The objective of this paper is to systematically review the literature that has examined maternal self-reported history of abuse in relation to an observational assessment of infantmother interaction. Electronic databases were searched and studies that met pre-defined criteria were included. A total of 13 studies (representing 12 independent samples) were included and assessed for quality using the EPHPP tool. Nine of the 13 studies (69% of reviewed articles) found a relationship between self-reported abuse and observed caregiving. Due to variation in sample characteristics and measurement the ability to compare studies is limited. Studies identified as having the highest methodological quality were most consistent, reporting an indirect effect of maternal abuse history on caregiving via parenting stress or depressive symptoms. This review would support the notion that self-reported abuse history in the mother is a risk factor for non-optimal caregiving behaviours; however there is a need for greater understanding of what pathways are responsible for this effect. The current review discusses strengths and limitations of the existing literature and offers suggestions for future research.

Background: The efficacy of behavioural activation (BA) treatments for depression has been demonstrated in various clinical trials (e.g. Dimidjian et al., 2006). Although a single session of BA intervention has shown significant changes in symptoms of depression in a college student population (Gawrysiak et al., 2009), this has not been evaluated with a clinical population. Despite a clear behavioural rationale and research evidence underlying BA treatments, questions regarding mechanisms of change remain unanswered. From a BA perspective, a key aim is to reduce depressive avoidance behaviours and increase healthy non-avoidance behaviours (Trew, 2011). Method: This study investigated the impact of one treatment session of Brief Behavioural Activation Treatment for Depression (Lejuez et al., 2001) on depressive symptomatology, self-reported avoidance and behavioural approach and avoidance tendencies measured using the Approach Avoidance Task (AAT; Rinck & Becker, 2007). A sample of 40 depressed participants from primary care psychological therapies services were randomised to either treatment or control group. Self-reports of symptoms and cognitive factors were assessed before (Time 1) and after the one-week intervention phase (Time 2), and at one-month follow-up (Time 3). Approach and avoidance behavioural tendencies were assessed at Times 1 and 2 using the AAT. Results: There was a significant decrease in depressive symptoms between Time 1 and Time 2 for the treatment group but not the control group. Performance on the AAT showed the expected pattern, with increases in approach to positive valence stimuli (happy faces), although effects failed to reach significance. Meditational analyses indicated small indirect effects of self reported change in activation and avoidance as mediators of the effect of condition on depressive symptoms. Discussion: This is the first study to demonstrate the efficacy of one session of BA for depression using a clinical sample. There was preliminary support for the hypothesis that reduced avoidance may mediate treatment effect. The theoretical and clinical implications of the study findings are discussed. Further replication of this study is needed, with changes in avoidance measured prior to changes in symptom outcomes to help establish a causal relationship.

Acquired memory impairment commonly occurs after acquired brain injury such as traumatic brain injury, stroke, seizure disorder and encephalitis and is one the defining features of progressive disorders, such as Alzheimer’s disease. There is a growing body of knowledge about the use of compensatory memory aids in the rehabilitation of memory disorders. This study investigated the effect of the systematic training of compensatory memory aids on everyday memory performance within a Memory Aids Clinic, a specialised outpatient clinic which supplied and trained the use of memory aids. A comparison was made between subjects with acquired memory disorders in a treatment group (n=63) and control group (n = 28) in a between subjects design. All subjects underwent a baseline session which was comprised of a neuropsychological assessment, clinical interview and goal setting session. Treatment subjects then underwent three training sessions, matching memory aids to goals, across a six week period. Training was based upon Sohlberg and Mateer’s (1989) application, acquisition and adaptation program. A follow-up session was conducted 12 weeks after the conclusion of training and included a review neuropsychological assessment and interview. Following the baseline session, control subjects were given written information about the management of memory problems and placed on an 18 week waiting list, prior to the three treatment sessions. The main outcome measure was everyday memory performance as assessed by a memory goal attainment diary. This was administered at baseline, the end of training and at the follow-up session. Outcome was also measured in terms of neuropsychological performance and performance on measures of mood, self-esteem, subjective memory performance, participation and carer strain. Generalisation was measured in terms of performance on a Problem Solving Inventory, a list of hypothetical memory scenarios which was developed for this study. The systematic training of memory aids in a Memory Aids Clinic was effective in improving everyday memory performance, but only across timefrom the end of training to follow-up. A significant difference in goal attainment was evident between the treatment and control group at follow-up but not at the end of training. Further analysis confirmed a significant treatment effect for participants with a non-progressive condition but not a progressive condition. This pattern is further illustrated by a series of case reports describing in detail the training content in the Memory Aids Clinic for both non-progressive and progressive subjects. In contrast to previous literature, there were no demographic or neuropsychological profile predictors of outcome in the current study. In addition, training in the Memory Aids Clinic did not impact upon the psychosocial measures of mood, self-esteem, participation, subjective memory function or carer strain. The treatment effect did generalise to the Problem Solving Inventory, notably for subjects with a progressive condition, suggesting adaptation of training to similar but diverse memory scenarios. Systematic training within the setting of a Memory Aids Clinic is beneficial for individuals with acquired memory problems as a consequence of a non-progressive condition. Improvement in everyday memory performance was attained with three training sessions and maintained across time. Training requires matching the memory aid to the client’s goals and scope remains for extension of training to encompass awareness of when to use the memory aid and acceptance of memory problems. Whilst the current results indicated that individuals with progressive memory disorders did not benefit from training in the Memory Aids Clinic, it is premature to suggest that this group cannot benefit from the use of memory aids. Additional training sessions may be required to facilitate generalisation into the home environment, to enhance the use of a significant other as co-therapist and to consolidate initial gains. A different and more general approach to using memory strategies including compensatory aids may be more beneficial in this group given more widespread and severe cognitive impairments. Finally, the results of the current study highlight the need for ecologically valid measures of outcome, including appropriate tools to determine self-efficacy and participation.

Difficulties in social and emotional processing appear to play a role in the psychopathology of eating disorders (ED). Theoretical models describe how problems in social and emotional processing are related to the development and maintenance of the illness. The findings from previous systematic reviews and meta-analyses show that individuals with ED have difficulties in multiple aspects of social and emotional processing. A comprehensive review of social processing in ED presented in this thesis lends further support for the presence of difficulties with social and emotional processing in suffers with ED. However, much of the data in this area were gathered from self-report, which is subject to bias. The aim of this thesis was to examine the relationship between ED status and several aspects of social and emotional processing and to consider these findings in relation to the Cognitive Interpersonal Maintenance Model of the illness (C-IMM; Schmidt & Treasure, 2006). Four empirical studies focused on measuring several aspects of social and emotional processing in women with ED using both experimental and behavioural measures. The first study examined the role of implicit negative self-concept in women with Anorexia Nervosa (AN) compared to healthy women. The second study investigated attentional response, identification of others’ emotion, subjective emotional response and facial expression towards the emotional displays of happiness, sadness and frustration in women with ED compared to healthy women. The third study examined maternal sensitivity to infant cues of happiness, sadness and frustration in women with ED compared to women without ED during late pregnancy. Finally, the fourth study examined newborn behaviour and mother-to-infant bonding during postpartum in women with ED compared to women without ED who were part of the same cohort of participants as in the third study. Overall the findings suggest that ED status is linked with specific rather than general anomalies in social and emotional processing. Women with ED had less facial expressivity towards displays of happiness in adults and infants. Women with ED underestimated happiness in infants. They experienced an amplified feeling of negative affect in response to infant sadness. Newborn infants of mothers with a current ED were more sensitive to environmental stress than newborns of mothers without ED. The strengths and limitations of these studies were considered and directions for future work were proposed in the context of the C-IMM of ED (Schmidt & Treasure, 2006). The clinical implications of the thesis were discussed in relation to treatment for these anomalies in social and emotional processing.

Introduction. The purpose of this thesis is to investigate the factors associated with predisposing, precipitating and perpetuating fatigue and disability in Chronic Fatigue Syndrome in adolescents. It presents novel evidence of psychological (including behavioural), social and physiological factors associated with adolescent Chronic Fatigue Syndrome. Methodology. In order to test a hypothesised psycho-physiological model of Chronic Fatigue Syndrome in adolescents, a cross-sectional and prospective case-control design was used. Eighty-five adolescents with Chronic Fatigue Syndrome, thirty-one adolescents with asthma and seventy-eight healthy control adolescents participated in the study. They were compared on a range of questionnaire measures at two time points. Experimental tasks were also used to test hypothesised maintaining factors for Chronic Fatigue Syndrome in adolescents derived from cognitive behavioural approaches. Physiological parameters were assessed during these tasks. Mothers of all adolescents completed questionnaire measures examining maternal distress and other psychological variables. Results. The Chronic Fatigue Syndrome group and their mothers scored significantly higher on all measures of unhelpful beliefs and behaviours in response to illness than the asthma group. Maternal distress and worse general health were also more common in the mothers of adolescents with Chronic Fatigue Syndrome. The adolescents and their parents had lower expectations of performance on the experimental tasks than the other two groups, most prominently on the exercise task. The Chronic Fatigue Syndrome group were more likely to attribute cognitive symptoms of stress to their illness rather than the stress of a speech task in comparison to the adolescents with asthma. The Chronic Fatigue Syndrome group had a significantly higher Heart Rate in anticipation of the speech and the exercise task as well as slower Heart Rate recovery compared to the other groups. The Chronic Fatigue Syndrome patients also had significantly lower Heart Rate Variability and higher Skin Conductance Response at baseline compared with the other two groups. Conclusions. This thesis confirms that cognitive, behavioural, emotional and social factors are associated with Chronic Fatigue Syndrome in adolescents. Some of these factors will need to be targeted in treatment. The differences between groups on physiological responses are consistent with the hypothesis that adolescents with Chronic Fatigue Syndrome may differ in their autonomic response to challenging situations. In particular they appear aroused in anticipation of exercise and recover more slowly from a stressful situation. The findings support the use of cognitive behavioural intervention methods in which the family is involved in assessment and treatment (Chalder et al., 2002).

Background: Advances in neuroscience have led to a deeper understanding of the neuro-circuitry associated with eating disorders (ED). There is however, a lack of brain-directed treatment options. Neuromodulatory techniques have therapeutic efficacy in other psychiatric disorders and evidence in ED is promising. There is a need for further studies of neuromodulation in ED, to probe disease mechanisms and to develop novel treatments. The aim of this research is to explore the use of neuromodulation in ED and specifically assess the utility of repetitive transcranial magnetic stimulation (rTMS) in anorexia nervosa (AN). Methods: An overview of ED and their neurocircuitry underpinnings is presented. A systematic review of the literature regarding the effects of neuromodulation on eating related outcomes was also conducted. The effects of neuronavigated (MRI-guided) rTMS in AN is explored in a single-session randomised control trial (RCT) and in a 20-session therapeutic case series. Results: The systematic review supports further research on neuromodulation in ED. The single-session RCT of real versus sham rTMS in 51 individuals with AN demonstrated that following real rTMS, individuals report reduced AN symptoms and an increased liking of specific foods. Real/sham rTMS did not alter salivary cortisol concentrations and levels of cortical excitability were associated with AN symptomatology. Lastly, rTMS proved to be safe, tolerable and acceptable in people with AN. A neurocognitive measure of intertemporal choice showed that rTMS encourages prudent decision making in AN: this may underlie the effects of rTMS on AN symptoms. Whilst a therapeutic case series of five individuals with enduring AN did not lead to weight gain, significant improvements in ED and general psychopathology were reported and sustained. Conclusions: rTMS has the ability to improve core symptomatology in AN and alter decision making processes. Therefore, neuromodulation may be a viable treatment adjunct for people with an ED.

The works presented in this thesis examine the neural effects of treatment on different features of depression, such as affective biases, working memory impairments and dysfunctional thinking. The thesis opens with a review of longitudinal studies that examined the effects of antidepressants and psychological therapies on the neural correlates of affective and cognitive processing. Motivated by the paucity in the number of fMRI studies that examined psychotherapy in depression, Chapter 2 examines the effects of Cognitive Behavioural Therapy (CBT) on dysfunctional thinking in depression. In Chapter 3, the effects of a dual acting serotonin norepinephrine reuptake inhibitor, duloxetine, on affective biases are examined using implicit affective paradigms comprising happy and sad facial expressions. Chapter 4 investigates the neural effects of duloxetine on working memory in depression utilizing a modified version of the Sternberg Working Memory Task. Another key focus in the thesis is to examine the potential of structural neuroimaging data to identify depression and predict clinical remission using machine learning algorithms in a sample of wide ethnic diversity from the community. Findings from this study are presented in Chapter 5. Overall, the results showed antidepressant treatment related increases in posterior cingulate during sad facial effect processing, consistent with preliminary findings that show increases in this region with antidepressants that potentiate the noradrenergic systems. The neural correlates of working memory, on the other hand, showed a significant group by time interaction during the rehearsal phase, such that there was a tendency for reductions in brain activations at the follow up scan compared to baseline in healthy controls in a network of brain areas extending from the prefrontal, to the cingulate, temporal and cerebellar regions, while no change was observed in patients. The tendency for decreased activations in controls in the follow up scan is perhaps indicative of less recruitment of these regions with increased familiarity with the task, while no change in activation in patients may reflect persistent recruitment of regions associated with working memory to maintain task performance. In the CBT study, an interaction effect was found in the left parahippocampal gyrus, which showed less attenuation in patients relative to controls at the follow up scan, perhaps reflecting an improvement in dysfunctional thinking with CBT with some persistent vulnerability. Investigation of neuroimagingbased biomarkers in depression indicated that structural neuroanatomy combining white and grey matter distinguished patients from controls at the highest accuracy of 81% with the most stable pattern being at around 70%. In contrast, the whole brain structural correlates of depression showed limited potential as a prognostic marker. These findings suggest some distinct neural effects of treatment on cognitive and affective processing and provide preliminary evidence to indicate that identification of depression is possible within a multi-ethnic group from the general community.

Introduction: Prevalence of common mental disorders such as depression and anxiety is highest among those aged 45-54, and lowest in those aged 75 or older. Method: Longitudinal analyses of secondary data were conducted using the data collected routinely in a London-based Improving Access to Psychological Therapy (IAPT) Service (N=77; f=39; m=38). Data were collected by IAPT clinicians and staff over a period of 4 years between 2008 and 2012. Demographical data, information regarding engagement with low intensity treatment as well as clinical outcome measures (PHQ-9, GAD7, W&SAS) were included in analyses. Findings: T-tests reveal significant improvement on scores of depression on the PHQ-9 (t=3.101; p=.003), anxiety on the GAD 7 (t = 3.623; p=.001). Wilcoxon signed-rank tests were run for W&SAS scores of functioning (r=2.507; p=.011), showing significant improvement from assessment to end of treatment. Linear regression showed that the type of treatment is a predictor of recovery from depression (t = 3.836, p=.000), but not from anxiety (t= -.307, p = .760). MBCT and Behavioural Activation seem to be the most engaging therapeutic options, while guided self-help, psycho-education and workshops on stress and anger have the highest rates of drop-out and failure to engage. Conclusions: Low intensity treatments offered to older adults referred to the IAPT service prove efficacious in decreasing anxiety and depression symptoms and increasing overall functioning in people who engage with the treatment. Engagement of older adults with the service may improve by further exploring the acceptability of low intensity treatments in this population while adaptations and adjustments may be needed in order to increase participation. Future investigations might need to consider the characteristics of people who fail to engage or drop out and reasons for disengagement with treatment.

Amyotrophic Lateral Sclerosis (ALS) is a debilitating and life–limiting neurodegenerative disorder that causes progressive muscle atrophy and spasticity. A small proportion of ALS patients experience co–morbid Frontotemporal Dementia (FTD). Milder cognitive–behavioural changes have been noted in ALS patients without dementia. In these patients, deficits in executive functioning, language, memory and behaviour have been documented. Recently, changes to emotional processing and social cognition (EMOSOC) in ALS have also been reported, albeit with inconsistent findings. The primary aims of the current thesis were i) to delineate the nature and extent of changes in EMOSOC in ALS and ii) to determine the relationship between such changes and interindividual differences in mood, behaviour, personality, empathy and ALS–related executive dysfunction. The results of the study indicate a profile of predominant executive dysfunction, with relative sparing of EMOSOC in non–demented ALS patients. However, the ALS patients did show impaired performance on a task requiring the attribution of thoughts and feelings to characters from cartoons and vignettes. ALS patients’ performance on EMOSOC tasks was predicted by their performance on tests of executive function, above and beyond mood, behaviour, personality and empathy variables. As a secondary aim, the impact of patients’ cognitive and behavioural changes on ALS caregivers’ outcomes (mood, perceived strain, burden and marital satisfaction) were examined. The data indicated patients’ behavioural dysfunction and functional impairment as key predictors of caregivers’ outcomes. Exploratory analyses revealed differences between patients’ and caregivers’ perceptions of patients’ personality, empathy and behaviour; these differences were associated with caregiver outcomes. In summary, the current thesis characterises the profile of EMOSOC changes in non–demented ALS and highlights the role of ALS–related executive dysfunction in these changes. It also assesses the relative impact of patients’ disease, cognitive and behavioural changes on ALS caregivers.

Tick-borne disease represents a growing problem in the UK. While some communications materials exist which encourage members of the public to adopt precautionary behaviours when in tick affected areas, these have not been informed by empirical evidence as to what factors promote uptake of protective behaviours and have not had their effectiveness formally tested. This research: • Identified knowledge and perceptions of risk concerning tick-borne disease in the UK that were associated with uptake of health protective behaviours; • Designed new communications materials promoting the uptake of health protective behaviours; • Tested whether the effect of these new materials was improved by also incorporating messages designed to reduce the emotion of disgust. Qualitative interviews allowed understanding of the thought processes of experts and the public with regards to the risk posed by ticks and tick-borne disease. Tick checking emerged as the most effective and accepted protective behaviour. A quantitative survey with members of London-based outdoor groups provided data showing that knowledge, perceived likelihood of being bitten, self-efficacy about tick removal and lower levels of disgust were the strongest predictors of checking behaviour. Both the qualitative and quantitative data fed into the design of communication materials that served as interventions against tick-borne disease risks. These were tested in a pilot randomised controlled trial where members of the public were sent one of three versions of the intervention, one including disgust reduction messages, one with messages based on behaviour change techniques developed from conventional models within health psychology and one with existing messages. The intervention based on conventional theories of health psychology proved most effective at increasing the uptake of tick checking behaviour and disgust reduction appeared to decrease behavioural engagement. Future research is needed to investigate the role of disgust as a driver of behaviour change, while policy makers need to be aware of the importance of engaging with the public and incorporating elements of health psychology theory into intervention design.