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Depressive disorder

Case study on Depression using a CBT Treatment

By Shanie WalkerPublished 3 years ago 14 min read
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helplessness, hopelessness, and despair

Joanne had struggled with depression ever since her divorce 3 years ago. Her self-esteem was at a real low point and her confidence was shattered. The depression took over her life making her sad with low moods swings. In its most severe form, she continually experienced feelings of helplessness, hopelessness, and despair (Destroy Depression, 2019). She began experiencing depressive episodes that flowed over into her life experiences to a decrease in her social activities, problems with relationships, and an increase in crying (ABCT, 2019). When she was not crying, she had a desire to cry even when she could not get the tears out. The depression was now a common psychological problem, and an inclusion to most experiences in her life, affecting her quality of life. These experiences of low mood became severe enough for Joanne to seek formal treatment.

self defeating feelings

Joanne’s GP referred her to a CBT Therapist. She is on antidepressant medication. In her initial session, together the therapist and Joanne identified some cognitive characteristics of her depressive state by conferring her thoughts, feelings, and experiences. Such as, loss of concentration and memory, self-defeating feelings of worthlessness, and affect to her working environment as well, a belief that things cannot be made better, and getting worse, she is worried things will become bad. She expresses a lot of sadness focusing on negative things about herself without enough attention on positive things (ABCT, 2019). Forming a positive alliance, using the technique of Socratic questioning, the CBT therapist uses genuine empathy and openness to engage Joanne to initialize therapy. Biological characteristics of her depression, of disrupted sleep or disturbances to her sleeping pattern, appetite, loss of sexual desire or lack of interest in sexual activity, and fatigue or tiredness during the day were also measured. The therapist used a collaborative relationship to discuss critical issues of her depression like matters of increased anxiety and feelings of any anger or hostility. When forming Joanne’s case formulation, the therapist, assessed if there were any other problems relating depression and alcohol or drugs (ABCT, 2019).

The Cognitive Behavior Therapist gave a brief overview on how CBT treatment works explaining psychoeducational tools for therapy. The therapist described Cognitive-behavioral therapy uses different approaches based on cognitive theory for successful treatments for anxiety and depression. In the CBT planning process of the coming sessions ahead, the therapist explained, together they would be focusing more on Joanne’s current situation and its solution, rather than the past. Using efficacious behavioral interventions to focus on problem solving. They would concentrate on her views and beliefs about life, not on her personality traits. Rather, Cognitive-behavioral therapy (CBT) would seek to help change how she thinks. Replacing ways of living that do not work well with ways of living that work, to give Joanne more control over her life (Holmes, 2018). CBT is a blend of cognitive and behavioral therapies which help the patient tune into their internal dialogue to change maladaptive thinking patterns. CBT specifically has processes to help challenge a depressive client's assumptions and beliefs. The patient learns how to change their thinking to be more realistic and begin to feel better. CBT therapy encourages the client to take an active role in their therapy with an emphasis on problem-solving and changing behaviors (Holmes, 2018).

depressive episodes

Cognitive-behavioral therapy is a proven therapy to be effective in treating symptoms of depression and anxiety. Major depressive disorder (MDD), known as depression, is a mental disorder categorized by at least two weeks of low mood to present across most situations. It frequently is accompanied by low self-esteem, loss of interest in normally enjoyable activities, low energy, and pain without a clear cause. People can also occasionally have false beliefs or see and hear things that others cannot. Some people have periods of depression separated by years in which they are normal, while others nearly always have symptoms present. Major depressive disorder can negatively affect a person's personal life, work life, or education. Also affecting their sleeping, eating habits, and general health. Between 2–8% of adults with major depression die by suicide, and about 50% of people who die by suicide had depression or another mood disorder. The more chronic form of depression, persistent depressive disorder (dysthymia) can be diagnosed if the mood disturbances continue at least 2 years in Adults (DSM Library).

depressed mood

People who experience a major depressive episode or major depressive disorder are at increased risk for suicide. Seeking help and treatment from a health professional dramatically reduces the individual's risk for suicide (DSM Library).

DSM-IV Criteria for Major Depressive Disorder (MDD)

• Depressed mood or a loss of interest or pleasure in daily activities for more than two weeks.

• Mood represents a change from the person's baseline.

• Impaired function: social, occupational, educational.

Specific symptoms, at least 5 of these 9, present nearly every day:

1. Depressed mood or irritable most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).

2. Decreased interest or pleasure in most activities, most of each day

3. Significant weight change (5%) or change in appetite

4. Change in sleep; Insomnia or hypersomnia

5. Change in activity; Psychomotor agitation or retardation

6. Fatigue or loss of energy

7. Guilt/worthlessness; Feelings of worthlessness or excessive or inappropriate guilt

8. Concentration: diminished ability to think or concentrate, or more indecisiveness

9. Suicidality: Thoughts of death or suicide, or has suicide plan

(DSM Library).

cognitive characteristic states

Case conceptualization conveys several domains of assessment to involve symptoms and diagnosis, the patient’s strengths, formative experiences, biopsychosocial aspects, contextual and cognitive factors to affect diagnosis and treatment, such as automatic thoughts or schemas (Flynn & Warren, 2014). The case formulation leads to a working hypothesis about the best course and focus of CBT. Collaborative empiricism bonds the therapeutic relationship to continually refine this working hypothesis. The client and therapist work together to investigate the hypotheses and all aspects of the client’s problem. Although no specific technique defines CBT, a customary practice is to educate the individual about interrelationships between behaviors/activities, thoughts, and mood (Flynn & Warren, 2014).

The ABC Model is the most well-known cognitive behavior therapy technique for analyzing a client’s thoughts, behavior, and emotions. The Basis of CBT works on the assumption that a client’s beliefs effect their emotions and behavior and by identifying and addressing problematic thoughts they can help to change their behavior and experiences for the better.

In therapy, the ABC Model of CBT can be used as an effective tool to record a sequence of events in terms of:

• A - Activating event (also described as a 'Trigger')

• B - Beliefs (e.g.; thoughts that occur to the client when the Activating event happens)

• C – Consequences, how the client feels and behaves when they have those Beliefs (consequences may be divided into two parts: their actions and their emotions). In Joanne’s case, depression is the consequence, and feelings of sad, lack of social activity etc.

(Bonham-Carter, 2019).

The analysis: Joanne can ask whether her beliefs are justified by the Activating Event. One of the approaches of CBT would be to ask the client to reflect on whether the beliefs are justified or are based on erroneous assumptions or thinking errors. The client’s beliefs may be justified with accurate beliefs, but they may not. It is important to clarify whether the situation and evidence justifies these beliefs and then decide how they want to act once they have done that. If on reflection the client considers the Beliefs are not justified, then they might think of some Balancing Statements which could remind them of when the activating event occurs for a more reasonable perspective (Bonham-Carter, 2019).

Example: "It is possible I am not working hard enough? They may possibly just be enquiring about my work with no personal meaning associated to it, just our deadline.” or

"I may be jumping to conclusions here because I am anxious about work and feel I need more support. It would be better for me to voice my concerns and seek some more help or more time rather than to try to pretend I am coping better than I am."

The CBT therapist’s role is supportive, helping Joanne explore more options to reach a balanced view. Joanne could use the technique of asking herself what a neutral person or a trusted reliable friend might say or think in the same circumstances. CBT encourages the patient to think about what options there are for dealing with negative or imbalanced thoughts. Balancing thoughts can address the client’s thought process and thinking about practical actions that could improve or cope with a problematic situation. Once rational balancing thoughts have been introduced into the thinking process, the idea is to make considered practical decisions about how they will act or respond in the situation (Bonham-Carter, 2019).

depressed mood or irritable

Using the ABC Model, Joanne could react in a more constructive way rather than responding defensively to other people’s statement, she might:

• Try to explain to her boss when difficulties arise and seek support.

• If that option is not possible or unrealistic, she might decide to seek help elsewhere within the organization to help deal with the issue.

• If neither of these approaches are useful, she might want to explore avenues external to the workplace to gain personal support or wind down from work pressures (Yoga, or Zen meditation, Art classes)

• She may even consider whether it would be practical to change jobs or roles if her genuine decision is that for whatever reason this role is not something she wants to stay in for the medium term.

Among psychotherapies, CBT’s superior efficacy for depressive disorders is well-established. The psychological and somatic symptoms present the core diagnostic criteria of affective disorders, depression is considered by maladaptive cognitive beliefs and biases, which lie at the heart of cognitive behavioral theories of depression (Jelinek, Quaquebeke and Moritz, 2017). Although Joanne’s dysfunctional beliefs have been shown to be relatively stable, they do appear to be malleable and, consequently, present a major target of cognitive behavioral therapy (CBT). The Therapist, initiates CBT techniques and an adaptive process to instigate important moderators, primarily focusing on metacognitive mechanisms of change training and cognitive capacity. Thus, changing the client’s dysfunctional cognition as well as their metacognitive beliefs to reduce the severity of depression. The therapist engages Joanne by using essential CBT elements to focus on distorted cognitions about herself, the world, and the future, and on behaviors which lead to maintain symptoms. Cognitive interventions seek to identify thoughts and beliefs that trigger emotional and behavioral reactions. Joanne expressed a loss of social activity and problems with relationships due to her low moods and feelings worthless. CBT helps question these beliefs to rational analysis and develop more adaptive beliefs (Current Psychiatry, 2014). When preparing for the therapy sessions, the CBT formulations intent is to support the therapist and client to understand the origin, status, and maintenance of the problem. In Joanne’s case, the therapist identifies specific methods to mediate patient outcomes and then initiate specific refinements. With the use of cognitive practices, a concrete understanding can be familiarized using adaptive CBT processes of rewards, technology, and interactive activities to increase motivation and engagement. Common elements of individualized case conceptualization, and collaborative empiricism can lay the foundation for the therapy (Current Psychiatry, 2014).

impaired function, social, occupational and educational

A mood activity log illuminate links between moods and activities and is useful with targeting interventions. Joanne symptoms manifest overwhelming feelings of sadness, worthless, and hopelessness. A CBT Activity Log can provide an insight into the linking between activity level and mood state. By Joanne tracking activities or lack thereof, throughout the day, she can monitor how her mood changes relative to the experiences. Furthermore, engaging in more activities can bring a sense of accomplishment or pleasure to increase positive emotions and decrease negative ones (Henry, 2015). The use of the Daily Mood Chart alongside CBT interventions help the client practice identifying the link between their environment, thoughts, and feelings. Every two hours Joanne will need to record the emotions she has experienced, and make note of what has happened during that time. The feelings of intensity of her feelings will be rated on a scale of 1-10. This exercise will prompt Joanne to think about her emotions from the past several hours alongside the environments and situations that influenced them. In therapy, together client and therapist will follow up and review the chart during her next session (Therapist Aid, 2019). A mood activity log can assist in developing a hierarchy of dreaded moods, avoidances and social situations. Joanne’s depression is causing her to experience a lack of motivation, fatigue, and feelings of discouragement. Her feelings and negative self-talk, convey internal thoughts connected with her depression, i.e.; she might tell herself to stay home, sleep more, and not participate in many activities. This downward spiral contributes to more inactivity that leads to greater depression and less happiness. By choosing to increase Joanne’s activity level, regardless of how she feels, she can increase exposure to potentially positive experiences. If low activity due the depression is a problem for her, by being more active is likely to improve her mood and reduce depression. However, experiences that provide a sense of accomplishment and/or pleasure in particular can have an even greater impact on the client’s emotional state (Henry, 2015). CBT exercises of behavioral activation (BA), should be factored into the formulation as a structured approach to help the patient. This method of therapy increases behaviors and experiences that are rewarding, overcomes barriers to engage in new behaviors, and decrease behaviors that maintain symptoms. BA is a useful intervention for people with depression characterized by lack of engagement or capacity for pleasurable experiences. During Joanne’s divorce, she experienced physical, social, and environmental changes that gradually deprived her of sources of pleasure and other reinforcing activities. BA can focus on developing creative solutions to regain access to create new opportunities for rewarding experiences and avoid behaviors, e.g., social withdrawal or physical activity restriction, preserving the depressed mood (Current Psychiatry, 2014).

mood, concentration and energy

In light of ongoing variations, there are significant aspects for the therapist to consider, making informed decision about CBT and selecting the right treatment for the patient with a major depressive disorder. The evidence of CBT’s efficacy would be reviewed upon selecting the CBT approaches in treating the specific disorder (Flynn & Warren, 2014). Accordingly, it would be necessity to appraise the effect of the CBT’s efficacy for the acute-phase treatment and relapse prevention. In practice, acute treatment of depressive disorders is sometimes more effective with combined antidepressants and CBT therapy that increase treatment adherence. (Kennard, et al. 2010). This case, has the rationale for a sequential treatment strategy to improve symptoms (e.g., mood, concentration, energy) with CBT therapy using psychosocial components and antidepressant medication in the continuation phase to optimize treatment gains. Joanne is more receptive to her treatment using CBT techniques that reduce depressive symptoms to improve her clinical status. Joanne’s progress will be monitored throughout her CBT exercises of Behavioral activation and Activity Mood log, working with the ABC Model. Strategies of Mindfulness based cognitive therapy (MBCT) applied can also help with a remission plan against subsequent relapse or perhaps recurrence. This option is considered as an alternative approach in Joanne’s CBT therapy as part of a complementary therapy. Joanne’ therapy sessions are scheduled for fifty minutes sessions for 16-20 sessions, over 6-9 months, in combination with antidepressants.

References

ABCT (2019). Depression. Association for Behavioral and Cognitive Therapies. Retrieved from http://www.abct.org/Information/?fa=fs_DEPRESSION

ADAA, (2010-2018). Depression. Retrieved from https://adaa.org/understanding-anxiety/depression

Bockting, C.L., Hollon., S., D., Jarrett, R., B., Kuyken, W., & Dobson, K. (2015). A lifetime approach to major depressive disorder: The contributions of psychological interventions in preventing relapse and recurrence. Clinical Psychology Review

41: 16-26. Retrieved from https://doi.org/10.1016/j.cpr.2015.02.003

Bonham-Carter, D. (2019). Self-help eBooks & articles. CBT Techniques & self-coaching tips. Retrieved http://www.davidbonham-carter.com/abcmodelcbt.html

Destroy Depression, (2019). 7 steps to a health happy life you control. Retrieved from https://destroydepression.com/?hop=3c3q2k11

DSM Library, (2019). Depressive disorders. American Psychiatric Association Publishing. Retrieved from https://doi.org/10.1176/appi.books.9780890425596.dsm04

Flynn, H.A., & Warren, R. (2014). Using CBT effectively for treating depression and anxiety. Current Psychiatry, 13(6):45-53.

Health line Media, (2019). How to manage a depressive episode. Retrieved from https://www.healthline.com/health/mdd/depression-episode#1

Holmes, L., (2018). Cognitive-behavioral therapy for depression and anxiety.

CBT is a great option if you're struggling with depression or anxiety. Verywell Mind.

Jelinek, L., Quaquebeke, N.V., Moritz, S. (2017). Cognitive and metacognitive mechanisms of change in metacognitive training for depression. Scientific Reports 7, 3449.

Kennard, B,D., Emslie, G., J. Mayes, T.L, Nightingale-Teresi, J.,

Nakonezny, P.A., Hughes, J, L, Jones, J.M., Tao, R., Stewart, S.M., and Jarrett, R.B. (2008). Cognitive-Behavioral Therapy to Prevent Relapse in Pediatric Responders to Pharmacotherapy for Major Depressive Disorder. J Am Acad Child Adolesc Psychiatry. 47(12): 1395–1404. doi: 10.1097/CHI.0b013e31818914a1

Knott, L & Cox, J. (2014). Cognitive and Behavioural Therapies. Mental Health (Psychiatry) Retrieved from https://patient.info/doctor/Cognitive-and-Behavioural-Therapies

Pratt, K. (2014). Reduce depression by using a CBT activity log. Healthypsych.

Therapist Aid, (2012-2019). Daily mood chart. Retrieved from https://www.therapistaid.com/therapy-worksheet/daily-mood-chart

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About the Creator

Shanie Walker

Shanie Walker is a Holistic Behavioural Therapist, awards, and honours in Art Therapy, Dialectic and CBT. Shanie is a Psychologist and Registered Professional Hypnotherapist. Accredited Nutritionist, and Master Degree in Fitness.

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