Computerized ambulatory monitoring in psychiatry: a multi-site collaborative study of acceptability, compliance, and reactivity

Contributions of mobile technologies to addiction research

Mobile technologies are revolutionizing the field of mental health, and particular progress has been made in their application to addiction research and treatment. The use of smartphones and other mobile devices has been shown to be feasible with individuals addicted to any of a wide range of substances, with few biases being observed concerning the repeated monitoring of daily life experiences, craving, or substance use. From a methodological point of view, the use of mobile technologies overcomes longstanding limitations of traditional clinical research protocols, including the more accurate assessment of temporal relationships among variables, as well as the reduction in both contextual constraints and discipline-specific methodological isolation. The present article presents a conceptual review of these advances while using illustrations of research applications that are capable of overcoming specific methodological barriers. Finally, a brief review of both the benefits and risks of mobile technology use for the treatment of patients will be addressed.

Mood Influences the Concordance of Subjective and Objective Measures of Sleep Duration in Older Adults

Objective/Background: Sleep plays a central role in maintaining health and cognition. In most epidemiologic studies, sleep is evaluated by self-report questionnaires but several reports suggest that these evaluations might be less accurate than objective measures such as polysomnography or actigraphy. Determinants of the discrepancy between objective and subjective measures remain to be investigated. The aim of this pilot-study was to examine the role of mood states in determining the discrepancy observed between objective and subjective measures of sleep duration in older adults.

Patients/Methods: Objective sleep quantity and quality were recorded by actigraphy in a sample of 45 elderly subjects over at least three consecutive nights. Subjective sleep duration and supplementary data, such as mood status and memory, were evaluated using ecological momentary assessment (EMA).

Results: A significant discrepancy was observed between EMA and actigraphic measures of sleep duration (p < 0.001). The magnitude of this difference was explained by the patient’s mood status (p = 0.020). No association was found between the magnitude of this discrepancy and age, sex, sleep quality or memory performance.

Conclusion: The discrepancy classically observed between objective and subjective measures of sleep duration can be explained by mood status at the time of awakening. These results have potential implications for epidemiologic and clinical studies examining sleep as a risk factor for morbidity or mortality.

Ecological momentary assessment versus standard assessment instruments for measuring mindfulness, depressed mood, and anxiety among older adults

As mobile data capture tools for patient-reported outcomes proliferate in clinical research, a key dimension of measure performance is sensitivity to change. This study compared performance of patient-reported measures of mindfulness, depression, and anxiety symptoms using traditional paper-and-pencil forms versus real-time, ambulatory measurement of symptoms via ecological momentary assessment (EMA). Sixty-seven emotionally distressed older adults completed paper-and-pencil measures of mindfulness, depression, and anxiety along with two weeks of identical items reported during ambulatory monitoring via EMA before and after participation in a randomized trial of Mindfulness-Based Stress Reduction (MBSR) or a health education intervention. We calculated effect sizes for these measures across both measurement approaches and estimated the Number-Needed-to-Treat (NNT) in both measurement conditions. Study outcomes greatly differed depending on which measurement method was used. When EMA was used to measure clinical symptoms, older adults who participated in the MBSR intervention had significantly higher mindfulness and significantly lower depression and anxiety than participants in the health education intervention at post-treatment. However, these significant changes in symptoms were not found when outcomes were measured with paper-and-pencil measures. The NNT for mindfulness and depression measures administered through EMA were approximately 25-50% lower than NNTs derived from paper-and-pencil administration. Sensitivity to change in anxiety was similar across administration modes. In conclusion, EMA measures of depression and mindfulness substantially outperformed paper-and-pencil measures with the same items. The additional resources associated with EMA in clinical trials would seem to be offset by its greater sensitivity to detect change in key outcome variables.

Data quality indicators for daily life chart methodology: prospective self-ratings of bipolar disorder and alcohol use

Background

Self-rating instruments which require a large number of repeated assessments over time are increasingly popular in psychiatry. They are well suited to describing variations in mental states, especially in order to investigate effects of behaviour and events on functioning and mood. For bipolar disorder, the self-rating instrument ‘NIMH daily life chart’ was developed to assess the course of the illness. This instrument has been validated in the customary ways, yet information about data quality (e.g. completeness, consistency, construct validity, reactivity) was lacking. The goal of this study was to develop several data quality indicators computed from data, in order to be able to detect respondents that provide less valid or reliable data.

Methods

During approximately 1 year on average, 137 patients with DSM-IV diagnosed bipolar disorder rated their mood, functioning and number of alcohol units consumed on a daily basis. Three kinds of quality indicators were developed: (1) compliance (i.e. completeness of recording on a daily basis), (2) the association between conceptually related variables—construct validity—and (3) reactivity: any changes in alcohol-drinking behaviour due to the assessments themselves. Relations were measured with Spearman’s rho.

Results

A relation was found between data quality and illness severity: respondents with lower data quality, according to our operationalisations, were more strongly affected by the illness, as expressed in the number of ill days, than respondents with higher data quality.

Conclusion

The more affected patients are by the illness, the lower the data quality to be expected in life chart reports.

A risk factor analysis of accumulated postoperative pain and swelling sensation after dental implant surgery using a cellular phone-based real-time assessment

PURPOSE

The purpose of this study was to identify the related risk factors of dental implant accumulated postoperative pain and swelling by cellular phone-based assessment.

METHODS

Subjects were a consecutive series of patients who received oral implant surgery at Okayama University Hospital. Cellular phone-based questionnaire was sent at pre-set schedule to each subject every 2h on the day of surgery, and every 24h from the 2nd to 7th day post-surgery. Subjects replied in real-time the pain and swelling levels at the operated sites by an 11- and 4-grade rating-scale questionnaire. Overall intensity of individual pain and swelling was calculated by means of area under curve that drew by their time-dependent changes. Predictor variables were age, gender, presence of diabetes mellitus and/or hypertension (DM/HT), history of implant surgery, number of inserted implants, flap operation, surgical duration, pre-surgery anxiety, osteoplasty, bone quality, premedication, dosage of prescribed analgesics and local anesthesia and accumulated postoperative pain/swelling. Compliance rate and risk factors correlated with accumulated postoperative pain and swelling were calculated by multiple regression analysis.

RESULTS

Final subjects were 18 females and 7 male (mean age: 59.3±7.32 yrs). Significant factors correlated with accumulated postoperative pain were DM/HT, surgical duration, premedication, bone quality, pre-surgery anxiety and postoperative swelling (R(2)=0.769, p=0.001, 0.013, 0.032, 0.007, 0.035 and 0.007, respectively). Meanwhile, significant factors associated with postoperative swelling were postoperative pain, DM/HT and bone quality (R(2)=0.365, p=0.002, 0.004, 0.008, respectively).

CONCLUSION

These results suggested DM/HT and bone quality are correlated to overall intensity of postoperative pain and swelling.

The feasibility of using electronic clinical outcome assessments in people with schizophrenia and their informal caregivers

Many clinical outcome assessments (COAs) were originally developed for completion via pen and paper. However, in recent years there have been movements toward electronic capture of such data in an effort to reduce missing data, provide time-stamped records, minimize administrative burden, and avoid secondary data entry errors. Although established in many patient populations, the implications of using electronic COAs in schizophrenia are unknown. In accordance with International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Task Force recommendations, in-depth cognitive debriefing and usability interviews were conducted with people with schizophrenia (n=12), their informal (unpaid) caregivers (n=12), and research support staff (n=6) to assess the suitability of administration of various electronic COA measures using an electronic tablet device. Minimal issues were encountered by participants when completing or administering the COAs in electronic format, with many finding it easier to complete instruments in this mode than by pen and paper. The majority of issues reported were specific to the device functionality rather than the electronic mode of administration. Findings support data collection via electronic tablet in people with schizophrenia and their caregivers. The appropriateness of other forms of electronic data capture (eg, smartphones, interactive voice response systems, etc) is a topic for future investigation.

Mobile technologies in the early detection of cognitive decline

The identification of biological and pathophysiological processes implicated in different forms of dementia is itself dependent on reliable descriptions of cognitive performance and capacities. However, traditional instruments are often unable to detect subtle declines in cognitive functions due to natural variation at the time of testing. Mobile technologies permit the repeated assessment of cognitive functions and may thereby provide more reliable descriptions of early cognitive difficulties that are inaccessible to clinic or hospital-based instruments. This assessment strategy is also able to characterize in real-time the dynamic associations between cognitive performance and specific daily life behaviors or activities. In a cohort of elderly rural residents, 60 individuals were administered neuropsychological and neuroimaging exams as well as a one-week period of electronic ambulatory monitoring of behavior, semantic memory performance, and daily life experiences. Whereas imaging markers were unrelated to traditional neuropsychological test scores, they were significantly associated with mobile assessments of semantic memory performance. Moreover, certain daily life activities such as reading or completing crossword puzzles were associated with increases in semantic memory performance over the subsequent hours of the same day. The revolution in mobile technologies provides unprecedented opportunities to overcome the barriers of time and context that characterize traditional hospital and clinical-based assessments. The combination of both novel and traditional methods should provide the best opportunity for identifying the earliest risk factors and biomarkers for Alzheimer's disease and other forms of dementia.

Feasibility and validity of ecological momentary assessment in the investigation of suicide risk

Ecological Momentary Assessment has been used to investigate a wide range of behaviors and psychiatric conditions. Previous investigations have consistently obtained promising results with high acceptance and compliance rates, and with only minor reactive effects for specific variables. Despite the promise of this methodology for the study of severe psychiatric populations, little is known about its feasibility in samples at risk for suicide. In the present study, four samples at varying risk for suicide completed an Ecological Momentary Assessment study by responding to five electronic assessments per day over a one-week period. Samples included healthy controls (n=13), affective controls (n=21), past suicide attempters (n=20), and recent suicide attempters (n=42). The results demonstrate satisfactory participation rates and high compliance with daily life repeated assessments across all groups. Importantly, negative thoughts or suicidal ideation were not reactive to the duration of the study, indicating that the repeated assessment of such cognitions in daily life have little or no effect on their frequency. The findings provide support for the use of Ecological Momentary Assessment in the study of suicidal ideation and suggest that mobile technologies represent new opportunities for the assessment of high-risk cognitive states experienced by patients in daily life.

Experience sampling and ecological momentary assessment for studying the daily lives of patients with anxiety disorders: a systematic review

Anxiety disorders are highly prevalent. Symptoms may occur unpredictably (e.g., panic attacks) or predictably in specific situations (e.g., social phobia). Consequently, it may be difficult to assess anxiety and related constructs realistically in the laboratory or by traditional retrospective questionnaires. Experience sampling methods (ESM) and ecological momentary assessment (EMA) can deepen the understanding of the course of anxiety disorders by frequently assessing symptoms and other variables in the natural environment. We review 34 ESM/EMA studies on adult panic disorder, generalized anxiety disorder, social phobia, post-traumatic stress disorder, and obsessive-compulsive disorder, as well as anxiety disorders in youth. Benefits of ESM/EMA for the study of anxiety disorders include generating insight into the temporal variability of symptoms and into the associations among daily affect, behaviors, and situational cues. Further, ESM/EMA has been successfully combined with ambulatory assessment of physiological variables and with treatment evaluations. We provide suggestions for future research, as well as for clinical applications.

Do people with schizophrenia have difficulty anticipating pleasure, engaging in effortful behavior, or both?

Motivation deficits are common in schizophrenia, but little is known about underlying mechanisms, or the specific goals that people with schizophrenia set in daily life. Using neurobiological heuristics of pleasure anticipation and effort assessment, we examined the quality of activities and goals of 47 people with and 41 people without schizophrenia, utilizing ecological momentary assessment. Participants were provided cell phones and called 4 times a day for 7 days, and were asked about their current activities and anticipation of upcoming goals. Activities and goals were later coded by independent raters on pleasure and effort. In line with recent laboratory findings on effort computation deficits in schizophrenia, relative to healthy participants, people with schizophrenia reported engaging in less effortful activities and setting less effortful goals, which were related to patient functioning. In addition, patients showed some inaccuracy in estimating how difficult an effortful goal would be, which in turn was associated with lower neurocognition. In contrast to previous research, people with schizophrenia engaged in activities and set goals that were more pleasure-based, and anticipated goals as being more pleasurable than controls. Thus, this study provided evidence for difficulty with effortful behavior and not anticipation of pleasure. These findings may have psychosocial treatment implications, focusing on effort assessment or effort expenditure. For example, to help people with schizophrenia engage in more meaningful goal pursuits, treatment providers may leverage low-effort pleasurable goals by helping patients to break down larger, more complex goals into smaller, lower-effort steps that are associated with specific pleasurable rewards.

Use of mobile assessment technologies in inpatient psychiatric settings

Mobile electronic devices (i.e., PDAs, cellphones) have been used successfully as part of research studies of individuals with severe mental illness living in the community. More recently, efforts have been made to incorporate such technologies into outpatient treatments. However, few attempts have been made to date to employ such mobile devices among hospitalized psychiatric patients. In this article, we evaluate the potential use of such devices in inpatient psychiatric settings using 33 hospitalized patients with schizophrenia. Employing an Experience Sampling Method approach, we provide support for the feasibility of using such devices, along with examples of potentially clinically-relevant information that can be obtained using such technologies, including assessment of fluctuations in the severity of psychotic symptoms and negative mood in relation to social context, unit location, and time of day. Following these examples, we discuss issues related to the potential use of mobile electronic devices by patients hospitalized at inpatient psychiatric settings including issues related to patients' compliance, assessment schedules, questionnaire development, confidentiality issues, as well as selection of appropriate software/hardware. Finally, we delineate some issues and areas of inquiry requiring additional research and development.

Daily life functioning of community-dwelling elderly couples: an investigation of the feasibility and validity of Ecological Momentary Assessment

Although ambulatory data collection techniques have been used in elderly populations, their feasibility and validity amongst elderly individuals with cognitive impairment and amongst couples remains unexplored. The main objective of this study is to examine the validity of Ecological Momentary Assessment (EMA) in elderly persons with or without cognitive impairment and their spouses. The sample included 58 retired farmers (mean 77.3 years, standard deviation [SD] 5.5) with or without cognitive impairment, recruited within a French cohort and 60 spouses (mean 73.4 years, SD 6.9). The presence of cognitive impairment determining by a panel of specialized neurologists permitted to define two groups: "The Cognitive Impairment Group" and "The Control Group". EMA procedures consisted of repeated telephone interviews five times per day during four days for each spouse. Our results demonstrate the validity of EMA procedures through a 92.1% level of compliance, the absence of fatigue effects, and the lack of evidence for major reactivity to the methods. However, the specificity of our sample may explain the acceptance (42%) and response (75%) rates and may reduce the generalizability of the results to the general population of elderly individuals. Finally, the validation of such techniques may contribute to future research examining community-dwelling elderly individuals and their spouses.

Cross-species approaches to pathological gambling: a review targeting sex differences, adolescent vulnerability and ecological validity of research tools

Decision-making plays a pivotal role in daily life as impairments in processes underlying decision-making often lead to an inability to make profitable long-term decisions. As a case in point, pathological gamblers continue gambling despite the fact that this disrupts their personal, professional or financial life. The prevalence of pathological gambling will likely increase in the coming years due to expanding possibilities of on-line gambling through the Internet and increasing liberal attitudes towards gambling. It therefore represents a growing concern for society. Both human and animal studies rapidly advance our knowledge on brain-behaviour processes relevant for understanding normal and pathological gambling behaviour. Here, we review in humans and animals three features of pathological gambling which hitherto have received relatively little attention: (1) sex differences in (the development of) pathological gambling, (2) adolescence as a (putative) sensitive period for (developing) pathological gambling and (3) avenues for improving ecological validity of research tools. Based on these issues we also discuss how research in humans and animals may be brought in line to maximize translational research opportunities.

Social modulation of decision-making: a cross-species review

Taking decisions plays a pivotal role in daily life and comprises a complex process of assessing and weighing short-term and long-term costs and benefits of competing actions. Decision-making has been shown to be affected by factors such as sex, age, genotype, and personality. Importantly, also the social environment affects decisions, both via social interactions (e.g., social learning, cooperation and competition) and social stress effects. Although everyone is aware of this social modulating role on daily life decisions, this has thus far only scarcely been investigated in human and animal studies. Furthermore, neuroscientific studies rarely discuss social influence on decision-making from a functional perspective such as done in behavioral ecology studies. Therefore, the first aim of this article is to review the available data of the influence of the social context on decision-making both from a causal and functional perspective, drawing on animal and human studies. Also, there is currently still a gap between decision-making in real life where influences of the social environment are extensive, and decision-making as measured in the laboratory, which is often done without any (deliberate) social influences. However, methods are being developed to bridge this gap. Therefore, the second aim of this review is to discuss these methods and ways in which this gap can be increasingly narrowed. We end this review by formulating future research questions.

Ecological Momentary Assessment of social functioning in schizophrenia: impact of performance appraisals and affect on social interactions

Research concerning the complex interplay between factors that contribute to poor social functioning in schizophrenia has been hampered by limitations of traditional measures, most notably the ecological validity and accuracy of retrospective self-report and interview measures. Computerized Ecological Momentary Assessment (EMAc) permits the real-time assessment of relationships between daily life experiences, thoughts, feelings, and behaviors. In the current study, EMAc was used to record daily social interactions, subjective performance appraisals of these interactions (e.g., "I succeeded/failed"; "I was liked/rejected"), and affect in 145 individuals with schizophrenia or schizoaffective disorder. Participants completed electronic questionnaires on a personal digital assistant (PDA) four times per day for one week. Time-lagged multilevel modeling of the data revealed that more positive interaction appraisals at any point in a day were associated with greater positive affect which, in turn, was a strong predictor of more social interactions over subsequent hours. Social functioning, therefore, was linked to positive performance beliefs about social interactions that were associated with greater positive affect. The findings suggest a useful treatment target for cognitive behavioral therapy and other psychosocial interventions that can be used to challenge defeatist beliefs and increase positive affect to enhance social functioning in schizophrenia.

Ecological momentary assessment in alcohol, tobacco, cannabis and opiate dependence: a comparison of feasibility and validity

BACKGROUND

Despite growing use of computerized ambulatory monitoring in substance dependence research, little is known about the comparative feasibility and validity of these novel methods by substance type. This study compares the feasibility and validity of computerized ambulatory monitoring in outpatients seeking treatment for alcohol, tobacco, cannabis or opiate dependence.

METHODS

A total of 109 participants were recruited from an outpatient treatment center and completed standard clinical instruments followed by 2 weeks of computerized ambulatory monitoring of daily life experiences and substance use.

RESULTS

Individuals with cannabis dependence had the lowest rates of study acceptance (31%) as well as compliance with the repeated electronic interviews (79.9%), while those with tobacco dependence had the highest rates (62% and 91.0%, respectively). Concurrent validity was found between scores from standard clinical instruments and similar constructs assessed in daily life, with no difference by substance group. While no fatigue effects were detected, change in some variables was observed as a function of time in the study.

CONCLUSIONS

Computerized ambulatory protocols are feasible and provide valid data in individuals with diverse forms of dependence, but compliance to repeated sampling methodology may vary by substance type.

A critical review of sex differences in decision-making tasks: focus on the Iowa Gambling Task

It has been observed that men and women show performance differences in the Iowa Gambling Task (IGT), a task of decision-making in which subjects through exploration learn to differentiate long-term advantageous from long-term disadvantageous decks of cards: men choose more cards from the long-term advantageous decks than women within the standard number of 100 trials. Here, we aim at discussing psychological mechanisms and neurobiological substrates underlying sex differences in IGT-like decision-making. Our review suggests that women focus on both win-loss frequencies and long-term pay-off of decks, while men focus on long-term pay-off. Furthermore, women may be more sensitive to occasional losses in the long-term advantageous decks than men. As a consequence hereof, women need 40-60 trials in addition before they reach the same level of performance as men. These performance differences are related to differences in activity in the orbitofrontal cortex and dorsolateral prefrontal cortex as well as in serotonergic activity and left-right hemispheric activity. Sex differences in orbitofrontal cortex activity may be due to organisational effects of gonadal hormones early in life. The behavioural and neurobiological differences in the IGT between men and women are an expression of more general sex differences in the regulation of emotions. We discuss these findings in the context of sex differences in information processing related to evolutionary processes. Furthermore we discuss the relationship between these findings and real world decision-making.

Predicting the occurrence, conviction, distress, and disruption of different delusional experiences in the daily life of people with schizophrenia

Recent research has shown that negative emotional states of increased anxiety and sadness prospectively predict the occurrence of persecutory ideation, but it is not known whether these findings extend to other subtypes of delusions. The current study explored whether these negative emotional states, as well as hallucinations, biased reasoning style (ie, jumping to conclusions), and negative self-esteem prospectively predict the occurrence and various dimensions of delusions of control, reference, and grandiosity in real time, as they occur in daily life. One hundred and thirty community-dwelling participants with schizophrenia or schizoaffective disorder completed laboratory measures and momentary self-reports generated by a personal digital assistant multiple times per day, over 7 consecutive days. Analyses were time lagged allowing simultaneous examination of person-level and within-person time-varying relationships among the variables. Approximately, half of the participants reported having at least one delusional experience during the week, and approximately, a quarter of those individuals reported experiencing all 3 delusion subtypes. Hallucinations were a significant predictor of the occurrence of delusions of control and reference over the subsequent hours of the same day, but negative emotional states of anxiety and sadness were not. Negative self-esteem predicted the frequency of all 3 delusion subtypes during the week, and a reasoning style characterized by reduced information gathering was a significant predictor of the frequency of delusions of control. Delusional dimensions of conviction, distress, and disruption had different associations with the variables tested for each delusion subtype.

Mobile assessment guide for research in schizophrenia and severe mental disorders

Mobile assessment techniques have been used for nearly 3 decades in mental health research, including in investigations of individuals with schizophrenia and other severe disorders. This article reviews the benefits of these data collection strategies relative to traditional self-report or clinician-administered measures administered in hospital or laboratory settings. A detailed discussion of the technical decisions facing researchers in the field is then presented, covering study design issues, questionnaire content development, and choices in hardware and software selection. Following these points, sample recruitment and retention strategies are discussed, as well as the main statistical issues that are necessary to consider in the exploitation of repeated measures data generated by this methodology.

Mobile Assessment and Treatment for Schizophrenia (MATS): a pilot trial of an interactive text-messaging intervention for medication adherence, socialization, and auditory hallucinations

Mobile Assessment and Treatment for Schizophrenia (MATS) employs ambulatory monitoring methods and cognitive behavioral therapy interventions to assess and improve outcomes in consumers with schizophrenia through mobile phone text messaging. Three MATS interventions were developed to target medication adherence, socialization, and auditory hallucinations. Participants received up to 840 text messages over a 12-week intervention period. Fifty-five consumers with schizophrenia or schizoaffective disorder were enrolled, but 13 consumers with more severe negative symptoms, lower functioning, and lower premorbid IQ did not complete the intervention, despite repeated prompting and training. For completers, the average valid response rate for 216 outcome assessment questions over the 12-week period was 86%, and 86% of phones were returned undamaged. Medication adherence improved significantly, but only for individuals who were living independently. Number of social interactions increased significantly and a significant reduction in severity of hallucinations was found. In addition, the probability of endorsing attitudes that could interfere with improvement in these outcomes was also significantly reduced in MATS. Lab-based assessments of more general symptoms and functioning did not change significantly. This pilot study demonstrated that low-intensity text-messaging interventions like MATS are feasible and effective interventions to improve several important outcomes, especially for higher functioning consumers with schizophrenia.

Mobile assessment in schizophrenia: a data-driven momentary approach

In this article, a data-driven approach was adopted to demonstrate how real-life diary techniques [ie, the experience sampling method (ESM)] could be deployed for assessment purposes in patients with psychotic disorder, delivering individualized and clinically relevant information. The dataset included patients in an acute phase of psychosis and the focus was on paranoia as one of the main psychotic symptoms (30 patients with high levels of paranoia and 34 with low levels of paranoia). Based on individual cases, it was demonstrated how (1) symptom and mood patterns, (2) patterns of social interactions or activities, (3) contextual risk profiles (eg, is being among strangers, as opposed to family, associated with higher paranoia severity?), and (4) temporal dynamics between mood states and paranoia (eg, does anxiety precipitate or follow the onset of increased paranoia severity?) substantially differ within individual patients and across the high vs low paranoid patient group. Most striking, it was shown that individual findings are different from what is found on overall group levels. Some people stay anxious after a paranoid thought came to mind. For others, paranoia is followed by a state of relaxation. It is discussed how ESM, surfacing the patient's implicit knowledge about symptom patterns, may provide an excellent starting point for person-tailored psychoeducation and for choosing the most applicable therapeutic intervention.

Anticipatory Anxiety as a Function of Panic Attacks and Panic-Related Self-Efficacy: An Ambulatory Assessment Study in Panic Disorder

Background: Panic attacks and anticipatory anxiety are considered to be inter-correlated, yet distinctive, features of panic disorder, both contributing to its onset and maintenance as well as to the associated impairment. Given the difficulty to yield ecologically valid data on these fluctuating symptoms the natural course of anticipatory anxiety and its correlates have seldom been addressed with adequate methods. Aims: The current study aimed at further exploring the natural variance of anticipatory anxiety and its interdependence with panic-related variables. In addition, impact of anxiety sensitivity, and perceived ability to cope with panic on the relation between panic attacks and subsequent anxiety was inspected. Method: Based on an Ecological Momentary Assessment approach, 21 patients with panic disorder rated study variables continuously over one week; 549 question sets were completed. Results: Anticipatory anxiety followed a diurnal pattern and was associated with situational and internal variables typically linked to panic experiences. Preceding panic attacks intensified anticipatory anxiety and associated negative emotional states; however, perceived ability to cope attenuated these effects. Conclusion: Based on natural observation data, results largely support the importance of cognitive appraisals for anticipatory anxiety, and its interplay with panic attacks as it has been suggested by cognitive theory and recent findings in extinction learning research.

Temporal patterns of anxious and depressed mood in generalized anxiety disorder: a daily diary study

Research suggests that anxiety disorders tend to temporally precede depressive disorders, a finding potentially relevant to understanding comorbidity. The current study used diary methods to determine whether daily anxious mood also temporally precedes daily depressed mood. 55 participants with generalized anxiety disorder (GAD) and history of depressive symptoms completed a 21-day daily diary tracking anxious and depressed mood. Daily anxious and depressed moods were concurrently associated. Daily anxious mood predicted later depressed mood at a variety of time lags, with significance peaking at a two-day lag. Depressed mood generally did not predict later anxious mood. Results suggest that the temporal antecedence of anxiety over depression extends to daily symptoms in GAD. Implications for the refinement of comorbidity models, including causal theories, are discussed.

Individual vulnerability to addiction

The process of addiction is often studied in the neurosciences as a function of the quantity or type of substance consumed, with the ultimate goal of counteracting these effects by other pharmacological means. However, epidemiology and clinical research have extensively demonstrated that most individuals who use drugs do not develop dependence. Numerous factors may explain an individual's propensity to addiction. This review discusses these paradigms and summarizes research on individual differences that encompass cultural and sociodemographic factors, psychiatric or psychological vulnerability, and biological or genetic propensity to addiction. Although these different factors often interact in the expression of vulnerable phenotypes, it is possible to alter or control specific sources of vulnerability. For these reasons, integrating individual vulnerability to addiction across different research disciplines is likely to provide the greatest advances for intervention and prevention efforts.

Real-time electronic ambulatory monitoring of substance use and symptom expression in schizophrenia

OBJECTIVE

Despite evidence demonstrating elevated comorbidity between schizophrenia and substance use disorders, the underlying mechanisms of association remain poorly understood. The brief time intervals that characterize interactions between substance use and psychotic symptoms in daily life are inaccessible to standard research protocols. The authors used electronic personal digital assistants (PDAs) to examine the temporal association of diverse forms of substance use with psychotic symptoms and psychological states in natural contexts.

METHOD

Of 199 community-dwelling individuals with schizophrenia or schizoaffective disorder who were contacted to participate in the study, 92% accepted and 73% completed the study. The 145 participants who completed the study provided reports of substance use, psychotic symptoms, mood, and event negativity multiple times per day over 7 consecutive days through PDAs.

RESULTS

Participants responded to 72% of the electronic interviews (N=2,737) across daily life contexts. Strong within-day prospective associations were observed in both directions between substance use and negative psychological states or psychotic symptoms, but considerable variation was observed by substance type. Consistent with the notion of self-medication, alcohol use was most likely to follow increases in anxious mood or psychotic symptoms. Cannabis and other illicit substances, demonstrating more complex patterns, were more likely to follow certain psychological states but were also associated with the later onset of psychotic symptoms.

CONCLUSIONS

The dynamic interplay of substance use and psychotic symptoms is in many cases consistent with both causal and self-medication mechanisms, and these patterns of association should be considered in the design of treatment and prevention strategies.

Experience sampling research in individuals with mental illness: reflections and guidance

OBJECTIVE

The experience sampling method (ESM) represents a valuable way of assessing clinical phenomena in real world settings and across time. Despite its theoretical advantages, using this methodology in psychiatric populations is challenging. This paper acts as a guide to researchers wishing to employ this approach when investigating mental illness.

METHOD

The contents represent the opinions of researchers around the United Kingdom and the Netherlands who are experienced at using the ESM.

RESULTS

In ESM studies, participants are required to fill in questions about their current thoughts, feelings and experiences when prompted by an electronic device (e.g. a wristwatch, PDA). Entries are typically made at fixed or random intervals over 6 days. This article outlines how to design and validate an ESM diary. We then discuss which sampling procedure to use and how to increase compliance through effective briefing and telephone sessions. Debriefing, data management and analytical issues are considered, before suggestions for future clinical uses of the ESM are made.

CONCLUSION

The last decade has seen an increase in the number of studies employing the ESM in clinical research. Further research is needed to examine the optimal equipment and procedure for different clinical groups.

Mood reactivity to daily events in patients with remitted bipolar disorder

Information about mood reactions to naturally occurring stress in remitted bipolar patients may help elucidate the mechanism by which stressors influence the propensity to manic or depressive relapse in these patients. Using the experience sampling method (ESM), we therefore investigated negative and positive mood states and their reactivity to daily hassles and uplifts in 38 outpatients with remitted bipolar disorder and 38 healthy volunteers. Multilevel regression analyses confirmed that mean levels of negative affect (NA) were higher and positive affect (PA) lower in bipolar patients. Reactivity of NA and PA to hassles and uplifts in bipolar patients was similar to controls and was unrelated to the number of previous episodes. Bipolar patients with subsyndromal depressive symptoms, however, showed particularly large NA responses to daily hassles, which they also rated as more stressful. Subsyndromal depressive symptoms in patients with remitted bipolar disorder thus appear to increase sensitivity to everyday stressors.

Computerized ambulatory monitoring in mood disorders: feasibility, compliance, and reactivity

Patients with depression (n=20) or bipolar disorder (n=21) completed computerized ambulatory monitoring for three consecutive days. Results indicate satisfactory rates of acceptance and compliance, with no salient fatigue effects. However, some evidence for reactive effects was found. The findings provide support for this approach in the study of mood disorders.