Case History: Major Depressive Disorder (MDD)

Patient Information:

 Name: Sarah Thompson

 Age: 28
 Occupation: Graphic Designer
 Presenting Problem: Persistent feelings of sadness, low energy, and loss of interest in
previously enjoyed activities.

Background: Sarah is a 28-year-old woman who works as a graphic designer at a local

advertising agency. She was referred to a mental health professional by her primary care
physician due to persistent symptoms of depression.

Medical History: Sarah has no significant medical history, and her physical health is
generally good. She reports no recent illnesses or major life changes that might explain her
current emotional state.

Psychosocial History: Sarah comes from a supportive family and has a close-knit group of
friends. She has been in a stable relationship with her boyfriend for the past three years.
There is no history of trauma or abuse in her childhood. Sarah describes her upbringing as
loving and nurturing.

Presenting Concerns: Over the past six months, Sarah has noticed a significant decline in her
mood and energy levels. She often feels fatigued, struggles with concentration, and has
experienced a noticeable decrease in her ability to derive pleasure from activities she used
to enjoy, such as socializing, working on design projects, and even spending time with her
boyfriend.

Symptoms:

1. Persistent Sadness: Sarah reports feeling sad and down most of the time, even on days
when there is no apparent reason for her low mood.
2. Loss of Interest: She has lost interest in activities that once brought her joy and a sense of
accomplishment.
3. Fatigue: Sarah feels constantly tired, both physically and mentally, despite getting a full
night's sleep.
4. Changes in Appetite: She has experienced a significant decrease in appetite, leading to
unintentional weight loss.
5. Sleep Disturbance: Sarah struggles with falling asleep and frequently wakes up during the
night, leading to disrupted sleep patterns.

Diagnostic Impressions: After conducting a thorough assessment, the mental health

professional diagnosed Sarah with Major Depressive Disorder (MDD). The symptoms she
 presented with align with the criteria outlined in the Diagnostic and Statistical Manual of
Mental Disorders (DSM-5) for a major depressive episode.

Treatment Plan: Sarah's treatment plan includes a combination of psychotherapy

(cognitive-behavioral therapy) and medication (selective serotonin reuptake inhibitor).
The mental health professional will work closely with Sarah to address her thoughts,
behaviors, and emotional responses while monitoring her progress and adjusting the
treatment plan as needed.

This case history illustrates a typical presentation of Major Depressive Disorder and
highlights the importance of a comprehensive assessment and tailored treatment plan for
individuals experiencing depressive symptoms.
Questionnaire for Parents:
1. How would you describe Sarah's overall mood and demeanor over the past six months?
 Answer: Sarah has seemed consistently sad and withdrawn.
2. Have you noticed any significant changes in Sarah's behavior, such as loss of interest in
activities, social withdrawal, or changes in sleep patterns?
 Answer: Yes, she has lost interest in activities she used to enjoy, and her sleep
patterns have become irregular.
3. How is Sarah managing her daily responsibilities at work and home?
 Answer: She has been struggling at work, and it seems challenging for her to handle
routine tasks.
4. Has Sarah mentioned any physical symptoms like changes in appetite or unexplained fatigue?
 Answer: Yes, she has experienced a significant decrease in appetite and constant
fatigue.
5. Have there been any recent life events or stressors that might be contributing to Sarah's
emotional state?
 Answer: There haven't been any significant recent events or stressors in her life.

Questionnaire for Colleagues:

1. How would you describe Sarah's work performance and enthusiasm compared to the past six
months?
 Answer: Sarah's work performance has declined, and she seems less enthusiastic
about projects.
2. Have you observed any changes in Sarah's social interactions or willingness to engage with
colleagues?
 Answer: She has become more socially withdrawn and less inclined to participate in
team activities.
3. Is Sarah seeking support or discussing her challenges with colleagues?
 Answer: Sarah has not been open about her challenges or sought support from
colleagues.
4. Have you noticed any changes in Sarah's physical appearance, such as weight loss or changes
in grooming habits?
 Answer: Yes, there has been noticeable weight loss, and her grooming habits seem
less consistent.
5. How is Sarah handling stress or pressure at work?
 Answer: It appears that she is struggling to cope with stress, and even minor
pressures seem to affect her more than usual.
Cognitive-Behavioral Therapy (CBT) Treatment Plan for Sarah Thompson:

1. Assessment:
 Conduct a thorough assessment of Sarah's current symptoms, the severity of her
depression, and the impact on her daily functioning.
2. Establishing Rapport and Psychoeducation:
 Build a strong therapeutic alliance to create a safe and trusting environment.
 Provide psychoeducation about Major Depressive Disorder (MDD), explaining the
nature of cognitive-behavioral therapy and its effectiveness in treating depression.
3. Goal Setting:
 Collaboratively set realistic and achievable short-term and long-term treatment
goals with Sarah.
 Goals may include improving mood, increasing daily functioning, and regaining
interest in previously enjoyable activities.
4. Identifying Negative Thoughts:
 Help Sarah recognize and identify negative thought patterns contributing to her
depression.
 Use thought records to track and challenge automatic negative thoughts.
5. Cognitive Restructuring:
 Assist Sarah in challenging and reframing negative thoughts.
 Teach her to identify cognitive distortions and replace them with more balanced
and positive thoughts.
6. Behavioral Activation:
 Develop a daily schedule to increase Sarah's engagement in activities she used to
enjoy.
 Gradually reintroduce pleasurable and meaningful activities to combat social
withdrawal and isolation.
7. Problem-Solving Skills:
 Teach Sarah effective problem-solving skills to address stressors and challenges in
her life.
 Encourage her to break down problems into manageable steps and generate
potential solutions.
8. Relaxation and Stress Management:
 Introduce relaxation techniques, such as deep breathing and progressive muscle
relaxation, to help Sarah manage stress and reduce physical symptoms of anxiety.
9. Homework Assignments:
 Assign homework exercises to reinforce skills learned in therapy.
  This may include completing thought records, engaging in scheduled activities, and
practicing relaxation techniques.
10. Monitoring Progress:
 Regularly assess Sarah's progress towards treatment goals.
 Adjust the treatment plan as needed based on her feedback and changing
circumstances.
11. Collaboration with Medication Management (if applicable):
 If Sarah is prescribed medication, collaborate with the prescribing psychiatrist to
ensure a holistic approach to treatment.
12. Termination and Relapse Prevention:
 Prepare for the conclusion of therapy by discussing relapse prevention strategies
and identifying potential signs of regression.
 Provide Sarah with tools to continue practicing learned skills independently.

Throughout the CBT treatment process, it's essential to maintain open communication,
validate Sarah's experiences, and adapt the therapeutic approach to her individual needs.
Regularly reassess and modify the treatment plan to address any emerging issues or
changes in her condition. Additionally, involve Sarah's support system, including family and
friends, to enhance the overall effectiveness of the treatment.

How would you describe your overall mood in the past six months?

 Answer: I have felt consistently sad and down most of the time.

2. Have you noticed any significant changes in your interest or pleasure in activities
that you used to enjoy?

 Answer: Yes, I've lost interest in activities that once brought me joy.

3. How has your energy level been recently?

 Answer: I've been feeling constantly tired, both physically and mentally.

4. Have you experienced any changes in your appetite or weight?

 Answer: Yes, I've had a significant decrease in appetite, leading to unintentional weight
loss.

5. How would you describe your sleep patterns?

 Answer: I've been struggling with falling asleep and frequently wake up during the night.

6. Have you faced difficulties concentrating or making decisions?

 Answer: Yes, it's been challenging to focus and make decisions.

7. Do you often feel a sense of worthlessness or excessive guilt?

 Answer: I have experienced feelings of worthlessness and guilt.

8. Have you had thoughts of death or suicide?

 Answer: I have had fleeting thoughts of death but no specific plans for suicide.

9. How has your performance at work been affected, if at all?

 Answer: My work performance has declined, and routine tasks feel challenging.

10. Have you shared your feelings with friends, family, or colleagues? - Answer: No, I
have not been open about my challenges or sought support.

11. Have there been any recent life events or stressors that you believe may be
contributing to your current emotional state? - Answer: No, there haven't been any
significant recent events or stressors.

12. How would you describe your social interactions with friends and colleagues
recently? - Answer: I've become more socially withdrawn and less inclined to participate
in activities.

13. Are there any physical symptoms you have noticed, such as changes in grooming
habits or appearance? - Answer: Yes, I have experienced noticeable weight loss, and my
grooming habits have become less consistent.