Cognitive Behavioral Therapy Case Study

1. Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, et al. No health without mental health. Lancet. 2007;370:859–877. doi: 10.1016/S0140-6736(07)61238-0. [PubMed]

2. Greenberg PE, Kessler RC, Birnbaum HG, Leong SA, Lowe SW, Berglund PA, et al. The economic burden of depression in the United States: how did it change between 1990 and 2000? J. Clin. Psychiatry. 2003;64:1465–1475.[PubMed]

3. Sobocki P, Jönsson B, Angst J. Rehnberg C. Cost of depression in Europe. J. Ment. Health Policy Econ. 2006;9:87.[PubMed]

4. Beck AT, Rush AJ, Shaw BF. Emery G. Cognitive therapy of depression. 1st ed. New York, NY: The Guilford Press; 1987. p. 425.

5. Garratt G, Ingram RE, Rand KL. Sawalani G. Cognitive processes in cognitive therapy: evaluation of the mechanisms of change in the treatment of depression. Clin. Psychol. Sci. Pract. 2007;14:224–239.

6. Lewinsohn PM, Hoberman HM. Rosenbaum M. A prospective study of risk factors for unipolar depression. J. Abnorm. Psychol. 1988;97:251–264.[PubMed]

7. Heim C, Owens MJ, Plotsky PM. Nemeroff CB. The role of early adverse life events in the etiology of depression and posttraumatic stress disorder. Focus on corticotropin-releasing factor. Ann. N. Y. Acad. Sci. 1997;821:194–207.[PubMed]

8. Maercker A, Michael T, Fehm L, Becker ES. Margraf J. Age of traumatisation as a predictor of posttraumatic stress disorder or major depression in young women. Br. J. Psychiatry. 2004;184:482–487.[PubMed]

9. Shrout PE, Link BG, Dohrenwend BP, Skodol AE, Stueve A. Mirotznik J. Characterizing life events as risk factors for depression: the role of fateful loss events. J. Abnorm. Psychol. 1989;98:460–467.[PubMed]

10. Abbass A, Sheldon A, Gyra J. Kalpin A. Intensive short-term dynamic psychotherapy for DSM-IV personality disorders: a randomized controlled trial. J. Nerv. Ment. Dis. 2008;196:211–216.[PubMed]

11. Cuijpers P, van Straten A, Andersson G. van Oppen P. Psychotherapy for depression in adults: a meta-analysis of comparative outcome studies. J. Consult. Clin. Psychol. 2008;76:909–922.[PubMed]

12. David D, Szentagotai A, Lupu V. Cosman D. Rational emotive behavior therapy, cognitive therapy, and medication in the treatment of major depressive disorder: a randomized clinical trial, posttreatment outcomes, and six-month follow-up. J. Clin. Psychol. 2008;64:728–746.[PubMed]

13. Ekers D, Richards D. Gilbody S. A meta-analysis of randomized trials of behavioural treatment of depression. Psychol. Med. 2008;38:611–624.[PubMed]

14. Leichsenring F, Rabung S. Leibing E. The efficacy of short-term psychodynamic psychotherapy in specific psychiatric disorders: a meta-analysis. Arch. Gen. Psychiatry. 2004;61:1208.[PubMed]

15. Dryden W, Ferguson J. Clark T. Beliefs and inferences: a test of a rational-emotive hypothesis 1. Performing in an academic seminar. J. Ration. Emot. Cogn. Behav. Ther. 1989;7:119–129. doi: 10.1007/BF01076184.

16. Beck AT. Thinking and depression: idiosyncratic content and cognitive distortions. Arch. Gen. Psychiatry. 1963;9:324–333.[PubMed]

17. Ellis A. Reason and emotion in psychotherapy. New York, NY: Lyle Stewart; 1962.

18. Moldovan R, Cobeanu O. David D. Cognitive bibliotherapy for mild depressive symptomatology: randomized clinical trial of efficacy and mechanisms of change. Clin. Psychol. Psychother. 2012;20:482–493.[PubMed]

19. Olioff M, Bryson SE. Wadden NP. Predictive relation of automatic thoughts and student efficacy to depressive symptoms in undergraduates. Can. J. Behav. Sci. Can. Sci. Comport. 1989;21:353.

20. Beck J. Cognitive therapy: basics and beyond. 1st ed. New York, NY: The Guilford Press; 1995. p. 338.

21. David D. Szentagotai A. Cognitions in cognitive-behavioral psychotherapies: toward an integrative model. Clin. Psychol. Rev. 2006;26:284–298.[PubMed]

22. Ellis A. Reason and emotion in psychotherapy. New York, NY: Carol Pub. Group; 1994a. p. 512.

23. Crow TJ. Is schizophrenia the price that Homo Sapiens pays for language? Schizophr. Res. 1997;28:127–141.[PubMed]

24. Fiske AP. Haslam N. Is obsessive-compulsive disorder a pathology of the human disposition to perform socially meaningful rituals? Evidence of similar content. J. Ment. Dis. 1997;185:211–222.[PubMed]

25. Mealey L. Anorexia: a “losing” strategy? Hum. Nat. 2000;11:105–116.[PubMed]

26. Nesse RM. Natural selection and the regulation of defenses: a signal detection analysis of the smoke detector principle. Evol. Hum. Behav. 2005;26:88–105.

27. Andrews PW. Anderson J. The bright side of being blue: depression as an adaptation for analyzing complex problems. Psychol. Rev. 2009;116:620–654.[PMC free article][PubMed]

28. Mineka S. Öhman A. Phobias and preparedness: the selective, automatic, and encapsulated nature of fear. Biol. Psychiatry. 2002;52:927–937.[PubMed]

29. Öhman A. Mineka S. Fears, phobias, and preparedness: toward an evolved module of fear and fear learning. Psychol. Rev. 2001;108:483–522.[PubMed]

30. Kessler RC, Berglund PA, Demler O, Jin R, Koretz D, Merikangas KR, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey replication (NCS-R) J. Am. Med. Assoc. 2003;289:3095–3105.[PubMed]

31. Nesse RM. Williams GC. Why do we get sick? The new science of Darwinian medicine. New York, NY: Times Books; 1994.

32. NIMS. Depression fact sheet. Bethesda, MD: National Institutes of Health; 1994.

33. Fisher HE. Thomson JAJ. Lust, romance, attachment: do the side effects of serotonin-enhancing antidepressants jeopardize romantic love, marriage and fertility? Evolutionary Cognitive Neuroscience. Cambridge: MIT Press; 2007.

34. Andreasen NC. The broken brain: the biological revolution in psychiatry. New York: Harper & Row; 1984.

35. Valenstein ES. Blaming the brain: the truth about drugs and mental health. New York, NY: Free Press; 1998.

36. Wolpert L. Malignant sadness: the anatomy of depression. New York, NY: Free Press; 1999.

37. Hagen EH. The bargaining model of depression. Genetic and cultural evolution of cooperation. Cambridge: MIT Press; 2003. pp. 95–123.

38. McGuire MT, Troisi A. Raleigh MM. Depression in evolutionary context. The maladapted mind: classic readings in evolutionary psychopathology. London: Erlbaum/Taylor & Francis; 1997.

39. Nesse RM. Emotional disorders in evolutionary perspective. Br. J. Med. Psychol. 1998;71:397–415.[PubMed]

40. Leith KP. Baumeister R. Why do moods increase self-defeating behavior? Emotion, risk-taking and self-regulation. J. Pers. Soc. Psychol. 1996;71:1250–1267.[PubMed]

41. Dobson KS. Shaw BF. Cognitive assessment with major depressive disorders. Cogn. Ther. Res. 1987;10:351–360.

42. Giosan C, Cobeanu O, Mogoase C, Muresan V, Malta LS, Wyka K, et al. Evolutionary cognitive therapy versus standard cognitive therapy for depression: a protocol for a blinded, randomized, superiority clinical trial. Trials. 2014;15:83.[PMC free article][PubMed]

43. Bailey KG. Gilbert P. Evolutionary psychotherapy: where from here? In: Gilbert P, Bailey KG, editors; Genes on the couch explorations in evolutionary psychotherapy. East Sussex: Brunner-Routledge; 2000. pp. 333–349.

44. Buss DM. Evolutionary psychology: the new science of the mind. 1st ed. Boston: Allyn & Bacon; 1998. p. 456.

45. Ellis A. Dryden W. The practice of rational emotive behavior therapy. New York, NY: Springer Publishing Company; 2007. p. 281.

46. Chamberlain JM. Haaga DAF. Unconditional self-acceptance and psychological health. J Ration-Emotive Cogn.-Behav. Ther. 2001;19:163–176.

47. Cosmides L. Tooby J. Origins of domain specificity: the evolution of functional organization. In: Hirschfeld LA, Cummins DD, editors; Mapping the mind: domain specificity in cognition and culture. Cambridge: Cambridge University Press; 1994. pp. 85–116.

48. Kurzban R. Why everyone (Else) is a hypocrite: evolution and the modular mind. New Jersey, NY: Princeton University Press; 2011.

49. Buss DM, Abbott M, Angleitner A, Asherian A, Biaggio A, Blanco-Villasenor A, et al. International preferences in selecting mates a study of 37 cultures. J. Cross-Cult. Psychol. 1990;21:5–47.

50. Trivers R. 1972. Parental investment and sexual selection. Available at http://www1.appstate.edu/∼kms/classes/psy2664/Documents/trivers.pdf [cited 2013 Sep 13]

51. Kenrick DT. Sex, murder, and the meaning of life: a psychologist investigates how evolution, cognition, and complexity are revolutionizing our view of human nature. New York, NY: Basic Books; 2011.

52. Sundie JM, Kenrick DT, Griskevicius V, Tybur JM, Vohs KD. Beal DJ. Peacocks, porsches, and thorstein veblen: conspicuous consumption as a sexual signaling system. J. Pers. Soc. Psychol. 2011;100:664–680.[PubMed]

53. Fraser B. Costly signalling theories: beyond the handicap principle. Biol. Philos. 2012;27:263–278.

54. McAndrew FT. New evolutionary perspectives on altruism: multilevel-selection and costly-signaling theories. Curr. Dir. Psychol. Sci. 2002;11:79–82.

55. Sloman L, Price JS, Gilbert P. Gardner R. Adaptive function of depression: psychotherapeutic implications. Am. J. Psychother. 1994;48:1–16.[PubMed]

56. First MB, Spitzer RL, Gibbon M. Williams JBW. Structured clinical interview for DSM-IV axis I disorders, clinician version. Washington, DC: American Psychiatric Publishing Inc; 1997.

57. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th edn. 2000. p. 996. DSM-IV-TR®, American Psychiatric Pub, Washington, DC.

58. Beck AT, Steer RA, Ball R. Ranieri W. Comparison of beck depression inventories -IA and -II in psychiatric outpatients. J. Pers. Assess. 1996b;67:588–597.[PubMed]

59. Beck AT, Steer AR. Brown GK. Manual for the beck depression inventory—II. San Antonio, TX: The Psychological Corporation; 1996a.

60. DiGiuseppe R, Robin M, Leaf R. Gorman A. A cross-validation and factor analysis of a measure of irrational beliefs. Oxford: England; 1989.

61. David D, Schnur J. Belloiu A. Another search for the “hot” cognitions: appraisal, irrational beliefs, attributions, and their relation to emotion. J. Ration-Emotive Cogn.-Behav. Ther. 2002;20:93–131.

62. Hollon SD. Kendall PC. Cognitive self-statements in depression: development of an automatic thoughts questionnaire. Cogn. Ther. Res. 1980;4:383–395.

63. David D. Scala de atitudini şi convingeri forma scurta˘ In: David D, editor. Sistem de evaluare clinica˘ [Clinical Assessment System] Cluj-Napoca: RTS; 2007.

64. Eaves G. Rush AJ. Cognitive patterns in symptomatic and remitted unipolar major depression. J. Abnorm. Psychol. 1984;93:31.[PubMed]

65. Watson D, Clark LA. Tellegen A. Development and validation of brief measures of positive and negative affect: the PANAS scales. J. Pers. Soc. Psychol. 1988;54:1063–1070.[PubMed]

66. Horvath AO. Greenberg LS. The development of the working alliance inventory: a research handbook. In: Greenberg L, Pinsoff W, editors; Psychotherapeutic processes: a research handbook. New York, NY: Guilford Press; 1986. pp. 529–556.

67. Horvath AO. Greenberg LS. Development and validation of the working alliance inventory. J. Couns. Psychol. 1989;36:223–233.

68. Atkinson MJ, Sinha A, Hass SL, Colman SS, Kumar RN, Brod M, et al. Validation of a general measure of treatment satisfaction, the Treatment Satisfaction Questionnaire for Medication (TSQM), using a national panel study of chronic disease. Health Qual. Life Outcomes. 2004;26:12.[PMC free article][PubMed]

69. Larsen DL, Attkisson CC, Hargreaves WA. Nguyen TD. Assessment of client/patient satisfaction: development of a general scale. Eval. Program. Plann. 1979;2:197–207.[PubMed]

70. Nguyen TD, Attkisson CC. Stegner BL. Assessment of patient satisfaction: development and refinement of a service evaluation questionnaire. Eval. Program. Plann. 1983;6:299–313.[PubMed]

71. Giosan C. Strategy Scale H-K. A measure of the high-k independent criterion of fitness. Evol. Psychol. 2006;4:394–405.

72. Giosan C. “Slow” reproductive strategy: a negative predictor of depressive symptomatology. Aust. J. Psychol. 2013;65:156–162.

73. Giosan C. Wyka KE. Is a successful High-K fitness strategy associated with better mental health? Evol. Psychol. 2009;7:28–39.

74. Eaton SB. Konner M. Paleolithic nutrition. N. Engl. J. Med. 1985;312:283–289.[PubMed]

75. Glantz K. Pearce J. Exiles from eden: psychotherapy from an evolutionary perspective. 2nd edn. São Paulo, Brazil: EvoEbooks; 2012. p. 308.

76. Abuissa H, O'Keefe JH., Jr Cordain L. Realigning our 21st century diet and lifestyle with our hunter-gatherer genetic identity. Dir. Psychiatry. 2005;25:SR1–SR10.

77. O'Keefe JH. Cordain L. Cardiovascular disease resulting from a diet and lifestyle at odds with our Paleolithic genome: how to become a 21st-century hunter-gatherer. Mayo Clin. Proc. 2004;79:101–108.[PubMed]

78. Cordain L, Gotshall RW. Eaton SB. Evolutionary aspects of exercise. World Rev. Nutr. Diet. 1997;81:49–60.[PubMed]

79. David D, Lynn SJ. Ellis A. Rational and irrational beliefs: research, theory, and clinical practice. New York, USA: Oxford University Press; 2009. p. 384.

80. Ellis A. Reason and emotion in psychotherapy [Internet] New York, NY: Carol Pub. Group; 1994b.

81. Dryden W. Neenan M. Dictionary of rational emotive behavior therapy. 1st ed. London, UK: Whurr Publishers; 1995. p. 174.

82. Dunbar RI. Neocortex size as a constraint on group size in primates. J. Hum. Evol. 1992;22:469–493.

83. Knaus WJ. The cognitive behavioral workbook for depression: a step-by-step program. 1st ed. Oakland, California: New Harbinger Publications; 2006. p. 368.

84. Gilson M. Freeman A. Overcoming depression: a cognitive therapy approach therapist guide. 2nd ed. New York, USA: Oxford University Press; 2009. p. 224.

Abstract

This case report describes a 24-year-old man diagnosed with multiple endocrine neoplasia type IIB and major depression. Because cognitive behavioural therapy (CBT) has proven effective in the treatment of major depression in the general population and patients with cancer, we decided to adapt and use this therapy and evaluate its impact on major depression and the patient’s quality of life. The therapy was conducted individually in 15 sessions that were given over a span of 25 weeks. The data show that therapy was a useful treatment that reduced depression according to the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV criteria and self-report instruments. CBT also helped improve the patient’s quality of life, and it was considered to be an acceptable intervention for the patient, with ongoing positive results 1 year after the last psychotherapy session. CBT is a potential option for treating depression in this population but further research is needed.

Background

Multiple endocrine neoplasia type IIB (MEN IIB) is a rare autosomal-dominant syndrome that predisposes affected individuals to the development of benign and malignant tumours in hormone-secreting glands. Of all cases of type II MEN (1:30 000 people), the MEN IIB subtype represents just 5% of the problem. Even though MEN IIB prevalence is low, it has been reported to be highly aggressive in patients.1

MEN IIB manifests itself in different ways: medullary thyroid carcinoma, pheochromocytomas, mucosal neuromas and ganglioneuromatosis. Individuals with MEN IIB may show developmental abnormalities, such as a decreased proportion of the upper or lower limb, skeletal deformities, tenderness of the joints and a body habitus similar to that of ‘Marfan syndrome’, and may exhibit a higher probability of death than other subtypes of MEN II.12

The clinical manifestations mentioned above cause many emotional problems in patients carrying this disease, such as sadness, disappointment, shock, anger, fear of death, grief, a negative image of one’s own body, anxiety and depression.3 However, because of its rarity, the psychological impact of MEN IIB on patients and the possible treatments intended to cure the condition have not been extensively evaluated. This lack of evaluation leaves a large gap in evidence in the field.

We report a case of a patient with MEN IIB who was concurrently diagnosed with major depression and did not want to be treated with medication. Because cognitive behavioural therapy (CBT) has proven effective in the treatment of major depression in the general population and patients with cancer,45 we decided to adapt and use this therapy and evaluate the impact of this therapy on major depression and the patient’s quality of life.

Case presentation

The 24-year-old male patient was a single university student living with his nuclear family. He had been diagnosed with MEN IIB and recurrent thyroid cancer. He had undergone different surgical procedures throughout his life: clubfoot correction, eyelid papilloma resection, resection of the gingiva due to chronic gingivostomatitis, resection of a palatal fibroid, hemithyroidectomy, total thyroidectomy, mediastinal dissection, resection of nodules and bilateral radical neck dissection. He had also been treated with chemotherapy and radiotherapy. The patient had the phenotype and features of patients with MEN IIB: micrognathia, marfanoid habitus, mucosal neuromas, a longer upper part of the body than the lower part of the body and prominent and thickened lips. At the beginning of the psychological evaluation, the patient had been diagnosed with major depressive disorder with 5 years of evolution, without antidepressants because he refused to receive this treatment. The patient had been discharged from radiotherapy treatment for 5 years, and his calcitonin levels had been monitored since then.

In addition to the diagnosis of major depression given by psychiatry and corroborated by psychology, we performed a functional analysis based on the clinical pathogenesis map to identify factors related to the problem.6 We also applied self-report instruments to identify the severity of the depression (Mexican validation of Beck’s 21-item questionnaire on depression, and a mood thermometer with a score ranging from 0 (without depressive mood) to 10 (top level of depressive mood)). Additionally, the European Organization for Research and Treatment of Cancer instrument (EORTC QLQ-C30) was used to evaluate the patient’s quality of life.78

From the information collected, it was found that the mockery, bullying and abuse associated with the phenotype and the emergence of cancer in the patient led to the occurrence of negative cognitive responses such as “I am very weird,” “people criticize me” and “my life is tragic and it is not worth it.” As an instrumental response, the patient would lock himself in his room and avoid interaction with people. The predominant emotions that he would experience were depression and anhedonia, which resulted in little social support, a lack of acceptance of his phenotype and disease, and development of the depression with suicidal ideation.

Treatment

CBT components that have been successfully tested in other populations with cancer were used and adapted. We created five intervention modules: (1) psychoeducation about depression and MEN IIB, (2) behavioural activation, (3) restructuring of negative thoughts, (4) training in social skills and (5) assertiveness. The therapy was conducted individually in 15 sessions that were given over a span of 25 weeks, with each session lasting 1 h. The outline of each session was organised in the following way: a review of tasks, a review of self-reports, psychoeducation (if required in the session), planned activities and a description of the main conclusions of the session and allocation of home activities. These activities were aimed to reinforce what the patient had learned during the session, and to make him capable of using the skills learnt during the session in everyday life. During the therapy, the patient kept a weekly register about his perception of his depression using a mood thermometer. There were two post-treatment assessments: the first was performed 1 week after the therapy had ended, and the second was performed 1 year after the end of the treatment.

Outcome and follow-up

During the pretreatment assessment, the patient matched all of the diagnostic criteria for major depression according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV criteria symptoms 1–4, 7, 8 and 9) and reached a score of 20 on the Beck Depression Inventory (BDI)-D, indicating moderate depression, and a score of 58 on the EORTC QLQ-30, showing that the patient had a regular quality of life. The post-treatment data and the data from the 1-year follow-up tended to show that the patient did not meet the diagnostic criteria for major depression. In a similar way, the Beck’s depression scores fell to minimal depression (5 and 9). The quality of life reported by the patient increased by up to 75 points in both assessments, and the postassessment scores on the functional scales were even better (table 1). The data from the mood thermometer showed that the perception of depression tended to decrease throughout the 25 weeks (figure 1).

Figure 1

Scores of mood thermometer. The figure showing that the perception of depression tended to decrease over the 15 sessions given over a span of 25 weeks and tended to maintain follow-up.

Discussion

The data show that CBT was a useful treatment that reduced depression according to the DSM-IV criteria and self-report instruments. CBT also helped to improve the patient’s quality of life and was considered to be an acceptable intervention for the patient, with ongoing positive results 1 year after the last session of psychotherapy. This finding is consistent with reports on the effectiveness of CBT in depressed and cancer populations, and is relevant due to the aggressiveness of the disease as well as the limited psychological research on MEN II, and particularly on subtype IIB, that have been reported in databases such as PubMed, PsycINFO and CINAHL.

Owing to the nature of the case study, many confounding variables that could have influenced the patient’s decrease in depression and improvement in quality of life were not controlled, making it necessary to develop studies that can control these variables. Owing to the rarity of the disease, we recommend the use of multicentre, randomised controlled trials to recruit the population, or the use of single-case experiments that would allow better control in the research. Despite the study’s limitations, to the best of our knowledge, this is the first case report that emphasises the impact of CBT on depression in a patient with MEN IIB and which concludes that CBT is a potential option for treating depression in this population.

Patient's perspective

  • The patient reported that he found the therapy useful because it reduced negative thoughts and increased his social activities, which led to an improvement of his mood.

Learning points

  • Multiple endocrine neoplasia type IIB is a very uncommon and distressing disease.

  • Cognitive behavioural therapy (CBT) is a potential option for treating depression and improving quality of life in this population.

  • As a next step, it is necessary to develop controlled studies to assess the effect of CBT in this population.

Footnotes

Competing interests: None.

Patient consent: Obtained.

Provenance and peer review: Not commissioned; externally peer reviewed.

References

1. Moline J, Eng C. Multiple endocrine neoplasia type 2: an overview. Genet Med 2011;13:755–64 [PubMed]

2. Marini F, Falchetti A, Del Monte F, et al. Multiple endocrine neoplasia type 2. Orphanet J Rare Dis 2006;14:45. [PMC free article][PubMed]

3. Sakurai A, Katai M, Hashizume K, et al. Familial neuroendocrine tumor syndromes: from genetics to clinical practice. Pituitary 2006;9:231–6 [PubMed]

4. Cuijpers P, van Straten A, Schuurmans J, et al. Psychotherapy for chronic major depression and dysthymia: a meta-analysis. Clin Psychol Rev 2010;30:51–62 [PubMed]

5. Fulcher CD, Badger T, Gunter AK, et al. Putting evidence into practice: interventions for depression. Clin J Oncol Nurs 2008;12:131–40 [PubMed]

6. Nezu AM, Nezu CM, Lombardo E. Cognitive-behavioral case formulation and treatment design: a problem-solving approach. New York: Springer Publishing Company, 2004

7. Jurado S, Villegas ME, Méndez L, et al. La estandarización del inventario de depresión de Beck para los residentes de la ciudad de México. Salud Mental 1998;21:26–31

8. Aaronson NK, Ahmedzai S, Bergman B, et al. The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst 1993;85:365–76 [PubMed]

Articles from BMJ Case Reports are provided here courtesy of BMJ Publishing Group

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