Depression is a highly debilitating illness for which there is currently sub-optimal treatment outcomes. Anhedonia (a loss of interest and pleasure) is a core symptom of depression that predicts poorer illness course and is currently not well repaired in psychological treatments. Acute and relapse prevention outcomes may be improved by clarifying which psychological mechanisms cause and maintain anhedonia, so that mechanisms can be systematically targeted in therapy. Mind wandering (a shift in contents of thoughts away from an ongoing task and/or events in the external environment to self-generated thoughts and feelings) has previously been linked to lower levels of happiness in the general population (e.g., Killingsworth & Gilbert, 2010). However, it has yet to be established if mind wandering relates to reduced positive affect in the context of depression. Therefore, the purpose of this thesis was to further explore the role of mind wandering in driving anhedonic symptoms. This thesis employed different research designs in order to establish if mind wandering is a causal mechanism driving anhedonia. Studies used a triangulation of measures to first establish correlational support (e.g. using self-report questionnaire measures, laboratory and real life positive mood inductions). Following this, studies aimed to examine if a causal relationship between mind wandering and positive affect exists by manipulating levels of mind wandering in the laboratory, real-world settings and using an empirically tested clinical intervention (Mindfulness Based Cognitive Therapy; MBCT). Using self-report measures of mindfulness and anhedonic symptoms, studies 1a and 1b found that the acting with awareness facet of mindfulness (a measure of trait mind wandering) was uniquely related to anhedonic depression symptoms in both a large community (n=440) and treatment-seeking previously depressed sample (n=409). These unique relationships remained significant when controlling for other facets of mindfulness and general depression symptoms. Study 2 (n=70) examined the relationship between mind wandering and reduced positive affect in both controlled laboratory and real world environments. Levels of mind wandering were found to be unrelated to emotional reactivity to positive laboratory mood induction tasks, but greater levels of mind wandering were significantly correlated with reduced happiness and increased sadness change to real world positive events. Next, two experimental studies were conducted on unselected samples which attempted to manipulate levels of mind wandering to observe the effect on emotional reactivity. In study 3 (n=90), a brief mindfulness manipulation of mind wandering proved unsuccessful, so it was not possible to determine how altering mind wandering impacted on positive reactivity. Analysis during the pre-manipulation mood induction revealed a significant correlation between greater spontaneous levels of mind wandering and lower self-reported happiness reactivity. In study 4 (n=95), participants followed audio prompts delivered via a smartphone application to manipulate mind wandering whilst completing everyday positive activities. This manipulation was successful but results revealed no significant condition differences in positive or negative emotional reactivity. Analysis during the pre-manipulation positive activity revealed greater mind wandering was trend correlated with reduced change in positive affect. A final empirical study (study 5; n=102) was designed to investigate the mediating role of mind wandering on the effect of MBCT on change in positive emotional experience. Recovered depressed participants undertaking MBCT were compared to recovered depressed participants in a no-intervention control group. Correlational analysis pre-intervention revealed no support for an association between mind wandering and positive reactivity to the mood induction tasks but mind wandering measured during everyday life (using experience sampling methodology; ESM) did relate to lower positive affect and higher negative affect. Participants in the MBCT group demonstrated a reduction in trait and ESM mind wandering, relative to participants in the control group. Furthermore, participants in the MBCT group demonstrated a significant decrease in anhedonic symptoms and increase in daily levels of positive affect. Change in trait mind wandering was found to mediate changes in self-reported anhedonic symptoms when controlling for change in other mindfulness facets, however change in ESM mind wandering did not mediate change in daily positive affect. MBCT also had no impact on emotional reactivity to positive mood induction tasks. Overall the findings from this thesis provide correlational support for the link between mind wandering and reduced positive affect in different testing environments. However, evidence of a causal relationship is currently limited. Consequently, a key recommendation from this thesis is to redirect attention to other driving mechanisms as targeting mind wandering in the treatment of anhedonic clients is unlikely to lead to large improvements. The theoretical, methodological and clinical implications of these findings are discussed along with suggestions for future research.

Background: Mounting evidence suggests that inflammation is involved in the pathophysiology of both Major Depressive Disorder (MDD) and schizophrenia. The presence of inflammation in the brain, however, is less clear. Microglial activation, a measure of neuroinflammation, can be quantified using PET ligands that bind to the Translocator Protein (TSPO) which is overexpressed by activated microglia. Previous PET studies using TSPO radioligands have shown some evidence for neuroinflammation in both MDD and schizophrenia. However some of these studies have been confounded by antidepressant/antipsychotic medication, low numbers and mild severity. We aimed to address some of these issues and investigate the relationship between neuroinflammation and peripheral inflammation, medication status, symptom severity and cognitive function. Method: Fourteen patients in a Major Depressive Episode (MDE) of at least moderate severity, sixteen patients with a diagnosis of schizophrenia of at least moderate severity and a total of eighteen age and gender-matched healthy volunteers underwent a 60 minute dynamic PET scan with the TSPO radioligand [11C](R)-PK11195 on the High Resolution Research Tomograph (HRRT). Parametric maps of binding potential (BPND) were generated using the simplified reference tissue model and a grey matter cerebellum input function. All of the MDD patients were antidepressant-free for at least eight months prior to scanning. Of the sixteen schizophrenia patients, eight were antipsychotic-free (for at least twelve months) and eight were on a long-acting injection of risperidone or paliperidone. All patients and healthy volunteers were medically healthy and had drug or alcohol abuse within the previous year. Results: We found a 26% mean increase in BPND values, indicative of microglial activation, in MDD patients compared to healthy volunteers. Exploratory analysis revealed significantly higher [11C](R)-PK11195 binding in the anterior cingulate cortex (ACC). We found no significant correlations between [11C](R)-PK11195 binding and peripheral markers of inflammation or with symptom severity. We also found a mean 27% increase in BPND values in the schizophrenia patients compared to healthy volunteers. There were significant correlations between [11C](R)-PK11195 and negative symptoms across multiple brain regions. When breaking the cohort down according to medication status, there was no difference between antipsychotic-free patients and healthy volunteers. However, mean BPND values were 30% higher in the ACC. The medicated patients exhibited higher BPND values than healthy volunteers, with a mean increase of 48%. Exploratory t-tests revealed significant increases in dorsolateral prefrontal cortex and ACC.Conclusions: Our findings are largely consistent with previous PET findings of increased microglial activation in a sample of antidepressant-free patients in a moderate-to-severe MDE, suggesting that neuroinflammation is present in MDD. We also investigated neuroinflammation in antipsychotic-free patients for the first time and found no evidence of microglial activation. However it is likely that the subgroup sample was underpowered. The medicated patients exhibited a 48% increase in [11C](R)-PK11195 binding compared to controls, suggesting that either medication or duration of illness might potentiate microglial activation. Our findings also point to an association between neuroinflammation and the negative symptoms of schizophrenia. The PET findings from both cohorts are largely overlapping, suggesting that neuroinflammation is not specific to either disorder but rather a common mechanism. This could reflect a common aetiology and/or an overlap in symptoms. Our findings suggest that inflammation could be used as a potential biomarker as well as a target for novel treatment strategies in both MDD and schizophrenia.

Background: Compassion Focused Therapy aims to reduce shame through the development of compassion towards the self (Gilbert & Proctor, 2006). In a recent meta-analysis, MacBeth & Gumley (2012), identified self-compassion as a good predictor of mental wellbeing in adult populations. In addition, Werner et al (2012) provided preliminary evidence that difficulties with self-compassion may contribute to the development and maintenance of social anxiety. Despite wide recognition that social anxiety arises in adolescence and can be a pre-cursor to the development of other psychological disorders, the relationship between self-compassion and social anxiety is yet to be explored in younger populations. Objective: The following portfolio aims to add to the current literature by firstly, completing a systematic review to examine whether the association between shame and social anxiety is supported by empirical research and secondly, examining the relationship between self-compassion and social anxiety in an adolescent community sample. The role of recognised cognitive factors of social anxiety i.e. fear of negative evaluation, self-focused attention and cognitive avoidance in mediating the relationship between self-compassion and social anxiety and the role of possible confounders i.e. depression and generalised anxiety were also examined. Method: A systematic review of studies that assess the association between shame and social anxiety symptomology was undertaken. The empirical study comprised a cross-sectional design in which 414 community based adolescents, aged 14-18, were recruited from 4 local schools to complete 7 validated psychometric questionnaires: Self-compassion Scale (Neff, 2003), The Social Phobia Inventory (Connor et al, 2000), the Social Anxiety Scale for Adolescents (LaGreca, 1998), The Cognitive Avoidance Questionnaire (Gosselin et al, 2002), the Self Consciousness Scales (Fenigstein et al, 1975), Screen for Child Anxiety Related Emotional Disorders (Birmaher et al, 1995) and the Short Mood and Feeling Questionnaire (Angold et al, 1995). Systematic Review Results: Twenty one studies met the inclusion criteria of the systematic review and demonstrated a positive association between shame and social anxiety symptomology. Methodological factors, depression and gender were found to impact on the power of this association. Empirical Project Results: Self-compassion was found to be inversely related to social anxiety, r=-.551, p < .0001, 95%CI[-.62, .48], with both fear of negative evaluation and cognitive avoidance, but not self-focused attention, partially mediating this relationship. Self-compassion was found to be a unique predict of social anxiety, explaining additional variance when depression and generalised anxiety were controlled for. Conclusions: The above studies extend existing literature on the relationship between shame, social anxiety and self-compassion. In particular the use of an adolescent sample provides evidence of the usability and applicability of self-compassion concepts with younger populations. Similarly, the above studies expand our understanding of the concepts underlying social anxiety, specifically in adolescents, for whom social anxiety is extremely prevalent. It is hoped that the above research may highlight associations in need of further investigation, in particular with clinical samples, and inform the development of compassion focused adaptations or interventions for this population.

Study one explored the service user experience of treatment for anorexia nervosa in the Welsh healthcare service. Factors such as treatment expectations, satisfaction, therapeutic alliance, motivation to change and engaging in treatment were considered by conducting indepth interviews with participants who had a diagnosis of anorexia nervosa and were receiving secondary care. Qualitative data were analysed using thematic framework analysis revealing six main concepts: service user description of anorexia; expectations of treatment for anorexia; the journey through the health service for anorexia; therapeutic alliance during treatment for anorexia; satisfaction with the health service; and service user recommendations to improve the health service. Mapping and interpretation of the concepts drawn from the interviews resulted in a model exploring the relationship between expectations and satisfaction of treatment for patients with anorexia nervosa, and the effect upon motivation to engage in treatment and recover. Another model describing factors that affect therapeutic alliance was developed. The results are described with particular reference to the Self-Determination Theory (Ryan & Deci, 2000). Study two used a four-stage, mixed-methods approach to develop and evaluate an anorexia nervosa awareness campaign for healthcare professionals. The campaign was developed using an integrative social marketing approach (NSMC: 2013): including formative research, process evaluation and outcome evaluation. Formative research included audience research (interviews and focus groups with healthcare professionals and healthcare professionals in training) in combination with theories of social cognition and persuasion to develop four posters. Process evaluation included campaign evaluation by healthcare professionals using questionnaires (open and closed ended questions). Appropriate modifications to the posters were made following the process evaluation, and two posters were chosen as the final intervention. Outcome evaluation of the campaign was conducted by using a brief, four-item evaluation questionnaire completed by healthcare professionals (General Practitioners and nurses). Results from all phases indicated that the use of posters as the medium of the anorexia Study three included development of a comprehensive audio-visual intervention to increase nursing students’ self-effcacy regarding initial management of patients with anorexia nervosa. The intervention was developed and underpinned using the Transtheoretical Model Framework (Levesque et al., 2001), and then evaluated using a pre-post-test design. The intervention was successful in significantly increasing nursing students’ self-efficacy regarding the initial management of anorexia nervosa. Furthermore, the nursing students’ self-efficacy was high prior to the intervention, indicating that nursing students already feel confident to manage patients with the disorder. The methodological and theoretical implications are discussed. nervosa awareness campaign did not sufficiently raise awareness of anorexia nervosa, and therefore the limitations of the second study were considered.

Background: Post-traumatic stress and exposure to early traumatic events are often characterised by negative self-cognitions and experiences of shame, guilt or blame. These symptoms are theoretically linked to the concept of self-compassion which is an important factor in affect regulation, and is predictive of mental wellbeing and psychological distress. Interventions aimed at increasing acceptance, non-judgement and self-compassion such as mindfulness may be useful in the treatment of post-traumatic stress symptoms. Methods: The first part of this portfolio presents a systematic review which aimed to collate and evaluate the existing research for the use of mindfulness based interventions to treat post-traumatic stress symptoms. The search process involved a systematic search of relevant research databases, hand search of relevant journals, and relevant authors were contacted. The second part of this portfolio presents a quantitative research study which explored the relationship between the experience of childhood trauma and self-compassion; and whether self-compassion was predictive of post-traumatic stress and growth in an adult clinical sample. Data were collected through postal survey and analysed using correlation and hierarchical regression analysis. Systematic Review Results: The systematic review resulted in 12 studies which met eligibility criteria, the majority of studies indicated positive outcomes with improvements in post-traumatic stress symptoms, particularly in reducing avoidance. Many of these studies lacked methodological rigour and further studies with more robust research design are required. Research Study Results: The quantitative study showed that greater experience of childhood emotional abuse, neglect, punishment and sexual abuse were significantly correlated with lower self-compassion in adulthood. Hierarchical regression showed that self-compassion was predictive of total post-traumatic stress symptoms, post-traumatic avoidance and intrusion when age, gender, exposure to traumatic events and childhood trauma were controlled. The experience of post-traumatic growth showed no significant relationship with self-compassion. Conclusions: Studies indicate that mindfulness interventions show promise for the treatment of PTSD symptoms, although further research with more robust methodology is needed. Greater experience of childhood abuse is related to lower self-compassion in adulthood and lower self-compassion is predictive of higher PTSD avoidance and intrusion symptoms. This suggests that future research investigating self-compassion interventions may be beneficial in treating PTSD.

Rett syndrome is a debilitating autistic spectrum disorder affecting one in ten thousand girls. Patients develop normally for up to eighteen months before a period of regression involving stagnation in head growth, loss of speech, hand use and mobility. It is almost exclusively caused by mutation in Methyl CpG binding Protein 2 (MeCP2). MeCP2 has traditionally been thought of as a transcriptional repressor, although its exact function remains unknown and it has recently been shown that the protein can also bind to hydroxymethylation and non-CpG methylation, which occurs predominantly at CAC sites in the mature nervous system. Genotype-phenotype studies of the most common Rett-causing mutations in affected patients revealed that a missense mutation, R133C results in a milder form of Rett syndrome. The reasons for this are unclear, as the mutation lies right in the heart of the methylated DNA binding domain. Previous in vitro studies of R133C showed a severe deficit in binding to methylated cytosine. A subsequent study found that R133C binding to hydroxymethylated cytosine was specifically impaired, whereas binding to methylated cytosine was indistinguishable from wildtype. Defining the DNA binding impairment of MeCP2R133C would yield important insights into Rett disease pathophysiology and provide an explanation for the phenotypic spectrum seen in patients. To shed light on these matters, a novel mouse model of the R133C mutation was created. The R133C mouse had a phenotype that was less severe than other missense mutant mice, in terms of survival, growth, Rett-like phenotypic score and some behavioural paradigms thus recapitulating the patient data. At the molecular level in adult mouse brain, MeCP2R133C protein abundance was reduced. Immunohistochemistry showed that MeCP2R133C had an abnormal pattern of localisation in the nucleus of neurons. In vitro electrophoretic mobility shift assays suggested that MeCP2R133C binding to (hydroxy)methyl-CAC may be reduced to a greater extent than binding to mCpG. Chromatin immunoprecipitation experiments confirmed the deficit in binding to methylated sites and supported a disproportionate reduction in binding to methylation in a CAC sequence context. Analysis of adult mouse cerebellar gene expression revealed a subtle upregulation of long genes and downregulation of short genes. Based on these data, it is proposed that Rett syndrome caused by the R133C mutation results from a combination of protein instability and defective binding to methylated DNA. Methyl-CAC binding is potentially abolished. The downstream biological consequence of this is a length-dependent deregulation of gene expression in the brain.

Since the findings of a Fatal Accident Inquiry (FAI) in 2010, clinicians working in Scotland have been advised to discuss the risk of Sudden Unexpected Death in Epilepsy (SUDEP) with patients immediately or soon after a diagnosis of epilepsy is made. A thematic analysis was used to describe the experiences discussing SUDEP of 10 clinicians (six Consultant Neurologists and four Neurology Registrars) working in Scotland. Five themes were found: Clinicians employ a ‘SUDEP protocol’, suggesting there is a standardised way of discussing SUDEP with patients and all clinicians routinely discuss SUDEP with newly diagnosed epilepsy patients; The FAI has diffused into practice through meetings and discussions with colleagues; ‘Breaking Good News’ refers to the ambivalence clinicians feel about discussing SUDEP; ‘Falsely anticipating anxiety’ refers to clinicians anticipating a distressed response from patients despite this very rarely occurring; Clinicians suggest that ‘pressure hinders effective communication’ to patients – suggesting that the pressure to discuss SUDEP early after diagnosis may have an emotional impact on patients and affect the amount of information they can take in. Implications for guideline development are discussed.

Background: Prevalence of psychosis is known to be higher in adults with intellectual disabilities (ID) than in the general adult population. However, there have been no attempts to develop a psychosis screening tool specifically for the adult ID population. The present study describes the development and preliminary evaluation of a new measure, the Glasgow Psychosis Screening tool for use in Adults with Intellectual Disabilities (GPS-ID). Method: An item pool was generated following: 1) focus groups with adults with ID and psychosis, and their carers and/or workers; 2) expert input from clinicians. A draft scale was compiled and refined following expert feedback. The new scale, along with the Psychotic Symptom Rating Scales was administered to 20 adults with ID (10 with and 10 without psychosis) and their relative or carers. Results: The GPS-ID total score, self-report subscale and informant rating-subscale differentiated psychosis and non-psychosis groups. The tool had good internal consistency (Cronbach’s α=0.91), and a cut-off score ≥4 yielded high sensitivity (90%) and specificity (100%). The method of tool development supports face and content validity. Criterion validity was not supported. Conclusions: Preliminary investigation of the tool’s psychometric properties is positive, although further investigation is required. The tool is accessible to adults with mild to moderate ID and can be completed in 15-30 minutes. The GPS-ID is not a diagnostic tool, therefore any adult exceeding the cut-off score of ≥4 should receive further assessment.

This inquiry adopts the non-dualist stance of Merleau-Ponty regarding embodiment, where the “body” is considered to be a socially embedded lived experience (Merleau-Ponty, 1945/1962), and considers whether this concept is useful to counselling psychologists who work with individuals with a diagnosis of anorexia nervosa. The study adopts a horizonal structure arising from understandings of Gadamer’s (1960) hermeneutics, which requires an awareness of the limitations afforded by different perspectives. Semi-structured interviews are conducted with eight practitioners of psychotherapy, who have experience with individuals diagnosed with anorexia nervosa. They are invited to speak about their experience of practice with these individuals, then to respond to a Merleau-Ponty quote regarding embodiment and to consider its usefulness in their work. Interview transcripts are thematically analysed (Braun & Clarke, 2006). Initial themes conceptualise anorexia nervosa as emotional control and denial of needs; where it is helpful to have a model of understanding; understand weight issues but don’t’ talk about food and weight, be aware of power-relations and avoid control battles, overemphasising weight gain and refeeding; and to understand ambivalence and work motivationally. The findings suggest practitioners use knowledge, in the form of theories, to provide structure and a familiar language with which to explore clients’ unfamiliar worlds. Embodied views are found to open up conceptualisations regarding ontology and embeddedness, where “anorexia” becomes an ontological split, with controlling minds punishing bodies, where words aren’t enough and the symptoms are a paradoxical solution to problems of power and agency. The study finds engaging with embodied views highlights the embedded nature of being, opens up ambiguity, challenges dichotomies and acknowledges non-psychological aspects of existence and practice. It is suggested this supports the humanistic value base of counselling psychology practice by raising awareness of the ways in which the use of theory iii can help and hinder intersubjective contact with clients and the importance of embodying hermeneutic openness.

This thesis presents an in-depth exploration of psychotherapists’ lived experience of working with borderline personality (BPD) disorder in psychodynamic psychotherapy, using interpretative phenomenological analysis (IPA). The existing research literature suggests that working with borderline patients is very difficult, as they can evoke negative counter transference experiences in therapists and thus make the working alliance difficult to maintain. The stigmatising and negative attitude towards BPD, which is found amongst mental health professionals, can cause many therapists to avoid working with this patient population, leaving many patients without the necessary help for treatment. Some literature also suggests that psychodynamic therapy may not be helpful for the treatment of BPD in its traditional form, because of the neutrality of the model and borderline patients’ ‘reduced capacity to mentalise’. Instead, empathy and the therapeutic relationship have been reported to be significant factors. This qualitative study aimed to provide a rich and detailed examination of the experiences, which psychodynamic psychotherapists and counselling psychologists might have in their work with BPD patients. Five psychodynamic psychotherapists were interviewed twice in one unstructured and one semi-structured interview, and IPA was used to analyse the data. The five master-themes (Negative countertransference feelings; “Sitting in the dark together”; Hindrance in therapeutic work; Therapist omnipotence; Labelling as problematic) found in this study suggested that borderline patients could benefit from a modified version of psychodynamic 1 Note that the ‘psychodynamic’ and ‘psychoanalytic’ terms will be interchangeably used in this study. 2 The researcher, as a trainee-counselling psychologist, is in favour of using the word ‘client’. However, psychodynamic practitioners talk about their ‘patients’ rather than ‘clients’, and as this study focuses on psychodynamic therapists’ experiences, the researcher will use these two terms interchangeably. Thus, the word ‘patient’ here is applied in the psychodynamic and not in the medical sense. 9 psychotherapy with a focus on empathy and a bond between therapist and patient. Furthermore, the therapists’ awareness of negative countertransference feelings and emergent obstacles in the therapeutic work, as well as their understanding of BPD as a label and its effects on their borderline patients were crucial. Finally, the therapists’ experienced ‘omnipotent’ feelings, which may have emerged in response to their negative countertransference feelings. While these findings support many of the previous publications and accounts reported in the literature, they also shed new light on therapists’ experiences, which might have implications for the approach that psychotherapists and counselling psychologists take towards working with borderline individuals within the psychodynamic modality.