Chapter 16 Depressive Disorders

The nurse is preparing a presentation about Beck's cognitive theory. Which cognitive distortion would the nurse include in the teaching session? 1. Negative expectation of the environment 2. Negative expectation of the present 3. Negative expectation of the career 4. Negative expectation of the family

Answer: 1 Rationale: 1 Negative expectations of the environment is one of the three cognitive distortions in Beck's Cognitive Theory. The other two are negative expectations of the self and future. 2 A cognitive distortion in Beck's Cognitive Theory is negative expectation of the future, not the present. 3 There is no negative expectation of the career in Beck's Cognitive Theory. 4 A cognitive distortion in Beck's Cognitive Theory is negative expectation of the self, not the family.

Which action should the nurse take when a depressed client refuses electroconvulsive therapy (ECT)? 1. Accept the client's decision 2. Inform the client that the procedure is mandatory 3. Tell the client that the signature verifies informed consent 4. Call the family to receive approval

Answer: 1 Rationale: 1 The nurse should accept the client's decision. Consent for ECT may be withdrawn at any time. 2 ECT is voluntary, not mandatory. 3 Just because the client signed the consent form does not indicate the client must receive the treatment. Consent may be withdrawn at any time. 4 The client is the priority decision-maker, not the family.

Which statement by a client who is beginning tricyclic antidepressant therapy indicates successful teaching? 1. "I will continue to take this medication even if the symptoms have not subsided." 2. "I will start to see results in about 2 weeks." 3. "I will continue to smoke." 4. "I will start to cut down on my alcohol intake and have only one glass of wine at supper."

Answer: 1 Rationale: 1 This statement indicates successful teaching. Clients should continue to take the medication even if symptoms have not subsided. The therapeutic effect may not be seen for as long as 4 weeks. 2 This statement does not indicate successful teaching. The therapeutic effect of tricyclic antidepressants may not be seen for as long as 4 weeks, not 2 weeks. 3 This statement does not indicate successful teaching. Clients should not smoke when taking this medication, as smoking increases the metabolism of tricyclic antidepressants. 4 This statement does not indicate successful teaching. The client should avoid alcohol while taking this medication. Taking alcohol and antidepressants potentiates the effects of each other.

The nurse is teaching about the diagnosis disruptive mood dysregulation disorder (DMDD). Which information should the nurse include? (Select all that apply.) 1. Symptoms include verbal rages or physical aggression toward people or property. 2. Temper outbursts must be present in at least two settings (at home, at school, or with peers). 3. DMDD is characterized by severe recurrent temper outbursts. 4. The temper outbursts are manifested only behaviorally. 5. Symptoms of DMDD must be present for 18 or more months to meet diagnostic criteria.

Answer: 1, 2, 3 Rationale: 1 Criteria for this diagnosis include, but are not limited to, the following: verbal rages or physical aggression toward people or property. This childhood disorder is called disruptive mood dysregulation disorder. 2 Criteria for this diagnosis include, but are not limited to, the following: temper outburst must be present in at least two settings (at home, at school, or with peers). This childhood disorder is called disruptive mood dysregulation disorder. 3 DMDD is characterized by severe recurrent temper outbursts. 4 The temper outbursts are manifested both behaviorally and/or verbally, not just behaviorally. 5 Symptoms of DMDD must be present for 12 months (not 18) or more months, to meet diagnostic criteria.

The depressed client is prescribed a monoamine oxidase inhibitor (MAOI). Which statements by the client should indicate to a nurse that the discharge teaching about this medication has been successful? (Select all that apply.) 1. "I'll have to let my surgeon know about this medication before I have my cholecystectomy." 2. "I guess I will have to give up my glass of red wine with dinner." 3. "I'll have to be very careful about reading food labels." 4. "I'm going to drink my caffeinated coffee in the morning." 5. "I'll be sure not to stop this medication abruptly."

Answer: 1, 2, 3, 5 Rationale: 1 The nurse should evaluate successful teaching when the client will tell the surgeon about taking this medication. The client needs to tell other physicians and surgeons about taking MAOIs, because of the risk of drug interactions. 2 The nurse should evaluate that teaching has been successful when the client states that MAOI should not be taken in conjunction with the use of alcohol. This action will prevent a hypertensive crisis. 3 The nurse should evaluate that teaching has been successful when the client states that reading food labels is necessary. This will prevent consuming foods high in tyramine while taking MAOI to prevent a hypertensive crisis. 4 The nurse should evaluate that teaching has not been successful when the client is going to drink coffee. The client will need to give up caffeinated coffee with this medication to prevent hypertensive crisis. 5 The nurse should evaluate that teaching has been successful when the client will not stop the medication abruptly. MAOIs should not be stopped abruptly.

An older adult client has a diagnosis of dysthymic disorder. Which signs and symptoms should the nurse expect the client to exhibit? (Select all that apply.) 1. Sad mood on most days 2. Mood rating of 2 out of 10 for the past 6 months 3. Labile mood 4. Sad mood for the past 3 years after spouse's death 5. Pressured speech when communicating

Answer: 1, 4 Rationale: 1 The nurse should anticipate that a client with a diagnosis of dysthymic disorder would experience a sad mood on most days for more than two years. 2 The client would need to be sad on most days for more than two years to meet the requirements for dysthymic disorder. Six months is not a long enough time. 3 The client would not have a labile mood in dysthymia. 4 The essential feature of dysthymia is a chronically depressed mood for at least 2 years, which can have an early or late onset. 5 The client with dysthymia would not experience pressured speech when communicating.

The depressed client is receiving light therapy. Which instruction would the nurse share with the client? 1. "White LED lights will be used with protective glasses to block ultraviolet rays." 2. "You will sit in front of the light box with your eyes open." 3. "The light sessions will start out at 5 minutes and work up to 30 minute intervals." 4. "Vagal stimulation from the light waves will help release melatonin in the brain."

Answer: 2 1 Light therapy uses white fluorescent tubes covered with a plastic screen that blocks ultraviolet rays. LED lights and protective glasses are not used. 2 The individual sits in front of the box with the eyes open (although the client should not look directly into the light). 3 Light therapy sessions usually begins with 10- to 15-minute sessions and gradually progresses to 30 to 45 minutes. Sessions do not start out at 5 minutes and work up to 30 minute intervals. 4 The mechanism of action for light therapy is believed to be related to retinal stimulation (not vagal stimulation), which triggers a reduction of melatonin (not an increase) but serotonin is increased in the brain.

After 5 months of taking nortriptyline (Aventyl) for depressive symptoms, a client reports that the medication doesn't seem as effective as before. Which question should the nurse ask to determine the cause of this problem? 1. "Are you consuming foods high in tyramine?" 2. "How many packs of cigarettes do you smoke daily?" 3. "Do you drink any alcohol?" 4. "When did you last eat yogurt?"

Answer: 2 Rationale: 1 The nurse would not ask this question. Tyramine is only an issue when MAOI medications are prescribed. Nortriptyline is a tricyclic. 2 The nurse would ask this question. Nortriptyline is a tricyclic antidepressant. Smoking should be avoided while receiving tricyclic therapy. Smoking increases the metabolism of tricyclics, requiring an adjustment in dosage to achieve the therapeutic effect. 3 The nurse would not ask this question. Alcohol potentiates/increases the effects of antidepressants. Alcohol does not decrease the effects. 4 The nurse would not ask this question. Yogurt, a food high in tyramine, is only an issue when MOAI medication is prescribed. Nortriptyline is a tricyclic antidepressant.

Which characteristic would help a nurse distinguish between dysthymia and major depressive disorder (MDD)? 1. Dysthymia is associated with the menstrual cycle. 2. Dysthymia is a chronically depressed mood. 3. MDD lasts for at least 2 years. 4. MDD does not have delusions or hallucinations.

Answer: 2 Rationale: 1 Dysthymia is not associated with the menstrual cycle. Signs and symptoms of premenstrual dysphoric disorder occur the week prior to the menses. 2 Dysthymia is somewhat milder than MDD but the essential feature is a chronically depressed mood for most of the day, more days than not, for at least 2 years. 3 Dysthymia lasts for at least 2 years, not MDD. 4 Dysthymia, not MDD, has no evidence of psychotic symptoms, like delusions or hallucinations. MDD has psychotic features.

The nurse is teaching the depressed client about bupropion (Wellbutrin). Which statement by the client indicates effective teaching? 1. "I will begin to wear short sleeves when outdoors." 2. "I will not take two pills if I miss a dose." 3. "I will discontinue the medication when my depression is gone." 4. "I will stand up smoothly and quickly to keep my balance."

Answer: 2 Rationale: 1 This statement does not indicate effective teaching. The client should use sunblock or protective clothing as skin sensitivity may occur. Short sleeves are not protective clothing. 2 This statement indicates effective teaching. Clients should never double up on a dose if they miss a day, as this could increase the risk of seizures or other adverse reactions. 3 This statement does not indicate effective teaching. Clients should only discontinue any medication under the guidance of their physician, not because the depression is gone. 4 This statement does not indicate effective teaching. Clients should rise slowly (not quickly) from a sitting or lying position to prevent a sudden drop in blood pressure.

Which scale would a nurse practitioner use to assess a depressed client? 1. Zung Depression Scale 2. Hamilton Depression Rating Scale 3. Beck Depression Inventory 4. AIMS Depression Rating Scale

Answer: 2 Rationale: 1 The Zung Self-rating Depression Scale is a self-rating scale. 2 One of the most widely used clinician-administered scales is the Hamilton Depression Rating Scale. The original version contains 17 items and is designed to measure mood, guilty feelings, suicidal ideation, sleep disturbances, anxiety levels, and weight loss. 3 The Beck Depression Inventory is a self-rating scale. 4 There is no AIMS Depression Rating Scale. However, the Abnormal Involuntary Movement Scale (AIMS) is a rating scale that measures involuntary movements associated with tardive dyskinesia.

The nurse performs a full physical health assessment on an older adult client admitted with a diagnosis of major depressive disorder. What is the rationale for the nurse's assessment? 1. The attention during the assessment is beneficial in decreasing social isolation in the elderly. 2. Depression can generate somatic symptoms that can mask actual physical disorders. 3. Physical health complications are likely to arise from antidepressant therapy. 4. Depressed geriatric clients avoid addressing physical health and ignore medical problems.

Answer: 2 Rationale: 1 The assessment does not decrease social isolation in the elderly. That is not the purpose of a physical assessment. 2 The nurse should determine that an older adult client with a diagnosis of major depressive disorder needs a full physical health assessment, because depression can generate somatic symptoms that can mask actual physical disorders. Many medical conditions, including endocrinological, neurological, nutritional, and metabolic disorders, often present with classic symptoms of depression. 3 While physical health complications can arise in the elderly from antidepressant therapy, the physical assessment is not the rationale for this. Careful monitoring and evaluation addresses this issue, not a physical health assessment. 4 Depressed geriatric clients do not avoid addressing physical health and ignoring medical problems.

The nurse is caring for a client with major depressive disorder who is withdrawn, uncommunicative, and secludes self in room. Which nursing diagnosis should the nurse add to the plan of care? 1. Spiritual distress 2. Social isolation 3. Low self-esteem 4. Powerlessness

Answer: 2 Rationale: 1 The client's behaviors do not indicate spiritual distress. Spiritual distress behaviors include expresses anger toward God or a higher being/power, expresses lack of meaning in life or a sudden change in spiritual practices. 2 The client's withdrawn and uncommunicative behavior and secluding self in the room indicates social isolation. Other behaviors include seeks to be alone, dysfunctional interaction with others and discomfort in social situations. 3 The client's signs and symptoms do not indicate low self-esteem. Low self-esteem behaviors include feelings of helplessness, uselessness, guilt, and shame; hypersensitivity to slight or criticism; negative, pessimistic outlook; lack of eye contact; and self-negating verbalizations. 4 The client's behaviors do not indicate powerlessness. Behaviors for powerlessness are apathy, verbal expressions of having no control, and dependence on others to fulfill needs.

The nurse is caring for a client with a postpartum emotional disorder. Which postpartum disorder is correctly matched with its presenting symptoms? 1. Baby blues (lack of concentration, agitation, guilt, and an abnormal attitude toward bodily functions) 2. Moderate postpartum depression (irritability, loss of libido, sleep disturbances, expresses concern about inability to care for baby) 3. Maternity blues (overprotection of infant, severe guilt, depressed mood, lack of concentration) 4. Postpartum depression with psychotic features (transient depressed mood, decisive, abnormal fear of child abduction, suicidal ideations)

Answer: 2 Rationale: 1 The symptoms listed do not relate to the baby blues. The symptoms of the "baby blues" include worry, sadness, and fatigue after having a baby and usually subside within a week or two. 2 The symptoms listed are characteristic of moderate postpartum depression and include fatigue, irritability, loss of appetite, sleep disturbances, loss of libido, and expressions of great concern about her inability to care for her baby. 3 The symptoms listed do not relate to the maternity blues. Maternity blues, also called "baby blues" is characterized by worry, sadness, and fatigue after having a baby. These symptoms usually subside within a week or two. 4 The symptoms listed do not relate to postpartum depression with psychotic features. Postpartum depression with psychotic features is characterized by depressed mood, agitation, indecision, lack of concentration, guilt, an abnormal attitude toward bodily functions, a lack of interest in, or rejection of, the baby, or a morbid fear that the baby may be harmed. Delusions, hallucinations, suicide and infanticide are also possible.

The client experiences sadness and melancholia in September continuing through November. Which factors should a nurse identify as most likely to contribute to the etiology of these symptoms? (Select all that apply.) 1. Gender differences in social opportunities 2. Increased production of melatonin 3. Hyposecretion of cortisol 4. Less exposure to natural sunlight 5. Blockade of histamine reuptake

Answer: 2, 4, Rationale: 1 Gender differences in social opportunities are not likely to contribute to the client's sadness and melancholia for a client with seasonal affective disorder (SAD) or major depressive disorder, recurrent with seasonal pattern. 2 The nurse should identify increased production of melatonin as contributing to the etiology of the client's symptoms. The client is experiencing major depressive disorder, recurrent with seasonal pattern, commonly called seasonal affective disorder (SAD). 3 Hyposecretion of cortisol has not been linked to the etiology of the client's symptoms. In clients who are depressed, the normal system of hormonal inhibition fails, resulting in a hypersecretion of cortisol. 4 The nurse should identify less exposure to natural sunlight as contributing to the etiology of the client's symptoms. The client is experiencing major depressive disorder, recurrent with seasonal pattern, commonly called seasonal affective disorder (SAD). 5 Blockade of histamine is not likely to contribute to the etiology of the client's symptoms. One side effect of antidepressants includes blockade of histamine reuptake, resulting in sedation, weight gain, and hypotension.

The nurse is assisting with electroconvulsive therapy (ECT). What is the rationale for administering 100% oxygen to a client during and after ECT? 1. To prevent brain damage from the electrical impulse of the procedure 2. To prevent decreased blood pressure, pulse, and respiration owing to electrical stimulation 3. To prevent anoxia resulting from medication-induced paralysis of respiratory muscles 4. To prevent blocked airway, resulting from seizure activity

Answer: 3 Rationale: 1 Oxygen is not administered to prevent brain damage. There is no evidence that ECT causes brain damage. 2 Oxygen is not administered to prevent diminished vital signs. 3 The nurse administers 100 percent oxygen during and after ECT to prevent anoxia resulting from medication-induced paralysis of respiratory muscles. Because succinylcholine paralyzes respiratory muscles, the client is oxygenated with pure oxygen during and after the treatment, except for the brief interval of electrical stimulation, until spontaneous respirations return. 4 Pure oxygen is not administered to prevent a blocked airway. If the airway is blocked, oxygen is not helpful. The airway must be open for oxygen to be delivered to the lungs and tissues.

The client with major depressive episode is experiencing command hallucination for self-harm. Which intervention should be the nurse's priority at this time? 1. Obtaining an order for locked seclusion until client is no longer suicidal 2. Conducting 15-minute checks to ensure safety 3. Placing the client on one-to-one observation while continuing to monitor suicidal ideations 4. Encouraging client to express feelings related to suicide

Answer: 3 Rationale: 1 Obtaining an order for locked seclusion until client is no longer suicidal is not therapeutic for the client and is illegal. 2 Conducting 15-minute checks to ensure safety would not keep the client safe, especially for one who is having command hallucinations. 3 The nurse's priority intervention when a depressed client hears voices commanding self-harm is to place the client on one-to-one observation while continuing to monitor suicidal ideations. By providing one-to-one observation, the nurse will be able to interrupt any attempts at suicide. 4 While encouraging the client to express feelings related to suicide is important, it is not the priority because it does not keep the client safe.

A client is prescribed transdermal selegiline (Emsam) for depressive symptoms. Which action would the nurse take to administer this medication? 1. Apply new patch to the lower abdomen. 2. Apply new patch to inner surface of upper arm. 3. Place new patch on dry, intact skin. 4. Place direct heat to new patch for a tight seal.

Answer: 3 Rationale: 1 The patch is applied to the upper torso, upper thigh or outer surface of upper arm, not to the lower abdomen. 2 The patch is applied to the upper arm, outer surface, not the inner surface. 3 The patch is applied to dry, intact skin at approximately the same time each day. 4 Direct heat (e.g., heating pads, electric blankets, heat lamps, hot tub, or prolonged direct sunlight) is not applied to the application site.

The nurse discovers a client has a history of divorce, job loss, family estrangement, and cocaine abuse. Which theory explains the etiology of this client's depressive symptoms? 1. Psychoanalytic theory 2. Object loss theory 3. Learning theory 4. Cognitive theory

Answer: 3 Rationale: 1 The psychoanalytic theory does not explain the etiology of the client's depression. Psychoanalytical theory postulates that once the loss of a loved object had been 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. 2 The object-loss theory does not explain the etiology of the client's depression. The theory of object loss 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. 3 The nurse should assess that, according to learning theory, this client's depressive symptoms may have resulted from repeated failures. The learning theory is a model of "learned helplessness" in which multiple life failures cause the client to abandon future attempts to succeed and leads to depression. 4 The cognitive theory does not explain the etiology of the client's depression. Cognitive theory suggests that the primary disturbance in depression is cognitive rather than affective. Depression is a product of negative thinking.

The nurse is preparing a staff education session about depression in adolescents. Which statement by a staff member indicates teaching has been effective? 1. "Adolescents are not likely to suffer from depression." 2. "Depressed adolescents normally seek immediate treatment." 3. "Many symptoms are attributed to normal adjustments of adolescents." 4. "Suicide is not common among depressed adolescents."

Answer: 3 Rationale: 1 This statement would not indicate successful teaching because adolescents suffer from depression. 2 This statement would not indicate effective teaching since depressed adolescents may not immediately seek treatment. This may be attributed to signs and symptoms of depression perceived as the normal emotional stresses of growing up. 3 This statement would indicate effective teaching because many symptoms of depression may be attributed to normal adjustments of adolescents. 4 This statement would not indicate successful teaching because suicide is common among depressed adolescents. Suicide is the second-leading cause of death in the 15- to 24-year old age group.

The nurse assesses a client with major depressive disorder. Which assessment finding would the nurse observe? 1. Sadness subsides quickly 2. Promiscuous behaviors 3. Unable to feel any pleasure 4. Excessive spending sprees

Answer: 3 Rationale: 1 Transient depression is associated with sadness that subsides quickly. In major depressive disorder the sadness deepens. 2 Promiscuous behaviors are not associated with major depressive disorder; but is associated with mania. The DSM-5 criteria state that there must never have been a manic episode or a hypomanic episode to meet the criteria for the diagnosis of major depressive episode. 3 The client being unable to feel any pleasure meets the diagnosis requirements of major depressive disorder. 4 Excessive spending sprees do not occur with major depressive disorder but does occur with mania. Clients with major depressive disorder have no energy to experience excessive spending sprees.

The nurse is preparing an antidepressant medication for a 13-year-old client who is experiencing major depressive disorder. Which FDA-approved medication should the nurse administer? 1. Paroxetine (Paxil) 2. Sertraline (Zoloft) 3. Citalopram (Celexa) 4. Escitalopram (Lexapro)

Answer: 4 Rationale: 1 Paroxetine (Paxil) is not FDA approved to treat depression in adolescents. 2 Sertraline (Zoloft) is not FDA approved to treat depression in adolescents. 3 Citalopram (Celexa) is not FDA approved to treat depression in adolescents. 4 Escitalopram (Lexapro) was FDA approved in 2009 for treatment of major depression in adolescents aged 12 to 17 years. Fluoxetine (Prozac) has also been approved by the FDA to treat depression in children and adolescents. All antidepressants carry an FDA warning for increased risk of suicide in children and adolescents.

The nurse determines that a depressed client is using the cognitive distortion of "automatic thoughts." Which client statement is evidence of the "automatic thought" of discounting positives? 1. "It's all my fault for trusting him." 2. "I don't play games. I never win." 3. "She never visits, because she thinks I don't care." 4. "Growing plants is so easy. Any old fool can grow a rose."

Answer: 4 Rationale: 1 Stating, "It's all my fault for trusting him," is not an example of discounting positives. It is an example of personalizing. 2 Stating, "I don't play games. I never win," is not an example of discounting positives. It is an example of all or nothing. 3 Stating, "She never visits because she thinks I don't care," is not an example of discounting positives. It is an example of mind reading. 4 Stating, "Growing plants is so easy. Any old fool can grow a rose," is an example of discounting positives. Examples of automatic thoughts in depression include discounting positives; for example, "The other questions were so easy. Any dummy could have gotten them right."

A client is taking phenelzine (Nardil). Which statement by the client should cause the nurse to intervene? 1. "I cannot use over-the-counter medications for my colds." 2. "I have to cut out eating my raisin bran every morning." 3. "I will have to avoid pepperoni pizza when eating with my friends." 4. "I am taking diet pills to lose weight for my friend's wedding."

Answer: 4 Rationale: 1 The nurse would not have to intervene because this is a correct statement. The client cannot use over-the-counter medications for colds since this could cause a hypertensive crisis with the interaction between the phenelzine, a MAOI, and the cold medication. 2 The nurse would not have to intervene because this is a correct statement. The client cannot eat raisins, a high tyramine food, and take phenelzine, a MAOI, together as this could cause a hypertensive crisis. 3 The nurse would not have to intervene because this is a correct statement. The client cannot eat pepperoni pizza, a high tyramine food, and take phenelzine, a MAOI, together as this could cause a hypertensive crisis. 4 The nurse would have to intervene because this is an incorrect statement and needs to be corrected. The client cannot take diet pills and phenelzine, a MAOI, together because this could cause a life-threatening hypertensive crisis.

Which highest priority outcome would the nurse add to the plan of care for a depressed client? 1. The client will promise to remain safe. 2. The client will discuss feelings with staff and family by day three. 3. The client will establish a trusting relationship with the nurse. 4. The client will not harm self during hospital stay.

Answer: 4 Rationale: 1 While safety is important, this is not the highest priority. The outcome should be specific and measurable, not that the client will promise. 2 While speaking about feelings is important, this is not the highest priority. Safety is the highest priority. Additionally, the outcome should be realistic. Speaking to staff and family about feelings by day three is not realistic. 3 While a trusting relationship is important, it is not the highest priority. Additionally, the outcome should have a time frame. 4 The nurse's highest priority should be that the client will not harm self during the hospital stay. Client safety should always be the nurse's highest priority.

Prioritize the depressive disorders and their predominant affective symptoms from least to most severe (1-4). (Enter the number of each disorder in the proper sequence, using comma and space format, such as 1, 2, 3, 4.) 1. Dysthymic disorder (helplessness, powerlessness, pessimistic outlook, low self-esteem) 2. Uncomplicated grieving (feelings of anger, anxiety, guilt, helplessness) 3. Major depressive episode (total despair, worthlessness, flat affect, apathy) 4. Transient depression (sadness, dejection, feeling downhearted, having "the blues")

Answer: 4, 2, 1, 3 Rationale: Feedback: Symptoms of transient depression are not necessarily dysfunctional. Affective symptoms include sadness, dejection, feeling downhearted, having the "blues." Symptoms at the mild level of depression are identified by those associated with uncomplicated grieving. Affective symptoms include denial of feelings, anger, anxiety, guilt, helplessness, hopelessness, sadness, despondency. Dysthymic disorder, which is an example of moderate depression, represents a more problematic disturbance. Affective symptoms include feelings of sadness, dejection, helplessness, powerlessness, hopelessness; gloomy and pessimistic outlook; low self-esteem; difficulty experiencing pleasure in activities. Severe depression is characterized by an intensification of the symptoms described for moderate depression. Examples of severe depression include major depressive episode. Affective symptoms include 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. The correct sequence is as follows: 1. Transient depression (sadness, dejection, feeling downhearted, having "the blues") 2. Uncomplicated grieving (feelings of anger, anxiety, guilt, helplessness) 3. Dysthymic disorder (helplessness, powerlessness, pessimistic outlook, low self-esteem) 4. Major depressive episode (total despair, worthlessness, flat affect, apathy)

____________________ is a pervasive and sustained emotion that may have a major influence on a person's perception of the world.

Depressive disorders