five cohorts were included with 18 cohorts reporting confirmed cognitive impairment. In the overall cohort, the completion rate was 74.4% and EMA protocol characteristics moderated completion rates. Participants with cognitive impairment had significantly lower completion rates compared with those without (p = .021). There were no significant moderators in the cognitive impairment group. Limitations included significant methodological issues in reporting of completion rates, sample characteristics, and associations with completion and dropout rates. These findings conclude that smart EMA is feasible for people with cognitive impairment. Future research should focus on the efficacy of using smart EMA within populations with cognitive impairment to develop an appropriate methodological evidence base.

Emotional experiences in male and female participants with schizophrenia spectrum disorders and healthy controls: an experience sampling method study

AIM

Schizophrenia spectrum disorders (SSD) are associated with disturbances in emotional experience, but sex differences and comparisons to healthy controls (HC) remain poorly explored. This exploratory study used Experience Sampling Method (ESM) to examine emotional variability, instability and daily/hourly patterns of positive and negative emotions across sexes in SSD and HC.

METHODS

A total of 103 SSD participants (47.9%) were compared to 112 HC (52.1%), matched for sex and age. Data on sociodemographics, clinical status, functioning and quality of life were collected. ESM assessed emotional experiences over one week.

RESULTS

For positive emotions, HC males reported higher levels on weekdays and morning-to-midday hours, whereas no sex differences emerged in SSD. Males with SSD showed greater weekly variability in positive emotions than HC males, while no significant differences were found among females. For negative emotions, females with SSD exhibited greater daily variability than female HC, with no significant sex differences within HC or SSD. Regarding emotional instability, female HC displayed higher instability than HC males, while no significant sex differences emerged in SSD.

CONCLUSION

This study shows significant sex differences in emotional experiences among SSD and HC, with different sex patterns in SSD. Targeted, sex-specific interventions are crucial for improving emotional regulation and treatment outcomes in SSD.Trial registration: ISRCTN.org identifier: ISRCTN21141466.

A systematic review of ecological momentary assessment in autism research

LAY ABSTRACT

Ecological momentary assessments assess people's in-the-moment thoughts and behaviours in their daily lives in natural environments. The number of ecological momentary assessment studies with autistic people has increased over the last decade. For the first time, this review (1) summarises how well ecological momentary assessment works for allowing autistic people to describe and express their thoughts, emotions and experiences, and (2) provides suggestions for the design of ecological momentary assessment to make this research method more accessible to future autistic participants. In total, we synthesised participation experiences from 930 autistic people. Overall, ecological momentary assessment is generally acceptable for autistic adults aged from 18 to 60 and with average or above-average intelligence and language. We also identified several issues in the ecological momentary assessment procedure and suggested researchers consider these when designing future ecological momentary assessment studies with autistic people. The findings of this review provide evidence that ecological momentary assessment can be used to investigate many different questions with autistic people and suggest a wider application of ecological momentary assessment in future studies with autistic people.

Real-time biopsychosocial antecedents and correlates of functional neurological symptoms in daily life: A pilot remote monitoring technology study

Functional neurological symptom disorder (FNSD) is a neuropsychiatric diagnosis referring to symptoms resembling those of neurological disorders, occurring without causal neuropathology. FNSD has a complex biopsychosocial aetiology but its mechanisms are poorly understood. Remote monitoring technologies (RMT) could provide critical insights into functional neurological symptoms (FNS) in real-world contexts. We examined the feasibility and acceptability of a novel RMT protocol, to identify psychobiological correlates and antecedents of FNS in everyday life. Seventeen individuals with FNS (seizures/motor) and 17 healthy controls (HC) completed ecological momentary assessments (EMA) eight times daily for 1-week, reporting FNS severity, associated physical and psychological symptoms, and subjectively significant events. Sleep quality was reported daily. Physiological variables were measured using wearable Fitbit 5 devices. Multilevel modelling examined variables associated with FNS variability. Average EMA completion rates were good in both groups (≥80%). At week-level, the FNS group reported significantly greater subjective arousal, pain, fatigue, dissociation, negative affect, daily events, stressful events, and sleep duration, compared to HC. Objective sleep disturbance and duration, and resting heartrate, were also significantly greater in the FNS sample. FNS severity correlated significantly with daily events, affect, subjective arousal, pain, fatigue and sleep disturbance, at day- or within-day levels. Daily events and negative affect were the most prominent time-lagged predictors of within-day moment-to-moment FNS severity. RMTs are feasible and acceptable tools for investigation of FNS in real-world settings, revealing daily events and negative affect as possible triggers of FNS. Interventions targeting affective reactivity and regulation might be beneficial in this group. Larger-scale, longer-term RMT studies are needed in this population.

Enabling analytical power calculations for multilevel models with autocorrelated errors through deriving and approximating the precision matrix

To unravel how within-person psychological processes fluctuate in daily life, and how these processes differ between persons, intensive longitudinal (IL) designs in which participants are repeatedly measured, have become popular. Commonly used statistical models for those designs are multilevel models with autocorrelated errors. Substantive hypotheses of interest are then typically investigated via statistical hypotheses tests for model parameters of interest. An important question in the design of such IL studies concerns the determination of the number of participants and the number of measurements per person needed to achieve sufficient statistical power for those statistical tests. Recent advances in computational methods and software have enabled the computation of statistical power using Monte Carlo simulations. However, this approach is computationally intensive and therefore quite restrictive. To ease power computations, we derive simple-to-use analytical formulas for multilevel models with AR(1) within-person errors. Analytic expressions for a model family are obtained via asymptotic approximations of all sample statistics in the precision matrix of the fixed effects. To validate this analytical approach to power computation, we compare it to the simulation-based approach via a series of Monte Carlo simulations. We find comparable performances making the analytic approach a useful tool for researchers that can drastically save them time and resources.

The Role of Childhood Trauma in Affective Stress Recovery in Early Psychosis: An Experience Sampling Study

BACKGROUND AND HYPOTHESES

Affective recovery, operationalized as the time needed for affect to return to baseline levels after daily stressors, may be a putative momentary representation of resilience. This study aimed to investigate affective recovery in positive and negative affect across subclinical and clinical stages of psychosis and whether this is associated with exposure to childhood trauma (sexual, physical, and emotional abuse).

STUDY DESIGN

We used survival analysis to predict the time-to-recovery from a daily event-related stressor in a pooled sample of 3 previously conducted experience sampling studies including 113 individuals with first-episode psychosis, 162 at-risk individuals, and 94 controls.

STUDY RESULTS

Negative affective recovery (ie, return to baseline following an increase in negative affect) was longer in individuals with first-episode psychosis compared with controls (hazard ratio [HR] = 1.71, 95% confidence interval [CI; 1.03, 2.61], P = .04) and in at-risk individuals exposed to high vs low levels of emotional abuse (HR = 1.31, 95% CI [1.06, 1.62], P = .01). Positive affective recovery (ie, return to baseline following a decrease in positive affect) did not differ between groups and was not associated with childhood trauma.

CONCLUSIONS

Our results give first indications that negative affective recovery may be a putative momentary representation of resilience across stages of psychosis and may be amplified in at-risk individuals with prior experiences of emotional abuse. Understanding how affective recovery contributes to the development of psychosis may help identify new targets for prevention and intervention to buffer risk or foster resilience in daily life.

Cognitive emotion regulation difficulties increase affective reactivity to daily-life stress in autistic adolescents and young adults

LAY ABSTRACT

Previous research has shown that autistic individuals report high levels of perceived stress and have an increased likelihood of developing mental health difficulties. Increase in individuals' negative emotions in relation to perceived stress (i.e. affective reactivity to stress) is a known risk factor for mental health difficulties. In this study, we investigated perceived daily stress and affective reactivity to stress in autistic (n = 39, age = 18.4) and non-autistic (n = 55, age = 18.1) adolescents and young adults. We used the ecological momentary assessment, a technique that allows to assess individuals repeatedly in their daily life using their smartphone. Moreover, participants filled a questionnaire to evaluate the strategies they use to regulate emotions when faced with difficulties. Finally, a clinical interview and a parent-report questionnaire were used to assess mental health symptoms. Autistic youth reported higher levels of perceived daily stress compared with non-autistic peers. Moreover, they showed increased affective reactivity to stress related to their daily activities. Autistic participants reported more emotion regulation difficulties (e.g. more repetitive thinking of difficulties) compared with non-autistic participants. Difficulties in emotion regulation increased negative emotions in relation to stress and might contribute to the severity of mental health symptoms. We conclude that adolescents and young adults with autism report high perceived stress in their daily lives. To minimize the negative impact of stress and the development of mental health symptoms, people supporting autistic young people could focus on stress management skills and the strategies that the youth use to manage emotions.

Emotional distress and dysregulation as treatment targets to reduce suicide in psychosis: a scoping review

There is a pressing need for effective treatments that address the high rate of suicide observed among people with psychosis. In this scoping review we highlight two suicidogenic treatment targets that have been relatively neglected in people with psychotic disorders: emotional distress and emotion dysregulation. We review the research on these constructs in psychosis and their relationship to suicide in this population, and then make clinical recommendations based on research findings. Emotional distress and emotional dysregulation may be promising treatment targets for suicide among people with psychosis.

Environmental stress and emotional reactivity: an exploratory experience sampling method study

Background

Previous studies have shown a relationship between environments and mental health. However, limited studies have investigated the impact of environment stress (ES) on emotional reactivity. Our study aimed to fill this gap by examining how daily ES affects momentary emotional reactivity using experience sampling method (ESM).

Methods

Participants were randomly recruited from a prospective cohort study in Hong Kong to participate in a 7-day ESM study. The participants received eight electronic signals daily assessing their ES, positive affect (PA) and negative affect (NA). Participants were categorized into depressed group or control group based on Revised Clinical Interview Schedule. Psychometric properties of the ESM assessment were evaluated. Multilevel linear regression analyzes were conducted to examine the association of ES with PA, NA and the group status of the participants (cases versus controls).

Results

A total of 15 participants with depression and 15 healthy controls were recruited, and 1307 momentary assessments were completed with a compliance rate of 77.8%. The depressed group demonstrated a significant increase in NA in response to ES, while the control group showed a decrease in PA. In addition, the depressed group reported a lower perception of control and interaction with their environment compared to the control group.

Conclusion

Using ESM, a valid, reliable, and easy-to-use self-reporting tool, our findings provided valuable insights on the potential mechanisms underlying emotional responses to stressful environments.

How mood is affected by environment and upsetting events: The moderating role of psychological flexibility

OBJECTIVE

Patients suffering from psychological disorders report decreased quality of life and low mood. The relationship of these symptoms to daily upsetting events or environments, and in the context of active coping mechanisms is poorly understood. The present study thus investigates the association between mood, psychological flexibility, upsetting events, and environment in the daily life of outpatients.

METHOD

We investigated 80 outpatients at the beginning of treatment, using event sampling methodology (ESM). Patients' mood, occurrence of upsetting events, current environment, and psychological flexibility were sampled six times per day during a one-week intensive longitudinal examination. Data were analyzed using linear mixed models (LMMs).

RESULTS

Participants reported worse mood the more upsetting events they experienced. Further, participants reported better mood when in private environments (e.g., with friends), and worse mood when at the hospital, compared to being at home. Higher levels of psychological flexibility, however, were associated with better mood, irrespective of the occurrence of upsetting events or current environment.

CONCLUSION

Results suggest that mood is positively associated with psychological flexibility, not despite, but especially during the dynamic and context-specific challenges of daily life. Psychological flexibility may thus potentially act as a buffer against distress-provoking situations as patients go about their daily lives.

TRIAL REGISTRATION

ISRCTN.org identifier: ISRCTN11209732.

Assessing depression recurrence, cognitive burden, and neurobiological homeostasis in late life: Design and rationale of the REMBRANDT Study

Background

Late-life depression is characterized by disability, cognitive impairment and decline, and a high risk of recurrence following remission. Aside from past psychiatric history, prognostic neurobiological and clinical factors influencing recurrence risk are unclear. Moreover, it is unclear if cognitive impairment predisposes to recurrence, or whether recurrent episodes may accelerate brain aging and cognitive decline. The purpose of the REMBRANDT study (Recurrence markers, cognitive burden, and neurobiological homeostasis in late-life depression) is to better elucidate these relationships and identify phenotypic, cognitive, environmental, and neurobiological factors contributing to and predictive of depression recurrence.

Methods

Across three sites, REMBRANDT will enroll 300 depressed elders who will receive antidepressant treatment. The goal is to enroll 210 remitted depressed participants and 75 participants with no mental health history into a two-year longitudinal phase focusing on depression recurrence. Participants are evaluated every 2 months with deeper assessments occurring every 8 months, including structural and functional neuroimaging, environmental stress assessments, deep symptom phenotyping, and two weeks of 'burst' ecological momentary assessments to elucidate variability in symptoms and cognitive performance. A broad neuropsychological test battery is completed at the beginning and end of the longitudinal study.

Significance

REMBRANDT will improve our understanding of how alterations in neural circuits and cognition that persist during remission contribute to depression recurrence vulnerability. It will also elucidate how these processes may contribute to cognitive impairment and decline. This project will obtain deep phenotypic data that will help identify vulnerability and resilience factors that can help stratify individual clinical risk.

Emotions under control? Better cognitive control is associated with reduced negative emotionality but increased negative emotional reactivity within individuals

Associations between impaired cognitive control and maladaptive emotion regulation have been extensively studied between individuals. However, it remains unclear if this relationship holds within individuals. In this study, we tested the assumption that momentary within-person fluctuation in cognitive control (working memory updating and response inhibition) is associated with emotional reactivity in everyday life. We conducted an experience sampling study (eight two-hourly prompts daily) where participants repeatedly performed short 2-back and Go/no-go tasks in daily life. We assessed negative and positive affective states, and unpleasantness of a recent event to capture emotional reactivity. We analyzed two overlapping samples: a Go/no-go and a 2-back dataset (N = 161/158). Our results showed that better momentary working memory updating was associated with decreased negative affect if the recent event was on average unpleasant for the given individual. However, better-than-average working memory updating in interaction with higher event-unpleasantness predicted higher negative affect levels (i.e., higher negative emotional reactivity). These findings may challenge the account of better cognitive control being universally related to adaptive emotion regulation. Although it is unlikely that emotional reactivity boosts working memory, future studies should establish the direction of causality.

Do deficits in subjective stress recovery predict subsequent stress sensitivity and symptoms in schizophrenia spectrum disorders?

High levels of stress play a crucial role in the development of psychotic symptoms, such as paranoia, and may stem in part from recovery deficits after stress exposure. However, it remains unclear whether deficient recovery causes a build-up of heightened stress levels that increases stress sensitivity and symptoms when exposed to another stressor. To test this, we investigated the effect of subjective stress recovery on the response to a subsequent stressor and paranoia. We applied two consecutive runs of the same combined physical and cognitive stressor separated by a recovery phase of 60 min in individuals with schizophrenia spectrum disorders (n = 49). We repeatedly assessed self-reported stress, negative affect, heart rate, heart rate variability, salivary cortisol, and paranoia. Recovery of self-reported stress was defined as the geometric mean of the percentage changes of self-reported stress during recovery after the first stressor, and was regressed on the response to the second stressor controlling for self-reported stress during the first stressor. Lower subjective stress recovery predicted higher levels of self-reported stress, negative affect, and paranoia in response to the second stressor. The subjective stress recovery was not predictive of the physiological stress response (heart rate, heart rate variability, or salivary cortisol). Taken together, the findings indicate that recovery deficits could contribute to high levels of self-reported stress, negative affect, and paranoia in schizophrenia spectrum disorders and that the improvement of stress recovery could be a promising approach for interventions.

Speech Features as Predictors of Momentary Depression Severity in Patients With Depressive Disorder Undergoing Sleep Deprivation Therapy: Ambulatory Assessment Pilot Study

BACKGROUND

The use of mobile devices to continuously monitor objectively extracted parameters of depressive symptomatology is seen as an important step in the understanding and prevention of upcoming depressive episodes. Speech features such as pitch variability, speech pauses, and speech rate are promising indicators, but empirical evidence is limited, given the variability of study designs.

OBJECTIVE

Previous research studies have found different speech patterns when comparing single speech recordings between patients and healthy controls, but only a few studies have used repeated assessments to compare depressive and nondepressive episodes within the same patient. To our knowledge, no study has used a series of measurements within patients with depression (eg, intensive longitudinal data) to model the dynamic ebb and flow of subjectively reported depression and concomitant speech samples. However, such data are indispensable for detecting and ultimately preventing upcoming episodes.

METHODS

In this study, we captured voice samples and momentary affect ratings over the course of 3 weeks in a sample of patients (N=30) with an acute depressive episode receiving stationary care. Patients underwent sleep deprivation therapy, a chronotherapeutic intervention that can rapidly improve depression symptomatology. We hypothesized that within-person variability in depressive and affective momentary states would be reflected in the following 3 speech features: pitch variability, speech pauses, and speech rate. We parametrized them using the extended Geneva Minimalistic Acoustic Parameter Set (eGeMAPS) from open-source Speech and Music Interpretation by Large-Space Extraction (openSMILE; audEERING GmbH) and extracted them from a transcript. We analyzed the speech features along with self-reported momentary affect ratings, using multilevel linear regression analysis. We analyzed an average of 32 (SD 19.83) assessments per patient.

RESULTS

Analyses revealed that pitch variability, speech pauses, and speech rate were associated with depression severity, positive affect, valence, and energetic arousal; furthermore, speech pauses and speech rate were associated with negative affect, and speech pauses were additionally associated with calmness. Specifically, pitch variability was negatively associated with improved momentary states (ie, lower pitch variability was linked to lower depression severity as well as higher positive affect, valence, and energetic arousal). Speech pauses were negatively associated with improved momentary states, whereas speech rate was positively associated with improved momentary states.

CONCLUSIONS

Pitch variability, speech pauses, and speech rate are promising features for the development of clinical prediction technologies to improve patient care as well as timely diagnosis and monitoring of treatment response. Our research is a step forward on the path to developing an automated depression monitoring system, facilitating individually tailored treatments and increased patient empowerment.

Trait Mindfulness in Psychotic Disorders: Dimensions Predicting Symptoms, Cognition, and Functional Outcome

Mindfulness-based treatments are efficacious for psychotic disorders (PD). However, which components of mindfulness (i.e., attentive monitoring and nonjudgmental acceptance) are most relevant treatment targets is unclear. Further, there is a dearth of literature examining clinical correlates of mindfulness in people with PD. The present study aimed to examine group differences and clinical correlates of mindfulness in people with PD. We hypothesized that PD would report lower monitoring and acceptance than CN and that mindfulness components would be associated with symptoms including dysfunctional beliefs, alexithymia, neurocognitive ability, positive symptoms, and mood symptoms. Groups included individuals with PD (n = 54) and nonpsychiatric controls (n = 55). Participants completed self-report measures of mindfulness and related constructs and clinical interviews of symptoms. Results of ANOVA models indicated that global mindfulness was lower in PD relative to CN, with greatest differences evident for acceptance in the affective psychosis group. Regression models found that greater monitoring was associated with improved neurocognitive performance, while acceptance was associated with lower defeatist beliefs, alexithymia, and depression/anxiety symptoms. Results highlight the importance of targeting acceptance in the psychosocial treatment of PDs, especially for those with mood symptoms.

Usability of the Experience Sampling Method in Specialized Mental Health Care: Pilot Evaluation Study

BACKGROUND

Mental health problems occur in interactions in daily life. Yet, it is challenging to bring contextual information into the therapy room. The experience sampling method (ESM) may facilitate this by assessing clients' thoughts, feelings, symptoms, and behaviors as they are experienced in everyday life. However, the ESM is still primarily used in research settings, with little uptake in clinical practice. One aspect that may facilitate clinical implementation concerns the use of ESM protocols, which involves providing practitioners with ready-to-use ESM questionnaires, sampling schemes, visualizations, and training.

OBJECTIVE

This pilot study's objective was to evaluate the usability of an ESM protocol for using the ESM in a specialized mental health care setting.

METHODS

We created the ESM protocol using the m-Path software platform and tested its usability in clinical practice. The ESM protocol consists of a dashboard for practitioners (ie, including the setup of the template and data visualizations) and an app for clients (ie, for completing the ESM questionnaires). A total of 8 practitioners and 17 clients used the ESM in practice between December 1, 2020, and July 31, 2021. Usability was assessed using questionnaires, ESM compliance rates, and semistructured interviews.

RESULTS

The usability was overall rated reasonable to good by practitioners (mean scores of usability items ranging from 5.33, SD 0.91, to 6.06, SD 0.73, on a scale ranging from 1 to 7). However, practitioners expressed difficulty in personalizing the template and reported insufficient guidelines on how to use the ESM in clinical practice. On average, clients completed 55% (SD 25%) of the ESM questionnaires. They rated the usability as reasonable to good, but their scores were slightly lower and more variable than those of the practitioners (mean scores of usability items ranging from 4.18, SD 1.70, to 5.94, SD 1.50 on a scale ranging from 1 to 7). Clients also voiced several concerns over the piloted ESM template, with some indicating no interest in the continued use of the ESM.

CONCLUSIONS

The findings suggest that using an ESM protocol may facilitate the implementation of the ESM as a mobile health assessment tool in psychiatry. However, additional adaptions should be made before further implementation. Adaptions include providing training on personalizing questionnaires, adding additional sampling scheme formats as well as an open-text field, and creating a dynamic data visualization interface. Future studies should also identify factors determining the suitability of the ESM for specific treatment goals among different client populations.

Increased affective reactivity to daily social stressors is associated with more severe psychotic symptoms in youths with 22q11.2 deletion syndrome

BACKGROUND

Increased reactivity to minor stressors is considered a risk factor for psychosis, especially in vulnerable individuals. In the present study, we investigated affective and psychotic stress reactivity as well as its link with psychotic symptoms and psychopathology in youths with 22q11.2 deletion syndrome (22q11DS), a neurogenetic condition associated with a high risk for psychosis.

METHODS

A 6-day ecological momentary assessment protocol was used to assess perceived daily-life stress as well as affective and psychotic reactivity to stress in participants with 22q11DS (n = 38, age = 18.4) and healthy controls (HC; n = 53, age = 19.1). Psychotic symptoms, general psychopathology, and coping strategies were also assessed through clinical interviews and questionnaires.

RESULTS

Participants with 22q11DS reported higher levels of perceived social stress (b = 0.21, p = 0.036) but lower levels of activity-related stress (b = -0.31, p = 0.003) in their daily lives compared to HC. The groups did not differ in affective or psychotic reactivity to stress, but individuals with 22q11DS who reported increased affective reactivity to social stressors showed more severe positive psychotic symptoms (rs = 0.505, p = 0.008). Finally, avoidance coping strategies moderated the association between stress and negative affects.

CONCLUSIONS

Our results suggest an increased vulnerability for daily social stress in youths with 22q11DS, and link elevated social stress reactivity to heightened psychotic symptom severity. Given the high risk for psychosis in 22q11DS, interventions should focus on reducing social stress and developing adaptive coping strategies.

Exploring putative therapeutic mechanisms of change in a hybrid compassion-focused, ecological momentary intervention: Findings from the EMIcompass trial

Compassion-focused interventions represent a promising transdiagnostic approach, but the mechanisms involved in hybrid delivery combining face-to-face sessions and an ecological momentary intervention remain unexplored. The current study aimed at exploring associations of putative mechanisms with clinical outcomes at post-intervention/follow-up and mediation of outcome at follow-up by preceding pre-to post-intervention changes in putative mechanisms. The compassion-focused EMIcompass intervention was applied in an exploratory randomized controlled trial (treatment as usual (TAU) vs. TAU + EMIcompass) with youth with early mental health problems. Data was collected before randomization, at post-intervention and at four-week follow-up. We recruited N = 92 participants, N = 46 were allocated to the experimental condition. After control for baseline levels of the target outcomes, baseline-to post-intervention improvement in adaptive emotion regulation was associated with lower levels of clinical outcomes (e.g. psychological distress b = -1.15; 95%CI = -1.92 to -0.39) across time points. We could not detect indirect effects, but we observed associations of change in self-compassion and adaptive emotion regulation with outcomes at follow-up in the mediation analysis (e.g., β = -0.35, 95%CI = -0.52 to -0.16). If successfully targeted by interventions, self-compassion and emotion regulation may be promising putative therapeutic mechanisms of change.

Moment-to-moment affective dynamics in schizophrenia and bipolar disorder

BACKGROUND

Affective disturbances in schizophrenia and bipolar disorder may represent a transdiagnostic etiological process as well as a target of intervention. Hypotheses on similarities and differences in various parameters of affective dynamics (intensity, successive/acute changes, variability, and reactivity to stress) between the two disorders were tested.

METHODS

Experience sampling method was used to assess dynamics of positive and negative affect, 10 times a day over 6 consecutive days. Patients with schizophrenia (n = 46) and patients with bipolar disorder (n = 46) were compared against age-matched healthy controls (n = 46).

RESULTS

Compared to controls, the schizophrenia group had significantly more intense momentary negative affect, a lower likelihood of acute changes in positive affect, and reduced within-person variability of positive affect. The bipolar disorder group was not significantly different from either the schizophrenia group or the healthy control group on any affect indexes. Within the schizophrenia group, level of depression was associated with weaker reactivity to stress for negative affect. Within the bipolar disorder group, level of depression was associated with lower positive affect.

CONCLUSIONS

Patients with schizophrenia endured a more stable and negative affective state than healthy individuals, and were less likely to be uplifted in response to happenings in daily life. There is little evidence that these affective constructs characterize the psychopathology of bipolar disorder; such investigation may have been limited by the heterogeneity within group. Our findings supported the clinical importance of assessing multiple facets of affective dynamics beyond the mean levels of intensity.

Psychosocial stress, interpersonal sensitivity, and social withdrawal in clinical high risk for psychosis: a systematic review

Stress has repeatedly been implicated in the onset and exacerbation of positive symptoms of psychosis. Increasing interest is growing for the role of psychosocial stress in the development of psychosis symptoms in individuals at Clinical High Risk (CHR) for psychosis. A systematic review was therefore conducted to summarize the existing evidence base regarding psychosocial stress, interpersonal sensitivity, and social withdrawal in individuals at CHR for psychosis. An electronic search of Ovid (PsychINFO, EMBASE, MEDLINE, and GLOBAL HEALTH) was conducted until February 2022. Studies that examined psychosocial stress in CHR were included. Twenty-nine studies were eligible for inclusion. Psychosocial stress, interpersonal sensitivity, and social withdrawal were higher in CHR individuals compared to healthy controls and there was some evidence of their association with positive symptoms of psychosis. Two types of psychosocial stressors were found to occur more frequently with CHR status, namely daily stressors, and early and recent trauma, while significant life events did not appear to be significant. Greater exposure to psychosocial stress, emotional abuse, and perceived discrimination significantly increased risk of transition to psychosis in CHR. No studies examined the role of interpersonal sensitivity on transition to psychosis in CHR. This systematic review provides evidence for the association of trauma, daily stressors, social withdrawal, and interpersonal sensitivity with CHR status. Further studies investigating the impact of psychosocial stress on psychosis symptom expression in individuals at CHR and its effects on transition to psychosis are therefore warranted.

Investigating associations between physical activity, stress experience, and affective wellbeing during an examination period using experience sampling and accelerometry

Previous studies reported that physical activity could buffer the negative association of psychological stress with affective wellbeing. However, the studies that examined this relation in everyday life have assessed physical activity only by self-report but not with objective measures such as accelerometry. We therefore investigated the associations of both subjectively and objectively measured physical activity with stress experiences and affective wellbeing. A total of 90 university students participated in a 10-day experience sampling and diary study during their examination period and reported about stress experiences, physical activity, and affective states. Physical activity was additionally assessed using accelerometry in 50 of the participants. Subjectively assessed physical activity and objectively assessed light physical activity were associated with feeling less stressed in the evening. Also, light physical activity during the day was associated with a smaller increase/higher decrease in feeling stressed from morning to evening. The association of stress experience with negative affect was moderated by objective light physical activity. No interactive effects of stress intensity and physical activity on affective wellbeing were found. On stressful days, physical activity may buffer the negative association between stress and affective wellbeing. Particularly light physical activity as assessed with accelerometry seems to play an important role. It may be beneficial for students' affective wellbeing to increase or at least maintain physical activity during examination periods.

Increased affective reactivity among depressed individuals can be explained by floor effects: An experience sampling study

Experience sampling studies into daily-life affective reactivity indicate that depressed individuals react more strongly to both positive and negative stimuli than non-depressed individuals, particularly on negative affect (NA). Given the different mean levels of both positive affect (PA) and NA between patients and controls, such findings may be influenced by floor/ceiling effects, leading to violations of the normality and homoscedasticity assumptions underlying the used statistical models. Affect distributions in prior studies suggest that this may have particularly influenced NA-reactivity findings. Here, we investigated the influence of floor/ceiling effects on the observed PA- and NA-reactivity to both positive and negative events. Data came from 346 depressed, non-depressed, and remitted participants from the Netherlands Study of Depression and Anxiety (NESDA). In PA-reactivity analyses, no floor/ceiling effects and assumption violations were observed, and PA-reactivity to positive events, but not negative events, was significantly increased in the depressed and remitted groups versus the non-depressed group. However, NA-scores exhibited a floor effect in the non-depressed group and naively estimated models violated model assumptions. When these violations were accounted for in subsequent analyses, group differences in NA-reactivity that had been present in the naive models were no longer observed. In conclusion, we found increased PA-reactivity to positive events but no evidence of increased NA-reactivity in depressed individuals when accounting for violations of assumptions. The results indicate that affective-reactivity results are very sensitive to modeling choices and that previously observed increased NA-reactivity in depressed individuals may (partially) reflect unaddressed assumption violations resulting from floor effects in NA.

Investigation of momentary negative symptoms in patients with early psychosis in daily life: An experience sampling study

Negative symptoms are a key therapeutic target in promoting functional recovery in early psychosis intervention, but momentary negative symptom manifestations remain understudied in the early stage of illness. We employed an experience-sampling methodology (ESM) to evaluate momentary affective experiences, hedonic capacity for an event recalled, current activities and social interactions, and associated appraisals for 6 consecutive days in 33 clinically-stable early psychosis patients (within 3 years of treatment for first-episode psychosis) and 35 demographically-matched healthy controls. Adjusted multilevel linear-mixed models revealed higher intensity and variability of negative affect in patients than controls, but no group difference in affect instability as well as positive affect intensity and variability. Patients demonstrated no significantly greater anhedonia for event, activity or social interactions relative to controls. Higher preference for company (when alone) and to be alone (when in company) was observed in patients than controls. No significant group difference in pleasantness to be alone or proportion of time being alone. Our results indicate no evidence for blunting of affective experiences, anhedonia (social and non-social) and asociality in early psychosis. Future research complementing ESM with multiple digital phenotyping measures will facilitate more refined negative symptom assessment in the daily life of patients with early psychosis.

The association between psychosocial stress, interpersonal sensitivity, social withdrawal and psychosis relapse: a systematic review

Psychosis is associated with a high risk of relapse, with 67% of clients relapsing within one year following a first episode. In light of the high personal, social, and healthcare costs of the illness, it is paramount to understand the risk factors associated with psychosis relapse. The current systematic review aims to critically review the role of psychosocial stress in psychosis relapse in individuals with an established psychotic disorder. This review systematically searched Ovid (PsycINFO, EMBASE, MEDLINE) literature databases from inception until 28th February 2022. Sixteen studies were eligible for inclusion. Most studies found that individuals with psychosis demonstrate high levels of psychosocial stress and are more likely to be socially withdrawn compared to healthy controls or other clinical presentations. Most studies reported a statistically significant association between psychosocial stress and psychosis relapse, as well as between social withdrawal and psychosis relapse. However, no studies examined the association between high levels of interpersonal sensitivity and psychosis relapse. Individuals with psychosis tend to experience high levels of psychosocial stress and social withdrawal, and these appear to increase the risk of psychosis relapse. Due to high levels of heterogeneity within the literature, we could only conduct a narrative synthesis of the findings. Future studies would benefit from employing a meta-analytic approach.

Exploring the perception of stress in childhood and early adolescence

Stressful life experiences may jeopardize the healthy development of children. To improve interventions, more knowledge is needed on the perception of stress by children. In adults, stress is regarded as a state of low valence and high arousal. It is unclear whether children perceive stress similarly. In the current study, 35 children of the general population completed three tasks aiming to provide insight into their knowledge of the concept stress. In the first task, participants were asked about their verbal knowledge of the concept stress. In the second task, they rated the valence and arousal of eight emotion-evoking vignettes. In the final task, participants completed an experience sampling survey for at least 1 day, consisting of a stress thermometer and pictorial scales of valence and arousal. Participants' perception of stress was found to be mainly valence focused. Age and sex were found to play a role in the degree of arousal focus. Older participants differentiated more in arousal levels than younger participants, as did girls in comparison with boys. Because the perception of stress depends on developmental and other individual factors, using stress as a single measurement dimension in a survey is not recommended.

The importance of high quality real-life social interactions during the COVID-19 pandemic

The coronavirus pandemic has brought about dramatic restrictions to real-life social interactions and a shift towards more online social encounters. Positive social interactions have been highlighted as an important protective factor, with previous studies suggesting an involvement of the amygdala in the relationship between social embeddedness and well-being. The present study investigated the effect of the quality of real-life and online social interactions on mood, and explored whether this association is affected by an individual's amygdala activity. Sixty-two participants of a longitudinal study took part in a one-week ecological momentary assessment (EMA) during the first lockdown, reporting their momentary well-being and their engagement in real-life and online social interactions eight times per day (N ~ 3000 observations). Amygdala activity was assessed before the pandemic during an emotion-processing task. Mixed models were calculated to estimate the association between social interactions and well-being, including two-way interactions to test for the moderating effect of amygdala activity. We found a positive relationship between real-life interactions and momentary well-being. In contrast, online interactions had no effect on well-being. Moreover, positive real-life social interactions augmented this social affective benefit, especially in individuals with higher amygdala being more sensitive to the interaction quality. Our findings demonstrate a mood-lifting effect of positive real-life social interactions during the pandemic, which was dependent on amygdala activity before the pandemic. As no corresponding effect was found between online social interactions and well-being, it can be concluded that increased online social interactions may not compensate for the absence of real-life social interactions.

Real-time Symptom Assessment in Patients With Endometriosis: Psychometric Evaluation of an Electronic Patient-Reported Outcome Measure, Based on the Experience Sampling Method

BACKGROUND

The experience sampling method (ESM) holds advantages over traditional retrospective questionnaires including a high ecological validity, no recall bias, the ability to assess fluctuation of symptoms, and the ability to analyze the temporal relationship between variables.

OBJECTIVE

This study aimed to evaluate the psychometric properties of an endometriosis-specific ESM tool.

METHODS

This is a short-term follow-up prospective study, including patients with premenopausal endometriosis aged ≥18 years who reported dysmenorrhea, chronic pelvic pain, or dyspareunia between December 2019 and November 2020. An ESM-based questionnaire was sent out by a smartphone application 10 times a day during 1 week on randomly chosen moments. Additionally, patients completed questionnaires concerning demographics, end-of-day pain scores, and end-of-week symptom scores. The psychometric evaluation included compliance, concurrent validity, and internal consistency.

RESULTS

Twenty-eight patients with endometriosis completed the study. Compliance for answering the ESM questions was as high as 52%. End-of-week pain scores were higher than ESM mean scores and showed peak reporting. ESM scores showed strong concurrent validity when compared with symptoms scored by the Gastrointestinal Symptom Rating Scale-Irritable Bowel Syndrome, 7-item Generalized Anxiety Disorders Scale, 9-question Patient Health Questionnaire, and the majority of questions of the 30-item Endometriosis Health Profile. Cronbach α coefficients demonstrated a good internal consistency for abdominal symptoms, general somatic symptoms, and positive affect, and an excellent internal consistency for negative affect.

CONCLUSIONS

This study supports the validity and reliability of a newly developed electronic instrument for the measurement of symptoms in women with endometriosis, based on momentary assessments. This ESM patient-reported outcome measure has the advantage of providing a more detailed view on individual symptom patterns and offers the possibility for patients to have insight in their symptomatology, leading to more individualized treatment strategies that can improve the quality of life of women with endometriosis.

Initial response to the COVID-19 pandemic on real-life well-being, social contact and roaming behavior in patients with schizophrenia, major depression and healthy controls: A longitudinal ecological momentary assessment study

The COVID-19 pandemic strongly impacted people's daily lives. However, it remains unknown how the pandemic situation affects daily-life experiences of individuals with preexisting severe mental illnesses (SMI). In this real-life longitudinal study, the acute onset of the COVID-19 pandemic in Germany did not cause the already low everyday well-being of patients with schizophrenia (SZ) or major depression (MDD) to decrease further. On the contrary, healthy participants' well-being, anxiety, social isolation, and mobility worsened, especially in healthy individuals at risk for mental disorder, but remained above the levels seen in patients. Despite being stressful for healthy individuals at risk for mental disorder, the COVID-19 pandemic had little additional influence on daily-life well-being in psychiatric patients with SMI. This highlights the need for preventive action and targeted support of this vulnerable population.

Delayed affective recovery to daily-life stressors signals a risk for depression

OBJECTIVE

The aim of this study is to investigate the time to affective recovery from daily-life stressors between healthy controls (HC) and two groups with an increased risk for developing depression: individuals with subclinical symptoms of depression (SSD), and individuals remitted from a depressive episode with residual symptoms of depression (RRS).

METHOD

The experience sampling method (ESM) was used to measure affective recovery to daily-life stressors. Affective recovery was defined as the moment that negative affect (NA) returned to baseline level following the first stressful event of the day. We assessed two different operationalizations of the baseline: NA at the moment before the stressful event (t_-1), and mean-person NA. The effect of stress intensity, and cumulative stress were also assessed.

RESULTS

Survival analyses showed significantly longer recovery times for the at risk groups in comparison to healthy individuals, albeit no significant difference was found between the two at risk groups (i.e. SSD and RRS). There was also an effect of cumulative stress, but not stress intensity on time to recovery in that cumulative stress resulted in significantly longer recovery times for all three groups.

LIMITATIONS

The present study is limited by the ESM sampling design, assessments take place post-stress and therefore do not capture peak stress. Additionally, we are only able to assess patterns at the group level. Finally, there is a significant age difference between groups.

CONCLUSION

Individuals at risk for depression display a delayed recovery to daily-life stressors when compared to healthy controls, which is not explained by differences in stress intensity or cumulative stress. Understanding what is driving this delay may help combat the development of depression.

Interoceptive sensibility differentiates the predictive pattern of emotional reactivity on depression

The role of emotional reactivity in the psychopathology of depression has been studied widely but not comprehensively. Inconsistencies in existing literature indicate the presence of other factors may affect this dynamic. An individual's method of processing their physiological sensations is a third variable because emotions are psychophysiological. This study identified the predictiveness of ease of activation, intensity, and duration of negative and positive emotions on depressive symptoms differentiated by interoceptive sensibility (IS). A total of 270 community participants filled-in questionnaires assessing their IS, habitual emotional reactivity, depressive severity, and response bias. A two-step clustering analysis identified the IS characteristics. Negative and positive reactivity models among each IS cluster were tested using bootstrapping regression, controlling for gender and response bias. IS can be clustered into "high IS," "low IS," and "worriers." Both positive and negative reactivity's predictiveness patterns on depression were different between IS clusters. Lower positive reactivity predicted depression among individuals with low IS (harder to activate positive emotions) and worriers (shorter duration of positive emotions) but not among individuals with high IS. Those with high IS also exhibited the highest positive reactivity. Ease of activating negative emotions predicted depression among high IS individuals, and a longer duration of negative emotions predicted depression among worriers. IS may affect the psychopathology of depression through subjective emotional reactivity. Thus, IS characteristics can be incorporated into intervention plans.

Applying multiverse analysis to experience sampling data: Investigating whether preprocessing choices affect robustness of conclusions

The experience sampling method (ESM) has revolutionized our ability to conduct psychological research in the natural environment. However, researchers have a large degree of freedom when preprocessing ESM data, which may hinder scientific progress. This study illustrates the use of multiverse analyses regarding preprocessing choices related to data exclusion (i.e., based on various levels of compliance and exclusion of the first assessment day) and the calculation of constructs (i.e., composite scores calculated as the mean, median, or mode) by reanalyzing established group differences in negative affect, stress reactivity, and emotional inertia between individuals with and without psychosis. Data came from five studies and included 233 individuals with psychosis and 223 healthy individuals (in total, 26,892 longitudinal assessments). Preprocessing choices related to data exclusion did not affect conclusions. For both stress reactivity and emotional inertia of negative affect, group differences were affected when negative affect was calculated as the mean compared to the median or mode. Further analyses revealed that this could be attributed to considerable differences in the within- and between-factor structure of negative affect. While these findings show that observed differences in affective processes between individuals with and without psychosis are robust to preprocessing choices related to data exclusion, we found disagreement in conclusions between different central tendency measures. Safeguarding the validity of future experience sampling research, scholars are advised to use multiverse analysis to evaluate the robustness of their conclusions across different preprocessing scenarios.

Deconstructing emotion regulation in schizophrenia: the nature and consequences of abnormalities at the identification stage

Existing evidence suggests that emotion regulation is abnormal in schizophrenia and associated with undesirable clinical outcomes. However, this literature is based predominantly on trait self-report and does not indicate which stages of emotion regulation (identification, selection, implementation) are impaired. The current study focused on determining the nature of abnormalities at the identification stage using ecological momentary assessment (EMA). Participants included clinically stable outpatients with schizophrenia (SZ; n = 48) and healthy controls (CN; n = 52) who completed 6 days of EMA. The EMA surveys assessed emotional experience, emotion regulation, and symptoms. Results indicated that SZ identified the need to regulate at a higher rate than CN. Specifically, SZ displayed an inefficient threshold for identifying the need to regulate, such that they regulated too much when negative affect was low and too little when negative affect was high. Emotion regulation effort exertion was also inefficient, such that effort was too high at low levels of negative affect and too low at high levels of negative affect in SZ. These identification stage abnormalities also demonstrated differential associations with positive and negative symptoms. Findings suggest that identification stage abnormalities may create a bottleneck that feeds forward and impacts subsequent stages of emotion regulation in SZ that are critically related to symptoms. Targeting the psychological processes underlying these identification stage abnormalities might offer a novel means of treating positive and negative symptoms in schizophrenia.

A systematic review and meta-analysis of the association between emotional stress reactivity and psychosis

AIM

Emotional stress reactivity may be a mediating factor in the association between trauma and psychosis. This review aimed to (i) identify, summarise and critically evaluate the link between emotional stress reactivity and psychotic experiences (ii) examine evidence for a 'dose-response' relationship between stress reactivity and psychosis in the wider psychosis phenotype (i.e., sub-clinical symptoms).

METHODS

Electronic database searches (PsychINFO, MEDLINE, EMBASE) were conducted for studies which investigated the link between stress reactivity and psychosis, psychotic symptoms, or a vulnerability to developing psychosis (wider phenotype). Cross-sectional, experimental and experience sampling method study designs were eligible for inclusion.

RESULTS

Fourty five eligible articles were identified (N participants = 8830). Narrative synthesis showed that increased emotional stress reactivity was associated with psychosis and subclinical psychotic experiences across all study designs, however, findings were inconsistent across studies. The preliminary meta-analysis (k = 4, n = 383) showed increases in emotional stress reactivity was associated with higher negative affect in response to event-related stress, in those with psychosis compared to controls (mean difference in beta coefficients = 0.05, 95% CI 0.02-0.08, p = .004). However, this difference was small with a considerable degree of heterogeneity (p = .001, I²  = 81%) so results should be interpreted with caution.

CONCLUSIONS

Overall, the evidence suggests that there is a link between emotional stress reactivity and psychosis in those with psychosis, those at high risk of developing psychosis and in relation to subclinical psychotic-like experiences in the general population.

A Web-Based Application for Personalized Ecological Momentary Assessment in Psychiatric Care: User-Centered Development of the PETRA Application

BACKGROUND

Smartphone self-monitoring of mood, symptoms, and contextual factors through ecological momentary assessment (EMA) provides insights into the daily lives of people undergoing psychiatric treatment. Therefore, EMA has the potential to improve their care. To integrate EMA into treatment, a clinical tool that helps clients and clinicians create personalized EMA diaries and interpret the gathered data is needed.

OBJECTIVE

This study aimed to develop a web-based application for personalized EMA in specialized psychiatric care in close collaboration with all stakeholders (ie, clients, clinicians, researchers, and software developers).

METHODS

The participants were 52 clients with mood, anxiety, and psychotic disorders and 45 clinicians (psychiatrists, psychologists, and psychiatric nurses). We engaged them in interviews, focus groups, and usability sessions to determine the requirements for an EMA web application and repeatedly obtained feedback on iteratively improved high-fidelity EMA web application prototypes. We used human-centered design principles to determine important requirements for the web application and designed high-fidelity prototypes that were continuously re-evaluated and adapted.

RESULTS

The iterative development process resulted in Personalized Treatment by Real-time Assessment (PETRA), which is a scientifically grounded web application for the integration of personalized EMA in Dutch clinical care. PETRA includes a decision aid to support clients and clinicians with constructing personalized EMA diaries, an EMA diary item repository, an SMS text message-based diary delivery system, and a feedback module for visualizing the gathered EMA data. PETRA is integrated into electronic health record systems to ensure ease of use and sustainable integration in clinical care and adheres to privacy regulations.

CONCLUSIONS

PETRA was built to fulfill the needs of clients and clinicians for a user-friendly and personalized EMA tool embedded in routine psychiatric care. PETRA is unique in this codevelopment process, its extensive but user-friendly personalization options, its integration into electronic health record systems, its transdiagnostic focus, and its strong scientific foundation in the design of EMA diaries and feedback. The clinical effectiveness of integrating personalized diaries via PETRA into care requires further research. As such, PETRA paves the way for a systematic investigation of the utility of personalized EMA for routine mental health care.

Stress and emotional arousal in urban environments: A biosocial study with persons having experienced a first-episode of psychosis and persons at risk

This article examines the entanglement between feelings of stress and discomfort, physiological arousal and urban experiences of persons living with early psychosis. It adopts a biosocial approach, using mixed methods combining ambulatory skin conductance monitoring, mobile interviews and contextual data, collected through GPS and video recordings. The study draws on and strives to cross-fertilize two recent strands of research. The first relates to the use of digital phenotyping in mental health research. The second explores stress and emotional arousal in cities using ambulatory physiological measures. Empirically, the paper is based on fieldwork in Basel, Switzerland, with nine participants recruited within the Basel Early Treatment Service (BEATS), and four controls. We focus on three salient elements in our results: visual perception of moving bodies, spatial transitions and openness and enclosure of the built environment. The analysis shows how these elements elicit physiological responses of arousal and expressed feelings of discomfort. In the concluding section we discuss the methodological implications of these results and suggest the notion of regime of attention as a focus for future biosocial research on urban mental health.

The Interplay Between Stress and Fullness in Patients With Functional Dyspepsia and Healthy Controls: An Exploratory Experience Sampling Method Study

OBJECTIVE

Fullness is a cardinal symptom in functional dyspepsia (FD). The use of real-time symptom assessment might provide more insight into factors, such as daily stress, that can influence fullness. Therefore, this study aimed to use the experience sampling method (a real-time, repeated-measurement method making use of repeated questionnaires available at random moments for a limited amount of time) to assess the association between stress and fullness in patients with FD and healthy controls (HCs).

METHODS

Thirty-five patients with FD (25 female, mean age = 44.7 years) and 34 HCs (24 female, mean age = 44.1 years) completed the experience sampling method (a maximum of 10 random moments per day) for 7 consecutive days. Stress and fullness were rated on an 11-point Numeric Rating Scale. Data between patients with FD and HCs were statistically compared using a Student samples t test and linear mixed-effects models with repeated measures (level 1) nested within participants (level 2).

RESULTS

Average fullness scores were 2.23 (standard error = 0.37) points higher in patients with FD compared with HCs (p < .001). Average stress scores were 1.37 (standard error = 0.30) points higher in patients with FD compared with HCs (p = .002).In FD, fullness scores increased with 0.14 for every 1-point increase in concurrent stress scores (p = .010). Fullness scores at t = 0 increased with 0.12 for every 1-point increase in stress scores at t = -1 (p = .019). T = 0 stress scores were not associated with change in t = -1 fullness scores. No associations between concurrent symptom scores were found for HCs.

CONCLUSIONS

Concurrent and preceding stress scores are positively associated with fullness scores in patients with FD, but not in HCs. These findings indicate that increased levels of stress may precede feelings of fullness in patients with FD.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT04204421.

The dynamical association between physical activity and affect in the daily life of individuals with ADHD

Exercise interventions in mental disorders have evidenced a mood-enhancing effect. However, the association between physical activity and affect in everyday life has not been investigated in adult individuals with ADHD, despite being important features of this disorder. As physical activity and affect are dynamic processes in nature, assessing those in everyday life with e-diaries and wearables, has become the gold standard. Thus, we used an mHealth approach to prospectively assess physical activity and affect processes in individuals with ADHD and controls aged 14-45 years. Participants wore accelerometers across a four-day period and reported their affect via e-diaries twelve times daily. We used multilevel models to identify the within-subject effects of physical activity on positive and negative affect. We split our sample into three groups: 1. individuals with ADHD who were predominantly inattentive (n = 48), 2. individuals with ADHD having a combined presentation (i.e., being inattentive and hyperactive; n = 95), and 3. controls (n = 42). Our analyses revealed a significant cross-level interaction (F(2, 135.072)=5.733, p = 0.004) of physical activity and group on positive affect. In details, all groups showed a positive association between physical activity and positive affect. Individuals with a combined presentation significantly showed the steepest slope of physical activity on positive affect (slope_inattentive=0.005, p<0.001; slope_combined=0.009, p<0.001; slope_controls=0.004, p = 0.008). Our analyses on negative affect revealed a negative association only in the individuals with a combined presentation (slope=-0.003; p = 0.001). Whether this specifically pronounced association in individuals being more hyperactive might be a mechanism reinforcing hyperactivity needs to be empirically clarified in future studies.

Impact of coping styles on substance use in persons with psychosis, siblings, and controls

BACKGROUND

Substance use is overrepresented in patients with psychosis. Maladaptive coping has been proposed as one of the mechanisms which might underlie this high prevalence. Patients are known to apply more maladaptive coping compared to the healthy population. However, it is unknown whether coping is associated with the use of different substances across those with different vulnerability for psychosis, and whether coping mediates the possible association between life events and substance use.

METHODS

In this multicenter, cohort study, 429 patients, 504 siblings, and 220 controls were included. We determined whether coping was associated with tobacco smoking, cannabis use, or alcohol consumption. Multivariable logistic regression models were applied whilst correcting for potential confounders. We performed post-hoc analyses to explore the association between negative life events, tobacco smoking, and the role of coping as a mediator in patients with psychosis.

RESULTS

A positive association was found in patients between passive coping and tobacco smoking (fully adjusted OR 1.65, 95% CI 1.18-2.31). Tobacco smoking patients experienced more negative life events compared to non-smoking patients and passive coping mediated this association. In siblings and controls, none of the coping strategies were associated with substance use.

CONCLUSIONS

The coping style of patients with psychosis is associated with tobacco smoking and mediates the association between negative events and tobacco smoking. No significant associations were found in siblings, controls or concerning other substance use. Future research is required to examine whether enhancing healthy coping strategies decreases tobacco use in patients with psychosis.

Adjunctive dietary intervention for bipolar disorder: a randomized, controlled, parallel-group, modified double-blinded trial of a high n-3 plus low n-6 diet

OBJECTIVE

To investigate the preliminary efficacy of a high n-3 plus low n-6 (H3-L6) dietary intervention in improving mood stability in Bipolar Disorder (BD) when compared to dietary intervention with usual U.S. levels of n-6 and n-3 polyunsaturated fatty acid (PUFA) intakes (control diet, CD).

METHODS

This 2-arm, parallel-group, randomized, modified double-blind, controlled 48-week study of 12-week intensive diet intervention in subjects with BD was conducted at a single suburban-rural site in the mid-Atlantic region. Participants with DSM-IV TR BD I or II with hypomanic or depressive symptoms were randomized, stratified on gender (N = 82). The intervention included the provision of group-specific study foods and dietary counseling. Variability of mood symptoms was measured by a twice-daily, 12-week ecological momentary analysis (EMA) paradigm, and group differences were analyzed using multilevel models. Circulating n-3 and n-6 fatty acids were measured at baseline and after 4, 8, and 12 weeks of diet exposure.

RESULTS

All 82 randomized participants were included in biochemical analyses. Seventy participants completed at least 2 EMA surveys and were included in primary EMA analyses. Variability in mood, energy, irritability, and pain as measured using EMA was reduced in the H3-L6 group compared to the CD group. No significant differences in mean ratings of mood symptoms, or any other symptom measures, were detected. The dietary intervention effect on target PUFAs significantly differed by the group over time.

CONCLUSIONS

A dietary intervention adjunctive to usual care showed preliminary efficacy in improving variability in mood symptoms in participants with BD.

TRIAL REGISTRATION

ClinicalTrials.Gov NCT02272010.

Associations between responses to voices, distress and appraisals during daily life: an ecological validation of the cognitive behavioural model

BACKGROUND

Cognitive models propose that behavioural responses to voices maintain distress by preventing disconfirmation of negative beliefs about voices. We used Experience Sampling Methodology (ESM) to examine the hypothesized maintenance role of behavioural responses during daily life.

METHOD

Thirty-one outpatients with frequent voices completed a smartphone-based ESM questionnaire 10 times a day over 9 days, assessing voice-related distress; resistance and compliance responses to voices; voice characteristics (intensity and negative content); appraisals of voice dominance, uncontrollability and intrusiveness.

RESULTS

In line with predictions, behavioural responses were associated with voice appraisals (dominance and uncontrollability), but not voice characteristics. Greater resistance and compliance were reported in moments of increased voice distress, but these associations did not persist after controlling for concurrent voice appraisals and characteristics. Voice distress was predicted by appraisals, and, unexpectedly, also by voice characteristics. As predicted, compliance and resistance were related to increases in distress at subsequent timepoints, whilst antecedent voice appraisals and characteristics had no such effect. Compliance, but not resistance, additionally predicted subsequent increases in voice uncontrollability. In both cases, the reverse models showed no association, indicating directional effects of responses on subsequent distress, and of compliance on uncontrollability appraisals.

CONCLUSIONS

These results provide support for the cognitive model by suggesting that momentary behavioural and emotional responses to voices are associated with concurrent negative voice appraisals. Findings suggest that behavioural responses may be driven by voice appraisals, rather than directly by distress, and may in turn maintain voice appraisals and associated distress during the course of daily life.

Real-time individual benefit from social interactions before and during the lockdown: the crucial role of personality, neurobiology and genes

Social integration is a major resilience factor for staying healthy. However, the COVID-19-pandemic led to unprecedented restrictions in social life. The consequences of these social lockdowns on momentary well-being are yet not fully understood. We investigated the affective benefit from social interactions in a longitudinal birth cohort. We used two real-time, real-life ecological momentary assessments once before and once during the initial lockdown of the pandemic (N = 70 participants; n~6800 observations) capturing the protective role of social interactions on well-being. Moreover, we used a multimethod approach to analyze ecological assessment data with individual risk and resilience factors, which are promising moderators in the relationship of social behavior, stress reactivity, and affective states (i.e., amygdala volume, neuroticism, polygenic risk for schizophrenia). Social contacts were linked to higher positive affect both during normal times and during the COVID-19-pandemic (beta coefficient = 0.1035), highlighting the beneficial role of social embedding. Interestingly, this relationship was differentially moderated by individual risk and resilience factors. In detail, participants with a larger left amygdala volume (beta coefficient = -0.0793) and higher neuroticism (beta coefficient = -0.0958) exhibited an affective benefit from more social interactions prior to the pandemic. This pattern changed during the pandemic with participants with smaller amygdala volumes and lower neurotic traits showing an affective gain during the pandemic. Moreover, participants with low genetic risk for schizophrenia showed an affective benefit (beta coefficient = -0.0528) from social interactions irrespective of the time point. Our results highlight the protective role of social integration on momentary well-being. Thereby, we offer new insights into how this relationship is differently affected by a person's neurobiology, personality, and genes under adverse circumstances.

Stress, Schizophrenia, and Violence: A Machine Learning Approach

This study employs machine learning algorithms to examine the causes for engaging in violent offending in individuals with schizophrenia spectrum disorders. Data were collected from 370 inpatients at the Centre for Inpatient Forensic Therapy, Zurich University Hospital of Psychiatry, Switzerland. Based on findings of the general strain theory and using logistic regression and machine learning algorithms, it was analyzed whether accumulation and type of stressors in the inpatients' history influenced the severity of an offense. A higher number of stressors led to more violent offenses, and five types of stressors were identified as being highly influential regarding violent offenses. Our findings suggest that an accumulation of stressful experiences in the course of life and certain types of stressors might be particularly important in the development of violent offending in individuals suffering from schizophrenia spectrum disorders. A better understanding of risk factors that lead to violent offenses should be helpful for the development of preventive and therapeutic strategies for patients at risk and could thus potentially reduce the prevalence of violent offenses.

Do positive and negative emotional reactions during war predict subsequent symptomatology? A prospective experience sampling study

While peritraumatic negative emotions have been associated with subsequent posttraumatic stress and depression, the predictive role of real-time emotional reactions to specific stressors during prolonged stress exposure is still unclear, particularly that of positive emotions. The current study uses experience sampling methodology to examine individual general levels of negative and positive emotions, and emotional reactivity to specific stressors during war, as prospective predictors of posttraumatic stress and depression. Ninety-six civilians exposed to rocket fire during the 2014 Israel-Gaza war reported exposure to rocket warning sirens and levels of ten negative and six positive emotions twice a day for 30 days. Symptoms of posttraumatic stress and depression were then assessed two months post-war. Participants reported higher negative emotions and lower positive emotions during assessment windows with sirens. Over time, negative emotions decreased and positive emotions increased. Higher levels of overall negative emotions predicted posttraumatic stress symptoms and depression symptoms two months later. Levels of positive emotions, and negative and positive emotional reactivity to sirens, were not associated with subsequent symptomatology. Our results indicate the stronger role of overall negative emotions as predictors of symptomatology compared with momentary emotional reactivity, and the stronger predictive role of negative compared with positive emotions.

The association between self-reported stress and cardiovascular measures in daily life: A systematic review

BACKGROUND

Stress plays an important role in the development of mental illness, and an increasing number of studies is trying to detect moments of perceived stress in everyday life based on physiological data gathered using ambulatory devices. However, based on laboratory studies, there is only modest evidence for a relationship between self-reported stress and physiological ambulatory measures. This descriptive systematic review evaluates the evidence for studies investigating an association between self-reported stress and physiological measures under daily life conditions.

METHODS

Three databases were searched for articles assessing an association between self-reported stress and cardiovascular and skin conductance measures simultaneously over the course of at least a day.

RESULTS

We reviewed findings of 36 studies investigating an association between self-reported stress and cardiovascular measures with overall 135 analyses of associations between self-reported stress and cardiovascular measures. Overall, 35% of all analyses showed a significant or marginally significant association in the expected direction. The most consistent results were found for perceived stress, high-arousal negative affect scales, and event-related self-reported stress measures, and for frequency-domain heart rate variability physiological measures. There was much heterogeneity in measures and methods.

CONCLUSION

These findings confirm that daily-life stress-dynamics are complex and require a better understanding. Choices in design and measurement seem to play a role. We provide some guidance for future studies.