Chapter 1. Joanne

1.1 Introduction

Professor

Lord Fairfax Community College

1.2 Presenting Complaint

Joanne is a 53-year-old Caucasian woman. She has an undergraduate degree in performing arts from a prestigious institution. During the course of her professional career, she has acted, appeared in television and print commercials, and owned and operated upscale women’s clothing boutiques. Ten years ago she was married for the first time to Jack, who is 12 years older. . Jack had been married three times and has four children from his first marriage,. Jack retired shortly after they married, and they moved from a large Northeastern city to a rural Midwestern area where he has a 200-acre farm.

Joanne had never lived in the country before. She used her creative talents to design decorate and furnish a beautiful new home, but she never quite got over leaving the city and her career. She and Jack have a good relationship, but she never was able to establish connections with Jack’s adult children. This was a great disappointment to her, as she did not have children of her own. Living out in the country, she had few opportunities to meet new people; her social circle consisted only of Jack’s old childhood friends. She never attempted to resume working or start a new business, given the distance of their home to the nearest large town.

Joanne once had had a lot of energy and was engaged in many artistic and creative activities, including painting, refurbishing furniture, and decorating. She longed for the days when she ran her trendy boutiques and went on buying trips to New York. She missed the days when she had a social life in the city, and went to movies, plays, and fine restaurants with sophisticated friends. She once or twice floated the idea that they leave the country and move to a small city, where she might open a shop or even work in one, or find other outlets for her creativity. The financial drain and constant work on the farm caused her to feel some resentment. After all, the farm was Jack’s dream, not hers.

Joanne was at the neurologist’s office—this was her fifth specialist doctor visit this year. In addition to medical doctors, she had been to a chiropractor, a massage therapist, and an acupuncturist. Though these practitioners gave her some relief for a day or so, she never felt better for long. In fact, she was getting worse. Jack, her husband, was waiting quietly with her. He was worried about her, of course, but he was getting tired of going from doctor to doctor, as Joanne searched for a diagnosis and treatment for her persistent problems.

Joanne had several presenting complaints. She felt extremely tired all the time and she had no energy. Sometimes she spent the entire day in bed. . She suffered from muscle aches in various parts of her body, including her shoulders, arms, and legs. Lately, she had developed a pain in one hip and she complained that her hip occasionally “went out”. She felt like it was buckling under her. However, the orthopedic doctors she consulted couldn’t find anything wrong with her hip.

Joanne spent hours on the Internet researching her problems. She had found all kinds of possible causes for her problem, but each time she went to a specialist, he or she ruled out her theories. For example, she had read that the estrogen she had been taking since a hysterectomy a few years back might be affecting her hip muscle. Her gynecologist told her that this was a rare phenomenon and certainly not her problem. A chiropractor manipulated her hip and she felt fine for a day or so, but then she was so sore she could not move.

Joanne’s problems seemed to worsen with higher stress levels at home. Her husband’s farm was in a remote and isolated part of the country near where he had grown up. Joanne had not made any friends in the 10 years they had lived there. Though they had a beautiful home, Joanne felt like she was suffocating. She had lived in the city for years, and now the novelty of living in the country had worn off. Furthermore, she was frustrated that she had not been able to establish close relationships with Jack’s children. This caused stress and dismay for Jack, but it bothered Joanne even more. Having no children of her own, she was hoping for close ties with her step-children.

Adding to Joanne’s dilemma, was the fact that Jack had just been diagnosed with a chronic heart condition. Though his condition was not life-threatening, he had been admitted to a hospital 50 miles away for several days. Joanne was so fatigued and sore that she could not stay with him for very long. She was worried about him, but she was also upset that she had to drive 100 miles round-trip to see him and then come home and collapse with no one to take care of her. When he came home, she felt that now she had to worry about him and his illness, and he was so focused on his medications and diet and exercise regime that he did not have time to worry about her. “What about me,” she thought. “I have a debilitating illness and can’t even get a diagnosis.” Jack understood her feelings, but deep down he wondered if she was jealous of the medical attention he was getting.

Though Jack had sympathy for Joanne, he was running out of patience with her problems. Now that he was retired, Jack wanted to spend his time on doing projects around the farm and antiquing -- activities they used to enjoy together. Joanne felt so weak that she feared doing anything in the house. A simple task like unloading the dishwasher left her exhausted. One day, she reached for a vase on a high shelf, only to complain for weeks of being so sore that she could not use her right arm. As for doing things outside the home, Joanne didn’t even try. Jack had been shopping and antiquing alone for months now. Joanne didn’t even go to the grocery store anymore. If neighbors dropped by Joanne would retire to her bedroom, saying she was too tired to talk.

Joanne had had a history of headaches, but she had not had one in a while. Now they had returned, and she was having a headache almost daily, for which she took over-the-counter pain medication. Recurrent headaches were now added to the list of other vague pains, weaknesses, and fatigue symptoms.

Jack was beginning to wonder about all of these symptoms. Jack didn’t know a lot about psychology, but he had once worked in human resources. He knew that people sometimes complained about physical problems but that these problems might have a mental, instead of a physical cause. He was beginning to wonder about not only her presenting problem, the soreness and the fatigue, but her headaches, as well. They seemed to come at a “convenient” time, such as when Joanne’s sister, Julia, from whom she was estranged, said she and her husband were coming for a visit, or when one of his children made one of their rare trips. Inevitably, Joanne would get a headache on the eve or midway through a visit, and he would be left to take care of the visitors on his own. In combination her pain and fatigue symptoms the headaches made her almost an invalid at times; she was in too much pain to cook, entertain visitors, or even leave the house to go out with guests.

1.3 Social/Family History

Joanne grew up in a solid middle-class family. Her mother, who died 12 years ago before Joanne married Jack, was a homemaker all her life. She died after a protracted struggle with leukemia, which hit her late in life. Joanne’s father was college-educated and worked as an engineer in a large manufacturing company in a Northeastern town. Joanne’s older sister, Julia, became a professor of performing arts at the university in their hometown. She and Joanne were more competitive than close siblings. Julia, who was five years older than Joanne, always felt that her parents “loved” Joanne more. Julia had been married to an attorney since she was in her 20s. About five years ago, Joanne became aware that Julia was an alcoholic. Joanne encouraged her to get help, but Julia was not ready to admit that she had a problem.

Joanne and Julia’s father died of colon cancer when there were teenagers. After his death, their mother focused all her energy on her daughters, something the sisters often resented. Joanne remembers her mother as always fearful that something terrible would happen to each of her daughters. Joanne recalled that her mother reacted with grave concern to every sniffle, scrape, or bruise that she manifested and continued the concerns even when she moved away from home. Her mother called Joanne and Julia almost daily and panicked if they did not return her calls by the end of the day. Sometimes she had even called their friends to ask them to tell Julia or Joanne to return her calls. Joanne felt that her mother had a lot of anxiety about her and her sister, especially after their father died. Joanne recalled how her mother’s hyper-vigilance often made her think that something was wrong with her that she didn’t know about. Maybe that was because when her mother asked how she was and Joanne answer that she was fine, her mother would ask again: “Are you sure? Maybe we better take you to see Dr. Sheffield.” “Mom,” I am fine, she would insist. But sometimes she couldn’t help wondering “Maybe I am not fine? Maybe Mom is right.” So off they would go to Dr. Sheffield only to be told that Joanne had a cold, or a sprained ankle, instead of some grave illness or injury.

Joanne’s mother had had a long and lingering spell of repeated hospitalizations and near-death experiences before she died. During this time, the tension between Julia and Joanne worsened. Sensing that Julia was less stable than Joanne, their mother left the family home to Joanne and made her the executor of her estate. Even though Joanne took good care of the estate and ended up giving Julia more than the mother had left to her, Julia resented Joanne even more. She felt that their mom’s choosing Joanne over her as executor of the estate proved that Joanne was the favorite child. Sometimes when Julia had been drinking, she called Joanne (they lived about 400 miles from each other) and blamed Joanne and her mother for her unhappiness and her drinking (though she did not admit she was abusing alcohol).

Although married and divorced twice, Jack felt he had met the love of his life when he met Joanne. He was still married when they met and their affair ended his third marriage. Jack was stable, steady, and friendly. He had grown up in the country and graduated from a rural university, but he had a good career with the federal government and rose up through the ranks until he retired. After the house was built he spent his time , working on the land, socializing with old friends and remaining family members, and attending auctions for antiques. Joanne used to accompany him on his antiquing trips, but lately she never went.

Jack was upset that he did not have close relationships with his three adult children. All of them seemed to resent his divorce of their mother, Jack’s first wife, and they never warmed to Joanne. He knew, however, that Joanne had gone out of her way to try to befriend his children. Jack was not close to them either, but they still both felt badly that they weren’t close to his children. For instance, they never got together at the holidays, so it was just the two of them.

Jack was unwavering in his love of and devotion to Joanne, but Joanne’s recent complaints added stress to the marriage. These odd complaints about pain and fatigue had him dumbfounded. No doctor could find anything wrong with her and he couldn’t fathom what was going on.

Joanne, too, was devoted to Jack and she was aware of his unfailing support However, she had long wondered if she had done the right thing in agreeing to leave the city and move to the country.

1.4 Multiple-Choice Questions

1.5 Treatment