Depression: Case Conceptualization and Treatment Planning

Assessment and Diagnosis

• Date of initial assessment: April 16, 2022
• PSEUDO Name: Amanda

Reason for Referral

The patient (Amanda, not her real name) registered for counseling after experiencing an emotional breakdown with her parents. Amanda stated that she “isolated herself from everyone” over the weekend” and locked herself to avoid people. The patient also indicated that she has a “hard time managing relationships,” especially when things go wrong. The patient was convinced that her condition was deteriorating given that she has no home-based emotional support since her parents have mental health-related problems. I assured Amanda that her private information was kept following confidential healthcare and the organization’s guidelines.

Source of Information: The data used to prepare the report originated from multiple sources. However, the patient’s medical history and reason description or problem presentation generated a larger portion of the data. Informal assessments were observations. I also obtained information, especially about the diagnosis, from the DSM-5 Manual. Lastly, I used mental health-related sites and Google Scholar to collect and use data about Cognitive Behavioral Therapy (CBT) in the patient’s condition.

Summary

Amanda is a 21-year-old female having both parents. The patient is a staunch Christian and believes in God. However, the patient is not safe at home, given that her parents have mental health-related problems. Currently, Amanda is having an emotional breakdown with her parents and opts to isolate herself, resulting in low self-esteem. Though medical records do not point to mental health problems, the current assessment indicates that Amanda is experiencing Major Depressive Disorder (MDD) and Dissociative Disorders. The patient experiences episodes of emotional breakdown and cannot manage relationships. The patient “feels sad” and shows disinterest in people. Generally, when Amanda visited for the first time, she was tearful and displayed inappropriate guilt. The patient had a difficult time explaining things. Amanda stated that she has never visited any physical therapists, backed by the client’s health records. In other words, the client is not on any treatment plan or medications. Amanda is a staunch Christian who believes in God. The patient is relieved and joyous when the discussion shifts to God and faith. According to Amanda, she “relies on my faith to make critical decisions.” the patient’s barrier to treatment is her dissociative disorder and manifesting guilt hindering her from pointing things out. Generally, Amanda believes that isolation is the best remedy for her problems.

DSM-5 Diagnosis

• Primary: F32.1 Major Depressive Disorder, Single Episode, Moderate

Z Code: F32.1

• Secondary: 309.28 (F43.23) Adjustment Disorder, Mixed anxiety, depressed mood

Z Code: F43.23

• Tertiary: 309.4 (F43.25) Adjustment Disorder, Mixed disturbance of emotions and conduct

Z Code: F43.25

Differential Diagnosis: Attention-deficit/hyperactivity disorder

Rationale

Amanda is diagnosed with MDD under F33.1 since her depressed mood and emotional breakdown is within two weeks. The patient displays a depressed mood (Criterion A1) by shutting down when things go wrong (American Psychiatric Association (APA), 2013). Amanda displays a “markedly diminished interest” (Criterion A2), especially in people. The patient is diagnosed with Adjustment Disorder under F43.23 since she displays significant impairment in social functioning (Criterion B2) or “difficulty to manage relationships.” Diagnosing Amanda with Adjustment Disorder under F43.25 is due to stress-related disturbance (Criterion C) (APA, 2013). Amanda is stressed due to a lack of home-based “emotional support,” disturbing her. The patient cannot concentrate since her parents are mentally ill. The differential diagnosis is meant to treat attention-deficit disorder experienced by Amanda. The emotional breakdown with parents might be due to reduced or no parental attention. The client’s parents are emotionally absent in her life, explaining why she hates home.

Case Conceptualization

Step 1: Client Concerns

• Relationship break-up
• Stressed
• Feeling sad
• Withdrawal from friends
• Low self-worth
• Conflict at work
• Worry about parents
• Concentration problems
• Feels like a failure
• Lacks emotional support
• Diminished interest
• Feels lonely
• Insomnia
• Craves parental attention

Step 2: Concerns’ Organization based on Descriptive-Diagnostic

MDD

• Feels lonely
• Insomnia
• Low self-worth
• Diminished interest
• Concentration problems
• Conflict at work
• Feels like a failure
• Withdrawal from friends

Adjustment Disorder

• Feeling sad and stressed
• Relationship break-up

Attention-deficit/hyperactivity disorder

• Worry about parents
• Lacks emotional support
• Craves parental attention

Step 3: Theoretical Inferencing

Depressed Thoughts (CBT)

• Believes they cannot successfully manage relationships.
• Perceiving oneself as worthless and a failure

Depressed behavior (CBT)

• Isolating from everyone due to emotional breakdown
• Shutting down due to difficulty in managing relationships in critical situations
• Displaying disinterest in socialization by closing ties
• Displaying low self-esteem and crying a lot

Step 4: Narrowed Inferences and Deeper Difficulties

Deepest Negative Distortions (CBT)

• “I don’t want to see anyone.”
• “I can’t interact with colleagues.”
• “My parents are worlds apart.”
• “I can’t confidently discuss things affecting me.”
• “I just want to be left alone.”
• “I am hopeless and feel empty.”

Narrative of the Case Conceptualization

Major Depression Disorder F33.1

Amanda’s problem description matched Major Depression Disorder (MDD). For example, during the clinical interview, the patient appeared tearful and reported that she was experiencing a depressed mood after an emotional breakdown with patients. Amanda reported that she was “hopeless and felt empty.” DSM-5 diagnoses MDD if the patient experiences depressed mood by things such as sadness and hopelessness (Criterion A.1) (APA, 2013). Besides, the patient showed a “markedly diminished interest” in people by isolating them from everyone. The patient indicated that she did not “want to see anyone,” could not “interact with colleagues,” and needed “to be left alone,” which corresponds to DSM-5’s MDD diagnosis’ (Criterion A.2) “markedly diminished interest.”

Adjustment Disorder F43.23

Amanda’s problem explanation also indicated that she suffered from Adjustment Disorder under F43.23. The patient displayed out-of-proportion distress that emanated from a parental fallout. For instance, Amanda stated that her “parents are worlds apart,” which resonated with Diagnosis Criterion B.1, making “markedly external distress which accelerates stressors” (APA, 2013). Also, Amanda was diagnosed with Adjustment Disorder since she could not perform ordinary social activities. For instance, the client could not manage relationships “when things go wrong.” a patient should be diagnosed with Adjustment Disorder, F43.23 when they display “significant impairment in social… areas of functioning” (Criterion B.2) as displayed by Amanda in “I can’t interact with colleagues.”

Adjustment Disorder F43.25

The patient also displayed symptoms of disturbing emotions and conducted explaining why she was diagnosed with Adjustment Disorder F43.25. Generally, Amanda’s emotions and conduct are disturbed by her parents’ absence in her life. The patient’s description of her parents’ involvement in her life showed her anxiousness. DSM-5 recommends F43.25 when the patient experiences Adjustment Disorder coupled with disturbing emotions and conduct (Criterion C) (APA, 2013).

Differential Diagnosis

The differential diagnosis was recommended after observing Amanda’s need for attention. Generally, the patient displays significant distractibility and heightened frustration since her parents are not part of her emotional life. Amanda stated, “My parents are worlds apart,” meaning they have never been present. After experiencing traumatizing childhood, Amanda cannot seek advice from her father explaining the roots of the emotional breakdown. The “I just want to be left alone” is more like a repelling technique used by the client to shield fear. Amanda craves parental guidance. DSM-5 requires clinicians to diagnose attention-deficit/hyperactivity disorder alongside mood-related disorders (APA, 2013).

Treatment Planning/Integration/Counseling Theory

Treatment Plan

Problems

1. MDD– Negative view of self, low self-worth, worry. Withdrawal from friends and family.
2. AD– Adjustment Disorder-Addressing the issues of feeling sad and stressed and relationship break-ups
3. ADHD– Differential Diagnosis: Attention-deficit/hyperactivity disorder

Goals for Change

MD (CBT)

• Investigate the link between low self-worth and human behavior
• Boost relationships’ perspective and improve interest in people
• Improve client’s concentration
• Increase engagement in non-depressed non-violent activities
• Decrease withdrawal from friends
• Reduce or eradicate failure- and low-self-worth-related thoughts
• Help in handling parents’ mental health-related problems

Adjustment Disorder (CBT)

• Increase interest in colleagues
• Understand the role of stress and crying
• Increase awareness about potential stressors and relaxers
• Shift focus from parental-based attention to other people, such as friends

Attention-Deficit/Hyperactivity Disorder (CBT)

• Evaluate and recommend appropriate emotional support programs and practices
• Reduce parental dependence
• Assume the parental role or position
• Reward the client when she understands and demonstrates the concept of parent-child dynamics

Therapeutic Interventions

11 weekly, individual sessions of CBT

Major Depressive Disorder

• Make the client understand how a depressed mood impairs quality of life using documented articles (Timulak et al., 2018).
• Provide personalized therapies using the accommodation model to help the client identify negative relationship behaviors and implicit schemas.
• Use the activation-deactivation model to eliminate underlying schemas and improve concentration (Huibers et al., 2021).
• Discuss with the client the negative implications of depressive and violent activities in society
• Conduct behavior analysis and record factors that influence withdrawal from friends
• Encourage parents to join counseling sessions to boost their self-esteem and self-worth.
• Recommend a six-week exercise intervention to increase the client’s adherence to non-depressive practices. It will also help remember parental-related problems.

Adjustment Disorder

Six weekly, individual sessions of CBT with AD-specific self-help books

• admonish the client to focus on the bigger picture and accommodate people surrounding her
• Provide relevant materials with psychological theories explaining the role and purpose of crying. The sessions will discourage the client from crying and tearful scenarios.
• Educate the client about depressive stressors and inform her that the Bible is a critical relaxation tool. Generally, Bible works well for staunch Christians.
• Offer psychoeducation on how to maintain the depressive symptoms and alter behaviors to realize desired behaviors.

ADHD

Six weekly, individual sessions of CBT

• Use psychoeducation techniques to help the client navigate the low frustration tolerance and improve organization and problem prioritization.
• Encourage the client to study multiple ADHD-specific books to understand her condition. The approach will help the client understand and evaluate her behaviors’ impact on people around her.
• Educate the client on the basics of time management skills which dictate how people manage relationships or related problems.

Outcome Measures of Change

• Therapist-observed Amanda’s self-report of desirable self-worth and stabilized mood
• Patient self-report of involvement in support seeking activities
• Colleague-observed client’s observation of highly approachable individuals ready to interact with everyone
• Patient self-report of involvement in non-depressed activities and supporting people struggling with depression
• A client that is interested in colleagues and creating awareness about stress
• Employer-observed self-report of a non-violent client who controls behaviors and engages in conflict resolutions
• Colleague-observed self-report of a client with no attention-deficit disorder. Colleagues should report that the client is no longer repulsive and is organized.
• A self-report indicating source of emotional support and highlighting their effectiveness in society.
• Clinician-observed self-report indicating the patient can make critical decisions without external force.
• employer-observed self-report of non-self-harming individual

Integration of Faith: Reflection

Generally, Amanda was an ideal client since she allowed me to integrate faith in counseling. First, I used “Psychology and Christianity: Five Views” to understand the concept of “Preserving the Person.” psychologists should work with clients knowing that spiritual-emotional transformation is critical in recovery (Myers et al., 2009). second, I worked with Amanda on the assumption that no one should judge someone except God. in the NIV Bible, Mathew warned against judging and said, “Do not judge, or you too will be judged.” I did not judge Amanda based on her depressed mood or violent behaviors since no one has such power. Third, I employed empathy and put myself in the client’s shoes. In other words, I did not brush off Amanda’s Christian beliefs and faith since that would be disrespectful. Counselors are meant to empathically listen to clients and think deeply before asking or answering questions. More specifically, Cognitive behaviorists should understand clients’ presenting problems and help them acquire desirable behaviors (Sabki et al., 2019). Fourth, I have changed my secular theory to meet God’s assertion in Genesis 1:1:26, saying that “all humans are created in the image and likeness of God.” I counsel people knowing that anyone can become mentally challenged since cognitive-related problems originate from various scenarios. Lastly, though I did not “fast” with the client, we usually prayed together, especially when starting counseling sessions. Generally, God is omnipresent and can prevail in whatever situation, irrespective of time. We prayed, knowing that God is the “Greatest Healer” Who could revert Amanda’s condition.

Personal Model of Counseling: Reflection

Though I used Cognitive Behavioral Therapy (CBT), I altered it in Amanda’s case. I used Mindfulness-CBT or MCBT to help the client cope with cognition-related difficulties and behaviors. According to Zhang et al. (2018), MCBT is a critical relapse prevention tool. The class-based mindfulness skills were meant to ensure that the client does not engage in treated conditions. For instance, I used the strategy to educate Amanda about potential relapse periods and encouraged her to drop rumination in post-depression. The fact is that no behaviorist or therapist wants their clients to relapse or re-start engaging in undesirable behaviors. I empowered the client to process her experiences through mindfulness meditation, and I am proud of the results. Amanda began realizing undesirable behaviors and evaluating negative feelings. The client also mastered the dangers of relapse.

References

American Psychiatric Association (APA). (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (5th Ed.). American Psychiatric Association.

Huibers, M. J., Lorenzo-Luaces, L., Cuijpers, P., & Kazantzis, N. (2021). On the road to personalized psychotherapy: A research agenda based on cognitive behavior therapy for depression. Frontiers in Psychiatry, 11, 1551. Front. Psychiatry 11:607508.

Myers, D. G., Jones, S. L., Roberts, R. C., Watson, P. J., Coe, J. H., Hall, T. W., & Powlison, D. A. (2009). Psychology & Christianity: five views. InterVarsity Press.

Sabki, Z. A., Sa’ari, C. Z., Muhsin, S. B. S., Kheng, G. L., Sulaiman, A. H., & Koenig, H. G. (2019). Islamic integrated cognitive behavior therapy: a shari’ah-compliant intervention for Muslims with depression. Malaysian Journal of Psychiatry, 28(1), 29-38. Web.

Timulak, L., Keogh, D., Chigwedere, C., Wilson, C., Ward, F., Hevey, D.,… & Irwin, B. (2018). A comparison of emotion-focused therapy and cognitive-behavioral therapy in the treatment of generalized anxiety disorder: study protocol for a randomized controlled trial. Trials, 19(1), 1-11.

Zhang, Z., Zhang, L., Zhang, G., Jin, J., & Zheng, Z. (2018). The effect of CBT and its modifications for relapse prevention in major depressive disorder: a systematic review and meta-analysis. BMC psychiatry, 18(1), 1-14.