Purpose: The systematic review aimed to review and evaluate constructs and measures of emotion regulation (ER) in the psychosis spectrum population literature. The empirical study aimed to examine the feasibility and acceptability of a trans-diagnostic emotion regulation (ER) group developed for an acute inpatient setting. Methods: The literature was systematically searched for research related to the measurement of emotion regulation (ER) in a psychosis spectrum population. A mixed method design was employed to assess acceptability and feasibility of a six session ER skills group delivered in an acute mental health inpatient setting. The group intervention was developed and piloted over a 5 month period. The mixed method design included a multiple single case series design and qualitative exit interviews, conducted with eight participants. Results: 24 papers met criteria for inclusion in the systematic review. 15 different self-report tools were identified as measures of ER strategies in this review. Descriptive data from the empirical study indicated high attendance and low attrition rates. Group level analysis identified large effect sizes for change in ER skills. Case series data indicated that sustained change, on at least one measured variable, occurred for four participants. Qualitative themes triangulate findings related to acceptability of the group, change in ER strategies and increased emotional acceptance. Conclusions: ER conceptualisation is variable in the literature reviewed, where the understanding of how ER and psychosis are linked is limited. The emphasis on the literature reviewed is on cognitive strategies of ER. The pilot study indicates that the intervention is feasible and acceptable, with preliminary evidence identifying potential clinical benefits. The challenges in evaluating interventions in an acute inpatient environment are discussed.

A pesquisa investiga transformações na leitura psicanalítica do discurso na psicose. Parte da análise realizada por Freud da biografia de Schreber, passando pela admissão por Lacan do termo ―discurso‖ para a psicose, até a referência de Lacan em “O aturdito” ao ―fora-do-discurso da psicose‖. Na formulação de hipóteses acerca do que significa e no que implica tal menção de Lacan não há consenso entre autores que se dedicaram ao tema. Com o propósito de indagar a pertinência de entender o ―fora-do-discurso‖ como fora dos quatro discursos, a pesquisa foi construída com base em uma abordagem topológica e a partir do método psicanalítico de investigação. Inicialmente, é problematizada a idéia do ―fora‖ enquanto exterioridade, posto que a oposição dentro-fora não implica alterações topológicas. A partir dos Esquemas L e Z são abordadas as conseqüências de na psicose o sujeito estabelecer uma relação direta com o semelhante, sem mediação Simbólica do Outro, de modo a permanecer no âmbito da rivalidade especular. A pesquisa faz referência, ainda, às alterações que o fora-do-discurso implica na sustentação do campo da realidade na psicose. A partir do Grafo do Desejo, é deflagrado o impasse de que incluir o desejo na relação com o outro implica a articulação entre os elementos do segundo andar do grafo. Na psicose, o discurso se rompe quando atinge o lugar do código, o que impede a passagem para o andar superior. Conclui-se que o fora-do-discurso da psicose faz referência à inviabilidade de aplicação do matema dos quatro discursos à estrutura psicótica, devido à impossibilidade de o sujeito ocupar o lugar de agente do discurso. Por fim, a partir da indagação relativa ao laço transferencial na psicose, são desdobradas as conseqüências da formulação da psicose como fora-do-discurso para o tratamento analítico. / The research investigates changes in psychoanalytic reading of the speech in the psychosis. The research starts from the analysis performed by Schreber's biography written by Freud, going through Lacan's admission on the term "discourse" for psychosis, until the Lacan's reference in "L'etourdit" to "out-of-speech‖ of psychosis. In the formulation of hypotheses about what it means and what implies such mention, there is no consensus among authors who have dedicated themselves to the theme. In order to investigate the relevance of understanding the "out-of-speech" as out of the four discourses, the research was built on a topological approach and from the psychoanalytic method of investigation. Initially, the idea of "outside" is questioned as externality, since the opposition inside-out does not imply topological changes. From the diagrams L and Z are addressed the consequences of psychosis in the subject to establish a direct relationship with the similar, without Symbolic mediation of the Other, in order to remain within the mirroring rivalry. The study also refers to changes that the out-of-speech of psychosis implies in the sustaining of the field of reality. From the Graph of Desire is triggered a impasse: to include the desire in relation to the other imply the relationship between the elements of the second floor of the graph. In psychosis, the speech is broken when it reaches the place of the code, which prevents the passage to the upper floor. We conclude that the out-of-speech of psychosis refers to the impossibility of application of mathema of four speeches to the psychotic structure, due to the inability of the subject to take the place of agent of discourse. Finally, from the inquiry on the bond transferential in psychosis are unfolded the consequences of the formulation of psychosis as out-of-speech for the analytical treatment.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Ao longo desta tese, investiga-se a relação do sujeito com o corpo, em especial na clínica da psicose que, em decorrência do mecanismo da foraclusão que marca essa estrutura, não é regido por uma norma fálica, sendo problemática a construção da ficção de um corpo próprio. Examina-se a hipótese de que as práticas corporais, na psicose, são tentativas do sujeito de inscrever um corpo, correlativas às tentativas de estabilização. Para isso, se percorrem as concepções de corpo, bem como o funcionamento da estrutura da psicose na obra de Sigmund Freud e Jacques Lacan. As práticas corporais como tentativas de fazer marcas se diferenciam quanto à sua complexidade, desde os cortes à criação artística, mas têm em comum a urgência de uma escrita pulsional, que não cessa de não se escrever. Verifica-se que o sinthoma é a forma princeps de suplência simbólica, que por meio da arte, poderá dar um suporte simbólico ao corpo. A perspectiva oferecida pela concepção de sinthoma transforma o psicótico em um artesão, que, por meio de um artifício poderá inventar aquilo que fará uma estabilização. Através do conceito de corpo dançante de Didier-Weill, analisa-se o caso do bailarino Nijinsky para que se discuta o possível alcance da criação artística para a psicose. Conclui-se que a criação artística poderá ser uma saída de mestre, onde o psicótico poderá fazer mestria de sua arte e, juntamente com ela, inventar uma nomeação para si, assim como um lugar no discurso que poderá fazer laço social. Assim, o trabalho permanente encontrado na psicose constitui-se em uma possibilidade de entrada do discurso analítico. Se há um trabalho do lado do analista com relação à psicose, é no acolhimento dessas tentativas de inscrição, como escritas da psicose. / Throughout this thesis we investigate the relation of the subject to the body, especially in the clinic of psychosis. As a result of the mechanism of forclusion which marks that structure, the body is not ruled by a phallic norm, being problematic then the construction of the fiction of a body of ones own. We examine the hypothesis that the body practices in psychosis are attempts of the subject to inscribe a body, correlated to the attempts of stabilization. For that purpose we consider the conceptions of body, as well as the functioning of the structure of psychosis, in the works of Sigmund Freud and Jacques Lacan. The body practices as attempts to make marks differ as to their complexity, from cuts to artistic creation, but they have in common the urgency of a pulsional writing that does not cease to not writing. We verify that the sinthoma is the princeps form of symbolic suppliance that, by means of art, may provide a symbolic support to the body. The perspective offered by the conception of sinthoma turns the psychotic into an artisan who by means of an artifice may invent that which will produce a stabilization. We analyse then the case of the ballet dancer Nijinsky having Didier-Weills concept of dancing body in mind to discuss the possibilities of artistic creation to psychosis. We conclude that artistic creation can be a masterly solution, the psychotic becoming skilled in her/his art and, together with it, inventing herself/himself a naming as well as a place in the discourse which may provide social connection. Thus, the permanent work found in psychosis constitutes itself in a possibility of the entering of the analytic discourse. If there is a work on the part of the analyst as it concerns to psychosis, it is in the acceptance of these attempts of inscriptions as writings of psychosis.

This thesis is comprised of three papers. Paper 1 presents a systematic review on the evidence for the relationship between appraisals of auditory verbal hallucinations and voice-related distress in psychosis. A literature search was conducted using the following electronic databases: Web of Science, PsycINFO, Embase and Pubmed. Twenty-four studies were identified that satisfied inclusion criteria for the review. Several types of appraisals were found to be associated with distress in voice-hearers: malevolence, control, power, origin of voices and benevolence beliefs. Evidence for an association was particularly strong for malevolence and control appraisals, indicating that these may be important to target in interventions. Overall findings generally supported that modification of voice appraisals, particularly malevolence, power and control appraisals, in cognitive therapy is associated with a reduction in voice-related distress. Paper 2 presents an experimental study which explored whether people who are exposed to stressful material are more likely to report hearing voices when they are not present (i.e. false alarms). Factors that may predict or moderate voice-hearing were also explored. A non-clinical sample (N = 130) completed measures of trauma history, hallucination proneness, dissociation, affect and attachment styles, before being allocated to view pictures depicting stressful interpersonal scenarios or pictures with neutral interpersonal scenarios. Participants then completed a voice detection task. False alarms were recorded as a proxy measure of voice-hearing. Participants in the stressful group reported significantly higher levels of stress than in the neutral group. No differences were found in false alarms. Physical abuse history and depersonalisation significantly correlated with false alarms. This study indicates that people with physical abuse history and dissociative tendencies may be more vulnerable to hearing voices; clinically, these factors should therefore be assessed. However, findings of this study should be interpreted tentatively due to lack of diversity within the sample. Paper 3 is a critical reflection of the systematic review, the empirical paper and the research process as a whole. Strengths and limitations of the presented research are discussed as well as directions for future research.

Introduction: Poor insight is included as a risk factor for violence in risk assessment tools such as the Historical Clinical Risk-Management-20 version 3 (HCR-20v3) yet there is a lack of consensus around the relationship between poor insight and violence in individuals with psychosis. A systematic literature review was therefore carried out to clarify this relationship. Relatedly, a research project aimed to outline the predictive validity of the HCR-20v3 total and sub-scale scores to violence in forensic inpatients. A secondary aim was to understand the predictive ability of 2 dynamic risk factors within the HCR-20v3 clinical sub-scale; insight and positive symptoms, alongside age and history of violence in relation to violence in psychosis. Method: A systematic search of studies investigating insight and violence in patients with psychosis, published between 1980 and 2016 was carried out on relevant databases.17 articles from combined search results of 5694, met the inclusion criteria. These were selected for full-text review and quality grading which was subject to inter-rater reliability. In the research project, the predictive validity of the HCR-20v3 to violence was assessed in N=167 forensic inpatients. A sub-sample of N=135 was then used to investigate insight, positive symptoms, age and history of violence in relation to violence. Data was extracted from case files, with the exception of violence data which was collected prospectively from date of HCR-20v3 publication via DATIX. Results: The systematic review found 8 studies in support of a positive relationship between poor insight and violence, whilst 9 studies did not support this relationship. The majority of better quality studies measured the clinical insight dimension which tended to demonstrate a positive relationship between poor insight and violence. Methodological limitations were apparent across studies. The research project found HCR-20v3 total and clinical and risk-management sub-scale scores to predict violence. The clinical sub-scale was the strongest predictor of violence and physical violence specifically. Sub-sample analysis found positive symptoms and history of violence to significantly predict violence generally whilst only positive symptoms demonstrated prediction of physical violence. Insight and age were not significantly associated with either violence type. Discussion: The systematic review found partial support for a positive relationship between poor insight and violence in psychosis. Future good quality research is required to develop a fuller understanding of this issue. Research project results support the use of the HCR-20v3 in the risk assessment and management of forensic inpatients. They reinforce the usefulness of dynamic risk factors within the clinical sub-scale in particular. In line with the majority of studies within the systematic review however, a relationship between insight and violence in a sub-sample of patients with psychosis was not found. Recommendations are made for the regular re-assessment of dynamic risk factors within the HCR-20v3 clinical sub-scale in order to support patients to reduce their level of risk, with the caveat that future research is still required to support a relationship between insight and violence in this patient group.

A pesquisa investiga transformações na leitura psicanalítica do discurso na psicose. Parte da análise realizada por Freud da biografia de Schreber, passando pela admissão por Lacan do termo ―discurso‖ para a psicose, até a referência de Lacan em “O aturdito” ao ―fora-do-discurso da psicose‖. Na formulação de hipóteses acerca do que significa e no que implica tal menção de Lacan não há consenso entre autores que se dedicaram ao tema. Com o propósito de indagar a pertinência de entender o ―fora-do-discurso‖ como fora dos quatro discursos, a pesquisa foi construída com base em uma abordagem topológica e a partir do método psicanalítico de investigação. Inicialmente, é problematizada a idéia do ―fora‖ enquanto exterioridade, posto que a oposição dentro-fora não implica alterações topológicas. A partir dos Esquemas L e Z são abordadas as conseqüências de na psicose o sujeito estabelecer uma relação direta com o semelhante, sem mediação Simbólica do Outro, de modo a permanecer no âmbito da rivalidade especular. A pesquisa faz referência, ainda, às alterações que o fora-do-discurso implica na sustentação do campo da realidade na psicose. A partir do Grafo do Desejo, é deflagrado o impasse de que incluir o desejo na relação com o outro implica a articulação entre os elementos do segundo andar do grafo. Na psicose, o discurso se rompe quando atinge o lugar do código, o que impede a passagem para o andar superior. Conclui-se que o fora-do-discurso da psicose faz referência à inviabilidade de aplicação do matema dos quatro discursos à estrutura psicótica, devido à impossibilidade de o sujeito ocupar o lugar de agente do discurso. Por fim, a partir da indagação relativa ao laço transferencial na psicose, são desdobradas as conseqüências da formulação da psicose como fora-do-discurso para o tratamento analítico. / The research investigates changes in psychoanalytic reading of the speech in the psychosis. The research starts from the analysis performed by Schreber's biography written by Freud, going through Lacan's admission on the term "discourse" for psychosis, until the Lacan's reference in "L'etourdit" to "out-of-speech‖ of psychosis. In the formulation of hypotheses about what it means and what implies such mention, there is no consensus among authors who have dedicated themselves to the theme. In order to investigate the relevance of understanding the "out-of-speech" as out of the four discourses, the research was built on a topological approach and from the psychoanalytic method of investigation. Initially, the idea of "outside" is questioned as externality, since the opposition inside-out does not imply topological changes. From the diagrams L and Z are addressed the consequences of psychosis in the subject to establish a direct relationship with the similar, without Symbolic mediation of the Other, in order to remain within the mirroring rivalry. The study also refers to changes that the out-of-speech of psychosis implies in the sustaining of the field of reality. From the Graph of Desire is triggered a impasse: to include the desire in relation to the other imply the relationship between the elements of the second floor of the graph. In psychosis, the speech is broken when it reaches the place of the code, which prevents the passage to the upper floor. We conclude that the out-of-speech of psychosis refers to the impossibility of application of mathema of four speeches to the psychotic structure, due to the inability of the subject to take the place of agent of discourse. Finally, from the inquiry on the bond transferential in psychosis are unfolded the consequences of the formulation of psychosis as out-of-speech for the analytical treatment.

A pesquisa investiga transformações na leitura psicanalítica do discurso na psicose. Parte da análise realizada por Freud da biografia de Schreber, passando pela admissão por Lacan do termo ―discurso‖ para a psicose, até a referência de Lacan em “O aturdito” ao ―fora-do-discurso da psicose‖. Na formulação de hipóteses acerca do que significa e no que implica tal menção de Lacan não há consenso entre autores que se dedicaram ao tema. Com o propósito de indagar a pertinência de entender o ―fora-do-discurso‖ como fora dos quatro discursos, a pesquisa foi construída com base em uma abordagem topológica e a partir do método psicanalítico de investigação. Inicialmente, é problematizada a idéia do ―fora‖ enquanto exterioridade, posto que a oposição dentro-fora não implica alterações topológicas. A partir dos Esquemas L e Z são abordadas as conseqüências de na psicose o sujeito estabelecer uma relação direta com o semelhante, sem mediação Simbólica do Outro, de modo a permanecer no âmbito da rivalidade especular. A pesquisa faz referência, ainda, às alterações que o fora-do-discurso implica na sustentação do campo da realidade na psicose. A partir do Grafo do Desejo, é deflagrado o impasse de que incluir o desejo na relação com o outro implica a articulação entre os elementos do segundo andar do grafo. Na psicose, o discurso se rompe quando atinge o lugar do código, o que impede a passagem para o andar superior. Conclui-se que o fora-do-discurso da psicose faz referência à inviabilidade de aplicação do matema dos quatro discursos à estrutura psicótica, devido à impossibilidade de o sujeito ocupar o lugar de agente do discurso. Por fim, a partir da indagação relativa ao laço transferencial na psicose, são desdobradas as conseqüências da formulação da psicose como fora-do-discurso para o tratamento analítico. / The research investigates changes in psychoanalytic reading of the speech in the psychosis. The research starts from the analysis performed by Schreber's biography written by Freud, going through Lacan's admission on the term "discourse" for psychosis, until the Lacan's reference in "L'etourdit" to "out-of-speech‖ of psychosis. In the formulation of hypotheses about what it means and what implies such mention, there is no consensus among authors who have dedicated themselves to the theme. In order to investigate the relevance of understanding the "out-of-speech" as out of the four discourses, the research was built on a topological approach and from the psychoanalytic method of investigation. Initially, the idea of "outside" is questioned as externality, since the opposition inside-out does not imply topological changes. From the diagrams L and Z are addressed the consequences of psychosis in the subject to establish a direct relationship with the similar, without Symbolic mediation of the Other, in order to remain within the mirroring rivalry. The study also refers to changes that the out-of-speech of psychosis implies in the sustaining of the field of reality. From the Graph of Desire is triggered a impasse: to include the desire in relation to the other imply the relationship between the elements of the second floor of the graph. In psychosis, the speech is broken when it reaches the place of the code, which prevents the passage to the upper floor. We conclude that the out-of-speech of psychosis refers to the impossibility of application of mathema of four speeches to the psychotic structure, due to the inability of the subject to take the place of agent of discourse. Finally, from the inquiry on the bond transferential in psychosis are unfolded the consequences of the formulation of psychosis as out-of-speech for the analytical treatment.

Hallucinations are often considered a sign of psychotic illness, but are also common in other diagnostic groups and individuals without mental health problems. This thesis uses Perceptual Control Theory (PCT), a cybernetic model which explains behaviour and cognition in terms of control processes regulating ongoing perception according to internally represented goals, as a theoretical framework to understand hallucinations. First, a theoretical/conceptual paper (Paper 1) examines how PCT provides an integrated account of (i) the mechanisms responsible for the formation of hallucinations, (ii) their phenomenological heterogeneity, (iii) the interaction between these mechanisms and environmental factors that might contribute to the formation of hallucinations, and (iv) the processes leading to different affective reactions to hallucinatory experiences (e.g. distress). The main implications of this model are discussed in the context of pertinent theoretical and empirical literature, and relevant clinical and research implications are considered. Second, this thesis includes an empirical investigation (Paper 2) examining two PCT-informed hypotheses in a cross-section of 22 clinical and 18 non-clinical individuals with auditory verbal hallucinations (“hearing voices”), namely (i) that the content of voices will be thematically linked to the participants’ personal goals, and (ii) that affective reactions to voices will depend on the extent to which voices facilitate and/or interfere with important personal goals. The analysis revealed that 82.5% of participants reported voices that thematically matched at least one of their reported goals. As predicted, affective reactions to voices were strongly associated with measures of interference and facilitation of goals, even when controlling for important covariates (e.g. participants’ history of mental health difficulties; voices’ content, frequency and duration).Finally, a critical evaluation is provided (Paper 3), where the methodological strengths and limitations of the work presented in the present thesis are discussed with the aim to reflect on the research process, and inform future investigations into the topics considered in this thesis.

Failure to acknowledge their mental illness occurs in approximately half of all psychotic patients. Interest has been recently been refocused on insight (i.e., awareness of mental illness), and its associations with treatment compliance and better prognosis. Researchers have called into question the traditional factor structure of insight, instead viewing and defining it as a multidimensional and continuous construct. While factor analytic research has suggested that insight is an independent feature of psychotic disorders rather than a secondary manifestation of psychotic symptoms, several factor analytic studies have identified only one higher-order factor. Furthermore, a significant amount of the research literature has assessed insight or analyzed its relationships using only a single insight score. The current study evaluated the structural model of insight and assessed the associations between the different proposed dimensions of insight and psychotic symptoms. One hundred and six participants recruited from both inpatient and outpatient settings with a diagnosis of schizophrenia, schizoaffective disorder, psychotic disorder NOS, or bipolar disorder with psychotic features were rated on David's Schedule for Assessing Insight-Expanded Version (SAI-E), Birchwood's Insight Scale (IS), and the Brief Psychiatric Rating Scale (BPRS) or the Positive and Negative Syndrome Scale (PANSS). Structural equation modeling (SEM) was utilized to provide stringent, confirmatory statistical tests of the hypothetical factor models while accounting for measurement error. Principal findings from the current study were that the three factor model of insight was supported and that the insight factors were meaningfully correlated to the two symptom factors. Moreover, the three factor insight model provided significantly better fit than a single factor model of insight.

Alzheimer’s disease (AD) is a progressive neurodegenerative disease that results in severe cognitive impairment and eventually is fatal. In addition to memory loss, AD patients also present with psychosis and emotional psychological symptoms. Neuropathologically, the disease is characterized by aggregation of amyloid-beta protein that accumulates into plaques and hyperphosporylation of tau protein which results in neurofibrillary tangles. Further, neuropathology in AD results in broad neuroinflammation. In recent years, there has been a research focus on novel treatments for AD because current medications have not been particularly effective and have significant side effects. In the current study, we analyzed whether PD340, a novel anti-inflammatory which inhibits the pro-inflammatory cytokine tumor necrosis factor-alpha (TNFα) would be effective to alleviate behavioral impairments in the 3xTg mouse model of AD. The 3xTg model is unique in comparison to previous rodent models of AD because it express three dementia-related transgenes and demonstrates a clear age-dependent onset of AD pathology. Mice were bred in our animal colony. Beginning at four months of age, a specialized diet was presented to the animals that contained 0, 3, 10, or 25 mg/kg of PD340. At approximately 6 months of age, which is before any neuropathology presents in this model, animals were behaviorally tested on three different tasks: The Barnes maze, which is a test of spatial memory; Prepulse inhibition (PPI), which is a measure of sensorimotor gating and is related to psychosis and cognition; and the elevated T-maze, which is a test of anxiety. Both males and females were tested. Results from Barnes maze testing revealed that females, but not males, administered 25 mg/kg of PD340 demonstrated a significant improvement in spatial bias towards the goal during acquisition. Regarding PPI, there were no sex differences, but groups receiving the 3 or 25 mg/kg dose of PD340 demonstrated significantly improved performance over animals administered the 0 mg/kg dose of PD340 dependent upon the auditory decibel level of the stimulus presented. On the elevated T-maze, there were no significant group differences, demonstrating anxiety is not present at 6 months of age in this model. Behavioral tests will also be performed at 12 and 15 months of age in these animals. However, at 6 months of age, it appears that PD340 is effective in alleviating behavioral deficits related to cognitive impairment in a mouse model of AD. Future work will analyze neuropathology in the hippocampus and prefrontal cortex, two brain areas that degenerate in AD and are important in cognitive function.