Journal of Contemporary Psychotherapy

, Volume 47, Issue 4, pp 201–210 | Cite as

Behavioral Activation for a Breast Cancer Patient with Major Depression and Coexistent Personality Disorder

Original Paper
  • 180 Downloads

Abstract

Behavioral activation is an empirically validated treatment for depression, with recent applications toward other psychological and medical conditions. However, modification to the treatment protocol may be necessary when symptoms, environment, or personality necessitate. This feasibility study applied Behavioral Activation Treatment for Depression (BATD) in a case of a woman with recurrent major depression and obsessive–compulsive personality disorder (OCPD) undergoing breast cancer treatment. A quasi-experimental design was used, comparing supportive psychotherapy (while she received radiation therapy) followed by eight sessions of BATD. Treatment was designed in accordance with patient and therapist goals of increasing exercise, decreasing fatigue, and reducing interference due to perfectionistic behaviors. The patient exhibited resistance to initiation of BATD, related to symptoms of OCPD, which necessitated modification of treatment strategies and scheduling. Following BATD, the patient reported a significant reduction in depressive symptoms, physical problems, and role limitations—gains not observed following supportive therapy. In addition, she demonstrated less psychological rigidity and interference due to OCPD symptoms within the therapeutic relationship and other interpersonal relationships. Consistent with previous research, results indicate BATD may effectively treat individuals with complex clinical presentations that include personality disorder pathology. In addition, methods of modification to BATD are discussed, as well as future directions for research in this area.

Keywords

Behavioral activation Depression OCPD Cancer Flexibility within fidelity 

Notes

Compliance with Ethical Standards

Conflict of interest

All authors declare that there are no conflicts of interest with this study.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Informed Consent

Informed consent was obtained from all individual participants included in this study.

Supplementary material

10879_2017_9359_MOESM1_ESM.xlsx (16 kb)
Supplementary material 1 (XLSX 16 KB)

References

  1. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th edn.). Arlington, VA: American Psychiatric Publishing.CrossRefGoogle Scholar
  2. Armento, M. E. A., & Hopko, D. R. (2007). The environmental reward observation scale (EROS): Development, validity, and reliability. Behavior Therapy, 38, 107–119.CrossRefPubMedGoogle Scholar
  3. Armento, M. E. A., & Hopko, D. R. (2009). Behavioral activation of a breast cancer patient with coexistent major depression and generalized anxiety. Clinical Case Studies, 8, 25–37.CrossRefGoogle Scholar
  4. Barrera, I., & Spiegel, D. (2014). Review of psychotherapeutic interventions on depression in cancer patients and their impact on disease progression. International Review of Psychiatry, 26(1), 31–43.CrossRefPubMedGoogle Scholar
  5. Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56, 893.CrossRefPubMedGoogle Scholar
  6. Beck, A. T., Steer, R. A., & Brown, G. (1996). Manual for the beck depression inventory–II. San Antonio, TX: Psychological Corporation.Google Scholar
  7. Beck, A. T. & Steer, R. A. (1991). Relationship between the Beck Anxiety Inventory and the Hamilton Anxiety Rating Scale with anxious outpatients. Journal of Anxiety Disorders, 5, 213–223.CrossRefGoogle Scholar
  8. Beck, A. T., Steer, R. A., Ball, R., & Ranieri, W. F. (1996). Comparison of Beck Depression Inventories-IA and -II in psychiatric outpatients. Journal of Personality Assessment, 67, 588–597.CrossRefPubMedGoogle Scholar
  9. Brazier, J. E., Harper, R., Jones, N. M. B., O’Cathain, A., Thomas, K. J., Usherwood, T., & Westlake, L. (1992). Validating the SF-36 health survey questionnaire: New outcome measure for primary care. British Medical Journal, 305, 160–164.CrossRefPubMedPubMedCentralGoogle Scholar
  10. Brière, F. N., Rohde, P., Seeley, J. R., Klein, D., & Lewinsohn, P. M. (2014). Comorbidity between major depression and alcohol use disorder from adolescence to adulthood. Comprehensive Psychiatry, 55, 526–533.CrossRefPubMedGoogle Scholar
  11. Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52, 685–716.CrossRefPubMedGoogle Scholar
  12. Chu, B. C., Colognori, D., Weissman, A. S., & Bannon, K. (2009). An initial description and pilot of group behavioral activation therapy for anxious and depressed youth. Cognitive and Behavioral Practice, 16(4), 408–419.CrossRefGoogle Scholar
  13. Ciaramella, A., & Poli, P. (2001). Assessment of depression among cancer patients: The role of pain, cancer type and treatment. Psycho-oncology, 10, 156–165.CrossRefPubMedGoogle Scholar
  14. Corruble, E., Ginestet, D., & Guelfi, J. D. (1996). Comorbidity of personality disorders and unipolar major depression: A review. Journal of Affective Disorders, 37, 157–170.CrossRefPubMedGoogle Scholar
  15. Cuijpers, P., Driessen, E., Hollon, S. D., van Oppen, P., Barth, J., & Andersson, G. (2012). The efficacy of non-directive supportive therapy for adult depression: A meta-analysis. Clinical Psychology Review, 32(4), 280–291.CrossRefPubMedGoogle Scholar
  16. Fann, J. R., Thomas-Rich, A. M., Katon, W. J., Cowley, D., Pepping, M., McGregor, B. A., & Gralow, J. (2008). Major depression after breast cancer: A review of epidemiology and treatment. General Hospital Psychiatry, 30, 112–126.CrossRefPubMedGoogle Scholar
  17. Fasick, V., Spengler, R. N., Samankan, S., Nader, N. D., & Ignatowski, T. A. (2015). The hippocampus and TNF: Common links between chronic pain and depression. Neuroscience and Biobehavioral Reviews, 53, 139–159.CrossRefPubMedGoogle Scholar
  18. Fava, M., Alpert, J. E., Borus, J. S., Nierenberg, A. A., Pava, J. A., & Rosenbaum, J. F. (1996). Patterns of personality disorder comorbidity in early-onset versus late-onset major depression. American Journal of Psychiatry, 153, 1308–1312.CrossRefPubMedGoogle Scholar
  19. Fava, M., & Kendler, K. S. (2000). Major depressive disorder. Neuron, 28, 335–341.CrossRefPubMedGoogle Scholar
  20. Ferrari, A. J., Charlson, F. J., Norman, R. E., Patten, S. B., Freedman, G., Murray, C. J. L., et al. (2013a). Burden of depressive disorders by country, sex, age, and year: Findings from the Global Burden of Disease study 2010. PLoS Medicine, 10(11), e1001547.CrossRefPubMedPubMedCentralGoogle Scholar
  21. Ferrari, A. J., Somerville, A. J., Baxter, A. J., Norman, R., Patten, S. B., Vos, T., & Whiteford, H. A. (2013b). Global variation in the prevalence and incidence of major depressive disorder: A systematic review of the epidemiological literature. Psychological Medicine, 43, 471–481.CrossRefPubMedGoogle Scholar
  22. Gawrysiak, M., Nicholas, C., & Hopko, D. R. (2009). Behavioral activation for moderately depressed university students: Randomized controlled trial. Journal of Counseling Psychology, 56, 468–475.CrossRefGoogle Scholar
  23. Greeno, C. G., Zimmerman, T., Kelly, M., Weaver, A., & Anderson, C. M. (2012). “What is Therapy?” A therapist-developed intervention to reduce missed appointments in community mental health. Social Work in Mental Health, 10(1), 1–11.CrossRefGoogle Scholar
  24. Hjerl, K., Andersen, E. W., Keiding, N., Mouridsen, H. T., Mortensen, P. B., & Jorgensen, T. (2003). Depression as a prognostic factor for breast cancer mortality. Psychosomatics, 44(1), 24–30.CrossRefPubMedGoogle Scholar
  25. Hopko, D. R., Armento, M. E. A., Robertson, S. M. C., Ryba, M., Carvalho, J. P., Johanson, L., … Lejuez, C. W. (2011). Brief behavioral activation and problem-solving therapy for depressed breast cancer patients: Randomized trial. Journal of Consulting and Clinical Psychology, 79, 834–839.CrossRefPubMedGoogle Scholar
  26. Hopko, D. R., Cannity, K. M., McIndoo, C. C., File, A. A., Ryba, M. M., Clark, C. G., & Bell, J. L. (2015). Behavior therapy for depressed breast cancer patients: Predictors of treatment outcome. Journal of Consulting and Clinical Psychology, 83, 225–231.CrossRefPubMedGoogle Scholar
  27. Hopko, D. R., Lejuez, C. W., LePage, J. P., Hopko, S. D., & McNeil, D. W. (2003). A brief behavioral activation treatment for depression: A randomized pilot trial within an inpatient psychiatric hospital. Behavior Modification, 27(4), 458–469.CrossRefPubMedGoogle Scholar
  28. Hopko, D. R., Lejuez, C. W., Ruggiero, K. J., & Eifert, G. H. (2003). Contemporary behavioral activation treatments for depression: Procedures, principles, progress. Clinical Psychology Review, 23, 699–717.CrossRefPubMedGoogle Scholar
  29. Hopko, D. R., McIndoo, C. C., & File, A. A. (2015). Depressive syndromes and medical comorbidities. In R. DeRubeis, & D. Strunk (Eds.), The Oxford handbook of mood disorders. New York: Oxford University Press.Google Scholar
  30. Hopko, D. R., Sanchez, L., Hopko, S. D., Dvir, S., & Lejuez, C. W. (2003). Behavioral activation and the prevention of suicidal behaviors in patients with borderline personality disorder. Journal of Personality Disorders, 17, 460–478.CrossRefPubMedGoogle Scholar
  31. Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12–19.CrossRefPubMedGoogle Scholar
  32. Jenkinson, C., Coulter, A., & Wright, L. (1993). Short form 36 (SF36) health survey questionnaire: Normative data for adults of working age. British Medical Journal, 306, 1434–1440CrossRefGoogle Scholar
  33. Kanter, J. W., Manos, R. C., Bowe, W. M., Baruch, D. E., Busch, A. M., & Rusch, L. C. (2010). What is behavioral activation? A review of the empirical literature. Clinical Psychology Review, 30(6), 608–620.CrossRefPubMedGoogle Scholar
  34. Katon, W., & Ciechanowski, P. (2002). Impact of major depression on chronic medical illness. Journal of Psychosomatic Research, 53, 859–863. doi: 10.1016/S0022-3999(02)00313-6.CrossRefPubMedGoogle Scholar
  35. Keller, M. B., Gelenberg, A. J., Hirschfeld, R. M. A., Rush, A. J., Thase, M. E., Kocsis, J. H., … Harrison, W.M. (1998). The treatment of chronic depression, part 2: A double-blind, randomized trial of sertraline and imipramine. Journal of Clinical Psychiatry, 59, 598–607CrossRefPubMedGoogle Scholar
  36. Kessler, R. C., Berglund, P., Demler, O., Jin, R., Koretz, D., Merikangas, K. R., … Wang, P. S. (2003). The epidemiology of major depressive disorder: Results from the National Comorbidity Survey Replication (NCS-R). Journal of the American Medical Association, 289, 3095–3105.CrossRefPubMedGoogle Scholar
  37. Krebber, A. M. H., Buffart, L. M., Kleijn, G., Riepma, I. C., de Bree, R., Leemans, C. R., … Verdonck-de Leeuw, I. M. (2014). Prevalence of depression in cancer patients: A meta-analysis of diagnostic interviews and self-report instruments. Psycho-Oncology, 23, 121–130.CrossRefPubMedGoogle Scholar
  38. Lejuez, C. W., Hopko, D. R., Aciemo, R., Daughters, S. B., & Pagoto, S. L. (2011). Ten-year revision of the brief behavioral activation treatment for depression: Revised treatment manual. Behavior Modification, 35, 111–161.CrossRefPubMedGoogle Scholar
  39. Lejuez, C. W., Hopko, D. R., & Hopko, S. D. (2001). A brief behavioral activation treatment for depression. Behavior Modification, 25, 255–286.CrossRefPubMedGoogle Scholar
  40. Lewinsohn, P. M. (1974). A behavioral approach to depression. In R. M. Friedman & M. M. Katz (Eds.), The psychology of depression: Contemporary theory and research. New York: Wiley.Google Scholar
  41. Loberiza, F. R., Rizzo, J. D., Bredeson, C. N., Antin, J. H., Horowitz, M. M., Weeks, J. C., & Lee, S. J. (2002). Association of depressive syndrome and early deaths among patients after stem-cell transplantation for malignant diseases. Journal of Clinical Oncology, 20(8), 2118–2126.CrossRefPubMedGoogle Scholar
  42. Lueboonthavatchai, P. (2007). Prevalence and psychosocial factors of anxiety and depression in breast cancer patients. Journal of the Medical Association of Thailand, 90, 2164–2174.PubMedGoogle Scholar
  43. MacPherson, L., Tull, M. T., Matusiewicz, A., Rodman, S., Strong, D. R., Kahler, C. W., … Lejuez, C. W. (2010). Randomized controlled trial of behavioral activation smoking cessation treatment for smokers with elevated depressive symptoms. Journal of Consulting and Clinical Psychology, 78, 55–71.CrossRefPubMedPubMedCentralGoogle Scholar
  44. McHorney, C. A., Ware, J. E., Lu, J. R., & Sherborne, C. D. (1994). The MOS 36-Item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Medical Care, 32, 40–66.CrossRefPubMedGoogle Scholar
  45. McHorney, C. A., Ware, J. E., & Raczek, A. E. (1993). The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Medical Care, 31, 247–263.CrossRefPubMedGoogle Scholar
  46. McIndoo, C. C., File, A. A., Preddy, T., Clark, C. G., & Hopko, D. R. (2016). Mindfulness-based therapy and behavioral activation: A randomized controlled trial with depressed college students. Behaviour Research and Therapy, 77, 118–128.CrossRefPubMedGoogle Scholar
  47. Mitchell, A. J., & Selmes, T. (2007). Why don’t patients attend their appointments? Maintaining engagement with psychiatric services. Advances in Psychiatric Treatment, 13(6), 423–434.CrossRefGoogle Scholar
  48. Moussavi, S., Chatterji, S., Verdes, E., Tandon, A., Patel, V., & Ustun, B. (2007). Depression, chronic diseases, and decrements in health: Results from the World Health Surveys. Lancet, 370(9590), 851–858.CrossRefPubMedGoogle Scholar
  49. Mulder, R. T. (2002). Personality pathology and treatment outcome in major depression: A review. American Journal of Psychiatry, 159, 359–371.CrossRefPubMedGoogle Scholar
  50. Newton-Howes, G., Tyrer, P., & Johnson, T. (2006). Personality disorder and the outcome of depression: Meta-analysis of published studies. British Journal of Psychiatry, 188, 13–20.CrossRefPubMedGoogle Scholar
  51. Newton-Howes, G., Tyrer, P., Johnson, T., Mulder, R., Kool, S., Dekker, J., & Schoevers, R. (2014). Influence of personality on the outcome of treatment in depression: Systematic review and meta-analysis. Journal of Personality Disorders, 28(4), 577–593.CrossRefPubMedGoogle Scholar
  52. Nezu, A., Ronan, G., Meadows, E., & McClure, K. (Eds.). (2000). Practitioner’s guide to empirically-based measures of depression (Vol. XIII). New York, NY: Kluwer Academic/Plenum.Google Scholar
  53. Osman, A., Kopper, B. A., Barrios, F. X., Osman, J. R., & Wade, T. (1997). The Beck Anxiety Inventory: Re-examination of factor structure and psychometric properties. Journal of Clinical Psychology, 53, 7–14.CrossRefPubMedGoogle Scholar
  54. Paton, C., Crawford, M. J., Bhatti, S. F., Patel, M. X., & Barnes, T. R. (2015). The use of psychotropic medication in patients with emotionally unstable personality disorder under the care of UK mental health services. Journal of Clinical Psychiatry, 76(4), 512–518.CrossRefGoogle Scholar
  55. Ryba, M. M., Lejuez, C. W., & Hopko, D. R. (2014). Behavioral activation for depressed breast cancer patients: The impact of therapeutic compliance and quantity of activities completed on symptom reduction. Journal of Consulting and Clinical Psychology, 82(2), 325.CrossRefPubMedGoogle Scholar
  56. Scheel, M. J., Hanson, W. E., & Razzhavaikina, T. I. (2004). The process of recommending homework in psychotherapy: A review of therapist delivery methods, client acceptability, and factors that affect compliance. Psychotherapy: Theory, Research, Practice, Training, 41(1), 38–55.CrossRefGoogle Scholar
  57. Shea, M. T., Pilkonis, P. A., Beckham, E., Collins, J. F., Elkin, I., Sotsky, S. M., & Docherty, J. P. (1990). Personality disorders and treatment outcome in the NIMH Treatment of Depression Collaborative Research Program. American Journal of Psychiatry, 147, 711–718.CrossRefPubMedGoogle Scholar
  58. Skinner, B. F. (1953). Science and human behavior. New York: Free Press.Google Scholar
  59. Skodol, A. E., Grilo, C. M., Keyes, K. M., Geier, T., Grant, B. F., & Hasin, D. F. (2011). Relationship of personality disorders to the course of major depressive disorder in a nationally representative sample. American Journal of Psychiatry, 168, 257–264.CrossRefPubMedPubMedCentralGoogle Scholar
  60. Stafford, L., Judd, F., Gibson, P., Komiti, A., Mann, G. B., & Quinn, M. (2015). Anxiety and depression symptoms in the 2 years following diagnosis of breast or gynaecologic cancer: Prevalence, course and determinants of outcome. Supportive Care in Cancer, 23(8), 2215–2224.CrossRefPubMedGoogle Scholar
  61. Tanenbaum, S. J. (2005). Evidence-based practice as mental health policy: Three controversies and a caveat. Health Affairs, 24(1), 163–173.CrossRefPubMedGoogle Scholar
  62. Vodermaier, A., Linden, W., Rnic, K., Young, S. N., Ng, A., Ditsch, N., & Olson, R. (2014). Prospective associations of depression with survival: A population-based cohort study in patients with newly diagnosed breast cancer. Breast Cancer Research and Treatment, 143, 373–384.CrossRefPubMedGoogle Scholar
  63. Ware, J. E., & Sherborne, C. D. (1992). The MOS 36-Item Short-Form Health Survey (SF-36): I. Conceptual framework and item selection. Medical Care, 30, 473–483.CrossRefPubMedGoogle Scholar
  64. Ware, J. E., Snow, K. K., Kosinski, M., & Gandek, B. (1993). SF-36 health survey manual and interpretation guide. Boston, MA: Health Institute.Google Scholar
  65. Wetherell, J. L., & Areán, P. A. (1997). Psychometric evaluation of the Beck Anxiety Inventory with older medical patients. Psychological Assessment, 9, 136–144.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  1. 1.Department of PsychologyThe University of Tennessee – KnoxvilleKnoxvilleUSA
  2. 2.KnoxvilleUSA

Personalised recommendations