Adolescent self-harm is a growing international concern. As the parent-child relationship and parental support can influence adolescent self-harm this review aimed to synthesise existing qualitative research on parents’ experiences of young people who selfharm. A systematic search of electronic databases was conducted, identifying 15 qualitative papers for the metasynthesis. Five concepts emerged: the turmoil of discovery and beyond; searching for certainty; the ultimate blame; vigilant parenting: treading carefully; and the ripple effect. Findings demonstrated the impact of adolescent self-harm on parental wellbeing, the challenges of understanding self-harm and how this behaviour influenced their ability to support their child. This understanding provides a framework for clinical services to offer support to parents of young people who self-harm. The second section of the thesis is the empirical paper. The aim of this research was to understand the experiences of young people who engage in self-harm whilst living in residential care. Five young people participated in semi structured interviews. Using Interpretive Phenomenological Analysis, four themes were identified: ‘The black hole of selfharm’, ‘Seeking genuine care through a protective mask’, ‘The cry to be understood’ and ‘Loss of control to the system’. Young people who self-harm in residential care are exposed to new experiences, boundaries and support networks, all of which can influence their selfharming behaviours. Clinical implications and future research recommendations are also discussed. Finally, the critical appraisal captures the journey throughout this research, including why the topics were chosen, the challenges with recruitment and reflections on the research process as a whole.

Adults with a diagnosis of Borderline Personality Disorder (BPD) often experience stigma due to the reductionist narrative that accompanies its conceptualisation. The aim of this research was to challenge the reductionist narrative by exploring a relational understanding of BPD and integrating the construct of compassion. In Chapter 1, qualitative research that explored the relationships between adults with a diagnosis of BPD and mental health professionals was synthesised. Twenty-four themes that described relational dynamics emerged. These dynamics were reconceptualised by applying psychological theory to develop 12 3rd order interpretation themes. During this process, compassionate terminology based upon psychological theory was integrated into the understanding. In addition, four cycles of relational dynamics were identified between adults with a diagnosis of BPD and mental health professionals based upon these 3rd order interpretations. In Chapter 2, a qualitative research study was conducted which explored experiences of compassion in adults with a diagnosis of Borderline Personality Disorder (BPD) to further the development of the construct of compassion in relation to BPD. Interpretative Phenomenological Analysis was used to develop themes from the narratives of six adults with a diagnosis of BPD. Five themes emerged: Emotional Connection to Suffering, Empathic Understanding, Prioritisation of Needs, A Model of Genuine Compassion and Developing Self-acceptance and a Sense of Worthiness. The themes were integrated into a recovery model that highlighted the process of recovery through therapeutic relationships that model genuine compassion. In addition, barriers to compassion and factors which facilitate compassion emerged from the analysis which have implications for clinical practice. In Chapter 3, a critical appraisal was conducted which outlined the rationale for the research and compared findings from the previous two chapters to consider how a compassionate and relational understanding can be integrated into the BPD narrative to challenge stigma and inform positive therapeutic relationships.

Psychopathy is a personality disorder that can be defined by profound disturbances in empathic response to others and repeated engagement in immoral behaviour. This thesis set out to investigate how individual differences in psychopathic traits in the general population are associated with variability in distinct components of empathy and morality. This thesis endeavoured to answer five outstanding research questions: 1) Given the complexity and multidimensionality of empathy and morality constructs, which components of these constructs are associated with psychopathic traits at the behavioural level? [Chapters 2-3] 2) Are behavioural correlates of empathy and morality in psychopathic traits specific to affective-interpersonal traits/lifestyle-antisocial traits, or common to both? [Cs. 2-3] 3) Are these correlates consistent across genders? [Cs. 2-3] 4) Are associations between psychopathic traits and empathic [C. 4] and 5) moral processing reflected at the neural level [C. 5]? This thesis’ findings suggest that: 1) individual differences in psychopathic traits are associated with lesser empathic response to emotional stimuli, lesser propensity to feel moral emotions and atypical moral decision-making; 2) empathic atypicalities are driven by the joint variance between affective-interpersonal and lifestyle-antisocial facets, but those related to affective aspects of moral cognition seem to be driven by variance in affective-interpersonal traits; 3) empathic and moral atypicalities seem to be similar in men and women; 4) atypical amygdala and anterior insula function may represent neural markers of disrupted empathic processing for individuals with high levels of psychopathic traits; and 5) atypical functioning of the vmPFC/mOFC during moral processing may contribute to the disordered lifestyle and antisocial behaviour exhibited by individuals with high levels of psychopathic traits. These findings contribute to a more comprehensive understanding of the empathic and moral processing impairments that underlie psychopathic traits.

This thesis focuses on the assessment of implicit cognition in disordered eating behaviour, and specifically on the role of implicit attitudes towards the self and food in sub-clinical levels of eating disorder (ED) pathology. Chapter I reviews key theoretical approaches to implicit cognition and an assessment of the properties of implicit attitudes. Chapter II discusses methodological approaches to implicit attitude assessment, with a focus on the Implicit Attitude Test (IAT) which was used in the empirical studies. Chapter III (Study 1) outlines research in implicit cognition in ED pathology and assesses differences in implicit self-esteem (i.e., implicit attitude towards the self) between high-pathology and low-pathology participants. While the results of the study supported the presence of a self-esteem discrepancy in the high-pathology group, the findings were insufficient to pursue further research in this area. The next three studies were focused on the role implicit food attitudes. Chapter IV (Study 2) introduces the hypothesis that implicit food attitudes and ego depletion may play a role in elevated ED pathology. However, the ego depletion procedure used was not successful and the results were therefore insufficient to either support or reject the hypothesis. Chapter V (Study 3) assessed similar questions to Study 2, but from the angle of automatic approach and avoidance towards food stimuli and dietary restraint failure. Contrary to expectations, the results suggested that it is unlikely that either ego depletion or a positive implicit attitude towards high-fat foods contributes to dietary restraint failure. Chapter VI (Study 4) was designed to clarify the findings of Study 3 and found that implicit food attitudes may change following novel goal activation or changes in behaviour. Chapter VII is a general discussion which summarises the findings, discusses the outcomes within the broader context of implicit cognition theories, and proposes directions for further study.

Introduction and aims Epilepsy is a common neurological condition and around 25% of patients are resistant to treatment with currently available drugs (Brodie et al., 2012). Currently there is only a limited ability to predict treatment outcome and no genome based biomarkers for treatment efficacy. The main aim for this thesis was to investigate clinical and genome based biomarkers for treatment response in newly diagnosed epilepsy as well as explore methodological aspects related to the assembly of a large scale international research cohort. Methods An EU-funded project entitled “Epilepsy Pharmacogenomics: delivering biomarkers for clinical use (EpiPGX)” was undertaken by a pan-European research consortium to explore genome-based biomarkers that could be used to individualize treatment of epilepsy. University of Liverpool led work on newly diagnosed epilepsy. Work presented in this thesis is solely based on this project. Cases with newly diagnosed epilepsy were either de-novo phenotyped or data was transferred from existing clinical databases. Analysis of clinical covariates using logistic and Cox regression, and a subsequent GWAS were performed. Methodological and data transfer quality aspects were assessed separately using descriptive statistics and Cohen's kappa and Lin’s coefficients. Results and Conclusion The following clinical factors were significantly associated with twelve month remission after application of first well tolerated antiepileptic drug: age at diagnosis, abnormal neurological examination, GTCs-only, epilepsy type, number of seizures before the treatment, MRI and EEG results. Heterogeneity of outcomes between cohorts, effect of mode of cases ascertainment was also demonstrated. Data quality assessment showed that simple variables can be robustly transferred between data bases whereas more complicated variables have a potential for introduction of bias. A GWAS was carried out on newly diagnosed cases with focal epilepsy and failed to identify any SNPs significantly associated with treatment outcome. Clinical factors associated with treatment outcome potentially can be useful in daily clinical practice when assessing patients with newly diagnosed epilepsy. Large scale multi-centre studies utilizing historical retrospective data are possible but prospective recruitment should be preferred. Sound methodology and quality assurance methods should be applied in future epilepsy pharmacogenetic research particularly involving large multi-centre cohorts.

Epilepsy is one of the most prevalent non-communicable conditions and also one of the most common neurological disorders affecting approximately 50 million people in the world, about 80% of who live in low and middle income countries (LMIC). It is characterized by recurrent (two or more) unprovoked seizures, with active epilepsy (AE) being defined as at least one seizure in the last 5 years although in LMIC it is often defined when one of the seizures is within 12 months of identification. Epilepsy is associated with significant psychosocial co-morbidities that impact on the healthrelated quality of life of patients and also influence prognosis. In LMIC, the perceptions of causes and consequences of epilepsy may differ from those in the high income countries (HIC) and often lead to stigmatization. The stigma may in turn hide a proportion of the burden of epilepsy since patients are unwilling to seek medical advice, translating into large treatment gaps. Many studies of LMIC have shown that the majority of PWE do not receive appropriate treatment despite the availability of cost effective treatment. The estimates of the burden of epilepsy in LMIC are based upon little data and between and within country estimates vary considerably. Causes of this heterogeneity have not been established but it is thought to be due to differences in methodological approaches, case definitions and ascertainment and lack of validation of screening instruments, as well as genuine differences in the magnitude of the burden of epilepsy.

This thesis is concerned with the lived experience of Post-Traumatic Stress Disorder (PTSD) following a medical event. It is comprised of a literature review and an empirical study. The literature review uses a meta-ethnographic methodology to synthesise data from qualitative literature and literature with a qualitative element that explores the lived experience of PTSD following childbirth. The results illustrate that difficulties trusting services, problems maintaining social relationships, and difficulties managing challenging emotions were common when participants developed PTSD following traumatic birth. The review demonstrated that women reported intrusive and worrying thoughts regarding their future as well as the event. These experiences may indicate health anxiety alongside PTSD following traumatic medical events. The review indicates that further qualitative exploration is needed into PTSD following different health conditions. It also demonstrates that further research is needed into the phenomenology of intrusive thoughts following medical trauma to explore whether these are indicative of PTSD or health anxiety. The empirical study is an Interpretative Phenomenological Analysis of stroke survivors' experience of PTSD. The findings illustrate that there is a complex range of psychosocial difficulties associated with PTSD following stroke. Findings closely mirrored those from previous qualitative research into the lived experience of PTSD following medical events. Results were considered in relation to cognitive models of PTSD, but consideration was also given to grief models to help explain findings. Study limitations, future research, and clinical implications were discussed.

With an acknowledgement to both the cultural and medical influences in the literature this thesis analyses the experiences of young people receiving in-patient treatment for anorexia nervosa. Due to the physical complications associated with anorexia nervosa and the age of diagnosis most often being during adolescence it is one of the few medicalised mental health conditions where specific in-patient treatment centres operate. Patients are often admitted for relatively long periods of time in order for safe weight gain and a behavioural approach is the underlying philosophy for treatment. The medicalisation of the disorder and focus on treatment and restoration of weight has been widely criticised for not acknowledging the societal and cultural factors that led to admission. Despite much research in this area treatment is often unsuccessful with clinicians referring to a revolving door phenomenon where young people are discharged and then deteriorate and are readmitted weeks or months later. This is often attributed to the resistance of the young people to treatment or their tenacity and determination to lose weight. There has been no research in to the treatment environments themselves and how access to and use of space within them may contribute to patient outcomes. This thesis addresses this through an interpretative phenomenological account of the lived experience of young people receiving in-patient treatment for anorexia nervosa in the United Kingdom. This approach was used because it is appropriate for examining major life experiences and how people make sense of them. Participants created mixed media posters expressing their experience of the spaces within and outside the centres where they were receiving treatment. The posters were then used as prompts during follow up, in depth, interviews. The data were then analysed both by individual case and by theme. The overarching message from the young people’s experience was that although the treatment centres provided a structure and the facilities of a therapeutic environment, the approaches to access and use of the treatment spaces were restrictive and inhibited the young people’s ability to develop the resilience they required to live fulfilling lives. In particular, the lack of access to outdoor space and the rules and dominance of the treatment teams left the young people feeling deviant and removed from society. This suggests that a more culturally informed treatment environment that enabled the young people to develop resilience would be more therapeutic. This thesis found that the treatment environments did not require structural change in order to become therapeutic in nature but the practices within them do need to change. Moving away from a philosophy of treatment and restoration of weight towards an environment that is more positive and focussed on developing the resilience required to live a fulfilling life could enhance current practice.

This study aims to develop and validate a new cultural measure of depression known as the Punjabi Depression Inventory (PDI). The PDI is used to detect depression in Punjabi-speaking individuals which may be triggered as a result of their cultural experiences. The PDI specifically targets Punjabi-speaking individuals who now permanently reside in the United Kingdom (UK), but originally migrated here from India. Therefore, the PDI is intrinsically linked to the Punjabi culture and language. There is a lack of empirical research investigating the impact of culture on depressive symptoms within such a cohort of individuals. In developing the new PDI measure, 191 participants were recruited to complete the questionnaire, which was analysed using Principle Components Analysis (PCA). Four subscales emerged from this data reduction analysis: 1) deflated (for example, “I am inadequate”); 2) somatic (for example, “I feel sore”); 3) religion (for example, “I have lost interest in going to my holy place of worship”); and 4) crying (for example, “I weep”). On the whole, the early developments of the PDI demonstrated good factor structure and internal consistency for each of the four subscales: 1) deflated (Cronbach’s α = .76); 2) somatic (Cronbach’s α = .84); 3) religion (Cronbach’s α = .79); and 4) crying (Cronbach’s α = .82). These findings suggest that the items from each of the four factors adequately measure the construct of cultural depression in its target cohort. As a result, the PDI could possibly be used as an aid to provide training to help mental health professionals and to enhance their cultural knowledge of working with this class of individuals. Furthermore, the emerging PDI measure may introduce an interesting new scope for mental health professionals to broaden their methods of assessment, formulation and treatment plans. This includes the introduction of a new cultural assessment which can be utilised to identify, and specifically target, cultural depression experienced by such a cohort. This is currently lacking and underexplored within the mental health professions. Finally, the present thesis will conclude by providing provisional guidelines for multicultural practice and training, followed by a discussion of the methodological constraints. This serves to inform any future research undertaken to further assess and explore the PDI.

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