Psychiatry · Year 3 · from Psychiatry

Case 1: Cognitive Behavioral Therapy for Depression

Patient Demographics

• Age: 38 years old
• Sex: Male
• Occupation: Software engineer

Chief Complaint

"I've been feeling worthless and stuck. I don't think medication alone is helping."

History of Present Illness

The patient is a 38-year-old man with major depressive disorder who was started on sertraline 100 mg daily 8 weeks ago with partial response. His PHQ-9 has improved from 19 to 13. He reports improved sleep and appetite but continues to experience low mood, anhedonia, and pervasive negative thoughts. He is interested in adding psychotherapy to his treatment.

He describes persistent thoughts that he is a "failure" despite objective success (senior position, good salary). He avoids social invitations because he believes people will find him boring. He has stopped exercising and hobbies he previously enjoyed, stating "what's the point?" He ruminates for hours about past mistakes and future failures.

Mental Status Examination

Appearance: Well-groomed, casual business attire

Behavior: Cooperative, psychomotor slowing noted

Mood: "Low, stuck"

Affect: Constricted, dysphoric

Thought Process: Linear but ruminative, negative bias evident

Thought Content: Pervasive negative self-evaluation; no suicidal ideation

Insight: Good - recognizes patterns of negative thinking

Judgment: Good

Diagnosis

• Major Depressive Disorder, Single Episode, Moderate, Partial Response to Pharmacotherapy

CBT Formulation

Activating Event: Receives constructive feedback at work

Automatic Thought: "My boss thinks I'm incompetent. I'm going to get fired."

Cognitive Distortions Identified:

• Mind reading ("My boss thinks I'm incompetent")
• Fortune telling ("I'm going to get fired")
• Catastrophizing (jumping to worst outcome)
• All-or-nothing thinking ("I'm either perfect or I'm a failure")
• Emotional reasoning ("I feel incompetent, so I must be incompetent")

Emotional Response: Anxiety, sadness, shame

Behavioral Response: Avoids boss, works late to overcompensate, withdraws from colleagues

Physiological Response: Muscle tension, fatigue, poor sleep

CBT Treatment Plan

Phase 1: Behavioral Activation (Sessions 1-4)

Rationale: Breaking the cycle of inactivity that maintains depression

• Monitor current activity levels with mood ratings
• Schedule pleasurable activities (exercise, hobbies, social contact)
• Graded task assignments (start small, build up)
• Track mood changes with increased activity

Homework:

• Activity log with mood ratings
• Schedule 3 pleasurable activities per week
• Resume exercise 2x weekly

Phase 2: Cognitive Restructuring (Sessions 5-12)

Identify Automatic Thoughts:

• Use thought records to capture triggering situations
• Identify specific automatic thoughts
• Rate belief strength (0-100%)

Examine Evidence:

• What evidence supports this thought?
• What evidence contradicts it?
• What would I tell a friend in this situation?
• What's the worst that could happen? Best? Most likely?

Example Thought Record:

Identify Deeper Beliefs:

• Core belief: "I'm not good enough"
• Developed from: Critical father, competitive childhood environment
• Work on modifying core beliefs with behavioral experiments

Phase 3: Maintaining Gains (Sessions 13-16)

• Review skills learned
• Develop relapse prevention plan
• Identify early warning signs
• Plan for future challenges

Session Example (Session 6)

Therapist: "Last week, you mentioned feeling worthless after the team meeting. Let's look at that using a thought record. What was the situation?"

Patient: "I was in a meeting and didn't speak up about an idea I had."

Therapist: "And what went through your mind at that moment?"

Patient: "That I'm too shy to succeed. That everyone thinks I'm useless."

Therapist: "Those are powerful thoughts. Let's examine them. What evidence supports the thought that everyone thinks you're useless?"

Patient: "Well... people didn't seem interested in what I was saying earlier."

Therapist: "Okay, any other evidence?"

Patient: "Not really. I guess I'm assuming."

Therapist: "And what evidence contradicts that thought?"

Patient: "My colleague asked my opinion on something after the meeting. And I did get positive feedback on my last project."

Therapist: "So based on all the evidence, what's a more balanced way to think about that meeting?"

Patient: "Maybe not speaking up doesn't mean everyone thinks I'm useless. It could just be I was hesitant that day."

Expected Outcomes

• CBT for depression: ~50-60% response rate
• Combined with medication: Best outcomes
• Skills are durable - lower relapse rates than medication alone when discontinued

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