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There is increasing evidence to support the use of cognitive behavioural therapy with adults, for a wide range of psychological disorders. However, the use of cognitive behaviour therapy with adults with learning disabilities is still being questioned as it is thought that they may lack the skills necessary to engage in this treatment method. The current research examines the presence of core cognitive behaviour therapy skills in a non-clinical population of 59 adults with learning disabilities with an IQ of 50-72 points. It examines the abilities of adults with learning disabilities to complete three different types of tasks; a) the ability to identify emotions from facial expressions, using Makaton Symbols; b) the ability to distinguish thoughts from feelings and behaviours and the effect of providing visual cues to assist with this task; and c) the ability to link thoughts to feelings and thoughts to behaviours in the context of prior experience. The results indicated that adults with learning disabilities were able to demonstrate these skills, though not always at the more complex level. Visual cues did not improve performance on the distinguishing thoughts, feelings and behaviour task. Level of intelligence was only related to the distinguishing thoughts, feelings and behaviour task, however level of receptive vocabulary was highly related to all three types of task. It is therefore suggested that cognitive behavioural therapy may be an appropriate form of treatment for adults with learning disabilities, once training has been given on these types of skills and consideration has been taken to level of language ability. The findings are discussed with reference to a range of theoretical and clinical implications and further research has been proposed.

ABSTRACT Trichotillomania was first defined over a hundred years ago as a self inflicted alopecia resulting from avulsion of hair. Previous Positron Emission Tomography (PET) studies have shown increased count density in the right superior parietal region of patients suffering from trichotillomania. It is unclear if this increase in count density might be a state or trait related marker of the disease. Research has indicated that Cognitive Behaviour Therapy can systematically modify cerebral metabolic activity which is significantly related to clinical outcome. In the case of Obsessive Compulsive Disorder (OCD), a decrease of metabolic activity has been demonstrated using Pet. The present study was undertaken to investigate whether similar metabolic changes as indicated by Single Beam Positron Emission Computerised Tomography. (SPECT), will be found in trichotillomania after Cognitive Behaviour Therapy. Twelve patients diagnosed as suffering from trichotillomania, using DSM-IV criteria, underwent brain SPECT scanning using 99mTc-HMPAO. Scanning was performed before and after Cognitive Behaviour Therapy intervention. The psychotherapy was conducted in 12-16 sessions. The response to Cognitive Behaviour Therapy was assessed using the Psychiatric Institute Trichotillomania Scale and the Hamilton Anxiety Rating Scale. Ratings were completed at the beginning and end of the trial. The analysis of the scan data was done by comparing the left to the right superior parietal region. For each patient the region of interest was applied on the superior transaxial brain slices where the cingulate gyrus fully appeared. Each region of interest had the average number of counts normalised to the maximal cerebellar uptake. Baseline studies showed a significant increased count of 99mTc-HMPAO in the right superior parietal areas compared to the same areas on the left (p<0.0003). This pattern normalised after Cognitive Behaviour Therapy, such that there was no significant difference between the right and left superior parietal areas in those patients who responded (n=9) to therapy. In the non-responder group (n=3), the pattern remained unchanged. Using SPECT this study confirms previous reports of increased density in the right superior parietal lobe. In addition, it suggests that the increased count of 99mTc-HMPAO in the right parietal area is a state related disturbance in neurophysiology in this disorder, as it resolves with successful treatment. Of substantial importance is the fact that this study demonstrates a neurophysiological substrate and impact of psychotherapy. In conclusion this data suggests that the increased count density in the right superior parietal area is a state related marker of trichotillomania. 99mTc-HMPAO brain SPECT can therefore be used to monitor therapy of patients suffering from this disease.

Psychological studies in bipolar affective disorder and analogue conditions suggest that mania may be the product of an abnormal defence against depression. In this study, currently manic bipolar individuals, currently depressed bipolar individuals, and normal controls were assessed using explicit and implicit measures of attributional style, an emotional Stroop test with euphoria-related and depression-related words and a recall measure of the selfschema. Manic individuals showed a normal self-serving bias on a version of the explicit attributional style questionnaire, attributing positive events more than negative events to self, in contrast to bipolar-depressed individuals who attributed negative events more than positive events to self. However, on an implicit test of attributional style, both manic and bipolar-depressed individuals attributed negative events more than positive events to self. Both bipolar-manic and bipolar-depressed individuals demonstrated slowed colour naming for depression-related but not euphoriarelated words on an emotional Stroop test. Manic individuals, like normal controls, endorsed primarily positive words as true to self on a self referent questionnaire, but like bipolar-depressed individuals, recalled primarily negative words in a surprise recall test afterwards. Findings from the implicit tests therefore indicate a common form of psychological organisation in manic and depressed individuals, whereas the contrasts between the scores on the implicit and explicit measures are in accord with the hypothesis of a manic-defence. Future avenues for research and implications for treatment are discussed.

Objective: The present studies aimed to examine temporal patterns of symptom change over the course of cognitive behavioural therapy (CBT) in individuals with treatment-resistant depression (TRD) and evaluate their relationship to outcomes. They further sought to investigate whether case-conceptualisation competence, client hope and processing were associated with therapeutic change. Method: Participants were 156 individuals with TRD receiving 12-18 sessions of CBT as part of a randomised controlled trial. Depressive severity was assessed at each session. Audio-recordings of therapy sessions proximal to sudden gains and control sessions for 25 sudden gainers and 25 non-sudden gainers were rated for client hope and emotional processing, and therapist competence in case-conceptualisation. Results: The overall shape of change was best described as cubic, with frequent discontinuities in symptom trajectories. Sudden gains were associated with reduced depressive severity and a greater likelihood of remission at 12 months. Sudden gainers demonstrated greater hope than non-sudden gainers and emotional processing increased prior to a gain. Therapists showed greater competence in case-conceptualisation with sudden gainers. Conclusion: The present study describes a non-linear shape of change in TRD and extends the phenomenon of sudden gains to this population. It suggests that the combination of hope for change with supported efforts to process and make meaning of experiences may predispose individuals favourably towards experiencing sudden gains in therapy.

Cognitive behaviour therapy is a well-documented first-line treatment for mild to moderate depression. Primary healthcare providers have encountered several barriers when trying to provide CBT in an office-based setting and as such, adoption of this evidence-based treatment has been suboptimal. Primary healthcare nurse practitioners (PHC NPs) have an in-depth knowledge of advanced nursing practice, and are responsible for the assessment, diagnosis and management of patients with acute and chronic conditions, such as depression. PHC NPs are also ideally situated in the health care system to deliver CBT to their patients. The objectives of this project were to develop a format for the delivery of brief CBT methods that was feasible in the PHC setting, increase PHC providers’ confidence to implement CBT and ultimately increase their adoption of CBT

Hyperacusis is a type of decreased sound tolerance where the individual has decreased loudness discomfort levels (LDL), normal hearing thresholds and is sensitive to ordinary environmental sounds. Persons with hyperacusis frequently seek help at audiological departments as they are often affected by other audiological problems. Regrettably, there is neither a consensus-based diagnostic procedure nor an evidence-based treatment for hyperacusis. The principal aim of this thesis was to gain knowledge about the clinical condition hyperacusis. The specific aim of Paper I was to compare hyperacusis measurement tools in order to determine the most valid measures for assessing hyperacusis. Items from a constructed clinical interview were compared with the LDL test, the Hyperacusis Questionnaire (HQ) and the Hospital Anxiety and Depression Scale (HADS). LDLs were significantly correlated with the anxiety subscale of the HADS. A third of the 62 investigated patients scored below the previously recommended cut-off for the HQ. The results suggest that HQ and HADS in combination with a clinical interview are useful as part of the assessment procedure in patients with hyperacusis. The aim of Paper II was to further investigate the patient group with respect to individual characteristics, psychiatric morbidity and personality traits. It was shown that anxiety disorders and anxiety-related personality traits were over-represented, which suggests common or cooperating mechanisms. Avoidance behaviour proved to be very common in the patient group, as was being unable to work due to hyperacusis. In Paper III it was investigated in a randomized controlled trial whether Cognitive Behaviour Therapy (CBT) could be helpful for patients with hyperacusis. The effect of CBT for hyperacusis was assessed with measures of LDLs, symptoms of hyperacusis and of anxiety and depression, fear of (re)injury due to exposure to sounds, and quality of life, compared to a waiting list control group. There were significant group effects for a majority of the measures with moderate and strong effect sizes within- and between groups. After assessment the waiting list group was also given CBT, and was then reassessed with similar effects. The results were maintained for 12 months, concluding CBT to be potentially helpful for these patients.

Background Different therapies have different theoretical backgrounds which makes their comparison difficult. Process research seeks to understand what the common mechanisms are at work which contribute to successful outcome. The current study sought to compare the content of two therapies (Cognitive Behaviour Therapy and Interpersonal Therapy) in the treatment of depression and measure any changes that participants reported. Method Taped therapy sessions of IPT and CBT were transcribed and a coding scheme measuring content of therapy was developed. Participants’ accounts of therapeutic change were recorded between the two models of therapy across three time periods using a mixed design. The times periods were divided into: beginning, middle and end of therapy. Quantitative content analysis was used to measure frequency of occurrence of categories in therapy. Qualitative Content Analysis was used to compliment quantitative findings and to compare participants' accounts of change between the beginning and end of therapy. Results The results indicated that differences in content reflected the theoretical background of both therapies. The categories: affect expression, task activation and review, behavioural change and cognitive change, solution generation, discussion of the model, homework and assumptions occurred significantly more in CBT compared to IPT. All other differences between the models were not significant. Differences in content of therapy occurred between the beginning, middle and end of therapy. There was a reduction in symptoms of depression for participants in both groups as measured by the BDI but this reduction was not significant. The discussion related the findings to the current literature and presented ideas for future research.

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