The sexuality and sexual development of individuals with autism-spectrum disorder (ASD) and an accompanying learning disability is a neglected area, despite the fact that this group have the same sexual desires as their typically developing peers. Due to the socially marginalised position these individuals are often placed in, parents play a key role in supporting them with their developing sexuality. It is therefore important to understand parents’ experiences and perspectives about their offspring’s socio-sexual needs. Five mothers of sons with ASD and a moderate to severe learning disability aged 16 to 24 were recruited from voluntary organisations and interviewed. Interviews were audio recorded then transcribed and analysed using interpretative phenomenological analysis (IPA) to draw out key themes from their narratives. These narratives were fraught with tensions; mothers’ acknowledged their sons’ sexuality as an important part of their developing identity, but their sons’ sexuality brought many challenges. They wanted to provide their sons with appropriate education, but were concerned that by doing so, they could increase problematic sexual behaviours, which could result in serious negative consequences. The mothers also expressed their concerns about who would love their sons when they grew up. There was an overarching sense that these mothers were desperate for support and information to help improve their confidence in supporting their sons’ socio-sexual needs. This study highlights the need for sensitive and person-centred support to both young people with ASD and an accompanying learning disability and their families in relation to their sexuality and sexual development. It also highlights that services need to consider how to meet this group’s need for physical intimacy and affection when their family members are no longer able to do so.

Background: The effects of physical illness and psychiatric disorders have been extensively investigated in fatal and non-fatal suicidal behaviour. Although different study designs have focused on the independent roles of physical and mental illness in suicidality, few studies have examined the relationship between co-occurring physical and mental health conditions (multimorbidity) and suicide risk. Considering the paucity of research, the present doctoral programme of research aimed to investigate if populations with physical/mental multimorbidity have an increased risk of suicidal thoughts and behaviours, compared to those with neither physical nor mental health conditions, and further investigate if this effect is stronger than either of the health conditions alone. Methods: Based on the well-established terms of comorbidity and multimorbidity, the effect of co-occurring health conditions in the risk of suicidality was investigated by undertaking an overview of reviews and a systematic review. Four empirical studies of existing datasets were conducted in order to explore if suicidality (suicidal thoughts and suicide attempts) varies as a function of physical/mental multimorbidity. Two national mental health surveys from the United Kingdom (National Psychiatric Morbidity Survey 2000, n = 8575; Adult Psychiatric Morbidity Survey 2007, n = 7389) and one cohort study carried out in Scotland (West of Scotland Twenty-07 study, n = 4510) were used and both cross-sectional and prospective study designs were employed. Results: Findings indicated that those with physical/mental multimorbidity are more likely to have suicidal thoughts and attempt suicide, compared to those with neither physical nor mental health conditions. The results were consistent: having both physical and mental health conditions did not increase risk of suicidal thoughts or attempts, beyond the risk conferred by mental illness alone. Having only physical health conditions was not associated with either suicidal thoughts or suicide attempts. Conclusions: Overall, the findings suggest a potential risk of suicidality for populations with physical/mental multimorbidity. Although multimorbidity was a predictor of suicidality, it did not increase the risk of any suicide-related outcome more than mental health conditions alone. The current findings highlight that health care professionals should focus on populations who have reached services for non-mental health issues, but subsequently develop mental illness, as this pattern of multimorbidity could potentially be a risk factor for suicidal thoughts and behaviours. Further research is needed to better understand the risk of suicide in individuals with physical/mental multimorbidity.

Background: Transition is increasingly recognised as an important aspect of healthcare provision. However, fairly little is known about the experiences and needs of Inflammatory Bowel Disease (IBD) patients as they pass through this process. This study aimed to explore the transition experiences and needs of adolescents with IBD, and their views on transitional care provision. Methods: Semi-structured interviews were conducted with seven adolescents with IBD who were in the process of transitioning or had completed transition from paediatric to adult care. Transcripts were analysed using Interpretative Phenomenological Analysis. Results: Two main themes were identified: (1) Moving from the Known to the Unknown with subthemes of uncertainty and mixed emotions, the importance of information and support, losing familiar relationships, overlap in care provision and timing of transition (2) A Less Coddled Approach with subthemes of transfer in responsibility and differences between paediatric and adult care. Conclusions: Adolescents experience a range of challenges and emotions in response to the multifaceted relational and systemic changes associated with healthcare transition. They like to be well informed about transition plans and adult care providers, value a gradual and structured transition process and benefit from opportunities to develop self-management skills. Joint appointments provide reassurance and build a bridge between paediatric and adult care.

Background: The present thesis sought to explore the relationship between sleep and paranoia, and investigate what factors mediate this relationship. The research was conducted at different levels, and in different groups including healthy members of the general population, people with a diagnosis of psychosis and clinicians. Method: in chapter 3, a cross-sectional study was conducted online to examine the relationships between sleep and paranoia in a non-clinical sample. Following this, chapter 4 outlines a systematic review that aimed to further understand how sleep has been investigated in clinical samples of people with psychosis. Next, chapter 5 examined the relationship between sleep disturbance and paranoia in a clinical sample using novel experience sampling methodologies. Finally, chapter 6 explored clinician perceptions of sleep problems in people with psychosis. Results: chapter 3 found evidence for a mediation model whereby sleep predicted paranoia, and this relationship was mediated by negative emotions, alexithymia and perceptual anomalies. Chapter 4 revealed that there is a range of methodologies used to assess and measure sleep and identified areas of bias. Chapter 5 found no relationship between sleep and paranoia in a clinical sample of people with psychosis. Finally, chapter 6 found that clinicians are fully aware of the range and types of sleep problems in people with psychosis but lack the training and skills to treat sleep problems. Discussion: Overall, the relationship between sleep and paranoia is inconsistent. Sleep disturbances are common and should be treated in people with psychosis. More work is required to develop effective intervention strategies to address the range and type of sleep disturbances found in people with psychosis.

Background: Borderline personality disorder (BPD) is the most common of personality disorders presenting in clinical practice. Limited research has been conducted on the potential overlap of neurodevelopmental disorders (NDDs) and personality disorder. However, increasing evidence demonstrates clinical symptom overlap and/or comorbidity between BPD and Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD). Aims: The primary aim was to pilot the feasibility of recruitment of young people with BPD to investigate the prevalence of NDDs. The secondary aim was to investigate profiles of young people with BPD with regards to NDDs, emotion regulation, attachment, and adverse childhood experiences (ACEs). Methods: Participants were recruited from a number of mental health teams and services. Data from psychometric assessment measures were collected over two meetings. Descriptive statistics were completed and exploratory analysis conducted. Results: Twenty-nine young people with BPD, aged between 15 and 33, were recruited. Of this group 58% (n = 17) screened positive for ASD and 80% ( n = 23) for ADHD. Twenty-two (76%) of the participants had experienced at least 1 ACE. This pilot study evidenced feasibility of recruitment of young people with BPD, indicating it could be conducted on a larger-scale. The selected psychometric assessment measures were helpful in facilitating a clearer understanding of the neurodevelopmental profile of young people with BPD. Conclusion: Given the importance of early intervention for young people with BPD, understanding the neurodevelopmental profile of these individuals presenting to mental health services may lead to improved long-term outcomes. The high proportion of participants screening positive for NDDs warrants further research.

Background: CBT has mixed findings for older people with mental health difficulties and has been described as no more efficacious than relaxation training for anxiety. Due to the types of difficulties associated with old age that cannot be changed, such as chronic health conditions and experiences of bereavement and retirement, a more acceptance-based approach, such as Acceptance and Commitment Therapy (ACT) could be more suitable; however, there are few clinical trials with ACT and older people. Objectives: This feasibility study used mixed methods to explore the acceptability and feasibility of delivering ACT groups to inpatient and outpatient older people. Method/Results: 14 participants were recruited, nine of these completed the group (defined as attending four of six sessions) and eight were interviewed. Results suggested that 12 weeks after the last session, completers’ anxiety and cognitive fusion scores significantly decreased. Interviews suggested that ACT was acceptable to participants. Conclusions: ACT is both a feasible and acceptable transdiagnostic intervention for older people in an outpatient setting. Preliminary quantitative analysis suggested the intervention reduced anxiety and cognitive fusion; however, this should be measured in future intervention studies with higher participant numbers. Qualitative analysis suggested older people engaged with ACT because of the focus on visual material and that it seemed to increase their perspective taking and self-efficacy. The latter needs to be explored quantitatively.

Objectives: Attachment insecurity and lower levels of compassion are both linked to psychopathology. There is a growing interest in the foundations of compassionate abilities, which may be rooted in attachment experiences. This systematic review aimed to explore the association between attachment and compassion. Method: A systematic search was conducted on 18th May 2018 using PsycInfo, Medline, EMBASE, Google Scholar, Psychology and Behavioural Sciences and the Cochrane Library to identify papers that examined any association between attachment and compassion in the past 10 years. Reference lists of identified papers were also searched. Articles were screened for inclusion by scrutiny of abstract and methodology. Findings were synthesised and effect sizes calculated where possible. Results: Ten studies were identified representing 12 samples. Significant associations were noted between both attachment anxiety and attachment avoidance and lower levels of compassion (Mr = -0.37 and Mr = -0.31) respectively. Conclusions: Greater attachment insecurity is associated with lower self-compassion. Evidence implicates attachment insecurity and compassion in psychopathology, and wellbeing. Future work is needed to explore the causal links between different attachment and compassion dimensions.

Objective: Evidence suggests that only a minority of service users experiencing psychosis have access to Cognitive Behavioural Therapy for psychosis (CBTp). Normalisation Process Theory (NPT) is a theoretical framework which focuses on processes by which interventions are implemented and normalised in clinical practice. This study explored the views and experiences of mental health professionals regarding the implementation of CBTp. Barriers and facilitators to implementation were explored using the NPT framework. Design: A qualitative methodology was adopted involving semi-structured focus groups and individual interviews. Methods: A total of 14 members of staff working in the community and crisis mental health teams were recruited. Thematic analysis was used to generate initial themes. The Framework approach was utilised to map initial themes to the NPT framework. Results: Inductive coding generated five overarching themes consisting of 15 individual subthemes which captured the perceived barriers to engagement; contextual barriers to implementation; optimisation of implementation; positive attitudes towards implementation; and expectations of implementing CBTp. All but two subthemes mapped on to the NPT framework. The deductive analysis suggested that difficulties in making sense of CBTp among professionals were reflected as service level barriers which impeded wider implementation. Conclusion: The results of this study suggested a mixture of barriers and facilitators to CBTp implementation. Interpreting our findings within an NPT framework indicates the importance of strong clinical leadership to address difficulties in sense-making and service investment in CBTp.

Background: Heart transplant candidates may wait a considerable and usually indeterminable length of time for a donor heart, uncertain if they will live or die. Despite this, there appears to be little research exploring how people experience this wait. Method: A qualitative design employed Interpretative Phenomenological Analysis. Male patients (n=7) on the routine waiting list for a heart transplant at an advanced heart failure service in Scotland participated in a semi-structured in-depth interview. Results: Three major themes, each with inter-related sub-themes were produced from the data. 1) ‘Threatened self identity’: this theme covered the challenge posed to the mens’ identities as a consequence of illness and their wait for transplant. This included a ‘diminished self’ and an ‘unwanted ill self’. 2) ‘Uncertain life or death’: this theme concerned the continuing uncertainty men had to live and cope with, and included ‘contemplating dying’ and ‘the unknowns of transplant’. 3) ‘Complex coping’: this theme covered the challenges of coping during the emotionally and physically challenging wait for transplant. Conclusions: The importance of finding meaning in waiting is discussed in relation to the revised transactional model of stress and coping, and the implications for health care professionals are discussed. There is a need for health care professionals to appreciate the individual meaning patients ascribe to their experiences.

Background: Child sexual abuse (CSA) is a prevalent crime which often leads to lifelong consequences for survivors, although has low rates of prosecution. Research on CSA disclosure in general suggests survivors may decide not to engage with the criminal justice process through ‘legal disclosure’ for various interpersonal, intrapersonal and systemic reasons. However, little research exists regarding legal disclosure. To support CSA survivors to access justice, it is necessary to understand the factors which influence their decisions around engaging with the legal system. Objective: To qualitatively explore the lived experience of decision-making around engagement with the legal system for adult survivors of CSA. Specifically, their perceptions of barriers and facilitators to engagement. Participants and Settings Clinicians in 3 NHS Scotland Psychological Trauma Services identified clients meeting study criteria. 7 participants took part in individual semi-structured interviews. Results: Interpretative phenomenological analysis was used. Two main themes were developed during analysis: 1) awareness of and preparedness for what the legal system involves and 2) weighing up the value of disclosure. Barriers and facilitators to engagement are discussed. Conclusions: This study found that, similarly to informal disclosure, various barriers and facilitators exist to legal disclosure. Legal disclosure may require a distinct foundation of supportive factors due to the formal investigative process which can follow. The findings can assist clinicians, police and legal professionals working with CSA survivors to promote support and engagement around legal disclosure.