Rozprawy doktorskie na temat „Mental illness Diagnosis”

For years research has demonstrated a varying incidence of medical disorders manifesting with psychiatric symptoms. A relatively conservative estimate of such so called "medical masquerades" is around 10%. It is important to ascertain whether health care professionals are aware of possible medical masquerades perhaps most especially in a mental health center outpatient setting where non-medically trained clinicians are the first line therapists for treatment in the majority of cases. This study set about to find out how aware three types of health care clinicians (psychiatrists, nonpsychiatrically trained medical doctors, and non-medically trained mental health psychotherapists) are of the prevalence of medical masquerades, and whether these three types of clinicians perform differently on three types of clinical vignettes (psychiatric, somatoform, and medical masquerades). Results revealed that all health care professionals surveyed are aware that there are a percentage of medical masquerades in the clinical population. Results also revealed that the three types of clinicians performed differently on the case vignettes.

Cognitive theory of depression predicts that the illness is associated with an information processing bias that interprets ambiguous information in a mood-congruent or depressive fashion. This negative interpretative bias may serve as a vulnerability factor or maintenance mechanism for a depressive illness. The majority of studies investigating such interpretative biases rely primarily on subjective experimental methodologies (eg., evaluative feedback and self-report) that are vulnerable to experimenter demand effects, response selection biases, and the influence of autobiographical memories. In addition, the results from these studies have been mixed, leading to no firm evidence for the existence of a depression-linked interpretative bias for ambiguous material. In order to avoid the limitations that have plagued subjective research, the present study utilised two of the most promising objective physiological measures of assessing interpretation: the Rapid Serial Viewing Presentation (RSVP) procedure and the affective modulation of the human eye blink reflex. The modified RSVP experiment recorded the reaction time of participants reading a textual scenario that was composed of an opening ambiguous sentence and various emotionally valenced continuations. Interpretation of the ambiguous sentence could be inferred from the reaction time as comprehension latency is inversely related to perceived plausibility. The affective modulation experiment recorded the blink amplitudes of participants startled while performing an imagery task. Blink amplitudes are augmented by negative stimuli and inhibited by hedonic stimuli. Thus, the affective interpretation of ambiguous stimuli could be inferred from the size of the recorded blink response. The results of both experiments did not support the predictions made by cognitive theory. There was no difference in the reaction time responses to the various textual stimuli between 2 depressed outpatients and healthy controls. However, antidepressant medication did have an influence upon the ability of patients to correctly judge the plausibility of the emotionally valenced continuation sentences. With regard to the eye blink experiment, there was also no difference between the depressed outpatients and the controls in terms of size of blink amplitude to the various categories of affective stimuli. Depressive, ambiguous, and distorted stimuli did not augment blink amplitudes in healthy controls or depressed patients without social anxiety disorder. However, depressed patients with a comorbid diagnosis of social anxiety disorder did react to the ambiguous stimuli in an aversive and anxious manner as indicated by increased blink amplitudes. This may be due to the social aspect of the experimental context, which engenders fears of evaluation and performance anxiety. The eye blink procedure can therefore be compromised by group selection, as the comorbidity of anxiety and depression can confound the investigation of depression-linked interpretative biases. In addition, the failure of depressive stimuli to augment blink amplitudes may render the procedure insensitive to the selection of such biases

Mental major illness, including psychotic disorders and mood disorders, has been linked to early prenatal/childhood factors and subsequent behavioral health concerns. For example, Watson et al. (1999) found that maternal illness and extreme stress during pregnancy disrupts fetal brain development, increasing the likelihood of depression or schizophrenia in later life. Research has also shown a dose-response effect between the number of adverse childhood experiences (ACEs) and mental health outcomes, with increasing ACEs linked to more severe mental health problems and suicide attempts (Merrick et al., 2017). Persons with major mental illness, like schizophrenia or bipolar disorder, are also at increased risk of suicidal and self-harm behaviors (Happell et al., 2012; Morden et al., 2009). These individuals also demonstrate a higher rate of substance use (Linszen et al., 1995) that often contributes to poor medical health (Dixon et al., 2000; Jeste et al., 1996). The current study sought to differentiate adolescents with and without major mental illness (i.e., psychotic or mood disorders) by investigating a sample of youth who were in a residential treatment facility for sexually abusive behaviors (N = 296). Data related to participants’ prenatal/birth concerns, ACE scores, history of suicide attempts and self-harm, and use of alcohol, tobacco, marijuana, and inhalants were gathered from archival records. Results indicated that there were a number of adolescents diagnosed with a psychotic disorder (n = 33) or mood disorder (n = 189). Two separate logistic regressions assisted with differentiating adolescents with and without psychotic or mood disorders using the specified predictors. A significant model (χ2 = 94.910, Nagelkerke’s R2 = 0.412, p < 0.001) correctly classified 76.4% of participants with a mood disorder. Adolescents with a mood disorder were 4 times as likely to have had prenatal or birth concerns (OR: 4.404, p < 0.001), and were significantly more likely to have higher ACE scores (OR: 1.148, p =.024). Further, those with a mood disorder were 2.5 times as likely to have self-harmed (OR: 2.673, p=.009), and approximately 23 times more likely to have attempted suicide (OR: 22.858, p=.003). Another significant model (χ2 = 29.842, Nagelkerke’s R2 = 0.210, p < 0.001) correctly classified 88.3% of participants with a psychotic disorder. Adolescents with a psychotic disorder diagnosis were significantly more likely to have higher ACE scores (OR: 1.237, p =.020), and were 4 times as likely to have a self-harm history (OR: 4.474, p=.005) compared to those without a psychotic disorder. Results indicate that prenatal/birth concerns appear to be a significant factor for those who are diagnosed with a mood disorder, but not with a psychotic disorder. Also, those with mood disorders, but not psychotic disorders, were more likely to have attempted suicide. Adolescents with either a mood or psychotic disorder both tended to self-harm and have experienced more ACEs. Interestingly, substance use was not higher among adolescents with mood or psychotic disorders, despite predictions and previous research findings.

Schizophrenia is a debilitating mental illness that strikes approximately 1 in 100 people in the population during their lifetimes. It is an illness that can have a severe impact on the sense of self of people affected. It is the purpose of this thesis to examine the processes by which such a sense of self is disrupted, rebuilt and maintained in people diagnosed with schizophrenia. Twelve people diagnosed with schizophrenia were interviewed with regards to the ongoing impact of their illness. In particular, interviews focused on processes relevant to their sense of identity before, during and after the diagnosis of schizophrenia. The thesis also thematises issues of power and social structure surrounding the person diagnosed with schizophrenia. It was found that, after medication, a number of social processes were important to rebuilding a sense of identity. These included the development of illness narratives, interaction with family and friends, illness management, life management, the setting of life goals and, in some cases, participation in organised religion. Identity was typically maintained through processes of stigma concealment and passing. The influence of psychiatrists, psychopharmaceutical companies and a deinstitutionalised environment in which severe mental illness is treated all emerged as significant factors in the process of rebuilding a sense of identity. The thesis seeks to make contributions to the sociology of schizophrenia and severe mental health concerns more widely. In particular, it deploys concepts of biographical crisis to make sense of the intensity of identity disruption people diagnosed with schizophrenia may experience. It also seeks to revise the perspectives of symbolic interactionism and phenomenology to better understand the emotive and embodied nature of identity processes in schizophrenia. Beyond this, the thesis explores the relationship between language, power and agency and its significance in shaping the experience of the patient diagnosed with schizophrenia. The concept of negotiated power networks is put forward to help make sense of these power relationships in a deinstitutionalised environment. Finally, the thesis proposes the concept of identity work as a way of understanding the operations of agency and relevant processes affecting identity.

This study examined the clinical utility of the recently released National Institute of Mental Health's (NIMH) research domain criteria (RDoC) by replicating and extending earlier work by using a demographically novel sample. Information retrieval and natural language processing of archival clinical records was used to achieve two main objectives: (1) estimate how well the RDoC domains match language used by clinicians by creating domain scores and (2) examine the differences between the DSM's and RDoC's ability to predict treatment outcome using these domain scores and DSM diagnoses. The social systems RDoC category was found to be the strongest predictor of treatment outcome across all diagnostic measures.

Dual Diagnosis (DD) refers to the co-existence of a Severe Mental Illness (SMI) and a Substance Use Disorder (SUD) in the same individual. The comorbid prevalence of these two diagnoses is very common, with Schizophrenia (SZ), Bipolar Disorder (BD), and Major Depressive Disorder (MDD) as the three most prevalent SMI among patients with SUD. The co-existence of SUD and these SMIs includes several clinical characteristics, related to evolution and prognosis, which may complicate a patient`s recovery from both disorders. However, nowadays there is an evident need to carry out studies that provide both theoretical and practical knowledge transferable to the clinical management of patients with DD. The present study aimed, as the first objective, to study personality characteristics in a sample of patients with SUD taking into account their comorbid SMI. We evaluated a sample of 104 male patients undergoing SUD treatment, considered in three groups according to the comorbid SMI: SZ+ Group (SUD and SZ; N=37), BD+ Group (SUD and BD, N=32), and MDD+ Group (SUD and MDD; N=35). Two instruments were used to measure personality, the Cloninger's Temperament and Character Inventory-Revised (TCI-R) and the Zuckerman-Kuhlman Personality Questionnarie (ZKPQ), both based on psychobiological models. In addition, we explored the influence of the SMI in the relationship among personality and clinical variables related to both SUD and SMI diagnoses. Our second objective was to explore the influence of DD in the coping strategies used in relation to addiction treatment. SUD treatment represents a challenging situation for all patients, but given DD clinical complications, we studied the possible differential profile in the coping strategies used between patients with SZ+ (the most prevalent diagnosis in our sample) and SUD only. To elucidate the influence of comorbidity, a sample of 89 male patients undergoing treatment for addiction was included and distributed in two groups: SZ+ Group (SUD and SZ; N=39) and SUD Group (SUD only; N=43); these patients were assessed using the Coping Strategies Inventory (CS) from Tobin and completed an exhaustive clinical evaluation as well. The main personality results indicate that patients with SZ+ are characterized by an increased anxiety and fear of uncertainty (high Harm Avoidance from the TCI-R), difficulties in persevering when facing frustration and fatigue (lower Persistence from TCI-R), and the preference for solitary activities or small groups (lower Sociability from ZKPQ). Our findings suggest that patients with SZ+ are the ones who would especially need strategies to manage negative expectations and anxiety, motivational strategies, and if possible, a gradual incorporation to the group therapy sessions used during SUD treatment. Regarding personality characteristics for patients with BD+, these are characterized by an exploratory activity in response to novel stimulation, being more impulsive, getting easily bored, and by the willingness to experiment strong emotions for the sake of these types of experiences (high Novelty Seeking from the TCI-R and Impulsivity- Sensation Seeking from the ZKPQ). In addition, BD+ diagnosis is highlighted by a higher level of worries, fears, tension, and general emotional upset (high Neuroticism-Anxiety from the ZKPQ). Therefore, patients with BD+ are the ones who would require a therapeutic approach which emphasizes impulsivity management, as well as, achieving the general activity and stimulation they require. Finally, considering patients with MDD+, these are characterized by being more pragmatic, realistic, having an unstable self-image, and an erratic world-view (lower Self-transcendence from the TCI-R). Taking also into account that in previous studies a lower Self-transcendence is linked to worse general well-being and dropping-out SUD treatment, it may be suggested that interventions with MDD+ patients could benefit from therapeutic strategies that aim to increase creativity and spirituality, which are both associated with a higher Self-transcendence. With regards to the main relationships founded among personality and SUD and SMI clinical variables, we observed that such relationships are also influenced by the type of comorbid SMI. Results from the TCI-R indicate that higher scores in Novelty Seeking for patients with BD+ are related to a higher severity of addiction. Harm Avoidance is only linked to clinical variables for patients with SZ+, with a higher Harm Avoidance in patients having a greater presence of negative symptoms and general psychopathology. While Persistence did not show any clinical implications for none of the groups, Self- transcendence only showed clinical implications for the MDD+ group, in which a later age of SUD onset is associated with a lower Self-transcendence. Regarding results from the ZKPQ, we observed a positive relationship between Neuroticism-Anxiety and manic symptoms for patients with BD+, and the number of suicide attempts for patients with SZ+. Lastly, a higher Sociability is related to a later age of SUD onset for patients with SZ+, and to a later age of SMI onset for patients with MDD+. The study about coping strategies using the CSI in patients with SZ+, revealed that they are less likely to employ Engagement Strategies (Problem Solving and Social Support) and they have a lower self-perceived capacity to cope with treatment, compared with patients with SUD only. Among patients with SZ+, a major use of the Problem Solving strategy is related to a later age of SUD onset, and the self-perceived capacity to cope with treatment is negatively linked to severity of addiction and to positive symptoms. According to normative data, both groups (SUD and SZ+) use the Disengagement Strategy of Self-Criticism frequently; although the use of Self-Criticism was lower for patients with SZ+. Additionally, a higher use of Self-Criticism is related to a higher daily amount of medications for the SZ+ group. Hence, the presence of DD is associated with a lower use of active coping strategies and points to the need of training problem solving strategies, as well as, abilities to seek for social support during SUD treatment of patients with SZ+. Working on these two strategies could potentially improve treatment adherence and therapeutic outcomes. In conclusion, the findings of this thesis showed that patients with DD have different personality characteristics depending on their comorbid SMI diagnosis. Moreover, the relationship among personality and SUD and SMI clinical variables is also influenced by the type of SMI. Our findings extend to the DD field previous data about personality dimensions as potential endophenotypes for SZ (high Harm Avoidance) and BD (high impulsivity). Likewise, we observed the potential endophenotypes for developing an addiction (high Novelty Seeking and Impulsivity-Sensation Seeking, which are suggested especially for alcohol SUD) in polydrug users, regardless of the main SUD´s substance and adding nuances according to the comorbid SMI. On the other hand, a lower use of active coping strategies in relation to addiction treatment for patients with SZ+ extends to the DD field previous observations done in patients with SUD only and with SZ. Our data point to the potential usefulness of working different aspects, related to personality and coping, during DD treatment considering the comorbid SMI. However, future research is needed to advance in those lines of research, as well as, to overcome the limitations of our work. Additional studies should include a clinical, personality, and coping assessment, and longitudinal measures combined with objective data such as genetic polymorphisms and functional neuroimaging.
El concepto de Patología Dual (PD) hace referencia a la concurrencia de un Trastorno Mental (TM) y un Trastorno por Uso de Sustancias (TUS) en una misma persona. La prevalencia conjunta de estos dos diagnósticos es muy frecuente, siendo los tres TM severos comórbidos más prevalentes en pacientes con TUS la Esquizofrenia (SZ), el Trastorno Bipolar (TB) y el Trastorno Depresivo Mayor (TDM). La coexistencia del TUS y estos TMs conlleva una serie de características clínicas, de evolución y pronóstico, que dificultan la recuperación del paciente en ambos trastornos. Sin embargo, en la actualidad existe una necesidad evidente de realizar estudios que aporten tanto conocimiento teórico como trasladable al manejo clínico de los pacientes con PD. El presente trabajo se propuso, como primer objetivo, estudiar las características de personalidad en una muestra de pacientes con TUS atendiendo al diagnóstico de TM severo comórbido. Evaluamos una muestra de 104 pacientes hombres en tratamiento para el TUS, considerados en tres grupos según el diagnóstico de TM severo comórbido: Grupo SZ+ (TUS y SZ; N=37), Grupo TB+ (TUS y TB; N=32) y Grupo TDM+ (TUS y TDM; N=35). Se utilizaron dos instrumentos de medición de la personalidad, el Temperament and Character Inventory-Revised (TCI-R) de Cloninger y el Zuckerman-Kuhlman Personality Questionnarie (ZKPQ), ambos basados en modelos psicobiológicos. Además, se exploró la influencia del TM en la relación entre personalidad y variables clínicas tanto del TUS como del TM. Nuestro segundo objetivo consistió en explorar la influencia de la PD en las estrategias de afrontamiento utilizadas en relación al tratamiento de la adicción. El tratamiento para el TUS representa un desafío para todos los pacientes, pero dadas las complicaciones clínicas de la PD se estudió el posible perfil diferencial de las estrategias de afrontamiento entre pacientes con SZ+ (diagnóstico más prevalente en nuestra muestra) y con sólo TUS. Para elucidar la influencia de la comorbilidad, se incluyó una muestra de 89 pacientes hombres en tratamiento para la adicción considerados en dos grupos: Grupo SZ+ (TUS y SZ; N=39) y Grupo TUS (N=43), a quienes se les aplicó el Coping Strategies Inventory (CSI) de Tobin junto con una exhaustiva evaluación clínica. Los principales resultados sobre personalidad indican que los pacientes con SZ+ destacan por una mayor ansiedad y temor a la incertidumbre (elevada Evitación del Riesgo del TCI-R), dificultad para perseverar ante la frustración y la fatiga (menor Persistencia del TCI-R) y preferencia por actividades en solitario o en grupos pequeños (menor Sociabilidad del ZKPQ). Nuestros hallazgos sugieren que los pacientes con SZ+ son quienes necesitarían especialmente de estrategias de manejo de expectativas negativas y ansiedad, de estrategias motivacionales y, siempre que sea posible, una incorporación paulatina a las sesiones grupales utilizadas durante el tratamiento para el TUS. Respecto a las características de personalidad de los pacientes con TB+, éstos destacan por la excitación frente a estímulos novedosos, ser más impulsivos, aburrirse fácilmente y poseer una necesidad de experimentar sensaciones fuertes por el mero hecho de vivirlas (elevadas Búsqueda de Novedad del TCI- R e Impulsividad-Búsqueda de Sensaciones del ZKPQ). Además, el diagnóstico de TB+ destaca por un mayor nivel de preocupaciones, miedos, tensión y malestar general (elevado Neuroticismo-Ansiedad del ZKPQ). Por tanto, serían especialmente los pacientes con TB+ quienes requieren de un énfasis terapéutico en el manejo de la impulsividad y en la búsqueda de la activación y estimulación que necesitan. Finalmente atendiendo a pacientes con TDM+, éstos se caracterizan por ser más pragmáticos, realistas, poseer una imagen más inestable de sí mismos y una visión más errática del mundo (menor Trascendencia del TCI-R). Considerando además que en estudios previos se ha relacionado una menor Trascendencia con peor bienestar general y con el abandono del tratamiento para el TUS, cabe sugerir que las intervenciones con estos pacientes se podrían beneficiar de incluir estrategias terapéuticas que incrementen la creatividad y la espiritualidad, ambas asociadas a una mayor Trascendencia. Respecto a las principales relaciones encontradas entre personalidad y variables clínicas del TUS y del TM, observamos que éstas también se hallan influenciadas por el tipo de TM severo comórbido. Los resultados del TCI-R indican que las puntuaciones superiores en Búsqueda de Novedad de los pacientes con TB+ se asocian a una mayor gravedad de la adicción. La Evitación del Riesgo sólo se relacionó con variables clínicas en pacientes con SZ+, siendo ésta más elevada cuanto mayor es la presencia de síntomas psicóticos negativos y de psicopatología general. Mientras que la Persistencia no mostró relaciones con variables clínicas en ningún grupo, la Trascendencia sólo mostró implicaciones clínicas en el grupo con TDM+, en el cual, una mayor edad de inicio del TUS se asoció a una menor Trascendencia. Respecto a los datos aportados por el ZKPQ, observamos una relación positiva entre el Neuroticismo-Ansiedad y la presencia de síntomas maníacos en pacientes con TB+, así como con la cantidad de intentos de suicidio en pacientes con SZ+. Finalmente, una mayor Sociabilidad se relaciona con una edad más tardía de inicio del TUS en pacientes con SZ+ y de inicio del TM en pacientes con TDM+. El estudio de estrategias de afrontamiento mediante el CSI en pacientes con SZ+ mostró que éstos utilizan con menor frecuencia estrategias de Manejo Adecuado del problema (Resolución de Problemas y Apoyo Social), y perciben que tienen menor capacidad para afrontar el tratamiento respecto a pacientes con sólo TUS. En pacientes con SZ+ un mayor uso de la estrategia de Resolución de Problemas se relaciona con una edad de inicio de TUS más tardía, y la capacidad para afrontar el tratamiento se asocia negativamente a la gravedad de la adicción y a los síntomas psicóticos positivos. Según baremos normativos ambos grupos (TUS y SZ+) recurrían muy frecuentemente a la estrategia de Manejo Inadecuado de Autocrítica, aunque su uso era menor en pacientes con SZ+. Además, una mayor Autocrítica se relaciona con más cantidad diaria de medicación en SZ+. Por tanto, la presencia de PD se vincula a un afrontamiento del tratamiento para la adicción menos activo y apunta a la necesidad de entrenar a los pacientes con SZ+ en el uso de estrategias de resolución de problemas y búsqueda de apoyo social durante su tratamiento para el TUS, pudiendo ello mejorar tanto la adherencia como la respuesta terapéutica. Como conclusión, los hallazgos de esta tesis muestran que los pacientes con PD difieren en las características de personalidad según su diagnóstico de TM severo comórbido. Además, la relación entre la personalidad y las variables clínicas del TUS y TM también se halla modulada por el tipo de TM. Nuestros resultados extienden al ámbito de la PD los datos previos sobre dimensiones de personalidad como posibles endofenotipos de la SZ (elevada Evitación del Riesgo) y del TB (elevada impulsividad). Así mismo, los posibles endofenotipos de personalidad para el desarrollo de la adicción (elevadas Búsqueda de Novedad e Impulsividad-Búsqueda de Sensaciones, que se sugieren especialmente para el TUS por alcohol) los observamos en pacientes policonsumidores, con independencia del tipo de sustancia principal del TUS, añadiendo matices según el TM severo comórbido. Por otra parte, el menor uso de estrategias de afrontamiento activas en relación al tratamiento de la adicción en pacientes con SZ+ extiende al ámbito de la PD observaciones previas realizadas en pacientes con TUS y con SZ. Los datos apuntan a la posible utilidad de trabajar aspectos diferenciales, relacionados con la personalidad y el afrontamiento, durante el tratamiento de la PD atendiendo al TM severo comórbido. Sin embargo, para poder progresar en esta área y superar las limitaciones de nuestros estudios, se requieren futuras investigaciones que, junto con la evaluación clínica, de personalidad y afrontamiento, incluyan registros longitudinales y medidas objetivas como polimorfismos genéticos y de neuroimagen funcional.

Past literature has showed that there have been several misdiagnosis of mental illness due to client’s delays in speech or introspection caused by an intellectual disability. It is believed that the intellectual disability is either interfering with the proper mental health diagnosis or a mental health diagnosis is unnecessarily being added to an intellectual disability. The study used a qualitative design that asked four psychiatrists on how they are treating their clients with an intellectual disability in addition to their mental illness. The interview guide asks about the difficulty in diagnosing individuals with a mental illness and a co-occurring intellectual disability. The proportion of clients also having an intellectual disability and co-occurring mental illness ranged from 5 to 20%. The problems that psychiatrists are running into are the fact that patients are not being correctly diagnosed before the age of 18 and are not able to get the resources that are needed, such as Inland Regional services.

Thesis (Ph. D.)--Ohio State University, 2005.
Title from first page of PDF file. Document formatted into pages; contains xii, 168 p.; also includes graphics (some col.) Includes bibliographical references (p. 152-168). Available online via OhioLINK's ETD Center

This study tested whether participants exposed to a vignette describing an individual experiencing symptoms of depression, which included only the specific diagnosis label of "depression," would report significantly less stigmatized responses than participants exposed to an otherwise identical vignette which included only the non-specific diagnosis label "mental illness." The study is grounded in past research on stigmatization of mental illness and is informed by three theoretical frameworks, the social identity perspective, attribution theory, and labeling theory. Participants were randomly assigned to read one of the two alternate vignettes, then respond to a series of measures testing desire for social distance, negative emotion (affective reaction), beliefs about people with mental illness, and perceived dangerousness of the character in response to the vignette they viewed. The results showed that labelling the character in the vignettes as struggling with "mental illness" did lead to greater perceived dangerousness of the character described, although labelling did not lead to more stigmatization in any of the other measures. This research demonstrated that people tend to consider a character in a vignette as less trustworthy and more of a risk based solely on the label "mental illness." The experiment also tested if people who have had a personal relationship with someone who has experienced mental illness will have less stigmatized responses to mental illness vignettes, but no significant difference was shown. Overall, the results imply that use of specific language in communication labelling an individual as experiencing a mental health condition is less stigmatizing than non-specific language and may improve chances for successful treatment-seeking and future patient outcomes.

Contrary to the long-held assumptions, borderline personality disorder (BPD) is now considered a treatable disorder. Timely assessment has been recognised as one of the key treatment enablers and basic assessment standards have been stipulated by the UK’s National Institute for Health and Clinical Excellence (NICE). The current study was the first to have specifically investigated the quality of the diagnostic process in light of the government recommendations. Interpretative phenomenological analysis was used to analyse semi-structured interviews with eight adult female service users about their lived experiences with the original diagnostic disclosure of BPD. Five master themes and several subthemes featured in the majority of the participants’ experience: a) answer with a question mark; b) if only…; c) BPD like a star sign; d) star signs are not enough; it’s what happens afterwards!; e) being at the mercy of the system. Most participants’ experiences suggested that the original diagnostic process was largely negative and did not follow the national guidelines. Nevertheless, a minority of positive views also emerged. The findings are discussed with reference to the existing literature, whilst also detailing the study’s limitations, clinical and research implications.

Research in several domains has revealed that when individuals are asked to estimate the probability that their judgments are correct, they reveal an overconfidence effect. Judgments produced in decision environments such as psychodiagnosis, which are by their nature ambiguous and complex, appear to be most vulnerable to overconfidence. By implication, this phenomenon threatens the validity of clinical judgment and subjects clients to risks of flawed diagnoses and unsuitable treatments.
In an effort to identify variables implicated in judgment confidence and overconfidence, this study examined the relationship between four different inferential biases (dispositionalism, confirmationism, truncated data search, and narrow problem formulation) and diagnostic confidence in the context of a psychological assessment task. A second aspect of this study examined the effect of clinical experience on psychodiagnostic confidence. Thirty-six clinicians (18 experienced professionals and 18 clinical trainees) were individually presented a written client casefile, which was segmented and serially presented, to read and clinically interpret aloud. Analyses of participants' verbal protocols revealed that one of the four inferential biases studied (i.e., dispositionalism) accounted for a significant proportion of the variance in psychodiagnostic confidence scores. The author concludes that other clinician variables likely moderate the relationship between particular heuristics and judgment confidence. Regarding the second hypothesis, the data revealed no difference between experienced clinicians and clinical trainees in the degrees of psychodiagnostic confidence manifested in their verbal protocols.
The author proposes that effective remedies to overconfidence begin in training programs that lead students through problem-solving experiences that can invalidate facile, premature, and dubious diagnostic judgments. The author delineates a number of strategies that may be used by educators to achieve this end.

The Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) published by the American Psychiatric Association (APA) in 1987 is currently the primary tool used by counselors in clinical settings for diagnosing clients' psychological and behavioral problems. Beginning with the third edition of the manual (DSM-III; APA, 1968) a multiaxial process for diagnosis was introduced to encourage a biopsychosocial perspective of client's problems.This study was designed to investigate if alterations in diagnosis on Axis IV and V could further encourage a biopsychosocial perspective. It was designed to imitate the rapid diagnostic process that takes place in many clinical settings. In the present study, the criterion for a biopsychosocial perspective was the maintenance of neutral perceptions and unbiased hypothesis-testing strategies following diagnosis of a client.Twenty-four counseling psychology trainees participated in the study. The counselor trainees diagnosed a client after listening to approximately 20 minutes of an audio-tape of an initial assessment interview. The 12 counselor trainees in the control group diagnosed the client using the standard multiaxial format for diagnosis. The 12 counselor trainees in the experimental group diagnosed the client using an alternative format which encouraged a focus on positive aspects of the client and the client's environment.The counselor trainees completed the Impression Formation Questionnaire to assess their perceptions of the client. They then wrote 12 questions they would ask the client in the next counseling session. These questions constituted their hypothesis-testing strategies for their diagnoses on Axis I and Axis II.The counselor trainees in both groups maintained primarily neutral perceptions of the client as measured by the IFQ. The counselor trainees in both groups favored confirmatory hypothesis-testing strategies when assigned to groups based on their hypothesis-testing strategy score (p < .05).The results of this study indicated that the standard and alternative multiaxial formats for diagnosis may encourage neutral perceptions of a client when counselors must diagnose the client based on very little information. Neither format for diagnosis was successful, however, in discouraging a biased, confirmatory search for information.
Department of Counseling Psychology and Guidance Services

In recent years there has been a significant increase in the number of people with a 'learning disability' also receiving a diagnosis of 'mental illness'. This shift in practice, heralded as scientific progress, has not been placed under close scrutiny. The aim of the current study was to explore the impact of this recent extension of medicalised accounts on people with a 'learning disability'. A discursive psychological approach was adopted to examine how seven people with a dual diagnosis negotiated and managed their ascribed identities during interviews. The initial research questions focused on the implications of subtle operations of power for individuals with a dual diagnosis, however on examination of the data it became apparent that this phenomenon was clearly evident in the research interviews conducted for the present study. The focus of the analysis was then directed at the sequential and procedural structure of the interviews, as an illustration of how they may be understood as an artefact of asymmetrical social roles and identities. This shift allowed for a greater focus on how the participants constructed their relationships with professionals, using their interaction with the interviewer as psychologist as an exemplar. The results provide further support for findings that individuals cast as questionable utilise strategies for accounting that indicate that they are vastly more 'competent' and 'rational' than they are credited for by the 'psy'-complex. The participants' construction and negotiation of their membership to social categories demonstrates that their identities are not fixed, but instead are occasioned and contestable, and dependent on the local institutional context. A further feature of the analysis highlights the politics that surrounds talk, displayed by the participants' construction of talk with a psychologist as 'helpful', as opposed to other forms of talk, such as talk that serves to challenge, as'unhelpful'. The findings call into question the probity of applying a conceptual framework that locates assumed pathology in individuals already deemed to be wholly impaired. Furthermore, the study highlights the necessity for psychologists, policy makers and researchers to investigate the interactional nature of so called 'impairment', and to explore their roles in creating and perpetuating oppressive practices. Potential avenues for further action are discussed

Background: Child homicide represents 11.5% of all homicides and parents are perpetrators in about 67% of all cases. Of parents who kill their children fathers have been found to more often be the perpetrator (filicide) in all age groups except in neonaticides, where mothers are nearly always responsible. Women have been found to be over-represented in rates of filicide. Diagnoses of mental illness (MI) have been found as a moderating variable for mothers who kill older children. The aim of the present study was to explore the conditions, processes and contexts that contribute to the development of maternal filicide (MF) in MI mothers. Method: Four mothers with a diagnosis of MI were interviewed using constructivist grounded theory methods to produce theorising about the development of MF. Due to the sensitivity of the research topic, the vulnerability of the population and the need to ensure support for study participants, the study design included only those mothers still receiving care from secure hospital services (N=30). Findings: The present study produced grounded theorising of a process of Disintegrating Security in a number of sequentially related domains: social, economic, relational and psychological as contributing to MF. Consistent with other research on filicide mothers with a diagnosis of MI, mothers were active in caring for their children but became hopeless and suicidal, believing that their own suicide would leave their children alone in a cruel and dangerous world. Conclusions: Mothers committed filicide in a perverse act of maternal love rather than out of anger, or as part of prolonged child abuse. A detailed account of the development of MF in MI mothers has been produced. The findings could be important to increase the understanding of MF for mental health professionals working with filicide mothers, surviving family members and mothers themselves.

Section A reviews the clinical and risk implications of dual diagnosis along with the treatment context. The value of gathering firsthand accounts of service users to inform the planning and delivery of healthcare is touched on. The second part of the paper centres on theories of motivation and how they might be applied to help explain low rates of dual diagnosis treatment uptake and engagement. Finally, gaps in the literature are highlighted with recommendations for further research. Section B There is an emerging evidence base to support the use of integrated approaches that treat co-existing mental health and substance use disorders simultaneously. However, low rates of treatment uptake and engagement remain a concern. To address this, it would seem important to understand dual diagnosis treatment motivation and engagement, an area that has received little attention from the research community. The aim of this study was to explore service users’ and clinicians' understandings of how treatment motivation and its relationship with treatment engagement relate specifically to people with dual diagnosis. Transcripts from semi-structured interviews with four service users and four clinicians were analysed using narrative methodology. The study suggests that the factors underpinning treatment motivation and engagement among people viewed as having dual diagnosis are similar to those thought to be associated with addictions and mental health disorders generally although their relative influence and interaction effect might be different. It is suggested that negative perceptions of services, difficulties with trust, and therapeutic relationship are particularly important issues among dual diagnosis populations. Clinical and theoretical implications of the study are discussed in relation to the literature as well as recommendations for future research. Section C: Critical Appraisal. This paper provides a general overview of narrative research, including strengths and limitations as they relate to this study. With reference to the literature, clinical and theoretical implications are elaborated along with recommendations for future research. The author’s critical self-reflections regarding the process of initiating, carrying out and completing the study are highlighted. Following this, there is a section on the ethical considerations of the study. Finally, the measures taken to ensure the quality of the study and maximise internal consistency are presented.

This work is born out of previous research, conducted by this researcher, into the effects of psychiatric labelling on individuals thus differentiated. Informed by the investigative thrust of phenomenological inquiry, it is the aim herein to provide an illumination of the dramatic confrontation of the labelled individual with the classificatory branding that is his or her label. The question asked is: What is the experience of the labelled individual, and how does the label function as a ‘scientific fact’ (Kiesler, 2000) suffused within his being? In answering these questions, the researcher aims to abandon his own expectations, as is fitting with the phenomenological method, and to devote his sympathies entirely to the subjective disclosures which, it is hoped, the participants will offer. On this point, an obvious tension exists insofar as expectation and hypothesis necessarily constitute the inception of any research endeavour; and so, the notion of a complete bracketing of assumption and anticipation seems methodologically vague. The explorative impetus within this dissertation aims towards an elucidation of the effect of psychiatric diagnosis on the labelled individual, in terms of the individual’s experience of being-with-others. The impact of the offering of the label upon the individual’s interpersonal and intersubjective presence will be explored so as to establish whether psychiatric labelling unfolds as a disconnection of the individual from his co-existence with others.

This thesis provides a comprehensive criticism of the current models of understanding and caring for the mentally ill in a western context. I will outline the debates surrounding the conceptualization, diagnosis and treatment of mental illness. The western, psychiatric, biologically based understanding of mental illness is the dominant model of understanding and treating mental illness, despite the evidence that it encompasses an incomplete understanding of the causation and nature of mental illness. I will outline the difficulties in the creation of a cohesive definition of mental illness, including philosophical and cultural perspectives. I will examine the impact of historical, societal and capital pressures on the creation of these definitions. I will describe the practical issues and ethical tensions inherent when a definition or diagnosis of mental illness is created and taken up by mental health practitioners, who use this definition to develop treatment plans for the mentally ill. I will conclude that these issues result in a system of conflicting values which leads to less than ideal care for a uniquely vulnerable population. In this light, I conclude that the exclusive use of the DSM diagnoses as an objective basis for the creation of treatment plans is ethically questionable. I call for a new model of professional practice based on individualized treatment and primarily I call for a reduced focus on diagnosis in the care of the mentally ill.
Cette thèse propose une critique complet des modèles actuels de compréhension et d'empathie pour les malades mentaux dans un contexte occidental. Je vais chercher à décrire la compréhension actuelle de l'Ouest et débats entourant le diagnostic et le traitement de la maladie mentale. Le western, psychiatrique, la compréhension fondée sur la biologie de la maladie mentale est augmentation de la prévalence et de l'influence dans le monde. Cependant, je vais montrer que d'autres modèles et de leurs les traitements associés ont le potentiel, et le font souvent, générer améliorée résultats. Je crois que ce que j'appelle le modèle occidental medical de la maladie mentale englobe une compréhension incomplète de la causalité et le traitement de la maladie mentale. Je vais mettre en lumière les problèmes pratiques et des tensions éthiques inhérentes quand une définition ou le diagnostic de la maladie mentale est créé et utilise par les praticiens de santé mentale , qui utilisent cette définition à élaborer des plans de traitement pour les malades mentaux. Je exposer les difficultés dans la création d'une définition cohérente de la maladie mentale, y compris les perspectives philosophiques et culturels. Je vais examiner l'impact des pressions sociétales sur la création de ces définitions. Je vais conclure que le modèle occidental répandue médical, tout en étant utile en tant qu'outil, est imparfait comme une approche exclusive de soins de santé mentale. Cette faiblesse est observé lorsque l'on prend note de la variation incroyable dans le diagnostic et l'expérience de la maladie mentale chez les individus. Dans cette optique, je conclus que l'exclusivité, l'utilisation aveugle des diagnostics comme une base objective pour la création de plans de traitement est éthiquement discutable. Je suggeste à un nouveau modèle de pratique professionnelle basée sur le traitement individualisé et je demande une moindre accent sur le diagnostic dans la prise en charge des malades mentaux.

Bibliography: leaves 233-306. A study of the phenomenon of somatization as it occurs in the primary care setting. The phenomenon was studied in terms of aspects of illness behaviour and risk of psychiatric morbidity. It is suggested that abnormal illness behaviour in the form of somatization may be an important factor in the non-recognition of mild non-psychotic psychiatric illness in the primary care setting. The results of the study indicate that an assessment of the patients' attitudes and beliefs about symptoms, and an exploration of psychosocial issues, may lead to a better understanding of why the patients have sought help, and may lead to early identification and appropriate treatment of somatizing behaviour and the psychiatric morbidity underlying such behaviour.

The aim of this study was to improve medical understanding of patients' illness experience and everyday thinking about physical distress, by focusing on patients' and physicians' narratives of medically unexplained symptoms. Semi-structured interviews were held with 16 Canadian and immigrant patients from two primary care clinics in Montreal, and separately with their physician. Detailed content analysis reveals that, despite the absence of diagnosis, both patient and physicians hold complex and dynamic models of illness. Physicians' explanations rely almost exclusively on biomedical constructs, whereas patients' models of illness draw from a much wider range of sources of experience and authority. Despite regular follow-up, physicians have very limited access to the intricate networks of meaning revealed in their patients' interviews. In fact, although there is some common ground of understanding, patients and physicians show low congruence of their models, and much discrepancy in the expected outcome and management. Eliciting patients' illness narratives rather than focusing on narrow biomedical issues offers promising possibilities for physicians to negotiate meaning with their patients. The richness of patients' models provides potential avenues leading out of the clinical impasse of medically unexplained symptoms.

Major Depressive Disorder (MDD) is exceedingly prevalent and considered to be one of the leading cause of disability worldwide. Depression is also a heterogeneous disorder characterized by complex diagnotic approaches with a lack of diagnostic biomarker, an inconsistent response to treatment, no established mechanism, and affecting multiple physiological systems such as endocrine, immunological and cardiovasular as well.

The growing impact of the analysis of complex signals on biology and medicine is fundamentally changing our view of living organisms, physiological systems, and disease processes. In this endeavour, the basic challenge is to reveal how the coordinated, dynamical behavior of cells and tissues at the macroscopic level, emerges from the vast number of random molecular interactions at the microscopic level. In this way, the fundamental questions could be: (i) how physiological systems function as a whole, (ii) how they transduce and process dynamical information, (iii) how they respond to external stimuli, and mostly (iv), how they change during a pathological processus.

These challenges are of interest from a number of perspectives including basic modeling of physiology and practical bedside approaches to medical and risk stratification.

The general purpose of this thesis, therefore, is to study physiological time series to provide a new understanding of sleep dynamics in health, specifically as they apply to the pathological condition of MDD. More precisely: (1) to quantitatively characterize the complex, nonlinear behaviour of cardiovascular (ECG) and electroencephalographic (EEG) time series during sleep, in health and in MDD. This project will test the hypotheses that both the sleep EEG and ECG detects reorganization in the system dynamics in patient suffering from depression. (2) To develop new diagnostic and prognostic tests for MDD, by detecting and extracting “hidden information” in the ECG and EEG datasets.

Three different methods are introduced in this thesis for the analysis of dynamical systems. The first one, detrended fluctuation analysis, can reveal the presence of long-term correlations ("memory" in the physiological system) even when embedded in non-stationary time series. Graph theoretical measures were then applied to test whether disrupting an optimal pattern ["small-world network"] of functional brain connectivity underlies depression. Finally, multiscale entropy method, which is aimed at quantifying the complexity of the systems' output resulting from the presence of irregular structures on multiple scales, was applied on the ECG signal.

The results indicate that healthy physiologic systems, measured through the EEG and the ECG signals, are the most complex. According to the decomplexification theory, the depressive disease model exhibits a loss of system complexity, with potential important applications in the development and testing of basic physiologic models, of new diagnostic and prognostic tools in psychiatry, and of clinical risk stratification.
Doctorat en Sciences médicales
info:eu-repo/semantics/nonPublished

Mental health and substance abuse treatment systems have a history of incompatible philosophies and conflicts that have been associated with poor treatment outcomes for persons dually diagnosed. The purpose of this study was to determine whether or not there are differences in attitudes between mental health and substance abuse professionals toward the dually diagnosed client and whether or not academic discipline, levels of training and experience, occupation, and amount of contact affect the attitudes of these professional groups. A non-experimental survey research design was used for this study, and data were collected by means of a revised Opinions About Mental Illness (OMI) survey instrument and supplemental demographic questionnaire. The modified OMI instrument was piloted by a panel of subject matter experts experienced in the treatment of persons who are dually diagnosed in which they rated each item for favorableness to concepts of dual diagnosis. The modified OMI survey and a demographic questionnaire were administered to a sample consisting of mental health and substance abuse professionals employed at a local community mental health center. A total of 86 respondents representing 95% of the sample population completed the modified OMI survey and demographic questionnaire. Data were analyzed using descriptive, independent sample t-test, and multiple analysis of variance (MANOVA) statistics. Results revealed no statistically significant differences in attitude between mental health and substance abuse professionals toward dually diagnosed clients. Analysis of the independent variables academic discipline, level of training and experience, occupation, and amount of contact demonstrated no significant interaction effects between mental health and substance abuse professionals. Despite the absence of statistically significant differences in attitude between the mental health and substance abuse professionals, the similarities may be significant in terms of the psychological value for building positive relationships. The atmosphere of agency culture and the significance of co-location of mental health and substance abuse professionals were also potentially important factors in the outcome of the present study.
Ed. D.

Over the past years, mental health has attracted increased attention throughout the world, in the form of initiatives, programs, support groups, etc. all with goals to increase awareness and support of mental health. The stark discrepancy between the vision driving this mental health movement and our reality comes from a basic misunderstanding. While there are both legislative and cultural efforts in place to reform our mental health system, the two must work hand in hand in order to affect substantial change. Rather than producing a collaborative effort, our legislators and society tend to ignore each other, resulting in isolated attempts at reform that are doomed to failure without the support of the other side. This thesis examines the obstacles that mentally ill individuals face in the U.S. today after receiving formal “mentally ill” diagnoses. In our current system, these individuals face limited options, all of which include a number of steep costs. This thesis proposes a shift toward a more collaborative approach in order to transform the costs and fear of diagnosis into benefits and desire for diagnosis. However, an approach such as the one suggested can only be successful after a fundamental shift in the perception of mental illness occurs. Whether or not such a shift is possible – and if so, how? – is a question too large to explore in the confines of this thesis, but one that the reader should consider.

Background: Co-occurring substance use disorders (SUDs) occur in as many as half to three quarters of patients with severe mental disorders such as schizophrenia and bipolar disorder, a phenomenon also described as dual diagnosis. Past research from high income countries have shown that the presence of co-occurring SUDs are associated with a number of demographic and clinical factors, including worse clinical outcomes. Although the clinical profile and negative impact on prognosis has been well characterised in research on dual diagnosis samples from high income countries, little is known in the low- and middle-income country (LAMIC) context about the prevalence and factors associated with SUDs in patients with SMI, its clinical identification and diagnosis, as well as factors associated with its treatment. Objectives: In part-I of the thesis I investigate the clinical epidemiology of dual diagnosis by determining the prevalence of substance use disorders (SUDs) and its association with various clinical and demographic factors in two datasets, the first dataset containing data from a homogeneous sample of Xhosa South African patients with schizophrenia and the second dataset with data from a clinically more heterogeneous sample of patients with major affective and non-affective psychotic disorders. In part-II of the thesis I determine the psychometric properties of two Xhosa language versions of brief substance screening instruments, the Alcohol, Smoking and Substance Involvement Screening Test (WHO-ASSIST version 3) and the Severity of Dependence Scale (SDS), against a gold standard diagnostic instrument, the Structured Clinical Interview for DSM-IV-TR Axis I disorders (SCID-I for DSM-IV). In part-III of the thesis I examine aspects in the pharmacotherapy of dual diagnosis, firstly the association between methamphetamine use and extra-pyramidal medication side-effects (EPS) in patients treated with antipsychotics, and second in a systematic review, the efficacy of risperidone versus other antipsychotics for people with a dual diagnosis. Methods: This thesis consists of secondary analyses of two datasets (datasets#1 and dataset#2) and a Cochrane systematic review of existing randomised trials. Dataset#1 contains data from case-control study with the original aim of investigating the genomics of schizophrenia in the South African Xhosa population. Dataset#2 contains data collected in a cross-sectional manner from 3 studies; one study that investigating the presentation and psychobiology of psychosis, another which was a pilot randomised controlled trial of a text message treatment partner intervention and a third which was a neuroimaging and electrophysiological study of psychotic disorders. Across dataset #1 and #2, demographic information, clinical variables and psychotic and substance use disorder diagnoses were determined using the SCID-I for DSM-IV. In addition, for dataset #2 (conducted in a multi-cultural and ethnic population) we recorded self-identified ethnicity. For self-identified ethnic groups, the terms “Coloured” “Black” and “Caucasian” and “Other” (Asian), were not intended to reify sociocultural constructs but were instead used to study ongoing health disparities. Psychosocial Axis-IV problems were determined using a checklist from the SCID-I and legal involvement was determined using the legal section of the Addiction Severity Index (ASI). Functioning was determined with the global assessment of function, or GAF scale. The ASSIST and SDS instruments were used in a study based on data from dataset #1 investigating the psychometric properties of these screening tools. In turn, I investigated the relationship between methamphetamine use and medication related extra-pyramidal side effects (EPS) in a heterogeneous sample of patients with major affective and non-affective psychotic disorders (from dataset #2). For this study the Simpson Angus Scale for Parkinsonism (SAS), the Barnes Akathisia Rating Scale (BARS) and the Abnormal Involuntary Movement Scale (AIMS) were used to measure EPS. For the first two objectives, logistic regression modelling was used to determine factors associated with having a cooccurring SUD. For the validation study of the Xhosa language versions of the ASSIST and SDS, I determined the internal consistency, concurrent validity, and discriminant validity of these instruments and compared the sensitivity, specificity and the receiver operating characteristics (ROC) for the ASSIST and SDS. Logistic and ROC regression was used for the comparison of ROC area-under-the-curves for ASSIST versus SDS and for determining the impact of co-variates on ROC respectively. In part III, I determined the association between methamphetamine use and the presence of EPS using logistic regression. Finally, I conducted a Cochrane systematic review of randomised trials after a comprehensive literature search of several databases and duplicate study selection and data extraction. Where possible outcomes were pooled, and meta-analyses conducted using random effects models. Primary outcomes were changes in substance use and mental state. Secondary outcomes included substance craving, subjective-wellbeing, adherence, adverse effects, study retention, quality of life and mortality. Study selection, data extraction and quality appraisals were independently conducted. Random-effects meta-analysis was conducted, and the Cochrane risk of bias and GRADE approach used to assess evidence quality. Results: In both datasets#1 and #2, consisting of a total sample size of N=1420 (dataset#1) and N=248 (dataset#2) we found a high prevalence of lifetime SUDs (47.8% and 55.6%) in patients with schizophrenia and major affective or non-affective psychosis, respectively. In multivariable logistic models younger age, male gender, and legal involvement were significantly associated with co-occurring SUDs. Multiple substances were often used together, and SUDs were significantly correlated with one another. Methamphetamine use disorders were significantly more prevalent in the Western Cape province of South Africa and ethnic differences were also apparent with Coloured participants significantly more likely to use methamphetamine compared to Black participants. In addition, we found significant associations between post-traumatic stress symptoms, anxiety symptoms and suicidality and alcohol use disorders. Inpatient status and higher levels of prior admissions were associated with cannabis and methamphetamine use disorders. In a sample of 351 participants from dataset#1 who completed either the ASSIST (N=190), SDS (N=299), or both (n=138), good internal reliability was obtained for both the ASSIST-TSI (total substance involvement score) (Cronbach α= 0.77) and SDS (Cronbach α=0.80). The ASSIST and SDS demonstrated good concurrent validity (rs= 0.50, p 3 years were significantly more likely to have EPS. We found a significant interaction effect between MA use disorders and standardised antipsychotic dose on the occurrence of EPS (ORadj = 1.01, 95% CI= 1.00-1.01, p=0.042). There were no significant associations with EPS with comorbid alcohol, cannabis, or methaqualone use disorders. In the Cochrane systematic review of randomised controlled trials involving risperidone versus other antipsychotics for dual diagnosis, we identified eight trials containing a total of 1073 participants with SMI and co-occurring SUD. Seven trials contributed useable data to the review. Risperidone was compared to clozapine, olanzapine, perphenazine, quetiapine and ziprasidone. Only one study contained data comparing risperidone with a first-generation antipsychotic (perphenazine). Quality of the included studies varied from low to very low. Outcome data were frequently missing and little, or no data was reported in most studies for craving, subjective-wellbeing, metabolic disturbances, global impression of illness severity, quality of life or mortality. For risperidone versus clozapine we found no clear differences between these two antipsychotics in the reduction of positive psychotic symptoms or reduction in cannabis use, improvement in subjective well-being, numbers discontinuing medication, extrapyramidal side-effects or leaving the study early. Clozapine was associated with lower levels of craving for cannabis. For risperidone versus olanzapine we found no clear differences in the reduction of positive psychotic symptoms, reduction in cannabis use, craving for cannabis, parkinsonism, or leaving the study early. For risperidone versus perphenazine, quetiapine and ziprasidone respectively, we found no clear differences in the number of participants leaving the study early. Conclusion: In the context of a dearth of research into dual diagnosis in LAMIC countries such as South Africa, this thesis contains a large-scale epidemiological investigation into substance use comorbidity in patients with schizophrenia and other psychotic disorders. In addition, for the first time we determine the psychometric properties and validity of the Xhosa language ASSIST and SDS and systematically investigate the relationship between methamphetamine use and extra-pyramidal side effects in people with psychotic disorders treated with antipsychotics. For the first time we also conduct a systematic review of the efficacy of risperidone compared to other antipsychotics for a number of primary and secondary outcomes. Our findings have a number of implications for clinicians and services planners. Firstly, SUDs occur in at least half of the people schizophrenia and other psychotic disorders. Accurate detection of SUDs is possible using brief screening tools such as the ASSIST and SDS. Some populations such a younger male population may need particular attention. Moreover, assessment of patients will need to include current and past legal involvement as well as careful assessment of associated comorbid anxiety, post-traumatic symptomology and suicide risk. In patients with co-occurring methamphetamine use disorders clinicians should regularly assess for the development of EPS and carefully titrate antipsychotic dosage from lower to higher doses to avoid EPS. Currently there is not sufficient high-quality evidence favouring the superiority of risperidone over any other antipsychotic in people with SMI and co-occurring SUDs. Results of ongoing trials are awaited, and future trials need to use consistent methodologies and adhere to CONSORT reporting guidelines.

Stigma has been described as the most significant obstacle to quality of life for individuals with major psychiatric diagnoses (Sartorious, 1998). Much of the psychological literature on stigma focuses on individual attributes and interactions at the micro level, rather than macro level dynamics. In critiquing this traditional focus, Link and Phelan (2001) present a model in which stigma ensues when labeling, stereotyping, separation, status loss, and discrimination co-occur in a situation of power imbalance. Even as the model fills a gap in conceptualizing stigma, its emphasis on power is unidirectional and fails to account for power as a form of resistance to stigmatization. This study explores the question of how a consumer/survivor activist perspective can inform the Link and Phelan model of stigma. A semi-structured interview methodology was used to gather qualitative data on the perspectives of 10 activists who are both the targets of stigma and active change agents in resisting stigma. The content of the interviews was thematically analyzed based on an iterative coding approach in order to identify the points of overlap with and divergence from the Link and Phelan model. The results of the study support the applicability of the model for psychiatric stigma. The participants' experiences illustrate which aspects of stigmatization take precedence in this context, indicating significant points for intervention. The anti-stigma work discussed by the participants illustrates the power of grassroots resistance, expanding the understanding of power presented in the model. Emergent discursive themes include the importance of similarity, the rejection of negative portrayals of mental illness, and a focus on a shared continuum of human experience. Participants' emphasis on the importance of having their voices silenced was a particularly recurring motif. Several respondents challenge the premises of the Link and Phelan model. These participants emphasize the positive aspects of diagnosis and labeling, while several other participants reject the choice of the term stigma because it may obscure the structural aspects of discrimination. These findings can serve as a guideline for designing future interventions, and focusing on strategies for social change.

Research in the field of dual diagnosis (the coexistence of symptoms indicative of a substance abuse problem and a mental health problem) has expanded immensely over the past 15 years. Unfortunately, much of the existing literature available on this topic is limited to adult populations. The researcher explored the rate of dual diagnosis in the adolescent population by conducting a secondary data analysis of the Canadian Incidence Study of Child Abuse and Neglect (CIS-2003; Trocme et al., 2005). The rate of having one or more substance abuse problems in the CIS-2003 was 8.8% and the rate of having one or more mental health problems was 23.6%. Dual diagnosis was found to be under-reported in the child welfare system in Canada. Results of the secondary data analysis indicate that 4.4% of the total sample of adolescents aged between 10 and 15 years old had symptoms indicative of a dual diagnosis over the 3 month study period (n=4381). By providing a profile of child and caregiver characteristics and risk factors associated with dual diagnosis, clinicians from all realms can become better equipped to understand these issues. In the future, Social Workers and other professionals can work collaboratively on identification of DD and improving outcomes for youth and families affected by symptoms of a dual diagnosis.

Personality disorder has been and continues to be a contested diagnosis. Those who attract this form of diagnosis have been particularly vulnerable to the effects of stigma and have tended to be excluded from service provision. This thesis provides an examination of how recent developments in law, policy and practice have impacted upon the status of personality disorder as a diagnosis of exclusion in Scotland. The theoretical framework that provides this thesis with its structure is derived from the post-empiricist approach proposed by Derek Layder. This approach seeks to contextualise emergent inductive findings within a broader historical and contemporary analysis. In the case of this research the broader context consists of the interplay between mental health law, policy and practice in the field of mental health and the diagnosis of personality disorder more specifically. The empirical enquiry at the core of this thesis is based upon an analysis of the views, beliefs and expectations of front-line staff (psychiatrists and social workers qualified as mental health officers) involved in the process of assessment and service provision. In addition to front-line staff (n = 27) a range of key informants who were in a position to shed light on the strategic imperatives underpinning recent developments in law and policy were also interviewed. This analysis is contextualised within a review of key developments in law and policy that have particular significance for anyone who may attract a diagnosis of personality disorder. Despite the ostensibly inclusive approach towards those who may attract a diagnosis of personality disorder evident within the Mental Health (Care and Treatment) (Scotland) Act 2003, the reality is a highly selective and very limited inclusion of those who attract this form of diagnosis. The effective inclusion of those who may attract a diagnosis of personality disorder has been obstructed by several key impediments: 1: an insufficiently robust policy framework to drive forward the process of inclusion; 2: residual ambivalence towards the legitimacy of the diagnosis of personality disorder itself and the legitimacy of the claims made upon services by those who may attract a diagnosis of personality disorder; 3: insufficient and inadequately focused resources; 4: service structures that have not been redesigned sufficiently to engage successfully with service users who may attract a diagnosis of personality disorder. As a consequence of these impediments to inclusion, the majority of those who may attract a diagnosis of personality disorder in Scotland are likely to continue to face high levels of marginalisation and exclusion.

A literature review in Section A reviews the conceptual and empirical literature with regard to the usefulness and challenges inherent in applying recovery approaches in secure services, with a particular focus on women with a diagnosis of personality disorder. Section B. Background: Some studies have suggested that recovery approaches could be facilitated in secure mental health services despite a number of inherent tensions. However, none have explored if this applies to women with a diagnosis of personality disorder in secure care. A group whose needs have historically been overlooked, and can present with complex care-seeking behaviours. Aims. To explore how staff working with these women understand and apply recovery approaches in secure units. Method. Eleven multidisciplinary staff members working in a medium-secure unit in the UK participated in in-depth interviews. The data was analysed using grounded theory. Results. A preliminary model was generated, which comprised of five categories: secure base, balancing tensions, therapeutic relationship, initiating recovery, and nurturing recovery. These appeared to interact and influence each other throughout the recovery process. Conclusions. Staff are required to continually balance a number of tensions and as such they need a secure base from which to explore the service-users’ unique recovery process through the medium of collaborative therapeutic relationships. Staff sharing a recovery ethos that is embedded in the culture of a conducive environment, and is supported by supervision and teamwork, fosters the actualisation of recovery principles of empowerment, identity formation, and hope. Section C provides a critical appraisal of the study as well as a personal reflection on what was learnt through the process of the conducting the study.

Patienter med somatisk och psykiatrisk samsjuklighet är en sårbar och vårdmässigt komplex grupp som löper större risk, jämfört med normalpopulationen, att avlida i förtid till följd av sjukdomar som kunde ha förebyggts. Bristande socioekonomiska resurser tycks vara en förklaring men forskning visar också på sämre bemötande av patientgruppen samt att fler diagnostiska misstag görs vid samsjuklighet. Syftet med denna studie var att undersöka hur läkare inom somatiken upplever svårigheter i diagnostik och behandling gällande samsjukliga patienter. Semistrukturerade intervjuer genomfördes med tio läkare verksamma inom somatisk vård. Induktiv tematisk analys visade att läkarnas upplevelser kunde delas in i fyra teman; Osäkerhet, Relationen, Kapacitet och Integration. Resultaten visar att läkare upplever svårigheter kopplat till individen, patient-läkar-relationen och vården i stort. Kärnkategorin Otillräcklighet är beskrivande för samt genomsyrar samtliga teman och handlar om en otillräcklighet i hela vården, hos såväl patient som vårdpersonal och organisation. Dessa fynd bekräftar dels tidigare forskning och tillför fördjupade perspektiv i en svensk kontext. Behov finns av vidare kvantitativ forskning inom ämnet för ett mer generaliserbart resultat.
Patients with somatic and psychiatric comorbidity constitute a vulnerable and care-wise complex group at higher risk, compared to the general population, of premature death due to preventable diseases. A lack of socio-economic resources seems to be one explanation, but research also shows that these patients are subjected to worse interpersonal treatment and that more diagnostic mistakes are made in relation to comorbid patients. The purpose of this study was to investigate how physicians in the somatic care experience difficulties in diagnosis and treatment of comorbid patients. Semi-structured interviews were conducted with ten physicians in the somatic care. Inductive thematic analysis showed that the experiences could be categorized into four themes; Uncertainty, The relationship, Capacity and Integration. The results show that physicians experience difficulties relating to the individual, the patient-physician-relationship, and the care system as a whole. The core category Insufficiency is descriptive of all themes and refers to an insufficiency regarding the patient herself as well as the staff and the organization. The findings confirm previous research and adds an in-depth perspective in a Swedish context. There is a need for future quantitative research on this topic in order to generate more generalizable results.

Athletic trainers (ATs) are professionals who are most directly responsible for athletes’ health care in a sport environment. ATs work with athletes on prevention, diagnosis, and treatment of athletic injury; it is through these interactions that put ATs in an ideal position to recognize the psychological and emotional distress that athletes may suffer. Consequently, the National Athletic Trainer’s Association (NATA) has called for ATs to be competent in implementing psychosocial strategies and techniques (e.g., goal-setting, imagery, positive self-talk), recognizing basic symptoms of mental disorders, and identifying and referring athletes in need of psychological help. I explored ATs’ ability to recognize, diagnose, and provide a referral for collegiate athletes who were presenting with symptoms of depression across three different scenarios. The study examined factors that may impact ATs’ abilities in these areas, including AT gender, athlete gender, and type of presenting problem (e.g., athletic injury, romantic relationship, or sport performance issue). Overall, female ATs were better at recognizing depressive symptoms than male ATs, though both were equally proficient at diagnosing depression. Regardless of gender of the AT, gender of the athlete, and presenting problem, ATs were most likely to refer the athletes to a counselor/psychologist, and to a lesser extent sport psychology consultant (SPC). ATs viewed referrals to an SPC as most appropriate for presenting problems related to sport (i.e., performance problem or injury). The results highlight a possible bias in referrals to an SPC, in that SPCs may not be considered an appropriate referral source for romantic relationship problems. Implications for ATs and recommendations for future research are discussed.

Thesis (MPhil (Sociology and Social Anthropology))--University of Stellenbosch, 2009.
ENGLISH ABSTRACT: South Africa has transformed its mental health service provision from in-hospital care to community-based rehabilitation. Although the idea is sound, the process places the caregiving families under an immense pressure. The aim of this study was to explore the impact that the de-institutionalisation process has had on the families as they care for their child with intellectual disability. The study was conducted by means of qualitative, unstructured interviews with families that have had a child de-institutionalised from Alexandra Hospital in the Western Cape. All of the patients were diagnosed with a dual diagnosis of intellectual disability and mental illness. Even though the patients were in group-homes or attended a day care centre, final responsibility for the patients lay with the parents. Three main themes emerged from the interviews that describe the impact of deinstitutionalisation, viz. the characteristics of the family member with intellectual disability (aggressive, abusive and self-destructive behaviour of the patient), the effect that these characteristics had on the family (marital stress and health risks to the care giver), and community and resource factors. The study placed the family central to its environment and discussed the impact deinstitutionalisation had on its environment as a whole. It was concluded that the burden that de-institutionalisation places on the families far exceeded their ability to cope with these circumstances. This status quo could be improved if adequate resources and skills are given to families prior to de-institutional
AFRIKAANSE OPSOMMING: In Suid-Afrika is geestesgesondheidsorg van hospitaliserende na gemeenskapsgebaseerde rehabilitasie, omskep. Terwyl hierdie stap wel as lewensvatbaar mag voorkom, plaas die proses ‘n hewige las op die sorggewende gesin. Die doel van hierdie studie was om die omvang van die impak hiervan op ‘n gesin met ’n lid met intellektuele gestremdheid en psiegiatriese siekte, te bepaal – nadat so ‘n pasient uit die inrigting ontslaan is. Die ondersoek is uitgevoer by wyse van kwalitatiewe, ongestruktureerde onderhoude met gesinne wie se lede met die diagnose uitgeplaas is deur die Alexandra Hospitaal in die Wes-Kaap. Elkeen van die pasïente is gediagnoseer met ernstige intellektuele gestremdheid, asook bykomende gedragsafwykings. Ten spyte van die feit dat die betrokke pasïente deur groepshuise of dagsorg eenhede versorg word, bly hulle hul ouers se verantwoordelikheid. Drie temas het ontstaan wat die impak van ontslag uit die inrigting omskryf, te wete die karaktertrekke van die gestremde gesinslid (aggressie, misbruikende en vernielsugtige gedrag van die pasïent), die effek van hierdie karaktertrekke op die gesin (stres op die huwelik en potensiële gesondheidsrisiko wat dit vir die versorger inhou), en die gemeenskap en ondersteunende faktore. Tydens die ondersoek is die gesin sentraal geplaas ten opsigte van die omgewing. Die impak van ontslag van die gediagnoseerde pasïent uit die inrigting op die omgewing as geheel, word bespreek. Daar is tot die slotsom gekom dat die vermoë van die gesin wat die las moet dra as gevolg van die ontslag, ver oorspan word. Hierdie toedrag van sake sou egter verlig kon word indien toereikende hulpbronne en vaardighede aan sulke gesinne beskikbaar gestel word alvorens so ‘n pasïent ontslaan is.

Smoking remains a leading cause of disability and mortality worldwide. Despite declining rates of smoking in developed countries, smoking prevalence remains high, and there is evidence that it has plateaued in recent years. Individuals with a comorbid psychiatric diagnosis represent a disproportionate percentage of those who continue to smoke and are particularly at-risk given they smoke at higher rates and consume more cigarettes compared to those with no diagnosis. Moreover, these individuals are often excluded from clinical trials of smoking cessation, making it difficult to generalize results of previous intervention studies. In the general literature of smoking cessation, smoking cessation self-efficacy, or one’s confidence in their ability to abstain from smoking, is a consistent predictor of positive abstinence outcomes. The overall purpose of this dissertation was to investigate smoking cessation self-efficacy as a predictor of abstinence outcomes in a population of treatment-seeking smokers with and without a history of psychiatric illness. To accomplish this, articles 1 and 2 investigated the psychometric properties of a multi-item measure of cessation self-efficacy. This entailed comparing the measure to other indices of smoking, and conducting a confirmatory factor analysis to ensure factor invariance and equivalence of the measure regardless of psychiatric status. We found a moderate correlation between our multi-item scale to a single-item measure of confidence to quit, as well as support for both the original two-factor model as well as a three-factor model, which explained 79.3% of the variance. Our results also supported the measure as being factor invariant across psychiatric diagnoses. Next, articles 3 and 4 investigated how this measure of cessation self-efficacy predicted several smoking outcomes (10-, 22- and 52-weeks following target-quit date), and whether this relationship was mediated by concurrent smoking and other interpersonal-indices of smoking cessation (nicotine withdrawal, negative affect). In article 3, we found support for a bidirectional and reciprocal relationship between smoking cessation self-efficacy and smoking status. While changes in concurrent behavior (smoking or abstinent) did impact subsequent evaluations of self-efficacy, the inverse was also true. Moreover, both concurrent smoking and cessation self-efficacy predicted outcomes at week 10. Article 4 built on this framework and investigated this relationship at 22- and 52-weeks post-target quit-date. Our results highlight the robust association between cessation self-efficacy and abstinence. Higher cessation self-efficacy was positively associated with better abstinence outcomes, even after controlling for concurrent smoking, withdrawal, and negative affect. Further, there was evidence that cessation self-efficacy partially mediated the impact of withdrawal and negative affect. In our fully adjusted model (adjusting for demographic characteristics, baseline smoking levels, withdrawal and negative affect), cessation self-efficacy along among the interpersonal-determinants predicted abstinence outcomes (Odds ratio = 1.078, 95% confidence interval (1.068 - 1.089). This was true for those with either a current, past, or no lifetime psychiatric diagnosis, and despite the finding that individuals in the lifetime (current or past diagnosis) category experienced overall lower self-efficacy. Overall, our results support the value of cessation self-efficacy as an important indicator of abstinence outcomes, and particularly highlight its potential utility for at-risk populations of comorbid psychiatric smokers.

Background: Current literature suggests that there is an underutilisation of mental health services among Chinese people in England and that most Chinese people only come into contact with mental health services when a crisis occurs. However, there is limited evidence to enhance understanding of how they enter and navigate through the mental health systems. Objectives: This study aimed to examine the pathway experience of Chinese people living with a diagnosis of severe mental illness and the experience of their social networks who became involved in this journey. Methodology: Adopting a phenomenological approach, this study involved 55 interviews relating to 16 Chinese people with severe mental illness. Participants included Chinese people with severe mental illness, their families and Chinese speaking workers working in different service settings. Data was analysed with the aid of the QSR Nvivo software program. Findings: This was the first qualitative study to help understand the experience of Chinese people with severe mental illness in England. It confirmed that language difference, a lack of knowledge about how to access mainstream services and different conceptualisation of the experience of mental illness were significant barriers to seeking help. However, contrary to existing literature, this study found that not all Chinese people with severe mental illness experienced delays in receiving professional support. The health beliefs and attitude of their social networks towards mental illness were the main factors shaping the duration and direction of individual journey. Family played an important role throughout this journey but most families did not have adequate resources to meet the mental health needs of their relatives. Therefore, they had to seek help from mental health professionals, Chinese speaking workers and their overseas connections. Discussion: The stigma attached to mental illness was reported as the key explanation for delays in help-seeking. The impact of stigma was felt more strongly by Chinese male than female family members. The worry that mental illness would ruin the family name and the family would lose face in the community explained the reluctance of Chinese men to seek help for their close relatives with severe mental illness. Chinese speaking workers provided vital resources for Chinese people to access mainstream mental health services. However, the strong belief in self-reliance and the perception that Chinese people held a more stigmatising attitude towards people with mental illness explained why some participants were resistant to seek help from outsiders, especially people from the Chinese community. Additionally, Chinese people living in remote areas were unable to reach and access these resources because of the unavailability of such resources in rural areas. Conclusion: This study expands our conceptual understanding of how the stigma associated with mental illness impacts on the utilisation of mental health services among Chinese people in England. Chinese speaking workers play an important role in facilitating access to mental health services. Hence, it is important to explore and develop different strategies to de-stigmatise mental illness so that Chinese people living in different parts of England can utilise resources from the Chinese and wider community.
published_or_final_version
Social Work and Administration
Doctoral
Doctor of Philosophy

In reviewing the literature on adult survivors of child sexual abuse/incest, it became apparent that one area has remained in its infancy: a systematic method of symptom assessment. Symptoms, both short and long term, have become clinically well documented. An index, the Sexual Abuse Survivors Symptom Index (evaluating absence/presence, frequency, severity, and impact of symptoms upon the survivor), was developed rationally from the literature was administered. A background questionnaire, simplified from one already in use, was also administered to provide information regarding variables that could confound the research.Approximately 130 female adult clinical subjects were approached to determine whether they would participate in the study. Thirty-three subjects agreed to participate. Due to the small sample size, results of the factor analysis cannot be considered reliable. The principal component factor analysis did produce eight factors, which did not converge in the varimax rotation, however, three factors did emerge. The three factors represented an affective component (almost one half of the symptoms), a somatic/sexual component, and an acting out component.The background questionnaire provided some basic support to the variables the literature reported as affecting symptom severity or likelihood for abuse to occur. Areas endorsed as most severe or correlated strongly and moderately to individual symptoms were ones that were directly connected to the abuse(i.e., age of first inappropriate sexual experience, duration of the abuse, multiple abusers, frequency of the abuse, fear of being hurt by the abusers, and overt/contact type of abuse). The variables that influenced the likelihood for abuse to occur, (i.e., substance abuse, strictness, rigid religious traditions, and physical discipline) were endorsed by slightly less than one half of the subjects, but may have had severe impact individually upon each survivor of abuse.
Department of Counseling Psychology and Guidance Services

The difficulty of distinguishing between genuine disorder and characteristics that can be attributed to high IQ increases the likelihood of diagnostic error by mental health practitioners. This mixed methods study explores the possibility of misdiagnosis of high IQ youth by mental health professionals. Participants were private practice mental health professionals who read case study vignettes illustrating high IQ youth exhibiting characteristics associated with their population. Participants then completed a survey and provided an assessment of the hypothetical client. In the study, 59% of participants were unable to recognize behavioral characteristics associated with high IQ youth unless suggested to them, and 95% of participants were unable to recognize emotional characteristics associated with high IQ youth unless suggested. The results of this study provide much-needed empirical exploration of the concern for misdiagnosis of high IQ youth and inform clinical practice and education.

Psychologists and other mental health professionals working in correctional institutions bear the considerable responsibility for identifying, diagnosing, and treating mentally disordered inmates. The importance of these responsibilities has been recognized in recent years because of the burgeoning population of inmates in general and the higher numbers of inmates with mental illness in particular. Research has demonstrated that the screens currently used in correctional settings to identify mentally disordered and suicidal inmates are either unvalidated or generally ineffective. This study investigates the validity of different mental health screens in a jail population. Inmates from the Grayson County Jail were administered three screens: the Referral Decision Scale (RDS), Personality Assessment Screener (PAS), and the Mental Disability/Suicide Intake Screen (MDSIS). Criterion measures were the Schedule for Affective Disorders and Schizophrenia (SADS) for Axis I disorders and the Suicide Probability Scale (SPS) for suicidal ideation. Results indicate that each screen most effectively assessed one clinical domain: the RDS for psychosis, the MDSIS for suicidality, and the PAS for depression. Gender differences were observed in screen items most effective for classifying inmates by suicide risk level.

The present study specifically focussed on Faith healing as an indigenous healing system and its influence on the diagnosis and treatment of mental illnesses in the Eastern Cape province of South Africa. The study aimed to provide a descriptive overview of Faith healers’ perspectives on the diagnosis and treatment of mental illnesses in the Eastern Cape, as well as to compare conclusions reached with other categories of indigenous healers. The inter-category comparisons on a broader level allowed for a further comparative discourse with the mainstream western medical psychiatric view of mental illness. Therefore, the scope of this study does not include in-depth analyses of findings, but rather the generation of themes for comparative discussions. While there exists vast literature on the diagnostic and treatment perspectives of the other two categories of indigenous healing systems (traditional healers and herbalists), a limited number of studies have been focussed on Faith healing as an indigenous mode of healing. The present study attempted to address this gap in the literature in an effort to promote future collaborative work across all viewpoints, in the management of mental illnesses. This study, grounded in qualitative research, utilized thematic analysis as its theoretical framework. Non probability judgmental sampling was used to secure self-identifying Faith healers, where conclusions from them were drawn from data collected, using in depth semi-structured interviews and observation. The main findings of the study indicated that Faith healers’ perspectives on the diagnosis and treatment of mental illnesses are based mainly on indigenous cultural theories. Furthermore, that collaboration with other viewpoints is hampered by animosity, feelings of distrust and the fear of appearing inferior.

O diagnóstico duplo, ou comorbidade, é considerado prevalente tanto pela literatura do discurso médico-psiquiátrico, como na realidade clínica de serviços de saúde mental e de drogas. Considera-se que o campo da saúde está imerso em sistemas de crenças, influenciadas por aspectos culturais e sociais, inclusive sobre o que se considera sofrimento psíquico como sinônimo de diagnóstico psiquiátrico, que inserido em contexto mais amplo, se conectaria a sofrimentos compartilhados socialmente. O consumo de drogas estaria imerso nesse mesmo contexto histórico e social compartilhado. Este trabalho se caracterizou como pesquisa qualitativa, cuja abordagem conversou com autores que consideram a pesquisa qualitativa como um exercício de sensibilidade, cujo foco na experiência em primeira pessoa. O objetivo geral foi conhecer sentidos e significados do consumo de drogas a partir de narrativas de história de vida de pessoas descritas com duplo diagnóstico. O objetivos específicos foram conhecer descrições sobre a experiência de sofrimento psíquico ao longo da vida; conhecer descrições sobre a experiência de consumo de drogas ao longo da vida; e conhecer descrições sobre experiências em que o consumo de drogas esteja associado a sofrimentos psíquicos. Este estudo exploratório, foi realizado em um CAPS II e um CAPS AD, da rede de atenção psicossocial, de um município do interior paulista. Participaram dezoito adultos, homens e mulheres, selecionados de maneira a diversificar possibilidades de quadros clínicos e consumo de drogas, em padrão considerado problemático. A coleta de dados foi feita por meio de entrevista de história de vida temática e anotações em caderno de campo. A análise foi feita a partir do material emergente de trabalho de campo, da literatura sobre diagnóstico duplo e sobre sofrimento social. As entrevistas foram consideradas narrativas, sendo selecionadas dez para sua apresentação pormenorizada, cujos critérios de seleção foram exequibilidade e diversificação dos quadros clínicos, sendo distribuídos quanto ao gênero e serviços onde eram atendidos. Os resultados foram apresentados juntamente com a discussão, foi descrito o processo de construção do campo e do tema estudado e depois, foram descritas as narrativas. As narrativas dos participantes, na sua maioria homens e vindos de classes trabalhadoras urbanas, foram circunscritas pelo universo cultural e social onde se inseriam, mas também pelas possibilidades de escuta de demandas dos serviços da rede estudada. Esta se conformou em serviços que os descreviam de maneira excludente entre usuários de drogas e doentes mentais, estando comprometidas com perfis construídos nas diversas relações sociais e institucionais estabelecidas, considerando-se contextos e discursos mais amplos. Os sentidos e significados do consumo de drogas para os participantes foram construídos ao longo da vida, junto aos diversos eventos e situações vividos nas diversas relações sociais e culturais, em que o sofrimento psíquico, por vezes, fazia presente. O consumo de drogas, compreendido como dispositivo, permitia agir diante das situações de sofrimentos psíquicos e sociais, vividos singularmente, mas compartilhados socialmente. Considera-se importante refletir sobre as experiências vividas por pessoas em sofrimento psíquico e que fazem uso de drogas, considerando-os inseridos em um contexto mais amplo de relações sociais e institucionais, em que sofrimentos sociais estão presentes
Dual diagnosis, or comorbidity, is considered prevalent by literature of medical-psychiatric discourse, as much as, in mental health services and those for drug use treatment. It is considered that the health field is immerse in systems of beliefs influenced by cultural and social aspects, including what is considered psychological suffering as a synonym of psychiatric diagnosis, which is, in a broader context, connected with sufferings shared socially. Drug use is also immersed in the same historical and social shared context. This work is characterized as qualitative research, whose approach is related to authors that consider qualitative research as a sensibility exercise , focusing in first person experience. The main objective was to acknowledge senses and meanings of drug use from life history narratives of persons described as dually diagnosed. The specific objectives were to acknowledge descriptions of drug use along life course, descriptions of psychological suffering along life course and descriptions of drug use associated to psychological suffering. This exploratory study has been developed in one CAPS II and one CAPS AD, part of psychosocial attention network of an inner city of São Paulo. Eighteen adults participated, men and women, selected to permit diversification of clinical presentations of psychiatric diagnosis and drug use, in pattern od use considered problematic. Data collection has been thematic life histories interview and field notes. Analysis emerged from fieldwork, dual diagnosis\' literature and social suffering\'s literature. Interviews were considered narratives, and ten were presented with more details, selected by practicability, diversification of clinical presentations criteria, distributed among genders and services where they came from. Results were presented concomitantly with discussion, and were described the process of construction of the field and of the theme studied, then narratives were described and discussed. Participants narratives, mainly men from urban labourers class, were circumscribed by cultural and social universe where they came from, as well as the possibility of storytelling to be heard in the health services network studied. This network was also constructed by describing their patients exclusively as drug users or mentally ill, compromised with profiles constructed in many social and institutional relationships, considering broader context and discourses. Senses and meanings of drug use for the participants were constructed along life course, together with diverse events and situations lived in diverse social and cultural relations, and social and psychological sufferings could, sometimes, be present. Drug use, understood as a device, allowed the participant to act in situations of psychological sufferings that were experienced singularly, but socially shared. It is considered important reflect upon experiences lived by people in psychological suffering that also use drugs, considering them as part as a broader context of social and institutional relations, in which social sufferings may be present

The aim of the thesis is to explore socially shared ideas about mental illness in everyday contexts. Drawing on social representation theory, organizations for users of mental health services and self-help groups are regarded as communities where social knowledge is constructed that makes intersubjective understanding of illness experiences possible. In order to investigate such knowledge as a resource in joint construction of meaning, a theoretical model is introduced where a distinction is made between a discursive level of situated ‘representational work’ and an underlying level of sociocultural resources. A focus group study was carried out with 27 participants who label their health problems as anxiety, depression or bipolar disorder, and were members of service user organizations. The focus group conversations were analysed with regard to thematic, interactional and discursive features to answer the questions: 1) how is mental illness represented, 2) how is the mentally ill person represented, and 3) how are others’ views on mental illness represented. The results show how mental illness is represented as a complex phenomenon that is contextualised to a number of frames of reference. Further, the analysis identified different types of resources that are utilized in representational work: local knowledge of the communities, medical concepts, different explanatory models, narrative structures, metaphors and conceptual dichotomies. It also revealed dialogical properties of the representational work that have rhetorical functions for self-presentation as a team performance. The discussion suggests that widely shared resources are put to use in group- and situation-specific representational projects, and that representations that are produced in group discourse can be characterised as ‘polemical social representations’ that respond to a double stigma of mental illness in everyday life where mental illness is regarded as a sign of ‘weakness’ as well as ‘otherness’.