S.04.01 - Monitoring the dynamics of real life psychopathology using ambulatory assessment

Abstract

Real-time mobile smartphone sampling of psychopathological symptoms and behaviour, sometimes also called Ambulatory Assessment [1], has become more and more popular in psychiatric research. This method offers three key advantages: real time assessment, real life assessment and the perspective on within-subject processes/mechanisms. Real time assessment eliminates retrospective biases. Real life assessment enables to investigate symptomatology in the most important context: the everyday life´s of our patients. The within-subject perspective offers the possibility to elucidate psychopathological mechanisms in everyday life. According to current research, the dynamics of affective states and the intentional regulation of emotions are even more important to psychological health and maladjustment, than the affective states itself. However, capturing the ebb and flow in everyday life is not trivial. Recent technical developments resulted in both fancy hardware to collect data in everyday life and powerful data modelling techniques to analyze it. All three advantages come with the promise of increasing validity and reliability and therewith decreasing costs and sample size for future studies. In my talk, I will focus on four examples of Ambulatory Assessment to illustrate opportunities in psychopathology research: a) utilizing high frequency data assessment to model affective dynamics in borderline personality disorder, b) using location-triggered e-diaries to investigate the relation between stress-reactivity and environmental components, which are presumed to be relevant for the development of schizophrenia, c) monitoring physical activity and telecommunication behaviour to predict upcoming episodes in bipolar patients, and d) using Ambulatory Assessment Intervention as a strategy for monitoring and coaching chronobiology and physical activity in ADHD and comorbid conditions. a) Affective instability is hypothesized to be the core pathology in patients with borderline personality disorder (BPD) and the ICD-10 even lists BPD under the category of emotionally unstable personality disorders. Surprisingly, recent work using e-diaries to assess affect over time did not reveal affective instability as a disorder-specific mechanism, as other disorders did impress by similar instability [2]. Accordingly, it has been hypothesized that statically modeling the dynamic interplay between affect and self-esteem is necessary to discriminate between transdiagnostic and disorder-specific mechanisms [3]. Using statistical models which allow decomposing random from true variability, modeling multiple subcomponents of affective processes at the same time, and modeling between-subject and group-specific differences in affective response and regulation processes in 90 patients with BPD and 90 healthy controls, we could reveal specific time based processes of affective instability and self-esteem instability in predicting self-mutilating behavior in patients with BPD. b) Psychiatric research is increasingly interested in the influence of social and environmental contexts on human health. According to recent findings, specific impacts of urban upbringing on neural social stress processing relate to the heightened prevalence of mental disorders, like schizophrenia, in cities [4]. Although this is a major societal problem, it still remains unknown which environmental components (e.g. psychosocial stressors, air pollutants, rare nature experience) are responsible. We use GPS-triggered e-diaries on smartphones to trace participants’ [5], therewith assessing both momentary mental states and exposure to environmental risk and resilience factors. In an ongoing longitudinal study [5], we combine real life psychopathology tracking using ambulatory assessment with functional magnetic resonance imaging and epigenetic approaches to investigate the most relevant environmental factors influencing mental health. c) Smartphone monitoring of mood and behavior-related parameters, like communication, physical activity and sleep, is a promising approach to detect early warning signs in the course of bipolar disorders and to prevent new illness episodes. We monitored communication habits such as length of calls, number of dialed contacts, number and length of messages, furthermore overall activity like smartphone usage, steps and travelled distance, as well as sleep, using end-of-the-day e-diaries, in 30 out-patient participants with bipolar disorder during 356 days, each. Psychopathological interviews for assessing current (hypo-)manic, depressive and euthymic states took place every two weeks. Data analyses revealed substantial associations between psychopathological states and smartphone behaviour. In an ongoing randomized multi-center, observer-blind trial, we test whether smartphone based automated feedback can effectively prolong states of euthymia and prevent hospitalization. d) To illustrate emerging opportunities using Ambulatory Assessment Intervention, I will report an ongoing study where we combine classical Ambulatory Assessment with an intervention component in patients with ADHD. We developed an m-Health system comprising of a smartphone and an activity sensor on the wrist. The smartphone delivers homework reminders, exercise interventions via video clips, and monitors treatment compliance. Feedback on performed treatment parameters is processed in real time, is generated automatically and is sent back to the participant´s smartphone to improve motivation and compliance. I will conclude my talk on specifying disadvantages and pitfalls of Ambulatory Assessment. In conclusion, Ambulatory Assessment does offer a wealth of methodological approaches to enhance the understanding of psychopathological symptoms in the most important context: the daily life´s of our patients.