Assessment Of Comorbidity Of Gad Ocd And Ptsd

Due to the high rate of current co-occurrence between depression and anxiety, it is always important for the clinician to inquire about anxiety disorders when interviewing patients who present for treatment of depression. However, the need to inquire is accentuated when soft signs are present. For example, a patient with a history of abuse would prompt a clinician to inquire about PTSD. A history of unreasonable fears, such as those related to contamination, would indicate the need to screen...

Frequency and Continuity of Sessions

Maintenance of continuity and consistency across sessions is also particularly important when treating more severe depression. Typical research protocols with such patients have specified the use of twice-weekly sessions for the first half of a 4-month protocol (DeRubeis et al., 2005 Dimidjian et al., 2006). Frequent sessions early in the course of treatment can maximize patient engagement with treatment and ensure success with initial homework assignments. In addition, such frequency helps the...

Objective 3 Developing a Cognitive Case Conceptualization for Suicide Behavior

The cognitive case conceptualization is an individualized cognitive map of the current automatic thoughts, conditional assumptions, and core beliefs activated before, during, and after suicidal behavior. It is based on collected data about the patient's early childhood experiences, typical activating events, associated automatic thoughts, emotional responses, and subsequent behavior. Figure 7.2 illustrates a completed cognitive case conceptualization diagram for a depressed suicide attempter....

Attention and Focus Redirection

Decreased attentional resources, particularly selective attention, or the ability to tune out distracting or extraneous stimuli, also present a challenge (McDowd & Birren, 1990). In particular, older patients' ability to focus on discussions in therapy, to conduct structured tasks, and to answer directive questions is affected by their ability to concentrate on the task at hand. Deficits in attention and focus look very much like tangential thinking in the therapy context. As an example, one...

Brief Problem Solving and Goal Setting

A fourth option is to assist the family with problem solving or goal setting which can be accomplished in the context of a few family meetings. This may be appropriate for some circumscribed family problems, or if the therapist believes that a few, relatively small behavior changes might make a big difference to the depressed individual or to his her family. For example, a depressed patient who believes I must take care of everything in the house or else it won't get done may take on a lot...

Diagramming The Cognitive Case Conceptualization And Presenting It To The Patient

To aid in the development of the cognitive case conceptualization, it may be useful for clinicians to diagram the conceptualization. Such a diagram can be useful in organizing the information available about the patient. J. S. Beck (1995) provided a Cognitive Conceptualization Diagram that we believe is particularly useful in mapping information about the patient. This diagram includes spaces for depicting the relationship between automatic thoughts, and emotional and behavioral reactions, as...

Psychoeducation and the Early Phases of CT with Older Adults

The initial phases of CT typically focus on first ascertaining the patient's reasons for seeking treatment, his her experience with therapy and expectations, then socializing the patient to CT. Older adults in particular may need considerable education about the expectations of therapy, as well as the structure of CT. Often, older adults' attitudes about their own age group can interfere with effective treatment (Knight, 2004 Laidlaw et al., 2003). Older people often have little exposure to...

Giovanni A Fava Stefania Fabbri

There is increasing awareness that the majority of depressed patients fails to respond to an appropriate trial of antidepressant drug of adequate dose and duration (less then 25 symptom reduction from baseline) or shows a partial response (25-49 symptom reduction from baseline), or achieves a response without remission (50 or greater symptom reduction from baseline but presence of residual symptomatology) (Fava, 2003). Several pharmacological strategies have been developed for depressed...

Laura Kohn Wood Glenetta Hudson Erin T Graham

The Surgeon General's report on mental health (U.S. Department of Health and Human Services, 1999) detailed the efficacy of available treatments for mental disorders in the United States. Cognitive therapy (CT) and cognitive-behavioral therapy (CBT) approaches to the treatment of major mood and anxiety disorders show particularly favorable outcomes in comparison to other psychotherapy and psychopharmacological interventions (for review see the Special Section of the Journal of Consulting and...

McMaster Structured Interview for Family Functioning

The McMaster Structured Interview for Family Functioning (McSIFF Bishop, Epstein, Keitner, Miller, & Zlotnick, 1980) is a 90-minute structured interview designed to assess the areas of family functioning in the McMaster model. Clinicians may choose to use this interview (or parts of it) to make sure that they are conducting a comprehensive assessment of family functioning. For example, the interview includes a broad list of family responsibilities (e.g., housecleaning, shopping, preparing...

Conceptualization Of Depression In Older Adults

Z is a 75-year-old, widowed man who suffers from macular degeneration and diabetes, which resulted in above-the-knee amputation. He lives on the second floor of a walk-up building and has difficulty leaving his apartment because of his poor eyesight, and because his prosthesis no longer fits his leg since Mr. Z's weight loss of 15 pounds in the past year. His only income is social security, with which he barely makes ends meet. Since his eyesight began to fail and his disability increased,...

Stages of Learning Acquisition Generalization and Maintenance of New Skills

C-CT draws liberally from learning theory and emphasizes strategies to promote acquiring, generalizing, and maintaining new responses (Ferster, 1973). Social learning theory (e.g., Bandura, 1977) emphasizes the impor- TABLE 6.1. Sample Compensatory Skills Learned during Cognitive Therapy Restructuring via hypothesis testing Understands that thoughts, feelings, and behaviors can contribute to depression. Notices how view of self, world, and future influences behavior. Recognizes and records...

Robin B Jarrett Jeffrey R Vittengl Lee Anna Clark

Relapse and recurrence prevention are essential to improving treatments for depressed individuals. In this chapter, we describe how to reduce the likelihood of relapse by using continuation-phase cognitive therapy (C-CT) for adults with recurrent major depressive disorder (Jarrett, 1989 Jarrett & Kraft, 1997), and we present an overview of the conceptual and empirical foundations of C-CT. We show why many patients may benefit from C-CT how to begin implementing this treatment to reduce...

Special Considerations

Clearly, this chapter points to the prevalence of depression among patients with PDs. It is evident the depression is very pervasive among most patients with PDs, causing difficulty in accurate diagnoses and subsequent treatment planning. The modification of standard CT provides an example of overcoming the complications of depression with comorbid conditions. Perhaps another approach is to examine depression as a separate issue, out of the mood disorder category and into the personality...

Brief Ongoing Assessment of Suicide

Following a comprehensive evaluation, the clinician conducts brief ongoing assessments of suicide risk to monitor changes in the patient's overall status. Knowledge about established risk factors helps the clinician make informed judgments about potential risk. Table 7.1 provides a summary of several of these risk factors that are initially assessed during the comprehensive evaluation and subsequently monitored closely during the course of treatment. During the therapy process, the clinician...

Middle Phase of Treatment Sessions

The therapeutic work completed during the middle phase of treatment is grounded in the generated cognitive conceptualization. The primary focus is on helping the patient to develop adaptive cognitive and behavioral skills to better manage future suicidal behavior. Objective 1 Modifying Negative Suicide-Relevant Automatic Thoughts and Core Beliefs Once the patient's automatic thoughts and core beliefs in relation to his her suicidal behavior are identified, the therapist first assists the...

Selecting Measurements Whats Available

At intake, differential diagnosis of MDD is necessary to identify appropriate alternative acute-phase treatment options, and throughout A-CT, symptom assessment is key in structuring therapy sessions, gauging acute-phase treat- ment response, and identifying which patients need C-CT. Instruments that clinicians may use to measure the syndrome and severity of depressive symptoms are described below. To assess the syndrome of depression, to rule out other disorders, and to diagnose concurrent...

Conceptualization Of Depression And Treatment For Ethnic Minorities

We often think that major depression and other disorders look the same for all groups of people however, several researchers have questioned the assumption of universality with regard to psychological distress and symptomatology (Johnson, Danko, Andrade, & Markoff, 1997), arguing that universal diagnostic criteria cannot adequately capture cultural or race-based aspects of emotional distress (Trierweiler & Stricker, 1998). Efforts to enhance the cultural validity of DSM-IV resulted in the...

DBTs Biosocial Theory of BPD

DBT organizes the nine DSM-IV criteria for BPD into five broad areas of dysregulation that clarify what skills the patient needs to learn and practice (Linehan, 1993a). These are (1) emotion dysregulation (labile affect and undercontrol overexpression of anger), (2) relationship dysregulation (stormy, chaotic relationships and fears of abandonment), (3) self-dys-regulation (lack of sense of identity, emptiness), (4) behavior dysregulation (suicidal and self-injurious behaviors, and other...

Mechanisms of Change and Predictors of Outcome in CT for Depression

Given the success of CT for depression, a number of ancillary questions arise, including questions related to how CT exerts its influence and whether the treatment is more or less appropriate for clients with known characteristics. The first of these questions was examined by mediational analyses and the examination of therapy processes related to outcome. Results of these studies include the observation that early completion of homework is associated with better clinical outcome (Startup &...

Approaches To Treatment

There are many options for integrating family interventions into individually based CT for depression. The integrative case conceptualization, as well as pragmatics, guides the choice of family intervention level and the specific strategies used. Options include (1) treating an individual alone (2) including family members in a few sessions for the purpose of assessment (3) providing psychoeducation to family members (4) brief problem solving with family members (5) including a family member as...

The Goal Of

The goal of C-CT is to teach, generalize, and maintain critical skills that prevent relapse and promote remission and recovery (Jarrett & Kraft, 1997). In short, cognitive therapists not only treat depressive symptoms but also teach new coping strategies. As in A-CT, therapists work to decrease, eliminate, and prevent the symptoms and syndrome of depression by teaching patients compensatory skills that include (1) understanding relations between cognition and other behavior, (2)...

Cluster C

Patients diagnosed with any of the Cluster C PDs have the best outcomes for therapy, particularly when compared to individuals with Cluster A or Cluster B disorders (Magnavita, 1997). Typically, patients with Cluster C disorders experience high levels of anxiety and fear, and have difficulty expressing emotions. Based upon this premise, patients in this cluster experience more impairment as they seek treatment services to fix Axis I disorders, such as depression and anxiety therefore, patients...

Adaptation of Standard CT for Depression

Given the invalidating climate in which LGB individuals typically are raised, it is imperative when working with this population that therapists not assume that all negative thinking is indicative of a cognitive distortion. Perhaps this is the greatest adaptation one needs to make when working with LGB patients. While attesting to the fact that lesbian and bisexual women generally have the same types of problems as nongay women, Wolfe (1992) suggested that irrational beliefs about need for the...

Assessment Of Depression For Ethnic Minorities

Although several instruments for assessing depressive symptoms and major depression exist, some measures may not adequately or appropriately include symptom patterns or idioms that characterize the illness for ethnic minority patients. Improved understanding of possible racial or ethnic variations in the manifestation of depressive symptoms will increase diagnostic accuracy (Ayalon & Young, 2003) and lead to better characterization and detection of disorders across distinct groups....

Conclusions

The primary goal of this chapter is to provide an overview of the clinical adaptations to CT for depression that may make it more effective for individuals with persistent depressive symptoms. The evidence from research studies is that a combination of CT and antidepressants can help to resolve or ameliorate the symptoms and social problems associated with this debilitating condition. In day-to-day practice, CT alone or in combination with medication appears to be a highly acceptable...

Objective 1 Engaging the Patient in Treatment

Depressed individuals with suicidal behavior may present for treatment due to pressure placed upon them by family members or friends, or they may at times appear apathetic, uninterested, or even hopeless about the therapeutic process. The general clinical recommendations we provided earlier have already emphasized the importance of therapy attendance and compliance, implementing a psychoeducation component, a team approach to intervention, and the role of sociocultural factors in treatment...

Review Of Efficacy Research

In 1989, Elkin and colleagues published the first report from what would soon become one of the most influential and controversial treatment studies, the National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Program (TDCRP). This multisite study was designed to test the efficacy of CT, interpersonal therapy, and pharmacotherapy in the context of a placebo-controlled, multisite trial (Elkin et al., 1989). Initial analyses found few significant differences...

Assessment Of Depression With Lgb Women And

Patient verbal self-report and written self-report measures are standard in clinical practice. Although standard self-report measures are useful, clinicians need to review their customary forms for heterosexist content. For example some questionnaires ask about social anxiety around people of the opposite sex. The assumption is that heterosocial anxiety will complicate the individual's establishing intimate relationships. However, simply rephrasing the question to ask whether the patient...

Case Conceptualization Of Comorbidity Of Gad Ocd And Ptsd

The case conceptualization of comorbidity is crucial in treatment. The approach described in this section is adapted from Persons and Davidson 2001 . The case formulation needs to be modified to account for comorbidity between depression and GAD, OCD, or PTSD. For the patient with comorbidity, the problem list likely includes difficulties related to both depression and the anxiety disorder. Some of these problems may result from the depression, the anxiety, or both disorders. The patient's...

Drug Tapering and Discontinuation

Sequential treatment offers a unique opportunity for antidepressant drug tapering and discontinuation. In fact, it offers the opportunity to monitor the patient in one of the most delicate aspects of treatment. In the original studies Fava et al., 1994, 1998 antidepressant drugs, mainly tricyclics, were decreased at the rate of 25 mg of amitriptyline or its equivalent every other week. When selective serotonin reuptake inhibitors SSRIs are involved, more gradual tapering is the better. It is...