5 Design study I: How to create an ambulatory app for patients with BPP 155 ‘sympathetic’ arousal elevates HR, blood pressure, and sweating, as well as redirects blood from the intestinal reservoir toward skeletal muscles, lungs, heart, and brain in preparation for motor action [17]. As these physiological processes are known to be directly influenced by emotional events [56], these variables could perhaps be used to provide patients with BPD with a real-time proxy of their emotional arousal. At the very least an awareness of the ongoing fluctuations of autonomic reactions of the body will become available, which might provide a basis to learn to recognize and to some extent regulate the continuous affective changes within daily life [30]. 2.1 Opportunities and challenges Although ‘measuring affect in the wild’ [57, 58] is still in its very infancy, tests of validity and reliability of affective computing under controlled laboratory circumstances already show very promising results [59-62]. The decoupling of physiological and emotional arousal, or low ‘response coherence’ poses a challenge on defining a ‘ground truth’ on when an emotion is present – especially with low emotional awareness or alexithymia: subjects can report only those emotional events they are aware of. However, one way this could be dealt with is by adopting Myrtek’s approach of detecting ‘emotional events’ [56, 63, 64]: “The basic idea of our method […] is to detect emotional events by a simultaneous on-line analysis of heart rate and physical activity in order to separate the metabolically induced heart rate from the emotionally induced heart rate with the use of a portable computer [64]”. At first thought, the user experience of an e-coach on emotional awareness may be mostly functional: provide the user with psychophysiological data in an accessible manner (e.g., cues whether currently measured values are low, medium or high relative to a personalized baseline) so he or she can act upon this information. Yet, wearing a sensor that measures physiological responses most likely will also be a significant emotional and social experience. Patients with BPD already often find themselves being stigmatized by friends, family and even therapists [65]. Wearing and using a conspicuous device could increase this stigma. As with other design studies, all common design aspects such as aesthetics, sensory appeal, focused attention, awareness, challenge, control, feedback, interest, motivation, novelty, et cetera, are of importance [66]. Yet the specific characteristics of a populationmarked by BPD seem to call for an even more careful and considerate approach when designing a mHealth intervention. We therefore formulated the following research question:
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