The exploratory value of cross-sectional partial correlation networks:Predicting relationships between change trajectories in borderline personality disorder

OBJECTIVE: Within the network approach to psychopathology, cross-sectional partial correlation networks have frequently been used to estimate relationships between symptoms. The resulting relationships have been used to generate hypotheses about causal links between symptoms. In order to justify such exploratory use of partial correlation networks, one needs to assume that the between-subjects relationships in the network approximate systematic within-subjects relationships, which are in turn the results of some within-subjects causal mechanism. If this assumption holds, relationships in the network should be mirrored by relationships between symptom changes; if links in networks approximate systematic within-subject relationships, change in a symptom should relate to change in connected symptoms. METHOD: To investigate this implication, we combined longitudinal data on the Borderline Personality Disorder Severity Index from four samples of borderline personality disorder patients (N = 683). We related parameters from baseline partial correlation networks of symptoms to relationships between change trajectories of these symptoms. RESULTS: Across multiple levels of analysis, our results showed that parameters from baseline partial correlation networks are strongly predictive of relationships between change trajectories. CONCLUSIONS: By confirming its implication, our results support the idea that cross-sectional partial correlation networks hold a relevant amount of information about systematic within-subjects relationships and thereby have exploratory value to generate hypotheses about the causal dynamics between symptoms

Using person-specific networks in psychotherapy:challenges, limitations, and how we could use them anyway

Background The complexity of psychopathology is evident from its multifactorial etiology and diversity of symptom profiles and hampers effective treatment. In psychotherapy, therapists approach this complexity by using case conceptualization. During this process, patients and therapists closely collaborate on a personalized working theory of the patient’s psychopathology. This is a challenging process and shows low reliability between therapists. With the experience sampling method (ESM), time-series data—valuable for case conceptualization—can be systematically gathered in a patient’s normal daily life. These data can be analyzed and visualized in person-specific networks (PSNs). PSNs may support case conceptualization by providing a schematic representation of association patterns between affective, cognitive, behavioral, and context variables. Main text We adopt a clinical perspective in considering how PSNs might be implemented to serve case conceptualization and what their role could be in psychotherapy. We suggest PSNs to be based on personalized ESM assessment to capture the unique constellation of variables in each patient. We reflect on the lack of a gold standard for creating PSNs, which may result in substantially different PSNs and thereby disparate information for case conceptualization. Moreover, even if PSNs are created in a consistent manner, results remain ambiguous as they are subject to multiple interpretations. Therefore, associations in PSNs do not allow for firm conclusions about a patient’s psychopathology, but they may nevertheless be valuable in the process of case conceptualization. PSNs are based on systematically gathered, ecologically valid ESM data and provide a unique personalized perspective. When used responsibly, PSNs may be able to support case conceptualization by generating questions that serve as a starting point for a dialog between therapists and patients. Well-targeted questions are an essential tool for therapists to gain insight into the patients’ psychopathology patterns and improve the quality of case conceptualization. Conclusions PSNs have limitations in terms of the reliability of the insights they provide directly. However, taking these challenges into account, we believe they have potential as a tool to help therapists and patients in their collaborative exploration of a patient’s psychopathology. Clearly, this would need to be validated in future clinical research

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

BACKGROUND: Smartphone self-monitoring of mood, symptoms, and contextual factors through ecological momentary assessment (EMA) provides insights into the daily lives of people undergoing psychiatric treatment. Therefore, EMA has the potential to improve their care. To integrate EMA into treatment, a clinical tool that helps clients and clinicians create personalized EMA diaries and interpret the gathered data is needed. OBJECTIVE: This study aimed to develop a web-based application for personalized EMA in specialized psychiatric care in close collaboration with all stakeholders (ie, clients, clinicians, researchers, and software developers). METHODS: The participants were 52 clients with mood, anxiety, and psychotic disorders and 45 clinicians (psychiatrists, psychologists, and psychiatric nurses). We engaged them in interviews, focus groups, and usability sessions to determine the requirements for an EMA web application and repeatedly obtained feedback on iteratively improved high-fidelity EMA web application prototypes. We used human-centered design principles to determine important requirements for the web application and designed high-fidelity prototypes that were continuously re-evaluated and adapted. RESULTS: The iterative development process resulted in Personalized Treatment by Real-time Assessment (PETRA), which is a scientifically grounded web application for the integration of personalized EMA in Dutch clinical care. PETRA includes a decision aid to support clients and clinicians with constructing personalized EMA diaries, an EMA diary item repository, an SMS text message-based diary delivery system, and a feedback module for visualizing the gathered EMA data. PETRA is integrated into electronic health record systems to ensure ease of use and sustainable integration in clinical care and adheres to privacy regulations. CONCLUSIONS: PETRA was built to fulfill the needs of clients and clinicians for a user-friendly and personalized EMA tool embedded in routine psychiatric care. PETRA is unique in this codevelopment process, its extensive but user-friendly personalization options, its integration into electronic health record systems, its transdiagnostic focus, and its strong scientific foundation in the design of EMA diaries and feedback. The clinical effectiveness of integrating personalized diaries via PETRA into care requires further research. As such, PETRA paves the way for a systematic investigation of the utility of personalized EMA for routine mental health care

Opening the contextual black box: A case for idiographic experience sampling of context for clinical applications

The experience sampling method (ESM) is increasingly used as a clinical tool in mental health care. Currently, ESM studies pay relatively little attention to assessing contextual factors, such as a person’s experience and perception of events, activities, and social interactions. This has been referred to as the 'contextual black box’. However, personalized context information is essential for applications in clinical settings to gain insight in triggering and maintaining factors of psychopathology. Typically, ESM context items are designed for nomothetic research questions, to capture broad factors that are shared across individuals, such as ‘unpleasant events’. We provide an overview of such items and argue that they have limited clinical utility. We instead propose an idiographic approach to ESM context assessment to obtain more specific and personalized information about individual clients. In the current manuscript, we outline three idiographic ESM techniques to context assessment with clinical potential. First, we illustrate qualitative ESM items that prompt clients to fill in text, such as a description of a specific unpleasant event they experienced. Second, we describe personalized response options and self-learning items that ask clients to define personally relevant response categories, such as types of events the client finds unpleasant. Third, we describe personalized ESM items that client and clinician select or formulate together for concepts of interest. We discuss the advantages and disadvantages of the idiographic approach. Additionally, we suggest future directions for clinical research aiming to address the ‘contextual black box’ and enhance the potential of ESM in mental health care

Integrating personalized experience sampling in psychotherapy: A case illustration of the Therap-i module

Background: The experience sampling methodology (ESM) is increasingly being suggested as a clinical tool in mental health care, as it offers ecologically valid, microlevel information on psychopathological processes. Patients and clinicians have recommended that applications of ESM should be personalized and integrated into the existing clinical process, but there is still much uncertainty about how implementation may look like. Objective: To provide an example of personalized ESM assessment and feedback being integrated into psychotherapy for depression, specifically looking at the collaborative use of ESM in case conceptualization. Methods: George, a 27-year-old man diagnosed with depression, and his therapist participated in the Therap-i randomized controlled trial, which investigates the efficacy of a personalized ESM module added to psychotherapy. Together, they created a personalized ESM questionnaire, aiming to capture their hypotheses and questions regarding George’s case conceptualization. George then filled out his ESM questionnaire five times per day, for 8 weeks. During this period, ESM data were discussed and interpreted by George, his therapist, and a researcher, in three feedback sessions. In these sessions, data were visualized in a flexible feedback interface that allowed for collaborative exploration of George’s data. Both patient and therapist evaluated the module through questionnaires and George also participated in a semi-structured evaluation interview. Results: George’s ESM questionnaire included personalized items on the topics of self-esteem and open versus withdrawn behavior. He completed 241 (89.3%) assessments. Discussions during the feedback sessions focused on two core themes: First, George’s low energy level, which was further explored with regard to his sleep, medication, and activity patterns. Second, his low sense of self-esteem, which led to an in-depth exploration of his thinking patterns and social interactions. The ESM module was seen as useful and insightful by both George and therapist. Conclusions: This case shows how ESM and ESM-based feedback can stimulate the collaborative exploration of the patient’s complaints, and how it can provide useful insights for treatment. We discuss how our personalized ESM module relates to current clinical principles and practices, and make suggestions for further implementation

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

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

Integrating personalized experience sampling in psychotherapy: A case illustration of the Therap-i module

BACKGROUND: The experience sampling methodology (ESM) is increasingly being suggested as a clinical tool in mental health care, as it offers ecologically valid, microlevel information on psychopathological processes. Patients and clinicians have recommended that applications of ESM should be personalized and integrated into the existing clinical process, but there is still much uncertainty about how implementation may look like. OBJECTIVE: To provide an example of personalized ESM assessment and feedback being integrated into psychotherapy for depression, specifically looking at the collaborative use of ESM in case conceptualization. METHODS: George, a 27-year-old man diagnosed with depression, and his therapist participated in the Therap-i randomized controlled trial, which investigates the efficacy of a personalized ESM module added to psychotherapy. Together, they created a personalized ESM questionnaire, aiming to capture their hypotheses and questions regarding George's case conceptualization. George then filled out his ESM questionnaire five times per day, for 8 weeks. During this period, ESM data were discussed and interpreted by George, his therapist, and a researcher, in three feedback sessions. In these sessions, data were visualized in a flexible feedback interface that allowed for collaborative exploration of George's data. Both patient and therapist evaluated the module through questionnaires and George also participated in a semi-structured evaluation interview. RESULTS: George's ESM questionnaire included personalized items on the topics of self-esteem and open versus withdrawn behavior. He completed 241 (89.3%) assessments. Discussions during the feedback sessions focused on two core themes: First, George's low energy level, which was further explored with regard to his sleep, medication, and activity patterns. Second, his low sense of self-esteem, which led to an in-depth exploration of his thinking patterns and social interactions. The ESM module was seen as useful and insightful by both George and therapist. CONCLUSIONS: This case shows how ESM and ESM-based feedback can stimulate the collaborative exploration of the patient's complaints, and how it can provide useful insights for treatment. We discuss how our personalized ESM module relates to current clinical principles and practices, and make suggestions for further implementation