Autonomic Regulation and Auditory Hallucinations in Individuals With Schizophrenia: An Experience Sampling Study

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.

Predicting the onset of psychotic experiences in daily life with the use of ambulatory sensor data - A proof-of-concept study

INTRODUCTION

Predictive models of psychotic symptoms could improve ecological momentary interventions by dynamically providing help when it is needed. Wearable sensors measuring autonomic arousal constitute a feasible base for predictive models since they passively collect physiological data linked to the onset of psychotic experiences. To explore this potential, we investigated whether changes in autonomic arousal predict the onset of hallucination spectrum experiences (HSE) and paranoia in individuals with an increased likelihood of experiencing psychotic symptoms.

METHOD

For 24 h of ambulatory assessment, 62 participants wore electrodermal activity and heart rate sensors and were provided with an Android smartphone to answer questions about their HSE-, and paranoia-levels every 20 min. We calculated random forests to detect the onset of HSEs and paranoia. The generalizability of our models was tested using leave-one-assessment-out and leave-one-person-out cross-validation.

RESULTS

Leave-one-assessment-out models that relied on physiological data and participant ID yielded balanced accuracy scores of 80 % for HSE and 66 % for paranoia. Adding baseline information about lifetime experiences of psychotic symptoms increased balanced accuracy to 82 % (HSE) and 70 % (paranoia). Leave-one-person-out models yielded lower balanced accuracy scores (51 % to 58 %).

DISCUSSION

Using passively collectible variables to predict the onset of psychotic experiences is possible and prediction models improve with additional information about lifetime experiences of psychotic symptoms. Generalizing to new individuals showed poor performance, so including personal data from a recipient may be necessary for symptom prediction. Completely individualized prediction models built solely with the data of the person to be predicted might increase accuracy further.

Methodological Characteristics and Feasibility of Ecological Momentary Assessment Studies in Psychosis: a Systematic Review and Meta-Analysis

BACKGROUND

Ecological momentary assessment (EMA) involves completing multiple surveys over time in daily life, capturing in-the-moment experiences in real-world contexts. EMA use in psychosis studies has surged over several decades. To critically examine EMA use in psychosis research and assist future researchers in designing new EMA studies, this systematic review aimed to summarize the methodological approaches used for positive symptoms in psychosis populations and evaluate feasibility with a focus on completion rates.

METHODS

A systematic review of PubMed, PsycINFO, MEDLINE, Web of Science, EBSCOhost, and Embase databases using search terms related to EMA and psychosis was conducted. Excluding duplicate samples, a meta-analysis was conducted of EMA survey completion rates and meta-regression to examine predictors of completion.

RESULTS

Sixty-eight studies were included in the review. Characteristics and reporting of EMA methodologies were variable across studies. The meta-mean EMA survey completion computed from the 39 unique studies that reported a mean completion rate was 67.15% (95% CI = 62.3, 71.9), with an average of 86.25% of the sample meeting a one-third EMA completion criterion. No significant predictors of completion were found in the meta-regression. A variety of EMA items were used to measure psychotic experiences, of which few were validated.

CONCLUSIONS

EMA methods have been widely applied in psychosis studies using a range of protocols. Completion rates are high, providing clear evidence of feasibility in psychosis populations. Recommendations for reporting in future studies are provided.

Experiencing hallucinations in daily life: The role of metacognition

BACKGROUND

Hallucinations have been linked to failures in metacognitive reflection suggesting an association between hallucinations and overestimation of performance, although the cross-sectional findings are inconsistent. This inconsistency may relate to the fluctuating hallucinatory experiences that are not captured in cross-sectional studies. Ecological Momentary Assessment (EMA) captures in-the-moment experiences over time so can identify causal relationships between variables such as the associations between metacognition and hallucinatory experience in daily life and overcome problems in cross-sectional designs.

METHODS

Participants (N = 41) experiencing daily hallucinations completed baseline questionnaires and smartphone surveys 7 times per day for 14 days. They were prompted to identify a task they would complete in the next 4 h and to make metacognitive predictions around the likelihood of completing the task, the difficulty of the task, and how well they would complete it (standard of completion).

RESULTS

76 % finished the 14-days of assessment with an average of 42.2 % survey completion. Less accurate metacognition was associated with more hallucinations, but less accurate likelihood and standard of completion was associated with fewer hallucinations. Using a cross-lagged analysis, metacognitive predictions around the likelihood of completion (p < .001) and standard of completion (p = .01) predicted hallucination intensity at the following timepoint, and metacognitive predictions regarding likelihood of completion (p = .02) predicted hallucination control at the following timepoint.

DISCUSSION

Interventions that aim to improve metacognitive ability in-the-moment may serve to reduce the intensity and increase the control of hallucinations.

Emotion regulation flexibility and psychosis: A longitudinal study disentangling components of flexibility in psychosis-proneness

OBJECTIVES

Flexibility in self-regulation has emerged as an important component of mental health. Previous findings found that deficits in two components of regulatory flexibility were linked cross-sectionally to psychosis-proneness. We aimed to replicate and extend these findings longitudinally.

METHODS

We measured psychosis-proneness and components of emotion regulation flexibility (i.e. context sensitivity, repertoire and feedback) at two time points with three months in between.

RESULTS

Two flexibility components predicted psychotic-like experiences. The ability to detect the absence of contextual cues was implicated in both positive and negative dimensions but through opposite pathways. Expressive suppression ability-a subcomponent of repertoire-predicted positive symptoms. None of the flexibility components predicted distress related to the symptoms.

CONCLUSIONS

The current study provides further evidence on the implication of emotion regulation flexibility in the longer-term maintenance of psychotic-like experiences. Future studies can advance this work further by evaluating possible bidirectional relationships between psychotic-like experiences and deficits in emotion regulation flexibility.

Designing daily-life research combining experience sampling method with parallel data

BACKGROUND

Ambulatory monitoring is gaining popularity in mental and somatic health care to capture an individual's wellbeing or treatment course in daily-life. Experience sampling method collects subjective time-series data of patients' experiences, behavior, and context. At the same time, digital devices allow for less intrusive collection of more objective time-series data with higher sampling frequencies and for prolonged sampling periods. We refer to these data as parallel data. Combining these two data types holds the promise to revolutionize health care. However, existing ambulatory monitoring guidelines are too specific to each data type, and lack overall directions on how to effectively combine them.

METHODS

Literature and expert opinions were integrated to formulate relevant guiding principles.

RESULTS

Experience sampling and parallel data must be approached as one holistic time series right from the start, at the study design stage. The fluctuation pattern and volatility of the different variables of interest must be well understood to ensure that these data are compatible. Data have to be collected and operationalized in a manner that the minimal common denominator is able to answer the research question with regard to temporal and disease severity resolution. Furthermore, recommendations are provided for device selection, data management, and analysis. Open science practices are also highlighted throughout. Finally, we provide a practical checklist with the delineated considerations and an open-source example demonstrating how to apply it.

CONCLUSIONS

The provided considerations aim to structure and support researchers as they undertake the new challenges presented by this exciting multidisciplinary research field.

Heart Rate Variability in Psychiatric Disorders: A Systematic Review

Introduction

Heart rate variability (HRV) is a measure of the fluctuation in time interval between consecutive heart beats. Decreased heart rate variability has been shown to have associations with autonomic dysfunction in psychiatric conditions such as depression, substance abuse, anxiety, and schizophrenia, although its use as a prognostic tool remains highly debated. This study aims to review the current literature on heart rate variability as a diagnostic and prognostic tool in psychiatric populations.

Methods

A literature search was conducted using the MEDLINE, EMBASE, Cochrane, and PsycINFO libraries to identify full-text studies involving adult psychiatric populations that reported HRV measurements. From 1647 originally identified, 31 studies were narrowed down through an abstract and full-text screen. Studies were excluded if they enrolled adolescents or children, used animal models, enrolled patients with another primary diagnosis other than psychiatric as outlined by the diagnostic and statistical manual of mental disorders (DSM) V, or if they assessed HRV in the context of treatment rather than diagnosis. Study quality assessment was conducted using a modified Downs and Blacks quality assessment tool for observational rather than interventional studies. Data were reported in four tables: 1) summarizing study characteristics, 2) methods of HRV detection, 3) key findings and statistics, and 4) quality assessment.

Results

There is significant variability between studies in their methodology of recording as well as reporting HRV, which makes it difficult to meaningfully interpret data that is clinically applicable due to the presence of significant bias in existing studies. The presence of an association between HRV and the severity of various psychiatric disorders, however, remains promising.

Conclusion

Future studies should be done to further explore how HRV parameters may be used to enhance the diagnosis and prognosis of several psychiatric disorders.

The phenomenology of auditory verbal hallucinations among clients with schizophrenia: The association with acceptance and autonomous action responses

BACKGROUND

Living with the experience of hearing voices without trying to ignore or suppress them is referred to as accepting auditory verbal hallucinations (AVH). It varies depending on the phenomenology of AVH itself; some clients may find it challenging to acquire new coping mechanisms with the voices.

AIM

Examine the association between the phenomenology of AVH and acceptance or autonomous action among clients with schizophrenia.

DESIGN

A descriptive correlational study was conducted on 200 clients with schizophrenia using the following instruments; Sociodemographic and clinical data tools, Psychotic Symptom Rating Scales (PSYRATS-AH), and Voices Acceptance and Action Scale (VAAS).

RESULTS

Most patients have moderate to severe levels of AVH (95.5 %), with a mean score of 25.34. The emotional characteristics reflected the high mean score (11.24). A highly statistically negative correlation was found between the total Voices Acceptance and Action Scale and severity of AVH (P = -0.448, sig = 0.000). A predictable significant effect of user acceptance and autonomous actions response coping with decreasing the severity of AVH was found (adjusted r square = 0.196, sig = 0.000) and model equation = Severity of Verbal auditory hallucinations = 31.990-0.257 X Total of Voice Acceptance and Autonomous Action Scale (VAAS).

CONCLUSION

The severity of all phenomenological characteristics of AVH can be successfully reduced by using voice acceptance and autonomous action responses rather than resistance or engagement responses. Subsequently, it must be improved and learned by psychiatric nurses the patients with schizophrenia in the hospitals by applying Acceptance and Commitment Therapy as a crucial intervention.

Combining actigraphy and experience sampling to assess physical activity and sleep in patients with psychosis: A feasibility study

BACKGROUND

Sleep disorders and reduced physical activity are common in patients with psychosis and can be related to health-related outcomes such as symptomatology and functioning. Mobile health technologies and wearable sensor methods enable continuous and simultaneous monitoring of physical activity, sleep, and symptoms in one's day-to-day environment. Only a few studies have applied simultaneous assessment of these parameters. Therefore, we aimed to examine the feasibility of the simultaneous monitoring of physical activity, sleep, and symptoms and functioning in psychosis.

METHODS

Thirty three outpatients diagnosed with a schizophrenia or other psychotic disorder used an actigraphy watch and experience sampling method (ESM) smartphone app for 7 consecutive days to monitor physical activity, sleep, symptoms, and functioning. Participants wore the actigraphy watch during day and night and completed multiple short questionnaires (eight daily, one morning, and one evening) on their phone. Hereafter they completed evaluation questionnaires.

RESULTS

Of the 33 patients (25 male), 32 (97.0%) used the ESM and actigraphy during the instructed timeframe. ESM response was good: 64.0% for the daily, 90.6% for morning, and 82.6% for evening questionnaire(s). Participants were positive about the use of actigraphy and ESM.

CONCLUSION

The combination of wrist-worn actigraphy and smartphone-based ESM is feasible and acceptable in outpatients with psychosis. These novel methods can help both clinical practice and future research to gain more valid insight into physical activity and sleep as biobehavioral markers linked to psychopathological symptoms and functioning in psychosis. This can be used to investigate relationships between these outcomes and thereby improve individualized treatment and prediction.

The relationship between appraisals of auditory verbal hallucinations and real-time affect and social functioning

In addition to being a hallmark symptom of schizophrenia-spectrum disorders, auditory verbal hallucinations (AVH) are present in a range of psychiatric disorders as well as among individuals who are otherwise healthy. People who experience AVH are heterogeneous, and research has aimed to better understand what characteristics distinguish, among those who experience AVH, those who experience significant disruption and distress from those who do not. The cognitive model of AVH suggests that appraisals of voices determine the extent to which voices cause distress and social dysfunction. Previous work has relied largely on comparisons of "clinical" and "non-clinical" voice hearers, and few studies have been able to provide insight into the moment-to-moment relationships between appraisals and outcomes. The current study examines longitudinal data provided through ecological momentary assessment and passive sensors of 465 individuals who experience cross-diagnostic AVH. Results demonstrated associations of AVH appraisals to negative affect and social functioning. Above and beyond within-individual averages, when a participant reported increased appraisals of their voices as powerful and difficult to control, they were more likely to feel increased negative affect and reduced feelings of safety. AVH power appraisals were also associated with next-day number and duration of phone calls placed, and AVH controllability appraisals were associated with increased time near speech and reduced next-day time away from primary location. These results suggest that appraisals are state-like characteristics linked with day-to-day and moment-to-moment changes in impactful affective and behavioral outcomes; intervention approaches should aim to address these domains in real-time.

A sister's search for the seeds of psychosis

Dr. Dolores Malaspina sought a better way to understand the origins of psychosis than a schizophrenogenic mother, as her family had been informed upon her sisters illness. She moved her attention from environmental biology and zoology, to medical science and assembled knowledge on the multilevel components purported to underpin severe mental illness. Her studies cross levels to consider connections among exposures and genetic etiologies, intrinsic homeostatic mechanisms, stimuli perception and clinical illness features. Original contributions include associating later paternal age with increasing risk for schizophrenia in offspring and proposing that de novo mutations with shorter cell cycles explained the association, showing increased resting hippocampal blood flow in psychosis and that it was associated with inflammation, and that autonomic nervous system dysfunction was related to hippocampal inflammation, plausibly reflecting vascular abnormalities. She has been a professor of psychiatry in medical schools at Columbia University, New York University and at Mount Sinai in New York, USA.

Design decisions and data completeness for experience sampling methods used in psychosis: systematic review

BACKGROUND

The experience sampling method (ESM) is an intensive longitudinal research method.  Participants complete questionnaires at multiple times about their current or very recent state. The design of ESM studies is complex. People with psychosis have been shown to be less adherent to ESM study protocols than the general population. It is not known how to design studies that increase adherence to study protocols. A lack of typology makes it is hard for researchers to decide how to collect data in a way that allows for methodological rigour, quality of reporting, and the ability to synthesise findings. The aims of this systematic review were to characterise the design choices made in ESM studies monitoring the daily lives of people with psychosis, and to synthesise evidence relating the data completeness to different design choices.

METHODS

A systematic review was conducted of published literature on studies using ESM with people with psychosis. Studies were included if they used digital technology for data collection and reported the completeness of the data set. The constant comparative method was used to identify design decisions, using inductive identification of design decisions with simultaneous comparison of design decisions observed. Weighted regression was used to identify design decisions that predicted data completeness. The review was pre-registered (PROSPERO CRD42019125545).

RESULTS

Thirty-eight studies were included. A typology of design choices used in ESM studies was developed, which comprised three superordinate categories of design choice: Study context, ESM approach and ESM implementation. Design decisions that predict data completeness include type of ESM protocol used, length of time participants are enrolled in the study, and if there is contact with the research team during data collection.

CONCLUSIONS

This review identified a range of design decisions used in studies using ESM in the context of psychosis. Design decisions that influence data completeness were identified. Findings will help the design and reporting of future ESM studies. Results are presented with the focus on psychosis, but the findings can be applied across different mental health populations.

Blunted pupil light reflex is associated with negative symptoms and working memory in individuals with schizophrenia

Two largely separate lines of research have documented altered pupillary dynamics in individuals diagnosed with schizophrenia. An older set of studies has demonstrated reductions in the pupillary light reflex (PLR) in individuals with schizophrenia; however, clinical and cognitive correlates of this blunted PLR have been relatively unexplored. More recently, a large body of work has demonstrated reductions in pupillary dilation in response to cognitive demands in individuals with schizophrenia, and the degree of this blunted pupil dilation has been related to more severe cognitive deficits and motivational negative symptoms. These clinically relevant alterations in the cognitive modulation of pupil size have been interpreted as reflecting insufficient information processing resources or inappropriate effort allocation. To begin to bridge these two lines of work, we investigated the PLR in 34 individuals with schizophrenia and 30 healthy controls and related the amplitude of the PLR to motivational negative symptoms and cognitive performance. Consistent with prior work, we found that the PLR was reduced in individuals with schizophrenia, and furthermore, that these measurements were highly reliable across individuals. Blunted constriction was associated with more severe motivational negative symptoms and poorer working memory among individuals with schizophrenia. These observed correlates provide a bridge between older literature documenting an altered PLR and more recent work reporting associations between negative symptoms, cognition, and blunted pupillary dilation in response to cognitive demands in individuals with schizophrenia. We provide possible mechanistic interpretations of our data and consider a parsimonious explanation for reduced cognitive- and light-related modulation of pupil size.

Dopamine, Psychosis, and Symptom Fluctuation: A Narrative Review

It has been hypothesized since the 1960s that the etiology of schizophrenia is linked to dopamine. In the intervening 60 years, sophisticated brain imaging techniques, genetic/epigenetic advances, and new experimental animal models of schizophrenia have transformed schizophrenia research. The disease is now conceptualized as a heterogeneous neurodevelopmental disorder expressed phenotypically in four symptom domains: positive, negative, cognitive, and affective. The aim of this paper is threefold: (a) to review recent research into schizophrenia etiology, (b) to review papers that elicited subjective evidence from patients as to triggers and repressors of symptoms such as auditory hallucinations or paranoid thoughts, and (c) to address the potential role of dopamine in schizophrenia in general and, in particular, in the fluctuations in schizophrenia symptoms. The review also includes new discoveries in schizophrenia research, pointing to the involvement of both striatal neurons and glia, signaling pathway convergence, and the role of stress. It also addresses potential therapeutic implications. We conclude with the hope that this paper opens up novel avenues of research and new possibilities for treatment.

An integrative study of the microbiome gut-brain-axis and hippocampal inflammation in psychosis: Persistent effects from mode of birth

The mechanism producing psychosis appears to include hippocampal inflammation, which could be associated with the microbiome-gut-brain-axis (MGBS). To test this hypothesis we are conducting a multidisciplinary study, herein described. The procedures are illustrated with testing of a single subject and group level information on the impact of C-section birth are presented.

METHOD

Study subjects undergo research diagnostic interviews and symptom assessments to be categorized into one of 3 study groups: psychosis, nonpsychotic affective disorder or healthy control. Hippocampal volume and metabolite concentrations are assessed using 3-dimensional, multi-voxel H1 Magnetic Resonance Imaging (MRSI) encompassing all gray matter in the entire hippocampal volume. Rich self-report information is obtained with the PROMIS interview, which was developed by the NIH Commons for research in chronic conditions. Early trauma is assessed and cognition is quantitated using the MATRICS. The method also includes the most comprehensive autonomic nervous system (ANS) battery used to date in psychiatric research. Stool and oral samples are obtained for microbiome assessments and cytokines and other substances are measured in blood samples.

RESULTS

Group level preliminary data shows that C-section birth is associated with higher concentrations of GLX, a glutamate related hippocampal neurotransmitter in psychotic cases, worse symptoms in affective disorder cases and smaller hippocampal volume in controls.

CONCLUSION

Mode of birth appears to have persistent influences through adulthood. The methodology described for this study will define pathways through which the MGBA may influence the risk for psychiatric disorders.

The relationship of antipsychotic treatment with reduced brown adipose tissue activity in patients with schizophrenia

BACKGROUND

Antipsychotic drug (APD) treatment has been associated with metabolic abnormalities. Brown adipose tissue (BAT) is the main site of adaptive thermogenesis and secretes various metabolism-improving factors known as batokines. We explored the association of BAT activity with APD treatment and metabolic abnormalities in patients with schizophrenia by measuring the blood levels of bone morphogenetic protein 8b (BMP8b), a batokine secreted by mature BAT.

METHODS

BMP8b levels were compared among 50 drug-free, 32 aripiprazole-treated, and 91 clozapine-treated patients with schizophrenia. Regression analysis was used to explore factors, including APD types, that might be associated with BMP8b levels and the potential effect of BMP8b on metabolic syndrome (MS).

RESULTS

APD-treated patients had decreased BMP8b levels relative to drug-free patients. The difference still existed after adjustment for body mass index and Brief Psychiatric Rating Scale scores. Among APD-treated group, clozapine was associated with even lower BMP8b levels than the less obesogenic APD, aripiprazole. Furthermore, higher BMP8b levels were associated with lower risks of MS after adjustment for BMI and APD treatment.

CONCLUSION

Using drug-free patients as the comparison group to understand the effect of APDs, this is the first study to show APD treatment is associated with reduced BAT activity that is measured by BMP8b levels, with clozapine associated a more significant reduction than aripiprazole treatment. BMP8b might have a beneficial effect against metabolic abnormalities and this effect is independent of APD treatment. Future studies exploring the causal relationship between APD treatment and BMP8b levels and the underlying mechanisms are warranted.

Metacognitive mastery moderates the relationship between positive symptoms and distress in adults with serious mental illness

BACKGROUND

Research supports the possibility that a person's metacognitive ability may influence the impact of positive symptoms. This connection is important because understanding how metacognitive capacity relates to positive symptoms and distress can guide treatment and bolster recovery.

AIMS

To explore this, we assessed the moderating role of Metacognitive Mastery on the relationship of positive symptoms to affective symptoms, or markers of distress, measured both concurrently and at a later time point (to assess durability of metacognition) with persons with serious mental illness. To rule out the possibility that any findings were the result of cognitive impairments or general psychopathology we included measures of neurocognition and symptoms as potential covariates.

METHODS

Participants were 67 individuals with the majority diagnosed with either schizophrenia spectrum disorder, major depressive disorder, or bipolar disorder. Metacognition was measured with the Metacognitive Assessment Scale-Abbreviated, symptoms were measured using the Brief Psychiatric Rating Scale and verbal memory was measured using the California Verbal Learning Test.

RESULTS

Metacognitive Mastery moderated the relationship between positive symptoms and affective symptoms at both time points with differential patterns at each point.

CONCLUSIONS

Metacognitive Mastery may exert a complex influence upon the effects of positive symptoms on distress.

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.

Real-time cognitive performance and positive symptom expression in schizophrenia

Deficits in cognitive functions are frequent in schizophrenia and are often conceptualized as stable characteristics of this disorder. However, cognitive capacities may fluctuate over the course of a day and it is unknown if such variation may be linked to the dynamic expression of psychotic symptoms. This investigation used Ecological Momentary Assessment (EMA) to provide mobile tests of cognitive functions and positive symptoms in real time. Thirty-three individuals with schizophrenia completed five EMA assessments per day for a one-week period that included real-time assessments of cognitive performance and psychotic symptoms. A subsample of patients and 31 healthy controls also completed a functional MRI examination. Relative to each individual's average score, moments of worsened cognitive performance on the mobile tests were associated with an increased probability of positive symptom occurrence over subsequent hours of the day (coef = 0.06, p < 0.05), adjusting for the presence of psychotic symptoms at the moment of mobile test administration. These prospective associations varied as a function of graph theory indices in MRI analyses. These findings demonstrate that cognitive performance is prospectively linked to psychotic symptom expression in daily life, and that underlying brain markers may be observed in the Executive Control Network. While the potential causal nature of this association remains to be investigated, our results offer promising prospects for a better understanding of the underlying mechanisms of symptom expression in schizophrenia.

Voice Hearing in Borderline Personality Disorder Across Perceptual, Subjective, and Neural Dimensions

BACKGROUND

Auditory verbal hallucinations (AVH) commonly occur in the context of borderline personality disorder (BPD) yet remain poorly understood. AVH are often perceived by patients with BPD as originating from inside the head and hence viewed clinically as "pseudohallucinations," but they nevertheless have a detrimental impact on well-being.

METHODS

The current study characterized perceptual, subjective, and neural expressions of AVH by using an auditory detection task, experience sampling and questionnaires, and functional neuroimaging, respectively.

RESULTS

Perceptually, reported AVH correlated with a bias for reporting the presence of a voice in white noise. Subjectively, questionnaire measures indicated that AVH were significantly distressing and persecutory. In addition, AVH intensity, but not perceived origin (i.e., inside vs outside the head), was associated with greater concurrent anxiety. Neurally, fMRI of BPD participants demonstrated that, relative to imagining or listening to voices, periods of reported AVH induced greater blood oxygenation level-dependent activity in anterior cingulate and bilateral temporal cortices (regional substrates for language processing). AVH symptom severity was associated with weaker functional connectivity between anterior cingulate and bilateral insular cortices.

CONCLUSION

In summary, our results indicate that AVH in participants with BPD are (1) underpinned by aberrant perceptual-cognitive mechanisms for signal detection, (2) experienced subjectively as persecutory and distressing, and (3) associated with distinct patterns of neural activity that inform proximal mechanistic understanding. Our findings are like analogous observations in patients with schizophrenia and validate the clinical significance of the AVH experience in BPD, often dismissed as "pseudohallucinations." These highlight a need to reconsider this experience as a treatment priority.

Insight-related beliefs and controllability appraisals contribute little to hallucinated voices: a transdiagnostic network analysis study

Hallucinated voices cause high levels of distress and disability. Current theories suggest that insight-related beliefs, about internal or external origin, perceived source location, and appraisals of controllability are important in mediating the impact of these experiences but previous findings have been mixed. We report two open code and open data network analytic studies of items in the Psychotic Symptoms Ratings Scale for auditory verbal hallucinations (PSYRATS-AH) in a large sample of patients with hallucinated voices to examine the network structure of items at (1) first assessment, and (2) differences over two consecutive assessments during a wait-list period. Networks were generated using least absolute shrinkage and selection operator (LASSO) and extended Bayesian information criterion (EBIC) with node predictability. In Study 1 (N = 386), we report that insight-related items made a negligible contribution to hallucinated voices and the controllability appraisal made at most a modest contribution. Items relating to distress and negative content were the most central and most predicted by the wider network. In Study 2 (N = 204), we tested the longitudinal stability of the structure of hallucinated voices over a period of several months, finding a small change in total hallucination score and global strength but no clear evidence for an alteration in the structural relationship. The insight-related and controllability items remained as least influential over time. Insight-related beliefs and controllability appraisals may contribute less than previously thought to distressing hallucinated voices although we do not discount that other appraisals may remain important.

Interoception abnormalities in schizophrenia: A review of preliminary evidence and an integration with Bayesian accounts of psychosis

Schizophrenia research has traditionally focused almost exclusively on how the brain interprets the outside world. However, our internal bodily milieu is also central to how we interpret the world and construct our reality: signals from within the body are critical for not only basic survival, but also a wide range of brain functions from basic perception, emotion, and motivation, to sense of self. In this article, we propose that interoception-the processing of bodily signals-may have implications for a wide range of clinical symptoms in schizophrenia and may thus provide key insights into illness mechanisms. We start with an overview of interoception pathways. Then we provide a review of direct and indirect findings in various interoceptive systems in schizophrenia and interpret these findings in the context of computational frameworks that model interoception as hierarchical Bayesian inference. Finally, we propose a conceptual model of how altered interoceptive inference may contribute to specific schizophrenia symptoms-negative symptoms in particular-and suggest directions for future research, including potential new avenues of treatment.

The relationship between conventional clinical assessments and momentary assessments of symptoms and functioning in schizophrenia spectrum disorders: A systematic review

BACKGROUND

Symptoms and functioning are critical dimensions in those with schizophrenia and are typically measured using validated conventional clinical assessments. Researchers and clinicians have begun to use real-time digital methods, such as ecological momentary assessment (EMA), to assess symptoms and functioning in the moment and outside of traditional hospital and laboratory settings, which may yield more naturalistic data. Although digital methods have advantages, it is unclear whether these momentary assessments capture core aspects of symptoms and functioning.

OBJECTIVE

This systematic literature review aimed to evaluate the association between conventional clinical and momentary-based assessments of functioning and symptoms in individuals with schizophrenia.

METHODS

Studies were included if they met the following criteria: (1) written or translated into English; (2) peer-reviewed; (3) included primary quantitative data; (4) 60% of the clinical sample included persons with schizophrenia spectrum disorders; (5) included a clinical assessment of functioning and/or symptoms; (6) included active momentary assessment and/or passive data; and (7) assessed the relationship between the momentary and conventional clinical assessments.

RESULTS

A total of 49 studies (87 analyses) were included. Conventional clinical assessments of functioning and positive, negative, and depressive symptoms were related to momentary assessments of these symptom domains. Passive data was beneficial for assessing negative symptoms, but research is warranted for other domains.

CONCLUSIONS

The reviewed studies highlight the utility of EMA methodologies to collect detailed data on symptoms and functioning. Such data is being used to develop more sophisticated models of schizophrenia to enhance our understanding of important mechanisms and develop targeted interventions.

Moment-to-moment dynamics between auditory verbal hallucinations and negative affect and the role of beliefs about voices

BACKGROUND

Negative affect (NA) has been suggested to be both an antecedent and a consequence of auditory verbal hallucinations (AVH). Furthermore, negative appraisals of voices have been theorized to contribute to the maintenance of AVH. Using the experience sampling method (ESM), this study examined the bi-directional relationship between NA and AVH, and the moderating effect of negative beliefs about voices.

METHODS

Forty-seven patients diagnosed with schizophrenia spectrum disorders with frequent AVH completed a clinical interview, followed by ESM for 10 times a day over 6 days on an electronic device. Time-lagged analyses were conducted using multilevel regression modeling. Beliefs about voices were assessed at baseline.

RESULTS

A total of 1654 data points were obtained. NA predicted an increase in AVH in the subsequent moment, and AVH predicted an increase in NA in the subsequent moment. Baseline beliefs about voices as malevolent and omnipotent significantly strengthened the association between NA and AVH within the same moment. In addition, the belief of omnipotence was associated with more hallucinatory experiences in the moment following NA. However, beliefs about voices were not associated directly with momentary levels of NA or AVH.

CONCLUSIONS

Experiences of NA and AVH drove each other, forming a feedback loop that maintained the voices. The associations between NA and AVH, either within the same moment or across moments, were exacerbated by negative beliefs about voices. Our results suggest that affect-improving interventions may stop the feedback loop and reduce AVH frequency.

Detecting Abnormal Brain Regions in Schizophrenia Using Structural MRI via Machine Learning

Utilizing neuroimaging and machine learning (ML) to differentiate schizophrenia (SZ) patients from normal controls (NCs) and for detecting abnormal brain regions in schizophrenia has several benefits and can provide a reference for the clinical diagnosis of schizophrenia. In this study, structural magnetic resonance images (sMRIs) from SZ patients and NCs were used for discriminative analysis. This study proposed an ML framework based on coarse-to-fine feature selection. The proposed framework used two-sample t-tests to extract the differences between groups first, then further eliminated the nonrelevant and redundant features with recursive feature elimination (RFE), and finally utilized the support vector machine (SVM) to learn the decision models with selected gray matter (GM) and white matter (WM) features. Previous studies have tended to report differences at the group level instead of at the individual level and cannot be widely applied. The method proposed in this study extends the diagnosis to the individual level and has a higher recognition rate than previous methods. The experimental results of this study demonstrate that the proposed framework distinguishes SZ patients from NCs, with the highest classification accuracy reaching over 85%. The identified biomarkers are also consistent with previous literature findings. As a universal method, the proposed framework can be extended to diagnose other diseases.

The impact of emotion awareness and regulation on psychotic symptoms during daily functioning

Emotion regulation (ER) difficulties are ubiquitous among individuals with schizophrenia and have been hypothesized to contribute to stress sensitivity and exacerbation of psychotic symptoms in this population. However, the evidence supporting this link is equivocal, potentially due to previous studies' reliance on retrospective assessments of ER and psychosis, as well as lack of consideration of putative moderators such as emotion awareness. To address these limitations, we employed experience sampling method using mobile electronic devices to investigate the links between momentary in vivo use of ER strategies (mER), emotion awareness, and psychotic symptoms during daily functioning. Fifty-four individuals with schizophrenia completed assessment of mER and psychotic symptoms, along with traditional retrospective measures of ER and symptoms. Use of mER suppression predicted significant increases in momentary experiences of thought insertion, mind reading, auditory and visual hallucinations. Use of mER reappraisal predicted significant increases in momentary experiences of suspiciousness, thought insertion, and mind reading. Emotion awareness, driven primarily by difficulties identifying feelings, moderated the impact of ER on psychotic symptoms. There were no associations between retrospective measures of ER and symptoms. Our results indicate that, among individuals with schizophrenia, emotion awareness significantly impacts the relationship between use of ER and exacerbations in psychotic symptoms during the course of daily functioning. Our results highlight the need to incorporate emotion awareness and regulation difficulties into the development of treatment models and interventions for psychosis. In addition, our results underscore the need to employ in vivo, high time-resolution assessment methods to study dynamic clinical phenomena such as ER and psychotic symptoms.

What Do People With Schizophrenia Do All Day? Ecological Momentary Assessment of Real-World Functioning in Schizophrenia

Schizophrenia is a major cause of disability worldwide. As new treatments for functioning are tested, the need grows to demonstrate real-world functioning gains. Ecological momentary assessment (EMA) may provide a more ecologically valid measure of functioning. In this study, smartphone-based EMA was used to signal participants with schizophrenia (N = 100) and controls (N = 71) 7 times a day for 7 days to respond to brief questionnaires about social interactions and functioning behaviors. Excellent adherence was found, with both groups completing an average of 85% of surveys and only 3% of participants with schizophrenia excluded for poor adherence. Four-week test-retest reliability was high (r = .83 for total productive behaviors). Relative to controls, participants with schizophrenia reported significantly less total productive activity (d = 1.2), fewer social interactions (d = 0.3), more nonproductive behaviors (d = 1.0; watching TV, resting), and more time at home (d = 0.8). Within the schizophrenia group, participants living independently showed better functioning on EMA relative to participants in supported housing (d = 0.8) and participants engaged in vocational activities showed better functioning than individuals not engaged in vocational activities (d = 0.55). Modest correlations were found between EMA and an in-lab self-report measure of functioning activities performed in the community, but not between EMA and measures of functional capacity or potential. This study demonstrated the feasibility, sensitivity reliability, and validity of EMA methods to assess functioning in schizophrenia. EMA provides a much-needed measure of what individuals with schizophrenia are actually doing in real-world contexts. These results also suggest that there may be important disjunctions between indices of abilities and actual real-world functioning.

Lexical analysis of emotional responses to "real-world" experiences in individuals with schizophrenia

Abnormalities in emotion perception, expression, and experience are considered a core component of schizophrenia. Previous laboratory studies have demonstrated that while individuals with schizophrenia report levels of positive emotions comparable to healthy individuals in response to positive stimuli, they also report co-occurring negative emotions in response to such stimuli. However, it is unknown whether this response pattern extends to "real world" naturalistic environments. To examine this question, we employed an experience sampling method (ESM) approach using mobile electronic devices to collect information up to 10 times/day over a two-day period from 53 individuals with schizophrenia and 19 non-clinical controls. As part of each experience sample, participants completed brief open-ended responses and answered questions about their emotional responses to three recent events (neutral, positive, and negative). Additionally, participants completed diagnostic and clinical measures. Lexical analyses were used to analyze ESM-based word production and characterize emotion word use. Compared to non-clinical controls, individuals with schizophrenia reported similar levels of positive emotion, but significantly higher negative emotion, which was associated with increased negative symptoms. The schizophrenia group used more anxiety words in response to negative and neutral events, and more anger words in response to positive events. Increased use of anger words was linked with elevations in positive symptoms as well as symptoms of depression, while use of sadness words was linked with anhedonia. Our findings support the co-activation of negative emotion hypothesis documented in laboratory settings and provide evidence of its ecological validity. Implications for functioning and future directions are discussed.

Blending active and passive digital technology methods to improve symptom monitoring in early psychosis

AIMS

Psychotic symptoms fluctuate over time and effective and regular monitoring may contribute to relapse prevention and improve long-term outcomes. In this proof-of-concept study we test the feasibility, acceptability and potential usefulness of a novel digital method assessing the association between physiological signals and psychotic symptom distress.

METHODS

Fifteen participants with first episode psychosis were asked to use a self-assessment mobile phone application for psychotic symptom monitoring for 10 days while using a wrist worn device continuously recording heart rate variability (HRV) and electrodermal activity (EDA). We compared physiological activity when participants reported experiencing distressing and non-distressing psychotic symptoms.

RESULTS

Participants completed on average 76% of the mobile phone symptom assessments. When reporting distressing hallucinations and delusions participants had significantly higher EDA levels and non-significant lower HRV values compared to when these symptoms were non-distressing.

CONCLUSIONS

This study provides further evidence linking psychotic symptom's distress, as experienced in everyday life, and autonomic deregulation. This proof-of-concept study may lead to further longer-term efforts to identify relapse biosignatures using automated methods based on passive monitoring. This method may allow for earlier interventions, contribute to improve relapse prevention and reduce symptoms interfering with recovery.

Autonomic arousal during psychosis spectrum experiences: Results from a high resolution ambulatory assessment study over the course of symptom on- and offset

INTRODUCTION

Ecological momentary assessment (EMA) studies show that stressors trigger the onset or increase of psychotic symptoms. These studies, however, predominantly rely on large sampling intervals and self-report assessment. This study aims to identify the autonomic stress-response to psychosis-spectrum experiences by using a one-day high-resolution EMA with continuous skin conductance and heart rate monitoring in a sample with attenuated positive symptoms.

METHODS

Sixty-two participants were equipped with a smartphone and wearable sensors to monitor skin conductance level (SCL) and heart rate variability (HRV) for 24 h. Every 20 min, participants answered questions on current stress, hallucination spectrum experiences (HSE), and paranoia. Sampling intervals were categorized into no event, pre-onset, event, pre-offset, and post-offset phases. We contrasted stress, SCL, and HRV between phases using multilevel regression models of sampling intervals nested in participants.

RESULTS

For paranoia, we found alterations in the autonomic and self-reported stress response prior to the onset that persisted until the episodes had ended. For HSE, we found no effects. Exploratory separate analyses of the different items aggregated into HSE yielded diverging results for intrusive thoughts, perceptual sensitivity, and hallucinations.

CONCLUSION

Physiological parameters are sensitive indicators of the onset of paranoia, which holds implications for preventive mobile interventions. To further explore the autonomic stress-response associated with HSE, further studies of the different HSE are needed.

Identifying psychosis spectrum disorder from experience sampling data using machine learning approaches

The ubiquity of smartphones opened up the possibility of widespread use of the Experience Sampling Method (ESM). The method is used to collect longitudinal data of participants' daily life experiences and is ideal to capture fluctuations in emotions (momentary mental states) as an indicator for later mental ill-health. In this study, ESM data of patients with psychosis spectrum disorder and controls were used to examine daily life emotions and higher order patterns thereof. We attempted to determine whether aggregated ESM data, in which statistical measures represent the distribution and dynamics of the original data, were able to distinguish patients from controls in a predictive modeling framework. Variable importance, recursive feature elimination, and ReliefF methods were used for feature selection. Model training, tuning, and testing were performed in nested cross-validation, based on algorithms such as Random Forests, Support Vector Machines, Gaussian Processes, Logistic Regression, and Neural Networks. ROC analysis was used to post-process these models. Stability of model performance was studied using Monte Carlo simulations. The results provide evidence that patterns in emotion changes can be captured by applying a combination of these techniques. Acceleration in the variables anxious and insecure was particularly successful in adding further predictive power to the models. The best results were achieved by Support Vector Machines with radial kernel (accuracy = 82% and sensitivity = 82%). This proof-of-concept work demonstrates that synergistic machine learning and statistical modeling may be used to harness the power of ESM data in the future.

Feasibility and Acceptability of Using a Mobile Phone App for Characterizing Auditory Verbal Hallucinations in Adolescents With Early-Onset Psychosis: Exploratory Study

Background

Auditory verbal hallucinations (AVH) are the most frequent symptom in early-onset psychosis (EOP) and a risk factor for increased suicide attempts in adolescents. Increased knowledge of AVH characteristics can lead to better prediction of risk and precision of diagnosis and help identify individuals with AVH who need care. As 98% of Norwegian adolescents aged 12 to 16 years own a mobile phone, the use of mobile phone apps in symptom assessment and patient communication is a promising new tool. However, when introducing new technology to patients, their subjective experiences are crucial in identifying risks, further development, and potential integration into clinical care.

Objective

The objective was to explore the feasibility and acceptability of a newly developed mobile phone app in adolescents with EOP by examining compliance with the app and user experiences. Indication of validity was explored by examining associations between AVH dimensions, which were correlated and analyzed.

Methods

Three adolescents with EOP and active AVH were enrolled. Real-time AVH were logged on an iPod touch using the experience sampling method (ESM), for seven or more consecutive days. The app included five dimensions of AVH characteristics and was programmed with five daily notifications. Feasibility and acceptability were examined using the mean response rate of data sampling and by interviewing the participants. Validity was assessed by examining associations between the AVH dimensions using nonparametric correlation analysis and by visual inspection of temporal fluctuations of the AVH dimensions.

Results

One participant was excluded from the statistical analyses but completed the interview and was included in the examination of acceptability. The sampling period of the two participants was mean 12 (SD 6) days with overall completed sampling rate of 74% (SD 30%), indicating adequate to high compliance with the procedure. The user experiences from the interviews clustered into four categories: (1) increased awareness, (2) personal privacy, (3) design and procedure, and (4) usefulness and clinical care. One participant experienced more commenting voices during the sampling period, and all three participants had concerns regarding personal privacy when using electronic devices in symptom assessment. The AVH dimensions of content, control, and influence showed moderate to strong significant correlations with all dimensions (P<.001). Days of data sampling showed weak to moderate correlations with localization (P<.001) and influence (P=.03). Visual inspection indicated that the app was able to capture fluctuations within and across days for all AVH dimensions.

Conclusions

This study demonstrates the value of including patients’ experiences in the development and pilot-testing of new technology. Based on the small sample size, the use of mobile phones with ESM seems feasible for patients with EOP, but the acceptability of using apps should be considered. Further investigation with larger samples is warranted before definitive conclusions are made.

Potential Applications of Digital Technology in Assessment, Treatment, and Self-help for Hallucinations

The field of digital mental health is rapidly expanding with digital tools being used in assessment, intervention, and supporting self-help. The application of digital mental health to hallucinations is, however, at a very early stage. This report from a working group of the International Consortium on Hallucinations Research considers particular synergies between the phenomenon of hallucinations and digital tools that are being developed. Highlighted uses include monitoring and managing intermittently occurring hallucinations in daily life; therapeutic applications of audio and video media including virtual and augmented reality; targeting verbal aspects of hallucinations; and using avatars to represent hallucinatory voices. Although there is a well-established Internet-based peer support network, digital resources for hallucinations have yet to be implemented in routine practice. Implementation may benefit from identifying how to market resources to the broad range of populations who experience hallucinations and identifying sustainable funding models. It is envisaged that digital tools will contribute to improved self-management and service provision for people experiencing hallucinations.