Psychiatric inpatient services provide important care for individuals with serious mental health problems. Studies show that passivity and social disengagement prevail in inpatient settings, and the transition to outpatient care is associated with increased suicide risk. Behavioural Activation is an intervention that targets depression by increasing personally meaningful activities. Preliminary research shows that Behavioural Activation can be used in inpatient settings. The overall aim of this thesis was to evaluate the feasibility and effectiveness of Behavioural Activation for individuals in psychiatric inpatient settings, and in the transition between inpatient and outpatient care. Study I investigated inpatient activities and associated experiences. Study II was a pilot single-case experimental study of the feasibility and effectiveness of inpatient Behavioural Activation. Study III, was an interrupted time series evaluation of nursing-adapted Behavioural Activation across three wards. In Study IV Behavioural Activation in the transition from inpatient to outpatient care was compared to Supportive Therapy in a randomised controlled trial with 64 participants. The primary outcome was that of self-reported depressive symptoms and participants were followed up 12 months after treatment completion. Doing nothing was the most common inpatient activity, along with meal related activities. Passive and solitary activities were associated with negative distress and reward profiles. The preliminary evaluation of Behavioural Activation found high patient and staff satisfaction, and four of six participants showed improvement in depressive symptoms and functioning. After nursing-adapted Behavioural Activation was implemented on three wards, engagement increased. Avoidance decreased but later returned to baseline levels. Depressive symptoms and global clinical severity did not improve after nursing-adapted Behavioural Activations was introduced. The randomised controlled trial found that adding Behavioural Activation in the transition to outpatient care had a small, short-term, advantage over Supportive Therapy for self-reported depression. In conclusion, inpatient disengagement is associated with distress, and Behavioural Activation is a feasible intervention in inpatient settings that can be used by both trained therapists and nursing staff to increase patients’ treatment engagement. Behavioural Activation seems useful in targeting depressive symptoms in the transition from inpatient to outpatient care, a period associated with increased risk of suicide and clinical deterioration.

This thesis explores the use of adapted Dialectical Behaviour Therapy (DBT) with individuals with Intellectual and Developmental Disabilities (ID/D). DBT is a multi-modal psychological intervention that aims to increase skills in interpersonal effectiveness, distress tolerance, emotional regulation and mindfulness. It was initially developed for individuals who presented with parasuicidal behaviours, and is recommended for the treatment of Borderline Personality Disorder (BPD). This thesis is presented in five papers; a systematic literature review, three empirical papers (a, b &c), and a critical review and reflection of the research process. The systematic literature review provides a narrative review of published research regarding the adaptations and outcomes of DBT for individuals with ID/D. Seven studies were reviewed using the Evaluative Method for Determining Evidence Based Practice (EBP) (Reichow, 2011). The findings detail the adaptations, results and critical appraisal of the research to date. The empirical papers consider the outcomes of adults with ID/D who received adapted DBT in a community psychological therapies service. The papers present different methodologies, and combined produce a consilience of evidence regarding the suitability of DBT for this population. Paper 2a found significant reductions on measures of depression, anxiety and anger, and increased mindfulness skills amongst 18 participants following DBT. Paper 2b uses repertory grid technique to explore the psychological changes that occur following DBT for seven participants, and found overall changes in personal construing and improvements in self-esteem. Paper 2c considers the psychological changes that occur in further depth through the presentation of two case studies. The case studies consider the complexity and idiosyncrasy of the individuals and gives consideration to the use of repertory grids to identify implicative dilemmas as part of clinical assessments. The final paper provides a critical review with personal reflections of the thesis. The author considers the research and clinical implications of the study.

Background: Psychological perfectionism, from a clinical perspective, started to be a topic of interest for cognitive behavioural clinicians at the beginning of the 1950s. Whilst many studies have identified perfectionism as a pivotal motivator in different conditions of neurosis, the exact nature of its interactions remains unclear. In the research community there is still a debate as to whether there is such a thing as good perfectionism, and there remains no consensual theory of psychopathological perfectionism. Aims: The aim of the study was to investigate why the nature of the phenomena remains a contentious issue, and to develop a robust theory of psychopathological perfectionism, within a cognitive behavioural framework, which will find general acceptance. From the literature review this appears to be the first qualitative study to develop such a theory. Method: Substantive grounded theory was developed within a framework of methodical hermeneutics which, it is argued, is capable of generating formative theory. 20 volunteers who came forward in response to advertisements became participants in semi-structured interviews using a post classic qualitative methodology, from which emerging data became the basis of categories leading to the development of the theory, and functions of the phenomena. Results and Conclusions: The study sets out reasons why there remains an impasse amongst researchers and clinicians about the condition of psychopathological perfectionism. A parsimonious theory of pathological perfectionism has been developed, the constructs of which are just necessary and sufficient to describe the condition. The developed theory makes a contribution to theories proposed prior to 1990 and to contemporary research. However as with all theories it is necessarily provisional, so that its usefulness is in need of further research and development. Psychopathological perfectionism has only two constructs, namely a demand to achieve perfectionism in at least one idiosyncratic sphere, which is in response to a core schema of conditional worth. A number of symptoms or functions of psychopathological perfectionism have also been identified, and there are suggestions as to how the condition develops and is maintained to the detriment of the sufferer. The study synthesizes over fifty years of theory and research into the phenomena. The developed theory and its symptoms or functions have important implications for clinical interventions, training, and for further psychological and psychosocial research. These implications are discussed.

Summaries in Afrikaans and English / Text in Afrikaans / Tourettesindroom is 'n lewenslange versteuring wat gekenmerk word deur motoriese en vokale trekkings saam met moontlik ook komorbiede simptome soos aandagtekort-hiperaktiwiteitsversteuring, obsessief-kompulsiewe versteuring, aggressie en depressie. Die sindroom kom in hoe mate in Suid-Afrika voor en die pastor kan dus heel moontlik daarmee te doen kry. Die beste behandeling vir die sindroom is medikasie saam met gedrags- en gesinsterapie toegedien deur 'n multidissiplinere span. Die pastor het 'n rol om te vervul in hierdie span probleme het aangesien persone met Tourettesindroom dikwels in hulle verhoudings met God, hulleself en ander mense. Vir effektiewe pastorale berading aan sodanige persone, moet die pastor deeglike kennis he van die sindroom en die simptome daarvan, asook van sy of haar invalshoek as pastor. 'n Moontlike kernmoment van die sindroom wat deur die pastor aangespreek kan word, is die verlies aan beheer wat deur dje lyer ervaar word. Die sindroom kan as 'n verskoning gedrag en gebruik word vir negatiewe en onverantwoordelike die pastor sal die lyer dus moontlik eties moet konfronteer op 'n medemenslike wyse. / Tourette Syndrome is a lifelong disorder. Symptoms are motoric and vocalic tics with possible comorbid symptoms such as attention deficit disorder with hyperactivity, obsessive-compulsive disorder, and depression. It is frequent among South Africans and the pastor will probably be confronted with persons struggling with the syndrome. The best therapy for Tourette Syndrome is medication in conjunction with behaviour and family therapy administered by a multi-disciplinary team. Persons with Tourette Syndrome have problems maintaining relationships with God, themselves and others. The pastor therefore has a definite role to play in the team. Knowledge of the syndrome and its symptoms, and of pastoral care are essential for succesful pastoral counseling. A possible central theme of the syndrome is the loss of control experienced by the person with the syndrome. The syndrome can become an excuse for negative and irresponsible behaviour and ethical confrontation may be necessary. / Philosophy, Practical & Systematic Theology / M. Th. (Praktiese Teologie)

La tesis doctoral que nos ocupa se enmarca dentro de la Psicología Clínica. Esta tesis tiene como objetivo principal realizar un estudio controlado con el fin de probar la eficacia de un programa de tratamiento (Terapia Dialéctica Comportamental, DBT) para la comorbilidad entre el trastorno límite de la personalidad y los trastornos de la conducta alimentaria (anorexia y bulimia nerviosas). Estas patologías, cuando se presentan de forma comórbida constituyen una problemática de muy difícil manejo. Por ello, son necesarios estudios para mejorar las intervenciones para estos problemas. La tesis se estructura en un marco teórico y un marco experimental. El marco teórico revisa y expone con claridad los estudios sobre el tema de la tesis doctoral. La estructura del marco experimental sigue el proceso del método científico: formulación de los objetivos e hipótesis, diseño del estudio experimental, recogida y análisis de los datos, interpretación y discusión de los resultados y obtención de las conclusiones. Las conclusiones de esta tesis doctoral constituyen una contribución al tratamiento de la comorbilidad entre el trastorno límite de la personalidad y trastornos alimentarios. Los datos señalan que el protocolo de tratamiento DBT fue más eficaz que el tratamiento estándar, indicando por tanto que la DBT es una intervención eficaz para pacientes con esta patología.

Cognitive Behaviour Therapy (CBT) leads the way as an evidenced based psychotherapy, and the evaluation of CBT training programs is increasingly seen as important if this position is to be maintained. In this dissertation, CBT case conceptualization, as a core psychotherapeutic competency, acquired in training, is evaluated. Case conceptualization, integrates precipitating, predisposing, maintaining, and protective factors, functioning as an explanatory and prescriptive roadmap for therapy. Gaining self-knowledge through exposure to some form of personal therapy is cited as important in gaining psychotherapeutic competency. Self-practice/ self-reflection, show promise as a form of personal therapy compatible with the principles of CBT. This study evaluates the content and quality of CBT case conceptualizations produced by a sample of 26 participants who have completed the Massey University Post Graduate Diploma, using three case conceptualization rating scales. In addition, the impact of a self-practice/self-reflection manualised training intervention designed to improve the quality of case conceptualization in trainee cognitive behaviour therapists, is explored using thematic analysis. The evaluation of the CBT conceptualizations showed predisposing factors and psychological mechanisms as receiving the most attention from participants. However, the majority of participants failed to pay attention to socio-cultural, biological, protective factors and factors pertaining to the therapeutic relationship. The majority of the participants were able to produce a 'good enough' CBT case conceptualization, however the ‘problem list’ was not well developed, and the conceptually relevant aspects of the therapeutic relationship and protective factors were given less attention. The effect of a self-practice/self-reflection training intervention on the quality of CBT case conceptualizations produced by the intervention group (n = 16) drawn from the main participant sample, was qualitatively evaluated using thematic analysis. Theoretical understanding of the model, self awareness, empathy, conceptualization of the therapeutic relationship, adaptation of clinical interventions, and clinical practice were all subjectively perceived by participants to have increased as a result of the intervention. An inferential analysis compared the performance of the intervention group (n=16) that of a comparison group (n=10), made up of the remainder of the larger sample described in the context of the first question. The comparison group had not been exposed to the manualised intervention. The comparison was both within, and between the two groups. The quality of the intervention group showed an improvement on one of the rating scales, indicating a possible link between the training intervention and case conceptualization competency, however, the improvement was not replicated by the other two rating scales. The findings are discussed in the context of improving CBT training with regard to case conceptualization.

Summaries in Afrikaans and English / Text in Afrikaans / Tourettesindroom is 'n lewenslange versteuring wat gekenmerk word deur motoriese en vokale trekkings saam met moontlik ook komorbiede simptome soos aandagtekort-hiperaktiwiteitsversteuring, obsessief-kompulsiewe versteuring, aggressie en depressie. Die sindroom kom in hoe mate in Suid-Afrika voor en die pastor kan dus heel moontlik daarmee te doen kry. Die beste behandeling vir die sindroom is medikasie saam met gedrags- en gesinsterapie toegedien deur 'n multidissiplinere span. Die pastor het 'n rol om te vervul in hierdie span probleme het aangesien persone met Tourettesindroom dikwels in hulle verhoudings met God, hulleself en ander mense. Vir effektiewe pastorale berading aan sodanige persone, moet die pastor deeglike kennis he van die sindroom en die simptome daarvan, asook van sy of haar invalshoek as pastor. 'n Moontlike kernmoment van die sindroom wat deur die pastor aangespreek kan word, is die verlies aan beheer wat deur dje lyer ervaar word. Die sindroom kan as 'n verskoning gedrag en gebruik word vir negatiewe en onverantwoordelike die pastor sal die lyer dus moontlik eties moet konfronteer op 'n medemenslike wyse. / Tourette Syndrome is a lifelong disorder. Symptoms are motoric and vocalic tics with possible comorbid symptoms such as attention deficit disorder with hyperactivity, obsessive-compulsive disorder, and depression. It is frequent among South Africans and the pastor will probably be confronted with persons struggling with the syndrome. The best therapy for Tourette Syndrome is medication in conjunction with behaviour and family therapy administered by a multi-disciplinary team. Persons with Tourette Syndrome have problems maintaining relationships with God, themselves and others. The pastor therefore has a definite role to play in the team. Knowledge of the syndrome and its symptoms, and of pastoral care are essential for succesful pastoral counseling. A possible central theme of the syndrome is the loss of control experienced by the person with the syndrome. The syndrome can become an excuse for negative and irresponsible behaviour and ethical confrontation may be necessary. / Philosophy, Practical and Systematic Theology / M. Th. (Praktiese Teologie)

Les personnes adultes autistes sans déficience intellectuelle ni trouble du langage représentent une population clinique en croissance avec une forte prévalence de comorbidité psychiatrique. Ceux-ci nécessitent des soins en psychothérapie, mais les services actuels en santé mentale sont rarement adaptés à leur besoin. Une revue systématique des guides de traitement a donc été menée afin de faire ressortir les principes suivis par la psychothérapie adaptée aux personnes autistes adultes sans déficience intellectuelle ni trouble du langage. Les adaptations recommandées sont présentées et leurs preuves d’efficacité ont été révisées. Puis, des principes directeurs pour la psychothérapie des personnes autistes adultes sans déficience intellectuelle ni trouble du langage sont proposés et critiqués. Enfin, les principaux défis de la psychothérapie et des pistes de solution futures sont discutés. / Autistic adults without an intellectual disability or language impairment represent a growing clinical population with a high prevalence of psychiatric comorbidity. They require psychotherapy, but current mental health services are rarely adapted to their needs. A systematic review of treatment guides was therefore carried out to highlight the principles followed by the psychotherapy adapted to autistic adult people without intellectual disabilities or language disorders. Recommended adaptations are presented, and their evidence of effectiveness has been reviewed. Then, guiding principles for the psychotherapy of adults with autism without intellectual disability or language disorder are proposed and criticized. Finally, the main challenges of psychotherapy and possible future solutions are discussed.

Perfectionism can be constructed as a trans diagnostic concept that co exists and probably contributes to the onset development and maintenance of a number of Axis 1 disorders. There is also a significant relationship between perfectionism and low self- esteem. There is considerable theoretical debate in the literature concerning whether perfectionism is uni or multi-dimensional with most therapies being based upon uni dimensional conceptualisations and thus overlooking interpersonal factors. This is also reflected in the relative absence of qualitative studies that explore perfectionism from a lived experience perspective. Aims: This study aims to explore the experiences of perfectionism and low self-esteem in different life domains. It also aims to evaluate the client’s experiences and efficacy of a proposed treatment protocol that targets perfectionism from a multidimensional perspective. Method: The study is divided into three phases. A Multiple baseline design is used to evaluate the treatment protocol including cognitive and behavioural interventions, compassionate mind training and assertiveness training to target perfectionism and low self-esteem. Two clinical groups experiencing Axis 1 disorders and high perfectionism are divided amongst the different phases of this study, 13 and 8 participants respectively. Mixed methods are administered to analyse the data with greater emphasis on the qualitative ones. Measures administered include the Beck Depression & Anxiety Inventories; the Rosenberg Self Esteem Scale; the Dysfunctional Attitudes Scale; the Multidimensional Perfectionism Scale by Frost and the Perfectionistic Self Presentation Scale. 8 semi-structured interviews are analysed utilising Interpretative Phenomenological Approach (IPA). Results: from the analysis of data it is evident that perfectionism is a multidimensional construct with strong interpersonal features that affect several different life domains. The proposed treatment protocol appears significantly effective in reducing perfectionism and Axis 1 disorder symptomatology. Additionally, there is a significant increase in self- esteem. Interventions that appear most helpful are behavioural experiments, assertiveness training, compassionate mind training, continuum and positive logging.

Social anxiety disorder (SAD) is a common psychiatric disorder associated with considerable suffering. Cognitive behaviour therapy (CBT) has been shown to be effective but a significant proportion does not respond or relapses, stressing the need of augmenting treatment. Using neuroimaging could elucidate the psychological and neurobiological interaction and may help to improve current therapeutics. To address this issue, functional and structural magnetic resonance imaging (MRI) were repeatedly conducted on individuals with SAD randomised to receive CBT or an active control condition. MRI was performed pre-, and post-treatment, as well as at one-year follow-up. Matched healthy controls were also scanned to be able to evaluate disorder-specific neural responsivity and structural morphology. This thesis aimed at answering three major questions. I) Does the brain’s fear circuitry (e.g., the amygdala) change, with regard to neural response and structural morphology, immediately after CBT? II) Are the immediate changes in the brain still present at long-term follow-up? III) Can neural responsivity in the fear circuitry predict long-term treatment outcome at the level of the individual? Thus, different analytic methods were performed. Firstly, multimodal neuroimaging addressed questions on concomitant changes in neural response and grey matter volume. Secondly, two different experimental functional MRI tasks captured both neural response to emotional faces and self-referential criticism. Thirdly, support vector machine learning (SVM) was used to evaluate neural predictors at the level of the individual. Amygdala responsivity to self-referential criticism was found to be elevated in individuals with SAD, as compared to matched healthy controls, and the neural response was attenuated after effective CBT. In individuals with SAD, amygdala grey matter volume was positively correlated with symptoms of anticipatory speech anxiety, and CBT-induced symptom reduction was associated with decreased grey matter volume of the amygdala. Also, CBT-induced reduction of amygdala grey matter volume was evident both at short- and long-term follow-up. In contrast, the amygdala neural response was weakened immediately after treatment, but not at one-year follow-up. In extension to treatment effects on the brain, pre-treatment connectivity between the amygdala and the dorsal anterior cingulate cortex (dACC) was stronger in long-term CBT non-responders, as compared to long-term CBT responders. Importantly, by use of an SVM algorithm, pre-treatment neural response to self-referential criticism in the dACC accurately predicted (&gt;90%) the clinical response to CBT. In conclusion, modifying the amygdala is a likely mechanism of action in CBT, underlying the anxiolytic effects of this treatment, and the brain’s neural activity during self-referential criticism may be an accurate and clinically relevant predictor of the long-term response to CBT. Along these lines, neuroimaging is a vital tool in clinical psychiatry that could potentially improve clinical decision-making based on an individual’s neural characteristics. / Social ångest är en av de vanligaste psykiska sjukdomarna. Mer än en miljon svenskar bedöms lida av detta. Social ångest leder ofta till svåra konsekvenser för den som drabbas, men även ökade kostnader för samhället har noterats, t ex i form av ökad sjukfrånvaro. Även om många som drabbas inte söker hjälp så finns effektiva behandlingar för social ångest, både farmakologiska och psykologiska behandlingar rekommenderas av Socialstyrelsen. Kognitiv beteendeterapi (KBT) är en evidensbaserad och rekommenderad psykologisk behandling för social ångest. Trots att nuvarande interventioner är effektiva så är det fortfarande en andel individer som inte blir förbättrade. Det finns en stor andel studier som visar att individer med social ångest, i jämförelse med friska individer, karakteriseras av överdriven aktivitet i ett nätverk som har till uppgift att tolka och reagera på hotfull information. Denna aktivitet är lokaliserad i rädslonätverket där området amygdala spelar en central roll. Det finns ett behov att utveckla nuvarande behandlingar och denna avhandling syftar till att öka vår förståelse för en neurobiologisk verkningsmekanism bakom KBT för social ångest. I detta forskningsprojekt har magnetresonanstomografi (MRT) använts för att undersöka personer som lider av social ångest. Upprepade mätningar har genomförts, innan, efter, och vid uppföljning ett år efter ångestlindrande behandling. Utöver detta har individer som inte lider av social ångest undersökts för att förstå hur patienter skiljer sig från friska personer, men också för att undersöka om behandlingen normaliserar patientens hjärna. Under tiden som deltagarna undersöktes med MRT genomfördes två experiment för att ta reda på hur hjärnan reagerar på affektiv information. Deltagarna tittade på bilder med ansikten som uttrycker emotioner, t ex arga och rädda ansiktsuttryck, samt information som innehöll kritiska kommentarer riktade till personen själv eller någon annan, t ex ”ingen tycker om dig” eller ”hon är inkompetent”. Strukturella bilder på deltagarnas hjärnor har också samlats in vid varje mättillfälle. Utöver detta fick alla deltagare instruktioner om att de efter MRT skulle hålla en muntlig presentation inför en publik. Denna uppgift är oftast den värsta tänkbara för individer med social ångest, och syftet med uppgiften var att relatera hjärnans struktur och aktivitet till hur mycket ångest som individerna upplevde inför denna situation. I arbetet med denna avhandling har tre frågor ställts. a) Uppstår strukturella och funktionella förändringar i rädslonätverket direkt efter avslutad KBT (Studie I och II)? b) Är de tidiga förändringarna efter behandlingen även kvarstående ett år senare (Studie III)? c) Kan hjärnans reaktioner i rädslonätverket förutspå vilka individer som kommer att bli förbättrade av en ångestlindrande psykologisk behandling på lång sikt? Resultat från studierna i denna avhandling sammanfattas nedan: Reaktioner till självriktad kritik i amygdala är överdrivna hos individer med social ångest, i jämförelse med friska individer Reaktioner i amygdala minskar efter att individerna blivit behandlade med KBT och minskningarna korrelerar till minskade symptom av social ångest Den strukturella volymen av amygdala korrelerar positivt med hur mycket ångest individerna upplever inför en muntlig presentation, och minskningen av dessa symptom korrelerar även med hur mycket volymen av amygdala minskar efter KBT Minskningen av amygdalavolym och den samtidigt minskade reaktiviteten i amygdala till självriktad kritik är korrelerade. Medieringsanalyser antyder att det är den minskade volymen som driver förhållandet mellan minskad reaktivitet och minskad ångest inför att hålla en muntlig presentation Den strukturella minskningen av amygdala ses både direkt efter behandlingens avslut, men även vid uppföljning ett år senare. Hjärnans reaktivitet till självriktad kritik i amygdala minskar direkt efter behandling, men är inte kvarstående vid uppföljning ett år senare Kopplingen mellan hjärnans reaktivitet till självriktad kritik i amygdala och dorsala främre cingulum var starkare hos de som inte blev förbättrade (jämfört med de som blev bättre) av en ångestlindrande behandling på lång sikt Med hjälp av en stödvektormaskin (en. support vector machine learning) och ett mönster av hjärnaktivitet i dorsala främre cingulum innan behandling påbörjades, predicerades (med 92% träffsäkerhet) vilka individer som ett år senare var fortsatt förbättrade av en effektiv psykologisk behandling Utifrån dessa observationer är slutsatserna att strukturell och funktionell påverkan på amygdala är en möjlig neurobiologisk mekanism för minskad social ångest efter KBT, samt att reaktivitet i främre cingulum kan ge kliniskt relevant data om vem som kommer att bli förbättrad av en psykologisk behandling. Denna information kan potentiellt vara viktig i framtidens psykiatri för att utveckla existerande behandlingar, men även för att stödja klinikers beslutsfattande huruvida en viss individ bör erbjudas en specifik behandling eller ej. / <p>Illustration on the cover by Jan Lööf. Cover image printed with permission from Jan Lööf and Bonnier Carlsen Förlag. The cover was art directed by Staffan Lager.</p><p>The thesis is reprinted and the previous ISBN was 9789176856888.</p>