Author: Taryn A. Myers, PhD, Virginia Wesleyan University
Please note: Clinical Choices allows you to enhance and test your understanding of the disorders and treatments covered in your textbook, in a simulated case study environment. It is not intended to replicate an actual intake interview or therapy session or provide training on therapeutic techniques. Clinical Choices is for educational purposes only and is not intended as a substitute for clinical training.
The receptionist hands you the intake paperwork prior to your interview with your new client, Joanne, and mentions that she seems somewhat impatient. Joanne has also requested that her husband, Jack, come into the interview with her. Although this request is a little unusual for adult clients, you know from past experience that getting information from someone close to the patient can be invaluable. Select the button below to review the paperwork before you begin the interview.
New Client
Joanne: Case #10110
Psychological Clinic
Intake Paperwork
Client Name: Joanne
Age: 53 years old
Gender: Female
Ethnicity: Caucasian
Occupation: Retired, used to own a boutique
Current living situation: I live with my husband on a farm
Why are you seeking services at our clinic? I have a lot of pain, muscle aches, and no energy. I’ve consulted many doctors, but no one can tell me what is wrong with me. My husband was diagnosed with a chronic heart condition, and it’s very stressful to have to worry about his health in addition to my own.
You will now ask Joanne and Jack a number of questions you would typically ask during the intake interview. As you conduct the interview with Joanne and Jack, begin to think about Joanne’s symptoms, what her diagnosis might be, and later, what type of treatment might be most helpful to her. Select the “play” button to hear Joanne’s and her husband’s responses to your questions. To read the transcript for these answers, select the “transcript” button.
“Hi, Joanne. It’s good to meet you. Jack, thank you for coming in with Joanne. What we are doing today is called an intake interview. I’m going to have you tell me what brought you here today, and I’m going to ask you some questions that I ask everyone who comes to the clinic. This information will tell me how best to help you. This may mean having you continue to come see me for therapy at this clinic, or it may involve referring you to another mental health professional or facility. Let’s start. Tell me about what brought you to the clinic today.”
Transcript
Joanne: The last doctor I saw, the neurologist, referred me to your office. This doesn’t make any sense [sounding annoyed] – my problems are physical [emphasis], not in my head! [sighs] But I guess I shouldn’t be surprised – the doctors keep passing me from person to person. You’re the sixth specialist I’ve seen this year, and that’s not even counting the chiropractor, massage therapist, and the acupuncturist. And nothing any of them has tried has helped for more than a day or so. [exasperated] The chiropractor worked on my hip and it felt okay for a day, but then it was so sore I couldn’t move my leg at all!
Jack: [quietly] I’m really getting tired of going to all these appointments with her.
Joanne: But we need to get to the bottom of this and figure out what’s wrong.
Hint
Think about what Joanne and Jack said about being here today.
“That sounds very frustrating, Joanne. Tell me about your physical symptoms. What’s been going on?”
Transcript
Joanne: The biggest thing is that I feel really, really tired all the time. I have absolutely no energy ... sometimes I just spend the whole day in bed. I have muscle aches all over ... in my arms and legs and ... [groans] ugh, my shoulders just really hurt most of the time. And the headaches ... I’ve always had headaches, but not this frequently for a long time. Now I get headaches just about every day, so I take Ibuprofen every day. And ... in a new development [sarcastically] ... I have a pain in my right hip. Periodically, my hip will buckle under me. But the orthopedist I saw a month ago “claims” [with disbelief] that there is “nothing wrong.” [incredulous, even a bit angrily] C’mon. How can there be “nothing wrong?”
Jack: I’m very worried about Joanne, but I’m getting really tired of going to all her doctors’ appointments. It’s a full-time job! What’s more, it’s exhausting and stressful, and I shouldn’t be that stressed right now.
“Oh, my goodness! That is a lot to deal with every day, Joanne. And I can certainly understand your frustration, Jack. What have the doctors you have consulted been able to tell you?”
Transcript
Joanne: [annoyed and exasperated] They aren’t telling me anything! I’m having to do all the work myself. I spend hours and hours on the internet looking up my symptoms. I can’t find any answers on WebMD ... that site is useless... so I have to dig deeper and really look at blogs and message boards and whatnot. I’ve found all kinds of possible explanations, but whenever I go to see one of these doctors, they rule out my theories! Let me give you an example. I was really worried about my hip, so I did a lot of digging around on that. I had a hysterectomy a few years ago, and I take estrogen for hormone replacement. Well, I found a link! I found a website that said that estrogen can affect your muscles. So I went to my OB-GYN and asked if it could be affecting my hip muscle. She said that this muscle problem is very rare and dismissed it.
Based on her initial report of her symptoms, which of the following disorders could Joanne be suffering from? Select all that are possible diagnoses for Joanne. To review the diagnostic criteria for each disorder, select the disorder name.
Factitious Disorder Imposed on Self
wCfH0QtRgXJ8o+c+Conversion Disorder
wCfH0QtRgXJ8o+c+Factitious Disorder Imposed on Another
wCfH0QtRgXJ8o+c+Mass Psychogenic Illness
bI0LPa9lfHQ+dYqkSomatic Symptom Disorder
bI0LPa9lfHQ+dYqkIllness Anxiety Disorder
Hint
Think about the severity of Joanne’s symptoms and how she views them.
“Joanne, I can hear how frustrating and painful all of your symptoms are, not to mention the challenges you face in figuring out what is going on. Have you noticed any patterns —that is, are there particular times or situations when your symptoms are worse?”
Transcript
Joanne: I feel like it’s worse when things are stressful at home. We live on Jack’s farm, which is in the middle of nowhere. Honestly it’s completely isolated. It’s beautiful, but I feel like I’m suffocating at times. Before we got married ... that was 10 years ago ... I’d always lived in the city. Life on the farm can be boring and sometimes I feel really alone – I’m not close to anyone in the area ... well, except for Jack, of course. And Jack has just been diagnosed with a chronic heart condition. It’s been completely overwhelming.
Jack: Not just overwhelming for you. And the farm is my sanctuary. [sadly] I didn’t realize how much you didn’t like living there.
“Jack, I’m so sorry to hear about your diagnosis. Do you all have any other family that can help you as you both deal with your medical conditions?”
Transcript
Jack: I’m ok. My condition isn’t life-threatening.
Joanne: When he first started having problems, he was in the hospital for several days. Because where we live is so isolated, the closest hospital is 50 miles away. So I did visit him, but that kind of drive really does a number on me, so I couldn’t stay long due to my soreness and feeling so tired. Then I’d have to drive another 50 miles home ... I’d be exhausted when I got back with no one there to help me.
Jack: To answer your question, I was married twice before, and I have three children. They are still resentful of me for divorcing their mom ... my first wife. They’re adults now.
Joanne: I never had kids. But I really wanted to get close to Jack’s kids.
Jack: [with empathy] Joanne has really gone out of her way to try get close to them. But they just don’t seem interested ... Makes for some lonely holidays.
Joanne: That’s been hard for me and for Jack ... I had really hoped we could be a close family, but they just don’t seem interested. Now that Jack is home, I have to take care of him. He is so focused on all his medications, what he’s eating, exercising ... and well ... he doesn’t seem to be concerned about me at all anymore. What about me? [frustrated] I have this debilitating illness and can’t even get a diagnosis!
Hint
Think about how Joanne expresses her thoughts and feelings.
“Jack, what has this been like for you? It sounds like you have been overwhelmed and frustrated, dealing with Joanne’s condition as well as your own.”
Transcript
Jack: [sounding fed up] Well ... let me be blunt here ... when she says stuff like that, I sometimes wonder if she’s jealous of the medical attention I’m getting with my heart condition. Believe me, this is no walk in the park!
Joanne: [incredulous] What? How dare you – I never!
Jack: [conciliatory] Joanne, I have a lot of sympathy for you, but now I’m running out of patience. I was hoping that when I retired, we could do projects around the farm and go antiquing together. You used to love doing stuff like that.
Joanne: [sorry for herself, whining a bit] I’ve been feeling weak. You know that. I don’t want to overwhelm myself. Even just unloading the dishwasher makes me exhausted.
Jack: [breaking in] And then a couple weeks ago, she reached for a vase on a high shelf, and ever since, she’s been complaining that she can’t use her right arm because it’s sore.
Joanne: [indignant, defensive] Well, it is!
Jack: [sad] I miss doing things together. I go shopping and antiquing alone now. You don’t even grocery shop any more. And when the neighbors stop by to say hi, you go hide in the bedroom.
Joanne: [defensively] I’m just too tired to talk.
Jack: Doc, I don’t know much about psychology, but I worked in human resources before I retired. I know that sometimes when people say they have physical problems, they aren’t aware that these problems could be in their heads, instead.
Joanne: [with an edge] So now I’m a liar, too?
Hint
Think about what Jack just said about Joanne’s symptoms.
“Whoa! If you don’t mind, I’ll step in here. Joanne, I don’t hear Jack calling you a liar. Let’s hear him out a little bit, consider what he’s saying as a hypothesis to be tested. Jack, can you explain what you mean a little bit more?”
Transcript
Jack: Well, her headaches and fatigue always seem to come at a “convenient” time.
Joanne: [jumping in] What? Like when?
Jack: Like I just said, when the neighbors come over. Or when your sister came for a visit, or one of the few times one of the kids comes to visit.
Joanne: I get headaches when I’m overwhelmed or stressed. [with mock patience] You know that. These have been going on for well over a year. And they’re like migraines, so I have to go lay down in a dark room.
Jack: Well ... That can make it tough on me, because I have to entertain our guests alone. I don’t mind cooking or going out with the guests alone, but I would prefer it if you could socialize with all of us. [tenderly] I feel like you are missing out.
Joanne: [Tearful] I feel like I’m missing out, too.
Hint
Think about the results of Joanne’s symptoms, beyond just her pain.
“Despite this rough patch, it seems like the two of you really have a strong relationship. A supportive relationship can really help while we try to figure out what is going on, Joanne. Tell me more about your relationship.”
Transcript
Jack: Joanne is the love of my life.
Joanne: [choking up] I feel the same way about you, Jack.
Jack: I was still married to my second wife when I met Joanne. I just couldn’t stay away from her. We had an affair, and it ended that marriage.
Joanne: Even though he’s 12 years older, I was completely bowled over by him.
Jack: We got married, and I retired pretty soon after. We moved out to the farm and ... apparently Joanne hates it. I didn’t realize that until today.
Joanne: I ... I don’t necessarily hate it. It’s just that it’s your dream, not mine. And when it’s not doing well, it’s so stressful. It’s your dream, not mine. I never lived in the country before we got married. And ... I never thought I’d end up on a farm.
“Joanne, you said the farm isn’t your dream, but Jack’s. What is your dream?”
Transcript
Joanne: You know, I used to feel like I knew, but now, I’m not so sure. I have a BA in performing arts from a prestigious school. When I lived in the city, I did some acting – I was on a couple TV shows, you know ... Dead Body #2 and that kind of thing, and I also did some commercials. I used to own a sophisticated women’s clothing boutique downtown. I tried to channel some of that creative energy when we first got married into decorating our home. I miss being creative. I miss running the boutique and going on buying trips to New York. I miss my friends and doing things in the city, like going to the theater, to movies, or out for drinks. I’ve talked to Jack about moving to a small city so I can work in a shop or maybe even own one again, but this farm is his life ... he’s not interested.
Jack: This is my dream. I’ve always wanted a farm. I worked for the state government, in HR, for years. I was tired of the ugliness and bleakness of the city. I grew up in the country and I went to college in a rural setting. I missed working on the land. Moving to the farm has allowed me to do that.
Joanne: Sometimes I wonder if this move was the right choice ...
Jack: [gasps] Do you mean – do you wonder if you should have married me?
Joanne: You know I love you, Jack. It’s just that, I feel so isolated on the farm. I’m not sure how I can find my creative side there.
Hint
Revisit your interview with Joanne and Jack to review what they say about their dreams.
“Joanne, it sounds like being artistic and creative is really important to you. Did you grow up in an artistic household?”
Transcript
Joanne: [laughs] No, not at all! My dad was an engineer for a large manufacturing company in the city, and my mom was a stay-at-home mom. Actually ... [as if just remembering] my older sister, Julia ... she’s artistic, too. She’s a professor of performing arts at the university back home. We were pretty competitive growing up. She’s 5 years older, and she had this crazy idea that my parents loved me more than her. I don’t know where she got that idea! She’s married, too, to a lawyer. [quieter] I worry about her sometimes. I think she’s an alcoholic. I’ve tried to get her help, but Julia doesn’t think she has a problem.
Hint
Think about what previous experiences might have influenced Joanne’s disorder.
“Joanne, have you or anyone in your family ever experienced a protracted illness when you were growing up? Something that would have resulted in repeated doctors’ visits or many hospital stays?”
Transcript
Jack: Your dad, right hon? And more recently your mom, too.
Joanne: Yeah, Jack’s right. My dad died of colon cancer when I was in my teens. He was in and out of the hospital a lot until the very end. And after he died, my mom was really afraid that something awful would happen to Julia or me. If we got a sniffle or fell and scraped our knees, she would freak out. She called us daily even when we were adults. She’d panic if we didn’t call her back right away. She’d even call my friends to check on me if I didn’t call her back fast enough! I felt like something was wrong with me that she knew about and I didn’t. I’d tell her I was doing fine, but she would say “Are you sure? Maybe we should take you to the doctor!” So I’d end up going to the doctor for all kinds of silly things, like a cold.
Jack: That’s kind of ironic, given how she died.
Joanne: I never thought of it that way before, but yeah. My mom ended up getting leukemia late in life, and she died of it 12 years before I met Jack, so it’s been awhile now.
Jack: From what you’ve told me, it tore you and Julia apart.
Joanne: Mom saw that Julia was having problems before I did – her paranoia finally came in handy, I guess. So she made me executor of the estate. I think I did a good job taking care of the estate ... I even gave Julia more money than mom left her. But [sighs] Julia didn’t see it that way – she saw this as proof that mom loved me more than her. She’ll call me, even now, 22 years later, drunk and blame me for everything.
Jack: Those calls are horrible. Julia blames Joanne for everything. I’ve started just letting it go to voicemail if I see it’s Julia calling so Joanne doesn’t have to hear that.
Joanne: [sighs] I always get a massive headache after she calls.
Which of the following symptoms is Joanne currently experiencing? Select all that apply.
Physical symptoms
wCfH0QtRgXJ8o+c+Symptoms that affect voluntary function
bI0LPa9lfHQ+dYqkRepeated, excessive thoughts about physical symptoms
wCfH0QtRgXJ8o+c+Symptoms that affect sensory function
wCfH0QtRgXJ8o+c+False creation of physical symptoms
bI0LPa9lfHQ+dYqkHigh anxiety about health implications of symptoms
wCfH0QtRgXJ8o+c+Deceptive production of injury
wCfH0QtRgXJ8o+c+Mild physical symptoms
bI0LPa9lfHQ+dYqkSpending a lot of time on symptoms
bI0LPa9lfHQ+dYqkSymptoms lasting at least 6 months
wCfH0QtRgXJ8o+c+Continuously checking body for signs of illness
Hint
Revisit your interview with Joanne to review her symptoms. Think about the time frame and symptoms she is experiencing.
From the File. You remember a former patient who experienced symptoms somewhat similar to Joanne’s. You review this case to help you diagnose Joanne.
Transcript
HOST: Then in 2011, healthwise, things changed dramatically for you. Tell me about that.
JOANNE: In January, that's when I was hit again. And then it was in February, I fainted, and I hit my head again. So after that, I went to the hospital. And they ran a whole bunch of tests, like head CT, everything. And I was looking pretty good still, so they sent me home.
But then that night, my legs began to start shaking just when I was like walking and stuff. And I could lay down and be fine, but when I started walking, my legs shaked. And it gradually got worse. So I went back to the hospital, and they ran more tests, did a lumbar puncture, everything.
HOST: That's a spinal tap.
JOANNE: Yep. Yep. And everything was still looking fine. They sent me home again. And the shaking progressed. And it was starting to look like I was having seizures-- like it was getting more constant. I was starting to stutter a bit. So I went back to the hospital. I was like, hey, something's going on. And they admitted me then. And they ran even more tests-- I stayed a few nights-- and the shaking just kept continuing.
HOST: You must have been terrified.
JOANNE: I thought I was dying. Instantly, I thought I was dying. I didn't know what was going on. And I had hit my head so many times, that I was so scared that my brain was bleeding. I didn't know what was going on.
HOST: And we have some video of you from that time to show our audience what you're talking about. We can roll that in, and we'll take a look at it. There you are in the hospital. This is the same girl-- what a year before, you were playing hockey.
Hint
Think about the severity of Joanne’s symptoms and how she views them.
Hint
Think about the number and variety of Joanne’s symptoms.
Hint
Think about what this statement is doing.
EPILOGUE
Joanne believed that her symptoms had a physical cause, so convincing her otherwise was tricky. Confrontation had not worked when her husband tried it, so as the therapist you decided to try suggestion. After building therapeutic rapport over many sessions, you gently suggested to Joanne that her symptoms would soon disappear, saying, “You know, sometimes people who are experiencing all of the physical symptoms that you report will find that they just go away on their own, out of the blue, one day.” Joanne was skeptical during these sessions, but came back to the after several sessions of your suggestions claiming that her pain, fatigue, and headaches were largely gone.
Because of your therapeutic relationship, Joanne was willing to stay in therapy to work on her other issues. In particular, she expressed sadness about her isolation and lack of direction living on the farm. She also confided that she was very worried about Jack’s health, particularly in light of how stressful managing the farm could be. You helped her role-play how she might broach this issue with Jack. Later, she reported that the two of them had a very sincere conversation where he also revealed his fears about the stress the farm was causing. He also admitted that he missed going to the theater or nice restaurants. They agreed to move to the city to be closer to Jack’s children. Their move meant Joanne was no longer your patient, but she called a few months later to let you know that she had spent Thanksgiving with Jack’s children and that she had hope of reconciling with Julia in the future, although Julia still was not open to getting help for her drinking. Joanne had found a job in a boutique and was planning to take the business over when the owner retired at the end of the year.
Real World Application
Watch this video and answer the questions that follow.
Transcript
NEWS ANCHOR: For months, doctors in Le Roy, New York have been trying to figure out what caused 12 girls to have severe ticks, almost like tourette syndrome. Now the State Health Department is weighing in.
THERA SANCHEZ: It was just supposed to be white right there.
REPORTER: 17-year-old Thera Sanchez says she isn't the same teenager she was a few months ago. She suffers from uncontrollable body movements, ticks, and verbal outbursts, much like tourette syndrome. Things Thera once loved, like going out with friends or cheerleading, are now, she says, nearly impossible.
THERA SANCHEZ: Well, I used to cheer everyday. I would go to art class. I used to go to two art classes every day. Now I'm not in school. I was always so active, and everybody was always happy to be around me. But I don't feel like myself anymore.
REPORTER: And Thera is not alone. At least 12 teenage girls at Le Roy High School in upstate New York say they're suffering from the same symptoms including Thera's friend, Katie Krautwurst
KATIE KRAUTWURST: My days are all different. Some days I'll just start twitching, and it won't stop for 10, 15, 20 minutes.
REPORTER: Both girls have seen their own doctors and are getting treatment, but they say symptoms continue. The New York State Health Department has been looking into the case for more than three months and says, the school building is not to blame.
MAN: We have conclusively ruled out any form of infection or communicable diseases. And there's no evidence of any environmental factor.
REPORTER: The State Health Department says, each student was examined by a private doctor and given a diagnosis.
NEWS ANCHOR: But it's important to reiterate, the State Health Department says it's confident students there are not at risk because of anything in or at Le Roy High School.