Volume 1 of this thesis evaluates the effectiveness of brief Psychoeducative Group Cognitive Behavioural Therapy (PGCBT) groups for depression and anxiety disorders. Volume 1 is presented in three parts. Part 1 is a systematic literature review of outcome studies on PGCBT for depression and common anxiety disorders, delivered in group format over eight or fewer sessions. Study quality was evaluated using the Downs and Black (1998) critical appraisal tool. Results indicated that the interventions were effective, more so for anxiety disorders than depression. Studies’ qualities and methodologies were variable, making a meta-analysis impossible and weakening the findings. The quality of the current evidence base and methodological issues are discussed and avenues for further research suggested. Part 2 is a qualitative study into what patients who completed a five session psychoeducative group delivered by an IAPT service found beneficial and how they incorporated benefits into their lives. Fifteen participants who showed reliable clinical benefit on a measure of anxiety or depression during intervention were interviewed approximately six months post-group and their responses evaluated using thematic analysis. Results showed that most people incorporated some CBT skills into daily life, either through deliberate use or less formal awareness of new ways to approach problems. However participants found the normative, cohesive and cathartic elements of the group more important in effecting change. Results were used to make recommendations to services in designing interventions and to highlight research opportunities. Part 3 is a critical appraisal of the qualitative study focused on the background to choice of research topic and methodology, followed by consideration of conceptual issues, and practical and methodological limitations to the research. It concludes with a consideration of the research process on participants and the researcher.

Volume 1 of this thesis is presented in three parts. Part 1 is a systematic review of Internet-based cognitive behavioural therapy for social anxiety disorder, which includes an objective assessment of study quality. Part 2 describes two studies exploring bowel/bladder-control anxiety (BBCA). Study 1 is an Internet-based survey to obtain initial clinical and demographic details about BBCA and study 2 uses postal questionnaires to explore the relationship of BBCA with panic attacks. This is a joint thesis as it forms part of a larger project and was conducted alongside that of another Trainee Clinical Psychologist. Part 3 is a critical appraisal of the research process, which considers implications of the conceptualisation of BBCA for the research project as well as multiple testing and advertising. It further discusses issues of conducting research and delivering psychological therapy via the Internet.

This volume consists of three parts. Part 1, the literature review, examines 20 papers to describe the current understanding of the relationship between therapist alliance, therapist adherence and outcome in individual psychotherapy. Part 2, the empirical paper, uses data from participants in the Positive Reinforcement targeting Abstinence In Substance misuse (PRAISe) randomised control trial being conducted in south east England. This trial investigates the effectiveness of contingency management (CM) interventions in opiate substitution therapy to improve attendance and abstinence of heroin. The paper explores the impact of CM interventions on levels of attendance in opiate substitution therapy and investigates the relationship between client factors, therapeutic alliance, therapist adherence to the CM and levels of attendance. Part 3, the critical appraisal, is in two sections. The first section explores the debate between research that attributes therapeutic outcome to factors that are common across different types of psychotherapy such as the therapeutic alliance, and research that highlights the importance of the contribution of theory specific interventions, measured by therapist adherence. The second section considers some of the moral and ethical concerns about using incentives in health care and some of the implications for future research and clinical practice.

Aims: The review examines the evidence that parents’ mentalizing predicts infant attachment security. Method: Studies were included if they examined primary care-givers’ mentalizing, defined as the capacity to understand mental states underlying behaviour, and infants’ attachment status. Results: Nine studies met criteria for review. Mentalizing was conceptualised and measured in different ways, including: reflective function (n = 1), maternal reflective function (n = 2), mind-mindedness (n = 5) and insightfulness (n = 1). Conclusion: The studies suggest that care-givers’ attachment contributes to infants’ attachment security. The evidence is limited however by the small number of studies, small sample sizes and methodological and conceptual differences between studies. Moreover mentalizing alone appears unlikely to account fully for the intergenerational transmission of attachment.

The atypical antipsychotic clozapine is a widely prescribed and effective treatment for the positive and negative symptoms of schizophrenia, but reports of side effects are common. In one study EEG abnormalities were observed in 53% of patients treated with clozapine, and the absence or presence of EEG abnormalities correlated with the plasma clozapine concentration. Here, epileptiform activity was present in conventional EEG recordings from a 32 year old male patient with psychiatric illness taking clozapine for 3 weeks. Brief (ca.100ms), transient epileptiform spikes occurred at a frequency of approximately 2 per h and originated primarily in parietal cortex. One month after withdrawal of clozapine, epileptiform spikes were no longer present. An in vitro model was developed using the equivalent region of association cortex, namely 2⁰ somatosensory cortex, in normal rat brain slices to probe such activity with increased spatial and temporal resolution, and to investigate mechanisms underlying its generation. Wide band in vitro recordings revealed that clozapine (10-20µM) induced regular, frequent very fast oscillations (VFO, > 70Hz) in this region. These VFO comprised short transient high frequency discharges and were maximal in patches along layer V. The atypical antipsychotic olanzapine, but not the classical antipsychotic haloperidol, also induced prominent VFO in this region. Sharp electrode intracellular recordings revealed that there was almost no correlation between the somatic activity of layer V regular spiking (RS) pyramidal cells and field VFO, but layer V intrinsically bursting (IB) cells did correlate to some extent with the local field. Interestingly, IB cell spikelets were also weakly correlated with field VFO suggesting a role for axonal hyperexcitability in this cell type in the mechanism. Clozapine-induced VFO persisted following blockade of AMPA, NMDA, and GABAA chemical synaptic receptors, and the gap junction blockers carbenoxolone and quinine also failed to significantly attenuate the power of this activity. Although octanol abolished clozapine-induced VFO, it was not clear that this effect resulted from blockade of gap junctions as this drug also blocks spikes. In addition to VFO events, clozapine (10-20µM) also induced occasional, spontaneous transient paroxysmal discharges, similar to the EEG phenomena, in 33% (11/33 slices) of slices in vitro. Sharp electrode intracellular recordings revealed that clozapine- induced full paroxysmal discharges were associated with spikes, EPSPs and IPSPs in layer V RS and IB cells, suggesting that these events were mediated via chemical synaptic transmission in both of these cell types. Multi-electrode array recordings of local field potentials and units suggested that clozapine-induced paroxysmal events started superficially in association cortex, moved deeper and then propagated horizontally along these deep layers. The onset of clozapine-induced VFO was accompanied by a significant elevation in parvalbumin immunoreactivity, particularly in layer II-IV, where there was a greater than twofold increase in the signal, and this may be relevant to the therapeutic action of the drug.

Background/aims: Recent evidence suggests that the psychosocial function for patients with Bipolar Disorder (BD) may not always be as favorable as originally proposed by Emil Kraeplin. This dysfunction has been statistically associated with neurocognitive measures (on tasks assessing working memory, learning and executive function) and emotional processing (on tasks assessing facial emotion labeling). Studies of Offspring of Bipolar Parents (OBP) in comparison with Offspring of Healthy Controls (OHC) demonstrate elevated risk for development of BD and limited evidence of impairment in neurocognitive function and emotional processing. The identification of an endophenotype for BD could help in early identification of BD, institution of early appropriate intervention and thereby perhaps limit this psychosocial dysfunction. The aims included the recruitment of a matched sample of OBP and OHC and investigation of neurocognitive function and facial emotion labelling in these two groups. The hypotheses were: OBP will show impairment in the domains of memory, learning and executive function, OBP will demonstrate more errors on facial emotion labeling tasks and the deficits in facial emotion labelling will not be related to impairments demonstrated on the domains of memory, learning and executive function. Results: OBP showed deficits in IQ, spatial working memory, visual and auditory working memory as compared to OHC. OBP also made more errors on tasks of facial emotion labeling; particularly on ‘fearful faces’ in comparison to OHC. The novel finding from this project was the lack of significant association between the reported neurocognitive deficits and facial emotion labeling deficits in OBP. Conclusion: The study identified deficits in neurocognitive function and facial emotion labeling in OBP which appear to be independent. These deficits met some criteria for being considered an endophenotype for BD. The study was limited by a small sample size, lack of blinding and low specificity of these deficits for BD. Further longitudinal research to study the evolution of these deficits would be the next step in confirmation of these deficits as a potential candidate endophenotype for BD. In addition research should focus on factors that might contribute to these deficits such as severity of parental BD (‘nature’) and family environment (‘nurture’).

This thesis attempts to develop a cognitive-psychosocial reformulation of depression and suicide in schizophrenia. An overview of the literature pertaining to psychotic illness, postpsychotic depression and suicide, and unipolar theories of depression is provided as a precursor to introducing the rationale to the research, namely that the onset of postpsychotic depression (and its established link with suicide), is a phenomenon distinct from the symptoms and course of psychosis, and drug treatment. An integration of cognitive and psychosocial models is developed within the framework of social ranking theory or social Darwinism. This model is tested using a prospective follow-up study of 105 participants, using a battery of measures, at the acute psychosis stage, discharge and for three follow-up interviews over the subsequent year. Results, presented in the form of three academic papers, support the hypotheses that neither symptoms of psychosis, pharmacogenic side-effects or drug dosage, nor depression during the acute stage, predict the onset of postpsychotic depression, which occurred in 36% of the sample. Consistent with the framework, patients' subjective appraisals of psychosis as embodying loss, humiliation and entrapment predated the onset of depression, as opposed to traditional cognitive vulnerability factors. Finally, the implications of the findings are discussed with respect to future research, intervention and treatment.

The modern conceptualization of schizophrenia is flawed. An accumulating body of research has challenged psychiatry's perspective on psychosis. It is no longer accepted that schizophrenia and spectrum disorders are a categorical phenomenon whereby the presence of psychotic symptoms are indicative of psychopathology that lead to poor outcomes (Ahmed, Buckley, & Mabe, 2012). Evidence from a litany of studies indicates that psychosis is better conceptualized dimensionally than categorically. Evidence shows that psychotic symptoms manifest along a continuum of severity long before the development of a diagnosable illness (Dominguez, Wichers, Lieb, Wittchen, & van Os, 2011a). Therefore, the psychosis continuum is maybe better thought of a 'risk pathway' where individuals may transiently move between infrequent but non distressing psychotic-like symptoms (PLEs) to persistent distressing psychotic-like symptoms (PLSs) and finally to functional impairment due to the persistent of distressing symptoms. Moving between these states may be contingent on biological, psychological, and social factors and the influence of the social environment including individual resilience to stress (Tamminga, 2010) . This thesis tests the psychosis continuum by modelling the latent structure of psychosis in a non-clinical sample using confirmatory factor analysis. The findings from chapter 2 suggest that the latent structure of psychosis is best represented by a five factor strucuture. Chapters 3, 4, and 5 examine how various demographic, behavioural, and social correlates can influence the expression of these experiences. The findings suggest that risk factors which are typically associated with clinical samples have the same capacity to influence psychopathology, and sub-clinical psychotic symptoms, thus lending weight to the proposition that a 'risk pathway' may well indeed exist. Chapters 5 and 6 then examine the relationship between different forms of adversity, psychotic-like experiences, and proposed intermediary mechanisms (i.e. perception of threat, salience, top-down, and bottom-up processing); factors which may help influence the expression of such symptoms. In closing, this thesis advances traditional perspectives on trauma and psychosis and demonstrates that from a social and behavioural perspective, subclinical psychosis can also manifest from lesser forms of adversity and not just severe trauma such as physical and sexual abuse.

Study Background and Aims: Specialist physiotherapy service processes for treating people with acquired brain injury (ABI) are poorly described and evaluated in the literature. The most important factor which limits the understanding of the physiotherapy service is the lack of a system to define, describe and record the interventions made by physiotherapists. The aim of this study was to develop and evaluate a physiotherapy documentation tool for use in inpatient ABI rehabilitation settings. To achieve this aim, it was imperative that the researcher consider all the different factors and identify all the key attributes of the documentation process followed in inpatient settings. It was therefore necessary to map the process of the physiotherapy rehabilitation service provided to patients with ABI. Mapping the process of the service helped the researcher to understand all aspects which make a large contribution to and have a great effect on the rehabilitation process so as to achieve the main aim of this study. It also helped to establish a theoretical basis for the documentation process and to develop a clear understanding of the specific attributes of rehabilitation services. Research Method: The researcher used a wide range of data collection methods, including interviews, questionnaires and observational processes. Interviews were conducted with the heads of rehabilitation teams working in inpatient rehabilitation services in the UK. Thereafter, a national questionnaire was sent to physiotherapists with experience of treating patients with ABI in the UK so as to capture the breadth and scope of current physiotherapy practice. It was also designed to identify the physiotherapy treatment activities provided to people with ABI in an inpatient rehabilitation setting. The validity, reliability and acceptability of the questionnaire were tested before the questionnaire was sent out to physiotherapists. Information gathered during the early phases was then used to design a physiotherapy treatment recording tool for use with people with ABI in an inpatient rehabilitation setting. The process of developing a new treatment recording tool went through many different stages, including considering all the reported advantages and disadvantages of the documentation methods currently used, as well as the policy, ethical and legal issues involved in physiotherapy documentation. Once the final draft of the treatment recording tool was developed, the reliability, validity and acceptability of the tool were evaluated. Six experienced physiotherapists working in one of the two rehabilitation centres treating ABI in Wales, UK were invited to take part in this stage of the study. Eighteen treatment sessions were observed and video recorded to evaluate the treatment recording tool. The piloting process included testing the treatment recording tool's comprehensiveness and its ability to describe physiotherapy treatment sessions. Results: The information gathered in this research and the descriptions provided by the ICF framework were used in this study to guide the process of describing the pathway that patients follow if they have an ABI. Four themes, namely pre-rehabilitation, rehabilitation and post-rehabilitation stages and the documentation process, were identified. Each theme had different sub-themes. The feedback from the heads of the rehabilitation teams and physiotherapists helped the researcher to gather in-depth details of these themes and sub-themes. A valid, reliable and acceptable treatment recording tool for use by physiotherapists with people with ABI in an inpatient rehabilitation setting was developed using the information gathered during the previous phases, including a literature review. The results show that the newly developed documentation tool has the ability to record comprehensive details of treatment sessions using a very simple coding process in a very quick way. The treatment recording tool offers a sufficiently structured method to collect information about treatment sessions, including treatment tasks, treatment positions, interventions provided, adjuncts used and the treatment duration of each treatment task. Treatment packages (combinations of physiotherapy interventions) were also investigated using a geometric coding process. The results showed that the treatment recording tool records more comprehensive and organised details about physiotherapy treatment sessions compared to SOAP notes completed by the same physiotherapists. Conclusion: The main outcome of this current study was the development of a new, valid, acceptable and reliable treatment recording tool. This tool brought an order and rigour to the description of physiotherapy treatment activities provided for people with ABI in an inpatient setting. It helped to characterise the many treatments, procedures and interventions used in physiotherapy, taking into account their multidimensionality with respect to content, purpose, intensity, duration, sequence, frequency and other characteristics of care provided. The new treatment recording tool has been designed to improve patient care by facilitating accurate and appropriate communication between physiotherapists, and between physiotherapists and other specialists. Developing the documentation method in inpatient settings will help other professionals to better understand physiotherapy practice and the role that physiotherapists play in the multidisciplinary rehabilitation service.

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