Background: Depression is a major health problem worldwide and the majority of patients presenting with depressive symptoms are managed in primary care. Current approaches for assessing depressive symptoms in primary care are not accurate in predicting future clinical outcomes, which may potentially lead to over or under treatment. The Allostatic Load (AL) theory suggests that by measuring multi-system biomarker levels as a proxy of measuring multi-system physiological dysregulation, it is possible to identify individuals at risk of having adverse health outcomes at a prodromal stage. Allostatic Index (AI) score, calculated by applying statistical formulations to different multi-system biomarkers, have been associated with depressive symptoms. Aims and Objectives: To test the hypothesis, that a combination of allostatic load (AL) biomarkers will form a predictive algorithm in defining clinically meaningful outcomes in a population of patients presenting with depressive symptoms. The key objectives were: 1. To explore the relationship between various allostatic load biomarkers and prevalence of depressive symptoms in patients, especially in patients diagnosed with three common cardiometabolic diseases (Coronary Heart Disease (CHD), Diabetes and Stroke). 2 To explore whether allostatic load biomarkers predict clinical outcomes in patients with depressive symptoms, especially in patients with three common cardiometabolic diseases (CHD, Diabetes and Stroke). 3 To develop a predictive tool to identify individuals with depressive symptoms at highest risk of adverse clinical outcomes. Methods: Datasets used: ‘DepChron’ was a dataset of 35,537 patients with existing cardiometabolic disease collected as a part of routine clinical practice. ‘Psobid’ was a research data source containing health related information from 666 participants recruited from the general population. The clinical outcomes for 3 both datasets were studied using electronic data linkage to hospital and mortality health records, undertaken by Information Services Division, Scotland. Cross-sectional associations between allostatic load biomarkers calculated at baseline, with clinical severity of depression assessed by a symptom score, were assessed using logistic and linear regression models in both datasets. Cox’s proportional hazards survival analysis models were used to assess the relationship of allostatic load biomarkers at baseline and the risk of adverse physical health outcomes at follow-up, in patients with depressive symptoms. The possibility of interaction between depressive symptoms and allostatic load biomarkers in risk prediction of adverse clinical outcomes was studied using the analysis of variance (ANOVA) test. Finally, the value of constructing a risk scoring scale using patient demographics and allostatic load biomarkers for predicting adverse outcomes in depressed patients was investigated using clinical risk prediction modelling and Area Under Curve (AUC) statistics. Key Results: Literature Review Findings. The literature review showed that twelve blood based peripheral biomarkers were statistically significant in predicting six different clinical outcomes in participants with depressive symptoms. Outcomes related to both mental health (depressive symptoms) and physical health were statistically associated with pre-treatment levels of peripheral biomarkers; however only two studies investigated outcomes related to physical health. Cross-sectional Analysis Findings: In DepChron, dysregulation of individual allostatic biomarkers (mainly cardiometabolic) were found to have a non-linear association with increased probability of co-morbid depressive symptoms (as assessed by Hospital Anxiety and Depression Score HADS-D≥8). A composite AI score constructed using five biomarkers did not lead to any improvement in the observed strength of the association. In Psobid, BMI was found to have a significant cross-sectional association with the probability of depressive symptoms (assessed by General Health Questionnaire GHQ-28≥5). BMI, triglycerides, highly sensitive C - reactive 4 protein (CRP) and High Density Lipoprotein-HDL cholesterol were found to have a significant cross-sectional relationship with the continuous measure of GHQ-28. A composite AI score constructed using 12 biomarkers did not show a significant association with depressive symptoms among Psobid participants. Longitudinal Analysis Findings: In DepChron, three clinical outcomes were studied over four years: all-cause death, all-cause hospital admissions and composite major adverse cardiovascular outcome-MACE (cardiovascular death or admission due to MI/stroke/HF). Presence of depressive symptoms and composite AI score calculated using mainly peripheral cardiometabolic biomarkers was found to have a significant association with all three clinical outcomes over the following four years in DepChron patients. There was no evidence of an interaction between AI score and presence of depressive symptoms in risk prediction of any of the three clinical outcomes. There was a statistically significant interaction noted between SBP and depressive symptoms in risk prediction of major adverse cardiovascular outcome, and also between HbA1c and depressive symptoms in risk prediction of all-cause mortality for patients with diabetes. In Psobid, depressive symptoms (assessed by GHQ-28≥5) did not have a statistically significant association with any of the four outcomes under study at seven years: all cause death, all cause hospital admission, MACE and incidence of new cancer. A composite AI score at baseline had a significant association with the risk of MACE at seven years, after adjusting for confounders. A continuous measure of IL-6 observed at baseline had a significant association with the risk of three clinical outcomes- all-cause mortality, all-cause hospital admissions and major adverse cardiovascular event. Raised total cholesterol at baseline was associated with lower risk of all-cause death at seven years while raised waist hip ratio- WHR at baseline was associated with higher risk of MACE at seven years among Psobid participants. There was no significant interaction between depressive symptoms and peripheral biomarkers (individual or combined) in risk prediction of any of the four clinical outcomes under consideration. Risk Scoring System Development: In the DepChron cohort, a scoring system was constructed based on eight baseline demographic and clinical variables to predict the risk of MACE over four years. The AUC value for the risk scoring system was modest at 56.7% (95% CI 55.6 to 57.5%). In Psobid, it was not possible to perform this analysis due to the low event rate observed for the clinical outcomes. Conclusion: Individual peripheral biomarkers were found to have a cross-sectional association with depressive symptoms both in patients with cardiometabolic disease and middle-aged participants recruited from the general population. AI score calculated with different statistical formulations was of no greater benefit in predicting concurrent depressive symptoms or clinical outcomes at follow-up, over and above its individual constituent biomarkers, in either patient cohort. SBP had a significant interaction with depressive symptoms in predicting cardiovascular events in patients with cardiometabolic disease; HbA1c had a significant interaction with depressive symptoms in predicting all-cause mortality in patients with diabetes. Peripheral biomarkers may have a role in predicting clinical outcomes in patients with depressive symptoms, especially for those with existing cardiometabolic disease, and this merits further investigation.

Personality disorder is common amongst individuals accessing mental health services, with research into its aetiology and impact on services increasing in recent years. This thesis has two parts. The first is a systematic review of the neuropsychological functioning among forensic samples with diagnoses of psychopathy and antisocial personality disorder (ASPD). Five databases were searched for cross-sectional studies exploring cognitive functioning in psychopathy and ASPD. Twelve studies were reviewed and indicated that individuals with psychopathy and ASPD demonstrate deficits in executive functions, attention, and memory, and that there are some differences in neuropsychological performance between the two disorders. The second part is an empirical study exploring factors that may influence mental health staff attitudes towards individuals with personality disorder. The study found that staff personality traits, emotion regulation style, empathy and job satisfaction were related to attitudes to personality disorder. Empathy and job burnout predicted attitudes, with higher scores on empathy and lower levels of burnout being related to positive attitudes to personality disorder. Implications for the findings of the systematic review and empirical study are discussed. Further research is required in both areas.

Background: Attachment theory [Bowlby, J. 1969, 1973, 1980 Attachment & Loss, Volumes I-III, London: Hogarth Press] proposes that a person’s experiences of care in infancy and childhood lay the foundations for their internal working models of themselves and others. Inconsistent, unpredictable or hostile caregiving can lead individuals to hold negative internal working models which can impact on their mental health later in life. Many looked after and accommodated young people have experienced this type of neglectful or abusive parenting. These experiences of parenting may lead looked after young people to have internal working models of themselves as ineffective and of others as powerful, thus leading them to develop a learned helplessness and a more external locus of control. Objectives: A systematic review was carried out in order to explore the mechanisms by which the relationship between attachment and depression functions in adolescence. An empirical study aimed to investigate whether young people with negative attachment experiences, those who are looked after and accommodated, have higher levels of depression or a more external locus of control than other young people of the same age and the role these play in their future thinking. Method: Nineteen papers investigating mediators and moderators of the attachmentdepression relationship in adolescence were reviewed. In the empirical study, a group of looked after and a group of non-looked after young people aged 15-18 were asked about their approach and avoidance goals for the future and were asked to rate beliefs in their control over, and likelihood of, achieving these goals. Results: Evidence was found for a number of mediators of the relationship between attachment and adolescent depression. There were also found to be significant differences between the two groups with differing care histories with regards to levels of depression and locus of control, with looked after young people having higher levels of depression and a more external locus of control. A mediation analysis found that locus of control mediated the relationship between looked after status and future thinking. Conclusions: A person’s attachment history and experiences of care in early childhood can impact on their levels of depression and locus of control. There are a number of factors which mediate or moderate the attachment-depression relationship, most of which can be attributed to an individual’s internal working model of either themselves or others. Locus of control plays a critical role in young people’s future thinking and professionals working with accommodated adolescents should facilitate these young people to have experiences which will help to increase the internality of their locus of control. Objective: Attachment security has been found to be a significant predictor of depression in adolescence. This review aimed to examine the pathways by which this relationship functions by reviewing studies which have investigated potential mediating or moderating factors. Method: Studies were included if they investigated mediation and/or moderation of the relationship between attachment and adolescent depression. Results: A number of cognitive and social factors were found to mediate the attachmentdepression relationship. Age was found to be a significant moderator of the relationship but the findings on gender were inconsistent. The findings should be treated with caution, however, as many of the studies reviewed were potentially underpowered. Conclusions: A model is proposed in which mediating factors were linked to the internal working models of self and others. The need for future research to be carried out in clinical adolescent populations with sample sizes large enough to ensure adequate power was identified.

This thesis portfolio consists of two key pieces of work, a systematic review and an empirical research project, both of which explore outcomes associated with traumatic experiences. Systematic Review – There is a growing body of literature which demonstrates that, alongside the difficulties people may experience following trauma, many individuals are also likely to report growth following the struggle to come to terms with the event. This review explores the evidence for a relationship between reported growth and distress following civilian, interpersonal trauma. The review includes 13 studies which met the inclusion criteria (9 cross-sectional and 4 prospective). Findings are inconsistent and suggest that prospective study designs are more likely than cross-sectional designs to report significant relationships. A number of methodological issues and the implications for future research are discussed. Empirical Research Project – Survivors of childhood sexual abuse (CSA) present with a wide range of difficulties and the current evidence base for the treatment of complex trauma is limited. It is proposed that self-compassion and forgiveness based approaches may have the potential to be of benefit to this population. This cross-sectional study explored the relationships between posttraumatic stress symptoms, dissociation, self-blame, self-compassion and forgiveness. A clinical sample of adult survivors of CSA (N = 19) completed all measures. In keeping with previous literature, significant relationships were found between posttraumatic stress and both dissociation and self-blame. Forgiveness was positively correlated with dissociation, but not the other variables and no significant relationships were found between self-compassion and the variables of interest. Findings, implications and study limitations are discussed.

This thesis describes an interpretative, qualitative study of one person centred planning, circle of support. The eight people in the circle support a person with a learning disability, to help plan the life the person would like, utilising person centred planning techniques and tools. This study uses an ontological foundation of phenomenology, existentialism, and social psychology to examine the authenticity of the process of person centred planning for the circle of support members, and the person they have all chosen to support (focused person). A variety of data collection methods are employed, particularly those utilising ethnographic characteristics, and participatory approaches. These include video of a circle of support meeting, informal interviews using a video elicitation technique with circle members, and the use of photographs of the person’s plan. The data analysis is interpretative, and uses a two stage thematic analysis. Findings focus on the key concepts of individual agency, social inclusion, rights, choice and social emancipation. In addition the study attempts to examine the individual’s “truth” of current service experiences, and of person centred planning as a method of life planning, for people with learning disabilities. This study adds to understandings of learning disability, and disability generally, by providing new insights into how people should be supported in the future. It emphasises recognising the importance of individual experience both as participants in circles of support, but also as people involved in, or using learning disability services in the United Kingdom. This includes appreciating that human experience is shaped not only by what can be observed and measured, but that individual agency, imagination, feelings and thought are just as important in how individuals view and experience their world.

Introduction: Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment seen within the outpatient orthopaedic clinic; therefore assessment and management of this common condition is of significant importance. Traditionally diagnosis has been made through detailed questioning; clinical examination and nerve conduction studies (NCS). There is however no true consensus as to the gold standard assessment of CTS and the use of NCS can confer additional costs and delay treatment. Previous studies have explored methods of predicting the presence of CTS including the clinician-administered Carpal Tunnel Questionnaire (CTQ) (Kamath and Stothard, 2003). The aim of the present studies is therefore to explore the versatility of the CTQ to see how a novel Patient-completed Version of the CTQ compares to the original Clinican-completed version. Psychometric properties of the questionnaire will be explored together the economic impact of integrating both versions within an orthopaedic care pathway. A further aim is to answer whether the CTQ more effective and cost-effective than NCS for patients referred to an orthopaedic clinic with suspected CTS. Method: 100 patients referred for further investigation of suspected CTS were assessed using parallel patient and clinician-completed versions of the CTQ and results were subsequently compared with those obtained from NCS. Item analysis explored each of the nine constructs of the questionnaire and the original scoring algorithm was validated using binary logistic regression and compared with alternative algorithms. Sensitivity and specificity of the questionnaire when compared to results of NCS was explored using Receiver Operating Characteristic (ROC) analyses. Inter-rater reliability was explored through Pearson’s correlation coefficient. Economic analysis and modelling was carried out to explore potential cost savings of use of the questionnaire rather than NCS for those with suspected CTS. Results demonstrated sensitivity of 92% and specificity of 54.67% (positive predictive value 95.35%) for the patient-completed questionnaire and 96% sensitivity with 70.67% specificity (98.15 positive predictive value) for the clinician-completed questionnaire when used to predict the outcome of NCS. Binary logistic regression confirmed the original scoring algorithm and a revised algorithm did not significantly improve sensitivity. Adoption of the clinician-completed CTQ would have screen out 54% of referrals for NCS, which in the case of the study site would have conferred cost savings of £73,305 per annum (base upon a referral rate of 750 per annum). The patient-completed CTQ in the current sample resulted in 43% of referrals with suspected CTS not requiring NCS to assist in diagnosis with a potential saving of £58,372.5 per annum. There are further considerations of the reduction in waiting times, which are explored further within the analysis. Conclusion: Economic evaluation is complex due to the variety of pathways adopted by different orthopaedic departments. While the results of the Patient-complete version of the CTQ may not be as convincing as the clinician completed the study does provide validation for its use and expands the versatility of this useful adjunct to the assessment of CTS. Both versions could potentially confer significant cost savings and reduce demands on investigative services, reducing waiting times and improving the patient journey in suspected CTS.

Mutual Support is an in depth exploration of the role and impact of peer support by people with learning difficulties. Built on one of the seven aims of Centres for Independent Living, the project has constructed a model of peer support based on accounts of direct experiences from people with learning difficulties. The overall aim of the research was to construct and critique the Mutual Support model of peer support and people with learning difficulties. This thesis reflects the process of that construction. The overall aim was met through a research situation in which knowledge was constructed in the interaction between the researcher and participants. This provided an opportunity for people with learning difficulties to reflect upon their relationships with one another, and the emancipatory potential of that support. The focus of the research was two pre-existing settings involving people with learning difficulties supporting one another: a Theatre Company using Forum Drama to facilitate changes in attitudes and policy, and a course facilitated by people with learning difficulties who mentored small groups. Methods used within the research were based on an Inclusive Research process which prioritises meaningful research interaction that is accessible and guided by participants. The research process intertwined meetings with advisory groups, and contact with other local groups of people with learning difficulties, with formal data collection within the two main settings. One to one experienced-based narrative interviews with people from the two main settings provided multiple opportunities for participants to speak about their experiences of peer support. These interviews formed the data used in formal analysis, which was a continual process, with subsequent interviews being based on views previously expressed. A further comprehensive descriptive content analysis of data, using the tools of Nvivo8 and mind-mapping, took place prior to the outputs of the whole project being evaluated during group sessions with those who had taken part. The emerging model is one of collective support which challenges assumptions about the role and impact of people with learning difficulties supporting one another and their capacity to engage in insightful interpersonal interaction. Mutual Support has the potential to break down barriers to inclusion. Mutual Support also demonstrates the value that people with learning difficulties place on giving and receiving support from one another. The outputs of Mutual Support include contribution to current debate in the areas of service user involvement, inclusive research, and the academic field of Disability Studies.

The psychiatric diagnosis of Borderline Personality Disorder (BPD) leads to service users experiencing stigmatising and disempowering attitudes from professional mental health staff. To date, a nursing theory has not been developed to understand mental health nurses’ personal and professional constructions towards service users with this diagnosis. The development of such theory may enable improved service user engagement, collaboration and recovery for this group of individuals. This study answered the questions of determining the nature of mental health nurses’ beliefs towards service users with a diagnosis of BPD and how these beliefs affect their therapeutic relationships with this service user group. An ethnographic approach was used in this study. Data was collected using a combination of observation of the patient assessment and allocation meeting within a community mental health team; and ethnographic interviews with named nurses for service users with a diagnosis of Borderline Personality Disorder. A reflective journal was also kept by the lead researcher. N-Vivo Version 7 was used to aid data analysis and this involved examining the scripts for repetitive patterns or sequences including descriptions, figures of speech, metaphors etc. in order to illuminate differences between different practices and contexts. Findings from the study elicited a model of how CPNs construct BPD categorisations and a potential pathway to alienation is described together with recommendations for the development of CMHTs and CPNs when working with BPD. Development of reflexive practice can be a vehicle for developing alternative constructions of BPD and recovery informed practice can reduce stigmatising practices experienced by service users with BPD.

This thesis explores how men with mild to moderate learning disabilities perceive and experience how disability, relative poverty and gender impact on their health. Its theoretical framework grounded in analysis of these social divisions, and informed by the men’s own accounts - previously neglected in research, reveals complex challenges affecting their health on a daily basis. Consistent with the thesis’ overarching perspective, key elements of a participatory approach were adopted in the fieldwork to ensure men with learning disabilities’ active research involvement. They comprised the steering group, and twenty men participated in qualitative interviews facilitated by accessible materials and detailed preliminary preparations. The findings showed the men were aware of health issues, but were grappling with the adverse health effects of impairment, including disabilist health care and victimisation. Low income associated with limited employment confined most men to relative poverty with negative effects on health. The findings demonstrated a sharp appreciation of masculinity. Marginalised by other men, they experienced health threatening abuse, but their resistance to conventional male disregard for health care, had positive implications for their health. The thesis provides a more informed, nuanced understanding of the adverse impact of different dimensions of social disadvantage on the health of men with mild to moderate learning disabilities. In doing so, it demonstrates the value of developing knowledge grounded in their perspectives and experience.

Given the limited empirical evidence to guide support for romantic functioning in Autism Spectrum Disorder (ASD), this research aims to explore how closeness is managed in romantic relationships when one member is diagnosed with ASD. 8 participants, 3 couples and 2 individuals aged between 26 and 80 took part in the study. Of these 5 (3 male and 2 female) were autistic and 3 (1 male and 2 females were non-autistic). Participants were recruited using a specialist nationwide organization and they were interviewed individually or conjointly, as well as observed during a 15- minute interaction. Constructivist grounded theory was used to analyse the data and a framework was produced to describe processes of managing closeness in ASD. The core concept to emerge from the analysis was entitled “reaching towards the unknown”. It consisted of three categories, termed “encountering the other”, “reaching for understanding” and “managing uncertainty”. The framework captured processes of joining with and adapting to someone very different, of stretching beyond familiar bounds in order to understand the other and manage uncertainty. This research offers an inter-subjective perspective of ASD. It frames socio-emotional reciprocity and adaptability within romantic relationships as relational phenomena, which are contingent upon factors outlined within the framework. The model considers pre-existing theories about romantic closeness in order to assist counselling psychologists in accommodating ASD within their couple therapy practice.