Aims: The primary aim of this study was to augment the body of largely quantitative empirical work informing psychological therapy with people diagnosed with eating disorders, in particular, anorexia nervosa, through a collaborative exploration of the lived experience of sufferers, focusing on imagery related to food, weight and shape. This involved the development of an understanding of the themes inherent in the experience of women with anorexia nervosa, based on their in-depth descriptions. Design: Interpretative Phenomenological Analysis (IPA) offers a framework for exploring the lived experience of people embedded within a context, and the meanings that people attach to their experience. This qualitative approach was considered suitable for this study, given its aim of engaging with rich descriptions of people’s experiences. Method: Participants were ten women aged between 18 and 30, with a current diagnosis of anorexia nervosa, who volunteered for interview. Indepth, semi-structured interviews were conducted with the aim of learning about the participants’ embodied experience and how they made sense of their experience. Findings: Analysis using IPA led to the emergence of three Master themes, each constituting a pair of constructs which represent polarities within a realm of experience, namely (1) fragmentation versus integration, (2) exposure versus protection and (3) isolation versus relatedness. Within each realm of experience, there was stronger support within the data for the first construct (namely, fragmentation, exposure and isolation) than for its polar opposite. Organisation of Master themes according to this interpretation allowed for the possibility that participants might potentially experience to a greater extent the opposite polarities of integration, security and relatedness. Conclusion: Psychological therapy for people diagnosed with anorexia nervosa can be enhanced by an understanding of the use of the body in constricting the self in order to feel safe. Imagery work may be integrated into therapy to support clients in developing the capacity for integrated, self-reflective and embodied engagement in their relating to self, others and the wider context.

A review of the literature in personality disorders leaves no doubt that more research is needed for the understanding and management of this clinical condition. The frequent misuse of drugs and alcohol within this population adds an extra complication for the treatment of these individuals who are often neglected or mistreated by the health care system. The creation of specialist personality disorder teams following the National Institute of Mental Health (NIMH) report in 2003 gave new hope for both patients and professionals working in this area. Mentalization Based Treatment (MBT) is one of the promising psychological interventions for personality disorders, and there is evidence that it works for Borderline Personality Disorder. The aim of this study was to investigate if MBT is effective in patients with various concomitant personality disorder types and with co-morbid addiction problems. Since most research has focused on whether MBT works, it seemed important to also find out ‘what’ is it that works in MBT i.e. what are the helpful therapy processes or ‘ingredients’ of change. A research based MBT program was established in an outpatient setting, with six patients considered to be suitable; they engaged in twice weekly group psychotherapy, periodic clinical reviews with the consultant psychiatrist in psychotherapy and additional support from a psychosocial nurse, all within a mentalizing framework. Close links with the Community Mental Health Team and the Community Drug and Alcohol Service were maintained. An adjudicated form of the Hermeneutic Single Case Efficacy Design method (HSCED) was used, aiming to gain deep, contextual, knowledge into a small number of cases undergoing treatment. A rich case record was obtained for each case, including quantitative and qualitative data. Following the collection of data two researchers have engaged in a reflexive process, trying to gather affirmative and sceptic evidence regarding the efficacy and effectiveness of treatment. Nine ‘judges’ were then invited to give their expert opinion on each case resembling a legalistic trial. The judges rated their conclusions on a scale from 0% (no change) to 100% (changed completely), indicating that after one year of treatment the patients have made considerable (60%) positive changes and that these changes can be attributed to the therapy programme to a substantial (80%) degree. A number of treatment ‘ingredients’ have been discovered but these appear to be common factors in many psychotherapeutic approaches rather than specific to MBT. The HSCED method was considered to be an appropriate choice, showing that it can be of value in cases of severe disturbance within complex treatment programs. Nonetheless, some adaptations are recommended.

Generalised anxiety disorder (GAD) is a common and distressing mental health problem that is characterised by uncontrollable worry, inattention, and physiological arousal. A better understanding of anxiety disorders could be enabled with effective human models and may improve upon the poor predictive validity of animal models in the identification of treatments. The inhalation of 7.5% carbon dioxide (CO2) produces robust increases in subjective and physiological symptoms of anxiety (Bailey, Argyropoulos, Kendrick, & Nutt, 2005) and impairs attentional control (Garner, Attwood, Baldwin, James, & Munafo, 2011a) in healthy volunteers. Research in animals (Ziemann et al., 2009) has provided evidence for the critical involvement of the amygdala in the detection and coordination of anxious behaviours to CO2, however the role of the amygdala in the human response to CO2 has not been identified. Study One used eye-blink startle magnitude, a well-validated, yet indirect measure of amygdala activity, to examine whether CO2 inhalation in humans might provoke a fear response coordinated by the amygdala. Despite producing strong anxiogenic effects on subjective mood and autonomic arousal, 7.5% CO2 had no effect on startle magnitudes. Instead, CO2 inhalation slowed eye-blink startle latencies. This may be due to fewer available processing resources to respond to an external threat. Study Two investigated the extent to which duloxetine, an effective treatment for GAD, might reduce subjective anxiety and associated deficits in attentional control experienced during 7.5% CO2inhalation. Using the antisaccade task, CO2 inhalation was found to increase the number of antisaccade errors (suggesting poor control of attention) in the placebo group; an effect that was not seen in the duloxetine group. No clear effect of duloxetine on CO2-induced subjective anxiety or physiological arousal was revealed. Study Three extended these findings with the novel drug memantine, a licenced treatment for cognitive degeneration in Alzheimer’s disease that has displayed some preclinical anxiolytic properties (Minkeviciene, Banerjee, & Tanila, 2008). Two week administration of memantine in healthy volunteers resulted in significantly fewer antisaccade errors than placebo, in the absence of any change in subjective mood. Collectively, these results suggest that modelled deficits in attentional control in healthy volunteers can be targeted by known and potential treatments of anxiety disorders, without a comparable decrease in subjective and autonomic symptoms. Examination of symptoms across the anxiety phenotype with human models could help identify better treatments, and understand the neural basis underlying pathological anxiety.

Dissociative Identity Disorder (DID) is a complex and often poorly understood dissociative disorder, characterised by disruption of identity with the presence of two or more distinct personality states (APA, 2013). Several theoretical models have been proposed to provide a framework within which to understand this client group. However little i known about the conceptualisation of this presentation by therapists working clinically with this population. The current study aimed to explore the subjective options of therapists regarding the conceptualisation of DID in clinical practice. Q-methodology was used in order to operationalise and analyse these subjective beliefs. A Q set of 54 statements was created from previously reported interview data (Stokoe, 2014) with clinicians who had significant experience in working with clients with DID. The Q set was then administered to 18 therapist participants, who were asked to Q sort the statements in relation to how essential the items were conceptualising or ‘formulating’ DID. Factor analysis identified three factors, suggesting the presence of three differing perspectives regarding the ‘essential’ features of the formulation of DID. Factor A focused on “Trauma, attachment and the internal system”, whilst Factor B, “The conscious experience of DID” prioritised the everyday experience of DID and Factor C emphasised the “Helpful aspects of DID Compartmentalising emotions to enable functioning”. There was consensus across all three factors regarding the ‘least essential’ items to include in their formulations. However, the identification of three statistically distinct factors indicates the existence of differing viewpoints amongst the therapist participants.

Anxiety disorders are an important cause of morbidity worldwide. Existing treatments for anxiety disorders have considerable shortcomings and new treatments are needed. Anxiety impairs attentional control through effects on central executive functions, whereas Mindfulness training has effects on executive function and attention. This thesis explores the potential for using mindfulness and transcranial direct current stimulation (tDCS) as treatment modalities for anxiety disorders, beginning with a literature review, and going on to describe a series of investigations in healthy volunteers. The first study compared the effects of two types of mindfulness training: focused attention (FA) vs. open monitoring (OM), on attention network function, using the Attention Network Test (ANT). The second study explored the effects of a strengthened, integrated FA and OM mindfulness training on attention to threat, using an antisaccade task. A third study examined the effects of a single session of guided FA vs. OM mindfulness on attention to threat (measured using an antisaccade task), during inhalation of air enriched with 7.5% carbon dioxide (CO2). The fourth study evaluated the effect of a single session of tDCS on attention network function (measured using the ANT). The final study examined the effect of a single session of tDCS on attention to threat (measured using the antisaccade task), during inhalation of 7.5% CO2. The main findings of these studies are as follows: A literature review demonstrated that Mindfulness-based interventions have a substantial evidence base for efficacy in depression and a growing evidence base in anxiety disorders. A meta-analysis of randomised controlled trials (RCTs) comparing active vs. sham tDCS in depression found that in patients with major depressive episodes, tDCS offers an effective and tolerable alternative to antidepressant medication for those who do not wish to take or cannot take tolerate medication, or cannot tolerate it: current evidence does not support the use of tDCS in treatment resistant depression, or as an augmentation treatment with antidepressant medication or Cognitive Control Training (CCT). There are no published RCTs of tDCS in anxiety disorders. Mindfulness interventions were associated with enhanced executive control function on the ANT, and attenuated the effects of 7.5% CO2 inhalation on anxiety A single session of tDCS was associated with enhanced executive control function on the ANT, but did not protect against anxiety during inhalation of 7.5% CO2. These findings suggest tDCS may be best utilised during the early stages of depression treatment pathways, and have implications for future design of mindfulness interventions for anxiety.

People with high levels of social anxiety often experience spontaneous observer perspective images of themselves while anticipating, taking part in, or recalling, social situations. These images are usually negatively distorted, and yet are often taken by the anxious person to be an accurate representation of their performance. Such images are thought to be cognitively demanding for the socially anxious person, drawing their attention to aspects of themselves which they perceive as deficient. Additionally, the images prevent socially anxious people from attending to the situation as it genuinely appears, and can form the basis of socially anxious people's post-event review of social situations. The first study in this series presents qualitative findings from an interview study and demonstrates differences between the content of both observer and field perspective images in high and low socially anxious people. The second set of studies uses experimental methods to assess the intrapersonal effects of observer and field perspective images and demonstrates that while cognitive aspects of social anxiety such as negative thoughts were not affected by imagery, more emotional aspects such as discomfort were. Additionally, these studies showed that field perspective imagery was particularly beneficial for low socially anxious people's opinions of interaction quality, in a way that did not appear to be the case for the high anxious participants. The final set of studies examines more interpersonal outcomes of imagery, and demonstrates that overall, observer perspective images led to negative outcomes for both high and low socially anxious people, as well as the mid-anxious people with whom they conversed. Additionally, imagery was shown to have an effect on the social goals that people selected in anticipation of a social interaction. Overall, it is concluded that observer perspective imagery has a range of negative outcomes on both inter and intrapersonal aspects of social anxiety. Additionally, it is suggested that field perspective images among socially anxious people may sometimes contain negative information. Results are discussed in the context of existing models of social anxiety and imagery, and of potential implications for treatment approaches.

This thesis investigates the role of specific, common and extratherapeutic factors in dialectical behaviour therapy (DBT) for borderline personality disorder (BPD) with self-harm, using both quantitative and qualitative methods. The overall aim is to generate evidence on the mechanisms by which patients with BPD can achieve change. The premise of the thesis is that DBT has been shown to be more effective than control treatments in reducing self-harm in patients with BPD (Brazier et al. 2007, Binks et al. 2006, Stöffers et al. 2012), but the mechanisms by which this is achieved have not been empirically established. Identification of these mechanisms could enable them to be enhanced in existing interventions or even in routine treatment for patients with BPD, so that improved outcomes are achieved (Llewellyn & Hardy 2001, Kazdin 2007). Theories on the mechanisms of change in psychotherapy have identified three types of factor that may contribute to treatment outcome: specific factors, common factors and extratherapeutic factors. Specific factors are those outlined in the theory of a particular therapy as a central mechanism for patient change (Oei & Shuttlewood 1996). In DBT, patients are taught a set of skills to better regulate their emotions, and patients’ use of these skills is identified in the DBT manual as a key mechanism for achieving change (Linehan 1993a, b). Linked to this, the thesis focuses on three specific factors in DBT: perceived understanding, frequency of use and perceived helpfulness of the DBT skills. Common factors are aspects of treatment which are common to all therapies (Oei & Shuttlewood 1996). The contextual theory outlines several factors common to all successful psychotherapy interventions, and argues that these common 17 factors are the key agents of change (Frank & Frank 1991, Wampold 2001). This thesis focuses on three common factors identified by the contextual theory: treatment credibility, the therapeutic alliance, and self-efficacy. Extratherapeutic factors are factors that influence outcome outside of the treatment context (Lambert 2003, Hubble et al. 2005). This thesis focuses on three extratherapeutic factors linked to social support from friends and family: perceived social support, number of social contacts and number of social confidantes. Previous research has shown that more frequent use of the DBT skills is associated with improved outcomes during DBT (Miller et al. 2000, Neacsiu et al. 2010, Stepp et al. 2008). This could suggest that skill use is a specific change mechanism in DBT. Alternatively, Wampold (2001) suggests that specific factors are associated with therapy outcome only because they enhance common factors. For instance, patients who use the skills more are likely to find their treatment more credible, to have a stronger alliance with their therapist, and to feel a stronger sense of self-efficacy. They may also receive more social support from friends and family. No research to date has examined whether skill use is associated with outcome independently of common and extratherapeutic factors. Such research could yield valuable information on how patients receiving DBT achieve change, and on what factors therapists and researchers should focus when aiming to improve outcomes. The first aim of this thesis is therefore to establish whether skills use is associated with the outcome of DBT for BPD independently of common and extratherapeutic factors. Secondly, patients with BPD are often considered to drop out of treatment more frequently than patients with other mental disorders (Bornovalova & Daughters 2004, 18 Horner & Diamond 1996, Kelly et al. 1992). However, very few studies have examined what processes occurring during treatment are associated with dropout. Previous research has shown that a stronger therapeutic alliance is associated with treatment completion in psychotherapy for BPD (Gunderson et al. 1997, Spinhoven et al. 2007, Yeomans et al. 1994). However, the predictive relevance of specific factors such as DBT skills use, other common factors such as treatment credibility or self-efficacy, and extratherapeutic factors such as social support, has not been evaluated. Furthermore, no study to date has examined whether the DBT skills are associated with treatment completion independently of common and extratherapeutic factors. Such research could enable a better understanding of why patients drop out of DBT treatment, and could inform what factors therapists should focus on to prevent this. The second aim of this thesis is therefore to establish whether skills use predicts treatment completion in DBT for BPD independently of common and extratherapeutic factors. Thirdly, quantitative research on the association between treatment processes and outcomes is arguably limited, because although it can show what factors are associated with outcome, it cannot show how these factors lead to better outcomes. By contrast, qualitative interviews with patients can yield valuable insights on how their experiences in therapy enabled them to achieve change, and can enable identification of barriers to change (Hodgetts & Wright 2007). This in turn can inform future quantitative work by giving an indication of what mediating and moderating factors could be evaluated, and can ensure that researchers’ understanding of change mechanisms during therapy remains rooted in the lived experiences of patients rather than tied to abstract academic theories (Black 1994, Denzin & Lincoln 1994, 19 Greenhalgh & Taylor 1997, Miles & Huberman 1994). Since the main focus of the present thesis is on the DBT skills, the qualitative element focuses on participants’ experiences of learning, using and gaining benefit from the skills. The aims are to explore how patients use the skills and how they come to gain maximum benefit from them, what factors facilitate this and what factors act as barriers to this. Based on the above aims, the thesis addresses the following three research questions: 1) Are the DBT skills associated with outcome independently of common and extratherapeutic factors? Specifically: a) Are the DBT skills associated with self-harm frequency during treatment independently of common and extratherapeutic factors? b) Are the DBT skills associated with BPD symptom severity during treatment independently of common and extratherapeutic factors? 2) Do the DBT skills predict treatment completion independently of common and extratherapeutic factors? 3) How do patients experience learning, using and gaining benefit from the DBT skills? Specifically: a) How do patients use the DBT skills? b) How do patients come to gain maximum benefit from the DBT skills? c) What factors facilitate patients in gaining maximum benefit from the DBT skills? d) What factors act as barriers to gaining maximum benefit from the DBT skills? 20 Questions One and Two are addressed using quantitative methods, whilst Question Three is addressed using qualitative methods. The structure of the thesis is outlined below. Chapters One to Four are Literature Review chapters whilst Chapters Five to Seven present empirical data collected and analysed by the doctoral candidate, and Chapter Eight is a Discussion chapter. Chapter One summarises the nature and treatment of BPD, the DBT model, evidence for its effectiveness and the need for research on its mechanisms. Chapter Two reviews the literature on specific, common and extratherapeutic factors in psychotherapy, describes the contextual model and reviews the evidence for and against it, and reviews evidence on the role of specific, common and extratherapeutic factors in DBT. Chapter Three systematically reviews the literature on predictors of symptom change in psychotherapy for BPD, in order to evaluate the weight of evidence in the field and to identify what potential predictors of outcome should be included in the predictive models evaluated in Chapter Five.

Autism is a disorder characterised by impairments in social behaviour. Central to infant social development is the ability to follow the actions of others (facilitating joint attention, which is impaired in autism). Additionally, prominent neurodevelopmental theories of autism render it plausible that action perception may be impaired in autism. Previous studies have aimed to further understand action perception in autism by using biological motion stimuli (point light animations of human action). The aim of this thesis is to build upon previous research by quantitatively examining whether: i) there is an autistic deficit for perceiving biological motion and ii) whether the perceptual processes used to detect biological motion are different in the case of autism In Chapter 1 a rationale is provided for studying biological motion perception in autism. Chapter 2 reviews previous studies of biological motion in autism. On the basis of this review, a model is developed, encompassing the range of different perceptual factors which could contribute to human action perception in autism, including: i) spatial configuration, ii) limb perception iii) kinematics iv) inter-agent synchronicity, v) action discrimination and vi) attention. Concise methodological standards are then developed, including the use of: threshold measurement, error measurement, and closely matched control conditions. Chapters 3-8 are individually dedicated to the above-mentioned perceptual factors in the respective order mentioned above. Results demonstrate no differences in perceptual thresholds between autistic and typically developing groups. Crucially, differences are found between sensitivity to upright and inverted biological motion in both groups (chapters 3, 5, 6 and 7), demonstrating the specificity, validity and reliability of our perceptual measurements. The results of our study demonstrate that - in visual psychophysical tasks - participants with autism show no differences in sensitivity to biological motion and do not recruit alternative perceptual processes.

To investigate whether comorbid behaviour disorder (conduct disorder, CD; oppositional defiant disorder, ODD) predicts treatment outcomes in depressed adolescents; to describe the characteristics of depressed adolescents with and without behaviour disorder (BD); and to examine whether there is a differential effect of cognitive behavioural therapy (CBT) on these outcomes in depressed adolescents with CD, ODD or no BD. Depressed adolescents with CD at baseline and 12 weeks will have greater overall difficulties, impairment, suicidality and depression than adolescents with ODD or no BD. There will be a significant CBT treatment within each group. CD cases are more likely to be poorer attenders and will show less improvement than cases of ODD or those with no BD. ODD cases will have intermediate findings for severity and improvement. Overall, there will be an improvement in behavioural symptoms after 12 weeks of treatment. A clinical sample of 208 adolescents with persistent moderate to severe depression was recruited for a randomised controlled trial (Adolescent Depression Anti depressant and Psychotherapy Trial, ADAPT). At baseline there were 30 cases of CD, 31 cases of ODD and 147 adolescents with no BD. Subjects all received a selective serotonin re-uptake inhibitor (SSRl) and treatment as usual (TAU), and half the sample was randomised to receiving weekly CBT during a 12 week acute treatment phase. Depressed adolescents with CD are likely to demonstrate greater impairment and suicidality than those with no BD or ODD, however, show similar levels of improvement after treatment with an SSRl and TAU, with or without CBT. Depressed adolescents with CD can benefit from depression treatment and should be monitored closely for suicide risk.

Background: The human genome project has affirmed the importance of non-genetic factors in human development. Attachment style is considered to be a diathesis for psychopathology and an important determinant regarding interpersonal functioning. Epidemiological research has indicated that there is significant aetiological continuity between symptoms of schizotypy and clinical symptoms of schizophrenia. Limited research has investigated the association between attachment and schizotypy. Aim: To investigate the predictive association between schizotypy and attachment styles, interpersonal functioning and depression within a stress-diathesis model of schizophrenia. Design and Methodology: A quantitative cross-sectional within group design using a clinical sample was employed. Hierarchical linear regressions and path models were computed to investigate the hypothesised predictive association between the variables. Main finding: The best predictor of schizotypy is understood in the context of an interaction between developmental vulnerability factors (attachment styles) and current stressors (level of interpersonal functioning). Depression mediated the impact of interpersonal functioning on schizotypy but was not a significant solo predictor of schizotypy. Discussion: The potential implications of the findings are discussed in regard to a dimensional stress diathesis model of schizophrenia. The robustness of the research design employed is discussed and suggestions for future research made.