There is an increased interest in exploring the use of sensory rooms in psychiatric inpatient care. Sensory rooms can provide stimulation via sight, smell, hearing, touch and taste in a demand-free environment that is controlled by the patient. The rooms may reduce patients' distress and agitation, as well as rates of seclusion and restraint. Successful implementation of sensory rooms is influenced by the attitudes and approach of staff. This paper presents a study of the experiences of 126 staff members who worked with sensory rooms in a Swedish inpatient psychiatry setting. A cross-sectional descriptive survey design was used. Data were collected by a web based self-report 12-item questionnaire that included both open- and closed-ended questions. Our findings strengthen the results of previous research in this area in many ways. Content analyses revealed three main categories: hopes and concerns, focusing on patients' self-care, and the room as a sanctuary. Although staff initially described both negative and positive expectations of sensory rooms, after working with the rooms, there was a strong emphasis on more positive experiences, such as letting go of control and observing an increase in patients' self-confidence, emotional self-care and well-being. Our findings support the important principals of person-centred nursing and recovery-oriented mental health and the ability of staff to implement these principles by working with sensory rooms.

Objective: Population studies demonstrate that attending cultural events is conducive to improved health when baseline health, income, education, and health habits are taken into account. Animal experiments suggest possible mechanisms. We studied the link in humans between attending cultural events and health in a randomized controlled trial. Methods: Members of the local government officers' union in the health services in Umea, Sweden, were invited to the experiment and 101 people registered for fine arts visits once a week for 8 weeks. They chose films, concerts, or art exhibitions visits, or singing in a choir and were then randomized into 51 cases, starting at once, and 50 controls starting after the trial. Health was assessed before randomization and after the experimental period using the instrument for perceived health, short form (SF)-36, and tests of episodic memory, saliva-cortisol and immunoglobulin. The results were analyzed using a mixed design analysis of variance. Results: The SF-36 Composite Score called physical health improved in the intervention group and decreased among controls during the experiment (F(1,87) = 7.06, p = .009). The individual factor of the SF-36 called social functioning, improved more in the intervention group than among controls (F(1,98) = 8.11, p = .005) as well as the factor vitality (F(1,98) = 5.26, p = .024). The six other factors and the Mental Health Composite Score, episodic memory, cortisol and immunoglobulin levels did not change otherwise than among controls. Mechanisms are left to be identified. Conclusion: Fine arts stimulations improved perceived physical health, social functioning, and vitality.

Bakgrund: Den psykiska ohälsan kraftigt ökar i dagens samhälle, med en befolkning som mår sämre i allt yngre åldrar. En del av den psykiska ohälsan är kopplad till det vi idag kallar Självskadebeteende. Detta i syfte att lindra sin ångest som en följd av ett tvång eller en impulsatt tillfoga sin kropp skada, motiverat av ett behov att bemästra psykisk ohälsa eller av att återvinna känslomässig balans.

Syfte: Syftet var att belysa hur patienter med självskadebeteende upplever bemötandet inom vården.

Metod: Denna studie är en kvalitativ innehållsanalys med induktiv ansats av självbiografier skrivna av personer med självskadebeteende.

Resultat: Positivt bemötande stärker patienternas självkänsla, lindrar det inre lidandet och ångesten och gav en grund för en tillitsfull relation mellan vårdgivare och patient, där istället negativt bemötande, stigmatisering, förutfattade uppfattningar och okunskap hos vårdpersonalen bidrar till en otrygg vårdupplevelse för denna patientgrupp.

Slutsats: Vårdpersonal som jobbar med självskadande patienter bör reflektera över sitt bemötande, sin yrkesroll och sitt ansvar gentemot patienten, då denna grupp ofta känner sig illa bemötta inom vården.

Klinisk betydelse: Denna studie lyfter problematiken runt vårdandet av patienter med självskadebeteende, vilket kan hjälpa sjuksköterskor och vårdgivande personal vid vårdmöten.

Aim: The aim was to describe significant others’ experiences of dialectical behaviour therapy- family skills training (DBT-FST), their life situation before and after DBT-FST, and measurement of their levels of anxiety and depressive symptoms. Methods: The study had a descriptive mixed method design. Data were collected with free text questionnaires (n= 44), group interviews (n= 53) and the HAD scale (n= 52) and analysed by qualitative content analysis and descriptive and inferential statistics. Results: The results show that life before DBT-FST was a struggle. DBT-FST gave hope for the future and provided strategies, helpful in daily life. For the subgroup without symptoms of anxiety and depression before DBT-FST, anxiety increased significantly. For the subgroup with symptoms of anxiety and depression the symptoms decreased significantly. This indicates, despite increased anxiety for one group, that DBT-FST is a beneficial intervention and most beneficial for those with the highest anxiety- and depressive symptoms.

Aim

The aim of this study was to describe significant others' experiences of living close to a person with borderline personality disorder and their experience of encounter with psychiatric care.

Methods

Data were collected by free-text questionnaires and group interviews and were analyzed by qualitative content analysis.

Results and Conclusion

The results revealed four categories: a life tiptoeing; powerlessness, guilt, and lifelong grief; feeling left out and abandoned; and lost trust. The first two categories describe the experience of living close to a person with BPD, and the last two categories describe encounter with psychiatric care.

Bakgrund: MI har visat sig vara en framgångsrik metod för att stärka den personcentrerade vården och behandla patienter i behov av livsstilsförändringar. Samtidigt har inte metoden etablerat sig överallt och det finns en okunskap om den.

Syfte: Syftet med föreliggande studie var att beskriva sjuksköterskors upplevelser av att använda motiverande samtal inom omvårdnad och vad de anser är metodens fördelar och hinder.

Metod: Studien är en litteraturstudie med tematisk innehållsanalys. Sammanlagt har sju artiklar analyserats utifrån ett vårdgivarperspektiv.

Resultat: Två teman identifierades i analysen fördelar med MI och hinder för att använda MI I dessa teman har totalt sex underteman tagits fram, där positiva resultat och utvecklande patient kommunikation återfinns i det första temat och Brist på kunskap och erfarenhet, tidsfaktorn, uppmuntran och stöttning samt ointresse finns i det andra.

Slutsatser: MI är en enkel metod som gynnar vården och patientkommunikationen men som skapar en viss osäkerhet hos utövaren då den skiljer sig mot många sjuksköterskorsutbildning. Huvudanledningarna till att MI inte används genomgående är att sjuksköterskorna inte kan metoden fullt ut, känner sig osäkra på den och tror att den tar längre tid att använda. Det finns också de som väljer bort MI då ledning och kollegor inte uppmuntrar till användning.

Personer med flyktingbakgrund löper betydligt högre risk för att utveckla psykisk ohälsa, däribland posttraumatiskt stressyndrom (PTSD). Det finns mycket stöd i forskningen som visar att traumafokuserade psykologiska behandlingar för PTSD är effektiva. Majoriteten av forskningen inkluderar dock inte flyktingar, vilket innebär att vi vet mindre om hur behandling av PTSD fungerar i gruppen. Den här rapporten utforskar det rådande forskningsläget om psykologiska interventioner för PTSD hos vuxna flyktingar. En kartläggande litteratursökning genomfördes i två steg för att identifiera: 1) nyligen publicerade metaanalyser om randomiserade kontrollerade studier (RCT-studier) och 2) RCT-studier publicerade efter metaanalyserna, som bemöter de kunskapsluckor som identifierats i dem.

Det aktuella forskningsläget summerades utifrån dessa källor. Sammantaget inkluderades fyra metaanalyser, som alla gav stöd för psykologiska interventioner för PTSD, med mest stöd för traumafokuserad kognitiv beteendeterapi (TF-KBT). Alla fyra metaanalyserna indikerade att majoriteten av studierna varken involverade jämförelser med aktiv behandling eller långsiktig uppföljning, samt var av varierande metodologisk kvalitet.

I den andra litteratursökningen identifierades 12 RCT-studier. Endasten av dessa involverade både en aktiv kontrollgrupp och långtidsuppföljning. I de inkluderade studierna var TF-KBT, Eye Movement Desensitization and Reprocessing (EMDR) and Narrativ Exponeringsterapi (NET) de oftast utvärderade psykologiska interventionerna för PTSD hos flyktingar. Den tillgängliga evidensen tyder på att dessa interventioner ger måttliga till stora effektstorlekar vid behandlingsavslut jämfört med ingen behandling hos flyktingar, vilket liknar funna effektstorlekar i RCT-studier i generell befolkning. För att dra säkra slutsatser krävs dock mer omfattande RCT-studier med aktiva jämförelser och långtidsuppföljning. Det vetenskapliga underlaget tyder tills vidare på att behandling med TF-KBT, EMDR and NET bör göras tillgänglig för flyktingar med PTSD.

The aim of this paper was to investigate the feasibility and impact of dialectical behaviour therapy (DBT) for patients with borderline personality disorder (BPD) in a clinical outpatient setting. Eighteen clinicians were trained and supervised in using DBT. Twenty-seven female patients were assessed on a number of variables before the treatment, as well as 5 and 12 months after the start of the DBT. Despite some barriers, DBT could be implemented successfully, and the professionals reported increased competence 1 year after the start of the therapy. Low treatment dropout rates suggested that DBT was well accepted by the patients. One year after the start of treatment, the patients reported significant decrease on most variables measuring psychological distress and number of parasuicidal behaviours. The study provides preliminary support for the feasibility and impact of DBT in the outpatient treatment of BPD in a cultural setting outside the United States.

Bakgrund: Rättspsykiatrisk vård är en ofrivillig vårdform som personer med en allvarlig psykiatrisk störning som begår ett brott kan dömas till. Patienter inom rättspsykiatrisk vård har en begränsad autonomi vilket grundar sig i förutbestämda riktlinjer som styr denna vårdform. Att möjliggöra patientens delaktighet inom rättspsykiatrisk vård kan vara en utmaning för vårdpersonalen då vården inte utgår från samtycke. Syfte: Att identifiera hur patienters delaktighet kan främjas inom den rättspsykiatriska vården. Metod: En litteraturöversikt som utgick från elva vetenskapliga artiklar med kvalitativ ansats. Artiklarna som inkluderades analyserades med tematisk innehållsanalys. Resultat: Patienterna uppgav att de ville ha större inflytande över den vård de erhöll. Vidare lyfte de vikten av att vårdpersonal gav dem information kring deras behandling och medicinering för att främja deras delaktighet i vården. Vårdrelationen mellan patienter och vårdpersonal präglas av ärlighet och utgör en central roll vid främjande av patienters delaktighet. Slutsats: Utifrån litteraturstudiens resultat identifierade författarparet att två nyckelfaktorer som visades påverka patienternas upplevelse av delaktighet negativt var brist på information och exkludering från behandlingskonferenser. Fortsatt forskning genom kvalitativa studier bör utföras med fokus på de arbetsmetoder som fungerat och inte fungerat gällande främjandet av rättspsykiatriska patienters delaktighet.

Bakgrund: Samtidigt som andligt utövande hos personer med psykossjukdom påverkar faktorer såsom välbefinnande, återhämtning och läkemedelsföljsamhet upplever dessa patienter att den andliga dimensionen inte tas i beaktning av sjuksköterskan i omvårdnaden. För att förbättra den holistiska omvårdnaden är det således av vikt att få en ökad förståelse för sjuksköterskans erfarenhet av andlig omvårdnad till patienter med psykossjukdom.

Syfte: Att beskriva psykiatrisjuksköterskans erfarenhet av andlig omvårdnad till patienter med psykossjukdom.

Metod: Kvalitativ litteraturöversikt med systematiskt tillvägagångssätt.

Betydelse: Genom att undersöka psykiatrisjuksköterskans erfarenheter av andlig omvårdnad hos patienter med psykossjukdom kan vi öka vår kunskap kring hur den andliga dimensionen kan integreras i omvårdnaden.

Resultat: Tre huvudteman formulerades: Sjuksköterskans förutsättningar; Definitionen av andlighet, Sjuksköterskans egna trossystem, Sjuksköterskans personliga egenskaper. Hindrande faktorer; Kunskapsbrist, Strukturella faktorer, Stigma. Främjande faktorer; Vårdrelationen, Livsberättelsen som verktyg, Andligt empatiskt förhållningssätt, och Betydelsen av klinisk erfarenhet.

Slutsats: Andlighet i vårdkontexten behöver definieras och andlig omvårdnad behöver utformas och implementeras i omvårdnaden. Sjuksköterskor behöver kunna prata om den andliga dimensionen och ha självkännedom om den egna andligheten. Sjuksköterskor behöver ha kunskap i kulturell och religiös normativitet samt hur andliga uttryck kan skiljas från psykotiska symtom, vilket behöver integreras i läroplanen.

Background: Despite the growing recognition of the impact of post-resettlement factors on the mental health of refugees, a clear definition of the concept of post-migration stress, as well as an updated, valid instrument for assessing the construct, are still lacking. The aim of the current study was to develop and validate the Refugee Post-Migration Stress Scale (RPMS), a concise, multi-dimensional instrument for assessing post-migration stress among refugees.

Results: Based on a review of previous research and observations from a refugee trauma clinic, a preliminary 24-item instrument was developed, covering seven hypothesized domains of post-migration stress: perceived discrimination, lack of host country specific competences, material and economic strain, loss of home country, family and home country concerns, social strain, and family conflicts.In the context of a population-based survey of mental health among refugees from Syria recently resettled in Sweden (n = 1215), the factorial structure of the RPMS was investigated. Confirmatory Factor Analysis revealed slightly insufficient fit for the initial theorized multi-domain model. Exploratory Factor Analysis in four iterations resulted in the omission of three items and an adequate fit of a 7-factor model, corresponding to the seven hypothesized domains of post-migration stress. To assess concurrent validity, correlational analyses with measures of anxiety, depression, post-traumatic stress disorder (PTSD), and mental wellbeing were carried out. All domains of post-migration stress showed significant correlations with anxiety, depression, and PTSD scores, and significant negative correlations with mental wellbeing scores.

Conclusions: The newly developed RPMS appears to be a valid instrument for assessing refugee post-migration stress. Our findings that post-migration stress primarily relating to social and economic factors seems to be associated with mental ill health among refugees is in line with previous research.

PURPOSE: Screening tools such as the Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder-7 (GAD-7) could potentially be used in resource-limited settings to identify adolescents who need mental health support. We examined the criterion validity of the isiXhosa versions of the PHQ-9 and GAD-7 in detecting depression and anxiety among adolescents (10-19 years) in South Africa.

METHODS: Adolescents were recruited from the general population and from nongovernmental organizations working with adolescents in need of mental health support. The PHQ-9 and GAD-7 were culturally adapted and translated into isiXhosa and administered to 302 adolescents (56.9% female). The Kiddie Schedule for Affective Disorders and Schizophrenia was administered by trained clinicians as the gold standard diagnostic measure for depression and anxiety.

RESULTS: For the PHQ-9, the area under the curve was 0.88 for the full sample of adolescents (10-19 years old). A score of ≥10 had 91% sensitivity and 76% specificity for detecting adolescents with depression. For the GAD-7, the area under the curve was 0.78, and cutoff scores with an optimal sensitivity-specificity balance were low (≥6). A score of ≥6 had 67% sensitivity and 75% specificity for detecting adolescents with anxiety.

DISCUSSION: The culturally adapted isiXhosa version of the PHQ-9 can be used as a valid measure for depression in adolescents. Further research on the GAD-7 for use with adolescents is recommended.

Introduction: Chronic heart failure is a severe condition that influences not just the physical dimension but also the mental dimension in patients. Comorbidity of depression and anxiety are prevalent and the quality of life is reduced. Despite the psychological impact there are no recommendations in the guidelines for psychosocial interventions for people with heart failure. The aim of this meta-review is to synthesize results of systematic reviews and meta-analyses on the outcomes of psychosocial interventions in heart failure.

Methods: Searches were conducted in PubMed, PsychInfo, Cinahl and the Cochrane Library. In total, seven articles were included after screening 259 studies for eligibility.

Results: The included reviews had, in total, 67 original studies included. The measured outcomes in the systematic reviews and meta-analyses were; depression, anxiety, quality of life, hospitalization, mortality, self-care and physical capacity. The results are inconsistent but show some short-term benefit of psychosocial interventions for reduced depression and anxiety and improved quality of life. However, the long-term effects were sparsely followed up.

Discussion: This meta-review appears to be the first in the field of the efficacy of psychosocial interventions in chronic heart failure. This meta-review identifies gaps in the current available evidence that need to be further explored, such as booster sessions, longer follow-up time for evaluation and incorporating clinical outcomes and measures of stress processes.

BACKGROUND: Forced migrant populations have high rates of trauma-related ill health, including post-traumatic stress disorder (PTSD). Physical activity (PA) is well-established as an effective stress reliever, while insufficient PA is associated with adverse effects on both mental and physical health. The aim of this study was to examine the prevalence of different levels of PA and its association with PTSD symptom severity, controlled for exposure to torture, among asylum seekers in Sweden.

METHODS: A cross-sectional survey study, with data from 455 asylum seekers, originating from Afghanistan, Eritrea, Iraq, Somalia, and Syria, residing at large housing facilities across Sweden. Level of PA was assessed by the Exercise Vital Sign and categorized as; Inactive, Insufficient PA, and Sufficient PA. Prevalence estimates for proportions of different levels of PA were calculated. Analysis of variance were conducted to determine the association between levels of PA and PTSD symptom severity, measured by the Harvard Trauma Questionnaire. Multivariable logistic regression analysis was performed to determine the contribution of PA on PTSD beyond sex, age, and exposure to torture.

RESULTS: About half of the participants (53.3, 95% CI: 48.6-58.1) met the recommendations for Sufficient PA. One third of the participants (33.3, 95% CI: 28.7-37.8) were insufficiently engaged in PA, and 13.4% (95% CI: 10.1-16.7) were inactive. There was a significant difference in PTSD symptom severity between groups of asylum seekers with different levels of PA (F_{(2, 316)} = 23.15, p < .001). When controlling for sex, age, and exposure to torture, Sufficient PA was found to be associated with less PTSD symptom severity compared to both Insufficient PA (B = 0.297, SE = 0.086, p < .001) and Inactive (B = 0.789, SE = 0.104, p < .001).

CONCLUSIONS: Insufficient PA was common among the asylum seekers and our findings suggest that more PA is highly associated with lower PTSD symptom severity. An increased focus on assessment and promotion of PA is justified and discussed as particularly pertinent considering the much extended time of asylum-seeking processes. The results support previous evidence of PA as a potentially important factor in the context of PTSD and forced migrants' health.

Background: Refugees with prolonged and repeated experiences of trauma, often in combination with post-migration living difficulties, are subjected to severe levels of stress and stress-related ill health, including post-traumatic stress disorder (PTSD). Physical activity (PA) is well-established as an effective stress reliever. However, the effect of PA and exercise has received scarce attention in the context of PTSD, and particularly in the field of refugees' health.

Objective: The objective of this study was to explore the experience of participation in PA and exercise as part of the treatment for trauma-afflicted refugees.

Method: An explorative qualitative research design was used. Six focus group discussions were conducted with 33 female and male participants that had experience of group-based PA and exercise treatment. The gathered data was analysed by qualitative content analysis.

Results: The analysis resulted in one over-arching theme reflecting the participants overall experience of PA and exercise as a process of building resilience. Participants experienced improvements in both physical and mental health domains. Increased self-awareness and self-confidence were seen as additional important benefits, and the interruption of daily stressors provided a sense of relief and recovery. The treatment group settings were experienced as becoming a vehicle for overcoming social fear and isolation, which also carried an empowering and strength-building impact over to participants' family life and social relationships. Treatment characteristics were experienced as highly supportive and often referred to as the basis of other positive experiences and perceived health benefits.

Conclusions: The result of this study outlines a detailed account of trauma-afflicted refugees' experiences and preferences of PA and exercise-based treatment from a broad range of perspectives. These findings provide a starting point for future research in this field and indicate a particular need for both research and intervention development to include the real-life impact of participating in such treatments.

Aim: The overall aim of this thesis was to explore psychosocial consequences on children with high and intermediate imperforate anus and their parents.

Material/Methods: Paper I was an explorative study involving interviews. The purpose was to illuminate the children s and parents experiences of imperforate anus (IA) and to create a baseline for further research. In Papers II-V, study-specific questionnaires were used to collect data from 25 children (8-13 years old) with high and intermediate imperforate anus and from their parents. The questionnaires comprised 45 items for the children and 59 items for the parents, covering psychosocial issues, items on child bowel function, and on experiences of hospital care. The parents also filled in the Child Behavior Checklist (CBCL), and the children s teachers filled in the Teacher s Report Form (TRF). Thirty children with juvenile chronic arthritis and 32 children with no chronic condition, along with their parents, served as Comparison Groups. In Paper VI, the psychometric properties of the child self-reported psychosocial items were evaluated with Rasch analysis.

Results: Four categories of effects of the malformation were disclosed in the interviews: physical, emotional, social, and family effects. The emotional effects permeated the interviews; the parents suffering was evident. In the questionnaires the children with imperforate anus reported being generally happy, they liked school, and had good relationships with peers. According to their parents, the children had fecal incontinence and constipation. In the CBCL, the children with imperforate anus were assessed to have more emotional/behavioral problems than the children with juvenile chronic arthritis. On the CBCL competence scales no differences were found between groups. In the TRF, the teachers reported few emotional/behavioral problems for the children with imperforate anus, though they assessed them to be less adapted in school than were the children with no chronic condition. Differences were found in answers on the psychological items, between the children and their mothers, on the pair level. The mothers of children with imperforate anus rated lower on their child s expression of will and on respecting their child s will, than did the other mothers. Fathers scored school items optimistically. Several parents of children with imperforate anus reported positive experiences in relation to their child s condition involving child development, parental development, and strengthening of family unity. The psychometric properties of the psychological and the social dimension in the child self-report questionnaire were reasonably good.

Conclusions: The children with imperforate anus might have some psychosocial difficulties, though informants do not agree. According to self-report questionnaires, the children appear to be well-adjusted, despite functional bowel problems. Parents of children with imperforate anus have to go through difficult experiences associated with their child s malformation, though some parents also report positive experiences. Psychosocial issues seem crucial to children with imperforate anus and to their parents, and qualified individualized assistance should be a central part of their continuing care to ameliorate or prevent difficulties. Collaboration with expertise from child and adolescent psychiatry may be required. Child autonomy needs more attention. Psychosocial interventions are requested as well as a follow-up study on these children and their parents. Further development of the measurement tools, the study-specific questionnaires, is required.

Imperforate anus including lack of a normal anorectum is an uncommon malformation. The parents of children born with high and intermediate imperforate anus have to take a big responsibility for the follow-up treatment. It has been revealed that children with imperforate anus have psychosocial problems, though knowledge of this is limited.

Aim: The overall aim of this thesis was to explore psychosocial consequences on children with high and intermediate imperforate anus and their parents.

Methods: In Paper I, the purpose was to illuminate the children s and parents experiences of imperforate anus and to create a baseline for further research. Interviews were done with three patients with high imperforate anus who had had severe problems with the malformation, and with their parents (5). Answers to the open-ended questions were analyzed with a qualitative method, editing analysis style . In Paper II and Paper III, study-specific questionnaires were used to collect data from 25 children (8-13 years old) with high and intermediate imperforate anus, and from their parents. The questionnaires comprised 59 items for the parents and 45 items for the children, covering psychosocial domains, one physical domain and one domain on experiences of hospital care. The parents filled in the Child Behavior Checklist (CBCL), and the children s teachers filled in the Teacher s Report Form (TRF). Two groups of children along with their parents served as comparison groups. They included 30 children with juvenile chronic arthritis and 32 healthy children.

Results: Paper I: The parents were outspoken in the interviews, and the children s answers were meagre. Four categories of effects of the malformation were revealed: physical, emotional, social, and family. The emotional effects permeated the interviews; the parents suffering was overwhelming. In Paper II, the children with imperforate anus displayed an overall positive attitude; they reported that they were in a good mood, that they liked school, and that they had good relationships with peers. Furthermore, the children had fecal incontinence and constipation, according to parents. In the CBCL, the children in the index group were assessed to have significantly more emotional/behavioral problems than the children in Comparison Group I. In the TRF, the teachers reported few symptoms for the index group children. Paper III showed disagreement on psychosocial variables from children with imperforate anus and their mothers (on a pair level). Differences were found in particular on psychological variables, i.e. the child s emotional life. The competence scales in the CBCL revealed no differences between the index group and the other two groups. In the TRF, the teachers assessed the children with imperforate anus to be less adapted and adjusted in school than the children in comparison groups.

Conclusions: Parents of children with high imperforate anus have to go through difficult experiences associated with the malformation. Children with imperforate anus in this study seem to be well adjusted psychosocially, despite fecal incontinence and/or constipation. The children might have some psychosocial difficulties, though informants do not agree. It is vital to assess the children s psychosocial function from more than a single informant. Psychosocial issues are crucial to children with imperforate anus and to their parents, and qualified advice and assistance should be a central part of their continuing care. Perhaps collaboration with expertise from child and adolescent psychiatry may be required.

The aims of the present thesis were: * To investigate how women patients with borderline personality disorder (BPD) perceive their suffering, quality of life and encounter with psychiatric care (paper 11 and III). * To describe BPD patients' and psychiatric professionals' perceptions of receiving and giving dialectical behavioural therapy, DBT (paper I). * To investigate how starting treatment of BPD patients with DBT affected the psychiatric professionals' experience of occupational stress and professional burnout (paper IV) Due to the different types of research questions the thesis deal with, it uses a mix of qualitative and quantitative research methods. In two of the studies (11 and 111) the main methods were qualitative. Data from free format questionnaires, individual- as well as group interviews and biographical texts, were analysed with content analysis or a hermeneutic approach. In study Ill the methods were quantitative. A summated rating scale measuring healthrelated quality-of-life (HRQOL) was analysed with descriptive and inferential statistics. In study IV quantitative and qualitative methods were combined. Two burnout inventories were analysed with descriptive and inferential statistics, and data from free format questionnaires and group interviews were analysed with qualitative content analysis. The main findings were that BPD patients suffer to an extent that is often unendurable, leading to deliberate self-harm (DSH) and suicide attempts to relieve suffering or just try to get away from it all (paper 11). In study Ill the BPD patients showed significantly poorer quality-of-life (even physical) than normal population controls of comparable age. The suffering, suicide attempts, DSH and poor quality-of-life (paper 11 and 111) put the patients in a position of voluntarily or involuntarily getting involved with psychiatric care. Study II revealed a double role of the psychiatric care in relation to BPD patients. On one hand, psychiatric professionals can add to the suffering by not being understanding and being disrespectful, on the other hand they can be helpful and relieve suffering by being respectful, understanding and validating. There was a clear relationship between the patients' experience of validation and the experience of being helped. DBT seems (both from the patients' and psychiatric professionals' perspective) to be a treatment with a philosophy, content and structure being able to relieve BPD patients suffering and helping them to independence and a bearable life-situation (paper I). Study IV confirms previous findings that psychiatric professionals experience treatment of self-harming patients as profoundly stressful. DBT was seen as stressful in terms of learning demands, but decreased the experience of stress in the actual treatment of the patients due to its high degree of structure and specific techniques. The DBT team-work and supervision were felt to be supportive, as was one particular facet of DBT, namely mindfulness training which some professionals felt also improved their handling of other work stressors not related to DBT. This finding also corresponds to BPD patients' perceptions of the mindfulness component in DBT, which they reported as particularly helpful (paper 1). It should be noted that the patient samples in the thesis may be considered as a "worse off" subgroup among BPD patients, as they usually entered special treatment programs after a period of escalating symptoms, which standard psychiatric services had had difficulties handling. The rather small number of participants and the lack of equivalent andlor concurrent control groups in the quantitative studies limit the generalization of the results.

OBJECTIVES: The aims of the study were to: (i) test the reliability of a health-related quality of life (HRQOL) instrument [Swedish Health-Related Quality of Life Survey (SWED-QUAL)] on women patients with borderline personality disorder (BPD); (ii) compare their HRQOL to a normal population group comparable in age; and (iii) test for subgroup differences in HRQOL considering psychiatric DSM axis-I comorbidity. METHOD: The study was conducted in connection to a randomized, controlled trial of psychotherapy for women BPD patients. Seventy-five women with BPD diagnosis were administered the SWED-QUAL. Statistic reliability was evaluated with inter-item correlations, total-item correlations and internal consistency criterions. The BPD patients' SWED-QUAL results were compared with data extracted from a published study and subgroup differences due to axis-I comorbidity were analysed. RESULTS AND CONCLUSIONS: SWED-QUAL could be considered as an instrument with acceptable reliability when assessing HRQOL in BPD patients. The BPD patients suffered significant impairments in HRQOL overall health dimensions compared to normal population. There were no subgroup differences due to axis-I comorbidity, which indicate that BPD in itself might be a predictor of substantial HRQOL impairment.

The aim of the study was to investigate life situations, suffering, and perceptions of encounter with psychiatric care among 10 patients with borderline personality disorder. The results are based on a hermeneutic interpretation of narrative interviews in addition to biographical material (diary excerpts and poems). The interpretation revealed three comprehensive theme areas: life on the edge , the struggle for health and dignity-a balance act on a slack wire over a volcano , and the good and the bad act of psychiatric care in the drama of suffering . These theme areas form a movement back and forth-from despair and unendurable suffering to struggle for health and dignity and a life worth living. Common beliefs regarding these patients among personnel and implications for psychiatric care are discussed in relation to the results.

The aim of the study was to investigate how starting to use dialectical behavioural therapy (DBT) in the work with young self-harming women showing symptoms of borderline personality disorder affected the psychiatric professionals (n = 22) experience of occupational stress and levels of professional burnout. The study was carried out in relation to an 18-month clinical psychiatric development project, and used a mix of quantitative and qualitative research methods [a burnout inventory, the Maslach burnout inventory-General Survey (MBI-GS), free format questionnaires and group interviews]. The result confirms previous reports that psychiatric health professionals experience treatment of self-harming patients as very stressful. DBT was seen as stressful in terms of learning demands, but decreased the experience of stress in the actual treatment of the patients. The teamwork and supervision were felt to be supportive, as was one particular facet of DBT, namely mindfulness training which some therapists felt also improved their handling of other work stressors not related to DBT. The inventory for professional burnout, the MBI-GS, showed no significant changes over the 18-month period, although there was a tendency for increased burnout levels at the 6-month assessment, which had returned to baseline levels at 18 months.

The aim was to investigate patients and therapists perception of receiving and giving dialectical behavioral therapy (DBT). Ten deliberate self-harm patients with borderline personality disorder and four DBT-therapists were interviewed. The interviews were analyzed with qualitative content analysis. The patients unanimously regard the DBT-therapy as life saving and something that has given them a bearable life situation. The patients and the therapists are concordant on the effective components of the therapy: the understanding, respect, and confirmation in combination with the cognitive and behavioral skills. The experienced effectiveness of DBT is contrasted by the patient's pronouncedly negative experiences from psychiatric care before entering DBT.

Objective: In order to assess costs - consequences of dialectal behavioural therapy (DBT) in suicidal women with borderline personality disorder (BPD), the present study takes advantage of pilot data collected during a training phase, in relation to a large scale randomised controlled trail (RCT). Method: Under a 18 month period, 22 suicidal women with BPD were treated with outpatient DBT, with focus on reducing parasuicidal behaviour. Outcome data collected retrospectively 12 months before therapy start, were compared to prospective data collected up to 18 months in therapy. The cost - analysis included direct health care costs only. Results & Conclusions: The results suggest that DBT may have a positive impact on treatment costs, which decreased significantly during the last 12 months in a 18 month therapy period. The reduction of costs is due to decrease in the number of psychiatric inpatient days. The conclusions that can be drawn from the results are, however, limited as the study was not made in RCT conditions and indirect costs to society were not assessed.

Bakgrund: Psykossjukdom är en av de allvarligaste psykiatriska sjukdomarna. Trots att det finns effektiva behandlingsstrategier får inte alla med psykossjukdom specialiserad vård, vilket kan ha allvarliga konsekvenser för deras livslängd och välbefinnande. Diskriminering och stigma kring psykossjukdom kan påverka patientens hälsa och prognos. Det är viktigt att tidigt upptäcka och behandla psykossjukdomar för att minimera funktionsnedsättning och förbättra prognosen. En utmaning inom vården för personer med förstagångsinsjuknande är att bibehålla terapeutisk allians och främja återhämtning.

Syfte: Syftet var att beskriva patienters erfarenheter av vården vid förstagångsinsjuknande i psykos.

Metod: En litteraturstudie med strukturerat tillvägagångssätt och kvalitativ ansats. 15 originalartiklar inkluderades och tematisk dataanalys genomfördes enligt Braun och Clarke.

Resultat: Litteraturstudien sammanställer tidigare forskning inom området och efter dataanalys framkom tre teman: Värdefulla relationer, Hjälpande insatser, Hinder och utmaningar för delaktighet med respektive subteman.

Slutsats: Erfarenheterna från vården för personer med förstagångsinsjuknande med psykos berör relationer till personal och medpatienter, praktiskt stöd och psykoedukation, och faktorer som rädsla för vården, bristande tillit och kontinuitet.

Purpose: Perfectionism has been found to predict outcomes in the treatment of eating disorders (ED). In the present study, we took advantage of longitudinal data to: a) investigate whether there are different patterns of perfectionism during the first six months after admission in a clinical sample of patients with ED, and b) describe how these patterns are related to long-term outcome. Methods: A sample of patients (N=294) from the Coordinated Evaluation and Research at Specialized Units for Eating Disorders database was divided into clusters according to perfectionism patterns measured with the EDI-2 perfectionism scale at baseline, and six months in treatment. Cluster analysis was performed on the extent and perseverance/changeability of self-oriented and socially described perfectionism. Outcome was measured with the EDI-2 and the SCL-63. Frequencies of eating disorder diagnoses were investigated. Results: Five clusters were identified. Low perfectionism was associated with lower levels of ED and psychiatric symptomatology at baseline. There were no significant differences between clusters on outcome variables at 36-month follow-up. Conclusions: Results indicated better psychiatric and psychological health three years after the initial measure. Patterns of relations between the extent and possible changes of perfectionism, measured with the EDI-P at baseline and after six months, did not appear to be associated with long-term outcomes on psychiatric health ratings.

Background: There is a substantial body of research on eating disorders and perfectionism. Also there are several studies on eating disorders and sense of coherence (SOC), but studies regarding all three subjects are sparse. Perfectionism and the degree of SOC are considered central and aggravating aspects of psychiatric conditions, not least in relation to eating disorders. Aims: The present study aimed to describe the relationship between perfectionism as operationalized by Garner in the Eating Disorder Inventory-2 and SOC as defined by Antonovsky in the SOC-29 scale. The hypothesis was that SOC should be negatively associated with perfectionism. Methods: Data from the two self-measuring instruments collected from 95 consecutively recruited eating disorder outpatients were analysed with descriptive and inferential statistics. Results: The patients in the present study scored consistently with other Swedish eating disorder samples on the Perfectionism subscale in the Eating Disorder Inventory-2 (EDI-P) and on the SOC-29, indicating a higher degree of perfectionism and weaker SOC than normal population groups. Perfectionism was significantly correlated to SOC. The correlation was negative, confirming the study hypothesis. The hypothesis was further confirmed in a subgroup analysis comparing patients with different degrees of SOC related to their EDI-P scores. Conclusions: Perfectionism is associated with SOC in patients with eating disorders. Clinical implications: The clinical implications derived from the study could be a recommendation to focus on the SOC in patients with an eating disorder with the hope of lowering the patients’ perfectionism as well.

Bakgrund: Många patienter från etniska grupper och minoritetsgrupper har kulturella behov och trossystem om vård och omsorg som skiljer sig från den vanliga befolkningen. För att kunna täcka behoven i det ständigt föränderliga samhället inom vården, behöver vårdpersonalen medvetenhet om skillnaderna mellan en patients kulturella bakgrund och deras hälsa och hur man kan hjälpa patienten i sin nya hälsorelaterade kulturmiljö. 

Syfte: Att utforska de barriärer och hinder som flykting- och asylsökande kvinnor ställs inför när de söker sjukvård för psykisk ohälsa i Sverige.

Metod: Kvalitativ djupintervjustudie. 

Resultat: Resultatanalysen genererade sju temas sågs som ett hinder för att söka sjukvård mot psykisk ohälsa bland flykting- och asylsökande kvinnor i Sverige. Kunskap om svensk sjukvård, Tillgång till sjukvården och språk, Somatiska hälsoproblem, Utbildningsnivå, Ekonomisk situation, Prioritering av saker i relation till hälsa samt Taboos, skam och rädsla av stigma kring psykisk ohälsa. 

Slutsatser: Denna studie visar att det finns hinder för flykting- och asylsökande kvinnor att söka sjukvård för psykisk ohälsa i Sverige. Studien belyser vårdpersonalens kunskapslucka om hur man ska implementera lagen om vård som inte kan anstå.

Bakgrund: Många patienter har samsjuklighet i psykisk ohälsa och substansbrukssyndrom vilket gör den patientgruppen svårbehandlad. Interaktion i samsjuklighet försämrar oftast båda tillstånd och patienter kan få svårare förlopp av dessa. Under behandling blir det oftast mer fokus på en av diagnoser vilket gör att patienterna inte får en optimal omvårdnad och behandling. Bristfällig kunskap om samsjuklighet leder till stigmatiseringen av denna patientgrupp. Detta leder i sin tur till att patienter undviker att söka vård, blir socialt diskriminerade och isolerade. Patienter med samsjuklighet upplever dessutom mer stigma än patienter med enbart en av dessa diagnoser. Allt detta sätter press på en specialistsjuksköterska i psykiatrisk omvårdnad för att tillgodose att patienter med samsjuklighet får en personcentrerad omvårdnad av god kvalitet.  

Syfte: Syftet är att beskriva upplevda erfarenheter av behandling och rehabilitering av substansbrukssyndrom hos personer med psykisk ohälsa.

Metod: Allmän litteraturstudie med kvalitativ ansats. Insamlade data analyserades med hjälp av tematisk analys.

Resultat: Det identifierades åtta teman, två huvudteman, och sex subteman. Huvudtemat ”Behandling och rehabilitering” hade fyra subteman: “Behandlingsmetoder”, ”Faktorer till en framgångsrik behandling och rehabilitering”, ”Hinder för behandling och rehabilitering” och ”Personalens roll i behandling och rehabilitering”. Därefter följde huvudtemat ”Stigma och lidande” med två subteman: “Självmedicinering av psykisk ohälsa” och “Dubbelt lidande”.

Slutsatsen: Patienterna upplevde att en personcentrerad omvårdnad och bemötande samt adekvat kunskap hos vårdpersonalen är viktiga faktorer för en lyckad behandling och rehabilitering. Dessa faktorer bidrar till minskad stigmatisering inom vården och gör att patienter vågar söka vård. Vid samsjuklighet i både psykisk ohälsa och substansbrukssyndrom fördubblas lidande, därför krävs det att sjuksköterskor ökar sin kompetens genom att uppdatera sig med ny evidens inom området.

Purpose: Our study aimed to validate culturally adapted English and Swahili versions of the Patient Health Questionnaire-9 (PHQ-9) for use with adolescents in Kenya. Criterion validity was determined with clinician-administered diagnostic interviews using the Kiddie Schedule of Affective Disorders and Schizophrenia.

Methods: A total of 250 adolescents comprising 148 (59.2%) females and 102 (40.8%) males aged 10-19 years (mean = 14.76; standard deviation = 2.78) were recruited. The PHQ-9 was administered to all respondents concurrently in English and Swahili. Adolescents were later interviewed by clinicians using Kiddie Schedule of Affective Disorders and Schizophrenia to determine the presence or absence of current symptoms of major depressive disorder. Sensitivity specificity, positive predictive value (PPV) and negative predictive value (NPV), and likelihood ratios for various cut-off scores for PHQ-9 were analyzed using receiver operating characteristic curves.

Results: The internal consistency (Cronbach's α) for PHQ-9 was 0.862 for the English version and 0.834 for Swahili version. The area under the curve was 0.89 (95% confidence interval, 0.84-0.92) and 0.87 (95% confidence interval, 0.82-0.90) for English and Swahili version, respectively, on receiver operating characteristic analysis. A cut-off of ≥ 9 on the English-language version had a sensitivity of 95.0%, specificity of 73.0%, PPV of 0.23, and NPV of 0.99; a cut-off of ≥ 9 on the Swahili version yielded a sensitivity of 89.0%, specificity of 70.0%, PPV of 0.20, and NPV of 0.90.

Discussion: Psychometric properties were comparable across both English-adapted and Swahili-adapted version of the PHQ-9, are reliable, and valid instrument to detect major depressive disorder among adolescents which can be used in resource-limited settings for early identification of adolescents in need of mental health support.

Background: Sexual risk behaviors and struggles in romantic relationships result in higher risk of unplanned pregnancy, sexually transmitted diseases, sexual victimization and lower satisfaction in relationships for young women with Attention Deficit Hyperactivity Disorder (ADHD). There is a need to better understand sexual behaviors and the consequences of relational difficulties to help health professionals promote sexual and reproductive health. To deepen knowledge in this area, this study aimed to identify and describe self-experienced sexual and reproductive health in young women with ADHD.

Methods: A qualitative design was used. Data was collected with individual and focus group interviews with 15 young women, aged 15–29, with an ADHD diagnosis, and analyzed with thematic analysis.

Results: Data analysis identified the themes Acceptance of being different and Feeling sexually secure. The women reveal feelings of being different from others without ADHD as they break norms of sexual behavior, struggle with romantic relationships, and have difficulties concentrating during sex. There is a need to be understood and accepted,to not feel judged, and to manage romantic relationships. Self-knowledge helps them to recognize needs for supportand to develop strategies that can improve sexual satisfaction. Feeling sexually secure illustrates the women’s need to feel comfortable with their own sexuality and in control in the sexual situation. Low self-esteem and a negative self-image, described as a consequence of living with ADHD, can compromise communication in sexual situations and increase fear of being rejected. Further, misjudging sexual partners and situations can contribute to sexual victimization.

Conclusions: This study provides knowledge of how ADHD affects emotions and sexual behaviors in young women.The results highlight the need for understanding and acceptance by peers and partners. It accentuates the value ofinvolving the partner in counselling and the importance of self-knowledge. Feeling insecure in sexual relationships further implies the importance of early diagnosis to prevent secondary outcomes of ADHD, and the need for sexual victimization screening in professional settings.