Purpose: A systematic review and meta-analysis was conducted to identify what factors have been investigated as correlates of the 4 key domains of treatment decision making capacity (TDMC) in people who have experienced psychosis (understanding, reasoning, appreciation, communication) and to provide estimates of the magnitude of these correlations, taking into account study quality. A novel empirical study was conducted to test the hypothesis that variance in psychosis-specific cognitive biases (including the well-established ‘jumping to conclusions’ bias) would account for unique variance in TDMC domains in those with psychosis, after taking into account the known contribution of symptoms and insight. A secondary aim of the empirical study was to examine for the first time the relationship between TDMC and personal recovery in this group, and post hoc analyses of the relationship between cognitive biases, emotional distress and TDMC were also conducted. Methods: Electronic databases were systematically searched for literature on the schizophrenia and psychosis and treatment decision making capacity. Pooled estimates of correlation were estimated for factors with data from three or more studies, and both study and outcome quality were systematically assessed. A cross-sectional observational study was conducted, and individuals with psychosis completed measures of TDMC, cognitive biases, psychotic symptoms and recovery. Multiple regression was used to examine the primary and secondary hypotheses, and mediation analyses were used to conduct the post hoc analyses. Additional data from a parallel study was incorporated to increase power. Results: Twenty-four studies met inclusion criteria for the systematic review and meta-analysis. Low to moderate quality evidence suggested that the ability of people with psychosis to understand treatment-relevant information was strongly associated with overall psychotic symptom severity, verbal cognitive functioning and years of education, but not depression (moderate quality evidence). Low quality evidence suggested reasoning was strongly associated with verbal cognitive functioning and moderately associated with symptoms. Appreciation was associated with symptoms, but it and communication were generally poorly studied. Findings from the empirical study suggest that cognitive biases, and the Jumping to Conclusions bias in particular, predicts a moderate amount of the variance in the understanding and reasoning TDMC domains, but did not add predictive power to a model containing symptoms, insight, and cognition. The appreciation domain was strongly predicted by cognitive biases, insight, and cognition. TDMC was not found to be correlated with personal recovery and post hoc analyses did not find that emotional distress mediated any relationship between cognitive biases and TDMC. Conclusions: The meta-analysis confirms there is a robust association between symptoms and TDMC in psychosis, as currently conceived. The empirical study suggests cognitive biases may be related to TDMC, even after taking into account the contribution of symptoms. Larger studies, perhaps employing experimental procedures, are required to clarify the exact nature of this relationship. The lack of any relationship between TDMC and service-user defined recovery from psychosis is notable, and lends support to those calling for a conceptualisation of TDMC that takes greater account of this concept.

The current research project aimed to investigate how various degrees of psychosis and autism traits were associated with different styles of reasoning. Therefore, a series of five studies were conducted that recruited participants who were considered to reside along different points of the psychosis and autism continua. Measures of intuitive and deliberative reasoning style were employed and were used to ascertain whether differing degrees of psychosis and autism reflected different profiles of reasoning style. In addition, a composite score was devised using the raw scores of measures of psychosis and autism traits to test Crespi and Badcocks (2008) diametric disorders hypothesis and to further explore the relationship between the two measures. Overall, the results revealed some evidence that psychosis traits were associated with a more intuitive relative to deliberative style of reasoning, whereas autism traits were reflective of the reverse profile. The findings were also able to shed further light on the intricate relationship between autism and psychotic spectrum disorders.

Paper one is a systematic literature review of qualitative studies examining psychosis in women using a metasynthesis approach. The review involved three stages: a systematic search of qualitative studies reporting the experiences of women with psychosis, critical appraisal of these studies, and the metasynthesis. Thirteen studies met the inclusion criteria, yielding data from 220 women in total. The synthesis of the studies demonstrated three overarching themes: (a) women's beliefs about their illness, (b) perceived consequences of illness, and (c) strategies to cope with illness. Important barriers to strategy use were identified and recommendations made for addressing them. In the second paper grounded theory methodology was used to explore recovery in women who had experienced psychosis following childbirth. Semi-structured interviews were conducted with 12 participants and data were analysed using grounded theory methodology. A theory of four superordinate themes was developed from the data, including: (a) the process of recovery; (b) evolving an understanding; (c) strategies for recovery; and (d) sociocultual context. It was concluded that women experienced a complex process of recovery which was ongoing. The role of other people, including professionals in the recovery process was central. Recommendations were made for professionals to assess women's position in terms of their recovery in order to offer timely, appropriate interventions. The final paper is a critical reflection of the work reported in the previous two papers. I reflected upon how my previous experiences influenced my decision to undertake this research and other aspects of the research process. I explored the rationale for my choice of research methodology and discussed the debates which exist around the use of these methods. Finally, my personal reflections upon the entire research process are included.

Background: Stigmatization of people with psychosis is a widespread and global issue that has been existing for a long time. While other psychological illnesses are getting less stigmatized, schizophrenia and psychosis tend to be unchanged. Aim: The aim of the study was to illuminate experiences of stigmatizations in people with psychosis. Method: This is a literature study based on qualitative research. Thirteen articles were analyzed according to Friberg's five-step model and resulted in four themes and seven sub-themes. Results: The main theme that emerged was: feeling powerless, experience of exclusion, being treated unfairly, a need to withdraw. The result showed that people with psychosis or schizophrenia experience stigma from different directions which includes family, society and healthcare. Conclusion: Stigma exist everywhere and to prevent stigmatization, more knowledge about the phenomenon is required. Stigmatization gives the person worse conditions in life. The recovery becomes more lengthy and complicated. / Med samhällets ökande stress och krav ökar också den psykiska ohälsan. Men vem vågar prata om sina psykiska problem i det rådande samhället? Vem vill bli kallad psykfall eller galning? När familj och vänner väljer att lämna dig på grund av dig och din sjukdom, och det enda som finns kvar är hemmets fyra väggar, vad gör du då? Psykisk ohälsa som schizofreni och psykos har en lång, mörk historia som präglats av stigmatisering. Utvecklingen går framåt, men i alldeles för långsam takt och dåtidens fördomar lever kvar. Medan behandlingsformerna har förändrats genom åren har stigman alltid funnits kvar, sida vid sida, inom vården men också i samhället. Stigma tar sig hänsynslöst över kulturer och länder och ter sig på ungefär samma sätt överallt. Stigma handlar om okunskap, fördomar, rykten och stereotyper, därför bör alla titta igenom sitt eget förråd av värderingar. Ger samhället de utsatta personerna förutsättningar att kunna leva fritt i samhället? Och vems ansvar är det att arbeta förebyggande för att krossa stigman? Personer som lider av psykossjukdom behöver få möjlighet till en hoppfull och ljus framtid efter allt mörker. I den här litteraturstudien har en kvalitativ metod använts och genom att ha sammanställt 13 vetenskapliga artiklar har fyra teman och sju underteman framkommit vilka visar att personer med psykos och schizofreni är en utsatt, stigmatiserad grupp i samhället och vården. Genom att belysa det här ämnet kan fler bli uppmärksammade på de fördomar som finns.

Background There now exist a range of efficacious options for the treatment of psychosis in mental healthcare. The importance of recovery, empowerment, dignity and choice among patients with severe mental health diagnoses are important topics in contemporary research and practice. This thesis presents a meta-analytic review followed by a randomised controlled experimental study. These address distinct but related questions which aim to further our understanding of the choices available for intervention in psychosis and whether intervention may improve the ability of psychosis patients to make those choices. Aims The first objective aimed to offer a comprehensive review of the effectiveness of social skills training (SST), which is a psychological intervention for psychosis. SST has fallen out of favour in the UK and is not widely implemented in practice. We hypothesised that SST would demonstrate superiority for the negative symptoms of psychosis. The second objective was to determine whether decision-making capacity regarding treatment among psychosis patients could be improved by the application of a brief psycho-educational intervention targeting the jumping-to-conclusions (JTC) bias, which is a commonly observed cognitive bias in psychosis. We hypothesised that the intervention would improve decision-making capacity. Methods Firstly, a series of 70 meta-analyses are presented in a systematic review assessing the efficacy of social skills training across a number of psychosis outcome domains: positive symptoms, negative symptoms, general symptoms, overall symptoms and social functioning outcomes. Secondly, a randomised controlled experimental study is presented in which 36 psychosis patients in NHS Lanarkshire and 1 in NHS Dumfries & Galloway were allocated to receive either a brief meta-cognitive training (MCT) intervention or an non-specific control presentation lecture. Capacity was assessed at baseline and post-treatment while the impact of the intervention upon capacity was estimated by ANCOVA. Mediation analyses assessed whether changes in the JTC bias mediated outcome. Findings In the meta-analytic review, SST demonstrated superiority over treatment as usual (TAU. g=0.3), active controls (g=0.2-0.3) and comparators pooled (g=0.2- 0.3) for negative symptoms; and over TAU (g=0.4) and comparators pooled (g=0.3) for general psychopathology. In the randomised controlled study, MCT demonstrated large effects on two capacity outcomes; overall capacity (d=0.96, p < .05) and appreciation (d=0.87, p < .05). Exploratory analyses suggested a mediating effect of JTC (d=0.64, p < .05). Interpretation SST demonstrates a magnitude of effect for negative symptoms similar to those commonly reported for CBT for positive symptoms and may have potential for wider implementation in mental healthcare settings. The randomised controlled study suggests that psycho-educational interventions targeting capacity have clinical utility and may be developed for implementation. Limitations included lack of blinding, no fidelity checks and inclusion based on clinical diagnosis therefore a larger randomised controlled trial addressing these limitations is warranted.

Le dispositif institutionnel s’avère particulièrement pertinent pour le traitement d’enfants psychotiques et autistes, comme le démontrent les expériences des premiers pédagogues et psychanalystes d’enfants en Europe à partir des années 1920. Nous allons situer les modalités d’intervention institutionnelle nous permettant de vérifier cette hypothèse,à partir de l’analyse de quatre expériences institutionnelles orientées par la psychanalyse. En effet, la doctrine freudienne et lacanienne permettent au clinicien d’inventer et de renouveler sans cesse les moyens d’accueillir les productions du sujet psychotique, en leur accordant toute sa dignité. Une clinique des psychoses s’élabore de cette manière et donne lieu à la transmission de ses résultats. Cela permet d’envisager une application de la psychanalyse en Équateur, à travers l’étude des paramètres permettant la mise en place d’un dispositif inédit d’élaboration clinique en institution pour enfants atteints de troubles psychiques. / The institutional device turns out to be particularly relevant for the treatment of psychotic and autistic children, as demonstrated by the experiences of early childhood educators and psychoanalysts in Europe from the 1920s onwards. We are going to place the modalities of institutional intervention, which allows us to verify this hypothesis, based on the analysis of four different institutional experiences oriented by psychoanalysis. The Freudian and Lacanian doctrine gives the clinician the opportunity to invent and to constantly renew the means to admit and encourage the productions of the psychotic subject, giving them all their place and dignity. A clinical approche of psychosis develops in this way, and results in the transmission of its effects. This allows to consider an application of psychoanalysis in Ecuador, through the study of the parameters for the implementation of an unprecedented clinical device, in order to treat on an institutionnal level children suffering from psychic disorders.

Demographic, historical, psychometric, and clinical data were obtained from the psychiatric files of all patients manifesting schizophrenic symptomatology who were hospitalized in an adolescent psychiatric facility during a five year period (N= 71). Factor analysis of the usable data resulted in three interpretable factors, which included: (1) aggressive behavior; (2) disturbed family functioning; and, (3) thought disorder. Age of first hospitalization correlated positively with factor three. The results provide support for concerns expressed by a number of scientists and clinicians that schizophrenia may not be a discrete, unitary disorder; and that uncritical downward extension of adult diagnoses to adolescents and prepubescent children may be questionable. The results further suggest that current DSM-III and DSMIII- R subtypes of schizophrenia (which are clinically derived and symptom based), are not validated by empirically derived subtypes that include objective indices of behavior along with clinical symptoms. The correlation of "age of first hospitalization" with one of the three factors suggests that developmental level at the onset of illness may represent an important mediating variable in the severity and prognosis of certain subtypes of schizophrenia.

There has been concern about the impact of cannabis use on the onset, course and relapse of psychosis. Evidence from retrospective and a small number of prospective studies has suggested that cannabis use may precipitate a latent psychosis, exacerbate psychotic symptoms and increase the likelihood of psychotic relapse. The purpose of the current study was to examine the influence of cannabis use on psychotic symptom exacerbation and relapse within the stress vulnerability-coping model of psychosis. Two studies were conducted. The influence of cannabis use on the onset and course of psychosis was retrospectively examined in the first study. The second study prospectively examined the influence of cannabis use on psychotic symptom exacerbation and relapse over a 6-month period. The influence of the severity of psychotic symptoms on a relapse in cannabis use was also explored. Eighty-four participants were assessed at admission, 81 of whom were followed up for a 6-month period. Measures consisted of structured diagnostic interviews and self-report measures of stress, medication compliance, family functioning, premorbid adjustment, quality of life, substance use and psychotic symptoms. The onset of cannabis use clearly preceded the onset of psychosis. Cannabis use was predictive of the severity of psychotic and general psychopathology symptoms at admission. Both the frequency and quantity of cannabis use was predictive of time to psychotic relapse over the 6-month follow up period. Psychotic symptom severity was predictive of a substantial increase in the quantity but not the frequency of cannabis use. Cannabis use was related to the onset, course and relapse of psychosis.

Background          Schizophrenia has been negatively observed in today’s society due to several major violent crimes and violent actions committed by persons with the diagnosis. The general populations’ lack of knowledge increases the risk of a faulty attitude when meeting individuals with schizophrenia. Schizophrenia is a psychosis which creates suffering for the effected. Common symptoms of schizophrenia are hallucinations, delusions, apathy and difficulties with emotional relations. Nearly half of all schizophrenics attempts suicide, at some point.   Aim                        The aim of this study was to describe how people with schizophrenia experience their life-world.               Method                  This study is based on six autobiographies and is analyzed with qualitative content analyses.   Results                   The study resulted in six categories which are perception of their illness, positive symptoms, negative symptoms, suffering, experiences of health care and medication and strategies towards a brighter future. During psychotic periods the individuals often experienced their surrounding as frightening because of hallucinations. Some of them live their lives alone because they are afraid of being perceived as crazy and want to conceal their diagnosis. The result shows strategies that the persons were using for reducing their suffering.                                  Conclusion            Prejudices about the disease can generate that persons with schizophrenia is not getting the care they need. If the patient is treated based on a life-world perspective, he or she will feel like being seen as a person rather than a diagnosis.

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