Significant shifts or discontinuities in symptom course can mark points of transition and reveal important change processes. The authors investigated 2 patterns of change in depression--the rapid early response and a transient period of apparent worsening that the authors call a depression spike. Participants were 29 patients diagnosed with major depressive disorder who enrolled in an open trial of an exposure-based cognitive therapy. Hierarchical linear modeling revealed an overall cubic shape of symptom change and that both the rapid response and spike patterns predicted lower posttreatment depression. Patients wrote weekly narratives about their depression. Early narratives of rapid responders were coded as having more hope than those of nonrapid responders. The narratives of patients with a depression spike had more cognitive-emotional processing during this period of arousal than those without a spike. Findings are discussed in the context of cognitive-emotional processing theories in depression and anxiety disorders.