Question

Client Profile

Betty, a 50-year-old woman, came to this country with her parents when she was 7 years old. The family members worked as migrant farm workers until they had enough money to open a restaurant. Betty married young. She and her husband worked in the family restaurant and eventually bought it from the parents. They raised seven children, all grown and living on their own. Betty and her husband live in a mobile home close to the restaurant. She does not work in the family restaurant anymore because she worries excessively about doing a poor job. Betty no longer goes out if she can help it. She stays at home worrying about how she looks, what people think or say, the weather or road conditions, and many other things. Betty is not sleeping at night and keeps her husband awake when she roams the house. She keeps her clothing and belongings in perfect order while claiming she is doing a poor job of it. She does not prepare large family dinners anymore, though she still cooks the daily meals; one daughter has taken over the family dinners. This daughter has become concerned about Betty being isolated at home and worrying excessively and calls the community mental health center for an appointment for Betty.

Betty presents at the community mental health center accompanied by her husband, her children and their spouses, several grandchildren, and a few cousins. When Betty’s name is called and she is told that the nurse is ready to see her, she frowns and says: “What will I say? I don’t know what to say. I think my slip is showing. My hem isn’t straight.”

Betty says she wants her whole family to go in to see the nurse with her. The nurse notices that Betty is extremely well groomed and dressed in spite of concerns she has been voicing about her appearance. Before the psychiatric nurse inter- views Betty alone, she hears from the daughter that Betty “worries all the time” and although she has always been known to be a worrier, the worrying has become worse over the past six or eight months. The husband shares that his wife is keeping him awake at night with her inability to get to sleep or stay asleep.

The nurse interviews Betty alone. The nurse notices that Betty casts her eyes downward, speaks in a soft voice, does not smile, and seems restless as she taps her foot on the floor, drums her fingers on the table, and seems on the verge of getting out of her chair. Themes in the interview include: being tired, getting tired easily, not being able to concentrate, not getting work done, trouble sleeping, worrying about whether her husband loves her anymore and whether she and her husband have enough money, and not having the energy to attend to the housework or her clothing.

The nurse has the impression that Betty’s anxiety floats from one worry to another. There is no convincing Betty that she looks all right. Any attempt to convince her that she need not worry about something in particular leads to a different worry before coming back to the earlier worry.

The community mental health psychiatrist examines Betty and, after a thorough physical examination and lab studies, finds nothing to explain her fatigue and difficulty sleeping other than anxiety. Betty produces her medicine bottles and says she is currently taking only vitamins, hormone replacement, and calcium. The psychiatrist asks the nurse to contact Betty’s family health care provider to get information on any medical or psychiatric conditions he is treating her for; the report comes back that she has no medical diagnoses and the family health care provider thinks she suffers from anxiety. The psychiatrist prescribes buspirone (BuSpar) for Betty.

Two weeks later, during a home visit to Betty, the nurse learns, with some probing, that Betty is upset with her husband for loaning all their savings to the daughter and her husband to build a new home, while they continue to live in an older mobile home. At the end of the nurse’s home visit, Betty’s daughter arrives and tells the nurse that she wonders if Betty is making any progress. Betty also worries she is not getting better and asks the nurse about taking some herbal medicines containing Kava and Passaflora that her sister got from a curandara (folk healer); her sister wants to take her to see the curandara and have her do a ritual to cure the evil eye that was placed on Betty and made her sick.

Questions

1. What behaviors does this client have that match the criteria for a diagnosis of Generalized Anxiety Disorder?

2. How common is the diagnosis of Generalized Anxiety Disorder? Is it common for clients with GAD to have comorbidity, and should this client be assessed for any particular condition?

3. What explanation do you have for the number of family members coming to the community mental health center with this client? If you were the nurse, how would you deal with Betty’s request for her whole family to accompany her to see you?

4. Before the nurse, or any other staff at the community mental health center, can talk with Betty’s family health care provider, what do they need to do?

5. What does the nurse need to know about buspirone? What teaching needs to be done with the client in regard to buspirone? What medications other than buspirone are being used in the treatment of GAD, and how effective are they?

6. What are some of the interventions, in addition to antianxiety drugs, that are being used with clients who have GAD?

7. At one point the daughter says that she thinks Betty is not showing progress. What progress, if any, do you think has been made? What can you tell the daughter?

8. What do you think about Betty’s sister using herbal remedies and rituals for driving out evil spirits in trying to cure Betty? Do herbal remedies work?

9. What nursing diagnoses would you write for Betty related to her Generalized Anxiety Disorder?

Answer 1

thanks