MENTAL HEALTH

1. Chapter s 29, 30, 31, 32 MENTAL HEALTH

2. Sexual disorder Chapter 29

3. Continuum of Sexual Responses • A wide range of sexual behaviors are now considered to be socially acceptable. • Sexual behaviors can be viewed as occurring along a continuum. • Adaptive • Sexual behaviors respect the rights and wishes of others. • Maladaptive • Sexual behaviors are harmful to self or others in some manner.

4. Continuum of Sexual Responses • An adaptive or healthy sexual response is sexuality that meets the following conditions: 1. Between two consenting adults 2. Satisfying to both 3. Not forced or coerced 4. Conducted in privacy • Self-awareness and sexuality • One’s self-awareness has a strong influence on discussion of sexual issues with clients. • Developing an awareness of one’s views about sexuality involves the process of defining and clarifying attitudes and values. • The caregiver’s effectiveness is directly related to levels of personal self-awareness and comfort.

5. Sexuality Throughout the Life Cycle • Expression of one’s sexuality begins at birth and ends with death. • Sexuality in childhood • Young children are unaware that gender is a permanent attribute. • Around the age of 2 years, children learn to label themselves according to their gender. • By school age, most children identify with their same-gender parent. • Sexuality in adolescence • Adolescents begin to encounter expectations for mature gender role behavior from both peers and adults. • Teens have difficulty believing that sex can occur without love, so each boy-girl attachment is seen as “true love.” • Adolescence is a time of intense searching and learning.

6. Sexuality Throughout the Life Cycle • Sexuality in adulthood • Among adults 25 to 59 years of age, relative monogamy appears to be the norm. • Sexual behaviors during adulthood change to accommodate the situation. • The sexuality patterns of middle-age adults have changed recently. • More women in their 30s and 40s are bearing children and beginning families. • Single parenthood is common. • Sexuality in older adulthood • The typical picture of the older adult as an asexual and uninterested individual is a myth. • The closeness, intimacy, and sharing of sexuality become more important than the physical act for most older adults. • Sexuality persists throughout life, and although sexual activity may decrease in frequency as one ages, established sexual patterns continue.

7. Sexuality Throughout the Life Cycle • Sexuality and disability • Many permanently disabled persons are able to enjoy rich and satisfying sexual lives with some adaptation. • Health problems such as diabetes, arthritis, cancer, and cardiovascular disease can affect one’s sexuality • These conditions affect only the expression of sexuality, not one’s sexuality itself. • Improving quality of life involves changing social attitudes that limit the disabled population.

8. Modes of Sexual Expression • An individual’s sexual attraction to others is one’s sexual orientation, or sexual preference. • Heterosexuality • Persons express their sexuality with members of the opposite gender. • Homosexuality • Sexual desire or preference for members of one’s own gender • Close-coupled relationships • Open-coupled relationships • Functional and dysfunctional • Asexual • Bisexuality • Persons are attracted to and engage in sexual activities with members of both genders. • Transvestism (cross-dressing) • Sexual excitement derived from wearing the clothing of the opposite gender

9. Modes of Sexual Expression • Theories related to psychosexual variations • Biological theories • Sexual variations result from differences in chromosomes, the genetic material that determines hereditary traits. • Psychoanalytical theories • Sexual variations are behaviors that have neurotic or psychopathic motivations. • Behavioral theories • Sexual expression is a learned, measurable response.

10. Psychosexual Disorders • Sexual disorders • Problems that cause distress and impaired functioning in an individual or others who are exposed to the sexual behavior • Sexual dysfunction • A disturbance that occurs at any point in the four stages of the sexual response cycle • Paraphilias- pg 328 • Pedophilia • Exhibitionism • Voyeurism- Arousal by observing unsuspecting persons who are naked

11. Psychosexual disorders • Gender identity disorder • Individual is unhappy with his or her gender. • Transsexualism- Persistent desire to become a member of the opposite sex • Sexual addiction • A progressive and chronic addiction characterized by patterns of compulsive sexual behavior despite negative consequences • Pg 329-signs

12. Therapeutic Intervention • Treatment for sexual problems • Depends on the cause, the distressing signs and symptoms, and the type of disorder • Behavioral therapies • Positive reinforcement • Aversive therapy- Focus on changing of managing the behaviors • Hormonal drug therapy – Reduces sexual drive • Environmental controls • Incarceration- Removed from society

13. Therapeutic Intervention • Psychosexual assessment • Be aware of the client’s level of comfort when assessing sexual functioning. • Nursing process • Nursing diagnoses for psychosexual disorders are based on each client’s identified problems. • Assessment and treatment • Advocacy and education

14. Therapeutic Intervention • Education is within the realm of nursing. • Topics on which clients should be educated include the following: • Prevention of HIV/AIDS • Prevention of other sexually transmitted diseases • Appropriate methods of preventing unwanted pregnancy • Various means of sexual expression

15. Personality Disorders Chapter 30

16. Continuum of Social Responses • Personality: Composite of behavioral traits and attitudes that identify one as an individual—the unique pattern of thoughts, attitudes, values, and behaviors each human develops to adapt to a particular environment and its standards • Highly functional people move freely along the continuum, recognizing and balancing their needs for intimacy with their needs for solitude. • Individuals with personality problems struggle to define and meet their social needs.

17. Personality Throughout the Life Cycle • Personality in childhood • When the infant’s needs for food, comfort, safety, and socialization are consistently met, a sense of trust and self-worth develops. • Toddlers develop object constancy. • Knowledge that a loved person or object continues to exist, even though it is out of sight • Morality begins to develop between the ages of 6 and 10 years.

18. Personality Throughout the Life Cycle • Personality in adolescence • Personality is well established. • Adolescents assert their independence from their parents. • Adolescents support each other in their struggles to assert themselves and cope with the stresses of becoming adults.

19. Personality Throughout the Life Cycle • Personality in adulthood • By young adulthood, most persons are • Self-sufficient • Involved in give-and-take relationships • Making occupational choices • Starting families • Growing in self-awareness • Sensitive to and accepting of the feelings of others • By middle adulthood, most persons are • Comfortable enough with themselves and their relationships to encourage independence in others • Growing and evolving relationships with friends and significant others • Experiencing changes in demands on their time

20. Personality Throughout the Life Cycle • Personality in older adulthood • Older adults must cope with loss and change. • Strength of personality carries them through life’s rougher times. • Do not assume that a personality change in an older adult is normal.

21. Theories Related to Personality Disorders • Biological theories • One’s temperament (the biological bases that underlie moods, energy levels, and attitudes) is genetically linked. • Abnormalities in certain neurotransmitters, such as dopamine and serotonin, are linked to maladaptive behaviors. • The brain mechanism that connects emotions with intellect may be missing or inefficient in persons with a personality disorder.

22. Theories Related to Personality Disorders • Psychoanalytical theories • According to psychoanalytical theories, infants begin to discover the nature of “good/bad” and “love/hate” as the superego grows. • If the mother responds in ways that cause frustration, distress, or pain, the child will have difficulty finding the proper fit between aggression and love. • Behavioral theories • Personality disorders are the result of conditioned responses caused by previous events. • Personality disorders are the result of unmet needs during critical developmental periods.

23. Theories Related to Personality Disorders • Sociocultural theories • The causes of personality disorders are embedded in one’s culture and society. • The foundation for personality disorders is built on society’s social and cultural stresses.

24. Personality Disorders • Personality disorders • Long-standing, maladaptive patterns of behaving and relating • All personality disorders are characterized by continual difficulties with interpersonal relations. • Some clients have maladaptive behaviors but are not given the diagnosis of mental illness. • The most important criterion for a personality disorder is that behaviors are “inflexible and maladaptive and cause significant functional impairment or subjective distress.” Theories Related to Personality Disorders

25. Personality Disorders • The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) has classified 10 separate personality disorders. • Personality disorders are grouped into three clusters on the basis of similar behaviors: • Eccentric-odd or strange behaviors, find it difficult to relate to others, • Erratic- Dramatic behavior • Fearful- anixety

26. Personality Disorders • Eccentric cluster • Characterized by odd or strange behaviors • Persons with problems in this cluster (group A) find it difficult to relate to others or to socialize comfortably. • Diagnoses in this cluster include the following personality disorders: • Paranoid – suspicious system of thinking behaviors marked by suspiciousness and mistrust • Schizoid – lacks the desire or willingness to have a close relationship, perfer solitary activities • Schizotypal- avoid people like schizoid however have strange behaviors, they believe that they have special powers , however they are suspicious of others and feel people are out to get them

27. Personality Disorders • Erratic cluster • The defining characteristic for this group of disorders is dramatic behavior. • The erratic cluster consists of four separate disorders: • Antisocial- Disregard for and violation of others rights, known as psychopaths, sociopaths they manipulate and lie to get their way • Borderline- pattern of instability in mood, thinking, and self image. Rapid shifts in personality, loving-cruel • Histrionic- Need to draw attention to self, excessive emotional expression, accompanied by attention-seeking behaviors • Narcissistic- characterized by a pattern of grandiosity and the need to be admired. Have unrealistic inflated beliefs about their accomplishments

28. Personality Disorders • Fearful cluster • The common characteristic of the fearful cluster is anxiety. • The three personality disorders in this cluster are • Avoidant- related to a fear of rejection and humiliation, to prevent possible rejection they narrow their interests • Dependent- associated with separation and abandonment, carry a deep fear of rejection, manifest itself as the need to be cared for • Obsessive-compulsive- anxiety and the uncertainty of the future. They are extremely orderly and so preoccupied with details that the accomplish very little • Each disorder is related to certain expressions of anxiety.

29. Personality Disorders • Dual diagnosis • When individuals with personality disorders also suffer from substance abuse or other mental health problems • Those who care for such clients must be aware of multiple problems involved with dual diagnosis clients. • Patients often are self medicating, can be homeless, unemployed or have legal troubles

30. Therapeutic Interventions • Patients do not often seek treatment because they do not recognize their problem • Treatment and therapy • Treatment decisions are guided by the client’s presenting symptoms, complaints, and problems. • Types of psychotherapy used successfully include • Psychodynamic • Cognitive • Behavioral • Group • Family therapy • Cure is not the goal of therapy- only hope is that patients are aware of how their habits affect their lives

31. Therapeutic Interventions • Nurses must exercise great care when administering medications to individuals with personality disorders. • If the client is being treated on an outpatient basis, the amount of any prescribed medication must never be large enough to allow a successful suicide. • Do not hesitate to assess every medicated client for suicidal thoughts or plans.

32. Schizophrenia and other Psychoses Chapter 31

33. Schizophrenia and Other Psychoses • Psychosis • The inability to recognize reality, relate to others, or cope with life’s demands • The most common psychosis is schizophrenia. • Other psychotic disorders include the following: • Brief psychotic disorder • Delusional disorder • Psychoses related to medical conditions or drug use

34. Continuum of Neurobiological Responses • The ability to change, function, and adapt, in psychiatry these interactions are known as: • Neurobiological functions • Can be viewed as existing along a continuum of behavioral responses • Highly adaptive, effective responses • Maladaptive, even destructive behaviors • People who do not adapt as well are placed at the middle of the spectrum.

35. Psychoses Throughout the Life Cycle • Psychoses in childhood • Failure to thrive syndrome • Slowed physical growth caused by an inability to integrate the physical, emotional, and sensorimotor realms of functioning • Related to neglect, environmental problems, and severe family stress • Risk factors for childhood schizophrenia • Genetic influences • Complications during pregnancy or birth- exposure to influenza in the 2nd trimester • Biochemical imbalances- problems with neurotransmitter, dopamine upset the system

36. Psychoses Throughout the Life Cycle • Psychoses in adolescence • The average teen is in contact with reality; the adolescent with schizophrenia is not. • Changes in behavior are noted: • Poor hygiene • Strange, vague speech- • Social withdrawal • Odd behaviors- talking to oneself • Bizarre thoughts and beliefs- unusual beliefs i.e. read minds • Unusual superstitions-remotely controlled by others

37. Psychoses Throughout the Life Cycle • Psychoses in adulthood • The onset of acute symptoms most often occurs in men during their middle 20s, while women usually present with symptoms in their late 20s. Men tend to respond less well to treatment and have higher relapse rates. • The prognosis for individuals with schizophrenia is better if adaptive interpersonal relationships and acceptable school performance and work histories were in place before the onset of symptoms. • Great strain is placed on the families, observing and caring for the patients

38. Psychoses Throughout the Life Cycle • Psychoses in older adulthood • Schizophrenia is seldom diagnosed in elderly people. • Elderly individuals with schizophrenia may spend the remainder of their days in long-term care facilities. • Remember that the acute onset of psychotic behavior in any elderly client must be investigated.

39. Theories Related to Psychoses • Schizophrenia exists in all cultures and socioeconomic groups. • Biological theories • Stress/disease/trauma model • Addresses the effects of stress on the individual, especially during the prenatal period • Neurochemical models • Neurotransmitters such as serotonin, norepinephrine, and dopamine have been implicated as possible causes of schizophrenia.

40. Theories Related to Psychoses • Other theories • Psychological models • Schizophrenia is caused by a basic character flaw combined with poor family relationships. • Overprotective mothers and uncaring fathers or couples who stayed together for the kids • Sociocultural theories • Effects of the environment may lead to the development of psychoses.

41. Schizophrenia- a cluster of related behaviors therefore it is classified in different groups • Subtypes of schizophrenia • Catatonic- Marked psychomotor problems, odd movements, rigid posture, immobility or excessive activity • Disorganized- thinking, speech, and behavior, affect is flat or inappropriate • Paranoid-Organized delusions of grandeur or persecution, auditory hallucinations • Undifferentiated- does not meet criteria for other subtypes, disorganized speech, behavior , hallucinations • Residual- has had one episode of schizophrenia, free of acute psychosis, present for many years

42. Psychotic Disorders • Schizophrenia • Signs, symptoms, and behaviors • The main characteristic of psychotic disorders is loss of contact with reality to the point where functioning is grossly impaired. • The signs and symptoms of schizophrenia affect perception, physical appearance, cognitive processes, language, speech, emotions, behavior, and social realms. • Characteristic symptoms fall into two broad categories—positive and negative. • Positive symptoms relate to maladaptive thoughts or behaviors. • Negative symptoms relate to lack of adaptive mechanisms.

43. Psychotic Disorders • Schizophrenia • Phases of becoming disorganized • The course of schizophrenia is marked by episodes of acute psychosis alternating with periods of relatively normal functioning. • The symptoms of schizophrenia must occur for at least 1 year before a diagnostic label is assigned. • The slide into schizophrenia commonly occurs over four stages: • Prodromal phase-withdrawal, lack of energy, and little motivation. Ideas and beliefs become odd, hygiene is ignored, speech difficult to follow • Prepsychotic phase- Usually quiet, passive, and obedient, like to be alone, hallucinations and delusions may be present, but behaviors are not completely disorganized yet • Acute phase – Disturbances in thought, perception, behavior, and emotion. Lose contact with reality, phase varies widely • Remission- ability to manage some basic activities of ADL individual receives some relief from the distress of psychosis

44. Psychotic Disorders • Other psychoses • Brief psychotic disorder • A psychotic disturbance that lasts longer than 1 day but less than 1 month • Delusional disorder • Characterized by more than 1 month of nonbizarre (reality-based) fixed ideas • Shared psychotic disorder • The individual is influenced by someone else who has an established delusion with similar content • Schizoaffective disorder • When depression or mania is also present

45. Psychotic Disorders therapeutic interventions • Goals of inpatient, short-term care include the following: • Stabilize the client. • Prevent further decline in functioning. • Assist the client in coping with his or her disorder. • Long-term goals include psychosocial and vocational rehabilitation.

46. Psychotic Disorders therapeutic interventions • Pharmacological therapy • Antipsychotic or neuroleptic • Slow the central nervous system (CNS) • After an antipsychotic drug is taken, hallucinations and delusions decrease, thought processes change, and hyperactivity subsides. • Examples • High potency anti-psychotics Prolixin, Haldol, • Moderate potency- Loxitane, Trilafon • Low Potency- Thorazine, Mellaril • Antypical- Clozaril, Seroquel, Risperdal

47. Therapeutic Interventions • Nursing process • Primary nursing diagnoses: • Disturbed thought processes • Disturbed sensory perceptions • Social isolation • Impaired communications • Ineffective management of therapeutic regimen • The basic goals of care are to assist clients in controlling their symptoms and achieving the highest possible level of functioning.

48. Therapeutic Interventions • Special considerations • The most common side effects of antipsychotic medications reflect alterations in CNS and peripheral nervous system functions: • Extrapyramidal side effects (EPSEs) • Sedation • Anticholinergic effects- dry mouth blurred vision • Akathisia- inability to sit still • Akinesia- absence of movement both physically and mentally • Bradykinesia- slowing body movements and diminished mental state • Dyskinesia-involuntary abnormal skeletal muscle movements, jerking motions • Dystonia- impaired muscle tone, produces rigidity in muscles • Neuroleptic malignant syndrome- potentially fatal side effect, usually when two or more meds are combined, can occur after a single dose or years on medication- pg 353

49. Therapeutic Interventions • Nursing responsibilities • Nurses should review desired actions, side effects, and incompatibilities for each medication prescribed. • Monitor client response to each medication. • Client and family education has a direct impact on the client’s level of functioning. • Monitor patients temperature frequently

50. Chronic Mental Health Disorders Chapter 32