Essential characteristics of psychotic phenomena include frequency of occurrence, variability over time, and the interplay with the context in which they are occurring. Despite the clinical relevance of these characteristics, very little of this information is available to the clinician or to the patient, for that matter. People are generally poor in providing accurate, global, retrospective reflections of real-life experiences, and behavior, and this appears to be especially problematic for patients with psychosis who experience a loss of reality testing and suffer from cognitive impairment. Furthermore, people are not always consciously aware of the patterns of behavior and the subtle interplay between experiences and environmental features.
Similar to advantages in somatic medicine of real-time monitoring of blood pressure9
or plasma glucose levels,10
real-time monitoring of psychiatric symptoms may considerably improve the understanding of the nature and expression of symptoms as well as actively engage patients in this assessment and monitoring process. Clinical studies are already underway for psychiatric disorders such as anxiety, eating disorders, or depression7,8,11
; however, researchers and clinicians alike have yet to explore these opportunities in psychosis.
Positive Symptoms of Psychosis
The positive symptoms of psychosis, such as disturbances in the content of thought and in sensory perception, tend to be difficult for patients to accurately self-monitor. Patients are often unaware of the deviant nature of these experiences; however, items, such as “preoccupation with thoughts,” “feeling paranoid,” “feeling controlled,” or “feeling unreal,” capture aspects of mental state that are associated with delusions and that patients can accurately report. Similarly, patients can provide veridical self-report about the intensity of hallucinations, even when they are not aware of the origin of these experiences.
Studies using ESM have demonstrated that there is considerable variation in the intensity of both delusions12,13
over periods of minutes and hours. Furthermore, this variability in symptom intensity is driven both by internal and external factors. Increases in paranoia, eg, were precipitated by a decrease in self-esteem13
(see ), an increase in anxiety,13,15
and increased feelings of subjective stress.16
External factors have also been implicated in the onset of positive symptoms including day-to-day urban exposure,17
and cannabis use.19
Cannabis use, eg, immediately increased positive affect, whereas the increase in hallucinations occurred thereafter. This temporal dissociation between the acute rewarding effects and the subsequent toxic influences may explain the vicious circle of deleterious use in these patients.
The PsyMate May Be Used to Capture Temporal Associations Between Real-Time Variability in Internal States (eg, Self-esteem) and in Symptoms (eg, Paranoia).
Negative Symptoms of Psychosis
Negative symptoms of psychosis reflect deficits in cognitive functioning, experience of pleasure, and interest, motivation, and engagement in the world.20,21
These symptoms seem even less accessible to real-life self-monitoring because current assessment instruments rely solely on observer-rated behavior.20
However, the experiential and behavioral manifestations of negative symptoms can be self-monitored by patients in real life. It was shown, eg, that patients with a psychotic disorder show increased intensity and variability of negative emotions but a reduced intensity of positive emotions.22
This may reflect anhedonia, diminished capacity to experience pleasure, or rather result from living a less pleasant life. In a second study, it was shown that patients with a psychotic disorder were equally if not more able to experience pleasure when something pleasant was happening, only fewer pleasant events were reported (Oorschot M, Lataster T, Thewissen V, et al., unpublished data). It was also shown that patients reported similar levels of pleasure during activities as control participants but reported less anticipatory pleasure from future goal-directed activities.23
These results represent group comparisons rather than assessing individual risk profiles of patients. Yet, these data show that self-monitoring of both positive and negative psychotic symptoms (a) is feasible, (b) provides a much more detailed and fine-grained picture of symptoms, and (c) reveals patterns of behavior that may be relevant for treatment. Thus, patients with psychosis, even during acute phases of the illness, can become active partners in the assessment of their symptoms. Furthermore, the fine-grained assessment of symptoms and behavior may accelerate and fundamentally broaden the assessment of treatment efficacy, both at the individual level as well as in clinical trials.