Annual Review of Clinical Psychology - Volume 5, 2009

Measures of psychological constructs are validated by testing whether they relate to measures of other constructs as specified by theory. Each test of relations between measures reflects on the validity of both the measures and the theory driving the test. Construct validation concerns the simultaneous process of measure and theory validation. In this article, we review the recent history of validation efforts in clinical psychological science that has led to this perspective, and we review the following recent advances in validation theory and methodology of importance for clinical researchers. These are: the emergence of nonjustificationist philosophy of science; an increasing appreciation for theory and the need for informative tests of construct validity; valid construct representation in experimental psychopathology; the need to avoid representing multidimensional constructs with a single score; and the emergence of effective new statistical tools for the evaluation of convergent and discriminant validity.

In this review, we examine studies that use item response theory (IRT) to explore the psychometric properties of clinical measures. Next, we consider how IRT has been used in clinical research for: scale linking, computerized adaptive testing, and differential item functioning analysis. Finally, we consider the scale properties of IRT trait scores. We conclude that there are notable differences between cognitive and clinical measures that have relevance for IRT modeling. Future research should be directed toward a better understanding of the metric of the latent trait and the psychological processes that lead to individual differences in item response behaviors.

The development of methodologies for assaying genetic variation at high resolution throughout the genome has revolutionized the search for susceptibility genes for common diseases. This search, however, has been less successful in psychiatry than in other areas of medicine. It is hypothesized that the imprecision and uncertain validity of psychiatric diagnoses are major factors in this disappointing progress. Here we discuss the methodologies employed for genetic investigation of mental disorders, including phenotyping strategies, approaches to genetic mapping, and use of animal models of psychopathology.

The relation between risk and outcome consists of myriad, complex, longitudinal processes. To study these relations requires research designs and statistical methods that are sensitive to the longitudinal structure of the risk, the outcome, and the risk-outcome relation. This review presents four longitudinal characteristics that can complicate psychopathology risk-outcome research. We represent each complication with an example data set. We demonstrate how conventional statistical approaches can yield highly misleading results. Finally, we review alternative statistical approaches that can handle these complications quite well.

The development of evidence-based treatments for anxiety disorders is a major achievement of clinical psychology, and cognitive behavior therapy is the best-established and most widely used method. The first form of this therapy, behavior therapy, was a combination of Pavlovian and Behavioristic ideas and methods and was particularly successful in reducing fears. The infusion of cognitive ideas in the late 1970s generated the wider and more flexible cognitive behavior therapy that independent agencies in the United States and United Kingdom now recommend as the treatment of choice for most of the anxiety disorders. Remaining theoretical problems and clinical limitations need to be tackled.

Evidence is growing that several computer-aided psychotherapy (CP) systems can effectively improve a range of common mental health problems. Most clients find CP acceptable because of its convenience, confidentiality, and reduction of stigma. CP can be accessed in a clinic, but recently clients have used CP especially on the Internet at home, with brief support on a telephone helpline and/or by email. Brief and efficient screening and support greatly reduce attrition. CP's efficacy, and encouragement of its dissemination and implementation by some national funding bodies and governmental agencies, has led to its spread as a regular care option and is increasing access to psychological therapies in some countries. Transfer of this new approach from use in tight research studies to use as an integrated part of everyday care under widely varying conditions generates teething problems that are being managed in diverse ways across different centers. Anonymized Internet audit of CP outcomes facilitates effective care and clinical governance. This review examines the current state of the art as well as the science and broad applications of CP.

In the past 25 years, the field of HIV prevention research has been transformed repeatedly. Today, effective HIV prevention requires a combination of behavioral, biomedical, and structural intervention strategies. Risk of transmitting or acquiring HIV is reduced by consistent male- and female-condom use, reductions in concurrent and/or sequential sexual and needle-sharing partners, male circumcision, and treatment with antiretroviral medications. At least 144 behavioral prevention programs have been found effective in reducing HIV transmission acts; however, scale up of these programs has not occurred outside of the United States. A series of recent failures of HIV-prevention efficacy trials for biomedical innovations such as HIV vaccines, treating herpes simplex 2 and other sexually transmitted infections, and diaphragm and microbicide barriers highlights the need for behavioral strategies to accompany biomedical strategies. This challenges prevention researchers to reconceptualize how cost-effective, useful, realistic, and sustainable prevention programs will be designed, delivered, tested, and diffused. The next generation of HIV prevention science must draw from the successes of existing evidence-based interventions and the expertise of the market sector to integrate preventive innovations and behaviors into everyday routines.

In this review, we examine randomized controlled trials of community interventions to affect health. The evidence supports the efficacy of community interventions for preventing tobacco, alcohol, and other drug use; several recent trials have shown the benefits of community interventions for preventing multiple problems of young people, including antisocial behavior. However, the next generation of community intervention research needs to reflect more fully the fact that most psychological and behavioral problems of humans are interrelated and result from the same environmental conditions. The evidence supports testing new comprehensive community interventions that focus on increasing nurturance in communities. Nurturing communities will be ones in which families, schools, neighborhoods, and workplaces (a) minimize biologically and socially toxic events, (b) richly reinforce prosocial behavior, and (c) foster psychological acceptance. Such interventions also have the potential to make neighborhoods more sustainable.

The predominant dimensional model of general personality structure within psychology is the five-factor model (FFM). Research indicates that the personality disorders of the American Psychiatric Association's diagnostic manual can be understood as maladaptive variants of the domains and facets of the FFM. The current review provides a proposal for the classification of personality disorder from the perspective of the FFM. Discussed as well are implications and issues associated with an FFM of personality disorder, including the integration of a psychiatric nomenclature with general personality structure, the inclusion of a domain of openness to experience, the identification of problems in living associated with maladaptive personality traits, the setting of a diagnostic threshold, prototypal matching, feasibility, and clinical utility.

Recent work has focused on explicating the relations among the current mood and anxiety disorders. This research has yielded some important findings (e.g., the very strong link between generalized anxiety disorder and the unipolar mood disorders). I discuss problems associated with disorder-based analyses, however, and I argue that they need to be supplemented by examining relations among the specific symptom dimensions within these diagnostic classes. I demonstrate that two quantitative elements need to be considered when analyzing the properties of symptoms—the level of specificity and the magnitude of the general distress variance. These quantitative elements can be used to organize relevant symptoms into four groups (i.e., a quadripartite model) that reflect varying combinations of distress and specificity. I illustrate the value of this approach by reviewing the properties of the major symptom dimensions within posttraumatic stress disorder, obsessive-compulsive disorder, and major depression.

Schizophrenia is a major mental disorder that affects approximately 1% of the population worldwide. Cognitive deficits are a key feature of schizophrenia and a primary cause of long-term disability. Current neurophysiological models of schizophrenia focus on distributed brain dysfunction with bottom-up as well as top-down components. Bottom-up deficits in cognitive processing are driven by impairments in basic perceptual processes that localize to primary sensory brain regions. Within the auditory system, deficits are apparent in elemental sensory processing, such as tone matching following brief delay. Such deficits lead to impairments in higher-order processes such as phonological processing and auditory emotion recognition. Within the visual system, deficits are apparent in functioning of the magnocellular visual pathway, leading to higher-order deficits in processes such as perceptual closure, object recognition, and reading. In both auditory and visual systems, patterns of deficit are consistent with underlying impairment of brain N-methyl-d-aspartate receptor systems.

The treatment of patients with borderline personality disorder (BPD) is challenging. Making a diagnosis is necessary to plan therapy. But since we do not know the etiology of BPD, treatment cannot be based on a well-established theory. Outcome research shows that most patients recover with time. A series of clinical trials show that a variety of psychotherapies are effective in BPD and that the effects of medication are unimpressive.

This review examines the development and etiology of disruptive behavior [symptoms of oppositional defiant disorder (ODD), conduct disorder (CD), and psychopathic features] and delinquency (particularly violence). We address selected key developmental issues, including (a) to what extent negative emotional ODD symptoms are associated with later internalizing disorders, (b) whether psychopathic features provide added predictive utility beyond traditional disruptive behaviors, and (c) the role of oppositional behavior and conduct problems in the development of violence. This review also focuses on the causes of ODD, CD, psychopathic features, and delinquency and explores the extent to which the causes of disruptive and delinquent behavior are the same. We examine the degree to which risk and promotive factors change with age and whether promotive factors buffer the impact of risk factors. Finally, we explore the question of whether there are developmental shifts in children's exposure to risk and promotive factors.

The present review summarizes our current knowledge of the development and management of anxiety in children and adolescents. Consideration is given to limitations of this knowledge and directions for future research. The review begins with coverage of the development and demographic correlates of anxiety in young people and then moves to systematic discussion of some of the key etiological factors, including genetics, temperament, parenting, and individual experiences. The second part of the review describes current treatment strategies and efficacy as well as factors thought to influence treatment outcome, including treatment features, child factors, and parent factors. The review concludes with brief coverage of some more recent developments in treatment including alternative models of delivery and prevention strategies.

Many years before receiving a clinical diagnosis of Alzheimer's disease (AD), patients experience evidence of cognitive decline. Recent studies using a variety of brain imaging technologies have detected subtle changes in brain structure and function in normal adults with a genetic risk for AD; these brain changes have similar pathological features as AD, and some appear to be predictive of future cognitive decline. This review examines the most recent data on brain changes in genetic risk for AD and discusses the benefits and potential risks of detecting individuals at risk.

Depression is less prevalent among older adults than among younger adults, but it can have serious consequences. More than half of cases represent a first onset in later life. Although suicide rates in the elderly are declining, they are still higher than in younger adults and are more closely associated with depression. Depressed older adults are less likely to endorse affective symptoms and more likely to display cognitive changes, somatic symptoms, and loss of interest than are depressed younger adults. Risk factors leading to the development of late-life depression likely comprise complex interactions among genetic vulnerabilities, cognitive diathesis, age-associated neurobiological changes, and stressful events. Insomnia is an often overlooked risk factor for late-life depression. We suggest that a common pathway to depression in older adults, regardless of which predisposing risks are most prominent, may be curtailment of daily activities. Accompanying self-critical thinking may exacerbate and maintain a depressed state. Offsetting the increasing prevalence of certain risk factors in late life are age-related increases in psychological resilience. Other protective factors include higher education and socioeconomic status, engagement in valued activities, and religious or spiritual involvement. Treatments including behavioral therapy, cognitive-behavioral therapy, cognitive bibliotherapy, problem-solving therapy, brief psychodynamic therapy, and life review/reminiscence therapy are effective but are too infrequently used with older adults. Preventive interventions including education for individuals with chronic illness, behavioral activation, cognitive restructuring, problem-solving skills training, group support, and life review have also received support.

Pedophilia is defined as a sexual interest in prepubescent children. It is empirically linked with sexual offending against children: Child pornography offenders and sex offenders with child victims are more likely to be pedophiles based on self-report or objective measures of sexual interests. At the same time, some pedophiles have not had any known sexual contact with children, and perhaps half of sex offenders against children would not meet diagnostic criteria for pedophilia. Pedophilia can be diagnosed using a variety of methods and is an important factor to consider in the assessment of sex offenders because pedophilic offenders are more likely to sexually reoffend and require different interventions. There is no evidence to suggest that pedophilia can be changed. Instead, interventions are designed to increase voluntary control over sexual arousal, reduce sex drive, or teach self-management skills to individuals who are motivated to avoid acting upon their sexual interests.

This article reviews the research on the treatment of cigarette smoking in individuals who have comorbid mental illnesses or non-nicotinic addictions. The prevalence of smoking in mentally ill and substance-abusing populations is presented, as well as reasons for this high prevalence. The historical role of cigarettes and tobacco in mental illness and addiction is reviewed to help the reader better understand the pervasiveness of smoking in these disorders and the relative absence of intervention efforts in mental heath and addiction treatment settings. The article then discusses the several reasons for integrating smoking treatment into mental health and addiction settings. The outcome research for adult and adolescent comorbid smokers is reviewed, and barriers to treatment are discussed. The review closes with a brief discussion of models of integration and thoughts about prevention.

There is little doubt that nicotine addiction sustains tobacco use in most people and that individual variation in response to tobacco has a strong biological basis. However, the great diversity in tobacco use behaviors observed between countries and within countries over time suggests that biology alone cannot fully explain these variations. This review examines the role of the social environment in understanding tobacco use behaviors and efforts to curb tobacco use at the population level. We conclude that the social environment plays a critical role in determining how innate biological factors involved in nicotine dependency actually get expressed at the population level. Tobacco use as reflected in population trends is seen as the product of the interaction of agent, host, and environmental factors. Government policies are seen as an important modifiable environmental influence that can alter how tobacco products are designed and marketed (agent factors) and how consumers perceive the risks and benefits of smoking (host factors). Evidence suggests that synergy is gained when tobacco control interventions directed at agent, host, and environmental factors are implemented together.

Although justice system policy and practice cannot, and should not, be dictated solely by studies of adolescent development, the ways in which we respond to juvenile offending should be informed by the lessons of developmental science. This review begins with a brief overview of the history, rationale, and workings of the American juvenile justice system. Following this, I summarize findings from studies of brain, cognitive, and psychosocial development in adolescence that have implications for the treatment of juveniles in the justice system. The utility of developmental science in this context is illustrated by the application of these research findings to three fundamental issues in contemporary justice policy: the criminal culpability of adolescents, adolescents' competence to stand trial, and the impact of punitive sanctions on adolescents' development and behavior. Taken together, the lessons of developmental science offer strong support for the maintenance of a separate juvenile justice system in which adolescents are judged, tried, and sanctioned in developmentally appropriate ways.