Objectives: Previous research has identified negative staff attitudes towards patients who self-harm, as well as stigma towards mental health problems in general hospital settings. This study extended this existing research to patients who present to general hospital settings with self-harm by measuring their perceptions of stigma in comparison with a control group of other hospital patients. The study also examined whether perceived stigma was related to aspects of current psychological distress. Method: Ten patients who were admitted to hospital following an episode of self-harm and ten hospital control patients completed a demographic questionnaire, the SCL-90-R measure of current psychological distress and a purpose-designed measure of perceived stigma. Results: Mann-Whitney U-tests revealed significant differences on SCL-90-R Interpersonal Sensitivity (U=17.50, p=0.011), Paranoid Ideation (U=21.00, p=0.029) and Psychoticism (U=23.00, p=0.043), together with marginally significant differences on Depression (U=24.50, p=0.052) and Hostility (U=24.50, p=0.052), between the two groups. A significant difference in perceived stigma scores (U=16.00, p=0.009) was also identified. One-tailed Spearman’s correlations highlighted positive associations between perceived stigma and SCL-90-R Interpersonal Sensitivity (ρ=0.685, p=0.014) and Depression (ρ=0.723, p=0.009) in the self-harm group, and SCL-90-R Depression (ρ=0.596, p=0.035) and Phobic Anxiety (ρ=0.595, p=0.035) in the control group. Conclusions: The results suggested that patients who self-harm perceive higher levels of stigma in general hospital settings compared to patients presenting with other types of injury. These differences appeared to relate to aspects of current psychological distress. Further research employing larger samples would help clarify this association.

The focus of this thesis was the disease senile dementia and in particular the impact that this condition has on the family carers of elderly people with dementia who live in the community. The study has two main aims. Primarily it set out to identify the stressful situations which carers were facing on a daily basis and to establish how they were coping with them. It also took this issue of coping further and attempted to quantify and measure the specific techniques used in the course of their general caring duties. Secondly, the study explored the concept of expressed emotion (EE) in this group of carers and linked this to coping. It was thought that those carers who were less able to cope with the situation may also have had a high level of EE. The EE concept has been shown to be a useful indicator of relapse in schizophrenia and it was thought that it may also have had predictive value in the outcome of care for the dementing elderly and their carers. The data was collected from 100 semi-structured interviews with carers of elderly people with dementia. The longitudinal aspect of this study allowed outcome data to be looked at one year after the initial interview. The results showed that carers identified stressful situations which were characterised by, inappropriate behaviour as a consequence of disorientation; refusal to co-operate with caregiving activities; incorrect interpretation of people or events; and provocative or hurtful comments. The carers dealt with these situations by, verbal action; practical action or withdrawal, which could be either physical or psychological. Running parallel to this was very often a lot of anger and frustration although this seemed to change over time.

Background: Allogeneic Haematopoietic stem cell transplant (HSCT) is a potentially curative treatment for haematological cancers however it is a particularly aggressive treatment that can impact individuals’ quality of life (QOL) in multiple ways. Due to the toxicity of the transplant, adults aged over fifty years have only recently become eligible for this treatment following the development of a reduced intensity regimen. As a result, little is known regarding the experience of QOL among recipients aged over fifty years. QOL information is an essential part of assessing the success of medical treatments and can help prepare recipients for any ways in which their lives and those of their families may be impacted post-transplant. Method Potential participants were recruited through the Beatson West of Scotland Cancer Centre (BWSCC) and a purposive sample of eight participants volunteered to take part in the study. A qualitative approach, Interpretative Phenomenological Analysis was used to explore the experience of QOL among recipients. Results Four superordinate themes emerged from the data; ‘Shifting sense of self and others’, ‘Adaptation and managing the impact’, ‘A new perspective on life and living’, and ‘Changing over time’. The findings helped highlight the challenges and gains experienced by HSCT recipients as well as the process of adaptation and adjustment which mediates the impact of HSCT on QOL. Conclusions The participants in this study demonstrated that there are a number of commonalities between younger and older recipients in terms of post transplant QOL when compared to the literature on younger recipients to date. However, increased age and stage of life was also shown to have a unique impact on the subjective experience of QOL after transplant. Increased age continues to represent a significant risk factor in terms of QOL and survival post transplant. However, the findings from this study suggest that this small sample of recipients is adjusting well to the challenges of HSCT. Further research is required in this area. Limitations of this study are discussed.

Background: The RSVP (Risk of Sexual Violence Protocol; Hart et al, 2003) is a structured professional judgement tool for assessing risk of sexual violence. Despite being widely used in forensic mental health settings, the reliability and validity of the RSVP has not been adequately established. There is an urgent need to investigate the inter-rater reliability of the tool in a multi-disciplinary clinical context. Method: Clinicians (n=28) with varying professions, levels of experience and training, used the RSVP to evaluate six case vignettes with varying offence characteristics, clinical-complexity and risk. ICC (Intra-class Correlation Coefficient) and percentage agreement statistics were used to evaluate inter-rater reliability of RSVP items, domains and steps. Items included additional forced-choice judgements relating to Scenario Planning and Case Management steps. Clinician responses were also compared to ‘gold-standard’ judgements developed by experts in the field of forensic risk assessment. Results: Inter-rater reliability was ‘fair’ overall with individual items ranging from ‘poor’ to ‘excellent’. Importantly, there was a ‘good’ level of inter-rater reliability on Summary Judgements and Supervision Recommendations. Inter-rater reliability was highest when used by professionals who were highly trained in forensic risk-assessment. On average, professionals with lower levels of specialist training agreed less with their colleagues and experts, and provided higher estimations of sexual violence risk. Lower levels of agreement were found in cases with moderate levels of complexity and risk. Conclusions: The RSVP can be used to attain adequate levels of inter-rater reliability. However this is dependant on the training and expertise of professionals who use the tool. Methodological strengths and limitations are considered, followed by a discussion of implications for training, practice and future research.

Background: Diabetes mellitus type 1 (DM1) is the most common form of diabetes in children. Strict glycaemic control can increase the risk of hypoglycaemia, which is characterised by a number of unpleasant and often frightening symptoms. Fear of Hypoglycaemia (FOH) is thought to contribute to psychological distress and diabetes management, however little is known about parents’ experiences of FOH. The aim of this study was to explore parents’ experience of FOH and its impact on their engagement with intensive insulin therapy. Methods: This qualitative study was conducted and analysed utilising an Interpretative Phenomenological Analysis (IPA) approach. Purposive, volunteer sampling was used. Semi-structured interviews were conducted with 4 parents in the hospital setting. These were transcribed and analysed. Results: The results of this study suggest that FOH is a very salient topic for parents of children with DM1. Four super-ordinate themes emerged: parents’ internal experience, coping, family unit and school. FOH appears to be characterised by a range of emotional and psychological symptoms. Parents attempt to manage the condition and their experiences through a combination of emotion-focused and problem-focused coping strategies. The systemic challenges of diabetes and FOH were highlighted by parents’ worries about their child’s safety when under the care of others and the burden that this places on them.

Milner and Goodale (1995, 2006) propose a model of vision that makes a distinction between ‘vision for perception’ and ‘vision for action’. Regarding hemispatial neglect, they, somewhat contentiously, hypothesize that this disorder is better explained by damage to a high-level representational structure that receives input from the ventral visual stream, but not from the dorsal-stream. Consequently, they postulate that neglect patients should code spatial parameters for action veridically. Another strong claim of the model is that the dorsal stream’s control of action is designed for dealing with target stimuli in the ‘here and now’, yet when time is allowed to pass and a reaction has to be made on the basis of a visual memory, the ventral stream is required for successful performance. One prediction from this is that neglect patients should be able to perform immediate actions, but should present specific impairments when the action is delayed. In Part I of this thesis the pattern of spared and impaired visuomotor abilities in patients with neglect, as specifically predicted by the perception and action model (Milner & Goodale, 1995, 2006), was investigated. In Chapter 1, the performance of patients with and without neglect after right hemisphere stroke was compared with that of age-matched controls. Participants were asked to point either directly towards targets or halfway between two stimuli (gap bisection), both with and without visual feedback during movement. No neglect-specific impairment was found in timing, accuracy or reach trajectory measures in either pointing or gap bisection. In Chapter 2, I tested whether neglect patients would be unimpaired in immediate pointing, yet show inaccurate pointing in a condition where a delay is interposed between the presentation of the stimulus and the response signal. Similarly to Chapter 1, it was found that neglect patients showed no accuracy impairments when asked to perform an immediate action. Conversely, when pointing towards remembered leftward locations they presented specific accuracy deficits that correlated with neglect severity. Moreover, an initial voxel-based lesion-symptom analysis further revealed that these deficits were associated with damage to occipito-temporal areas which were also mostly damaged in the neglect group. Furthermore, training of grasping the centre of rods (visuomotor feedback training) has been shown to improve neglect (Robertson, Nico & Hood, 1997; Harvey et al., 2003). It is postulated that by using the spared visuomotor abilities in these patients it is possible to ‘bootstrap’ their perceptual deficits through some ‘dorsal-to-ventral recalibration’. Hence, in Part II the immediate and long-term effects of visuomotor feedback training were explored on neglect conventional measures, as well as in daily life tasks. I found that this technique improves neglect symptoms and crucially that these improvements were long lasting, as they were present even after 4-months post-training. Importantly, I also show that the training effects generalize to the patient’s daily lives at follow-up. These findings are very encouraging for the rehabilitation of neglect as this condition has been shown to be the best single predictor of poor recovery after stroke and very difficult to treat.

This thesis reports six studies adopting a self-determination theory (SDT; Deci & Ryan, 1985) approach to understanding motivation and behaviour in health and social contexts. The research focuses on the internalisation and integration of goals and motives extrinsic to the individual and the effects of internalisation on psychological and behavioural outcomes. Two studies also explore the role of social agents in facilitating internalisation through provision of autonomy support. The research addresses gaps in the SDT literature and contributes to the advancement of theory and practice. A meta-analysis of effects of autonomy support on health-related psychological and behavioural outcomes (Chapter 2), based on the methods of Hunter and Schmidt (1994), indicated the significance and consistency of adaptive effects of autonomy support across the literature. A path analysis was also used to test a modified representation of Williams et al.’s (2006) SDT process model of health-related behaviour. Results supported the motivational sequence postulated within the model, as the effect of autonomy support on behaviour was mediated by need satisfaction and autonomous motivation. The studies reported in Chapters 3 and 4 make a novel contribution to the SDT health literature by employing measures of chronically-accessible physical activity outcomes and motives to represent spontaneous motivational influences on behaviour. The results presented in Chapter 3 indicated that chronically-accessible appearance-related outcomes are associated with controlling forms of motivation, while the findings reported in Chapter 4 showed that planning-based strategies to maintain physical activity under situations of success and failure in goal striving are differentially effective for chronically autonomous and controlled individuals. These studies also offer guidance for health practitioners in promoting physical activity, by highlighting the potentially maladaptive effects of appearance-related goals and the importance of tailoring planning-based interventions to individuals’ chronically-accessible motives. The study reported in Chapter 5 substantiated a core theoretical assumption of SDT by providing empirical support for people’s inclination to distinguish between intrinsic and extrinsic goals. Adopting methods from the literature on memory and attitudes, cluster analysis was performed on participants’ self-generated and recalled physical activity goal data to determine the presence of clustering by goal type. Although findings supported individuals’ ability to distinguish intrinsic and extrinsic goals at some level of representation, participants were not able to reliably code their goals at an explicit level. It was therefore concluded that differentiation between goal types may not occur consciously. The scale-development study in Chapter 6 also supported a key tenet of SDT in establishing construct, nomological, and predictive validity of a scale measuring integrated regulation for physical activity. The factorial validity of the scale, developed through an extensive literature search, expert ratings, and confirmatory factor analyses, was supported in both a high and a lower-active sample. Consistent with predictions, latent means analysis indicated the high active sample reported significantly greater integrated regulation. The scale provides a valid and reliable tool that may be used to evaluate the process of integration following autonomy-supportive interventions in health-related contexts. Finally, Chapter 7 details the development of a brief autonomy-supportive intervention and observational checklist system for ensuring fidelity to protocol that can be modified for use in a number of contexts requiring behaviour change. The intervention was implemented in a higher education setting over the duration of a single course module and significantly increased two autonomy-supportive teaching behaviours in postgraduate tutors. However, the intervention did not significantly increase the perceived autonomy support, self-determination, or coursework grades of the experimental tutors’ students relative to the control condition, although there was a trend towards a trend towards an interaction between time and experimental condition for level of self-determination towards studying. While students in the experimental group reported an increase in self-determination over time, students within the control condition reported a decrease in self-determination between the first and second, and first and third waves of data collection. The thesis concludes with a general discussion of findings and directions for future research and practice.

The work within the thesis aimed to integrate concepts from three psychological frameworks, including self-determination theory (SDT), the theory of planned behaviour (TPB), and the hierarchical model of motivation (HMM), into a model to understand the processes that underpin motivation and intention toward health and safety behaviours. The first tenet of the model (derived from SDT and HMM), namely the trans-contextual effect of motivation, hypothesised that self-determined motivation for a given activity related to self-determined motivation for undertaking health-promoting behaviour associated with the activity. The second tenet of the model (derived from the strength, limitation, and theoretical assumptions of SDT and the TPB) speculates that the effects of self-determined motivation for health and safety behaviour on intention and behaviour were mediated by social cognitive variables. A total of eight studies were employed to test the two tenets of the integrated model across various health contexts (i.e., sport injury rehabilitation and prevention (Study 1 to 5)), occupational injury rehabilitation and prevention (Study 6 and 7), and myopia prevention (Study 8), and these studies are presented in five related research chapters (Chapters 2 to 6) in this thesis. The results provided preliminary evidence in support of both tenets of the integrated model, in which motivation from a general life domain is transferred to motivation, and antecedent social cognitive variables, for behaviour in a health and safety domain. The final chapter (Chapter 7) of the thesis summarises the findings of the eight studies and offers explanations and interpretations of the overall pattern of results. Conclusions were then drawn with respect to the theoretical and practical implications of the findings. Consideration was also given to the methodological limitations of the thesis and the scope for further studies to improve the predictive power, utility, measurement reliability, and evidence base for the model.

Stimulus control (SC) is a core component of cognitive behavioural therapy (CBT) for insomnia and is the single intervention for which there is most empirical evidence. Nonetheless, little is known about whether all of the elements within SC are critical to sleep improvement. This study, therefore, investigated the impact on sleep of the Quarter of an Hour Rule (QHR) a single, situational element considered central to SC for insomnia. The mechanisms of effect of SC intervention remain also unclear. An associated aim of the present study, therefore, was to contrast two forms of administration of the QHR to test aspects of the learning theory presumed to underlie the SC model. In addition adherence to the behavioural intervention was investigated and the possibility of using actigraphy to measure adherence objectively was explored. Prior to the randomised controlled trial (primary study), two preliminary studies were conducted. The first preliminary study aimed at determining the optimal cut-off to represent normalcy in sleep onset latency (SOL). The results indicated it to be fifteen minutes and, therefore, participants in studies two and three were asked to apply the QHR if they were not asleep within a quarter of an hour. Study two comprised three single cases and tested the feasibility of the QHR as a standalone therapy for insomnia. Visual inspection of the data and interrupted time series analyses evidenced SOL, wake after sleep onset (WASO) and sleep efficiency (S.E.) improvements in two out of three participants. Their Pittsburgh Sleep Quality Index (PSQI) score at the end of the intervention was reduced by 50% compared to baseline. The participant, whose sleep was not improved, following the intervention, had not applied the QHR. The results of this exploratory, single case, study warranted further investigation of the QHR. In study three forty-one GP and self referred volunteers, aged 18-72 years, with SOL and/or WASO complaints, formed 3 randomised groups: QHRin bed, QHRout of bed and control. Both QHR conditions required to ‘read if not asleep within a quarter of an hour’, with groups differing only with the location (in bed versus out of bed) where to apply the QHR. Sleep diary pre-treatment (two weeks) and post-treatment (three weeks), home polysomnography (PSG) (two nights pre-, two post-treatment) and sleep related questionnaire (pre and post) data were collected. Adherence with the QHR was measured objectively (actigraphy + light monitoring) and subjectively (adherence diary). Following QHR treatments, statistically significant reductions in SOL (QHRout) and WASO (QHRin and QHRout),an increase in S.E. (QHRin and QHRout) and a decrease in PSQI score (QHRin and QHRout) were found. Trends also indicated increased total sleep time (TST). Clinically significant improvements (SOL and WASO ≤ 31 minutes or reduced by 50%, PSQI ≤5 or reduced by 50%) were obtained in 33-57% of active groups participants.

Cardiovascular disease is the leading cause of death in the western world. As accumulating evidence emerges that risk of developing cardiovascular disease increases with higher levels of blood pressure, the early detection of those with hypertension becomes an increasing priority. Blood pressure is influenced by numerous factors, including the properties of the large arteries. This thesis sought to examine the effects of acute physiological and psychological stress on indices of arterial function. During likely elevation of sympathetic outflow following isometric exercise, indices of conduit and central artery function indicated stiffening in excess of 10%. During and following acute mental stress the large arteries exhibited a similar stiffening response, despite decreased resistance in the peripheral vasculature. These decreases in arterial compliance resulted in increased amplitude and premature return of arterial pressure waves and lead to a 15% augmentation in central systolic pressure during both forms of stress. These findings may have important clinical implications as increased central pressure elevates left ventricular workload. During graded dynamic exercise, reduced arterial compliance was shown to have progressive influence on the interaction between the heart and the vasculature. These studies provide valuable insight into the cardiovascular response to physiological and environmental stress.