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Chapter s 29, 30, 31, 32
Sexual disorder


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.

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.
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 samegender 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.

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.

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.

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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

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.

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

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

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

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

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
Chapter 30
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.
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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.

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.

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

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.

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.

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.

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.

Personality disorders
 Long-standing, maladaptive patterns of behaving and
relating
Theories
Related to
Personality
Disorders
 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.”

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

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

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

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.

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
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


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

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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


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.
Chapter 31

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


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.

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

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 speechSocial withdrawal
Odd behaviors- talking to oneself
Bizarre thoughts and beliefs- unusual beliefs i.e. read minds
Unusual superstitions-remotely controlled by others

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

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.
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.

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.

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

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.

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

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

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.

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

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.

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

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
Chapter 32
Chronic mental disorders are disabling for
persons in every society and culture.
 One in every five families is affected by a
severe mental illness in their lifetime.
 The estimated costs of treating persons
with mental disorders are about 4% of
total U.S. direct health care costs.
 Inpatient stays cost more than $12 billion
per year.



Chronic mental illness carries social stigmas.
Because mental illness affects every area of
functioning, each chronically mentally
troubled person has a unique life experience.

The effects of deinstitutionalization
 In 1960s, chemical restraints replaced physical
restraints (i.e., in institutions).
 State psychiatric hospitals began to discharge
long-term patients into the community through
deinstitutionalization.
 Aftercare, which was a critical part of the overall
plan for providing community psychiatric services,
failed to be implemented.

Meeting basic needs
 Issues facing the mentally troubled population are similar to those
faced by the rest of the population:
▪ Adequate food
▪ Shelter
▪ Clothing
▪ Gainful employment
▪ Access to health care
 People with chronic mental illness, however, must strive to meet their needs on a daily
basis.

Access to health care

Today, a new generation of individuals with chronic mental illness is emerging; they are
known as the young chronically mentally ill.
▪ Individuals are young.
▪ They are severely ill.
▪ Most have never sought treatment.
▪ Those who do receive treatment refuse to follow therapeutic advice.
▪ Many self-medicate to relieve distressing symptoms.
Each person’s experiences with mental illness are
unique.
 Diagnoses serve only to group and label certain
behaviors.
 Certain features are common to all persons who
must live with mental illness.

 Characteristics are divided into two categories:
▪ Psychological characteristics, depression, loneliness, helplessness,
low self esteem
▪ Behavioral characteristics- difficulty with behaviors and activities
that require successful living

Psychological characteristics
 Individuals have several intellectual, emotional, social, and spiritual
features in common.
▪ Chronic low self-esteem, depression, loneliness, hopelessness
 Mentally troubled individuals often see themselves as helpless,
ineffective, and incapable of change.

Behavioral characteristics
 Often, these individuals are unable to function socially or
occupationally.
 Assaultive behaviors or criminal activities may occur.
 Sexual behaviors of these individuals place them at increased risk for
contracting and sharing sexually transmitted diseases.
 Violence is an unfortunate experience of many chronically mentally
troubled people.
Chronic mental health problems can begin at any
stage in life, but they usually are not noted until
adulthood.
 Children and adolescents

 Children with mental retardation have problems with the
intellectual and emotional aspects of life.
 Children with autism are in a world of their own.
 Several chronic mental health problems may develop
during adolescence.
▪ Eating disorders, personality disorders, schizophrenia, and
depression

Older adults with chronic mental illness
 The most commonly acquired mental health
problems in older adulthood are Alzheimer’s
disease and other dementias.
 Depression is another frequent chronic mental
health problem of older adults.
 The mental health of at least two generations
depends on timely and supportive health care
interventions.

Persons with multiple disorders
 The word co-morbidity refers to the presence of
two or more mental health disorders.
▪ Dual diagnosis
 The multidisciplinary treatment team seems to
offer the most promising approach to helping
clients with co-morbid disorders cope with their
problems in each area of functioning.

Inpatient settings
 Persons with chronic mental health problems are hospitalized only
when their behaviors pose a threat to themselves or others.
 The average length of stay for mental illness is about 10 days.
 State psychiatric institutions still provide care for more than 50% of all
psychiatric inpatients.
 The justice system also provides inpatient psychiatric care for many
chronically mentally ill individuals.

Outpatient settings
 Once an acute psychiatric episode has subsided, many chronically
mentally disordered clients are discharged to halfway houses or other
group-living environments.
 Many persons with chronic mental illness live with their families.

Psychiatric rehabilitation
 A multidisciplinary approach uses the special
talents of physicians, psychologists, nurses,
occupational and physical therapists, dietitians,
and other specialists.
 Offers opportunities for persons with severe
mental illness to meet their often neglected social
needs

Treatments and therapies
 Basic goals for chronically disordered mental
health clients are as follows:
▪ Achieve stabilization.
▪ Maintain the highest possible level of daily functioning.
 Therapies are designed on the basis of:
▪ Identified problems
▪ Available resources
▪ Client’s willingness to cooperate with the therapeutic
regimen

Pharmacological therapy
 Antianxiety agents
 Antidepressants
 Antipsychotics (neuroleptics)

Nurses must carefully monitor clients routinely for
compliance with medications.

Nursing (therapeutic) process
 Nurses must perform thorough histories and must assess clients’
physical status, perceptions, and behaviors.
 Nursing diagnoses for chronically mentally ill clients are selected
according to the client’s identified problems.
 Therapeutic interventions then are designed to help the client solve
the identified problems.