Abstract
BACKGROUND: Congenital heart disease (CHD) affects 1% of live births globally. Although depression and anxiety are commonly recognized in adults with CHD, psychological challenges extend beyond traditional diagnoses to include regulatory flexibility and cognitive adaptability, which influence coping strategies. CASE SUMMARY: A 40-year-old woman with a history of complex CHD presented for psychological support before major cardiac surgery. The patient described feeling "at war" with her body, demonstrating patterns of counterdependency and analytical problem-solving. Assessment revealed specific deficits in cognitive flexibility and mentalization capacity. Psychodynamic treatment spanning 56 sessions across presurgical, surgical, and postsurgical phases addressed these regulatory patterns. By treatment conclusion, PROMIS (Patient-Reported Outcomes Measurement Information System) Global Health scale showed substantial improvements in both physical health (T score increased from 16 to 39.8) and mental health (T score increased from 31.3 to 41.1) domains. The patient reported a shift from feeling "at war" to being "at home" in her body by the end of the treatment. DISCUSSION: Regulatory flexibility provides a valuable framework for understanding psychological adaptation in CHD patients. By honoring existing strengths while addressing rigid coping styles, psychotherapy can help adults with CHD develop more sustainable adaptation patterns for both physical and psychological well-being.