Self-employed builder with a history of diabetes

Peter, a 52-year-old self-employed builder with a history of diabetes presents at the Accident
and Emergency Department complaining of insomnia and fatigue over the past 4 months. He
says that his blood sugars are “all over the place”. When further enquiries are made, Peter
states that he generally does not worry too much about his diabetic control. He says his wife
“keeps an eye on him” and that she has insisted he see a doctor.
Peter also has hypertension and has been receiving antihypertensive medication for the last five
years. He also takes medication to lower his cholesterol. Peter says he smokes about twenty
cigarettes a day and drinks alcohol frequently. When asked about his lifestyle choices Peter
states that his father drank and smoked all his adult life and lived to a “grand age”.
Peter appears to be overweight and he has a body mass index of 31. On his last medical review
his HbA1c level had increased from 8% to 9.2% and his cholesterol level was 5.8mmol/l. His
current blood pressure is 145/85 mm/Hg.
Peter reveals that he feels increasingly stressed by the downturn in the construction industry
which has caused him some economic hardship. He talks vaguely about family issues. He
describes his relationship with his unemployed “no hoper” son as strained and this in turn has
caused tension with his wife.
Peter displays little spontaneous emotion, avoids eye contact and speaks quietly. He says he is
“fed up” and needs to “pull himself together” but says his current circumstances are making
this difficult.
Q1.Choose one defense mechanism and explain how this helps you to better understand Peter’s
presenting problems.
Denial
Q2. Discuss how “Stress Theory” might be applied to the Peter’s current situation.
Q3. How would you respond to Peter’s statement about being “fed up” and needing to “pull
himself together”? Your answer must include specific therapeutic communication techniques.
Q4.Nurses can have a collaborative role with other professions in treating anxiety disorders.
Choose one treatment and explain how this would be applied with Peter

Case Study: Peter

1. One defence ego self defence mechanism that is displayed by Peter is denial, that is, arguing
   against an anxiety provoking reality by stating that and/or behaving as if, it doesn’t exist. Peter lives
   as if he does not have diabetes, yet he has the condition: he is not keen to observe taking medication

nor watch healthy living consistent with diabetes, such as minimizing alcohol intake. He lives in
denial about the signs and symptoms related to diabetes for (not just a few weeks, but actually)
4months! And even then, he has had to be compelled by his wife to see the doctor.

2. Peter is undergoing stress that affects him both physiologically and psychologically. Factors
   leading to physiological effects of stress include dyslipidemia, poorly regulated hypertension
   (currently grade I, systolic), poorly regulated blood sugars, alcohol effect and toxicity by substantive
   smoking. All these cause physical deterioration. The same contribute to psychological damping, as
   they affect hormonal pattern in the body. Withdrawal, denial, fatigue and insomnia are psychological
   symptoms of stress. Having identified the aetiology, Peter can be helped by counselling aimed at
   making him face the stressors in the right way Cox & Mackay (1976) rather than being distanced
   from it.
3. I would ask Peter open- ended questions that will enable him to expound on what makes him
   feel “fed up” (exploration.) I would listen, chip in humorous comments where possible to reduce
   tension in him, and accept his explanation without judging him. I’d give him relevant information
   concerning his health. Then, I would assist him formulate a plan of action on how to “pull himself
   together,” and suggest possible ideas on how to move on.
4. Anxiety disorders, such as general anxiety disorders, is collaboratively managed by the
   general practitioner (GP), consultant psychiatrists (CP), the patient and the care manager (the nurse).
   The GP diagnoses the type of anxiety disorder and recommends the treatment Muntingh et al.
   (2009). Cognitive behavior therapy is one of the effective methods available. For this method, the
   nurse picks data (such as childhood data), which will reveal Peter’s core beliefs/ assumptions that
   determine his coping strategy. Peter can be asked to journal thoughts that cause anxiety. The notes are
   compared in order for him to understand the root of anxiety verses his coping mechanism and hence

behavior (behavior exposure). The therapist then helps Peter to examine these in order to overcome
his stressors. Each session may last 50 minutes each. The progress is discussed with the GP, and with
the CP when necessary, for further intervention as necessary, Anxiety UK (n.d.)

REFERENCES

Anxiety UK ,n.d., ‘Cognitive Behaviour Therapy’