Metacognitive Therapy for Adjustment Disorder in a Patient With Newly Diagnosed Pulmonary Arterial Hypertension: A Case Report

Abstract

Adjustment disorders (ADs) belong to the worldwide most diagnosed mental disorders and are particularly frequent in patients with an underlying physical illness. Pulmonary arterial hypertension (PAH) is a severe and disabling disease, which significantly impacts on quality of life and has high mortality rates. The authors here present the case of a young female who developed a severe adjustment disorder with both anxious and depressive symptoms after a diagnosis of PAH requiring intensive care treatment due to right heart failure. Psychosocial functioning was severely impaired, and physical health reduced. Following hemodynamic stabilization and the establishment of PAH treatment, the patient was admitted to the Department of Psychiatry, Social Psychiatry and Psychotherapy and received metacognitive therapy (MCT). AD with mixed anxiety and depressed mood was diagnosed according to DSM-V criteria. At the start of treatment, she reported significant mental distress, indicated by a total sum score of the Hospital Anxiety and Depression Scale (HADS) of 20 points. The 6-min walking distance was only 358 m before the patient was exhausted. She then was treated with MCT without further psychopharmacological drugs. After only four MCT sessions, she fully remitted from AD which was accompanied by an 11-point reduction in the HADS (to 9 points). MCT specific scores also improved (MCQ-30 sum score decreased from 77 to 35). Notably, physical capacity improved as well, documented by an improved walking distance (439 m; +22%). This is the first case of a patient with AD in the context of PAH treated with MCT. The case report suggests that MCT is a possible psychotherapeutic treatment option for AD in the context of a potentially life-threatening disease. The study design does not permit an attribution of outcome to MCT but it suggests MCT is a potentially viable and acceptable treatment option.

Metacognitive beliefs and their relationship with anxiety and depression in physical illnesses: A systematic review

“…The results of the review mirror findings in mental health settings, which demonstrate that metacognitive beliefs are associated with anxiety and depression [29,[70][71][72][73][74][75][76][77] and that negative metacognitive beliefs of uncontrollability and danger show the strongest and most reliable relationships with these symptoms [29]. It seems therefore, that the relationships observed between anxiety, depression and metacognitions in non-clinical and mental health populations are similar to those found in patients with a range of physical health conditions.…”

“…Fisher et al [ 68 ] evaluated metacognitive therapy for emotional distress in an open trial for adult cancer survivors. Winter et al [ 69 ] conducted a case study of MCT for adjustment disorder in a patient with pulmonary arterial hypertension. These initial studies suggest that MCT is an acceptable and feasible intervention that was associated with positive outcomes.…”

“…This is important when considering psychological interventions, suggesting that interventions targeting metacognitive beliefs may be more helpful than those that target cognition. Preliminary studies of metacognitive therapy for treating anxiety and depression within physical illnesses show promising evidence [67][68][69]. Fisher et al [68] evaluated metacognitive therapy for emotional distress in an open trial for adult cancer survivors.…”

Prevalence of Mental Disorders and Impact on Quality of Life in Patients With Pulmonary Arterial Hypertension

“…It is conceivable that this may have been the best time for therapeutic intervention, which may have prevented the development of manifest psychiatric disorders in some patients. Recently, successful psychological treatment of a patient with newly diagnosed PAH suffering from severe adjustment disorder using metacognitive treatment was described (22). Metacognitive treatment belongs to the wide spectrum of "third wave" cognitive behavioral therapies (23) and has the advantage of relatively short treatment duration.…”

Health Disparities and Differences in Health-Care-Utilization in Patients With Pulmonary Arterial Hypertension

“…Recent studies have shown a higher prevalence of adjustment disorders among mental disorders in patients with PAH (13). Metacognitive treatment, a cognitive behavioral therapy, has been successfully applied to a patient with newly diagnosed PAH suffering from severe adjustment disorder (30,31). With only limited data on psychiatric treatment options in patients with PAH, further studies are needed.…”