Mood Disorders: Exam 3 Flashcards
Grief is the painful emotional response to the ___________ of something or someone significant.
Loss
Initially, clients may have difficulty accepting that the loss has really occurred. Denial is a common first reaction.
Denial
Clients who are grieving often experience strong feelings of anger. They may express anger toward self, others, or even the lost person.
Anger
During grief, clients may attempt to strike a deal with God or some higher power for an alternative plan. For example, a person may plead, “If you will let me live to see my daughter’s wedding, I’ll accept my cancer diagnosis.”
Bargaining
Of course, clients that are grieving will experience intense feelings of sadness, sorrow, and loss.
Depression
Eventually, most clients come to accept the loss. They utilize coping strategies and become less preoccupied with it. That’s not to say they no longer feel the loss or grieve. They still have ups and downs. But they’ve found new ways to stay connected to the loss as they continue life.
Acceptance
What are the stages in KÜBLER-ROSS MODEL OF GRIEF?
Denial
Anger
Bargaining
Depression
Acceptance
What are the types of grief?
Normal grief
Anticipatory grief
Maladaptive grief
Bereavement Overload
Clients experience the stages of grief (denial, anger, bargaining, etc.). Somatic complaints are common (e.g., headaches, nausea, fatigue, sleep difficulties). Some authors say that clients usually achieve some degree of acceptance by six months. Keep in mind, each situation is unique and there is no set time limit for grieving.
Normal Grief
Occurs when a client experiences the stages of grief before the loss occurs (e.g., when a loved one is in hospice care). Sometimes clients are not aware they are experiencing this type of grief since the loss has not yet occurred.
Anticipatory Grief
Occurs when the grief response may be inhibited, exaggerated, or prolonged. A helpful way to distinguish normal grief from maladaptive grief is that the latter is often accompanied by feelings of ___________________ or low self-esteem.
Worthlessness
Maladaptive Grief
Occurs when an individual experiences too many losses at too rapid of a pace. Older adults are especially prone to experiencing this.
Bereavement Overload
Clients have a depressed mood and/or loss of interest in pleasurable activities (anhedonia). Clients can feel extreme guilt and feelings of worthlessness. Sleep abnormalities are common (increased or decreased). Appetite changes are common (increased or decreased). Clients can be incredibly fatigued, making it difficult to climb out of bed. Some, however, experience psychomotor agitation and irritation. In some cases, suicidal thoughts and behaviors can occur.
Major Depressive Disorder
What are the depression sub-types?
Melancholic features
Mood-congruent psychotic features
Seasonal pattern
Peripartum onset
This is a severe version of depression in which a client’s mood is extremely dark and unremitting. Even extremely positive news will not temporarily lift the client’s spirits. Clients often experience early morning ______________ and loss of appetite. _______________ ideation is common.
Awakenings
Suicidal
Melancholic features
Some clients with depression experience delusions that involve strong feelings of guilt. They may believe they are responsible for someone’s death or a natural catastrophe. Alternatively, they may believe they have a severe illness or that their body is “rotting.” Auditory hallucinations can also occur.
Mood-congruent psychotic features
This is a form of depression that reoccurs seasonally (usually ____________ ). Light therapy is an effective treatment.
Winter
Seasonal Patterns
This subtype of depression is associated with pregnancy. Some of these clients will develop __________ features.
Psychotic
Peripartum Onset
Depression is often called the “common _________ ” of mental disorders. The lifetime prevalence of depression is about 17%. It’s nearly twice as common in _________ . Depression can occur at any age, but it is less common in older adults.
A common problem is relapsing. The chance of relapsing after one episode is _____ %. After two episodes, the relapse rate is ______ %.
Cold
Women
50%
80%
What is the etiology for Major Depressive Disorder?
Psychological Factors
Cognitive-behavioral theorists note that depressed clients have a similar pattern of thinking: negative beliefs about the world, themselves, and the future. In addition, depressed clients exhibit several cognitive distortions (e.g., all-or-nothing thinking, personalization, mind reading, discounting positives).
Biological Factors
Depression may be related to deficiencies of serotonin, norepinephrine, and dopamine in the brain.
Sometimes depression is caused by a general medical condition (e.g., hypothyroidism) or medication use (e.g., alcohol, beta blockers, steroids, withdrawing from a stimulant like cocaine or amphetamine).
What are the effective treatments for Major Depressive Disorder?
Psychotherapy
Effective psychotherapy includes CBT and group therapy.
Pharmacotherapy
Antidepressants (SSRIs, SNRIs, TCAs, MAOIs) are commonly used. SSRIs are usually the first-line agents since their side effects are milder.
Brain Stimulation Therapies
Electroconvulsive therapy (ECT) is an effective option for clients who are extremely suicidal or have failed numerous other treatments. The evidence supporting ECT for these clients is strong.
Transcranial magnetic stimulations (TMS) is another option. TMS, as the name suggests, is procedure in which strong magnetic pulses are sent through the skull into the brain—usually the left prefrontal cortex. Unfortunately, the evidence for TMS is not strong.
Nursing Interventions:
Safety is always the top priority. Depressed clients might be suicidal. Assess for suicidal ideation often and monitor closely.
Convey ____________ and unconditional positive regard.
Teach the stages of grief and explain that these are normal feelings.
Allow clients to express anger and don’t take offense. Physical activity (e.g., jogging, hitting a punching bag, etc.) may also be a healthy outlet.
Explain that crying is OK. Use silence; don’t rush to change the subject.
Encourage clients to seek out spiritual support and a support group.
Teach clients with low self-esteem assertiveness techniques.
Explain that antidepressants can take up to _______ weeks to begin working.
Empathy
Four
Mania can feel extremely pleasurable. Clients may feel exuberant, extremely confident, and highly creative. They seem to have endless energy, are always moving about, and may feel little or no need for sleep. They are high on life. Their thoughts race (flight of ideas) and their speech is “pressured.” It may be difficult to get a word in while talking to them. Dangerous behaviors are common (e.g., drugs, risky sex, reckless spending). They are highly distractible and may begin massive projects that they cannot complete (e.g., a simple plan to paint a bedroom may morph into a whole house renovation). Not all is cheery; agitated outbursts are common. Psychotic delusions (usually grandiose) and hallucinations (usually auditory) may also occur. Manic episodes usually end with a crash into deep depression.
Hypomania is a less severe version of mania. Clients experience an elevated mood, enhanced creativity, increased energy, and may act intrusively. Hypomania by itself does not cause significant impairment.
Bipolar Disorder
These clients experience __________ (and usually depression). What type of bipolar disorder is this?
Mania
Bipolar 1
These clients experience _____________ and depression. What type of bipolar disorder is this?
Hypomania
Bipolar 2
What is the epidemiology for Bipolar Disorder?
The lifetime prevalence of bipolar disorders is about 1%. Rates are roughly equal in men and women. The average age of onset 18 years for bipolar 1 and 20 years for bipolar 2.
What is the etiology for Bipolar Disorder?
Psychological Factors
Stressful life events in childhood seem to increase the risk of developing bipolar disorder.
Biological Factors
Bipolar disorder has a strong GENETIC basis. Having a first-degree relative with bipolar disorder increases a person’s lifetime risk to 5-10%.
Excessive levels of norepinephrine and dopamine likely play a role in bipolar disorder. There is also evidence of deficient levels of serotonin (even during manic states).
Bipolar depression seems to have a different etiology than unipolar depression; does not respond as well to antidepressants.
What are the effective treatments for Bipolar Disorder?
Psychotherapy
CBT and group psychoeducation can help clients learn coping skills and improve medication adherence.
Pharmacotherapy
Pharmacotherapy is ESSENTIAL to the treatment of bipolar disorder.
Common medications include lithium, anticonvulsants (valproate, lamotrigine, carbamazepine), and second generation antipsychotics (e.g., aripiprazole, clozapine, ziprasidone). Antidepressants are often ineffective and sometimes precipitate mania.
Brain Stimulation Therapy
ECT can help clients with extreme manic behavior or who are having difficulty achieving symptom control (e.g., have failed numerous medication regimens).
Nursing Interventions for Bipolar Disorder:
Decrease environmental ________________ (e.g., low lighting, low noise, fewer people) when clients are manic. Do not, however, isolate a client.
Assess for suicidal and homicidal thoughts.
Remove all ___________objects when clients are agitated, confused, or suicidal.
Assess for illicit drug use. Substances can increase the risk of harm and make medication management more difficult.
Maintain a calm demeanor and tone of speech. Remember that anxiety can be contagious.
Stimuli
Dangerous
Nursing Interventions for Bipolar Disorder:
Set ________ on dangerous and manipulative behaviors. Clearly describe was is expected. Explain the consequences if limits are broken. Ensure entire team is enforcing the same limits. Give immediate feedback when limits are broken. Don’t argue, bargain, try to reason, or become emotional with the client. Provide positive reinforcement for non-manipulative behaviors.
Listen to and act on legitimate complaints.
Avoid ____________ struggles; don’t become emotional.
Provide outlets for physical energy (e.g., exercise, punching bag).
Clients experiencing mania have increased caloric needs and may have difficulty sitting down to eat meals. Monitor ___________ status. Provide high-protein, high-calorie, portable foods and drinks.
Promote good sleep hygiene and limit caffeine use during manic episodes.
Limits
Power
Nutritional
In 2016, nearly ___________ people killed themselves in the United States, making it the _______ leading cause of death. Misclassification is common; the true number is probably much higher. The most common methods of suicide are firearms (50%), suffocation/hanging (25%), and poisoning/overdose (15%).
More than _____ % of people who kill themselves have a diagnosable mental illness. Mood disorders and substance abuse are most common.
45,000
10th
90%
What are the long-term risk factors for suicide?
Age - The highest risk group now is 45- to 64-year olds.
Gender - Males have the highest rate of suicide, but women have more attempts.
Ethnicity/race - Whites are the highest risk group. American Indians are the second highest risk group. Marital status - Single, divorced, and widowed individuals have a higher risk. LGBT individuals also have a higher risk.
Socioeconomic status - The very poor and very rich have a higher risk.
Occupation - Physicians, law enforcement officers, dentists, mechanics, lawyers, and insurance agents have a higher risk.
Religion - People who lack close religious affiliation have a higher risk.
Family history - Having a family member who committed suicide increases risk.
Military - Suicide rates among military personnel are higher than the general population.
Previous attempts - 50-80% of people who commit suicide have at least one previous attempt.
What are the imminent risk factors for suicide? The IS PATH WARM mnemonic can help you recognize imminent warning signs.
Ideation - Does the client have a plan? The means to complete the plan? How lethal is the plan? A lethal plan that a client has the means to carry out is a major warning sign.
Substance abuse - Substances (e.g., alcohol) disinhibit people and interfere with judgment. Purposelessness - Does the client see no meaning or purpose for living?
Anger - Is the client angry? One extra painful emotion can push a client over the edge.
Trapped - Does the client believe there is no way out of his or her current predicament?
Hopelessness - Does the client see any other alternatives besides suicide to solve their problems? Withdrawing - Is the client letting go, saying goodbye? This is not always obvious. Examples include sending flowers with a note, taking out a life insurance policy, getting finances in order, giving gifts, etc. Anxiety - Is the client anxious? One extra painful emotion can push a client over the edge. Also, anxiety can cause insomnia—another risk factor.
Recklessness - Is the client engaging in thoughtless, dangerous behaviors? This can be a sign they no longer value life.
Mood shifts - Is there a sudden change in the client’s mood (positive or negative). A sudden, positive shift mean the client has decided to commit suicide.
Nursing Interventions for Suicide:
When assessing for suicidal ideation, be direct and matter-of-fact (e.g., “Do you ever think about suicide?”). Research shows assessing for suicidal ideation does not increase the risk of attempts; it decreases risk.
A helpful way to raise an uncomfortable topic like is suicide is to use the _____________ technique. For example, “Sometimes when clients are going through intense emotional pain, they have thoughts about killing themselves. Have you had any thoughts like that?”
Pay attention to __________ statements (e.g., “I don’t have anything worth living for anymore.”) Assess for suicidal ideation when you hear statements like these.
Be alert to the warning signs (i.e., IS PATH WARM). Remember, a lethal plan that a client has the means to carry out is a major warning sign. If a client has rehearsed the plan, the risk is even greater.
Normalization
Indirect
Nursing Interventions for Suicide:
If a client has suicidal thoughts, remove all potentially dangerous objects (e.g., shoe strings, glass, cords, belts, metal eating utensils, plastic bags, potential poisons, etc.) and initiate one-on-one constant supervision —even while going to the bathroom.
Encourage the client to participate in establishing a detailed safety plan. For example, whom would they call if they started having a strong desire to carry out the plan?
Ensure that clients are not “cheeking” medications. Clients may save these pills to attempt an overdose.
A sudden _____________ in a client’s mood can indicate the client intends to commit suicide in the near future.
Improvement
ECT often has a negative stigma. What is the source of this stigma?
There are disturbing media portrayals of ECT.
ECT was originally overused/misused.
The procedure itself is unusual.
ECT is a very effective treatment for severe ____________ . Other indications include bipolar disorder (depression and mania), schizophrenia (especially with catatonic features), and schizoaffective disorder. What is this?
Depression
Efficaciousness
In the vast majority of cases, clients give informed consent. In cases where a client is too ill or lacks the capacity to consent, the provider must seek a court order. Because of the controversy associated with ECT, the informed consent process is very detailed.
Informed consent
Clients are given a short-acting anesthetic (e.g., propofol) to render them unconscious during the procedure. In addition, a paralytic (e.g., succinylcholine) is given to prevent muscle contractions and injury. Clients are unconscious, feel no pain, and do not convulse like you may have imagined. 🎬
A standard treatment course is two or three treatments per week for a total of six to 12 treatments. Unfortunately, relapse is common. Thus, many clients also receive maintenance ECT.
Anesthesia
ECT is one of the safest procedures performed under general anesthesia. It can even be performed on clients who are ______________ . Nonetheless, there are adverse effects. These include:
Pregnant
Headache - This is the most common adverse effect of ECT.
Elevated vitals - Seizures will temporarily increase blood pressure, heart rate, and intracranial pressure. If a client has cardiovascular or cerebrovascular disease, ECT might be too risky.
Memory loss - Clients often experience temporary confusion and memory loss. Sometimes memory loss is permanent.
Miscellaneous - Other possible effects include aspiration, dental and tongue injuries, muscle soreness, and nausea.
Nursing Interventions for Electroconvulsive Therapy (ECT):
Assess the client and family’s understanding of ECT. Help correct any misconceptions.
Know your medications. An anticholinergic (atropine or glycopyrrolate) is given before the procedure to dry up secretions and prevent a seizure-induced vagal response (i.e., bradycardia).
AIRWAY is your top priority when clients have been under anesthesia.
Monitor vital signs and mental status before and after the procedure. If a client has a history of hypertension, make sure it is under control.
Maintain the client’s IV until recovery is fully completed.
Stay with the client. Reorient client to time and place. Explain what has occurred. Provide reassurance.
