Group Therapy Case Conceptualization: Anxiety and Depression

Background and Presenting Problem

Clients' Biopsychosocial History

This case conceptualization covers a weekly outpatient relationships group consisting of fifteen members between the ages of 25 and 50. All group members have been formally diagnosed with Generalized Anxiety Disorder (GAD) and/or Major Depressive Disorder (MDD), and some with more than one clinical disorder. Additionally, all members have attended this group for at least six months, most on a regular weekly basis.

Of the fifteen group attendees, seven are female and eight are male. All have been in treatment for at least six months and have received formal diagnoses based on clinical assessments administered by a referring psychologist or psychiatrist. Six clients have been diagnosed with Depression. Five have been diagnosed with Generalized Anxiety Disorder. Four have been diagnosed with both Depression and Generalized Anxiety Disorder. Additionally, three of the clients have been diagnosed with substance use disorder.

In terms of ethnic backgrounds, five of the clients are white, one is East Asian, one is South Asian, two are African American, four are Latino, and two are of mixed heritage. Their ages range between 25 and 40, and they come from diverse socioeconomic backgrounds and levels of educational attainment: three hold advanced degrees, and seven hold undergraduate degrees. Religious affiliation is important to ten of the fifteen group members. Of those ten, five identify as Christian/Protestant, two as Catholic, one as Jewish, and one as Muslim. Of the remaining five members who do not cite religion as important in their lives, three claim some form of spiritual practice or belief system outside of organized religion, and the other two identify as either agnostic or atheist.

Behavioral Observations and Clinical Interpretations

Behavioral Observations

Using a mental status exam, formal observations and assessment methods were applied to provide an overview of client functioning. Specific sections of the mental status exam included the following. First, general physical observations were made related to the clients' appearance, manner of dress, and mannerisms, followed by observations of speech patterns and interactions with others in the group. Second, thinking patterns and cognitive-emotional states were assessed based on the content of each client's speech, including expressions of emotion, whether the client was more focused on the past or the future, the clarity of the client's judgments, and the level of self-awareness or insight. Because of the diversity of the clients comprising the group, behavioral observations reflect individual differences. Given their dedication to attending regular meetings, all group members are actively engaged and cooperative with respect to keeping group regulations, such as refraining from judgment or interruption.

Clinical Interpretations

Based on clinical observations of the group, clinical interpretations reflect the formal appraisal of client performance in conjunction with valid assessments that lead to formal diagnoses. Using a combination of cognitive-behavioral therapy and psychoanalysis allows for nuanced clinical interpretations that account for the intricacies and idiosyncrasies of an individual's upbringing, social climate, educational attainment, job status, gender, and other variables. "Part of the counselor's job is to decide which theoretical approach is a good fit with the client's needs, and then use that approach to finish the case conceptualization" ("Clinical Thinking Skills," n.d., p. 31). Therefore, clinical interpretations for individual clients will vary depending on the formal diagnoses of each client and their individual therapeutic needs.

Diagnostic Impressions: GAD and Depression

Overview

The mental and behavioral health team contributes to diagnostic impressions based on the results of formal assessments such as the GAD-7 and GAD-2, which are validated instruments used to assess clients for generalized anxiety disorder (Plummer, Manea, Trepel, et al., 2016). Comorbidity — particularly between GAD and MDD — was evident among group members. However, the tools used to assess clients may have varying degrees of sensitivity. As Van Loo, Schoevers, Kendler, et al. (2015) point out, a low threshold for diagnosing major depressive disorder is more likely to lead to a comorbidity diagnosis. While the DSM-5 does not offer guidelines for classifying patients as mild, moderate, or severe, clinicians may still discriminate between depression severity among patients with the same diagnosis (Tolentino & Schmidt, 2018). It is also worth noting the various "overlapping mechanisms in generalized anxiety disorder and major depressive disorder," especially with regard to negative emotion generation (MacNamara, Kotov, & Hajcak, 2016, p. 275). Differential diagnoses involved screening clients according to DSM-5 guidelines as described below.

Generalized Anxiety Disorder (GAD)

Notoriously "challenging" to diagnose, GAD manifests differently for different people (Glasofer, 2019, p. 1). Primary symptoms include persistent worry that is "excessive," difficult to manage, and which interferes with daily life for a period of at least six months (Glasofer, 2019, p. 1). To receive a formal diagnosis of GAD, the client must also exhibit at least three of the following symptoms: restlessness, fatigue, irritability, difficulty concentrating, muscle aches, and difficulty sleeping. Differential diagnosis allows the clinician to determine whether the client has some other related disorder — such as social anxiety disorder, an eating disorder, obsessive-compulsive disorder, or panic disorder — some of which could co-occur with GAD.

Group discussions related to anxiety focused on examples of how the symptoms of GAD manifest, taking great care to show how age, gender, race, religion, and other factors might affect symptom expression. Going over the DSM-5 checklist of symptoms in the group helped those diagnosed with GAD to recognize the rationale for their diagnosis and set appropriate, reasonable treatment goals. Open discussion also permitted differential diagnosis for those whose symptoms might be related to other conditions, or who might qualify for a dual diagnosis, as several group members did.

Depression

To be diagnosed with clinical depression, a client must exhibit five or more of the following symptoms over a two-week period: daily depressed mood, diminished interest in life activities, change in eating habits or appetite, slowed thoughts and physical movements, fatigue, feelings of worthlessness or guilt, inability to concentrate, and suicidal ideation. Some of these symptoms overlap with anxiety disorder, which is why comorbidity is common. Both GAD and MDD must also be differentiated from disorders that can produce similar symptoms — and both need to be distinguished from depression or anxiety caused by acute trauma or the use of alcohol or drugs.

As with GAD, the group leader discussed the symptoms of depression to help members reflect on the progression of their illness and monitor signs of recovery. Group members also shared their subjective impressions regarding how their mental health issues were perceived by friends, family members, and coworkers, how they first became aware of their condition, and how their diagnosis might motivate greater self-awareness.