Ecological momentary assessment of everyday social experiences of people with schizophrenia: A systematic review
Introduction
Our ability to navigate our social world is a key facet of daily life. People with schizophrenia (SZ) exhibit difficulties with multiple domains of social functioning, including social skill deficits (Bellack et al., 1990; Mueser et al., 1991), social cognition impairments (Green et al., 2015), loneliness (Lim et al., 2018), reduced social network size (Gayer-Anderson and Morgan, 2013), social motivation impairments (Fulford et al., 2018), and elevated trait social anhedonia (Blanchard et al., 1994, 2001). Studies of social impairment in SZ have relied primarily on retrospective or trait self-report interviews, questionnaires, or laboratory-based measures of functioning (e.g., role plays, facial emotion identification tasks), assessments that have had their reliability and ecological validity called into question (Bowie et al., 2007; Burns and Patrick, 2007; Sabbag et al., 2012; Yager and Ehmann, 2006). Limitations of these methods include lack of coverage of context-specific aspects of social experiences in a naturalistic setting (e.g., how one feels in the presence of a family member versus a stranger) as well as the difficulties in examining interactions among different social experiences over time (e.g., whether positive affect experienced during social activity predicts future social activity). These important qualities of the social worlds of people with SZ are left unmeasured in currently available “gold-standard” functioning assessments.
Ecological momentary assessment (EMA), also known as the experience sampling method, allows researchers to understand participants’ in-the-moment, everyday experiences. Typically, participants are provided with a mobile device (e.g., a Personal Digital Assistant, digital wristwatch, smartphone) that is programmed to signal them multiple times per day over a series of days or weeks to answer brief, specific questions as they go about their daily life. EMA has many strengths over traditional functioning assessment methods. It allows for the relatively unobtrusive, remote assessment of a variety of context-specific experiences, thus providing a more ecologically valid assessment of phenomena (Csikszentmihalyi and Larson, 2014; Devries, 1987; Myin-Germeys et al., 2009; Shiffman et al., 2008). EMA does not require a participant to summarize experiences over a long duration of time, minimizing the biases inherent in other self-report assessments. For example, a person may more easily and accurately reflect on a recent social interaction through EMA (e.g., “How involved were you in your most recent interaction?“) compared to reflecting on several previous social interactions during an interview (e.g., “How involved were in you all of your social interactions over the past month?“). Further, EMA does not rely as heavily on cognitive skills that people with SZ often struggle with and other assessment strategies rely on, such as memory and abstract reasoning. For example, one might obtain a more accurate assessment of social pleasure by asking a person with SZ to reflect on how they feel immediately following a social interaction using EMA versus asking them to imagine how they would feel in a hypothetical social interaction (e.g., on a survey) or how they feel in response to a smiling face on a computer screen (e.g., in a laboratory task).
Because laboratory-based and clinical assessments are used to make inferences about the social functioning of people with SZ, it is important to understand whether they are related to the social experiences that people with SZ have in their daily lives or whether they represent other constructs that are correlated with one’s social world (e.g., beliefs about one’s social competence, social experience memory recall, etc.). For example, recent research has shown that people with SZ show intact hedonic responding in the presence of positive social interactions in laboratory settings (Aghevli et al., 2003; Martin et al., 2019) despite reporting social anhedonia on trait-based measures (Blanchard et al., 1994, 2001). Thus, different assessment methods may measure different aspects of social pleasure (e.g., in-the-moment hedonic responding versus beliefs regarding social pleasure) rather than reflecting the same dysfunction (“social anhedonia”). If EMA-reported social experiences during real-world social interactions relate to clinical functioning assessments, this would suggest that the two methods reflect the same construct. Alternatively, if social functioning assessments are not related to EMA-reported social outcomes, these methods may reflect separate constructs under the broader umbrella of “social functioning” in SZ.
While EMA has been used as a method to understand the social experiences of people with SZ over the past two decades, no systematic efforts to date have been conducted to summarize our understanding of this literature. As such, in the current study, we systematically reviewed research that utilized EMA to understand the social experiences of people with SZ. Our primary goals were to 1) examine the utility of using EMA to assess everyday social experiences in people with SZ, and 2) explore whether EMA-reported social outcomes were related to traditional social functioning assessments. We were interested in aspects of experiences related to time participants spent both alone (including the quantity of time spent alone, the affective experience of being alone, and whether participants preferred to be with others) and with others (including whom participants spent time with, the extent of involvement in a given social experience, the affective experience of being with others, whether participants preferred to be alone when with others, and factors related to spending time with others). We were also interested in EMA studies that included laboratory-based or clinical assessments of functioning, to better understand whether and in what contexts these measures were related to momentary social experiences of people with SZ. We included discussion of differences between people with and without SZ for each domain of social experience assessed through EMA when studies included a healthy comparison group. Additionally, when relevant, we included discussion of the relationship between other outcomes that were studied (e.g., psychiatric symptoms) and these domains of momentary social experiences in people with SZ.
Section snippets
Literature search strategy
We conducted a systematic review of EMA studies assessing our pre-determined characterizations of social experiences. We utilized the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA; Moher et al., 2009) guidelines for this review. The electronic databases of PubMed and PsycINFO were searched for combinations of the following key word terms within the abstract of a given study: “schizo*“, “psychosis”, or “psychotic”; and “ecological momentary”, “experience sampl*“,
Results
The database search and reference list review returned 139 results, providing 118 unique articles after duplicates were removed (see Fig. 1). After 47 articles were excluded at the title/abstract stage of review, a remaining 49 were excluded after reviewing the full text of the citation. At this stage, articles were excluded due to the following reasons: researchers utilized EMA to assess outcomes other than social experiences (n = 28); researchers utilized EMA to assess an aspect of social
Discussion
In this review, we summarize studies conducted over the past two decades on the assessment of social experiences in people with SZ using EMA. Despite the heterogeneity of questions asked, EMA has provided granular assessments of a variety of social experiences, including quantity of experiences across discrete periods, affect in the context of social activity, and the relationship between social experiences and other facets of the disorder (symptoms, stigma, suicidality, etc.). While many
Role of the funding source
The authors declare no source for this manuscript.
Contributors
All authors contributed to this manuscript with conception and design of the study, literature review and analysis, drafting, and critical revision and editing. All authors have approved the final manuscript.
Declaration of competing interest
All authors declare that they have no conflicts of interest.
Acknowledgments
The authors wish to thank Samuel Abplanalp, Cristina Colon-Semenza, Arti Gandhi, and Kathryn Gill for their comments on an earlier draft of this manuscript.
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