The objective of this study is to understand how people with psychiatric diseases who are enrolled at a psychiatric clinic experience the recovery process and which internal motivations and external factors influence the process. The study is based on interviews with five people who have been enrolled at a psychiatric clinic. Another aim of the study is to understand how the importance of the outpatient care for the personal recovery and the improvement opportunities of the support from the rehabilitation unit that the interviewees see. The study is qualitative and abductive approach was chosen. This means that the study is based on empirical data supported by established theories. The interviews have been semi-structured and the results have been analyzed based on previous research about recovery from psychiatric diseases. The results show that there are several similarities between the individual recovery stories in the study and there are also clear links to the findings of the international research that has been taken into account in this study. The study shows a painful but at the same time hopeful recovery process where all respondents developed strategies to handle the psychiatric disease and the symptoms of it. The medication, some kind of faith and memories of life before the psychiatric disease occurred all proved to be of importance in the recovery process. It is also clear that the recovery process is closely related to a social process where friends, colleagues, family members and professional caretakers contribute with support, continuity and by creating a sense of belonging. Furthermore, the study shows that the closest family not only has an externally supporting function. It also works as an inner motivation to keep on fighting to get back. The meeting premises of the psychiatric clinic and the accessibility of the caretakers also proved to be of importance in the recovery process. Three clear improvement opportunities where discovered in the study: More organized group activities for a specific type of patients, increased knowledge sharing and transfer about psychiatric diseases and that people involved in the process pass on a stronger feeling of hope. / Denna studie handlar om hur personer inskrivna på en öppenpsykiatrisk rehabiliteringsenhet för människor med psykossjukdom upplever återhämtningsprocessen och vilka inre motiv och yttre faktorer det är som stödjer denna process. Studien baseras på fem intervjuer av personer inskrivna på rehabiliteringsenheten. Ett mål har också varit att undersöka vilken betydelse öppenvården har för den personliga återhämtningen och vilka önskningar de intervjuade personerna har i syfte att förbättra stödet från rehabiliteringsenheten. Studien har en kvalitativ ansats och en abduktiv forskningsstrategi valdes. Detta innebär att studien utgår från empiriska data men att teoretiska moment samtidigt har beaktats. Semistrukturerade intervjuer har genomförts och resultatet analyserades utifrån tidigare forskning om återhämtning från psykisk sjukdom. Resultatet visar att det finns flera likheter mellan de individuella återhämtningsberättelserna som personerna i studien delar med sig av och likheter i relation till den nationella och internationella forskningen. Studien ger en bild av en smärtsam men samtidigt hoppfull återhämtningsprocess där samtliga intervjupersoner utvecklat strategier i förhållande till psykossjukdomen och dess symtom. Medicinerna, någon form av tro eller andlighet och minnet av livet innan insjuknandet i psykossjukdom visar sig vara betydelsefullt i återhämtningsprocessen. Samtidigt framgår det också hur återhämtningen så starkt är förbunden med en social process där vänner, arbetskollegor, professionella och familjemedlemmar bidrar med stöd, samhörighet och kontinuitet. Vidare visar studien att den närmaste familjen har en yttre stödjande funktion men att de också utgör ett inre motiv till att fortsätta kämpa, återhämta sig eller tillfriskna. Enhetens träfflokal och personalens lättillgänglighet visar sig vara betydelsefullt för de intervjuade. Tre önskningar om enhetsförändringar förmedlas genom studien: En mer organiserad gruppverksamhet riktad mot en specifik grupp brukare, en ökad kunskapsförmedling om psykiska sjukdomar och en ökad förmedling av hopp.

SANTRAUKA Slaugytojams tenka svarbus vaidmuo, slaugant alkoholį vartojančius pacientus, tačiau apie tai dar yra skirta mažai mokslinių publikacijų, informacijos. Darbo tikslas. Išanalizuoti slaugos procesą ūmių alkoholinių psichozių skyriuje. Tyrimas buvo atliekamas Respublikinėje Vilniaus psichiatrijos ligoninės (RVPL) ūmių alkoholinių psichozių (ŪAP) ir kituose psichiatrijos skyriuose 2007 metais. Planas. Iš viso apklausta abiejų lyčių įvairaus amžiaus 278 respondentai, besigydantys RVPL ŪAP ir kituose psichiatrijos skyriuose. Jie buvo suskirstyti į 2 grupes, priklausomai nuo skyriaus kuriame gydėsi. Buvo pildomos anoniminės anketos. Rezultatai. ŪAPS ir kitų skyrių slaugytojos, pakankamai kvalifikuotai teikia pacientams psichologinę pagalbą. 95,2 proc. respondentų pasitiki savo slaugytoja, ji padeda jiems spręsti iškilusias sveikatos problemas 89,3 proc., 60,6 proc. respondentų jaučiasi suprasti ir 76,8 proc. respondentų kreipiasi į slaugytoją, kai juos pradeda varginti nerimas ar baimė. Svarbiausios ŪAPS slaugytojos savybės, yra pagarba pacientui 63,0 proc. bei 58,7 proc. profesionalumas, o kitų skyrių pacientams - slaugytojos užuojauta 68,3 proc. ir profesionalumas 57,5 proc. ŪAPS respondentai, kad ir pasitiki, dažniau 33,0 proc. išsako savo poreikius slaugytojai nei kitų skyrių respondentai 19,2 proc. bei nuoširdžiai bendradarbiauja su slaugytoja 93,5 proc. nei kitų skyrių respondentai 89,2proc. Tačiau ŪAPS respondentai dažniau 23,9 proc. jaučiasi nesuprasti slaugytojų... [toliau žr. visą tekstą] / SUMMARY Nurses take important part in nursing of patients, who have alcohol addiction, but there is lack of scientific publications and information about it. The objective of thesis is to traverse nursing process in sudden alcoholic psychosis department. The research was made in sudden alcoholic psychosis and other psychiatric departments of Republican Vilnius Psychiatric Hospital in year 2007. Design. There were interwied 278 different age and gender respondents, who were hospitalised in sudden alcoholic psychosis and other psychiatric departments of RVPL. They were divided into two groups, according from department. Anonymous questionnaires were filled. Results. Nurses from sudden alcoholic psychosis and other departments ensure professional psychological help. 95,2 proc. of respondents trust in nurse, she helps to deal with health problems 89,3 proc., 60,6 proc - feel understood and 76,8 proc. – ask for help of nurses, when anxiety and fear trouble them. The most important features of nurses are respect for patient 63,0 proc. and professional work 58,7 proc., while in other departments – compassion 68,3 proc. and professional work 57,5 proc.. In sudden alcoholic psychosis department respondents despite the fact that they trust in nurses, more often 33.0 proc. tell about their needs to them than respondents from other departments 19.2 proc. and collaborate accordingly 93.5 and 89.2 proc. However in sudden alcoholic psychosis department respondents more often 23.9 proc. feel... [to full text]

The aim of this thesis was to describe and analyse perceptions of psychosis care among those involved in care, foreign‐born persons with psychoses, their families and health care staff, and further to reach agreement about core components in psychosis care. This was in order to find out whether current psychosis care in Sweden is suitable for foreign‐born persons and theirfamilies. The study design was explorative and descriptive. Health care staff (n=35), persons with psychosis (n=22) and families (n=26) of persons with psychosis were chosen from different regions in Southern Sweden. To capture health care staff’s experiences and to explore whether specific needs occurred within psychiatric care, nine focus group interviews were held. The perspectives of psychosis care among persons with psychoses and their families were captured through individual interviews. Finally, a study was accomplished all over Sweden in which staff, foreign‐born persons with psychosis and foreign-born families of persons with psychoses answered a questionnaire to identifycore components in psychosis care of foreign‐born persons and their families. There was agreement that the core components in psychosis care concern general psychiatric caring, even though varying perceptions were identified. Asking about foreign‐born persons’ religious and ethnic background or having the possibility to decide whether care should be provided by male or female staff were agreed to be less important. No agreement could be reached concerning the importance of considering different perceptions of psychosis care, treatments and different ways of managing the psychosis. Nor could agreement be reached as to whether staff should have specific cultural knowledge and whether interpreters should be unknown to the family but speak the right dialect. Perceptions among staff in somatic and psychiatric care as well as perceptions among foreign‐and Swedish‐born persons with psychosis and their families were more similar than different. General psychiatric care is important for Swedish‐born as well as foreign‐born persons with psychosis and their families, indicating the importance of not letting culturally determined perceptions dictate the care and take away energy from health care staff and make them lose their focus on the basic elements in general psychiatric care. However, within the general care there were individual perceptions on whose importance those involved in care did not agree. Further development suggested is to illuminate the importance of identifying individual perceptions which may differ between different persons and could be related to cultural background. Staff need to acquire strategies so they can easily manage to encounter and offer general care to foreign‐born persons. Development must be achieved on both an organizational level and an individual level. / Disseration

Research Doctorate - Doctor of Philosophy (PhD) / Newly single and working the graveyard-shift at his local railway station, Peter Lawson is a complete failure. Yet, inexplicably, he has never felt better in his life. This confidence swells when a newsreader on morning television and an astrologer at the city’s loudest tabloid both agree: Peter is 'The One'... What follows next tests the limits of his mind, and his faith, as he lurches from crisis to catastrophe – being helped along in his journey by a psychiatrist, a priest, and a class full of autistic boys – before meeting Maya, the woman who guides him home. Set between Sydney, London, and the foothills of the Himalayas, 'The Triumphant Approach' is a tale about love, lunacy and the attraction of belief: a meditation on identity, and the redemptive power of losing one’s mind, in modern day Australia. Following the novel is a critical exegesis that charts the genesis and development of The Triumphant Approach by examining its various thematic elements with a focus on madness and writing, giving particular attention to the mental illness and spirituality shared by the protagonist and the author. The exegesis examines how identity is changed by mental illness and explores the inherent challenges for the writer intent on expressing that through fiction, as well as looking at the relationship between mental illness and belief – with a view to understanding the symbiotic relationship between the two.

Research Doctorate - Doctor of Philosophy (PhD) / Newly single and working the graveyard-shift at his local railway station, Peter Lawson is a complete failure. Yet, inexplicably, he has never felt better in his life. This confidence swells when a newsreader on morning television and an astrologer at the city’s loudest tabloid both agree: Peter is 'The One'... What follows next tests the limits of his mind, and his faith, as he lurches from crisis to catastrophe – being helped along in his journey by a psychiatrist, a priest, and a class full of autistic boys – before meeting Maya, the woman who guides him home. Set between Sydney, London, and the foothills of the Himalayas, 'The Triumphant Approach' is a tale about love, lunacy and the attraction of belief: a meditation on identity, and the redemptive power of losing one’s mind, in modern day Australia. Following the novel is a critical exegesis that charts the genesis and development of The Triumphant Approach by examining its various thematic elements with a focus on madness and writing, giving particular attention to the mental illness and spirituality shared by the protagonist and the author. The exegesis examines how identity is changed by mental illness and explores the inherent challenges for the writer intent on expressing that through fiction, as well as looking at the relationship between mental illness and belief – with a view to understanding the symbiotic relationship between the two.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Ao longo desta tese, investiga-se a relação do sujeito com o corpo, em especial na clínica da psicose que, em decorrência do mecanismo da foraclusão que marca essa estrutura, não é regido por uma norma fálica, sendo problemática a construção da ficção de um corpo próprio. Examina-se a hipótese de que as práticas corporais, na psicose, são tentativas do sujeito de inscrever um corpo, correlativas às tentativas de estabilização. Para isso, se percorrem as concepções de corpo, bem como o funcionamento da estrutura da psicose na obra de Sigmund Freud e Jacques Lacan. As práticas corporais como tentativas de fazer marcas se diferenciam quanto à sua complexidade, desde os cortes à criação artística, mas têm em comum a urgência de uma escrita pulsional, que não cessa de não se escrever. Verifica-se que o sinthoma é a forma princeps de suplência simbólica, que por meio da arte, poderá dar um suporte simbólico ao corpo. A perspectiva oferecida pela concepção de sinthoma transforma o psicótico em um artesão, que, por meio de um artifício poderá inventar aquilo que fará uma estabilização. Através do conceito de corpo dançante de Didier-Weill, analisa-se o caso do bailarino Nijinsky para que se discuta o possível alcance da criação artística para a psicose. Conclui-se que a criação artística poderá ser uma saída de mestre, onde o psicótico poderá fazer mestria de sua arte e, juntamente com ela, inventar uma nomeação para si, assim como um lugar no discurso que poderá fazer laço social. Assim, o trabalho permanente encontrado na psicose constitui-se em uma possibilidade de entrada do discurso analítico. Se há um trabalho do lado do analista com relação à psicose, é no acolhimento dessas tentativas de inscrição, como escritas da psicose. / Throughout this thesis we investigate the relation of the subject to the body, especially in the clinic of psychosis. As a result of the mechanism of forclusion which marks that structure, the body is not ruled by a phallic norm, being problematic then the construction of the fiction of a body of ones own. We examine the hypothesis that the body practices in psychosis are attempts of the subject to inscribe a body, correlated to the attempts of stabilization. For that purpose we consider the conceptions of body, as well as the functioning of the structure of psychosis, in the works of Sigmund Freud and Jacques Lacan. The body practices as attempts to make marks differ as to their complexity, from cuts to artistic creation, but they have in common the urgency of a pulsional writing that does not cease to not writing. We verify that the sinthoma is the princeps form of symbolic suppliance that, by means of art, may provide a symbolic support to the body. The perspective offered by the conception of sinthoma turns the psychotic into an artisan who by means of an artifice may invent that which will produce a stabilization. We analyse then the case of the ballet dancer Nijinsky having Didier-Weills concept of dancing body in mind to discuss the possibilities of artistic creation to psychosis. We conclude that artistic creation can be a masterly solution, the psychotic becoming skilled in her/his art and, together with it, inventing herself/himself a naming as well as a place in the discourse which may provide social connection. Thus, the permanent work found in psychosis constitutes itself in a possibility of the entering of the analytic discourse. If there is a work on the part of the analyst as it concerns to psychosis, it is in the acceptance of these attempts of inscriptions as writings of psychosis.

The aim of this thesis was to explore the relationship between anger and aggression, insecure attachment, paranoia and social cognition in psychosis. It is presented as three separate papers: 1) a systematic review examining the relationship between paranoia and aggression in schizophrenia spectrum disorders, 2) an empirical study investigating predictors and mediators of trait anger across the psychosis continuum: the role of insecure attachment, paranoia and social cognition and 3) a critical reflection of the research process. Paper one provides a systematic review of the relationship between paranoia and aggression in schizophrenia spectrum disorders. A comprehensive search of the published literature identified fifteen eligible studies. The quality of the included articles is critically appraised during the synthesis of the findings. Methodological limitations, clinical implications and recommendations for future research are considered. Paper two provides an examination of predictors and mediators of trait anger across the psychosis continuum, considering the role of insecure attachment, paranoia and social cognition. Tests of theory of mind and measures of attachment, hostile attribution bias, paranoia and anger were administered to 174 participants (14 ultra-high risk of psychosis, 20 first-episode psychosis, 20 established psychosis and 120 non-clinical). Multiple regression analysis found attachment avoidance, paranoia and hostile attribution bias were significantly related to trait anger. Mediation analysis revealed paranoia mediated the relationship between attachment avoidance and trait anger. The results are discussed with consideration to previous research and limitations of the study. Clinical implications and recommendations for future research are also offered. Paper three provides a critical reflection of papers one and two, with reference to their design, implementation and interpretation. Personal reflections of the research process as a whole are also provided.

Leukocyte telomere length is an emerging marker for pathologically accelerated cellular aging. First discovered to be associated with aging-related disorders, such as type 2 diabetes mellitus and cardiovascular disease, in young individuals, leukocyte telomeric degeneration is also garnering growing attention in psychiatric illnesses. Comorbid metabolic symptoms and physiological dysregulation observed in schizophrenia patients imply a plausible association between pathological telomere biology and psychosis. Available data on the relationship between leukocyte telomere length and schizophrenia is limited largely to small-sample, cross-sectional studies unable to fully account for the large body of potentially confounding factors on telomere length (psychotropic medication, chronic stress and history of trauma, comorbidities, paternal age, substance use, subject-level variables). The most comprehensive meta-analysis to date reveals a significant trend of shortened telomeres in schizophrenia patients as compared to healthy controls. Some findings suggest a linear relationship between telomeric attrition and disease chronicity/severity. However, overall findings are insufficient to gauge the potential of leukocyte telomere length as a predictive, diagnostic biomarker in this patient population. Future longitudinal studies with carefully controlled covariates are required to verify the promising potential of a new marker for schizophrenia onset and a possible new direction for adjunctive antipsychotic treatment.

“Non-affective” psychotic disorders are in fact associated with a high rate of emotional disorders. A number of attachment-based models of impairments in emotion regulation and mentalization in psychosis have been put forward. The present thesis aimed to explore psychobiological markers of emotion regulation in order to develop and pilot a novel psychological intervention. The portfolio consists of six peer-reviewed published articles. Four studies were conducted involving 167 psychosis patients and 66 community controls resulting in four original articles, a theory paper and a metaanalysis. Paper 1- 3 explored emotion regulation using different methods (self-report, hormonal, attachment-based narrative). Paper 4 lays out a compassion-focused model for promoting emotional recovery from psychosis. Paper 5 presents data from a feasibility trial of Group Compassion Focused Therapy. Paper 6 presents an updated attachment- and compassion-focused model of emotion regulation and mentalization in the context of a meta-analysis of effects of intranasal oxytocin on symptoms and social cognition in psychosis. Childhood trauma – especially emotional abuse - was strongly associated with dissociation in psychosis patients compared to non-psychotic community controls – most strongly in chronic patients (Paper 1). Psychosis patients with childhood trauma showed significantly lower basal cortisol levels indicative of impaired stress regulation than those without childhood trauma (Paper 2). Impaired emotion regulation operationalised as attachment-based mentalisation was associated with problematic adolescent development and emotional and interpersonal adaptation to a first episode of psychosis in qualitative interviews. A novel attachment-based model for improving emotion regulation in psychosis by way of strengthening the caregiving/ receiving and affiliation system through Compassion Focused Therapy (CFT) was put forward (Paper 4). A feasibility trial showed that group CFT was safe, well-accepted and associated with greater clinical improvement and greater increases in compassion compared to treatment as usual. Increases in compassion in CFT were associated with reductions in shame, perceived social marginalisation, fear or relapse and depression (Paper 5). A metaanalysis of oxytocin administration as a biological way of strengthening the care-giving/receiving and affiliation system in psychosis was conducted yielding medium effects despite significant heterogeneity (Paper 6). Findings replicated the strong association between childhood trauma and dissociation in psychosis patients relative to controls highlighting the importance of emotional abuse and suggesting underlying difficulties with regulating distress related to early interpersonal trauma. Lower basal cortisol in patients with childhood trauma appeared to support the presence of emotion regulation difficulties due to early interpersonal trauma on a physiological level. Qualitative findings helped to generate hypotheses about inhibitors and facilitators of recovery and targets for intervention including the moderating role of mentalization. A novel attachment- and compassion-focused model was outlined and successfully piloted yielding important signals of change such as increases in compassion, which appear to reduce depression and social marginalisation in particular. This model helped account for inconsistencies in oxytocin studies of psychosis. In summary, findings extend existing research on emotion regulation in psychosis by supporting links to early interpersonal trauma and attachment and offer a promising novel attachment-and compassion-focused psychological intervention and a comprehensive biopsychosocial framework for further improving emotion regulation and mentalization in people with psychosis.

This thesis explored the ways in which people experiencing psychosis respond to their distressing experiences. Mixed methodology was used to address the research questions. Chapter two included a thorough systematic review and meta-analysis to investigate the relationship between safety seeking behaviours and psychosis. This review concluded that safety seeking behaviours, avoidance and resistance were associated with increased distress whereas engagement was associated with reduced distress. The review also highlighted some conceptual difficulties with differentiating between safety seeking and coping in this population. Study one, a qualitative exploration of how people respond to the experience of psychosis is presented in chapter four. This study found three key themes relating to perceived importance of responses, accuracy of threat appraisals and perceptions of ability to control experiences. An overarching theme of fighting a daily battle to maintain functioning was also identified. This analysis provided some support for the model of safety seeking responses but also demonstrated additional complexities in the way that people respond to their distressing experiences. Chapter five presents study two, the development and validation of a measure of responses to psychosis. Principal Components Analysis identified three subscales: threat monitoring and avoidance, social control and reassurance seeking and conscious self-regulation attempts. The subscales were found to have good internal consistency and convergent validity. To build on this work, study three used Structural Equation Modelling to test an integrative cognitive and metacognitive model of voice hearing (chapter six). In support of this model, it was found that voice hearing predicted beliefs and beliefs predicted responses and negative affect. Responses were not predicted either by voice hearing or negative affect. It was also found that both schematic beliefs and meta-worry mediated the relationship between avoidance and negative affect. Finally, in study four, presented in chapter seven, the response styles of attentional avoidance and attentional focusing were manipulated in response to an ambiguous auditory task in an experimental study. It was found that the attentional avoidance response resulted in a significantly greater increase in words heard during the task. However, the manipulation did not have an impact on distress levels. This thesis has demonstrated significant relationships between response styles, distress, appraisals and voice hearing. This, therefore, confirms the important role of responses to unusual experiences in models of psychosis. It appears that avoidance is likely to be unhelpful however, it should not be assumed that other responses are either helpful or unhelpful as this is likely to be person and context specific. The clinical and research implications of this are discussed.