Study Guide (NSG 150) Test 2 (unit 2)

2.1 Stress
1.1 know key terms in chapters
1.2 compare/contrast the biological , multi causal & psychosocial theories of physiological diseases
Biological- views physiologic disease as a result of malfunctions of the body's organs & cells.
Signs & symptoms are observable & quantifiable
does not explain the causes of all disease.
Multicausal- focus on the capability of every living organism to maintain its internal environment or homeostasis ( dynamic
state that is created by the feedback & regulation processes).
Three mast feedback systems in the body are:
Neurologic, endocrine, and immune systems.
Systems are capable of managing & responding to multiple incoming stimuli from internal & external
environments.
Psychosocial- emphasize the impact of stressful stimuli & the interaction of psychologic, physiologic, and social factors as
supportive factors in the adaptation process & as causative factors in the development of illness or disease.
Mental, spiritual & emotional response cause illness & disease
1.3 discuss the general adaptation syndrome according to Selye
stress- both as a response to noxious or stressful stimuli & as a stimulus that produces biologic, emotional, &
psychologic responses.
Distress (negative)- subjective response to internal or external stimuli that are threatening or perceived as
threatening to the self. Includes fatigue, pain, fear, and acute/chronic disease.
Eustress (positive)- nonspecific stress response that is associated w/ desirable events. Ex. Wedding, job promotion,
birth etc.
Psychologic stress- all processes, internal or external, that demand a cognitive appraisal of the event before a
response or the activation of any other system.
General adaptation syndrome- three stages of the individuals innate behavioral responses to any stress stimulus.
1. A brief alarm-fight-or-fight stage, which alerts the individual to the presence of stressful stimuli.
Reciprocal reaction b/t the autonomic nervous system, endocrine, and the immune system
release of hormone epinephrine from the sympathetic branch of the autonomic nervous system
places the person on alert
activation of the hypothalamic-pituitary-adernal axisresults in the release of cortisol
elevation of bp; tachycardia; constriction of blood vessels and the diversion of blood from
nonessential organs to the heart, brain, & skeletal muscles; increased blood sugar; dilated pupils;
increased muscle tone; increased alertness; and free-floating anxiety
fight or flight response
2. Resistance- body stabilizes & returns to normal homeostasis.
Stabilization
Hormonal levels return to normal
Parasympathetic nervous system activity
Adaptation to stressors
If the body does not adapt and the stressor continues to be prominent the individual enters the 3rd stage
3. Exhaustion- all the individual's resources are used & the individual is unable to adapt to the stressor.
Body becomes exhausted & Is unable to sustain the necessary changes that are activated during the
alarm stage.
Can manifest itself in the form of illness such as infections, headaches, hypertension, asthma attacks,
chronic fatigue syndrome, depression, anxiety disorders, & many other chronic conditions
increased physiological response as noted in the alarm reaction
decreased energy levels
decreased physiological adaptation

death
general inhibition syndrome (possum response)- person freezes or shuts down & is unable to respond
in any manner. Result of over-stimulation of the parasympathetic nervous system, & it is activated
automatically as a means of survival that has a paralyzing or numbing effect when a person is
facing a life-threatening event.

1.4 Identify the appraisal-transaction theory

Lazarus & Folkman stated that stress is a transaction process rather than an event
Process occurs as the person makes a cognitive appraisal of each stress encounter & assesses it's intensity as
either harmful, a threat of harm, or a challenge to overcome.
Secondary appraisal determines what the response will be, such as selecting the coping method to use to reduce
the effect of the stress.
Response depends on the individuals current & past experiences w/ stressors
timing of the event & person's use of coping skills also influence the response
problem-focused skills- strategies that help to resolve the stressful situation
emotion-focused coping responses- r/t to fear & anxiety frequently manifest as ego-defense mechanisms, such as
denial or repression.
Daily hassles- annoying or troublesome concerns, states of confusion or turmoil, & events that the person cannot
control.
1.5 rate yourself on the social adjustment scale
outlines 43 stressors that are each assigned a point value
add up the # of points of the life events that occurred to you within the past year
the greater the # of points the higher the probability of developing a physical illness.
Job stress is commonly cited as a cause for frustration & illness
death of spouse is ranked # 1 100 point value-----minor violations of the law ranked last11 point value
1.6 Describe PNIE on the development of diseases
Psychoneuroimmunoendocrinology- a new multidisciplinary approach to the study of the intricate mind-body
interactions among the neurologic system, the endocrine, & the immune system.
Examine the effect of perceived psychosocial stressors & the biopsychologic stress response on the development of
disease.
Provides a holistic framework for research & screening risk factors of health problems, lifestyle, & sociologic
factors.
A greater emphasis on health promotion across the life span, self-care management. & a holistic approach to the
management of acute & chronic psychosocial & physiologic health problems.
1.7 Define the role of coping mechanisms in response to stressful events
coping- use of resourcefulness & the ability to manage the stress of daily circumstances
conscious/unconscious adaptive/maladaptive
conscious mechanisms are sometimes learned unconscious mechanisms are often referred to as protective ego
defenses
adaptive conscious mechanisms-distractions such as reading, praying, meditating, using relaxation techniques, &
seeking social support.
Maladaptive conscious mechanisms- withdrawing from social contacts, changes in dietary habits, smoking, drug &
alcohol abuse, participating in other unhealthy behaviors & sudden outbursts of anger.
Unconscious ego defense mechanisms- repression, denial, rationalization, & regression. Often prevent the
individual from realistically appraising himself/herself, other people, or situations.
The goal is to use strategies that minimize unnecessary sources of stress & to promote effective adaptive responses.
People use these responses to protect their integrity. A response is often a temporary measure until the immediate
crisis is resolved or until the person is able to control the situation.
1.8 List examples of chronic diseases which have been linked to the mind-body response to stress
cardiovascular, stroke, respiratory, & renal disorders
cancer
diabetes, HIV/AIDS, RA, MS

schizophrenia, bipolar disorder

amputations, paralysis, blindness
migraines
allergies
lupus
hypertension
Asthma
symptoms such as pain, fatigue, nausea, anorexia, sleep disturbances, & the steady decline in the functioning
ability challenge coping skills.
Adaptation is a complex & continuous process of restructuring life around the chronic conditions
the uncertainty of the progress of chronic diseases often leads to depression, anger, & feelings of hopelessness &
helplessness.

1.9 Identify the 3 stages of the stress response according to Selye (discussed in detail in previous EO)
1. Alarm stage
2. resistance stage
3. exhaustion stage
1.10 Describe the locus of control & how perception determines response to stress
how individuals perceive the issues around them will determine how they will respond to untoward events
locus of control
can be measured along a continuum b/t internal & external control
includes ones thoughts, beliefs, behaviors, aptitudes, culture, & value system
those who demonstrate an internal locus of control view their capability to have personal success or failure as
having to do w/ their own efforts & their ability to complete a task.
Those who demonstrate an external locus of control view task completion as having to do w/ circumstances
beyond his/her control, such as luck & the influence of external forces (e.g, nature).
1.11 describe the differences b/t complementary/alternative medicine & traditional therapies
complementary/alternative medicine
encompasses a broad range of healing philosophies, approaches, therapies & their accompanying theories &
beliefs.
More than 1800 approaches to healing in this field
NCCAM classified this into 7 broad categories
alternative medicine systems
traditional Chinese medicine, including acupuncture
folk medicine
naturopathy
mind-body interventions
mediation
prayer
yoga
humor
exercise
hypnosis
pharmacologic & biologic-based therapies
vaccines & medicines not yet approved by mainstream medicine (animal cartilage, chelating chemicals)
herbal medications
Chinese herbals
American herbals
European herbals
diet, nutrition, supplements, & lifestyle changes
vitamins, minerals , supplements
vegetarian diets
ethnic-based diets
manipulative & body-based methods

chiropractic
acupressure
therapeutic touch
energy therapies
biofeedback
light therapy
bone-growth stimulation

Allopathic medicine ( traditional, or conventional, biomedical model)

major focus is on disease rather than the p/t as a whole person
biomedical model is based primarily on the following assumptions
the scientific method identifies the cause of a disease, & providers implement curative treatments to correct
abnormal physiology
the germ theory defines infections
the prevention of disease is based on proper hygiene, public sanitation, & personal life style choices
disease is usually tangible & measurable
illness- highly individual & personal response that is exhibited as pain, suffering or distress.
1.12 describe mind-body interventions, pharmacologic, biological, & alternative medical practices
mind-body interventions
mediation- lowers heart-rate, bp rates, serum levels of adrenal corticosteroids. Increases immunity to disease, a
sense of calmness, peace, & mental alternatives.
Biofeedback, visual imagery, yoga
select a special time & place
assume a comfortable position
deep breathing exercise
focus attention on chosen mental image
Prayer- communication w/ God or a superior being
silent or spoken
conversational or formal
mindfulness-based therapy-paying attention to ones own inner experience by quieting the mind & investigation the
mind through personal experiences & asking questions such as who am I?
one learns how to balance physical, mental , & spiritual health by using all the senses
the goal is not to change the thoughts but to allow an awareness to emerge by paying attention only to the
present moment & being nonjudgmental about all thoughts that pass through the mind.
Use of the arts- music, dance, drama, literature, humor, & art.
Humor- relieves tensions & anxiety, expressing emotions, coping w/ painful or unpleasant situations.
Exercise
animal-assisted therapy
hypnosis
Pharmacolgoic & biological
a variety of drugs & vaccines that are not yet included in the mainstream medicine.
Some stimulate the immune system to ward off disease & consist of older herbal remedies; all are considered
nontoxic.
Shark & other animal cartilage that is used to treat AIDS, cancer, & arthritis
Alternative medical practices
acupuncture
ayurvedic
homeopathic
naturopathic
traditional Chinese medicines
environmental medicines
anthroposophically extended medicine
1.13 describe the negative side to alternative therapies

lack of guidelines to ensure the purity & dosage accuracy of herbal remedies & supplements
many methods are not tested
potential interactions may occur w/the concurrent use of herbal treatments & other drugs w/ prescribed meds

1.14 list some of the more common food/herbal/drug interactions (box 27-5 Pg 635)
Gingko-interferes w/ blood clotting
calcium carbonate- interferes w/ thyroid hormones
Grapefruit juice should be avoided with so many drugs, should advise not to use
St. Johns wort can cause central serotonin syndrome if used w/ SSRIs, also many drug interactions
many fortified foods (calcium fortified orange juice, breakfast cereals) have high calcium & other minerals that
bind w/ antibiotics & prevent drugs from being absorbed
2.2 Anxiety disorder
1.1 define key terms
1.2 describe & contrast the 4 levels of anxiety as described by Peplau
1. Mild
Physiologic: vital signs normal; minimal muscle tension; pupils normal & constricted
Cognitive/Perceptual: Perceptual field is broad; awareness of multiple environmental & internal stimuli;
thoughts are often random but controlled
Emotional/Behavioral: Feelings of relative comfort & safety; relaxed & calm; performance automatic; habitual
behaviors occur
functioning people operate in this range.
Facilitates learning, creativity, & personal growth. (ex. Nursing students as they strive to excel in their work)
2. Moderate
Physiologic: vital signs normal or slightly elevated; tension experienced; p/t is uncomfortable or experiences
pleasure (labeled as tense or excited)
Cognitive/Perceptual: Alert: perception narrowed & focused; optimum state for problem solving & learning;
attentive
Emotional/Behavioral: feelings of readiness & challenges energized; engages in competitive activity & learns
new skills; voice & facial expression interested or concerned.
Adaptive mechanism to cope w/ pleasant or unpleasant situation.(ex. Nursing student who
is giving an important oral presentation)
moderate or severe anxiety are either acute or chronic
3. Severe
fight-or-flight response; ANS excessively stimulated (vital signs increased, diaphoresis, urinary urgency &
frequency all increase, diarrhea present, dry mouth, appetite decreased, pupils dilated); muscles rigid & tense;
senses affected hearing decreased; pain sensation decreased
Cognitive/Perceptual: perceptual field greatly narrowed; problem solving difficult; selective attention (focuses
on 1 detail); selective inattention (blocks out threatening stimuli); distortion of time (things seem faster/slower
than they actually are); dissociative tendencies; detachment; vigilambulism(automatic behavior)
Emotional/Behavioral: feels threatened & startles w/ new stimuli; feels on overload;activity
increases/decreases (may pace, run away, wring hands, moan, shake, stutter, become very disorganized or
withdrawn, freezes in position, or be unable to move); appears & feels depressed; demonstrates denial;
complains of aches or pains; is agitated or irritable; need for space increases; eyes move around room or gaze
is fixed; some p/ts close eyes to shut out the environment.
P/t focuses energy primarily on reducing the pain & discomfort of anxiety rather than on coping w/ the
environment.
Often requires help to reverse the situation.
4. Panic

Physiologic: above symptoms increase until SNS release occurs; person becomes pale; Bp decreases;
hypotension occurs; muscle coordination poor; pain & hearing sensations minimal
Cognitive/Perceptual: perception totally scattered or closed; unable to take in stimuli; problem solving &
logical thinking highly improbable; perception or unreality about self, environment, or event; dissociation
often occurs

Emotional/Behavioral: feels helpless, w/ a total loss of control; p/t is angry or terrified becomes combative or
totally withdrawn, cries or runs away; completely disorganized; behavior is usually extremely active or
inactive.

1.4 Discuss the etiology of anxiety disorders using the biological, psychodynamic & behavioral models.
Biological Model
Darwin postulated that emotional expression & anatomic structures both changed during the course of evolution to
enable the species to adapt to its environment.
Linked the endocrine system w/ emotions, first by establishing the relationship of the adrenal medulla in the
production of epinephrine, which results in the fight-flight response.
Amygdala & the hippocampus relate to the fear response. Changes in size & function when an individual is
experiencing symptoms seen w/ anxiety disorders such as PTSD, social phobia, & generalized anxiety disorder
(GAD).
Amygdala is involved in the fight-or-flight response, some hypothesized that different anxiety disorders affect
different parts of the amygdala.
Chronic stress possibly causes changes in the amygdala, hippocampus, & the pre-frontal cortex.
Genetics play a role. When performing functional MRI researchers found that some of the research subjects had
one or two copies of a short variant of the human serotonin transporter gene as apposed to the long variant of this
same gene.
They found that adults w/ one long gene and one short gene tended to be more anxious than those w/ two copies of
the long gene.
Psychodynamic Model
in psychoanalytic terms, anxiety is a warning to the ego that it is in danger from either an internal or external
threat.
Anxiety is involved in the development of personality & personality functioning & in the development & treatment
of neuroses & psychoses.
3 types
reality anxiety
a painful emotional experience that results from the perception of danger in the external world, such as the
fear of the possibility of a terrorist attack.
Moral anxiety
the ego's experience of guilt or shame. (ex. Of moral anxiety is experiencing guilt for expressing anger at
a family member)
Neurotic anxiety
The perception for a threat according to one's instincts. Neurotic symptoms develop in an attempt to
defend against anxiety, including somatic symptoms, obsessions, compulsions, & phobias.
Behavioral Model
Clinicians who believed that the psychoanalytic model & methods were lacking designed behavioral models in
psychiatry & psychology.
They identified experimental psychology as a resource for ideas from which to develop new treatments.
The etiology of anxiety symptoms is a generalization from an earlier traumatic experience to a benign setting or
objects. (ex. Awkward child whose parents ridiculed him while he was bowling. As a result, he associates
embarrassment & shame w/ sports events in indoor facilities & develops panic attacks during BB games).
Anxiety occurs when an individual encounters a signal that predicts a painful or feared event.
Joseph Wolpe systematic desensitization is a method that comes from the learning theory. The therapist
exposes a deeply relaxed p/t to a graded hierarchy of phobic stimuli. Others have redefined this method further into
in vivo desensitization, whereby the therapist exposes the individual progressively to more anxiety provoking
situations.
Systematic desensitization works for people who have agoraphobia (overwhelming fear of places)
1.5 Discuss the etiology of somatoform, factitious, & dissociative disorders using the biological behavioral, & cognitive
theories.
Somatoform disorders: include a group of disorders that convert anxiety into physical symptoms for which there is no
identifiable physical dx.
complex interactions b/t mind & body, w/ serious impairment in the person's social & occupational functioning.
Biological theory: changes in the structure & function of the brain caused by prolonged stress or trauma can result
in somatoform disorders by altering the individual's perceptions & interpretations of bodily functions.

Behavioral theory: believe that some individuals learn to use somatic symptoms to communicate helplessness & to
manipulate others.
Alexithymia- the inability of an individual to describe his/her feelings in words. Tend to express feelings w/
somatic concerns.
Ex. a woman who is angry w/ her boss. Instead of being able to discuss her angry feelings w/ her friend, she
reports stomach pain & frequently calls in sick to work.
Cognitive theory: p/ts w/ somatic symptoms misinterpret the meaning of body functions & sensations & become
overly alarmed by them.
Somatization disorder- formerly called hysteria & briquet syndrome.
Symptoms must begin before the p/t is 30 yrs old & not be adequately explained by any general medical
disorder or the direct effects of a substance.
Symptoms have a distinct pattern that differs from general medical conditions in the following 3 criteria:
there is involvement of multiple organ system (gastrointestinal, reproductive, neurologic)
the symptoms exhibit an early onset & a chronic course w/o the development of physical signs or
structural abnormalities
the clinical laboratory abnormalities that are commonly associate w/ general medical conditions are
absent.
Pain Disorder: pain in one or more anatomic sites. Associated w/ psychologic factors.
Conversion Disorder: exhibit one or more symptoms that affect voluntary motor or sensory function. Not
intentionally produced. 3 defining characteristics:
psychologic factors are identified as being r/t to the onset or exacerbation if the symptoms
specific & identifiable conflicts or stressors precede the development of the conversion symptoms
the person demonstrates an obvious lack of concern about the seriousness of the symptoms, which is
inconsistent w/ the problem
this lack of concern is called la belle indifference or beautiful indifference
Hypochondriasis: six major criteria
first, individual focuses on fears of having or the idea of having serious medical disorder on the basis of
his/her misinterpretation of bodily symptoms.
Second, this misinterpretation of symptoms persists despite appropriate medical evaluation & reassurance.
Third, the individuals preoccupation w/ symptoms is not as intense or distorted as it would be w/ a delusional
disorder nor is it as restricted as it would be with BDD.
Fourth, preoccupation causes clinically significant distress or impairment in social, occupational ,or other
major areas of functioning.
Fifth, duration of the disturbance must be at least 6 months
sixth, is that hypochondriasis is not caused by another anxiety disorder, somatoform disorder, or major
depressive episode
Body dysmorphic disorder: occurs when a p/t is preoccupied w/ self-perceived defect in appearance. Causes
distress or impairment in social or occupational functioning, & is not the result of another mental disorder.
ex. of symptoms include excessive grooming, checking in the mirror, skin picking, & multiple cosmetic
surgeries to fix the deficit.

Factitious disorder:
intentionally produce physical or psychologic sings & symptoms to assume the sick role.
Individual performs this behavior for economic gain, to avoid school or legal responsibility, or to improve his/her
physical well-being.
Unconscious aspect to the p/t's behavior & thought pattern.
May also have a personality disorder. Their relationships are often disturbed, few attachments, some delusions or
grandiosity as well as some thought distortions.
Dissociative Disorders
dissociative amnesia: one or more episodes of inability to recall important personal info that is usually of a
traumatic or stressful nature, & the loss of memory is too extensive for ordinary forgetting to explain.
Dissociative Fugue: sudden & unexpected travel away from home or ones customary place of work w/ an inability
to recall one's past or where one has been.
Dissociative identity disorder: criteria for this disorder
first criterion is that the individual must demonstrate two or more distinct identities or personality states, each
w/ its own relatively enduring pattern of perceiving, relation to, & thinking about the environment & the self.

Second, at least two of these personality states recurrently take control of the person's behavior. The individual
is unable to recall important personal info to a degree that is too extensive for ordinary forgetting to explain.
Depresonalization disorder: persistent or recurrent episodes of feelings of detachment or estrangement from one's
self. Sensations of being outside of one's body or mental processes or being an observer of ones body often occur.

1.6 Describe cultural variations in the dx of anxiety disorders, samatoform, factitious, & dissociative disorders.
Symptoms that define disorders are representative of U.S culture.
Establish cultural norms when evaluating p/ts for anxiety & r/t disorders.
Some cultures restrict womans participation in public activities, thus, agoraphobia is less commonly diagnosed.
Many cultures have rituals to mark important events in peoples lives. The observation of these rituals is not
indicative of OCD unless it exceeds norms for that culture.
W/ the exception of OCD & social phobia, anxiety r/t disorders exhibit a higher prevalence among women than
men. This represents a cultural variation.
1.7 & 1.8 & 1.9 Assess the p/t w/ a dx of anxiety, somatoform, factitious, or dissociative disorders
it is important for all nurses to identify dysfunctional manifestations of anxiety so that treatment can be
implemented promptly.
Nurses are the first HCP to come in contact with p/t's who are experiencing their first symptoms of panic disorders.
The p/t w/ agoraphobia sometimes comes to the attention of a nurse when the nurse is preparing a p/t for diagnostic
testing that includes a CT or MRI.
Most often p/ts w/ anxiety symptoms do not present w/ anxiety as their primary reason for seeking treatment.
Nurses who use an assessment tool that addresses each identified human response pattern will obtain cues from the
p/t who is experiencing anxiety that indicate further assessment.
thoroughly assess each p/t w/o considering the possibility that the p/t is feigning the physical symptoms.
Understand the possible anxiety precipitants of the somatic concerns will help the p/t to reduce his/her focus on the
physical sensations.
Diagnosis
nurse relies on info that is obtained during the assessment process.
Nurse identifies defining characteristics of the target dx from the p/t & together the nurse & p/t jointly identify
etiologic factors.
Etiologic factors influence the selection of the appropriate interventions.
Risk for suicide; anxiety; death anxiety; hopelessness: chronic pain (191+211)
Outcome Identification
somatization disorder: p/t will
construct an exercise program that includes anxiety reducing techniques
address 2 positive somatic responses (e.g, massage therapy, the satisfied feeling after a successful exercise
session.)
keep a journal to document somatic preoccupation & stressors, including intrusive thoughts & concerns
help the therapist to coordinate the info from the primary care provider & any other involved specialists.
Take meds as prescribed & be able to identify the rationales for the meds
contact the therapist for more frequent visits if somatization increases.
Dissociative identity disorder
: p/t will
alert the therapist or use a hotline such as or 1-800-273-TALK when feeling suicidal
respond to his/her name when addressed by a member of the treatment team
refer to himself/herself in the first-person pronoun form (e.g., I think)
identify periods of increasing anxiety
inform others about dissatisfaction in a nonthreatening manner
use assertive-response behaviors to meet his/her needs
keep a written journal to identify stressors & when the dissociation occurs.
Generalized anxiety disorder: p/t will
demonstrate a significant decrease in physiologic, cognitive behavioral, & emotional symptoms of anxiety.
Demonstrate the use of mindfulness meditation when experiencing symptoms of heightened anxiety
(concentrate on body; pay attention to the act of breathing; observe the act of breathing; meditation
discourages, p/t agrees to deal w/ the subject of the intrusive thought at a later time; p/t feels in control of
his/her body)

OCD: p/t will

participate actively in learned strategies to manage anxiety & to decrease OCD behaviors.
Demonstrate the ability to cope effectively when thoughts or rituals are interrupted.
PSTD: p/t will
demonstrate concern for personal safety by beginning to verbalize worries.
Assume a decision making role for his/her own health care needs

Planning
complex & varied
p/ts w/ severe BBD often require hospitalization to prevent a suicidal occurrence.
Treated in an outpatient setting, often w/ the use of different modalities, including individual psychotherapy, group
therapy, family therapy, art therapy.
Nurses provide p/ts & families w/ information about treatment alternatives, & they also provide comprehensive
discharge planning.
Implementation (interventions)
identify the degree of suicidal ideation & depression in p/ts w/ all types of anxiety & associated disorders.
Monitor your own level of anxiety, & make a conscious effort to remain calm. Anxiety is readily transferable from
one person to another. Individuals w/ somatoform illnesses have high risk.
Recognize that the p/ts use of relief behaviors focuses on somatic sensations as indicators of anxiety
more on pg 213
anxiety-reducing strategies include progressive relaxation techniques; mindfulness mediation
; slow deep- breathing exercises; focusing on a single object in the room; listening to soothing music or relaxation
tapes; visual imagery or nature r/t DVDs; exercise
Evaluation
if p/t does not make satisfactory progress, the nurse modifies either the expected outcomes or the interventions.
Examines all factors that relate to the outcomes.
Somatoform disorders & the dissociative disorders are chronic & enduring. It takes patience & support for the p/t
to determine the pattern of his/her behavior & to incorporate methods to initiate change.
1.10 describe the drugs used to treat anxiety disorders by classification. Take into account actions, special considerations,
side effects, & nursing interventions for the following med groups:
Generalized anxiety disorder:
excessive worry, poor concentration, insomnia, & an unidentifiable cause characterize anxiety disorder.
Symptoms last more than 6 months
treatment drugs used are:
Benzodiazepines:
clonazepam(Klonopin) longer acting, lorazepam (ativan), & alprazolam (xanax) treat GAD
rapid onset (1 week or less)
disadvantages cognitive impairment, decreases coordination, potential drug abuse, & withdrawal
symptoms
Antidepressants:
2nd generation antidepressants have proven to be effective for treatment of anxiety disorders.
Venlafaxine more rapid onset than other other antidepressants treats GAD
advantages: effective for p/ts w/ co-occurring disorders such as major depression or other anxiety
disorders; lower potential for drug dependence & abuse.
Disadvantage: longer onset of peak action compared to benzodiazepines (4 weeks vs 1); less efficacy for
the treatment of the physical or somatic symptoms of anxiety.
Adverse effects of SSRIs & venlafaxine include GI upset, insomnia, irritability, headache, & sexual
dysfunction.
Buspirone:
not effective for panic disorders
disadvantage: longer onset (2-4 weeks).
Initial therapy includes the addition of benzopdiazepines until the p/t sees the effect of buspirone.
OCD:
presence of either obsessions (persistent & recurrent thoughts, images, impulses & behaviors that are distressing to
the individual & that impair daily function), compulsions (repetitive behaviors that the person feels driven to
perform in response to an obsession ex. Repeated hand washing, checking), or both.

obsessive thoughts are part of their own thoughts as opposed to coming from somewhere else as occurs with
thought insertion, which may be present w/ schizophrenia.
The behaviors or thoughts are an attempt to prevent or reduce the distress invoked by the obsession or to prevent
some dreaded threatening situation from occurring.
Treatment drugs are:
Antidepressants: SSRIs & clomipramine
choice of a particular SSRI depends on side effects, patient tolerance, & potential drug interactions.
Drug interactions occur w/ clozapine, TCAs. & theophylline; a reduction in the dose of these drugs is
recommended.
Tricyclic Antidepressants Desipramine & imipramine are not. Clomipramine has the usual side-effect
profile of the TCAs including sedation, anticholinergic side effects, orthostatic hypotension, sexual
dysfunction & seizure risk. TCAs are second line therapy.
Augmentation therapy cognitive behavioral therapy nonpharmacologic intervention for OCD. Other
augmentation therapies include the use of:
1. dopamine-blocking agents
2. buspirone(limit grapefruit juice 8oz daily or grapefruit b/c of drug food interaction leading to
toxicity).
3. Lithium
4. clonazepam

PSTD:
Pattern of response after a traumatic event. Person must have experienced or witnessed a traumatic event that
included a feeling of being threatened w/ death or severe injury.
Responses include intense fear, helplessness, or horror. Person experiences the traumatic event by having recurrent
& intrusive disturbing recollections of the trauma like thoughts, images or perceptions about the incident.
Evidence of avoidance & numbing:
efforts to avoid thoughts, feelings or conversation about the trauma
efforts to avoid persons or places that evoke memories of the trauma
inability to remember an important aspect of the trauma (repression)
diminished interest or participation in significant activities
a feeling of estrangement or detachment from others
restricted range of affect
a sense of impending doom
increased arousal is common- sleep disturbances, irritability or angry outburst, difficulty concentrating,
hypervigilance & an exaggerated startle response.
Treatment drugs:
Antidepressants: SSRIs; TCAs & MAOIs not used b/c of their side-effect profile, & potential drug & food
interactions.
Benzopdiazepines: Clonazepam (effective to reduce flashbacks & nightmares). Problem is tolerance &
dependence. Risk for p/t w/ alcohol abuse b/c of additive depressant effects.
Mood stabilizers: Lithium, divalproex, & carbamazpine are adjunct therapies for explosiveness, irritability, &
other symptoms that are associated w/ PTSD.
Social Phobia:
individual experiences an overwhelming fear of being in a social situation or having to interact w/ many people at
once.
They have a great concern that people are criticizing him/her, & he/she worries about acting in a manner that will
be humiliating or embarrassing.
Avoid situations or endure them in intense anxiety & fear
have difficulty in a group so group therapy might not be the best option
treatment individual attention and meds such as SSRIs (Paxil)
treatment drugs:
antidepressants SSRIs (paroxetine, fluoxetine, fluoxamine, sertraline, & citalopram)
onset (4 weeks) , optimal effects seen after 8-12 weeks.
Benzodiazepines Clonazepam (Klonopin) & alprazolam (xanax)
Gabapentin 900-3600 mg/day. Side effects include sedation, dizziness, dry mouth
Herbal therapy for anxiety
Kava Kava (piper methysticum) herb that has anxiolytic & sedative properties.

Recommended does 100-125mg dried kava kava root extract 3x/daily

Side effects: associated hepatitis, cirrhosis, & liver failure. Altered judgment, altered motor reflexes, GI upset,
skin rash, & visual disturbances.
Herb-Drug interactions: barbiturates, benzodiazepines, dopamine agonists, alcohol, & MAOIs.
Valerian (valeriana officinalis) has anxiolytic & hypnotic properties.
Treats mild-moderate insomnia as well as for restlessness & tension.
Dose for anxiety relief is 220mg 3x/daily
side effects: hepatotoxicity w/ the long term use of valerian. Sedation & withdrawal symptoms that are similar
to those associated w/ the benzodiazepines
Beta Blockers
Beta-blockers are drugs that bind to beta-adrenoceptors and thereby block the binding of norepinephrine and
epinephrine to these receptors.
This inhibits normal sympathetic effects that act through these receptors. Therefore, beta-blockers are
sympatholytic drugs.
Beta-blockers, (beta-adrenergic antagonists), such as propranolol, atenolol and pindolol, often rapidly reduce
anxiety in panic disorder, GAD and social and specific phobias.
Beta-blockers may be useful in the treatment of anxiety in patients with pronounced cardiac symptoms or tremor,
as the attenuation of physical symptoms has a calming effect in some patients.
Beta-blockers have a rapid onset of clinical effect and can be taken either as a single dose or on a regular basis
beta-blockers may increase peristalsis in the gastrointestinal tract, thereby exaggerating rather than diminishing the
effects of anxiety on this system.
At high dosages, beta-blockers that can cross the bloodbrain barrier (eg propranolol) may cause tiredness, vivid
dreams, depression and, rarely, delirium.
Antihistamines
often sedating and so are sometimes used for the treatment of anxiety disorders; the sedation has a quick onset, and
rapid relief from anxiety symptoms is observed.
Histamine is a neurotransmitter that plays an important role in arousal.
Antihistamines induce drowsiness, sedation and, in high dosages, impair psychomotor performance of complex
tasks
side effects: disturbed co-ordination, weakness, inability to concentrate, urinary frequency, palpitations and
hypotension.
Their anticholinergic properties make them poor choices for patients taking other anticholinergic agents, such as
TCAs, neuroleptics and anti-arrhythmic agents.
no abuse potential, they have an immediate effect in relieving acute anxiety symptom

Summary:
serotonergic antidepressants, particularly the SSRIs & venlafaxine are a better choice for treatment of anxiety
disorders. The SSRIs & venlafaxine have better safety profiles & do not involve the risk of substance abuse,
tolerance, & dependence that are associated w/ the benzodiazepines. However, they have slow onset of action.
Benzodiazepines are still widely prescribed b/c of their rapid onset of action & lack of associated sexual
dysfunction.
1.11 Discuss non-pharmacologic treatments
cognitive behavioral therapy
treat p/ts w/ somatoform disorders & dissociative disorders
p/t's ability to understand that physical symptoms are a response to thoughts or feelings about behaviors that occur
in daily life (important for success of treatment)
target symptoms & then examine the circumstances associated w/ the symptoms.
Change either the cognitions (thoughts) or the behaviors.
Short-term treatment that demands active participation on both the p/t & the therapist.
Rational emotive therapy
people's beliefs strongly affected their emotional functioning. In particular certain irrational beliefs made people
feel depressed, anxious or angry and led to self-defeating behaviors
With an emphasis on the present, individuals are taught how to examine and challenge their unhelpful thinking
which creates unhealthy emotions and self-defeating/self-sabotaging behaviors.
assist individuals in coping with and overcoming adversity as well as achieving goals

places a good deal of its focus on the present.

REBT addresses attitudes, unhealthy emotions (e.g., unhealthy anger, depression, anxiety, guilt, etc.) and
maladaptive behaviors (e.g., procrastination, addictive behaviors, aggression, unhealthy eating, sleep disturbance,
etc.) that can negatively impact life satisfaction.

2.3- Sleep Disorders

1.1 Identify and define key terms
1.2- define the sleep-wake regulation and the role of melatonin
Circadian Rhythm- Body's internal biologic clock
located in hypothalamus
adjust sleep-wake intervals to a cyclic 24-hr pattern because of its sensitivity to the external cues of light and
darkness.
Events that can disrupt this biologic clock
E.g., Shift work, travel over several time zones, etc.
Neurotransmitters
No specific sleep neurotransmitter
Adenosine, acetylcholine, and melatonin have a sleep promoting function
serotonin, hypocretin, and norepinephrine most likely maintain arousal/wakefulness
Melatonin
a chemical mediator that promotes sleep from the pineal gland
Neurosensory stimulation of the photoreceptors in the retina by light suppresses the release of melatonin.
Darkness stimulates its release
1.3 Compare and contrast primary and secondary sleep disorder
Primary sleep disorders (biologic disturbances)
Dyssomnias- occur as a result of abnormalities of the physiologic mechanisms that regulate sleep and wakefulness.
Abnormalities in amount, quality, or timing of sleep.
Insomnia- difficulty initiating or maintaining sleep or of experiencing nonresotrative sleep for a least 1 month.
Narcolepsy- sudden onset of brief sleep attacks that last 10-20 min. & typically take place 2-6x/day. They fall
asleep while engaging in meaningful activities such as driving a car, eating, or interacting w/ people. Not
common in children; generally initially recognized during puberty/adolescence.
Cataplexy- a common sign of Narcolepsy. Sudden loss of muscle tone & voluntary muscle movement.
Strong emotional experiences such as laughing or crying may cause this reaction.
Sleep paralysis- also reported in people w/ narcolepsy. Not able to speak or move just before the onset of
or upon awakening from a brief sleep attack. Some report hallucinations & experience vivid sensory
perceptual experiences either upon wakening (hypnopompic hallucinations) or when entering the brief
sleep episode (hypnagogic hallucinations).
Breathing-related sleep disorders-result from a sleep-related breathing condition such as obstructive or central
sleep apnea syndrome or central alveolar hypoventilation
obstructive sleep apnea- typically have some degree of narrowing or the complete obstruction of the upper
airway. Results in loud snoring and regular apneic periods during sleep that last for 10-30 sec. (sleep
apnea- absence of breathing)
Risk factor obesity & large neck circumference
Circadian Rhythm sleep disorder- sleep pattern disturbances w/ a persistent or recurrent pattern of sleep
disruption that result from a difference in an imposed sleep wake cycle & the individual's own circadian sleepwake pattern requirements.
Result from a delayed sleep phase, jet lag, shift work, or an unspecified source.
Parasomnias- occur as a result of the activation of physiologic systems at incorrect times during the sleep wake cycle,
thereby resulting in abnormal behavior or physiologic events during the sleep state. Abnormal behavior or events occurring
in association w/ sleep. More common among children.
Nightmare disorder takes place during the REM period late in the sleep cycle.
Fragmented sleep

frighting dreams that threaten their survival, security, or self-esteem.

Able to recall the nightmares in vivid details
Sleep terror disorder- experience of arousal during NREM sleep.
Awakening during the early part of the night due to extreme anxiety or panic.
Crying, screaming, and may appear disoriented
unable to recall the event
Sleepwalking disorder- (somnambulism)
engagement in walking, dressing, toileting, and driving while they are in a deep NREM stage of sleep.
Appears to be in a trance, and arousal is difficult.
Sometimes they wake up while performing complex tasks, but most frequently returns to sleep.
Unable to recall events that took place during the sleepwalking episode
Parasomnia not otherwise specified / due to General Medical Condition or substance use

Secondary sleep disorders (often result from a variety of psychiatric illness or medical conditions)
mood disorders
effects of substances- alcohol, stimulants (caffeine), amphetamines, cocaine, sedatives (opiates, hypnotics &
antianxiety meds)
general medical conditions (endocrine)
1.4 Identify the role of biochemical alterations in neurotransmitters as they relate to the sleep-wake cycle
Biochemical alterations in neurotransmitters such as serotonin, melatonin, neorepinephrine, and dopamine may play a major
role in the deregulation of sleep and wakefulness.
An inherent physiologic imbalance of these chemical mediators increases an individuals change of developing a
sleep pattern disturbance.
Narcolepsy results from a deficiency of hypocretin, a neurotransmitter that is produced by the hypothalamus.
1.5 List psychiatric/medical conditions associated w/ secondary sleep disorders
depression
dysthymia
mania
generalized anxiety disorder
substance use/abuse/discontinuance
chronic pain
endocrine disorder
1.6 Assess the patient with a sleep pattern disturbance
Obtain both subjective data from the affected individual & his/her bed partner
obtain comprehensive, objective and quantifiable data
Assess # of hrs of sleep per night
Time of day/night that the p/t goes to bed or falls asleep
any recent changes in established sleep patterns & routinesif changes reportedassess inhibiting/enhancing
factors
regularityregular/irregular
night time awakenings (describe)
napping (describe)
use of sleep aids or substances that disrupt sleep (e.g, stimulants, antidepressants, sleep meds, alcohol)
present stressors & those from recent or remote past
objective data from the bed partner (e.g, snoring, apneic periods) or from parents (e.g, sleepwalking, nightmares)
1.7 formulate a nursing dx & develop, implement, & evaluate a plan of care for the p/t w/ a sleep disorder
Nursing diagnosis
sleep deprivation
readiness for enhanced sleep
insomnia

 ineffective breathing pattern

anxiety
fatigue
ineffective coping
ineffective role performance
risk for injury
impaired spontaneous ventilation
Planning
requires the active participation of the p/t w/ the members of the multidisciplinary health care team
comprehensive & includes relevant biologic, psychosocial, & cognitive treatment modalities.
Implementation
most p/t's w/ sleep pattern disturbances present in the community practice setting unless the sleep disturbance is a
co-occurring problem that is associated w/ a psychiatric condition or medical disorder. In the latter instance, the p/t
often presents in the acute care setting.
Interventions: according to p/t's needs. From most urgent to least urgent. (p. 447)
Assessment
Monitoring of sleep patterns and risk factors
Education regarding precursors
Teaching new coping skills
Medication compliance
Life-style changes (use of substances that impact sleep disorders)
Referral to a specialist when indicated
Evaluation
psychiatric nurse & the members of the health care teamincluding the p/tneed to participate in both formal &
informal evaluation processes
1.8 Identify pharmacological & non-pharmacological interventions
Pharmacological:
Insomnia Benzodiazepine and non-benzodiazepines - for short term use only (2 weeks) to prevent tolerance & withdrawal
symptoms
OTC antihistamines
Antidepressants when co-occurring mood disorders
Narcolepsy and Hypersomnia CNS stimulant Modafinil (provigil)
CNS stimulants such as Dexedrine, Concerta, Ritalin (not usually the first choice)
Tricyclic Antidepressants or SSRIs (Wellbutrin)
Obstructive sleep apnea SSRIs & tricyclic antidepressants b/c reduce REM sleep when apnea is most likely to take place.
Parasomnias agents that suppress the REM sleep; tricyclic or benzodiazepine hypnotic drugs
Non-pharmacological
cognitive reframing
behavioral modification
sleep practices/sleep hygiene
CPAP for apnea
light therapy for regulating circadian rhythms
exposure to sunlight
establishment of a sleep wake-cycle
2.4 Mood disorders (part 1)
1.2 Distinguish b/t unipolar & bipolar disorder
Unipolar mood disorders

p/ts who usually have only depressive episodes or, rarely, only manic episodes.
Bipolar disorders
occur when people experience periods of depression that alternate w/ periods of elevated mood, impulsivity, &
hyperactivity, which is known as mania.

1.3 Define theories about the etiology of mood disorders including biological (neurotransmission, neuroendocrine
dysregulation, & genetics) & psychosocial factors (psychodynamic, cognitive, hopelessness, stress, & adjustments).
Biologic theories:
Neutrotransmission:
brain neurotransmitter functioning affects mood regulation & controls a wide range of behaviors & functions,
including appetite, arousal, sleep, cognition, & movement.
Norepinephrine & serotonin, their metabolites, & their receptors as somehow being altered during episodes of
depression & mania.
Less-than-normal neurotransmission activity during depression & more-than-normal neurotransmission
activity during mania.
Recent investigations focused on changes n receptors; ion channel processes that involve sodium, potassium,
& calcium; & neurotropic growth factors (brain-derived neurotropic factor) that nourish neurons
kindling- stress initially alters neutortransmission mechanisms, & results in a first episode of depression or
mania.
This initial episode creates an electrophysiologic sensitivity to future stress, thereby requiring less stress to
trigger another depressive or manic state.
Kindling creates new hard-wiring of the brain or long-lasting alterations of neuronal functioning that influence
many changes in cellular processes, brain structures, cell dendrites, & cellular metabolism
PET scan examines the brain physiology of depressed persons and focus on metabolism of glucose & oxygen
prefrontal cortex & the limbic system (including the amygdala) appear to have physiologic & anatomic
changes in the brains of persons who are experiencing depression.
Neuroendocrine Dysregulation
mood disorders have been linked to dysregulation of the limbic hypothalamic-pituitary-adrenal (HPA) axis.
The hypothalamus, pituitary, adrenal glands, & the hippocampus make up the HPA axis, which controls
physiologic responses to stress.
Hypothalamus: regulates endocrine functions & the ANS; r/t to fight-or-flight response, eating, sleep, & sex;
manufactures serotonin (major neurotransmitter in mood disorders); releases corticotropin releasing hormone
(stimulates the anterior pituitary to secrete adrencoricotropic hormone)
Adrencoricotropic hormone triggers release of cortisol (elevated during stress) stimulates ANS (which
increases epinephrine & norepinephrine)
feedback mechanism cortisol levels signal the hypothalamus via the hippocampus to increase or decrease
corticotropin-releasing hormone production.
Overtime high levels of cortisol can damage the hippocampus.
HPA axis r/t to the 24hr cycle of circadian rhythms that control physiologic processes.
Genetic Transmission
researchers select families who exhibit mood disorders & then examine the risks that relatives have for
developing these disorders.
The first degree relatives of persons w/ bipolar disorder & unipolar depression have a greater risk for the
development of a mood disorder.
Risk is particularly high for relatives of persons w/ bipolar disorder, which indicates that genetics plays a
greater role in bipolar disorder than in unipolar depression.
If one monozygotic twin suffers from bipolar disorder, there is a strong chance that the other twin will have a
disorder as well.
Unipolar disorders continue to be higher for monozygotic twins & twin types have a higher concordance than
individuals in the general population.
Psychodynamic theory
unconscious processes result in the expression of symptoms, including depression & mania.
Freud: Loss generates intense hostile feelings toward the lost object. The person then turns these feelings inward
onto the self, thereby creating guilt & loss of self-esteem. Thus, depression is linked w/ loss & aggression.
Mania is a defense against depression. P/t denies feelings of anger, low self-esteem, & worthlessness & reverses
his/her affect so that there is a triumphant feeling of self-confidence.

Mania represents a conquered superego w/ little inclination to control id impulses; however, over time, this
distorted view of reality waivers, & the p/t demonstrates outward hostility toward others, often focusing on the
weaknesses of others that are similar to the internal weaknesses that they are avoiding.
Few data support this theory, but there is evidence that p/ts w/ depression have experienced more early childhood
loss & trauma than persons w/o depression.
Cognitive theory
errors of logical thinking may be one causative factor of depression.
Underlying cognitive structures, some of which are not fully conscious, influence mood.
In a diatheses-stress model, when individuals who are predisposed to depression w/ negative schemata encounter
stress, the negative processing is activated, thereby resulting in depressive thinking.
Levels of cognition that influence depression: automatic thoughts, schemata or assumptions, & cognitive
distortions.
Automatic thoughts- thoughts that a person responds to but usually does not recognize as a basis for behavior &
thinking. They form the persons perception of a situation, it is this perception rather than the objective facts about
the situation that results in emotional & behavioral responses. If perceptions are distorted, inferences & responses
will be maladaptive.
Schemata- internal representations of the self & the world. They facilitate info processing, b/c the mind uses them
to understand, code, & recall information.
Beck proposed a triad of thinking (schemata) that gives rise to the development of depression:
negative, self-deprecating views of the self-care
pessimistic views of the world, which result in life experiences being interpreted in a negative way
belief that negativity will continue into the future, which promotes a negative view of future events.
This mind-set results in the misinterpretation of events & situations so that the p/t sees the self as worthless, & the
world & the future as hopeless. This faulty cognitive processing leads to assumptions & continued errors of logic
that result in depressive symptoms & an ongoing negative view of life.
All-or-nothing thinking (seeing only two opposite categories or options) discounting the positive (not believing that
positive experiences matter) & magnification (placing a distorted emphasis on a single event or error)
Learned hopelessness theory
further revision of learned helplessness.
Hopelessness is a sufficient cause of depression.
Individual's inferred negative outcomes & negativity about the self are key elements of depression.
ex. p/t perceives that she is not able to recover from divorce (instability) that her entire life is ruined (globalization,
and that her former marriage is the only focus of her life (importance).
Stress theory
all life events even pleasant ones are capable of causing various degrees of stress.
Early life stress, including child abuse & loss, influences the development of depression, most likely by disrupting
the functioning of the HPA axis.
Individuals who experience early life stress become vulnerable w/ regard to how their stress response influences
the onset & course of depression.
Adjustment
life stressors sometimes can lead to adjustment disorders which are different from major depression.
The main distinction is that a specific psychosocial stressor can be identified for the adjustment disorder.
Adjustment disorders/adjustment reactions can occur in response to any type of stressor, including but not limited
to loss, personal tragedy, change in life style, maturational crisis, or even success or gain.
Acute: occurs within 3 months of a stressor
chronic: symptoms last more than 6 months after the occurrence of the stressor.
Can occur in anyone, regardless of age, gender, or socioeconomic status.
Time limited
highly individualized.

1.5 discuss mood disorders across the life span

mood disorders- group of psychiatric illnesses in which the predominant symptom is the dysregulation of mood or
emotion.
Occur throughout the life span, & often cause personal suffering, difficulty w/ relationships. Impaired functioning,
high costs to society & health care systems.
Sometimes fatal, w/ high risk of suicide.

Depression (major depressive disorder) & bipolar disorder (manic-depressive illness) two severe mood
disorders that pose significant public health problems that require attention & often long term treatment.
Characterized by shifts in mood which is a subjective feeling state.

1.6 describe how the comorbidity of other psychiatric diagnoses, medical conditions, & some meds & substances contribute
to mood disorders.
Medical conditions/ mood disorders/psychiatric diagnoses/meds/substances
comorbidity (co-occurrence) identified in several ways:
a medical p/t develops a mood disorder as a stress response to a serious medical conditions a medical p/t
develops a mood disorder as a physiologic response to either medical pathology or meds
a psychiatric p/t w/ persistent mood disorder develops common medical disorders
a psychiatric p/t w/ persistent mood disorder has an exacerbation of symptoms as a result of medical
pathology or treatment
HCP identify previously unrecognized relationships b/t mood & medical disorders.
The pathophysiology of a medical condition or a response to the meds given for a medical condition
sometimes results in a mood disorder.
Cardiovascular disorders linked w/ major depression.
Cancer, thyroid disease, HIV mood disturbances
high co-occurrence of mood disorders w/ other major mental illnesses, esp. substance abuse & dependence.
Increase in the # of p/ts who w/ comorbid medical & psychiatric disorders who are also showing signs of
dementia.
30-50% of p/ts w/ Alzheimer's disease have significant depressive symptoms.
Two new diagnostic categories will become available that are separate from existing depressive disorders.
Substances associated w/ mood disorders
digitalis, Thiazide diuretics, Reserpine, Propranolol, Anabolic steroids, Oral contraceptives, Disulfiram,
Sulfonamides, Alcohol & other substances of dependence, Marijuana
1.7 identify seasonal affective disorder, melancholic, atypical, & postpartum depression as additional types of mood
disorders
Seasonal Affective disorder: emotional
depression b/t October/November & March/April
Melancholic depression:
Emotional: Anhedonia; Increased depression in the morning
Cognitive: excessive feelings of guilt
Behavioral: waking at least 2 hrs before normal & being unable to fall back to sleep: psychomotor retardation
or agitation; significant weight loss
Atypical depression:
Emotional: mood reactivity; ability to react to positive stimuli
Cognitive: sensitivity to interpersonal rejection
Behavioral: significant weight gain or increase in appetite; hypersomnia; Leaden paralysis
Postpartum depression:
Behavioral: Difficulty caring for child
1.8 Assess the p/t w/ mood disorder according to the mental status criteria

nurses must maintain awareness of their own personal reactions to the p/t & the ways in which these reactions
affect the nurse-p/t relationship & subsequent care.
Mental status criteria
Mood: the internal manifestation of a subjective feeling state
Affect: the external expression or manifestation of a feeling state
Temperament: observable differences in the intensity & duration of arousal & emotionality
Emotion: The experience of a feeling state
Emotional reactivity: tendency to respond to internal or external events w/ emotion
Emotional regulation: ability to control or modify the occurrence & intensity of feelings
Range of affect: the span of emotional expression experienced & displayed by an individual

1.9 List possible nursing dx for p/ts w/ mood disorders

depression
risk for suicide
fatigue
insomnia
risk for loneliness
both types of imbalanced nutrition
powerlessness
anxiety
constipation
Mania
risk for self-directed & other -directed violence
disturbed thought processes
ineffective health maintenance
care-giver role strain
defensive coping
1.10 plan & implement the care of p/ts w/ mood disorders. Include teaching & monitoring activities
Planning & implementing
care provided in every setting
nursing care addresses acute episodes & p/ts ongoing risk for recurrent episodes.
Interventions during the acute depressive or manic episodes are effective
plan interventions for each p/t on the basis of the p/ts particular behaviors, needs, & concerns.
Plan of action varies depending on whether p/t is depressed or manic.
Interventions cover a wide range of biopsychosocial areas, w/ consideration of the effects of depression &
mania on the physiologic, cognitive, psychologic, behavioral, & social domains.
Interventions require nurse to maintain self-awareness & boundaries regarding their own reactions to p/ts b/c
p/t depression, irritability, anger, negativity, euphoria, & hyperactivity can readily influence nursing responses.
Be consistent, caring, concerned, empathetic, & genuine.
A knowledgeable, non demanding, & matter-of-fact approach is reassuring to p/ts & promotes their confidence
in the nurse.
1.11 Biological interventions: ECT, brain stimulating therapies, photo-therapy
ECT
involves the use of electrically induced seizures to treat severe depression or less frequently intense mania that
is not controlled w/ lithium or antipsychotics.
Believed to be r/t to the alteration of neurotransmission.
Brain stimulating therapies
Transcranial Magnetic Stimulation
noninvasive procedure in which an electromagnet is placed on the scalp. Electrical current is generated by
rapid pulsing in the magnetic field, which causes the cortical neurons to depolarize.
Increases monoamine concentrations in the brain when used repetitively.
Effects unipolar depression
Vagal Nerve Stimulation
induced w/ a vagal nerve stimulator device that is implanted in the left chest wall under the collarbone to
electrically stimulate the vagus nerve.
Helpful for p/ts w/ treatment-resistant depression
Deep Brain Stimulation
electrode is inserted deep into the brain, & an electrical current stimulates the brain.
Phototherapy
lessened symptoms of SAD
exposure to morning light causes a circadian rhythm shift that regulates the normal relationships b/t sleep &
circadian rhythms & that ultimately affects mood regulation.
P/ts sit or lie in front of the light box for 30 min to several hours, depending on the strength of the light source
antidepressant effect usually occurs within 2-4 days & is complete after 2 weeks.

 Some fail to respond, others experience only a partial response.

1.12 pharmacological interventions: include classification, actions, side effects, & adverse effects
Tricyclic
Classification: Tricyclic antidepressants (TCAs) are a class of antidepressant medications that share a similar
chemical structure and biological effects.
Action: Tricyclic antidepressants increase levels of norepinephrine and serotonin, two neurotransmitters, and
block the action of acetylcholine, another neurotransmitter.
Side effects: blurred vision, dry mouth, constipation, weight gain or loss, low blood pressure on standing, rash,
hives, and, increased heart rate.
Use w/ MAOIs may increase risk of neuroleptic malignant syndrome, seizures. Hypertensive crisis, &
hyperpyrexia
use w. oral anticoagulants can result in bleeding. Use w/ clonidine can cause severe hypertension
herbal considerations: St. John's wort & SAM-e may increase the p/ts risk for serotonin syndrome.
Monoamine:
Antidepressants such as MAOIs ease depression by affecting chemical messengers (neurotransmitters) used to
communicate between brain cells. Like most antidepressants, MAOIs work by changing the levels of one or
more of these naturally occurring brain chemicals.
An enzyme called monoamine oxidase is involved in removing the neurotransmitters norepinephrine,
serotonin and dopamine from the brain. MAOIs prevent this from happening, which makes more of these brain
chemicals available. This is thought to boost mood by improving brain cell communication.
The most common side effects of MAOIs include: Dry mouth, Nausea, diarrhea or constipation, Headache,
Drowsiness, Insomnia, Skin reaction at the patch site, Dizziness or light headedness
Avoid caffeine, chocolate, & all tyramine-containing foods ( aged cheese) within several hrs of ingestion of
MAOIs b/c the combination may cause sudden & severe hypertension or hypertensive crisis
Third line agents after SSRIs & TCAs have been tried
signs of toxicity include increased headaches & palpitations
MAOIs should not be taken within 14 days of taking SSRIs
herbal considerations: parsley & St. John's wort pose some risk for serotonin syndrome
SSRIs
SSRIs block the reabsorption (reuptake) of the neurotransmitter serotonin in the brain.
SSRIs are called selective because they seem to primarily affect serotonin, not other neurotransmitters.
Side effects of SSRIs may include, among others: Nausea, Nervousness, agitation or restlessness, Dizziness,
Reduced sexual desire or difficulty reaching orgasm or inability to maintain an erection (erectile dysfunction),
Drowsiness, Insomnia, Weight gain or loss, Headache, Dry mouth, Vomiting, Diarrhea
first-line antidepressant therapy
may cause fatal reactions w/ MAOIs by causing serotonin syndrome, hypertensive crisis, rigidity, &
neuroleptic malignant syndrome
serotonin syndrome- occur when medicines that are used to treat migraine headaches (5-hydroxytryptamine
receptor agonists, & medicines that are used to treat depression SSRIs & serotonin-norepinephrine reuptake
inhibitors (SNRIs) which are medicines from different classes) are used together
episodes of self-harm & potential suicidal behavior are reportedly higher in p/ts who are younger than 18.
use w/ caffeine increases agitation; use w/ alcohol increases sedation. Effectiveness is decreased w/ cigarette
smoking.
Should not be taken w/ lithium
herbal considerations: st. John's wort & SAM-e may cause serotonin syndrome. Use w/ ascorbic acid
(grapefruit juice) may alter the elimination of the drug & it's plasma concentration.
SNRIs
SNRIs block the absorption (reuptake) of the neurotransmitters serotonin and norepinephrine in the brain.
The most common side effects of SNRIs include: Nausea, Dry mouth, Dizziness, Excessive sweating
indicated for social anxiety disorder & general anxiety disorder
Venlafaxine is not approved for indications in children & adolescents b/c of the lack of efficacy & concerns
about increased hostility & suicidal ideation.

Mood stabilizers including lithium

Mood stabilizers balance certain brain chemicals (neurotransmitters) that control emotional states and
behavior.
effective for the treatment of mania in p/ts w/ bipolar disorders.
Most widely used is lithium
lithium acts as a salt within the body, & its blood levels are closely linked to the p/ts hydration & sodium
intake.
Side effects of lithium: neuromuscular &CNS effects (tremor, forgetfulness, slowed cognition), gastrointestinal
effects (nausea, diarrhea), weight gain, hypothyroidism & renal effects (polyuria).
blood levels of 0.6 mEq/L to 1 mEq/L more than 1.5 is toxic
lithium excreted through the kidneys, nurses need to use caution w/ p/ts w/ renal disease.
Herbal considerations: dandelion, goldenrod, juniper, & parsley increase lithium's effects & toxicity
Monitor p/t's sodium intake, b/c significant changes will alter lithium excretion. Black & green tea, coffee,
cola nut, guarana, plantains, & yerba mate may all decrease lithium levels.
Anticonvulsants
divided into 3 classes (first, second, & third generation) indicated for manic symptoms

Anticonvulsants work by calming hyperactivity in the brain in various ways. For this reason, some of
these drugs are used to treat epilepsy, prevent migraines, and treat other brain disorders.
They are often prescribed for people who have rapid cycling four or more episodes of mania and
depression in a year.
Anticoagulants used to treat bipolar disorder include: Depakote, Depakene (divalproex sodium,
valproic acid, or valproate sodium), Lamictal (lamotrigine) , Tegretol (carbamazepine)
Common side effects include: Dizziness, Drowsiness, Fatigue, Nausea, Tremor, Rash, Weight gain.
Used in place of lithium
abrupt withdrawal may cause seizures
labs=liver function, CBC w/ diff.
Antipsychotic
Antipsychotics are thought to work by altering the effect of certain chemicals in the brain, called dopamine,
serotonin, noradrenaline and acetylcholine.
atypical antipsychotics. These are sometimes called second-generation antipsychotics and include:
amisulpride, aripiprazole, clozapine, olanzapine, quetiapine, risperidone and sertindole.

typical well-established antipsychotics. These are sometimes called first-generation antipsychotics and
include: chlorpromazine, flupentixol, haloperidol, levomepromazine, pericyazine, perphenazine, pimozide,
sulpiride, trifluoperazine, and zuclopenthixol.
side-effects include: Dry mouth, blurred vision, flushing and constipation
Immediate treatment of psychotic behavior necessary to prevent exhaustion & infection due to body working
too hard. W/o treatment cardiac collapse can occur.
Mood disorders (part 2)
1.1 compare & contrast interpersonal, psychoanalytical, & sociological theories regarding the etiology of suicide
Interpersonal theory
harry Sullivan emphasized the importance of interpersonal relationship factors.
Individuals are never isolated from the interactions of significant people in their lives.
Suicidal act needs to be viewed within the context of the perceptions of the suicidal person by his/her
significant others.
Suicide is evidence of a failure to resolve interpersonal conflicts.
Psychoanalytical theory
Freud described self-destruction as anger directed inward toward the internalized love object.
Menninger described several sources of suicidal impulses: the wish to be killed, & the wish to die.
Jung said the suicidal person holds an unconscious wish for spiritual rebirth after feeling that life has lost its

meaning
Adler identified the importance of inferiority, narcissism (self-absorption), & low self-esteem in suicidal acts.
Horney believed that suicide was a solution for someone who is experiencing extreme alienation for the self as
result of a great gap b/t idealized self & the perceived psychosocial self.
Sociological theories
Emile Durkheim 4 subtypes
Anomic- acts of self-destruction by individuals who have become alienated from important relationships
in their groups, especially a this relates to their standard of living (suicides after 1929 stock market crash)
Egoistic- the self-inflicted deaths of individuals who turn against their own conscience (suicide of a
devout Catholic adolescent after she has had an abortion that was forbidden by her religion)
Altruistic- self-inflicted deaths on the basis of obedience to a group's goals rather than reflecting the
person's own best interests (falling on a grenade)
Fatalistic- self-inflicted deaths that result from excessive regulation (suicide of a convicted prisoner who
hung himself to escape a prolonged period of incarceration)

1.2 discuss prevalence & factors contributing to suicide in the U.S

present among people of all ages, members of both sexes, individuals in all ethnic groups and at all socioeconomic
levels.
In 2007, 34,598 people died as a result of suicide in the U.S
recent psychiatric sources have cited on social media networks as a possible factor in depression & suicide in teens
who may be vulnerable to cyber-bullying & other negative messages
females in general attempt suicide more frequently than males
suicidal behavior is strongly associated w/ psychiatric disorders
1.3 name important indicators of suicide including co-occurrence w/ other health issues.
Suicidal behaviors is strongly associated w/ psychiatric disorders
mood disorders, substance abuse, schizophrenia, borderline personality, & panic disorders have a co-occurrence w/
high-risk suicidal behaviors.
Depression remains the single best predictor of suicide risk for all age groups
suicide is the leading cause of death during the first 10 years of the course of schizophrenic illness
the research is mixed regarding the correlation of suicide w/ panic disorders, but its associated w/ suicide risk,
especially when panic disorder coexists w/ depression, OCD, or phobias
independent of another specific psychiatric dx, alcohol use & abuse are highly correlated w/ most suicidal acts,
esp. among youth. Suicide is under diagnosed & underreported among older adults.
Chronic physical illness contributes to suicidal behavior. More than half of the outpatients who committed suicide
in several studies had physical health problems.
1.4 assess risk factors, formulation of a plan, means to carry out plan, & lethality of the plan
Risk factors
age- b/t 15-24; older adults 65 yrs & older; 85 & over most vulnerable
sex-men have a greater incidence of completed suicides. Women have a higher rate of suicide attempts &
gestures
Race & ethnicity- whites are 2x higher than those of nonwhites. African American men who are older than 85
are increasing faster than those for any other group. Native American males second most at risk.
Physical & emotional symptoms-serious depression, significant changes in weight, serious sleep disturbances,
extreme fatigue & loss of energy, self-deprecation, anger, feelings of hopelessness, & preoccupation w/ themes
of death & dying.

Suicide plan- plans that are more precise, detailed, & explicit about the method indicate high risk.
History of previous attempts
social supports & resources- lack of support or resources increase risk
recent losses- unresolved grief reactions lead to depression & suicidal behavior
medical problems
alcohol & other drugs
cognition & problem- solving ability
Lethality
potential for causing death r/t to the level of danger associated w/ the suicide plan
3 elements
specificity of details
lethality of proposed method
availability of means
p/ts level of hopelessness, intent (method chose & it's accessibility), imminence (likelihood that an event will
occur within a specific time period) often help to determine the level of lethality & extent of interventions
required for safety.

1.5 distinguish b/t suicidal ideation, gestures, threat, attempt (para suicide), & successful suicide.
Suicidal ideation: this involves direct or indirect thoughts or fantasies of suicide or self-injurious acts that are
expressed verbally or through writing or artwork w/o definite intent or action expressed. Sometimes p/ts this
symbolically.
Suicide threats: these are direct verbal or written expressions of intent to commit suicide but w/o action.
Suicide gestures: these self-directed actions result in no injury or minor injury by persons who neither intended to
end their lives nor expected to die as a result. However, they were done in such a way that others interpret the act
as suicidal in purpose.
Suicide attempts: these are serious self-directed actions that sometimes result in minor or major injury by persons
who intend to end their lives or to seriously harm themselves. Gestures & attempts that are unsuccessful & to low
lethality are sometimes called (para suicidal) behavior.
Completed suicide: the deaths of persons who end their lives by their own means w/ conscious intent to die are
described as complete suicide. However, it is important to note that some suicides sometimes occur on the basis of
the unconscious intent to die (engaging in high-risk activities).
1.6 select appropriate nursing diagnoses for the suicidal p/t..
risk for suicide
risk for self-directed violence secondary diagnoses may include
ineffective coping
hopelessness
powerlessness
chronic low self-esteem
social isolation
disturbed thought processes
1.7 develop plan of care for the suicidal p/t
outcome criteria
remain safe & free from self-harm
verbalize the absence of suicidal ideation, planning or intention
therapeutic nursing interventions

 all unit precautions for preventing suicide should be strictly enforced.

Routinely count silverware & all other sharp objects before & after the p/t's use of them
providing roommate
requesting visitors to clear all personal items for the p/t or any gifts w/ staff
1.8 implement
psychotherapeutic interventions vary & include insight oriented techniques, cognitive reframing, & brief solution
focused crisis interventions.
ECT sometimes used w/ adults whose response patterns reflect a lack of positive response to medication.
Pharmacologic interventions is often primary consideration. Antidepressants, anxiolytics, & antipsychotic are often
used.
1.9 evaluate
p/t's response is crucial.
Helps nurse to target areas of outcomes that are critical to the p/t's continued survival.
Helps ensure the p/t's continued safety & readiness for discharge
1.10 examine your own beliefs & feelings about suicidal p/ts