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published_or_final_version / abstract / toc / Educational Psychology / Master / Master of Social Sciences

Damage to the orbitofrontal cortex (OFC) has been associated with disinhibited or socially inappropriate behaviour and emotional irregularities in both humans and monkeys. Prominent characteristics of several personality disorder syndromes, in particular Borderline Personality Disorder (BPD), are impulsivity and affective instability. This investigation aimed to determine if certain aspects of the Borderline Personality syndrome, in particular impulsivity, are associated with OFC dysfunction. Basic questionnaires of personality, emotion, and impulsivity together with tasks sensitive to frontal lobe dysfunction that assess possible factors related to impulsivity, including time perception, sensitivity to reinforcers, and spatial working memory (SWM), were administered to OFC lesion, BPD, non-OFC prefrontal cortex lesion control, and normal control participants. OFC and BPD patients performed similarly, in that they were more impulsive, reported more inappropriate behaviours, BPD traits, anger, and less happiness than both control groups. They were also less open to experience and had a faster perception of time (in terms of time production) than normal controls. They performed differently on other tasks: BPD patients were less extraverted and conscientious and more neurotic and emotional than all other groups. OFC patients had more severe deficits in reversing stimulus-reinforcer associations compared to all other groups and had a faster perception of time (in terms of time estimation) than normal controls. Both OFC and non-OFC lesion patients had mixed lesions that included dorsolateral prefrontal cortex (DLFC) damage. Accordingly, they both had SWM deficits, a task used to control for DLFC damage, compared to normal and BPD participants. Since BPD participants were not impaired on this task and non-OFC patients did not perform poorly on the same tests that OFC patients did, the neuropsychological deficits of BPD and OFC patients could not be attributed to SWM deficits or DLFC dysfunction. The findings suggest that some of the cognitive/behavioural deficits commonly found in BPD patients are related to OFC dysfunction while others are unrelated and are perhaps related to other brain systems. The possibility of amygdala dysfunction is discussed. The similarities and dissociations found between BPD and OFC patients on certain tasks may lead to a better understanding of the aetiology of BPD and the functions of the OFC. Theoretical and therapeutic implications of the findings are discussed.

The experience of psychosis (e.g. threatening symptoms such as persecutory delusion and terrifying hallucinations) and its treatment (e.g. coercive measures such as involuntary admission and seclusion) are distressing. In view of the potential severity of the distress associated with psychosis, previous research has applied the trauma model to understand the experience of psychosis and its treatment and found that 11-67% of psychotic patients presented with clinically significant PTSD reactions in response to their psychosis and treatment experience. This phenomenon is termed as post-psychotic PTSD (PP-PTSD). However, previous research generally failed to find consistent relationship between PP-PTSD reactions and objective psychotic and treatment experiences (except for positive psychotic symptoms). Cognitive conceptualization of PTSD opines that it is the cognitive appraisal of the traumatic event, rather than the trauma per se, that is related to the development of PTSD. The present study aims to contribute to a better understand of PP-PTSD through a cognitive perspective. The present study applies Ehlers and Clark’s cognitive model of PTSD in understanding PP-PTSD. It explores the roles of fear of relapse and perceived risk of relapse, attribution of the causes of psychosis, perceived stigma and rejection and perceived consequence of the psychotic illness in PP-PTSD. The present study was a cross-sectional study and recruited 38 patients with schizophrenia-spectrum disorders. Semi-structured interview was used to determine whether the patients met the PP-PTSD diagnosis. The patient’s positive psychotic symptoms and social and occupational functioning were assessed by semi-structured interview while their PP-PTSD symptoms, trauma history and cognitive appraisals were measured using self-report questionnaires. Results showed that 15.8% of patients meet the full criteria of PP-PTSD and more than 50% of patients demonstrated some PP-PTSD reactions, which provides support for the application of the PP-PTSD construct in the local context. Treatment experiences were found to induce more severe PP-PTSD reactions than psychotic experience. Cognitive appraisals were found to be associated with PP-PTSD and there was some support for the application of Ehlers and Clark’s model in PP-PTSD. Specially, the present study found that fear of relapse, higher perceived risk of relapse, perceived helplessness and self-blame of causing the onset of psychosis, stable attribution of the cause of psychosis onset, perceived stigma, perceived large and chronic consequence of psychosis were all associated with more severe PP-PTSD reactions. Fear of relapse was also found to predict PP-PTSD severity. Clinical implications on the prevention, assessment and treatment with reference to the present results are discussed. / published_or_final_version / Clinical Psychology / Master / Master of Social Sciences

Purpose: A systematic review and meta-analysis tested the 'paranoia as a defence' model's original prediction that those experiencing persecutory delusions would take excessive credit for positive events as part of an attributional style that protects them from low self-esteem. The empirical project explored forensic mental health nurses' experiences of a Cognitive Analytic Therapy (CAT) training programme with an emphasis on complex case conceptualisation and implications for clinical practice. Methods: In relation to the systematic review and meta-analysis, those experiencing persecutory delusions were compared to those with non-paranoid psychosis, depression, and healthy controls, in terms of the magnitude of internalising attributional bias (IAB) for positive events. Correlation analysis also examined the association between magnitude of IAB and paranoia severity. In the empirical study, 10 forensic mental health nurses took part in semi-structured interviews to qualitatively explore their experiences and applications of CAT training. Results: Consistent with the model, an internalising attributional bias was present for those experiencing paranoid delusions when compared to individuals with depression. Contrary to the model, there were no differences between the other control groups and there was no significant correlation between IAB and paranoia severity. Internal attributions for positive events appear to be associated with depression, rather than paranoia. Analysis of the empirical data provided a rich account of nurses' experiences of the CAT training and how this helped them to conceptualise complex patients and promoted more positive ways of working. Conclusions: The findings from the systematic review and meta-analysis do not support the original model, but are consistent with the modified 'paranoia as a defence' model of persecutory delusions. Other cognitive models also help explain paranoia suggesting that refining the existing models further could be useful. The empirical findings suggest that CAT could be a valuable model of psychologically informed practice for nurses working in a forensic setting. Specifically, training appeared to help nurses develop a better understanding of their patients, greater self-reflection skills, and improved clinical care approaches.