Sexuality is basic human need. This need is present at every developmental stage and as age increases, it become more dominant. According to Freud if person fixated at one stage or its needs repressed then in later life it comes in his behavior (Townsend, 2006). According to Muslim Public Affairs Council (1996) sex and sexuality are consider taboo subjects in Pakistan. Our culture also doesn’t allow talking about these issues openly before marriage and consider legal to satisfy sexual desire only after marriage. Religion also doesn’t support to discuss these matters openly.
It is important to discuss on this topic in mental health because if we don’t discuss on sexuality, the patient may start expressing his thoughts in unacceptable manner which is against our norms of society and it is called as “sexual disinhibition”.
The study uncovered that 26.7% of persistent schizophrenic patients had huge obsessive enthusiastic indications, with a high prevalence in the age set ‘underneath 35 years.’ Obsessive habitual side effects were more serious in patients with term of sickness more than 5 years. The obsessive impulsive indications were more common around paranoid schizophrenics (Hemrom et al, 2009).
A 33 yr. old female admitted in Karwan-e-Hayat with complain of schizophrenia. On assessment I found her depressed and prepared to give teaching on coping mechanism. While giving teaching to her on coping strategies she suddenly started telling her sexual thoughts, desire and feelings to have a sexual intercourse. Even she was ready to have an intercourse with his divorced husband and wanted to get married. When she was telling this I was quiet, anxious, uncomfortable, and not confident to discuss. Once I thought that I was not able to assess her problem for which she needed help.
In schizophrenia obsessive compulsive symptoms that of being contamination, sexual, and aggressive thoughts is the positive sign. In a research it has been found that 10% of schizophrenic patient had these obsession symptoms (Hemrom et al, 2009). Sexual obsession is common in schizophrenic patients and relates the DSM-IV criteria of schizophrenia and OC (Bancroft, 2008). Who encounter such a sort of “unadulterated fixations” (i.e., fixations that are regularly portrayed by the absence of unmistakable impulses) assess unpleasant considerations as unsafe and excessively significant and, hence, fight to control their beliefs (Dell’Osso et al, 2012). The patient was suffering from schizophrenia so having sexual obsession could be the part of her disease process as Turkcan et al. (2007) reported that 16% of patient had obsessive compulsive symptoms with schizophrenia.
According to Freud (1961), psychoanalytic theory describes formation of personality through five stages of psychosexual development. Fixation of libido (sexual drive or instinct) at any stage of development certainly results in psychopathology (Townsend, 2006) and fixation at any stage will also influence the behavior of person in later life (McLeod, 2008). As in case of my patient, she was divorced due to which her sexual desires were repressed and unable to fulfill them. It results in fixation of sexual needs due to which her sexual needs are at extreme level that, she have intense feeling to have intercourse and have sexual thoughts, which may change into behavior at any time.
On the other hand, literature shows that some antipsychotic drugs induce sexual disinhibition which includes risperidone and quntipien (Lam et al, 2007). Risperidone side effect is that it increases sex drive and also decreases sexual function in some cases. Some cases have been reported which shows the effect of risperidone in increasing the sexual obsession compulsive thoughts (Basil et al, 2002). So, my patient was also taking risperidone it may be one of the factor for having compulsive thought. Whereas, there is also literature support for medication that decreases sexual desires such as one of the late study evaluate that second generation antipsychotic i.e. risperidone, olanzapine, quntipien, and haloperidol is the biggest study to date to assess sexual dysfunction and reproductive side effects (Kelly & Conley, 2004).
Therefore, it is important to take alternative medications to treat these symptoms. Whereas various late medicine studies and narrative case reports have indicated an adjunctive particular serotonin reuptake inhibitor (SSRI) may be a convincing medications to treat OC in schizophrenia. Patients getting clozapine and other atypical antipsychotics as their support medicine ought to be thoroughly screened for new onset or compounding of prior OC indications (Hwang et al, 2006).
Although my patient had intense thoughts and desires to have intercourse, so with the pharmacological management it is important to do cognitive therapy because patient only have thoughts, but her thoughts can be change into behavior. It is important to change her thoughts through cognitive therapy. There are different strategies through which inappropriate behavior of patient can be change and these are discussing below.
Cognitive therapy helps dependent upon perception, and all the more particularly, the particular judgment evaluation by a single person of an occasion, and the feelings or practices that come about because of that examination. Cognitive techniques include identifying and modifying repeated thoughts (thinking errors) and schemas interior values (Townsend, 2006).
The goal of cognitive therapy is to change irrelevant beliefs, faulty way of thinking, and negative self- statements that cause behavioral problems (Stuart, 2013).
Cognitive therapy focuses on controlling and reducing obsessive compulsive behaviors by behavioral strategies for managing symptoms, thoughts, beliefs and feelings are perused and examine for relevance and validity. Behavior modification system is dependent upon the precise examination and requisition of fortification. Support is the procedure by which new reactions are obtained and existing ones are fortified (Jessor, 2013).
Moreover, motivational interventions can be done to develop patient’s motivation to change. By asking open-ended question can help to identify patient agenda. Affirming, reinforcing positive statements, and hopeful can emphasize that change is possible and it will also increase the self esteem of patient which will help him and motivate to change (Stuart, 2013).
Role modeling can be done to teach the behavior. Lifestyle change to help an individual identify high-risk situations, change cognitive distortions or faulty thinking, and cope with stressful or high-risk situations that may trigger relapse (Townsend, 2006)
Furthermore, nurse role is important in recognizing these issues in mental health. As, in my patient scenario it was my lacking that I was unable to recognize patient needs correctly so as nurse it is important to asses patient needs rightly and to do interventions accordingly. For this nurse should be competent in communication skills, confident to talk on this sensitive topic. She should have complete knowledge about the topic, positive approach and effective communication style can greatly improve the interaction. An approach that rises strengthening and self-governance ought to be utilized and the suitable health-advancement messages through consultation for individual client (Gott et al, 2004).
All in all, prevalence of inappropriate behavior with schizophrenia is high; therefore as nurse it is important to asses patient needs and play the role of counselor, advocator, and as a care giver in giving awareness to families about patient disease process. Family and health care support also helps patient to cope his situation. In mental health it is important to modify the behavior of client according to needs through required techniques.