Adjustment Disorder with Mixed Anxiety and Depressed Mood

Cognitive Behavior Therapy
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Summary of the client’s issues and diagnosis based on the DSM-V
In this roleplay, the client presented concerns about boundaries in her relationships, specifically with her partner. She reported feeling insecure and unappreciated, expressing that she often feels she is giving more to the relationship than she is receiving in return. The client expressed a desire to work on establishing boundaries to protect herself from being hurt or taken advantage of. The client shared that she often feels invalidated by her partner and friends, who minimize her feelings and tell her to be patient. This experience of invalidation has been a long-standing one for the client, who reported that her family did not respect her boundaries or validate her feelings as a child. The client described her relationship's pain, frustration, and loneliness, citing stonewalling, dismissal, and defensiveness from her partner. She reported feeling unimportant and worthless due to her partner's behavior.
Based on the DSM-V, from the client's descriptions of feeling "nervous," "sad," and "frustrated" during the session, she may be suffering from adjustment disorder (AD) with Mixed Anxiety and Depressed Mood (MADM code: F43. 23) (American Psychiatric Association, 2013). The client expressed feelings of being taken for granted, unappreciated, and disregarded in her relationships, which may contribute to anxiety and depression. Furthermore, the client's descriptions of her partner's behavior - including stonewalling, dismissing her feelings, and not reciprocating her care - could contribute to her experiencing anxiety around the relationship, as well as feelings of worthlessness or emptiness that may be associated with depression. The client's mention of a difficult childhood in which her feelings were often invalidated may also suggest a longstanding pattern of experiences that could contribute to both anxiety and depression. While the client has not been formally diagnosed with adjustment disorder (AD) with Mixed Anxiety and Depressed Mood, the session transcript suggests several indicators could warrant further exploration of this possibility.
The client expresses concerns about feeling invalidated and disregarded in relationships with her partner and her friends. She also references childhood experiences in which her family did not respect her boundaries or validate her feelings. These experiences raise the possibility that the client may have post-traumatic stress disorder (PTSD- Code: F43. 10). People with PTSD often experience anxiety, avoidance, and emotional numbing in response to traumatic events. They may also share hypervigilance, intrusive thoughts, and nightmares (Substance Abuse and Mental Health Services Administration, 2014). The client's experiences of feeling shut out and unheard in her relationships could be related to PTSD symptoms such as avoidance and emotional numbing. Additionally, her descriptions of feeling like she is constantly pouring into others without reciprocation could suggest hypervigilance, as she may be anxiously trying to maintain relationships to feel safe. While the client does not explicitly mention experiencing any other symptoms typically associated with PTSD, the possibility should be explored further in future sessions to understand her experiences better and provide appropriate treatment.
The client appears to struggle with relationship issues, self-worth, and boundaries. A diagnosis of adjustment disorder with Mixed Anxiety and Depressed Mood or post-traumatic stress disorder (PTSD) could be considered based on the client's symptoms.
Literature review
The cognitive behavioral therapy (CBT) approach, developed by Aaron Beck in the 1960s, has become one of the most widely used and effective therapies for treating anxiety and depression. Beck (2011) posits that dysfunctional thoughts and behaviors are critical factors in maintaining anxiety and depression. Thus, by changing these thoughts and behaviors, individuals can manage their symptoms and improve their well-being.
Evidence for the efficacy of CBT in treating anxiety and depression is extensive. For example, Zhang et al. (2018) conducted a meta-analysis of 115 studies and found that CBT is an effective treatment strategy for depression. The study also showed that combining CBT with pharmacotherapy resulted in significantly better outcomes than pharmacotherapy alone. Benefits of CBT for patients with depression include a reduction in symptoms, modification of underlying schemas or beliefs that maintain the depression, and the resolution of various psychosocial problems. Additionally, CBT has increased the likelihood of recurrence and improved adherence to recommended medical treatments.
Many studies have demonstrated the efficacy of cognitive behavioral therapy (CBT) in treating depression. For example, Zhang et al. (2018) found that CBT and its various modifications—including cognitive therapy, behavioral therapy, and mindfulness-based cognitive therapy—were all effective in treating depression and preventing relapse. However, their study also noted some limitations; specifically, CBT may not be as effective in preventing relapse among patients with more previous episodes. Thus, additional research is necessary to elucidate the effectiveness of CBT in different populations.
CBT is a versatile treatment approach, with evidence suggesting that it is effective in both outpatient and inpatient settings. Gautam et al. (2020) argue that CBT can be tailored to meet the specific needs of each individual, making it a practical intervention for patients with depressive disorders. Their study revealed that individuals who received CBT had lower relapse rates than those who only received medication. The authors attributed this finding to the mechanisms through which CBT works. For instance, CBT helps individuals identify and change dysfunctional thought patterns and behaviors contributing to their anxiety and depression. By addressing these maladaptive patterns, individuals can develop more adaptive ways of thinking and behaving, which can help reduce symptoms. Moreover, CBT emphasizes problem-solving and goal-setting while teaching individuals specific skills to manage their symptoms and prevent relapse. These components together make CBT an instrumental approach for treating depression.
Cognitive behavioral therapy (CBT) is an empirically supported intervention that effectively treats anxiety and depression. According to Curtiss et al. (2021), CBT benefits individuals who may not respond well to pharmacological interventions or prefer a non-pharmacological approach to managing their symptoms. The authors note that CBT can address significant psychosocial stressors through cognitive and behavioral techniques, which can improve outcomes for individuals with anxiety and depression. Furthermore, the versatility of CBT allows it to be delivered in various settings and tailored to meet individual needs.
Several recent studies support the efficacy of CBT in treating anxiety and depression. Li et al. (2020) conducted a study comparing the effectiveness of CBT to other treatments in reducing symptoms of anxiety and depression in patients with chronic medical conditions. The results indicated that CBT was more effective than other treatments in alleviating symptoms. Similarly, Zhou et al. (2017) examined the efficacy of CBT compared to other psychotherapies in reducing anxiety and depressive symptoms in adults. The study found that CBT was superior to other therapies in reducing symptoms. Collectively, these studies provide evidence for the utility of CBT in treating anxiety and depression.
The efficacy of cognitive behavioral therapy (CBT) in treating anxiety disorders has been well-established in both randomized placebo-controlled trials and effectiveness studies. Otte (2022) notes that CBT techniques involve psychoeducation, self-monitoring, somatic exercises, cognitive restructuring, and exposure to feared stimuli. According to the author, effect sizes for CBT in treating anxiety disorders range from small to large, suggesting that this therapy can be helpful for a variety of patients. Furthermore, CBT is effective in real-world settings, which bolsters its practicality.
CBT is also frequently recommended as a first-line treatment for depression. Fenn and Byrne (2013) highlight the long-term benefits of CBT, including reduced risk of relapse and recurrence. They also contend that CBT is a cost-effective treatment option due to the savings from reduced medication costs over time. In the United Kingdom, the Improving Access to Psychological Therapies (IAPT) program has successfully expanded access to CBT by training new therapists and providing services to the public. The authors also discuss the potential for CBT to be adapted in primary care settings, enabling general practitioners to use CBT techniques with their patients. The evidence suggests that CBT is a versatile and practical treatment option for various mental health conditions.
The cognitive behavioral therapy (CBT) approach has effectively treated various psychological disorders, including social anxiety and post-traumatic stress disorder (PTSD). Concerning social anxiety, CBT focuses on addressing both cognitive and behavioral factors that contribute to the maintenance and exacerbation of symptoms. Research has consistently demonstrated the efficacy of CBT in reducing social anxiety symptoms. For example, a recent study by Sigurðardóttir et al. (2022) showed that participants who underwent CBT experienced significant reductions in anxiety symptoms that were maintained over time.
CBT has also been found to be effective in treating PTSD. A 2017 meta-analysis by Coventry et al. (2020) concluded that CBT could reduce PTSD symptoms and that the long-term outcomes were comparable to other therapies. Furthermore, a 2016 study by Watkins et al. (2018) compared the efficacy of CBT to other treatments, including exposure therapy, stress management, and pharmacotherapy. The study found that CBT was the most effective treatment for PTSD.
Kaczkurkin and Foa (2015) highlight the importance of addressing distorted or irrational thoughts to reduce symptoms of anxiety, depression, and PTSD. CBT, in particular, aims to assist individuals in identifying and challenging these negative thought patterns. Individuals can better manage their symptoms by developing more adaptive and realistic perspectives. CBT also focuses on helping individuals develop coping skills that can be utilized in various situations. As these skills are honed and confidence increases, symptoms tend to diminish.
Moreover, Carpenter et al. (2018) emphasize using exposure techniques in CBT. By gradually confronting feared situations or stimuli in a safe and controlled manner, individuals can become desensitized to these stressors. This increased tolerance further aids in reducing anxiety-related symptoms. These elements make CBT an effective treatment for many anxiety-related disorders.
Overall, ample evidence supports the use of CBT in treating anxiety, depression, and PTSD. CBT targets dysfunctional thoughts and behaviors and helps individuals manage their symptoms and improve their overall well-being.
A cognitive and behavioral conceptualization of the client based on the presenting issues
Cognitive conceptualization
The client's presenting concerns suggest that she may be experiencing symptoms of adjustment disorder (AD) with Mixed Anxiety and Depressed Mood. AD often develops in response to an identifiable stressor or series of stressors and is characterized by emotional or behavioral symptoms that develop within three months of the stressor (American Psychiatric Association, 2013). The client reported feelings of insecurity, frustration, and pain stemming from her relationship with her partner, which appears to be the primary stressor in her life. Additionally, the client mentioned childhood experiences in which her family members would invalidate her feelings and not respect her boundaries, which could contribute to her current struggles with setting boundaries in her relationship. The client's anxiety symptoms seem to manifest in her worry and fear about her partner not reciprocating her love and care, as well as her anticipation of being rejected when she sets boundaries. Additionally, the client's feelings of being "too much" and being "a burden" to her partner suggested that she may be experiencing negative thoughts and cognitive distortions about herself. Her depressive symptoms are evident in her feelings of sadness, emptiness, and loneliness, as well as her lack of energy and motivation to engage in activities that she once enjoyed. It is also possible that the client may be experiencing symptoms of post-traumatic stress disorder (PTSD) due to her childhood experiences of emotional invalidation and boundary violations. PTSD is characterized by intrusive memories of the traumatic event, avoidance of reminders of the event, negative alterations in mood and cognition, and increased arousal or reactivity (American Psychiatric Association, 2013). The client's reports of feeling "stonewalled" and "ignored" by her partner, as well as her struggle to trust her partner, could be indicative of these symptoms. From a cognitive perspective, the client's concerns may be understood in terms of her core beliefs and automatic thoughts. Core beliefs are deeply held beliefs about oneself, others, and the world that often develop in childhood and are reinforced over time (Beck, 2011). The client's core beliefs may include thoughts such as "I am not worthy of love," "People will always let me down," or "I am a burden to others." These core beliefs may result in automatic thoughts, or negative, repetitive thoughts that arise in response to certain situations. For example, when the client's partner does not respond to her messages, she may experience automatic thoughts such as "He doesn't care about me," "I am not important to him," or "I am too much for him." These automatic thoughts can contribute to the client's anxiety and depressive symptoms. Overall, the client's presenting concerns suggest that she may be experiencing symptoms of adjustment disorder or PTSD and that her concerns may be rooted in her core beliefs and automatic thoughts. The goals of cognitive behavioral therapy (CBT) would be to help the client identify and challenge these beliefs and thoughts, develop coping skills, and build a stronger sense of self-worth.
Behavioral conceptualization
The client presents with several concerns that suggest potential diagnoses of adjustment disorder (AD) with mixed anxiety and depressed mood, or post-traumatic stress disorder (PTSD). These concerns include struggles with boundaries in relationships, feeling invalidated and unappreciated, and experiencing pain and frustration as a result of these dynamics. The client's reported difficulties with boundaries in relationships could be conce...