Initial treatment success followed by failure: How do we deal with toxic core beliefs in the context of comorbid major depression with psychotic features, social phobia, and axis II pathology?

This article presents a diagnostically complicated case involving comorbid major depressive disorder with psychotic features, social phobia and personality pathology (including avoidant, paranoid, and obsessive compulsive traits). gMr. Xg was a 45-year-old single White male who was unemployed and living with his parents at the time of treatment. He presented with severe anxiety (Beck Anxiety Inventory = 43) and depression (Beck Depression Inventory = 41) as well as active psychotic symptoms (e.g., self-depreciating auditory hallucinations). Although a cognitive case formulation and treatment plan led to initial success in terms of improvements in symptomatology and functional impairment, we speculate that failure to adequately address core toxic beliefs (e.g., gI am inadequateg) ultimately contributed to a precipitous return of symptomatology, followed by a suicide attempt and premature treatment termination. We discuss the challenges of working within a cognitive framework with this client and suggest alternative approaches that might have proven more successful.