A 35-year-old woman comes to the office due to sad mood, low motivation, and sleep disturbance over the past several months. The patient was recently let go from her job because the company was downsizing, and she has been feeling worthless and hopeless about getting another job. She says, "I'm sure it was just a matter of time before I was fired anyway. Nothing I try has ever worked out. I feel like a failure, and I don't think anything will change." The patient has been reluctant to apply for another job as she assumes she wouldn't be offered the position or would be fired as soon as her shortcomings became evident. She has had increased appetite and difficulty falling asleep. The patient has been avoiding her friends, who "try to be supportive but don't seem to understand what I'm going through." She and the physician decide on a course of nonpharmacological treatment to help with her depression. Which of the following is the most appropriate treatment for this patient?
Modality | Primary indications | Features |
Cognitive-behavioral therapy |
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Interpersonal psychotherapy |
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Supportive psychotherapy |
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Psychodynamic psychotherapy |
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Motivational interviewing |
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Dialectical behavioral therapy |
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Biofeedback |
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OCD = obsessive-compulsive disorder; PTSD = post-traumatic stress disorder. | ||
Cognitive-behavioral therapy (CBT) is an evidence-based, standardized modality of psychotherapy that targets persistent maladaptive thought patterns and behaviors. This patient's automatic negative interpretation of experiences and avoidance behavior make her a good candidate for CBT.
CBT is used as monotherapy or in combination with medication to treat a variety of mental illnesses (eg, depression, anxiety disorders, obsessive-compulsive disorder, eating disorders). Treatment is generally time limited (approximately 5-20 sessions) and structured, and involves homework. Therapists work with patients to identify and change cognitive distortions, such as overgeneralization (eg, believes nothing ever works out) and catastrophizing (eg, assumes the worst outcome). Behavioral techniques such as graded exposure target the avoidance behaviors that stem from these distortions.
(Choice A) Biofeedback involves using signals from the body (ie, heart rate, muscle tension, skin temperature, blood pressure) as indicators of emotional distress. Patients are taught to identify and control their responses to various stimuli.
(Choice C) Dialectical behavioral therapy was developed for borderline personality disorder and targets the emotional dysregulation and self-destructive and suicidal behaviors associated with this disorder.
(Choice D) Interpersonal psychotherapy is an evidence-based therapy primarily used for depression that focuses on the interplay between depressive symptoms and interpersonal stressors. This patient does not have a specific interpersonal conflict. Her general cognitive distortions and avoidance behaviors are the main cause of her distress and are best targeted with CBT.
(Choice E) Motivational interviewing is commonly used to treat substance abuse and involves the therapist assuming a nonjudgmental stance, acknowledging ambivalence, focusing on the patient's motivation for change, and tolerating resistance to change.
(Choice F) Psychodynamic psychotherapy focuses on the role of unconscious conflict and gaining insight into how past experience shapes present situations. It does not specifically target thought patterns and avoidance behaviors.
(Choice G) Supportive psychotherapy is used to reinforce a patient's ability to cope with stressors and is commonly used for low-functioning patients or those in crisis who are at risk of decompensation. For a more stable patient, such as this woman, CBT provides a more in-depth and targeted approach.
Educational objective:
Cognitive-behavioral therapy focuses on reducing automatic negative thoughts and avoidance behaviors that cause distress. It is effective as monotherapy or in combination with medication for a wide range of psychiatric disorders.