After the I-SOH procedure is finished the CBASP patient`s manual for patients is distributed and the patient is prepared for the SA/IDE phase of treatment that starts in the subsequent session. In the period until the beginning of the first therapy session of the SA/IDE phase of treatment the TH is formulated in the absence of the patient, especially in early-onset chronically depressed patients with a history of family violence or childhood trauma (McCullough, 2006: page 130; McCullough, 2012b). For this purpose, the dominant interpersonal-emotional theme domain is defined by the therapist. The interpersonalemotional theme reflects the early learning history of the patient and is derived from the CTCs. CBASP assumes four transference areas of interaction in early-onset chronically depressed patients that, from the perspective of developmental psychology, play an important role in the patient's relationship with significant others. His theoretical considerations concerning the transference hypothesis refer to the concept of "tacit knowledge"(Polanyi, 1966) and the idea of "reasoning based on implicit causal theories" (Nisbett and Wilson, 1977). Specifically, McCullough (2006) describes working with the construct of transference as an exercise in "focused attention." The TH differs from Freud's concept of transference since it can be actively acted out in session with the therapist and then processed within the IDE. From a learning theory perspective the transference hypothesis includes the hypothesized core content of the patient`s in-session interpersonal fear that most likely reflects the patient's expectancy of the therapist's reactions toward the individual (McCullough et al., 2010). The four transference areas of interpersonal dysfunction in that "hot spots" occur are:

The TH then becomes central in the IDE because it defines the starting point of IDE or interpersonal "hot spot". Through the controlled use of the IDE in "hot spot" situations it becomes possible for the patient during the course of the treatment, to clearly distinguish the therapeutic relationship from the relationships the patient experienced with his SOs (Schoepf & Neudeck, 2011).

## **2.8. Therapeutic goals of the SA/IDE phase of treatment**

168 Psychiatric Disorders – New Frontiers in Affective Disorders

dysfunction in that "hot spots" occur are:

emotional punishment (mistake and failure area).

need area).

area).

(Schoepf & Neudeck, 2011).

**formulation of the TH**

**2.7. Identification of the dominant interpersonal-emotional theme domain and**

After the I-SOH procedure is finished the CBASP patient`s manual for patients is distributed and the patient is prepared for the SA/IDE phase of treatment that starts in the subsequent session. In the period until the beginning of the first therapy session of the SA/IDE phase of treatment the TH is formulated in the absence of the patient, especially in early-onset chronically depressed patients with a history of family violence or childhood trauma (McCullough, 2006: page 130; McCullough, 2012b). For this purpose, the dominant interpersonal-emotional theme domain is defined by the therapist. The interpersonalemotional theme reflects the early learning history of the patient and is derived from the CTCs. CBASP assumes four transference areas of interaction in early-onset chronically depressed patients that, from the perspective of developmental psychology, play an important role in the patient's relationship with significant others. His theoretical considerations concerning the transference hypothesis refer to the concept of "tacit knowledge"(Polanyi, 1966) and the idea of "reasoning based on implicit causal theories" (Nisbett and Wilson, 1977). Specifically, McCullough (2006) describes working with the construct of transference as an exercise in "focused attention." The TH differs from Freud's concept of transference since it can be actively acted out in session with the therapist and then processed within the IDE. From a learning theory perspective the transference hypothesis includes the hypothesized core content of the patient`s in-session interpersonal fear that most likely reflects the patient's expectancy of the therapist's reactions toward the individual (McCullough et al., 2010). The four transference areas of interpersonal

1. In-session moments of intimacy (either felt by the patient or the therapist) that evoke in the patient (Pavlovian) fear of being physically or emotionally abused (intimacy area). 2. In-session events in which the patient discloses emotional needs toward the therapist that evoke in the patient (Pavlovian) fear of being ridiculed or censored (disclosure of

3. In-session events during which the patient makes mistakes towards the therapist (i.e. not doing his or her homework or being unable to solve problems presented during therapy sessions) that evoke in the patient (Pavlovian) fear of severe physical or

4. In-session events in which the patient expresses negative affects towards the therapist that evoke in the patient (Pavlovian) fear of punishment (expression of negative affect

The TH then becomes central in the IDE because it defines the starting point of IDE or interpersonal "hot spot". Through the controlled use of the IDE in "hot spot" situations it becomes possible for the patient during the course of the treatment, to clearly distinguish the therapeutic relationship from the relationships the patient experienced with his SOs The SA/IDE phase of treatment starts with introducing the SA. The major therapeutic goals of this phase are:

## **2.9. Achieving in-session two-way circular functioning in the SA/IDE phase of treatment**

The core content of the patient's interpersonal fear is counter-conditioned in the SA/IDE phase of treatment due to IDE work. The technique of IDE was formerly described by our group as a bottom-up technique that is assumed to be the major CBASP technique of (explicit) in-session acquisition learning (Schoepf et al. 2007; Schoepf & McCullough, 2009; Schoepf et al., 2011; Schoepf & Neudeck, 2011). In general, bottom-up techniques like the IDE are designed to lead the patient from the concrete therapeutic situation to interpersonal situations which resemble the therapeutic situation (Neudeck et al., 2012).

Table 1 represents the learning context and the different phases of the IDE (adapted from Schoepf et al., 2011; Schoepf & Neudeck, 2011).

The starting point of an IDE is defined by the presence of an in-session "hot-spot" event/moment. The core content of the patient's interpersonal fear is activated any time the dyad encounters an in-session relationship issue signaling that a relational "hot spot" is encountered (McCullough et al., 2010). Three different forms of the IDE are applied in Bonn out-patients:

## **Learning context**

The therapist directs the focus of attention to the just happened "hot spot"in-session event/moment and writes the patient's "hot spot" behaviour on the flip-chart. Then the three phases of the IDE are consecutively carried out.

CBASP with Intensified Significant Other History Exercise for Chronic Major Depression with Antecedent Dysthymic Disorder in Outpatient Treatment: Rationale, Assessment and Effects on the Hypothesized… 171

SOs. It is recommended to use the three various forms of the IDE in relation to the progress of therapy throughout the SA/IDE phase of treatment, table 2 (Schoepf et al., 2011; Schoepf

When patients show sufficient symptom reduction in the pre-SA phase of treatment and fast benefit of SA-work during the SA/IDE phase of treatment the cognitive form of IDE has approved itself to specifically reduce interpersonal distress by helping the patient to cognitively discriminate the therapist's interactional behaviour in "hot spot" in-session events from the interactional behaviour of hurtful SOs in similar past encounters

When patients show sufficient symptom reduction in the pre-SA phase of treatment and delayed benefit of SA work during the SA/IDE phase of treatment the emotional form of IDE has approved itself to modify closed perceptual trauma domains that perpetuate the cognitive-emotional dilemma of the patient (Schoepf et al., 2011; Schoepf & Neudeck, 2011).

When patients show little symptom reduction in the pre-SA phase of treatment and do not benefit from SA work during the SA/IDE phase of treatment a modified form of the IDE (double-counter conditioning) to modify strikingly maladaptive in-session behavior has approved itself to be successful (Schoepf et al., 2011). An example of the modified form of

**Table 2.** Early benefit, delayed benefit and no benefit in CBASP psychotherapy as orientation for the

The goal of measuring if interpersonal safety is achieved in the domain in which the origin of the patient's interpersonal fear is established is accomplished with the use of the Personal Questionnaire (PQ). The PQ represents a patient-self-report methodology comprised of paired comparisons using three cards that are each compared to one another (McCullough, 2006). The three cards contain the same content of the TH used in the various forms of IDE work, but formulated with (1) a baseline illness-level indicating no perceived change observed between the therapist and malevolent SOs, (2) an improvement-level indicating some perceived change observed between the therapist and malevolent SOs, and a (3) recovery level indicating clear perceived change observed between the therapist and malevolent SOs. The scoring of specific increases in expected in-session emotional safety with respect to CBASP`s TH construct are done by the patient himself and blind to the therapist before the beginning of every session and in the absence of the therapist. The

**First option** – when a patient shows early benefit in SA work

**Second option** – when a patient shows delayed benefit in SA work

**Third option** – when a patient does not show benefit in SA work

use of the three various forms of the IDE in the SA/IDE phase of treatment.

**2.10. Evaluation of the safety-signal impact**

IDE is published elsewhere (Schoepf et al. 2011; Schoepf & Neudeck 2011).

& Neudeck, 2011; table 2).

(McCullough et al., 2011).

### **Negative phase**

The patient is gently asked to recall a typical past social interaction with one or two of his maltreating "Significant Other's" in a similar situation. In the cognitive form the patient has to describe the behavioral consequences on himself caused by the behaviour of his significant other. In particular bad thoughts are evoked through tacit knowledge. In the emotional form the patient is additionally gently asked to re-experience the associated hurtful (refractory) emotions in the presence of the therapist. In particular negative feelings like fear, pain and sadness are evoked. Counter-conditioning according to the principle of reciprocal inhibition takes place by the benevolent therapist's reaction (Schoepf et al., 2007; Schoepf et al., 2011; Schoepf & Neudeck, 2011).

## **Positive phase**

After the intensity of negative thoughts and emotions is decreased the patient is gently asked to describe his perception of the therapist's reactions. Furthermore, he has to characterize the feelings that have been evoked by the current incident with the therapist. He is then asked to compare the therapist's behaviour to the recalled behaviour (and the corresponding emotion in the emotional form of IDE) of his significant others in a similar situation. The felt distress of the patient usually decreases at this moment of the exercise.

### **Healing phase**

Sensitive to the timing and the magnitude of the felt decrease of distress in the healing phase of the IDE, the patient is encouraged by the therapist to identify the contrast between the therapist's behaviour and the significant other's' behaviour. "Automatically" there results a felt increase of the potency of the therapist to specifically reduce interpersonal distress during the experienced "hot spot" situation and a new interpersonal reality of the therapist-patient relationship comes into being meaningful to the patient.

**Table 1.** Learning context, negative phase, positive phase and healing phase of the IDE (adapted from Schoepf & Neudeck, 2011).

3. In the double counter conditioning form of the IDE interpersonal fear is first counterconditioned with the goal of modifying strikingly maladaptive behavioral patterns. Then the cognitive or the emotional form of the IDE is coupled contrasting the reactive behaviour of the therapist against the maladaptive behaviour of one or two SOs (adapted from Schoepf et al., 2011; Schoepf & Neudeck, 2011).

### *2.9.1. The three options to use the various forms of the IDE*

The IDE is used in it various forms to address, train, and thereby "repair" developmental trauma memories and associated symptoms arising from negative experiences with abusive

SOs. It is recommended to use the three various forms of the IDE in relation to the progress of therapy throughout the SA/IDE phase of treatment, table 2 (Schoepf et al., 2011; Schoepf & Neudeck, 2011; table 2).

**First option** – when a patient shows early benefit in SA work

170 Psychiatric Disorders – New Frontiers in Affective Disorders

three phases of the IDE are consecutively carried out.

Schoepf et al., 2011; Schoepf & Neudeck, 2011).

The therapist directs the focus of attention to the just happened "hot spot"in-session event/moment and writes the patient's "hot spot" behaviour on the flip-chart. Then the

The patient is gently asked to recall a typical past social interaction with one or two of his maltreating "Significant Other's" in a similar situation. In the cognitive form the patient has to describe the behavioral consequences on himself caused by the behaviour of his significant other. In particular bad thoughts are evoked through tacit knowledge. In the emotional form the patient is additionally gently asked to re-experience the associated hurtful (refractory) emotions in the presence of the therapist. In particular negative feelings like fear, pain and sadness are evoked. Counter-conditioning according to the principle of reciprocal inhibition takes place by the benevolent therapist's reaction (Schoepf et al., 2007;

After the intensity of negative thoughts and emotions is decreased the patient is gently asked to describe his perception of the therapist's reactions. Furthermore, he has to characterize the feelings that have been evoked by the current incident with the therapist. He is then asked to compare the therapist's behaviour to the recalled behaviour (and the corresponding emotion in the emotional form of IDE) of his significant others in a similar situation. The felt distress of the patient usually decreases at this moment of the exercise.

Sensitive to the timing and the magnitude of the felt decrease of distress in the healing phase of the IDE, the patient is encouraged by the therapist to identify the contrast between the therapist's behaviour and the significant other's' behaviour. "Automatically" there results a felt increase of the potency of the therapist to specifically reduce interpersonal distress during the experienced "hot spot" situation and a new interpersonal reality of the

**Table 1.** Learning context, negative phase, positive phase and healing phase of the IDE (adapted from

3. In the double counter conditioning form of the IDE interpersonal fear is first counterconditioned with the goal of modifying strikingly maladaptive behavioral patterns. Then the cognitive or the emotional form of the IDE is coupled contrasting the reactive behaviour of the therapist against the maladaptive behaviour of one or two SOs

The IDE is used in it various forms to address, train, and thereby "repair" developmental trauma memories and associated symptoms arising from negative experiences with abusive

therapist-patient relationship comes into being meaningful to the patient.

(adapted from Schoepf et al., 2011; Schoepf & Neudeck, 2011).

*2.9.1. The three options to use the various forms of the IDE*

**Learning context**

**Negative phase**

**Positive phase**

**Healing phase**

Schoepf & Neudeck, 2011).

When patients show sufficient symptom reduction in the pre-SA phase of treatment and fast benefit of SA-work during the SA/IDE phase of treatment the cognitive form of IDE has approved itself to specifically reduce interpersonal distress by helping the patient to cognitively discriminate the therapist's interactional behaviour in "hot spot" in-session events from the interactional behaviour of hurtful SOs in similar past encounters (McCullough et al., 2011).

**Second option** – when a patient shows delayed benefit in SA work

When patients show sufficient symptom reduction in the pre-SA phase of treatment and delayed benefit of SA work during the SA/IDE phase of treatment the emotional form of IDE has approved itself to modify closed perceptual trauma domains that perpetuate the cognitive-emotional dilemma of the patient (Schoepf et al., 2011; Schoepf & Neudeck, 2011).

**Third option** – when a patient does not show benefit in SA work

When patients show little symptom reduction in the pre-SA phase of treatment and do not benefit from SA work during the SA/IDE phase of treatment a modified form of the IDE (double-counter conditioning) to modify strikingly maladaptive in-session behavior has approved itself to be successful (Schoepf et al., 2011). An example of the modified form of IDE is published elsewhere (Schoepf et al. 2011; Schoepf & Neudeck 2011).

**Table 2.** Early benefit, delayed benefit and no benefit in CBASP psychotherapy as orientation for the use of the three various forms of the IDE in the SA/IDE phase of treatment.

## **2.10. Evaluation of the safety-signal impact**

The goal of measuring if interpersonal safety is achieved in the domain in which the origin of the patient's interpersonal fear is established is accomplished with the use of the Personal Questionnaire (PQ). The PQ represents a patient-self-report methodology comprised of paired comparisons using three cards that are each compared to one another (McCullough, 2006). The three cards contain the same content of the TH used in the various forms of IDE work, but formulated with (1) a baseline illness-level indicating no perceived change observed between the therapist and malevolent SOs, (2) an improvement-level indicating some perceived change observed between the therapist and malevolent SOs, and a (3) recovery level indicating clear perceived change observed between the therapist and malevolent SOs. The scoring of specific increases in expected in-session emotional safety with respect to CBASP`s TH construct are done by the patient himself and blind to the therapist before the beginning of every session and in the absence of the therapist. The

patient is instructed not to tell the therapist the scoring results. The therapist obtains after 32-35 therapy sessions a feedback about the scoring of the results. The safety signal impact of the therapist on the hypothesized core content of the patient's in-session interpersonal fear is highest at a scoring of 1 and lowest at a scoring of 4. The procedure is clearly outlined by McCullough (McCullough, 2006, pp 163-167). The self-report questionnaire represents a cost-effective option to systematically, reliably, and validly evaluate the safety signal impact of the therapist on the patient because it is inexpensive in terms of professional time needed for administration, and does not require special training for administration.

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**Identification of key causal relations between the past and the presence (flip-**

**Preparation theorem: The impact of my father on me/my everyday relationships**

I am convinced that something bad will happen if I do not follow the rules of

First sub-step (underlying compensatory rule): Avoiding closeness to my father

Third sub-step (CTC): I am afraid of authoritarian dominant men - if I come closer

I am afraid of dominant-hostile women, i.e. if I come closer to women then I will be

I am afraid of attractive hysterical women, i.e. if I come closer to attractive women I

**TASK 4: Translation of tacit knowledge into explicit causal knowledge (flip-chart)**

Second sub-step (up-coming event when acting against the rule): Overt

**CTCs of other listed SOs, i.e. after the patient has formulated one CTC for each SO**  Mother (exerted a negative formative influence with high impact)

First girlfriend (exerted a negative formative influence with traumatically

Second girl-friend (exerted a positive formative influence with low impact)

**Determination of the dominant interpersonal theme domain - ascertained in the absence**

**Transference hypothesis, i.e. the associated in-session transference prediction related to**

Travelling companion (exerted a positive formative influence with low impact) If I interact with a calm and composed non-authoritarian man who has no

The patient does not know how to relate emotionally with humans. He can not

If I (patient) come emotionally close to Dr. Schoepf, I am sure that he will point on my deficits and something hurtful will happen that is lying out of my control and that will make me feel lonely (here formulated as a baseline illness sentence).

If I keep distance then I can trust a woman in some way.

prejudice against my background I feel happy**.**

**chart)**

**is that….**

authorities (3).

punishment.

protected me to get hurt.

punished irrationally.

will become existentially hurt.

trust in relations (intimacy area)

processed impact)

**of the patient**

**Table 3.**

**the therapist for IDE work**

I do not disclose what I feel (1\*). I do not express my own opinion (2\*).

I avoid conflicts by running away (3\*) I submit myself authorities (4\*).

to a authoritarian man then I freeze -

## **2.11. Assessment of the I-SOH procedure up-to the TH**

**Table 3.**

**TASK 1: Preparing, see text**

**Example of first listed SO**

school 4\*.

**SO`s.**

**TASK 2: Focussing, see text (flip-chart)**

**behavioral terms (using the flip-chart)**

patient is instructed not to tell the therapist the scoring results. The therapist obtains after 32-35 therapy sessions a feedback about the scoring of the results. The safety signal impact of the therapist on the hypothesized core content of the patient's in-session interpersonal fear is highest at a scoring of 1 and lowest at a scoring of 4. The procedure is clearly outlined by McCullough (McCullough, 2006, pp 163-167). The self-report questionnaire represents a cost-effective option to systematically, reliably, and validly evaluate the safety signal impact of the therapist on the patient because it is inexpensive in terms of professional time needed

List of SOs reported by the P: Father, mother, first girl friend, later girl friend, and

**\*: T teaches P to respectively describe one typical key interpersonal encounter in**

quick-tempered, i.e. he often yelled and demanded obedience without notice1\*. He punished verbally if someone did not follow his rules2\*. In addition he always reacted angrily if someone disclosed an emotional need. He himself had great difficulties in showing any of his feelings. He reacted extremely angry if I had a different opinion 3\*. On the other hand he helped his friends and he was proud of his son. Confidence on each other is his highest inner worth until today. Another attitude of him is, that you have to work harder then the rest to be respected. He sent me to an off-shore oil platform after

**Second sub-step: Elicitation of self-referential interpretations and identification**

I (always) froze when I saw the anger in his face before he yelled at me (3\*).

**of key causal relations between the past and the presence Eliciting self-referential interpretations (flip-chart)**  I (always) felt defeated when he yelled at me (1\*.)

I (always) thought that I am a looser (2\*).

I (always) felt so lonely (4\*).

Report of the patient. My father was frequently absent. His manner was

his travelling companion. **TASK 3: Reconstruction of closed perceptual systems in antecedent-consequent way (flip-chart). To note, the third and the fourth tasks are carried out successively for all**

Father (exerted a negative formative influence with high impact) **First sub-step: Creation of awareness for key past encounters**

for administration, and does not require special training for administration.

**2.11. Assessment of the I-SOH procedure up-to the TH**

## **3. Third part**

## **3.1. Treatment trajectories of early-onset chronically depressed outpatients**

Typical treatment trajectories over 32 sessions in 48 weeks (figures 1-5) of 5 younger to middle age adult chronic MDD outpatients with antecedent dysthymic disorder that were treated according to the modified protocol are represented without further systematic statistical evaluation as the studies are still running.

CBASP with Intensified Significant Other History Exercise for Chronic Major Depression with Antecedent Dysthymic Disorder in Outpatient Treatment: Rationale, Assessment and Effects on the Hypothesized… 175

**Figure 2.** Female patient in middle age under 50 years. The pre-SA phase of treatment was interrupted with no ones fault between the fifth until the 12th week. Full syndromal remission is reached at week 13 (BDI-II</= 10). The highest possible safety-signal impact of the therapist is reached at the start of the SA/IDE phase of

**Figure 3.** Female patient under 40 years. The highest possible safety-signal impact of the therapist is reached at week 6 (arrow) and maintained until the end of treatment. Full syndromal remission at week

17 (BDI-II </= 10). PD = Panic Disorder..

treatment (week 17, arrow) and maintained until the end of treatment. Axis labels as in figure 1.

The SCID I and II were used for diagnosis. Early life trauma and live events were assessed by using the Childhood Trauma Questionnaire and the Early Trauma Inventory. The external ratings (HAMD or MADRAS as primary-outcome measures) were done blind to the therapy method; the PQ ratings were done blind to the therapist. All therapy sessions were videotaped. Concerning feasibility, all patients completed the treatment. The adapted I-SOH procedure protocol proved to be feasible and there were no major difficulties with side effects of potential symptom aggravations, affective overflow or potential retraumatization.

**Figure 1.** Female patient under 30 years. X-axis: Prä-S = pre-screening. 0 = just before start of treatment. 1st Y axis (left): Full syndromal remission according to self-ratings at week 36 (BDI-II </= 10). 2nd Y axis (right): The highest possible safety-signal impact of the therapist on the hypothesized core content of the patient's in-session interpersonal fear at the start of the SA/IDE phase of treatment (week 6, arrow) maintained until the end of treatment.

CBASP with Intensified Significant Other History Exercise for Chronic Major Depression with Antecedent Dysthymic Disorder in Outpatient Treatment: Rationale, Assessment and Effects on the Hypothesized… 175

174 Psychiatric Disorders – New Frontiers in Affective Disorders

statistical evaluation as the studies are still running.

**3.1. Treatment trajectories of early-onset chronically depressed outpatients**

Typical treatment trajectories over 32 sessions in 48 weeks (figures 1-5) of 5 younger to middle age adult chronic MDD outpatients with antecedent dysthymic disorder that were treated according to the modified protocol are represented without further systematic

The SCID I and II were used for diagnosis. Early life trauma and live events were assessed by using the Childhood Trauma Questionnaire and the Early Trauma Inventory. The external ratings (HAMD or MADRAS as primary-outcome measures) were done blind to the therapy method; the PQ ratings were done blind to the therapist. All therapy sessions were videotaped. Concerning feasibility, all patients completed the treatment. The adapted I-SOH procedure protocol proved to be feasible and there were no major difficulties with side effects of potential symptom aggravations, affective overflow or potential

**Figure 1.** Female patient under 30 years. X-axis: Prä-S = pre-screening. 0 = just before start of treatment. 1st Y axis (left): Full syndromal remission according to self-ratings at week 36 (BDI-II </= 10). 2nd Y axis (right): The highest possible safety-signal impact of the therapist on the hypothesized core content of the patient's in-session interpersonal fear at the start of the SA/IDE phase of treatment (week 6, arrow)

**3. Third part**

retraumatization.

maintained until the end of treatment.

**Figure 2.** Female patient in middle age under 50 years. The pre-SA phase of treatment was interrupted with no ones fault between the fifth until the 12th week. Full syndromal remission is reached at week 13 (BDI-II</= 10). The highest possible safety-signal impact of the therapist is reached at the start of the SA/IDE phase of treatment (week 17, arrow) and maintained until the end of treatment. Axis labels as in figure 1.

**Figure 3.** Female patient under 40 years. The highest possible safety-signal impact of the therapist is reached at week 6 (arrow) and maintained until the end of treatment. Full syndromal remission at week 17 (BDI-II </= 10). PD = Panic Disorder..

CBASP with Intensified Significant Other History Exercise for Chronic Major Depression with Antecedent Dysthymic Disorder in Outpatient Treatment: Rationale, Assessment and Effects on the Hypothesized… 177

The treatment trajectories clearly show - without any further necessary explanation – a positive short-term effect of the I-SOH procedure on the hypothesized core content of the patient's in-session interpersonal fear in relation to symptom reduction. In addition, over the period of the treatment a state of full syndromal remission was achieved in all patients. In addition, the treatment trajectories demonstrate that under out-patient study conditions the adapted study protocol works best with a dosage of up-to 35 sessions. The first three figures represent treatment trajectories of CBASP only treated patients which were highly motivated for the method. Figures four and five represent trajectories of CBASP add-on treatment to non-response to previous 8-week SSRI treatment. The SSRI medication was further prescribed and controlled during the course of therapy. Both patients had no preference for one of the two methods but were highly motivated to be included into the

Around 3.7 million children are assessed for childhood maltreatment each year alone in the United States. Converging data support adverse effects of early life stress on morphologic development of corticostriatal-limbic structures (Edmiston EE, et al., 2011). Clinically, there is ample evidence that a persisting state of depressed emotion and interpersonal anxiety in chronic MDD with antecedent dysthymic disorder cannot be shacked easily by any kind of antidepressant medication or biophysical intervention; neither in a dozen of disorder specific therapy sessions that are embedded in a conceptually framework that has just started to point in public to the exposure aspects of its major techniques of change (Neudeck et al., 2012) nor by simply changing the situational thoughts and/or problem solving capabilities (Schoepf et al., 2007; Kocsis et al., 2009; Schoepf & Neudeck, 2011; Schoepf et al.;

Animals and human beings view the world causally; exactly the same early-onset chronically depressed patients. However, the patient's bottoms-up and top-down driven processes largely operate in the absence of cognitive awareness as stimulus learning of stressful encounters with their SO`s in the past dominates over social adaptive outcomeeffect learning in the presence. Based on my clinical experiences and the treatment effects of my self treated patients that are represented in this chapter article in the form of simple treatment trajectories without further statistical evaluation, I assume that the successful mastering of the I-SOH procedure in the presented exposure based form - that primarily focuses on activating and restructuring past helplessness memories with SOs in the early phase of treatment - represents a key stepping stone in CBASP out-patient treatment that turns the page from the patient's idiosyncratic functioning at the beginning of therapy to circular formal-operational functioning and long term success in the later therapy process. McCullough would say: The I-SOH procedure in the presented form thrusts the therapist into the core perceptual-emotional arena involving the patient and his SOs. I have to add, that at the end of the pre-SA phase of treatment, the technique loosens these emotional connections, replacing them with a salubrious new connection to the therapist. Additionally, every SA a patient brought to therapy in the second treatment phase played in the dominant

study.

**3.2. Challenges and future directions**

2011; McCullough, 2012).

**Figure 4.** Male patient with age under 50 years. Start with SSRI treatment alone. CBASP added after week 8 because of non-response (Reduction MADRAS sum score < 20%). Red vertical line signifies the start of CBASP. The highest safety-signal impact of the therapist is reached at week 16 (arrow) and maintained until the end of treatment. Full syndromal remission at week 18 (BDI-II </=10).

**Figure 5.** Female patient with age under 40 years. Start with SSRI treatment alone. CBASP added after week 8 because of non-response (Reduction MADRAS sum score < 20%). Red vertical line signifies the start of CBASP. The time period of the I-SOH procedure is short. Correspondingly, the safety-signal impact of the therapist is low (arrow) at the beginning of the SA/IDE phase. The highest safety-signal impact of the therapist is reached at week 35 on a stable niveau. Full syndromal remission is achieved at week 14 (BDI-II </=10).

The treatment trajectories clearly show - without any further necessary explanation – a positive short-term effect of the I-SOH procedure on the hypothesized core content of the patient's in-session interpersonal fear in relation to symptom reduction. In addition, over the period of the treatment a state of full syndromal remission was achieved in all patients. In addition, the treatment trajectories demonstrate that under out-patient study conditions the adapted study protocol works best with a dosage of up-to 35 sessions. The first three figures represent treatment trajectories of CBASP only treated patients which were highly motivated for the method. Figures four and five represent trajectories of CBASP add-on treatment to non-response to previous 8-week SSRI treatment. The SSRI medication was further prescribed and controlled during the course of therapy. Both patients had no preference for one of the two methods but were highly motivated to be included into the study.

## **3.2. Challenges and future directions**

176 Psychiatric Disorders – New Frontiers in Affective Disorders

**Figure 4.** Male patient with age under 50 years. Start with SSRI treatment alone. CBASP added after week 8 because of non-response (Reduction MADRAS sum score < 20%). Red vertical line signifies the start of CBASP. The highest safety-signal impact of the therapist is reached at week 16 (arrow) and maintained until the end of treatment. Full syndromal remission at week 18 (BDI-II </=10).

**Figure 5.** Female patient with age under 40 years. Start with SSRI treatment alone. CBASP added after week 8 because of non-response (Reduction MADRAS sum score < 20%). Red vertical line signifies the start of CBASP. The time period of the I-SOH procedure is short. Correspondingly, the safety-signal impact of the therapist is low (arrow) at the beginning of the SA/IDE phase. The highest safety-signal impact of the therapist is reached at week 35 on a stable niveau. Full syndromal remission is achieved at

week 14 (BDI-II </=10).

Around 3.7 million children are assessed for childhood maltreatment each year alone in the United States. Converging data support adverse effects of early life stress on morphologic development of corticostriatal-limbic structures (Edmiston EE, et al., 2011). Clinically, there is ample evidence that a persisting state of depressed emotion and interpersonal anxiety in chronic MDD with antecedent dysthymic disorder cannot be shacked easily by any kind of antidepressant medication or biophysical intervention; neither in a dozen of disorder specific therapy sessions that are embedded in a conceptually framework that has just started to point in public to the exposure aspects of its major techniques of change (Neudeck et al., 2012) nor by simply changing the situational thoughts and/or problem solving capabilities (Schoepf et al., 2007; Kocsis et al., 2009; Schoepf & Neudeck, 2011; Schoepf et al.; 2011; McCullough, 2012).

Animals and human beings view the world causally; exactly the same early-onset chronically depressed patients. However, the patient's bottoms-up and top-down driven processes largely operate in the absence of cognitive awareness as stimulus learning of stressful encounters with their SO`s in the past dominates over social adaptive outcomeeffect learning in the presence. Based on my clinical experiences and the treatment effects of my self treated patients that are represented in this chapter article in the form of simple treatment trajectories without further statistical evaluation, I assume that the successful mastering of the I-SOH procedure in the presented exposure based form - that primarily focuses on activating and restructuring past helplessness memories with SOs in the early phase of treatment - represents a key stepping stone in CBASP out-patient treatment that turns the page from the patient's idiosyncratic functioning at the beginning of therapy to circular formal-operational functioning and long term success in the later therapy process. McCullough would say: The I-SOH procedure in the presented form thrusts the therapist into the core perceptual-emotional arena involving the patient and his SOs. I have to add, that at the end of the pre-SA phase of treatment, the technique loosens these emotional connections, replacing them with a salubrious new connection to the therapist. Additionally, every SA a patient brought to therapy in the second treatment phase played in the dominant

interpersonal theme domain, in which recurrent experiences of helplessness were earlier made. This is motivation to change and approaching behaviour from the patient's side and challenges the therapist.

CBASP with Intensified Significant Other History Exercise for Chronic Major Depression with Antecedent Dysthymic Disorder in Outpatient Treatment: Rationale, Assessment and Effects on the Hypothesized… 179

modified protocol have been discussed with Jim McCullough, Kim Penberthy and Henrik Walter since 2006 and later Knut Schnell. The fifth colleague of this core working group is Peter Neudeck who joined the Bonn CBASP Centre of Competence 2009. Peter is an excellent exposure therapist whom I supervise in CBASP until today as I have been supervised by Jim McCullough once (2007-2008). All of us strongly emphasize the aspects of modern learning theory in CBASP as CBASP therapists and all of us feel the need to further dismantle CBASP`s interventions for better treatment. Hopefully, this chapter has persuasively articulated a constructive use of the modified out-patient protocol for chronic MDD patients with antecedent dysthymic disorder. It is again my concern to bring into consciousness that disciplined personal involvement CBASP techniques that are both reliable and valid can only be learned through intensive training. This is the reason why, to this day, even McCullough himself conducts training for selected learning therapists, using video-supervised case studies. As CBASP-providers, CBASP-supervisors and CBASPtherapists, these therapists are responsible for the distribution and quality control of CBASP in their respective countries (Schoepf & Neudeck, 2011). Further information is available at www.cbasp.org. Like the last year, when I wrote the 2011 CBASP overview chapter, I found myself again fueled by hope that this articulation can be of assistance to other psychiatrists and psychotherapists, as well to other mental health practioners who are interested in working with chronically depressed patients in a constructive way to help their patients to get out of their prison of negative thoughts and outcome expectations, as well as to change

I am grateful for the collaboration of James P McCullough JR, Commonwealth University of Virginia; Jennifer Kim Penberthy, University of Virginia Health System; Wolfgang Maier, Department of Psychiatry, University of Bonn; Henrik Walter, now Department of Psychiatry, University of Berlin; Knut Schnell, now Department of Psychiatry, University of Heidelberg; and Elisabeth Schramm, Department of Psychiatry, University of Freiburg. I also thank CBASP-network and the whole Bonn CBASP-1 and CBASP-2 study team for their

American Psychiatric Association: Diagnostic and statistical manual of mental disorders, 4th edition, text revision (2000). Washington DC, American Psychiatric Association. Bandura A (1969). Principles of behaviour modification. New York; Holt, Rineheart &

their destructive interpersonal behaviors.

*CBASP-Centre of Competence, Germany*

*Bonn University, Department of Psychiatry and Psychotherapy,*

pro-active work, as well as the whole team of my inpatient department.

**Author details**

**Acknowledgement**

Dieter Schoepf

**4. References**

Winston.

Behaviour therapists often express that working with exposure is quite rewarding, as fear inhibitory learning allows the therapist and the patient a more flexible adjustment of fear related associations in changing environments, exposure is intellectually and behaviourally stimulating, and exposure has the potential to facilitate lasting change in the patient. However, in the treatment of chronic MDD with antecedent dysthymic disorder potential challenges may come about severe side effects of potential symptom aggravations, potential retraumatization and affective overflow that may be caused by techniques like the I-SOH procedure that confront the patients with their helplessness memories that are sometimes traumatically processed. Indeed, helplessness memories and associated core-beliefs are often quite painful for patients to acknowledge, and sustained attention to closed perceptual systems in session is usually associated with an increase of negative affect and agitation. Not only then, it is important for the therapist to be able to be oneself with the patient in the therapy, i.e. that the patient encounters an authentic therapist who is neither afraid to be himself nor to walk with the patient as a "comrade" (McCullough, 2012). It is also imperative, that the patient learns from the beginning of therapy to effectively use specific interventions of CBASP`s functionality teaching and skills teaching dimension to deal with these inevitable and for the progress of therapy necessary symptom aggravations. Because fear inhibitory learning is not attained fully after one session, the patient may experience a temporary increase in symptoms in between sessions. Therapists should anticipate this and should meet special agreements in the form of additional short sessions.

Although CBASP, as a "difficult to learn" treatment package that can only be acquired through intensive training, showed significant effects for treating refractory outpatients with chronic MDD in one of the two large NIHM funded studies, especially in its combination with medication (Keller et al., 2000) and developmental trauma (Nemeroff et al., 2003), rarely research is conducted concerning the role exposure aspects play in patient change. Thus, a much-needed direction for future research is to dismantle specific CBASP interventions and to evaluate their efficacy in reducing depressive symptoms, improving functioning, and improving quality of life. Such process research has to involve a time-series analysis of standardized assessments completed at the beginning and the end of each therapy session, and across the course of multiple sessions. In addition, by the research on the neural mechanisms of chronic depression and the impact of CBASP on behavioural and neural functioning (Schnell et al., 2010), more is learned about the fundamental processes of learning and memory that take place during administering CBASP intervention strategies (Walter et al., 2009).

## **3.3. General conclusion**

In this chapter, I have given an overview of an important excerpt of my clinical work under study conditions that I have carried out in the last six years. The I-SOH procedure and the modified protocol have been discussed with Jim McCullough, Kim Penberthy and Henrik Walter since 2006 and later Knut Schnell. The fifth colleague of this core working group is Peter Neudeck who joined the Bonn CBASP Centre of Competence 2009. Peter is an excellent exposure therapist whom I supervise in CBASP until today as I have been supervised by Jim McCullough once (2007-2008). All of us strongly emphasize the aspects of modern learning theory in CBASP as CBASP therapists and all of us feel the need to further dismantle CBASP`s interventions for better treatment. Hopefully, this chapter has persuasively articulated a constructive use of the modified out-patient protocol for chronic MDD patients with antecedent dysthymic disorder. It is again my concern to bring into consciousness that disciplined personal involvement CBASP techniques that are both reliable and valid can only be learned through intensive training. This is the reason why, to this day, even McCullough himself conducts training for selected learning therapists, using video-supervised case studies. As CBASP-providers, CBASP-supervisors and CBASPtherapists, these therapists are responsible for the distribution and quality control of CBASP in their respective countries (Schoepf & Neudeck, 2011). Further information is available at www.cbasp.org. Like the last year, when I wrote the 2011 CBASP overview chapter, I found myself again fueled by hope that this articulation can be of assistance to other psychiatrists and psychotherapists, as well to other mental health practioners who are interested in working with chronically depressed patients in a constructive way to help their patients to get out of their prison of negative thoughts and outcome expectations, as well as to change their destructive interpersonal behaviors.

## **Author details**

178 Psychiatric Disorders – New Frontiers in Affective Disorders

challenges the therapist.

(Walter et al., 2009).

**3.3. General conclusion**

interpersonal theme domain, in which recurrent experiences of helplessness were earlier made. This is motivation to change and approaching behaviour from the patient's side and

Behaviour therapists often express that working with exposure is quite rewarding, as fear inhibitory learning allows the therapist and the patient a more flexible adjustment of fear related associations in changing environments, exposure is intellectually and behaviourally stimulating, and exposure has the potential to facilitate lasting change in the patient. However, in the treatment of chronic MDD with antecedent dysthymic disorder potential challenges may come about severe side effects of potential symptom aggravations, potential retraumatization and affective overflow that may be caused by techniques like the I-SOH procedure that confront the patients with their helplessness memories that are sometimes traumatically processed. Indeed, helplessness memories and associated core-beliefs are often quite painful for patients to acknowledge, and sustained attention to closed perceptual systems in session is usually associated with an increase of negative affect and agitation. Not only then, it is important for the therapist to be able to be oneself with the patient in the therapy, i.e. that the patient encounters an authentic therapist who is neither afraid to be himself nor to walk with the patient as a "comrade" (McCullough, 2012). It is also imperative, that the patient learns from the beginning of therapy to effectively use specific interventions of CBASP`s functionality teaching and skills teaching dimension to deal with these inevitable and for the progress of therapy necessary symptom aggravations. Because fear inhibitory learning is not attained fully after one session, the patient may experience a temporary increase in symptoms in between sessions. Therapists should anticipate this and

should meet special agreements in the form of additional short sessions.

Although CBASP, as a "difficult to learn" treatment package that can only be acquired through intensive training, showed significant effects for treating refractory outpatients with chronic MDD in one of the two large NIHM funded studies, especially in its combination with medication (Keller et al., 2000) and developmental trauma (Nemeroff et al., 2003), rarely research is conducted concerning the role exposure aspects play in patient change. Thus, a much-needed direction for future research is to dismantle specific CBASP interventions and to evaluate their efficacy in reducing depressive symptoms, improving functioning, and improving quality of life. Such process research has to involve a time-series analysis of standardized assessments completed at the beginning and the end of each therapy session, and across the course of multiple sessions. In addition, by the research on the neural mechanisms of chronic depression and the impact of CBASP on behavioural and neural functioning (Schnell et al., 2010), more is learned about the fundamental processes of learning and memory that take place during administering CBASP intervention strategies

In this chapter, I have given an overview of an important excerpt of my clinical work under study conditions that I have carried out in the last six years. The I-SOH procedure and the Dieter Schoepf *Bonn University, Department of Psychiatry and Psychotherapy, CBASP-Centre of Competence, Germany*

## **Acknowledgement**

I am grateful for the collaboration of James P McCullough JR, Commonwealth University of Virginia; Jennifer Kim Penberthy, University of Virginia Health System; Wolfgang Maier, Department of Psychiatry, University of Bonn; Henrik Walter, now Department of Psychiatry, University of Berlin; Knut Schnell, now Department of Psychiatry, University of Heidelberg; and Elisabeth Schramm, Department of Psychiatry, University of Freiburg. I also thank CBASP-network and the whole Bonn CBASP-1 and CBASP-2 study team for their pro-active work, as well as the whole team of my inpatient department.

## **4. References**

American Psychiatric Association: Diagnostic and statistical manual of mental disorders, 4th edition, text revision (2000). Washington DC, American Psychiatric Association.

Bandura A (1969). Principles of behaviour modification. New York; Holt, Rineheart & Winston.

Bouton ME (2007). Learning and behaviour: A contemporary synthesis. Sunderland; Mass: Sinauer Associates, Inc.

CBASP with Intensified Significant Other History Exercise for Chronic Major Depression with Antecedent Dysthymic Disorder in Outpatient Treatment: Rationale, Assessment and Effects on the Hypothesized… 181

McCullough JP (2006). Treating chronic depression with disciplined personal involvement:

Nemeroff CB, Heim CM, et al. (2003). Differential responses to psychotherapy versus pharmacotherapy in patients with chronic forms of major depression and childhood trauma. Proc Natl Acad Sci USA; 100(24):14293-6. Erratum in Proc Natl Acad Sci U S A.

Neudeck P, Walter H, Schoepf D (2012). Exposure aspects of the interpersonal discrimination exercise (IDE) and the situational analysis (SA) in Cognitive Behavioral Analysis System of Psychotherapy (CBASP). In: Exposure Therapy - Rethinking the Model - Refining the Method (ed. by Peter Neudeck & Hans-Ulrich Wittchen). Springer

Nisbett, Richard, & Wilson, Timothy (1997). Telling more than we can know: verbal reports

Penberthy JK (2010). CBASP and the chronically depressed alcoholic. WCBCT, Boston, June

Schmidt, JA et al., (1999). Psychometric and circumplex properties of the Octant Scale Impact Message Inventory (IMI-C): A structural evaluation. Journal of Counselling

Schnell K, Schoepf D, et al. (2010). Insights into the "Helpless Brain"– an fMRI-Model of perceived functionality in chronic depression. WCBCT, Boston, June 3; Symposium 33:

Schoepf D, Neudeck P (2011). Cognitive Behavioral Analysis System of Psychotherapy (CBASP): a disorder-oriented, theory-driven psychotherapy method from the "third generation" of behaviour therapy models, designed for the treatment of chronic depression. In: Uehara T (Ed.) Psychiatric Disorders - Worldwide Advances (pp. 87-

Schoepf D, Neudeck P, Walter H (2011). Learning theory aspects of the Interpersonal Discrimination Exercise (IDE) and Clinical Applications. International CBASP-Network

Schoepf D, Penberthy JK (2010). Cognitive Behavioural Analysis System of Psychotherapy (CBASP): new applications and neurobiological mechanisms. WCBCT, Boston, June 3;

Schoepf D, McCullough JR (2009). CBASP`s cutting edges to change the behaviour of the chronically depressed patient. Paper presented at the professional 2-day workshop with the author of the CBASP present at the second day, University Bonn, September 19th

Schoepf D, Schnell K, Walter H (2008). Das Cognitive Behavioral Analysis System of Psychotherapy (CBASP): Theoretische Basis und Therapiestrategien. DGPPN Kongress,

Schoepf D, Konradt B, Walter H (2007). Specific psychotherapy of chronic depression with the Cognitive Behavioral Analysis System of Psychotherapy. Nervenheilkunde 26: 790-

P-012-: Depression, II, Track: Depression/Affektive Erkrankungen

International (pp. 153-166). 233 Spring Street, New York, NY 10013, U.S.A.

on mental processes. Psychological Review, 84: 231-259.

Polany Mi (1966). The tacit dimension. Doubleday; Garden City, NY.

CBASP. New York; Springer.

2005 Nov 8; 102(45):16530.

3; Symposium 33: KCB 101.

Psychology, 46, 325–334.

120). ISBN: 978-953-307-833-5.

Symposium 33: KCB 101.

Conference, Lübeck, August 25 - 27.

KCB 101.

and 20th.

802.

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180 Psychiatric Disorders – New Frontiers in Affective Disorders

Clinical Psychology; 79 (3): 342-352.

Arch Gen Psychiatry; 66:1178-1188.

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337.

USA.

disorder. Psychiatr Clin North Am; 19 (1): 41-53.

today makes me sad. Open Journal of Psychiatry; 2: 9-11.

supervisor meeting in CBASP Vs SYSP. Freiburg, Germany.

violence. Current Biology; 21 (33): doi: 10.1016.

Disorder. Behaviour Research and Therapy, 38, 319-345.

traumatic experiences. New York: Oxford University Press.

Sinauer Associates, Inc.

165(12):1069-1077.

Bouton ME (2007). Learning and behaviour: A contemporary synthesis. Sunderland; Mass:

McCrory EJ, et al. (2011). Heightened neural reactivity to threat in child victims of family

Edmiston EE, et al. (2011). Corticostriatal-limbic gray matter morphology in adolescents with self-reported exposure to childhood maltreatment. Arch Pediatr Adolesc Med;

Ehlers, A & Clark, DM (2000). A cognitive model of persistent Posttraumatic Stress

Foa EB, et al., (2007). Prolonged exposure therapy for PTSD: Emotional processing of

Keller MB, McCullough JP, et al. (2000) A comparison of nefazadone, the cognitive behavioural analysis system of psychotherapy, and their combination for treatment of

Klein DN et al. (2011). Social problem solving and depressive symptoms over time: a randomized clinical trial of Cognitive-Behavioral Analysis System of Psychotherapy, Brief Supportive Psychotherapy, and Pharmacotherapy. Journal of Consulting and

Klein DN, Kocsis JH, et al. (1996). Symptomatology in dysthymic and major depressive

Kocsis JH, Gelenberg AJ, et al. (2009). REVAMP Investigators: Cognitive behavioural analysis system of psychotherapy and brief supportive psychotherapy for augmentation of antidepressant nonresponse in chronic depression: the REVAMP Trial.

McCullough JP (2012a). The way early-onset chronically depressed patients are treated

McCullough JP (2012b). Answer of McCullough to official request of E. Schramm after

McCullough JP et al. (2011). The significant other history: An interpersonal-emotional history procedure used with the early-onset chronically depressed patient. Am J

McCullough JP et al. (2010). A method for conducting intensive psychological studies with early-onset chronically depressed patients. American Journal of Psychotherapy; 64: 317-

McCullough JP, McCullough RF (2009). CBASP intensive training workbook. A 2-day-CBASP-professional workshop. The author of the CBASP present at the second day.

McCullough JP (2008). Personal discussion between workshop leader (McCullough) and coleaders (Penberthy and Schoepf) during one work intensive training week. Richmond,

McCullough JP (2007). What are we trying to teach our early-onset chronically depressed patients? Contemporary learning therapy and CBASP psychotherapy for chronic depression (book in preparation). Los Angeles; Psychiatry Grand Rounds, June 26.

University Bonn, CBASP Centre of Competence, September 19th and 20th.

chronic depression. New England Journal of Medicine; 342: 1462-1470.

Schramm et al. (2011). Comparative efficacy of the Cognitive Behavioral Analysis System of Psychotherapy versus Supportive Psychotherapy for early onset chronic depression: design and rationale of a multisite randomized controlled trial*.* BMC Psychiatry, 11:134*.*

**Chapter 8**

© 2013 Oertel-Knöchel and Schoepf, licensee InTech. This is an open access chapter distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is

distribution, and reproduction in any medium, provided the original work is properly cited.

© 2013 Oertel-Knöchel and Schoepf, licensee InTech. This is a paper distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

properly cited.

Karl Leonhard in 1957 (Beckmann, 1999).

**Adaptation of Cognitive Behavioral**

**Analysis System of Psychotherapy in a 29**

**Year Old Female Patient with Chronic Major**

**Who Switched Under Combined SSRI/CBASP**

**Outpatient Treatment into Bipolarity:**

**d**isorder (MDD) and **b**ipolar **d**isorder (BD) to schizoaffective disorder.

**A Case Report**

http://dx.doi.org/10.5772/51963

**1. Introduction**

Viola Oertel-Knöchel and Dieter Schoepf

Additional information is available at the end of the chapter

**Depression and Antecedent Dysthymic Disorder**

Affective disorders are among the main psychiatric illnesses reaching from **m**ajor **d**epressive

Under a historical perceptive, the beginning of the conceptualisation of affective disorders was done in 1854, when Jean-Pierre Falret named recurrent episodes of mania and depression as *folie circulaire* (Sedler & Falret, 1983). This was followed by Emil Kraepelin's definition as *manic-depressive psychosis*, which include the observation by Kraepelin that symptom-free intervals and acute illness episodes alternates in these patients (Kraepelin, 1921). A categorical distinction between two spectra with different diseases and different clinical courses, i.e. the *unipolar* spectrum and the *bipolar* spectrum, was first introduced by

With respect to the unipolar spectrum, MDD is among the most debilitating diseases worldwide with high disability compared with all human diseases (Falagas, Vardakas, & Vergidis, 2007). Lifetime prevalence of MDD is up to 20% once a life (Williams et al., 2007). In one third of the cases, the course of the illness is chronic, with often "difficult to treat" patients suffering from high social disturbances, resulting in a higher rate of mortality

**Adaptation of Cognitive Behavioral Analysis System of Psychotherapy in a 29 Year Old Female Patient with Chronic Major Depression and Antecedent Dysthymic Disorder Who Switched Under Combined SSRI/CBASP Outpatient Treatment into Bipolarity: A Case Report**

Viola Oertel-Knöchel and Dieter Schoepf

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/51963

## **1. Introduction**

182 Psychiatric Disorders – New Frontiers in Affective Disorders

Suppl. 2, 173-182.

Psychoanalysis; 30: 69-75.

Schramm et al. (2011). Comparative efficacy of the Cognitive Behavioral Analysis System of Psychotherapy versus Supportive Psychotherapy for early onset chronic depression: design and rationale of a multisite randomized controlled trial*.* BMC Psychiatry, 11:134*.* Walter H, Berger M, Schnell K (2009) Neuropsychotherapy. Conceptual, Empirical and Neuroethical Issues. European Archives of Psychiatry and Clinical Neuroscience 259,

Winnicott DW (1949). Hate in the counter transference. International Journal of

Affective disorders are among the main psychiatric illnesses reaching from **m**ajor **d**epressive **d**isorder (MDD) and **b**ipolar **d**isorder (BD) to schizoaffective disorder.

Under a historical perceptive, the beginning of the conceptualisation of affective disorders was done in 1854, when Jean-Pierre Falret named recurrent episodes of mania and depression as *folie circulaire* (Sedler & Falret, 1983). This was followed by Emil Kraepelin's definition as *manic-depressive psychosis*, which include the observation by Kraepelin that symptom-free intervals and acute illness episodes alternates in these patients (Kraepelin, 1921). A categorical distinction between two spectra with different diseases and different clinical courses, i.e. the *unipolar* spectrum and the *bipolar* spectrum, was first introduced by Karl Leonhard in 1957 (Beckmann, 1999).

With respect to the unipolar spectrum, MDD is among the most debilitating diseases worldwide with high disability compared with all human diseases (Falagas, Vardakas, & Vergidis, 2007). Lifetime prevalence of MDD is up to 20% once a life (Williams et al., 2007). In one third of the cases, the course of the illness is chronic, with often "difficult to treat" patients suffering from high social disturbances, resulting in a higher rate of mortality

© 2013 Oertel-Knöchel and Schoepf, licensee InTech. This is an open access chapter distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 Oertel-Knöchel and Schoepf, licensee InTech. This is a paper distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

compared to pure MDD, higher economic costs and bad long-term prognoses compared to pure MDD (Schoepf et al., 2007). Chronicity is defined as unipolar depressive disorder lasting two or more years with less than a two-month period during which the individual reports no symptoms. The rating is contingent upon the density of symptoms at the time of assessment, every day in chronic MDD and more days than not in dysthymia. Manic, mixed or hypomanic episodes are listed as exclusion criteria (Schoepf & Neudeck, 2011). Studies assessing the course of unipolar depression (15 years range) indicate that approximately 15%-46% of the patients initially diagnosed with non-psychotic MDD or chronic MDD develop their symptoms into BD (Walden & Grunze, 2006). It is important to note, that 80% of initially unipolar diagnosed patients who suffer of a psychotic MD-episode develop their symptoms into the classic phenotype of manic-depressive illness within 5 years. This phenomenon is called *switch*. In general, the most obvious characteristic of BD are mood fluctuations and mental excitement those usually cause a marked change in the patient's baseline level of daily functioning (AACAP 1995). In paediatric BD, instability of mood in the early course of the disorder often interfere with the child's capacity to develop or maintain stable representations of self and others and results more often than not in difficulties to develop or maintain self-esteem. Bipolar children show co-morbidity rates of 13% with conduct disorder, 88% with oppositional defiant disorder, 98% with attention deficit hyperactivity disorder, and 11% with pervasive developmental disorders. In "older adolescent-onset" BD (aged 14-19 years) the symptom presentation, natural course of illness, phenomenology, and mental co-morbidity appear more similar to the classical symptoms described for adults in DSM-IV. In adult patients with manic depressive illness the life-time prevalence of concomitant occurrence of BD and other psychiatric disorders is 100% for one co-morbid axis-I disorder and 96% for > two co-morbid axis-I disorders with the highest comorbidity rates for substance use disorders (alcoholism 30% -50%) and anxiety disorders (45%). Life-time prevalence rates of BD range from 5 % to 10% in the general population for all types and subtypes within the bipolar spectrum (Angst 1998). Further important public health issues are that BD (1) is a lifelong cyclical illness, (2) that the peak onset of BD is between 15–30 years, (3) that suicide is highest within 10 years of the onset of BD, (4) that frequent and repeated hospitalizations occur more often than not, (5) that the rate of promiscuity is increased compared to the general population, (6) that financial disasters, repeated job changes and/or losses are often associated with acute illness states, (7) that the coexistence of BD with other psychiatric disorders results in higher recurrence rates, higher suicide rates and a greater extent of psychosocial impairment, (8) that non-adherence to medication is common, and (9) that BD is associated with an increased risk of cardiovascular mortality on the long run of the illness. Commonly, a BD disorder needs approximately eight years to be correctly diagnosed (Wagner & Bräunig, 2000). One reason of the delay in correct diagnosis is that the disorder frequently starts with MD-episodes (60-80 % of all cases; (Wagner & Bräunig, 2000), so that primarily a MDD is diagnosed (Walden & Grunze, 2006). Further more, - clinical pathological - hypomanic or manic symptomatic states are often, mainly at the beginning of an episode, without psychological strain for the involved person (M. Hautzinger & Meyer, 2002). To be finished, the currently existing diagnostic instruments to validate manic or depressive symptoms might be impaired by self-evaluation (M. Hautzinger & Meyer, 2002).

Adaptation of Cognitive Behavioral Analysis System of Psychotherapy in a 29

Year Old Female Patient with Chronic Major Depression and Antecedent Dysthymic Disorder ... 185

With respect to disease classification within the bipolar spectrum, the current prominent psychiatric classification systems, which are used in clinical and research settings, are the *Diagnostic and Statistic Manual of Mental Disorders* (DSM-IV; American Psychiatric Association, 1994), and the *International Classification of Disease* (ICD-10; World Health Organization, 1992). In general, both don't differ in the descriptions of the symptomatology of BD, but there are differences regarding the definition of the subcategories: In the DSM-IV, the occurrence of depressed and hypomanic episodes during the course of the illness is subsumed under the diagnosis BD-II, whereas the occurrence of MD-episodes and manic or mixed episodes are classified as BD-I. In the longitudinal course of BD-I, mayor mood episodes are demarcated by either partial or full remission for at least 2 month or a switch to an episode of opposite polarity. The categorical approach of DSM-IV (Text Revision 2000) conceptualises four heterogeneous phenotypes of BD and works out two subtypes of BD-I

1. BD-I, the classic "phenotype" of manic-depressive illness, that is diagnosed when a patient experiences at least one full manic episode severe enough to require psychiatric hospitalisation or is accompanied by DSM-IV psychotic features of psychotic misperceptions of environmental stimuli. DSM-IV manic features can include elation, irritability, and increased energy with hyperactivity, racing thoughts, pressured rapid speech, a decreased need for sleep, and an increased involvement of pleasured activities. BD-I has a life-time prevalence of approximately 1% of the world's

2. The "softer" BD–II phenotype, defined as one or more MD-episodes and hypomania over lifetime. BD-II is more common in females, young patients and early-onset patients with a strong association to depressive mixed states, atypical features of depression,

3. Cyclothymic disorder, defined as a period of 1 year or more in which there are depressive and hypomanic symptoms that do not meet full criteria for either a MD-

4. BD **n**ot **o**therwise **s**pecified (BD-NOS): Patients, who have very brief (shorter than a week), although sometimes severe, episodes that do not fall within the DSM-IV definition of rapid-cycling but are classified as having BD not otherwise specified. 5. Rapid cycling (RC): The phenomena of rapid cycling (first introduced by Dunner 1974) in the long-term course of BD is defined as the occurrence of at least four episodes (MD,

6. Ultra-RC and Ultradian-RC: Cycle lengths as short as 48 hours or even 24 hours are sometimes referred to as Ultra-RC (episodes occurring within the course of days to week) and Ultradian RC (moods shifts within a day), respectively (Kramlinger 1996). At present, it is unclear whether RC, ultra-RC and ultradian-RC are distinct subtypes of BDs or just a clinical phenomenon toward one extreme on a continuum of episode frequencies (Bauer, 1996). Rapid cycling has been associated with female gender, BD-II, a longer duration of illness, a positive family history of mood disorders, the presence of clinical or subclinical hypothyroidism, non-response to prophylactic lithium treatment, and the use of

episode or a manic episode, but that do interfere with daily functioning.

manic-, mixed-, or hypomanic episode) within a given year.

and BD-II according to episode frequency:

population.

and rapid-cycling features.

With respect to disease classification within the bipolar spectrum, the current prominent psychiatric classification systems, which are used in clinical and research settings, are the *Diagnostic and Statistic Manual of Mental Disorders* (DSM-IV; American Psychiatric Association, 1994), and the *International Classification of Disease* (ICD-10; World Health Organization, 1992). In general, both don't differ in the descriptions of the symptomatology of BD, but there are differences regarding the definition of the subcategories: In the DSM-IV, the occurrence of depressed and hypomanic episodes during the course of the illness is subsumed under the diagnosis BD-II, whereas the occurrence of MD-episodes and manic or mixed episodes are classified as BD-I. In the longitudinal course of BD-I, mayor mood episodes are demarcated by either partial or full remission for at least 2 month or a switch to an episode of opposite polarity. The categorical approach of DSM-IV (Text Revision 2000) conceptualises four heterogeneous phenotypes of BD and works out two subtypes of BD-I and BD-II according to episode frequency:

184 Psychiatric Disorders – New Frontiers in Affective Disorders

(M. Hautzinger & Meyer, 2002).

compared to pure MDD, higher economic costs and bad long-term prognoses compared to pure MDD (Schoepf et al., 2007). Chronicity is defined as unipolar depressive disorder lasting two or more years with less than a two-month period during which the individual reports no symptoms. The rating is contingent upon the density of symptoms at the time of assessment, every day in chronic MDD and more days than not in dysthymia. Manic, mixed or hypomanic episodes are listed as exclusion criteria (Schoepf & Neudeck, 2011). Studies assessing the course of unipolar depression (15 years range) indicate that approximately 15%-46% of the patients initially diagnosed with non-psychotic MDD or chronic MDD develop their symptoms into BD (Walden & Grunze, 2006). It is important to note, that 80% of initially unipolar diagnosed patients who suffer of a psychotic MD-episode develop their symptoms into the classic phenotype of manic-depressive illness within 5 years. This phenomenon is called *switch*. In general, the most obvious characteristic of BD are mood fluctuations and mental excitement those usually cause a marked change in the patient's baseline level of daily functioning (AACAP 1995). In paediatric BD, instability of mood in the early course of the disorder often interfere with the child's capacity to develop or maintain stable representations of self and others and results more often than not in difficulties to develop or maintain self-esteem. Bipolar children show co-morbidity rates of 13% with conduct disorder, 88% with oppositional defiant disorder, 98% with attention deficit hyperactivity disorder, and 11% with pervasive developmental disorders. In "older adolescent-onset" BD (aged 14-19 years) the symptom presentation, natural course of illness, phenomenology, and mental co-morbidity appear more similar to the classical symptoms described for adults in DSM-IV. In adult patients with manic depressive illness the life-time prevalence of concomitant occurrence of BD and other psychiatric disorders is 100% for one co-morbid axis-I disorder and 96% for > two co-morbid axis-I disorders with the highest comorbidity rates for substance use disorders (alcoholism 30% -50%) and anxiety disorders (45%). Life-time prevalence rates of BD range from 5 % to 10% in the general population for all types and subtypes within the bipolar spectrum (Angst 1998). Further important public health issues are that BD (1) is a lifelong cyclical illness, (2) that the peak onset of BD is between 15–30 years, (3) that suicide is highest within 10 years of the onset of BD, (4) that frequent and repeated hospitalizations occur more often than not, (5) that the rate of promiscuity is increased compared to the general population, (6) that financial disasters, repeated job changes and/or losses are often associated with acute illness states, (7) that the coexistence of BD with other psychiatric disorders results in higher recurrence rates, higher suicide rates and a greater extent of psychosocial impairment, (8) that non-adherence to medication is common, and (9) that BD is associated with an increased risk of cardiovascular mortality on the long run of the illness. Commonly, a BD disorder needs approximately eight years to be correctly diagnosed (Wagner & Bräunig, 2000). One reason of the delay in correct diagnosis is that the disorder frequently starts with MD-episodes (60-80 % of all cases; (Wagner & Bräunig, 2000), so that primarily a MDD is diagnosed (Walden & Grunze, 2006). Further more, - clinical pathological - hypomanic or manic symptomatic states are often, mainly at the beginning of an episode, without psychological strain for the involved person (M. Hautzinger & Meyer, 2002). To be finished, the currently existing diagnostic instruments to validate manic or depressive symptoms might be impaired by self-evaluation

At present, it is unclear whether RC, ultra-RC and ultradian-RC are distinct subtypes of BDs or just a clinical phenomenon toward one extreme on a continuum of episode frequencies (Bauer, 1996). Rapid cycling has been associated with female gender, BD-II, a longer duration of illness, a positive family history of mood disorders, the presence of clinical or subclinical hypothyroidism, non-response to prophylactic lithium treatment, and the use of

antidepressants (Shelton, 2000). In general, rapid-cycling is associated with increased resistance to standard pharmacological treatments and a poorer prognosis than classic BD (Calabrese, 2001). Some of the subcategories are not present in the ICD-10, but can be relevant for diagnostic and pharmacological considerations. Other subtypes which were conceptualized by clinical researchers include the BD-III1/2 (multiple substance abuse caused hypomanic- and manic episodes) and BD-IV (individuals who develop depression later in life from a lifelong background of hyperthymic temperament) concept. This concept was first introduced by Gerald Klerman in 1981 (Young & Klerman, 1992). Akiskal (Akistal, 1995), enlarged the concept by Gerald Klerman and defined six different types of bipolar disorders based on clinical features. However, in the current classification systems, these subtypes are not included. Nevertheless, current researchers dispute the use and the clinical relevance of these concepts. With respect to the classification of schizoaffective disorder as a mood disorder there is a worldwide controversy and a poor agreement rate, i.e. schizophrenia, schizoaffective disorder and BD with psychotic symptoms overlap in many dimensions as they involve as well psychotic as affective symptoms.

Adaptation of Cognitive Behavioral Analysis System of Psychotherapy in a 29

Year Old Female Patient with Chronic Major Depression and Antecedent Dysthymic Disorder ... 187

**Figure 1.** Pathophysiological mechanisms of affective disorders and dimensional classification of

affective disorders spectrum.

Current pathophysiological models of affective disorders imply that a large number of pathophysiological mechanisms which have been implicated in MDD and BD as well. Beside genetic and environmental risk factors, abnormal molecular factors, aberrant neuronal mechanisms and dysfunction of neuronal networks are known to have important implications for the disease progression, see Figure 1 (Schneider et al., 2011).

Common treatment models of BDs combine individual pharmacological and psychotherapeutic strategies (Grunze & Walden, 2003). The treatment of acute hypomanic or manic episodes is normally implemented during inpatient therapy. In exceptional cases, like if there is a good psychosocial network, a good compliance and only slight symptoms, it might be possible to treat acute hypomanic / manic symptoms with an outpatient form of therapy. Many recent studies have demonstrated benefits from the addition of psychotherapy to pharmacotherapy, especially when an individual is still in an acute episode (Frank et al. 2005). From a perspective of disorder-specific psychotherapy, several research groups have adapted revised behaviour theory approaches like cognitive therapy of Beck, interpersonal theory approaches like Klerman's interpersonal therapy and familyfocused psycho educational treatment of BD. The most promising and best evaluated adaptation seems the **I**nterpersonal and **S**ocial **R**hythm **T**herapy (IPSRT) by Ellen Frank, a therapy which built on a model of aetiology that is widely accepted in the field. IPSRT strongly focuses on modulating both biological and psychosocial factors to mitigate the patient's circadian and sleep-wake cycle vulnerabilities, to improve overall functioning, and better manage the potential chaos of bipolar symptomatology (Frank et al. 2000).

### **1.1. Overview of chapter**

In this chapter-article, we describe the adaptation of **C**ognitive **B**ehavioral **A**nalysis **S**ystem of **P**sychotherapy (CBASP), the only model of psychotherapy that is specifically developed for chronic MDD, to a female early-onset chronically depressed outpatient who switched Adaptation of Cognitive Behavioral Analysis System of Psychotherapy in a 29

Year Old Female Patient with Chronic Major Depression and Antecedent Dysthymic Disorder ... 187

186 Psychiatric Disorders – New Frontiers in Affective Disorders

antidepressants (Shelton, 2000). In general, rapid-cycling is associated with increased resistance to standard pharmacological treatments and a poorer prognosis than classic BD (Calabrese, 2001). Some of the subcategories are not present in the ICD-10, but can be relevant for diagnostic and pharmacological considerations. Other subtypes which were conceptualized by clinical researchers include the BD-III1/2 (multiple substance abuse caused hypomanic- and manic episodes) and BD-IV (individuals who develop depression later in life from a lifelong background of hyperthymic temperament) concept. This concept was first introduced by Gerald Klerman in 1981 (Young & Klerman, 1992). Akiskal (Akistal, 1995), enlarged the concept by Gerald Klerman and defined six different types of bipolar disorders based on clinical features. However, in the current classification systems, these subtypes are not included. Nevertheless, current researchers dispute the use and the clinical relevance of these concepts. With respect to the classification of schizoaffective disorder as a mood disorder there is a worldwide controversy and a poor agreement rate, i.e. schizophrenia, schizoaffective disorder and BD with psychotic symptoms overlap in many

Current pathophysiological models of affective disorders imply that a large number of pathophysiological mechanisms which have been implicated in MDD and BD as well. Beside genetic and environmental risk factors, abnormal molecular factors, aberrant neuronal mechanisms and dysfunction of neuronal networks are known to have important

Common treatment models of BDs combine individual pharmacological and psychotherapeutic strategies (Grunze & Walden, 2003). The treatment of acute hypomanic or manic episodes is normally implemented during inpatient therapy. In exceptional cases, like if there is a good psychosocial network, a good compliance and only slight symptoms, it might be possible to treat acute hypomanic / manic symptoms with an outpatient form of therapy. Many recent studies have demonstrated benefits from the addition of psychotherapy to pharmacotherapy, especially when an individual is still in an acute episode (Frank et al. 2005). From a perspective of disorder-specific psychotherapy, several research groups have adapted revised behaviour theory approaches like cognitive therapy of Beck, interpersonal theory approaches like Klerman's interpersonal therapy and familyfocused psycho educational treatment of BD. The most promising and best evaluated adaptation seems the **I**nterpersonal and **S**ocial **R**hythm **T**herapy (IPSRT) by Ellen Frank, a therapy which built on a model of aetiology that is widely accepted in the field. IPSRT strongly focuses on modulating both biological and psychosocial factors to mitigate the patient's circadian and sleep-wake cycle vulnerabilities, to improve overall functioning, and

dimensions as they involve as well psychotic as affective symptoms.

implications for the disease progression, see Figure 1 (Schneider et al., 2011).

better manage the potential chaos of bipolar symptomatology (Frank et al. 2000).

In this chapter-article, we describe the adaptation of **C**ognitive **B**ehavioral **A**nalysis **S**ystem of **P**sychotherapy (CBASP), the only model of psychotherapy that is specifically developed for chronic MDD, to a female early-onset chronically depressed outpatient who switched

**1.1. Overview of chapter**

**Figure 1.** Pathophysiological mechanisms of affective disorders and dimensional classification of affective disorders spectrum.

into a first hypomanic episode during the outpatient treatment course. The reported case is a 29-years aged female patient, who was initially diagnosed as chronic MDD with antecedent dysthymic disorder during inpatient treatment in University Frankfurt, at that time suffering from a moderate(-to severe) MD-episode. There was no direct or indirect evidence for an earlier manic, mixed or hypomanic episode. After 27 sessions of CBASP – that included a prolonged SOH procedure according to a modified protocol - she reached a stable state of full syndromal remission and achieved in-session two-way circular functioning. She switched under combined SSRI/CBASP outpatient treatment for 6 months, without any obvious forewarning or stressful encounter, into a first hypomanic episode (Type II) (ICD-10 F 31 [WHO, 1992]). The hypomanic episode was followed by a prolonged phase of mood instability before another hypomanic episode occurred one year later. The applied psychotherapy from session 28-50 faithfully followed the conception of CBASP in an adapted way. We attempt to illustrate which part of the CBASP concepts might be useful in acute hypomanic/manic episodes of BDs. We suggest that the presented strategies here might be implemented in an advanced form of BD treatment strategies.

Adaptation of Cognitive Behavioral Analysis System of Psychotherapy in a 29

Year Old Female Patient with Chronic Major Depression and Antecedent Dysthymic Disorder ... 189

helplessness. This results in a pervasive degree of social isolation, which worsens the depressive mood. CBASP specifically focuses on central mechanisms of affective and motivational regulation via an interpersonal contemporary learning acquisition model, utilizing disciplined personal involvement to aid acquisition of perceived functionality in the patient. For example, a basic CBASP technique is to enable the patient to recognize his own impact on the therapist's behaviour (adapted and modified from the 2010 proposal written by K.Penberthy: "CBASP: New applications and Neurocognitive mechanisms").

There are the following recommended practices for a positive prognosis of the long-term course of BD: Good responses to the pharmacological treatment, avoidance of misuse of drugs and alcohol, early detection of acute episodes, social capabilities and a good relationship to attachment figures. Current BD treatment models combine individual pharmacological and psychotherapeutic strategies (Grunze & Walden, 2003). The pharmacological treatment includes mood stabilizer, antidepressant, benzodiazepine and neuroleptic medication (Wagner & Bräunig, 2000) in dependence of the respective illness state. Psychotherapy has to be seen as supplementary to the pharmacological treatment, not instead of. The psychotherapeutic measures are divided into different stages, acute (manic / depressive) treatment, maintenance (inter-episodic) treatment and prophylaxis. But it is important to see the whole spectrum of illness states, not only single stages. The best suitable starting time to begin an outpatient psychotherapy is after the retreat of acute symptoms (M. Hautzinger & Meyer, 2011). There are a number of classical

In general, the psychotherapeutic concepts set the focus on improvement of compliance for medication, psycho education, relapse prevention, prophylaxis and social rhythms strategies (Meyer & Hautzinger, 2000). Examples of approaches focusing on those subjects are the *cognitive-behavioral therapy* (CBT; (Basco & Rush, 2005), the IPSRT, (Frank, 2005)), the *familyfocused treatment approach* (FFT; (Miklowitz & Goldstein, 1997)) and the *psychoeducation-based*

The FFT is a cognitive-behavioral-based method that focuses on the integration of attachment figures into the therapy. The goal is to modify dysfunctional thoughts of the

The IPSRT (Frank, 2005) consists of three modules, including compliance for medication, social rhythms and reduction of interpersonal difficulties. Interpersonal psychotherapy (IPT) including maintenance IPT, brief IPT, and interpersonal and social rhythm therapy for the treatment of BD have recently adapted for both group and individual treatment of both BD and unipolar disorders. In addition, Frank recently completed a study with Italian researchers (University Pisa) that aims to achieve a better understanding of the clinical importance of sub-syndromal mood and anxiety conditions and their impact on the

attachment figures, to modify social skills and to identify early symptoms.

outcome of interpersonal psychotherapy and SSRI for depression.

**3. Main treatment concepts of bipolar disorders**

psychotherapeutic methods used in the treatment of BD.

*group therapy (PEG)*(Schaub, Bernhard, & Gauck, 2004).

## **2. CBASP**

CBASP was originally developed by James McCullough for the specific treatment of chronic depression as an outpatient protocol that is not yet evaluated for the treatment of BD (McCullough, 2000, 2006). CBASP`s interventions include elements from both classical and cognitive behaviour therapies as important elements of "third generation" psychotherapy methods that deal with models of self-regulation with respect to motivational and perceptual factors in meta-cognitive processing. In contrast to any other psychotherapy model the therapist is viewed as the primary choreographer of behaviour change using a disciplined personal involvement role that stands in contrast to the relationships the earlyonset chronic depressed patient has experienced with his **S**ignificant **O**ther's (SOs) during childhood (Schoepf & Neudeck, 2011). CBASP demonstrated significant therapeutic effects for treatment patients with chronic MDD with antecedent dysthymic disorder as well as chronic MDD without antecedent dysthymic disorder. Especially, CBASP has demonstrated greater efficacy than antidepressant medication for patients with histories of childhood trauma ranging from childhood maltreatment (sexual abuse, physical abuse or emotional abuse) to experiencing neglect to witnessing domestic violence or to having a life-threatening injury (Schoepf et al., 2007; Schoepf & McCullough, 2009; McCullough et al., 2010; Schoepf & Penberthy, 2010; Schoepf & Neudeck, 2011; McCullough, 2012; Schoepf, in this book).

Treatment resistance or chronic MDD is quickly becoming a clinical reality, with up to 15% of patients not responding to intensified pharmacological and psychotherapeutic approaches. McCullough suggests that chronically depressed individuals have a primitive cognitive functioning that is unaffected by the logical reasoning and reality-based views of others. In addition, these patients most often perceive that the causal influences in their life are beyond their personal control. They have a poor ability to use a problem-focused coping style and problems are described in a global way, resulting in feelings of hopelessness and helplessness. This results in a pervasive degree of social isolation, which worsens the depressive mood. CBASP specifically focuses on central mechanisms of affective and motivational regulation via an interpersonal contemporary learning acquisition model, utilizing disciplined personal involvement to aid acquisition of perceived functionality in the patient. For example, a basic CBASP technique is to enable the patient to recognize his own impact on the therapist's behaviour (adapted and modified from the 2010 proposal written by K.Penberthy: "CBASP: New applications and Neurocognitive mechanisms").

## **3. Main treatment concepts of bipolar disorders**

188 Psychiatric Disorders – New Frontiers in Affective Disorders

**2. CBASP**

into a first hypomanic episode during the outpatient treatment course. The reported case is a 29-years aged female patient, who was initially diagnosed as chronic MDD with antecedent dysthymic disorder during inpatient treatment in University Frankfurt, at that time suffering from a moderate(-to severe) MD-episode. There was no direct or indirect evidence for an earlier manic, mixed or hypomanic episode. After 27 sessions of CBASP – that included a prolonged SOH procedure according to a modified protocol - she reached a stable state of full syndromal remission and achieved in-session two-way circular functioning. She switched under combined SSRI/CBASP outpatient treatment for 6 months, without any obvious forewarning or stressful encounter, into a first hypomanic episode (Type II) (ICD-10 F 31 [WHO, 1992]). The hypomanic episode was followed by a prolonged phase of mood instability before another hypomanic episode occurred one year later. The applied psychotherapy from session 28-50 faithfully followed the conception of CBASP in an adapted way. We attempt to illustrate which part of the CBASP concepts might be useful in acute hypomanic/manic episodes of BDs. We suggest that the presented strategies here

CBASP was originally developed by James McCullough for the specific treatment of chronic depression as an outpatient protocol that is not yet evaluated for the treatment of BD (McCullough, 2000, 2006). CBASP`s interventions include elements from both classical and cognitive behaviour therapies as important elements of "third generation" psychotherapy methods that deal with models of self-regulation with respect to motivational and perceptual factors in meta-cognitive processing. In contrast to any other psychotherapy model the therapist is viewed as the primary choreographer of behaviour change using a disciplined personal involvement role that stands in contrast to the relationships the earlyonset chronic depressed patient has experienced with his **S**ignificant **O**ther's (SOs) during childhood (Schoepf & Neudeck, 2011). CBASP demonstrated significant therapeutic effects for treatment patients with chronic MDD with antecedent dysthymic disorder as well as chronic MDD without antecedent dysthymic disorder. Especially, CBASP has demonstrated greater efficacy than antidepressant medication for patients with histories of childhood trauma ranging from childhood maltreatment (sexual abuse, physical abuse or emotional abuse) to experiencing neglect to witnessing domestic violence or to having a life-threatening injury (Schoepf et al., 2007; Schoepf & McCullough, 2009; McCullough et al., 2010; Schoepf &

Penberthy, 2010; Schoepf & Neudeck, 2011; McCullough, 2012; Schoepf, in this book).

Treatment resistance or chronic MDD is quickly becoming a clinical reality, with up to 15% of patients not responding to intensified pharmacological and psychotherapeutic approaches. McCullough suggests that chronically depressed individuals have a primitive cognitive functioning that is unaffected by the logical reasoning and reality-based views of others. In addition, these patients most often perceive that the causal influences in their life are beyond their personal control. They have a poor ability to use a problem-focused coping style and problems are described in a global way, resulting in feelings of hopelessness and

might be implemented in an advanced form of BD treatment strategies.

There are the following recommended practices for a positive prognosis of the long-term course of BD: Good responses to the pharmacological treatment, avoidance of misuse of drugs and alcohol, early detection of acute episodes, social capabilities and a good relationship to attachment figures. Current BD treatment models combine individual pharmacological and psychotherapeutic strategies (Grunze & Walden, 2003). The pharmacological treatment includes mood stabilizer, antidepressant, benzodiazepine and neuroleptic medication (Wagner & Bräunig, 2000) in dependence of the respective illness state. Psychotherapy has to be seen as supplementary to the pharmacological treatment, not instead of. The psychotherapeutic measures are divided into different stages, acute (manic / depressive) treatment, maintenance (inter-episodic) treatment and prophylaxis. But it is important to see the whole spectrum of illness states, not only single stages. The best suitable starting time to begin an outpatient psychotherapy is after the retreat of acute symptoms (M. Hautzinger & Meyer, 2011). There are a number of classical psychotherapeutic methods used in the treatment of BD.

In general, the psychotherapeutic concepts set the focus on improvement of compliance for medication, psycho education, relapse prevention, prophylaxis and social rhythms strategies (Meyer & Hautzinger, 2000). Examples of approaches focusing on those subjects are the *cognitive-behavioral therapy* (CBT; (Basco & Rush, 2005), the IPSRT, (Frank, 2005)), the *familyfocused treatment approach* (FFT; (Miklowitz & Goldstein, 1997)) and the *psychoeducation-based group therapy (PEG)*(Schaub, Bernhard, & Gauck, 2004).

The FFT is a cognitive-behavioral-based method that focuses on the integration of attachment figures into the therapy. The goal is to modify dysfunctional thoughts of the attachment figures, to modify social skills and to identify early symptoms.

The IPSRT (Frank, 2005) consists of three modules, including compliance for medication, social rhythms and reduction of interpersonal difficulties. Interpersonal psychotherapy (IPT) including maintenance IPT, brief IPT, and interpersonal and social rhythm therapy for the treatment of BD have recently adapted for both group and individual treatment of both BD and unipolar disorders. In addition, Frank recently completed a study with Italian researchers (University Pisa) that aims to achieve a better understanding of the clinical importance of sub-syndromal mood and anxiety conditions and their impact on the outcome of interpersonal psychotherapy and SSRI for depression.

In Germany, the most established cognitive-behavioral program for the therapy of BD is the CBT approach of Meyer and Hautzinger (2004), which contains four modules, including psycho education, prophylaxis, and relapse prevention, modification of dysfunctional cognitive beliefs and formatting of additional interpersonal and social skills. The module psycho- education has the aim of training the patient about the cause of the illness and treatment possibilities. During prophylaxis, patients are trained to identify and modify early symptoms through the keeping of a daily diary. Also, they are taught to improve social rhythms. During acute hypomanic / manic episodes, the program tries to reduce acute symptoms, e.g., sleep disturbances, blowing money, agitation and distractibility. To reduce such symptoms, the manual shows strategies to reduce the activity level, to reduce social contacts and to introduce breaks and calm activities.

Adaptation of Cognitive Behavioral Analysis System of Psychotherapy in a 29

Year Old Female Patient with Chronic Major Depression and Antecedent Dysthymic Disorder ... 191

The female patient was born and raised in a family with father, mother and a younger sister (- 2 years). The father worked as a teacher, the mother was a housewife. There was no family history of psychiatric disorders according to DSM-IV criteria (American Psychiatric Association, 1994). She reported a close relationship to the other family members, but, the patient noted that, beside this close relationship, there was a lot of pressure to perform. During her childhood, the patient was a successful athlete of track and fields athletics. This was very important for her relationship to her father, because he joined every training and competition session and assisted her a lot. At the age of 17 years, her performance decreased due to a lack of body height. She called this event as a personal "trauma", because this was a break in the close relationship to her father. Since then, she refused to do any sports. The patient finished school at the age of 19 years, and then she began a formation in the field of advertising. She broke off the education after one year due to conflicts with her boss. After a few months of unemployment, she began to work in shifts work as an employee in a company. Further, she married in the age of 30 years and is living together with her

During the six-week combined pharmacologic and psychotherapeutic inpatient treatment, the course of the symptoms was measured weekly using the Beck Depression Inventar (BDI-II, (M. Hautzinger, Keller, & Kühner, 2006)). The BDI-II is a 21 item multiple-choice selfreport questionnaire. It is one of the most widely used instruments for measuring the severity of depression. The applied psychotherapy during this phase mainly included basic psychotherapeutic strategies with an emphasis on supportive elements in order to relieve the patient from symptom pressure. This was followed by 50 outpatient psychotherapeutic sessions (each lasting 45 minutes), during a time span of 25 months. An adaptation of CBASP was used after the switch into bipolarity. The frequency of the sessions differed between weekly during acute episodes and monthly during symptom-free episodes. The psychotherapy was complemented by pharmacological treatment prescribed from a

During the inpatient stay, a pharmacological treatment with Citalopram (40 mg / d) to reduce the acute depressive symptoms was initiated. This resulted in a reduced score of the BDI-II: Week 1: 41 points, week 6: 35 points; view Figure 1). The following progress of medical treatment reflects the clinical perspective of the responsible psychiatrist, showing a changed symptomatology including hypomanic symptoms according to the operationalized criteria. The antidepressant therapy was reduced during the first hypomanic episode six months after the start of the outpatient therapy (Citalopram 30 mg/d), and a neuroleptic treatment (Aripiprazol) was initiated. Under this medical treatment, the patient gained 10

**4.2. Autobiographical history**

husband, without a child.

**5. Progress of therapy**

psychiatrist.

**5.1. Progress of medical treatment**

## **4. Case history**

In the following sections, we describe the psychotherapeutic treatment of a 29-years-aged female patient, who was initially diagnosed with "difficult to treat" chronic MDD with antecedent dysthymic disorder during inpatient treatment in the University Frankfurt, at that time suffering from a moderate (-to severe) non-psychotic MD-episode. The inpatient treatment lasted 6 weeks, followed by an outpatient treatment, lasting 25 months, using an adaptation of the CBASP. This was the first in- and outpatient psychiatric and psychotherapeutic treatment for the affected patient. After six months of combined SSRI/CBASP outpatient treatment, the patient switched from a state of syndromal remission, without any obvious forewarning or stressful encounter, into a hypomanic episode (Type II) (ICD-10 F 31 (WHO, 1992)). This was followed by a prolonged phase of mood instability before another hypomanic episode occurred one year later.

## **4.1. Psychiatric and medical history**

Clinically, the patient suffered from "double depression", made obvious by social withdrawal, loss of energy and drive since the age of 17 years with superimposed MDepisodes. Eight weeks in advance of the inpatient treatment, worsening of depressive symptoms had led to the onset of a new MD-episode: Mood changed for the worse, she cried a lot. In addition, there was also a loss of concentration and a loss of social, domestic and job-related capacities. This was followed by sleep disorders, undifferentiated anxiety and uneasiness. Just before she wanted to start outpatient treatment, she felt like wishing to commit suicide and told this to her sister. The operationalized diagnosis of a recurrent depressive disorder, moderately (-to severe) episode (ICD-10 (WHO, 1992), F 33.1) together with an antecedent dysthymic disorder (F 34.1) ("double depression") was ensured using the Structured Clinical Interview for DSM-IV (SKID-I and SKID-II, (Wittchen, Zhao, Abelson, Abelson, & Kessler, 1996). There was neither any direct or indirect sign for a prior hypomanic episode nor of hypomanic features (irritability, mood swings, crowded thoughts, sexual arousal, psychomotor acceleration, increased talkativeness) during the current MD-episode. There was no significant somatic history. The patient stated to smoke 20 cigarettes / daily; no other drugs were consumed.

### **4.2. Autobiographical history**

190 Psychiatric Disorders – New Frontiers in Affective Disorders

contacts and to introduce breaks and calm activities.

before another hypomanic episode occurred one year later.

20 cigarettes / daily; no other drugs were consumed.

**4.1. Psychiatric and medical history**

**4. Case history**

In Germany, the most established cognitive-behavioral program for the therapy of BD is the CBT approach of Meyer and Hautzinger (2004), which contains four modules, including psycho education, prophylaxis, and relapse prevention, modification of dysfunctional cognitive beliefs and formatting of additional interpersonal and social skills. The module psycho- education has the aim of training the patient about the cause of the illness and treatment possibilities. During prophylaxis, patients are trained to identify and modify early symptoms through the keeping of a daily diary. Also, they are taught to improve social rhythms. During acute hypomanic / manic episodes, the program tries to reduce acute symptoms, e.g., sleep disturbances, blowing money, agitation and distractibility. To reduce such symptoms, the manual shows strategies to reduce the activity level, to reduce social

In the following sections, we describe the psychotherapeutic treatment of a 29-years-aged female patient, who was initially diagnosed with "difficult to treat" chronic MDD with antecedent dysthymic disorder during inpatient treatment in the University Frankfurt, at that time suffering from a moderate (-to severe) non-psychotic MD-episode. The inpatient treatment lasted 6 weeks, followed by an outpatient treatment, lasting 25 months, using an adaptation of the CBASP. This was the first in- and outpatient psychiatric and psychotherapeutic treatment for the affected patient. After six months of combined SSRI/CBASP outpatient treatment, the patient switched from a state of syndromal remission, without any obvious forewarning or stressful encounter, into a hypomanic episode (Type II) (ICD-10 F 31 (WHO, 1992)). This was followed by a prolonged phase of mood instability

Clinically, the patient suffered from "double depression", made obvious by social withdrawal, loss of energy and drive since the age of 17 years with superimposed MDepisodes. Eight weeks in advance of the inpatient treatment, worsening of depressive symptoms had led to the onset of a new MD-episode: Mood changed for the worse, she cried a lot. In addition, there was also a loss of concentration and a loss of social, domestic and job-related capacities. This was followed by sleep disorders, undifferentiated anxiety and uneasiness. Just before she wanted to start outpatient treatment, she felt like wishing to commit suicide and told this to her sister. The operationalized diagnosis of a recurrent depressive disorder, moderately (-to severe) episode (ICD-10 (WHO, 1992), F 33.1) together with an antecedent dysthymic disorder (F 34.1) ("double depression") was ensured using the Structured Clinical Interview for DSM-IV (SKID-I and SKID-II, (Wittchen, Zhao, Abelson, Abelson, & Kessler, 1996). There was neither any direct or indirect sign for a prior hypomanic episode nor of hypomanic features (irritability, mood swings, crowded thoughts, sexual arousal, psychomotor acceleration, increased talkativeness) during the current MD-episode. There was no significant somatic history. The patient stated to smoke The female patient was born and raised in a family with father, mother and a younger sister (- 2 years). The father worked as a teacher, the mother was a housewife. There was no family history of psychiatric disorders according to DSM-IV criteria (American Psychiatric Association, 1994). She reported a close relationship to the other family members, but, the patient noted that, beside this close relationship, there was a lot of pressure to perform. During her childhood, the patient was a successful athlete of track and fields athletics. This was very important for her relationship to her father, because he joined every training and competition session and assisted her a lot. At the age of 17 years, her performance decreased due to a lack of body height. She called this event as a personal "trauma", because this was a break in the close relationship to her father. Since then, she refused to do any sports. The patient finished school at the age of 19 years, and then she began a formation in the field of advertising. She broke off the education after one year due to conflicts with her boss. After a few months of unemployment, she began to work in shifts work as an employee in a company. Further, she married in the age of 30 years and is living together with her husband, without a child.

## **5. Progress of therapy**

During the six-week combined pharmacologic and psychotherapeutic inpatient treatment, the course of the symptoms was measured weekly using the Beck Depression Inventar (BDI-II, (M. Hautzinger, Keller, & Kühner, 2006)). The BDI-II is a 21 item multiple-choice selfreport questionnaire. It is one of the most widely used instruments for measuring the severity of depression. The applied psychotherapy during this phase mainly included basic psychotherapeutic strategies with an emphasis on supportive elements in order to relieve the patient from symptom pressure. This was followed by 50 outpatient psychotherapeutic sessions (each lasting 45 minutes), during a time span of 25 months. An adaptation of CBASP was used after the switch into bipolarity. The frequency of the sessions differed between weekly during acute episodes and monthly during symptom-free episodes. The psychotherapy was complemented by pharmacological treatment prescribed from a psychiatrist.

## **5.1. Progress of medical treatment**

During the inpatient stay, a pharmacological treatment with Citalopram (40 mg / d) to reduce the acute depressive symptoms was initiated. This resulted in a reduced score of the BDI-II: Week 1: 41 points, week 6: 35 points; view Figure 1). The following progress of medical treatment reflects the clinical perspective of the responsible psychiatrist, showing a changed symptomatology including hypomanic symptoms according to the operationalized criteria. The antidepressant therapy was reduced during the first hypomanic episode six months after the start of the outpatient therapy (Citalopram 30 mg/d), and a neuroleptic treatment (Aripiprazol) was initiated. Under this medical treatment, the patient gained 10

kg of weight during a time span of 3 months most likely due to unrestrained eating behaviour. This was the reason to change the pharmacological therapy to the mood stabilizer Lithium. The following combined antidepressant and mood-stabilizing therapy was continuously kept up until the patient stopped it rapidly without consultation. This was followed by a second hypomanic episode. The treatment was then changed to Valproat going on through the whole following therapy time span without any further problems. The progress of medical treatment after the switch reflects the diagnostic dilemma in a switch situation. Although - according to the operationalized criteria - definitely a switch into BD-II is described, it has to be indirectly assumed that the responsible psychiatrist has done his clinical decisions from a clinical perspective of a transition from early-onset chronic MDD to BD-I.

Adaptation of Cognitive Behavioral Analysis System of Psychotherapy in a 29

Year Old Female Patient with Chronic Major Depression and Antecedent Dysthymic Disorder ... 193

continued by setting up the *therapy hypothesis* (TH). Key past encounters with her SOs were characterized by a lot of pressure for performance, strong devaluation, ignoring the feelings of the patient and a lot of dominant behaviours. As described in 4.2, there was a meaningful personal trauma at the age of 17 years, when she was refused to do any further track and fields athletics. Beyond this age, the father did no longer support her and he stopped to give her any heed. The father was one of her SOs who had exerted a negative formative influence with high impact on her life. Additionally, *s*hortly after the end of the track and fields athletics, her mother asked the patient to leave her parents' home. The patient remembered that "the mother's motivation was the wish for her daughter to be autonomous". However, in the view of the patient, this was a meaningful refusal by one of her SOs. The reconstruction of the emotional learning history resulted in the identification of the dominant interpersonal-emotional theme domain that she had to "perform well all the time" as she "always underachieved the expectations of others". According to CBASP`s TH construct, in this patient in-session events during which she makes mistakes towards the therapist (i.e. not doing her homework or coming late) evoke in her (Pavlovian) fear of punishment (mistake and failure area). The TH includes the hypothesized core content of the patient`s in-session interpersonal fear that most likely reflects the patient's expectancy of the therapist's reactions toward the individual (McCullough et al., 2010). The TH *was*: "If I make a mistake during the session, Ms. Oertel will punish me in some way".

Altogether, the first treatment phase lasted 10 therapeutic sessions. This was uncommonly long compared to McCullough's original outpatient protocol due to the generalization of the

The SA/IDE phase of treatment started with introducing the technique of *Situational Analysis* (SA) with the major treatment goal to help her to start thinking and acting more according

At a glance, SA has the aim to train the patient in a highly structured sequence to perform in a goal-orientated way. However, SA can also be seen as a top-down intervention that strengthens the executive functions by: (1) reinforcing and sensitizing the perceptive and interpretative performance by means of attention-focused interventions under aspects of awareness; (2) building-up the ability to control and perform with competence in a given situation, by means of contrasting past behaviour with the desired goal behaviour; and (3) shaping mental functions to think and act according to formal operational criteria. In this patient, SA work predominantly focussed on the counter-conditioning of fear reactions those occurred during the practising of realistic and goal-oriented behaviour in the

Second, the core content of the patient's interpersonal fear was counter-conditioned due to *Interpersonal Discrimination Exercise* (IDE) work. IDE work helped this patient to perceive how the patient-therapist relationship differed from her past relationships with her SOs due

heavy personal trauma (sports) into all other social and performance situations.

*5.2.2. Sessions 11-27: Second out-patient treatment phase (SA/IDE phase)*

to formal operational criteria (Schoepf *et al.*, 2007).

elicitation phase of SA work.

## **5.2. Outpatient CBASP therapy before switch into bipolarity**

At the beginning of outpatient therapy the symptom-severity was reduced to a slight characteristic (BDI-II sum score: 25 points). The patient mainly reported social withdrawal, undifferentiated anxiety and bad social skills as core symptoms at this state. Interestingly, during the whole time span of therapy, the outside appearance of the patient was eyecatching, with multi-coloured clothes and hair. The psychotherapy faithfully followed the conception of CBASP in an adapted way including two treatment phases.

## *5.2.1. Sessions 1-10: First out-patient treatment phase (pre-SA phase)*

The major therapeutic goals of the early treatment phase (pre-SA phase) are summarized in the Schoepf chapter in this book. Here, the major treatment goals were:

continued by setting up the *therapy hypothesis* (TH). Key past encounters with her SOs were characterized by a lot of pressure for performance, strong devaluation, ignoring the feelings of the patient and a lot of dominant behaviours. As described in 4.2, there was a meaningful personal trauma at the age of 17 years, when she was refused to do any further track and fields athletics. Beyond this age, the father did no longer support her and he stopped to give her any heed. The father was one of her SOs who had exerted a negative formative influence with high impact on her life. Additionally, *s*hortly after the end of the track and fields athletics, her mother asked the patient to leave her parents' home. The patient remembered that "the mother's motivation was the wish for her daughter to be autonomous". However, in the view of the patient, this was a meaningful refusal by one of her SOs. The reconstruction of the emotional learning history resulted in the identification of the dominant interpersonal-emotional theme domain that she had to "perform well all the time" as she "always underachieved the expectations of others". According to CBASP`s TH construct, in this patient in-session events during which she makes mistakes towards the therapist (i.e. not doing her homework or coming late) evoke in her (Pavlovian) fear of punishment (mistake and failure area). The TH includes the hypothesized core content of the patient`s in-session interpersonal fear that most likely reflects the patient's expectancy of the therapist's reactions toward the individual (McCullough et al., 2010). The TH *was*: "If I make a mistake during the session, Ms. Oertel will punish me in some way".

Altogether, the first treatment phase lasted 10 therapeutic sessions. This was uncommonly long compared to McCullough's original outpatient protocol due to the generalization of the heavy personal trauma (sports) into all other social and performance situations.

## *5.2.2. Sessions 11-27: Second out-patient treatment phase (SA/IDE phase)*

192 Psychiatric Disorders – New Frontiers in Affective Disorders

BD-I.

kg of weight during a time span of 3 months most likely due to unrestrained eating behaviour. This was the reason to change the pharmacological therapy to the mood stabilizer Lithium. The following combined antidepressant and mood-stabilizing therapy was continuously kept up until the patient stopped it rapidly without consultation. This was followed by a second hypomanic episode. The treatment was then changed to Valproat going on through the whole following therapy time span without any further problems. The progress of medical treatment after the switch reflects the diagnostic dilemma in a switch situation. Although - according to the operationalized criteria - definitely a switch into BD-II is described, it has to be indirectly assumed that the responsible psychiatrist has done his clinical decisions from a clinical perspective of a transition from early-onset chronic MDD to

At the beginning of outpatient therapy the symptom-severity was reduced to a slight characteristic (BDI-II sum score: 25 points). The patient mainly reported social withdrawal, undifferentiated anxiety and bad social skills as core symptoms at this state. Interestingly, during the whole time span of therapy, the outside appearance of the patient was eyecatching, with multi-coloured clothes and hair. The psychotherapy faithfully followed the

The major therapeutic goals of the early treatment phase (pre-SA phase) are summarized in

1. That she learned to self-monitor the intensity of her depression and to work through the results of the BDI II from a behavioral perspective together with the therapist. 2. To shape a sensitive patient-therapist relationship in the early treatment phase. The patient's stimulus value was initially hostile-submissive, i.e. the patient had always a jacket and a cap on at the beginning of out-patient therapy, evoking *hostile-dominant* responses in the therapist. For enhancing and accelerating the up-coming tasks, the therapist always responded to the patient in a non-dominant and friendly way. In addition, the SOs (parents, husband, sister) of the patient were asked by the patient to fill out the *Impact Message Inventory* (IMI-R; (Kiesler, 1987). The feedback was positive (friendly, adorable, interesting person) so that the patient was very impressed. The resulting changes in her hostile-submissive interpersonal messages, as perceived by the therapist and the supervisor, were associated with decreased anxiety and approaching behaviour. After six therapeutic sessions, the patient appeared, for the first time, without her cap. Additional elements comprised fundamental and additional CBASP specific

therapeutic interventions that are described elsewhere (Schoepf & Neudeck, 2011). 3. The reconstruction of the patient`s *emotional learning history* in antecedent consequent way. This was achieved by applying the SOH procedure over a prolonged time interval of up-to 8 sessions of therapy with eliciting the *causal theory conclusions* of the patient,

**5.2. Outpatient CBASP therapy before switch into bipolarity**

conception of CBASP in an adapted way including two treatment phases.

*5.2.1. Sessions 1-10: First out-patient treatment phase (pre-SA phase)*

the Schoepf chapter in this book. Here, the major treatment goals were:

The SA/IDE phase of treatment started with introducing the technique of *Situational Analysis* (SA) with the major treatment goal to help her to start thinking and acting more according to formal operational criteria (Schoepf *et al.*, 2007).

At a glance, SA has the aim to train the patient in a highly structured sequence to perform in a goal-orientated way. However, SA can also be seen as a top-down intervention that strengthens the executive functions by: (1) reinforcing and sensitizing the perceptive and interpretative performance by means of attention-focused interventions under aspects of awareness; (2) building-up the ability to control and perform with competence in a given situation, by means of contrasting past behaviour with the desired goal behaviour; and (3) shaping mental functions to think and act according to formal operational criteria. In this patient, SA work predominantly focussed on the counter-conditioning of fear reactions those occurred during the practising of realistic and goal-oriented behaviour in the elicitation phase of SA work.

Second, the core content of the patient's interpersonal fear was counter-conditioned due to *Interpersonal Discrimination Exercise* (IDE) work. IDE work helped this patient to perceive how the patient-therapist relationship differed from her past relationships with her SOs due

to the various forms of the IDE - that were employed in relation to the progress of therapy (Schoepf, this book). The technique of IDE was formerly described by us as a bottom-up technique that is assumed to be the major CBASP technique of (explicit) in-session acquisition learning (Schoepf et al. 2007; Schoepf & McCullough, 2009; Schoepf et al., 2011; Schoepf & Neudeck, 2011). For a further description of the use of the various forms of the IDE see the I-SOH chapter in this book (Schoepf).

Adaptation of Cognitive Behavioral Analysis System of Psychotherapy in a 29

Year Old Female Patient with Chronic Major Depression and Antecedent Dysthymic Disorder ... 195

perceive that the relationship to the therapist did not depend on her performance during the tasks. This was visible in the following obvious signs: After 13 therapeutic sessions she appeared without her jacket. Also, during the 13th session, the patient asked the therapist, for the first time, a personal question (about clothes). This was interpreted as reduced interpersonal distance. The IDE showed that the patient felt to be closer to the therapist than before. Simultaneously, the BDI-II sum score was reduced to 9 points. From then on, the patient always participated without the cap and the jacket. To receive positive feedback of a social interaction partner was a new and unexpected experience of the patient with respect to her interpersonal history. The positive feedback together with the IDE by the therapist helped the patient to reduce interpersonal anxiety and was therefore useful in this case although this is not common in early-onset chronically depressed patients. In the following sessions, a marked reduction of interpersonal anxiety developed, which the patient was able to keep up outside the therapy. With respect to CBASP`s skills teaching dimension the patient started to keep a diary of the relationship between behaviour and consequences ("effective diary"). For example, the patient was asked to test the consequences of doing any kind of sports (which she had been refused to do for years, see above). Through this exercise, she learned that physical training improves mood. Since that moment, the patient reintegrated sports into her leisure time. At the end of the SA/IDE phase she reached a stable state of full syndromal remission, i.e. here defined as a BDI-II sum score <=10. As described in the I-SOH chapter by Schoepf, the course of treatment in this young female patient demonstrates that under out-patient conditions an adapted CBASP protocol with a prolonged SOH procedure works best with a dosage of up-to 35 sessions in patients with

chronic MDD and antecedent dysthymic disorder.

**bipolarity (adapted phase)**

*5.3.1. First hypomanic episode*

14 days.

**5.3. Sessions 28-50: Adapted CBASP out-patient therapy after switch into**

Starting at session 28, the patient switched, without any obvious forewarning or stressful encounter, into a hypomanic episode (Type II) (ICD-10 F 31 (WHO, 1992)). She had less need for sleep, elevated mood and energy level, extravagant style, expanded self-esteem, increased consumption of nicotine and alcohol, she talked more often and had higher mood. The pharmacological treatment was changed as described in 5.1. The hypomanic state lasted

Behaviour-related strategies were adopted to reduce acute symptoms, i.e. calm activities, more breaks between activities, quiet environment. Another weekly inventory (beside the BDI-II), the *Bech Rafaelsen Mania Scale* (BRMAS)(Bech, Rafaelsen, Kramp, & Bolwig, 1978), asking for hypomanic / manic behaviour, was introduced into the therapeutic sessions. The scores of the BRMAS increased between the 28th and the 30th session (up to 41 points), but decreased in the following weeks. In addition, the technique of *Contingent Personal Responsivity* (CPR) was applied more frequently than before in a "here to now" way to consequate "difficult to treat" inpatient behaviour by disclosing personal responses and

**Learning context:** The patient usually brings into therapy a completed SA worksheet of either a distressing or pleasant daily living encounter that happened during the last week. The review of the worksheet is usually carried out in two consecutively phases on the flipchart (some therapists additionally distinguish a learning and transfer phase for didactic reasons).