Affective Disorder

Psych - Exam 2

Major Depressive Disorder (MDD)

• DSM-5-TR; ≥5 symptoms present during the same 2-week period (must include depressed mood OR anhedonia)

• Symptoms: depressed mood, anhedonia, significant weight change (±5% in 1 month), insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, worthlessness or excessive guilt, diminished concentration, recurrent thoughts of death or suicidal
  ideation

• Causes clinically significant distress or functional impairment

• Not attributable to substance use or another medical condition

• Mnemonic: SIG E CAPS (Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor changes, Suicidal ideation)

Bipolar I Disorder

• Requires ≥1 manic episode lasting ≥7 days (or ANY duration if hospitalization is required)

• Manic episode: elevated, expansive, or irritable mood WITH increased energy/activity

• ≥3 symptoms (4 if mood is only irritable): grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, increased goal-directed activity, excessive involvement in risky activities

• Mnemonic: DIG FAST (Distractibility, Indiscretion/Impulsivity, Grandiosity, Flight of ideas,
  — Activity increase, Sleep deficit, Talkativeness)

• Depression is common but NOT required for diagnosis

Bipolar II Disorder

• Requires ≥1 hypomanic episode (≥4 days) AND ≥1 major depressive episode

• Hypomania does NOT cause marked functional impairment or require hospitalization

• Hypomania does NOT include psychotic features

• Bipolar II is NOT a "milder" form of Bipolar I - the depressive episodes are often more severe and chronic

Cyclothymic Disorder

• Chronic, fluctuating mood disturbance for ≥2 years (≥1 year in children/adolescents)

• Numerous periods of hypomanic and depressive symptoms that do NOT meet full criteria for hypomania or major depression

• Never symptom-free for >2 months

Peripartum Mood Disorders-(PPD)

Baby Blues

• Onset: 2–3 days postpartum

• Resolves by ~2 weeks

• Key Features: Mood lability, tearfulness, anxiety, irritability; self- limiting

• Intervention: Educate, reassure, monitor; if symptoms persist >2 weeks → screen for PPD

Peripartum Depression

• During pregnancy or within 4 weeks postpartum (DSM-5-TR); clinically may present up to 12 months

• Weeks to months if untreated

• MDD symptoms + difficulty bonding with infant, excessive anxiety about baby's health, thoughts of harming self or baby

• Screen ALL postpartum patients (Edinburgh Postnatal DepressionScale — EPDS); refer for treatment; SSRIs safe during breastfeeding (sertraline preferred)

Peripartum Psychosis

• Within first 2 weeks postpartum (typically)

• Psychiatric emergency

• Hallucinations, delusions, severe confusion, disorganized behavior, risk of infanticide

• PSYCHIATRIC EMERGENCY; hospitalize immediately; separate mother and
  infant for safety; antipsychotics + mood stabilizers

Normal Grief

• Trigger: Identifiable loss

• Duration: Variable gradually decreases

• Self-esteem: Generally preserved

• Mood pattern: Comes in waves; pangs of gried triggered by reminders

• Functioning: gradually improves

• Suicidal ideation: may include passive wishes to join the decreased

• Positive emotions: can experience positive emotions alongside grief

• Identity: maintained

• Guilt: related to the decreased (“I wish I had done more”)

Prolonged Grief Disorder (PGD)

• Trigger: Death of someone close (>12 months ago for adults, >6 months for children)

• Duration: >12 months (adults); 6 months (children)

• Self-esteem: may be preserved or impaired

• Mood pattern: persistant, pervasive preoccupation with the decreased

• Functioning: significant functional impairment

• Suicidal ideation: may include active ideation

• Positive emotions: difficulty experiencing positive emotions

• Identity: disrupted sense of identity, feels '“part of self has died”

• Guilt: Intense, pervasive guilt about the death

Major Depressive

• Trigger: may or may not have identifiable trigger

• Duration: >2 weeks of continous symptoms

• Self-esteem: often impaired; worthlessness

• Mood pattern: persistent, pervasive depressed mood

• Functioning: significant functional impairment

• Suicidal ideation: common, may include plan/intent

• Positive emotions: Anhedonia; pervasive lack of pleasure

• Identity: may feel worthless or like a burden

• Guilt: generalized, irrational guilt

Monoamine Hypothesis — Biological

• Deficiency in serotonin (5-HT), norepinephrine (NE), and/or dopamine (DA)

• Clinical Application: SSRIs, SNRIs, NDRIs target specific neurotransmitter systems

Neuroendocrine (HPA Axis) — Biological

• Chronic stress → elevated cortisol → hippocampal atrophy → impaired mood regulation

• Explains why chronic stress is a risk factor; basis for stress reduction interventions

Genetics — Biological

• First-degree relatives have 2–3x higher risk for MDD; heritability of bipolar ~80%

• Family history assessment is essential
  
  

Kindling Theory — Biological

• Each episode increases vulnerability to future episodes; episodes may eventually occur without external stressors

• Early, aggressive treatment prevents kindling; medication adherence prevents recurrence

Beck’s Cognitive Triad — Cognitive

• Negative view of SELF ("I'm worthless"), WORLD ("Everything is terrible"), FUTURE ("Nothing will ever get better")

• Foundation of CBT; nurse reinforces cognitive restructuring
  
  

Learned Helplessness (Seligman) — Behavioral

• Repeated exposure to uncontrollable events → perception that nothing can change → passivity, hopelessness

• Behavioral activation; empowerment; restoring sense of control

Psychodynamic

• Unresolved grief, early attachment disruption, anger turned inward

• Psychodynamic psychotherapy; nurse assesses attachment history

Interpersonal Theory

• Depression linked to role transitions, role disputes, grief, interpersonal deficits

• Interpersonal Therapy (IPT) — evidence-based for MDD

Circadian Rhythm Disruption

• Sleep-wake cycle dysregulation; melatonin disruption; seasonal light exposure

• Light therapy for seasonal pattern MDD; sleep hygiene; social rhythm therapy for bipolar

Etiology of Affective Disorders

• Epigentic

— Environmental factors can modify gene expression without changing DNA sequence

• Inflammatory Markers

— Elevated CRP, IL-6, TNF- alpha in depression; neuroinflammation theory

• Gut-brain axis

— emerging evidence for microbiome mood connection

• Adverse Childhood Experience (ACEs)

— dose-response relationship between ACEs and adult depression

• Hormonal Factors

-— thyroid dysfunction, peripartum hormonal shifts, HPA axis

Nursing Assessment of Affective Disorders

Systematic Nursing Assessment - Affective Disorders:
SAFETY FIRST

• Suicide risk assessment (ideation, plan,
  intent, means, prior attempts)

• Homicidal ideation

• Self-harm behaviors

• Ability to care for self (ADLs)

Mental Status Exam (MSE)

1. Appearance

• Disheveled, poor hygiene, weight loss

• Flamboyant dress, excessive makeup/jewelry

2. Behavior

• Psychomotor retardation, poor eye contact

• Psychomotor agitation, hyperactivity, intrusive

3. Speech

• Slow, soft, monotone, decreased volume

• Pressured, loud, rapid, difficult to interrupt

4. Mood

• "Sad," "empty," "hopeless," "numb"

• "Great," "on top of the world," "unstoppable"

5. Affect

• Flat, blunted, tearful, constricted

• Labile, euphoric, irritable, expansive

6. Thought Process

• Slowed, rumination, poverty of thought

• Flight of ideas, tangentiality, loose associations

7. Thought Content

• Worthlessness, guilt, death, suicidal ideation

• Grandiosity, paranoia, delusions of grandeur

8. Perception

• Usually intact (psychotic features in severe MDD)

• May have hallucinations/delusions in severe mania

9. Cognition

• Impaired concentration, indecisiveness

• Distractibility, impaired judgment

10. Insight/Judgment variable

• May have insight; judgment variable

• Often impaired — lack of insight is hallmark of mania

Screening Tools

PHQ-9

• Depression severity

• 0–4: Minimal; 5–9: Mild; 10–14: Moderate; 15–19: Mod-Severe; 20–27: Severe

MDQ

• Bipolar spectrum screening

• Positive screen: ≥7 "yes" answers + ≥2 occurring simultaneously + moderate-serious impairment

C-SSRS

• Suicide risk

• Escalating questions: wish to be dead → plan with intent

YMRS

• Mania severity

• 11-item clinician-rated scale

GAD-7

• Comorbid anxiety

• 0–4: Minimal; 5–9: Mild; 10–14: Moderate; ≥15: Severe

CBT

• Identifies and modifies negative thought patterns; behavioral
  activation

• Reinforce skills learned in therapy; challenge cognitive distortions
  therapeutically

IPT

• Addresses interpersonal issues: grief, role disputes, role transitions, interpersonal deficits

• Assess social functioning; support communication skills
  
  

DBT Skills

• Mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness

• Reinforce skills on the unit; model mindfulness; support use of coping cards

Behavioral Activation

• Scheduling pleasurable and mastery activities to combat withdrawal

• Encourage activity participation; document engagement levels

Millieu Therapy

• Structured, safe, therapeutic environment

• Maintain therapeutic milieu; set limits; model appropriate behavior; facilitate groups

Light Therapy

• 10,000 lux light box, 20–30 minutes in the morning

• For seasonal pattern MDD; educate on proper use; monitor for hypomania switch in bipolar

TMS (Transcranial Magnetic Stimulation)

• Repetitive transcranial magnetic stimulation - noninvasive brain stimulation

• FDA-approved for treatment-resistant depression; outpatient procedure; no anesthesia needed

VNS (vagus nerve stimulator)

• Vagus nerve stimulation via implanted device

• For treatment-resistant depression; surgical implant; adjunct to medications

Psychoeducation

• Teaching about illness, medications, relapse signs, coping

• CORE nursing function; individualize to literacy level and culture

Clinical Picture & Epidemiology

1. Specific prevalence data:
   — MDD: Lifetime prevalence ~17%; 12-month prevalence ~7%
   — Bipolar I: ~1% lifetime prevalence
   — Bipolar II: ~0.4–0.6% lifetime prevalence
   — Dysthymia/Persistent Depressive Disorder: ~2%

2. Age of onset specifics:
   — MDD: Mean age of onset ~32 years; can occur at any age
   — Bipolar: Mean age of onset ~25 years; often presents in late adolescence

3. Racial/ethnic disparities in diagnosis: African Americans and Hispanics are often
   underdiagnosed for mood disorders and overdiagnosed with psychotic disorders

4. Peripartum depression - affects ~15% of women; onset during pregnancy or within 4
   weeks postpartum

5. Persistent Depressive Disorder (Dysthymia)
   — Depressed mood for most of the day, more days than not, for ≥2 years (≥1 year for
   children/adolescents)
   — ≥2 additional symptoms: appetite changes, sleep changes, low energy, low self-
   esteem, poor concentration, hopelessness
   — Never without symptoms for >2 months during the 2-year period
   — May have episodes of major depression superimposed ("double depression")

Economic Burdens of MDD

• Major depressive disorder ranks second (~$333.7B annually).

• Depression carries substantial workplace-related costs, including absenteeism and presenteeism.

• This disorder illustrates the importance of early intervention and coordinated behavioral health care.
  

Indirect costs:

• Absenteeism (missing work)

• Presenteeism (at work but not productive - accounts for ~50% of workplace costs)

• Disability costs

• Caregiver burden

• Healthcare utilization

Cue Recognition Example in Affective Disorder

Observed Cue → Possibel Clinical Signifcance

• Patient stopped bathing, wearing same clothes for 3 days → Psychomotor retardation, depression, self-neglect

• Rapid, pressured speech; won't let you complete a question → Manic episode

• Patient says "I'm fine" but has flat affect and avoids eye contact → Incongruent mood/affect - requires further assessment

• Patient has not eaten in 2 days → Depression-related appetite loss; safety concern

• Patient suddenly gives away personal belongings → Suicide warning sign

• Patient reports sleeping only 2 hours but feels "amazing" → Decreased need for sleep - cardinal sign of mania

• Patient's credit cards are maxed out (per family) → Impulsive spending - mania symptom

Nursing Diagnosis for Affective Disorders

Nursing Diagnosis: Related Cues

• Risk for Suicide: Hopelessness, prior attempts, access to means, substance use

• Hopelessness: Negative statements about future, passive behavior, decreased
  participation

• Ineffective Coping: Poor problem-solving, substance use, social withdrawal

• Disturbed Sleep: Pattern Insomnia or hypersomnia, fatigue, non-restorative sleep

• Imbalanced Nutrition Less Than Body Requirements: Weight loss >5%, decreased appetite, refusal to eat

• Social Isolation: Withdrawal from activities, limited support system

• Self-Neglect: Poor hygiene, inability to perform ADLs

• Risk for Self-Directed Violence: Impulsivity (mania), suicidal ideation (depression)

• Noncompliance / Ineffective Health Maintenance: Medication refusal, missed appointments (common in mania

Priority Diagnosis

• ALWAYS: Safety first - Risk for Suicide takes priority over all other diagnoses

Outcome Identification Goals

Acute

• Patient will deny suicidal ideation and identify 2 coping strategies within 48
  hours of admission

• Patient will sleep ≥5 hours per night within 3 days with pharmacological
  support

Continuation

• Patient will attend ≥2 therapy sessions per week and verbalize understanding
  of medication regimen by Week 4

• Continuation Patient will identify 3 personal triggers for depressive relapse within 2 weeks

Maintenance

• Patient will maintain medication adherence for ≥6 months and demonstrate
  use of coping strategies during stressful events

• Maintenance Patient will maintain social engagement by attending ≥1 community activity
  weekly

Planning Interventions for Affect Disorders

Acute Phase Intervention

• 1:1 observation if suicidal; environmental safety check; medication initiation; nutritional support; sleep promotion; therapeutic communication

Continuation Phase Intervention

• Reinforce therapy skills; psychoeducation about relapse; medication adherence strategies; support return to work/school; family education

Maintenance Phase Intervention

• Monitor for early warning signs of relapse; support group referral; wellness recovery action plan (WRAP); stress management; community resource linkage

SSRIs

• Fluoxetine (Prozac): Longest half-life; fewest withdrawal effects; FDA-approved for children ≥8

• Sertraline (Zoloft): First-line for MDD, PTSD, OCD, panic disorde

• Paroxetine (Paxil) Highest risk for withdrawal syndrome; avoid in pregnancy (Category D)

• Escitalopram (Lexapro): Fewer drug interactions; well-tolerated

• Citalopram (Celexa): QTc prolongation at doses >40 mg; max 20 mg in adults >60

SNRIs

• Venlafaxine (Effexor): Monitor blood pressure (can cause dose-related HTN)

• Duloxetine (Cymbalta): Also approved for chronic pain, fibromyalgia, diabetic
  neuropathy

TCAs

• Amitriptyline, nortriptyline, imipramine

• Side effects: anticholinergic effects (dry mouth, constipation, urinary retention,
  blurred vision), sedation, orthostatic hypotension, weight gain

• HIGHLY LETHAL IN OVERDOSE - cardiac arrhythmias (QTc prolongation)

• Not first-line due to side effect profile and lethality

MAOIs

• Phenelzine (Nardil), tranylcypromine (Parnate)

• Tyramine restriction - avoid aged cheeses, smoked meats, fermented foods, red wine, soy sauce, beer → hypertensive crisis (severe headache, stiff neck, diaphoresis, elevated BP)

• 14-day washout period required when switching to/from SSRIs

• Multiple drug interactions - OTC cold medications containing pseudoephedrine or dextromethorpha

• Last-line treatment due to dietary and drug restrictions

Atypical Antidepressants

• Bupropion (Wellbutrin): Norepinephrine-dopamine reuptake inhibitor; NO sexual side effects; also used for smoking cessation; lowers seizure threshold - contraindicated in eating disorders (bulimia/anorexia) and seizure disorders

• Mirtazapine (Remeron): Sedating; increases appetite; good for patients with insomnia and weight loss

• Trazodone: Primarily used for insomnia as adjunct; priapism risk (rare but requires education

Mood Stabilizers

• Therapeutic level: 0.6–1.2 mEq/L

• Maintenance level: 0.6–1.0 mEq/L

• Toxic level: >1.5 mEq/L

• Monitoring: Levels drawn every 1–2 weeks initially, then every 2–3 months; draw 12 hours after last dose (trough level)

• Baseline labs: Renal function (BUN/Cr), thyroid (TSH, T3, T4), ECG, pregnancy test,
  CBC

• Ongoing monitoring: Renal function and thyroid Q6 months; weight; lithium level

• Teaching: Maintain adequate sodium and fluid intake; avoid dehydration; avoid
  NSAIDs (increase lithium levels); report signs of toxicity immediately

• Conditions that INCREASE lithium levels: Dehydration, sodium restriction, NSAIDs, ACE inhibitors, renal impairment, vomiting/diarrhea

• Pregnancy Category D - Ebstein's anomaly (cardiac malformation)

Anticonvulsants Mood Stabilizers

• Valproate (Depakote)
  — Monitor liver function and CBC; teratogenic (neural tube defects); weight gain; thrombocytopenia; therapeutic level: 50-125 mcg/mL

• Carbamazepine (Tegretol)
  — Monitor CBC (agranulocytosis, aplastic anemia); many drug interactions (induces CYP450); Stevens-Johnson syndrome risk; therapeutic level: 4–12 mcg/mL

• Lamotrigine (Lamictal)
  — First-line for Bipolar II (depressive episodes); must titrate SLOWLY to avoid Stevens-Johnson syndrome (life- threatening rash); teach patient to report ANY rash immediately

Atypical Antipsychotics

• Quetiapine (Seroquel):
  — Bipolar depression and mania; sedation, metabolic syndrome

• Olanzapine (Zyprexa):
  — Weight gain, metabolic syndrome, diabetes monitoring

• Aripiprazole (Abilify):
  — Weight-neutral; adjunct for MDD

• Lurasidone (Latuda):
  —FDA-approved for bipolar depression; take with food (≥350 calories)

• Monitor: weight, fasting glucose, lipid panel, waist circumference (These medicines can cause metabolic syndrome)

Electroconvulsive Therapy

• Mechanism: Electrically induced generalized seizure (30–60 seconds) under general anesthesia

• Indications: Severe MDD (especially with suicidality or psychotic features), treatment-resistant depression, catatonia, severe mania, pregnancy (when medications are contraindicated)

• Contraindications: Increased intracranial pressure (pheochromocytoma is a relative contraindication)

• Treatment course: Typically 6–12 sessions, 2–3 times per week

• Anesthesia: Methohexital (short-acting barbiturate) or propofol

• Muscle relaxant: Succinylcholine (prevents injury during seizure)

• Pre-procedure nursing: NPO 6–8 hours; informed consent verified; remove dentures, jewelry, hairpins; void bladder; baseline vital signs; IV access; atropine may be given to reduce secretions

• Post-procedure nursing: Position on side until gag reflex returns; monitor vital signs Q15 min; reorient patient (temporary confusion expected); assess for headache, nausea, muscle soreness; document seizure duration

• Side effects: Temporary confusion, short-term memory loss (retrograde and anterograde), headache, nausea, muscle aches

• Long-term memory: Most memory issues resolve within weeks to months; some patients report persistent memory gaps

• Patient teaching: Explain that confusion is temporary; someone must drive them home; review treatment schedule

Teamwork, Support Groups, Health Teaching

• Multidisciplinary approach

• Support groups aid recovery

• Teach med adherence, side effects, relapse signs

• Safety: Suicide precautions, teamwork.

• Teaching: Psychoeducation, coping skills.

• NAMI (National Alliance on Mental Illness) — primary support organization for patients and families

• DBSA (Depression and Bipolar Support Alliance) — peer-led support groups

• AA/NA — for co-occurring substance use disorders

• Wellness Recovery Action Plan (WRAP) — patient- driven recovery tool

• Family psychoeducation — reduces relapse rates by up to 50% in bipolar disorder

Evaluation of Outcomes

• Reassess symptom severity

• Monitor functional improvement

• Validate goal achievement

• Reassess mood, functioning, adherence.

• Use scales to reassess (PHQ-9).

• Adjust care plan as needed

Evaluation Metrics

What to evaluate = evaluation tool

• Depression severity = PHQ-9 (readminister at intervals)

• Mania severity = YMRS

• Suicide risk = C-SSRS (reassess at every transition of care)

• Medication adherence = Patient self-report, pharmacy refill data, serum levels (lithium, valproate)

• Functional improvement = Return to work/school, ADL performance, social
  engagement

• Side effects = Systematic side effect assessment; metabolic
  monitoring for antipsychotics

• Patient satisfaction = Patient-reported outcome measure

Lithium Toxicity

Therapeutic level

• 0.6–1.2

• Expected side effects: fine hand tremor, mild nausea, mild thirst, polyuria, mild diarrhea, weight gain

Early Toxicity

• 1.5–2.0

• Coarse hand tremor, persistent GI symptoms (nausea, vomiting, diarrhea), muscle weakness, drowsiness, ataxia (unsteady gait), slurred speech, tinnitus

Advanced Toxicity

• 2.0–2.5

• Severe ataxia, blurred vision, confusion, large output of dilute urine, severe hypotension,
  muscle twitching, clonic movements

Severe/Life Threatening

• >2.5

• Seizures, coma, cardiac arrhythmias, cardiovascular collapse, death

Nursing Interventions for Lithium Toxicity

1. HOLD the lithium - DO NOT administer next dose

2. Notify provider immediately

3. Obtain STAT lithium level and BMP (monitor sodium, potassium, renal function)

4. IV normal saline - to support renal excretion (lithium is renally excreted)

5. Monitor cardiac rhythm - ECG for arrhythmias

6. Monitor I&O - lithium toxicity can cause diabetes insipidus-like syndrome

7. Hemodialysis - may be required for levels >2.5 mEq/L or severe symptoms

8. There is NO antidote for lithium toxicity - treatment is supportive

Factors That INCREASE Lithium Levels (Must Teach Patients)

• Dehydration (exercise, heat, illness with vomiting/diarrhea)

• Low-sodium diet

• NSAIDs (ibuprofen, naproxen)

• ACE inhibitors

• Diuretics (especially thiazides)

• Renal impairment

• Advanced age
  

Patient Teaching:

• Maintain consistent sodium and fluid intake (2-3 L water daily)

• Avoid dehydration - extra fluids in hot weather and during exercise

• Use acetaminophen instead of NSAIDs for pain

• Report early toxicity signs immediately

• Do NOT change sodium intake drastically (e.g., starting a low-salt diet)

• Keep regular lab appointments

• Carry medical ID indicating lithium use

Loss

Loss

• Actual or perceived change in status of something valued

Grief

• Internal emotional response to loss

Mourning

• Outward, social expression of grief (culturally influenced)

Bereavement

• State of having experienced a loss through death

Types of Loss

• Death: Loss of spouse, child, parent, friend

• Health: Diagnosis of chronic illness, amputation, disability

• Relationship: Divorce, estrangement, breakup

• Role: Retirement, "empty nest," job loss

• Identity: Loss of independence, cognitive decline

• Safety/Security: Natural disaster, trauma, financial ruin

• Perceived/Symbolic: Loss of dreams, missed milestones, infertility

Types of Grief

• Normal/Uncomplicated: Expected emotional, physical, cognitive, and behavioral responses that diminish over time

• Anticipatory: Grief that occurs BEFORE the actual loss (e.g., during terminal diagnosis)

• Disenfranchised: Grief that is not openly acknowledged or socially supported (e.g., loss
  of pet, death of ex-spouse, perinatal loss, death related to stigmatized
  cause)

• Complicated/Prolonged: Grief that is persistent, pervasive, and interferes with functioning beyond expected timeframes

• Absent: No outward expression of grief - may indicate denial or cultural variation

• Delayed: Grief response that is postponed - may emerge months or years later

• Inhibited: Only some aspects of grief are expressed while others are suppressed

Kübler-Ross - Five Stages of Grief (1969)

• Denial → Anger → Bargaining →Depression → Acceptance; stages
  are NOT linear; not all people experience all stages

• Framework for understanding grief responses; do NOT impose stages on patients; validate where they are

Worden - Four Tasks of Mourning (199

• Task 1: Accept the reality of the loss

• Task 2: Process the pain of grief

• Task 3: Adjust to the world without the deceased;

• Task 4: Find an enduring connection with the deceased while embarking on a new life

• Active, task-based model; useful for clinical goal-setting; helps identify "stuck" points in grie

Bowlby - Attachment Theory

• Grief response is a form of separation anxiety; intensity of grief related to strength of attachment

• Assess attachment patterns; anticipate grief intensity based on relationship closeness

Stroebe & Schut - Dual Process Model (1999)

• Grieving oscillates between loss- oriented coping (processing grief) and restoration-oriented coping (adjusting to life changes); healthy grieving involves movement
  between both

• Most current model; normalizes "good days" and "bad days"; validates that distraction and life engagement are part of healthy grief

Rando - Six "R" Processes of Mourning (1993)

• Recognize, React, Recollect & Re-experience, Relinquish, Readjust, Reinvest

• Comprehensive process model; helps identify which phase the patient is in

Manifestations of Normal Grief

• Emotional: Sadness, anger, guilt, anxiety, loneliness, yearning, relief (in prolonged illness), numbness, shock

• Cognitive: Disbelief, confusion, preoccupation with the deceased,
  sense of presence, difficulty concentrating, forgetfulness

• Physical: Fatigue, sleep disturbance, appetite changes, somatic complaints (headache, chest tightness, "heartache"), susceptibility to illness, sighing respirations

• Behavioral: Crying, social withdrawal, restlessness, searching behavior, visiting places associated with the deceased, treasuring belongings, avoiding reminders

• Spiritual: Questioning faith, searching for meaning, anger at God, renewed faith, existential questioning

• Social: Changes in relationships, need for support, difficulty in
  role functioning

Prolonged Grief Disorder PGD (Complicated Grief): DSM-5-TR

• Death of someone close to the bereaved ≥12 months ago (adults) or ≥6 months (children/adolescents)

• Since the death, persistent and pervasive grief response characterized by intense yearning/longing for the deceased AND/OR preoccupation with thoughts/memories of the deceased

• ≥3 of the following to a clinically significant degree, nearly every day for ≥1 month:
  — Identity disruption (feeling part of self has died)
  — Marked sense of disbelief about the death
  — Avoidance of reminders that the person is dead
  — Intense emotional pain (anger, bitterness, sorrow)
  — Difficulty reintegrating into relationships and activities
  — Emotional numbness
  — Feeling that life is meaningless
  — Intense loneliness
  — Causes clinically significant distress or functional impairment
  — Duration and severity exceeds expected social, cultural, or
  religious norms

Risk Factors for Prolonged Grief Disorder

• Sudden or violent death (homicide, suicide, accident)

• Death of a child

• Insecure attachment style

• Prior mental health conditions (depression, anxiety)

• Limited social support

• Concurrent stressors (financial, health, other losses)

• Caregiver burden prior to death

• Ambivalent or dependent relationship with the deceased
  

Treatment:

• Complicated Grief Treatment (CGT) - evidence-based psychotherapy

• Interpersonal Therapy (IPT)

• Medication may address comorbid depression or anxiety (not PGD itself)

• Support groups for bereaved individuals

Cultural Variations in Grief

• Western/American: Funeral, burial or cremation, memorial service; black clothing; limited mourning period

• Hispanic/Latinx: Novena (9 days of prayer); Día de los Muertos; strong family involvement; open emotional expression

• African American: Extended family and church involvement; celebration of life; may include home-going service

• Asian/Pacific Islander May vary widely; some cultures restrict emotional expression; ancestor veneration; specific mourning periods (e.g., 49 days in Buddhist tradition)

• Jewish Shiva (7-day mourning period); Kaddish prayer; tearing of garments (keriah); one-year mourning period (avelut)

• Muslim/Islamic Burial within 24 hours; Iddah (mourning period); specific bathing and shrouding rituals; extended family support

• Native American Varies by tribe; may include specific ceremonies; some avoid speaking the deceased's name; connection to land and ancestors

Developmental Consideration for Grief

Toddler (1–3)

• No understanding; senses absence; reacts to caregiver distress

• Maintain routine; provide comfort objects; stay with trusted adult

Preschool (3-5)

• Views death as temporary/reversible; magical thinking

• Use concrete language ("died" not "went to sleep"); reassure child is not the cause

School Age (6-12)

• Understands death is permanent and universal; may personify death; fears own death

• Encourage questions; allow participation in rituals if desired; provide honest, age-appropriate informatio

Adolescent (13-18)

• Adult-like understanding; existential questioning; may mask grief with behavior

• Allow expression; peer support; watch for risk-taking behavior and depression

Adult

• Full understanding; grief influenced by relationship, circumstances, and coping history

• Assess coping, support system, and risk for complicated grief

Older Adult

• Accumulated losses; may be more accepting; "bereavement overload" possible

• Assess for depression vs. grief; monitor for suicidal ideation; address social isolation

Nursing Assessment of the Grieving Client

Nature of the Loss

• Who/what was lost?

• Circumstances of the death (sudden vs. anticipated, natural vs. traumatic)

• Relationship to the deceased

Grief Response

• Emotional, cognitive, physical, behavioral, spiritual manifestations

• Duration and intensity of grief

• Functional status (ADLs, work, social engagement)

• Coping strategies (adaptive vs. maladaptive

Risk Assessments

• Screen for depression (PHQ-9)

• Screen for suicidal ideation (C-SSRS) - especially in older adults and those with sudden/traumatic loss

• Screen for substance use

• Assess for complicated/prolonged grief indicators

Support System

• Family, friends, community, faith community

• Quality of relationships

• Access to bereavement resources

Cultural and Spiritual Assessment

• Grief practices

• Spiritual beliefs about death and afterlife

• Rituals and ceremonies

• Role of faith community

Prior Loss History

• Previous experiences with loss

• Coping patterns with prior losses

• Unresolved grief from previous losses

Do’s & Don’ts for Nursing Interventions for Grieving Clients

Do

• "I'm so sorry for your loss."

• "Would you like to tell me about [name]?"

• "There are no right or wrong feelings in grief."

• "It's okay to cry. I'm here with you."

• Sit in silence with the patient — therapeutic presence

• "What has been the hardest part for you?"

• Use the deceased person's NAME

Dont

• "I know how you feel.”

• "At least they're no longer suffering."

• "You need to be strong for your family."

• "It was God's will." (unless patient expresses this belief first)

• Rush to fill silence with platitudes

• "You should be getting over this by now."

• Avoid the topic of death

Ethical Principles in End of Life

• Autonomy Patient has the right to make informed decisions about their own care, including refusing treatment

• Beneficence Act in the patient's best interest; promote comfort

• Nonmaleficence Do no harm; avoid prolonging suffering

• Justice Fair allocation of resources; equal access to palliative/hospice care

• Fidelity Keep promises; honor commitments to the patient and family

• Veracity Be truthful; provide honest information about prognosis