Schizophrenia ,Cognitive Disorders, & Sexual disorders I-Schizophrenia Schizophrenia a serious mental disorder which affects 1% of the population.

Onset is usually in the late teens to mid 20¶s and the prognosis is frequently poor. It is a cause of loss of productivity and high medical and social services costs. The suffering of patients with schizophrenia and their families is often great (Singh, 2005). Some fortunate individuals, however, manage relatively uninterrupted lives, and research into aetiology and treatment is progressing. Schizophrenia comprises a group of behaviors whose prominent common features include retreat from reality, emotional blunting, and a disturbance in thinking. These features vary in severity from case to case. Frequently, the presence of other symptoms causes disagreement among clinical professionals about classification. Schizophrenia originally meant "split diaphragm" because classical philosophers thought the mind was located in the midriff. A popular misconception is that schizophrenia is a split personality ("phrenos" means mind, and "schizophrenia" means "split mind" ). Schizophrenia cannot be defined as a single illness; rather, schizophrenia is thought of as a syndrome or disease process with many different varieties and symptoms. It is the most severe major mental illness. A schizophrenic person's odd speech and behavior may cause others to laugh nervously, but these symptoms are the product of torment rather than playfulness. Being unable to order and control one's own thoughts, being isolated by a vision of reality all one's own, being commanded to act by disembodied voices²these are the experiences that make schizophrenia such a frightening and lonely experience. Epidemiology - Gender and Age Usually begins before age 25, persists throughout life and affects persons of all social classes Equally prevalent in men and women but differs in onset Peak ages of onset: Men ± 10 to 25 years Women ± 25 to 35 years with second peak occurring in middle age(with 3 to 10% of women present with disease onset after age 40) Generally, the outcome for female schizophrenia patient is better than that for male schizophrenia patient Late-onset schizophrenia: when onset occurs after age 45.

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Etiology Stress-Diathesis Model: A person may have specific vulnerability (diathesis) that, when acted on by a stressful influence, allows the symptoms of schizophrenia to develop. Neurobiology Dopamine Hypothesis: Posits that schizophrenia results from too much dopaminergic activity. Other Neurotransmitters: Serotonin: Antagonism at the serotonin 5-HT2 receptor has been emphasized as important in reducing psychotic symptoms & in mitigating the development of D2-antagonismrelated movement disorder. Norepinephrine: Increasing amounts of data suggest that the noradrenergic system modulates the dopaminergic system in such a way that abnormalities of the noradrenergic system predispose a prognosis to relapse frequently. GABA: Available data are consistent with the hypothesis that some patients with schizophrenia have a loss of GABAergic neurons in the hippocampus. The loss of inhibitory GABAergic neurons could theoretically lead to the hyperactivity of dopaminergic & noradrenergic neurons Glutamate: Hypotheses proposed about glutamate include those of hyperactivity, hypoactivity & glutamate-induced neurotoxicity Neuropeptides cholecystokinin neurotensin Genetic Factors Most commonly implicated: long arms of chromosome 5, 11, & 18, the short arm of chromosome 19 & the X chromosome Also implicated: loci on chromosomes 6, 8, & 22. Psychosocial factors Subtypes

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The following are the types of schizophrenia. The diagnosis is made according to the client¶s predominant symptoms: Paranoid type: characterized by persecutory (feeling victimized or spied on) or grandiose delusions, hallucinations, and, occasionally, excessive religiosity (delusional religious focus) or hostile and aggressive behavior Disorganized type: characterized by grossly inappropriate or flat affect, incoherence, loose associations, and extremely disorganized behavior Catatonic type: characterized by marked psychomotor disturbance, either motionless or excessive motor activity. Motor immobility may be manifested by catalepsy (waxy flexibility) or stupor. Excessive motor activity is apparently purposeless and is not influenced by external stimuli. Other features include extreme negativism, mutism, and peculiarities of voluntary movement, echolalia, and echopraxia. Undifferentiated type: characterized by mixed schizophrenic symptoms(of other types) along with disturbances of thought, affect, and behavior Residual type: characterized by at least one previous, though not a current, episode; social withdrawal; flat affect; and looseness of associations. Related Disorders:Other disorders are related to but distinguished from schizophrenia in terms of presnting symptoms and the duration or magnitude of impairment.. The DSM-IV-TR (APA,2000) categorizes these disorders as: Schizophreniform disorder: the client exhibits the symptoms of schizophrenia but for less than the 6 months necessary to meet the diagnostic criteria for schizophrenia. Schizoaffective disorder: the client exhibits the symptoms of psychosis and, at the same time, all the features of a mood disorder, either depression or mania. Delusional disorder: the client has one or more non-bizarre delusions-that is, the focus of the delusion is believable. Brief Psychotic disorder: the client experiences the sudden onset of at least one psychotic symptom, such as delusions, hallucinations or disorganized speech or behavior, which lasts from 1 day to 1 month. Shared psychotic disorder (folie à deux): two people share a similar delusion. The person with this diagnosis develops this delusion in the context of a close relationship with someone who has psychotic delusions.      

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The following table summarize types of schizophrenia and the necessary nursing interventions.

SCHIZOPHRENIA
y

CONCEPT
y y

Schizophrenia is a group of psychotic disorders that affect thinking, behavior, emotions, and the ability to perceive reality. The term ³Psychosis´ refers to the presence of hallucinations, delusions, or disorganized speech or catatonic behavior. The typical age at onset is late teens and early twenties, but schizophrenia has occurred in young children and may begin in later adulthood. DISORGANIZED CATATONIC RESIDUAL UNDIFFERENTIAT ED (MIXED TYPE) y Client has symptoms for schizophrenia, but does not meet criteria for any of the other types (no one clinical presentation dominates (e.g. paranoid, disorganized, catatonic) y Any positive or negative symptoms may be present (has active-phase symptoms (does have hallucinations, delusions, and bizarre behaviors) y Eccentric y Psychotic features are extreme: o Fragmente d delusions o Vague hallucinati ons o Bizarre, disorganiz ed behavior o Disorienta

TYPES/ SUBTYPES

PARANOID

y

y

FEATURES
y

Characteri zed by suspicion toward others Dominant: Hallucinati ons and Delusions (positive symptoms) NO Disorganiz ed speech, disorganiz ed behavior, catatonia or inappropri ate affect present. (No negative symptoms )

y

y

y

y y y y

y y

Characterized by withdrawal from society and very inappropriate behaviors, such as poor hygiene, or muttering constantly to self. Frequently seen in the homeless population Dominant: Disorganized speech, disorganized behavior, and inappropriate affect. Marked regression Poor Reality Testing Poor social skills Inappropriate emotional responses Outbursts of laughter Silly behavior

y

y

y

y

Characterized by abnormal motor movements. There are two stages: the withdrawn stage and the excited stage. WITHDRAWN STAGE: o Psychomotor retardation; client may appear comatose. o Waxy Flexibility or stupor o Echolalia and/or Echopraxia o Client often has extreme selfcare needs, such as for tube feeding due to inability to eat EXCITED STAGE: o Peculiar voluntary movement: Unusual posturing, Stereotyped movements, Prominent mannerisms, Prominent Grimaces o Excessive purposeless motor activity (agitation)

y

y

Active-phase (positive) symptoms are not longer present (Delusions, hallucinations, disorganized speech and behaviors) However, the client has two or more ³residual symptoms´ (some negative symptoms) such as: o Marked social isolation or withdrawa l o Impaired role function (wage earner, student, homemak er) o Anergia, Anhedoni a, or Avolition o Alogia (speech problems) o Odd

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o

o

Self-care needs may predominate Client may be a danger to self or others

o

o

o

behavior, such as walking in a strange way Impaired personal hygiene Lack of initiative, interest or energy Blunted or inappropri ate affect

tion, Incoheren ce

ASSESSMENT

DISEASE PROGRESSION:

CHARACTERISTI C DIMENSIONS OF SCHIZOPHRENIA (No single symptom is always present in all cases)

Diagnostic criteria: The four ³A´s: 1. Affect: Refers to the outward manifestation of a person¶s feelings or emotions. In Schizophrenia, clients may display flat, blunted affect. 2. Associative Looseness: Refers to haphazard and confused thinking that is manifested in jumbled and illogical speech and reasoning. The term ³looseness of association´ is also used 3. Autism: Refers to thinking that is not bound to reality, but reflects the private perceptual world of the individual. Delusions, hallucinations, and neologisms are examples of autistic thinking in persons with schizophrenia. (Also termed as ³response to internal stimuli´) 4. Ambivalence: Refers to simultaneously holding two opposite emotions, attitudes, ideas, or wishes toward the same person, situation, or object. Schizophrenia is characterized by periods of exacerbations and remissions. Has three phases: o ACUTE PHASE: Periods of both positive and Negative symptoms o MAINTENANCE PHASE: Acute symptoms decrease in severity o STABILIZATION PHASE: Symptoms in remission o Alterations in perception: Hallucinations: Sensory perceptions for which no external stimulus exists (auditory, visual, olfactory, tactile), Personal Boundary Difficulties, Depersonalization, POSITIVE SYMPTOMS: Derealization o Alterations in thinking:: Delusions: A false belief held and These are the most easily identified maintained as true, even with evidence to the contrary, concrete symptoms thinking, thought broadcasting, thought insertion, thought withdrawal, delusions of being controlled) o Alterations in speech: Associative looseness (Disorganized Speech), Neologisms, Echolalia, Clang Association, Word Salad. o Alterations in behavior (Bizarre behavior): Extreme motor agitation, stereotyped behaviors, Automatic obedience, waxy flexibility, stupor, negativism) NEGATIVE SYMPTOMS (THE FIVE o AFFECT: usually Blunted (narrow range of normal expression) or ³A´s): Flat (Facial expression never changes). o ALOGIA: Poverty of thought or speech; client may sit with a visitor These symptoms are more difficult to treat but may only mumble or respond vaguely to questions successfully than positive symptoms o AVOLITION: Lack of motivation in activities and hygiene o ANHEDONIA: Inability to find pleasure in life; the client is indifferent to things that often make others happy o ANERGIA: Lack of energy, chronic fatigue

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COGNITIVE SYMPTOMS: Problems with thinking make it very difficult for the client to live independently

o o o o o o

DEPRESSIVE SYMPTOMS:

o o

Disordered thinking Poor problem-solving skills Poor decision-making skills Inattention; easily distracted (Difficulty concentrating to perform tasks) Impaired judgment Impaired memory  Long-term memory loss  Working Memory loss (such as inability to follow directions to find an address) Hopelessness Suicidal Ideation

EXPECTED OUTCOMES

INTERVENTIONS

MEDICATIONS

ACTIVE PHASE: -Client safety and medical stabilization STABILIZATION PHASE: MAINTENANCE PHASE: -Target negative symptoms -Adherence to medication regimen -Anxiety Control -Understanding schizophrenia -Relapse prevention -Participation of client and family in psycho educational activities ACUTE PHASE: (Hospitalization, Client Safety, Stabilization Of Symptoms) MAINTENANCE AND STABILIZATION PHASES: 1. Administer antipsychotic medication as prescribed -Psychosocial education 2. Observe client behavior closely -Relapse prevention skills 3. Set limits on inappropriate behavior 4. Increase reality testing when delusional or hallucinating 5. Do not touch without warning 6. Offer foods that are not easily contaminated 7. Assist with ADLs as needed 8. Supportive counseling 9. Milieu Therapy 10. Family psycho education TYPICAL (CLASSIC) ANTISYCHOTICS ATYPICAL ANTIPSYCHOTICS (Treatment of both positive and (Treatment of positive symptoms) negative symptoms) o HALDOL (Haloperidol) o ZYPREXA (Olanzapine) o THORAZINE (Chlorpromazine) o RISPERDAL (Risperidone) o PROLIXIN (Fluphenazine) o SEROQUEL (Quetiapine) o SERENTIL (Mesoridazine) o GEODONE (Ziprasidone) o TRILAFON (Pherphenazine) o CLORAZIL (Clozpine) o MELLARIL (Thioridazine) o ABILIFY (Aripriprazole)

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II- Cognitive Disorders Cognition involves the brain¶s ability to process, retain, and use information. Cognitive abilities include reasoning, judgment, perception, attention, comprehension, and memory. Disruption of these functions impairs the person¶s ability to make decisions, solve problems, interpret the environment, and learn new information. A-Delirium Delirium: a syndrome that involves disturbance of consciousness accompanied by a change in cognition ,Acute and fluctuating Difficulty paying attention, distractibility, and disorientation Sensory disturbances include illusions, misinterpretations, hallucinations Disturbances in sleep/wake cycle, anxiety, fear, irritability, euphoria, apathy Risk factors: hospitalization for general medical conditions, older acutely ill clients, severe physical illness, older age, and baseline cognitive impairment Etiology: almost always results from an identifiable physiologic, metabolic, or cerebral disturbance or disease or from drug intoxication or withdrawal Treatment and Prognosis Treatment of the underlying medical condition will usually resolve delirium Clients with head injury or encephalitis may have cognitive, emotional, or behavioral impairment due to brain damage from the disease or injury Delirious clients who are quiet and resting need no other medication for delirium. Those who are restless or a safety risk may require low-dose antipsychotic medication. Sedatives and benzodiazepines may worsen the delirium Nursing Process: Delirium Assessment History: medical illness, prescribed medications, alcohol, illicit drugs, and over-the-counter medications General appearance and motor behavior: restless, picking at covers, agitated, getting out of bed, or sluggish and lethargic; speech is less coherent as delirium worsens
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Mood and affect: client has rapid and unpredictable mood shifts with wide range of emotions Thought process and content: difficult to assess thought process accurately due to disorientation and impaired cognition Sensorium and intellectual processes: sensory misperceptions, disorientation, confusion, lack of attention and concentration Judgment and insight: impaired judgment, varied insight Roles and relationships: usually no long-term effect unless previous problems existed Self-concept: frightened or feel threatened; may feel helpless or powerless; may feel guilt, shame, and humiliation Physiologic and self-care considerations: trouble sleeping, may ignore body cues such as hunger, thirst, or the urge to urinate or defecate Data Analysis Nursing diagnoses may include: -Risk for Injury -Acute Confusion -Disturbed Sensory Perception -Disturbed Thought Processes -Disturbed Sleep Pattern -Risk for Deficient Fluid Volume -Risk for Imbalanced Nutrition: Less Than Body Requirements Outcomes The client will: -Be free of injury -Demonstrate increased orientation and reality contact -Maintain an adequate balance of activity and rest -Maintain adequate nutrition and fluid balance -Return to optimal level of functioning (pre-delirium)
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Intervention -Promoting safety -Managing confusion -Promoting sleep and nutrition Evaluation -Has the underlying cause of delirium been successfully treated? -Has the client returned to his or her previous level of functioning? -Does the client and caregiver or family understand what health care practices are necessary to avoid a recurrence (this may involve monitoring a chronic health condition, careful use of medications, or abstaining from alcohol or other drugs)? B- Dementia Dementia involves multiple cognitive deficits, primarily memory impairment, and at least one of the following: Aphasia ,Apraxia ,Agnosia ,Disturbance in executive functioning. Dementia is progressive unless the underlying cause is treatable, such as vascular dementia, which is rare Onset and Clinical Course Mild (excessive forgetfulness, difficulty finding words, loses objects, anxiety about loss of cognitive abilities) Moderate (confusion, progressive memory loss, can¶t do complex tasks, oriented to person and place, recognizes familiar people; by the end of this stage requires assistance and supervision) Severe (personality and emotional changes, delusional, wanders at night, forgets names of spouse and children, requires assistance with activities of daily living) Nursing Process: Dementia Assessment History: may be unable to provide an accurate and thorough history; interview family, friends, or caregivers General appearance: aphasia, perseveration, slurring, eventual loss of language

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Motor behavior: apraxia, cannot imitate demonstrated tasks, finally gait disturbance making unassisted ambulation unsafe, then impossible May demonstrate uninhibited behavior: inappropriate jokes, sexual comments, undressing in public, profanity; familiarity with strangers Mood and affect: initially anxious and fearful over lost abilities, labile moods, emotional outbursts, catastrophic emotional responses; verbal or physical aggression possible; may become emotionally listless, apathetic, withdrawn Thought processes and content: initially loses ability to think abstractly; cannot solve problems; cannot generalize knowledge from one situation to another; later, delusions of persecution are common Sensorium and intellectual processes: initially memory deficits that worsen over time; confabulation to fill in memory gaps; agnosia; cannot write or draw simple objects; inability to concentrate; chronic confusion, disorientation (eventually even to person); visual hallucinations common. Judgment and insight: initially recognizes he or she is losing abilities, and then insight fades altogether; judgment impaired due to cognitive deficits worsens over time; at risk for wandering, getting lost, injuring self, unable to perceive harm. Self-concept: initially client is frustrated at losing things or forgetting, sad about ³getting old´; sense of self deteriorates until client doesn¶t recognize own reflection in mirror Roles and relationships: can no longer work, cannot fulfill roles at home, cannot attend social events, eventually confined to home; family members often become caregivers but feel loved one has become a stranger Physiologic and self-care considerations: disturbances in sleep/wake cycle, ignoring body cues to eat, drink, urinate, etc.; lose abilities to do personal hygiene, even feeding self Data Analysis Nursing diagnoses include: ‡ ‡ ‡ ‡ ‡
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Risk for Injury Disturbed Sleep Pattern Risk for Deficient Fluid Volume Risk for Imbalanced Nutrition Chronic Confusion

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Impaired Environmental Interpretation Syndrome Impaired Memory Impaired Socialization Impaired Verbal Communication Ineffective Role Performance

Outcomes The client will: ‡ ‡ Be free of injury Maintain an adequate balance of activity and rest, nutrition, and hydration and elimination Function as independently as possible given his or her limitations Feel respected and supported Remain involved in his or her surroundings Interact with others

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Intervention ‡ ‡ ‡ ‡ Promoting safety Promoting adequate sleep, nutrition, hygiene, and activity Structuring the environment and routine Providing emotional support ‡ ‡ Supportive touch

Promoting interaction and involvement ‡ ‡ ‡ ‡ Reminiscence therapy Distraction Time away Going along

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‡ ‡

Evaluation Is the client maintaining independence to the greatest degree possible considering the stage of cognitive impairment? Are family members and caregivers able to carry out their changing roles as the client¶s condition worsens? III-Sexual disorders

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Normal sexuality: It depends on four interrelated factors: 1- Sexual identity: genotype (XY or XX). 2- Gender identity: firm conviction of maleness or femaleness. 3- Gender role: behaviour that is build up cumulatively through experiences and learning. 4- Sexual Orientation: describes that object of person¶s sexual impulses (hetero, homo, or bisexual). Four-phase response cycle: 1- Desire: fantasies and desire to have sexual activity. 2- Excitement: brought by psychological and physiological stimulation. 3- Orgasm: peaking of sexual pleasure with contraction of the perineal muscles and pelvic reproductive organs. 4- Resolution: brings body back to its resting state. (sense of well-being and muscular relaxation Sexual Disorders: The DSM of Mental Disorders: classified sexual disorders into: 1. Sexual dysfunctions 2. Paraphilias 3. Gender identity disorders 1-Sexual Dysfunction: ‡ A disturbance in the process that characterize the sexual response cycle or by pain associated w/ sexual intercourse

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The dysfunction causes ± disturbed interpersonal relationships & marked distress for the individual, the partner, or both.

The Human Sexual Responses (Masters & Johnsons 1960¶s) 1. Sexual desire ± interest, intention, willingness. 2. Excitement/arousal ± neurologic & vascular changes; cognitive & emotional changes 3. Orgasms ±height of the arousal phase- strong rhythmic contractions in the pelvis. 4. Resolution ± sense of general relaxation, well being, & muscle relaxation. Sexual Dysfunctions Types: 1- Sexual desire disorder: ‡ Hypoactive desire: Often use inhibition of desire in a defensive way to protect against unconscious fears about sex.

2- Sexual arousal disorder: Persistent and recurrent inability to attain or maintain until completion of sexual activity, lubrication in female or erection in male. 3- Orgasmic disorder: ‡ ‡ Female Orgasmic Disorders Persistent /recurrent delay in/absence of orgasm following a normal sexual excitement phase.(Age/adequacy/experience) Male Orgasmic Disorder Persistent /recurrent delay in or in absence of orgasm following a normal sexual excitement phase, considering the person¶s age & other factors. Premature Ejaculation Persistent /recurrent ejaculation w/ minimal sexual stimulation/or before on, or shortly after penetration, and before the desires it ( age, newness partner/situation/ frequency)

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4- Sexual pain disorder: a. Dyspareunia: recurrent genital pain occuring before, during, or after intercourse. b. Vaginismus: involuntary muscle constriction of the outer third of the vagina that interferes with penile
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2. Paraphilias: Persistent, intense, and recurrent sexual urges, fantasies, or behaviors that involve nonliving objects, other non consenting persons ( children/adults), or humiliation or pain ; occur at least 6 mos. Paraphilias Types: 1. Exhibitionism: exposure of one¶s genitals to unsuspecting stranger(s), followed by sexual arousal. 2. Fetishism: use of objects for purpose sexual arousal and during sexual activity. 3. Frotteurism : touching or rubbing against a non consenting person, to stimulate sexual arousal. 4. Pedophilia -sexual activity w/ a prepubescent child /children 13 y/o or below at least 16 y/o & at least 5 years older than the child/ren -May be homosexual, heterosexual, or bisexual -May be limited to incest -Exclusive type ±attracted only to children -Non exclusive ± attracted also to adults 5. Sexual Masochism: the act of being humiliated, beaten , bound, or otherwise made to suffer during sexual activity while alone (masturbating) or with others. 6. Sexual Sadism: acts in which physical or psychologic suffering of the victim is sexually arousing to the perpetrator. 7. Tranvestic fetishism: a) The act of cross dressing by a heterosexual males b) Does not meet the criteria for gender identity disorder, non transexual type; or transexualism. 8. Voyeurism: the act of observing an unsuspecting person who is naked, in the act of disrobing, or engaging in sexual activity to achieve sexual arousal. 9. Paraphilia not otherwise specified:

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-Telephone scatologia ± lewdness; obcene phone calling; sex line telephoning. -Necrophilia ± sexual activities w/ corpses. -Partialism ± exclusive focus on body part that generates sexual arousal. -Zoophilia ± sexual activity w/ animals; bestiality. -Coprophilia ± sexual arousal on contact w/ feces -Klismaphilia ± sexual arousal generated by the use of enemas -Urophilia ± sexual arousal on contact w/ urine -Ephebophilia ± fondling & other types of sexual activities ± dev. Sexual characteristics 13-18y/o -Paraphilic coercive disorder ± rape, aggressive sexual assault ± against female 3. Gender Identity Disorder: ‡ Persistent, strong desire to be the opposite sex or insistence that one is the opposite sex ( cross-gender identification disorder) Persistent discomfort w/ own sex & feelings of inappropriateness in the gender role of the assigned sex.

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Nursing Care: Child and Adolescent Disorders

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