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Identifying momentary risk and protective mechanisms may enhance our understanding and treatment of mental disorders. Affective stress reactivity is one mechanism that has been reported to be altered in individuals with early and later stages of mental disorder. Additionally, initial evidence suggests individuals with early and enduring psychosis may have an extended recovery period of negative affect in response to daily stressors (ie, a longer duration until affect reaches baseline levels after stress), but evidence on positive affective recovery as a putative protective mechanism remains limited.
This study aimed to investigate trajectories of positive affect in response to stress across the continuum of mental disorder in a transdiagnostic sample.
Using the Experience Sampling Method, minor activity-, event-, and overall stress and positive affect were assessed 10 times a day, with time points approximately 90 minutes apart on six consecutive days in a pooled data set including 367 individuals with a mental disorder, 217 individuals at risk for a severe mental disorder, and 227 controls. Multilevel analysis and linear contrasts were used to investigate trajectories of positive affect within and between groups.
Baseline positive affect differed across groups, and we observed stress reactivity in positive affect within each group. We found evidence for positive affective recovery after reporting activity- or overall stress within each group. While controls recovered to baseline positive affect about 90 minutes after stress, patients and at-risk individuals required about 180 minutes to recover. However, between-group differences in the affective recovery period fell short of significance (all
The results provide first evidence that positive affective recovery may be relevant within transdiagnostic subclinical and clinical stages of mental disorder, suggesting that it may be a potential target for mobile health interventions fostering resilience in daily life.
When developing a mental disorder, an individual is commonly assumed to experience a state in which psychological distress and symptoms gradually increase without fully meeting diagnostic criteria [
There is consistent evidence on high comorbidity in at-risk individuals, which has been taken to suggest a pluripotent risk state or early shared mechanisms, from which individuals may transition to different, more specific exit syndromes of severe mental disorder, for example, psychotic or affective disorders [
Focusing on underlying mechanisms, experience sampling studies have emphasized the importance of investigating risk and resilience mechanisms when studying transdiagnostic and subclinical samples in daily life [
So far, research into momentary mechanisms has focused on negative affect. There is initial evidence that individuals with early mental health problems may experience extended momentary negative affective recovery from minor stressors in daily life, that is, they take longer to overcome minor adversities in daily life [
Against this background, this study aimed to investigate trajectories of momentary positive affect following exposure to minor stressors in daily life across transdiagnostic stages of mental disorder in a pooled sample of patients with a mental disorder (ie, psychotic disorder, depressive disorder with residual symptoms), individuals with an increased psychometric or familial risk for developing a severe mental disorder, and controls. To examine, in detail, the entire positive affective recovery process from minor stressors through to recovery to baseline levels, we aimed to investigate (1) levels of positive affect prior to reporting a minor daily stressor; (2) initial positive affective reactivity following the stressor—operationalized as the decrease in positive affect associated with minor (i) event-related, (ii) activity-related, and (iii) composite stress (as previously operationalized in experience sampling studies [
H1: Within each group (patients with a mental disorder, at-risk individuals, controls), exposure to (i) event-related, (ii) activity-related, or (iii) composite stress is associated with (a) an initial decrease in positive affect (ie, stress reactivity) and (b) subsequent to initial stress reactivity, lower levels of positive affect before recovering to baseline level (ie, affective recovery).
H2: Baseline levels of positive affect, that is, prior to reporting (i) event-related, (ii) activity-related, or (iii) composite stress, are lower in (a) patients with a mental disorder than in controls, (b) at-risk individuals than in controls, and (c) at-risk individuals than in patients with a mental disorder.
H3: Positive affective reactivity from minor stress is greater in (a) patients with a mental disorder than in controls, (b) at-risk individuals than in controls, and (c) at-risk individuals than in patients with a mental disorder.
H4: Positive affective recovery from minor stress, that is, the average decrease of positive affect from baseline before returning to baseline levels of positive affect following (i) event-related, (ii) activity-related, or (iii) composite stress, is greater in (a) patients with a mental disorder than in controls, (b) at-risk individuals than in controls, and (c) at-risk individuals than in patients with a mental disorder.
The pooled sample comprised participants from 8 previously conducted studies that used a similar protocol and are part of the ESM merge file. These studies included individuals with a mental disorder, that is, psychotic disorder [
All 8 studies received approval by their respective medical ethics committees in the Netherlands and Belgium as stated in the original references and all procedures were performed in accordance with the ethical standards of the responsible medical ethics committee. This study was registered on OSF (Open Science Framework) before data access [
Data were collected using the ESM, a structured diary technique [
For the current analysis, experience sampling constructs available in all included studies were selected to measure positive affect, momentary event-related stress, and momentary activity-related stress. Positive affect was measured with 3 items beginning with “I feel” followed by the adjectives “cheerful,” “relaxed,” and “satisfied” (1=not at all; 7=very much). Based on previous experience sampling studies [
Mean scores of the 3 positive affect items were centered around the person and day means and z standardized. In addition to momentary event– and activity-related stress, after justifying its use by principal component analysis (see
Stata version 16.0 (StataCorp LLC) was used for statistical analysis [
To test the hypotheses, the procedure described by Vaessen et al [
For each momentary stressor (event-related, activity-related, and composite stress), separate models were fitted. For each model, observations were excluded (i) for participants who never reported the specific type of stress, (ii) for days on which the specific type of stress was not reported, and (iii) for days on which the specific type of stress was reported on the first prompt of the day so that no baseline measure was available.
All models were adjusted for age (centered using the grand mean) and gender (for unadjusted models, see
The sample comprised 921 participants. This includes 422 individuals with a mental disorder (ie, 293 with psychotic disorder and 129 with remitted depressive disorder with residual symptomatology), 246 at-risk individuals (ie, 178 with familial and 68 with psychometric risk), and 253 controls. Participants completed a total of 42,778 prompts. Average compliance was 75% (45/60 prompts) for patients, 78% (47/60 prompts) for at-risk individuals, and 82% (49/60 prompts) for controls (
Hence, the analytic sample consisted of 811 participants (patients/at-risk/controls: n=367/217/227) with a total of 39,903 valid prompts (patients/at-risk/controls: n=16,122/9997/10,784). Sample characteristics of the analytic sample are depicted in
Basic sample characteristics.
Characteristic | Patients (n=367) | At-risk (n=217) | Controls (n=227) | Test statistic | Significant contrasts | ||
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Male | 187 | 90 | 93 |
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Female | 180 | 127 | 134 |
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Age, mean (SD) | 38.07 (11.42) | 36.41 (13.12) | 35.50 (12.56) | .04 | Patients versus controls | ||
Observations per person, mean (SD) | 43.93 (10.07) | 46.07 (9.21) | 47.51 (9.10) | <.001 | Patients versus controls | ||
Stressful days per person, mean (SD) | 5.92 (0.58) | 5.96 (0.41) | 5.99 (0.48) | .25 |
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Time of first stressora, mean | 2:59 PM | 3:07 PM | 2:55 PM | .72 |
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Unpleasantness of first stressora, mean (SD) | 2.00 (0.62) | 1.88 (0.63) | 1.91 (0.63) | .04 | Patients versus at-risk | ||
Positive affect, mean (SD) | 4.27 (0.93) | 4.89 (0.94) | 5.16 (0.71) | <.001 | At-risk versus controls; patients versus controls; patients versus at-risk |
aExcluding stressors that were reported at the first prompt of the day.
Patients showed a decrease in positive affect in response to all types of stress (event-related stress:
At-risk individuals showed a decrease in positive affect in response to all types of stress (event-related stress:
As with the other groups, controls showed a decrease in positive affect in response to all types of stress (event-related stress:
Within-group analysis of all stress measures comparing positive affect at baseline (t–1) with time points t0 (stress reactivity), t1, and t2 (all groups recovered) adjusted for age and gendera.
Stress type | Patients | At-risk | Controls | ||||||||||||||
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t0 | –0.35 (–0.43 to –0.28) | <.001c | –0.34 (–0.43 to –0.26) | <.001c | –0.27 (–0.35 to –0.19) | <.001c |
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t1 | –0.06 (–0.13 to 0.02) | .16 | –0.08 (–0.16 to 0.02) | .10 | –0.04 (–0.13 to 0.04) | .32 |
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Age | –0.002 (–0.01 to 0.01) | .52 | 0.01 (0.002 to 0.02) | .01c | 0.01 (0.004 to 0.02) | .001c |
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Gender | –0.13 (–0.28 to 0.03) | .11 | 0.06 (–0.14 to 0.27) | .56 | 0.001 (–0.16 to 0.16) | .99 |
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t0 | –0.49 (–0.60 to –0.38) | <.001c | –0.54 (–0.68 to –0.40) | <.001c | –0.60 (–0.74 to –0.46) | <.001c |
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t1 | –0.14 (–0.26 to –0.02) | .02c | –0.17 (–0.33 to –0.02) | .03 | –0.15 (–0.30 to 0.001) | .05 |
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t2 | 0.008 (–0.12 to 0.13) | .90 | –0.09 (–0.25 to 0.07) | .27 | –0.09 (–0.24 to 0.06) | .25 |
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Age | –0.0004 (–0.01 to 0.01) | .92 | 0.01 (0.004 to 0.02) | .005c | 0.009 (0.001 to 0.02) | .03 |
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Gender | –0.22 (–0.42 to –0.02) | .03 | 0.05 (–0.21 to 0.30) | .72 | 0.07 (–0.16 to 0.29) | .55 |
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t0 | –0.38 (–0.45 to –0.31) | <.001c | –0.38 (–0.46 to –0.30) | <.001c | –0.32 (–0.40 to –0.25) | <.001c |
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t1 | –0.11 (–0.19 to –0.04) | .004c | –0.11 (–0.20 to –0.03) | .01 | –0.07 (–0.15 to 0.01) | .10 |
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t2 | –0.02 (–0.09 to 0.06) | .66 | –0.05 (–0.14 to 0.03) | .23 | –0.09 (–0.18 to –0.01) | .03 |
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Age | –0.001 (–0.01 to 0.01) | .71 | 0.01 (0.004 to 0.02) | .003c | 0.01 (0.003 to 0.02) | .002c |
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Gender | –0.12 (–0.27 to 0.03) | .12 | 0.07 (–0.12 to 0.27) | .47 | –0.01 (–0.17 to 0.14) | .88 |
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aTime point t–1 (ie, baseline) serves as reference category; effect of female gender is depicted.
bMissing cases: nindividuals=30; nprompts=1182.
cSignificant after Simes correction.
dMissing cases: nindividuals=348; nprompts=7680.
When controlling for subsequent stressors in the within-group analysis, that is, the presence or absence of a stressor at the time points after the initial stressor, none of the groups showed a delayed recovery irrespective of the type of stressor. For the composite stress measure, all groups showed a decrease in positive affect at t0 compared with t–1 (controls:
Within-group analysis of all stress measures comparing positive affect at baseline (t–1) with time points t0 (stress reactivity), t1, and t2 (all groups recovered) adjusted for age and gender, and subsequent stressa.
Stress type | Patients | At-risk | Controls | ||||||||||||
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t0 | –0.36 (–0.43 to –0.29) | <.001c | –0.35 (–0.44 to –0.27) | <.001c | –0.29 (–0.37 to –0.21) | <.001c | ||||||||
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t1 | 0.07 (–0.01 to 0.15) | .08 | –0.02 (–0.11 to 0.08) | .74 | 0.01 (–0.08 to 0.10) | .82 | ||||||||
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Age | –0.003 (–0.01 to 0.004) | .45 | 0.01 (0.002 to 0.02) | .01 | 0.01 (0.004 to 0.02) | .001 | ||||||||
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Gender | –0.11 (–0.26 to 0.04) | .16 | 0.06 (–0.14 to 0.27) | .55 | 0.01 (–0.14 to 0.17) | 0.87 | ||||||||
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Subsequent stress | –0.54 (–0.61 to –0.47) | <.001c | –0.37 (–0.46 to –0.28) | <.001c | –0.39 (–0.48 to –0.30) | <.001c | ||||||||
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t0 | –0.49 (–0.60 to –0.38) | <.001c | –0.54 (–0.68 to –0.40) | <.001c | –0.61 (–0.75 to –0.47) | <.001c | ||||||||
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t1 | –0.07 (–0.19 to 0.05) | .23 | –0.07 (–0.23 to 0.10) | .42 | –0.08 (–0.23 to 0.07) | .28 | ||||||||
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t2 | 0.07 (–0.06 to 0.19) | .30 | –0.03 (–0.19 to 0.14) | .74 | –0.07 (–0.23 to 0.08) | .35 | ||||||||
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Age | –0.001 (–0.01 to 0.01) | .90 | 0.01 (0.003 to 0.02) | .008 | 0.009 (0.0002 to 0.02) | .04 | ||||||||
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Gender | –0.21 (–0.41 to –0.01) | .04 | 0.06 (–0.19 to 0.31) | .65 | 0.07 (–0.15 to 0.29) | .54 | ||||||||
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Subsequent stress | –0.58 (–0.73 to –0.44) | <.001c | –0.66 (–0.87 to –0.45) | <.001c | –0.60 (–0.80 to –0.40) | <.001c | ||||||||
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t0 | –0.38 (–0.45 to –0.31) | <.001c | –0.38 (–0.46 to –0.31) | <.001c | –0.32 (–0.40 to –0.25) | <.001c | ||||||||
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t1 | 0.03 (–0.04 to 0.11) | .42 | –0.03 (–0.11 to 0.06) | .53 | 0.02 (–0.06 to 0.10) | .58 | ||||||||
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t2 | 0.08 (0.01 to 0.16) | .04 | 0.02 (–0.07 to 0.10) | .72 | –0.02 (–0.10 to 0.06) | .65 | ||||||||
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Age | –0.001 (–0.01 to 0.01) | .69 | 0.01 (0.003 to 0.02) | .004 | 0.01 (0.003 to 0.02) | .003 | ||||||||
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Gender | –0.11 (–0.26 to 0.04) | .15 | 0.073 (–0.119 to 0.265) | .45 | –0.003 (–0.155 to 0.148) | .966 | ||||||||
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Subsequent stress | –0.53 (–0.60 to –0.47) | <.001c | –0.40 (–0.48 to –0.32) | <.001c | –0.47 (–0.54 to –0.39) | <.001c |
aTime point t–1 (ie, baseline) serves as reference category; effect of female gender is depicted.
bMissing cases: nindividuals = 30; nprompts = 1182.
cSignificant after Simes correction.
dMissing cases: nindividuals = 348; nprompts = 7680.
Trajectories of positive affect following composite stress. (Adjusted predictive margins of the multilevel regression analysis for the composite stress measure are displayed. Error bars represent 95% CIs.)
Differences in baseline positive affect (t–1), stress reactivity (t0), and affective recovery (average deviation of positive affect from baseline levels during t1 – t2) between groupsa.
Stress type | At-risk versus controls | Patients versus controls | Patients versus at-risk | ||||||
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t–1 | –0.34 (–0.57 to –0.11) | .003b | –0.74 (–0.95 to –0.54) | <.001b | –0.40 (–0.60 to –0.21) | <.001b | ||
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t0 | 0.06 (–0.15 to 0.27) | .57 | 0.11 (–0.07 to 0.29) | .23 | 0.05 (–0.13 to 0.23) | .58 | ||
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t1–t2 | –0.01 (–0.21 to 0.18) | .89 | 0.05 (–0.12 to 0.22) | .57 | 0.06 (–0.11 to 0.23) | .46 | ||
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t0 | –0.07 (–0.19 to 0.05) | .27 | –0.09 (–0.19 to 0.03) | .13 | –0.02 (–0.13 to 0.09) | .76 | ||
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t–1 | –0.28 (–0.43 to –0.13) | <.001b | –0.44 (–0.57 to –0.31) | <.001b | –0.44 (–0.57 to –0.31) | <.001b | ||
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t0 | –0.06 (–0.17 to 0.06) | .35 | –0.06 (–0.16 to 0.05) | .30 | 0.001 (–0.10 to 0.11) | .99 | ||
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t1–t2 | 0.01 (–0.10 to 0.12) | .89 | 0.02 (–0.07 to 0.12) | .62 | 0.02 (–0.08 to 0.11) | .74 |
aAdjusted for age and gender.
bSignificant after Simes correction.
cModel for t–1 did not converge.
This study aimed to investigate trajectories of positive affect in response to daily life stress across different transdiagnostic clinical stages in a pooled sample of patients with a mental disorder, individuals at psychometric or familial risk, and controls. All groups showed a similar trajectory of positive affect in response to momentary stress, as indicated by a decrease in positive affect to event-related, activity-related, or composite stress, and a continuously lower level of positive affect before recovering to baseline level in response to activity-related or composite stress (H1). We observed a continuous recovery period of 180 minutes on average in patients and at-risk individuals, whereas controls required 90 minutes on average to recover. Comparisons across groups revealed that patients with a mental disorder and at-risk individuals had lower baseline levels of positive affect in daily life compared with controls (H2). Contrary to our prediction, patients had lower levels of positive affect compared with at-risk individuals. Differences in positive affective reactivity to daily stress between groups (H3) and in positive affective recovery fell short of statistical significance (H4).
Several methodological considerations should be taken into account when interpreting the reported findings. First, because this study used existing data, participants with different clinical characteristics were pooled to form transdiagnostic groups as an approximation to representing subclinical and clinical stages of mental disorder based on the literature of clinical staging. To further support the staging approach and ensure that participants with different clinical characteristics form a group regarding severity of symptoms or functional impairment as suggested by clinical staging, latent class analysis may be used in future analysis to identify groups with similar behavioral patterns. Furthermore, participants may be recruited according to recently developed criteria for clinical staging as there is first evidence for their validity as a way of identifying individuals in early stages with predictive power for transition between stages [
Second, the dichotomous operationalization of stress as the presence or absence of a stressor does not account for the degree of unpleasantness of a reported activity or event, which reduces variance. An activity or event rated as –3 may impact positive affect longer than an activity or event rated as –1. Similarly, Vaessen et al [
Third, stress reactivity at t0 was modeled in a cross-sectional manner, that is, ratings of stress and positive affect measured at the same time point were used to define stress reactivity. Therefore, temporal order between the first stressor of a day and an associated decrease in positive affect remains unclear as a stressor may lead to a decrease in positive affect, or vice versa. Yet, the cross-sectional modeling does not restrict interpretations regarding the recovery period, which was of main interest in this study, operationalized using time points chronologically before and after the occurrence of stress.
Relatedly, the exploratory finding that positive affective recovery within groups may be accounted for by cumulative stress at the following time points should be interpreted with caution. A recent review showed that experiencing positive affect can impact the neural signaling of stress, which may lead to less self-reported stress [
Last, the composite stress measure combining event- and activity-related stress may hold restrictions. Both stress types may be related to affective recovery in different ways. Specifically, event-related stress is a retrospective judgment of the most important event that happened since the last prompt. As the time points were approximately 90 minutes apart, the unpleasant event might have happened up to 90 minutes before the rating, meaning that an immediate drop in positive affect after the event and the beginning of the recovery period might not have been recorded by the random sampling procedure. Activity-related stress, by contrast, measures the unpleasantness of the current activity. The sampling procedure does not reveal when an unpleasant activity started or for how long it was continued after the measurement, which may also influence positive affect ratings at baseline or during the recovery period. We found no recovery period after event-related stress and effect sizes were lower at t0 for event-related stress than at the same time point for activity-related stress (
In line with previous research [
Furthermore, the magnitude of differences in positive affective reactivity and recovery between groups might have been too small to be detected with the number of observations per day in our models. In addition, criteria other than clinical status might be relevant to index risk and identify group differences in trajectories of positive affect in response to minor stressors, such as childhood adversities. In line with the stress sensitization hypothesis [
To our knowledge, this is the first study to transdiagnostically investigate the trajectories of positive affect after minor stressors in daily life. It has been shown that positive and negative affect can be conceptualized as 2 distinct factors [
In this study, we found first evidence for different trajectories of positive affect following minor daily stressors in a transdiagnostic sample covering the continuum of mental health. Whether positive affective recovery on the scale of minor stressors in daily life may be a putative indicator for momentary resilience should be investigated further in the context of childhood adversity, specifically focusing on healthy, that is, resilient, individuals exposed to adversities. When disentangling this putative protective mechanism further, trajectories of affective recovery may potentially serve as a target for ecological momentary interventions, a mobile health approach using mobile devices to deliver interventions in daily life [
Graphic illustration of the expected trajectories of positive affect in the context of a minor daily stressor in subclinical and clinical stages of mental disorder.
Overview of pooled studies.
Principle component analysis of the composite stress measure.
Unadjusted within-group analysis comparing positive affect at baseline (t-1) to time points t0 (stress reactivity) to tn (all groups recovered).
experience sampling methodology
This work was supported by the German Federal Ministry of Education and Research (grant number 01EC1904B) and a Heisenberg professorship from the German Research Foundation (grant number 389624707) to UR. IM-G was supported by an FWO Odysseus grant (G0F8416N). TV was supported by an FWO junior postdoctoral fellowship (ZKD6724). We thank all researchers that substantially contributed to the conception and design of the included experience sampling studies and/or contributed to compile and check the data in this combined ESM data set. In alphabetical order: M. Bak, D. Collip, N. Nicolson, I. Myin-Germeys, N. Geschwind, C. Henquet, N. Jacobs, M. Janssens, M. Lardinois, J. Lataster, T. Lataster, C. Menne-Lothmann, M. van Nierop, M. Oorschot, C.J.P. Simons, V. Thewissen, and M. Wichers. We also thank all research personnel that provided general administrative support in preparing the ESM data set, in particular T. Driesen.
Data pertain to the ESM merge file. The ESM merge file is a data set combining multiple ESM studies that have been performed at Maastricht University. Data are available upon reasonable request from researchers. Researchers can send their request to the Department of Psychiatry & Neuropsychology of Maastricht University, School for Mental Health and Neuroscience, by sending an email to info@esm-maastricht.nl.
LA performed data analysis and drafted the manuscript. AS and UR supervised the study and AS, CS, IM-G, and UR were involved in critical revision of the manuscript. TV provided advice on statistical analysis and LA, AS, and UR interpreted the findings. LA, AS, IM-G, TV, and UR developed the conception and all authors contributed to the design of this study. CS, PD, and IM-G were involved in data acquisition for the data used in the analysis. All authors have read and approved the final version of the manuscript.
None declared.