The impact of emotion awareness and regulation on psychotic symptoms during daily functioning

The study investigates whether and how momentary, in vivo use of emotion regulation (ER) strategies (suppression and reappraisal) relates to fluctuations in specific psychotic symptoms during daily life in schizophrenia, and whether emotion awareness moderates these relationships. Prior work shows people with schizophrenia commonly exhibit ER difficulties, with greater reliance on suppression and less on reappraisal, but links to psychotic symptoms have been inconsistent, often due to retrospective assessments, focus on total psychosis rather than specific symptoms, and limited consideration of emotion awareness (alexithymia components). The authors hypothesize that experience sampling (ESM) assessments will reveal temporal associations between momentary ER use and psychotic symptoms, and that poorer emotion awareness will strengthen these associations.

Background literature indicates: (a) ER difficulties are core in schizophrenia; reappraisal is generally adaptive while suppression is maladaptive in nonclinical samples. (b) Individuals with psychosis-spectrum conditions tend to use more suppression and less reappraisal; meta-analytic evidence supports this. (c) Prior links between ER and psychosis are mixed, often relying on retrospective self-reports vulnerable to memory biases and focusing on overall psychosis burden rather than specific symptoms; only limited symptom-specific findings (e.g., paranoia) have been reported. (d) Emotion awareness (alexithymia components, especially difficulties identifying and describing feelings) is frequently impaired in schizophrenia and may undermine ER effectiveness, yet has rarely been examined as a moderator in ER–psychosis links. ESM studies suggest patients initiate ER at lower negative affect thresholds, select more and less context-appropriate strategies, and show poorer ER effectiveness; suppression has been linked to state paranoia. However, prior ESM studies often measured either ER or symptoms retrospectively, focused narrowly on paranoia, or did not test moderation by emotion awareness.

Design: Ambulatory experience sampling method (ESM) over 36 hours (10 am Day 1 to 10 pm Day 2) with mobile devices prompting 10 random beeps/day (total ~20 prompts), assessing current psychotic symptoms, a stressor since the last beep (~up to 1.5 hours), and degree of use of ER strategies to address that stressor. Responses were on 1–100 scales. Participants: N=54 adults with DSM-IV schizophrenia-spectrum disorders (41 schizophrenia, 11 schizoaffective, 2 schizophreniform), ages 18–55, English-speaking, IQ>80, with moderate or greater hallucinations/delusions (SAPS ≥3). Exclusions: recent street drug use (urine tox), low reading ability (WTAR<7), severe cardiac conditions. Data pooled from two parallel studies at NYSPI (baseline assessments), identical procedures (June 2008–May 2013). IRB-approved; informed consent obtained. Measures:

• Diagnoses: DIGS interview.
• Psychotic symptoms: Retrospective—SAPS (past week). In vivo ESM—suspiciousness, thought insertion, mind reading, auditory/visual hallucinations.
• Emotion regulation: Retrospective—ERQ (reappraisal: 6 items; suppression: 4 items). Momentary in vivo (mER)—four ERQ-adapted items: suppression index = mean of “keep emotions to myself” and “careful not to express emotions”; reappraisal index = mean of “think about it in a way to stay calm” and “controlled emotions by changing thinking.”
• Emotion awareness: Toronto Alexithymia Scale (TAS-20) Total, and subscales DIF (difficulties identifying feelings) and DDF (difficulties describing feelings); EOT excluded due to reliability concerns.
• Covariates/descriptives: demographics, medication (CPZ equivalents), WTAR, depression/anxiety (BDI/BAI). Procedures: Training on device use; participants carried Palm Tungsten T3 devices; concurrent cardiopulmonary monitoring (not reported here). Participants completed baseline diagnostic/symptom/EA/ER evaluations within 2–3 weeks of enrollment; ESM on weekdays. Data quality: Excluded participants with <33% ESM compliance; mean completed prompts ~15.07 (SD 4.12); response rate ~75.4%. Statistical analyses: (1) Pearson correlations for associations between retrospective ER (ERQ) and retrospective psychotic symptoms (SAPS). (2) Linear mixed-effects models (subject random intercepts), outcome: momentary psychotic symptom at time i; predictors: mER suppression or mER reappraisal; adjusted for day effect. (3) Moderation by emotion awareness (TAS-20 Total, DIF, DDF) via interaction terms; Holm’s sequential Bonferroni for multiple testing.

Sample: N=54; mean age 32.31 (SD 8.23); 60% female; diverse racial/ethnic composition; mean education 14.73 years (SD 3.48); WTAR 39.61 (SD 8.42); mean antipsychotic dose 323.79 CPZ equivalents (SD 335.42); average 15.07 ESM samples (SD 4.12; 75.4% response rate). Retrospective associations: No significant associations between ERQ suppression or reappraisal and SAPS-indexed psychotic symptoms. Momentary ER predicting momentary psychotic symptoms (linear mixed models):

• Suppression:
  • Thought insertion: Estimate 0.14, SE 0.05, t=2.97, p=0.0032 (significant increase).
  • Mind reading: Estimate 0.09, SE 0.05, t=1.98, p=0.05 (borderline/significant per table marking not bold; reported as prediction of increases).
  • Auditory hallucinations: Estimate 0.08, SE 0.03, t=2.31, p=0.02 (significant increase).
  • Visual hallucinations: Estimate 0.11, SE 0.03, t=3.25, p<0.01 (significant increase).
  • Suspiciousness: Estimate 0.07, SE 0.05, t=1.62, p=0.11 (ns).
• Reappraisal:
  • Suspiciousness: Estimate 0.10, SE 0.04, t=2.21, p=0.03 (significant increase).
  • Thought insertion: Estimate 0.26, SE 0.04, t=5.99, p<0.0001 (significant increase).
  • Mind reading: Estimate 0.22, SE 0.04, t=5.02, p<0.0001 (significant increase).
  • Auditory hallucinations: Estimate −0.01, SE 0.03, t=−0.31, p=0.76 (ns).
  • Visual hallucinations: Estimate 0.02, SE 0.03, t=0.50, p=0.62 (ns). Moderation by emotion awareness (TAS-20):
• Poor emotion awareness significantly strengthened the positive associations between mER suppression and thought insertion (standardized effect ≈ 0.01, p<0.01) and mind reading (standardized effect ≈ 0.01, p<0.0001).
• Moderation also observed for mER reappraisal and paranoia (suspiciousness); details indicate effects primarily driven by difficulties identifying feelings (DIF).

Findings show that momentary, in vivo use of ER strategies relates to concurrent increases in specific psychotic symptoms among individuals with schizophrenia, whereas retrospective ER–symptom associations were not detected. Suppression predicted elevations in thought insertion, mind reading, and auditory/visual hallucinations. Reappraisal unexpectedly predicted increases in suspiciousness, thought insertion, and mind reading, suggesting that although patients attempt reappraisal in daily life, their efforts may be ineffective or ill-suited to the context, particularly under higher symptom severity and environmental demands. Critically, poorer emotion awareness (especially difficulties identifying feelings) amplified the impact of ER (notably suppression) on psychotic symptoms, supporting models that emphasize emotion labeling as foundational for effective ER. These results address the research questions by demonstrating temporal, symptom-specific links and highlighting emotion awareness as a key moderator, underscoring the need to consider emotional granularity and awareness in understanding and treating psychotic symptom fluctuations.

This study is the first to characterize in vivo, in situ links between momentary ER use, emotion awareness, and specific psychotic symptoms during daily functioning in schizophrenia. It shows that both suppression and reappraisal (as used in daily life) can be associated with transient exacerbations of certain positive symptoms, and that poorer emotion awareness intensifies these effects. Clinically, integrating assessment and training of emotion awareness and ER into psychosis interventions is warranted, and high time-resolution methods like ESM are valuable for capturing dynamic symptom processes. Future research should expand to additional ER strategies, evaluate emotion awareness momentarily via ESM, include measures of memory to parse recall biases, and test whether improving emotion labeling/granularity enhances ER effectiveness and reduces symptom exacerbations.

• Only two ER strategies (suppression, reappraisal) were examined; other strategies may have different effects.
• ER use and psychotic symptoms were assessed within the same ESM prompts, so common-method or momentary mood influences cannot be fully excluded.
• Emotion awareness was measured as a trait (TAS-20), not momentarily via ESM.
• Episodic memory was not assessed; potential recall biases (even over short intervals) could affect reports.
• Sample included individuals with moderate or greater positive symptoms, which may limit generalizability to less symptomatic populations.