CASE REPORT

Cognitive evolutionary therapy for depression: a case study

Cezar Giosan1,2,a, Vlad Muresan2 & Ramona Moldovan2
1
Liberal Arts, Berkeley College, 12 East 41st Street, New York City, New York, 10017
2
Clinical Psychology and Psychotherapy, Babesß-Bolyai University, Republicii 37, Cluj-Napoca, Cluj, Romania

Correspondence Key Clinical Message

Cezar Giosan, Liberal Arts, Berkeley College,
12 East 41st Street, New York City, New We present an evolutionary-driven cognitive–behavioral intervention for a mod-
York, 10017. Tel: +1-212-444-8577; erately depressed patient. Standard cognitive and behavioral therapy techniques
E-mail: [email protected] focused on the patient’s perfectionistic and self-downing beliefs, while novel, evo-
lutionary-informed techniques were used to guide behavioral activation and con-
Funding Information
This work was supported by a grant of the
ceptualize secondary emotional problems related to anger. The treatment reduced
Romanian Authority for Scientific Research, depressive symptomatology and increased evolutionary fitness.
CNCS-UEFISCDI, project number PN-II-ID-
PCE-2011-3-0230. Keywords

Received: 28 February 2014; Revised: 21 May Cognitive–behavioral therapy, darwinian psychotherapy, depression, evolution-
2014; Accepted: 24 May 2014 ary psychology, evolutionary psychotherapy.

Clinical Case Reports 2014; 2(5): 228–236

doi: 10.1002/ccr3.131

a
The first two authors contributed equally to
this work.

There is evidence that cognitive–behavioral approaches

Theoretical and Research Basis for
(e.g., see the American Psychological Association’s list of
Treatment
empirically validated treatments at www.apa.org) are
among the best empirically supported, both in terms of
Depression
theory and intervention.
Depression is one of the most prevalent mental disorders Cognitive and behavioral therapy (CBT) is an umbrella
and the third largest contributor to global disease burden, term including a variety of therapeutic approaches (i.e.,
outranking heart disease [1]; it is the number one contrib- cognitive therapy, rational emotive and behavioral ther-
utor to disease burden in developed countries, costing an apy, multimodal therapy, schema-focused therapy, etc.),
estimated $81 billion in the U.S. alone [2] and €118 billion sharing a common rationale: the mediational role of dys-
in Europe, where it is the most costly mental disorder [3]. functional cognitions in maintaining, predisposing or
The etiology of depression is far from being completely causing depression [15–17]. This has resulted in a prolif-
understood. Factors such as dysfunctional cognitions [4, 5] eration of publications and the development of treatment
demographics [6], prior major depression [6], early traumatic approaches designed to alter the cognitive contents or
experiences [7, 8], or negative life experiences (e.g., job loss, processes hypothesized to be depressogenic [18, 19].
loss of a close one) [9] have been shown to be involved. Beck’s theory of depression is arguably the most influ-
ential model developed around the causes, course, and
treatment of depression [5]. Literature has been consis-
Current psychological standard of care in
tently showing that people have relatively stable cognitive
depression
patterns that develop as a consequence of early learning,
Evidence-based treatments for depression are available and that leads them to make negative and distorted inter-
and extensively used [10–14]. pretations of specific life events [20]. CBT does not

228 ª 2014 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use,
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C. Giosan et al. Cognitive evolutionary therapy for depression

provide an elaborate view of the origin of emotional dis- fitness or reproductive success, which are thought to lead
turbance, though it acknowledges that it is very likely that to depression when prevented from functioning optimally
different people disturb themselves about highly aversive [42]. Such an approach enhances the CBT paradigm by
events differently [21]. More specifically, CBT is based on including information about the hypothesized adaptive
the premise that psychological problems stem from dys- functions of depressive symptoms, along with direct inter-
functional/irrational cognitions [20, 22] and, as such, the ventions on fitness-enhancing factors. In addition, atten-
therapist works with the client to identify and focus on tion is paid to unhealthy behaviors that generally lower
those cognitions in order to modify them and remedy fitness, targeting them specifically in the therapeutic pro-
associated emotional and/or behavioral consequences. cess [42, 43].
Human behavior generally revolves around a finite set
of biological and social adaptive problems (e.g., shelter/
Depression from an evolutionary
security, nutrition, sexuality, mating, parenting, and in-
perspective
group and between-group interaction [44]. Research has
Because of the universality and prevalence of mental illness, shown that when people are successful at meeting these
attempts have been made in Evolutionary Psychology to goals, they generally experience well-being and happiness
explain the possible functions of utility of some symptoms [43]. Not meeting these goals has been associated with
[23–25]. From this perspective, some mental disorders are dissatisfaction, depression, tension, or frustration [43].
seen as having present or past fitness advantages [26] and CET enhances the classical CBT approach by focusing on
therefore might have been naturally selected (e.g., mild and guiding the patients in solving fitness-related problems and
moderate depression) [27] or are viewed as exaggerated by using an evolutionary-aware conceptualization in some
responses to certain stimuli that constituted dangers in our of the problems they may encounter [42]. Like in the classi-
evolutionary history (e.g., phobias) [28, 29]. cal CBT, at the beginning of the therapy the psychothera-
Depression has been tackled in the evolutionary psy- pist and the patient select and define the list of problems
chology research because of its high prevalence (5–10% in that will be addressed during treatment. However, unlike
the US) [30], universality [31], and upward course [32], the classical CBT, where the patients typically volunteer
as well as because it sometimes leads to devastating fitness these problems, in CET they are identified at intake by an
consequences, such as suicide [33]. Unlike the prevalent evaluation of the patients’ fitness [42]. During the therapy,
medical view, which views depression as a brain disorder discussions about human nature from an evolutionary
[34–36], current evolutionary insights explain this condi- standpoint can encourage the patients to experience accep-
tion by hypothesizing the functions it may serve [37–39]. tance, a key ingredient in CBT [45, 46], by acknowledging
From this perspective, depression is seen as a mechanism basic human limitations. These evolutionary arguments
signaling fitness (i.e., reproductive) problems or risks can become powerful tools in the disputing process, com-
(e.g., low mood is associated with lesser likelihood of monly used in the standard CBT. Thus, evolutionary psy-
engaging in risk-taking behaviors) [40]. chology concepts (e.g., cognitive modularity [47, 48],
parental investment theory [49, 50], conspicuous con-
sumption [51, 52] and costly signaling theory [53, 54]) can
Cognitive evolutionary therapy for
offer useful explanations for depressive symptomatology
depression
and the mechanisms underpinning it.
CBT focuses on changing dysfunctional cognitions, thus While some authors have hypothesized the potential
leading to improvements in the depressive symptoms [4, therapeutic benefits of evolutionary approaches in clinical
20]. From this perspective, dysfunctional beliefs are seen practice [55], there is virtually no empirical research test-
as proximate, or immediate causes of depression. But ing the clinical implications (and applications) of these
some have argued, for example, that Beck’s cognitive dis- theories. To our knowledge no study has so far addressed
tortions are a consequence of depression, not a cause of it the practical implications of this recent progress. The
[41]. In other words, the underlying evolutionary, or ulti- present case study is a first attempt aimed at examining
mate causes that might contribute to depression and to the efficacy of CET for depression.
dysfunctional thinking are not addressed directly in the
current therapeutic approaches and a unifying evolution-
Case Formulation
ary-driven paradigm providing explanations about the
ultimate causes of depression is lacking.
History
A Cognitive Evolutionary Therapy for depression (CET)
would focus, besides proximal causes, on distal (ultimate, For the present case study we selected the treatment of
or evolutionary) mechanisms as well, such as inclusive one of the patients enrolled in a randomized clinical trial,

ª 2014 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd. 229
Cognitive evolutionary therapy for depression C. Giosan et al.

which tests the efficacy of CET for Depression [42]. This

Assessment
study was approved by the Ethics Commission of Babeș–
Bolyai University. Self-report measures and the Structured Clinical Interview
Judy (not the real name) is a 22-year-old student who for DSM-IV [56] were administered to the patient
was referred for therapy by friends after a difficult break- throughout the treatment. Table 1 presents them, along
up that affected her school performance and personal life. with the scores (Table 1).
She is the only child of a typical middle-class family, liv- The Structured Clinical Interview for DSM-IV (SCID)
ing by herself during the school year and going back [56] is the most widely used diagnostic exam used to
home (to a different city) during the holidays. determine DSM-IV Axis one disorders, designed to be
The patient enrolled in treatment after signing an administered by a mental health professional. It consists
informed consent. The initial psychiatric evaluation in the Overview, Mood Episodes, and Anxiety Disorders
revealed that she had no prior history of depression or modules. The Overview module collects information
other psychiatric conditions. about socio-demographic variables (i.e., date of birth,
The patient underwent CET following the protocol marital status, number of children, level of education,
described by Giosan et al. [42]. The initial problem list and employment status), drugs use, drinking, medication,
presented by the patient included depressed mood, feel- physical and psychological treatment history (including
ings of guilt, and anger because of the dissolution of a any treatments, past or current, for depression), and cur-
6-month-old dysfunctional relationship. Judy felt person- rent social functioning. The Mood Episodes and Anxiety
ally responsible for the break-up, and believed that she Disorders Modules follow the diagnostic criteria of the
would never be able to experience a similar level of emo- DSM-IV-TR [57] for mood episodes and anxiety disor-
tional involvement again. Judy’s goals for therapy were ders.
to get over the relationship and better cope with her sit- The Beck Depression Inventory-II (BDI-II) [58] is one of
uation. (At the time, in an attempt to distract herself, the most widely used self-report measures of depression
the patient was involved in binge drinking and reckless symptoms, and it includes 21 items referring to various
partying). psychological and physical symptoms (e.g., feeling sad,
We selected this specific case because it illustrates the guilty, hopeless, being agitated). It has high test–retest
specific techniques used in CET and the rationale behind reliability (1 week) (Pearson r = 0.93) and high internal
using it as an add-on to the classical CBT intervention. consistency (Chronbach’s a = 0.91) [58, 59].
As further detailed below, the clinical conceptualization The Attitude and Belief Scale II (ABS-II) [60] is a self-
and the actual treatment both benefited from the evolu- report scale, with good psychometric properties, designed
tionary theory [2] by explaining the difficulties in over- to measure irrational beliefs. The ABS-II has been shown
coming depression using evolutionary insights and [3] by to be a reliable and valid measure of rational and irratio-
guiding and explaining the relevance of secondary goals nal beliefs [60, 61].
(diet, exercise) in treating the patient’s primary goals The Automatic Thoughts Questionnaire (ATQ) [62] is a
(depressive symptoms). 30-item self-report measure used to asses depression-

Table 1. Scores for the self-report measures administered at the beginning, during, at the end of treatment, and at follow-up.

Session number

Instrument Intake 1 2 3 4 5 6 7 8 9 10 11 12 Final FU

BDI-II 22 23 20 20 24 17 17 10 7 7 8 4 5 7 13
ABS-II 106 116 119 94 96
ATQ 112 103 68 67 77
PANAS-P 28 29 31 31 36
PANAS-N 40 29 24 25 36
FES 103 146 139
ETO 32 28 30
WAI 75 77
CSQ 30 30 32 31 32 32 32 32 32 32 32 32

BDI-II, beck depression inventory-II [58]; ABS, attitudes and beliefs scale 2 [60]; ATQ, automatic thoughts questionnaire [62]; PANAS-P, positive
and negative affect schedule – positive score; PANAS-N, positive and negative affect schedule – negative score [65]; FES, fitness evaluation scale;
ETO, expectation of therapeutic outcome; WAI, working alliance inventory [67]; CSQ, client satisfaction questionnaire [68].

230 ª 2014 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.
C. Giosan et al. Cognitive evolutionary therapy for depression

related cognitions, with good convergent validity, internal symptomatology measured with the BDI-II was 23, signi-
consistency, and test–retest reliability [63]. The ATQ has fying moderate depressive symptomatology [58], confirm-
also been shown to be sensitive to changes in the depres- ing the initial SCID clinical diagnosis. The level of
sion levels [64]. expectancy for therapeutic outcome was 32 out of 32,
The Positive and Negative Affect Scale (PANAS) [65] is showing that the patient was highly motivated and
a 20-item self-report questionnaire, designed to assess believed in the efficacy of the intervention offered. She
positive and negative affect. The PANAS can be used to reported intense depressed mood and bereavement, guilt,
assess mood on various time scales by altering the anger, trouble concentrating, and diminished interest in
instructions. Possible time scales include moment, today, pleasurable activities. The completion of the FES revealed
past few days, week, past few weeks, year, and general. fitness deficiencies on the following dimensions: (1) low
The validity and internal consistency of the PANAS is perceived attractiveness (the patient believed that she was
good, with test–retest reliability being the highest for the not attractive, despite evidence to the contrary such as
“general” temporal instruction [65]. her friends’ opinions and the therapist’s own judgment);
The Expectancies of the Therapeutic Outcome are mea- (2) poor eating habits (the patient predominantly con-
sured using four items on a 9-point Likert Scale. The sumed junk food), and (3) lack of physical exercise. Thus,
items measure the patient’s perceived usefulness of the the therapy goals list set at the beginning of the treatment
treatment (e.g., “How logical does this treatment seem to included working on the dysfunctional coping behaviors
you?”; “How efficient do you think this treatment will in (e.g., weekend drinking) and improving on the fitness
reducing the symptoms that you experience?”). The scores deficiencies identified by the FES. The patient was offered
range from 0 to 32. a clinical conceptualization that centered on the evolu-
The Working Alliance Inventory (WAI) is a 12-item self- tionary causes of depressive symptomatology (i.e., fitness
report global measure of the working, or therapeutic alli- problems) and proximal causes consisting of dysfunc-
ance, presenting good psychometric properties [66, 67]. tional cognitions. Specifically, Judy’s depression was
The Client Satisfaction Questionnaire [68–70] is an 8- explained as being caused by a set of fitness-related issues,
item instrument used to evaluate the patients’ satisfaction namely, unbalanced diet, lack of exercise, and poor self-
with the treatment. image expressed through dysfunctional cognitions. The
The Fitness Evaluation Scale (FES) is a 45-item (58 if latter led to rigid irrational thoughts such as “I must be
the patient has children) scale, adapted and expanded by appreciated by my ex-boyfriend or else I am worthless”,
the authors from the High-K Strategy Scale (HKSS) [71], “I will never find someone that will make me feel the
tapping into various dimensions and biosocial goals theo- same, and that is horrible”, or and “I am a stupid, weak
rized to make up the indicators of fitness, as detailed in person for not getting over it already.”
the Background section. The HKSS has been shown to be The main focus of treatment was to engage the patient
negatively associated with depressive symptomatology in behaviors targeted at increasing fitness, while challeng-
[72] and psychopathology in general [73]. The FES was ing the dysfunctional thoughts and increasing confidence
preliminarily validated on a sample of 146 subjects and in more rational and functional alternatives.
presents good internal consistency (Cronbach’s
Alpha = 0.93). The FES is the therapist’s starting point in
Course of Treatment
prescribing the evolutionary-driven interventions, as fur-
ther detailed below. Following the protocol described elsewhere [42], the first
treatment session focused on educating the patient about
depression and psychotherapy in general, emphasizing the
Procedure
importance of homework, taking responsibility for change
Judy was assessed for eligibility for treatment with the and adjusting her expectations about what can be gained
SCID [56]. Following the initial assessment the patient through therapy. Judy had a clear understanding about
was assigned to treatment and evaluated psychologically what psychological treatment entailed and what her
regularly as detailed in Table 1. responsibilities as a patient were.
Also, in the first session we focused on specific CET
insights that helped her to gain a clearer understanding of
Case conceptualization
the problems she was confronting, thus leading to a more
Judy is a 22-year-old female student, belonging to a mid- accepting attitude about her symptoms. Thus, the patient
dle-class family, who was referred to psychotherapy after was explained that cognitive structures that were adaptive
a difficult break-up that affected school performance and in a Pleistocene environment are now “mismatched” with
general quality of life. At intake, the level of depressive the current environment, sometimes leading to dysfunc-

ª 2014 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd. 231
Cognitive evolutionary therapy for depression C. Giosan et al.

tional emotions and behaviors [74, 75]. The patient was effect visible in a 7-point drop on the BDI-II after the
also explained that some scholars see Depression as an fourth session (see Table 1). Judy was explained that in
adaptation that might have conferred fitness benefits in the tribal living of the EEA, being rejected by a desirable
the Environment of Evolutionary Adaptedness (EEA) mate in the group had severe fitness, status and reputa-
[31], by encouraging cooperation and eliciting support tion costs. In this context, a strong motivation for not
from group members, things that are much harder to being rejected and for hanging on to what we now call a
achieve in the modern society. Finally, the patient was dysfunctional relationship, would have been adaptive.
informed about the research linking depression and fit- However, she was further explained, the environment we
ness-enhancing behaviors, namely the relationship are adapted to was very different from the present one:
between diet and depression [76, 77] and exercising and Firstly, there were few potential partners to choose from,
depression [78]. While the patient had a general idea as we lived in groups of 150–200 tribe members [82].
about the positive associations between diet, exercise and Secondly, being rejected often had higher reputational
health, the realization that these associations hold true in costs than today, and finding another high-quality mate
the case of depression, too, helped in motivating her to was less likely. This evolutionary mismatch proved to be
begin exercising more and thinking about adjusting her an important argument toward explaining to Judy why
diet in the sense of incorporating foods that our ancestors she was so fixated on her ex-boyfriend, further helping
typically consumed [76, 77]. This was the point in Session her to accept herself as a fallible human being. This
1 where we established a realistic behavioral activation important milestone in the treatment was followed by
plan that would tap into the above-mentioned fitness- cognitive restructuring homework focused on changing
related dimensions (diet and exercise). The homework the irrational belief “I should get over it faster, and if I
focused on detailing the behavioral activation plan with can’t I’m a weak, worthless person” to its more rational
specific behaviors that the patient was instructed to work and useful counterpart “I’d like to get over it faster, but I
on in the following weeks. can accept if it takes some more time, and if it does, it
The next few sessions [3–7] focused on standard CBT doesn’t mean I’m a weak person, but a normal, fallible
tasks and techniques, aimed at enhancing the therapeutic human being”. After challenging this perfectionistic
relationship and negotiating behaviors that addressed fit- demand, cognitive work focused on the global evaluation
ness problems revealed at intake by FES. A specific prob- that underlined her depressive mood (e.g., “If he rejects
lem that benefited in an important way from the me that means I’m unattractive and worthless” and “If
evolutionary conceptualization was the difficulty Judy had I’m not going to feel the same thing again nothing is
to accept her reaction to the break-up. After realizing that worth living for”). We will not go into great detail about
being rejected affected her more than what she expected, the CBT techniques as we followed existing CBT guide-
she began to experience anger with herself. This kind of lines for depression [4, 83, 84]. Instead we will focus on
secondary emotions (i.e., emotions about emotions) are specific evolutionary-informed techniques used in this
often an obstacle to the therapeutic change [45, 79, 80]. patient’s treatment.
In Judy’s case, her anger about her depression was caused Sessions 7–11 focused on maintaining the behavioral
by rigid beliefs such as: “I shouldn’t be so upset about habits of healthier dieting and exercise, by finding alterna-
him; I’m a weak person because I’m depressed over the tive behaviors, so as not to reach saturation. Indeed, our
end of the relationship”. In clinical practice, the therapist ancestors would have likely travelled in different places
cannot address the problem of depression until the sec- every day, and we tried to build such variation in Judy’s
ondary emotion (anger in this case) is resolved [45, 81]. exercising routine, to avoid reaching boredom. Dieting
Indeed, one of the main reasons why Judy didn’t get over was also addressed with behavioral techniques, by guiding
the break-up by herself was her inability to accept her fal- the patient to replace fast-foods with healthier alternatives
libility (i.e., the fact that as a fallible human being, she is such as vegetables and foods low in saturated fats and
allowed to make mistakes, and feel depressed). Further- high in Omega-3’s [76], while continuously reinforcing
more, every attempt from her friends or from the thera- the connection between a healthy diet and positive health
pist to help with the depression resulted in the activation and psychological outcomes. By session 8 Judy’s depres-
of her perfectionistic belief (“I shouldn’t be depressed sive symptomatology was down substantially (from 22 at
about him, and I am a weak, worthless person because I intake to 7 on the BDI-II at the eight session, a decrease
am”) and the resulting anger, which prevented her from of 68%), and at this point we began to address expecta-
gaining insight on why she was depressed in the first tions about relationships, namely that a relationship based
place. on a rollercoaster of physical and verbal aggression fol-
The evolutionary conceptualization of Judy’s depression lowed by intense physical attraction isn’t sustainable or
greatly helped in teaching the patient to accept herself, an desirable on the long run. Assertive communication was

232 ª 2014 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.
C. Giosan et al. Cognitive evolutionary therapy for depression

also practiced with her, and we explored the patient’s niques, however, can be used regardless of the patient’s
expectations and preferences about future romantic religious beliefs.
partners. By the end of therapy Judy was beginning a new These findings add support to recent studies that doc-
relationship, based on the mutual respect and communi- ument links between depression and reproductive success
cation, which was satisfying and enjoyable for both part- [72]. Further studies should examine the effects of
ners. The patient successfully rejected her ex’s advances targeting fitness factors on depression in a controlled
when he tried to get her back, something that she previ- manner.
ously never thought she would be able to do.
As a consequence of working on self-acceptance [45,
Conflict of Interest
79, 80] and developing her rational thinking skills, her
low opinion about her own attractiveness – one of the None declared.
problems identified at intake by the FES – improved sub-
stantially by the end of therapy. References
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