This dissertation for the Doctorate of Clinical Psychology at the University of Liverpool focuses on the experiences of receiving dialectical behaviour therapy (DBT) in the community by adults diagnosed with borderline personality disorder (BPD). It comprises three distinct chapters, namely a literature review, an article detailing an empirical study, and an extended discussion. Chapter one presents the findings from a literature review that systematically searched the qualitative literature for studies that explored the experiences of receiving community-based DBT by adults diagnosed with BPD. The chapter begins by briefly describing the history, diagnostic criteria, prevalence, and symptoms of BPD, before describing the components of DBT, a psychological treatment that has received strong empirical support for the treatment of BPD. Findings from the systematic search of the qualitative literature reveal five articles that fit the review’s inclusion criteria; this paucity of qualitative research investigating clients’ accounts of DBT in actual clinical settings is surprising considering that DBT has received growing support for its efficacy since the publication of its treatment manual in 1993. When considering the findings from the five qualitative articles, the picture of clients’ experiences of DBT is unclear, as the studies vary fundamentally in their research design. For example, the qualitative studies differ in their research design, including the use of structured interviews, semi-structured interviews, and focus groups, and vary in the methodological approaches deployed to analyse the data. Also, the DBT programmes from which participants were recruited in the qualitative studies differ in their fidelity to the DBT model. With the systematic search of the qualitative literature revealing so few studies exploring the experience of receiving community-based DBT by adults diagnosed with BPD, together with their methodological and analytical differences contributing to an unclear account of the experience, chapter two of this dissertation presents an empirical study aiming to augment the qualitative literature that explores the experience of receiving community-based DBT by adults diagnosed with BPD. This empirical study is vital as not only does it consolidate the existing qualitative research, but, remarkably, is believed to be only the second study of its kind to be conducted in the National Health Service (NHS), with the first being conducted over 6 years ago. The aims of the empirical research are to capture participants’ expectations and experiences of the DBT programme, the impact and experience of the multi-modal components of the programme, determine the meaning of a ‘life worth living’ to someone diagnosed with BPD, and gauge whether DBT contributes to a ‘life worth living’, which is DBT’s overarching aim. Six participants are interviewed, all of whom are diagnosed with BPD and have experience of a community-based DBT programme delivered by the NHS. Six themes are found from analysing the qualitative data derived from the interview transcripts. As the intention is to publish both the literature review and empirical paper in academic journals, and academic journals invariably set a limit regarding the maximum number of words or pages for research articles, the third chapter of this dissertation elaborates on the points made in the discussion section of the empirical article in chapter two. The elaborations extend the implications of the findings to the wider research. Links are made to the wider research literature that focuses on group therapies, and the literature suggesting that those diagnosed with BPD struggle to foster therapeutic alliances with therapists. Links are also made to clinical practice, especially in light of fundamental changes to the landscape of the NHS, such as the Coalition Government’s target to make £20 billion of efficiency savings within the NHS by 2014, and the NHS now facing competition from ‘Any Willing Provider’ offering healthcare provisions. Overall, the participants’ experiences of DBT found by the empirical study presented here is encouraging, and it is hoped that such positive views from users of the NHS may go some way to balance the criticism the NHS has received over the years regarding the quality of care it provides to the public. Chapter three also includes a different version of the empirical article, written for employees and clients of the Trust in which the research was conducted. Chapter three concludes with a section detailing how the empirical research presented in this study could be usefully extended.

Objectives: People who identify as transgender are reported to experience high levels of mental health problems in comparison to people who do not identify as transgender. The minority stress model has been used to explain these high prevalence rates. But this model was designed to be used in lesbian, gay and bisexual (LGB) populations (Meyer, 1995, 2003). Researchers have applied some of the hypothesised processes of the model to people who identify as transgender. However, evidence testing the minority stress model in this population is limited. The model postulates that minority stress processes (namely, distal stress, internalised stigma, vigilance and concealment) lead to adverse mental health outcomes. It also states that coping and social support moderate and ameliorate the stress processes. However research on this aspect is inconclusive, with other researchers stating that coping and social support meditate the relationship between internalised stigma and psychological distress. In light of the current literature, this research aimed to test the application of the minority stress model in a sample of people who identified as transgender. It also aimed to test the moderating and mediating roles of coping and social support. Furthermore, this research endeavoured to develop an alternative model (i.e. based on the findings and the literature). Methods: A cross-sectional design was used. Participants were recruited from transgender forums, social groups, transgender events and social media. Those who identified as transgender, under the umbrella term, were invited to complete an online survey (N = 270; mean age = 27.5). The majority of participants (60.4%) described their gender identity as trans women. Results: Multiple linear regression, mediation and moderation analyses were conducted. Results showed that, individually, all the stress processes (distal stress process, internalised stigma, vigilance and concealment) were significantly associated with psychological distress. However, when assessed in combination, only certain stress processes emerged as being significant. With internalised stigma emerging as being significant in all the regression models (i.e. depression, anxiety and stress). No moderation effects were found for coping and social support. Instead, passive coping and social support were found to partially mediate the relationship between internalised stigma and psychological distress. Structural equation modelling was also used to develop hypothesised models based on this data. Conclusion: Limited support was found for the minority stress model within this sample. Hypothesised models were developed instead, to highlight the stress processes involved in depression, anxiety and stress. However, future research is warranted to test these models.

Allergic responses are mainly mediated by immunoglobulin E (IgE) and mast cells or basophils expressing the high-affinity IgE receptor FcεRI. Cross-linking of FcεRI and IgE complexes with allergen induces basophil degranulation and release of inflammatory chemical mediators, leading to clinical symptoms. Common allergy diagnostic tests such as ImmunoCAP, focused on the measurement of specific IgE in patients, commonly lead to misdiagnosis. The allergen-specific IgE in patients’ sera might not always lead to FcεRI cross-linking on mast cells or basophils, resulting in no related clinical symptoms, as observed in some food allergies. In order to mimic the allergic response and generate an in vitro diagnostic device to address these issues, a basophil-microarray platform that couples the diversity of a protein array with the biological output of basophilic cells is being developed. This platform allows testing of up to five thousand allergens using a drop of patient’s blood. In this study, the optimisation steps and preliminary results are presented. The platform in development relies upon the use of a humanised rat basophilic leukaemia (RBL) cell line RBL-703/21 and different methods to measure the levels of basophil activation. ß-hexosaminidase assay showed that the human FcεRI expressing RBL-703/21 cell line was able to bind human IgE in the presence of anti-IgE/allergens and led to degranulation. Fibronectin has shown to greatly avoid cell losses during experiments, calcium ionophore A23187 is an unsuitable positive control due to a fast down regulation of VLA-4 and subsequent detachment of cells. The commercial Ca2+ probe (fluo-4, AM) was shown to efficiently measure the intracellular calcium flux upon activation in the micro-well plate, but due to the lack of a detection system, it can not to be used in the microarray. Two reporter plasmids encoding GFP or DsRed with an NFAT promoter region were transfected into RBL-703/21s and optimised. Both reporter systems were able to detect the presence of functional allergen-specific IgE in the sera of patients, and showed the expected bell–shaped dose response curves. Results correlated with those measured by clinical diagnostic methods. The fluorescence system developed using reporter genes does not need further processing, making it an ideal system for the future development of basophil microarray platforms.

Reports of inter-ethnic differences in metabolism for phenytoin and carbamazepineh have raised questions concerning the importance of monitoring serum levels to the standardised population therapeutic concentrations. Although the pharmacokinetics of phenytoin, carbamazepine, valproic acid and phenobarbitone displayed both intra and inter-individual variations, the influence of ethnicity is still unclear. This thesis has thus set its objectives of investigating the impact of ethnicity on the efficacy of these therapeutic ranges and pharmacokinetics of these drugs. A total 1554 serum concentrations were randomly selected by a set of criteria from 470 Malays, 423 Chinese and 322 Indian of adult and paediatric patients. The Mantel-Haenzel method was used to estimate for inter-ethnic differences in response to the defined therapeutic ranges. The influence of ethnicity on pharmacokinetics was examined by the test of heterogeneity of the slopes estimates in the linear relationship of either serum concentration or clearance to dose. Coefficient of variation on the ratios of the above relationships was used to measure for inter individual variation. The results showed a highly variable response to treatment within the defined therapeutic ranges. Therapeutic response is not dependent on ethnicity and age although the latter was determined on carbamazepine and valproic acid treated patients only. The pharmacokinetics of carbamazepine, valproic acid and phenobarbitone showed high inter-individual variations and were unaffected by weight, age or ethnicity. Similar high inter-individual variation for phenytoin pharmacokinetic parameters (Km and Vmax) were observed. However, Km and Vmax(mg/day) of adult Chinese patients were significantly lower than Malay or Indian patients. The relationship between Km and Vmax and age or weight were insignificant. These findings demonstrate that Malaysian patients only differed in handling phenytoin therapy and support the use of ethnic specific phenytoin pharmacokinetic parameters during therapy.

The aim of this thesis was to identify both patient and carer factors relating to caregiver strain in spouses of stroke patients. The secondary aim was also to assess the effectiveness of an intervention in reducing levels of strain, involving the provision of cognitive assessment information to both patients and spouses. Previous research has not investigated specific cognitive impairment after stroke in relation to strain and reports of the relationship between patient disability and strain are not consistent. Assessment of physical function and detailed neuropsychological examination was carried out with stroke patients in Nottingham, Derby and Mansfield as part of a prospective, multicentre, single-blind randomised controlled trial. The assessment battery included measures of general mental state, language, perception, memory, executive function and praxis. Individualised information about cognitive function was provided in verbal and written form to each patient and carer. Carer strain was assessed in 57 spouses three and six months later. Around a third of spouses experienced significant strain. Results confirmed the importance of patient physical function with disability becoming an important factor with time. Basic self-care skills (Barthel Index) measured at three and six months, were significantly associated with carer strain at six months. Impairment of the patient's general mental state on the Mini-Mental State Examination (MMSE) and communication difficulties on the Sheffield Screening Test for Aphasia (SST) were related to carer strain and were also associated with emotional rather than physical strains. Carer strain was not significantly associated with other cognitive deficits, including impairments of perception, memory, executive function and praxis. Previous research has not assessed specific carer characteristics in relation to strain. In order to identify these, 222 spouses of stroke patients were sent questionnaire measures of strain, stress, mood, handicap, adjustment, social support, life satisfaction and personality and their perceptions of the patient's mood and independence in activities of daily living. Univariate analysis suggested that strain was associated with increased carer handicap, high stress, poor mood, 'chance' health locus of control, expression of depressed mood, low optimism, low positive affectivity, high negative affectivity and low self-esteem. Strain was also related to poor adjustment, low satisfaction with life, less emotional and practical support and a greater discrepancy between actual and ideal levels of support and increased help from professional services. Strained carers also perceived poor mood and increased disability in the stroke patient. Multivariate analysis indicated that the most important factors were low carer mood on the General Health Questionnaire-12 (GHQ-12), poor perceived patient independence in activities of daily living on the Extended Activities of Daily Living Scale (EADL) and high negative affectivity on the Positive and Negative Affect Schedule (PANAS). The relationship between these factors and strain needed to be tested prospectively. In a multicentre study of 116 spouses in Nottingham and Leicester, carers were sent the CSI, GHQ-12, EADL and PANAS at three and six months after the stroke. Again, over a third of carers experienced significant strain. Results confirmed those of the previous study and mood, perceived disability and negative affectivity at three months were found to predict high levels of carer strain six months after stroke. The most important caregiver factors were therefore the spouse's appraisal of their partner's disability, together with two emotional components of subjective well-being, one transient and one stable. The results also highlighted the role of other factors, including incontinence, disturbed sleep, communication difficulties and the amount of time spent caregiving in carer strain. Early identification of carers who may be at risk of strain later on will enable services to be targeted at prevention rather than cure. There was a non-significant trend towards reduced strain in carers who had received information about cognitive deficits after stroke. Spouses may benefit from individualised information about their partner's stroke. Strain is emotionally laden and services might focus on teaching effective coping strategies to reduce depression and provide emotional support. More research is needed to identify services that are effective in alleviating or indeed preventing strain. NB. This ethesis has been created by scanning the typescript original and may contain inaccuracies. In case of difficulty, please refer to the original text.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in partial fulfillment of the requirements for the degree of Master of Medicine in the branch of Psychiatry Johannesburg, 2017 / Introduction. Eating disorders are an important group of mental illnesses in Psychiatry. The aetiology is multifactorial, developing from distorted beliefs around body image and shape, with resultant abnormal eating behaviours. This study explores the views and perceptions of a group of university students regarding their peers’ body image and shape and eating behaviours, which they experienced (at the time) during their senior high school years. The majority of these students attended high schools in Johannesburg. Method. This was an explorative, qualitative study using qualitative methods. A sample of 153 participants was voluntarily recruited from students in the Faculty of Health Sciences at the University of the Witwatersrand. A manually distributed anonymous questionnaire was used, with questions about their high school peers’ personality traits, early and late childhood experiences, eating behaviour, and the last three years of high school environment. Questions in each section were deconstructed and categorised into subthemes. Subthemes were further deconstructed into replicated ideas. These subthemes and ideas were presented in hierarchical tables. Findings in this study were compared with the literature. Results. The most commonly described subtheme of participants’ perceptions of high school peers’ personality traits was “poor self-confidence”. The most replicated subthemes of views on peers’ childhood experiences were “personal conflict with members of the family”, “a disruptive home environment” and “mother’s attitude”. In terms of peers’ eating behaviour, a subtheme on “body shapes” included “fat”, “skinny” and “fit” and “muscular” bodies. In terms of the high school environment, the subtheme of “bullying and peer discrimination” was regarded as important, while “the impact of media” was regarded as extremely important. Fifty percent of participants viewed body image to be important for social status. There were mixed views on whether specific programmes should be introduced to identify pupils at risk. Conclusion. Although bullying and peer pressure have been described as contributing factors in the development of eating behaviour problems in high school learners, as perceived by a group of university students, the most prominent potential contributing factor considered was the media, specifically social media. This finding could contribute to further research looking at the role of social media, not only its relationship in the potential development of a Psychiatric Illness, but possibly, too, its role in the educational and rehabilitation process. / MT2017

To investigate the subjective experience of children diagnosed with anxiety disorders and the presenting complaints that children with anxiety disorders are referred with to a child and adolescent psychiatry unit.

"The Clinic's interest in the problem of withdrawals led to the development of this study. The purpose was to attempt to discern some of the possible factors pertaining to the failure of forty-eight patients to return to the Clinic following the evaluation interview and offer of treatment. It was believed that an analysis of certain data obtained from the case records of the Clinic through use of a case reading schedule of eleven items and follow-up interviews with a group of twenty patients who did not return to the Clinic for the recommended treatment, would give some indication of the possible factors involved. An analysis of these data may lead to more knowledge of some of the factors involved when patients fail to return and will aid the Clinic in ascertaining whether the loss of patients was due to procedures within the agency setting, factors within the patient and his environment, or perhaps a combination of both"--Introduction. / Typescript. / "June, 1961." / "Submitted to the Graduate School of Florida State University in partial fulfillment of the requirements for the degree of Master of Social Work." / Advisor: Helen M. Manahan, Professor Directing Study. / Includes bibliographical references (leaves 73-75).

A Organização Mundial de Saúde prevê que a porcentagem da morbidade mundial atribuída aos transtornos mentais e de comportamento aumente de 12%, verificada no ano de 1999, para 15% no ano de 2020. Esse aumento será particularmente pronunciado nos países em desenvolvimento, devido ao envelhecimento da população e à rápida urbanização. As repercussões sociais e econômicas e a perda da produção devido às altas taxas de desemprego entre as pessoas com transtornos mentais e seus cuidadores são alguns dos custos mais evidentes e mensuráveis dessa projeção. Como custos menos evidentes citamos a redução da qualidade de vida e a tensão emocional sofrida pelos pacientes e suas famílias. O gerenciamento de casos contrapõe-se ao hospital psiquiátrico tradicional e constitui uma alternativa para a atenção à saúde mental que se mostrou viável e possível em alguns países e baseia-se no preparo do doente mental enquanto responsável pelo seu cuidado e por mantê-lo na comunidade em contato com o serviço, mas não dependendo dele, desenvolvendo relações entre seus pares sem a necessidade constante de intervenção. O objetivo geral deste estudo foi apresentar a experiência de gerenciamento de casos de 20 pacientes psiquiátricos durante o período de seis meses. Identificaram-se as etapas e alguns indicadores de atenção em enfermagem com o uso dessa estratégia de cuidado. Avaliou-se assim a viabilidade do gerenciamento de casos na prática da enfermeira em saúde mental. Este estudo configura-se como de abordagem qualitativa, de caráter descritivo, sendo que a partir do método etnográfico são traçados o planejamento da coleta dos dados assim como a apresentação e análise dos mesmos. Os dados foram coletados no período de primeiro de setembro de 2003 a primeiro de março de 2004, na Unidade de Emergência Psiquiátrica do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (UE-HCFMRP-USP), posteriormente, no domicílio dos pacientes que participaram da pesquisa. Nossos sujeitos foram os pacientes que procuraram atendimento na UE-HCFMRP-USP, durante o mesmo período. A estratégia de atenção em saúde empregada foi o gerenciamento de casos comunitário e intensivo, do tipo clínico com ênfase nas dificuldades apresentadas pelos pacientes. A coleta dos dados teve início após a aprovação pelo Comitê de Ética em Pesquisa da referida instituição. Os resultados nos mostram que, apesar de todos os avanços na área da psiquiatria, o paciente psiquiátrico ainda tem sofrido o estigma da doença mental, as incapacidades associadas aos sintomas residuais que não são contempladas, a inexistência de projetos terapêuticos para essa pessoas e a falta de articulação dos serviços de saúde mental. Dentre outros desdobramentos do estudo, inclui-se o de oferecer aos enfermeiros psiquiátricos da assistência e do ensino um repertório de possibilidades de trabalho com o doente mental que amplie sua autonomia, dado que isso também integra as ações do cuidar. / The World health Organization forecasts that the global morbidity percentage due to mental and behavioral disorders will rise from 12% in 1999 to 15% in 2020. This increase will be particularly pronounced in developing countries, due to population aging and rapid urbanization. Social and economic repercussions and production losses as a result of high unemployment rates among persons with mental disorders and their caregivers are some of the most evident and measurable costs of this forecast. Less evident costs include reduced quality of life and the emotional tension suffered by patients and families. Case management is opposed to the traditional psychiatric hospital and appears as a mental health care alternative that has revealed its viability and possibility in some countries and is based on preparing mental patients as responsible for their own care and maintaining them in the community, in contact with the service, but not depending on it; developing relations with their peers without constant intervention needs. The general aim of this study was to present and analysis of case management involving 20 psychiatric patients during a sixmonth period, identifying the steps and some nursing care indicators with the use of this care strategy and thus evaluating the viability of case management in mental health nursing practice. This descriptive study adopted a qualitative approach. Data collection planning, presentation and analysis were traced on the basis of the ethnographic method. Data were collected from September 1st 2003 until March 1st 2004, at the psychiatric Emergency Unit of the University of São Paulo at Ribeirão Preto Medical School Hospital das Clínicas (UE-HCFMRP-USP) and later at the homes of study participants. Subjects were patients who sought care at the UE-HCFMRP-USP during the same period. The clinical type of community and intensive case management was used as a health care strategy, emphasizing the patients’ difficulties. Data collection started after the study’s approval by the research ethics Committee at the above mentioned institution. Results show that, in spite of all psychiatric advances, psychiatric patients still suffer from the stigma of mental illness, the disabilities associated with residual symptoms that are not taken into consideration, the inexistence of therapeutic projects for these persons and the mental health services’ lack of articulation. Further developments of this study include offering psychiatric nurses from practice and teaching a repertoire of possibilities for working with mental patients which expand their autonomy, as this is also part of care actions.

by Shing Chi Yuen. / Thesis (M.S.Sc.)--Chinese University of Hong Kong, 1990. / Bibliography: leaves 49-56. / ABSTRACT --- p.ii / ACKNOWLEDGEMENTS --- p.iv / TABLE OF CONTENTS --- p.V / LIST OF TABLES --- p.vi / LIST OF APPENDICES --- p.vii / Chapter CHAPTER I - --- INTRODUCTION --- p.1 / The influence of family --- p.1 / Coping responses --- p.7 / Hopelessness --- p.13 / Purpose of the Present Study --- p.18 / Chapter CHAPTER II - --- METHOD --- p.21 / Subjects --- p.21 / Instruments --- p.21 / Procedure --- p.25 / Chapter CHAPTER III - --- RESULTS --- p.26 / "Differences between child psychiatric patients and school children in family relations, hopelessness, and coping responses" --- p.26 / "Interrelationships among family relations, hopelessness, coping responses and emotional disturbance" --- p.29 / "Predictive power of family relations, hopelessness and coping responses in predicting emotional disturbance" --- p.33 / The mediating effect of coping responses --- p.38 / Chapter CHAPTER IV - --- Discussion --- p.41 / REFERENCES --- p.49 / APPENDICES --- p.57