CBT Case Study: Depression and Opioid Dependence Treatment

Patient Overview and Chief Complaint

The patient is a 31-year-old Hispanic male of Puerto Rican origin. He is the father of one son, aged 10. Born and raised in Puerto Rico, he emigrated to the United States at age 11 and now lives alone in Brooklyn, New York. He is separated from the mother of his son; his son currently lives with her. The patient is unemployed.

The patient's chief complaint is that he is "feeling down and alone recently" and that he feels separated from his family: "I also haven't seen my son for a while." He is clearly depressed about his living situation, his prospects, and his health.

The patient reports that over the past two weeks he has felt depressed, cannot sleep, has little to no energy, cannot concentrate, and cannot eat. He does not report any major fluctuations in mood — no elevations or expansiveness. He does experience auditory hallucinations (mumbling voices) but not visual hallucinations. He does not report paranoid ideation, ideas of reference, or delusions. He is not currently taking any psychiatric medication, solely because he failed to follow up on his hospital discharge prescription from seven months prior. His son has been with his mother for the past few months, deepening the patient's isolation and depression. The patient has a poor relationship with his son's mother, and his son has a developmental problem with which the patient would like to help — a situation made difficult by their physical separation.

Medical, Psychiatric, and Social History

The patient has four brothers and four sisters, all born and raised in Puerto Rico. The family emigrated to the United States when the patient was 11 years old. The patient reports no history of sexual, emotional, or physical abuse within his family. He has provided no further family medical or psychiatric history beyond the number of siblings and their Puerto Rican nationality. He has confirmed, however, that his family continues to provide him with some financial support while he is unemployed, indicating that he maintains some contact with his siblings and parents.

The patient has had two prior hospitalizations. The most recent, seven months ago, followed a suicide attempt in which he stepped in front of a bus while under the influence of drugs. He has also undergone detox and rehabilitation treatment on multiple occasions, the most recent following that suicide attempt. The patient is dependent upon opioids and marijuana. He has Hepatitis B and C, as well as chronic back pain secondary to being struck by a car; he received back surgery in 2007.

His psychiatric history includes a Mood Disorder diagnosis (DSM-IV-TR) made at age 23. The patient has declined to elaborate on his hospitalizations, saying he is "embarrassed" by them. He acknowledges that he has not followed through on outpatient psychiatric referrals and has not used prescriptions provided in the past.

It is worth noting that mood disorders are little changed from DSM-IV to DSM-5, with a few exceptions: "missing from DSM-5 is the DSM-IV entity of mood disorder NOS, which has been replaced with unspecified bipolar disorder and unspecified depressive disorder; people who present with an unclear pattern will have to be designated as one or the other" (Parker, p. 187, 2014). A DSM-5 diagnosis for this patient would most likely be unspecified depressive disorder, as there is little indication of bipolar disorder.

The patient's developmental history is scarce. His educational attainment consists of a GED. There is no known employment history beyond the fact that he is currently unemployed.

The patient was expelled from school in the 11th grade after smoking marijuana and getting into a fight, following which he was hospitalized (he did not provide specifics about that hospitalization or the fight). He subsequently earned his GED. He affirms that the fight was his only act of violence and that he was never violent during any hospital stay. He has spent some months in jail — the exact number was not disclosed — for dealing drugs; he was arrested twice, marking him as a repeat offender. He is currently without work and receives financial assistance from his family.

Substance Abuse History and Mental Status Examination

The patient has a significant history of substance use and abuse. He is currently using heroin at a rate of five to eight bags per day and has done so for the past three years. He has also smoked marijuana occasionally. He has undergone multiple detox and rehabilitation treatments for opioid dependence, the most recent being seven months prior to this evaluation.

The patient is a Hispanic male who appears his stated age. He was sniffling and grimacing during the examination but maintained adequate eye contact. He appeared physically uncomfortable with both himself and his surroundings. He was sufficiently groomed, not unkempt, and had no distinguishing features. His speech was articulate, with a normal rate, volume, and rhythm. His English was fluent and his word choices appropriate.

His thought processes were appropriate and linear; he was clearly goal-oriented in his thinking without any wandering. His primary focus is on obtaining relief from drug withdrawal symptoms, and he openly acknowledges that he needs detox. He did indicate perceptual disturbance in the form of auditory hallucinations. He demonstrates neither suicidal ideation nor violent ideation at this time. His mood is depressed, producing anxiety and dysphoria. His impulse control is intact. His cognitive functions are oriented to person, time, place, and situation — he is not disoriented. His capacity for abstract thinking is appropriate for his age and education level, and his attention span is fair. He has insight into his own symptoms, recognizes the presence of illness, and acknowledges the need for rehabilitation. His judgment, however, is poor, given his pattern of relapse.

Diagnosis and Theoretical Framework

The patient suffers from Mood Disorder and Depression.

Cognitive-Behavioral Therapy (CBT) would be an appropriate primary intervention for this patient, as it has been used to treat both depression and a range of other mental disorders (McKay et al., 2015). The core principle of CBT is that it addresses current problems by helping patients change harmful thinking and behavior through deliberate attention-focusing techniques. The CBT therapist recognizes that harmful actions sometimes arise not from rational choice but from a failure to control impulses — what Aristotle called akrasia, a softness of the will. By addressing both the behavioral and cognitive dimensions of the patient's life, the therapist can guide him toward overcoming a stimulus-avoidance response characterized by repeated lapses in judgment and relapses into drug abuse. The central aim of this intervention is to examine the relationship between thought and action and to align the two so that there is less risk of relapse due to avoidance (Beck, 2011).

Interpersonal psychotherapy may also be beneficial, as it directs attention toward the patient's relational environment — specifically, how he relates to various people in his life (Rogers, 2012). Supportive psychotherapy could similarly be useful. Supportive psychotherapy views every individual's character as a work in progress and holds that structural changes should come from the individual rather than being imposed by the therapist. It helps the patient relieve symptoms and learn to live with them, rather than attempting to eradicate them entirely. While CBT and supportive psychotherapy sit at opposite ends of a spectrum, a combination of the two could be beneficial in this case. CBT is nonetheless recommended as the primary intervention, given the diagnoses of mood disorder, drug dependence, and depression.

The rationale for CBT is grounded in the relationship between self-concept, self-awareness, and the "acting self." One's self-concept reflects how one views oneself on an intellectual or role-playing level; self-awareness is how one interprets one's own actions and beliefs; and self-esteem reflects how one evaluates one's emotional self — whether one feels positive or negative about oneself. Good self-esteem produces confidence and security, while low self-esteem generates insecurity and feelings of shame or despair (Hewitt, 2009, p. 217). The acting self is a composite of intellectual beliefs, physical attributes, and willpower, and it responds to both conscious and sensory factors (Tsakiris & Haggard, 2005, p. 387).

Sarason (2005) notes that while psychoanalytic theories offer a penetrating view of the psychological makeup of a depressed patient, behavioral therapy is often needed to reinforce psychological and behavioral development. Sarason observes that "psychoanalytic theorists have suggested that clinical episodes of depression happen because the events that set off the depression revive dimly conscious, threatening views of the self and others that are based on childhood experience" (p. 349). In the case of the present patient, there is no clear indication of childhood trauma. However, the uprooting of his family from Puerto Rico and their relocation to the United States at a developmentally impressionable age may have had lasting significance in the patient's difficulties with adaptation. Sarason's approach would therefore suggest that both psychoanalytic exploration and CBT would be beneficial: by bringing to consciousness the inner conflicts residing in the patient's subconscious, therapy may ease his depressive affliction and help free him from recurring depressive episodes.

The school of behaviorism combines theory, philosophy, and methodology to better understand behavior. Various branches exist, including radical behaviorism, which relates to pragmatic philosophy. Today, behaviorism is more broadly practiced as behavior analysis. Classical conditioning, based on Pavlov's research, demonstrates that responses to stimuli can be shaped over time. Operant conditioning, based on the work of Skinner, examines voluntary actions and how they are shaped by environmental consequences. Both differ from observational learning, which occurs through social observation — the subject actively watches rather than being acted upon directly.

CBT is ultimately the best-fitting intervention for this patient because of its goal-oriented approach and its capacity to help him alter entrenched patterns of thought and behavior. This should alleviate his anxiety and relieve his depression by giving him more effective tools for managing his feelings. Because the patient is withholding information about his past, it may also be necessary to administer a psychological test (such as the MMPI) in order to rule out any possible personality disorder, which could be implicated in his prior suicidal tendency.

References

Beck, J. (2011). Cognitive Behavior Therapy: Basics and Beyond. NY: Guilford Press.

Hewitt, J. P. (2009). Oxford Handbook of Positive Psychology. Oxford University Press.

McKay, D. et al. (2015). Efficacy of cognitive-behavioral therapy for obsessive-compulsive disorder. Psychiatry Research, 225(3): 236–246.

Parker, G. F. (2014). DSM-5 and Psychotic and Mood Disorders. Journal of the American Academy of Psychiatry and the Law Online, 42(2): 182–190.

Rogers, C. (2012). On Becoming a Person: A Therapist's View of Psychotherapy. NY: Houghton Mifflin.

Sarason, I. (2005). Abnormal Psychology: The Problem of Maladaptive Behavior (11th ed.). Upper Saddle River, NJ: Pearson Education.

Tsakiris, M., & Haggard, P. (2005). Experimenting with the acting self. Cognitive Neuropsychology, 22(3): 387–407.