Chapter 1. Patient: Tina

1.1 Introduction

1.2 Presenting Complaint

Forty-two-year-old Tina was waiting for her first appointment with a psychotherapist. She could not believe she was here. If her friends, her daughters, or, heaven forbid, her mother, knew she was here she would never live it down.

But Tina was desperate. After weeks of suffering from shortness of breath, dizziness, and "the shakes," as she called the trembling in her hands, she had gone to see her family physician. She was sure she had heart problems or high blood pressure.

A thorough examination and lab workup revealed that she was fine, physically. She was overweight, though, and the doctor told her she needed to quit smoking. Tina smoked two packs a day, as she had since she was in her 20s. She had also taken to drinking to "calm her nerves," but she did not tell the doctor about that. She really did not like the taste of liquor, but it was the only thing that calmed her down enough to sleep. She felt as if her body was tied up in knots all the time—especially at night. A friend suggested a massage to help relieve her muscle tension, but massages were expensive. And a nightcap was cheap and helped her to sleep.

And Tina needed sleep. Since Harry, her husband of 24 years died, the days had been miserable. She had a sense that something else bad was about to happen. Maybe her 14-year-old twin daughters would be abducted on the way to the bus stop. Maybe the bus would be in a horrible crash and they would be killed. Added to her constant worry was an irritability born of dealing with teenagers. She used to be able to put up with the twins playing music too loud, talking on the phone too long, and squabbling among themselves. Now the least thing set her off. With taking care of them, worrying about what was going to happen, and getting no sleep at night, it was no wonder that Tina complained of being tired all the time.

Tina's friends told her that she needed something to do. They urged her to take any kind of job to get her out of the house while the girls were in school. “Get out of the house?” she would say. She did not tell them that she had gotten to where she hated to drive. Why, one day just last week she pulled over when she found herself gasping for air. When she stopped, she felt her heart pounding. Her palms were so sweaty she was losing her grip on the steering wheel. She thought she was dying of a heart attack.

That frightening episode sent Tina to the doctor. She was so nervous driving to the therapist's office that she thought she would have to turn around and go home. Traffic was tied up at the bridge. She dreaded crossing bridges to start with (and there were a lot of bridges in the coastal Florida community where Tina lived). Lately she had wondered how safe those bridges were, and if they might not collapse just as she reached the top. A part of her was able to see that her fear was ridiculous. After all, she had lived here all of her life and a bridge had never collapsed. But maybe that's why it will collapse with her on it, she worried. Maybe it's about time for them all to crumble and fall into the river. The bad part was that there was nothing that Tina could do to avoid bridges. Not in this town. You had to cross a bridge of some sort to get most anyplace. The normal tension that Tina felt got worse every time she crossed one of the larger bridges. She felt a sense of panic as she approached these dreaded structures.

When she asked her family physician for something to help her sleep, he said he would consider it, but not until she went to a psychologist. If a therapist thought medication was advisable, Tina could get a referral back to him or on to a psychiatrist. The doctor believed Tina might be suffering from an anxiety disorder and, if so, several medications could be considered.

1.3 Social/Family History

Tina was the fourth child in a family of six. Her family was poor, but not poverty-stricken. Her father was a laborer and her mother worked out of the home cleaning houses. Tina was good in school but had no interest in going to college or working. She married Harry, her childhood sweetheart, when they were both 18.

Harry had a good job driving a truck for a food distribution company. In his spare time, he worked on other people’s cars. Harry was a good man and loved Tina, but he was very controlling. His father had died when he was 12, and being the oldest of three boys, he became the "man" of the family. His mother was in poor health and had been very dependent on his father. She had never even learned to drive, so Harry had to help his mother keep the family and home together.

When Harry married Tina, he just naturally took over running their house. This was fine at first with Tina. She liked being the center of Harry's attention, for she had gotten little in her large family. When Harry started working on cars at home, he kept her busy running into town to get parts and typing bills for his clients. That got old after awhile, for Tina felt like Harry was always ordering her around and showed little appreciation for her dedication to his side business. But she kept her mouth shut. She didn't want to work and besides, eventually Harry had made enough for them to buy a comfortable home.

Tina and Harry had twin daughters, and Harry doted on them. He was a controlling and authoritarian parent, but the girls loved him. And Tina was so soft-hearted that she could always temper Harry's harshness.

Two years ago, out of the blue, Harry was diagnosed with lymphoma, a deadly and fast-growing form of cancer. Tina was devastated. She could not imagine life without Harry. But she put so much energy into his treatment and taking care of him that she did not have time to worry about the future. Harry was not an easy patient. He had six surgeries and several periods of radiation. Tina drove him to and from these treatments. Between treatments and surgeries their home was a hospital. Harry died a year to the day after his diagnosis. And it was just a year ago that Harry died.

Tina had a rough time in the year after Harry's death, but there was so much to take care of that she did not have time to worry. She smoked more and ate more. But, as she told the girls, who worried about her, that helped her keep "body and soul" together. Harry had plenty of life insurance and Tina was able to sell his mechanic's tools and equipment. Harry had credit life insurance on the house, so the mortgage was paid for. He also had great medical insurance, so there were no leftover medical bills—a burden to so many other widows. Tina considered herself fortunate. She still did not have to work.

But now that the details of Harry's death were taken care of, she found herself at loose ends after the girls left for school. No longer needing to cook for Harry (he insisted that she make large dinners for the family and he refused to eat leftovers), and with the housework taking less time with him gone, she didn't have much to take up her days. But the evenings and weekends were the worst. Since that is when Harry worked on cars, she was always busy helping him hold something or getting parts. The twins spent their weekends with friends or their friends came over. But they sure didn't want Tina hanging around with them.

A few weeks ago, it seemed as if her world had come crashing down on her. She had gone from her parents’ home to life with Harry. She had never been independent. Now Harry was gone, the twins didn't need her (or so she thought), and here she was, 42 years old, facing a life alone. Not that she could imagine ever marrying someone else, but a date now and then would be nice. “But who would want her?” she mused. Not only her age, but also her weight and the fact that she had two children—surely that would run off any good man. And there are no good men anyway. They are all married, she reasoned.

The way Tina saw it, her life was getting grimmer with every passing day. That is when she started feeling funny—and went to see her family doctor. Maybe he was right. Maybe a psychologist can help her.

1.4 Multiple-Choice Questions

1.5 Treatment