At the age of sixty-five, Mary was referred to the older adult Community Psychiatric Nurses (Appendix 1), and has been an ongoing client ever since, under the care of two of my colleagues prior to my own involvement from November 2001. Mary has a long history of involvement with medical and psychiatric services, and the following case study examines Mary’s past and present care in order to examine more global issues of whether care of ‘health anxiety’, ‘frequent attending’, or hypochondriasis has changed within this time. The study examines possible factors for the hypothesised improvement, including improved clinician education and the ageism debate.
Mary was born just before Christmas 1932, the older of two sisters, to working class parents in Port Glasgow. She describes her childhood as happy and spent her teens, along with her friends, flirting with local German prisoners of war and leaving school without qualifications, to go to work in the local sugar factory at the age of fourteen.
At twenty-two she married the boy next door, and wanted to emigrate to Canada with him to join him in his Navy posting. She failed the medical though, with kidney problems and suspected TB, and spent a good deal of the next year in hospital being treated. Her diagnosis and prognosis were never straightforward or clear however, and medical opinions conflicted as to the existence or absence of disease. Her mother and father were highly supportive throughout.
Her husband returned from Canada to live, and in trying for a family Mary had an ectopic pregnancy at twenty-seven. She remained childless thereafter. Around this time her father died from bowel cancer on his 57th birthday. Her sister meanwhile married a successful local businessman, to whom she has two children and now two grandchildren.
Mary worked throughout her career in various factories, which she seemed to enjoy on the whole. It does appear however that she was very sensitive to arguments and confrontations, and describes herself as a lifelong worrier. She lost two jobs through excessive sick time sparked by a dislike and fear of a colleague. Her husband meanwhile successfully worked in the shipyards, rising to foreman and shop steward by 1972. Mary says it was at this point that he began to drink heavily and alone. Previously she had generally had a happy marriage, the pair just drinking socially. They had many fights thereafter, and Mary increasingly turned to medical services for help, presenting to her GP mainly with stomach pains.
Mary was initially referred to the psychiatric services in 1979, following divorce. The referral letter is in Appendix 2, but basically describes signs and symptoms very much prevalent in Mary today; eg generally ‘feeling awful’, defined in somatic, mainly gastric complaints. Following this is a list medication, including benzodiazepines, prescribed in attempt to remedy these. The tone of the letter is pessimistic, possibly reflecting the clinician’s stress with the non-responsive nature of Mary’s symptoms (Hartz, Noyes, Bentler, Damiano, Willard and Momany 2000).
Mary was diagnosed with ‘agitated depression’ in February 1980 by the consultant psychiatrist, who admitted her to the acute psychiatric ward for assessment. He was at this time considering ECT should tri-cyclic antidepressants fail to elevate her mood. Though the antidepressants did indeed fail, it was felt that ECT was contraindicated to her mainly anxiety related symptoms, and it was not given. (Despite the presentation and contraindication remaining the same, ECT was given in 1985, with no effect.)
Amongst other somatic complaints such as generalised and non-specific pain, Mary was frightened she may have undiagnosed cancer (like her father), and an undetected pregnancy (following an affair with a married man), despite negative testing for these.
During this admission Mary was variously described by nurses, consultants, psychologists and GPs as; ‘whingy’ (GP), ‘immature neurotic personality’ and ‘histrionic’ (psychologist), ‘marked hysterical behaviour’ and ‘obsessive neurotic’ (consultant), and ‘attention seeking’ (nurses). Physical investigations for specific complaints returned negative, further fuelling negative responses such as ‘we cannot cope with her’ (GP), and ‘unfortunately, there is not a lot I can think of to help her’ (consultant). The consultant follows up his position by suggesting denying further admissions.
Hypochondriasis is first mentioned in the notes in December 1980 by a locum psychiatrist, whose plan of action involved avoiding ‘rewarding crazy behaviour’, and rewarding (with attention) ‘reasonable behaviour’. This was very much the tail end of the era of Skinner, Watson and Dennett behaviourist movement (Brown 2001), who utilised behaviour modification techniques based on stimulus-response theory and shaping. This was the forerunner of currently popular cognitive behaviour therapy techniques, which unlike pure behaviourism, (which appears to underpin the locum’s ideas above), acknowledges the concepts of choice and self-determination.
The nursing care of the time was indeed very behavioural in nature, and it is difficult to establish whether the approach was a major factor in Mary’s recovery or not, as it is not documented. Nevertheless, Mary recovered from her initial illness episode by February 1981, following reconciliation with her husband the previous month.
The following May Mary lost a job through excessive sick time due to feeling bullied by colleagues, and her renewed relationship with her husband again deteriorated. Following readmission, the hypochondriasis label this time is picked up by all disciplines, and the concept of Parson’s ‘sick role’ (Turner 1986) is mentioned for the first time, suggesting the notion of positive gain for Mary by ‘appearing’ ill.
Professional tolerance remains low, and frustration is felt, especially by those who put many hours work in to helping Mary, apparently to no avail. The clinical psychologist eventually suggested that Mary ‘pluck up the courage to face her anxiety and stop hiding from it’. Again, Mary spontaneously recovered, or appeared to recover.
Psycho-social components of Mary’s illness and recovery however seem to centre around her perceived stability regarding work and relationships with health professionals and more importantly her family, particularly husband and mother. Mary improved around the time of remarrying her ex husband and restarting work for example. Likewise, she understandably deteriorated at times of marital difficulty, premature discharge from hospital, work arguments, and most notably the illness and deaths of her husband (four years ago) and mother (ten years ago).
Also, divergence in life fortunes between the sisters appears to play a part in Mary’s illness history as she sees it, compounded by Mary’s sister’s allegedly unsympathetic attitude to her. This does seem to be corroborated by the CPN present in 1998 when Mary’s husband died. Within earshot of Mary, her sister declared that she couldn’t care for Mary as she herself had a family.
Throughout her illness, Mary has attended day hospital in one form or another. She currently attends a day hospital twice weekly within Inverclyde Hospital, and attends a social work run functional illness group one afternoon. CPN services first became involved in 1987, ongoing with my present once weekly involvement. She is also currently seen by a support worker on the other weekday.
I believe it is highly relevant to Mary’s care to state that I like her, and look forward to my visits. Along with this being demonstrably beneficial empirically (Little, Everitt, Williamson, Warner, Moore, Gould, Ferrier and Payne 2001), it ‘feels’ right (Benner, Tanner and Chesla 1999). Despite often being self-absorbed regarding her illness, she is not selfish by nature, and takes a great interest in my well being also. She has a self-deprecating sense of humour and genuine warmth. She is a well-known and popular lady, and going shopping with her can be a lengthy business, as she seems to know everyone!
Mary’s current Community Nursing care plan is in Appendix 3. The model of nursing care incorporates the activities of living as defined by Roper Logan and Tierney (1996) (initially in 1980), and is illustrated in this work on page eight.
The care plan more specifically monitors and addresses her mental health through the ongoing therapeutic relationship built between us, and in this respect, mirrors the principles of cognitive behaviour therapy (CBT). CBT basically attempts here to address Mary’s ‘faulty thinking’ in order to allow her to take control of her own problems and to manage her life in such a way that future problems are dealt with in a more adaptive way. This ‘faulty thinking’ is illustrated by Lam and Gale (2000), and their paper discussing CBT is in Appendix 4:
(Lam and Gale (2000) fig 1, p 445)
Formal objective testing utilising psychometrics such as Geriatric Depression Scale (Sheik and Yesavage 1986) is also used in Mary’s plan.
A care plan, even if utterly objective, pertinent and accurate regarding the client’s current issues, is only a snapshot in time, and thus out of date the minute it is written. The model of care is probably useful as a framework of thought however, and therefore useful as a model for purposes of reflective practice in delivery of dynamic care such as proposed by Bellman (1996). Roper Logan and Tierney acknowledge this themselves (Tierney 1998). Academic arguments currently contemplate whether nursing needs conceptual frameworks at all, viewing them as oppressive fabrications as opposed to meaningful representations of reality (Tierney 1998).
(Roper Logan and Tierney’s 1996 model of nursing. Tierney (1998) p79)
Biley (1992) for example believes that nursing models may have been an essential historical step, but are now redundant in practice with the ‘intuitive’ replacing the ‘empirical’, in line with Benner’s thinking on nursing expertise (Benner, Tanner and Chesla 1999). But care still needs to be given, whether intuitively or empirically. Perhaps it would be reasonable to suggest that a care plan should probably reflect the level of competence of the person implementing it. What may appear vague and non specific to a novice for example, may appear flexible and empowering to an ‘expert’ (Benner et al 1999), and conversely step by step planning may be critical to less experienced nurses and a paper exercise to those more senior colleagues.
There is nothing fundamentally incompatible with post modernist ideals of caring and empowerment (Varcoe 1996) and the ideals of Roper Logan and Tierney (1996). Likewise, a gap between nursing theory and practice is inevitable, and probably healthy (Rafferty, Allcock and Lathlean 1996).
What is personally noteworthy to Mary is that she feels better treated now than was initially apparent in the 1980s. The GP no longer complains about her weekly visits for example, her admissions are viewed as unavoidable hazards as opposed to system failure, and Mary’s inability to spontaneously respond to the ‘therapy of the day’ no longer elicits emotive cries for banishment from the service.
Yet her presentation, to all intents and purposes, is the same as it was twenty years ago. There could be many factors for this, but given that her age may have anything to do with her improving treatment, could this be as a result of overall improvement in attitudes to care of the elderly? Lothian and Philip (2001) believe it so.
For example, Roy (1996) suggested that a nurse’s pessimism towards older adults could translate into loss of dignity, identity, and decision making for them. The Health Advisory Service (2000) recently found that prejudicial attitudes to elders and their care existed at “almost every level of the service”. Some research has even suggested that health professionals hold more ageist attitudes than the general population (Stevenson 1989).
This does not appear to be personally experienced by Mary however. Running counter to the above negative findings on ageism, along with Lothian and Philips’ (2001) contention, is Gilhooly’s (2001) refutation of endemic ageism in NHS, suggesting rather that people are treated globally poorly regardless of age. However, Gilhooly suggests that people still believe there is ageism in the NHS.
More positive is the suggestion that specialised elder services hold more positive attitudes to their clients, concluding that this is due to their more specialised training in gerontology (Hope 1994). This appears to be supported by evidence citing the importance and efficacy of exposure to positive learning experiences in gerontology for student nurses (Peach and Pathy 1982) and general increased exposure to healthy and happy older adults (Roy 1996, Lookinland and Anson 1995).
Another improvement is probably attributable to the notion of abandoning ‘curative options’. This was first mooted as a positive method of treatment in July 1990 by Dr M (Appendix 5), who shifted the goal to achieving ‘periods of comparative well being’ for Mary. This attitude shift continued throughout the 90s, to the apparent benefit of Mary, who continued to use services as before, but without the aggressive treatment and associate negative attitudes of the 80s.
Mary has at one time or another been prescribed virtually every anxiolitic and anti depressant ancient and modern. She is currently, for example on Phenelzine, a Mono Amine Oxidase Inhibitor (MAOI), a rarely prescribed antidepressant due to it’s lethality in overdose and the necessity to comply with a strict Tyramine free diet (eg no beef extract, Chianti wine, cheese). Mary has also a history of taking every typical and atypical antipsychotic, due to their anxiolitic properties , due to their anxiolitic properties, all with very little short-term effect. She nearly always exhibits side effects to these drugs however, such as dry mouth, constipation and nausea, which may in turn mirror the complaints she initially presented with. Polypharmacy is a well-documented problem (Sullivan 1998), raised in Mary’s case by Dr M in 1990 (Appendix 5).
Most recently, Mary became increasingly anxious and depressed just before Christmas time 2001. This is the time of her husband’s death three years earlier. As with previous crises, she presented more often at her GP, and contacted emergency services with abdominal and atypical chest pain, for which she was admitted to a local medical ward in Jan 2002.
Following negative physical investigations, Mary was admitted to the over 65 psychiatric admission unit in Feb 2002, for what turned out to be a 3 month admission, during which time her medication was rationalised once again. Her discharge diagnosis, in May 2002 was ‘mild dependent personality syndrome’, a description possibly attributable to everyone. The labels of hypochondria remained.