Negative symptoms – reductions in expression, motivation, pleasure and sociability – are observed across the spectrum of functional psychoses. They have been identified as a significant predictor of poor outcomes following first-episode psychosis and are a treatment priority for individuals with lived-experience of psychosis. However, the mechanisms underlying negative symptoms remain poorly understood. This thesis aims to contribute to our understanding of negative symptoms in the early phase of psychosis using a mixed methods approach. Participants in the EDEN study (n = 1006) were followed up for 12 months following acceptance into UK Early Intervention in Psychosis services. Negative symptom severity data were modelled using latent class growth analysis, allowing latent classes comprising individuals with similar patterns of change in negative symptoms severity over time to be identified. Predictors of latent class membership were ascertained and the relationship between negative symptom trajectories and concurrent social recovery explored. Subsequently, transcripts of qualitative interviews conducted with a subsample (n = 24) of the cohort were analysed thematically. Comparisons were made between the accounts of members of the identified latent classes. Experiences and personal understandings of negative symptoms, psychosis, treatment and recovery were explored, providing insights into potential mechanisms underlying negative symptoms and their relationship with social recovery. The quantitative and qualitative findings were integrated and interpreted in relation to existing research and theory. Together they informed the development of a conceptual model of negative symptoms and their relationship with poor social recovery following first-episode psychosis. The model suggests that active psychological processes may be important to negative symptoms and their contribution to poor social recovery. It is proposed that offering tailored psychosocial interventions at the earliest stage of disorder – after the onset of nonspecific negative symptoms but before the emergence of attenuated positive symptoms – may be warranted to improve outcomes following psychosis onset.

The first part of this thesis consists of a systematic literature review of the effectiveness of independently delivered interventions incorporating implementation intentions on health outcomes. The second part is a research study examining the effectiveness of a self-help intervention aiming to improve social confidence for people with visible skin conditions in a randomised controlled trial. In the literature review, ten studies examining the effectiveness of independently delivered interventions incorporating implementation intentions on physical or mental health outcomes were systematically reviewed and critically appraised. Effectiveness was measured by extracting data from the studies and undertaking a meta-analysis. The results showed that independently delivered interventions incorporating implementation intentions had a small, but reliable, overall effect (g+ = 0.16). In the research study, 326 participants with a variety of visible skin conditions were randomised to either (i) self-help enhanced with implementation intentions, (ii) standard self-help without implementation intentions or (iii) a wait-list control condition. The results showed that participants exhibited clinically significant levels of social anxiety, ‘mild’ symptoms of generalised anxiety and ‘moderate’ symptoms of depression. There was no evidence that the standard or enhanced self-help interventions reduced fear of negative evaluation, symptoms of anxiety or symptoms of depression in comparison to the wait-list control condition.

Therapists are differentially effective, a concept that has been termed ‘therapist effects’. Research has shown that therapist effects account for around 5% of the variability in outcomes of psychological therapy. However, there has been little research investigating whether such therapist effects are stable over time. A systematic review was conducted to provide a contemporary synopsis of therapist effects research. The review comprised 21 studies that focussed on therapist effects for outcomes, extending the most recent review of Baldwin and Imel (2013). Results found an average therapist effect of 5% which was in common with previous findings. New research areas included low intensity treatment settings and comparisons of different outcome measures. In order to investigate the stability of therapist effects over time, the research report analysed data from steps 2 (low intensity) and 3 (high intensity) of an Improving Access to Psychological Therapies service, comprising 12,949 patients and 141 therapists. Multilevel modelling was used to determine the therapist effect of the whole service over 40 months. Then, for five equal time periods, Markov chain Monte Carlo procedures compared therapist effects over time. Results found an overall therapist effect of 4.9% with no statistical difference between time periods. Therapist effects for step 2 of 2.9% and for step 3 of 4.9% were found. However, such effects were not statistically stable over time. Further studies with higher patient and therapist sample sizes are recommended.

This thesis was concerned with the psychosocial experience of living with a significant change to facial appearance acquired through trauma or disease. The thesis comprises a literature review and a report of an original research study. The review used a meta-ethnography approach to synthesise qualitative literature on the experience of altered facial appearance following cancer. The findings demonstrate the varying experience of changed facial appearance depending on the stage of the disease or treatment, with appearance being more salient at less acute stages of cancer treatment. Changes to appearance lead to experiences of stigma and threatened self-image and self-identity, necessitating a range of coping strategies. Clinical implications and future research needs are outlined. The research study aimed to understand the experience of living with a facial prosthesis using Interpretative Phenomenological Analysis. Findings indicate that a prosthesis could restore normalcy and enable social participation, however the impact of having altered facial appearance continued to pervade the experience and practicalities continued to be problematic. Social support and humour were notable factors contributing to positive adjustment. This research implicates a role for peer support interventions in this population, and further research is needed to explore different stages and levels of adjustment.

Systemic family therapy is an approach to psychological therapy that is increasingly being offered to adults with learning disabilities and their families. To date there has been no published evaluation of the degree to which this is an approach that is effective in alleviating distress for this client group. The present study aimed to explore the experiences of adults with learning disabilities and their family members, who had attended systemic family therapy together. It also aimed to investigate whether it was an experience that had been helpful and in what ways, if any it impacted on their lives. Ten families and six adults with learning disabilities were interviewed about their experiences of attending systemic family therapy. The transcripts were analysed using Interpretative Phenomenological Analysis (IPA). Participants had mixed views about the degree to which systemic therapy had been helpful to them. Some family members saw it as having a positive impact on their views about and ways of approaching particular issues. However, for other families systemic therapy had not offered the kind of help they had expected and the experience was seen as relatively insignificant, vague or confusing. For the participants with learning disabilities there was a general sense that the opportunity to talk about difficulties was seen as valuable. However, the degree to which some of these participants felt they had a voice was limited. A combination of feeling pressure to 'know' what to say, and the presence of other family members in the meetings made it difficult for them to have their say. These findings suggest that although systemic family therapy can be helpful, particular aspects of the process may need to be adapted to ensure it is an approach that is accessible for this client group and their families.

Despite clinical recognition and anecdotal reports of attentional difficulties the status of attention in MS arguably remains unclear with inconsistent findings in the research literature. The impact of sustained attention was discerned from other theoretical types of attention and the assessment of it provided the focus for study. The Sustained Attention to Response Task (SART) was developed for using with the traumatic brain-injured population and is purported to be a sensitive and valid measure of sustained attention. The main aim of the study was to investigate whether performance on it could be replicated with an MS population.  The principal hypothesis stated that there would be a significant difference between a sample of MS patients and a healthy control group across attentional measures. The Lottery and Elevator Counting subtests from the Test of Everyday Attention, the Symbol Digits Modalities Test formed the main assessment tools used. Another aim of the study was to determine how well performance on these tests predicted everyday cognitive functioning, as measured by the self and informant-reported Cognitive Failures Questionnaire. The results demonstrated that sustained attention deficits were indeed a part of the cognitive profile in this sample of MS patients. In its current format performance on the SART was not found to be a valid measure for using with the MS population. The other three attentional tests were however able to discern a significant difference in performance between the two groups. Performances on these tests were also found to significantly correlate with and hence be predictive of everyday cognitive functioning as measured by the informant-reported Cognitive Failures Questionnaire.

This study compares a group receiving cognitive-behavioural treatment (CBT) for auditory hallucinations to a control group, who received standard care only. All group members were adult in-patients who experienced distressing auditory hallucinations. Four CBT groups were conducted, three by individual clinical psychologists and one by nursing staff, who first participated in a brief training programme. The treatment groups provided education about 'voices', coping strategies, self-esteem building exercises, as well as general discussion and support. Evaluation included both quantitative and qualitative assessment methods. The effectiveness of the group treatment was evaluated in terms of measurable improvement in severity of auditory hallucinations, total number of psychiatric symptoms, level of insight into psychotic illness, beliefs about 'voices', and number of available coping strategies. In addition, the nursing staff were evaluated on their ability to follow the protocol and conduct CB T groups to standards equivalent to that of experienced clinical psychologists.

Early onset psychosis' (Eap) refers to the diagnosis of schizophrenia and other related psychoses with onset prior to age 18. Neuropsychological function in Eap has been studied less, relative to the available literature on schizophrenia with onset in adulthood. Short-comings of the small number of previous studies of neuropsychological function in EOP include assessment of limited cognitive functions and failure to control for cognitive ability, thus limiting the neuropsychological significance of such studies. Hence the neuropsychological profile of Eap remains to be fully established. This is the first report of EOP patients in Northern Ireland and includes a sample of patients with autistic spectrum disorder, thereby allowing comparison to another neurodevelopmental disorder. The primary aim of this thesis was to investigate the neuropsychological profile in early onset psychosis and to consider consistency with that reported in adults. The thesis aimed t6 examine specificity of impairments, beyond general cognitive dysfunction. Finally, the neuropsychological profiles of autistic and psychotic patients were compared to determine whether or not these profiles were distinguishable. Neuropsychological test performance was assessed III adolescents with psychosis (n=22), adolescents with autistic spectrum disorder (n=18) and healthy adolescent controls (n=15). Participants received an extensive neuropsychological evaluation including measures of intelligence, attention, memory, executive function and language. Relative to controls, psychotic patients showed selective deficits in the areas of attention (auditory sustained attention and response inhibition), executive function (cognitive set shifting, planning and problem solving, and strategic planning), memory (general memory, learning and verbal long-term memory), and language (reading, writing, imming and verbal fluency). These deficits were of neuropsychological significance as they could not be accounted for by reduced cognitive ability. There was consistency with the pattern reported in adults (i.e. deficits in verbal memory, sustained attention, response inhibition, set shifting, planning and problem solving, and verbal fluency). Autistic patients' shared some deficits in attention and executive function with Eap patients, but not the memory and language impairments displayed by Eap patients. Therefore the profiles of these patients were clearly dissociable, as cognitive functions were differentially impaired in both groups.

<i>Experiment One</i> Plasma concentrations of oxytocin-associated neurophysin and prolactin were measured before and after the first treatment in a course of electro- convulsive therapy (ECT) given to 25 depressed patients. Plasma neurophysin concentration was measured by the radioimmunoassay (RIA) of Robinson (1975). The percentage peak increase in plasma neurophysin concentration was three times greater (p < 0.001) in the 16 depressed patients who had a good outcome two months after the last ECT compared with the nine who did not. The rise in plasma neurophysin concentration correlated (rho = 0.46, p < 0.05) with improvement in symptoms measured by the Hamilton Rating Scale for Depreseion (HRSD). There was no difference in the percentage peak increase in plasma prolactin concentration between patients who had a good outcome two months after the last ECT and those who did not. The rise in plasma prolactin concentration did not correlate with improvement in HRSD score. <i>Experiment Two</i> Serum concentrations of the vasopressin- (nHpI) and oxytocin-associated neurophysins (hNpII) were measured by the RIA of Legros et al. (1969) before and after the first ECT in a course of treatment given to 19 unipolar depressed patients. The percentage peak increase in nHpII was four times greater (p < 0.001) in the six patients who had a good outcome two months after the last ECT than in the patients who had a poor outcome. The rise in serum hNpII correlated with improvement in HRSD score (r = 0.50, p < 0.05) and improvement in score on the Montgomery and Asberg Depression Rating Scale (r = 0.47, p < 0.05). The rise in serum nHpI concentration did not correlate with improvement. There were no significant correlations between spikewave activity or total seizure activity measured by a six-channel electroencephalogram (EEG) and the rise in either of the neurophysins. <i>Experiment Three</i> Serum concentrations of the nHpI and nHpII were measured at the first and last treatments in a course of ECT given to 17 unipolar depressed patients (seven of whom also took part in Experiment Two). There were no significant differences in the average release of either neurophysin between the first and last treatments. There were no significant correlations between alterations in the release of the neurophysins between the first and last treatments and improvement in symptoms of depression. <i>Conclusions</i> Although there is a correlation between the release of hNpII after the first ECT and improvement in symptoms of depressive illness, the correlation is not sufficiently close to be of clinical utility in the prediction of ECT outcome. The reason for the correlation is not known. There was no support for the hypothesis that the release of nHpII was a correlate of cerebral seizure activity. The release of nHpII may be a sensitive measure of electrical stimulation in the midbrain or may occur at the same time as the release of a neurotransmitter with mood-regulating activity.

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