Linguistic style as a digital marker for depression severity: An ambulatory assessment pilot study in patients with depressive disorder undergoing sleep deprivation therapy.

BACKGROUND: Digital phenotyping and monitoring tools are the most promising approaches to automatically detect upcoming depressive episodes. Especially, linguistic style has been seen as a potential behavioral marker of depression, as cross-sectional studies showed, for example, less frequent use of positive emotion words, intensified use of negative emotion words, and more self-references in patients with depression compared to healthy controls. However, longitudinal studies are sparse and therefore it remains unclear whether within-person fluctuations in depression severity are associated with individuals' linguistic style. METHODS: To capture affective states and concomitant speech samples longitudinally, we used an ambulatory assessment approach sampling multiple times a day via smartphones in patients diagnosed with depressive disorder undergoing sleep deprivation therapy. This intervention promises a rapid change of affective symptoms within a short period of time, assuring sufficient variability in depressive symptoms. We extracted word categories from the transcribed speech samples using the Linguistic Inquiry and Word Count. RESULTS: Our analyses revealed that more pleasant affective momentary states (lower reported depression severity, lower negative affective state, higher positive affective state, (positive) valence, energetic arousal and calmness) are mirrored in the use of less negative emotion words and more positive emotion words. CONCLUSION: We conclude that a patient's linguistic style, especially the use of positive and negative emotion words, is associated with self-reported affective states and thus is a promising feature for speech-based automated monitoring and prediction of upcoming episodes, ultimately leading to better patient care.

Speech Features as Predictors of Momentary Depression Severity in Patients With Depressive Disorder Undergoing Sleep Deprivation Therapy: Ambulatory Assessment Pilot Study.

BACKGROUND: The use of mobile devices to continuously monitor objectively extracted parameters of depressive symptomatology is seen as an important step in the understanding and prevention of upcoming depressive episodes. Speech features such as pitch variability, speech pauses, and speech rate are promising indicators, but empirical evidence is limited, given the variability of study designs. OBJECTIVE: Previous research studies have found different speech patterns when comparing single speech recordings between patients and healthy controls, but only a few studies have used repeated assessments to compare depressive and nondepressive episodes within the same patient. To our knowledge, no study has used a series of measurements within patients with depression (eg, intensive longitudinal data) to model the dynamic ebb and flow of subjectively reported depression and concomitant speech samples. However, such data are indispensable for detecting and ultimately preventing upcoming episodes. METHODS: In this study, we captured voice samples and momentary affect ratings over the course of 3 weeks in a sample of patients (N=30) with an acute depressive episode receiving stationary care. Patients underwent sleep deprivation therapy, a chronotherapeutic intervention that can rapidly improve depression symptomatology. We hypothesized that within-person variability in depressive and affective momentary states would be reflected in the following 3 speech features: pitch variability, speech pauses, and speech rate. We parametrized them using the extended Geneva Minimalistic Acoustic Parameter Set (eGeMAPS) from open-source Speech and Music Interpretation by Large-Space Extraction (openSMILE; audEERING GmbH) and extracted them from a transcript. We analyzed the speech features along with self-reported momentary affect ratings, using multilevel linear regression analysis. We analyzed an average of 32 (SD 19.83) assessments per patient. RESULTS: Analyses revealed that pitch variability, speech pauses, and speech rate were associated with depression severity, positive affect, valence, and energetic arousal; furthermore, speech pauses and speech rate were associated with negative affect, and speech pauses were additionally associated with calmness. Specifically, pitch variability was negatively associated with improved momentary states (ie, lower pitch variability was linked to lower depression severity as well as higher positive affect, valence, and energetic arousal). Speech pauses were negatively associated with improved momentary states, whereas speech rate was positively associated with improved momentary states. CONCLUSIONS: Pitch variability, speech pauses, and speech rate are promising features for the development of clinical prediction technologies to improve patient care as well as timely diagnosis and monitoring of treatment response. Our research is a step forward on the path to developing an automated depression monitoring system, facilitating individually tailored treatments and increased patient empowerment.

Assessing affect in adolescents with e-diaries: multilevel confirmatory factor analyses of different factor models.

In the last two decades, e-diary studies have gained increasing interest, with a dominant focus on mood and affect. Although requested in current guidelines, psychometric properties are rarely reported, and methodological investigations of factor structure, model fit, and the reliability of mood and affect assessment are limited. We used a seven-day e-diary dataset of 189 adolescent participants (12-17 years). The e-diary affect assessments revealed a considerable portion of within-person variance. The six-factor model showed the best model fit compared to the less complex models. Factor loadings also improved with the complexity of the models. Accordingly, we recommend that future e-diary studies of adolescents use the six-factor model of affect as well as reporting psychometric properties and model fit. For future e-diary scale development, we recommend using a minimum of three items per scale to enable the use of confirmatory multilevel factor analyses.

Predicting Delay in Goal-Directed Action: An Experience Sampling Approach Uncovering Within-Person Determinants Involved in the Onset of Academic Procrastination Behavior.

Academic procrastination involves the delayed implementation of actions required to fulfill study-related tasks. These behavioral delays are thought to result from momentary failures in self-regulation (i.e., within-person processes). Most previous studies focused on the role of trait-based individual differences in students' procrastination tendencies. Little is known about the within-person processes involved in the occurrence of procrastination behavior in real-life academic situations. The present study applied an event-based experience sampling approach to investigate whether the onset of task-specific delay behavior can be attributed to unfavorable changes in students' momentary appraisals of tasks (value, aversiveness, effort, expectations of success), which may indicate failures in self-regulation arise between critical phases of goal-directed action. University students (N = 75) used an electronic diary over eight days to indicate their next days' intentions to work on academic tasks and their task-specific appraisals (n = 582 academic tasks planned). For each task, a second query requested the next day determined whether students' task-related appraisals changed and whether they implemented their intention on time or delayed working on the respective task (n = 501 completed task-specific measurements). Students' general procrastination tendency was assessed at baseline using two established self-report questionnaires. Stepwise two-level logistic regression analyses revealed that within-person changes in task-related appraisals that reflected a devaluation of the study-related tasks increased the risk for an actual delay. The risk to delay decreased when students maintained a positive attitude toward the task. Students' general procrastination tendency did not predict individual differences in their task-specific delay behavior. We discuss these findings in light of the growing effort to understand the within-person processes that contribute to induce procrastination behavior under real-life academic conditions and illustrate how this knowledge can benefit the design of tasks and instructions that support students' self-regulation to their best.

Specific or transdiagnostic? The occurrence of emotions and their association with distress in the daily life of patients with borderline personality disorder compared to clinical and healthy controls.

Borderline personality disorder (BPD) is characterized by more frequent and more intense negative emotions and less frequent positive emotions in daily life than healthy controls (HC) experience, but there is limited empirical evidence regarding whether this is a transdiagnostic or disorder-specific finding and which specific emotions are especially distressing in BPD. We assessed participants' current emotions and distress every 15 min over a 24-h period using e-diaries to investigate the frequency, intensity, and the associated distress of specific emotions. To test the disorder specificity, we used multilevel modeling to compare 43 female patients with BPD, 28 patients with posttraumatic stress disorder (PTSD), 20 patients with bulimia nervosa (BN), and 28 HC. Patients with BPD exhibited anger more frequently than any of the clinical or healthy control groups, demonstrating specificity. The quality of anger accounted for additional distress beyond the pure emotional intensity. In patients with BPD, joy was associated with reduced distress, which was not the case in HC or PTSD. However, the majority of the comparisons (anxiety, sadness, shame, disgust, jealousy, guilt, interest) revealed transdiagnostic patterns. The distress-enhancing or distress-reducing effects of anger and joy might represent an important part of affective dysregulation in BPD.

The short version of the Borderline Symptom List (BSL-23): development and initial data on psychometric properties.

BACKGROUND: The full version of the Borderline Symptom List (BSL; for clarification now labeled BSL-95) is a self-rating instrument for specific assessment of borderline-typical symptomatology. The BSL-95 items are based on criteria of the DSM-IV, the revised version of the Diagnostic Interview for Borderline Personality Disorder, and the opinions of both clinical experts and borderline patients. The BSL-95 includes 95 items. In order to reduce patient burden and assessment time, a short version with 23 items (BSL-23) was developed. METHODS: The development of the BSL-23 was based on a sample of 379 borderline patients, considering the items from the BSL-95 that had the highest levels of sensitivity to change and the highest ability to discriminate borderline patients from other patient groups. In a second step, the psychometric properties of the BSL-23 were investigated and compared with the psychometric properties of the BSL-95 in 5 different samples, including a total of 659 borderline patients. RESULTS: In all of the samples, a high correlation of the sum score was found between the BSL-23 and the BSL-95 (range: 0.958-0.963). The internal consistency was high for both versions (BSL-23/Cronbach's alpha: 0.935-0.969; BSL-95/Cronbach's alpha: 0.977-0.978). Both BSL-23 and BSL-95 clearly discriminated borderline personality disorder patients from patients with an axis I diagnosis (mean effect sizes were 1.13 and 0.96 for the BSL-23 and BSL-95, respectively). In addition, comparisons before and after 3 months of dialectical behavior therapy revealed a numerically larger effect size for the BSL-23 (d = 0.47) compared to the BSL-95 (d = 0.38). CONCLUSION: The results indicate that the BSL-23 is an efficient and convenient self-rating instrument that displays good psychometric properties comparable to those of the BSL-95. The BSL-23 also demonstrated sensitivity to the effects of therapy.

[Short version of the borderline symptom list (BSL-23): development and psychometric evaluation]. / Kurzversion der Borderline-Symptom-Liste (BSL-23): Entwicklung und Uberprüfung der psychometrischen Eigenschaften.

The Borderline Symptom List (BSL-95) has initially been developed as a self-rating instrument for specific assessment of borderline-typical symptoms. In order to reduce patient burden and assessment time we developed a short-version of the BSL. Twenty-three of the original 95 BSL-items were included into the short-version (BSL-23). The evaluation was based on five different samples with borderline patients (n=694). The internal consistency of the BSL-23 was high: Cronbach's alpha: 0.94-0.97. The remaining results regarding test-retest-reliability, validity, ability to discriminate between patient groups and sensitivity for change according to therapy were very satisfactory throughout. The results indicate that the BSL-23 is an efficient and convenient self-rating instrument that displays very good psychometric properties comparable to those of the full version of the BSL.

Do improvements after inpatient dialectial behavioral therapy persist in the long term? A naturalistic follow-up in patients with borderline personality disorder.

Three months of inpatient dialectical behavior therapy proved to be highly effective in patients with borderline personality disorder. This study investigates whether the effects of DBT persist after the patients returned to their usual lives. Thirty-one patients with a diagnosis of borderline personality disorder (DSM-IV) were prospectively followed-up for an observation period of 21 months after discharge from the DBT program, under naturalistic conditions.Improvements as observed after discharge persisted over the full follow-up period. This is reflected in a steady rate of remitted patients and in a broad range of psychopathology showing statistically and clinically significant effect-sizes ranging from 0.70 to 1.71. Analyses of courses over time revealed a high intraindividual concordance, indicating that short term treatment response predicted remission after 2 years follow-up. The effects of inpatient dialectical behavior therapy seem to persist after patients returned to their usual lives.

Motives for nonsuicidal self-injury among women with borderline personality disorder.

Patients with borderline personality disorder (BPD) are known to use nonsuicidal self-injury (NSSI) as a dysfunctional strategy to regulate intense emotions. The primary purpose of this study was to clarify the motives for NSSI along with their interrelations. We further investigated the variety of emotions preceding NSSI and possible effects of NSSI on these emotions. To this end, a structured self-rating questionnaire on NSSI was administered to 101 female BPD-patients exhibiting NSSI. Most patients reported multiple motives for NSSI. The motives were more likely to compound than to exclude one another. Negative reinforcement was almost always involved in NSSI, whereas positive reinforcement (e.g., "getting a kick") played an additional role among about half of the patients. NSSI was usually preceded by a large variety of negative feelings that were reported to clearly improve with NSSI. In conclusion, therapists should anticipate a multidimensional functional spectrum when exploring motives of NSSI.

Specificity of emotion sequences in borderline personality disorder compared to posttraumatic stress disorder, bulimia nervosa, and healthy controls: an e-diary study.

BACKGROUND: Patients with borderline personality disorder (BPD) exhibit dysregulated emotion sequences in daily life compared to healthy controls (HC). Empirical evidence regarding the specificity of these findings is currently lacking. METHODS: To replicate dysregulated emotion sequences in patients with BPD and to investigate the specificity of the sequences, we used e-diaries of 43 female patients with BPD, 28 patients with posttraumatic stress disorder (PTSD), 20 patients with bulimia nervosa (BN), and 28 HC. To capture the rapid dynamics of emotions, we prompted participants every 15 min over a 24-h period to assess their current perceived emotions. We analyzed group differences in terms of activation, persistence, switches, and down-regulation of emotion sequences. RESULTS: By comparing patients with BPD to HC, we replicated five of the seven previously reported dysregulated emotion sequences, as well as 111 out of 113 unaltered sequences. However, none of the previously reported dysregulated emotion sequences exhibited specificity, i.e., none revealed higher frequencies compared to the PTSD group or the BN group. Beyond these findings, we revealed a specific finding for patients with BN, as they most frequently switched from anger to disgust. CONCLUSIONS: Replicating previously found dysregulated and unaltered emotional sequences strengthens the significance of emotion sequences. However, the lack of specificity points to emotion sequences as transdiagnostic features.

Improving motor activity assessment in depression: which sensor placement, analytic strategy and diurnal time frame are most powerful in distinguishing patients from controls and monitoring treatment effects.

BACKGROUND: Abnormalities in motor activity represent a central feature in major depressive disorder. However, measurement issues are poorly understood, limiting the use of objective measurement of motor activity for diagnostics and treatment monitoring. METHODS: To improve measurement issues, especially sensor placement, analytic strategies and diurnal effects, we assessed motor activity in depressed patients at the beginning (MD; n=27) and after anti-depressive treatment (MD-post; n=18) as well as in healthy controls (HC; n=16) using wrist- and chest-worn accelerometers. We performed multiple analyses regarding sensor placements, extracted features, diurnal variation, motion patterns and posture to clarify which parameters are most powerful in distinguishing patients from controls and monitoring treatment effects. RESULTS: Whereas most feature-placement combinations revealed significant differences between groups, acceleration (wrist) distinguished MD from HC (d=1.39) best. Frequency (vertical axis chest) additionally differentiated groups in a logistic regression model (R2=0.54). Accordingly, both amplitude (d=1.16) and frequency (d=1.04) showed alterations, indicating reduced and decelerated motor activity. Differences between MD and HC in gestures (d=0.97) and walking (d=1.53) were found by data analysis from the wrist sensor. Comparison of motor activity at the beginning and after MD-treatment largely confirms our findings. LIMITATIONS: Sample size was small, but sufficient for the given effect sizes. Comparison of depressed in-patients with non-hospitalized controls might have limited motor activity differences between groups. CONCLUSIONS: Measurement of wrist-acceleration can be recommended as a basic technique to capture motor activity in depressed patients as it records whole body movement and gestures. Detailed analyses showed differences in amplitude and frequency denoting that depressed patients walked less and slower.

Effectiveness of inpatient dialectical behavioral therapy for borderline personality disorder: a controlled trial.

Dialectical Behavioral Therapy (DBT) was initially developed and evaluated as an outpatient treatment program for chronically suicidal individuals meeting criteria for borderline personality disorder (BPD). Within the last few years, several adaptations to specific settings have been developed. This study aims to evaluate a three-month DBT inpatient treatment program. Clinical outcomes, including changes on measures of psychopathology and frequency of self-mutilating acts, were assessed for 50 female patients meeting criteria for BPD. Thirty-one patients had participated in a DBT inpatient program, and 19 patients had been placed on a waiting list and received treatment as usual in the community. Post-testing was conducted four months after the initial assessment (i.e. four weeks after discharge for the DBT group). Pre-post-comparison showed significant changes for the DBT group on 10 of 11 psychopathological variables and significant reductions in self-injurious behavior. The waiting list group did not show any significant changes at the four-months point. The DBT group improved significantly more than participants on the waiting list on seven of the nine variables analyzed, including depression, anxiety, interpersonal functioning, social adjustment, global psychopathology and self-mutilation. Analyses based on Jacobson's criteria for clinically relevant change indicated that 42% of those receiving DBT had clinically recovered on a general measure of psychopathology. The data suggest that three months of inpatient DBT treatment is significantly superior to non-specific outpatient treatment. Within a relatively short time frame, improvement was found across a broad range of psychopathological features. Stability of the recovery after one month following discharge, however, was not evaluated and requires further study.

Dissociation predicts poor response to Dialectial Behavioral Therapy in female patients with Borderline Personality Disorder.

A substantial proportion of Borderline Personality Disorder (BPD) patients respond by a marked decrease of psychopathology when treated with Dialectical Behavioral Therapy (DBT). To further enhance the rate of DBT-response, it is useful to identify characteristics related to unsatisfactory response. As DBT relies on emotional learning, we explored whether dissociation-which is known to interfere with learning- predicts poor response to DBT. Fifty-seven Borderline Personality Disorder (BPD) patients (DSM-IV) were prospectively observed during a three-month inpatient DBT program. Pre-post improvements in general psychopathology (SCL-90-R) were predicted from baseline scores of the Dissociative Experiences Scale (DES) by regression models accounting for baseline psychopathology. High DES-scores were related to poor pre-post improvement (ß = -0.017 ± 0.006, p = 0.008). The data yielded no evidence that some facets of dissociation are more important in predicting DBT-response than others. The results suggest that dissociation in borderline-patients should be closely monitored and targeted during DBT. At this stage, research on treatment of dissociation (e.g., specific skills training) is warranted.

Borderline typical symptoms in adult patients with attention deficit/hyperactivity disorder.

Adult attention deficit/hyperactivity disorder (ADHD) and borderline personality disorder (BPD) share several clinical features, e.g. emotional lability and impulsivity. This study aimed to delineate differences and similarities between ADHD and BPD with respect to borderline typical symptomatology and gender specifics. Borderline symptomatology was assessed in 60 adult patients with ADHD with the borderline symptom list (BSL) and compared to both 60 gender- and age-matched BPD patients and control subjects. The BSL is a standardized instrument including 95 items on 7 subscales (self-perception, affect regulation, self-destruction, dysphoria, loneliness, intrusions and hostility). Adult ADHD patients showed significantly higher BSL total scores and all of the seven subscales compared to healthy controls (p < 0.001) but lower scores than BPD patients (p < 0.001). With respect to the seven subscales, the largest differences between ADHD and BPD patients were found with respect to self-destruction (d = 1.12) and affect dysregulation (d = 0.90), whereas the smallest difference was found with respect to loneliness (d = 0.36). In females, the BSL subscales "loneliness" and "hostility" did not differentiate between BPD and ADHD. Borderline typical symptoms are common in adult patients with ADHD but seem to be less pronounced than in patients with BPD. Females with ADHD and BPD share more clinical features than males. However, symptoms of self-destruction and affect dysregulation appear to be more severe in BPD patients.

Attention-deficit hyperactivity disorder as a potentially aggravating factor in borderline personality disorder.

BACKGROUND: Clinical experience suggests that people with borderline personality disorder often meet criteria for attention-deficit hyperactivity disorder (ADHD). However, empirical data are sparse. AIMS: To establish the prevalence of childhood and adult ADHD in a group of women with borderline personality disorder and to investigate the psychopathology and childhood experiences of those with and without ADHD. METHOD: We assessed women seeking treatment for borderline personality disorder (n=118) for childhood and adult ADHD, co-occurring Axis I and Axis II disorders, severity of borderline symptomatology and traumatic childhood experiences. RESULTS: Childhood (41.5%) and adult (16.1%) ADHD prevalence was high. Childhood ADHD was associated with emotional abuse in childhood and greater severity of adult borderline symptoms. Adult ADHD was associated with greater risk for co-occurring Axis I and II disorders. CONCLUSIONS: Adults with severe borderline personality disorder frequently show a history of childhood ADHD symptomatology. Persisting ADHD correlates with frequency of co-occurring Axis I and II disorders. Severity of borderline symptomatology in adulthood is associated with emotional abuse in childhood. Further studies are needed to differentiate any potential causal relationship between ADHD and borderline personality disorder.

Psychometric properties of the Borderline Symptom List (BSL).

BACKGROUND: The Borderline Symptom List (BSL) was developed as a self-rating instrument to specifically quantify borderline-typical symptomatology. The items are based on the criteria of the DSM-IV, the Diagnostic Interview for Borderline Personality Disorder - revised version, the opinions of clinical experts and borderline patients. The psychometric properties and validity of the BSL have been investigated in several studies. SAMPLING AND METHODS: A total of 380 borderline patients and 204 healthy controls scored the items. A factor analysis of the BSL items suggests the following subscales: 'self-perception', 'affect regulation', 'self-destruction', 'dysphoria', 'loneliness', 'intrusions' and 'hostility'. RESULTS: The internal reliability as well as the test-retest reliability within 1 week are high. Different aspects of validity (e.g. comparison between groups) provide favorable results. Pre-post comparisons after 3 months of dialectical behavioral treatment reveal a significant reduction of the total score and of 5 of the 7 subscales. CONCLUSIONS: This indicates that the BSL is sensitive to therapeutically induced change of borderline-typical impairment.