Showing papers in "Annual Review of Clinical Psychology in 2005"

Stress and Depression

Abstract: Improved methods of assessment and research design have established a robust and causal association between stressful life events and major depressive episodes. The chapter reviews these developments briefly and attempts to identify gaps in the field and new directions in recent research. There are notable shortcomings in several important topics: measurement and evaluation of chronic stress and depression; exploration of potentially different processes of stress and depression associated with first-onset versus recurrent episodes; possible gender differences in exposure and reactivity to stressors; testing kindling/sensitization processes; longitudinal tests of diathesis-stress models; and understanding biological stress processes associated with naturally occurring stress and depressive outcomes. There is growing interest in moving away from unidirectional models of the stress-depression association, toward recognition of the effects of contexts and personal characteristics on the occurrence of stressors, and on the likelihood of progressive and dynamic relationships between stress and depression over time-including effects of childhood and lifetime stress exposure on later reactivity to stress.

Cognitive Vulnerability to Emotional Disorders

Abstract: A review of recent research on cognitive processing indicates that biases in attention, memory, and interpretation, as well as repetitive negative thoughts, are common across emotional disorders, although they vary in form according to type of disorder. Current cognitive models emphasize specific forms of biased processing, such as variations in the focus of attention or habitual interpretative styles that contribute to the risk of developing particular disorders. As well as predicting risk of emotional disorders, new studies haveprovided evidence of a causal relationship between processing bias and vulnerability. Beyond merely demonstrating the existence of biased processing, research is thus beginning to explore the cognitive causes of emotional vulnerability, and their modification.

Stress and Health: Psychological, Behavioral, and Biological Determinants

Abstract: Stressors have a major influence upon mood, our sense of well-being, behavior, and health. Acute stress responses in young, healthy individuals may be adaptive and typically do not impose a health burden. However, if the threat is unremitting, particularly in older or unhealthy individuals, the long-term effects of stressors can damage health. The relationship between psychosocial stressors and disease is affected by the nature, number, and persistence of the stressors as well as by the individual's biological vulnerability (i.e., genetics, constitutional factors), psychosocial resources, and learned patterns of coping. Psychosocial interventions have proven useful for treating stress-related disorders and may influence the course of chronic diseases.

The psychobiology of depression and resilience to stress: implications for prevention and treatment.

Abstract: This review discusses neurobiological and psychosocial factors associated with stress-induced depression and compares these factors with those believed to characterize stress resilience. Neurobiological factors that are discussed and contrasted include serotonin, the 5-HT1A receptor, polymorphisms of the 5-HT transporter gene, norepinephrine, alpha-2 adrenergic receptors, neuropeptide Y, polymorphisms of the alpha-2 adrenergic gene, dopamine, corticotropin-releasing hormone (CRH), dehydroepiandrosterone (DHEA), cortisol, and CRH receptors. These factors are described in the context of brain regions believed to be involved in stress, depression, and resilience to stress. Psychosocial factors associated with depression and/or stress resilience include positive emotions and optimism, humor, cognitive flexibility, cognitive explanatory style and reappraisal, acceptance, religion/spirituality, altruism, social support, role models, coping style, exercise, capacity to recover from negative events, and stress in...

Positive Psychology in Clinical Practice

Abstract: Positive psychology is the scientific study of positive experiences and positive individual traits, and the institutions that facilitate their development. A field concerned with well-being and optimal functioning, positive psychology aims to broaden the focus of clinical psychology beyond suffering and its direct alleviation. Our proposed conceptual framework parses happiness into three domains: pleasure, engagement, and meaning. For each of these constructs, there are now valid and practical assessment tools appropriate for the clinical setting. Additionally, mounting evidence demonstrates the efficacy and effectiveness of positive interventions aimed at cultivating pleasure, engagement, and meaning. We contend that positive interventions are justifiable in their own right. Positive interventions may also usefully supplement direct attempts to prevent and treat psychopathology and, indeed, may covertly be a central component of good psychotherapy as it is done now.

Structural equation modeling: strengths, limitations, and misconceptions.

Abstract: Because structural equation modeling (SEM) has become a very popular data-analytic technique, it is important for clinical scientists to have a balanced perception of its strengths and limitations. We review several strengths of SEM, with a particular focus on recent innovations (e.g., latent growth modeling, multilevel SEM models, and approaches for dealing with missing data and with violations of normality assumptions) that underscore how SEM has become a broad data-analytic framework with flexible and unique capabilities. We also consider several limitations of SEM and some misconceptions that it tends to elicit. Major themes emphasized are the problem of omitted variables, the importance of lower-order model components, potential limitations of models judged to be well fitting, the inaccuracy of some commonly used rules of thumb, and the importance of study design. Throughout, we offer recommendations for the conduct of SEM analyses and the reporting of results.

Categorical and Dimensional Models of Personality Disorder

Abstract: We review major categorical and dimensional models of personality pathology, highlighting advantages and disadvantages of these approaches. Several analytic and methodological approaches to the question of the categorical versus dimensional status of constructs are discussed, including taxometric analyses, latent class analyses, and multivariate genetic analyses. Based on our review, we advocate a dimensional approach to classifying personality pathology. There is converging evidence that four major domains of personality are relevant to personality pathology: neuroticism/negative affectivity/emotional dysregulation; extraversion/positive emotionality; dissocial/antagonistic behavior; and constraint/compulsivity/conscientiousness. Finally, we discuss how dimensional approaches might be integrated into the diagnostic system, as well as some of the major issues that must be addressed in order for dimensional approaches to gain wide acceptance.

The development of alcohol use disorders.

Abstract: Pathological alcohol use is a complex and costly problem. This chapter focuses on recent developments in the etiology of alcohol use disorders. Literature is reviewed from the fields of epidemiology, genetics, personality, neuropsychology, parenting, and social influences. In addition, theoretical models that describe pathways to the development of alcohol use disorders are presented. Particular emphasis is given to ways in which genetic, environmental, psychopharmacological, and personological literatures can inform one another.

State of the science on psychosocial interventions for ethnic minorities.

Abstract: According to a recent report of the Surgeon General (U.S. Department of Health and Human Services 1999), a range of treatments exist for most mental disorders, and the efficacy of those treatments is well documented. However, a supplement to that report (U.S. Department of Health and Human Services 2001) notes that minorities are largely missing from the efficacy studies that make up the evidence base for treatments. Because of this omission, questions arise as to whether it is appropriate to advocate for providing evidence-based care for minority populations. Do efficacious treatments generalize to minority populations? Should we adapt care for each cultural group? Does poverty affect outcomes of care? If we were better able to encourage ethnic minorities to enter care, would outcomes be similar to those found for majority patients? New data have become available regarding the impact of mental health interventions on ethnic minorities. Although data are not available to answer each question posed above, we examine what is known about outcomes of mental health treatments for ethnic minorities and begin to answer these important questions about providing care to our growing and diverse ethnic minority populations. Outcomes of mental health care are obtained through two types of research, efficacy and effectiveness studies. Efficacy studies, or randomized, controlled trials, are useful in identifying the outcomes that are likely to be associated with precisely defined care provided by experts. These studies identify the impact of interventions on outcomes, such as decreases in psychiatric symptoms and remission of syndromes. The goal of efficacy studies is to determine whether or not an intervention works for a specific syndrome. Thus, the populations studied need to meet criteria for that syndrome and be relatively free of comorbid disorders. Furthermore, highly trained, specialized clinicians provide the care under carefully specified conditions. To date, these studies have predominantly been conducted in nonminority populations; well-controlled efficacy studies examining outcomes of mental health care for minorities are rarely available. In fact, in an analysis conducted for the report of the Surgeon General entitled “Mental Health: Culture, Race and Ethnicity” (U.S. Department of Health and Human Services 2001), it was found that of 9266 participants involved in the efficacy studies forming the major treatment guidelines for bipolar disorder, schizophrenia, depression, and attention deficit/hyperactivity disorder (ADHD), only 561 Black, 99 Latino, 11 Asian American/Pacific Islanders, and zero American Indians/Alaskan Natives were included. Few of these studies had the power necessary to examine the impact of care on specific minorities. In this chapter, we examine available data from treatment outcome studies with minorities. Effectiveness studies are also important when thinking about outcomes of psychosocial interventions because these studies help evaluate outcomes of care given in real-world settings. Once an intervention is found to be efficacious, effectiveness studies then determine how they work within more diverse (both in terms of diagnosis and comorbidities) populations and when given by less-specialized clinicians. Clinicians in effectiveness studies are more likely to be generalists working in clinical settings. Outcomes often include factors such as whether or not care is sought, length of care, and adequacy of interventions. In addition, because of generally larger sample sizes, some of these trials are able to examine outcomes associated with not only symptom reduction, but also with functioning, quality of life, and cost effectiveness of care. Newer studies tend to include more diverse samples and a few have specifically included a minority sample. Again, we examine data available for minorities and compare outcomes with nonminority samples.

The Cognitive Neuroscience of Schizophrenia

Abstract: Individuals with schizophrenia experience a range of cognitive deficits and associated dysfunctions in the neural systems that support cognitive processes. This chapter reviews the literature on disturbances in working memory, executive control, and episodic memory in schizophrenia. Advances in basic cognitive neuroscience are described to help explain the cognitive neuroscience of schizophrenia. For working memory in schizophrenia, evidence is reviewed regarding deficits in the verbal (phonological loop) and nonverbal (visual-spatial scratch pad) buffer systems as well as in the central executive function. In the domain of episodic memory, evidence is reviewed for deficits in recollection versus familiarity processes in episodic memory. Also discussed are conceptual issues and potential confounds relevant to understanding the cognitive neuroscience of schizophrenia, including the role that cognitive deficits play in the developmental course of schizophrenia, relationships to specific symptom domains, beh...

Clinical Judgment and Decision Making

Abstract: When clinical psychologists make judgments, are they likely to be correct or incorrect? The following topics are reviewed: (a) methodological advances in evaluating the validity of descriptions of personality and psychopathology, (b) recent findings on the cognitive processes of clinicians, and (c) the validity of judgments and utility of decisions made by mental health professionals. Results from research on clinical judgment and decision making and their relationship to conflicts within the field of clinical psychology are discussed.

Cultural Differences in Access to Care

Abstract: As high-profile reviews have appeared and international interest has grown, sophisticated studies of the U.S. population continue to document racial and ethnic disparities in initiation of mental health care and in continuity of care. Many explanations focus on cultural factors: trust and treatment receptiveness, stigma, culturally distinctive beliefs about mental illness and mental health, culturally sanctioned ways of expressing mental health-related suffering and coping styles, and client preferences for alternative interventions and treatment-seeking pathways, as well as unresponsive programs and providers. The research itself has become more rigorous and informative, but it continues to lack theoretical focus and does not yet yield cumulative findings. Too few studies have addressed community and regional differences or differences between mental health treatment programs and systems, or considered mental health-related policies that are very likely linked to disparities. Theoretically well-formulated studies on representative samples can provide a comprehensive explanation of access disparities in cultural and culture-related terms that inform a broad-based plan of remedial intervention.

The Development of Psychopathy

Abstract: In this review, we explore two aspects of the development of psychopathy. First, we examine what psychopathy looks like across time. Second, we ask where psychopathy comes from. Much recent empirical work supports the idea that psychopathy in childhood and adolescence looks much like psychopathy in adulthood. Research utilizing recently created juvenile psychopathy indices demonstrates that juvenile psychopathy can be assessed reliably and that the nomological network surrounding the construct is quite similar to the one around adult psychopathy. Juvenile psychopathy is robustly related to offending, other externalizing problems, low levels of Agreeableness and Conscientiousness, and deficits in emotional processing and inhibition. Juvenile psychopathy is also relatively stable across adolescence. Much less research has examined from whence psychopathy comes, although several theories are reviewed. We close with a discussion of recent objections to the downward developmental extension of psychopathy to juveniles and some suggestions for additional research.

Cognitive Approaches to Schizophrenia: Theory and Therapy

Abstract: A theoretical analysis of schizophrenia based on a cognitive model integrates the complex interaction of predisposing neurobiological, environmental, cognitive, and behavioral factors with the diverse symptomatology. The impaired integrative function of the brain, as well as the domain-specific cognitive deficits, increases the vulnerability to aversive life experiences, which lead to dysfunctional beliefs and behaviors. Symptoms of disorganization result not only from specific neurocognitive deficits but also from the relative paucity of resources available for maintaining a set, adhering to rules of communication, and inhibiting intrusion of inappropriate ideas. Delusions are analyzed in terms of the interplay between active cognitive biases, such as external attributions, and resource-sparing strategies such as jumping to conclusions. Similarly, the content of hallucinations and the delusions regarding their origin and characteristics may be understood in terms of biased information processing. The int...

Decision making in medicine and health care

Abstract: Decision making is central to health policy and medical practice. Because health outcomes are probabilistic, most decisions are made under conditions of uncertainty. This review considers two classes of decisions in health care: decisions made by providers on behalf of patients, and shared decisions between patients and providers. Considerable evidence suggests wide regional variation exists in services received by patients. Evidence-based guidelines that incorporate quality of life and patient preferences may help address this problem. Systematic cost-effectiveness analysis can be used to improve resource allocation decisions. Shared medical decision making seeks to engage patients and providers in a collaborative process to choose clinical options that reflect patient preferences. Although some evidence indicates patients want an active role in making decisions, other evidence suggests that some patients prefer a passive role. Decision aids hold promise for improving individual decisions, but there are ...

Psychological treatment of eating disorders.

Abstract: Manual-based cognitive behavior therapy (CBT) is presently the most effective treatment of bulimia nervosa. Its efficacy is limited, however. Different strategies for improving upon current manual-based CBT are discussed, including combining CBT with antidepressant medication, integrating CBT with alternative psychological therapies, and expanding the scope and flexibility of manual-based CBT. CBT is underutilized in clinical practice. Dissemination of evidence-based treatment is a priority. Research on anorexia nervosa is minimal. Effective treatments have yet to be developed, although the Maudsley method of family therapy has shown the most promise in the treatment of adolescents. The most commonly seen eating disorders in clinical practice are those classified as "eating disorder not otherwise specified." With the exception of binge eating disorder (BED), however, they have been neglected by researchers. Several psychological therapies have been shown to be effective in treating BED. Controversy exists over whether treatment-specific effects have been identified. Whereas treatments have proved effective in eliminating binge eating and associated eating disorder psychopathology, achieving clinically significant weight loss remains a challenge.

Gender Identity Disorder in Children and Adolescents

Abstract: Gender identity disorder entered the psychiatric nomenclature in the DSM-III in 1980. This article reviews three domains of empirical research on gender identity disorder in children and adolescents: diagnosis and assessment, associated psychopathology, and developmental trajectories.

Panic disorder, phobias, and generalized anxiety disorder.

Abstract: This chapter provides a review of recent empirical developments, current controversies, and areas in need of further research in relation to factors that are common as well as specific to the etiology and maintenance of panic disorder, phobias, and generalized anxiety disorder. The relative contribution of broad risk factors to these disorders is discussed, including temperament, genetics, biological influences, cognition, and familial variables. In addition, the role that specific learning experiences play in relation to each disorder is reviewed. In an overarching hierarchical model, it is proposed that generalized anxiety disorder, and to some extent panic disorder, loads most heavily on broad underlying factors, whereas specific life history contributes most strongly to circumscribed phobias.

A History of Clinical Psychology as a Profession in America (and a Glimpse at Its Future)

Abstract: Clinical psychology emerged as a profession in the United States in the 1890s with studies conducted by psychologists with patients in the mental asylums of that time, and with the founding of Witmer's psychological clinic, where he treated children with learning and behavioral problems. This chapter traces the history of clinical psychology as a profession, from the focus on assessment at the turn of the twentieth century to the provision of psychotherapy that would come to dominate the field after World War II. It concludes with a discussion of some of the contemporary concerns in the profession and how those might impact the future practice of clinical psychologists.

Psychology, psychologists, and public policy.

Abstract: Evidence-based policy is being encouraged in all areas of public service ( Black 2001 ). Unprecedented federal legislation reflects a faith in science "as a force for improved public policy" ( Feuer et al. 2002 ). The objective of evidence-based policy is to use scientific research to drive decision making. Thus, the link between social science research and public policy seems to be a natural one. The purpose of this chapter is to address how psychological science in general, and clinical psychology in particular, can be of use to public policy makers. We discuss how psychological science can be relevant and applicable to informing policy, and we describe the role clinical scientists might play in generating, disseminating, and implementing that information. We also note distinct limitations on the usefulness of psychological research in driving public policy. We discuss some pitfalls and recommend areas where clinical psychology might best serve public policy.