Annual Review of Clinical Psychology - Volume 2, 2006

Over the past century, the ideas set out in psychoanalytic theory have permeated the field of psychology as well as literature, art, and culture. Despite this popularity, analytic theory has only recently received empirical support. In this chapter, we seek to highlight several fundamental concepts of analytic theory (the unconscious, drives, defenses, object relations, Oedipus complex) and psychodynamic treatments (transference, countertransference, interpretations, resistance). The first section of the chapter offers a comprehensive definition and historical background for each concept. This foundation is followed by a review of the empirical evidence supporting the reliability and validity of these concepts, their impact on treatment, and their broader influence on the future of psychology.

Competing models of doctoral training in clinical psychology are described and compared within their historical contexts. Trends in the field are examined critically with a focus on the impact of managed care on doctoral training and clinical practice. Implications for the future of doctoral training are considered, and a blueprint for the future of doctoral training in clinical psychology is presented.

Functional magnetic resonance imaging (MRI) is a noninvasive, highly repeatable, and increasingly available method to study disordered brain activity among patients with psychological or neurological disorders. In this chapter the biophysical principles underlying functional MRI are presented, and methodological limitations of the method are discussed. Artifacts related to the biophysical basis of the functional MRI signal or associated with image acquisition methods are presented, as are artifacts related to baseline effects—especially those associated with medication, caffeine, and nicotine use. The difficulties associated with the comparison of groups of subjects differing in performance receive special attention. The limitations of cognitive subtraction designs for functional MRI are also discussed. Functional MRI studies of schizophrenia patients are used to illustrate these points.

Structural analysis of social behavior (SASB) is a model that can be used to assess interpersonal and intrapsychic interactions in terms of three underlying dimensions: (a) focus (other, self, introject), (b) affiliation-hostility (love-hate), and (c) interdependence-independence (enmeshment-differentiation). Assessment of individuals or groups in terms of these dimensions can be made by self-ratings on the SASB Intrex questionnaires, ratings by others using the same questionnaires, or by objective observer ratings. Data generated by questionnaires or formal codes yield identical summary parameters, making it possible to compare directly objective observer assessments with self-ratings, if desired. The goal of this chapter is to help the reader understand the structure of SASB, become aware of how it has been used in studying interpersonal and intrapsychic events, assess its validity, assess the substance and relevance of criticisms, and consider future possibilities.

Comorbidity has presented a persistent puzzle for psychopathology research. We review recent literature indicating that the puzzle of comorbidity is being solved by research fitting explicit quantitative models to data on comorbidity. We present a meta-analysis of a liability spectrum model of comorbidity, in which specific mental disorders are understood as manifestations of latent liability factors that explain comorbidity by virtue of their impact on multiple disorders. Nosological, structural, etiological, and psychological aspects of this liability spectrum approach to understanding comorbidity are discussed.

This review surveys the field of women's mental health, with particular emphasis on its evolution into a distinct area of biomedical research. The field employs a biomedical disease model but it also emphasizes social and cultural influences on health outcomes. In recent years, its scope has expanded beyond studies of disorders occurring in women at times of reproductive transitions and it now encompasses a broader study of sex and gender differences. Historical and conceptual influences on the field are discussed. The review also surveys gender differences in the prevalence and clinical manifestations of mental disorders. Epidemiological findings have provided a rich resource for theory development, but without research tools to test theories adequately, findings of gender differences have begged the question of their biological, social, and cultural origins. Clinical depression is used to exemplify the usefulness of a sex/gender perspective in understanding mental illness; and major theories proposed to account for gender differences are critically evaluated. The National Institutes of Health (NIH) is the primary federal funding source for biomedical women's mental health research. The review surveys areas of emphasis in women's mental health research at the NIH as well as some collaborative activities that represent efforts to translate research findings into the public health and services arenas. As new analytic methods become available, it is anticipated that a more fundamental understanding of the biological and behavioral mechanisms underlying sex and gender differences in mental illness will emerge. Nonetheless, it is also likely that integration of findings predicated on different conceptual models of the nature and causes of mental illness will remain a challenge. These issues are discussed with reference to their impact on the field of women's mental health research.

Posttraumatic stress disorder (PTSD) results from exposure to a traumatic event that poses actual or threatened death or injury and produces intense fear, helplessness, or horror. U.S. population surveys reveal lifetime PTSD prevalence rates of 7% to 8%. Potential reasons for varying prevalence rates across gender, cultures, and samples exposed to different traumas are discussed. Drawing upon a conditioning model of PTSD, we review risk factors for PTSD, including pre-existing individual-based factors, features of the traumatic event, and posttrauma social support. Characteristics of the trauma, particularly peritraumatic response and related cognitions, and posttrauma social support appear to confer the greatest risk for PTSD. Further work is needed to disentangle the interrelationships among these factors and elucidate the underlying mechanisms. Based upon existing treatment outcome studies, we recommend use of exposure therapies and anxiety management training as first-line treatment for PTSD. Among psychopharmacological treatments, selective serotonin reuptake inhibitors evidence the strongest treatment effects, yet these effects are modest compared with psychological treatments.

In this chapter we review research on the diagnosis, course, etiology, and pharmacological and psychosocial treatment of bipolar disorder (BD). BD is a highly recurrent and severe illness, with high rates of suicidality and functional impairment. The disorder is heritable and appears to share susceptibility genes with schizophrenia. It is characterized by dysregulation in the dopamine and serotonin systems and by pathology in the brain systems involved in regulating emotion. Psychosocial stressors, notably life events and familial expressed emotion, significantly influence the course of the illness in the context of these vulnerabilities. Findings of randomized clinical trials indicate that psychosocial interventions enhance long-term outcomes when added to pharmacotherapy. Much remains to be clarified about the interactive contributions of genetic, neurobiological, and psychosocial factors to the course of the disorder, and the moderators and mediators of treatment effects.

Suicide is the third leading cause of death in adolescence, and medically serious suicide attempts occur in approximately 3% of adolescents. This review examines a number of risk factors that contribute to suicidal behavior. A prior suicide attempt is one of the best predictors of both a repeat attempt and eventual completed suicide. Depression, disruptive behavior disorders, and substance-use disorders also place adolescents at high risk for suicidal behavior, with comorbidity further increasing risk. Research on families indicates that suicidal behavior is transmitted through families. Groups at high risk for suicidal behavior include gay, lesbian, and bisexual youths, incarcerated adolescents, and homeless/runaway teens. Although abnormalities in the serotonergic system have not been consistently linked to suicidal behavior, genetic and neurobiologic studies suggest that impulsive aggression may be the mechanism through which decreased serotonergic activity is related to suicidal behavior. Findings from prevention and intervention studies are modest and indicate the need for substantially more theory-driven treatment research.

Common mental disorders such as schizophrenia, bipolar disorder, and severe major depression are highly heritable, but differ from single-gene (Mendelian) diseases in that they are the end products of multiple causes. Although this fact may help explain their prevalence from an evolutionary perspective, the complexity of the causes of these disorders makes identification of disease-promoting genes much more difficult. The “endophenotype” approach is an alternative method for measuring phenotypic variation that may facilitate the identification of susceptibility genes for complexly inherited traits. Here we examine the endophenotype construct in context of psychiatric genetics. We first develop an evolutionary theoretical framework for common mental disorders and differentiate them from simpler, single-gene disorders. We then provide a definition and description of endophenotypes, elucidating several features that will make a proposed endophenotype useful in psychiatric genetic research and evaluating the methods for detecting and validating such endophenotypes. We conclude with a review of recent results in the schizophrenia literature that illustrate the usefulness of endophenotypes in genetic analyses of mental disorders, and discuss implications of these findings for models of disease causation and nosology. Given that in mental disorders as in behavior generally, the pathways from genotypes to phenotypes are circuitous at best, discernment of endophenotypes more proximal to the effects of genetic variation will aid attempts to link genes to disorders.

Schizotypal personality research holds the promise of critically important insights into the etiology and ultimate prevention of schizophrenia. This article provides a critical overview of diagnostic, developmental, demographic, psychosocial, genetic, neurodevelopmental, psychophysiological, neurochemical, neurocognitive, brain imaging, and prevention-treatment issues pertaining to this personality disorder. It is argued that genetic and early environmental influences act in concert to alter brain structure/function throughout development, resulting in disturbances to basic cognitive and affective processes that give rise to three building blocks of schizotypy—cognitive-perceptual, interpersonal, and disorganized features. Two clinical subtypes are hypothesized: (a) neurodevelopmental schizotypy, which has its roots in genetic, prenatal, and early postnatal factors, is relatively stable, has genetic affinity to schizophrenia, and may benefit preferentially from pharmacological intervention, and (b) pseudoschizotypy, which is unrelated to schizophrenia, has its roots in psychosocial adversity, shows greater symptom fluctuations, and may be more responsive to psychosocial intervention.

In this review of the research literature on autism, we argue that the application of developmental and neuropsychological perspectives has contributed importantly to the understanding of the core deficits in autism and their underlying neural bases. The three classes of theories postulated to explain the developmental and neuropsychological deficits in autism are considered in terms of the specificity, uniqueness, and universality of these impairments in autism. Because we believe that a primary reason for our lack of understanding of the developmental trajectory in autism stems from our inability to diagnose the syndrome in the first three years of life, research approaches to early identification are discussed, as are longitudinal studies aimed at identifying later-life outcomes and their predictors. In contrast to the progress made in defining the core deficits and arriving at criteria for diagnosis, less progress has been made in identifying the causes of autism and in creating and testing interventions aimed at ameliorating the impairments of autism, possibly because these activities have been less tied to the developmental and neuropsychological models that have enlightened the investigation of core deficits.

The prevalence of obesity is growing at an alarming rate. Thus, investigation into the etiology, comorbidities, and treatment of obesity has burgeoned in recent years. While novel therapies—both behavioral and pharmacological—have been developed and tested, the mean weight losses achieved with nonsurgical approaches have remained virtually unchanged over the past 20 years. Fortunately, the modest weight losses achieved with these methods are associated with significant reductions in obesity-related health problems. With the most intensive available treatment (i.e., bariatric surgery), many patients achieve remission of comorbid conditions. This article defines obesity and provides an overview of the disease conditions associated with excess weight. Treatment options and outcomes are reviewed and future steps—including efforts to prevent obesity—are identified. Finally, the literature on the relationship between obesity and depression is examined.

Mild cognitive impairment (MCI) is a clinical syndrome thought to represent the transition between normal function and dementia. This review describes data that support the existence of such a transitional phase, outlines the heterogeneity of MCI and how that has influenced the evolving concept of MCI, and discusses the impact of heterogeneity on recent MCI clinical trials.

Aging has effects on many features of normal functioning, particularly in the domains of cognition and adaptive life skills. Several psychiatric conditions also affect cognition and adaptive functioning; most of the research on these topics has been performed on patients early in their lives. The amount of research on older patients is smaller than in younger patients, but there is a developing research literature in several aspects of aging and psychopathology. This chapter reviews aging effects on two major psychiatric conditions: schizophrenia and depression. We examine changes in symptoms and cognitive functioning with aging and the functional implications of the development or worsening of cognitive performance. We also identify risk factors for cognitive changes within each condition and examine the implication of early- versus late-life onset. We believe that cognitive changes with aging are potentially predictable, possibly sharing a mechanism with normal aging-related changes and certainly laden with prognostic implications. We see cognitive changes as a possible commonality across persistent psychiatric disorders as well as healthy aging in late life.

Clinical research trials demonstrate the efficacy of contingency management procedures in treating substance use disorders. Usually, reinforcement, in the form of vouchers exchangeable for retail goods and services, is provided for drug abstinence in patients treated in psychosocial or methadone maintenance clinics. Recently, the types of reinforcers have been adapted to include lower cost alternatives, and reinforcement is being expanded to alter other target behaviors such as attendance at treatment, adherence to treatment goals, and compliance with medication. This chapter provides an overview of the populations and behaviors to which contingency management approaches have been applied. It also reviews design features that appear critical in the successful adaptation of the techniques. In addition, areas for future research are described.

Several personality characteristics have been linked in multiple well-designed prospective studies to subsequent physical health outcomes, such as longevity and the development and course of cardiovascular disease. The evidence is strongest for negative affectivity/neuroticism, anger/hostility and related traits, and optimism. Models of mechanisms underlying these associations have emphasized physiological effects of stress, exposure to stressors, and health behavior. Preliminary evidence supports the viability of some mechanisms, but formal mediational tests are lacking. In addition to addressing limitations and inconsistencies in this literature, future research should address developmental aspects of these psychosocial risk factors, contextual moderators of their health effects, and intervention applications in the prevention and management of disease. In these efforts, greater incorporation of concepts and methods in the structural, social-cognitive, and interpersonal perspectives in the field of personality are needed.

The issues surrounding repressed, recovered, or false memories have sparked one of the greatest controversies in the mental health profession in the twentieth century. We review evidence concerning the existence of the repression and recovery of autobiographical memories of traumatic events and research on the development of false autobiographical memories, how specific therapeutic procedures can lead to false memories, and individual vulnerability to resisting false memories. These findings have implications for therapeutic practice, for forensic practice, for research and training in psychology, and for public policy.