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

Altered cardiac autonomic functioning associates with self-disorders in schizophrenia

Elevated resting heart rate (RHR) and reduced heart rate variability (HRV) are signs of autonomic nervous system dysfunction identified in schizophrenia (SCZ). This dysfunction has been found to manifest prior to the onset of the clinical diagnosis. Yet whether such autonomic dysfunction is associated with vulnerability to schizophrenia remains unknown. This case-control study included recent onset SCZ patients (n = 35) and healthy controls (HC) (n = 33). Patients were scored for self-disorders (SD's) using the EASE manual and all participants underwent a 5-minute resting state electrocardiogram (ECG) recording. Patients were included from outpatient clinics in Denmark. The main measures comprised EASE total scores (SDs), RHR (beats per minute) and three standard HRV measures usually included in testing autonomic nervous system dysfunction: root mean squared of successive differences (RMSSD), standard deviation of normal-to-normal interval (SDNN) and high-frequency/ low frequency ratio (HF/LF). Pearson correlations and linear regression models adjusted for age, sex and medication were used in the SCZ group. The main finding was a positive moderate association between SDs and RHR (r = 0.463; p = 0.005) and a negative association between SDs and HRV (RMSSD) (r = -0.440; p = 0.008) in the SCZ group. Linear regression models found SDs to explain 22 % of the variance of RHR and 19 % in RMSSD. SDs correlated with LF/HF (r = 0.434; p = 0.009), but non-significantly with SDNN. The study provides evidence of an intriguing link between SDs as a susceptibility trait for schizophrenia spectrum disorders and altered cardiac autonomic functioning.

Eight-month intensive meditation-based intervention improves refractory hallucinations and delusions and quality of life in male inpatients with schizophrenia: a randomized controlled trial

AIM

This study investigated the impact of an 8-month daily-guided intensive meditation-based intervention (iMI) on persistent hallucinations/delusions and health-related quality of life (QoL) in male inpatients with schizophrenia with treatment-refractory hallucinations and delusions (TRHDs).

METHODS

A randomized controlled trial assigned 64 male inpatients with schizophrenia and TRHD equally to an 8-month iMI plus general rehabilitation program (GRP) or GRP alone. Assessments were conducted at baseline and the third and eighth months using the Positive and Negative Syndrome Scale (PANSS), 36-Item Short Form-36 (SF-36), and Five Facet Mindfulness Questionnaire (FFMQ). Primary outcomes measured PANSS reduction rates for total score, positive symptoms, and hallucinations/delusions items. Secondary outcomes assessed PANSS, SF-36, and FFMQ scores for psychotic symptoms, health-related QoL, and mindfulness skills, respectively.

RESULTS

In the primary outcome, iMI significantly improved the reduction rates of PANSS total score, positive symptoms, and hallucination/delusion items compared with GRP at both the third and eighth months. Treatment response rates (≥25% reduction) for these measures significantly increased in the iMI group at the eighth month. Concerning secondary outcomes, iMI significantly reduced PANSS total score and hallucination/delusion items, while increasing scores in physical activity and mindfulness skills at both the third and eighth months compared with GRP. These effects were more pronounced with an 8-month intervention compared with a 3-month intervention.

CONCLUSIONS

An iMI benefits patients with TRHDs by reducing persistent hallucinations/delusions and enhancing health-related QoL. Longer iMI duration yields superior treatment outcomes.

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.

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.

Emotion regulation in daily life in early psychosis: The role of contextual appraisals

BACKGROUND

Little is known about whether and how contextual appraisals relate to emotion regulation (ER) strategy use across the ultra-high risk and first episode stages of psychosis. The present study extends previous research by investigating the extent to which different appraisal dimensions of the most negative and positive events of the day are associated with ER strategy use in individuals with ultra-high risk (UHR) and first-episode psychosis (FEP).

METHOD

Sixty-eight UHR individuals and fifty-five FEP individuals filled out an experience sampling evening questionnaire for six consecutive days, in which their appraisal of intensity, importance and perceived control concerning the most negative or positive event of the day, and the ER strategies they deploy in response to these events were measured.

RESULTS

Multilevel mixed effect models showed that intensity appraisal was most closely associated with ER strategy use, as opposed to importance and controllability appraisals. Higher intense negative events were associated with more rumination and social sharing, while less intense negative events were associated with more reappraisal. Higher intense positive events were associated with a greater number of deployed strategies and more efforts in using savoring, expression and social sharing. The UHR and FEP individuals did not significantly differ regarding effects of above-mentioned appraisal dimensions on ER.

CONCLUSIONS

These results provide evidence supporting ER flexibility in early psychosis, and event intensity emerged as the dimension most strongly associated with ER. Future research should better account for other situational factors (such as social context) that might affect ER use in psychosis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Ecological Momentary Assessment Of State Fluctuations In Mindfulness And Symptoms In Psychotic Disorders

Mindfulness skills are a component of many modern cognitive-behavioral therapies that are used to treat a wide range of disorders, including psychotic disorders. While habitual (i.e., trait) mindfulness is associated with clinical outcomes, the effects of momentary (i.e., state) mindfulness are unclear. This is due in part to previous studies using cross-sectional designs relying on trait self-report questionnaires. Although such approaches are invaluable, they lack temporal specificity to evaluate momentary changes and effects of mindfulness. To address these limitations, the current study used ecological momentary assessment (EMA) to evaluate state levels of two mindfulness skills, acceptance and monitoring, and their association with state fluctuations in symptoms. Participants included individuals with affective and non-affective psychotic disorders (PD; n = 49) and healthy controls (CN; n = 53) who completed six days of EMA. Results indicated that the PD group endorsed lower state acceptance than CN; however, the groups did not significantly differ in monitoring. Further, greater state mindfulness skills in both acceptance and monitoring were associated with greater positive affect, reduced negative affect, and reduced negative symptoms. However, participants with a predominantly affective psychosis presentation showed differential effects compared to those with non-affective presentations. These findings suggest that mindfulness training for people with psychotic disorders may benefit from focusing on improving acceptance in order to improve emotional experience and build on existing monitoring skills. Further, mindfulness based psychosocial interventions may offer a novel means of treating negative symptoms in people with PD, which are currently stalled and largely unresponsive to other treatments.

Components of emotion regulation flexibility and psychosis: The association between psychosis-proneness and context sensitivity

OBJECTIVES

Emotion regulation flexibility has been conceptualized as a multi-componential construct involving context sensitivity, repertoire and feedback responsiveness. Psychosis research has yet to incorporate these new developments in the study of emotion regulation. Thus, we sought to advance even further the knowledge on emotion regulation in psychosis by adopting the emotion regulation flexibility approach as proposed by Bonanno and Burton (Perspectives on Psychological Science, 2013, 8, 591).

METHOD

In total, 401 participants completed 4 scales assessing the multi-components of emotion regulation flexibility and psychosis-proneness.

RESULTS

Our results indicated that Context Sensitivity (i.e., Cue Absence) and Feedback Responsiveness (i.e., Evaluation) were associated with psychosis-proneness. Cue absence was specifically associated with the positive dimension, while both Cue Absence and Enhancement ability were associated with the negative dimension.

CONCLUSIONS

Overall, our results suggest that emotional context insensitivity is the most relevant component of regulatory flexibility in the case of psychosis-proneness. Thus, the disruption in this first step of flexible emotion regulation might be already present in those prone to psychosis. Difficulties in decoding appropriately the contextual cues might further disrupt the other steps of emotion regulation contributing to the psychotic (-like) experiences. This study needs replication in clinical and non-clinical samples.

Beliefs About the Uncontrollability and Usefulness of Emotion in the Schizophrenia-Spectrum: Links to Emotion Regulation and Negative Symptoms

Background

Beliefs about the usefulness and controllability of emotions are associated with emotion regulation and psychological distress in the general population. Although individuals with schizophrenia-spectrum disorders evidence emotion regulation abnormalities, it is unclear whether emotional beliefs contribute to these difficulties and their associated poor clinical outcomes.

Methods

Participants included 72 individuals with schizophrenia-spectrum diagnoses (outpatients with schizophrenia n = 38; youth at clinical high-risk for psychosis, n = 34) and healthy controls (CN: n = 61) who completed the Emotional Beliefs Questionnaire, Emotion Regulation Questionnaire, and measures of clinical symptom severity.

Results

Those with schizophrenia-spectrum diagnoses reported believing that emotions were less controllable than CN; however, groups did not differ regarding beliefs about the usefulness of emotion. Greater beliefs of the uncontrollability of emotion were associated with greater use of suppression, less use of reappraisal, and increased negative symptoms. Emotion regulation partially mediated the association between emotional beliefs and negative symptoms.

Conclusions

Individuals in the schizophrenia-spectrum display superordinate beliefs that emotions are uncontrollable. These beliefs may influence emotion regulation strategy selection and success, which contributes to negative symptoms. Findings suggest that beliefs of emotional uncontrollability reflect a novel process related to both emotion regulation and negative symptoms that could be targeted in psychosocial treatments.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10608-023-10357-w.

Emotion regulation and social knowledge in youth at clinical high-risk for psychosis and outpatients with chronic schizophrenia: Associations with functional outcome and negative symptoms

AIM

Previous studies indicate that several aspects of social cognition are associated with poor social and vocational outcome in the chronic phase of psychosis. However, it is less clear whether specific aspects of social cognition are impaired in those at clinical high-risk (CHR) for psychosis and associated with functioning. The current study evaluated two understudied components of social cognition, emotion regulation knowledge and social knowledge, to determine whether CHR and chronic schizophrenia (SZ) samples demonstrated comparable magnitudes of impairment and associations with functioning.

METHODS

Two studies were conducted. Study 1 included n = 98 outpatients with chronic SZ and n = 88 demographically matched healthy controls (CN). Study 2 included 30 CHR and 30 matched CN participants. In both studies, participants completed the emotion management and social management subtests of the Mayer-Salovey-Caruso Emotional Intelligence Test to assess emotion regulation knowledge and social knowledge, respectively. A battery of clinical interviews was also administered, including measures of: role and social functioning, positive symptoms, negative symptoms, disorganization and general symptoms.

RESULTS

Individuals with SZ demonstrated lower emotion management and social management scores than CN participants. CHR demonstrated lower scores in social management than CN but did not display deficits in emotion management. In both studies, reduced social knowledge was associated with worse functioning and negative symptoms.

CONCLUSIONS

Findings indicate that deficits in social knowledge are transphasic across the SZ spectrum, and are associated with clinical functioning. Social knowledge may be a novel treatment target for psychosocial interventions.

Ambulatory audio and video recording for digital phenotyping in schizophrenia: Adherence & data usability

Ambulatory audio and video recording provides a wealth of information which can be used for a broad range of applications, including digital phenotyping, telepsychiatry, and telepsychology. However, these technologies are in their infancy, and guidelines for their use and analysis have yet to be established. The current project used ambulatory assessment data from individuals with schizophrenia (N = 52) and controls (N = 55) over a week to assess factors influencing sufficiency and useability of video and audio data. Logistic multilevel models examined the effect of relevant variables on video provision and video quality. There was no difference by group in video provision or quality. Videos were less likely to be provided later in the study and later in the day. Video quality was lower later in the day, particularly for controls. Participants were more likely to provide videos if alone or at home than in other settings. Black participants were less likely to have analyzable video frames than White participants. These results suggest potential racial disparities in camera technologies and/or facial analysis algorithms. Implications of these findings and recommendations for future study development, such as instructions to provide to participants to optimize video quality, are discussed.