Comparisons of Self-Report With Objective Measurements Suggest Faster Responding but Little Change in Response Quality Over Time in Ecological Momentary Assessment Studies.

Response times (RTs) to ecological momentary assessment (EMA) items often decrease after repeated EMA administration, but whether this is accompanied by lower response quality requires investigation. We examined the relationship between EMA item RTs and EMA response quality. In one data set, declining response quality was operationalized as decreasing correspondence over time between subjective and objective measures of blood glucose taken at the same time. In a second EMA study data set, declining response quality was operationalized as decreasing correspondence between subjective ratings of memory test performance and objective memory test scores. We assumed that measurement error in the objective measures did not increase across time, meaning that decreasing correspondence across days within a person could be attributed to lower response quality. RTs to EMA items decreased across study days, while no decrements in the mean response quality were observed. Decreasing EMA item RTs across study days did not appear problematic overall.

A meta-cognitive Wisconsin Card Sorting Test in people with schizophrenia and bipolar disorder: Self-assessment of sorting performance.

People with serious mental illness have challenged self-awareness, including momentary monitoring of performance. A core feature of this challenge is in the domain of using external information to guide behavior, an ability that is measured very well by certain problem-solving tasks such as the Wisconsin Card Sorting Test (WCST) . We used a modified WCST to examine correct sorts and accuracy decisions regarding the correctness of sort. Participants with schizophrenia (n = 99) or bipolar disorder (n = 76) sorted 64 cards and then made judgments regarding correctness of each sort prior to feedback. Time series analyses examined the course of correct sorts and correct accuracy decisions by examining the momentary correlation and lagged correlation on the next sort. People with schizophrenia had fewer correct sorts, fewer categories, and fewer correct accuracy decisions (all p<.001). Positive response biases were seen in both groups. After an incorrect sort or accuracy decision, the groups were equally likely to be incorrect on the next sort or accuracy decision. Following correct accuracy decisions, participants with bipolar disorder were significantly (p=.003) more likely to produce a correct sort or accuracy decision. These data are consistent with previous studies implicating failures to consider external feedback for decision making. Interventions aimed at increasing consideration of external information during decision making have been developed and interventions targeting use of feedback during cognitive test performance are in development.

Time-course and convergence of positive and negative moods in participants with schizophrenia: An ecological momentary assessment study.

INTRODUCTION: Many people with schizophrenia report low levels of negative affect (NA), which may reflect biases in emotion processing. In the general population there is an inverse correlation between positive affect (PA) and NA. It is possible that this relationship is different among people with schizophrenia. This study aims to understand the relationship between PA and NA among people with schizophrenia, and explore PA and NA variability in relationship to social context. METHOD: 105 participants with schizophrenia answered ecological momentary assessment (EMA) surveys seven times/day for seven days. They reported their experiences of mood states on a scale of one to seven: happiness, sadness, relaxation, and anxiety, as well as their social context (alone vs. with someone). Mood variability was calculated using the mean square of successive difference, and multilevel modeling was used to understand the time-course of reported moods within- and between-person. RESULTS: 45% of surveys reported the absence of NA, though there was an inverse within-subjects correlation between PA and NA. Between-subjects, there was a large inverse correlation between PA and NA. Greater mood variability was associated with a greater number of social interactions. DISCUSSION: The results of this study point to both the role of social context in mood variability, and momentary trends in mood experiences, with some individuals reporting no NA, some indicating both PA and NA, and some indicating a more normative affect pattern. Later research should address the possible impact of emotion perception bias and social interactions on moods states in schizophrenia.

Negative mood states as a correlate of cognitive performance and self-assessment of cognitive performance in bipolar disorder versus schizophrenia.

INTRODUCTION: Mood states have been reported to manifest a cross-sectional correlation with self-assessment accuracy across functional domains and psychiatric conditions. Ecological momentary assessment (EMA) provides a strategy to examine the momentary course and correlates of mood states. This study tested the association of moods assessed longitudinally with accuracy of immediate self-assessments of cognitive test performance in participants with schizophrenia and bipolar disorder. METHODS: 240 well-diagnosed participants with schizophrenia and bipolar disorder completed a subset of tests from the MATRICS Consensus Cognitive Battery and an immediate self-assessment of cognitive performance. Differences between actual and self-reported performance were used to index the accuracy of self-assessment. Daily smartphone EMA, 3× per day for 30 days, sampled participants´ momentary moods (sad, happy, relaxed, anxious), aggregated into positive affect and negative affect (NA). RESULTS: Bipolar participants had better cognitive performance, but both samples had equivalent mis-estimation. Repeated-measures analyses found that NA did not manifest significant variability over time either between or within participants in the two diagnostic groups. Within-group analyses found that higher average NA was associated with greater mis-estimation and poorer cognitive performance in participants with bipolar disorder, but not in those with schizophrenia. CONCLUSION: Negative moods had a significant association with impairments in self-assessment of cognitive performance in participants with bipolar disorder. Our study did not confirm previous cross-sectional findings of more accurate self-assessment associated with greater NA in schizophrenia. These findings suggest that cross-sectional assessments, particularly self-reports, may lead to different results than aggregated data from longitudinal evaluations.

Accuracy of immediate self-assessment of neurocognitive test performance: Associations with psychiatric diagnosis and longitudinal psychotic symptoms.

Participants with schizophrenia (SCZ) and bipolar disorder (BD) have challenges in self-evaluation of their cognitive and functional abilities, referred to as introspective accuracy (IA). Although psychotic symptoms are commonly found to be uncorrelated with cognitive performance, many models of the development of delusions focus on failures in self-assessment and responses biases during momentary monitoring. We performed a single 4-test cognitive assessment on 240 participants (schizophrenia n = 126; bipolar disorder n = 114) and asked them to make a judgment about their performance immediately after completion of each task. We related performance and these judgments to results of Ecological Momentary Assessments (EMA) of the momentary occurrence of psychotic symptoms (Voices, paranoid ideas, other delusions) collected over up to 90 surveys over a 30 days prior to the single cognitive assessment. We examined test performance and the accuracy of self-assessment at that assessment, looking at diagnostic differences in performance and mis-estimation of performance. Participants with bipolar disorder had better cognitive performance, but there were no differences in mis-estimation. Analyses of the correlation between cognitive performance and self-assessment were all significant and better cognitive performance predicted reduced errors in self-assessment. Examination of the 30-day course of psychotic symptoms and IA could only be performed in participants with schizophrenia, revealing correlations between more common occurrences of all three psychotic symptoms and increased absolute values for IA errors. These data are consistent with theories of cognitive response biases and the formation of delusions.

Revisiting how People with Schizophrenia Spend Their Days: Associations of lifetime milestone Achievements with Daily Activities examined with Ecological Momentary Assessment.

Milestone achievements are reduced in people with schizophrenia and are lower in comparison to people with bipolar disorder. However, it is not clear what the implications are for engagement in momentary activities based on milestone achievements. Further, some recent research has suggested that psychotic symptoms are associated with challenges in self-assessment of activities, but there is less information about the correlations of milestone achievements and ongoing psychotic symptoms. We examined momentary activities and symptoms as a function of lifetime milestone achievement in 102 individuals with schizophrenia and 71 with bipolar disorder. Ecological Momentary Assessment (EMA) was used to sample daily activities and concurrent symptoms 3 times per day for 30 days. Each survey asked the participant where they were, who they were with, and what they were doing, as well as sampling the concurrent presence of psychotic symptoms. Not being financially responsible for their residence was associated with engaging in fewer productive activities. Participants who never had a relationship were more commonly home and alone and engaged in fewer social interactions. A lifetime history of employment was correlated with engaging in more productive activities, including at home. More common momentary psychosis was seen in participants who failed to achieve each of the functional milestones. Lifetime milestone achievements were associated with greater frequencies of productive behaviors and with fewer momentary experiences of psychosis, suggesting that psychotic symptoms may have importance for sustaining disability that would be challenging to detect without momentary information.

The association of momentary sad moods, concurrent productive behaviour, and global functional outcomes: a 30-day ecological momentary assessment study of people with bipolar illness.

BACKGROUND: Previous weekly sampling studies found that persistent sad moods are associated with disability in bipolar illness. However, those data were collected retrospectively. We examined the momentary quality of activities (productive, unproductive, and passive recreation) in an ecological momentary assessment (EMA) study and related sadness at each survey to quality of momentary activities and overall everyday functioning. METHODS: Participants with bipolar illness (N = 91) were sampled three times per day for 30 days. Each survey queried participants as to where they were, with whom, what they were doing, and their mood state. Activities were characterised according to predetermined criteria and related to momentary sadness. Observer ratings of everyday functioning were related to daily reports of sadness and activities. RESULTS: Sadness was associated with the quality of activities. Momentary reports of unproductive activities were associated with the most sadness (p < .001), followed by passive recreation, and productive activities. Momentary sadness and momentary unproductive activities correlated with observer ratings of competence in work, everyday activities, and social outcomes (p < .001). Using both predictors led to the best model. CONCLUSIONS: This study on the course of sad moods in people with bipolar illness to EMA found that momentary sadness correlatesdwith the quality of concurrent activities and that both sadness and the quality of everyday activities predicted observer ratings of everyday functioning. Although we cannot determine the causal direction, these findings support the hypothesis that momentary sadness leads to reductions in productive activities and impairments in everyday functioning.

Momentary severity of psychotic symptoms predicts overestimation of competence in domains of everyday activities and work in schizophrenia: An ecological momentary assessment study.

OBJECTIVES: Schizophrenia participants generate self-reports of their competencies that differ from objective information. They may base their reports on momentary moods or experiences rather than objective data. Theories of delusion formation implicate overconfidence during self-assessment as a cause. METHODS: Ecological momentary assessment (EMA) was used to sample activities and experiences in 101 participants with schizophrenia up to 3 times a day for 30 days. Each survey asked where and with whom they were, what they were doing, and moods and psychotic symptoms they were experiencing. Self-reports and observer ratings of competence in work and everyday activities were collected. RESULTS: Being home was associated with self-reports of better functioning in activities and work skills (p<.001) and being alone correlated with better self-reported functioning in activities (p<.001). Participants who reported more occurrences of hearing voices, paranoid ideation, and other psychotic symptoms reported their functioning as better (p<.001). IMPLICATIONS: Schizophrenia was marked by a disconnect between momentary activities and self-assessments. Being home more was associated with better self-reported functioning on tasks that are only performed away from home. Psychotic  symptoms were associated with overestimation, consistent with previous theories positing that overconfidence and suspension of plausibility assessment may be associated with psychotic experiences.

A cross-diagnostic study of Adherence to Ecological Momentary Assessment: Comparisons across study length and daily survey frequency find that early adherence is a potent predictor of study-long adherence.

BACKGROUND: Ecological momentary assessment (EMA) offers a highly valid strategy to assess everyday functioning in people with severe mental illness. Adherence is generally good, but several questions regarding the impact of study length, daily density of sampling, and symptom severity on adherence remain. METHODS: EMA adherence in two separate studies was examined. One sampled participants with schizophrenia (n=106) and healthy controls (n=76) 7 times per day for 7 days and the other sampled participants with schizophrenia (n=104) and participants with bipolar illness (n=76) 3 times per day for 30 days. Participants were asked where they were, who they were with, what they were doing and how they were feeling in both studies. The impact of rates of very early adherence on eventual adherence was investigated across the samples, and adherence rates were examined for associations with mood state and most common location when answering surveys. RESULTS: Median levels of adherence were over 80% across the samples, and the 10th percentile for adherence was approximately 45% of surveys answered. Early adherence predicted study-long adherence quite substantially in every sample. Mood states did not correlate with adherence in the patient samples and being home correlated with adherence in only the bipolar sample. IMPLICATIONS: Adherence was quite high and was not correlated with the length of the study or the density of sampling per study day. There was a tendency for bipolar participants who were more commonly away from home to answer fewer surveys but overall adherence for the bipolar patients was quite high. These data suggest that early nonadherence is a potential predictor of eventual nonadherence and study noncompletion.

Performance-based assessment of social skills in a large sample of participants with schizophrenia, bipolar disorder and healthy controls: Correlates of social competence and social appropriateness.

INTRODUCTION: Performance-based assessments of social skills have detected impairments in people with severe mental illness and are correlated with functional outcomes in people with schizophrenia and bipolar disorder. The most common of these assessments, the Social Skills Performance Assessment (SSPA), has two communication scenarios and items measuring both social competence and appropriateness. As real-world competence and appropriateness appear to have different correlates, we hypothesized that SSPA Items measuring competence and appropriateness would be distinct and have different correlations with other outcomes. METHODS: We aggregated data from 557 people with schizophrenia, 106 with bipolar disorder, and 378 well controls from 4 separate research studies. All participants were assessed with both SSPA scenarios and other performance based and clinician-rated measures. A single expert rated the SSPA interactions for competence and appropriateness while blind to participant diagnoses. RESULTS: Participants with bipolar disorder and schizophrenia performed more poorly on every item of the SSPA than healthy controls. Items measuring social competence and appropriateness in communication were intercorrelated across scenarios, as were elements of socially competent communication, although the items measuring competence did not correlate substantially with appropriateness. Items assessing social competence, but not social appropriateness, correlated with better cognitive and functional performance and residential and financial independence. DISCUSSION: Social competence and social appropriateness were distinct elements of performance-based social skills with potential differences in their functional correlates. As both social competence and appropriateness impact functional outcomes, improvement in the measurement and treatment of appropriate communication seems to be an important goal.

Capturing Clinical Symptoms with Ecological Momentary Assessment: Convergence of Momentary Reports of Psychotic and Mood Symptoms with Diagnoses and Standard Clinical Assessments.

Objective: The development and deployment of technology-based assessments of clinical symptoms are increasing. This study used ecological momentary assessment (EMA) to examine clinical symptoms and relates these sampling results to structured clinical ratings. Methods: Three times a day for 30 days, participants with bipolar disorder (n=71; BPI) or schizophrenia (n=102; SCZ) completed surveys assessing five psychosis-related and five mood symptoms, in addition to reporting their location and who they were with at the time of survey completion. Participants also completed Positive and Negative Syndrome Scale (PANSS) interviews with trained raters. Mixed-model repeated-measures (MMRM) analyses examined diagnostic effects and the convergence between clinical ratings and EMA sampling. Results: In total, 12,406 EMA samples were collected, with 80-percent adherence to prompts. EMA-reported psychotic symptoms manifested substantial convergence with equivalent endpoint PANSS items. Patients with SCZ had more severe PANSS and EMA psychotic symptoms. There were no changes in symptom severity scores as a function of the number of previous assessments. Conclusions: EMA surveyed clinical symptoms converged substantially with commonly used clinical rating scales in a large sample, with high adherence. This suggested that remote assessment of clinical symptoms is valid and practical and was not associated with alterations in symptoms as a function of reassessment, with additional benefits of "in the moment" sampling, such as eliminating recall bias and the need for informant reports.

Ecological momentary assessment of interpersonal theory of suicide constructs in people experiencing psychotic symptoms.

BACKGROUND: People with psychotic disorders are at an increased risk of suicide, but there is little understanding of suicidal ideation (SI) in this population. The Interpersonal Psychological Theory of Suicide posits that perceived burdensomeness (PB) and thwarted belonginess (TB) contribute to SI. To our knowledge there are no studies using ecological momentary assessment (EMA) to assess these interpersonal risk factors in a sample of individuals with psychotic disorders. This study investigated the validity and variability of PB and TB, and whether SI, EMA-measured psychotic symptoms, mood, and social context relate to PB and TB. METHOD: Ninety-six participants with a psychotic disorder, including mood disorders with psychosis completed in-lab assessments of current SI, and then EMA surveys on a smartphone 3×/day for 10 days, answering questions about burdensomeness, belongingness, symptoms (i.e., hearing voices, experiencing suspiciousness), mood (i.e., happy, sad), and social context. RESULTS: Burdensomeness varied within-participants less than belongingness (t (95) = -3.74, p=< .001). Participants with SI had higher mean burdensomeness ratings (t (94) = -2.70, p < .01) and lower mean belongingness ratings (t (94) = 3.68, p < .001) than did participants without SI. Being with others, greater psychotic experiences, less happiness, and greater sadness related to greater burdensomeness. SI status, being alone, greater psychotic experiences, less happiness, and greater sadness related to less belongingness. CONCLUSIONS: This study examined the real-time influences of SI and psychotic symptoms on burdensomeness and belongingness. Hearing voices, suspiciousness, mood, and SI are related to interpersonal suicide-related risk factors. In this sample, social context had a differential effect on burdensomeness and belongingness.

Evidence for avolition in bipolar disorder? A 30-day ecological momentary assessment comparison of daily activities in bipolar disorder and schizophrenia.

OBJECTIVES: Disability is common in bipolar disorder (BD) and predicted by persistent sadness. We used ecological momentary assessment (EMA) to examine daily activities in people with BD and schizophrenia. We classified activities as productive, unproductive, or passive recreation, relating them to momentary sadness, location, and social context. METHODS: 71 people with BD and 102 people with schizophrenia were sampled 3 times/day for 30 days with an EMA survey. Each survey asked where they were, with whom, what they were doing, and if they were sad. RESULTS: People with BD were home more than 50% of the time. There were no differences in prevalence of activity types across diagnoses. People with BD were less likely to report only one activity since the prior survey, but the most surveys still reported only one. For both groups, sadness and being home and alone since the last survey was associated with less productive activity and more passive recreation. CONCLUSIONS: Participants with BD and schizophrenia manifested high levels of unproductive and passive activities, predicted by momentary sadness. These activity patterns are consistent with descriptions of avolition and they minimally differentiated people with BD and schizophrenia. Previous reports of negative symptoms in BD may have been identifying these behaviors.

Self-reported social functioning and social cognition in schizophrenia and bipolar disorder: Using ecological momentary assessment to identify the origin of bias.

OBJECTIVES: People with schizophrenia (SCZ) and bipolar illness (BPI) generate self-reports of their functioning that diverge from objective information. It has been suggested that these participants do not base such reports on daily experiences, relying on other information. We used ecological momentary assessment (EMA) to sample socially relevant daily activities in SCZ and BPI and related them to self-reported and observer-rated social functioning and social cognitive ability. METHODS: 71 people with (BPI) were compared to 102 people with SCZ. Participants were sampled 3 times per day for 30 days with a smartphone-based survey. Each survey asked where they were, with whom they were, what they were doing, and if they were sad. Participants and observers were asked to provide ratings on social functioning and social cognitive abilities at the end of the EMA period. RESULTS: There was no association between being home or alone and self-reports of everyday social functioning. In contrast observer ratings were highly correlated with the momentary survey results. Reports of very low levels of sadness were associated with overestimated functioning and participants who were commonly home and alone rated their social functioning as better than participants who were commonly away in the presence of others. IMPLICATIONS: Both SCZ and BPI were marked by a disconnect between momentary experiences and self-reports. The largest effect was overestimation of functioning by participants who reported no sadness. Experience appears important, as participants who were routinely home and alone reported better social functioning than participants who spent more time others.

Cognitive and Social Cognitive Self-assessment in Autistic Adults.

An aspect of metacognition associated with broader functional abilities in several clinical conditions, but previously unexamined in autism, is self-assessment (i.e., the ability to accurately self-evaluate one's own performance). We compared self-assessment between 37 autistic adults without intellectual disability to 39 non-autistic (NA) controls on a series of three general cognitive and three social cognitive tasks. Whereas autistic adults and NA adults did not differ in their self-assessment accuracy on general cognitive tasks, they did on social cognitive tasks, with autistic adults demonstrating lower accuracy. The direction of their inaccuracy was variable (i.e., both over and underestimation), and self-assessment was largely unrelated to their level of social functioning. Over versus underestimation may have different functional implications, and warrants future investigation.

Confidence, performance, and accuracy of self-assessment of social cognition: A comparison of schizophrenia patients and healthy controls.

Impairments in self-assessment in schizophrenia have been shown to have functional and clinical implications. Prior studies have suggested that overconfidence can be associated with poorer cognitive performance in people with schizophrenia, and that reduced awareness of performance may be associated with disability. However, overconfidence is common in healthy individuals as well. This study examines the correlations between performance on a social cognitive test, confidence in performance, effort allocated to the task, and correlates of confidence in patients with schizophrenia and healthy controls (HC). Measures included self-reports of depression, social cognitive ability, and social functioning. A performance-based emotion recognition test assessed social cognitive performance and provided the basis for confidence judgments. Although schizophrenia patients had reduced levels of overall confidence, there was a substantial subset of schizophrenic patients who manifested extreme overconfidence and these people had the poorest performance and reported the least depression. Further, a substantial number of HC over-estimated their performance as well. Patients with schizophrenia, in contrast to HC, did not adjust their effort to match task difficulty. Confidence was minimally related to task performance in patients but was associated with more rapid decisions in HC, across both correct and incorrect responses. Performance on social cognitive measures was minimally related to self-reports of social functioning in both samples. These data suggest global self-assessments are based on multiple factors, with confidence affecting self-assessments in the absence of feedback about performance.

Self-assessment of social cognitive ability in schizophrenia: Association with social cognitive test performance, informant assessments of social cognitive ability, and everyday outcomes.

BACKGROUND: Impairments in self-assessment are common in people with schizophrenia and impairments in self-assessment of cognitive ability have been found to predict impaired functional outcome. In this study, we examined self-assessment of social cognitive ability and related them to assessments of social cognition provided by informants, to performance on tests of social cognition, and to everyday outcomes. The difference between self-reported social cognition and informant ratings was used to predict everyday functioning. METHODS: People with schizophrenia (n=135) performed 8 different tests of social cognition. They were asked to rate their social cognitive abilities on the Observable Social Cognition Rating Scale (OSCARs). High contact informants also rated social cognitive ability and everyday outcomes, while unaware of the patients' social cognitive performance and self-assessments. Social competence was measured with a performance-based assessment and clinical ratings of negative symptoms were also performed. RESULTS: Patient reports of their social cognitive abilities were uncorrelated with performance on social cognitive tests and with three of the four domains of functional outcomes. Differences between self-reported and informant rated social cognitive ability predicted impaired everyday functioning across all four functional domains. This difference score predicted disability even when the influences of social cognitive performance, social competence, and negative symptoms were considered. IMPLICATIONS: Mis-estimation of social cognitive ability was an important predictor of social and nonsocial outcomes in schizophrenia compared to performance on social cognitive tests. These results suggest that consideration of self-assessment is critical when attempting to evaluate the causes of disability and when trying to implement interventions targeting disability reduction.

Depression in Schizophrenia: Associations With Cognition, Functional Capacity, Everyday Functioning, and Self-Assessment.

Depressed mood has a complex relationship with self-evaluation of personal competence in multiple populations. The absence of depression may be associated with overestimation of abilities, while mild depression seems to lead to accurate self-assessment. Significant depression may lead to underestimation of functioning. In this study, we expand on our previous work by directly comparing the association between different levels of depression, everyday functioning, cognitive and functional capacity performance, and self-assessment of everyday functioning in a large (n = 406) sample of outpatients with schizophrenia. Participants with very low self-reported depression overestimated their everyday functioning compared with informant reports. Higher levels of depression were associated with more accurate self-assessment, but no subgroup of patients underestimated their functioning. Depressive symptom severity was associated with poorer informant-rated social functioning, but there were no differences in vocational functioning, everyday activities, cognitive performance, and functional capacity associated with the severity of self-reported depression. There was minimal evidence of impact of depression on most aspects of everyday functioning and objective test performance and a substantial relationship between depression and accuracy of self-assessment.

Self-assessment of social cognitive ability in individuals with schizophrenia: Appraising task difficulty and allocation of effort.

Patients with severe mental illnesses manifest substantial deficits in self-assessment of the abilities that impact everyday functioning. This study compares patients with schizophrenia to healthy individuals on their social cognitive performance, their assessment of that performance, and the convergence between performance and indicators of effort in solving tasks. Patients with schizophrenia (n=57) and healthy controls (HC; n=47) completed the Bell-Lysaker Emotion Recognition Test (BLERT), a psychometrically sound assessment of emotion recognition. Participants rated their confidence in the accuracy of their responses after each item. Participants were instructed to respond as rapidly as possible without sacrificing accuracy; the time to complete each item was recorded. Patients with schizophrenia performed less accurately on the BLERT than HC. Both patients and HC were more confident on items that they correctly answered than for items with errors, with patients being less confident overall; there was no significant interaction for confidence between group and accuracy. HC demonstrated a more substantial adjustment of response time to task difficulty by taking considerably longer to solve items that they got wrong, whereas patients showed only a minimal adjustment. These results expand knowledge about both self-assessment of social cognitive performance and the ability to appraise difficulty and adjust effort to social cognitive task demands in patients with schizophrenia.