Nicole D. Anderson
Healthy aging is accompanied by decrements in episodic memory and working memory. Significant efforts have therefore been made to augment episodic and working memory in healthy older adults. Two principal approaches toward memory rehabilitation adults are restorative approaches and compensatory approaches. Restorative approaches aim to repair the affected memory processes by repeated, adaptive practice (i.e., the trained task becomes more difficult as participants improve), and have focused on recollection training, associative memory training, object-location memory training, and working memory training. The majority of these restorative approaches have been proved to be efficacious, that is, participants improve on the trained task, and there is considerable evidence for maintenance of training effects weeks or months after the intervention is discontinued. Transfer of restorative training approaches has been more elusive and appears limited to other tasks relying on the same domains or processes. Compensatory approaches to memory strive to bypass the impairment by teaching people mnemonic and lifestyle strategies to bolster memory performance. Specific mnemonic strategy training approaches as well as multimodal compensatory approaches that combine strategy training with counseling about other factors that affect memory (e.g., memory self-efficacy, relaxation, exercise, and cognitive and social engagement) have demonstrated that older adults can learn new mnemonics and implement them to the benefit of memory performance, and can adjust their views and expectations about their memory to better cope with the changes that occur during healthy aging. Future work should focus on identifying the personal characteristics that predict who will benefit from training and on developing objective measures of the impact of memory rehabilitation on older adults’ everyday functioning.
Jonathan S. Abramowitz
Obsessive-compulsive disorder (OCD) is one of the most destructive psychological disorders. Its symptoms often interfere with work or school, interpersonal relationships, and with activities of daily living (e.g., driving, using the bathroom). Moreover, the psychopathology of OCD is seemingly complex: sufferers battle ubiquitous unwanted thoughts, doubts, and images that, while senseless on the one hand, are perceived as signs of danger on the other hand. The thematic variation and elaborate relations between behavioral and cognitive signs and symptoms can be perplexing to even the most experienced of observers. Cognitive-behavioral models of OCD explain these phenomena and account for their heterogeneity. These models also have implications for how OCD is treated using exposure and response prevention, which research indicates are effective short- and long-term interventions.
Katy W. Martin-Fernandez and Yossef S. Ben-Porath
Attempts at informal personality assessment can be traced back to our distant ancestors. As the field of Clinical Psychology emerged and developed over time, efforts were made to create reliable and valid measures of personality and psychopathology that could be used in a variety of contexts. There are many assessment instruments available for clinicians to use, with most utilizing either a projective or self-report format. Individual assessment instruments have specific administration, scoring, and interpretive guidelines to aid clinicians in making accurate decisions based on a test taker’s answers. These measures are continuously adapted to reflect the current conceptualization of personality and psychopathology and the latest technology. Additionally, measures are adapted and validated to be used in a variety of settings, with a variety of populations. Personality assessment continues to be a dynamic process that can be utilized to accurately and informatively represent the test taker and aid in clinical decision making and planning.
Felipe B. Schuch and Brendon Stubbs
Depression is a leading cause of global burden affecting people across all ages, genders, and socioeconomic groups. Antidepressants are the cornerstone of treatment, yet treatment response is often inadequate. While some psychological interventions such as cognitive behavioral therapy can also help alleviate depressive symptoms, alternative and complimentary treatment options are required. In particular, therapeutic interventions that also address the greatly increased levels of obesity and cardiovascular disease among people with depression may offer added value. With the rising burden of premature mortality due to cardiovascular disease in people with depression and promising evidence base for physical activity to improve depressive symptoms, it is important to review the role, benefits, and underlying neurobiological responses of exercise among people with depression.
There has been a growing body of evidence to suggest that higher levels of physical activity reduce a person’s risk of incident depression. It appears that lower levels of cardiorespiratory fitness increase an individual risk of depression, suggesting that physical activity and physical fitness have a key role in the prevention of depression. Moreover, exercise can improve depressive symptoms in those with subthreshold depressive symptoms and major depressive disorder. Despite the effectiveness of exercise, the optimal dose and frequency are yet to be fully elucidated. Nonetheless, exercise appears to be well accepted by people with depression, with relatively low levels of dropout from interventions, particularly when supervised by qualified professionals with expertise in exercise prescription. Various barriers to engaging in exercise exist and motivational strategies are essential to initiate and maintain exercise. A number of hypotheses have been postulated to determine the antidepressant effect of exercise; however, most are based on animal models or models elucidated from people without depression. Therefore, future representative research is required to elucidate the neurobiological antidepressant response from exercise in people with depression. Physical activity interventions targeting fitness should be a central part of the prevention and management of depression. In particular, physical activity interventions offer a viable option to prevent and address cardiometabolic abnormalities and cardiovascular disease, which account for a significant amount of premature deaths in this population and are not addressed by standard pharmacological and psychological therapies.
Scott O. Lilienfeld
Although psychotherapy is on balance effective for a broad array of psychological problems, a relatively small but steadily accumulating body of evidence suggests that at least some psychological interventions are harmful. Until recently, however, relatively little research attention has been paid to the identification of harmful psychological treatments. Although it has long been recognized that a nontrivial minority of people become worse following therapy, this finding does not necessarily mean that they have become worse because of therapy. Nevertheless, recent research has homed in on a small subset of interventions that may produce psychological harm, physical harm, or both. In addition, there is growing interest in pinpointing potential mechanisms of deterioration effects in psychotherapy, as well as in distinguishing harmful therapies from harmful therapists.
Trent A. Petrie
Although the specific prevalence rates may vary, eating disorders (ED) affect male and female athletes regardless of sport type and competitive level. Generally, rates of subclinical disorders are much higher than clinical ones, with the most frequent clinical classification being Eating Disorders Not Otherwise Specified. Further, EDs occur not only among active athletes, but are also found in samples of retired athletes as well. Existing research on the prevalence of EDs in athletes, however, has been limited due to its reliance on out-of-date diagnostic criteria, sometimes small samples, and a focus on point prevalence to the exclusion of examining how rates might change over time. Central to prevalence research and clinical assessments is the ability to accurately assess EDs in athletes. Although structured clinical interviews represent the most valid approach, they are time consuming and not often used in determining prevalence. Researchers have relied on self-report measures instead. Such measures include those developed initially in nonathletes, but used to study athletes (e.g., Questionnaire for Eating Disorder Diagnosis; Mintz, O’Halloran, Mulholland, & Schneider, 1997), and those specifically for athletes (e.g., Athletic Milieu Direct Questionnaire; Nagel, Black, Leverenz, & Coster, 2000). Most of these measures, though having adequate psychometric properties, are based on diagnostic criteria that are no longer in use, so additional research that employs prevalence measures that reflect DSM-5 criteria is needed with athletes. Most ED research in sport has used samples of active athletes; few studies have considered how the transition out of sport might affect athletes’ perceptions of their bodies, their relationship to food, and their approaches to exercise and being physically active. Retirement from sport generally is considered to be a developmental stressor and thus may exacerbate ED symptoms and body image concerns in some athletes. Yet, for other athletes, retirement may represent a positive transition in which they emerge from a sport culture, focused on weight and appearance, to reclaim themselves and their bodies. Initial qualitative findings appear to support each hypothesis in part, though longitudinal quantitative studies that track athletes from active competition through retirement are needed to understand the changes athletes experience in relation to their bodies, food, and exercise, and when such changes are most likely to occur.
Nadeeka N. Dissanayaka
Progressive neurological disorders are incurable disorders with gradual deterioration and impacting patients for life. Two common progressive neurological disorders found in late life are Parkinson’s disease (PD) and motor neuron disease (MND). Psychological complications such as depression and anxiety are prevalent in people living with PD and MND, yet they are underdiagnosed and poorly treated.
PD is classified a Movement Disorder and predominantly characterized by motor symptoms such as tremor, bradykinesia, gait problems and postural instability; however, neuropsychiatric complications such as anxiety and depression are common and contribute poorly to quality of life, even more so than motor disability. The average prevalence of depression in PD suggest 35% and anxiety in PD reports 31%. Depression and anxiety often coexist. Symptoms of depression and anxiety overlap with symptoms of PD, making it difficult to recognize. In PD, daily fluctuations in anxiety and mood disturbances are observed with clear synchronized relationships to wearing off of PD medication in some individuals. Such unique characteristics must be addressed when treating PD depression and anxiety. There is an increase in the evidence base for psychotherapeutic approaches such as cognitive behavior therapy to treat depression and anxiety in PD.
Motor neuron disease (MND) is classified a neuromuscular disease and is characterized by progressive degeneration of upper and lower motor neurons is the primary characteristic of MND. The most common form of MND is Amyotrophic lateral sclerosis (ALS) and the terms ALS and MND are simultaneously used in the literature. Given the short life expectancy (average 4 years), rapid deterioration, paralysis, nonmotor dysfunctions, and resulting incapacity, psychological factors clearly play a major role in MND. Depression and suicide are common psychological concerns in persons with MND. While there is an ALS-specific instrument to assess depression, evaluation of anxiety is poorly studied; although emerging studies suggesting that anxiety is highly prevalent in MND. Unfortunately, there is no substantial evidence-base for the treatment of anxiety and depression in MND.
Caregivers play a major role in the management of progressive neurological diseases. Therefore, evaluating caregiver burden and caregiver psychological health are essential to improve quality of care provided to the patient, as well as to improve quality of life for carers. In progressive neurological diseases, caregiving is often provided by family members and spouses, with professional care at advanced disease. Psychological interventions for PD carers addressing unique characteristics of PD and care needs is required. Heterogeneous clinical features, rapid functional decline, and short trajectory of MND suggest a multidisciplinary framework of carer services including psychological interventions to mitigate MND. A Supportive Care Needs Framework has been recently proposed encompassing practical, informational, social, psychological, physical, emotional, and spiritual needs of both MND patients and carers.
Simon J. Haines, Jill Talley Shelton, Julie D. Henry, Gill Terrett, Thomas Vorwerk, and Peter G. Rendell
Tasks that involve remembering to carry out future intentions (such as remembering to attend an appointment), and the cognitive processes that enable the completion of such tasks (such as planning), are referred to as prospective memory (PM). PM is important for promoting quality of life across many domains. For instance, failures in remembering to meet social commitments are linked to social isolation, whereas failures in remembering to fulfill occupational goals are linked to poorer vocational outcomes. Declines in PM functioning are of particular concern for older adults because of the strong links between PM and functional capacity. The relationship between age and PM appears to be complex, dependent on many factors. While some aspects of PM appear to hold up relatively well in late adulthood, others appear to show consistent age-related decline. Variability in age differences appears to partially reflect the fact that there are diverse types of PM tasks, which impose demands on a range of cognitive processes that are differentially affected by aging. Specifically, the level and type of environmental support associated with different PM task types appears to be a meaningful determinant of age-related effects. Given the worldwide changing age demographics, the interest in age-related effects on PM will likely intensify, and a primary focus will be how to optimize and maintain PM capacity for this population. This is already reflected in the increasing research on interventions focused on enhancing PM capacity in late adulthood, and points to important future directions in this area of study.
Mary V. Minges and Jacques P. Barber
Psychodynamic psychotherapies (PDP) is an umbrella term for a variety of therapeutic modalities that have evolved out of the psychoanalytic/psychodynamic tradition, each theorizing a trajectory of human development that includes an etiology of and treatment for psychopathology. PDPs have in common the belief that people have an unconscious mind that influences thoughts and behaviors outside of the individual’s awareness. These processes operate from birth till death and are responsible for adaptive and maladaptive functioning at the level of interpersonal relationships and daily living.
The psychodynamic therapist creates a case formulation for the individual seeking treatment, which incorporates a formal diagnosis with an understanding of the underlying dynamic factors contributing to the individual’s suffering. From this case formulation a treatment plan is created specific to the individual. During treatment, the therapist develops a strong working alliance while utilizing psychodynamic-specific techniques targeted at bringing insight into these unconscious thoughts and behaviors. Greater self-understanding enables greater choice ability and flexibility in functioning.
In contrast to prevalent views, empirical research has found support for the efficacy of PDP in the treatment of mental disorders, including but not limited to: depression, anxiety disorders, somatic disorders, and personality disorders. In general, PDP was found more effective than control conditions and not different from active treatments. PDP effects have been shown to remain stable post treatment.
Jarred Gallegos, Julie Lutz, Emma Katz, and Barry Edelstein
The assessment of older adults is quite challenging in light of the many age-related physiological and metabolic changes, increased number of chronic diseases with potential psychiatric manifestations, the associated medications and their side effects, and the age-related changes in the presentation of common mental health problems and disorders. A biopsychosocial approach to assessment is particularly important for older adults due to the substantial interplay of biological, psychological, and social factors that collectively produce the clinical presentation faced by clinicians. An appreciation of age-related and non-normative changes in cognitive skills and sensory processes is particularly important both for planning the assessment process and the interpretation of findings. The assessment of older adults is unfortunately plagued by a paucity of age-appropriate assessment instruments, as most instruments have been developed with young adults. This paucity of age-appropriate assessment instruments is an impediment to reliable and valid assessment. Notwithstanding that caveat, comprehensive and valid assessment of older adults can be accomplished through an understanding of the interaction of age-related factors that influence the experience and presentation of psychiatric disorders, and an appreciation of the strengths and weaknesses of the assessment instruments that are used to achieve valid and reliable assessments.
Simona C. Kaplan, Michaela B. Swee, and Richard G. Heimberg
Social anxiety disorder (SAD) is characterized by fear of being negatively evaluated by others in social situations. Multiple psychological interventions have been developed to treat SAD. The most widely studied of these interventions stem from cognitive-behavioral, acceptance-based, interpersonal, and psychodynamic conceptualizations of SAD. In cognitive-behavioral therapy (CBT), patients learn to identify and question maladaptive thoughts and engage in exposures to feared situations to test the accuracy of biased beliefs. Mindfulness and acceptance-based approaches to treating SAD focus on mindful awareness and acceptance of distressing internal experiences (i.e., psychological and physiological symptoms) with the ultimate goal of behavior change and living a meaningful life based on identified values. Interpersonal psychotherapy links SAD to interpersonal problem areas and aims to reduce symptoms by targeting interpersonal difficulties. Psychodynamic psychotherapy for SAD focuses on identifying unresolved conflicts that lead to SAD symptoms, fostering insight and expressiveness, and forming a secure helping alliance.
Generally, CBT is the most well-studied of the psychological treatments for SAD, and research demonstrates greater reductions in social anxiety than pill placebo and waitlist controls. Results from randomized controlled trials (RCTs) suggest that mindfulness—and acceptance-based therapies may be as efficacious as CBT, although the body of research remains small; four of five RCTs comparing these approaches to CBT found no differences. RCTs comparing CBT to IPT suggest that CBT is the more efficacious treatment. Two RCTs comparing CBT to psychodynamic psychotherapy suggest that psychodynamic psychotherapy may have efficacy similar to CBT, but that it takes longer to achieve similar outcomes. RCTs examining CBT and pharmacotherapy suggest that the medications phenelzine and clonazepam are as efficacious as CBT for treating SAD and are faster acting, but that patients receiving these medications may be more likely to relapse after treatment is discontinued than patients who received CBT. Research generally does not indicate added benefit of combining psychotherapy with pharmacotherapy above each monotherapy alone, although this body of research is quite variable. Effectiveness studies indicate that CBT is equally effective in community clinics and controlled research trials, but studies of this nature are lacking for other psychological approaches.
Nancy A. Pachana, Nicola W. Burton, Deirdre McLaughlin, and Colin A. Depp
Research on healthy aging has begun to address mental health issues in later life. Despite the debates about exactly what constitutes healthy aging and which are the most useful or valid determinants of this construct to study, there is substantial evidence for several determinants of successful aging, including physical activity, cognitive stimulation, and social networks. All three of these determinants support mental health, including cognition, in later life. Resilience is another construct that plays an important role in healthy aging, but it has not received as much research attention at the end of life as in earlier periods. Factors that reduce the risk of mental distress or promote resilience with respect to mental health in the face of challenges in later life remain fruitful areas for further investigations.
Schema therapy has evolved since the late 1980s as an efficacious and increasingly widely used psychotherapeutic treatment for personality disorders and many other complex disorders that correlate with underlying maladaptive schemas. Only recently, attention among clinical geropsychologists has been growing for the application of schema therapy in older adults. Schema therapy is very feasible for both therapists and older patients. Schema therapy is an integrative psychotherapy, which draws on the cognitive-behavioral, attachment, psychodynamic, and emotion-focused traditions. In this treatment model, early maladaptive schemas are considered core elements of persistent and pervasive psychopathology, including personality disorders. The goal of treatment is to decrease the impact of maladaptive schemas and to replace negative coping responses and maladaptive schema modes with more healthy alternatives so that patients succeed in getting their core emotional needs met. The emerging attention for schema therapy in older adults is in line with the increased attention for personality disorders in later life, and also with the maturing field of psychotherapy for older adults. The first scientific evidence for the feasibility and the effectiveness of schema therapy has recently been shown. Despite these developments, much work is still to be done. The question is whether schema theory, which was developed for adults in young and middle adulthood, equally applies to those in later life. Although the first tests of effectiveness of schema therapy in older adults are encouraging, age-specific adaptations of existing therapy protocols, both for individual and group schema therapy, are wanted. Furthermore, the research that has been conducted so far has focused on the young-old. Especially for the growing and highly complex group of oldest-old patients, the development of feasible and effective schema-based interventions is needed. Integrating age-specific moderators for change, such as wisdom enhancement, attitudes to aging, and integrating the action of positive schemas, deserves recommendation.
Kathleen Someah, Christopher Edwards, and Larry E. Beutler
There are many approaches to psychotherapy, commonly called “schools” or “theories.” These schools range from psychoanalytic, to variations of insight- and conflict-based approaches, through behavioral and cognitive behavioral approaches, to humanistic/existential approaches, and finally to integrative and eclectic approaches. Different and seemingly new approaches typically have been informed by older and more established ones. For instance, cognitive behavioral therapy (CBT), one of the more widely used approaches, evolved from traditional behavior therapy but has become sufficiently distinct by adding its own complex variations so as functionally to represent an approach of its own.
New approaches abound both in number and in complexity. Modern clinicians have had to become increasingly widely read and creative in trying to understand the ways in which patients may be helped. The sheer number of approaches, which has climbed into the hundreds, has challenged the field to find ways of ensuring that the treatments presented are effective. The advent of Evidence Based Practices (EBP) throughout the healthcare fields has placed the responsibility on those who advocate for particular types of treatment scientifically to demonstrate their efficacy and effectiveness. While this movement has brought standards to the field and has offered some assurance that psychotherapy is usually helpful, there remains much debate about whether the many different schools produce different results from one another. The debate about how best to optimize positive effects of psychotherapy continues, and there remain many questions to be asked of psychotherapy theories and of research on these approaches.
Christopher M. Bader and Scott B. Martin
As a field of study, sport psychology is relatively young, gaining its formalized start in the United States in the 1920s. Then and now, the practice of sport psychology is concerned with the recognition of psychological factors that influence performance and ensuring that individuals and teams can perform at an optimal level. In the past 30 years, sport psychologists have made their way into intercollegiate athletics departments providing mental health and performance enhancement services to intercollegiate student-athletes. The differentiation between mental health practice and performance enhancement practice is still a source of some confusion for individuals tasked with hiring sport psychology professionals. Additionally, many traditionally trained practitioners (in both mental health and performance enhancement) are unaware of the dynamics of an intercollegiate athletic department. The interplay of the practitioner and those departmental dynamics can greatly influence the efficacy of the practitioner.
Katherine Nieweglowski and Patrick W. Corrigan
Stigma is a complex process that results from the interaction of stereotypes, prejudice, and discrimination. When applied to health conditions (e.g., mental illness, HIV/AIDS, diabetes, obesity), stigma can contribute to a lack of recovery and resources as well as devaluation of the self. People with stigmatized health conditions may be too embarrassed to seek treatment and others may not provide them with equal opportunities. This often results in discrimination in employment, housing, and health care settings. Strategies have been proposed to prompt stigma change with strategic contact between those with the health condition and everyone else likely to have the best effects.
Stephen J. Bright
In the 21st century, we have seen a significant increase in the use of alcohol and other drugs (AODs) among older adults in most first world countries. In addition, people are living longer. Consequently, the number of older adults at risk of experiencing alcohol-related harm and substance use disorders (SUDs) is rising. Between 1992 and 2010, men in the United Kingdom aged 65 years or older had increased their drinking from an average 77.6 grams to 97.6 grams per week. Data from Australia show a 17% increase in risky drinking among those 60–69 between 2007 and 2016. Among Australians aged 60 or older, there was a 280% increase in recent cannabis use from 2001 to 2016. In the United States, rates of older people seeking treatment for cocaine, heroin, and methamphetamine have doubled in the past 10 years. This trend is expected to continue.
Despite these alarming statistics, this population has been deemed “hidden,” as older adults often do not present to treatment with the SUD as a primary concern, and many healthcare professionals do not adequately screen for AOD use. With age, changes in physiology impact the way we metabolize alcohol and increase the subjective effects of alcohol. In addition, older adults are prone to increased use of medications and medical comorbidities. As such, drinking patterns that previously would have not been considered hazardous can become dangerous without any increase in alcohol consumption. This highlights the need for age-specific screening of all older patients within all healthcare settings.
The etiology of AOD-related issues among older adults can be different from that of younger adults. For example, as a result of issues more common as one ages (e.g., loss and grief, identity crisis, and boredom), there is a distinct cohort of older adults who develop SUDs later in life despite no history of previous problematic AOD use. For some older adults who might have experimented with drugs in their youth, these age-specific issues precipitate the onset of a SUD. Meanwhile, there is a larger cohort of older adults with an extensive history of SUDs. Consequently, assessments need to be tailored to explore the issues that are unique to older adults who use AODs and can inform the development of age-specific formulations and treatment plans. In doing so, individualized treatments can be delivered to meet the needs of older adults. Such treatments must be tailored to address issues associated with aging (e.g., reduced mobility) and may require multidisciplinary input from medical practitioners and occupational therapists.
Kim Van Orden, Caroline Silva, and Yeates Conwell
Suicide in later life is a significant public health problem around the world—a problem that will increase in magnitude in the coming years with the impact of population aging. Adults age 70 and older have higher suicide rates than younger groups worldwide in both lower-income and higher-income countries. While suicide rates tend to increase with age, suicide in later life is not an expected or normative response to stressors that accompany the aging process. Instead, a constellation of risk factors places an older adult at elevated risk for suicide. These factors can be remembered as the Five D’s: psychiatric illness (primarily
Quincy J. J. Wong, Alison L. Calear, and Helen Christensen
Internet-based cognitive behavioral therapy (ICBT) is the provision of cognitive behavioral therapy (CBT) using the Internet as a platform for delivery. The advantage of ICBT is its ability to overcome barriers to treatment associated with traditional face-to-face CBT, such as poor access, remote locations, stigmas around help-seeking, the wish to handle the problem alone, the preference for anonymity, and costs (time and financial). A large number of randomized controlled trials (RCTs) have tested the acceptability, efficacy, and cost-effectiveness of ICBT for anxiety disorders, mood disorders, and associated suicidality. A meta-review was conducted by searching PsycINFO and PubMed for previous systematic reviews and meta-analyses of ICBT programs for anxiety, depression, and suicidality in children, adolescents, and adults. The results of the meta-review indicated that ICBT is effective in the treatment and prevention of mental health problems in adults and the treatment of these problems in youth. Issues of adherence and privacy have been raised. However, the major challenge for ICBT is implementation and uptake in the “real world.” The challenge is to find the best methods to embed, deliver, and implement ICBT routinely in complex health and education environments.