Background: Post Traumatic Stress Disorder (PTSD) is frequently linked with substance use disorder (SUD). However, the nature of this association remains unclear. A clearer understanding of the dynamic associations between PTSD and SUD may shed light on the course of these two disorders thereby, identifying areas for intervention, which may potentially reduce some of the associated costly and harmful outcomes. Methods: Firstly, a systematic review was conducted to investigate the evidence base regarding the relationship between PTSD and SUD. Secondly, an empirical project was undertaken to explore functional associations between PTSD and SUD. This was achieved by comparing, motives for substance use, anxiety and depression symptoms, and SUD symptom severity amongst treatmentseeking adults with and without PTSD. Results: Results from the systematic review suggest that individuals with comorbid PTSD and SUD have more severe clinical profiles compared to individuals with a SUD alone. The results from the empirical study indicate that those with PTSD endorse coping-related motives for substance use significantly more than those without PTSD. Furthermore, those with PTSD had significantly elevated SUD severity ratings and higher anxiety and depression scores. Conclusions: Findings suggest that individuals with comorbid PTSD and SUD are motivated to use substances to cope with negative affect. The clinical implications of this are discussed.

The thesis includes three papers: paper 1 is a literature review, paper 2 is an empirical study and paper 3 is a critical reflection. Paper 1 and 2 have been prepared for submission to Clinical Psychology and Psychotherapy. Paper 1 systematically reviews the qualitative literature pertaining to individual experiences of psychotherapy for PTSD. A meta-synthesis of twelve studies was facilitated using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) principles. The meta-synthesis aimed to explore aspects of psychotherapy for PTSD that were deemed helpful or unhelpful. The strengths and limitations of the study are considered, as are their implications for clinical practice. Paper 2 was a qualitative exploration of basic emotions and the affective phenomena of PTSD. Semi-structured interviews were conducted with ten participants and transcripts were analysed using a deductive-inductive thematic analysis. The results highlight the importance of considering a range of basic emotions in the assessment, formulation and psychotherapy relating to PTSD. The strengths and limitations of the study are considered, as are their implications for clinical practice. Paper 3 is not intended for publication and is a critical reflection of the overall study process. It evaluates the strengths and limitations of both paper 1 and paper 2 in more detail, in addition to offering a critical and reflective account of conducting the research.

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Background Individually both migraine and post-traumatic stress disorder (PTSD) prevalence estimates are higher among women. However, there is limited data on the association of migraine and PTSD in women during pregnancy. Methods We examined the association between migraine and PTSD among women attending prenatal clinics in Peru. Migraine was characterized using the International Classification of Headache Disorders (ICHD)-III beta criteria. PTSD was assessed using the PTSD Checklist-Civilian Version (PCL-C). Multivariable logistic regression analyses were performed to estimate odds ratios (OR) and 95% confidence intervals (CI) after adjusting for confounders. Results Of the 2922 pregnant women included, 33.5% fulfilled criteria for any migraine (migraine 12.5%; probable migraine 21.0%) and 37.4% fulfilled PTSD criteria. Even when controlling for depression, women with any migraine had almost a 2-fold increased odds of PTSD (OR: 1.97; 95% CI: 1.64–2.37) as compared to women without migraine. Specifically, women with migraine alone (i.e. excluding probable migraine) had a 2.85-fold increased odds of PTSD (95% CI: 2.18–3.74), and women with probable migraine alone had a 1.61-fold increased odds of PTSD (95% CI: 1.30–1.99) as compared to those without migraine, even after controlling for depression. In those women with both migraine and comorbid depression, the odds of PTSD in all migraine categories were even further increased as compared to those women without migraine. Conclusion In a cohort of pregnant women, irrespective of the presence or absence of depression, the odds of PTSD is increased in those with migraine. Our findings suggest the importance of screening for PTSD, specifically in pregnant women with migraine.

There is a growing body of research in support of the relationship between self-compassion and psychological health (Neff, Kirkpatrick & Rude, 2007). However, studies are limited on the malleability of self-compassion specifically within clinical populations, and its influence on psychiatric symptom reduction (Raes, 2011). This study therefore aimed to explore self-compassion, through examination of the underlying components (self-kindness, common humanity and mindfulness), and their impact on maladaptive functioning, specifically for participants diagnosed with PTSD. The study used an exploratory mixed methods design, with eight participants recruited by their attendance at two PTSD CBT/IPT (with self-compassion) group treatment interventions. Participants were adults, with a diagnosis of PTSD and a history of recurrent or current depression. Participants attended a group interview and two therapists who facilitated each treatment group were also interviewed. Participants completed quantitative measures pre and post intervention; Self-Compassion Scale (Neff, 2003a) and Clinician-Administered PTSD Scale (Blake et al., 1995), and session data was recorded using the PTSD checklist (PCL-C; Weathers, Litz, Huska & Keane, 1994) and the Session Feedback Form (AccEPT Primary Care Psychological Therapies Service). The findings demonstrate the importance that individuals place on self-compassion in their PTSD recovery, particularly in relation to self-kindness and the generation of positive self-belief and a compassionate inner-voice. The study also indicates that a clinically significant change in self-compassion is possible for individuals with PTSD, supporting the malleability of self-compassion within clinical populations.

Abstract BACKGROUND: The PTSD Checklist-civilian (PCL-C) is one of the most commonly used self-report measures of PTSD symptoms, however, little is known about its validity when used in pregnancy. This study aims to evaluate the reliability and validity of the PCL-C as a screen for detecting PTSD symptoms among pregnant women. METHODS: A total of 3372 pregnant women who attended their first prenatal care visit in Lima, Peru participated in the study. We assessed the reliability of the PCL-C items using Cronbach's alpha. Criterion validity and performance characteristics of PCL-C were assessed against an independent, blinded Clinician-Administered PTSD Scale (CAPS) interview using measures of sensitivity, specificity and receiver operating characteristics (ROC) curves. We tested construct validity using exploratory and confirmatory factor analytic approaches. RESULTS: The reliability of the PCL-C was excellent (Cronbach's alpha =0.90). ROC analysis showed that a cut-off score of 26 offered optimal discriminatory power, with a sensitivity of 0.86 (95% CI: 0.78-0.92) and a specificity of 0.63 (95% CI: 0.62-0.65). The area under the ROC curve was 0.75 (95% CI: 0.71-0.78). A three-factor solution was extracted using exploratory factor analysis and was further complemented with three other models using confirmatory factor analysis (CFA). In a CFA, a three-factor model based on DSM-IV symptom structure had reasonable fit statistics with comparative fit index of 0.86 and root mean square error of approximation of 0.09. CONCLUSION: The Spanish-language version of the PCL-C may be used as a screening tool for pregnant women. The PCL-C has good reliability, criterion validity and factorial validity. The optimal cut-off score obtained by maximizing the sensitivity and specificity should be considered cautiously; women who screened positive may require further investigation to confirm PTSD diagnosis. / Revisión por pares

<p><font face="Times New Roman"> <p align="left">Limitations of the study include the issue of counsellor variables and the fact that the participants varied between receiving a debriefing on a group or individual basis. The experience of the trauma debriefings were explored but more specific information relating to debriefing could have been elicited. Therefore, these findings cannot be generalised and further research could<font face="Times New Roman"> explore the utility and efficacy of trauma debriefing.</font></p> </font></p>

<p><font face="Times New Roman"> <p align="left">Limitations of the study include the issue of counsellor variables and the fact that the participants varied between receiving a debriefing on a group or individual basis. The experience of the trauma debriefings were explored but more specific information relating to debriefing could have been elicited. Therefore, these findings cannot be generalised and further research could<font face="Times New Roman"> explore the utility and efficacy of trauma debriefing.</font></p> </font></p>

Objective: This study aims to explore the traumatic experiences and to estimate prevalence and predictor factors for PTSD, depression and general psychiatric morbidity amongst Palestinian adults living in the Gaza Strip. Method: A total of 500 Palestinian adults were recruited from four areas of the Gaza Strip using a snowball sampling. The same sample was used for both quantitative studies. Four scales were employed to identify predictors for trauma, PTSD, depression and general mental health. Participants were divided into three age groups: young adults (18 to 25 years), adults (26 to 49 years) and older adults (50 to 65 years). The third qualitative study was aimed at exploring the traumatic experiences of adults living in the Gaza Strip to expand upon the outcomes from the quantitative studies. Results: For Studies 1 and 2, the prevalence rate of PTSD symptoms was 90% and 36.7% met the criteria of DSM-IV for PTSD. Study 2 found depression was 38.4%, and general mental health comorbidity was 67.1%. Study 2 revealed significant differences in PTSD between age groups. Novel results were found amongst adults and older adults on the re-experiencing subscale for PTSD. Participants who lived in Gaza City scored significantly higher on the PTSD subscale for hyperarousal compared to those living in the middle Gaza region. Study 3 expanded on the psychometric data through interviewing members of the Gaza community. When analysed five main themes were identified: Siege related stressors; war related trauma; psychological negative effects; re-experiencing initial event and coping strategies. Conclusions: The findings indicated that blockade was the predominant cause of the increased prevalence rate of PTSD. These studies found that the Palestinian adult participants in Gaza had been exposed to a variety of traumatic events on an ongoing basis that was having a detrimental impact on their mental health.

Background: The aim of this study was to explore the experience and sense making oftherapists working with clients who present with a PTSD diagnosis. The study engaged with therapists experience and understanding of predisposing factors to PTSD and how they incorporate this understanding into the therapy process. Further to this the experience of the therapists understanding of the influence of predisposing factors on the expression of PTSD was explored. Literature Review: A literature review is presented identifying core research relating to PTSD, predisposing factors to the development of PTSD and the treatments used when working with PTSD as a presenting issue. Methodology: To address the aims of the study 9 therapist participants were interviewed. Semi-structured, one to one, in-depth interviews were utilised to elicit participant’s experience of the issues outlined within the aims. Interpretative Phenomenological Analysis (IPA) was used to identify re-current themes across the interviews and analyse the data, which emerged. Findings: The main findings present thirteen sub-ordinate themes that reflect the essence of the participant’s experience of the phenomenon under investigation. These were based around eight Super-ordinate (master) themes of Previous history, Therapy relationship, Psychoeducation and Normalisation, Identity, Culture, Attachment, Presenting Therapy Themes, and Support Systems. Discussion and Conclusion: The study identified the participant’s experience of predisposing factors on the expression of PTSD. There was consensus from the participant’s in relation to the significant impact of client’s previous life experience on their expression of PTSD. The participants further identified that the client’s previous life experience influenced their formulation and treatment of PTSD. Significant issues that were described by all of the participants regardless of their theoretical or therapeutic perspective were (1) the central importance of the therapeutic relationship, (without a strong, trusting and safe relationship the participants would not engage the therapy work), (2) the importance of in-depth history taking (identification of previous life experience and its impact on the current response to the trauma), (3) the impact of previous trauma(s), and (4) the impact of support systems, environment and identity. These issues are discussed alongside the existing literature around this topic. Additionally, suggestions for future directions of research and recommendations for practice are presented.