Two decades of research on obsessive-compulsive disorder (OCD) has helped us develop a strong understanding of why obsessions are often followed by the performance of a compulsive act. What we have understood less well is why that act is repeated, even though it often results in an increase, rather than decrease, in discomfort. Emergent research on compulsive checking implicates a number of beliefs—including perceived responsibility, perceived harm, need for certainty, and beliefs about one’s memory— that may influence behavioural parameters (e.g., check duration) of checking episodes. Furthermore, it has also been suggested that the act of compulsive checking may recur in part because of a self-perpetuating mechanism in which checking has paradoxical effects on these beliefs. Finally, some researchers have proposed that attentional focus (e.g., focus on threat) during checking may be related these paradoxical outcomes. At present, these ideas are mostly speculative, in part because there have been so few detailed studies of the actual phenomenology of compulsive rituals. The purpose of the present research was to gather phenomenological data on compulsions as performed by a clinical sample under ecologically valid conditions. Study 1 extended emergent research suggesting that compulsions may persist because the act of checking has a number of ironic effects on beliefs. Individuals with a diagnosis of obsessive-compulsive disorder (OCD) and anxious controls (AC) completed a naturalistic stove task in our laboratory kitchen. Participants were fitted with portable eyetracking equipment and left on their own to boil a kettle, turn the stove off, and check to ensure that the stove is safe before leaving the kitchen. Surrounding the stove were household items that are “threatening” (e.g., matches) or “non-threatening” (e.g., mugs). Ratings of mood, responsibility, harm (severity, probability) and memory confidence were taken pre- and post-task and a portable eyetracker was used to monitor attention throughout the stove task. We examined the relations between behavioural indices (check duration, attentional focus) and pre- and post-task ratings of responsibility, perceived harm, mood, and memory confidence. Although we found that OCD (as compared to AC) participants took significantly longer to leave the kitchen after using the stove, we found no evidence that stronger pre-task ratings of responsibility, perceived harm, or memory confidence were associated with longer check duration. However, we found some evidence of an ironic effect whereby greater check duration was associated with greater perceived harm and decreased certainty about having properly ensured the stove was off. Of note, these ironic effects were not unique to participants with OCD, but were also observed in the AC group. With respect to the eyetracking data, we found minimal evidence linking threat fixations and beliefs in participants with OCD. In contrast, a number of interesting relations emerged in the eyetracking data of our anxious control participants. For AC participants, a greater proportion of time spent looking at the stove was associated with greater post-task sense of responsibility for preventing harm, greater post-task harm estimates, decreased certainty (about having ensured the stove was off), and decreased confidence in memory for the task. In Study 2, individuals with a diagnosis of OCD completed a structured diary of their compulsions as they occurred naturally over a three˗day period. Participants recorded the circumstances leading to each compulsion and reported on the acts involved in the compulsive ritual, the duration and repetitiveness of the ritual, and the criteria used to determine completeness of the ritual. The findings of this study suggest that unsuccessful compulsions (i.e., compulsions in which certainty was not achieved) were associated with a longer duration (trend), more repetitions, a higher standard of evidence, and offered little in the way of distress reduction. These findings are discussed within the theoretical context of cognitive˗behavioural model of obsessive˗compulsive disorder and clinical implications are offered.

In this study the phenomenon of persistent physical symptoms (PPS) has been examined by realist evaluation of research and practice. Nimnuan et al., (2001) have shown that up to 35% of patients in primary care and 66% in specialist out-patient clinics have presented with such ‘medically unexplained’ symptoms. The cost in medical investigation to reach diagnosis for PPS is an estimated 10% of the annual UK National Health Service budget (Bermingham et al., 2010) but poor patient outcomes prevail (Dwamena et al., 2009). Currently, PPS is linked to high comorbidity with anxiety and depression (DH 2011b) and Cognitive Behavioural Therapy (CBT) is advised as the evidence based treatment for PPS (IAPT, 2014). However, a shortfall in clinical skills to address PPS is also demonstrated and engagement could be improved (De Lusignan et al., 2014). Moreover, the pragmatic study of alternative therapy modalities and processes for PPS is recommended (Leichsenring, 2005). To obtain a broader knowledge of process for patients with or without co-morbidity, practice based experience suggests that one such alternative is a brief psychodynamic intervention (STPP) for PPS. A Realist Literature Synthesis (Wong et al. 2013) highlights effective psychotherapeutic STPP interventions in real world circumstances in 5 comparison with CBT interventions for heterogenous PPS. STPP for PPS is found at least as effective as CBT, with improved engagement rates. Additionally, common factors were discovered between ‘third generation’ STPP and CBT for effective PPS interventions and these were developed into a preliminary cross-modality theoretical analytical framework. In the realist contextual evaluation (Pawson and Tilley, 1997) of a psychosexual service delivery, the majority of PPS sufferers were found only moderately co-morbid with anxiety and depression. For complete investigative study, clinical tools are developed providing integrative CBT/STPP principles for engagement with PPS for teaching, training and practice. In conclusion, the findings suggest that the reflexive insider position of the realist Therapist-Evaluator facilitates systematically derived Practice-Based Evidence of PPS process, meeting recommendations of Deary et al., (2007) to explore and define process and outcomes with PPS. The findings contribute to development of a conceptual platform to support health professionals in overcoming physical/mental health barriers to addressing PPS and wider patient access to effective care (NHSE, 2014, 2015).

Aims: There is a well-established link between asthma and anxiety, leading to exacerbations for both conditions. National guidelines and policy documents recommend the provision of psychological interventions for this comorbidity, although evidence for their effectiveness is inconclusive. This thesis had two objectives: a) to evaluate cognitive-behavioural therapy (CBT) interventions for reducing anxiety in adults and/or children with asthma, given that CBT has a stronger evidence base for relevant respiratory and mental health conditions, b) to explore the lived experience of the interplay between childhood asthma and anxiety directly from the affected population in order to identify specific thinking and behaviour patterns that may maintain this comorbidity. Method: The first journal article outlined a systematic review. Three major electronic databases and manual searches were used to find relevant published and unpublished research. Trials meeting inclusion criteria, primarily utilising validated anxiety measures and employing both cognitive and behavioural techniques, were evaluated using adapted quality criteria. The second empirical article implemented interpretative phenomenological analysis (IPA) to explore the mechanisms maintaining the interplay between asthma and anxiety as experienced by 11 young people (aged 11-15) living with the comorbidity. Results: Fourteen trials met the inclusion criteria for the systematic review. The reviewed trials showed reasonable preliminary support for the effectiveness of CBT for anxiety in individuals with asthma across the age range. The favourable results were largely maintained long-term. The empirical article revealed three super-ordinate themes: i) ‘the influence of asthma’ by inhibiting valued activities or developmental tasks, triggering catastrophic thinking and leading to a generalisation of asthma coping strategies to managing anxiety; ii) ‘the influence of anxiety’ by affecting appropriate medication use and triggering hyperventilation-induced asthma exacerbations; and iii) ‘the interaction between asthma and anxiety’ by forming an unhelpful positive feedback loop and triggering symptom confusion. Conclusions: The systematic review discussed the moderate overall study quality and called for more methodologically robust research, examining CBT models tailored to this population and utilising clinically representative samples. The empirical article pointed to possible maintaining mechanisms identified, which lend themselves to a cognitive-behavioural framework, potentially including mindfulness-based interventions, and may be used to tailor psychological treatments.

Magister Psychologiae - MPsych / Increased rates of alcohol abuse and childhood trauma have been reported in previous studies of anxiety disorders, and social anxiety disorder (SAD) in particular. Yet the exact nature of this relationship remains unclear. This study aimed to assess whether SAD is a risk factor for later development of alcohol use disorders (AUD) and to investigate the association of childhood trauma with the prospective SAD-AUD comorbidity in adults with SAD. Data from fifty seven adult participants (N=57) with a primary diagnosis of SAD (mean age 36.7; 60% male) completed the self-rated Childhood Trauma Questionnaire (CTQ) as well as the Liebowitz Social Anxiety Scale (LSAS), a measure of SAD symptom severity. Alcohol abuse and dependence information were assessed with the Structured Clinical Interview for Axis I Disorders-Patient Version (SCID-I/P). Data from sixty two adult age and gender match controls were used as a comparison group. A Cognitive Behavioural Model and the Social Learning Model are the theoretical frameworks utilised in the conceptualisation of this research. The data is quantitative in nature and will be statistically analysed using descriptive statistics, logistic regression and ANOVA using the Statistical Package for the Social Sciences (SPSS) version 17.0. Informed consent was obtained in writing from all participants. The findings of the study were that 73.7% of the SAD sample met severity criteria for at least one type of childhood abuse or neglect as measured by the CTQ subscales using previously established thresholds. Physical neglect was found to be significantly associated with increased SAD symptom severity.17.5% of the SAD sample had a comorbid lifetime alcohol use disorder (AUD) and of those 80% reported experiencing childhood trauma. In conclusion there was a high rate of childhood trauma in individuals with SAD and there is a strong association between childhood trauma and comorbid AUDs in those with SAD.Thus screening for childhood trauma in SAD individuals is clinically prudent.

This thesis has been prepared in the paper based format and includes a systematic review, a novel empirical piece of research and a critical reflection. The thesis focuses on the implementation of the National Institute for Health and Clinical Excellence’s (NICE) guidance recommendations for the psychological interventions for those people suffering from schizophrenia. Papers 1 and 2 have been prepared for submission in ‘Psychology and Psychotherapy: Theory, Research and Practice’ and the ‘Journal of Mental Health’ respectively. Paper 1 includes a systematic literature search and narrative synthesis exploring if the recommendations for psychological interventions for schizophrenia were being met. Rates of implementation for Cognitive Behavioural Therapy (CBT) and Family Intervention (FI) were compared. The barriers against implementation and the strategies aimed at improving implementation were reviewed. Rates of implementation varied from 4% to 100% for CBT and 0% to 53% for FI. Previously reported barriers to implementation were found, with organisational barriers being most common. Implementation strategies discovered included training packages for CBT and FI. Rates of implementation are below recommended levels suggesting inequalities in the provision of psychological interventions for schizophrenia are present. Strategies to improve implementation that are comprehensive and supported from all levels of the NHS are considered to be most effective. Paper 2 reports a quantitative piece of research exploring if behaviourally specific and plain English language guidance can improve healthcare professional intentions to perform actions in line with recommendations for schizophrenia. An independent measure, single blind, randomised controlled design was used to disseminate guidance in two formats; the ‘original’ and ‘alternative’. Self-report measures revealed no significant results when comparing the original guidance to the alternative for the cognitive determinants of behaviour, actual behaviour change, or comprehension and satisfaction with the guidance. Behaviourally specific and plain English language does not affect intentions or behaviour to implement recommended guidance for the provision of psychological interventions for schizophrenia. A more multi-factorial approach including organisational culture may be required. Paper 3 is a critical reflection of the submitted papers and research process as a whole. Strengths and limitations of the included studies, the findings in the context of wider research, implications for clinical practice and future research are discussed.

The aim of this qualitative research project was to investigate the experiences of clients who had received Cognitive Behavioural Therapy (CBT) and Person Centred Therapy (PCT) in primary care. The rationale for the investigation was to inform the assessment and referral process whereby prospective clients are assigned to the two different therapies. A total of 16 clients responded to an invitation to attend an unstructured interview (PCT = 9; CBT = 7) to talk about their experiences of therapy. The resulting transcripts were analysed using Grounded Theory methodology. Transcripts were broken down into meaning units and conceptualised as categories, using the constant comparison method. The categories were integrated, a core category conceptualised and a theory generated. A comparison of the accounts revealed similar and contrasting experiences. The main categories (eg Accessing therapy, Engaging with the therapy) could be organised in the chronological order of the client`s journey through therapy. All participants entered therapy with a particular view of reality. In successful therapy this view changed and they went on to manage their lives in a more constructive way. Participants attributed this change to different elements of the therapy (categorised as It did the trick) which brought about a new understanding (categorised as The key). Where therapy was unsuccessful this did not occur. The mechanism of change was personal to the individual and did not appear to be specific to either therapy. Some of the mechanisms appeared to be consistent with the therapy received (eg. Carrying out tasks, in the CBT group). Others appeared counterintuitive (eg. Putting me straight, in the PCT group). The differences and similarities in the participant`s experiences appeared to be due to the therapist and client`s capacity to respond to each other in order to make the therapy “work.” The Core Category, Reciprocal Responsiveness, was chosen to explain this. The findings also suggest that the ability of the therapist and client to respond to each other will affect the outcome of therapy. The theory was constructed that the outcome of therapy is determined by the occurrence of a sufficient degree of Reciprocal Responsiveness. This study has implications for the assessment process as the findings suggests that, when making a referral, it may be helpful, to take into account the potential client`s activity and responsiveness rather than relying solely on diagnosis. It also contributes to the growing body of literature emphasising the importance of therapist responsiveness to the individual needs of the client, rather than strict adherence to one therapeutic approach. The study is limited to two therapies within primary care. Future studies may consider clients experiences within other settings and with other therapeutic approaches.

This research explores the beliefs and behaviour of individuals who have suffered a traumatic experience, specifically the violent crimes of assault, motor vehicle hijackings and armed robbery. The researcher focuses on the occurrence of residual, subclinical symptoms of PTSD that individuals experience subsequent to the specified violent crimes. By identifying and describing trends in commonalities that exist between research participants’ accounts of such residual, subclinical symptoms the research aims to explore and describe these trends, enabling a common understanding and awareness of the longstanding effects that these experiences have on individuals. The qualitative research design allowed for an exploration aimed at understanding the meaning that individuals ascribe to specific events. Three case studies were examined. The researcher ensured the exclusion of individuals who met the criteria for PTSD by making use of the PCL-S. From this approach a thematic analysis was done using the transcriptions of audiotaped interviews with the participants. The three participants chosen for the study were aged twenty-nine (29), thirty (30) and thirty-one (31) independently. Two of the participants experienced an armed robbery, which were, independently, followed by non-violent crime of housebreaking and theft. A third participant experienced an armed robbery during her early childhood, and an additional crime of aggravated robbery in adulthood. The studied violent crimes had taken place between one year eleven months and six years prior to this study. None of the participants have received therapy following their traumatic experience. Five important findings were identified and discussed. Firstly, some individuals still meet the requirements for a diagnosis of PTSD, even years following their experiences with traumatic events. Secondly, following the experience of a violent crime some individual’s core cognitive schemas regarding themselves, their world and their relationships undergo various changes. Thirdly, some individuals experience numerous posttraumatic symptoms, which are not extensive enough to validate the diagnosis of PTSD, but that affect the individual’s life on a regular basis. Nine symptoms were identified in this study. Fourthly, some individuals may experience additional effects following exposure to violent crimes, e.g. physical illness, that is not classified as posttraumatic symptoms. Fifthly, a few individuals who have been the victim of more than one crime may experience cumulative or diminished effects when one explores the overall effects of revictimisation. Results also indicated that individuals may experiences similar posttraumatic symptoms, but that the presentation of these symptoms are unique and are influenced by an individual’s history, cognitive schemas and the characteristics of the crimes that they have experienced. Finally, these findings explored and described the phenomenon of partial posttraumatic stress disorder in order to expand the understanding of this occurrence. / Dissertation (MA)--University of Pretoria, 2014. / tm2015 / Psychology / MA / Unrestricted

Purpose: The purpose of this study was to determine whether levels of physical activity in people with chronic pain change after participating in a Chronic Pain Management Program (CPMP) at Groote Schuur Hospital (GSH). Methods: A pre-experimental pre-test, post-test study was conducted, consisting of 14 men and women suffering from chronic pain who were referred to a Chronic Pain Management Program (CPMP) from the Chronic Pain Management Clinic at GSH in Cape Town, South Africa. Subjective and objective measuring tools, including pedometry, were used to collect data and non-parametric analysis was conducted to analyse data. Results: 14 participants met the Inclusion criteria. Levels of physical activity changed markedly, but not significantly. Objectively-tested and self-reported physical activity levels changed significantly among participants who took part in a CPMP. Significant improvements in Pain Severity Scores and Pain Interference Scores occurred after the CPMP and there was convergent validity between self-reported and objectively-tested levels of physical activity in those suffering from chronic pain after the CPMP. Conclusion: The Chronic Pain Management Program at Groote Schuur Hospital in Cape Town has shown to improve function and physical activity of those patients living with chronic pain who take part in the CPMP, with function improving significantly, and physical activity nearly doubling in the group being tested who took part in the 5-week long program. The CPMP at GSH should be seen as the beginning of a greater movement towards increasing physical activity in the chronic pain sphere. Research in more public healthcare facilities is needed to increase knowledge around education, pacing and implementation strategies across South Africa.

In South Africa sexual abuse has reached pandemic proportions and continues to increase in the sense that thousands of people are being sexually abused every day and the long term effects of sexual abuse are there to stay. These long term effects are imprinted in the pre-verbal dynamics of the living body and they can appear at any time in the present upon a conscious trigger. This research study seeks to investigate the effectiveness of two therapeutic modalities which are Philophonetics counselling and Trauma Focused Cognitive Behavioural Therapy in the treatment of sexually abused individuals within the South African context. Philophonetics counselling extends the therapeutic conversation into the nonverbal dimension of human communication, which enables the client to go beyond the limitations of verbal expression and access directly feelings, emotions, reactive patterns, old defenses and new potential embedded in the deep layers of the living body. It is a method of exploration, expression, and transformation of inner experiences, since words are limited in the amount of our experience that they convey. Trauma-Focused Cognitive Behavioural Therapy is a type of intervention modality that represents a synthesis of traumasensitive interventions and well established CBT (Cognitive Behavioural Therapy) principles developed from the Cognitive Behavioural school of Psychology.

Background: Postpartum Depression (PPD) affects up to one in five mothers. While psychotherapy can effectively reduce symptoms of PPD, it is unclear how PPD treatment affects maternal psychophysiology. Determining physiological changes in response to cognitive behavioural therapy (CBT) could provide insights into the mechanisms underlying effective treatment and/or help predict treatment outcomes. This study examined if treating PPD with CBT led to changes in frontal cortical activity and heart rate variability, two markers of maternal emotion regulatory capacity. Methods: Community-dwelling mothers with PPD (Edinburgh Postnatal Depression Scores ≥10) were randomized to receive nine weeks of group CBT delivered by recovered peers (i.e., those who had previously recovered from PPD) (n=26) or be put on a waitlist to receive the intervention nine weeks later (n=24). Electroencephalographic (frontal alpha asymmetry), electrocardiographic (heart rate variability), and clinical (depression, anxiety) data were collected at baseline and nine weeks later. Results: Participants in both the immediate treatment and waitlist control groups reported moderate levels of depression and anxiety at baseline. After treatment, mothers in the treatment group showed greater improvements in depression (p<0.01, Cohen d=1.22), and anxiety (p<0.005, Cohen d = 1.48), and high-frequency heart rate variability (p<0.05, Cohen d=0.70), but not frontal alpha asymmetry, compared to the waitlist control group. Conclusion: Group CBT for PPD can improve symptoms of depression and anxiety and parasympathetic nervous system function. Future research should attempt to replicate and extend these findings using larger samples, additional biomarkers, and longer periods of follow up. Examining how evidence-based treatments for PPD affect maternal psychophysiology can improve our understanding and potentially predict treatment effects. / Thesis / Master of Science (MSc) / Postpartum depression affects up to one in five mothers in the first year after delivery. When treated promptly with talking therapies (i.e., psychotherapy) such as cognitive behavioural therapy (CBT), many experience significant improvements in their symptoms. However, the changes occurring in the brain and the remainder of the nervous system occurring in response to psychotherapy is not well known. It is important that this is understood so that we can develop more effective treatments and better predict who will respond to different types of treatments. In particular, the role of the frontal lobe of the brain, and the body’s parasympathetic system is poorly understood in the context of PPD. This thesis aimed to examine the impact of CBT on women’s frontal lobe functioning using a measure called frontal alpha asymmetry (FAA) measured via electroencephalography (EEG), and parasympathetic nervous system-based heart rate variability (HRV) using electrocardiography (ECG). In this study, we compared mothers with PPD treated with CBT to those who did not receive this treatment. We found that HRV responded in mothers who received CBT compared to women who were in the control group. No significant changes were found for FAA after treatment. These results suggest that HRV may be explored further as a valid treatment outcome for CBT when provided to women with PPD.