This thesis is an exploration of some of the risks associated with Bipolar Disorder and the lived experiences of people with Bipolar Disorder. It begins with a systematic review of the risk factors associated with Substance Use Disorder in adolescents with Bipolar Disorder. Eleven research papers, consisting of seven separate research projects were included for review. Support for a number of risk factors being implicated as causing a higher risk for the development of substance use disorder were identified. The majority of these consisted of individual factors such as co morbid mental health issues and exposure to trauma. However, these finding must be considered within the context of the methodological limitations of the current research body. Implications with regards to clinical practice are discussed. The second paper reports on an Interpretative Phenomenological Analysis exploring the experiences of mania in adults with Bipolar Disorder. Six participants were recruited to this study and interviewed using semi-structured interviews. Three super ordinate themes emerged from the data; ‘if you could bottle it and sell it’, ‘the darker side of mania’ and ‘Loss - past, present and future’. Participant’s accounts were characterised by recognition of the positive but unsustainable nature of their manic experiences. Participants reflected upon the aftermath of their manic experiences and what it meant to live now as a person who had had this experience. Finally, participants considered the losses they had encountered as a part of their manic experiences, and the existential questions they had been forced to ask about their identities. The clinical implications of the findings and future directions for research are discussed. The final paper is a reflective account of the researcher’s journey through the research process. Particular attention is given to the researcher’s sense of transitioning from trainee to competent researcher.

Kashin-Beck disease is endemic chronic degenerative osteoarthropathy whose main pathological changes occur in the growth plate and articular cartilage of human limbs and joints, where it is manifest as cartilage degeneration and necrosis. The effects of the disease on the growth plate therefore alter growth in children and can lead to growth arrest (short stature and limbs) and developmental deformities (crooked joints). In adulthood patients present with pain and deformity commonly affecting the hand, wrist, elbow, knee and ankle with radiological features and joint pattern involvement similar to those seen in rheumatoid arthritis. Past and current research suggests that Kashin-Beck disease, with its endemic geographical distribution in China and Tibet, is due to the combined presence of fungal mycotoxins (found on the stored food ingested by affected populations) and a regional selenium deficiency in the environment providing local food sources. This evidence is supported by the correlation between the geographical occurrence of these 2 factors and the incidence of Kashin-Beck disease. The objective of this study was to develop and in vitro cartilage culture system to mimic the changes seen in Kashin-Beck disease and thus determine the effects different sources of selenium, in the presence or absence of Nivalenol, had on cartilage neograft metabolism. Our hypothesis was that growth and metabolism of cartilage will be affected by exposure to either selenium or the mycotoxin Nivalenol or both in combination and these effects will mimic those found in Kashin-Beck disease. Collectively, the results of this study suggest that Nivalenol is the major contributor to cartilage pathology in this in vitro system that mimics Kashin-Beck disease, and that these deleterious effects are largely independent from selenium supplementation.

The threat to public health from antibiotic resistance has increased, with growing evidence that antibiotic use is a major driver of resistance. This has led to campaigns to reduce prescribing of antibiotics by GPs, particular for respiratory tract infections (RTIs). These are among the most common reasons for prescribing antibiotics in primary care, in spite of the fact that there is evidence that most RTIs recover at a similar rate without antibiotic treatment, rarely resulting in complications if untreated. There are concerns, that a ‘blanket’ reduction in prescribing may occur, with reductions in prescribing that may benefit patients, leading to an increase in complications that can arise from untreated RTIs. The aim of this thesis was to explore the relationships between community antibiotic dispensing, complications from RTIs and resistance. We showed that decreasing rates of antibiotic dispensing in Wales coincided with increases in hospital diagnosed complications such as pneumonia and septicaemia from 1996-2006. At a practice level, there was evidence of a negative association between dispensing and complications. While a positive association was found between lagged dispensing and resistance, no clear pattern was found between change in dispensing and resistance for any of the organism/ antibiotic combinations examined possibly due to a lack of power. At an individual patient level, antibiotics are not justified to reduce the risk of a complication in those diagnosed with an acute RTI or sore throat. However, for patients presenting with a chest infection, the risk of developing a complication is higher and antibiotics appear to reduce the risk of complications; GPs should therefore consider prescribing for these patients. Further research is required to examine different lag periods of dispensing and their association with resistance and also to identify subgroups of patients at high risk of complications to help GPs target their prescribing of antibiotics.

The difficulties faced by individuals attracting a diagnosis of Borderline Personality Disorder (BPD) are multiple and varied. Whilst the psychological difficulties characteristic of this diagnosis have a significant impact on these clients’ everyday lives, they also contend with others’ attitudes and responses to their diagnosis, which has proved both controversial and stigmatising. Chapter one concentrates on the stigma that surrounds the BPD label by presenting a systematic review of the literature relating to professionals’ attitudes and responses to individuals diagnosed with BPD. This highlights the predominantly negative perceptions of this client group, the strength of countertransference experienced by professionals working with this client group, and the ways in which clinicians respond to this. Chapter two concentrates on the perspectives of clients with BPD by reporting an empirical study investigating the lived experiences of parenting for mothers with BPD. The experiences of six mothers are explored using a phenomenological approach and the themes emerging from their interviews are discussed in detail. The findings are considered in relation to the existing literature and the implications in terms of providing support for mothers with BPD are discussed. Chapter three continues the theme of motherhood by presenting a reflective paper focussing on the analysis of parenting–related dreams experienced by the author during the course of the research. The personal and professional implications of the dream analysis and research completion are considered.

Background/Aim Diabetes is a chronic metabolic condition with worldwide prevalence and burden increasing rapidly, particularly in ethnic minority groups (EMGs). Health inequalities and inadequate provision of diabetes care services to EMGs are recognised, primarily because EMGs express a strong cultural element in healthcare and some healthcare professionals lack sufficient cultural competence. The primary aim of this research was therefore to develop an in-depth understanding of cultural barriers within diabetes services and recommend how services can be tailored to meet the needs of EMGs with diabetes in a medium-sized UK ethnically mixed city. Methods Two systematic reviews were completed. Primary data were collected using mixed methods: a General Practice survey, participatory case study and interviews with ethnic minority patients and health workers. These were analysed using descriptive statistics and thematic comparisons. Results The findings showed cultural barriers to the uptake of diabetes services across global multi-ethnic populations and some effective interventions. The first systematic review on cultural barriers in accessing effective diabetes care services, included 22 heterogeneous studies and identified eight cultural barriers, perceived by EMGs as compromising their care. The second review elucidated approaches to overcome or minimise these barriers by investigating the impact of culturally-competent interventions from 11 experimental studies. Using a novel culturally competent assessment tool (CCAT) to assess existing interventions, it was found that any structured intervention, tailored to EMGs by integrating elements of culture, language, religion, and health literacy skills, produced a positive impact on important patient outcomes. In the Population General Practice survey, one in three people with diabetes from the diabetic population compared with one in five staff were from EMGs. Ninety-four per cent of General Practices reported the ethnicity of their populations. Improved number of diabetes annual checks was seen in the majority white British population compared to EMGs. Key cultural barriers included language and strong traditions around food, coupled with less culturally competent providers. Cultural issues were further explored in one participatory research General Practice case study. This practice selected and prioritised the designing of a Diabetes Specialist Multilingual Link Worker (DSMLW) model, aimed at bridging the inequality gaps in diabetes primary care service provision. Conclusions/recommendations This research proposes that future culturally-competent interventions should be structured, including elements of culture, language, religion and health literacy skills, tailored to the individual ethnic minority population. These components should be assessed to ensure they meet the needs of specific EMGs. In the absence of linguistically and/or culturally-competent staff, a DSMLW Service framework may support primary care. Future studies and clinical audits involving EMGs, are warranted.

Eating disorders is considered as a well researched area. Although, an increasing number of mental health clinicians are becoming better equipped in recognising eating disorders in individuals, specialist eating disorder services still underrepresent various groups. This doctoral thesis examines two of those groups specifically, men and ethnic minorities, in particular for the latter, South Asian women and eating disorders. The first paper reviews published research and examines the link between eating disorders in men and gender differences. It specifically focuses on the factors, which are argued to have a causal link to the development and maintenance of eating disorders in men. It further examines the validity and reliability of eating disorder research in this area and explores the implications for clinical practice. The second paper presents an empirical study exploring the development and experiences of eating disorders in South Asian women including a comparative analysis with Caucasian women. The final paper provides a reflective account of my journey in carrying out this research.

Past research has indicated that people diagnosed as being on the autism spectrum have unusual sensory experiences when compared with typically developing individuals (e. g., Tomchek & Dunn, 2007; Watling et al., 2001). However, an examination of the available evidence has revealed that little is known about either the nature or developmental course of these unusual sensory experiences (e. g., Leekam et al., 2007; O'Neill & Jones, 1997). The aim of this project is to investigate the patterns and developmental pathway of these unusual sensory experiences. Chapter I reviews the published literature on the developmental pathway of unusual sensory experiences and highlights a need to identify patterns of sensory processing in people on the autism spectrum. Chapter 2 describes an empirical study that investigates patterns of these unusual sensory experiences. The results support previous research that indicates that children with ASD have co-existing patterns of hypo- and hyper-responsiveness. Chapter 3 presents a reflective account of the research process as a whole.

Hemoglobinopathies are disorders of the protein hemoglobin (Hb), one of the most common inherited disorders, and pose an increasing healthcare problem. Worldwide, approximately 200 million people have hemoglobinopathies (Hartwell et al. 2005), and whilst the majority of them are clinically silent, some are life-threatening. Screening programs for hemoglobinopathies traditionally employ chromatography and electrophoretic techniques, which only provide presumptive identification of clinically important hemoglobin disorders. The definitive characterisation of these disorders requires protein sequence elucidation or DNA analysis. The development of a rapid population screening method for hemoglobinopathies, which could also provide definitive diagnosis of a disorder, is of significant interest to the healthcare profession. Mass spectrometry (MS) is currently used to routinely characterise variants but not as a validated clinical diagnostic tool. The work undertaken addresses the increasing demand for population screening. Different mass spectrometry-based approaches to hemoglobinopathy detection have been developed based on previously described procedures found in literature. The methods, for intact globin chain analysis and targeted variant specific peptide analysis, have been optimised and evaluated using clinical blood samples on a triple quadrupole system. Intact globin chain analysis and targeted tryptic peptide screening methods have been evaluated in a clinical trial analysing 2017 blood samples to identify clinically significant variants routinely screened as a requirement by the NHS Screening programme and to quantify minor globin chains (HbA2 and HbF) suitable for the diagnosis of thalassemic and other disorders. This work was carried out in a three month mirrored testing experiment against existing clinical laboratory methods. The results obtained showed an excellent correlation to values from current clinical methods, as all clinically significant variants were detectable by MS methods. In addition, MS was able to detect Hb variants undetected by electrophoretic or chromatographic methods and highlighted some issues with the current phenotypic methods which can lead to misdiagnosis. A top-down ETD method utilising an iontrap mass spectrometer has been developed and applied to provide fragmentation for positive identification of known hemoglobin variants. This method was evaluated by analysing 1000 samples in a pilot study as a sideproject to the clinical trial. The generation of an automated report with the detection of clinically significant variants and minimal sample preparation are some of the benefits associated with this approach. This method has been shown to meet the majority of requirements for a rapid diagnostic screening method and has the potential to become a validated tool in the clinical laboratory screening in the near future.

This thesis includes an examination of the rehabilitation process of adult male offenders with a mental disorder. More specifically, it examines the effectiveness of treatment, and the community rehabilitation of adult mentally disordered offenders (MDOs). In Chapter 1 a literature review following a systematic approach examined the effectiveness of cognitive-behavioural interventions with adult MDOs in inpatient settings. Results revealed such interventions have the potential to improve: problem solving ability, social-cognitive skills, social adjustment, hostile and aggressive behaviour, and awareness of illness, ultimately bringing about a reduction of antisocial thinking and behaviour. The review findings were considered in relation to study quality and methodological limitations and recommendations for future research were discussed. In Chapter 2, an empirical research study gathered qualitative information of the experiences of adult male MDOs under Section 37/41 of the Mental Health Act (1983) who had been given a conditional discharge into the community. Results offered preliminary indications of influential factors at the individual level for the process of MDOs reintegration into the community. Recommendations for future research were discussed along with the clinical implications of the findings. A case study is presented in Chapter 3, evaluating the effectiveness of a cognitive-behavioural intervention with an adult male offender suffering anxiety and depression serving a sentence at HMP Cardiff. This case study demonstrated the importance of individual assessment and formulation in developing appropriate and effective interventions to meet client needs and highlighted the need to address prisoners’ mental health before they are released into the community. Future directions were considered with regards to working with offenders in prison settings. In Chapter 4 a critique of the CRIME-PICS-II (Frude, Honess & Maguire, 1994) offered a review of the tool in terms of its development, purpose, use, relevance to intervention planning and assessment, scientific and psychometric properties and its ease of use and accessibility. Further, it considered the tools applicability to forensic and clinical settings before exploring some of the limitations associated with its use. The implications of the thesis findings are finally considered in terms of existing limitations, clinical implications and future research.

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