6 Design study II: Development of an ambulatory biofeedback app 189 1. Introduction 1.1 Context Borderline personality disorder (BPD) is a psychological disorder that influences all domains of life. It is characterized by a pervasive pattern of unstable relations, a distorted self-image, and profound difficulties in regulation of one’s emotions [1]. Self-harming behaviors are common [2-5]. A lack of emotional awareness or the ability to timely recognize the onset of emotions and their increasing or decreasing intensity plays a role in emotional instability and dysregulated and self-harming behaviors in BPD [6-11]. Patients with BPD seem to especially have less focus on the level of emotional arousal than controls [12]. Perception of internal bodily states is found to be of significant importance to subjective experience, awareness, labeling, and understanding of emotional processes [18-21]. Interestingly, people with low emotional awareness, in general, do respond to emotional triggers physiologically, and to a certain extent, behaviorally, but lack the experience of the emotion—the feeling [19,23,24]. Therefore, available evidence suggests that treatment of low emotional awareness in BPD should focus on bodily signals and could very well involve biofeedback [6,1217]. Although there are indications that emotional awareness can improve with psychological interventions [22], development and testing these interventions is in its infancy [25,26]. From literature and information gathered from patients and professionals, we identified a need to improve the treatment of low emotional awareness in BPD [13,22,27]. We started a project to develop a biosensor-informed e-coaching app on emotional awareness in the challenging environment of a psychiatric ward for patients with severe BPD. We gave the app the name Sense-IT, as it refers to both its intended purpose for patients (sense it) and its technological nature (IT: information technology). Importantly, it should help its users to learn to better recognize changes in their physiological and, with that, emotional arousal and thus increase emotional awareness. To the best of our knowledge, this project is one of the first in providing ambulatory biofeedback to this group of users. We previously developed an initial prototype [28]. The aim of this study was to complete the next step and deliver a working version of the Sense-IT app that is deemed useful and usable by 3 important groups of stakeholders: patients with BPD and low emotional awareness, mental health professionals working with these patients, and experts on user-centered design (UCD). 1.2 Initial Prototype We decided to design our app for wearable technology that comes equipped with essential biosensor technology that is widely available for consumers, is affordable, and runs on a mature operating system (OS) that offers easy-to-use application programming interfaces (APIs) by which one can develop native apps and access
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