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Individuals who are at high-risk of developing psychosis can experience distressing thoughts, feelings and behaviours. This can include hearing or seeing things that others cannot, having unusual beliefs or distrustful thoughts. These experiences can vary in terms of intensity, frequency and duration but are often reported as distressing. They are typically reported during late adolescence or early adulthood, when individuals may still be living at home with their family. They may impact on an individual's relationships with their family and how family members communicate with them. Research typically focuses on the outcomes for individuals, whilst the experiences of family members or other caregivers (family/carer) are often unknown. The research included: 1. What we know so far about the attitudes, behaviours and communication in the family environment. 2. Critical comments and controlling behaviours of family members (questionnaires completed by individuals and family/carers). 3. Individuals' and family/carers' depression and anxiety (self-report questionnaires), and individuals' symptoms (structured assessment). 4. Family/carers' experiences (interviews). Critical comments and controlling behaviours were found in this population. The more critical comments and controlling behaviours that individuals reported, the more likely that they would experience long-term depression and intensified unusual beliefs and experiences (psychotic symptoms). Family/carers may experience increased worry, emotional isolation and lack confidence in their caregiving role. The author discusses the mixed-methods approach as a strength of the research. A limitation is that the majority of participants were White British mothers, and therefore the results may be different in other cultures or socio-ethnic backgrounds. In summary, involving family/carers in sessions that focus on communication and relationships, as well as developing educational resources could have long-term benefits for service users, family members and services.

Non-affective-psychosis tends to have a relapsing and remitting course. Relapses have profound adverse consequences for individuals and are costly to health services. Early signs interventions use timely prediction of relapse to prompt preventative action with the aim of averting, or lessening the impact of, relapse. The aim of this thesis was to investigate whether early signs interventions are efficacious and how they might be improved. To this end, existing studies testing early signs interventions were reviewed and four empirical studies were conducted. These studies examined the facilitators of, and barriers to, early signs interventions and tested whether adding 'basic symptoms' to conventional early signs and using smartphone technology to monitor these hypothesised predictors improves relapse prediction. Chapter 1 of the thesis outlines the importance of relapse prevention, provides background information about early signs, basic symptoms and symptom monitoring apps, and outlines the theoretical context of the thesis. Chapter 2 provides a detailed critical analysis of the methods used in the thesis and describes additional methods that were not covered in the five published PhD papers that are presented in Chapters 3 to 7. Findings from these papers are integrated with each other and with the wider literature in the discussion section of the thesis (Chapter 8), followed by an analysis of their theoretical, clinical and research implications. A systematic review of trials using early signs to target medication or psychosocial support (Chapter 3) showed that there is scope to further refine such interventions. Relapse rates were higher when targeted medication was used as an alternative to adequately dosed maintenance medication; although, not as high as when no medication was used. Targeted psychosocial interventions showed promise but there were insufficient studies of high enough quality to draw firm conclusions. To examine how early signs interventions might be improved, the thesis examined potential facilitators and barriers. Qualitative interviews with patients who had recently relapsed (Chapter 4) suggested that early signs monitoring may be easier for those who have the assistance of a family member or carer, an integrating recovery style, higher levels of insight and a good rapport with clinicians. Conversely, early signs monitoring may be more difficult for those with cognitive difficulties, low levels of literacy, a sealing over recovery style, a lack of insight, and high levels of residual psychotic symptoms. Some participants had encountered service-related barriers when attempting to seek help for an emerging relapse in the past; the capacity of a service to respond quickly to early signs is fundamental to a successful early signs intervention. With regard to relapse prediction, a systematised review of prospective cohort studies (Chapter 3) showed that conventional early signs have modest predictive validity and that studies using a wider variety of predictors and more frequent early signs assessments predicted relapse most accurately. Accordingly, the later PhD studies aimed to broaden the range of predictors (by adding basic symptoms) and to facilitate more frequent monitoring (using a smartphone app). The PhD findings supported the hypothesis that adding basic symptoms to conventional early signs improves relapse prediction. In retrospective interviews (Chapter 5), 74% of participants reported basic symptoms that began or increased in the three months before relapse. Prospective reports (Chapter 7), gathered using a smartphone app, showed that basic symptoms predicted increases in some psychotic symptoms items three weeks later, and that adding basic symptoms to early signs improved prediction in most cases. Prospective findings (Chapter 7) also indicated that using a smartphone app to assess early signs, basic symptoms and psychotic symptoms on a weekly basis was feasible and valid; qualitative interviews (Chapter 6) demonstrated that this method was largely acceptable to a sample with established psychosis. Therefore, app-facilitated assessment of these variables is recommended in future research; for example, a large-scale prospective cohort study or a trial of an early signs intervention incorporating both conventional early signs and basic symptoms.

Psychological interventions that target the core processes which are proposed to maintain distress across diagnostic categories might have advantages over disorder-specific approaches for people experiencing first-episode psychosis (FEP). This thesis aimed to evaluate the feasibility and acceptability of a transdiagnostic cognitive therapy called Method of Levels (MOL) for people experiencing FEP, and to consider whether adaptations are needed to support its implementation into routine practice. MOL is designed to ameliorate distress, rather than reduce symptoms. A related aim, therefore, was to increase our understanding of the sources of distress for this population. The results of the thesis will be used to inform decision making about the suitability of MOL for further testing in a larger clinical trial. The thesis comprises three studies described over four papers: (i) a qualitative metasynthesis exploring sources of distress in FEP (Chapter 3); (ii) a feasibility randomised controlled trial (RCT) of MOL for FEP (Chapters 4 and 5); and (iii) a qualitative study exploring experiences of receiving MOL amongst people with FEP (Chapter 6). The metasynthesis is the first review to address the question of what causes distress in people experiencing FEP from a first-person perspective. Following a systematic review, findings from qualitative studies (n = 33) were synthesised using thematic analysis. Sources of distress for this population were found to be diverse and multifaceted. The results suggest that practitioners who pay attention to wider sources of distress will be experienced as more helpful by people experiencing FEP. Participants (n = 36) were successfully recruited to the RCT and randomised to one of two conditions: treatment as usual (TAU) or TAU plus MOL. Retention at final follow up was 97%, substantially higher than the 80% threshold pre-specified as a successful feasibility outcome. This was the first study of its kind and the results provide evidence that it is feasible to recruit and retain participants experiencing FEP in a trial of MOL, suggesting that it is suitable for further testing in a larger trial. It also provides preliminary evidence of MOL's acceptability for this population. A proportion of participants from the RCT (n = 12) were interviewed about their experience of receiving MOL. Results were analysed using thematic analysis. Four superordinate themes were identified: 'The therapist's approach'; 'I was in control'; 'Thinking and talking'; and 'Looking at problems from a different perspective'. Engaging with MOL was predominantly perceived to be a helpful experience. The study provides additional evidence of the acceptability of MOL for people experiencing FEP. This thesis makes a novel contribution to the literature on psychotherapeutic interventions for people experiencing first-episode psychosis and increases our general understanding of the lived experiences of this population.

Background/Aims: People with a diagnosis of psychosis often experience stigmatising social encounters. These social encounters may influence the beliefs people hold, as research suggests that people develop a range of processes in an attempt to interpret information about both themselves and others. The internalisation of negative stereotypes about psychosis is one process used to explain how people's beliefs are influenced. Cognitive models highlight the relationship between self and social knowledge and mood. How people process social information might therefore have an important role in pathways to distress in psychosis. There is limited understanding of how different expressions of emotional distress might relate to the processing of social information. This research portfolio therefore has two aims. Firstly it aims to systematically review literature on the relationship between internalised stigma and distress for people with a schizophrenia spectrum diagnosis. It also aims to explore the relationship between attachment style, reflective functioning, personal beliefs about illness, and emotional distress in people who experience psychosis. Method: These two aims are addressed through two studies. The first study is reported in Chapter 1, where literature exploring the relationship between internalised stigma and measures of emotional distress was systematically reviewed. For this review, a search of electronic databases was conducted, included studies were assessed for quality, and results were outlined through a narrative synthesis. The empirical project reported in Chapter 2 employed a cross-sectional design to gather quantitative data from people who had a diagnosis related to psychosis. Mediation modelling was then used to explore cognitive appraisals as mediatory variables between attachment anxiety and emotional distress whilst controlling for psychotic symptomatology as a potential confounding variable. Results: Thirty studies were included in the systematic review, with over half of these being cross-sectional in design. Systematic review findings indicate a significant association between internalised stigma and depression, however the association with other measures of distress was inconsistent. Limited data was therefore available regarding the utility of cognitive interventions focusing upon internalised stigma for improving symptoms of distress in psychosis. Results from the empirical study indicate associations between attachment anxiety, cognitive appraisals, and emotional distress but not reflective functioning. Personal beliefs about illness regarding shame and control were found to mediate the relationship between attachment anxiety and distress. Conclusions: When reviewed systematically the relationship between internalised stigma and distress remained unclear. This is due in part to methodological limitations of included studies which did not allow the exploration of whether these negative beliefs about the self in relation to others around them leads to distress. However, findings from the empirical study suggested personal beliefs about illness could influence the relationship between attachment and emotional distress. Future interventions focusing upon internalised stigma as a vehicle for improving symptoms of distress in psychosis might therefore target perceptions of shame and control whilst recognising a wider range of outcomes for distress.

Purpose The systematic review aimed to identify, synthesise and evaluate the state of evidence regarding quality of social relationships and interpersonal patterns experienced by people with early psychosis, including those with at risk mental states (ARMS). The research study aimed to explore relationships between experiences of trauma and neglect, ability to mentalise and interpersonal problems in people with psychosis. Method The review article included a systematic search of four electronic databases, the search revealed eighteen articles. The research study involved gathering data via questionnaires, a semi-structured interview and a cartoon-based task from 48 participants with experience of psychosis. These outcome measures assessed childhood adversity, trauma related distress, ability to mentalise, interpersonal problems and psychotic symptomatology. Results The review revealed that people in the early stages of psychosis and those with ARMS experience poor quality relationships and have difficulties with relating to others, such as struggling to prioritise and assert their own needs. These difficulties appear early in the disorder and there was some evidence to suggest they may be related to distress. Further research is required to establish the predictors and consequences of these difficulties. The research article found that participants experienced high levels of trauma related distress and poor mentalising ability. Experience of childhood trauma and neglect was found to influence interpersonal problems via emotional distress and trauma related distress. Trauma related distress was also found to mediate the relationship between childhood adversity and negative symptoms. Mentalising was found to be unrelated to trauma and interpersonal problems. Conclusions Taken together the above findings indicate that people with psychosis experience relational difficulties. These difficulties appear to occur early in the disorder and potentially prior to onset. Difficulties in relationships appear to be influenced by experience of trauma, trauma related distress and emotional distress, indicating that a person's adaptation to trauma is significant. Distress (e.g. depression, emotional distress, trauma symptoms) appears to be related to relational functioning. Results reflect that some people may cope with the aftermath of trauma by 'deactivating' and numbing emotional experiences, as trauma was found to indirectly affect negative symptoms via trauma related distress. Findings regarding mentalising appear inconsistent and potentially measures of mentalising require review and refinement.

Introduction. Families play an important role in the clinical and personal recovery outcomes of people with lived experience of psychosis, yet they are also affected by their informal caregiving role. The contributions that families make to service user personal recovery outcomes, as well as to their own personal recovery journeys, has been referred to as ‘family recovery’. The aim of this review was to identify the core components of family recovery by reviewing the empirical research and existing models of family recovery. Methods: A systematic literature review of peer reviewed published literature on family recovery was undertaken. Assia, CINAHL, psychinfo, Medline, and Web of Science bibliographic databases were searched. Results: Twelve papers were identified that met inclusion criteria. These comprised eight descriptive models of family recovery and four empirical qualitative papers exploring staff and service user perspectives on family recovery. Family recovery reflected three key components: 1) how families promote the recovery outcomes of people with psychosis 2) the personal recovery needs of family members, and 3) promoting the recovery of the family system. Conclusions: An understanding of the family experiences of recovery may help to facilitate improved personal recovery outcomes for families. However, the literature remains in its infancy and is hampered by a lack of empirical research. Implications for practice and further research are outlined.

Criteria have been developed to identify individuals at ultra-high risk (UHR) of developing a psychotic disorder. Many UHR young people exhibit marked and persistent impairments in social and occupational functioning, regardless of symptomatic remission or transition to full-threshold psychotic disorder. In this thesis, I sought to identify factors that drive and sustain functional impairment in this group. The aim was to identify risk factors for poor functional outcome in this population. This in turn could potentially help to inform interventions. In Paper 1, I conducted a systematic review of factors associated with functional deficits in the UHR population. This was the first systematic review examining this issue. The review identified negative symptoms, disorganisation and neurocognitive deficits as robust predictors of poor outcome. I also identified areas that had been little studied, including the effect of childhood trauma, social cognitive dysfunction and the drivers of poor “real world” outcomes such as long term unemployment. Exposure to childhood trauma is common among the UHR group. I provided an extended rationale for examining its association with functioning in Paper 2, citing a range of literature linking exposure to trauma to functional deficits in people with severe mental illnesses. I then analysed which of a range of clinical and sociodemographic variables at baseline, including trauma, were the strongest predictors of long-term functioning in a large UHR cohort (Paper 3). Only childhood trauma and transition to psychosis were significant independent predictors of poor long-term functioning in the multivariate analyses. Paper 4 is the first study to investigate the long-term unemployment rate and baseline predictors of employment status at follow-up in an UHR cohort. After 2-13 years (mean = 7), 23% of the sample was not in employment, education or training. Childhood trauma and the duration of untreated illness at baseline were significant independent predictors of employment status at follow-up. Paper 5 identified a cross-sectional association between performance on a theory of mind task and a measure of global functioning that remained significant after controlling for negative symptoms and stress in multivariate analyses. Finally, in Paper 6 I reported the findings of a qualitative study that I conducted with twenty UHR service-users. Participants reported a range of impairments in their social and occupational functioning which they attributed to a combination of clinical, cognitive and psychological factors. This included negative symptoms, cognitive deficits and adverse childhood experiences, as well as variables which had been largely unexplored previously, such as self-stigmatising attitudes and dysfunctional metacognitive beliefs, providing new targets for future research. Based on these findings, the quantitative analyses and my literature review, I propose a model that attempts to explain how these variables interact to drive and sustain functional impairment in the UHR group. This thesis provides new insights into factors that underlie functional deficits in the UHR group. I end the thesis with a discussion of these findings and their clinical implications, consider the strengths and limitations of this work and identify areas for future research.

Psychotic symptoms are prevalent in a wide variety of psychiatric and neurological disorders. Yet, despite decades of research, the neurobiological mechanisms via which these symptoms come to manifest themselves remain to be elucidated. I argue in this thesis that using a mechanistic approach towards understanding psychosis that borrows heavily from the predictive coding framework, can help us understand the relationship between neurobiology and symptomology. In the first results chapter I present new data on a biomarker that has often been cited in relation to psychotic disorders, which is glutamate levels in the anterior cingulate cortex (ACC), as measured with magnetic resonance spectroscopy. In this chapter I aimed to replicate previous results that show differences in glutamate levels in psychosis and health. However, no statistically significant group differences and correlations with symptomology were found. In order to elucidate the potential mechanism underlying glutamate changes in the anterior cingulate cortex in psychosis, I tested whether a pharmacological challenge of Bromocriptine or Sulpiride altered glutamate levels in the anterior cingulate cortex. However, no significant group differences were found, between medication groups. In the second results chapter I aimed to address a long-standing question in the field of computational psychiatry, which is whether prior expectations have a stronger or weaker influence on inference in psychosis. I go on to show that this depends on the origin of the prior expectation and disease stage. That is, cognitive priors are stronger in first episode psychosis but not in people at risk for psychosis, whereas perceptual priors seem to be weakened in individuals at risk for psychosis compared to healthy individuals and individuals with first episode psychosis. Furthermore, there is some evidence that these alterations are correlated with glutamate levels. In the third results chapter I aimed to elucidate the nature of reward prediction error aberrancies in chronic schizophrenia. There has been some evidence suggesting that schizophrenia is associated with aberrant coding of reward prediction errors during reinforcement learning. However it is unclear whether these aberrancies are related to disease years and medication use. Here I provide evidence for a small but significant alteration in the coding of reward prediction errors that is correlated with medication use. In the fourth results chapter I aimed to study the influence of uncertainty on the coding of unsigned prediction errors during learning. It has been hypothesized by predictive coding theorists that dopamine plays a role in the precision-weighting of unsigned prediction error. This theory is of particular relevance to psychosis research, as this might provide a mechanism via which dopamine aberrancies, might lead to psychotic symptoms. I found that blocking dopamine using Sulpiride abolishes precision-weighting of unsigned prediction error, providing evidence for a dopamine mediated precision-weighting mechanism. In the fifth results chapter I aimed to extend this research into early psychosis, to elucidate whether psychosis is indeed associated with a failure to precision-weight prediction error. I found that first episode psychosis is indeed associated with a failure to precision-weight prediction errors, an effect that is explained by the experience of positive symptoms. In the sixth results chapter I explore whether the degree of precision-weighting of unsigned prediction errors is correlated with glutamate levels in the anterior cingulate cortex. Such a correlation might be plausible given that psychosis has been associated with both. However, I did not find such a relationship, even in a sample of 137 individuals. Thus I concluded that anterior cingulate glutamate levels might be more related to non-positive symptoms associated with psychotic disorders. In summary, a mechanistic approach towards understanding psychosis can give us valuable insights into the disease mechanisms at play. I have shown here that the influence of expectations on perception is different across disease stage in psychosis. Furthermore, aberrancies in prediction error mechanisms might explain positive symptoms in psychosis, a process likely mediated by dopaminergic mechanisms, whereas evidence for glutamatergic mediation remains absent.

Psychotic disorders represent a severe category of mental disorders affecting about one percent of the population. Individuals experience a loss or distortion of contact with reality alongside other symptoms, many of which are still not adequately managed using existing treatments. While animal models of these disorders could offer insights into these disorders and potential new treatments, translation of this knowledge has so far been poor in terms of informing clinical trials and practice. The aim of this project was to improve our understanding of these pre-clinical studies and identify potential weaknesses underlying translational failure. I carried out a systematic search of the literature to provide an unbiased summary of publications reporting animal models of schizophrenia and other psychotic disorders. From these publications, data were extracted to quantify aspects of the field including reported quality of studies, study characteristics and behavioural outcome data. The latter of these data were then used to calculate estimates of efficacy using random-effects meta-analysis. Having identified 3847 publications of relevance, including 852 different methods used to induce the model, over 359 different outcomes tested in them and almost 946 different treatments reported to be administered. I show that a large proportion of studies use simple pharmacological interventions to induce their models of these disorders, despite the availability of models using other interventions that are arguably of higher translational relevance. I also show that the reported quality of these studies is low, and only 22% of studies report taking measures to reduce the risk of biases such as randomisation and blinding, which has been shown to affect the reliability of results drawn. Through this work it becomes apparent that the literature is incredibly vast for studies looking at animal models of psychotic disorders and that some of the relevant work potentially overlaps with studies describing other conditions. This means that drawing reliable conclusions from these data is affected by what is made available in the literature, how it is reported and identified in a search and the time that it takes to reach these conclusions. I introduce the idea of using computer-assisted tools to overcome one of these problems in the long term. Translation of results from studies looking at animals modelling uniquely-human psychotic disorders to clinical successes might be improved by better reporting of studies including publishing of all work carried out, labelling of studies more uniformly so that it is identifiable, better reporting of study design including improving on reporting of measures taken to reduce the risk of bias and focusing on models with greater validity to the human condition.

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.

Paper one is a meta-synthesis of qualitative literature exploring the views of service users and carers/family members regarding their experiences of engaging with EIS. Following a standardised approach, four databases were searched and a sample of 14 papers were identified. Using an inductive thematic analysis (ITA) approach, within a critical realist epistemological framework, three main themes were identified: the importance of a personal relationship with an EIS staff member, the impact of this relationship and the consideration of life after EIS. The results highlighted the importance of service users and/or carers/family members building and maintaining a strong therapeutic bond with at least one member of EIS staff. Paper two is a qualitative study investigating service users' experiences of transitioning from EIS. Semi-structured interviews were completed with 15 participants who had either been discharged to primary care or to Community Mental Health Teams (CMHTs) and analysed, again using ITA, adopting a critical realist stance. Analysis identified five main themes: feeling ready for discharge, relationships and trust, planning for discharge, expectations of future care and the safety net of early intervention. The results and discussions offer practical implications and recommendations for services. Paper three provides a critical reflection of the research process. It includes reflections on the methodological approaches used, strengths, limitations and implications of the findings for research and clinical practice.

Research suggests that reasoning biases play a key role in the development and maintenance of paranoia. A number of cognitive interventions have been developed to ameliorate these biases, with the view that this will improve symptoms, functioning and quality of life in individuals with psychosis. Numerous research studies have tested the efficacy of these therapies, and integrating the evidence has important implications for individual, family and service-wide outcomes. The two papers presented in this thesis, a systematic review and an empirical study, aim to contribute to research in the area. The final section, which aims to place the thesis in a wider context, discusses the overall findings, personal reflections on the research process, some limitations of the two studies, and outlines implications for clinical interventions and future research.

The aim of this thesis was to explore the relationships between worry, rumination, psychotic symptoms and sleep disturbance. The thesis is presented as three papers; a systematic literature review, an empirical study and a critical appraisal. The systematic literature review in paper one gathered findings from clinical studies on the role of worry and rumination in psychosis. Robust evidence was found for a positive association between worry and persecutory delusions but not auditory hallucinations. Little evidence was found for a relationship between rumination and persecutory delusions or auditory hallucinations, yet conclusions remained tentative due to the limited number of studies in this area. The empirical study in paper two used experience sampling methodology (ESM) to investigate the relationship between objective, actigraphy defined, sleep disturbance and next-day worry, rumination and psychotic symptoms in people experiencing psychosis. Sleep disturbance did not predict worry, rumination or psychotic symptoms. Worry and rumination predicted concurrent auditory hallucinations and worry additionally predicted concurrent persecutory delusions. Effect estimates were small, as was the sample size, meaning the findings must be interpreted with caution. The critical appraisal in paper three evaluates and reflects upon the entire research process for both the literature review and empirical study. Strengths and weaknesses of the research are considered as well as implications for theory, clinical practice and future research.

This thesis aimed to explore the construct of stigma and its relationship with experiences of psychosis. In particular, it sought to investigate the role of assessment, lived experience, and therapeutic response to stigma, with those who experience psychosis. To achieve these objectives multiple methods were utilised including qualitative interviews, cross-sectional and longitudinal methods, systematic narrative synthesis and meta-analysis, and a feasibility randomised controlled trial. Chapter one provides a review of the stigma literature applied to people who experience psychosis. Chapter two provides an overview of the methodology utilised in this thesis and outlines the six academic papers which comprise the bulk of this thesis. Chapter three (Study 1) describes a systematic narrative synthesis and meta-analysis of psychosocial interventions for internalised stigma in psychosis. This review identified that no current trials of psychosocial intervention improved internalised stigma, but low-quality evidence limited the conclusions drawn. Further research examining psychosocial interventions is required. Chapter four (Study 2; n=79) outlines the development of semi-structured interview measure of stigma (SIMS) in psychosis. A reliable, valid and clinically relevant measure of stigma was developed specifically for people who experience psychosis. Chapter five (Study 3; n=25) outlines a qualitative exploration of stigma experiences with psychiatric inpatients who experience psychosis. This study identified three superordinate themes of 'stigmatising social environments and networks', 'stigmatised person with psychosis', and 'stigma interactions'. Chapter six (Study 4; n=79), explored relationships between stigma and psychological factors in psychosis. It identified that internalised shame and self-esteem were significant mediators between the relationships of experienced and perceived stigma with depression, hopelessness and recovery. Based on the evidence examined in chapters one to six, chapter seven (Study 5) outlined an integrative cognitive model of internalised stigma in psychosis. Chapter eight (Study 6), based on the model described in chapter seven, describes a feasibility randomised controlled trial (n=30) that was conducted examining the efficacy and acceptability of a brief internalised stigma CBT intervention, comparing it to a psychoeducational intervention, with acute inpatients who experience psychosis. The intervention was shown to be feasible and acceptable but a larger definitive trial is required. Finally chapter nine outlines an overall discussion and reflections on the previous chapters.

This thesis investigated the application of the Self-Regulatory Executive Function (S-REF) model (Wells & Matthews, 1994, 1996) to distressing experiences of psychosis. A multi-method approach tested a series of hypotheses derived from the S-REF model. The methods included systematic review, meta-analysis, cross-sectional and experimental designs. Statistical methods examined relationships between metacognitive beliefs, coping strategies, positive symptoms and distress. Chapter 1 provides a general introduction to psychosis and metacognition, and outlines the aims and objectives of the thesis. Chapter 2 provides an overview of the methods used in subsequent studies and presents a detailed rationale for the choice of design and analysis. Chapters 3 and 4 (study 1 and 2) present the findings of two systematic reviews and meta-analyses. The reviews reflect two fundamental aspects of the S-REF model (metacognitive beliefs and unhelpful coping strategies) and summarise the current empirical position of research in each area respectively. Study 1 revealed a high level of similarity between metacognitive beliefs endorsed by people with psychosis and people with emotional disorder. Study 2 revealed several plausible links between unhelpful coping strategies, experiences of psychosis and negative affect. The reviews identified areas that require further investigation and guided the development of the subsequent studies. Chapter 5 (study 3) examines the relationships between metacognitive beliefs, positive symptoms and negative affect in a clinical sample. The results showed that metacognitive beliefs predict negative affect over and above the topological characteristics of positive symptoms. The findings highlight the influence of metacognitive beliefs in negative affective states when the contribution of psychotic symptoms is controlled. In a similar design, chapter 6 (study 4) examines the relationships between unhelpful coping strategies and positive and negative outcomes in a clinical sample. The results revealed that coping strategies did not predict positive symptoms, negative affect, quality of life or recovery. However, metacognitive beliefs emerged as consistent and unique predictors of these variables when the comorbidities were controlled. The findings further highlight the influence of metacognitive beliefs on subjective wellbeing. Chapters 7 and 8 examine the relationship between metacognitive beliefs, paranoia and negative affect. Chapter 7 (study 5) tested whether experimental manipulation of negative metacognitive beliefs could increase paranoid intrusions and negative affect. The study utilised a fake-EEG paradigm, whereby metacognitive beliefs were manipulated with the suggestion that detection of a paranoid thought by the EEG would result in a loud noise. The findings were not statistically significant, but demonstrated the manipulations worked and the experimental paradigm is feasible. Chapter 8 (study 6) explored the combined role of cognition (i.e. schemas) and metacognition in non-clinical paranoia. The findings suggest that schemas predict paranoia frequency whilst metacognitive beliefs moderate distress. This thesis has extended current research by demonstrating novel links between metacognition and negative affect in the context of experiences of psychosis. The findings have relevance for psychological approaches as they support the investigation of both cognitive and metacognitive factors. The findings also have relevance for psychological intervention as they support the consideration of metacognitive approaches.

This thesis explored the impact of causal beliefs on treatment outcome and stigma in people who have experience of psychosis. A multi-method approach was utilised. Chapter 1 provides a background to the thesis and an overview of current findings and this is followed by a review of the methodologies in Chapter 2. Study one (Chapter 3) provides a systematic review and narrative of current research on this topic. This identified a distinct lack of research within this area of study and highlighted mixed findings in relation to the importance of causal beliefs on treatment outcome. Study two (Chapter 4) used qualitative interviews to examine factors that influenced the development and maintenance of causal beliefs using a thematic approach. This identified a number of themes, including the role of information processing and affect. Study three (Chapter 5) explored the opinions about the cause of psychosis in a group of clinicians and the relationship between these beliefs and opinions about the helpfulness of treatment. Clinicians who endorsed psychosocial causes viewed CBT as more helpful, whilst clinicians with biogenetic beliefs were more likely to believe medication would be helpful. Study four (Chapter six) explored the causal beliefs of a large group of service-users and how these beliefs were related to perceptions about the helpfulness of treatment and the treatment accessed. This study found that service-users endorsed a number of different causes but preferred a psychosocial model overall. Only a small number of significant relationships between beliefs and treatment were identified. Study five (Chapter 7) utilised an experimental design to examine the impact of two explanatory models (biogenetic vs. psychosocial) on internalised and external stigma in people experiencing psychosis. Results indicated a significant reduction in internalised stigma in both groups. Only those in the psychosocial group observed a reduction of external stigma. Study six (chapter 8) explored the relationship between causal beliefs and different aspects of treatment (perceptions, adherence, outcome) with individuals participating in an RCT. Psychosocial beliefs were associated with a belief that therapy would be helpful, whilst biogenetic beliefs were associated with a belief that medication would be helpful. No relationships were identified between beliefs and adherence with medication or engagement with therapy or treatment outcome. This thesis has provided an overview of current causal beliefs in a large group of service-users and clinicians. These suggest that both groups endorse a multi-factorial model, but prefer psychosocial explanations. Some relationships were found between beliefs and treatment, in particularly in relation to opinions about the helpfulness of treatment. This suggests that beliefs may influence attitudes in a meaningful way. However, beliefs were found not to influence treatment adherence, engagement or perceptions about the helpfulness of different treatment options. Finally, the experimental study identified some interesting relationships between beliefs and the different domains of stigma, suggesting that aetiological information influences internalised stigma and external stigma differentially. The clinical and research implications of this are discussed.

The aim of this thesis was to explore which day-time pre-sleep factors contribute to night-time sleep disturbance in the context of insomnia and psychosis. It is presented to the reader as three separate papers. 1) A systematic literature review exploring the utility of physical activity interventions for improving sleep outcome for people presenting with insomnia disorder and insomnia symptoms. 2) An empirical study investigating which day-time pre-sleep factors contribute to sleep disturbance for people with psychosis.3) A critical appraisal and personal reflection of the whole research process. Paper one presents a systematic review of the existing literature that explores physical activity interventions for improving sleep outcome for people presenting with insomnia disorder and insomnia symptoms. Thirteen articles were identified which met the review criteria. The mythological quality and evidence derived from the studies was mixed; however, there was evidence that exercise has the potential to improve sleep outcomes for people with insomnia disorder and insomnia symptoms. Recommendations for future research were suggested along with potential clinical implications which arose from the review. The empirical study presented in paper two used experience sampling methodology to explore which day-time pre-sleep factors contribute to night-time sleep disturbance for 21 people with psychosis. Physical activity, social interaction and sleep preoccupation served as primary variables, whereas negative affect, stress, arousal, napping, and psychotic symptomatology served as exploratory variables. Multilevel modelling was performed to evaluate associations between these predictor variables and objective sleep parameters including Total Sleep Time (TST), Sleep Efficiency (SE) and Sleep Fragmentation (SF). Social interaction was the only significant predictor found; increased social interaction predicted increased TST and increased SE the following night. Methodological strengths and limitations, clinical implications and ideas for future research are also discussed. Paper three provides the reader with a critical reflection of the whole research process, including a discussion of the background literature, rationale for topic choice, methodological and personal reflections, clinical implications, and directions for future research.

Psychotic experiences (PEs) occur in the general population, beyond psychotic disorders. PEs are a risk factor for mental ill health in young people but can occur benignly in selected samples of adults. Environmental factors predispose to PEs but their underlying mechanisms are not well-understood. Progress in understanding PEs may be limited by diverse conceptualisations, imprecise measurement and a lack of explanatory frameworks that can bridge the gaps between aetiological factors, their effects on the brain and their behavioural manifestations. In this thesis, I undertook a comprehensive investigation of the measurement, health implications, aetiology and computational mechanisms of PEs in adolescents and young adults using data from two large cohort samples, supplemented with smaller-scale behavioural studies. I first investigated the measurement of PEs. I assessed and optimised the measurement of PEs in young people by two self-report instruments. I then used latent variable modelling to show that a self-report and interview instrument measured the same underlying psychotic phenomena. Both instruments were able to measure severe PEs, while the self-report questionnaire also measured more mild psychotic phenomena. I then investigated the health implications of PEs. Using cluster analysis in both cohorts, I found replicable patterns of PEs at similar levels of intensity and persistence but with and without depressive symptoms and with varying risk of mental disorder. Paranoid ideation was more associated with depressive symptoms than non-paranoid unusual perceptions and beliefs. Childhood adversity was associated with both PE-prone groups, but later social support from family and friends was far higher in those with PEs and low depressive symptoms than those with PEs and high depressive symptoms. Subsequently, I investigated the role of the social environment in the development of PEs and psychopathology using longitudinal structural equation modelling. I found that asocial dispositions increased or preceded increase in PEs over one year, mediated by detriment to social support. Conversely, PEs did not precede or increase asociality. I then showed that dimensions of PEs and depressive symptoms were promoted by childhood adversity but differentially affected by later social support, with paranoid ideation being more influenced by support than non-paranoid unusual perceptions/beliefs. Finally, I investigated specific mechanisms of PEs in two behavioural studies. In the seventh study, I used computational modelling of reward learning to link PEs to reduced ability to modulate learning by confidence, replicating computational effects of a pharmacological model of psychosis. I also used a novel visual task to show that the manifestation of PEs as anomalous perceptions versus anomalous beliefs might be explained by over-reliance on different types of prior knowledge in perceptual inference. These results suggest that different conceptual approaches to PEs might be synthesised despite issues with their measurement. PEs in young people, while not entirely benign, are heterogeneously associated with psychopathology. Importantly, they characterise a minority of young people who are at very high transdiagnostic risk of mental illness but also occur without distress in young people, often in the context of a supportive social environment. Health outcomes in young people with PEs are predicted and potentially modified by social functioning and social relationships. PEs might arise from atypicalities in how the influences of information sources on perception and belief-updating are modulated according to their reliabilities.

Background There now exist a range of efficacious options for the treatment of psychosis in mental healthcare. The importance of recovery, empowerment, dignity and choice among patients with severe mental health diagnoses are important topics in contemporary research and practice. This thesis presents a meta-analytic review followed by a randomised controlled experimental study. These address distinct but related questions which aim to further our understanding of the choices available for intervention in psychosis and whether intervention may improve the ability of psychosis patients to make those choices. Aims The first objective aimed to offer a comprehensive review of the effectiveness of social skills training (SST), which is a psychological intervention for psychosis. SST has fallen out of favour in the UK and is not widely implemented in practice. We hypothesised that SST would demonstrate superiority for the negative symptoms of psychosis. The second objective was to determine whether decision-making capacity regarding treatment among psychosis patients could be improved by the application of a brief psycho-educational intervention targeting the jumping-to-conclusions (JTC) bias, which is a commonly observed cognitive bias in psychosis. We hypothesised that the intervention would improve decision-making capacity. Methods Firstly, a series of 70 meta-analyses are presented in a systematic review assessing the efficacy of social skills training across a number of psychosis outcome domains: positive symptoms, negative symptoms, general symptoms, overall symptoms and social functioning outcomes. Secondly, a randomised controlled experimental study is presented in which 36 psychosis patients in NHS Lanarkshire and 1 in NHS Dumfries & Galloway were allocated to receive either a brief meta-cognitive training (MCT) intervention or an non-specific control presentation lecture. Capacity was assessed at baseline and post-treatment while the impact of the intervention upon capacity was estimated by ANCOVA. Mediation analyses assessed whether changes in the JTC bias mediated outcome. Findings In the meta-analytic review, SST demonstrated superiority over treatment as usual (TAU. g=0.3), active controls (g=0.2-0.3) and comparators pooled (g=0.2- 0.3) for negative symptoms; and over TAU (g=0.4) and comparators pooled (g=0.3) for general psychopathology. In the randomised controlled study, MCT demonstrated large effects on two capacity outcomes; overall capacity (d=0.96, p < .05) and appreciation (d=0.87, p < .05). Exploratory analyses suggested a mediating effect of JTC (d=0.64, p < .05). Interpretation SST demonstrates a magnitude of effect for negative symptoms similar to those commonly reported for CBT for positive symptoms and may have potential for wider implementation in mental healthcare settings. The randomised controlled study suggests that psycho-educational interventions targeting capacity have clinical utility and may be developed for implementation. Limitations included lack of blinding, no fidelity checks and inclusion based on clinical diagnosis therefore a larger randomised controlled trial addressing these limitations is warranted.

Introduction: Poor insight is included as a risk factor for violence in risk assessment tools such as the Historical Clinical Risk-Management-20 version 3 (HCR-20v3) yet there is a lack of consensus around the relationship between poor insight and violence in individuals with psychosis. A systematic literature review was therefore carried out to clarify this relationship. Relatedly, a research project aimed to outline the predictive validity of the HCR-20v3 total and sub-scale scores to violence in forensic inpatients. A secondary aim was to understand the predictive ability of 2 dynamic risk factors within the HCR-20v3 clinical sub-scale; insight and positive symptoms, alongside age and history of violence in relation to violence in psychosis. Method: A systematic search of studies investigating insight and violence in patients with psychosis, published between 1980 and 2016 was carried out on relevant databases.17 articles from combined search results of 5694, met the inclusion criteria. These were selected for full-text review and quality grading which was subject to inter-rater reliability. In the research project, the predictive validity of the HCR-20v3 to violence was assessed in N=167 forensic inpatients. A sub-sample of N=135 was then used to investigate insight, positive symptoms, age and history of violence in relation to violence. Data was extracted from case files, with the exception of violence data which was collected prospectively from date of HCR-20v3 publication via DATIX. Results: The systematic review found 8 studies in support of a positive relationship between poor insight and violence, whilst 9 studies did not support this relationship. The majority of better quality studies measured the clinical insight dimension which tended to demonstrate a positive relationship between poor insight and violence. Methodological limitations were apparent across studies. The research project found HCR-20v3 total and clinical and risk-management sub-scale scores to predict violence. The clinical sub-scale was the strongest predictor of violence and physical violence specifically. Sub-sample analysis found positive symptoms and history of violence to significantly predict violence generally whilst only positive symptoms demonstrated prediction of physical violence. Insight and age were not significantly associated with either violence type. Discussion: The systematic review found partial support for a positive relationship between poor insight and violence in psychosis. Future good quality research is required to develop a fuller understanding of this issue. Research project results support the use of the HCR-20v3 in the risk assessment and management of forensic inpatients. They reinforce the usefulness of dynamic risk factors within the clinical sub-scale in particular. In line with the majority of studies within the systematic review however, a relationship between insight and violence in a sub-sample of patients with psychosis was not found. Recommendations are made for the regular re-assessment of dynamic risk factors within the HCR-20v3 clinical sub-scale in order to support patients to reduce their level of risk, with the caveat that future research is still required to support a relationship between insight and violence in this patient group.

This is a thesis on madness and moments and what happens in between. I invite the reader into the world of a post-psychotic woman living within and without a Kuwaiti culture. As a fragmented and traumatised researcher I use my chaotic and dismembered writing as a narrative quilt creating a layered account of conversations and stories, in other words, “moments of meeting”. Moments that make us, define us and continue to create knowledge. In those moments, I dialogue with myself, with other people representing different cultures as well as the different “messy” theorists I draw on in my work. The messy theorists include writers such as Alec Grant, Sophie Tamas, Helene Cixous and Susanne Gannon. Through the creative freedom afforded me by their theories I begin to explore my chaotic psychic landscape. Those explorations are, what I call in this thesis, process inputs as they are also reflections of my personal process in writing this autoethnography. They exist alongside the moments of meeting to create snapshots of my experiences from different perspectives at different times. In this work, as a bipolar Kuwaiti woman, I have a dual purpose, where I give voice to my lived experience of a severe mental illness highlighting my struggle with narrative coherence as well as to provide a Kuwaiti I-account detailing my experience of being “othered” as a result of my “mad episodes”. I hope to, in the process, provide people with severe mental illnesses, Kuwaiti women and members of marginilised communities who have been forced out of the cultural scripts or master narratives of their country with constitutive narrative resources and alternative story lines that they can draw on in their journey towards “a more functional state” in the case of severe mental illness and the creation of a dialogue with people who are unable to, for cultural reasons communicate about their experiences.

Introduction: This research portfolio set out to examine service user defined recovery in psychosis. A systematic review was undertaken to examine the evidence-base for the effectiveness of psychosocial interventions on personal recovery, empowerment and other recovery-related outcomes. An empirical study was conducted to examine the relationships between self-stigma, decisional capacity for treatment and personal recovery in service users with psychosis. Methods: A review of published literature identified ten randomised controlled trials investigating the effects of psychosocial interventions on personal recovery. A narrative synthesis was reported for findings relating to primary and secondary outcomes, and standardised effect sizes were calculated to quantify within-group change from pre-to post-intervention and follow-up. Studies were assessed for risk of bias. The empirical study recruited twenty-four participants with diagnoses of non-affective psychosis. Semi-structured interviews and self-report measures were administered to assess self-stigma, decisional capacity for treatment, psychopathology, emotional distress and personal recovery. Results: A small number of studies found that recovery-focused psychosocial interventions improved personal recovery. There were more consistent effects on psychiatric symptoms, functioning and depression. The empirical study found that self-stigma and personal recovery were associated with each other. Large effect sizes were found for the associations between self-stigma and symptoms. These associations persisted when controlling for personal recovery scores. Understanding of treatment was predicted by excitement symptoms, but no other prediction model emerged for decisional capacity. Conclusion: Taken together, the systematic review and empirical project support service user definitions of recovery which highlight the role of psychosocial factors. The systematic review found some evidence for the role of recovery-focused psychosocial interventions in improving personal recovery. Further research is needed so that interventions specifically targeting the processes in personal recovery can be developed. The findings from the empirical project suggested that interventions designed to overcome self-stigmatising beliefs and reduce emotional distress are likely to improve personal recovery outcomes in psychosis. More research is needed to develop a broader conceptualisation of decisional capacity in psychosis, to support the active participation of service users in their recovery journey.

This thesis explored the ways in which people experiencing psychosis respond to their distressing experiences. Mixed methodology was used to address the research questions. Chapter two included a thorough systematic review and meta-analysis to investigate the relationship between safety seeking behaviours and psychosis. This review concluded that safety seeking behaviours, avoidance and resistance were associated with increased distress whereas engagement was associated with reduced distress. The review also highlighted some conceptual difficulties with differentiating between safety seeking and coping in this population. Study one, a qualitative exploration of how people respond to the experience of psychosis is presented in chapter four. This study found three key themes relating to perceived importance of responses, accuracy of threat appraisals and perceptions of ability to control experiences. An overarching theme of fighting a daily battle to maintain functioning was also identified. This analysis provided some support for the model of safety seeking responses but also demonstrated additional complexities in the way that people respond to their distressing experiences. Chapter five presents study two, the development and validation of a measure of responses to psychosis. Principal Components Analysis identified three subscales: threat monitoring and avoidance, social control and reassurance seeking and conscious self-regulation attempts. The subscales were found to have good internal consistency and convergent validity. To build on this work, study three used Structural Equation Modelling to test an integrative cognitive and metacognitive model of voice hearing (chapter six). In support of this model, it was found that voice hearing predicted beliefs and beliefs predicted responses and negative affect. Responses were not predicted either by voice hearing or negative affect. It was also found that both schematic beliefs and meta-worry mediated the relationship between avoidance and negative affect. Finally, in study four, presented in chapter seven, the response styles of attentional avoidance and attentional focusing were manipulated in response to an ambiguous auditory task in an experimental study. It was found that the attentional avoidance response resulted in a significantly greater increase in words heard during the task. However, the manipulation did not have an impact on distress levels. This thesis has demonstrated significant relationships between response styles, distress, appraisals and voice hearing. This, therefore, confirms the important role of responses to unusual experiences in models of psychosis. It appears that avoidance is likely to be unhelpful however, it should not be assumed that other responses are either helpful or unhelpful as this is likely to be person and context specific. The clinical and research implications of this are discussed.

Introduction: Impaired neurocognition, especially social cognition, predicts disability in schizophrenia. Early intervention to target impairment is theoretically attractive as a means to minimise chronic disability. Many trials confirm that Cognitive Remediation (CR) produces meaningful, durable improvements in cognition and functioning but few interventions remediate social cognition or focus on the early stages of schizophrenia. Methods: A systematic review and meta-analysis of 11 randomised controlled trials (RCTs) of CR in first episode psychosis (FEP) was completed. A randomised controlled pilot trial was then conducted to investigate a combined CR and social cognition training (CR+SCT) intervention in FEP compared to CR alone, assessing cognition, functioning and symptoms at baseline and follow-up. Qualitative feedback was also obtained in a nested feasibility and acceptability study to assess engagement, intervention suitability and attrition. Results: In the systematic review and meta-analysis, random effects models revealed a non-significant effect of CR on global cognition in FEP. However, there was a significant effect on functioning and symptoms, which was larger in trials with adjunctive psychiatric rehabilitation and small group interventions. In the pilot trial, the CR+SCT group had significantly better social functioning scores post-treatment, especially on the interpersonal relationships scale, however there was no significant effect on social cognition. CR+SCT also improved visual learning and set-shifting. There was no specific effect on symptoms. The nested feasibility and acceptability study found CR and CR+SCT to be acceptable and feasible for early intervention in psychosis service users, with high engagement rates and high user-reported satisfaction. Users perceived improvements in neurocognition and reported using strategies learnt during CR in daily life. Conclusions: Meta-analysis suggests that CR is beneficial in FEP. Evidence from the pilot trial shows that a CR intervention enhanced with SCT can improve functioning more than CR alone and that such an intervention is feasible and acceptable. A larger RCT is required to explore the full benefits of a CR+SCT intervention compared to CR and treatment as usual.

The overall theme of the thesis is the investigation of psychological mechanisms of the relationship between early adversity and psychosis. Firstly, a systematic literature review regarding the psychological mediators of the relationship between childhood trauma and psychosis is presented. Paper 1 provides a comprehensive review of 30 studies investigating putative psychological mediators of the relationship between childhood trauma and psychosis symptomatology. The review critically synthesises and evaluates the research that has been carried out and published to date. Different traumatic sequalae received some support including post-traumatic symptoms, affective symptoms, emotion regulation, dissociation and insecure attachment; some factors were more tentative, including negative schema and self-esteem. The results are considered in relation to methodological limitations, clinical implications and recommendations for future research. Secondly, research was carried out to explore dissociation as a potential mediating variable within the fearful attachment and voice-hearing relationship. Paper 2 presents an investigation involving 50 participants with a diagnosis of psychosis. The participants completed a range of self-report measures. Mediation analysis indicated that a fear-based attachment style may predispose an individual to voice-hearing if dissociation is a sequalae of this experience, and highlights the importance of affect regulation in this pathway. The findings are considered in relation to limitations of the study and possible clinical implications and recommendations for future research. Thirdly, a critical evaluation and reflection of the two papers mentioned above was carried out. Strengths and weaknesses regarding the chosen methodology, directions for theory, clinical practice and future research were considered. Finally, the overall research process was reflected upon.

There are a considerable number of children who fulfil a young carer role for a parent, sibling or relative. Research into the experiences of young carers is growing, and has explored the areas of supporting parents and siblings with physical and mental health difficulties. Although research into the experience of adult carers of individuals with psychosis-related difficulties is well established, the experience of young carers supporting a parent with a psychosis-related difficulty are yet to be studied. The aim of this study was to gain a richer understanding of the lived experience of young carers supporting a parent with a psychosis-related difficulty from a retrospective position. Semi-structured interviews were conducted with seven adults who were young carers for a parent with a psychosis-related difficulty. The interview transcripts were split into two parts and analysed using Interpretative Phenomenological Analysis. Part one explored the experience of caring at the time, with two themes emerging from participant's accounts: 'Feeling isolated and alone' and 'Caring was taking the parent role'. Part two explored the integration of the experience into the current self, with two themes emerging: 'Understanding the experience is an ongoing struggle' and 'Making sense of the person I have become'. The findings are discussed in light of the current research literature and show both areas of agreement and unique insights into the experiences of this particular group. Clinical implications in light of the findings and future research suggestions are also considered.

A key feature of many psychiatric disorders, including schizophrenia and bipolar disorder, are pervasive deficits in several domains of cognition. Episodic memory is one of the most consistently observed cognitive deficits exhibited by patients with schizophrenia, and can be a predictor of overall functional outcome. Several neuroimaging studies have assessed episodic memory in psychosis, however the neural mechanisms underlying this deficit remain somewhat unclear. Studying the impact of rare genetic variants of large effect can offer a powerful method to further our understanding of the pathophysiology of psychiatric disorders. One such gene, DISC1 (Disrupted in Schizophrenia 1) is a putative susceptibility gene for a spectrum of major psychiatric disorders such as schizophrenia, bipolar disorder and major depression. DISC1 was originally identified in a large Scottish pedigree, in which it is disrupted by a balanced translocation between chromosomes 1 and 11, and this translocation confers a dramatically increased risk of major psychiatric disorder. However, the impact of this translocation on brain imaging measures is largely unknown. The rarity of this variation results in small group numbers for analysis, however rare variants are likely to have large neural effects. This thesis offers a unique investigation into the effects of the t(1;11) translocation, by examining fMRI of members of the original Scottish pedigree. Four groups of participants; 19 family members (8 with the translocation, 11 without), 30 patients with schizophrenia, 11 patients with bipolar disorder and 40 healthy controls underwent a functional MRI episodic memory encoding and recognition paradigm. Data processing and statistical analyses were performed using the standard approach in SPM8. The primary aim of this work was to investigate functional activation during episodic memory in individuals with and without the translocation, to examine the impact of the t(1;11) translocation. Analyses were also performed to examine differences between controls and patients with schizophrenia and bipolar disorder, to compare the effects of the translocation to the effects of a having a psychotic illness. During encoding of neutral scenes, translocation carriers showed greater activation of the left posterior cingulate, right fusiform gyrus and right superior frontal gyrus compared to non-carriers. During recognition, carriers showed greater activation in the right fusiform gyrus, left posterior cerebellum, right superior temporal gyrus, left anterior cingulate, right ventrolateral prefrontal cortex (VLPFC) and right dorsolateral prefrontal cortex (DLPFC). For both contrasts, no regions were found to be more active in family members without the translocation when compared to carriers. There were no significant differences between the groups in terms of their performance or reaction time on encoding and recognition conditions. Compared to healthy controls, patients with schizophrenia demonstrated increased activation during encoding in the inferior parietal lobe bilaterally, and decreased activation during recognition in a region encompassing the caudate nucleus and anterior cingulate cortex. Patients with bipolar disorder showed no difference in activation compared to controls during encoding, and increased activation during recognition in a region encompassing the caudate and anterior cingulate, extending to the inferior frontal lobe and insula. There was also a significant difference between patients with schizophrenia and bipolar disorder during recognition, with patients with bipolar disorder again showing increased activation in the caudate extending to the anterior cingulate cortex. These findings support previous research suggesting overactivation of fronto-limbic and striatal structures including the anterior cingulate and caudate in bipolar disorder, with a relative underactivation in schizophrenia. This thesis presents the first evidence of functional alterations during episodic memory in association with the translocation, primarily in fronto-temporal regions. Brain regions that were over activated in translocation carriers have been shown to be involved in memory encoding and recognition, and are known to be affected in patients with major psychiatric disorders and unaffected relatives. Family members with the translocation demonstrated a more similar pattern of activation during recognition to patients with bipolar disorder compared to schizophrenia, perhaps due to the fact that most diagnoses in the carriers were of an affective disorder rather than a schizophrenia-related psychosis. Based on these findings it can be argued that the translocation has an influence on brain activations in areas associated with episodic memory processes. These findings begin to provide a better understanding of the neural effects of the t(1;11) translocation, and highlight the significance of rare but biologically informative genetic variants in understanding psychosis.

Purpose: A systematic review and meta-analysis was conducted to identify what factors have been investigated as correlates of the 4 key domains of treatment decision making capacity (TDMC) in people who have experienced psychosis (understanding, reasoning, appreciation, communication) and to provide estimates of the magnitude of these correlations, taking into account study quality. A novel empirical study was conducted to test the hypothesis that variance in psychosis-specific cognitive biases (including the well-established ‘jumping to conclusions’ bias) would account for unique variance in TDMC domains in those with psychosis, after taking into account the known contribution of symptoms and insight. A secondary aim of the empirical study was to examine for the first time the relationship between TDMC and personal recovery in this group, and post hoc analyses of the relationship between cognitive biases, emotional distress and TDMC were also conducted. Methods: Electronic databases were systematically searched for literature on the schizophrenia and psychosis and treatment decision making capacity. Pooled estimates of correlation were estimated for factors with data from three or more studies, and both study and outcome quality were systematically assessed. A cross-sectional observational study was conducted, and individuals with psychosis completed measures of TDMC, cognitive biases, psychotic symptoms and recovery. Multiple regression was used to examine the primary and secondary hypotheses, and mediation analyses were used to conduct the post hoc analyses. Additional data from a parallel study was incorporated to increase power. Results: Twenty-four studies met inclusion criteria for the systematic review and meta-analysis. Low to moderate quality evidence suggested that the ability of people with psychosis to understand treatment-relevant information was strongly associated with overall psychotic symptom severity, verbal cognitive functioning and years of education, but not depression (moderate quality evidence). Low quality evidence suggested reasoning was strongly associated with verbal cognitive functioning and moderately associated with symptoms. Appreciation was associated with symptoms, but it and communication were generally poorly studied. Findings from the empirical study suggest that cognitive biases, and the Jumping to Conclusions bias in particular, predicts a moderate amount of the variance in the understanding and reasoning TDMC domains, but did not add predictive power to a model containing symptoms, insight, and cognition. The appreciation domain was strongly predicted by cognitive biases, insight, and cognition. TDMC was not found to be correlated with personal recovery and post hoc analyses did not find that emotional distress mediated any relationship between cognitive biases and TDMC. Conclusions: The meta-analysis confirms there is a robust association between symptoms and TDMC in psychosis, as currently conceived. The empirical study suggests cognitive biases may be related to TDMC, even after taking into account the contribution of symptoms. Larger studies, perhaps employing experimental procedures, are required to clarify the exact nature of this relationship. The lack of any relationship between TDMC and service-user defined recovery from psychosis is notable, and lends support to those calling for a conceptualisation of TDMC that takes greater account of this concept.

While a correlation between suffering from psychosis and an increased risk of engaging in aggressive behaviours has been established, many factors have been explored which may contribute to increasing this risk. Patients with a diagnosis of psychosis have been shown to have significant difficulties in facial affect recognition (FAR) and some authors have proposed that this may contribute to increasing the risk of displaying aggressive or violent behaviours. A systematic review of the current evidence regarding the links between facial affect recognition and aggression was conducted. Results were varied with some studies providing evidence of a link between emotion recognition difficulties and aggression, while others were unable to establish such an association. Results should be interpreted with some caution as the quality of included studies was poor due to small sample sizes, insufficient power and limited reporting of results. Adequately powered, randomised controlled studies using appropriate blinding procedures and validated measures are therefore required. There is a substantial evidence base demonstrating difficulties in emotional perception in patients with psychosis, with evidence suggesting a relationship with reduced social functioning, increased aggression and more severe symptoms of psychosis. In this review we aim to review this field to assess if there is a causal link between facial affect recognition difficulties and psychosis. The Bradford Hill criteria for establishing a causal relationship from observational data were used to generate key hypotheses, which were then tested against existing evidence. Where a published meta-analysis was not already available, new meta-analyses were conducted. A large effect of FAR difficulties in those with a diagnosis of psychosis, with a small to moderate correlation between FAR problems and symptoms of psychosis was found. Evidence was provided for the existence of FAR problems in those at clinical high risk of psychosis, while remediation of psychosis symptoms did not appear to impact FAR difficulties. There appears to be good evidence of the existence of facial affect recognition difficulties in the causation of psychosis, though larger, longitudinal studies are required to provide further evidence of this.

Sleep problems are a common complaint in clinical samples. Specifically, the high level of co-occurring sleep disturbances, such as insomnia and hypersomnia, amongst patients with schizophrenia and bipolar disorder suggests a relationship between poor sleep and psychopathology. Furthermore, recent evidence consistently indicates that sleep disturbance may be related to symptoms of psychosis such as hallucinations and delusions. The research described in this thesis attempts to explore the relationship between sleep in psychosis. Paper 1 presents a systematic review entitled: Evaluating the Effectiveness of Sleep Treatments in Severe Mental Illness. The review identified fifteen controlled trials of pharmacological and non-pharmacological interventions for the treatment of sleep disturbance in patients with severe mental illness. The outcomes of the review indicated that sleep could be reliably improved in persons with schizophrenia and bipolar disorder. Significant improvements to sleep were observed for some pharmacological interventions as well as for non-pharmacological interventions. Paper 2 describes an empirical study aimed at exploring the effects of poor sleep on the cognitive mechanisms underlying psychotic experiences. Using an independent groups design, two, well-defined, non-clinical groups comprising good sleepers and poor sleepers (those meeting criteria for insomnia disorder) were recruited to the study. The two groups were compared on a series of questionnaires and computer tasks designed to assess mechanisms underlying hallucinations and delusions, with a view to determine whether there was a difference in performance between groups that could be attributed to sleep. No significant differences were found between groups, although the study was underpowered. The findings are discussed in the context of sample characteristics and tests used to compare groups. The final paper offers a critical reflection on the systematic review and empirical study, drawing together conclusions about the role and treatment of sleep in relation to psychotic experiences.

This thesis is comprised of three papers. Paper 1 presents a systematic review on the evidence for the relationship between appraisals of auditory verbal hallucinations and voice-related distress in psychosis. A literature search was conducted using the following electronic databases: Web of Science, PsycINFO, Embase and Pubmed. Twenty-four studies were identified that satisfied inclusion criteria for the review. Several types of appraisals were found to be associated with distress in voice-hearers: malevolence, control, power, origin of voices and benevolence beliefs. Evidence for an association was particularly strong for malevolence and control appraisals, indicating that these may be important to target in interventions. Overall findings generally supported that modification of voice appraisals, particularly malevolence, power and control appraisals, in cognitive therapy is associated with a reduction in voice-related distress. Paper 2 presents an experimental study which explored whether people who are exposed to stressful material are more likely to report hearing voices when they are not present (i.e. false alarms). Factors that may predict or moderate voice-hearing were also explored. A non-clinical sample (N = 130) completed measures of trauma history, hallucination proneness, dissociation, affect and attachment styles, before being allocated to view pictures depicting stressful interpersonal scenarios or pictures with neutral interpersonal scenarios. Participants then completed a voice detection task. False alarms were recorded as a proxy measure of voice-hearing. Participants in the stressful group reported significantly higher levels of stress than in the neutral group. No differences were found in false alarms. Physical abuse history and depersonalisation significantly correlated with false alarms. This study indicates that people with physical abuse history and dissociative tendencies may be more vulnerable to hearing voices; clinically, these factors should therefore be assessed. However, findings of this study should be interpreted tentatively due to lack of diversity within the sample. Paper 3 is a critical reflection of the systematic review, the empirical paper and the research process as a whole. Strengths and limitations of the presented research are discussed as well as directions for future research.

The current research project aimed to investigate how various degrees of psychosis and autism traits were associated with different styles of reasoning. Therefore, a series of five studies were conducted that recruited participants who were considered to reside along different points of the psychosis and autism continua. Measures of intuitive and deliberative reasoning style were employed and were used to ascertain whether differing degrees of psychosis and autism reflected different profiles of reasoning style. In addition, a composite score was devised using the raw scores of measures of psychosis and autism traits to test Crespi and Badcocks (2008) diametric disorders hypothesis and to further explore the relationship between the two measures. Overall, the results revealed some evidence that psychosis traits were associated with a more intuitive relative to deliberative style of reasoning, whereas autism traits were reflective of the reverse profile. The findings were also able to shed further light on the intricate relationship between autism and psychotic spectrum disorders.

Sleep disturbance is a prevalent complaint amongst individuals with a diagnosis of schizophrenia. However, very little research has explored the effects of sleep difficulties on the experience of psychotic symptoms and functioning. Therefore, this thesis provides a detailed examination of the role of sleep disturbance in people with a diagnosis of schizophrenia. It is presented in three papers: (1) a systematic review; (2) an empirical study and (3) a critical evaluation and reflection on the research process. Paper one presents a systematic review of the relationship between objective and subjective sleep disturbance and psychosis severity, within the context of schizophrenia-spectrum diagnoses. Twenty six papers were identified through electronic database searches and reference list searches of relevant articles and reviews. All papers met pre-defined inclusion and exclusion criteria. Both objective and subjective sleep disturbance was associated with increased psychosis severity; however, evidence was weak-to-moderate in quality as few studies controlled for confounders. Recommendations for future research were suggested to improve the quality of prospective studies aiming to elucidate the sleep-psychosis relationship. Paper two presents the first, well-controlled, longitudinal examination of the relationship between objective and subjective sleep parameters, next-day psychotic symptoms and functioning. Objective and subjective sleep parameters were assessed across six days and nights of actigraphy and completion of morning sleep diaries. Using Experience Sampling Methodology (ESM), assessments of mood, psychotic symptoms and functioning were completed five times each day, by twenty-two participants with a schizophrenia-spectrum diagnosis. All objective and subjective sleep parameters predicted impaired next-day functioning, which remained significant after controlling for symptom severity. Reduced sleep efficiency and increased sleep fragmentation predicted next-day auditory hallucinations, while increased sleep fragmentation and reduced sleep quality predicted next-day paranoia and delusions of control. A proportion of all significant relationships between sleep and next-day variables were mediated by morning negative affect. Paper three describes a critical evaluation and reflection of the research process. This includes reflections on key methodological decisions and their underlying rationale, personal reflections on the completion of papers one and two and discussion of the overall findings within the context of clinical practice. Paper three concludes that sleep disturbance appears related to symptom severity and impaired functioning in people with a diagnosis of schizophrenia. Sleep could therefore represent a key target for therapeutic intervention, which has the potential to enhance both symptomatic and functional recovery.

There is little doubt that social and interpersonal processes are key factors in the development and maintenance of, as well as recovery from, psychosis. Many aspects of the social world have been researched in relation to psychotic experiences and much learnt about the impact of early family life, difficulties in social cognition and the importance of social support, rejection and stigma. However, little is understood about the lived experiences of these interpersonal processes from the point of view of those with psychosis themselves. The aim of the following study was to explore how people with psychosis experience other people and make sense of their interpersonal experiences. Semi-structured interviews were conducted with two men and five women experiencing psychosis. Interpretative Phenomenological Analysis (IPA) was used to analyse the verbatim transcripts, from which three master themes emerged. These were: 'Finding a place in society', 'Interpersonal mistrust' and 'Undermined by inner/outer disturbance'. These findings are discussed in relation to the literature on interpersonal processes and psychosis along with the limitations of the current study. Implications and suggestions for future research and clinical practice are also discussed.

Poor insight has clinical significance as a predictor of non-adherence to treatment, increased number of relapses, hospitalisations, recovery and risk of violence. Empirical research has led to advances in the redefinition, knowledge and understanding of insight in psychosis. However, the use of a wide range of definitions and measures has created difficulties in interpreting research findings, without clarifying the concepts being measured and evaluating the quality of their associated assessment tool. Therefore, the aim of the first piece of work, a Systematic Review (SR), was to identify and describe the constructs of insight in psychosis and their assessment tools and briefly evaluate their psychometric properties. Insight in psychosis is particularly relevant to Forensic Mental Health Services, given its link with offending behaviour and risk to others. However, outside of those provided by risk appraisal tools, there are no current guidelines that specifically target the assessment, or intervention, of insight. Therefore, the second piece of work, a research project (RP), aimed to explore current practices, as described by experienced clinicians. The SR identified twelve assessment tools and fourteen papers for detailed analysis. Twelve theoretical constructs were identified, the most prominent being awareness of mental illness and awareness of the need for treatment. Other prominent theoretical constructs included awareness of negative consequences of illness and awareness of generic or specific symptoms. However, few of the subscales associated with each theoretical construct were supported by empirical evidence. Further work to clarify aspects of insight that are important areas for intervention, along with the provision of data to support these, should continue to be a focus for on-going research. The RP was a qualitative design using Thematic Analysis. Data was collected by semi-structured interviews from 11 qualified Clinical Psychologists working in Forensic Mental Health Services across Scotland. The RP identified three overarching themes. The first “risk related” illustrated the influence of risk to other when assessing and treating patients. The second “holistic approach” illustrated that insight or mental illness was rarely looked at in isolation. The third theme “no specific or satisfactory unified approach” illustrated the diversity of the conceptualising, assessment and treatment of insight. Opportunities exist to develop a more uniformed approach and to introduce or develop outcome measures for interventions.

Purpose: The systematic review aimed to review and evaluate constructs and measures of emotion regulation (ER) in the psychosis spectrum population literature. The empirical study aimed to examine the feasibility and acceptability of a trans-diagnostic emotion regulation (ER) group developed for an acute inpatient setting. Methods: The literature was systematically searched for research related to the measurement of emotion regulation (ER) in a psychosis spectrum population. A mixed method design was employed to assess acceptability and feasibility of a six session ER skills group delivered in an acute mental health inpatient setting. The group intervention was developed and piloted over a 5 month period. The mixed method design included a multiple single case series design and qualitative exit interviews, conducted with eight participants. Results: 24 papers met criteria for inclusion in the systematic review. 15 different self-report tools were identified as measures of ER strategies in this review. Descriptive data from the empirical study indicated high attendance and low attrition rates. Group level analysis identified large effect sizes for change in ER skills. Case series data indicated that sustained change, on at least one measured variable, occurred for four participants. Qualitative themes triangulate findings related to acceptability of the group, change in ER strategies and increased emotional acceptance. Conclusions: ER conceptualisation is variable in the literature reviewed, where the understanding of how ER and psychosis are linked is limited. The emphasis on the literature reviewed is on cognitive strategies of ER. The pilot study indicates that the intervention is feasible and acceptable, with preliminary evidence identifying potential clinical benefits. The challenges in evaluating interventions in an acute inpatient environment are discussed.

Computational modelling has been gaining an increasing amount of support from the neuroscience community as a tool to assay cognition and computational processes in the brain. Lately, scientists have started to apply computational methods from neuroscience to the study of psychiatry to gain further insight into the mechanisms leading to mental disorders. In fact, only recently has psychiatry started to move away from categorising illnesses using behavioural symptoms in an attempt for a more biologically driven diagnosis. To date, several neurobiological anomalies have been found in schizophrenia and led to a multitude of conceptual framework attempting to link the biology to the patients’ symptoms. Computational modelling can be applied to formalise these conceptual frameworks in an effort to test the validity or likelihood of each hypothesis. Recently, a novel conceptual model has been proposed to describe how positive symptoms (delusions, hallucinations and thought disorder) and cognitive symptoms (poor decision-making, i.e. “executive functioning”) might arise in schizophrenia. This framework however, has not been tested experimentally or against computational models. The focus of this thesis was to use a combination of behavioural experiments and computational models to independently assess the validity of each component that make up this framework. The first study of this thesis focused on the computational analysis of a disrupted prediction-error signalling and its implications for decision-making performances in complex tasks. Briefly, we used a reinforcement-learning model of a gambling task in rodents and disrupted the prediction-error signal known to be critical for learning. We found that this disruption can account for poor performances in decision-making due to an incorrect acquisition of the model of the world. This study illustrates how disruptions in prediction-error signalling (known to be present in schizophrenia) can lead to the acquisition of an incorrect world model which can lead to poor executive functioning or false beliefs (delusions) as seen in patients. The second study presented in this thesis addressed spatial working memory performances in chronic schizophrenia, bipolar disorder, first episode psychosis and family relatives of DISC1 translocation carriers. We build a probabilistic inference model to solve the working memory task optimally and then implemented various alterations of this model to test commonly debated hypotheses of cognitive deficiency in schizophrenia. Our goal was to find which of these hypotheses accounts best for the poor performance observed in patients. We found that while the performance at the task was significantly different for most patients groups in comparison to controls, this effect disappeared after controlling for IQ in one group. The models were nonetheless fitted to the experimental data and suggest that working memory maintenance is most likely to account for the poor performances observed in patients. We propose that the maintenance of information in working memory might have indirect implications for measures of general cognitive performance, as these rely on a correct filtering of information against distractions and cortical noise. Finally the third study presented in this thesis assessed the performance of medicated chronic schizophrenia patients in a statistical learning task of visual stimuli and measured how the acquired statistics influenced their perception. We find that patient with chronic schizophrenia appear to be unimpaired at statistical learning of visual stimuli. The acquired statistics however appear to induce less expectation-driven ‘hallucinations’ of the stimuli in the patients group than in controls. We find that this is in line with previous literature showing that patients are less susceptible to expectation-driven illusions than controls. This study highlights however the idea that perceptual processes during sensory integration diverge from this of healthy controls. In conclusion, this thesis suggests that impairments in reinforcement learning and Bayesian inference appear to be able to account for the positive and cognitive symptoms observed in schizophrenia, but that further work is required to merge these findings. Specifically, while our studies addressed individual components such as associative learning, working memory, implicit learning & perceptual inference, we cannot conclude that deficits of reinforcement learning and Bayesian inference can collectively account for symptoms in schizophrenia. We argue however that the studies presented in this thesis provided evidence that impairments of reinforcement learning and Bayesian inference are compatible with the emergence of positive and cognitive symptoms in schizophrenia.

This thesis sought to explore the phenomenon of discontinuing neuroleptic medication for psychosis. It comprises three standalone papers. Papers one and two have been prepared for submission to journals and in accordance with the journal guidelines. Paper one is a systematic literature review synthesising studies investigating the association between neuroleptic discontinuation and functional outcomes. Databases were systematically searched and thirteen studies were included in the review. Evidence regarding the association between discontinuation from neuroleptic medication and functional outcomes was mixed. Findings are limited by the scarcity of evidence, diversity in the study methods and designs used, and methodological and design quality issues. Paper two is a qualitative study exploring personal accounts of making choices about neuroleptic medication, specifically considering decisions to discontinue. Twelve participants were interviewed and a constructivist grounded theory approach was used to analyse transcripts. The findings suggest that making sense of choices relates to a continuation-discontinuation spectrum and involves three interrelated tasks. The tasks are: forming a personal theory of the need for, and acceptability of, neuroleptic medication; negotiating the challenges of forming alliances with others; and weaving a safety net to safeguard wellbeing. A theoretical model explaining the processes involved in the tasks and the mediating factors is presented and discussed. The clinical implications of the findings are discussed with reference to existing literature. Paper three is not intended for publication and is a critical review of the research process, in which the strengths and weaknesses of the systematic review and empirical study are evaluated. Personal and professional reflections on the experience of conducting a systematic review and an empirical qualitative study are discussed and the implications of the research for future clinical practice and research are considered.

The aim of this thesis was to explore the relationship between anger and aggression, insecure attachment, paranoia and social cognition in psychosis. It is presented as three separate papers: 1) a systematic review examining the relationship between paranoia and aggression in schizophrenia spectrum disorders, 2) an empirical study investigating predictors and mediators of trait anger across the psychosis continuum: the role of insecure attachment, paranoia and social cognition and 3) a critical reflection of the research process. Paper one provides a systematic review of the relationship between paranoia and aggression in schizophrenia spectrum disorders. A comprehensive search of the published literature identified fifteen eligible studies. The quality of the included articles is critically appraised during the synthesis of the findings. Methodological limitations, clinical implications and recommendations for future research are considered. Paper two provides an examination of predictors and mediators of trait anger across the psychosis continuum, considering the role of insecure attachment, paranoia and social cognition. Tests of theory of mind and measures of attachment, hostile attribution bias, paranoia and anger were administered to 174 participants (14 ultra-high risk of psychosis, 20 first-episode psychosis, 20 established psychosis and 120 non-clinical). Multiple regression analysis found attachment avoidance, paranoia and hostile attribution bias were significantly related to trait anger. Mediation analysis revealed paranoia mediated the relationship between attachment avoidance and trait anger. The results are discussed with consideration to previous research and limitations of the study. Clinical implications and recommendations for future research are also offered. Paper three provides a critical reflection of papers one and two, with reference to their design, implementation and interpretation. Personal reflections of the research process as a whole are also provided.

The present thesis presents the first known systematic investigation of the personal goals and motivations of people with persecutory delusions. Motivational characteristics of goals are both theoretically implicated in symptom persistence and clinically relevant to the refinement of psychological therapies. Goals motivated by avoidance, rather than approach, and by external motivations rather than internal 'self-concordant' ones, have been implicated in the persistence of depression, and an analogous role in delusion persistence is feasible. Thirty participants with persecutory delusions and schizophrenia-spectrum diagnoses completed measures of depression, anxiety and paranoia, as well as of goals and motivations. It was hypothesised that higher depression scores would be associated with fewer approach motivations, more avoidance motivations and lower self-concordance of goals, as has been found previously in groups without psychosis. A phenomenological profile of participants' personal goals is presented. Two of the three study hypotheses were supported. Higher levels of depression were associated with more avoidance motivations and lower goal self-concordance in the group. An exploratory link of avoidance motivations with paranoia was also identified. The hypothesised association of depression with approach motivations was not found. The findings are consistent with a proposal that avoidant and externally-motivated goal pursuit might contribute to the persistence of persecutory delusions, as well as depression. Therapeutic outcomes may be facilitated by supporting clients to identify self-concordant goals to approach valued achievements, rather than avoiding feared consequences. It is hoped that further research can continue to develop a motivational perspective on the experiences of those holding distressing persecutory beliefs, with the aim of improving psychological therapies for the future.

Objectives. Mindfulness and acceptance-based therapies are becoming increasingly popular in practise and meta-analyses have been conducted to evaluate their effects on a range of mental health difficulties. The purpose of this review was to evaluate the evidence base for mindfulness and acceptance-based therapies in the treatment of distressing auditory hallucinations. Method. Five electronic databases were searched in addition to an internet search engine. Authors of included studies were contacted and reference lists were reviewed. Quality criteria were developed and studies were rated independently by three raters. Results. Nine studies met the inclusion criteria; four controlled studies and five case studies. There was substantial variation in study design and outcomes. Overall, the quality of the studies was poor. Reductions in hallucination-related distress, belief conviction, cognitive appraisals and hallucination proneness were noted. Participants’ ability to respond mindfully to hallucinations increased. Conclusion. Although the results of this review suggest that mindfulness and acceptance-based therapies may result in several beneficial effects, the quality of these studies was poor and the results are likely to have been subject to considerable bias. More research is needed before such therapies can be considered evidence-based treatments for distressing hallucinations. Suggestions for future research are made.

Papers one and two have been prepared for submission to the journal Psychology and Psychotherapy: Theory, Research and Practice. Paper one provided a review of studies investigating staff views about psychosocial aspects of recovery in psychosis. Fifteen studies met the criteria for the review. The first eight studies investigated staff views about recovery in psychosis more broadly. The remaining studies were grouped together according to similarities of recovery themes being investigated. Each study was summarised and critiqued with regards to their findings and limitations. Limitations to the review are also considered. The overall literature is evaluated and discussed with regards to clinical implications and suggestions for future research. Paper two investigated staff and service user views about mindfulness-based cognitive therapy groups for psychosis (MBCT). Q-methodology was used to explore participants’ beliefs about a range of views about MBCT for psychosis and to compare similarities and differences between views. Staff and service user data were analysed separately. Analysis resulted in a single consensus factor for staff views, and four factors for service user views about MBCT for psychosis. Overall, the staff sample strongly disagreed that mindfulness is harmful but were uncertain about its usefulness in the treatment of psychosis. The service user sample advocated the utility of mindfulness interventions for promoting wellbeing and reducing the symptomatic distress associated with psychosis. Paper three provides a critical reflection of the systematic review (paper one), and the empirical paper (paper two). An appraisal of the research process as whole is provided, in addition to how findings from paper one and paper two relate to the wider context of theory, research and practice.

Hallucinations are often considered a sign of psychotic illness, but are also common in other diagnostic groups and individuals without mental health problems. This thesis uses Perceptual Control Theory (PCT), a cybernetic model which explains behaviour and cognition in terms of control processes regulating ongoing perception according to internally represented goals, as a theoretical framework to understand hallucinations. First, a theoretical/conceptual paper (Paper 1) examines how PCT provides an integrated account of (i) the mechanisms responsible for the formation of hallucinations, (ii) their phenomenological heterogeneity, (iii) the interaction between these mechanisms and environmental factors that might contribute to the formation of hallucinations, and (iv) the processes leading to different affective reactions to hallucinatory experiences (e.g. distress). The main implications of this model are discussed in the context of pertinent theoretical and empirical literature, and relevant clinical and research implications are considered. Second, this thesis includes an empirical investigation (Paper 2) examining two PCT-informed hypotheses in a cross-section of 22 clinical and 18 non-clinical individuals with auditory verbal hallucinations (“hearing voices”), namely (i) that the content of voices will be thematically linked to the participants’ personal goals, and (ii) that affective reactions to voices will depend on the extent to which voices facilitate and/or interfere with important personal goals. The analysis revealed that 82.5% of participants reported voices that thematically matched at least one of their reported goals. As predicted, affective reactions to voices were strongly associated with measures of interference and facilitation of goals, even when controlling for important covariates (e.g. participants’ history of mental health difficulties; voices’ content, frequency and duration).Finally, a critical evaluation is provided (Paper 3), where the methodological strengths and limitations of the work presented in the present thesis are discussed with the aim to reflect on the research process, and inform future investigations into the topics considered in this thesis.

The aim of this thesis was to explore the relationships between the constructs of self-compassion (SC), self-esteem (SE) and recovery in psychosis. It is presented to the reader as three separate papers. 1) A systematic literature review exploring the relationships between SE and the positive symptoms of psychosis, 2) an empirical study investigating SC, SE, recovery in psychosis and positive psychotic symptoms and 3) a critical appraisal and personal reflection of the processes involved in conducting the research. Paper one presents a systematic review of the existing literature that explores the relationships between SE and the positive symptoms of psychosis. Thirty-four articles were identified which met the strict criteria. The evidence was mixed and much of it inconclusive. There was some support for the relationship between SE and delusions, in particular paranoia. The evidence for hallucinations was much less conclusive. Recommendations for future research were suggested as were potential clinical implications which arose from the review. The empirical study presented in paper two explores the relationships between SE, SC and recovery in psychosis, and aimed to assess whether SC was a unique predictor of recovery in psychosis, over and above the impact of SE (using cross-sectional and longitudinal analysis). Further exploratory analysis was conducted to ascertain whether specific positive symptoms of psychosis were related to SC and SE. At baseline, the results indicated that SC did not contribute unique variance in recovery from psychosis over and above that attributable to SE. Longitudinally, SC at baseline was not related to recovery at follow up. Exploratory analysis revealed levels of SE and SC were significantly different in groups who had a presence or absence hallucinations, but not delusions. Methodological strengths and limitations, clinical implications and ideas for future research discussed. Paper three provides the reader with a critical reflection of the processes involved in the undertaking of the two papers presented. Implications for clinical practice are discussed as well as directions for future research.

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.

This thesis aimed to explore service users’ priorities and preferences for treatment of psychosis-spectrum difficulties, and experiences of Cognitive Behavioural Therapy (CBT). A literature review (Chapter 1) summarised current understanding and treatment of psychosis. A narrative review of qualitative studies examined treatment priorities and preferences of people with experience of psychosis (Chapter 2), and found that common priorities and preferences included improving social and functional ability, reducing symptoms of psychosis, and individualised, collaborative approaches to care, including alternatives to routine psychiatric treatment. A Delphi study of priorities and preferences for treatment of psychosis was conducted (Chapter 3), and identified priorities that included improving difficult emotional and cognitive states, understanding, coping, and self-esteem, along with treatment preferences such as individualised, collaborative care, greater provision of information, and choice of treatment. Three qualitative studies were conducted. The first (Chapter 4) explored the subjective experiences of young people seen in an Early Detection (ED) for psychosis service. Findings indicated that reluctance to communicate mental health concerns delayed help-seeking for the majority of participants. Disclosure of such concerns to staff in the ED service was considered helpful, especially in the context of CBT. The second qualitative study (Chapter 5) explored subjective experiences of CBT for psychosis. CBT-specific processes were summarised as ‘structured learning’, and the most commonly perceived benefits included improved understanding of psychosis and self, and normalisation. The ‘hard work’ of CBT was also highlighted, especially the disclosure and discussion of difficult life experiences and psychological problems. The third qualitative study (Chapter 6) evaluated experiences of involvement in a randomised trial of CBT for young people at risk of developing psychosis. Having a ‘chance to talk’ about mental health concerns was consistently valued by participants in both the control and the treatment arm of the trial. Valued experiences of CBT included ‘rethinking things’, especially through psychological formulation and re-appraisal of distressing beliefs. Participants also described difficult aspects of CBT, such as personal disclosure, though these were often considered necessary for recovery. Across studies, the importance of individualised, collaborative treatment was highlighted consistently. It is also evident that along with reductions in distressing psychological problems, participants across studies also highly valued social and functional aspects of recovery. The methodological limitations and strengths of these studies, along with implications for clinical practice and future research, are discussed.

This thesis explored conceptualisations of recovery, associated psychological factors and predictors, measurement of subjective recovery, and attitudes towards recovery. A multi-method approach was utilised, including reviewing evidence from the existing literature, cross-sectional, survey and longitudinal designs, and a computer based implicit association task. Chapter 1 provided a review of the literature, followed by an overview of the methodology employed throughout this thesis in chapter 2. Chapter 3 (study 1) included a user informed review of existing recovery measures. The Recovery Assessment Scale appeared to be the most valid and acceptable measure currently in use, although the Questionnaire about the Process of Recovery (QPR) received particularly positive feedback from service users, but lacked further psychometric validation. Consequently, chapter 4 (study 2, N=335) went on to explore the psychometric properties of the QPR. Exploratory factor analysis suggested a one factor model with high internal consistency, test re-test reliability and convergent validity. Recommendations for the use of the QPR in routine clinical practice was discussed. Chapter 5 (study 3, N=381) utilised the Delphi method to consult a large sample of service users about their views on recovery. A high level of consensus (>80%) was reached for a number of items on defining recovery, factors which help and hinder recovery and factors which show recovery. Implications for clinical practice and future research are discussed. Chapter 6 (study 4, N=110) examined longitudinal predictors of recovery. Negative emotion, positive self-esteem, hopelessness, and to a lesser extent symptoms and functioning predicted subjective recovery. Psychosocial factors and negative emotion appear to be the strongest longitudinal predictors of subjective recovery. Chapter 7 (study 5, N=146) used an online survey and computer task to explore attitudes towards recovery in health professionals and the general public. Explicit attitudes towards recovery were generally positive, with health professionals having significantly more positive attitudes than the general public group. Positive attitudes towards recovery were predicted by greater knowledge of recovery and a preference for psychosocial causal models of psychosis. Implications for focussing on psychosocial causal explanations in recovery training and awareness programmes for health professionals and the general public are discussed. This thesis has advanced our understanding of recovery by reaching consensus about what recovery means to individuals with experiences of psychosis, evaluating tools for measuring recovery and determining some of the key psychological processes and predictors of recovery, including causal beliefs, locus of control and negative emotion. These findings appear to fall into four main themes: conceptualising and defining recovery, measurement of recovery, relationships between psychological processes and recovery, and facilitating recovery. Further research is needed to explore recovery across the continuum of psychosis and investigate recovery focussed interventions which target the key psychological processes identified throughout this thesis.

This thesis explored how psychosis stigma affects the psychological wellbeing of young people at risk of psychosis and people with psychosis. The efficacy of psychosocial methods to reduce stigma in young people were explored. Multiple methods were used including qualitative, cross sectional, longitudinal and a randomsied controlled trial. Chapter 1 included a comprehensive review of the literature on stigma. Chapter 2 provided a review of the methodology used throughout the thesis. Study 1 (Chapter 3) examined the subjective experience of psychosis using Interpretative Phenomenological Analysis. Three super ordinate themes of judgment, disclosure and psychological distress were identified. Analysis of the data suggested a directional relationship between the themes with societal judgments, affecting issues of disclosure and judgment and disclosure issues increasing psychological distress. Possible exits from distress were suggested. Study 2 (Chapter 4) explored relationships between internalised stereotypes (IS) of psychosis and emotional dysfunction in people at risk of developing psychosis. Correlational analyses indicated significant relationships between IS, depression, social anxiety, and distress. Multiple regression analyses indicated that baseline IS predicted depression at follow up. Results suggested that IS may increase psychological distress and in particular depression in young people at risk of psychosis. Study 3 (Chapter 5) explored relationships between IS and emotional dysfunction in people with psychosis not taking antipsychotic medication. The findings revealed significant positive relationships between IS, depression and social anxiety. Multiple regression analysis suggested that baseline IS predicted depression at follow-up but this did not remain significant when controlling for baseline depression. These results replicate the findings of previous research carried out in other psychosis populations. Study 4 (Chapter 6) explored differences in the level of IS and the strength of relationship between IS and emotional dysfunction, between those at risk of psychosis and those with psychosis. Results of the cross sectional analysis indicated no significant differences between the groups on level of IS or on the strength of correlation between IS and emotional dysfunction. This interesting find suggests that young people at risk of psychosis may be internalising stereotypes early and before official diagnostic labels are applied. Study 5 (Chapter 7) examined the efficacy of internet based anti-stigma interventions for young people. Results indicated a non-significant trend towards reduction in stigma, immediately post intervention for the contact and psychosocial educational conditions, however superiority over control was not demonstrated. Findings indicated that internet based interventions for this group should be brief and ensure maximum engagement. This thesis has demonstrated that stigma affects the wellbeing of people whose experiences exist along the psychosis continuum. Research is required to better understand the feasibility and efficacy of clinical and mass media interventions to reduce the negative effects of stigma in people with psychosis and the public.

Research demonstrating the positive effects of Mindfulness-Based Interventions (MBIs) has led to a growing interest in the use of mindfulness across a range of populations and psychological difficulties. This thesis explores the feasibility and benefits of mindfulness in relation to self-esteem and psychosis. Paper one is a systematic review exploring the relationship between mindfulness and self-esteem. The review had two main aims: to synthesise and critically appraise studies exploring the association between mindfulness and self-esteem, and studies investigating the impact of MBIs on self-esteem. Thirty-two studies were identified and quality assessed to guide interpretation of results. All cross-sectional studies found significant positive correlations between dispositional mindfulness and self-esteem, whilst improvements in self-esteem were found in the majority of MBI studies. Despite largely positive findings, the review highlighted the need to interpret these with caution due to methodological weaknesses. Priorities for research were identified, with further investigations needed to assess the impact of mindfulness as an intervention for low self-esteem. Paper two is an empirical paper investigating the feasibility of Mindfulness-Based Cognitive Therapy (MBCT) for psychosis. Sixteen participants, with experience of psychosis, completed an 8-week MBCT group. A repeated measures design was used to explore psychological wellbeing and clinical outcomes following MBCT, including clinical functioning, mindfulness, psychotic symptoms, recovery, beliefs about self, others and voices; and to provide a preliminary exploration of changes in the way a person construes their self, others and their experience of psychosis, following MBCT, using repertory grids. Findings from this feasibility and pilot study were promising, indicating that MBCT groups for psychosis are feasible. Preliminary outcome data highlighted potential areas of change for further investigation in a large scale controlled trial, with possible improvements in participants’ self-reported ability to act with awareness and in recovery, and with some evidence of changes in construing following MBCT. The study demonstrated the feasibility and potential benefits of MBCT groups for people experiencing psychosis, and provided a platform for future research. Paper three is a critical reflection of the papers presented and the research process as a whole. Areas of strengths and weaknesses are highlighted, with an evaluation of the decisions made throughout. The implications for clinical practice are discussed as well as areas for further research.