Annual Review of Clinical Psychology - Volume 6, 2010

The historical basis of personality assessment that led to the development of today's approaches and applications is described. The modern era of personality assessment began in late nineteenth-century Europe. Early twentieth-century highlights included the development of projective techniques like the Rorschach and several early self-report inventories, culminating in the development of the most widely used measure, the Minnesota Multiphasic Personality Inventory (MMPI). The most recent 30-year period showed expansions into personnel screening; clinical assessment, including wide use in forensic settings; and therapeutic assessment. However, contemporary controversies are apparent with two of the most widely used measures, the Rorschach and the MMPI instruments. These controversies are described, including concerns about the Exner Comprehensive System for the Rorschach and the last five years of changes to the MMPI-2, including the introduction of the Restructured Clinical (RC) Scales, the adoption of the Fake Bad Scale (FBS) into the instrument, and the release of the MMPI-2 Restructured Form (MMPI-2-RF). Current challenges facing psychologists in personality assessment are highlighted.

The proposal that psychologists should pursue prescriptive authority was first put forth 25 years ago, and it has been an official goal of the American Psychological Association for 15 years. Since then some form of prescriptive authority has been approved by three states, the Territory of Guam, and three branches of the military. Psychologists are also eligible to prescribe in the Public Health Service and the Indian Health Service. The movement has generated strong opinions both in favor and in opposition. Supporters focus particularly on increasing access to appropriate care and changing the role of psychologists within the healthcare system, while opponents raise concerns about how prescriptive authority will change professional psychology and whether psychologists will prescribe safely. This review provides a summary of milestones in the movement to date, as well as the arguments that have been raised for and against prescriptive authority.

Starting with the Daubert case, courtroom rules and guides regulating the admissibility of scientific evidence have undergone major revisions over the past 10 to 15 years. We review these changes and current legal rules and guides, in particular their impact on the admission of behavioral sciences evidence and testimony. We examine commonly intended meanings, conceptualizations, and language use relating to science and the admission of evidence within the legal system and their relation to more familiar terms and concepts within the behavioral sciences, identifying points of continuity and discontinuity. We then review illustrative legal cases involving challenges to the admission of psychological and psychiatric evidence and their implications for mental health professionals. Finally, we offer a framework for conceptualizing and prioritizing key legal criteria for determining admissibility and appraising standing on these factors within the mental health field. Increased mutual understanding between psychology and law should further enhance productive interfaces between the disciplines and add to the many instances in which the proper use of science in the courtroom has facilitated fair resolution of legal conflicts.

In this review, we explore recent developments in the area of linear and nonlinear generalized mixed-effects regression models and various alternatives, including generalized estimating equations for analysis of longitudinal data. Methods are described for continuous and normally distributed as well as categorical (binary, ordinal, nominal) and count (Poisson) variables. Extensions of the model to three and four levels of clustering, multivariate outcomes, and incorporation of design weights are also described. Linear and nonlinear models are illustrated using an example involving a study of the relationship between mood and smoking.

Group-based trajectory models are increasingly being applied in clinical research to map the developmental course of symptoms and assess heterogeneity in response to clinical interventions. In this review, we provide a nontechnical overview of group-based trajectory and growth mixture modeling alongside a sampling of how these models have been applied in clinical research. We discuss the challenges associated with the application of both types of group-based models and propose a set of preliminary guidelines for applied researchers to follow when reporting model results. Future directions in group-based modeling applications are discussed, including the use of trajectory models to facilitate causal inference when random assignment to treatment condition is not possible.

The measurement of functional capacity in mental illness is an important recent development. Determination of functional capacity may serve as a surrogate marker for real-world functioning, thereby aiding clinicians in making important treatment determinations. This article provides an overview of a model of functioning, discusses the various areas of functioning relevant to real-world performance in persons with mental illness, and reviews existing measures that assess functional capacity. Limitations of existing methods of assessing functional capacity are discussed, and future areas of research are suggested.

A pressing need for interrater reliability in the diagnosis of mental disorders emerged during the mid-twentieth century, prompted in part by the development of diverse new treatments. The Diagnostic and Statistical Manual of Mental Disorders (DSM), third edition answered this need by introducing operationalized diagnostic criteria that were field-tested for interrater reliability. Unfortunately, the focus on reliability came at a time when the scientific understanding of mental disorders was embryonic and could not yield valid disease definitions. Based on accreting problems with the current DSM-fourth edition (DSM-IV) classification, it is apparent that validity will not be achieved simply by refining criteria for existing disorders or by the addition of new disorders. Yet DSM-IV diagnostic criteria dominate thinking about mental disorders in clinical practice, research, treatment development, and law. As a result, the modern DSM system, intended to create a shared language, also creates epistemic blinders that impede progress toward valid diagnoses. Insights that are beginning to emerge from psychology, neuroscience, and genetics suggest possible strategies for moving forward.

Before the 1980s, no randomized controlled trials had been carried out to test whether major depressive episodes could be prevented. In the past 30 years, several trials have reported success in reducing the incidence (the number of new cases) of major depressive episodes. These studies suggest that major depression can be prevented. Given the large burden of disease caused by major depression, it is time for substantial systematic efforts to replicate these studies, carry out multisite trials, and widely disseminate prevention interventions found to be effective. The present review examines the conceptual and practical differences between treatment and prevention trials and the importance of identifying groups at high short-term risk for major depressive episodes to make prevention trials feasible. We also list the randomized controlled prevention trials that have been carried out to date and discuss the need for prevention interventions that go beyond the limits of traditional face-to-face interventions.

This article examines issues and challenges in the design of cultural adaptations that are developed from an original evidence-based intervention (EBI). Recently emerging multistep frameworks or stage models are examined, as these can systematically guide the development of culturally adapted EBIs. Critical issues are also presented regarding whether and how such adaptations may be conducted, and empirical evidence is presented regarding the effectiveness of such cultural adaptations. Recent evidence suggests that these cultural adaptations are effective when applied with certain subcultural groups, although they are less effective when applied with other subcultural groups. Generally, current evidence regarding the effectiveness of cultural adaptations is promising but mixed. Further research is needed to obtain more definitive conclusions regarding the efficacy and effectiveness of culturally adapted EBIs. Directions for future research and recommendations are presented to guide the development of a new generation of culturally adapted EBIs.

The present review summarizes empirical developments in the psychosocial treatment of panic and panic disorder by focusing on four key themes that have been emphasized in this literature: (a) treatment efficacy, effectiveness, and innovation; (b) modulating and process variables in treatment; (c) effective dissemination of treatment; and (d) prevention of panic. Cognitive behavioral treatments (CBTs) for panic are very good, even in the context of comorbidity, but the level of efficacy does not appear to be increasing over time. Unfortunately, there have been relatively few substantive innovations in CBT protocols since the 1980s, and despite progress in the use of computer technology, dissemination of these treatments is lagging. The prevention of panic-spectrum psychopathology is a promising area linked with advances in the identification of panic-relevant risk factors that appear to modulate CBT outcomes.

Medically unexplained symptoms are the defining feature of somatoform disorders (SFD) as currently included in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and the International Classification of Diseases, Tenth Edition. Cognitive, behavioral, biological, and social variables are important to our understanding of SFD. Research in the past decade has highlighted the central role of (a) prolonged attention allocation to bodily sensations, (b) the dysfunctional role of catastrophizing symptoms as signs of severe illness, (c) neuroendocrine alterations, and (d) the influence of illness behavior (e.g., the avoidance of physical activity) on the maintenance and chronicity of SFD. Additionally, conditioning approaches have demonstrated that perceiving somatic discomfort can easily be learned. In addition to current models of etiology and pathogenesis, the existing evidence on the efficacy and effectiveness of psychotherapy for SFD is reviewed. Finally, future directions and some current blind spots in research on SFD are outlined.

Cognitive theories of depression posit that people's thoughts, inferences, attitudes, and interpretations, and the way in which they attend to and recall information, can increase their risk for depression. Three mechanisms have been implicated in the relation between biased cognitive processing and the dysregulation of emotion in depression: inhibitory processes and deficits in working memory, ruminative responses to negative mood states and negative life events, and the inability to use positive and rewarding stimuli to regulate negative mood. In this review, we present a contemporary characterization of depressive cognition and discuss how different cognitive processes are related not only to each other, but also to emotion dysregulation, the hallmark feature of depression. We conclude that depression is characterized by increased elaboration of negative information, by difficulties disengaging from negative material, and by deficits in cognitive control when processing negative information. We discuss treatment implications of these conclusions and argue that the study of cognitive aspects of depression must be broadened by investigating neural and genetic factors that are related to cognitive dysfunction in this disorder. Such integrative investigations should help us gain a more comprehensive understanding of how cognitive and biological factors interact to affect the onset, maintenance, and course of depression.

Studying the genetics of mood disorders has never been more exciting. We have moved rapidly from establishing the genetic basis of depression to asking questions about how genes are expressed. This has been made possible by the capacity to collect and sequence DNA for large samples cheaply. But “multidisciplinary” approaches investigating interrelationships between risk factors have also been increasingly adopted, encouraging collaborations between those studying genes and those studying the brain, cognition, and/or the social environment. In this review, we first describe findings from quantitative and molecular studies investigating the genetic basis of depression. Second, we present overviews of three hot topics of genetic research: gene-environment interplay, which considers how genetic factors shape exposure and responses toward the social environment; endophenotypic research, which identifies neurophysiological and psychological mediators of genetic risk; and epigenetics, which explain how early environments can foster changes in gene expression, altering subsequent emotional development.

People have engaged in self-injury—defined as direct and deliberate bodily harm in the absence of suicidal intent—for thousands of years; however, systematic research on this behavior has been lacking. Recent theoretical and empirical work on self-injury has significantly advanced the understanding of this perplexing behavior. Self-injury is most prevalent among adolescents and young adults, typically involves cutting or carving the skin, and has a consistent presentation cross-nationally. Behavioral, physiological, and self-report data suggest that the behavior serves both an intrapersonal function (i.e., decreases aversive affective/cognitive states or increases desired states) and an interpersonal function (i.e., increases social support or removes undesired social demands). There currently are no evidence-based psychological or pharmacological treatments for self-injury. This review presents an integrated theoretical model of the development and maintenance of self-injury that synthesizes prior empirical findings and proposes several testable hypotheses for future research.

Adolescence is a time of exploration of the self, and this exploration may involve the use of alcohol and drugs. Sadly, for some, adolescence also marks the first signs of a psychosis. The temporal proximity between the onset of substance use and of psychosis has been the cause of much debate. Here we review the association of alcohol, cannabis, stimulants, and other drugs with psychosis, and we conclude that the use of cannabis and the amphetamines significantly contributes to the risk of psychosis.

Diagnostic systems, phenotype models, and theories of etiology incorporate propositions on the underlying nature of psychosis and schizophrenia phenotypes. These propositions, whether implicit or explicit, are that the distributions of the phenotypes, or the phenotype experiences themselves, are dimensional or categorical. On one hand, evidence on the epidemiology of schizophrenia phenotypes suggests symptom phenotypes may not be bound by conventional diagnostic thresholds but instead may blend imperceptibly with subclinical, statistically frequent experience, supporting continuum viewpoints. On the other hand, evidence on the population structure suggests a latent categorical structure; the population may be composed of two types of people. However, both sets of evidence are beset by methodological limitations that point unequivocally to the need to move beyond current diagnostic conceptualizations, observation, and anamnesis of psychosis, and toward responsive and scientifically refutable formulations of schizophrenia.

We review the literature on pathological narcissism and narcissistic personality disorder (NPD) and describe a significant criterion problem related to four inconsistencies in phenotypic descriptions and taxonomic models across clinical theory, research, and practice; psychiatric diagnosis; and social/personality psychology. This impedes scientific synthesis, weakens narcissism's nomological net, and contributes to a discrepancy between low prevalence rates of NPD and higher rates of practitioner-diagnosed pathological narcissism, along with an enormous clinical literature on narcissistic disturbances. Criterion issues must be resolved, including clarification of the nature of normal and pathological narcissism, incorporation of the two broad phenotypic themes of narcissistic grandiosity and narcissistic vulnerability into revised diagnostic criteria and assessment instruments, elimination of references to overt and covert narcissism that reify these modes of expression as distinct narcissistic types, and determination of the appropriate structure for pathological narcissism. Implications for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and the science of personality disorders are presented.

Although there are a large and growing number of scientifically questionable treatments available for children with autism spectrum disorder (ASD), intervention programs applying the scientific teaching principles of applied behavior analysis (ABA) have been identified as the treatment of choice. The following article provides a selective review of ABA intervention approaches, some of which are designed as comprehensive programs that aim to address all developmental areas of need, whereas others are skills based or directed toward a more circumscribed, specific set of goals. However, both types of approaches have been shown to be effective in improving communication, social skills, and management of problem behavior for children with ASD. Implications of these findings are discussed in relation to critical areas of research that have yet to be fully explored.

Children aged birth to five years are exposed to a disproportionately increased amount of potentially traumatic events compared to older children. This review examines the prevalence of traumatic exposure in the birth-to-five age range, the indicators and diagnostic criteria of early traumatic stress, and the contextual issues associated with the experience of early trauma. The article also selectively reviews the impact of trauma on the biological, emotional, social, and cognitive functioning of young children's development along with some promising clinical treatment and service interventions that target the parent-child relationship as a vehicle of trauma recovery. Despite extensive documentation of the negative impact of trauma on the normal development of young children, research, clinical, and policy efforts to address the psychological repercussions of early victimization remain remarkably limited. Future directions in research and clinical practice as well as implications for policy are discussed.