Background: There is a paucity of research into Cluster C personality disorders, however there is increasing recognition that they are highly prevalent, associated with significant distress and frequently present alongside co-occurring axis I disorders. Research has led to significant progress in the understanding of the psychological mechanisms and has guided the development of evidence based treatment for borderline personality disorder and therefore it is likely that increased focus on Cluster C personality disorders may lead to similar developments. This thesis aimed to examine and evaluate current research on psychological interventions for the treatment of Cluster C personality disorders. It also sought to explore psychological factors involved in the development and maintenance of cluster C personality disorder. Method: A systematic literature review examining the effectiveness of psychological treatments for cluster C personality disorder identified 16 studies. The empirical study recruited individuals identified by clinicians as meeting criteria for Cluster C personality disorders. Participants completed a range of self-report measures of personality psychopathology, interpersonal problems and axis I disorders and a series of interviews exploring adult attachment style, reflective function, autobiographical memories. These were completed at 2 time points, 4 months apart. Participants also provided responses to a semi-structured qualitative interview to gain insight into their beliefs about their difficulties. Additional information was also gained through participants’ psychiatric notes. Results: The systematic review results indicate that psychological interventions are effective in the treatment of cluster C personality disorders however studies generally focused on cognitive behavioural or psychodynamic approaches. There is a lack of clarity over which treatment components are most effective in treating particular features of cluster C personality disorders. The empirical paper identifies no significant changes in personality psychopathology, anxiety and depressive symptoms, interpersonal problems, reflective function and autobiographical memory across time. Participants demonstrated insecure adult attachment styles. Conclusions: Results from the systematic review and empirical study identify a need for more research to explore the complexity of personality psychopathology and co-occurring axis I and axis II disorders. It is also necessary for research to identify psychological factors involved in the development and maintenance of Cluster C personality disorders in order to guide evidence based treatments. The systematic review highlights the need for research to identify the most effective psychological treatments for cluster C personality disorders and to establish which components of treatment are most effective in targeting particular symptoms associated with cluster C personality disorder.

We aimed to elucidate the role of vitamin D supplementation on adipokines through a systematic review and a meta-analysis of randomized placebo-controlled trials (RCTs). The search included PUBMED, Scopus, Web of Science and Google Scholar through July 1st, 2015. Finally we identified 9 RCTs and 484 participants. Meta-analysis of data from 7 studies did not find a significant change in plasma adiponectin concentrations following vitamin D supplementation (mean difference [MD]: 4.45%, 95%CI: -3.04, 11.93, p=0.244; Q=2.18, I(2)=0%). In meta-regression, changes in plasma adiponectin concentrations following vitamin D supplementation were found to be independent of treatment duration (slope: 0.25; 95%CI: -0.69, 1.19; p=0.603) and changes in serum 25-hydroxy vitamin D [25(OH)D] levels (slope: -0.02; 95%CI: -0.15, 0.12; p=0.780). Meta-analysis of data from 6 studies did not find a significant change in plasma leptin concentrations following vitamin D supplementation (MD: -4.51%, 95%CI: -25.13, 16.11, p=0.668; Q=6.41, I(2)=21.97%). Sensitivity analysis showed that this effect size is sensitive to one of the studies; removing it resulted in a significant reduction in plasma leptin levels (MD: -12.81%, 95%CI: -24.33, -1.30, p=0.029). In meta-regression, changes in plasma leptin concentrations following vitamin D supplementation were found to be independent of treatment duration (slope: -1.93; 95%CI: -4.08, 0.23; p=0.080). However, changes in serum 25(OH)D were found to be significantly associated with changes in plasma leptin levels following vitamin D supplementation (slope: 1.05; 95%CI: 0.08, 2.02; p=0.033). In conclusion, current data did not indicate a significant effect of vitamin D supplementation on adiponectin and leptin levels. / Revisión por pares

Paper one is a systematic review aimed at improving our understanding of the culturally determined risk factors of postnatal depression (PND) within 'Sub-Saharan Africa', by integrating evidence from quantitative and qualitative studies. A mixed-method systematic review approach was employed, nine quantitative and three qualitative studies were quality assessed, synthesised, and integrated. Stressful life events, adhering to cultural values and traditions, the effects of negative cultural perceptions and difficulties within the African extended family system were found to be risk factors for the development and maintenance of PND in Sub-Saharan Africa. The objective of paper two was to explore the lived experience of postnatal depression in West African mothers living in the UK. A qualitative design using semi-structured interviews with six West African mothers (Nigeria = 3; Ghana = 3) who were experiencing low mood in the postnatal period was undertaken. Participants were recruited from mother and baby groups within the National Health Service. Interpretative Phenomenological Analysis was used to explore and analyse the data. Five overarching themes emerged: (1) conceptualiszing PND, (2) isolation, (3) loss of identity, (4) issues of trust and (5) relationships as a protective factor. Each theme consisted of a number of subthemes. Women exhibited symptoms of PND but did not regard it as an illness, with the name 'depression'. They viewed their emotional distress as a result of social stress, and described feelings of isolation, loss of identity and relationship difficulties. Women's cultural background influenced their help-seeking behaviour; participants often avoided talking about their feelings and kept their distress to themselves. The findings have clinical implications in how services should be designed to meet the needs of African communities. Paper three reflects on the process of developing culturally competent research through the development of the current thesis. Suggestions for future research and reflections on the strengths and limitations of the research process are embedded throughout. Clinical implications are discussed with reference to a community psychology model.

Mentalising is an "imaginative mental activity that enables us to perceive and interpret human behaviour in terms of internal mental states (e.g. needs, desires, feelings, beliefs, goals, purposes and reasons)" (Bateman & Fonagy, 2012; page 4). While this has been studied within an adult population, there has been a lack of research in understanding this construct in adolescence and its associations with mental health. This thesis aimed to systematically review the literature to establish if there was an association between mentalising difficulties and mental health disorders in adolescence. It further aimed to empirically investigate using a questionnaire-based study with adolescents, the constructs of mentalising and their associations with mental wellbeing. The review found a negative association, indicating that low mentalising skills were a risk factor for mental health difficulties. However, there was a lack of research in this area and methodological and conceptual concerns about the measurement of mentalising. The empirical study found that the theoretical model of mentalising did not fit for adolescents. This was discussed in relation to the need for further adolescent specific research to understand this developing construct. In addition, a refined model that was hypothesised to be 'self-awareness' was suggested that was found to predict the mental wellbeing outcomes, indicating a potential risk factor for mental health difficulties in adolescence.

INTRODUCTION: In psychosis, low engagement with mental health services is both prevalent and frequently associated with negative outcome. The overarching objective of this thesis was to investigate the role of psychological variables in service engagement in people with psychosis. A systematic review was conducted to examine the evidence for clinical and psychological correlates of engagement. An empirical study sought to investigate the association between engagement and psychological variables of a relational nature (i.e. mentalizing and interpersonal functioning). METHODS: A systematic search strategy across four electronic databases yielded seventeen journal articles. For the empirical study, forty-two people with multiple-episode psychosis completed self-report measures of service engagement, symptoms, mentalizing and interpersonal functioning, within a cross-sectional design. RESULTS: The review found relatively robust evidence supporting the association between engagement and numerous clinical variables. Eleven psychological variables were revealed as significant correlates of service engagement, encompassing developmental, individual and relational factors. Assessment of quality and risk of bias highlighted a number of limitations within included studies. In the empirical study, greater cognitive/disorganization symptomology was predictive of lower service engagement. Service engagement was significantly correlated with mentalizing, but not with interpersonal functioning. The relationship between cognitive/disorganized symptomology and engagement was not mediated by mentalizing performance. CONCLUSION: Numerous psychological variables are associated with service engagement, which has the potential to inform clinical practice in view of enhancing engagement. Qualitative and longitudinal studies with both service user and provider samples are required to capture the contextual information surrounding fluctuations in levels of engagement.

Thesis Portfolio Abstract Background Whilst the role of Psychological Flexibility on psychosocial outcomes has been assessed in some chronic health conditions and cancers, its role in psychosocial outcomes in men with prostate cancer has not been established. Fear of cancer recurrence has been shown to be associated with poorer psychosocial outcomes. The relationship of Psychological Flexibility on the impact of fear of cancer recurrence has not be evaluated. Research into the measurement of Psychological Flexibility in individuals with chronic ill health has not revealed a definitive measure. Methods A systematic review of the reliability and validity of measures of Psychological Flexibility in individuals with chronic health conditions was conducted. A quality assessment of the included studies was conducted and relevant results were synthesised. A cross-sectional study utilising a survey methodology was conducted to establish the role of Psychological Flexibility and fear of cancer recurrence in psychological distress and quality of life in men with prostate cancer. Regression analyses were used to establish whether fear of cancer recurrence or Psychological Flexibility significantly predicted any variance in distress or quality of life. Whether Psychological Flexibility mediated or moderated the relationship between fear of cancer recurrence and psychosocial outcomes was assessed with conditional process analysis. Results The systematic review revealed no single definitive measure of Psychological Flexibility, and that many measures currently in use within research and clinical settings have not been fully validated in individuals with chronic ill health conditions. The cross-sectional study found that Psychological Flexibility and fear of cancer recurrence each significantly predict variance in psychological distress and quality of life. Psychological Flexibility mediated and moderated the relationship between fear of cancer recurrence and psychological distress and mediated the relationship between fear of cancer recurrence and quality of life. Conclusions In the absence of a definitive measure of Psychological Flexibility, information on the measures identified were provided to allow clinicians and researchers to choose the most appropriate measure for their use. Future research might focus on further validation of existing measures of Psychological Flexibility rather than the development of additional measures. The challenges underlying using a psychometric approach to measure contextual science concepts was discussed. Due to the role of Psychological Flexibility within psychosocial outcomes in prostate cancer, it was suggested as a potential treatment target. The relevance of treatments such as Acceptance and Commitment Therapy, which aim to increase Psychological Flexibility, for men with prostate cancer was discussed. Future research avenues to further assess the role of Psychological Flexibility in psychosocial outcomes was discussed.

Background An increasing body of research is suggesting that childhood trauma and adversity may be associated with various adverse mental health outcomes, including psychosis. Cognitive functioning is often compromised in psychosis, and research has shown that there may be a link between early trauma and cognitive impairment in people with psychosis. No systematic review of the literature of this link has been undertaken, and very few studies have examined samples of individuals at high clinical risk for psychosis, to assess whether the potential link between adversity and cognitive functioning exists, without the confounding factors of length of illness, antipsychotic medication and chronicity of symptoms. Method The systematic review of all relevant electronic databases investigates the research to date on the association between childhood adverse experiences and cognitive ability in psychosis, and the conclusions that can be drawn from the existing literature, taking into account relevant considerations regarding sample, methodology and statistical analysis. The subsequent empirical study utilizes a sample at clinical high risk of developing psychosis, and a healthy control group to investigate whether any putative association in specific domains of cognitive functioning, or global cognitive ability and childhood adversity exist in those at clinical high risk, compared to controls. Results The systematic review indicated that at present, the literature looking into childhood adversity and cognitive ability in relation to psychosis is heterogeneous, with some studies finding that this association only occurs in patients, whilst others suggest it only occurs in the control groups. Some studies found it to be specific to certain cognitive domains, whilst others suggest it was a more global impairment. Methodology, samples and analysis differed considerably across studies, and likely contribute to the heterogeneity of the literature. The empirical paper showed a significant interaction effect between group (high risk versus controls) in the high childhood adversity group, in relation to global cognitive ability. Interestingly, this was not related to psychotic symptom severity or distress. Conclusion Several limitations of the existing studies limit the conclusions that can be drawn from the existing evidence regarding the link between childhood adversity and cognitive ability, and future research in prodromal samples is essential. The empirical study showed that there is a link between childhood adversity and cognitive ability in those at clinical high risk of developing psychosis, before disorder onset, that is not present in controls. This suggests that this may form a vulnerability in those at high risk for psychosis, rather than a more general mechanism present in the typical population.

This thesis is an exploration of two interconnected areas: Acceptance and Commitment Therapy (ACT) training for helping professionals (HPs) and psychological flexibility in helping professionals. The ACT model holds that HPs need to be psychologically flexible (or, herein, flexible) in order to be effective ACT practitioners, and thus a primary goal of ACT training is to enhance participant flexibility. The first chapter is a systematic review of studies that have evaluated the effectiveness of ACT training. It focused on ACT training practices and outcomes related to knowledge, skills, and psychological flexibility in HPs. The results of this review suggested that ACT training can be effective in providing HPs from a range of occupational background with the necessary knowledge and competency to deliver ACT interventions. Furthermore, ACT training can increase HP flexibility. However, confidence in these findings is limited due to methodological weaknesses, particularly variability in ACT training practices, inconsistent use of available measures, a lack of psychometrically robust measures to assess ACT knowledge, and the absence of a flexibility measure designed for use with HP populations. Recommendations were made regarding future research needs in this area, including the development of a HP-specific measure of flexibility. The second chapter reports on the development and initial validation of a measure designed to assess flexibility in the specific context of professional helping, called the Mindful Healthcare Scale (MHS). The results of two studies employing two separates samples of HPs provided good preliminary evidence of the MHS's factor structure and internal validity. The MHS was also found to converge in theoretically-consistent ways with other measures of flexibility and constructs related to the occupational functioning of HPs including burnout syndrome, self-compassion, and empathy. These findings suggest that the MHS may have considerable utility in relation to ACT training for HPs and may also advance our understanding of flexibility's role in HP occupational well-being and functioning.

Os fatores que possam promover e incrementar a osseointegração, ou prejudicar o processo biológico, aumentando o índice de falhas, têm sido cada vez mais investigados com o objetivo de ampliar indicações e as taxas de sobrevivência dos implantes dentais assim como controlar fatores adversos. O objetivo desta tese foi identificar, analisar e sintetizar as evidências científicas quanto a influência das estatinas, do envelhecimento e da experiência do cirurgião no processo osseointegração e na sobrevivência de implantes dentais. Este volume apresenta um compilado de três revisões sistemáticas orientadas pelas recomendações PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). O processo de revisão foi realizado por meio de uma busca sistemática em cinco bases de dados eletrônicas (PubMed, Scopus, Web of Science, Embase e Cochrane Library), além de busca manual nas referências bibliográficas dos estudos incluídos. A meta-análise, quando cabível, foi realizada com o auxílio do software Review Manager (RevMan, Versão 5.3). O grau de heterogeneidade entre os estudos foi verificado por meio do teste Q de Cochran e I2. O viés das publicações foi avaliado com o auxílio das escalas Newcasttle-Ottawa e Cochrane Collaboration\'s Tool. A síntese dos dados permitiu a publicação de três artigos científicos dispostos nesta tese. / Factors that may promote and enhance osseointegration, or impair the biological process, have been increasingly investigated in order to expand the indications and survival rates of dental implants and control the adverse factors. The aim of this thesis is to identify and summarize the scientific evidence of statins, ageing and surgeon related factors that can influence osseointegration and survival of dental implants. This volume presents a compilation of three systematic reviews structured by PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). The review process was carried out through a systematic search in five electronic databases (PubMed, Scopus, Web of Science, Embase and Cochrane Library) and bibliographical references of the included studies. Meta-analyses, when appropriate, were performed using the software Review Manager (RevMan version 5.3). The degree of heterogeneity in the studies was verified by Q Cochran test and I2. The bias of the publications was assessed with the assistance of Newcastle-Ottawa Scale and Cochrane Collaboration Tool\'s. The synthesis of the data was included in three papers prepared for this thesis.

<p><strong>Aim</strong>: The purpose of this study was to highlight in what forms and manifestations spirituality emerges in medical patients whether they consider themselves believers or not. The other aim was to analyse spiritual ideas of nursing scientists – authors of the patients’ oriented studies to come to the better understanding of the situation with spirituality in caring. <strong>Method</strong>: Descriptive meta-synthesis was chosen, in which 12 nursing studies were analyzed and compiled in a new integrity. <strong>Results</strong>: The analysis shows that caregivers must be ready to meet and confirm the spiritual dimension consisting of Faith, Meaning, Relationship and Questions without answers in the various forms and expressions they emerge in patient’s experience. Nursing scientists showed ideas broad enough to confirm patients’ experience. <strong>Relevance for clinical practice</strong>: By include spirituality only to religion and culture the dimension are easily forgotten, it can also in those forms mean that caregivers doesn’t see it as theirs to confirm. Nursing science do not with hold that small view of spirituality, instead the science presents a broad spectra of forms in which patients spirituality can appear. Newinsights about patients’ spirituality can be used by health care professionals to improve the care of patients as multidimensional human beings.</p>