NLE Psychiatric Disorders — Anxiety, Obsessive-Compulsive, and Trauma-Related DisordersRevision Notes

Exam tips

• If a question asks 'what is the FIRST nursing action during a panic attack?' — the answer is almost always: STAY WITH THE CLIENT and remain calm.
• If a question asks about the perceptual field — remember the inverse relationship: MORE anxiety = LESS perceptual field.
• Questions about defense mechanisms often describe a behavior — identify the mechanism by its definition, not its name alone.
• Remember Maslow: Safety needs come FIRST during panic. Physiologic stabilization before psychosocial interventions.

Key points

• Anxiety is a VAGUE, SUBJECTIVE feeling of apprehension to an UNKNOWN or NONSPECIFIC threat — this distinguishes it from FEAR, which is a response to a KNOWN, IDENTIFIABLE threat.
• Anxiety exists on a continuum: Mild → Moderate → Severe → Panic. As anxiety INCREASES, the perceptual field NARROWS.
• MILD anxiety: Heightens awareness, improves learning and problem-solving — BENEFICIAL level.
• MODERATE anxiety: Narrowed perceptual field; client can still focus if directed; some physical symptoms begin.
• SEVERE anxiety: Greatly reduced perceptual field; scattered details; physical symptoms prominent (headache, palpitations, tremors, diaphoresis); cannot learn or problem-solve.
• PANIC: Most extreme level; loss of rational thought; disorganized behavior; terror; possible loss of control — THIS IS A SAFETY EMERGENCY.
• KEY NLE RULE: Do NOT attempt teaching with a SEVERELY anxious or PANICKING client. Wait until anxiety decreases to at least moderate level.
• Defense mechanisms (repression, denial, projection, displacement, sublimation) are UNCONSCIOUS ego strategies to manage anxiety. They become MALADAPTIVE when overused.
• NANDA nursing diagnoses for anxiety: 'Anxiety,' 'Fear,' 'Ineffective Coping,' 'Disturbed Sleep Pattern.'

Definitions

Common mistakes

• Confusing ANXIETY (unknown threat) with FEAR (known threat) — these are distinct concepts on the NLE.
• Attempting to teach or reason with a client during SEVERE anxiety or PANIC — always reduce anxiety FIRST.
• Thinking ALL anxiety is pathological — MILD anxiety is actually BENEFICIAL for learning and performance.
• Forgetting that as anxiety RISES, the nurse must SIMPLIFY communication (shorter sentences, calmer tone, one direction at a time).

Exam tips

• NLE question pattern: A client is described as always worried about everything for the past year — this is GAD, not panic disorder.
• When asked about nursing interventions for an anxious client, REDUCING STIMULATION and STAYING WITH THE CLIENT are almost always correct.
• CBT is the gold standard non-pharmacologic treatment for GAD — know this for theory questions.
• Buspirone = used for CHRONIC anxiety (GAD), NOT for acute panic attacks because it takes 2-4 weeks to work.

Key points

• GAD is characterized by EXCESSIVE, UNCONTROLLABLE WORRY about multiple areas of life (work, health, family, finances) for AT LEAST 6 MONTHS, more days than not.
• Associated symptoms: restlessness or feeling keyed up, easy fatigability, difficulty concentrating, irritability, MUSCLE TENSION, and sleep disturbance.
• Client often RECOGNIZES the worry is excessive but CANNOT STOP IT — this is key to differentiating from normal worry.
• GAD causes significant distress and functional impairment.
• First-line pharmacologic treatment: SSRIs (e.g., sertraline, escitalopram). Buspirone is also used for chronic GAD.
• First-line non-pharmacologic treatment: Cognitive-Behavioral Therapy (CBT).
• Nursing interventions: calm low-stimulation environment, short simple communication, relaxation techniques (deep breathing, progressive muscle relaxation, guided imagery), help client identify triggers and coping strategies.
• NANDA diagnosis: 'Anxiety related to perceived threat as evidenced by excessive worry and muscle tension.'

Definitions

Common mistakes

• Confusing GAD (chronic, multiple worries, 6+ months) with Panic Disorder (episodic, unexpected attacks).
• Forgetting the TIME CRITERION — the worry must be present MORE DAYS THAN NOT for at least 6 MONTHS.
• Overlooking MUSCLE TENSION as a hallmark physical symptom of GAD.

Exam tips

• NLE CLASSIC: 'A client is hyperventilating and says she feels like she is dying. What is the FIRST nursing action?' — Stay with the client, remain calm, guide slow breathing.
• The 'stay with the client' principle is rooted in Maslow's SAFETY AND SECURITY needs — your presence prevents harm.
• If asked about a client who avoids going to malls, churches, or markets for fear of having a panic attack — think AGORAPHOBIA.
• Remember: NO TEACHING during panic. Teaching resumes when anxiety drops to MILD or MODERATE level.

Key points

• Panic disorder: RECURRENT, UNEXPECTED panic attacks + persistent concern about future attacks or their consequences, OR significant behavioral changes related to the attacks.
• Panic attacks peak within MINUTES and include: palpitations, chest pain, dyspnea, choking sensation, dizziness, paresthesias, derealization/depersonalization, fear of dying, fear of 'going crazy,' sweating, trembling.
• AGORAPHOBIA: Fear of being in situations where escape is difficult or help unavailable during a panic attack (e.g., crowds, public transportation, open spaces). Often complicates panic disorder.
• Physical symptoms of panic attacks MIMIC MI (myocardial infarction) — clients frequently present to the ER. ALWAYS rule out cardiac causes first.
• PRIORITY NURSING INTERVENTIONS DURING A PANIC ATTACK:
• 1. STAY WITH THE CLIENT — never leave a panicking client alone (safety priority)
• 2. REMAIN CALM — the nurse's calm demeanor is therapeutic (therapeutic use of self)
• 3. Move to a QUIET, LOW-STIMULATION ENVIRONMENT
• 4. Use CALM, REASSURING VOICE with SHORT, CLEAR DIRECTIONS
• 5. Guide SLOW, CONTROLLED BREATHING to counter hyperventilation
• 6. Do NOT teach, reason, or problem-solve during peak panic
• First-line medications: SSRIs (long-term); Benzodiazepines (acute, short-term relief).
• Behavioral therapy: Systematic desensitization, interoceptive exposure.

Definitions

Common mistakes

• Leaving a panicking client alone to 'get help' — NEVER leave them unattended; call for assistance without leaving.
• Trying to EXPLAIN or TEACH during the peak of a panic attack — the client cannot process information at this level of anxiety.
• Forgetting that chest pain during a panic attack must have cardiac causes RULED OUT first — always assess physiologic causes.
• Confusing AGORAPHOBIA (fear of inability to escape) with SPECIFIC PHOBIA (fear of a specific object or situation).

Exam tips

• NLE CLASSIC: 'What therapy is used for phobias?' = SYSTEMATIC DESENSITIZATION.
• Remember the ORDER: RELAXATION FIRST, then gradual exposure. You cannot expose before the client has a coping tool.
• Social phobia + performance situations (e.g., public speaking) = beta-blockers (propranolol) can help manage physiologic symptoms.
• If the question describes 'gradual exposure to feared object while learning to relax' = systematic desensitization.

Key points

• A PHOBIA is a persistent, irrational, excessive fear of a SPECIFIC object or situation that causes marked avoidance and functional impairment.
• THREE TYPES:
• 1. SPECIFIC PHOBIA: Fear of a specific object or situation (animals, heights, blood, injections, flying).
• 2. SOCIAL ANXIETY DISORDER (Social Phobia): Fear of scrutiny, embarrassment, or humiliation in social situations.
• 3. AGORAPHOBIA: Fear of situations from which escape is difficult (as covered under panic disorder).
• Treatment: BEHAVIORAL APPROACHES are the mainstay — specifically SYSTEMATIC DESENSITIZATION.
• SYSTEMATIC DESENSITIZATION: Gradual, step-by-step exposure to the feared stimulus PAIRED WITH RELAXATION techniques. Developed by Joseph Wolpe. Steps: (1) teach relaxation, (2) construct anxiety hierarchy, (3) gradual exposure from least to most feared.
• FLOODING (Implosion Therapy): Immediate, intense exposure to the most feared stimulus without gradual steps. More distressing but faster.
• Nursing role: SUPPORT the client through the exposure hierarchy. Do NOT force or rush confrontation with the feared stimulus.
• SSRIs and beta-blockers (for social phobia) may be used as adjuncts.

Definitions

Common mistakes

• Confusing SYSTEMATIC DESENSITIZATION (gradual exposure + relaxation) with FLOODING (immediate intense exposure) — they are opposite approaches.
• Thinking the nurse should FORCE the client to confront their fear immediately — always work at the CLIENT'S PACE.
• Forgetting that in BLOOD-INJECTION-INJURY phobia, the client may faint (vasovagal response) — a unique physiologic response not seen in other phobias.

Exam tips

• NLE CLASSIC: 'A client with OCD performs handwashing rituals repeatedly. What is the BEST nursing intervention?' = Allow the client to complete the ritual and set gradual limits over time.
• The NLE may describe skin breakdown (redness, excoriation on hands) — recognize this as a PHYSICAL complication of OCD handwashing and address it under 'Impaired Skin Integrity.'
• ERP = gold standard therapy for OCD. SSRIs = first-line pharmacology for OCD.
• Remember: OCD is now classified SEPARATELY from anxiety disorders in DSM-5, but its mechanism is still anxiety-driven — this distinction may appear in NLE theory questions.

Key points

• OCD = OBSESSIONS (intrusive thoughts/urges/images causing anxiety) + COMPULSIONS (repetitive behaviors/mental acts to REDUCE that anxiety).
• OBSESSIONS: recurrent, unwanted, intrusive thoughts/images/urges. Client recognizes them as their own but cannot control them. Common: contamination, harm, symmetry, forbidden thoughts.
• COMPULSIONS: Repetitive behaviors or mental acts performed to neutralize the obsession's anxiety. Common: handwashing, checking, counting, arranging. Client usually KNOWS the rituals are excessive but cannot stop.
• Rituals are TIME-CONSUMING (>1 hour/day) and impair functioning.
• THE CENTRAL NURSING PRINCIPLE: THE RITUAL IS THE CLIENT'S MECHANISM TO CONTROL ANXIETY. Do NOT abruptly interrupt or stop the ritual early in treatment — this ESCALATES ANXIETY and breaks trust.
• Nursing management:
• 1. ALLOW TIME for the ritual (structured schedule).
• 2. Gradually SET LIMITS on time spent in rituals as the client improves.
• 3. PROTECT SKIN INTEGRITY if handwashing rituals cause excoriation or breakdown.
• 4. Convey ACCEPTANCE of the person while working to reduce ritual time.
• 5. Support EXPOSURE AND RESPONSE PREVENTION (ERP) therapy — the gold standard behavioral treatment.
• Pharmacology: SSRIs (fluoxetine, fluvoxamine, sertraline, paroxetine) are first-line. Higher doses may be needed than for depression.
• NANDA diagnoses: 'Anxiety,' 'Ineffective Coping,' 'Impaired Skin Integrity' (for handwashing rituals).

Definitions

Common mistakes

• Abruptly STOPPING or INTERRUPTING the client's ritual — this is WRONG nursing action early in treatment; it escalates anxiety and damages the therapeutic relationship.
• Judging or showing disgust at rituals (e.g., excessive cleaning) — maintain ACCEPTANCE and NONJUDGMENTAL ATTITUDE.
• Forgetting SKIN INTEGRITY as a physical nursing concern in clients with handwashing compulsions.
• Confusing OCD (ego-dystonic — client knows it's irrational) with OCPD/Obsessive-Compulsive Personality Disorder (ego-syntonic — client sees the behavior as appropriate and desirable).

Exam tips

• NLE CLASSIC SCENARIO: Survivor of Typhoon Yolanda presenting with nightmares, flashbacks, avoiding anything that reminds them of the storm, 6 months after the event = PTSD (>1 month).
• TRUST and SAFETY are the FIRST nursing priorities for PTSD — this is the correct NLE answer before any other psychosocial intervention.
• Suicide risk screening = ALWAYS for PTSD clients. Use simple, direct questions: 'Are you having thoughts of harming yourself?'
• EMDR and Trauma-Focused CBT are the evidence-based psychotherapies for PTSD — know both names for NLE theory questions.

Key points

• PTSD develops after exposure to actual or threatened DEATH, SERIOUS INJURY, or VIOLENCE (directly experienced, witnessed, or learned about).
• FOUR CORE SYMPTOM CLUSTERS:
• 1. INTRUSION: Flashbacks, nightmares, distressing memories, intense psychological distress at cues.
• 2. AVOIDANCE: Avoidance of trauma-related thoughts, feelings, people, places, activities.
• 3. NEGATIVE ALTERATIONS IN MOOD AND COGNITION: Persistent negative beliefs, guilt, blame, emotional numbing, detachment, inability to experience positive emotions.
• 4. HYPERAROUSAL AND REACTIVITY: Exaggerated startle response, hypervigilance, irritability, reckless behavior, sleep disturbance, difficulty concentrating.
• DURATION CRITERION — CRITICAL FOR NLE:
• ACUTE STRESS DISORDER: 3 DAYS to 1 MONTH after trauma
• PTSD: Symptoms PERSIST FOR MORE THAN 1 MONTH
• Philippine context: PTSD is a major public health concern after typhoons (Yolanda/Hainan), earthquakes, Marawi siege. RA 11036 (Mental Health Act) mandates disaster mental health response.
• NURSING MANAGEMENT:
• 1. ESTABLISH TRUST AND SAFETY FIRST — foundational before any other intervention.
• 2. NONJUDGMENTAL, SUPPORTIVE RELATIONSHIP — allow client to share at their OWN PACE, never force disclosure.
• 3. Teach GROUNDING TECHNIQUES for flashbacks (5-4-3-2-1 sensory grounding).
• 4. Help re-establish ROUTINE and SOCIAL SUPPORT.
• 5. ASSESS FOR: Depression, Substance Use, and SUICIDE RISK — these frequently co-occur with PTSD.
• Pharmacology: SSRIs (sertraline, paroxetine) are first-line. Prazosin for nightmares.
• Psychotherapy: Trauma-Focused CBT; Eye Movement Desensitization and Reprocessing (EMDR).
• NANDA diagnoses: 'Post-Trauma Syndrome,' 'Disturbed Sleep Pattern,' 'Risk for Self-Directed Violence,' 'Ineffective Coping.'

Definitions

Common mistakes

• Confusing ACUTE STRESS DISORDER (3 days to 1 month) with PTSD (more than 1 month) — the TIME FRAME is the NLE key.
• FORCING the client to recall trauma details prematurely — this is RE-TRAUMATIZING. Always establish trust and safety FIRST.
• Forgetting to ASSESS FOR SUICIDE RISK in all PTSD clients — PTSD has high comorbidity with suicidal ideation.
• Thinking PTSD only follows combat — in the Philippine context, it follows typhoons, earthquakes, sexual violence, and interpersonal trauma.

Exam tips

• For ALL dissociative disorders, the NLE answer for FIRST priority = SAFETY.
• NLE CLASSIC: 'A client says she feels like she is watching herself from outside her body' = DEPERSONALIZATION.
• DID is associated with severe, repeated childhood trauma — a background history of abuse in the scenario is a diagnostic clue.
• Dissociative Fugue involves travel — 'A client is found in another province and cannot remember who they are' = Dissociative Amnesia with Fugue.

Key points

• Dissociative disorders involve DISRUPTION in the normally integrated functions of CONSCIOUSNESS, MEMORY, IDENTITY, or PERCEPTION, usually as a DEFENSE AGAINST OVERWHELMING TRAUMA.
• THREE MAJOR TYPES:
• 1. DISSOCIATIVE AMNESIA: Inability to recall important autobiographical information, typically of a traumatic nature, beyond ordinary forgetfulness. May include DISSOCIATIVE FUGUE — sudden, unexplained travel from home with amnesia for identity.
• 2. DISSOCIATIVE IDENTITY DISORDER (DID): Presence of TWO OR MORE distinct personality states (alters) with GAPS IN MEMORY between them. Associated with severe, repeated childhood trauma.
• 3. DEPERSONALIZATION/DEREALIZATION DISORDER: Persistent feelings of DETACHMENT from one's own body (depersonalization) or surroundings (derealization). Client feels like an outside observer.
• Nursing care PRIORITIES:
• 1. SAFETY IS THE TOP PRIORITY — dissociative clients are at high risk for SELF-HARM and self-neglect.
• 2. CALM, SECURE, STRUCTURED ENVIRONMENT.
• 3. BUILD TRUST gradually — establish a therapeutic alliance before exploring trauma.
• 4. Do NOT flood the client with information about their trauma before a therapeutic alliance is established.
• 5. Help client RECOGNIZE AND COPE WITH STRESSORS and triggers.
• 6. In DID: Learn the names/traits of alters, maintain consistent boundaries across all alter states.
• NANDA diagnoses: 'Disturbed Personal Identity,' 'Risk for Self-Directed Violence,' 'Impaired Memory,' 'Anxiety.'

Definitions

Common mistakes

• Forcing discussion of traumatic memories BEFORE establishing a therapeutic alliance — this is harmful and re-traumatizing.
• Forgetting that SAFETY is the PRIORITY in dissociative disorders — risk of self-harm is HIGH.
• Confusing DEPERSONALIZATION (feeling detached from SELF) with DEREALIZATION (feeling detached from SURROUNDINGS).
• Treating DID alters as 'fake' or refusing to acknowledge them — the nurse works WITH the client's experience, maintaining consistent and safe boundaries.

Exam tips

• SSRI + MAOI = SEROTONIN SYNDROME. This is a priority patient safety NLE question.
• NLE CLASSIC: 'A client on sertraline says it is not working after 1 week.' Correct response: 'SSRIs take 2–4 weeks to work; continue taking as prescribed.'
• Benzodiazepine overdose = FLUMAZENIL. Opioid overdose = NALOXONE. Do not confuse these antidotes.
• Benzodiazepine withdrawal = SEIZURE risk — always TAPER, never abrupt discontinuation.
• Fall risk and sedation = key benzodiazepine concerns especially for elderly Filipino patients in community settings (RA 9173 scope of community nursing).

Key points

• SEROTONIN REUPTAKE INHIBITORS (SSRIs) — FIRST-LINE PHARMACOLOGY:
• Examples: Fluoxetine, Sertraline, Paroxetine, Escitalopram, Fluvoxamine.
• Used for: GAD, panic disorder, social phobia, OCD, PTSD — BROAD spectrum anxiety treatment.
• Mechanism: Block reuptake of serotonin in the synaptic cleft, increasing serotonin availability.
• KEY TEACHING POINTS FOR SSRIs:
• 1. FULL THERAPEUTIC EFFECT TAKES 2–4 WEEKS (up to 6 weeks). Tell client: 'Do not stop just because you don't feel better right away.'
• 2. DO NOT STOP ABRUPTLY — tapering required to prevent DISCONTINUATION SYNDROME (dizziness, flu-like symptoms, irritability, 'brain zaps').
• 3. Common early side effects: nausea, headache, insomnia or drowsiness, SEXUAL DYSFUNCTION (frequent cause of nonadherence — ask about this).
• 4. Monitor for INCREASED SUICIDAL IDEATION in adolescents and young adults during the FIRST FEW WEEKS (Black Box Warning — energy returns before mood lifts).
• 5. SEROTONIN SYNDROME risk — when combined with other serotonergic drugs: MAOIs, triptans, tramadol, St. John's Wort. Signs: hyperthermia, agitation, tremor, hyperreflexia, CLONUS, diaphoresis. NEVER combine SSRI with MAOI — observe WASHOUT PERIOD.
• BENZODIAZEPINES — SHORT-TERM ACUTE ANXIETY:
• Examples: Lorazepam, Diazepam, Alprazolam, Clonazepam, Chlordiazepoxide.
• Mechanism: Enhance the effect of GABA (inhibitory neurotransmitter) → CNS depression → reduces anxiety.
• KEY TEACHING POINTS FOR BENZODIAZEPINES:
• 1. RAPID ONSET — useful for ACUTE anxiety and panic attacks.
• 2. SHORT-TERM USE ONLY — HIGH RISK of TOLERANCE, DEPENDENCE, and WITHDRAWAL with prolonged use.
• 3. CNS DEPRESSION — sedation, impaired coordination. CAUTION: driving, machinery, FALL RISK IN ELDERLY.
• 4. AVOID ALCOHOL and other CNS depressants — ADDITIVE, POTENTIALLY FATAL RESPIRATORY DEPRESSION.
• 5. NEVER STOP ABRUPTLY — withdrawal can cause: rebound anxiety, tremors, SEIZURES (life-threatening).
• 6. TAPER GRADUALLY under medical supervision.
• 7. ANTIDOTE for benzodiazepine overdose = FLUMAZENIL.
• BUSPIRONE:
• Non-benzodiazepine anxiolytic for CHRONIC GAD.
• NO dependence, NO CNS depression, NO additive effect with alcohol.
• TAKES 2–4 WEEKS to work — NOT for acute panic attacks.
• NANDA diagnoses related to pharmacology: 'Risk for Injury,' 'Deficient Knowledge,' 'Noncompliance.'

Definitions

Common mistakes

• Telling a client the SSRI should work in 2–3 days — SSRIs take 2–4 WEEKS for full therapeutic effect.
• Forgetting the BLACK BOX WARNING: SSRIs can INCREASE SUICIDAL IDEATION in adolescents and young adults during the first weeks of treatment.
• Allowing a client on benzodiazepines to stop the medication abruptly — WITHDRAWAL SEIZURES can be FATAL.
• Thinking benzodiazepines are safe for long-term use — they are SHORT-TERM ONLY due to dependence risk.
• Giving buspirone to a client having an acute panic attack — it will not work; it takes weeks.
• Forgetting FLUMAZENIL as the antidote for benzodiazepine overdose.

Exam tips

• NLE theory questions may ask about client rights under RA 11036 — memorize: humane treatment, informed consent, no discrimination, community-based care.
• When asked about the nurse's role in patient teaching for SSRIs — always include: 2–4 weeks onset, no abrupt discontinuation, monitor for suicidal ideation.
• Philippine community nursing context: barangay health centers and LGU health teams now have mandated mental health roles under RA 11036.
• HOPELINE (02-804-HOPE) is the DOH-affiliated crisis hotline — relevant for discharge planning and community referral questions.

Key points

• Client and family education is a core nursing responsibility under RA 9173 (Philippine Nursing Act of 2002) and is guided by the Mental Health Act (RA 11036).
• RA 11036 (Mental Health Act): Guarantees every Filipino's right to mental health services, informed consent, privacy and confidentiality, humane treatment, community-based care, and freedom from discrimination.
• Reduce STIGMA — a major barrier to mental health care-seeking in the Philippines. Normalize help-seeking behavior within cultural context.
• KEY PATIENT TEACHING POINTS:
• 1. Nature of the disorder — anxiety disorders are MEDICAL CONDITIONS, not personal weakness ('kahinaan ng loob').
• 2. SSRI: Takes 2–4 weeks to work; do not stop abruptly; report suicidal thoughts immediately.
• 3. BENZODIAZEPINE: Short-term use only; avoid alcohol; do not stop abruptly; do not drive when sedated.
• 4. Practice relaxation techniques DAILY, not only during anxiety episodes.
• 5. Avoid caffeine, alcohol, and recreational drugs — these worsen anxiety.
• 6. SEEK HELP immediately if: symptoms worsen, thoughts of self-harm appear, or cannot function at work/home.
• 7. Connect clients to community mental health services — available through local government units under DOH guidelines and RA 11036.
• MENTAL HEALTH RESOURCES IN THE PHILIPPINES:
• National Center for Mental Health (NCMH), Mandaluyong
• DOH Tele-mental health services
• LGU-based community mental health teams (mandated by RA 11036)
• Collaborative care in barangay health centers
• Crisis hotlines: HOPELINE (02-804-HOPE)

Definitions

Common mistakes

• Dismissing the cultural belief that anxiety is 'lambing' or 'nagpapanggap' — nurses must address stigma with psychoeducation, not reinforcement.
• Failing to teach about the GRADUAL TAPERING required for both SSRIs and benzodiazepines.
• Not assessing for SUICIDE RISK at every mental health nursing encounter.
• Forgetting that community-based mental health care is a RIGHT under RA 11036 — the nurse can advocate for referral to LGU mental health services.