Medical illness and medical care can enter into cognitive-behavioral case conceptualization in a number of ways. For example, symptom and disease attributions can help to inform case conceptualization. It is important to determine whether patients attribute depression or anxiety symptoms to their medical illness, and whether they attribute their medical illness to stress, depression, anxiety, or other problems (Day, Freedland, & Carney, 2005; Freedland, 2005).

In developing a case conceptualization, it is important to consider the extent to which the patient is distressed about the consequences or implications of his/her illness, rather than about the illness per se. Dysfunctional Thought Records reveal that many patients spend little time ruminating about their medical condition but frequently have distressing thoughts about its consequences or implications. For example, a patient may experience less distress about her cancer than about the belief that she is to blame for it. A patient may have few automatic thoughts about his recent heart attack, yet be overwhelmed with concerns about being unable to return to his former lifestyle, or with guilt about letting his family down by not taking better care of himself. When patients dwell on recent medical events, therapists can expect these events to dominate collaborative agenda setting during the first few sessions. However, many patients are eager to leave their medical crises behind and move on with their lives. In such cases, it is not helpful to emphasize the medical event in the case conceptualization or treatment plan.

Whether the relationship between the patient's medical and psychological problems is a central focus of therapy or only a peripheral issue varies from case to case. An individual may be identified as a "cancer patient" or a "heart patient," yet be depressed about something distantly related, if related at all, to the medical illness. One patient, for example, had been hospitalized repeatedly for heart and lung disorders. She had been ill for 10 years and was coping very well with her medical problems, but she was distressed about her grandson's drug abuse and about her daughter's irresponsibility as a parent. It would have been counterproductive, at best, to make this patient's medical problems the centerpiece of the case conceptualization. This is in contrast to other cases, in which medical problems are responsible for much of the patient's distress.

Depressed patients' medical illnesses should be considered from a developmental lifespan perspective. Core beliefs, intermediate cognitions, and compensatory strategies begin to develop early in life, at a stage when the chronic illnesses of middle- and old-age are just remote abstractions. When medical illness strikes, it often does so unexpectedly, in ways that violate the patient's beliefs. It is hard to adjust to a serious medical illness if one believes, for example, "Other people can get sick, but not me." It is also hard to adjust to illnesses that strike at a younger age than their victims have any reason to expect. One of our patients developed severe CHF in his early 30s, not long after the birth of his first child. He expressed a profound sense of shock and existential betrayal at having been stricken with "something that only happens to old people" and that would prevent him from being the father and husband he had always wanted to be. In some cases, however, medical illnesses do not violate core beliefs, but instead confirm and activate them. The onset of cancer, for example, might reinforce a patient's long-held belief that "I'm defective" or that "I've been doomed from the start."

Medical illnesses can also disrupt compensatory strategies that were more or less successful during the healthier years of the patient's life. An individual with a core belief of unlovability, for example, might compensate for it with a very active social life. If the emergence of a chronic illness prevents her from maintaining her social activities, she may have no alternative strategies with which to defend herself against feeling unwanted.

A developmental lifespan perspective is also helpful in conceptualizing the psychosocial effects of medical illnesses that affect younger individuals. For example, a recent study examined the efficacy of CT for depression in patients with epilepsy. The participants were young adults whose epilepsy deprived them of opportunities to gain independence, to pursue a career, to develop an adult social network, or to find a partner. The depressogenic problems that confronted them were the opposite of those experienced by many older individuals, who enjoyed decades of good health and independence before developing a chronic medical illness.

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