This thesis describes the development and evaluation of a self-monitoring and patient-initiated follow-up service for people with rheumatoid arthritis (RA) or psoriatic arthritis (PsA) on methotrexate. Using a mixed methods approach including a randomised controlled trial (RCT) and qualitative semi-structured interviews. The overall aims of this thesis were to design an alternative model of care which could be delivered in rheumatology outpatients by clinical nurse specialists (CNS) in order to reduce the burden of established patients in clinic. This is followed by an evaluation of intervention effectiveness and safety, along with an exploration of the mechanisms of action and patient acceptability. One hundred patients from University College Hospital London (UCLH) with either RA or PsA on methotrexate were recruited into the trial and were followed for six consecutive blood tests. Patients randomised to the intervention group were required to monitor their symptoms, side effects and laboratory results and use this information to initiate care from the CNS. The results indicated that patients were able to accurately initiate a consultation with their nurse on approximately 75% of occasions. The intervention led to 55% fewer appointments with the CNS (p < 0.0001) and 39% fewer GP appointments (p = 0.07) compared to usual care, with tentative evidence to suggest cost savings. There were no significant differences in clinical or psychosocial well-being, including function, pain, quality of life and mood. Intervention participants were positive about the new model of care, valuing its efficiency and tailored approach. The service allowed patients to gain new knowledge and use this information along with the skills they obtained to take control of their health and arthritis. This model of care may, therefore, be a viable alternative for established RA and PsA patients on methotrexate in order to reduce healthcare utilisation without compromising clinical or psychosocial well-being.

'The early phase of psychosis is understood to be formative in biological, psychological, and social terms, thus affording major opportunities for secondary prevention' (Birchwood & Fiorillo, 2000, p.182). The current thesis considers the experience of early psychosis and how variables of social cognition, trauma and dissociation, influence this crucial and formative period. Chapter I presents a systematic literature review that explores affect perception in early psychosis. The review suggests the presence of an affect perception deficit in early psychosis, which may be more pronounced for perception of negative emotions. In exploring the nature and impact of an affect perception deficit in early psychosis, it is noted that further research is needed to fully understand the implications. However, affect perception deficit in early psychosis may be improved through psychological interventions. Chapter II presents an empirical paper that explores the relationship between trauma, dissociation and early psychosis, and specifically whether dissociation mediates the relationship between experience of trauma and early psychosis. Results indicated that first episode psychosis clients reported significantly greater experiences of trauma and dissociation, and that correlations between trauma experiences and dissociative symptoms in the first episode psychosis group were stronger compared to a healthy control group. Furthermore, dissociation positively mediated the relationship between experience of trauma and first episode psychosis. Results are discussed in relation to existing evidence and theoretical models. Considerations for future research and clinical implications are also discussed. Chapter III presents a reflective paper, which considers the researcher’s experiences of conducting research in the area of early psychosis. Particular attention is given to the discussion of ethical and methodological considerations in relation to undertaking research in the context of current NHS Early Intervention for Psychosis services.

The thesis consists of three papers; literature review, empirical paper, and reflective paper. The literature review evaluates the effectiveness of psychological interventions for perfectionism in adults. The systemic review analysed 12 papers comprising of; randomised control trials, group intervention studies, and single case designs. Interventions were varied in delivery, such as face-to-face or web-based with the majority using a CBT intervention. A number of studies showed effectiveness for the treatment of perfectionism in adults, but some were narrow in use of population e.g. a high proportion of female participants. Clinical implications are discussed. The empirical paper investigated the relationship between multidimensional perfectionism, self-criticism, self-esteem, and mood in primary school children. A non-clinical population (9-11 years of age) of 90 children were recruited with quantitative measures utilised. Mediation models were used to establish if any relationships existed. Results showed a significant relationship between self-esteem and mood, and perfectionism dimensions, such as sensitivity to mistakes and mood were significantly mediated by self-esteem and self-criticism. Results are discussed in comparison with previous research and clinical and education implications are discussed. The reflective paper reflects upon the personal and professional doctoral thesis journey. Starting from generation of idea, moving through the emotional journey of design, recruitment and write-up, and focusing on aspects such as self-care.

The increasing prevalence of people who are overweight and obese is a global health concern, with associated physical health problems that are highly linked to mortality and morbidity. As well as physical health consequences, there are also psychological and social consequences of obesity. The factors that are involved in why excessive amounts of food are being consumed have been explored. Such explanations as to why adults and children are overweight include individual factors as well as social, cultural and environmental influences. CHAPTER ONE: The literature review critically evaluates the research that has explored the attitudes towards dieting and weight loss of people in ethnic minority groups. The review indicated a number of factors that impact upon individuals ability to manage weight, including individual factors such as the impact on emotional well-being, as well as cultural influences such as tensions around living in two cultures and the dilemma of making different food choices. Clinical implications included tailoring interventions in order to account for individual, family and cultural factors that influence a person’s ability to manage their weight. CHAPTER TWO: The empirical paper aimed to explore weight-related views and opinions of young people who are overweight and were actively engaged within a weight management programme, using a Grounded Theory approach. A model of participants experiences was developed that reflected how participant’s sense of self and how they made sense of being overweight were interlinked, and sat within the wider category of how they manage being overweight. Such factors were further influenced by others in the wider systemic context. The findings suggested implications for tailoring interventions to individuals, as well as exploring the impact of interventions for the family as a whole. CHAPTER THREE: This paper summarises the reflections of the personal and professional experiences of talking with young people about their weight management journey. The categories within the Grounded Theory model were considered, as were the reflections of doing research with young people.

The alexithymia construct first appeared in academic literature over 30 years ago, but has recently undergone a revival in terms of research and clinical interest. The aim of this thesis was to explore the concept of alexithymia, in the hope of elucidating the impact that it can have on mental health difficulties, and offering suggestions for intervention. The first chapter is a literature review focussing on the stability of alexithymia in relation to different medical and psychiatric disorders, and evaluating the evidence for it being either a transient state or permanent trait. Emphasis is placed on implications for treatment, as well as directions for future research. The second chapter reports findings from a cross-sectional study examining the relationship between alexithymia and attachment in individuals with diagnosed anorexia nervosa, compared to a group of non-clinical controls. The focus is on the high prevalence of alexithymia and insecure attachment experiences in the clinical group, and on the associations between alexithymia and insecure attachments, alexithymia and eating disorder pathology, and insecure attachment and eating disorder pathology. The third chapter is a reflective paper examining the impact of the research process on the researcher in terms of personal and professional development. Consideration is paid to methodological and conceptual issues related to the research process, and the impact that conducting empirical work can have on clinical practice.

It appears that over time, individuals appraise challenging health situations differently; they take a variety of meanings from them and report differing outcomes for similar events (Scherer, Shorr, & Johnstone, 2001). This variability has been attributed to differences in coping processes employed by individuals. Chapter 1 is a critical review of the evidence for Positive Growth in Multiple Sclerosis (MS PG). Whilst MS PG is not reported by all individuals with the condition, evidence suggests that it is particularly evident in areas of psychosocial functioning and health benefits. Implications for future research and clinical practice are also discussed. The wide reaching implications which invariably arise as a result of neurological conditions affect people’s families as well as individuals, this can lead to re-appraisal of circumstances in family member’s themselves. Chapter 2 examines the implications a partner’s stroke has on a spouse’s own health and their desire to remain healthy. 8 females were interviewed using semi-structured interviews. Within this chapter a grounded theory model is proposed which describes barriers and facilitators to an individual’s health following their partner’s stroke. Within the results section the 3 main categories and 11 sub-categories are illustrated by participant quotes. Clinical implications, methodological limitations and directions for future research are outlined. The final chapter, a reflective account, introduces and reflects upon the research process using therapeutic letters. This chapter also explores the dual purpose of therapeutic letters and includes two letters; one to the research participants and one to the principal researcher. The usefulness of each letter is assessed in terms of the functions identified for therapeutic letters. Finally the author reflects and decides upon whether to send the letter to participants.

There are 30,000 people in the UK who are on dialysis or that have received a transplant for chronic kidney failure (Stein & Wilde, 2006). Those with a diagnosis of End Stage Renal Failure (ESRF) face a gruelling treatment regimen with dialysis providing only 5% of the function two healthy kidneys would supply (Stein & Wilde, 2006). Patients face many changes to their lifestyle and these are often difficult to manage. The treatment necessary for such a condition is complex and includes restrictions to diet and fluid intake as well ingestion of medication and attending dialysis. Many patients struggle with adhering to this treatment and it is important to have an understanding of the psychological factors that contribute to this issue. Understanding the experience of being diagnosed and treated for ESRF for specific groups of patients is an important area of research if the best quality care is to be provided. This thesis is made up of three chapters, the first two are a literature review and an empirical paper that focus on two under-researched areas in the field of ESRF. Those with ESRF often struggle to adhere to prescribed medical treatments with rates estimated to be between 50-80% (Christensen, 2000; Morgan, 2001). The social and psychological effects of this diagnosis on adherence have been well recognised by the research. Chapter one presents a critical review of the literature that considers psychological factors of adherence to the treatment for ESRF in its entirety (rather than dietary restrictions or medication intake alone) in the last ten years. The review reveals a number of important psychological factors related to adherence to ESRF treatment. The review finds evidence to support the argument that psychological factors associated with adherence are an important consideration for supporting this group. The review highlights many of the limitations of the current literature and identifies directions for future research. Chapter two presents an empirical study exploring working age men’s experiences of ESRF and haemodialysis. There is a lack of research into the experiences of specific groups with this diagnosis and treatment experience. This includes working age men, and there are no qualitative studies of this group. The paper focuses on the experience of diagnosis, treatment and coping using Interpretative Phenomenological Analysis. Findings revealed three superordinate themes these were: ‘The many sides of the HD treatment experience’, ‘Coping the best way you can’ and their experience of ESRF as a ‘Hidden diagnosis’. Clinical implications and directions for future research are then discussed. Chapter three is a reflective paper highlighting some of the issues that arose for the researcher during the research process. This paper considers the different roles of the researcher within and outside the research context, how they have converged and the impact they have had. They include reflections that may be beneficial to future researchers in this area.

Self-esteem was defined as the cognitive process in which an individual perceives characteristics of themselves, as well as their behavioural and affective reactions to those characteristics. It was measured by the Southampton Self-Esteem and Sources of Self-Esteem scale (SSESS). The purpose of the three studies within this thesis was to assess quantitative and qualitative aspects of self-esteem, and symptoms of depression in homogeneous groups of the diverse RA population. The first study was a cross-sectional between-group analysis of elderly adults with RA and an non-RA control group. The elderly RA participants had significantly higher self-reports of depressive symptoms and lower self-esteem than control participants. In addition, the length of RA disease duration was positively correlated with depressive symptoms. This indicates that for older adults longer RA duration was associated with increased reports of depressive symptoms. The second cross-sectional study evaluated depressive symptoms, self-esteem and other variables including perceptions of RA pain, coping strategies and functional ability reported by individuals with amyloidosis as a potentially fatal consequence of RA in comparison with an RA-only group. Although there was no significant difference between the groups' depressive symptom scores, the amyloid participants reported significantly lower scores of self-esteem and lower RA pain reports than the RA-only participants. The third study was longitudinal in design with two assessments separated by six-months. Prior reports of RA pain, helplessness beliefs, passive coping strategies and low self-esteem significantly distinguished participants with elevated symptoms of depression from non-depressed participants. Regression analyses of this study suggested that self-esteem was a direct antecedent and a direct consequence of functional ability as a behavioural aspect of RA.

The distinction between state and trait dissociation informed the development and psychometric validation of the State Scale of Dissociation (SSD) and the study of concurrent electro-encephalographic (EEG) correlates of experimentally induced dissociative states. Existing scales measure trait dissociation. The need for a state scale was addressed by the development and testing of a present-state, self-report measure. Fifty-eight preliminary items were sorted into 7 subscales: derealisation, depersonalisation, identity confusion, identity alteration, conversion, amnesia, and hypermnesia. A revised 56-item SSD was administered with other psychiatric scales (DES, BDI, BAI, SCI-PANSS) to patients with DSM-IV major depressive disorder (n=19), schizophrenia (n=18), alcohol withdrawal (n=20), dissociative disorders (n=10), and controls (n=63). The SSD was demonstrated to be a valid and reliable measure of severity, and changes in severity, of dissociation at the time of its completion. Discriminant validity, content, concurrent, predictive, internal criterionrelated, internal construct, and convergent validities were confirmed statistically by factor analysis, Spearman's rho correlations, confidence intervals, predictive analysis, and parametric and non-parametric comparisons of dependent and independent samples. It showed high internal consistency (Cronbach's alpha = 0.97) and high splithalf reliability (Guttman coefficient = 0.92). The conversion subscale clustered with the other subscales into one general factor on factor analysis and did not support its segregation from dissociative disorders in DSM-IV. State characteristics of dissociation were also examined in 11 patients with complex partial epilepsy. The relationship between concurrent EEG and experimentally induced dissociative states was examined by repeated SSD and baseline DES measurements after spectral analysis of EEG. Canonical analysis demonstrated significant SSD-EEG correlations. Amnesia, identity alteration, and identity confusion correlated with theta, frontal delta, and fast wave EEG activity respectively. The SSD now allows for further investigation of the suggested state continuum of severity and trait continuum of frequency of dissociation in more comprehensive studies of concurrent neurobiological correlates.

In a review of research on the relationship between shame and psychopathology it is suggested that too little attention has been paid to the actual context in which shame is experienced by people with psychological difficulties. An attempt is then made to link existing models of pathological shame with recent literature on emotion and it is suggested that shame associated with psychological disorder is of an enduring script like nature, termed 'marker shame'. Literature on the relationship between shame and disclosure is introduced. It is argued that in addition to presenting an opportunity to investigate the operation of shame in a social context research on the dynamics of shame and disclosure is important given the central role that emotional disclosure plays in psychotherapy. The empirical part of the thesis consists mainly of a diary and interview study designed to explore the nature of shame in the context of psychotherapy patients' daily lives and the role of shame in the context of disclosure or non-disclosure of unpleasant emotional experiences. Quantitative data on the nature, context and disclosure of shame and the other unpleasant emotional experiences is reported.A major finding is that the majority of unpleasant emotions experienced by the participants were not disclosed and that 'marker shame' appeared to play a role in this non-disclosure. An empirical approach to qualitative data analysis is then introduced and used to explore the apparent 'emotional isolation' of participants. The findings again appear to illustrate the operation of 'marker shame'. A qualitative analysis of participants' accounts of emotions that they did disclose is reported and a shame-related account of disclosure dynamics is shown to compare favourably with a number of alternative theoretical accounts of the benefits of disclosure. Qualitative analysis from a second interview study focusing on significant emotional memories is presented which appears to replicate most of the earlier findings in a seconds ample of psychotherapy patients.