Case Report Exemplar 1 1

Case Report Exemplar 1

Cognitive behavioural treatment for depression and comorbid anxiety

Student Name (Student SID)

University of Western Sydney

Word count: 2552

Relevant policies within the placement organisation were observed in relation to the need for
informed consent from the client for the submission of a de-identified case report for the
purpose of academic assessment.

Signed: A Supervisor

Date:

Placement number: Student Name, Student SID

Case Report Exemplar 1 2

Case Introduction
Amy* is a 17 year old female who is currently undertaking her Year 12 Higher School
Certificate (HSC) at a selective high school. Amy currently lives with her parents who are
both of Indian origin, Amys only sister, Natasha* who is eight years her senior is also living
in the family home. Amy was referred for individual treatment at the placement name by her
mother, Sabrina* due to concerns of anxiety, panic and school refusal.

Diagnostic assessment summary

During initial assessment, Amy reported that her primary difficulties were coping with
emotional distress, namely, depressed mood and anxiety. In turn, Amys goals of treatment
were to cope with her depressive symptoms and reduce anxiety. After several unstructured
diagnostic interview sessions and formal assessment measures, a number of presenting
problems were apparent. These included severe depressive symptoms including low mood,
loss of pleasure in activities, fatigue, feelings of hoplessness, increase in appetite,
hypersomnia, social withdrawal, suicidal ideation, and perceptions of a bleak future. In
addition, severe anxiety symptoms included classic panic symptoms (e.g., increased heart rate,
dizziness, shakiness, thoughts that she was dying), regular feelings of irritability, poor
concentration and avoidance behaviours (e.g., school absences, cessation of studying for
exams).
Amy reported that she has always been a worrier but that she was able to cope with
her worry because it had rarely interfered with her social or academic functioning. For
example, Amy reported that before 2010, she was seldom absent from school or did she avoid
studying when examinations were near. She also reported to have maintained regular contact
with her school peers afterschool. However, Amy reported that after she received her HSC
examination timetable, her anxiety increased due to pre-existing family pressures and values

Placement number: Student Name, Student SID

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placed upon academic achievement and a greater workload. Amy reported that after
experiencing this stressor and resultant anxiety, her depressive symptoms developed soon
after.
Upon presentation, Amy was a well-groomed adolescent who was dressed in her
school uniform. The rate of Amys speech was fast and was perceived to be pressured
however its quality was logical and coherent. In addition, Amy was open and cooperative and
showed good insight for her symptoms. Amy did not show any unusual behaviours, delusions
or hallucinations.
Formal assessments
The Beck Depression Inventory-Second Edition (BDI-II) and Beck Anxiety Inventory
(BAI) were administered during the first session. The BDI-II is a standard measure used with
every client at the placement name to screen for suicidal ideation whereas the BAI is used to
accompany diagnostic interview information when a client presents with anxiety. Amys
score on the BDI-II and BAI were 34 and 31 respectively, indicating severe depressive and
anxiety symptoms.
Current Diagnoses
Amy was diagnosed with Major Depressive Disorder (MDD), Single Episode, Severe
Without Psychotic Symptoms and comorbid Generalised Anxiety Disorder. Amy met seven
out of the nine criteria for a Major Depressive Episode. That is, (a) Amy has experienced low
mood almost every day since May 2010, this was consistent with subjective reports from
Amys mother upon referral (b) Amy has lost interest and pleasure in a number of activities
which were previously enjoyable. For example, Amy reported that she used to enjoy watching
DVDs as a reward for studying however, this enjoyment has diminished over the last few
months (c) Amy reported that she has gained weight since May 2010, this is because she has
increased her appetite due to comfort eating and reported that she has been eating a lot more

Placement number: Student Name, Student SID

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junk food (d) Amy reported difficulties sleep at night and has been prescribed with Seroquel
to remedy this. However, Amy reported that she has increased her daytime napping
substantially (e) Amy reported that she is easily fatigued which has affected her sleep,
attendance at school and studying behaviours (f) Amy reported that she avoids studying
because she is unable to concentrate on her work, and (g) Amy reported to have recurrent
suicidal ideation without specific plans, means or intent. According to Amys reported history,
she has not met criteria for a Manic, Mixed or Hypomanic Epsiode. In addition, Amy did not
report any substance abuse, general medical condition or psychotic symptoms thus ruling out
Substance-Induced Mood Disorder, Mood Disorder due to a General Medical Condition, and
psychotic disorders such as Schizoaffective Disorder.
Amy was given an additional diagnosis of Generalised Anxiety Disorder to account
for her anxiety symptoms. Amy reported excessive worries about her academic future, her
HSC examinations and her emotional well-being in the future. These worries cause marked
anxiety and were difficult to control, for example, when worrying about her academic future,
Amy rated her Subjective Units of Distress (SUDS) to be a 10/10 and reported sleep
difficulties due to rumination. Amy also reported cognitive and physical symptoms indicative
of worry and anxiety including difficulties concentrating, irritability almost every day, and
disturbed sleep. Even though Amy reported panic-like symptoms, her core fear was not the
fear of additional panic attacks but worry over a number of activities in her life. Also, Amy
did not report fear of social embarrassment, fear of separation from attachment figures or
being contaminated.
Amy reported that both depressive and anxiety symptoms have caused clinically
significant distress in her social and academic functioning. For example, Amy has been
avoiding her friends due to anhedonia as well as anxiety related to her HSC exams. In
addition, Amy reported that her depressive and anxiety symptoms have caused her to avoid

Placement number: Student Name, Student SID

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most activities such as studying, attending school, and socialising. Amy reported that to
escape from these activities, she engages in daytime napping and eats junk food.

Cognitive Behavioural Formulation for Depressive and Anxiety Symptoms

To conceptualise Amys presenting problems a cognitive behavioural formulation was
developed. Particularly, maintaining factors for her depressive and anxiety symptoms were
identified, first, this included avoidance behaviours and/or a passive style of coping. For
example, Amy was absent from school, engaged in daytime napping and procrastinated or
avoided studying. Second, Amy experienced anhedonia in which she lacked enjoyment in
social and previously pleasurable activities (e.g., DVD watching) therefore Amy limited her
activities to sleep and eating. Finally, Amy reported cognitive distortions and thinking errors
such as should rules (e.g., I should do well, especially for my parents) and catastrophising
(e.g., I am behind on everything, I am screwed).

Treatment Plan
Based on the cognitive behavioural formulation developed after the second session, a
treatment plan was outlined for the remaining five sessions. First, a high treatment priority
was placed on the severe level of inactivity and avoidance behaviours Amy reported. It was
judged that these maintaining factors would be most detrimental to Amys psychological,
physical and educational functioning. Second, consideration of clients current HSC year was
important to the management of stress and plans for the future.
The initial treatment plan involved 1) psycho-education and behavioural activation to
reduce depressed mood, 2) structured problem solving to reduce worrying and anxiety related
to the HSC, 3) thought challenging to reduce anxiety, 4) behavioural experiments for negative
beliefs, 5) distress tolerance strategies and relapse prevention. However, due to some

Placement number: Student Name, Student SID

Case Report Exemplar 1 6

treatment non-compliance during implementation of behavioural activation techniques the
treatment plan shifted to an emphasis on these techniques and behavioural experiments were
implemented to reduce Amys strength of negative beliefs related to physical activity.
Psycho-education
Psychoeducation was provided to Amy with an emphasis on negative cognitions
regarding self-efficacy, behavioural inactivation and the maintenance of low mood. In
addition, the maintaining cycle of anxiety was provided with adaptive information based on
Amys presenting problems (i.e., catastrophising about HSC exams have led to avoidance of
exam-related studying and an increase in anxiety and stress). It was suggested that
maintaining factors needed to be addressed in treatment to break the cycle of depression
and anxiety.
Behavioural activation
It has been well-established that behavioural activation is an important component to
the treatment of depressed individuals (Task Force on Promotion and Dissemination of
Psychological Procedures, 1995). A rationale of behavioural activation techniques were
provided to the client, this explanation involved the negative consequences of behavioural
inactivation including losses or reductions in opportunities for positive reinforcement which
lead to low mood (Manos, Kanter & Busch, 2010). With this rationale, Amy was instructed to
brainstorm a list of activities which she perceived to be enjoyable. This list included baking
cookies and cakes, browsing the internet, listening to music and watching the television series
Alias and Modern Family. Due to the sedentary activities which were listed, the intern
prompted minimal exercise (e.g., ten minute walk) as an important activity which could be
coupled with listening to music to increase mood. After agreement with Amy, a schedule was
developed for the week which involved at least one pleasurable activity per day, this was
advised to be completed as home-based tasks. In addition, Amy was advised to rate her

Placement number: Student Name, Student SID

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feelings of pleasure/enjoyment on a scale from 0 to 10 (0 equating to no pleasure/enjoyment
and 10 equating to extreme pleasure/enjoyment).
After a homework review, Amy reported that she did not completely adhere to the
activity schedule (i.e., she did not engage in a 10 minute walk nor did she bake). The barriers
to these activities involved unintentional forgetting (stimulus control deficit) and intense
feelings of anxiety. When setting a similar activity schedule, Amy rated her confidence to be
a 6/10. To increase this confidence rating, Amy was instructed to brainstorm how she may
avoid identified barriers by implementing reminders to improve homework compliance
(Baruch, Kanter, Bowe & Pfennig, in press). During the end of the session, Amy decided to
post a reminder behind her bedroom door and set an alarm on her phone. After this was done,
Amy rated her confidence to be a 9/10 for successful completion. Amy was also given a
thought monitoring sheet to examine her thoughts and feelings prior to exercise.
When reviewing the home-based activity schedule, Amy was able to bake cookies for
her family and friends however she did not engage in her ten minute walk. Amy reported on
her thought monitoring sheet that she thought exercise would not help increase her mood but
instead worsen it. Normalisation of these thoughts was provided and a rationale for
behavioural activation was repeated.
Behavioural experiments
To test the validity of Amys belief that exercise would not be helpful to her mood, a
behavioural experiment (BE) was conducted (Antony & Swinson, 2000). For this BE, Amy
reported that this strength of belief was a 9/10 due to previous experiences in which walking
to the station made her fatigued thus irritable. Amy was instructed to rate her irritability and
fatigue from 0 to 10 before and after exercise. During the next session, Amy reported that her
irritable mood was reduced from an 8/10 to a 6/10 although ratings of fatigue were the same
before and after exercise. As a result, Amys initial strength of belief rating reduced to a 7/10

Placement number: Student Name, Student SID

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and when these BEs were repeated until the termination of treatment, her strength of belief
rating further reduced to a 4/10.
Structured problem solving
During the fourth treatment session, structured problem solving was implemented to
reduce worrying related to the HSC (Treatment Protocol Project, 2004). A plan of action
included a balance lifestyle consisting of scheduled social activities, exam-related studying,
relaxation and pleasurable activities. Amy was instructed to rate her anxiety related to her
worry before and after implementation of her smart studying plan of action. After this plan
was successfully completed, Amy reported that her anxiety reduced from a 10/10 to a 7/10.
Thought challenging
The Intolerance of Uncertainty Model suggests that individuals with GAD worry
about situations and/or events in which the outcomes are uncertain (Ladouceur, Talbert &
Dugas, 1997). Therefore, Amys uncertainty towards HSC events (e.g., trial exams) was
identified to trigger negative cognitions related to threat (e.g., I am screwed, What if I fail,
I wont go to uni and my parents will be disappointed) (Ladouceur, Talbert & Dugas, 1997).
Thought challenging was used for these negative cognitions by listing evidence for and
against such cognitions in which a more realistic thought resulted. These realistic cognitions
were strengthened by an emphasis on structured problem solving to increase the likelihood of
performing well during Amys HSC exams as well as an emphasis that after her exams, the
uncertainty of her grades needed to be tolerated.

Treatment outcome
At the end of treatment, the BDI and BAI were re-administered to evaluate treatment
outcomes. Amys scores on the BAI were reduced from 31 to 23 which indicated moderate
symptoms of anxiety. However, Amys scores on the BDI were only minimally reduced from

Placement number: Student Name, Student SID

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34 to 30 which indicated severe symptoms of depression. These scores were interpreted to
reflect treatment implementation whereby anxiety-reducing interventions were strongly
emphasised due to the pragmatic importance of increasing educational functioning. Therefore,
due to current severe levels of depressive symptoms and moderate levels of anxiety, Amy was
referred to a Clinical Psychologist in the placement name team to continue psychological
treatment.

Reflective personal and professional practice

Upon personal reflection, feelings of frustration were apparent when Amy was noncompliant towards the implementation of behavioural activation. Therefore, a personal
development area includes an increased understanding of the adolescent population group and
reasons for why this population group are more likely to be non-compliant with treatment
compared to other population groups. In addition, anticipation of non-compliance may
prevent the allocation of further sessions to problem solve this. For example, behavioural
activation may be initially coupled with thought monitoring sheets to identify possible
negative beliefs related to homework
Upon professional reflection, it may have been helpful to liaise with other
professionals which were originally managing Amys case. For example, assessment sessions
may have been shortened by obtaining existing information from a previous psychologist
whom Amy had sought treatment with. In addition, non-CBT techniques such as motivational
interviewing may have increased intrinsic motivation to change inactivity and resolve
ambivalence to change (Brody, 2009) which Amy displayed.

* All names and identifying details have been altered to protect confidentiality.

Placement number: Student Name, Student SID

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References
Antony, M. M., & Swinson, R. P. (2000). Phobic disorders and panic in adults: A guide to
assessment and treatment. Washington: American Psychological Association.
Baruch, D. E., Kanter, J. W., Bowe, W, M., & Pfennig, S. L. (in press). Improving homework
compliance in career counselling with a behavioural activation functional assessment
procedure: A pilot study. Cognitive and Behavioural Practice.
Brody, A. E. (2009). Motivational interviewing with a depressed adolescent. Journal of
Clinical Psychology: In Session, 65, 1168-1179.
Ladouceur, R., Talbert, F., & Dugas, M. J. (1997). Behavioural expressions of intolerance of
uncertainty: A study of a theoretical model of worry. Behaviour Research and
Therapy, 38, 933-941.
Manos, R. C., Kanter, J. W., & Busch, A, M. (2010). A critical review of assessment
strategies to measure the behavioural activation model of depression. Clinical
Psychology Review, 30, 547-561.
Task Force on Promotion and Dissemination of Psychological Procedures (1995). Training in
and discussion of empirically validated treatments: Report and recommendations. The
Clinical Psychologist, 48, 3-23.
Treatment Protocol Project (2004). Management of Mental Disorders: Treatment Protocol
Project. Darlinghurst: World Health Organisation.

Placement number: Student Name, Student SID