Background Stroke is the foremost medical condition responsible for acquired disability and dependency. The initial psychological and physical deficits should arguably be identified early to allow interventions to be put in place if potential long-term sequelae are to be minimised. Physical impairments within stroke cohorts have been extensively researched and reported. We have access to numerous scales that describe general physical functioning during daily activities and its effects on independence and quality of life. Deficits in movement are easily identified and attributes of physical movements can be associated with such obvious measurement terms as strength, speed, co-ordination and task completion. As these attributes can be graded, it is simple to compare patients over time, within stroke cohorts and against the general population: controlled studies are straightforward, even if natural biological variation demands large samples. However, though physical impacts on a patient may be easily observed and measured, corresponding deficits in cognition and mood are less easily detected and quantified. Psychological problems are common within stroke populations, and exert both short and long term effects throughout all stages of rehabilitation. Despite our awareness of the potentially critical effects of psychological factors on patient outcome, there is a dearth of high quality research in this area. Although many cognitive and mood assessments are available, including some that were developed specifically for use in stroke, these are neither regularly administered nor have been convincingly shown to be accurate and reliable in identifying specific deficits. Thus, it is understandable that research available to us that describes prevalence and effects of cognitive and mood problems post-stroke is sparse in comparison to our knowledge of physical deficits. Methodology In order to begin to understand the effects that cognition and mood have on patient outcome post-stroke, a way of identifying prominent issues is required. Knowing that their effects can have both short and long term impact, reliable screening beginning early after stroke onset could offer opportunities to improve patient outcome through early implementation of interventions. Before an appropriate screening tool can be selected, evidence is required to support its feasibility and accuracy within acute stroke cohorts. In this thesis, I investigate cognitive and mood-screening assessments in stroke, across a series of linked projects. I carried out a review of the current research and I surveyed stroke units to identify which cognitive and mood assessments are commonly implemented. I collated and offer synthesis of the published data on accuracy of cognitive assessment instruments. I used these results to inform a diagnostic test accuracy study, examining selected measures that are commonly used in UK practice to screen for cognitive and mood problems. Based on these results, I designed (and was awarded grant funding for) a clinical study to assess test properties of cognitive and mood screening instruments in a rehabilitation setting and to describe potential obstacles affecting patient assessment. Findings There is heterogeneity in the choice of cognitive and mood tests employed across research and clinical practice. There was some overlap in assessment choice within these domains but no clear consensus on a preferred assessment tool. This is in part explained by the substantial number of tests available, it is telling that the most popular assessments accounted for only a fraction of the tool assessments employed. My literature based work also points to a relative lack of published science employing a cognitive or mood assessment tool. My review of diagnostic test accuracy found that properties of cognitive tools commonly used in practice and research (Folstein’s Mini Mental State Examination: MMSE, the Montreal Cognitive Assessment: MoCA, the Addenbrookes’ Cognitive Examination Revised: ACE-R and the Cambridge Cognitive Examination revised: R-CAMCOG) were susceptible to changing populations and purpose of assessment, with test properties differing when screening tools are used in acute and chronic stage of stroke. Depending on the cut-offs that are used to define “screen positive” cases, these tools would have varying ability to identify multi=domain cognitive impairment or dementia. Generally when applying standard (i.e. the traditional cut-off described for test use in an unselected population) cut-offs, sensitivity was good but specificity was low. Specificity could be improved when the cut-offs were altered while maintaining reasonable sensitivity and this suggests that screen positive thresholds may need to be altered to suit a stroke population The need for lowering our standard cut-offs suggests that there may be factors present in typical acute stroke patients which affect assessment accuracy compared to the populations and purpose for which these scales have been developed. Using the MOCA in the acute setting of my clinical study, confirmed that stroke cohorts require altered cut-offs to improve accuracy in cognitive impairment detection. A stroke cognitive assessment that can be derived from a standard neurological examination *the Cog4) has been described. Cross sectional comparison of MoCA and Cog 4 suggest that Cog4 has questionable validity and stroke specific cognitive measures are required since scores derived from other types of measures are not necessarily testing the most appropriate domains for stroke deficits. A lack of published data on cognitive and mood screening in the first days post-stroke suggested that describing the feasibility of assessing stroke patients in an acute setting would be a useful topic for research. My subsequent clinical study incorporated verbal and non-verbal assessments for mood and the MOCA. As well as usual test accuracy outcomes I considered feasibility issues such as proportion of patients suitable for initial approach, acceptance of assessment, prevalence of common stroke related impairments that mandate assistance or cause difficulty in completing assessments, or that preclude assessment altogether. A moderate proportion of patients who were approached declined to take part and several others required external assistance to complete the assessments. Shorter, less cognitively demanding assessments required less assistance and appeared to offer higher accuracy for predicting mood problems at follow-up. These results suggest that delaying cognitive and mood assessments until later during the post-stroke period may reduce the interference from acute stroke deficits. The final piece of work generated from my PhD studies, and that is ongoing, continues the theme of feasibility of cognitive and mood assessments. Cognitive and mood assessments are performed in stroke rehabilitation centres. The rehabilitation setting was chosen, as it will include varying patterns of physical and cognitive impairment. By comparing brief assessments and more lengthy measures of cognition, I hope to identify the most appropriate testing scheme that minimises patient burden. As part of this work I will describe the impact of stroke deficits on assessment and quantification of the patient’s psychological capabilities. Conclusions In conclusion, these studies have demonstrated a lack of guidance and of protocols for cognitive and mood assessment post-stroke. The evident heterogeneity in choices of assessment in research and usual practice indicated a need for evidence based accuracy studies. In conducting these I found that usual measures are susceptible to the population, timing, and cut-off used to define test positive cases, together indicating undesirable sources of variation. Transient stroke-related problems may lead to overestimation of persistent impairments. Although acute screening of cognition and mood would be possible, such screening may not be widely acceptable to patients and would require a high level of assistance from health professionals. Acute screening should only be performed if there are potential benefits that could impact on the patient from identification of cognitive or mood problems at this early stage. With the transient changes in cognition and mood that the majority of stroke survivors experience, screening is best left until later in the patient journey. However, there may still be potential feasibility issues of administration and assessment completion during later stages. Therefore, I suggest that studies that investigate what assessments are feasibly administered to stroke patients in later stages are required. This will inform future trial recruitment for complete data requirements as well as provide clearer picture of stroke survivors’ affected cognitive domains and or mood problems.

This thesis aimed to examine the roles of growth differentiation factor 5 (GDF5), a secreted member of the TGF-β superfamily of ligands with a well characterised role in limb morphogenesis, in the developing hippocampus and sympathetic nervous system. Previous studies have demonstrated that GDF5 promotes the growth and elaboration of dendrites from developing mouse hippocampal neurons in vitro and in vivo. As a first step to investigating whether GDF5 plays additional roles in the development of the mouse hippocampus, brains of P10 and adult Gdf5+/+, Gdf5+/bp and Gdf5bp/bp mice were analysed by anatomical MRI. The gross morphology and total volume of hippocampi were not significantly different between the three genotypes at either age, making it unlikely that GDF5 plays a significant role in modulating other aspects of hippocampal development in addition to promoting the growth and elaboration of dendrites. For this reason, no further time was spent on investigating whether GDF5 plays novel roles in regulating hippocampal development. Developing sympathetic neurons of the mouse superior cervical ganglion (SCG) require nerve growth factor (NGF) to promote their survival and target field innervation in vivo. Data in this thesis has revealed that GDF5 modulates NGF promoted survival and enhances NGF promoted process outgrowth in cultures of P0 SCG neurons. In addition, GDF5 promotes process outgrowth and branching from cultured perinatal SCG neurons in the absence of NGF. P10 Gdf5bp/bp mice, that lack functional GDF5 expression, display a marked deficit in sympathetic innervation of the iris, but not the submandibular gland, compared to P10 Gdf5+/+ mice. Whole-mount analysis of sympathetic innervation in P10 Gdf5bp/bp and Gdf5+/+ mice has revealed that GDF5 is required for correct innervation of the trachea and heart, but not the pineal gland. Further in vitro and in vivo investigations have suggested that the neurotrophic effects of GDF5 on developing SCG neurons are mediated by a receptor complex that includes the type 1 receptor, BMPR1A. These findings highlight a role for GDF5 in promoting the sympathetic innervation of selective target fields in vivo.

Background: Delusions are common in psychosis, defined as fixed, false beliefs. Some studies, however, have found that they may be less fixed than previously thought, possibly changing in response to talking about them. Relatives of people with psychosis or clinical staff often ask how to respond to them when they talk about their delusions, but no available advice appears to be evidence based. Aims: To review evidence on everyday communication about delusions and find out how people with delusions talk about them with others, taking three perspectives (patients, their nominated relatives and clinicians) and to construct a model for communication in relation to the delusion according to each party independently. Methods: 36 patients were engaged in semi-structured interviews about their mental state generally (Comprehensive Psychopathological Rating Scale) and their delusion (Maudsley Assessment of Delusions Schedule). Each patient was asked to nominate a relative and a professional to whom s/he spoke about the delusion. Relatives and staff were interviewed by different researchers. Results: Most patients reported speaking to others about their delusion and nominated an informant. Most felt emotionally disturbed by their delusions, but, against prediction, this did not affect nomination; nor did their delusion content. There was good agreement between the three parties on occurrence of such communication. Some patients had self-harmed; only some relatives or staff concurred with them on attributing this to the delusion. A testable hypothesis was generated that the intrusiveness of delusions resulted in personal change for the patient and sense of changed relationship and detachment for the others. Conclusions: No previous study has investigated communication about delusions between three parties. It was striking that so few relatives were engaged. If patients, their families and clinicians could improve mutual understanding of delusions, the safety of the patient and others as well as treatment might be improved.

Tumour necrosis factor (TNF) is an extensively well characterised proinflammatory cytokine. It is expressed as a type two membrane glycoprotein that is active both as a membrane-integrated ligand and as a soluble ligand following proteolytic release of the ectodomain from the cell membrane. TNF signals via two receptors, TNFR1 and TNFR2. In the immune system, it has been shown that these receptors can function as ligands for membrane-integrated TNF and initiate TNF reverse signalling. I was a member of a team that discovered, characterised and evaluated the physiological significance of TNF reverse signalling in the nervous system. We showed that TNFR1 is expressed in tissues innervated by sympathetic neurons and that this initiates TNF reverse signalling in postnatal sympathetic axons, which in turn enhances their growth and branching locally. Using a tissue whole mount method to visualize sympathetic fibres, I found that the innervation of multiple tissues that receive their innervation exclusively or predominantly from the paravertebral sympathetic chain is defective both in mice lacking TNF and mice lacking TNFR1. Sympathetic fibres reach these tissues in these mice but fail to grow and branch extensively in these tissues. In contrast, tissues that receive their sympathetic innervation predominantly from prevertebral ganglia are either unaffected, in mice lacking TNF and TNFR1, or hyperinnervated. Using live calcium imaging, pharmacological blockers of calcium channels and shRNA gene knockdown, I obtained evidence that T-type calcium channels are required for the effects of TNF reverse signalling on axon growth. I also showed that TNF reverse signalling enhances the growth of sensory axons, during an earlier stage in development than sympathetic neurons. This work establishes that TNF reverse signalling is widely involved in regulating axon growth in the developing peripheral nervous system.

Amyotrophic lateral sclerosis (ALS) is an aggressive neurodegenerative disease characterised by the loss of upper and lower motor neurons, resulting in progressive paralysis, muscular atrophy and eventual death, on average, within 2-5 years post diagnosis. In ∼5% of patients with familial ALS (fALS), causative mutations occur within the gene encoding the RNA-binding protein, Fused in Sarcoma (FUS). Normally, FUS is predominantly localised to the nucleus and has several known roles in transcription, splicing and mRNA transport. Yet, in ALS patients with mutant forms of FUS, the protein becomes dramatically mislocalised to the cytoplasm and abnormal proteinaceous inclusions of FUS in the cytoplasm are observed post-mortem. Several questions remain: How do large pathological inclusions of FUS form? Is pathology induced via a gain or loss of protein function? Can aggregation in the cytoplasm of this normally nuclear protein be sufficient to produce toxicity? This thesis provides detailed characterisation of a novel pathway through which FUS may aggregate following its mislocalisation to the cytoplasm. This pathway is distinct from recruitment into stressinduced stress granules and can lead to the formation of large RNA-based FUS aggregates in a concentration-dependent manner. It was demonstrated that reduced protein-RNA interaction through transcriptional inhibition resulted in the dissolution and reassembly of these FUS aggregates into higher order RNA-free structures, reminiscent of inclusions seen in ALS-FUS patients. We also show in vivo that an initial insult of FUS aggregation in the cytoplasm is sufficient to elicit ALS-like pathology. In addition, how loss of FUS from the nucleus could affect the nuclear architecture was investigated, highlighting an important role for FUS in the maintenance of a protective subnuclear body, the paraspeckle, the disruption of which may contribute to the pathogenesis of FUSopathies. As such, this thesis identifies several novel mechanisms involved in the development and progression of FUSopathy, which may be useful for future therapeutic strategies targeting ALS caused by FUS mutation.

22q11.2 Deletion Syndrome (22q11.2DS) is one of the strongest known risk factors for schizophrenia. The syndrome provides a rare opportunity to prospectively examine development that precedes schizophrenia. 22q11.2DS is also associated with a range of psychiatric disorders and cognitive deficits. The overall aim of this thesis is to examine the neuropsychiatric phenotype of 22q11.2DS through a developmental lens. This thesis uses data from Cardiff University’s ECHO (Experiences of CHildren with cOpy number variants) study which includes a longitudinal cohort of children with 22q11.2DS. Development in 22q11.2DS is contrasted to that of the unaffected siblings of children with 22q11.2DS. First psychopathology is examined longitudinally across early adolescence in 22q11.2DS. Children with 22q11.2DS have a significant burden of psychopathology across early adolescence, including attention-deficit/hyperactivity disorder (ADHD), anxiety disorders and autism spectrum disorder (ASD). There is a striking increase in the prevalence of psychotic experiences and a decrease in ADHD prevalence. The ASD phenotype is examined further using a diagnostic interview of developmental history. ASD and subthreshold phenomenology is found to be highly prevalent in the early development of children with 22q11.2DS. Next cognitive development in 22q11.2DS is considered and contrasted to that in unaffected siblings. Cognitive deficits across a range of domains are present in 22q11.2DS. Cognitive development in 22q11.2DS is found to be similar to that reported in children who later develop idiopathic schizophrenia. This is followed by an exploration of the relations between psychopathology and cognitive development in 22q11.2DS. Cognitive development is found to predict the emergence of psychotic experiences and the persistence of ADHD in 22q11.2DS. This thesis extends what is known about the development of the neuropsychiatric phenotype in 22q11.2DS. Furthermore, findings give an insight into the developmental pathways associated with a high risk of developing schizophrenia.

Individuals with Major Mental Illness (such as schizophrenia and bipolar disorder) experience increased rates of physical health comorbidity compared to the general population. They also experience inequalities in access to certain aspects of healthcare. This ultimately leads to premature mortality. Studies detailing patterns of physical health comorbidity are limited by their definitions of comorbidity, single disease approach to comorbidity and by the study of heterogeneous groups. To date the investigation of possible sources of healthcare inequalities experienced by individuals with Major Mental Illness (MMI) is relatively limited. Moreover studies detailing the extent of premature mortality experienced by individuals with MMI vary both in terms of the measure of premature mortality reported and age of the cohort investigated, limiting their generalisability to the wider population. Therefore local and national data can be used to describe patterns of physical health comorbidity, investigate possible reasons for health inequalities and describe mortality rates. These findings will extend existing work in this area.

No description available.

Complex regional pain syndrome (CRPS) is a painful, debilitating condition that is poorly understood. The syndrome is characterised by pain, motor disturbances and abnormalities in trophic, sudomotor, vascular temperature and sensation. The underlying mechanisms are unknown. Clinical observations have identified a novel phenomenon whereby patients pay little attention to, and fail to care for, their painful affected limb. The literature describes this phenomenon in terms of neglect-like symptoms similar to neurological neglect as described in stroke literature. However, this does not seem to fully fit with or explain the nature of clinical observations. Therefore the aim of the qualitative first study was to more fully describe the phenomenon through an investigation of the patient experience and words used to describe those experiences. Six themes emerged from the data and were as follows: hostile feelings; spectrum of disassociation; disparity between what is apparent and what is felt; distorted mental image of affected parts; awareness of limb position and conscious attention. From these findings a theory emerged which serves to further our understanding of body perception disturbance in CRPS. Based on these findings, the second study aimed to quantify a feature of body perception disturbance by measuring limb position accuracy of those with CRPS compared to Healthy Controls (HC) and those with Rheumatological Pain (RP). The CRPS group were significantly less accurate in positioning of both the affected and unaffected upper limbs (median=9°, Interquartile rang e (IQR), 5.7°-13.3°) compared to both HC (6.5°, IQR, 4°-10.7°) and RP groups (7.7°, IQR, 5 °-11.7°). In the CRPS group position accuracy of the affected limb significantly improved with vision (8.3° in view, 10.7° not in view). Pain intensity was significantly greater in the CRPS (6.5, IQR, 5.4-7.7) than the RP group (4.6, IQR, 3.6-5.7). Based on the findings of this research programme, a definition of body perception disturbance in CRPS is presented. Furthermore, a disrupted body schema model is proposed as an explanation of the central mechanisms responsible for body perception disturbance in CRPS.

Insomnia is a common disturbance of sleep which can be treated effectively with cognitive behavioural therapy; a multicomponent ‘package’ of cognitive and behavioural strategies. Sleep restriction therapy is thought to be one of the most potent behavioural components of cognitive behavioural therapy. Subjective measures of sleep and daytime functioning improve not only with cognitive behavioural therapy, but also during and following sleep restriction therapy. However, it is unknown when these changes occur or if there are associated objective changes. This thesis addresses these issues, and presents: 1. a review of the literature of therapy and original research; 2. evaluates the nature and timing of changes in self-reported daytime functioning during therapy; 3. profiles potential objective changes (in measurements of sleep, plasma and salivary cortisol concentrations & temperature); and 4. compares patients with different subtypes of insomnia and healthy good sleeping controls for possible differences within the brain that might serve as future targets for treatment. The final general discussion ties together the results of these data-based chapters. The following section aims to provide a brief summary of the overall thesis. This Ph.D. was undertaken as Cotutelle Agreement between the Universities of Glasgow, United Kingdom and Sydney, Australia. Specific chapters relate to the data collection performed at these two sites. Consequently this thesis has been split into specific chapters from where the data were obtained. Chapters four and five consist of data acquired from Glasgow, United Kingdom whilst in chapters six and seven the data were acquired in Sydney, Australia.