Depression and Bipolar Disorder (Exam 2)

Environmental Factors of Aggression

Crowding, temperature, and noise

Sociological Theories

Durkheim's Theory Interpersonal Theory of Suicide The Three-Step Theory

Self-Care Deficit (Hygiene, Grooming)

*Behaviors* Uncombed hair Disheveled clothing Offensive body odor

Stimulus generalization.

The process by which the fear response is elicited from similar stimuli

Imbalanced Nutrition: Less than body requirements

*Behaviors* Weight loss Poor muscle tone Pale conjunctiva and mucous membranes Poor skin turgor Weakness

Social Isolation/Impaired Social Interaction

*Behaviors* Withdrawn Uncommunicative Seeks to be alone Dysfunctional interaction with others Discomfort in social situations

History of Aggression and Violence

A history of violent behavior or impulsive acts has been associated with increased risk for suicide Recent evidence suggests that impulsive traits are higher in individuals with suicide ideation but not necessarily associated with more attempts

Diagnostic Criteria for Disruptive Mood Dysregulation Disorder

A. Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation B. The temper outbursts are inconsistent with developmental level C. The temper outbursts occur, on average, three or more times per week D. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., parents, teachers, peers) E. Criteria A-D have been present for 12 or more months. Throughout that time, the individual has not had a period lasting 3 or more consecutive months without all of the symptoms of Criteria A-D F. Criteria A and D are present in at least two of three settings (i.e., at home, at school, with peers) and are severe in at least one of these G. The diagnosis should not be made for the first time before age 6 or after age 18 years H. By history or observation, the age at onset of Criteria A-E is before 10 years I. There has never been a distinct period lasting more than 1 day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met Note: Developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation, should not be considered as a symptom of mania or hypomania J. The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder (e.g., autism spectrum disorder, posttraumatic stress disorder, separation anxiety disorder, persistent depressive disorder [dysthymia]) Note: This diagnosis cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder, though it can coexist with others, including major depressive disorder, attention-deficit/hyperactivity disorder, conduct disorder, and substance use disorders. Individuals whose symptoms meet criteria for both disruptive mood dysregulation disorder and oppositional defiant disorder should only be given the diagnosis of disruptive mood dysregulation disorder. If an individual has ever experienced a manic or hypomanic episode, the diagnosis of disruptive mood dysregulation disorder should not be assigned K. The symptoms are not attributable to the physiological effects of a substance or to another medical or neurological condition

Vagal Nerve Stimulation and Deep Brain Stimulation

Involves implanting an electronic device in the skin to stimulate the vagus nerve The mechanism of action is not known, but preliminary studies have shown that many clients with chronic recurrent depression improved when treated with VNS

Guided Relaxation

Aimed at reducing autonomic response to anxiety Techniques may include deep breathing, imagery, mindfulness meditation, and other exercises These techniques also increase awareness of conscious control over breathing, anxiety symptoms, and thoughts

Cognitive therapy is goal oriented and problem focused

At the beginning of therapy, the client is encouraged to identify what he or she perceives to be the problem or problems With guidance from the therapist, goals are established as outcomes of therapy

Situation My girlfriend broke up with me (Three-Column Thought Recording)

Automatic Thoughts -I'm a stupid person. No one would ever want to marry me Emotional Response -Sadness; depression

Know that change is constant (Tidal Model)

Because change is a constant in everyone's life, important decisions and choices must be made along the path to recovery in order for growth to occur Professional competencies -Helping the individual develop awareness of the changes that are occurring -Helping the individual develop how he or she has influenced these changes. The task of the professional helper is to develop awareness of how change is happening and to support the person in making decisions regarding the course of the recovery voyage

Atypical Antidepressants

Bupropion (Wellbutrin, Zyban) 200-450mg Forfivo XL 450mg TI: Not well established Maprotiline B/21-25 25-225mg TI: 200-300 (including metabolite) Mirtazapine (Remeron) C20-40 15-45mg TI: Not well established Nefazodonet (Serzone) C/2-4 200-600mg TI: Not well established Trazodone C/4-9 250-600mg TI: 800-1,600

Activity Scheduling

Clients are asked to keep a daily log of their activities on an hourly basis and rate each activity, for mastery and pleasure, on a 0-to-10 scale The schedule is then shared with the therapist and used to identify important areas needing concentration during therapy

Cognitive therapy aims to be time limited

Clients often are seen weekly for a couple of months, followed by a number of biweekly sessions, then possibly a few monthly sessions Some clients want periodic "booster" sessions every few months

Recovery is based on respect (Guiding Principles of Recovery)

Community, systems, and societal acceptance and appreciation for people affected by mental health and substance use problems—including protecting their rights and eliminating discrimination—are crucial in achieving recovery There is a need to acknowledge that taking steps toward recovery may require great courage Self-acceptance, developing a positive and meaningful sense of identity, and regaining belief in one's self are particularly important

Social Class & Depression

Current treatments were less effective for working-class individuals than for middle-class counterparts, regardless of whether they received therapy or medication This finding may be influential in higher levels of depression among lower socioeconomic class members

Reciprocal Inhibition

Decreases or eliminates a behavior by introducing a more adaptive behavior, but one that is incompatible with the unacceptable behavior

Shaping

Reinforcements are given for increasingly closer approximations to the desired response

Senescence (Developmental Implications)

Depression is the most common psychiatric disorder of the elderly, who make up 14.5 percent of the general population of the United States This is not surprising considering the disproportionate value our society places on youth, vigor, and uninterrupted productivity These societal attitudes continually nurture the feelings of low self-esteem, helplessness, and hopelessness that become more pervasive and intensive with advanced age The aging individual's adaptive coping strategies may be seriously challenged by: -Major stressors, such as financial problems, physical illness, changes in bodily functioning -An increasing awareness of approaching death The problem is often intensified by the numerous losses individuals experience during this period in life, such as spouse, friends, children, home, and independence Some symptoms of depression in the elderly are similar to those in younger adults However, depressive syndromes are often confused by other illnesses associated with the aging process Symptoms of depression are often misdiagnosed as neurocognitive disorder (NCD) when in fact the memory loss, confused thinking, or apathy symptomatic of NCD actually may be the result of depression This condition is often referred to as pseudodementia The early awakening and reduced appetite typical of depression are common among many older people who are not depressed Compounding this situation is that many medical conditions, such as endocrinological, neurological, nutritional, and metabolic disorders, often present with classic symptoms of depression Many medications commonly used by the elderly, such as antihypertensives, corticosteroids, and analgesics, can also produce a depressant effect Depression accompanies many illnesses that are common among older people, such as Parkinson's disease, cancer, arthritis, and the early stages of Alzheimer's disease Treating depression in these situations can reduce unnecessary suffering and help afflicted individuals cope with their medical problems The most effective treatment of depression in the elderly individual is thought to be a combination of psychosocial and biological approaches Antidepressant medications are administered with consideration for age-related physiological changes in absorption, distribution, elimination, and brain receptor sensitivity Because of these changes, plasma concentrations of these medications can reach very high levels despite moderate oral doses Anticholinergic side effects associated with tricyclic antidepressants can be problematic for the elderly, and SSRIs have been associated with inducing significant hyponatremia in this population, so careful evaluation and monitoring is essential Electroconvulsive therapy (ECT) is an important alternative for treatment of major depression in the elderly, especially considering the problematic side effects of antidepressants in this population The response to ECT appears to be slower with advancing age, and the therapeutic effects are of limited duration. Research has identified ECT as generally safe for the acute treatment of late-life depression It may be considered the treatment of choice for the elderly individual who is an acute suicidal risk or is unable to tolerate antidepressant medications Confusion, a side effect of ECT that typically last a few minutes to several hours, is generally more pronounced in the elderly Other therapeutic approaches include: -Interpersonal psychotherapy -Behavioral psychotherapy -Cognitive psychotherapy -Group psychotherapy -Family psychotherapy Appropriate treatment of the depressed elderly individual can bring relief from suffering and offer a new lease on life with a feeling of renewed productivity

Cognitive

Relating to the mental processes of thinking and reasoning

Biological Theories

Genetics Biochemical Influences Neuroendocrine Disturbances Physiological Influences

Helplessness (Schemas)

Maladaptive/ Negative -No matter what I do, I will fail -I must be perfect. If I make one mistake, I will lose everything Adaptive/Positive -If I try and work very hard, I will succeed -I am not afraid of a challenge. If I make a mistake, I will try again

Unlovability (Schemas)

Maladaptive/ Negative: -I'm stupid. No one would love me -I'm nobody without a man Adaptive/Positive -I'm a lovable person -People respect me for myself

Marital Status & Depression

Marriage has a positive effect on psychological well-being compared to those who are single or do not have a close relationship with another person Marital stress was associated with increased risk for depression, suggesting that social stress may also be an important variable to consider

Bipolar Disorder

Mood disorders as they are manifested by cycles of mania and depression

Hypomania

Not severe enough to cause marked impairment in social or occupational functioning or to require hospitalization, and it does not include psychotic features

Role Modeling

One of the strongest forms of learning Children model their behavior at a very early age after their primary caregivers, usually parents. How parents or significant others express anger becomes the child's method of anger expression

Cognitive therapy initially emphasizes the present

Resolution of distressing situations that are based in the present usually leads to symptom reduction It is more beneficial to begin with current problems and delay shifting attention to the past until (1) the client expresses a desire to do so, (2) the work on current problems produces little or no change, or (3) the therapist decides it is important to determine how dysfunctional ideas affecting the client's current thinking originated

Conditioned Response

Response was not reflexive but had been learned

Moderate Postpartum Depression

Symptoms -Depressed mood varying from day to day, with more bad days than good, worsening toward evening and associated -Fatigue -Irritability -Loss of appetite -Sleep disturbances -Loss of libido -Mother expresses a great deal of concern about her inability to care for her baby These symptoms begin somewhat later than those attributable to the baby blues and take from a few weeks to several months to abate Moderate depression may be relieved with supportive psychotherapy and continuing assistance with home management until the symptoms subside

Recovery emerges from hope (Guiding Principles of Recovery)

The belief that recovery is real provides the essential and motivating message of a better future—that people can and do overcome the internal and external challenges, barriers, and obstacles that confront them Hope is internalized and can be fostered by peers, families, providers, allies, and others Hope is the catalyst of the recovery process

Anaclitic Depression

The concept was introduced in 1946 by psychiatrist René Spitz to refer to children who became depressed after being separated from their mothers for an extended period of time during the first year of life Symptoms include -Excessive crying -Anorexia -Withdrawal -Psychomotor retardation -Stupor -Generalized impairment in the normal process of growth and development Some researchers suggest that loss in adult life afflicts people much more severely in the form of depression if the individuals have suffered early childhood loss

Premack Principle

To encourage more of a particular behavior that an individual is not doing very often, a situation is created in which the person must perform that behavior before being permitted to do the "fun stuff" that he or she prefers to do

Examining Options and Alternatives

To help the client see a broader range of possibilities than originally considered, the therapist guides the client in learning how to generate alternatives

Didactic (Educational) Aspects

To prepare the client to eventually become his or her own cognitive therapist The therapist provides information to the client about what cognitive therapy is, how it works, and the structure of the cognitive process Explanation about expectations of both client and therapist is provided Reading assignments are given to reinforce learning Some therapists use audiotape or videotape sessions to teach clients about cognitive therapy A full explanation about the relationship between depression (or anxiety, or whatever maladaptive response the client is experiencing) and distorted thinking patterns is an essential part of cognitive therapy

Craft the step beyond (Tidal Model)

The individual and the practitioner decide together what needs to be done immediately Any 'first step' is a crucial step, revealing the power of change and potentially pointing towards the ultimate goal of recovery Practitioner competencies -Helping the individual determine what kind of change would represent a step toward recovery -Helping the patinet determine what he or she needs to do to take that first step in the progress toward that goal

Arbitrary Inference

The individual automatically comes to a conclusion about an incident without the facts to support it or even despite contradictory evidence Two months ago, Mrs. B. sent a wedding gift to the daughter of an old friend. She has not yet received acknowledgment of the gift. Mrs. B. thinks, "They obviously think I have poor taste."

Substance/Medication-Induced Bipolar Disorder

The disturbance of mood associated with this disorder is considered to be the direct result of physiological effects of a substance (e.g., ingestion of or withdrawal from a drug of abuse or a medication) The mood disturbance may involve elevated, expansive, or irritable mood with inflated self-esteem, decreased need for sleep, and distractibility The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

Learning Theory (Psychosocial Theories)

The model of "learned helplessness" arises out of Seligman's (1973) experiments with dogs The animals were exposed to electrical stimulation from which they could not escape Later, when they were given the opportunity to avoid the traumatic experience, they reacted with helplessness and made no attempt to escape A similar state of helplessness exists in humans who have experienced numerous failures (either real or perceived) The individual abandons any further attempt to succeed Seligman theorized that learned helplessness predisposes individuals to depression by imposing a feeling of lack of control over their life situations They become depressed because they feel helpless; they have learned that whatever they do is futile Learned helplessness can be especially damaging very early in life, because the sense of mastery over one's environment is an important foundation for future emotional development

Durkheim's Theory

The more cohesive the society and the more that the individual felt an integrated part of society, the less likely he or she was to carry out suicide 1. Egoistic Suicide 2. Altruistic Suicide 3. Anomic Suicide

Value the voice (Tidal Model)

The person is encouraged to tell his or her story The person's story represents the beginning and endpoint of the helping encounter, embracing not only an account of the person's distress, but also the hope for its resolution Practitioner competencies -A capacity to actively listen to the person's story -To help the person record the story in his or her own words

Personalization

The person takes complete responsibility for situations without considering that other circumstances may have contributed to the outcome Jack, who sells vacuum cleaners door-to-door, has just given a 2-hour demonstration to Mrs. W. At the end of the demonstration, Mrs. W tells Jack that she appreciates his demonstration, but she won't be purchasing a vacuum cleaner from him. Jack thinks, "I'm a lousy salesman" (when in fact, Mrs. W.'s husband lost his job last week, and they have no extra money to buy a new vacuum cleaner at this time)

Flat Affect

The state of a person who lacks emotional expression and is often seen in severely depressed clients

Automatic Thoughts

Those that occur rapidly in response to a situation and without rational analysis. These thoughts are often negative and based on erroneous logic

Be transparent (Tidal Model)

Transparency is important in the teambuilding process between the individual and the professional helper Professionals are in a privileged position and should model confidence by being transparent at all times, helping the person understand exactly what is being done and why Professional competencies -Ensuring that the individual is aware of the significance of all interventions -Ensuring that the individual receives copies of all documents related to the plan of care

Phase II of Individual Psychotherapy

Treatment focuses on helping the client resolve complicated grief reactions This may include resolving the ambivalence with a lost relationship and assistance with establishing new relationships Other areas of treatment focus may include interpersonal disputes between the client and a significant other, difficult role transitions at various developmental life cycles, and correction of interpersonal deficits that may interfere with the client's ability to initiate or sustain interpersonal relationships

Minimization

Undervaluing the positive significance of an event Mrs. M. is feeling lonely. She telephones her granddaughter Amy, who lives in a nearby town, and invites her to visit. Amy apologizes that she must go out of town on business and would not be able to visit at that time. While Amy is out of town, she calls Mrs. M. twice, but Mrs. M. still feels unloved by her granddaughter

Risk for Suicide

Vulnerable to self-inflicted, life-threatening injury *Behaviors* -Depressed mood -Feelings of hopelessness and worthlessness -Anger turned inward in the self -Misinterpretations of reality -Suicidal ideation, plan, and available means *Goal* Short-term goals -Client will seek out staff when feeling urge to harm self -Client will not harm self Long-term goal -Client will not harm self *Interventions* Create a safe environment for the client. Remove all potentially harmful objects from client's access (sharp objects, straps, belts, ties, glass items, alcohol). Supervise closely during meals and medication administration. Perform room searches as deemed necessary Assess frequently for the presence and lethality risk of suicidal ideation. The intensity of suicide ideation can change over the course of hours or days, so it is important to assess subjective and objective data to evaluate current risk. Discussion of suicidal feelings with a trusted individual provides some relief to the client Convey an attitude of unconditional acceptance of the client as a worthwhile individual Encourage the client to actively participate in establishing a safety plan. Suicidal clients are often very ambivalent about their feelings. Discussion of strategies for maintaining safety with a trusted individual may provide assistance before the client experiences a crisis situation Maintain close observation of the client. Depending on level of suicide precaution, provide one-to-one contact, constant visual observation, or checks at least every 15 minutes conducted at irregular intervals. Place the client in a room close to the nurse's station; do not assign to a private room. Accompany the client to off-ward activities if attendance is indicated and, if necessary, to the bathroom. Close observation is necessary to ensure that the client does not harm self in any way. Being alert for suicidal and escape attempts facilitates being able to prevent or interrupt harmful behavior Maintain special care in administration of medications. This prevents saving up to overdose or discarding and not taking Make rounds at frequent, irregular intervals (especially at night, toward early morning, at change of shift, or other predictably busy times for staff). This prevents staff surveillance from becoming predictable. Awareness of client's location is important, especially when staff is busy, unavailable, or less observable Encourage verbalizations of honest feelings. Through exploration and discussion, help the client identify symbols of hope in his or her life Encourage the client to express angry feelings within appropriate limits. Provide a safe method of hostility release. Help the client identify the true source of anger and work on adaptive coping skills for use outside the treatment setting. Depression and suicidal behaviors may be viewed as anger turned inward on the self. If this anger can be verbalized in a nonthreatening environment, the client may be able to eventually resolve these feelings Identify community resources that the client may use as a support system and from whom he or she may request help if feeling suicidal once discharged from the hospital. Having a concrete plan for seeking assistance during a crisis may discourage or prevent self-destructive behaviors Orient the client to reality, as required. Point out sensory misperceptions or misinterpretations of the environment. Take care not to belittle the client's fears or indicate disapproval of verbal expressions Most importantly, spend time with client. This provides a feeling of safety and security while also conveying the message, "I want to spend time with you because I think you are a worthwhile person."

Biochemical Factors of Aggression

Testosterone is identified as playing a key role, while deficits in serotonin have been associated with an increase in impulsivity

Complicated Grieving

*Behaviors* A disorder that occurs after the death of a significant other [or any other loss of significance to the individual], in which the experience of distress accompanying bereavement fails to follow normative expectations and manifests in functional impairment

Insomnia

*Behaviors* Difficulty falling asleep Difficulty staying asleep Lack of energy Difficulty concentrating Verbal reports of not feeling well rested

Spiritual distress

*Behaviors* Expresses anger toward God Expresses lack of meaning in life Sudden changes in spiritual practices Refuses interactions with significant others or with spiritual leaders

Disturbed Through Processes

*Behaviors* Inappropriate thinking Confusion Difficulty concentrating Impaired problem-solving ability Inaccurate interpretation of environment Memory deficit

Biochemical Influences (Biological Theories)

*Biogenetic Amines* The catecholamine norepinephrine has been identified as a key component in the mobilization of the body to deal with stressful situations Neurons that contain serotonin are critically involved in the regulation of many psychobiological functions, such as mood, anxiety, arousal, vigilance, irritability, thinking, cognition, appetite, aggression, sleep-wake cycles, eating, and intestinal motility Tryptophan, the amino acid precursor of serotonin, has been shown to enhance the efficacy of antidepressant medications and on occasion to be effective as an antidepressant itself The level of dopamine in the mesolimbic system of the brain is thought to exert a strong influence over human mood and behavior A diminished supply of these biogenic amines inhibits the transmission of impulses from one neuronal fiber to another, causing a failure of the cells to fire or become charged More recently, the biogenic amine hypothesis has been expanded to include another neurotransmitter, acetylcholine Because cholinergic agents have profound effects on mood, electroencephalograms, sleep, and neuroendocrine function, it has been suggested that the problem in depression and mania may be an imbalance between the biogenic amines and acetylcholine Cholinergic transmission is thought to be excessive in depression and inadequate in mania The precise role that any neurotransmitters play in the etiology of depression is unknown because these chemicals cannot be measured in the brain It has been theorized that since selective serotonin reuptake inhibitors (SSRIs) are drugs that elevate serotonin levels, low serotonin levels in the brain must be responsible for depression However, SSRIs also seem to be beneficial in the treatment of anxiety, leading to the hypothesis that low serotonin levels are responsible for anxiety Further, too much serotonin has also been implicated in anxiety states and in schizophrenia All of this seemingly contradictory information has led many current researchers to believe that neurotransmitters such as serotonin might be better explained as modulators of intense emotional states rather than associated with any one particular emotion

Lamotrigine (Lamictal) (Anticonvulsant)

*Pregnancy Category/Half-Life/Indications* C/~33 hr/ -Epilepsy Unlabeled use: -Bipolar disorder *Mechanism of Action* Action in the treatment of bipolar disorder is unclear *Contraindications/Precautions* -Hypersensitivity -Caution in renal and hepatic insufficiency, pregnancy, lactation, and children <16 years old *Daily Adult Dosage Range/Therapeutic Plasma Range* -100-200 mg/ -Not established

Neuroendocrine Disturbances (Biological Theories)

*Hypothalamic-Pituitary-Adrenocortical Axis* The normal system of hormonal inhibition fails, resulting in a hypersecretion of cortisol This elevated serum cortisol is the basis for the dexamethasone suppression test that is sometimes used to determine if an individual has somatically treatable depression *Hypothalamic-Pituitary-Thyroid Axis* Thyrotropin-releasing factor (TRF) from the hypothalamus stimulates the release of thyroid-stimulating hormone (TSH) from the anterior pituitary gland In turn, TSH stimulates the thyroid gland Diminished TSH response to administered TRF is observed in approximately 25 percent of depressed persons and appears to be associated with increased risk for relapse despite treatment with antidepressants About 4.6 percent of the U.S. population suffers from hypothyroidism (more women than men), and depression is a common symptom (in addition to a host of other symptoms) Laboratory testing to evaluate TSH is relevant to distinguish between depressive disorders and thyroid disorders, since in thyroid disorders the symptoms of depression are treated with hormone replacement rather than antidepressants.

Physiological Influences (Biological Theories)

*Medication Side Effects* A number of drugs, either alone or in combination with other medications, can produce a depressive syndrome Most common are those that have a direct effect on the central nervous system, such as anxiolytics, antipsychotics, sedative-hypnotics (including barbiturates and opioids), and anticonvulsant mood stabilizers Many drugs used to treat general medical conditions have also been associated with inducing depression, and several are listed here: -Antibacterial agents, antifungal agents, and antiviral agents -Antimalarials (including mefloquine) -Antihypertensives and statins (including beta blockers and calcium blockers) -Antineoplastics (including vincristine and zidovudine) -Dermatologics (including isotretinoin and finasteride) -Hormones (including contraceptives) -Nonnucleoside reverse transcriptase inhibitors (HIV medications) -Respiratory agents (leukotriene inhibitors) -Steroids -Smoking cessation agents (varenicline) -Vigabatrin (anticonvulsant) *Neurological Disorders* An individual who has suffered a cardiovascular accident (CVA) may experience despondency unrelated to the severity of the CVA These are true mood disorders, and antidepressant drug therapy may be indicated Brain tumors, particularly in the area of the temporal lobe, often cause symptoms of depression Agitated depression may be part of the clinical picture associated with Alzheimer's disease, Parkinson's disease, and Huntington's disease Agitation and restlessness may also represent underlying depression in the individual with multiple sclerosis *Electrolyte Disturbances* Excessive levels of sodium bicarbonate or calcium can produce symptoms of depression, as can deficits in magnesium and sodium Potassium is also implicated in the syndrome of depression Symptoms have been observed with excesses of potassium in the body as well as in instances of potassium depletion *Hormonal Disturbances* Depression is associated with dysfunction of the adrenal cortex and is commonly observed in both Addison's disease and Cushing's syndrome Other endocrine conditions that may result in symptoms of depression include hypoparathyroidism, hyperparathyroidism, hypothyroidism, and hyperthyroidism An imbalance of the hormones estrogen and progesterone has been implicated in the predisposition to PMDD, although the exact etiology is unknown The interaction of these hormonal changes has an impact on serotonin levels, which may contribute to the depression associated with this disorder It is also noted that individuals with PMDD often have underlying depression and anxiety, so it is possible that hormone changes are exacerbating an already existing condition *Nutritional Deficiencies* Deficiencies in proteins, carbohydrates, vitamin B1 (thiamine), vitamin B2 (riboflavin), vitamin B6 (pyridoxine), B9 (folate), vitamin B12, iron, zinc, calcium, chromium, iodine, lithium, selenium, potassium, and omega-3 fatty acids have all been associated with symptoms of depression A recent large study also found that vitamin D deficiency was linked to depressive symptoms It is not a surprise that individuals with anorexia nervosa, who have significant nutritional deficiencies, commonly have comorbid depression *Other Physiological Conditions* Other conditions that have been associated with secondary depression include: Collagen disorders -Systemic Lupus Erythematosus (SLE) -Polyarteritis Nodosa Cardiovascular disease -Cardiomyopathy -congestive heart failure -Myocardial infarction Infections -Encephalitis -Hepatitis -Mononucleosis -Pneumonia -Syphilis Metabolic disorders, -Diabetes Mellitus -Porphyria

Lurasidone (Latuda) (Antipsychotic)

*Pregnancy Category/Half-Life/Indications* B/18 hr/ -Depressive episodes in bipolar I disorder -Schizophrenia *Daily Adult Dosage Range/Therapeutic Plasma Range* -20-120 mg/ -Not established

Olanzapine and fluoxetine (Symbyax) (Antipsychotic)

*Pregnancy Category/Half-Life/Indications* C/(see individual drugs)/ -Treatment of depressive episodes associated with bipolar disorder *Daily Adult Dosage Range/Therapeutic Plasma Range* -6/25-12/50 mg/ -Not established

Clonazepam (Klonopin) (Anticonvulsant)

*Pregnancy Category/Half-Life/Indications* C/18-60 hr/ -Petit mal, akinetic, and myoclonic seizures -Panic disorder Unlabeled uses: -Acute manic episodes -Uncontrolled leg movements during sleep -Neuralgias *Mechanism of Action* Action in the treatment of bipolar disorder is unclear *Contraindications/Precautions* -Hypersensitivity, glaucoma, liver disease, lactation -Caution in elderly; liver, renal disease; pregnancy *Daily Adult Dosage Range/Therapeutic Plasma Range* -0.5-20 mg/ -0.02-0.08 mcg/mL

Oxcarbazepine (Trileptal) (Anticonvulsant)

*Pregnancy Category/Half-Life/Indications* C/2-9 hr/ -Epilepsy Unlabeled uses: -Bipolar disorder -Diabetic neuropathy -Neuralgia *Mechanism of Action* Action in the treatment of bipolar disorder is unclear *Contraindications/Precautions* -Hypersensitivity -Caution in renal and hepatic impairment, pregnancy, lactation, children, and the elderly *Daily Adult Dosage Range/Therapeutic Plasma Range* -600-2,400 mg/ -Not established

Topiramate (Topamax) (Anticonvulsant)

*Pregnancy Category/Half-Life/Indications* C/21 hr/ -Epilepsy -Migraine prophylaxis Unlabeled uses: -Bipolar disorder -Cluster headaches -Bulimia -Binge eating disorder -Weight loss in obesity *Mechanism of Action* Action in the treatment of bipolar disorder is unclear *Contraindications/Precautions* -Hypersensitivity -Caution in renal and hepatic impairment, pregnancy, lactation, children, and the elderly *Daily Adult Dosage Range/Therapeutic Plasma Range* -50-400 mg/ -Not established

Olanzapine (Zyprexa) (Antipsychotic)

*Pregnancy Category/Half-Life/Indications* C/21-54 hr/ -Schizophrenia -Acute manic episodes -Management of bipolar disorder -Agitation associated with schizophrenia or mania Unlabeled uses: -Obsessive-compulsive disorder *Mechanism of Action* Efficacy in schizophrenia is achieved through a combination of dopamine and serotonin type 2 (5HT2) antagonism. Mechanism of action in the treatment of mania is unknown. Action may be mediated via effects on dopamine and serotonin (5HT2a) receptor antagonism *Contraindications/Precautions* -Hypersensitivity, children, lactation -Caution with hepatic or cardiovascular disease, history of seizures, coma or other CNS depression, prostatic hypertrophy, narrow-angle glaucoma, diabetes or risk factors for diabetes, pregnancy, elderly and debilitated patients, history of suicide attempts *Daily Adult Dosage Range/Therapeutic Plasma Range* -10-20 mg/ -Not established

Chlorpromazine (Antipsychotic)

*Pregnancy Category/Half-Life/Indications* C/24 hr/ -Bipolar mania -Schizophrenia -Emesis, hiccoughs -Acute intermittent porphyria -Preoperative apprehension Unlabeled uses: -Migraine headaches *Daily Adult Dosage Range/Therapeutic Plasma Range* -75-400 mg/ -Not established

Asenapine (Saphris) (Antipsychotic)

*Pregnancy Category/Half-Life/Indications* C/24 hr/ -Schizophrenia -Bipolar mania *Daily Adult Dosage Range/Therapeutic Plasma Range* -10-20 mg/ -Not established

Risperidone (Risperdal) (Antipsychotic)

*Pregnancy Category/Half-Life/Indications* C/3-20 hr/ -Bipolar mania -Schizophrenia Unlabeled uses: -Severe behavioral problems in children -Behavioral problems associated with autism -Obsessive-compulsive disorder *Daily Adult Dosage Range/Therapeutic Plasma Range* -1-6 mg/ -Not established

Gabapentin (Neurontin) (Anticonvulsant)

*Pregnancy Category/Half-Life/Indications* C/5-7 hr/ -Epilepsy -Postherpetic neuralgia Unlabeled uses: -Bipolar disorder -Migraine prophylaxis -Neuropathic pain -Tremors associated with multiple sclerosis *Mechanism of Action* Action in the treatment of bipolar disorder is unclear *Contraindications/Precautions* -Hypersensitivity and children <3 years -Caution in renal insufficiency, pregnancy, lactation, children, and the elderly *Daily Adult Dosage Range/Therapeutic Plasma Range* -900-1,800 mg/ -Not established

Aripiprazole (Abilify) (Antipsychotic)

*Pregnancy Category/Half-Life/Indications* C/50-80 hr/ -Bipolar mania -Schizophrenia *Daily Adult Dosage Range/Therapeutic Plasma Range* -10-30 mg/ -Not established

Quetiapine (Seroquel) (Antipsychotic)

*Pregnancy Category/Half-Life/Indications* C/6 hr/ -Schizophrenia -Acute manic episodes *Daily Adult Dosage Range/Therapeutic Plasma Range* -100-800 mg/ -Not established

Ziprasidone (Geodon) (Antipsychotic)

*Pregnancy Category/Half-Life/Indications* C/7 hr (oral)/ -Bipolar mania -Schizophrenia -Acute agitation in schizophrenia *Daily Adult Dosage Range/Therapeutic Plasma Range* -40-160 mg/ -Not established

Lithium carbonate (Eskalith, Lithobid) (Antimanic)

*Pregnancy Category/Half-Life/Indications* D/24 hr/ -Prevention and treatment of manic episodes of bipolar disorder Unlabeled uses: -Neutropenia -Cluster headaches (prophylaxis) -Alcohol dependence -Bulimia -Postpartum affective psychosis -Corticosteroid-induced psychosis *Mechanism of Action* Not fully understood but may modulate the effects of various neurotransmitters (e.g., norepinephrine, serotonin, dopamine, glutamate, and GABA) that are thought to play a role in the symptomatology of bipolar disorder (may take 1-3 weeks for symptoms to subside) *Contraindications/Precautions* -Hypersensitivity Cardiac or renal disease, dehydration, sodium depletion, brain damage, pregnancy and lactation -Caution with thyroid disorders, diabetes, urinary retention, history of seizures, and the elderly *Daily Adult Dosage Range/Therapeutic Plasma Range* Acute mania: 1,800-2,400 mg Maintenance: 900-1,200 mg/ Acute mania: 1.0-1.5 mEq/L Maintenance: 0.6-1.2 mEq/L

Carbamazepine (Tegretol) (Anticonvulsant)

*Pregnancy Category/Half-Life/Indications* D/25-65 hr (initial); 12-17 hr (repeated doses)/ -Epilepsy -Trigeminal neuralgia Unlabeled uses: -Bipolar disorder -Resistant schizophrenia -Management of alcohol withdrawal -Restless legs syndrome -Postherpetic neuralgia *Mechanism of Action* Action in the treatment of bipolar disorder is unclear *Contraindications/Precautions* -Hypersensitivity With MAOIs, lactation -Caution with elderly; liver, renal, cardiac disease; pregnancy *Daily Adult Dosage Range/Therapeutic Plasma Range* 200-1,600 mg/ 4-12 mcg/mL

Valproic acid (Depakene; Depakote) (Anticonvulsant)

*Pregnancy Category/Half-Life/Indications* D/5-20 hr/ -Epilepsy -Manic episodes -Migraine prophylaxis -Adjunct therapy in schizophrenia *Mechanism of Action* Action in the treatment of bipolar disorder is unclear *Contraindications/Precautions* -Hypersensitivity, liver disease -Caution in elderly; renal, cardiac diseases; pregnancy and lactation *Daily Adult Dosage Range/Therapeutic Plasma Range* -5 mg/kg-60 mg/kg/ -50-150 mcg/mL

Genetics (Biological Theories)

*Twin Studies* Suggest a strong genetic factor in the etiology of affective illness, including depressive disorders Heritability is estimated at 40 to 50 percent *Family Studies* Most family studies have shown that major depression is more common among first-degree biological relatives of people with the disorder than among the general population The evidence to support an increased risk of depressive disorder in individuals with positive family history is quite compelling. *Adoption Studies* Support for heritability as an etiological influence in depression comes from studies of the adopted offspring of biological parents with depression Some studies have found a threefold increase in depression among children of biological relatives with affective illness, but other studies have found no difference in the rate of mood disorders Conversely, adoption studies have also been used to examine the effects of being reared by an adoptive parent (particularly the maternal parent) with depression and the risks for depression in their nongenetically similar children Interestingly, these studies have demonstrated an increased risk of depression (as well as oppositional defiant disorder and conduct disorder) in adopted children that cannot be explained by genetics

Behavioral Interventions

1. Activity Scheduling 2. Graded Task Assignments 3. Distraction 4. Miscellaneous Techniques

Principles of Cognitive Therapy

1. Cognitive therapy is based on an ever-evolving formulation of the client and his or her problems in cognitive terms 2. Cognitive therapy requires a sound therapeutic alliance 3. Cognitive therapy emphasizes collaboration and active participation 4. Cognitive therapy is goal oriented and problem focused 5. Cognitive therapy initially emphasizes the present 6. Cognitive therapy is educative, aims to teach the client to be his or her own therapist, and emphasizes relapse prevention 7. Cognitive therapy aims to be time limited 8. Cognitive therapy sessions are structured 9. Cognitive therapy teaches clients to identify, evaluate, and respond to their dysfunctional thoughts and beliefs 10. Cognitive therapy uses a variety of techniques to change thinking, mood, and behavior

What Is Recovery?

1. Health -Overcoming or managing one's disease as well as living in a physically and emotionally healthy way 2. Home -A stable and safe place to live 3. Purpose -Meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income, and resources to participate in society 4. Community -Relationships and social networks that provide support, friendship, love, and hope

Aggression

A behavior intended to threaten or injure the victim's security or self-esteem May include verbal and physical attacks that intend harm to another and often reflect a desire for dominance and control May range from a self-protective response to a destructive, violent act

Cyclothymic Disorder

A chronic mood disturbance of at least 2 years' duration, involving numerous periods of elevated mood that do not meet the criteria for a hypomanic episode and numerous periods of depressed mood of insufficient severity or duration to meet the criteria for major depressive episode The individual is never without the symptoms for more than 2 months

Selective Abstraction (Mental Filter)

A conclusion that is based on only a selected portion of the evidence. The selected portion is usually the negative evidence or what the individual views as a failure, rather than any successes that have occurred Jackie just graduated from high school with a 3.98/4.00 grade point average. She won a scholarship to the large state university near her home. She was active in sports and activities in high school and well liked by her peers. However, she is very depressed and dwells on the fact that she did not earn a scholarship to a prestigious Ivy League college to which she had applied

Schizoaffective Disorder

A condition in which the individual expresses symptoms of a mood disorder as well as symptoms of schizophrenia

Contingency contracting

A contract is drawn up among all parties involved The desired behavior change and specified reinforcers for performing this behavior are stated explicitly in writing. The negative consequences, or punishers, that will be rendered for not fulfilling the terms of the contract are also delineated

Complicated Grieving

A disorder that occurs after the death of a significant other [or any other loss of significance to the individual], in which the experience of distress accompanying bereavement fails to follow normative expectations and manifests in functional impairment *Behaviors* Depression Preoccupation with thoughts of loss Self-blame Grief avoidance Inappropriate expression of anger Decreased functioning in life roles *Goal* Short-term goals -Client will express anger about the loss -Client will identify coping strategies and rational thought patterns in response to loss Long-term goal -Client will be able to recognize his or her own position in the grief process while progressing at own pace toward resolution. *Interventions* Determine the stage of grief in which the client is fixed. Identify behaviors associated with this stage. It is important to obtain accurate baseline assessment data to effectively plan care for the grieving client Develop a trusting relationship with the client. Show empathy, concern, and unconditional positive regard. Be honest and keep all promises. Convey an accepting attitude, and encourage the client to express feelings openly Encourage the client to express anger. Do not become defensive if the initial expression of anger is displaced on the nurse or therapist. Help the client explore angry feelings so that the feelings may be directed toward the actual intended person or situation Help the client to discharge pent-up anger through participation in large motor activities (e.g., brisk walks, jogging, physical exercises, volleyball, punching bag, exercise bike). Physical exercise provides a safe and effective method for discharging pent-up tension Teach the stages of grief and behaviors associated with each stage. Help the client understand that feelings such as guilt and anger toward the lost concept/entity are appropriate and acceptable during the grief process and should be expressed rather than held inside. Knowledge of acceptability of the feelings associated with grieving may help relieve some of the guilt that these responses generate Encourage the client to review the relationship with the lost concept/entity. With support and sensitivity, point out the reality of the situation in areas where misrepresentations are expressed. The client must give up an idealized perception and be able to accept both positive and negative aspects about the lost concept/entity before the grief process is complete Communicate to the client that crying is acceptable. This can be accomplished by verbal reassurance and, in some cases, with caring touch. Use of touch must also consider cultural influences and trauma history before including this as part of the intervention Assist the client in problem-solving as he or she attempts to determine methods for more adaptive coping with the experienced loss. Provide positive feedback for strategies identified and decisions made Encourage the client to reach out for spiritual support during this time in whatever form is desirable to him or her. Assess spiritual needs of the client and assist as necessary in the fulfillment of those needs Encourage the client to attend a support group of individuals who are experiencing life situations similar to his or her own. Help the client to locate a group of this type

Behavior Therapy

A form of psychotherapy that aims to modify maladaptive behavior patterns by reinforcing more adaptive behaviors

Stage III: Delirious Mania

A grave form of the disorder characterized by severe clouding of consciousness and an intensification of the symptoms associated with acute mania This condition has become relatively rare since the availability of antipsychotic medication *Mood* Mood is very labile He or she may exhibit feelings of despair, quickly converting to unrestrained merriment and ecstasy or becoming irritable or totally indifferent to the environment Panic-level anxiety may be evident. *Cognition and Perception* Characterized by a clouding of consciousness, with accompanying confusion, disorientation, and sometimes stupor Other common manifestations include religiosity, delusions of grandeur or persecution, and auditory or visual hallucinations The individual is extremely distractible and incoherent *Activity and Behavior* Psychomotor activity is frenzied and characterized by agitated, purposeless movements The safety of these individuals is at stake unless this activity is curtailed Exhaustion, injury to self or others, and eventually death could occur without intervention

Tidal Model

A mental health nursing recovery model that may be used as the basis for interdisciplinary mental health care The authors use the power of metaphor to engage with the person in distress The metaphor of water is used to describe how individuals in distress can become emotionally, physically, and spiritually shipwrecked Was the first recovery model to be developed by nurses in practice, drawing largely on nursing research, and in collaboration with users and consumers of mental health services Uses a person-centered approach to help people deal with their problems of human living Focus is on the individual's personal story, which is where his or her problems first appeared and where any growth, benefit, or recovery will be found Barker and Buchanan-Barker developed a set of essential values upon which the model is based These values, which they call the 10 Tidal Commitments, provide practitioners with a philosophical focus for empowering people to make their own life changes rather than health-care professionals trying to manage or control "patient symptoms" From these commitments, the authors developed the following Tidal Competencies, which reflect the ways the commitments are practiced in the clinical setting: 1. Value the voice 2. Respect the language 3. Develop genuine curiosity 4. Become the apprentice 5. Use the available toolkit 6. Craft the step beyond 7. Give the gift of time 8. Reveals personal wisdom 9. Know that change is constant 10. Be transparent Not a typical boxes-and-arrows diagram to use and follow. Instead, it is way of thinking, a paradigm for giving person-centered care that is strength-based, empowering, and relational

Mood

A pervasive and sustained emotion that may have a profound influence on a person's perception of the world Examples of mood include depression, joy, elation, anger, and anxiety

Recovery

A process of movement toward improvement in health and quality of life A deeply personal, unique process of changing one's attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by illness. Involves the development of new meaning and purpose in one's life as one grows beyond the catastrophic effects of mental illness

Aversive Stimulus

A stimulus that follows a behavioral response and decreases the probability that the behavior will recur

The Wellness Recovery Action Plan (WRAP)

A structured system for monitoring uncomfortable and distressing symptoms and, through planned responses, reducing, modifying or eliminating those symptoms. It also includes plans for responses from others when a person's symptoms have made it impossible to continue to make decisions, take care of him/herself and keep him/herself safe Steps 1. Developing a Wellness Toolbox 2. Daily Maintenance List 3. Triggers 4. Early Warning Signs 5. Things Are Breaking Down or Getting Worse 6. Crisis Planning A systematic method for developing skills in self-management and empowerment. It provides a means for individuals with a mental illness to work more collaboratively with healthcare providers. It is highly individualized and addresses the unique needs of the person and his/her situation. It is applicable to most any long-term illness/disability or problem situation. These benefits suggest that it can be used more widely and should be introduced as an option for individuals in need of a self-management system

Systematic Desensitization

A technique for assisting individuals to overcome their fear of a phobic stimulus. It is "systematic" in that there is a hierarchy of anxiety-producing events through which the individual progresses during therapy

Role-Play

A technique that should be used only when the relationship between client and therapist is exceptionally strong and there is little likelihood of maladaptive transference occurring The therapist assumes the role of an individual in a situation that produces a maladaptive response in the client The situation is played out in an effort to elicit recognition of automatic thinking on the part of the client

Daily Record of Dysfunctional Thoughts (DRDT)

A tool commonly used in cognitive therapy to help clients identify and modify automatic thoughts Two more columns are added to the three-column thought record presented earlier Clients are then asked to rate the intensity of the thoughts and emotions on a 0 percent to 100 percent scale The fourth column asks the client to describe a more rational cognition than the automatic thought identified in the second column and rate the intensity of the belief in the rational thought In the fifth column, the client records any changes that have occurred as a result of modifying the automatic thought and the new rate of intensity associated with it With this tool, the client is able to modify automatic thoughts by identifying them and actually formulating a more rational alternative

Cognitive therapy requires a sound therapeutic alliance

A trusting relationship between therapist and client must exist for cognitive therapy to succeed The therapist must convey warmth, empathy, caring, and genuine positive regard Development of a working relationship between therapist and client is an individual process, and clients with various disorders will require varying degrees of effort to achieve this therapeutic alliance

Overt Sensitization

A type of aversion therapy that produces unpleasant consequences for undesirable behavior For example, disulfiram (Antabuse) is a drug given to individuals who wish to stop drinking alcohol

Token Economy

A type of contingency contracting in which the reinforcers for desired behaviors are presented in the form of tokens

Cognitive Therapy

A type of psychotherapy based on the concept of pathological mental processing. The focus of treatment is on the modification of distorted cognitions and maladaptive behaviors

What, then, differentiates mood disorder from the typical stormy behavior of adolescence?

A visible manifestation of behavioral change that lasts for several weeks is the best clue for a mood disorder Examples: -The normally outgoing and extroverted adolescent who has become withdrawn and isolates herself -The good student who previously received consistently high marks but is now failing and skipping classes -The usually self-confident teenager who is now inappropriately irritable and defensive with others

Shame and Humiliation

A way to prevent public humiliation following a social defeat such as a sudden loss of status or income. Often, these individuals are too embarrassed to seek treatment or other support systems

Diagnostic Criteria for Hypomanic Episode

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day B. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a significant degree: 1. Inflated self-esteem or grandiosity 2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep) 3. More talkative than usual or pressure to keep talking. 4. Flight of ideas or subjective experience that thoughts are racing 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation 7. Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic D. The disturbance in mood and the change in functioning are observable by others E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) NOTE: A full hypomanic episode that emerges during antidepressant treatment (medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a hypomanic episode diagnosis. However, caution is indicated so that one or two symptoms (particularly increased irritability, edginess or agitation following antidepressant use) are not taken as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bipolar diathesis

Diagnostic Criteria for Manic Episode

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary) B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree, and represent a noticeable change from usual behavior: 1. Inflated self-esteem or grandiosity 2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep) 3. More talkative than usual or pressure to keep talking 4. Flight of ideas or subjective experience that thoughts are racing 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity) 7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or to another medical condition. Note: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis

Diagnostic Criteria for Persistent Depressive Disorder (Dysthymia)

A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year B. Presence, while depressed, of two (or more) of the following 1. Poor appetite or overeating 2. Insomnia or hypersomnia 3. Low energy or fatigue 4. Low self-esteem 5. Poor concentration or difficulty making decisions 6. Feelings of hopelessness C. During the 2-year period (1 year for children or adolescents) of the disturbance, the individual has never been without the symptoms in Criteria A and B for more than 2 months at a time D. Criteria for a major depressive disorder may be continuously present for 2 years E. There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder F. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hypothyroidism) H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning Specify if: -With anxious distress -With mixed features -With melancholic features -With atypical features -With mood-congruent psychotic features -With mood-incongruent psychotic features -With peripartum onset Specify if: -With pure dysthymic syndrome -With persistent major depressive episode -With intermittent major depressive episodes, with current episode -With intermittent major depressive episodes, without current episode Specify if: -In partial remission -In full remission Specify if: -Early onset (onset before age 21 years) -Late onset (onset at 21 years or older) Specify if: -Mild -Moderate -Severe

Diagnostic Criteria for MDD

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure Note: Do not include symptoms that are clearly due to another medical condition 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful) Note: In children and adolescents, can be irritable mood 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation) 3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day Note: In children, consider failure to make expected weight gain 4. Insomnia or hypersomnia nearly every day 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) 6. Fatigue or loss of energy nearly every day 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide B. The symptoms cause clinically significant distress or impairment in social, occupation, or other important areas of functioning C. The episode is not attributable to the physiological effects of a substance or another medical condition Note: Criteria A-C represent a major depressive episode Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual's history and the cultural norms for the expression of distress in the context of loss D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders E. There has never been a manic episode or a hypomanic episode Specify -With anxious distress -With mixed features -With melancholic features -With atypical features -With mood-congruent psychotic features -With mood-incongruent psychotic features -With catatonia -With peripartum onset -With seasonal pattern

Diagnostic Criteria for Cyclothymic Disorder

A. For at least 2 years (at least 1 year in children and adolescents) there have been numerous periods with hypomanic symptoms that do not meet criteria for hypomanic episode and numerous periods with depressive symptoms that do not meet the criteria for a major depressive episode B. During the above 2-year period (1 year in children and adolescents), the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time C. Criteria for a major depressive, manic, or hypomanic episode have never been met D. The symptoms in Criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder E. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism) F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning Specify if: With anxious distress

Diagnostic Criteria for Premenstrual Dysphoric Disorder (PMDD)

A. In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses B. One (or more) of the following symptoms must be present: 1. Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful or increased sensitivity to rejection) 2. Marked irritability or anger or increased interpersonal conflicts 3. Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts 4. Marked anxiety, tension, feelings of being keyed up or on edge C. One (or more) of the following symptoms must additionally be present, to reach a total of five symptoms when combined with symptoms from Criterion B above. 1. Decreased interest in usual activities (e.g., work, school, friends, hobbies) 2. Subjective difficulty in concentration 3. Lethargy, easy fatigability, or marked lack of energy 4. Marked change in appetite; overeating; or specific food cravings 5. Hypersomnia or insomnia 6. A sense of being overwhelmed or out of control 7. Physical symptoms, such as breast tenderness or swelling, joint or muscle pain, a sensation of "bloating," weight gain Note: The symptoms in Criteria A-C must have been met for most menstrual cycles that occurred in the preceding year.] D. The symptoms are associated with clinically significant distress or interferences with work, school, usual social activities, or relationships with others (e.g., avoidance of social activities, decreased productivity, and efficiency at work, school, or home).] E. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co-occur with any of these disorders) F. Criteria A should be confirmed by prospective daily ratings during at least two symptomatic cycles. (Note: The diagnosis may be made provisionally prior to this confirmation) G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or another medical condition (e.g., hyperthyroidism)

Reattribution

Aims to reverse negative attribution of clients from self-blame (common in depression) or placing blame solely on others (common in some personality disorders) to a more balanced attribution of responsibility

Suicide and Age

Although rates among women remain fairly constant throughout life, rates among men increase with age Although adolescents may statistically have a lower rate of suicide than some other age groups, it is still important to note that suicide has been the third-leading cause of death in this population over several years, and in 2013 jumped to the second-leading cause of death where it remained in 2014 -Several factors put adolescents at risk for suicide, including impulsive and high-risk behaviors, untreated mood disorders (e.g., major depression and bipolar disorder), access to lethal means (e.g., firearms), and substance abuse Among children younger than age 10, the statistics demonstrate a low number of suicides, and some have argued that younger children do not have the capacity to intentionally consider and follow through with a suicide attempt Almost 84 percent of elderly suicides are male, which is about five times greater than for females, and firearms are the most common means of taking one's own life. The overall rate of suicide for females declines after age 65

Catastrophic Thinking

Always thinking that the worst will occur without considering the possibility of more likely positive outcomes On Janet's first day in her secretarial job, her boss asked her to write a letter to another firm and put it on his desk for his signature. She did so and left for lunch. When she returned, the letter was on her desk with a typographical error circled in red and a note from her boss to redo the letter. Janet thinks, "This is it! I will surely be fired now!"

Tricyclics

Amitriptyline D/31-46 50-300mg TI: 110-250 (including metabolite) Amoxapine C/8 50-300mg TI: 200-500 Clomipramine (Anafranil) C/19-37 25-250mg TI: 80-100 Desipramine (Norpramin) C/12-24 25-300mg TI: 125-300 Doxepin C/8-24 25-300mg TI: 100-200 (including metabolite) Imipramine (Tofranil) D/11-25 30-300mg TI: 200-350 (including metabolite) Nortriptyline (Aventyl; Pamelor) D/18-44 30-100mg TI: 0-150 Protriptyline (Vivactil) C/67-89 15-60mg TI: 100-200 Trimipramine (Surmontil) C/7-30 50-300mg TI: 180 (including metabolite)

Depression

An alteration in mood expressed by feelings of sadness, despair, and pessimism There is a loss of interest in usual activities, and somatic symptoms may be evident. Changes in appetite, sleep patterns, and cognition are common

Mania

An alteration in mood that may be expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, racing thoughts, and accelerated speech Can occur as part of the psychiatric disorder bipolar disorder, as part of some other medical conditions, or in response to some substances

Time-Out

An aversive stimulus or punishment during which the client is removed from the environment where the unacceptable behavior is being exhibited

Anger

An emotional state that varies in intensity from mild irritation to intense fury and rage

Stimulus

An environmental event that interacts with and influences an individual's behavior

Recovery is supported through relationships and social networks (Guiding Principles of Recovery)

An important factor in the recovery process is the presence and involvement of people who believe in the person's ability to recover; who offer hope, support, and encouragement; and who suggest strategies and resources for change Family members, peers, providers, faith groups, community members, and other allies form vital support networks Through these relationships, people leave unhealthy and/or unfulfilling life roles behind and engage in new roles (e.g., partner, caregiver, friend, student, employee) that lead to a greater sense of belonging, personhood, empowerment, autonomy, social inclusion, and community participation

Bipolar I Disorder

An individual who is experiencing a manic episode or has a history of one or more manic episodes The client may also have experienced episodes of depression This diagnosis is further specified by the current or most recent behavioral episode experienced For example, the specifier might be single manic episode (to describe individuals having a first episode of mania) or current (or most recent) episode manic, hypomanic, mixed, or depressed (to describe individuals who have had recurrent mood episodes) Psychotic or catatonic features may also be noted

Psychological Theories

Anger Turned Inward Hopelessness and Other Symptoms of Depression History of Aggression and Violence Shame and Humiliation

Positive Functions or Constructive Uses of Anger

Anger energizes and mobilizes the body for self-defense Communicated assertively, anger can promote conflict resolution Anger arousal is a personal signal of threat or injustice against the self. The signal elicits coping responses to deal with the distress Anger is constructive when it provides a feeling of control over a situation and the individual is able to assertively take charge of a situation Anger is constructive when it is expressed assertively, serves to increase self-esteem, and leads to mutual understanding and forgiveness

Neurophysiological Factors of Aggression

Any factors which increase the activity or reactivity of the brainstem (e.g., chronic traumatic stress, testosterone, dysregulated serotonin or norepinephrine systems) or decrease the moderating capacity of the limbic or cortical areas (e.g., neglect) will increase an individual's aggressivity, impulsivity, and capacity to display violence

Nurse-Client Collaboration in the WRAP Model

Assessment -Client develops a wellness toolbox by creating a list of tools, strategies, and skills that have been helpful in the past -Client identifies strengths and weaknesses -Nurse provides assistance and feedback Interventions Client creates a daily maintenance list: -How he or she feels at best -What must be done daily to maintain wellness -Reminder list of other things that need to be accomplished -Client identifies triggers that cause distress or discomfort and identifies what to do if triggers interfere with wellness -Client identifies signs of worsening of symptoms and develops a plan to prevent escalation -Client identifies when symptoms have worsened and help is needed -Client identifies when he or she can no longer care for self and makes decisions (in writing) about treatment issues (what type, who will provide, who will represent client's interests) -Nurse offers support and provides feedback and assistance when needed Outcomes -Client develops skills in self-management -Client develops self-confidence and hope for a brighter future

Nurse-Client Collaboration in the Psychological Recovery Model

Assessment -Client is feeling hopeless and powerless Client seeks meaning of the illness -Nurse helps by offering hope -Client begins to develop an awareness of the need to take control of and responsibility for his or her life Interventions -Client resolves to begin work of recovery Client and nurse identify strengths and weaknesses -Nurse assists client to learn about effects of the illness and how to recognize, monitor, and manage symptoms -Client identifies changes he or she wishes to occur and sets realistic goals to rebuild a meaningful life Outcomes -Client develops a positive self-identity separate from the illness -Client maintains commitment to recovery in the face of setbacks -Client feels a sense of optimism and hope of a rewarding future

Nurse-Client Collaboration in the Tidal Model

Assessment -Client tells his or her personal story -Nurse actively listens and expresses interest in the story -Nurse helps client record story in client's own language -Client identifies specific problems he or she wishes to address -Nurse and client identify client's strengths and weaknesses Interventions -Nurse and client determine what has worked in the past -Client suggests new tools he or she would like to try -Client decides what changes he or she would like to make and sets realistic goals -Nurse and client decide what must be done as the first step -Nurse gives positive feedback for client's efforts to make life changes and for successes achieved -Nurse encourages client to be as independent as possible but offers assistance when required -Nurse gives the "gift of time" Outcomes -Client acknowledges that change has occurred and is ongoing -Client feels empowered to manage own self-care -Nurse is available for support

Stage I: Hypomania

At this stage, the disturbance is not sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization *Mood* Cheerful and expansive An underlying irritability surfaces rapidly when the person's wishes and desires go unfulfilled, however The nature of the hypomanic person is volatile and fluctuating *Cognition and Perception* Perceptions of the self are exalted—the individual has ideas of great worth and ability Thinking is flighty, with a rapid flow of ideas. Perception of the environment is heightened, but the individual is so easily distracted by irrelevant stimuli that goal-directed activities are difficult *Activity and Behavior* Exhibit increased motor activity They are perceived as being extroverted and sociable and thus attract numerous acquaintances However, they lack the depth of personality and warmth to formulate close friendships They talk and laugh a great deal, usually very loudly and often inappropriately Increased libido is common Some individuals experience anorexia and weight loss The exalted self-perception leads some hypomanic individuals to engage in inappropriate behaviors, such as phoning the President of the United States or running up debt on a credit card without having the resources to pay

Situation My girlfriend broke up with me (Daily Record of Dysfunctional Thoughts [DRDT])

Automatic Thoughts -I'm a stupid person. No one would ever want to marry me. (95%) Emotional Response -Sadness; depression (90%) Rational Response -I'm not stupid. Lots of people like me. Just because one person doesn't want to date me doesn't mean that no one would want to (75%) Outcome: Emotional Response -Sadness; depression (50%)

Situation I was turned down for a promotion (Three-Column Thought Recording)

Automatic Thoughts -Stupid boss! He doesn't know how to manage people. It's not fair! Emotional Response -Anger

Situation I was turned down for a promotion (Daily Record of Dysfunctional Thoughts [DRDT])

Automatic Thoughts -Stupid boss! He doesn't know how to manage people. It's not fair! (90%) Emotional Response -Anger (95%) Rational Response -I guess I have to admit the other guy's education and experience fit the position better than mine. The boss was being fair because he filled the position based on qualifications. I'll try for the next promotion that fits my qualifications better (70%) Outcome: Emotional Response -Anger (20%) -Disappointment (80%) -Hope (80%)

Use the available toolkit (Tidal Model)

Concentration is given to the individual's strengths, which are the major tools in the recovery process The story contains examples of 'what has worked' for the person in the past or beliefs about 'what might work' for this person in the future. These represent the main tools that need to be used to unlock or build the story of recovery Practitioner competencies -Helping individuals identify what efforts may be successful in relation to solving identified problems -Helping the individual identify which persons in the individual's life may be able to provide assistance

Preparation (The psychological recovery Model)

Begins with the individual's resolve to begin the work of recovery Hope -Hope is manifested in the mobilization of personal and external resources to foster self-care and find pathways to goals -This includes identifying strengths and weaknesses, gathering knowledge and information, and seeking out available support systems Responsibility: -Involves learning about the effects of the illness and how to recognize, monitor, and manage symptoms -Taking charge of one's life also includes the ability to be independent and take care of basic needs. Self and identity -The person takes stock of his or her skills and strengths in order to build on them to rediscover a positive sense of identity -The person is willing to take risks and try new activities to reestablish a sense of self -Lost aspects of self are rediscovered, new aspects are identified, and both are incorporated into a new self-identity Meaning and purpose -The basis for a meaningful life lies in solid core values -Living according to one's valued directions gives meaning to the work of recovery, and for this reason, some people hold on tenaciously to their goals -Each individual must live by certain tenets that make life personally valuable and enriching -Individuals living with a severe mental illness may require a reordering of priorities and setting of new goals as part of their recovery

Flooding

Believed to produce results faster than systematic desensitization; however, some therapists report more lasting behavioral changes with systematic desensitization

Manifestations of Aggression

Can arise from a number of feeling states, including anger, anxiety, guilt, frustration, or suspiciousness Aggressive behaviors can be classified as: Mild (e.g., sarcasm) Moderate (e.g., slamming doors), Severe (e.g., threats of physical violence against others), Extreme (e.g., physical acts of violence against others) -Pacing, restlessness -Threatening body language -Verbal or physical threats -Loud voice, shouting, use of obscenities, argumentative -Threats of homicide or suicide -Increase in agitation, with overreaction to environmental stimuli -Panic anxiety, leading to misinterpretation of the environment -Suspiciousness and defensive posturing -Angry mood, often disproportionate to the situation -Destruction of property -Acts of physical harm toward another person

Distraction

Can occur by engaging in activities that redirect the client's thinking and divert him or her from the intrusive thoughts or depressive ruminations that are contributing to the maladaptive responses

Give the gift of time (Tidal Model)

Change happens when the individual and practitioner spend quality time in a therapeutic relationship The challenge is using time for things that are important Practitioner competencies -Acknowledging (and helping the individual understand) the importance of time dedicated to addressing the needs of the individual -The planning and implementing of care

Recovery is culturally based and influenced (Guiding Principles of Recovery)

Characteristics such as race or ethnicity, religion, low socioeconomic status, gender, age, mental health, disability, sexual orientation or gender identity, geographic location, or other characteristics historically linked to exclusion or discrimination are known to influence health status" The diverse representations of culture and cultural background (including values, traditions, and beliefs) are keys to determining a person's journey and unique pathway to recovery What may work for adults in recovery may be very different for youth or older adults in recovery The promotion of resiliency in young people, and the nature of social supports, peer mentors, and recovery coaching for adolescents and transitional age youth are different than recovery support services for adults and older adults Services should be culturally grounded, attuned, sensitive, congruent, and competent, as well as personalized to meet each individual's unique needs

Postpartum depression with psychotic features

Characterized by -Depressed mood -Agitation -Indecision -Lack of concentration -Guilt -An abnormal attitude toward bodily functions -Lack of interest in or rejection of the baby -A morbid fear that the baby may be harmed -Delusions -Hallucinations. The symptoms can be severe and incapacitating Risks of suicide and infanticide should not be overlooked There is a 30 to 50 percent likelihood of postpartum psychosis recurring with subsequent pregnancies The etiology of postpartum depression remains unclear May be treated with antidepressant medication along with supportive psychotherapy, group therapy, and possibly family therapy

Bipolar Disorder Due to Another Medical Condition

Characterized by an abnormally and persistently elevated, expansive, or irritable mood and excessive activity or energy judged to be the direct physiological consequence of another medical condition The mood disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning Types of physiological influences are included in the discussion of predisposing factors associated with bipolar disorders

Major Depressive Disorder (MDD)

Characterized by depressed mood or loss of interest or pleasure in usual activities, impaired social and occupational functioning that has existed for at least 2 weeks, no history of manic behavior, and symptoms that cannot be attributed to use of substances or a general medical condition The diagnosis is specified according to whether it is a single episode (the individual's first encounter with a major depressive episode) or recurrent (the individual has a history of previous major depressive episodes) The diagnosis will also identify the degree of severity of symptoms (mild, moderate, or severe) and whether there is evidence of psychotic, catatonic, or melancholic features The presence of anxiety and severity of suicide risk may also be noted

Bipolar II Disorder

Characterized by recurrent bouts of major depression with episodic occurrence of hypomania The individual who is assigned this diagnosis may present with symptoms (or history) of depression or hypomania The client has never experienced a full manic episode, and the symptoms are not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization The diagnosis may specify whether the current or most recent episode is hypomanic, depressed, or with mixed features If the current syndrome is a major depressive episode, psychotic or catatonic features may be noted

Depressive Disorder Due to Another Medical Condition

Characterized by symptoms associated with a major depressive episode that are the direct physiological consequence of another medical condition The depression causes clinically significant distress or impairment in social, occupational, or other important areas of functioning Types of physiological influences are included in the discussion on predisposing factors to depression

SSRIs

Citalopram (Celexa) C/~35 20-40mg TI: Not well established Escitalopram (Lexapro) C/27-32 10-20mg TI: Not well established Fluoxetine (Prozac; Sarafem) C/1-16 days (including metabolite) 20-80mg TI: Not well established Fluvoxamine (Luvox) C/13.6-15.6 50-300mg TI: Not well established Paroxetine (Paxil) D/21 (CR: 15-20) 10-50mg (CR: 12.5-75) TI: Not well established Sertraline (Zoloft) C/26-104 (including metabolite) 25-200mg TI: Not well established Vilazodone (Viibryd) (also acts as a partial serotonergic agonist) C/25 40mg TI: Not well established Vortioxetine (Trintellix) C/66 5-20mg TI: Not well established

Hopelessness and Other Symptoms of Depression

Hopelessness has long been identified as a symptom of depression and an underlying factor in the predisposition to suicide The strength of the person's intention to die has also been identified as significant

Adolescence (Developmental Implications)

Depression may be even harder to recognize in an adolescent than in a younger child Feelings of sadness, loneliness, anxiety, and hopelessness associated with depression may be perceived as the normal emotional stresses of growing up Therefore, many young people whose symptoms are attributed to the "normal adjustments" of adolescence do not get the help they need Depression is a major cause of suicide among teens, and suicide is the second-leading cause of death in the 15- to 24-year-old age group Common symptoms of depression in the adolescent -Inappropriately expressed anger -Aggressiveness -Running away -Delinquency -Social withdrawal -Sexual acting out -Substance abuse -Restlessness -Apathy -Loss of self-esteem -Sleeping and eating disturbances -Psychosomatic complaints are also common Adolescents become depressed for all the same reasons discussed under childhood depression In adolescence, however, depression is a common manifestation of the stress and independence conflicts associated with the normal maturation process Depression may also be the response to death of a parent, other relative, or friend or to a breakup with a boyfriend or girlfriend This perception of abandonment by parents or the closest peer relationship is thought to be the most frequent immediate precipitant to adolescent suicide Treatment of the depressed adolescent is often conducted on an outpatient basis Hospitalization may be required: -Cases of severe depression -Threat of imminent suicide -When a family situation is such that treatment cannot be carried out in the home -When the physical condition precludes self-care of biological needs -When the adolescent has indicated possible harm to self or others in the family In addition to supportive psychosocial intervention, antidepressant therapy may be part of the treatment of adolescent mood disorders fluoxetine (Prozac) has been approved by the FDA to treat depression in children aged 8 and older escitalopram (Lexapro) was approved in 2009 for treatment of MDD in adolescents aged 12 and older The other SSRI medications, such as sertraline, citalopram, and paroxetine, and the serotonin-norepinephrine reuptake inhibitor (SNRI) antidepressants duloxetine, venlafaxine, and desvenlafaxine have not been approved for treatment of depression in children or adolescents, although they have been prescribed to children by physicians in "off-label use"—a use other than the FDA-approved use

SNRIs

Desvenlafaxine (Pristiq) C/11 50-400mg TI: Not well established Duloxetine (Cymbalta) C/8-17 40-60mg TI: Not well established Venlafaxine (Effexor) C/5-11 (including metabolite) 75-375 TI: Not well established

Major Components fo Cognitive Therapy

Didactic aspects Cognitive techniques Behavioral interventions

Imbalance Nutrition Less Than Body Requirements/Insomnia

Intake of nutrients insufficient to meet metabolic needs Insomnia is defined as a disruption in amount and quality of sleep that impairs functioning *Behavior* -Loss of weight -Amenorrhea -Refusal or inability to sit still long enough to eat -Difficulty falling asleep -Sleeping only short periods *Goals* Short-term goals -Client will consume sufficient finger foods and between-meal snacks to meet recommended daily allowances of nutrients -Within 3 days, with the aid of a sleeping medication, client will sleep 4 to 6 hours without awakening Long-term goals -Client will exhibit no signs or symptoms of malnutrition -By time of discharge from treatment, client will be able to acquire 6 to 8 hours of uninterrupted sleep without medication *Interventions* -In collaboration with the dietitian, determine the number of calories required to provide adequate nutrition for maintenance or realistic (according to body structure and height) weight gain. Determine client's likes and dislikes, and provide favorite foods if possible. The client is more likely to eat foods that he or she particularly enjoys -Provide the client with high-protein, high-calorie, nutritious finger foods and drinks that can be consumed "on the run." Because of the hyperactive state, the client has difficulty sitting still long enough to eat a meal. He or she is more likely to consume food and drinks that can be carried around and eaten with little effort. Have juice and snacks available on the unit at all times. Regular nutritious intake is required to compensate for increased caloric requirements of hyperactivity -Maintain an accurate record of intake, output, and calorie count. Weigh the client daily. Administer vitamin and mineral supplements as ordered by the physician. Monitor laboratory values, and report significant changes to the physician. It is important to carefully monitor data that provide an objective assessment of the client's nutritional status -Assess the client's activity level. He or she may ignore or be unaware of feelings of fatigue. Observe for signs such as increasing restlessness; fine tremors; slurred speech; and puffy, dark circles under eyes. The client could collapse from exhaustion if hyperactivity is uninterrupted and rest is not achieved -Monitor sleep patterns. Provide a structured schedule of activities that includes established times for naps or rest. Accurate baseline data are important in planning care to help the client with this problem. A structured schedule, including time for short naps, will help the hyperactive client achieve much-needed rest -Client should avoid intake of caffeinated drinks, such as tea, coffee, and colas. Caffeine is a central nervous system (CNS) stimulant and may interfere with the client's achievement of rest and sleep -Before bedtime, provide nursing measures that promote sleep, such as back rub; warm bath; warm, nonstimulating drinks; soft music; and relaxation exercises -Administer sedative medications as ordered to help client achieve sleep until normal sleep pattern is restored

Moderate Depression

Dysthymia (also called persistent depressive disorder) is an example of moderate depression and represents a more problematic disturbance, which is characterized by symptoms that are enduring for at least 2 years Symptoms associated include the following Affective -Feelings of sadness -Feelings of dejection -Feelings of helplessness -Feelings of powerlessness -Feelings of hopelessness -Gloomy and pessimistic outlook -Low self-esteem -Difficulty experiencing pleasure in activities Behavioral -Sluggish physical movements (i.e., psychomotor retardation) -Slumped posture -Slowed speech -Limited verbalizations, possibly consisting of ruminations about life's failures or regrets -Social isolation with a focus on the self -Increased use of substances possible -Self-destructive behavior possible -Decreased interest in personal hygiene and grooming Cognitive -Slowed thinking processes -Difficulty concentrating and directing attention -Obsessive and repetitive thoughts, generally portraying pessimism and negativism -Verbalizations and behavior reflecting suicidal ideation Physiological -Anorexia or overeating insomnia or hypersomnia -Sleep disturbances -Amenorrhea -Decreased libido -Headaches -Backaches -Chest pain -Abdominal pain -Low energy level -Fatigue and listlessness -Feeling best early in the morning and continually worse as the day progresses (possibly related to the diurnal variation in the level of neurotransmitters that affect mood and level of activity)

Schizophrenia & ECT

ECT can induce a remission in some clients who present with acute schizophrenia, particularly those who have marked positive, catatonic, or affective (depression or mania) symptomatology It does not appear to be of value to individuals with chronic schizophrenic illness

Others uses for ECT

ECT has been reported as useful in episodic psychosis, atypical psychosis, obsessive-compulsive disorder, delirium, and medical conditions such as neuroleptic malignant syndrome, hypopituitarism, intractable seizure disorders, and Parkinson's disease, particularly when there is comorbid depression For pregnant women and elderly individuals who are unable to take medication, ECT may be a safer alternative 40 percent of pregnant patients treated with ECT in their study demonstrated full recovery ECT is not effective in somatization disorders (unless there is comorbid depression), personality disorders, and anxiety disorders

Major Depression & ECT

ECT has been shown to be effective in the treatment of severe depression, particularly among depressed clients who are also experiencing psychotic symptoms, catatonia, psychomotor retardation, and neurovegetative changes, such as disturbances in sleep, appetite, and energy ECT is typically considered only after a trial of therapy with antidepressant medication has proved ineffective It may be considered the treatment of choice when the need for treatment response is urgent, such as in patients who are extremely suicidal or are refusing food and are nutritionally compromised

Mania & ECT

ECT is indicated in the treatment of acute manic episodes and is at least as effective as lithium At present, it is rarely used for this purpose because lithium and other pharmacotherapies are so effective in the short and long term However, ECT has been shown to be effective in the treatment of manic clients who do not tolerate or fail to respond to lithium or other drug treatment or when life is threatened by dangerous behavior or exhaustion ECT should not be used while a patient is receiving lithium because lithium lowers the seizure threshold and may cause prolonged seizures when combined with ECT Recent evidence has supported the use of ECT in the treatment of bipolar disorders with mixed states (concurrent depressive and manic features) This is especially beneficial, since this type of bipolar disorder is often more severe than other types, with lower interepisode remission and higher risk for suicide It is still used only when the patient has failed to respond to medication

Cognitive therapy sessions are structured

Each session has a set structure which includes (1) reviewing the client's week, (2) collaboratively setting the agenda for this session, (3) reviewing the previous week's session, (4) reviewing the previous week's homework, (5) discussing this week's agenda items, (6) establishing homework for next week, and (7) summarizing this week's session This format focuses attention on important items to maximize the use of therapy time

Facts About Suicide

Eight out of 10 people who kill themselves have given definite clues and warnings about their suicidal intentions. Very subtle clues may be ignored or disregarded by others Most suicidal people are very ambivalent about their feelings regarding living or dying. Most are "gambling with death" and see it as a cry for someone to save them Suicidal ideation and risk fluctuate over time and may be time-limited. If provided adequate support and resources, a suicidal person can go on to lead a normal life. However, multiple suicide attempts may reflect greater chronicity of suicidal ideation. Reassessment over time is important to identify current risks Most suicides occur within about 3 months after the beginning of "improvement," when the individual has the energy to carry out suicidal intentions Suicide is not inherited. It is an individual matter and can be prevented. However, suicide by a close family member increases an individual's risk factor for suicide Although a majority of people who attempt suicide are extremely unhappy or clinically depressed, they are not necessarily psychotic. They are merely unable at that point in time to see an alternative solution to what they consider an unbearable problem All suicidal behavior must be approached with the gravity of the potential act in mind. Attention should be given to the possibility that the individual is issuing a cry for help Gunshot wounds are the leading cause of death among suicide victims Between 50% and 80% of all people who ultimately kill themselves have at least one previous attempt People often contemplate, imagine, plan strategies, write notes, post things on the Web. The importance of in-depth exploration and assessment cannot be overstated Annually, 30 to 35 children under the age of 12 take their own lives and not all are clinically depressed

Seasonality & Depression

Episodes are most common in fall or winter, but some clients have recurrent summer episodes Reported benefits of light therapy may support a seasonal cause for depression during winter months when there is often less exposure to natural sunlight, but more research is needed to determine a causal relationship

Magnification

Exaggerating the negative significance of an event Nancy hears that her colleague at work is having a cocktail party over the weekend, and she is not invited. Nancy thinks, "She doesn't like me."

The Three-Step Theory

Factors that elevate suicide ideation to an active risk for attempts 1. Pain (usually psychological pain) when combined with hopelessness significantly increases suicide ideation 2. Connectedness prevents suicide ideation from escalating in those at risk, but when pain and hopelessness exceed one's sense of connectedness to others, suicide ideation becomes active 3. When strong, active suicide ideation is present, it leads to an attempt only if one has the capacity to make an attempt

Suicide Risk Factors

Factors that have statistically been correlated with a higher incidence of suicide

Group Therapy

Forms an important dimension of multimodal treatment for the depressed client Once an acute phase of the illness has passed, groups can provide an atmosphere in which individuals may discuss issues in their lives that cause, maintain, or arise from having a serious affective disorder The element of peer support provides a feeling of security, as troublesome or embarrassing issues are discussed and resolved Some groups have other specific purposes, such as helping to monitor medication-related issues or serving as an avenue for promoting education related to the affective disorder and its treatment Therapy groups help members gain a sense of perspective on their condition and encourage them to link up with others who have common problems A sense of hope is conveyed when the individual is able to see that he or she is not alone or unique in experiencing affective illness

Psychoanalytical Theory (Psychosocial Theories)

Freud observed that melancholia occurs after the loss of a loved object, either actually by death or emotionally by rejection, or the loss of some other abstraction of value to the individual Freud indicated that in melancholia, the depressed patient's rage is internally directed because of identification with the lost object Freud believed that the individual predisposed to melancholia experienced ambivalence in love relationships He postulated, therefore, that once the loss is incorporated into the self (ego), the hostile part of the ambivalence that had been felt for the lost object is then turned inward against the ego

Cognitive therapy is educative, aims to teach the client to be his or her own therapist, and emphasizes relapse prevention

From the beginning of therapy, the client is taught about the nature and course of his or her disorder, about the cognitive model (i.e., how thoughts influence emotions and behavior), and about the process of cognitive therapy The client is taught how to set goals, plan behavioral change, and intervene on his or her own behalf

Melancholia

Hippocrates believed it was caused by the effect of excess black bile, a heavily toxic substance produced in the spleen or intestine, on the brain A severe form of depressive disorder in which symptoms are exaggerated and interest or pleasure in virtually all activities is lost

Crisis Planning (WRAP Model)

Identifies symptoms indicating that individuals can no longer care for themselves, make independent decisions, or keep themselves safe This stage is multifaceted and meant for use by caregivers on behalf of the individual who developed the plan. It is composed of the following parts Part 1: Gathers information that describes what the person is like when well Part 2: Identifies the symptoms that indicate when others need to take responsibility for the person's care Part 3: Provides names of supporters previously identified by the individual to speak on his or her behalf Part 4: Includes the name of health-care providers and phone numbers; medications currently using; allergies to medications; medications the individual would prefer to take, if additional medication is necessary; medications that the individual refuses to take Part 5: Includes the individual's preferred treatments and treatments that he or she wishes to avoid Part 6: Identifies the individual's preferences in treatment facilities (e.g., home, community care, respite center) Part 7: Identifies acceptable facilities if previous preferences cannot be executed. Facilities to avoid are also indicated Part 8: Includes an extensive description of what the individual expects from identified supporters who are acting on his or her behalf during a crisis situation Part 9: Consists of a list of indicators, developed by the individual, that communicates to supporters when their services are no longer required The individual should update this plan periodically when he or she learns new information or changes his or her mind about certain situations Assurance of the use of the crisis plan may be increased if it is notarized and signed in the presence of two witnesses To further increase its potential for use, the person may appoint a durable power of attorney, although because of the variability of the legality of these documents from state to state, there is no guarantee that the plan will be followed

Anomic Suicide

In response to changes in an individual's life (e.g., divorce, loss of job) that disrupt feelings of relatedness to the group

Age and Gender & MDD

Incidence is higher in women than it is in men by almost two to one The gender difference is less pronounced between ages 44 and 65, but after age 65, women are again more likely than men to be depressed This occurrence may be related to gender differences in social roles and economic and social opportunities and the shifts that occur with age The construction of gender stereotypes, or gender socialization, promotes typical female characteristics, such as helplessness, passivity, and emotionality, that are associated with depression. In contrast, some studies have suggested that "masculine" characteristics are associated with higher self-esteem and less depression

Negative Reinforcement

Increases the probability that a behavior will recur by removal of an undesirable reinforcing stimulus

Family Therapy

Indicated if the disorder jeopardizes the patient's marriage or family functioning or if the mood disorder is promoted or maintained by the family situation Family therapy examines the role of the mood-disordered member in the overall psychological well-being of the whole family; it also examines the role of the entire family in the maintenance of the patient's symptoms

Altruistic Suicide

Individual is excessively integrated into the group The group is often governed by cultural, religious, or political ties, and allegiance is so strong that the individual will sacrifice his or her life for the group

Respect the language (Tidal Model)

Individuals are encouraged to speak their own words in their own unique way The language of the story—complete with its unusual grammar and personal metaphors—is the ideal medium for illuminating the way to recovery. We encourage people to speak their own words in their distinctive voice Practitioner competencies -Helping individuals express in their own language their understanding of personal experiences through use of stories, anecdotes, and metaphors

Recovery occurs via many pathways (Guiding Principles of Recovery)

Individuals are unique with distinct needs, strengths, preferences, goals, culture, and backgrounds (including trauma experiences) that affect and determine their pathways to recovery Recovery is built on the multiple capacities, strengths, talents, coping abilities, resources, and inherent value of each individual Recovery pathways are highly personalized They may include professional clinical treatment, use of medications, support from families and in schools, faith-based approaches, peer support, and other approaches Recovery is nonlinear, characterized by continual growth and improved functioning that may involve setbacks Because setbacks are a natural, though not inevitable, part of the recovery process, it is essential to foster resilience for all individuals and families Abstinence is the safest approach for those with substance use disorders -Use of tobacco and nonprescribed or illicit drugs is not safe for anyone In some cases, recovery pathways can be enabled by creating a supportive environment -This is especially true for children, who may not have the legal or developmental capacity to set their own course.

Suicide and Socioeconomic Status

Individuals in the very highest and lowest social classes have higher suicide rates than those in the middle classes

Recovery involves individual, family, and community strengths and responsibility (Guiding Principles of Recovery)

Individuals, families, and communities have strengths and resources that serve as a foundation for recovery Individuals have personal responsibility for their own self-care and journeys of recovery and should be supported in speaking for themselves Families and significant others have responsibilities to support their loved ones, especially children and youth in recovery Communities have responsibilities to provide opportunities and resources to address discrimination and to foster social inclusion and recovery Individuals in recovery also have a social responsibility and should have the ability to join with peers to speak collectively about their strengths, needs, wants, desires, and aspirations

Impaired Social Interaction

Insufficient or excessive quantity or ineffective quality of social exchange *Behavior* Inability to develop satisfying relationships Manipulation of others for own desires Use of unsuccessful social interaction behaviors *Goals* Short-term goal -Client will verbalize which of his or her interaction behaviors are appropriate and which are inappropriate within 1 week Long-term goal -Client will demonstrate use of appropriate interaction skills as evidenced by lack of, or marked decrease in, manipulation of others to fulfill own desires *Interventions* -Recognize the purpose these behaviors serve for the client: to reduce feelings of insecurity by increasing feelings of power and control. Understanding the motivation behind the manipulation may help to facilitate acceptance of the individual and his or her behavior -Set limits on manipulative behaviors. Explain to the client what is expected and what the consequences are if the limits are violated. Terms of the limitations must be agreed on by all staff who will be working with the client. The client is unable to establish own limits, so this must be done for him or her. Unless administration of consequences for violation of limits is consistent, manipulative behavior will not be eliminated. Comorbid borderline personality disorder has been identified as a risk in patients with bipolar disorder -Do not argue, bargain, or try to reason with the client. Merely state the limits and expectations. Individuals with mania can be very charming in their efforts to fulfill their own desires. Confront the client as soon as possible when interactions with others are manipulative or exploitative. Follow through with established consequences for unacceptable behavior. Because of the strong id influence on the client's behavior, he or she should receive immediate feedback when behavior is unacceptable. Consistency in enforcing the consequences is essential if positive outcomes are to be achieved. Inconsistency creates confusion and encourages testing of limits -Provide positive reinforcement for nonmanipulative behaviors. Explore feelings and help the client seek more appropriate ways of dealing with them -Help the client recognize that he or she must accept the consequences of behaviors and refrain from attributing them to others. The client must accept responsibility for own behaviors before adaptive change can occur -Help the client identify positive aspects about self, recognize accomplishments, and feel good about them. As self-esteem increases, the client will feel less need to manipulate others for own gratification

Monoamine Oxidase Inhibitors

Isocarboxazid (Marplan) C/Not established 20-60mg TI: Not well established Phenelzine (Nardil) C/2-3 45-90mg TI: Not well established Tranylcypromine (Parnate) C/2.4-2.8 30-60mg TI: Not well established Selegiline Transdermal System (Emsam) C/18-25 (including metabolites) 6/24-hr-12/24-hr patch TI: Not well established

Light Therapy

Light therapy, or exposure to light, has been shown an effective treatment for SAD The light therapy is administered by a 10,000-lux light box, which contains white fluorescent light tubes covered with a plastic screen that blocks ultraviolet rays The individual sits in front of the box with eyes open (although one should not look directly into the light) Therapy usually begins with 10- to 15-minute sessions and gradually progresses to 30 to 45 minutes The mechanism of action is believed to be related to retinal stimulation, which triggers a reduction of melatonin and an increase in serotonin in the brain A recent study demonstrated benefits of bright light therapy in nonseasonal affective disorders as well

Low Self-Esteem

Low self-esteem Negative self-evaluating/feelings about self or self-capabilities [either long-standing or in response to a current situation] Self-care deficit Impaired ability to perform or complete [activities of daily living (ADLs)] for self *Behaviors* Expressions of helplessness, uselessness, guilt, and shame Hypersensitivity to slight or criticism Negative, pessimistic outlook Lack of eye contact Self-negating verbalizations *Goal* Short-term goals -Client will verbalize attributes he or she likes about self -Client will participate in activities of daily living (ADLs) with assistance from health-care provider Long-term goals -By time of discharge from treatment, the client will exhibit increased feelings of self-worth as evidenced by verbal expression of positive aspects of self, past accomplishments, and future prospects -By time of discharge from treatment, the client will exhibit increased feelings of self-worth by setting realistic goals and trying to reach them, thereby demonstrating a decrease in fear of failure -By time of discharge from treatment, the client will satisfactorily accomplish ADLs independently *Interventions* Be accepting of the client, and spend time with him or her even though pessimism and negativism may seem objectionable. Focus on strengths and accomplishments and minimize failures Promote attendance in therapy groups that offer the client simple methods of accomplishment. Encourage the client to be as independent as possible Encourage the client to recognize areas of change and provide assistance toward this effort Teach assertiveness techniques: the ability to recognize the differences among passive, assertive, and aggressive behaviors and the importance of respecting the human rights of others while protecting one's own basic human rights. Self-esteem is enhanced by the ability to interact with others in an assertive manner Teach effective communication techniques, such as the use of "I" messages Emphasize ways to avoid making judgmental statements Encourage independence in the performance of ADLs, but intervene when client is unable to perform Show the client how to perform activities with which he or she is having difficulty. When a client is depressed, he or she may require simple, concrete demonstrations of activities that would be performed without difficulty under normal conditions Keep strict records of food and fluid intake. Offer nutritious snacks and fluids between meals. The client may be unable to tolerate large amounts of food at mealtimes and may therefore require additional nourishment at other times during the day to receive adequate nutrition Before bedtime, provide nursing measures that promote sleep, such as back rub; warm bath; warm, nonstimulating drinks; soft music; and relaxation exercises

Indictions for ECT

Major Depression Mania Schizophrenia + Others

Childhood (Developmental Implications)

Major depressive disorder as an entity in children and adolescents that can be identified using criteria similar to those used for adults It is not uncommon, however, for the symptoms of depression to be manifested differently in childhood, and the picture changes with age *Up to age 3* -Feeding problems -Tantrums -Lack of playfulness and emotional expressiveness -Failure to thrive, -Delays in speech and gross motor development *Ages 3 to 5* -Accident proneness -Phobias -Aggressiveness -Excessive self-reproach for minor infractions -Mood-congruent auditory hallucinations are not uncommon The incidence of depression among preschool children is estimated to be between 0.3 and 0.9 percent *Ages 6 to 8* -There may be vague physical complaints and aggressive behavior -Children may cling to parents and avoid new people and challenges -They may lag behind their classmates in social skills and academic competence *Ages 9 to 12* -Morbid thoughts -Excessive worrying -Poor self-esteem -May reason that they are depressed because they have disappointed their parents in some way -There may be lack of interest in playing with friends The incidence of depression among school-aged children is estimated to be around 2 to 3 percent *Other symptoms of childhood depression* -Hyperactivity -Delinquency -School problems -Psychosomatic complaints -Sleeping -Eating disturbances -Social isolation -Delusional thinking -Suicidal thoughts or actions. The APA (2013) has included a new diagnostic category in the Depressive Disorders chapter of the DSM-5. This childhood disorder is called disruptive mood dysregulation disorder Children may become depressed for various reasons -A genetic predisposition toward the condition, which is then precipitated by a stressful situation Common precipitating factors -Physical or emotional detachment by the primary caregiver -Parental separation or divorce -Death of a loved one (person or pet) -A move -Academic failure -Physical illness In any event, the common denominator is loss The focus of therapy with depressed children is to alleviate the child's symptoms and strengthen his or her coping and adaptive skills, with the hope of possibly preventing future psychological problems Some studies have shown that untreated childhood depression may lead to subsequent problems in adolescence and adult life Most children are treated on an outpatient basis Hospitalization of the depressed child usually occurs only if he or she is actively suicidal, when the home environment precludes adherence to a treatment regimen, or if the child needs to be separated from the home because of psychosocial deprivation Parental and family therapy are commonly used to help the younger depressed child Recovery is facilitated by emotional support and guidance to family members Children older than age 8 usually participate in family therapy In some situations, individual treatment may be appropriate for older children Medications such as antidepressants can be important in the treatment of children, especially for the more serious and recurrent forms of depression The SSRIs have been used with success, particularly in combination with psychosocial therapies However, because there has been some concern that the use of antidepressant medications may cause suicidal behavior in young people, the U.S. Food and Drug Administration (FDA) has applied a black-box warning (described in the next section) to all antidepressant medications

Psychotherapeutic Combinations

Olanzapine and fluoxetine (Symbyax) C/(see individual drugs) 6/25-12/50mg TI: Not well established Chlordiazepoxide and fluoxetine (Limbitrol) D/(see individual drugs) 20/50-40/100mg TI: Not well established Perphenazine and amitriptyline (Etrafon) C-D/(see individual drugs) 6/30-16/200mg TI: Not well established

Suicide and Gender

More women than men attempt suicide, but men succeed more often Successful suicides number about 70 percent for men and 30 percent for women This success rate has to do with the lethality of the means Women tend to overdose; men use more lethal means, such as firearms Women are more likely than men to seek and accept help from friends or professionals

Recovery is supported by peers and allies (Guiding Principles of Recovery)

Mutual support and mutual aid groups, including the sharing of experiential knowledge and skills as well as social learning, play an invaluable role in recovery Peers encourage and engage other peers and provide each other with a vital sense of belonging, supportive relationships, valued roles, and community Through helping others and giving back to the community, one helps oneself, too Peer-operated supports and services provide important resources to assist people along their journeys of recovery and wellness In addictions recovery, peer support has long been recognized as foundational, especially in 12-step programs such as Alcoholics Anonymous In mental health treatment, although formal peer support is a newer approach, the premises are similar These individuals, sometimes called peer support specialists, may be trained and/or certified in supportive skills but all share the experience of living with mental illness and, as such, can provide a unique perspective for support and trust in ongoing relationships In a fully implemented recovery model, peer support specialists should be considered equal members of the treatment team Professionals can also play an important role in the recovery process by providing clinical treatment and other services that support individuals in their chosen recovery paths While peers and allies play an important role for many in recovery, their role for children and youth may be slightly different Peer supports for families are very important for children with behavioral health problems and can also play a supportive role for youth in recovery

Race and Culture & Depression

No consistent relationship between race and affective disorder Clinicians tend to underdiagnose mood disorders and overdiagnose schizophrenia in clients who have racial or cultural backgrounds different from their own This misdiagnosis may result from language barriers between clients and physicians who are unfamiliar with cultural aspects of nonwhite clients' language and behavior

Develop genuine curiosity (Tidal Model)

Nurses and other caregivers need to express genuine interest in the story so that they can better understand the storyteller and the story. Genuine curiosity reflects an interest in the person and the person's unique experience Practitioner competencies -Showing interest in the person's story -Asking for clarification of certain points -Assisting the person to unfold the story at his or her own pace

Operant Conditioning

Occurs when a specific behavior is reinforced A positive reinforcement is a response to specific behavior that is pleasurable or offers a reward A negative reinforcement is a response to specific behavior that prevents an undesirable result from occurring

Behavioral Rehearsal

Often accomplished through role-play, affords the client an opportunity to practice a new way of responding to distressing situations and explore possible outcomes with the counselor before trying out the behavior in real-life situations

Manifestations of Anger

Often described as a secondary emotion -Frowning facial expression -Clenched fists -Low-pitched verbalizations forced through clenched teeth -Yelling and shouting -Intense eye contact or avoidance of eye contact -Hypersensitivity, easily offended -Defensive response to criticism -Passive-aggressive behaviors -Lack of control or overcontrolled emotions -Intense discomfort; continuous state of tension -Flushed face -Anxious, tense, angry facial expression (affect)

Automatic Thought Records

One of the most frequently used methods of recognizing automatic thoughts, is taught to and discussed with the client in the therapy session Assigned as homework for the client outside of therapy The client is asked to keep a written record of situations that occur and the automatic thoughts elicited by the situation This is called a two-column thought recording Some therapists ask their clients to keep a three-column recording, which includes a description of the emotional response also associated with the situation

Unconditioned Response

Organisms can learn to respond in specific ways if they are conditioned to do so

Daily Maintenance List (WRAP Model)

Part 1 -The individual writes a description of how he or she feels (or would like to feel) when experiencing wellness (e.g., bright, cheerful, talkative, happy, optimistic, capable) -This information is used as a reference point Part 2 Using the wellness toolbox as a reference, the individual makes a list of things he or she needs to do every day to maintain wellness This is an important part of the plan and must be realistic so as not to set the individual up for failure or create additional frustration -Eat three healthy meals and three healthy snacks -Drink at least six 8-ounce glasses of water -Avoid caffeine, sugar, junk foods, and alcohol -Exercise for at least 30 minutes -Have 20 minutes of relaxation or meditation time -Write in my journal for at least 15 minutes -Take medications and vitamin supplements -Spend at least 30 minutes enjoying a fun, affirming, and/or creative activity Part 3 The individual keeps a list of things that need to be done The individual reads this list daily as a reminder, and items may be considered for accomplishment on any given day at the individual's discretion -Spend time with counselor or case manager -Make an appointment with health-care professional -Spend time with friend or partner -Be in touch with my family -Spend time with children or pets -Buy groceries -Do the laundry -Write some letters -Remember someone's birthday or anniversary

Triggers (WRAP Model)

Part 1 The individual lists events or circumstances that, should they occur, would cause distress or discomfort These triggers are situations to which the individual is susceptible or that have triggered or increased symptoms in the past. -The anniversary dates of losses or trauma -Being exhausted -Work stress -Family friction -A relationship ending -Being judged, criticized, or teased -Financial problems -Physical illness -Sexual harassment or inappropriate sexual behavior -Substance abuse Part 2 The individual uses items from the wellness toolbox to develop a plan for what to do if triggers interfere with wellness

Things Are Breaking Down or Getting Worse (WRAP Model)

Part 1 The individual lists symptoms that indicate that the situation has worsened The symptoms are producing great discomfort, but the individual is still able to take some action on his or her own behalf Immediate action is required to prevent a crisis from developing Symptoms at this stage differ greatly from person to person What may mean 'things are breaking down' to one person may mean 'crisis' to another She lists a number of examples of symptoms, which may include the following: -Irrational responses to events and the actions of others -Inability to sleep or sleeping all the time -Headaches -Not eating or overeating -Social isolation -Thoughts of self-harm -Substance abuse or chain smoking -Bizarre behaviors -Seeing things that are not there -Paranoia Part 2 The individual makes a plan that he or she thinks will help when the symptoms have worsened to this degree The plan must be very specific and direct, with clear instructions Some examples include the following -Call my health-care professional; ask for and follow directions -Arrange for someone to stay with me around the clock until my symptoms subside -Take action so that I cannot hurt myself if my symptoms get worse, such as giving my medication, checkbook, credit cards, and car keys to a previously designated friend for safe keeping -Make sure I do everything on my daily check list -Have at least two peer counseling sessions daily -Increase use of items from wellness toolbox (e.g., relaxation exercises, physical exercises, creative activities)

Early Warning Signs (WRAP Model)

Part 1 Identification of subtle signs that indicate a possible worsening of the situation. Recognizing early warning signs and reviewing them regularly will help the person to become more aware of these early warning signs, allowing the person to take action before the signs worsen Some types of early warning signs include -Anxiety -Forgetfulness -Lack of motivation -Avoiding others or isolating -Increased irritability -Increase in smoking -Using substances -Feeling worthless and inadequate Part 2 The individual develops a plan for responding to the early warning signs that result in relief or in preventing them from escalating The plan may include items such as -Consulting a supporter or counselor -Increasing focus on peer counseling -Increasing time spent in relaxation exercises -Utilizing other interventions from the wellness toolbox until warning signs diminish

Reveals personal wisdom (Tidal Model)

People often do not realize their own personal wisdom, strengths, and abilities A key task for the professional is to help the person reveal and come to value that wisdom, so that it might be used to sustain the person throughout the voyage of recovery Practitioner competencies -Helping individuals identify personal strengths and weaknesses -Helping the patient develop self-confidence in their ability to help themselves.

Myths About Suicide

People who talk about suicide do not act on their ideas. Suicide happens without warning You cannot stop a suicidal person. He or she is fully intent on dying Once a person is suicidal, he or she is suicidal forever. Improvement after severe depression means that the suicidal risk is over Suicide is inherited, or "runs in families." All suicidal individuals are mentally ill, and suicide is the act of a psychotic person Suicidal thoughts and attempts should be considered manipulative or attention-seeking behavior and should not be taken seriously People usually take their own lives by overdosing on drugs If an individual has attempted suicide, he or she will not do it again Suicide always happens in an impulsive moment Young children (aged 5-12) can't be suicidal

Transcranial Magnetic Stimulation (TMS)

Procedure that is used to treat depression by stimulating nerve cells in the brain Involves the use of very short pulses of magnetic energy to stimulate nerve cells at localized areas in the cerebral cortex, similar to the electrical activity observed with ECT However, unlike with ECT, the electrical waves generated by TMS do not result in generalized seizure activity The waves are passed through a coil placed on the scalp to areas of the brain involved in mood regulation It is noninvasive and considered generally safe A typical course of treatment is 40-minute sessions, three to five times a week for 4 to 6 weeks Some clinicians believe that TMS holds a great deal of promise in the treatment of depression

Psychosocial Theories

Psychoanalytical Theory Learning Theory Object Loss Theory Cognitive Theory The Transactional Model

The Psychological Recovery Model

Psychological recovery is necessary whether mental illness is biologically based or the result of the exacerbation of emotional problems caused by stress The Psychological Recovery Model does not emphasize the absence of symptoms but focuses on the person's self-determination in the course of his or her recovery process Four components that were consistently evident in the recovery process: Hope: Finding and maintaining hope that recovery can occur Responsibility: Taking responsibility for one's life and well-being Self and identity: Renewing the sense of self and building a positive identity Meaning and purpose: Finding purpose and meaning in life Stages 1. Moratorium 2. Awareness 3. Preparation 4. Rebuilding 5. Growth Recovery from serious mental illness is more than staying out of the hospital or a return to some arbitrary level of functioning It is more than merely coping with the illness. In [the growth] stage, the notion of wellbeing replaces that of wellness While wellness implies the absence of illness, wellbeing refers to a more holistic psychological experience of fulfilling life Although we may not expect everyone (including those who do not have a mental illness) to reach the highest levels of self-actualization, we can expect that all people have the opportunity to develop a positive sense of self and identity and to live a meaningful life filled with purpose and hope for the future

Suicide and Religion

Rates among Protestants and Jews have been higher than among Roman Catholic or Muslim populations, but the degree of orthodoxy and affiliation with one's religion may be an important variable Men and women who consider themselves affiliated with a religion are less likely than their nonreligious counterparts to attempt suicide

Cognitive Strategies

Recognizing and modifying automatic thoughts and recognizing and modifying schemas

Guiding Principles of Recovery

Recovery emerges from hope Recovery is person driven Recovery occurs via many pathways Recovery is holistic Recovery is supported by peers and allies Recovery is supported through relationships and social networks Recovery is culturally based and influenced Recovery is supported by addressing trauma Recovery involves individual, family, and community strengths and responsibility Recovery is based on respect

Recovery is holistic (Guiding Principles of Recovery)

Recovery encompasses an individual's whole life, including mind, body, spirit, and community This holistic view includes addressing self-care practices, family, housing, employment, education, clinical treatment for mental and substance use disorders, services and supports, primary health care, dental care, complementary and alternative services, faith, spirituality, creativity, social networks, transportation, and community participation The array of services and supports available should be integrated and coordinated

Miscellaneous Techniques

Relaxation exercises, assertiveness training, role modeling, social skills training, and contingency management contracts are all types of behavioral interventions used in cognitive therapy to help clients modify dysfunctional cognitions Thought-stopping techniques may also be used to restructure dysfunctional thinking patterns

Covert Sensitization

Relies on the individual's imagination rather than on medication to produce unpleasant symptoms. The technique is under the client's control and can be used whenever and wherever it is required.

Recovery is person driven (Guiding Principles of Recovery)

Self-determination and self-direction are the foundations for recovery as individuals define their own life goals and design their unique paths toward those goals Individuals optimize their autonomy and independence to the greatest extent possible by leading, controlling, and exercising choice over the services and supports that assist their recovery and resilience They are empowered and provided the resources to make informed decisions, initiate recovery, build on their strengths, and gain or regain control over their lives

Severe Depression

Severe depression (also called major depressive disorder) is characterized by an intensification of the symptoms described for moderate depression Symptoms include the following Affective -Feelings of total despair, hopelessness, and worthlessness -Flat (unchanging) affect, appearing devoid of emotional tone -Prevalent feelings of nothingness and emptiness -Apathy -Loneliness -Sadness -Inability to feel pleasure Behavioral -Psychomotor retardation so severe that physical movement may literally come to a standstill, or psychomotor behavior manifested by rapid, agitated, purposeless movements -Slumped posture -Sitting in a curled-up position -Walking slowly and rigidly -Virtually nonexistent communication (when verbalizations do occur, they may reflect delusional thinking) -No personal hygiene and grooming -Social isolation is common, with virtually no inclination toward interaction with others Cognitive -Prevalent delusional thinking, with delusions of persecution and somatic delusions being most common -Confusion, indecisiveness, and an inability to concentrate -Hallucinations reflecting misinterpretations of the environment -Excessive self-deprecation, self-blame, and thoughts of suicide NOTE: Because of the low energy level and slow thought processes, the individual may be unable to follow through on suicidal ideas. However, the desire is strong at this level Physiological -A general slowdown of the entire body, reflected in sluggish digestion, constipation, and urinary retention -Amenorrhea -Impotence -Diminished libido -Anorexia -Weight loss or weight gain associated with appetite changes -Changes in sleep patterns, including difficulty falling asleep and awakening very early in the morning -Feeling worse early in the morning and somewhat better as the day progresses (as with moderate depression, this may reflect the diurnal variation in the level of neurotransmitters that affect mood and activity)

Persistent Depressive Disorder (Dysthymia)

Somewhat milder than, those ascribed to MDD Individuals with this mood disturbance describe their mood as sad or "down in the dumps." There is no evidence of psychotic symptoms The essential feature is a chronically depressed mood (or possibly an irritable mood in children or adolescents) for most of the day, more days than not, for at least 2 years (1 year for children and adolescents) The diagnosis is identified as early onset (occurring before age 21 years) or late onset (occurring at age 21 years or older)

Moratorium (The psychological recovery Model)

Stage identified by dark despair and confusion It seems 'life is on hold'" Hope -Hopelessness prevails -Consumers may even perceive feelings of hopelessness from practitioners when treatment plans emphasize stabilization and maintenance, thereby conveying messages of no hope for recovery Responsibility -The individual feels out of control and powerless to change Self and identity -Individuals feel "as though they no longer know who they are as a person" -An individual's sense of identity as a valuable and functional member of society can be lost with a diagnosis of mental illness Meaning and purpose -The diagnosis of severe mental illness is a traumatic event that can challenge an individual's fundamental beliefs, creating a loss of meaning and purpose in life

Schemas (Core Beliefs)

Structures that contain the individual's fundamental beliefs and assumptions Develop early in life from personal experience and identification with significant others These concepts are reinforced by further learning experiences and, in turn, influence the formation of beliefs, values, and attitudes

Object Loss Theory (Psychosocial Theories)

Suggests that depressive illness occurs as a result of having been abandoned by or otherwise separated from a significant other during the first 6 months of life Because the mother represents the child's main source of security during this period, she is considered the "object." This absence of attachment, which may be either physical or emotional, leads to feelings of helplessness and despair that contribute to lifelong patterns of depression in response to loss

Interpersonal Theory of Suicide

Suicide ideation and suicide attempts need to be understood as distinct processes Low connectedness and a high sense of burden interact with each other to increase suicide thoughts and desires, but those features in the presence of high capability for suicide are strongly associated with the move from ideation to lethal attempts

Anger Turned Inward

Suicide was a response to intense self-hatred The anger originated toward a love object but was ultimately turned inward against the self Suicide occurred as a result of an earlier repressed desire to kill someone else

Overgeneralizations (Absolutistic Thinking)

Sweeping conclusions are made on the basis of one incident—an "all-or-nothing" kind of thinking Frank submitted an article to a nursing journal, and it was rejected. Frank thinks, "No journal will ever be interested in anything I write."

Baby Blues

Symptoms -Worry -Sadness -Fatigue after having a baby These symptoms affect about 80 percent of mothers and usually subside on their own within a week or two Baby blues usually needs no treatment beyond a word of reassurance from the physician or nurse that these feelings are common and will soon pass Extra support and comfort from significant others also is important

Mild Depression

Symptoms at the mild level of depression are like those associated with uncomplicated grieving Alterations at the mild level include the following Affective -Denial of feelings -Anger -Anxiety -Guilt -Helplessness -Hopelessness -Sadness -Despondency Behavioral -Tearfulness -Regression -Restlessness -Agitation -Withdrawal Cognitive -Preoccupation with the loss -Self-blame -Ambivalence -Blaming others Physiological -Anorexia or overeating -Insomnia or hypersomnia -Headache -Backache -Chest pain -Other symptoms associated with the loss of a significant other

Transient Depression

Symptoms at this level of the continuum are not necessarily dysfunctional; in fact, they may be considered part of the broad range of typical human emotional responses that accompany everyday disappointments in life Subsides quickly, and the individual is able to refocus on other goals and achievements Alterations include the following: Affective -Sadness -Dejection -Feeling downhearted -Having the blues Behavioral -Some crying possible Cognitive -Some difficulty getting mind off of one's disappointment Physiological -Feeling tired and listless

Stage II: Acute Mania

Symptoms of acute mania may progress in intensification from those experienced in hypomania, or they may be manifested directly Most individuals experience marked impairment in functioning and require hospitalization *Mood* Uphoria and elation The person appears to be on a continuous "high." However, the mood is always subject to frequent variation, easily changing to irritability and anger or even to sadness and crying *Cognition and Perception* Fragmented and often psychotic in acute mania Accelerated thinking proceeds to racing thoughts; overconnection of ideas; and rapid, abrupt movement from one thought to another (flight of ideas) and may be manifested by a continuous flow of accelerated, pressured speech (loquaciousness) to the point that conversing with this individual may be extremely difficult When flight of ideas is severe, speech may be disorganized and incoherent Distractibility becomes all-pervasive. Attention can be diverted by even the smallest of stimuli Hallucinations and delusions (usually paranoid and grandiose) are common *Activity and Behavior* Psychomotor activity is excessive. Sexual interest is increased There is poor impulse control and low frustration tolerance The individual who is normally discreet may become socially and sexually uninhibited Excessive spending is common In acute mania, the individual typically has little insight into his or her behavior and communication This lack of insight manifests at times as unreliable reporting of events and denial of problems when confronted by friends or family, which may be interpreted as lying Energy seems inexhaustible, and the need for sleep is diminished An individual experiencing acute mania may go for many days without sleep and still not feel tired Hygiene and grooming may be neglected Dress may be disorganized, flamboyant, or bizarre, and the use of excessive makeup or jewelry is common

Cognitive therapy emphasizes collaboration and active participation

Teamwork between therapist and client is emphasized They decide together what to work on during each session, how often they should meet, and what homework assignments should be completed between sessions

Cognitive therapy uses a variety of techniques to change thinking, mood, and behavior

Techniques from various therapies may be used within the cognitive framework Emphasis in treatment is guided by the client's particular disorder and directed toward modification of the dysfunctional cognitions that contribute to the maladaptive behavior associated with his or her disorder

Client and Family Education for Calcium Channel Blocker

The Client Should: Take medication with meals if gastrointestinal upset occurs Use caution when driving or when operating dangerous machinery. Dizziness, drowsiness, and blurred vision can occur Refrain from discontinuing the drug abruptly. To do so may precipitate cardiovascular problems. Physician will administer orders for tapering the drug when therapy is to be discontinued Report occurrence of any of the following symptoms to physician immediately: irregular heartbeat, shortness of breath, swelling of the hands and feet, pronounced dizziness, chest pain, profound mood swings, severe and persistent headache Rise slowly from a sitting or lying position to prevent a sudden drop in blood pressure Avoid taking other medications (including over-the-counter medications) without physician's approval Carry a card at all times describing medications being taken

Phase I of Individual Psychotherapy

The client is assessed to determine the extent of the illness Complete information is given to the individual regarding the nature of depression, symptom pattern, frequency, clinical course, and alternative treatments If the level of depression is severe, interpersonal psychotherapy has been shown more effective if conducted in combination with antidepressant medication The client is encouraged to continue working and participating in regular activities during therapy A mutually agreeable therapeutic contract is negotiated

Client and Family Education for Antipsychotics

The client should: Use caution when driving or operating dangerous machinery. Drowsiness and dizziness can occur Refrain from discontinuing the drug abruptly after long-term use. To do so might produce withdrawal symptoms, such as nausea, vomiting, dizziness, gastritis, headache, tachycardia, insomnia, and tremulousness. Physician will administer orders for tapering the drug when therapy is to be discontinued Use sunblock lotion and wear protective clothing when spending time outdoors. Skin is more susceptible to sunburn, which can occur in as little as 30 minutes Report the occurrence of any of the following symptoms to the physician immediately: sore throat, fever, malaise, unusual bleeding, easy bruising, persistent nausea and vomiting, severe headache, rapid heart rate, difficulty urinating, muscle twitching, tremors, dark-colored urine, excessive urination, excessive thirst, excessive hunger, weakness, pale stools, yellow skin or eyes, muscular incoordination, or skin rash Rise slowly from a sitting or lying position to prevent a sudden drop in blood pressure Take frequent sips of water, chew sugarless gum, or suck on hard candy, if dry mouth is a problem. Good oral care (frequent brushing, flossing) is very important Consult the physician regarding smoking while on antipsychotic therapy. Smoking increases the metabolism of these drugs, requiring an adjustment in dosage to achieve a therapeutic effect Dress warmly in cold weather, and avoid extended exposure to very high or low temperatures. Body temperature is harder to maintain with this medication Avoid drinking alcohol while on antipsychotic therapy. These drugs potentiate each other's effects Avoid taking other medications (including over-the-counter products) without the physician's approval. Many medications contain substances that interact with antipsychotic medications in a way that may be harmful Be aware of possible risks of taking antipsychotics during pregnancy. Safe use during pregnancy has not been established. Antipsychotics are thought to readily cross the placental barrier; if so, a fetus could experience adverse effects of the drug. Inform the physician immediately if pregnancy occurs, is suspected, or is planned Be aware of side effects of antipsychotic medications. Refer to written materials furnished by health-care providers for safe self-administration Continue to take the medication even if feeling well. Symptoms may return if medication is discontinued Carry a card or other identification at all times describing medications being taken

Premenstrual Dysphoric Disorder (PMDD)

The essential features include markedly depressed mood, excessive anxiety, mood swings, and decreased interest in activities during the week prior to menses, improving shortly after the onset of menstruation, and becoming minimal or absent in the week postmenses

Recovery is supported by addressing trauma (Guiding Principles of Recovery)

The experience of trauma (such as physical or sexual abuse, domestic violence, war, disaster, and other events) is often a precursor to or associated with alcohol and drug use, mental health problems, and related issues Services and supports should be trauma informed to foster safety (physical and emotional) and trust and should promote choice, empowerment, and collaboration

Affect

The external, observable emotional reaction associated with an experience

Extinction

The gradual decrease in frequency or disappearance of a response when the positive reinforcement is withheld

Awareness (The psychological recovery Model)

The individual comes to a realization that a possibility for recovery exists It involves an awareness of a possible self other than that of 'sick person': a self that is capable of recovery Hope -There is a dawn of hope that indeed "life is not over." -This feeling of hope may emanate from significant others, professionals, or family members -Individuals may also be inspired by others who have recovered -Hope may also be derived from strong inner determination and from personal faith and spirituality Responsibility: -The individual develops an awareness of the need to take control of his or her life -Feelings of control and responsibility lead to a sense of personal empowerment that paves the way for recovery Self and identity -The individual comes to realize that he or she is a person independent of the illness -The person realizes that there still exists an 'intact self' capable of taking action on one's own behalf Meaning and purpose -The individual strives for a personal comprehension of the illness, why it occurred, and what the implications of the illness are for his or her future -Seeking a meaning of the illness can be explained by theories of cognitive control, in which one tries to understand unexplainable negative events by finding a reason for them

Developing a Wellness Toolbox (WRAP Model)

The individual creates a list of tools, strategies, and skills that he or she has used in the past (or has heard of in the past that he or she would like to try) to assist in relieving disturbing symptoms -Talking to a friend or health-care professional -Peer counseling or exchange listening -Relaxation and stress reduction exercises -Guided imagery -Journaling -Physical exercise -Attending a support group -Doing something special for someone else -Listening to music

Become the apprentice (Tidal Model)

The individual is the expert on his or her life story, and he or she must be the leader in deciding what needs to be done Professionals may learn something of the power of that story, but only if they apply themselves diligently and respectfully to the task by becoming apprentice-minded Practitioner competencies -Developing a plan of care for the individual based on his or her expressed needs or wishes -Helping the individual identify specific problems and ways to address them

Phase III of Individual Psychotherapy

The therapeutic alliance is terminated With emphasis on reassurance, clarification of emotional states, improvement of interpersonal communication, testing of perceptions, and performance in interpersonal settings, interpersonal psychotherapy has been successful in helping depressed persons recover enhanced social functioning

Rebuilding (The psychological recovery Model)

The individual takes the necessary steps to work towards his or her goals in rebuilding a meaningful life Hope -The individual has hope for and looks forward to a more fulfilling life -Realistic goals are set, and the individual is encouraged to pursue the recovery process at his or her own pace. With each success, hope is renewed Responsibility: -Through setting and working towards goals, the person begins to actively take control of his or her life; not only management of symptoms, but also enlisting social support, improvement of self-image, handling social pressures, and building social competence -Assuming control of treatment decisions and illness management is an essential part of the recovery process Self and identity -The individual elaborates and enhances his or her sense of identity, having succeeded in previous stages in developing a positive self-identity separate from the illness and a new sense of self-confidence by succeeding at new activities -The work of examining core values and working toward value-congruent goals reinforces a positive sense of identity and a commitment to recovery Meaning and purpose -Having realistic goals and a positive sense of identity provides a sense of purpose in life. Individuals need a reason to start each day -Finding meaning [in life] is more than finding a valued occupation, but rather is more akin to finding a way to live. This may include, but is not limited to, vocational goals. It includes examining one's spirituality or philosophy of life. The journey is, in itself, a source of meaning for many

Electroconvulsive Therapy

The induction of a grand mal (generalized) seizure through the application of electrical current to the brain

Powerlessness

The lived experience of lack of control over a situation, including a perception that one's actions do not significantly affect an outcome *Behaviors* Apathy Verbal expressions of having no control Dependence on others to fulfill needs *Goal* Short-term goal -Client will participate in decision-making regarding own care within 5 days Long-term goal -Client will be able to effectively problem-solve ways to take control of his or her life situation by time of discharge from treatment, thereby decreasing feelings of powerlessness *Interventions* Encourage the client to take as much responsibility as possible for his or her own self-care practices. In the most acute stage of severe depression, clients may have extreme difficulty making decisions. At this point, it may be more helpful to use active communication to help the client accomplish even basic ADLs. For example, "It's time to eat lunch," rather than, "Would you like to eat lunch now?" Ongoing assessment is important so that the client can be encouraged to make choices as soon as possible. Providing the client with choices whenever possible will increase feelings of control. For example, -Include the client in setting the goals of care he or she wishes to achieve -Allow the client to establish own schedule for self-care activities -Provide the client with privacy as need is determined -Provide positive feedback for decisions made. Respect the client's right to make those decisions independently, and refrain from attempting to influence him or her toward those that may seem more logical Help the client set realistic goals. Unrealistic goals set the client up for failure and reinforce feelings of powerlessness Help the client identify areas of his or her life situation that can be controlled. The client's emotional condition interferes with his or her ability to solve problems. Assistance is required to perceive the benefits and consequences of available alternatives accurately Discuss with the client areas of life that are not within his or her ability to control. Encourage verbalization of feelings related to this inability in an effort to deal with unresolved issues and accept what cannot be changed

Cognitive Theory (Psychosocial Theories)

The primary disturbance in depression is cognitive rather than affective The underlying cause of the depression is cognitive distortions that result in negative, defeated attitudes Three cognitive distortions that are believed to serve as the basis for depression: 1. Negative expectations of the environment 2. Negative expectations of the self 3. Negative expectations of the future These cognitive distortions arise out of a defect in cognitive development, and the individual feels inadequate, worthless, and rejected by others Outlook for the future is one of pessimism and hopelessness Cognitive theorists believe that depression is the product of negative thinking This is in contrast to the other theorists, who suggest that negative thinking occurs when an individual is depressed Cognitive therapy focuses on helping the individual alter mood by changing the way he or she thinks The individual is taught to control negative thought distortions that lead to pessimism, lethargy, procrastination, indecisiveness, and low self-esteem

Egoistic Suicide

The response of the individual who feels separate from the mainstream of society Integration is lacking, and the individual does not feel a part of any cohesive group

Postpartum Depression

The severity of depression in the postpartum period varies from a feeling of the blues, to moderate depression, to severe depression with psychotic features About 50 percent of these episodes actually begin prior to delivery (APA, 2013), and the onset of symptoms during pregnancy, including the "baby blues," increases risk for major depression in the postpartum period. Major depression with psychotic features occurs in about 1 or 2 out of 1,000 postpartum women Baby blues may be associated with hormonal changes, tryptophan metabolism, or alterations in membrane transport during the early postpartum period Besides being exposed to these same somatic changes, the woman who experiences moderate to severe symptoms probably possesses a vulnerability to depression related to heredity, upbringing, early life experiences, personality, or social circumstances A history of depression appears to be a risk factor for postpartum depression The etiology of postpartum depression may very likely be a combination of hormonal, metabolic, and psychosocial influences Treatment of postpartum depression varies with the severity of the illness

Suicide and Marital Status

The suicide rate for single, never-married persons is twice that for married persons and divorce increases risk for suicide particularly among men, who are three times more likely than divorced women to take their own lives Widows and widowers have also been identified at higher risk Divorced men are twice as likely as married men to die by suicide

Substance/Medication-Induced Depressive Disorder

The symptoms are considered the direct result of physiological effects of a substance (e.g., a drug of abuse, a medication, or toxin exposure) This disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning The depressed mood is associated with intoxication or withdrawal from substances such as alcohol, amphetamines, cocaine, hallucinogens, opioids, phencyclidine-like substances, sedatives, hypnotics, or anxiolytics The symptoms meet the full criteria for a relevant depressive disorder A number of medications have been known to evoke mood symptoms Classifications include anesthetics, analgesics, anticholinergics, anticonvulsants, antihypertensives, antiparkinsonian agents, antiulcer agents, cardiac medications, oral contraceptives, psychotropic medications, muscle relaxants, steroids, and sulfonamides.

Cognitive Rehearsal

Uses mental imagery to uncover potential automatic thoughts in advance of their occurrence in a stressful situation A discussion is held to identify ways to modify these dysfunctional cognitions. The client is then given "homework" assignments to try these newly learned methods in real situations.

Decatastrophizing

The therapist assists the client to examine the validity of a negative automatic thought The client is assisted to examine "what is the worst thing that could happen?" and then to develop a plan of action Even if some validity exists, the client is encouraged to review ways to cope adaptively and move beyond the current crisis situation

Cognitive therapy is based on an ever-evolving formulation of the client and his or her problems in cognitive terms

The therapist identifies the event that precipitated the distorted cognition Current thinking patterns that serve to maintain the problematic behaviors are reviewed The therapist then hypothesizes about certain developmental events and enduring patterns of cognitive appraisal that may have predisposed the client to specific emotional and behavioral responses

Socratic Dialogue (Guided Discovery)

The therapist questions the client to elaborate the "who, what, when, where, why, and how" of his or her situation The client is asked to describe feelings associated with specific scenarios Questions are primarily restatements of the client's own words in a way that may stimulate insight into possible dysfunctional thinking and produce dissonance about the validity of the thoughts

The Transactional Model (Psychosocial Theories)

The transactional model recognizes the combined effects of genetic, biochemical, and psychosocial influences on an individual's susceptibility to depression

Anger Management

The use of various techniques and strategies to control responses to anger-provoking situations. The goal is to reduce both the emotional feelings and the physiological arousal that anger engenders

Suicide risk assessment is an ongoing process, and level of risk can increase or decrease over time

This includes assessing over time for fluctuations in risk factors, changes in stress level, changes in intensity of ideation, changes in intention to act on suicide ideation

Suicide risk assessment attempts to discern the underlying message

This includes attempting to discern when the patient is communicating unbearable distress, feeling trapped, feeling hopeless, and/or feeling driven to avoid additional emotional or physical pain

Establishment of a therapeutic relationship is foundational to effective suicide risk assessment

This includes establishing trust through empathy and respect, which provides a safe environment for the client to tell his or her story

Suicide risk assessment is complex and challenges the nurse to use many different communication strategies

This includes exploring the client's thoughts, feelings, and behaviors from a variety of perspectives

Screening for suicide risk should be conducted as an essential component of health assessment, and risk factors, warning signs, and threats should be taken seriously

This includes identifying through detailed assessment the individual's unique situation to discern additional resources, consults, and interventions needed to ensure patient safety

Collaboration with the client and other sources of information facilitates confidence in clinical judgments

This includes information provided by other people who are familiar with the client from home, work, or school and other clinical team members. Collaboration also implies that all those involved in the client's care are working together

Suicide risk assessment considers cultural context.

This includes recognizing that anyone regardless of race, religion, or culture may be at risk for suicide. Some cultural or religious prohibitions may influence someone's willingness to openly discuss personal feelings

Suicide risk assessment is documented in detail

This includes risk factors, warning signs, underlying themes, level of risk, clinical judgments, and recommended interventions

Suicide risk assessment uses direct rather than indirect language

This includes using terminology such as "suicide" and "death" rather than "not happy with living" or other indirect statements. It also communicates to the client that these are acceptable topics to discuss

Graded Task Assignments

This intervention is used with clients who are facing a situation that they perceive as overwhelming The task is broken down into subtasks that clients can complete one step at a time Each subtask has a goal and a time interval attached to it Successful completion of each subtask helps to increase self-esteem and decrease feelings of helplessness

Growth (The psychological recovery Model)

This is a dynamic stage and that personal growth is a continuing life process Hope -The individual feels a sense of optimism and hope of a rewarding future -Skills that have been nurtured in the previous stages are applied with confidence, and the individual strives for higher levels of well-being Responsibility: -Achieving control requires sustained commitment in the face of set-backs -Individuals exhibit confidence in managing their illnesses and are resilient when relapses occur -They are empowered by personal input and decision-making regarding their treatment. Self and identity: -The individual has developed a strong, positive sense of self and identity -Many consumers have reported feeling that they are a better person as a result of their struggle with the illness -Participants reported developing personal qualities, including strength and courage; more confidence in the self; resourcefulness and responsibility; a new philosophy of life; compassion and empathy; a sense of self-worth; and being happier and more carefree Meaning and purpose: -Individuals who have reached the growth stage often report a more profound sense of meaning -Some describe having achieved a sense of serenity and peace, and for others it takes the form of a spiritual awakening -Some individuals find reward in educating others about the experience of mental illness and recovery

Cognitive therapy teaches clients to identify, evaluate, and respond to their dysfunctional thoughts and beliefs

Through gentle questioning and review of data, the therapist helps the client identify his or her dysfunctional thinking, evaluate the validity of the thoughts, and devise a plan of action This is done by helping the client examine evidence that supports or contradicts the accuracy of the thought rather than directly challenging or confronting the belief

Models of Recovery

Tidal Model WRAP Model Psychological Recovery Model

Dichotomous Thinking

Views situations in terms of all-or-nothing, black-or-white, or good-or-bad Frank submits an article to a nursing journal, and the editor returns it and asks Frank to rewrite parts of it. Frank thinks, "I'm a bad writer," instead of recognizing that revision is a common part of the publication process

Risk for Violence: Self-Directed or Other-Directed

Vulnerable to behaviors in which an individual demonstrates that he or she can be physically, emotionally, and/or sexually harmful to [self or to others] *Behavior* Manic excitement Delusional thinking Hallucinations Impulsivity *Goals* Short-term goals -Within [a specified time], client will recognize signs of increasing anxiety and agitation and report to staff (or other care provider) for assistance with intervention. -Client will not harm self or others Long-term goal -Client will not harm self or others *Interventions* -Maintain a low level of stimuli in the client's environment (low lighting, few people, simple decor, low noise level). Anxiety level rises in a stimulating environment. A suspicious, agitated client may perceive individuals as threatening -Assess for concurrent substance use issues. There is a high incidence of comorbid substance use disorders in clients with bipolar disorder. Substance use issues can increase the client's risk for harm to self or others. In addition, the use of mood-altering chemicals beyond what is prescribed can make the evaluation of pharmacotherapy more difficult -Observe the client's behavior frequently. Do this while carrying out routine activities so as to avoid creating suspiciousness in the individual. Close observation is necessary so that intervention can occur if required to ensure client (and others') safety -Remove all dangerous objects from the client's environment so the client may not use them to harm self or others in an agitated, confused state -Intervene at the first sign of increased anxiety, agitation, or verbal or behavioral aggression. Offer empathetic response to client's feelings: "You seem anxious (or frustrated, or angry) about this situation. How can I help?" Validation of the client's feelings conveys a caring attitude and offering assistance reinforces trust. Since the client may be highly distractible, providing a distraction can aid in diffusing anxiety and agitation as well -It is important to maintain a calm attitude toward the client. As the client's anxiety increases, offer some alternatives: participating in a physical activity (e.g., punching bag, physical exercise), talking about the situation, taking antianxiety medication. Offering alternatives to the client gives him or her a feeling of some control over the situation -Have sufficient staff available to indicate a show of strength to the client if it becomes necessary. This shows the client evidence of control over the situation and provides some physical security for staff -If the client is not calmed by "talking down" or by medication, use of mechanical restraints may be necessary -If restraint is deemed necessary, ensure that sufficient staff is available to assist. Follow protocol established by the institution -As agitation decreases, assess the client's readiness for restraint removal or reduction. Remove one restraint at a time while assessing the client's response. This minimizes the risk of injury to client and staff

Insulin Coma Therapy

Was introduced by the German psychiatrist Manfred Sakel in 1933 His therapy was used for clients with schizophrenia The insulin injection treatments induced a hypoglycemic coma, which Sakel claimed was effective in alleviating schizophrenic symptoms This therapy required vigorous medical and nursing intervention through the stages of induced coma Some fatalities occurred when clients failed to respond to efforts directed at termination of the coma The efficacy of insulin coma therapy has been questioned, and its use has been discontinued in the treatment of mental illness

Pharmacoconvulsive Therapy

Was introduced in Budapest in 1934 by Ladislas Meduna He induced convulsions with intramuscular injections of camphor in oil in clients with schizophrenia He based his treatment on clinical observation and theorized the existence of a biological antagonism between schizophrenia and epilepsy By inducing seizures he hoped to reduce schizophrenic symptoms Because he discovered that camphor was unreliable for inducing seizures, he began using pentylenetetrazol (Metrazol) Some successes were reported in terms of reduction of psychotic symptoms, and until the advent of ECT in 1938, pentylenetetrazol was the most frequently used method for producing seizures in clients with psychosis There was a brief resurgence of pharmacoconvulsive therapy in the late 1950s, when flurothyl (Indoklon), a potent inhalant convulsant, was introduced as an alternative for individuals who were unwilling to consent to ECT for the treatment of depression and schizophrenia This therapy is no longer used in psychiatry

Positive Reinforcement

When the reinforcing stimulus increases the probability that the behavior will recur

Suicide and Ethnicity

Whites are at highest risk for suicide (14.7%) Followed by American Indian and Alaska Natives (10.9%), Hispanic Americans (6.3%), Asian Americans (5.9%), and African Americans (5.5%)