Personality, Somatic, and Eating Disorders - Detailed Explanation
This chapter covers three major groups of psychiatric disorders that frequently appear in the Philippine Nursing Licensure Examination (NLE): personality disorders, somatic symptom and related disorders, and eating disorders. These conditions share a common thread — they all involve maladaptive patterns of thinking, feeling, and behaving that cause significant distress and impairment. As a nursing graduate, you must understand not only the clinical features of each disorder but also the correct nursing management, prioritization of care, and the legal framework under the Philippine Mental Health Act (Republic Act No. 11036), which guides humane, rights-based psychiatric nursing practice. Eating disorders carry the highest mortality of any psychiatric illness, making accurate assessment and early intervention critical. Throughout this review, Maslow's hierarchy of needs guides your priority-setting: physiological stability and safety always come before psychosocial interventions.
Personality Disorders: Definition, Clusters, and General Principles
Examples
A client with Borderline Personality Disorder tells Nurse Ana, 'You are the only nurse who really understands me. The other nurses don't care about me at all.' The next day, the client tells another nurse that Nurse Ana is 'incompetent and uncaring.'
Solution
This is classic splitting behavior. The nursing team should meet and agree on a consistent, unified care plan. Nurse Ana should not feel flattered by idealization, and the other nurse should not feel hurt by devaluation. Both should respond calmly and maintain firm, consistent limits.
Splitting is the defense mechanism where the client cannot integrate positive and negative qualities — people are either all good or all bad. A unified team approach prevents the client from manipulating staff by playing one against another. Consistent communication among nurses is the priority nursing intervention.
A client with Antisocial Personality Disorder repeatedly violates ward rules, argues that the rules 'don't apply' to him, and convinces a student nurse to bring his personal phone despite hospital policy.
Solution
The nurse should firmly and calmly enforce the rules without becoming punitive or angry. The team should re-orient the student nurse on the importance of consistent limit-setting. Document all behavior objectively.
Clients with Antisocial PD use charm and manipulation to test limits and circumvent rules. Firm, consistent, non-punitive enforcement by the entire team is essential. Inconsistency from any team member reinforces the manipulative behavior.
A personality disorder is an enduring, pervasive, and inflexible pattern of inner experience and behavior that deviates significantly from cultural expectations. It typically begins by adolescence or early adulthood, is stable over time, and leads to distress or functional impairment. Unlike mood or psychotic disorders, personality disorders are ego-syntonic — the person often does not recognize their own behavior as problematic, making therapeutic engagement challenging. The DSM-5 organizes the ten personality disorders into three clusters based on descriptive similarities:
Cluster A — 'Odd or Eccentric': Paranoid (pervasive distrust and suspiciousness), Schizoid (social detachment, emotional coldness, preference for solitary activities), and Schizotypal (social discomfort, magical thinking, odd beliefs, and perceptual distortions). These clients are often perceived as strange or unusual by others. The nursing approach emphasizes honesty, consistency, and respect for the client's need for personal space and distance without forcing closeness.
Cluster B — 'Dramatic, Emotional, or Erratic': Borderline (instability in relationships, self-image, and affect; impulsivity; fear of abandonment; self-harm; splitting), Antisocial (disregard for others' rights; manipulation; deceitfulness; lack of remorse), Histrionic (excessive emotionality; attention-seeking; theatrical behavior), and Narcissistic (grandiosity; need for admiration; lack of empathy). This cluster is the most clinically significant in nursing practice, particularly Borderline Personality Disorder (BPD) because of the high risk of self-harm and suicidal behavior.
Cluster C — 'Anxious or Fearful': Avoidant (social inhibition; feelings of inadequacy; fear of rejection and criticism), Dependent (excessive need to be taken care of; difficulty making independent decisions; clinging behavior), and Obsessive-Compulsive Personality Disorder or OCPD (preoccupation with orderliness, perfectionism, and control — distinct from OCD, which has true obsessions and compulsions). The nursing approach promotes independence, assertiveness, and gradual responsibility-taking.
General nursing management across all personality disorders includes: maintaining a consistent, structured therapeutic environment; setting clear and enforceable limits; using a unified team approach to prevent splitting (especially in Cluster B); ensuring physical safety; and facilitating the client's recognition of how their behavior affects themselves and others. Under RA 11036, all clients retain their rights to dignity, privacy, and informed consent even during psychiatric hospitalization.
Applications
- Priority nursing diagnosis for Borderline PD: Risk for Self-Mutilation or Risk for Suicide — physiological safety (Maslow Level 1 and 2) is always first
- Use NANDA nursing diagnoses: Ineffective Coping, Disturbed Personal Identity, Risk for Self-Directed Violence
- Limit-setting in clinical practice: clearly state the behavior, the limit, and the consequence consistently and without anger
- Document behaviors objectively (e.g., 'Client struck the wall with his fist' not 'Client was angry')
- In Philippine community settings under RA 11036, community-based mental health services (Barangay Mental Health Programs) may provide ongoing support for clients with personality disorders
Common misconceptions
- Misconception: Personality disorders are the same as OCD. Fact: OCPD is a personality disorder; OCD is an anxiety-related disorder with true obsessions and compulsions — different diagnoses requiring different management.
- Misconception: Clients with Antisocial PD are always violent. Fact: The hallmark is manipulation and lack of remorse, not necessarily physical violence.
- Misconception: Splitting means the client is lying. Fact: Splitting is a genuine defense mechanism — the client truly perceives people as all-good or all-bad at that moment.
- Misconception: DBT is used for all personality disorders. Fact: DBT is specifically evidence-based for Borderline PD; other approaches are used for other disorders.
- Misconception: Medication cures personality disorders. Fact: Medication only targets specific symptoms (mood instability, impulsivity) — the disorder itself is treated through long-term psychotherapy.
Related concepts
- Defense mechanisms (splitting, projection, rationalization)
- Therapeutic communication techniques
- Suicide and self-harm risk assessment
- Dialectical Behavior Therapy (DBT)
- RA 11036 — Philippine Mental Health Act
- Nursing process: ADPIE applied to psychiatric nursing
Common exam questions
Example
A client with Borderline PD has just cut her wrists superficially. What is the nurse's priority action? Answer: Ensure the client's physical safety and assess the wound — physiological safety first, then notify the physician and document.
Approach
Apply Maslow's hierarchy — safety (self-harm, suicide risk) is always the priority for BPD. Then look for options addressing consistent limit-setting and unified team approach.
Example
A 28-year-old male has repeatedly violated laws, shown no remorse for harming others, and consistently blames others for his actions. Which personality disorder is most consistent? Answer: Antisocial Personality Disorder (Cluster B).
Approach
Know the defining features of each: BPD = fear of abandonment + splitting + self-harm; Antisocial = manipulation + no remorse; OCPD = perfectionism + control (no true obsessions). Match the clinical scenario to the cluster and specific disorder.
Example
A client with Paranoid PD accuses the nurse of poisoning her medication. Best response: 'I understand you are concerned. I can open the medication package in front of you so you can see it is sealed.'
Approach
Select the response that is consistent, honest, non-judgmental, and maintains appropriate limits without being punitive or dismissive.
Key points to remember
- Personality disorders = enduring, inflexible, pervasive patterns beginning in adolescence or early adulthood
- Cluster A = Odd/Eccentric: Paranoid, Schizoid, Schizotypal — nurse approach: honest, consistent, non-intrusive
- Cluster B = Dramatic/Erratic: Borderline, Antisocial, Histrionic, Narcissistic — nurse approach: firm, consistent limits; unified team
- Cluster C = Anxious/Fearful: Avoidant, Dependent, OCPD — nurse approach: promote independence, support assertiveness
- Ego-syntonic = client often doesn't see own behavior as the problem
- Splitting (all-good or all-bad) is a hallmark of Borderline PD — staff must communicate consistently to prevent manipulation
- DBT (Dialectical Behavior Therapy) is the evidence-based treatment of choice for Borderline PD
- OCPD ≠ OCD: OCPD is a personality pattern; OCD has true intrusive obsessions and compulsions
- Medication targets specific symptoms (impulsivity, mood instability) not the personality disorder itself
- All care governed by RA 11036 (Philippine Mental Health Act)
Borderline Personality Disorder: In-Depth Clinical Focus
Examples
A hospitalized client with BPD threatens to cut herself if the nurse does not allow her an extra phone call. The nurse feels pressured.
Solution
The nurse should calmly acknowledge the client's distress: 'I can see you are very upset right now.' Then firmly maintain the limit: 'The unit policy is one call per hour. I am concerned about your safety. Can you tell me what you are feeling right now?' Ensure the environment is safe and remove any sharp objects. Do not give in to the threat, but do not abandon the client.
This is coercive behavior related to fear of abandonment. The nurse must balance empathy with firm limit-setting. Giving in reinforces the maladaptive behavior. Removing means and staying present addresses the immediate safety priority.
Borderline Personality Disorder (BPD) is the most clinically challenging and NLE-relevant personality disorder because of its high risk for self-harm and suicide. The core features of BPD revolve around instability — in relationships, in self-image, in affect (emotions), and in behavior. Clients with BPD have a profound fear of abandonment, whether real or imagined, and will go to great lengths to prevent it, including making suicidal gestures.
Key clinical features of BPD (remember with the mnemonic 'I DESPAIR'):
- Impulsivity in at least two self-damaging areas (spending, sex, substance use, reckless driving, binge eating)
- Disturbance of identity (unstable self-image, sense of self)
- Emptiness (chronic feelings of emptiness)
- Suicidal behavior, gestures, threats, or self-mutilating behavior (cutting, burning)
- Paranoic ideation (transient, stress-related) or dissociative symptoms
- Affective instability (intense episodic dysphoria, irritability, or anxiety)
- Intense unstable relationships (alternating between idealization and devaluation = SPLITTING)
- Rage (inappropriate, intense anger or difficulty controlling anger)
Splitting is the hallmark defense mechanism of BPD. The client cannot hold both positive and negative qualities of a person simultaneously, so people (including nurses) are seen as either entirely good ('you are the best nurse') or entirely bad ('you are the worst nurse'). This creates staff conflict if the team is not communicating consistently.
Nursing Management Priority:
- First priority: Client safety — assess for suicidal ideation, self-harm, and means (Maslow: physiological safety)
- Establish a consistent therapeutic relationship — be honest, genuine, and predictable
- Set clear, firm limits — state expectations calmly and consistently
- Unified team approach — all staff agree on the same care plan; document and communicate consistently
- Avoid power struggles — do not argue or engage in debates about the rules
- Implement DBT skills (distress tolerance, emotion regulation, mindfulness, interpersonal effectiveness)
- Do not reinforce splitting by taking sides or responding with emotional intensity
NANDA Nursing Diagnoses for BPD:
- Risk for Self-Mutilation
- Risk for Suicide
- Disturbed Personal Identity
- Ineffective Coping
- Impaired Social Interaction
- Chronic Low Self-Esteem
Applications
- In the NLE, BPD scenarios often test: (1) recognizing splitting, (2) correct limit-setting responses, (3) priority nursing diagnosis selection (safety first), and (4) identifying DBT as the treatment of choice
- In Philippine hospital settings, the psychiatric unit should have a clearly documented care plan shared among all staff to prevent splitting
- Under RA 11036, voluntary admission is preferred; involuntary admission requires proper documentation and due process — know the criteria
Common misconceptions
- Misconception: Self-mutilation in BPD always means the client wants to die. Fact: Self-harm is often used to regulate overwhelming emotions or to feel something when feeling numb — suicidal intent must be assessed each time, but intent varies.
- Misconception: Being kind and flexible is the best way to help a BPD client. Fact: Inconsistency and flexibility in enforcing limits actually worsens the disorder by reinforcing maladaptive coping.
- Misconception: BPD is untreatable. Fact: DBT has strong evidence for reducing self-harm and improving functioning in BPD.
Related concepts
- Splitting as a defense mechanism
- Dialectical Behavior Therapy (DBT)
- Suicide risk assessment
- Therapeutic limit-setting
- Antisocial Personality Disorder (contrast: manipulation without fear of abandonment)
Common exam questions
Example
A client tells the day nurse she is wonderful, then tells the evening nurse the day nurse is cruel and incompetent. This behavior is best described as: A) Projection B) Splitting C) Rationalization D) Repression. Answer: B) Splitting.
Approach
Look for the pattern of idealizing then devaluing the same person — this is splitting, the hallmark of BPD.
Example
A BPD client demands that a rule be broken 'just this once.' Best response: 'I understand you are frustrated. The rule applies to everyone on the unit and I am not able to make exceptions.'
Approach
Choose the response that is empathetic AND maintains firm limits — neither dismissive nor accommodating of the manipulative behavior.
Key points to remember
- Fear of abandonment is the core driving anxiety in BPD
- Splitting = seeing people as all-good or all-bad; the primary defense mechanism in BPD
- Self-mutilation (cutting, burning) is often used to relieve emotional pain, NOT necessarily to end life — but suicidal risk is still real
- Priority: SAFETY first — always assess for suicidal ideation and self-harm means
- DBT = Dialectical Behavior Therapy — the treatment of choice for BPD
- Nursing approach: consistent, firm, non-punitive limits; unified team communication
- Avoid staff splitting by holding team conferences and communicating the care plan consistently
- Transient paranoid ideation can occur under stress — this is not schizophrenia
- Medications are adjunctive: mood stabilizers, low-dose antipsychotics for impulsivity and paranoia
Somatic Symptom and Related Disorders
Examples
A client has been admitted multiple times with complaints of chest pain, abdominal pain, and headache. All cardiac and neurological workups are negative. She spends hours researching diseases online and believes she has cancer. She becomes distressed when the doctor tells her all tests are normal.
Solution
This presentation is consistent with Illness Anxiety Disorder. The nurse should acknowledge her distress ('I understand these symptoms are very real and frightening for you'), avoid dismissing her concerns, limit unnecessary reassurance-seeking, and help her explore the relationship between her anxiety and her physical symptoms. Referral to a consistent mental health provider is appropriate.
Illness Anxiety Disorder clients are not reassured by negative tests — in fact, negative results may temporarily increase anxiety. The nurse's role is to validate the experience, not debate the reality of symptoms, while gently redirecting toward coping and stress management.
After a stressful family conflict, a 30-year-old woman develops sudden inability to move her left arm. Neurological examination finds no anatomical basis. When the nurse asks her about it, she seems unconcerned and says, 'Oh, it'll probably get better.'
Solution
This is Conversion Disorder. The 'la belle indifférence' (apparent lack of concern about a serious symptom) is the clinical clue. The nurse should assess for a precipitating stressor, acknowledge the symptom, maintain a calm and supportive demeanor, and focus on functional rehabilitation rather than the symptom itself.
La belle indifférence is the key distinguishing feature of conversion disorder — the client's lack of distress is disproportionate to what would be expected for their degree of apparent disability.
Somatic symptom and related disorders are characterized by physical symptoms or health preoccupation that cause significant distress and impairment. The critical point is that these symptoms are REAL to the client — they are not faking or malingering — and the symptoms are not intentionally produced (except in factitious disorder, which is a separate category). Understanding this distinction is essential for therapeutic communication and nursing management.
Key disorders in this group:
1. Somatic Symptom Disorder: One or more distressing physical symptoms (pain, fatigue, gastrointestinal complaints) accompanied by excessive thoughts, feelings, and behaviors about them. The client devotes disproportionate time and energy to health concerns. The symptoms persist despite negative medical workup.
2. Illness Anxiety Disorder (formerly Hypochondriasis): Preoccupation with having or acquiring a serious illness, with minimal or no actual physical symptoms. The client has high health anxiety and is not reassured by negative test results. They frequently check their body for signs of illness and seek medical consultations ('doctor-shopping').
3. Conversion Disorder (Functional Neurological Symptom Disorder): Neurological symptoms (motor weakness, paralysis, blindness, seizures, aphonia) that are inconsistent with recognized neurological or medical disease. A hallmark feature is 'la belle indifférence' — the client shows a surprising lack of concern about their apparent disability. A preceding psychosocial stressor is often identified.
4. Factitious Disorder (Munchausen Syndrome): Deliberate falsification or induction of signs and symptoms to assume the sick role, WITHOUT external incentive. This IS intentional but the motivation is the sick role itself (internal gain), not financial or other external gain. Factitious disorder imposed on another (previously Munchausen by Proxy) involves producing symptoms in another person (such as a child).
Note: Malingering is NOT a mental disorder — it is deliberate feigning of symptoms for external gain (e.g., avoiding military duty, financial compensation). This is distinguished from both somatic disorders and factitious disorder.
Nursing Management:
- Always rule out a genuine medical cause first — these clients can also develop real physical illness, and dismissing symptoms can be dangerous and violates nursing standards of care under RA 9173
- Acknowledge the client's experience — say 'I can see you are in pain' not 'There is nothing wrong with you'
- Do NOT confront the client with 'it's all in your head' — this damages the therapeutic relationship and increases distress
- Limit secondary gain — avoid excessive attention and reinforcement of the sick role; respond in a calm, matter-of-fact manner
- Gradually help the client connect emotional stress to physical symptoms — this is a long-term therapeutic goal
- Teach adaptive coping and stress management skills
- Maintain a consistent primary provider to reduce unnecessary testing and multiple consultations
- For conversion disorder, acknowledge the symptom while focusing on function: 'We will work on what you can do'
Applications
- NLE scenarios often test: recognizing la belle indifférence in conversion disorder, distinguishing factitious disorder from malingering, and identifying the correct therapeutic communication response
- In Philippine clinical settings (PHilHealth-accredited hospitals and RHUs), consistent care coordination prevents unnecessary resource utilization from doctor-shopping
- Nursing diagnosis priority: Anxiety, Ineffective Coping, and — in factitious disorder — Risk for Injury (due to self-inflicted harm to produce symptoms)
Common misconceptions
- Misconception: Clients with somatic disorders are 'just seeking attention' and their symptoms are fake. Fact: Symptoms are genuinely experienced — dismissing them is both therapeutically harmful and potentially dangerous if a real illness is missed.
- Misconception: Factitious disorder and malingering are the same. Fact: Factitious disorder = internal gain (sick role); malingering = external gain (money, legal). Both involve intentional deception, but motivation differs.
- Misconception: Reassuring a client with Illness Anxiety Disorder that tests are normal will relieve their anxiety. Fact: Reassurance is temporarily effective at best and may worsen the pattern over time.
Related concepts
- Anxiety disorders (distinguished from somatic disorders by the primary locus of concern)
- Pain management and chronic pain nursing
- Therapeutic communication: validation vs. reassurance
- Secondary gain in illness behavior
- Malingering vs. factitious disorder
Common exam questions
Example
A client deliberately induces vomiting to get admitted to the hospital because she enjoys the attention of medical staff. No external gain is involved. This is: A) Malingering B) Somatic Symptom Disorder C) Factitious Disorder D) Conversion Disorder. Answer: C) Factitious Disorder — intentional, for the sick role (internal gain).
Approach
Use the key differentiators: intentional vs. unintentional production, internal vs. external gain, presence or absence of symptoms.
Example
Client says, 'I know something is seriously wrong with me even though the tests are normal.' Best nurse response: 'It sounds like you are very worried about your health. Tell me more about what you have been experiencing.'
Approach
Select the response that validates the client's experience without reinforcing illness behavior or confronting the psychological nature of the symptom.
Key points to remember
- Symptoms are REAL to the client and NOT intentionally produced (except factitious disorder)
- Do NOT say 'it's in your head' — acknowledge the client's experience always
- Somatic Symptom Disorder = distressing physical symptoms + excessive health-related thoughts and behaviors
- Illness Anxiety Disorder = high health anxiety + minimal physical symptoms + not reassured by negative tests
- Conversion Disorder = neurological symptoms + inconsistency with known disease + 'la belle indifférence'
- Factitious Disorder = DELIBERATE symptom production for the sick role (internal gain) — NOT malingering
- Malingering = deliberate symptom feigning for EXTERNAL gain (financial, legal) — NOT a mental disorder
- Rule out real medical illness FIRST — safety and physiological assessment precede psychiatric labeling
- Limit secondary gain, maintain consistent provider, link stress to symptoms over time
- Nursing diagnosis: Ineffective Coping, Anxiety, Chronic Pain (related to psychological factors)
Eating Disorders: Anorexia Nervosa and Bulimia Nervosa
Examples
A 19-year-old female is admitted with a BMI of 14.5. She insists she is 'still fat' and refuses to eat. On physical assessment, the nurse notes bradycardia (HR 48 bpm), blood pressure 88/56 mmHg, amenorrhea for 6 months, and fine downy hair on her forearms and back.
Solution
This is anorexia nervosa (restricting type). The nurse's PRIORITY is physical stabilization — correct electrolytes, cardiac monitoring, and careful nutritional reintroduction. The fine downy hair is LANUGO. The distorted body image ('I am still fat' despite BMI 14.5) is the cognitive distortion of anorexia.
Applying Maslow's hierarchy: physiological stabilization (cardiac monitoring, electrolyte correction, nutritional reintroduction) is the absolute first priority. Psychological interventions (CBT, body image work) come after medical stabilization. Lanugo is a classic NLE-tested finding.
A 22-year-old college student visits the campus clinic. She is of normal weight. The school dentist referred her because of unusual tooth enamel erosion. During the interview, she admits to binge eating and self-induced vomiting 'a few times a week.' The nurse notices small scars on the knuckles of her right hand.
Solution
This presentation is consistent with Bulimia Nervosa. The dental erosion is from repeated acid exposure from vomiting. The scars on the knuckles are RUSSELL'S SIGN. Despite being normal weight, the metabolic and physical damage from purging is significant. Electrolytes (especially potassium) and cardiac rhythm must be assessed.
Russell's sign is the specific physical finding in bulimia from self-induced vomiting. Dental erosion is another objective assessment finding. Normal weight makes bulimia less visually obvious — the nurse must look for these specific signs.
Eating disorders are severe psychiatric conditions involving disturbed eating behaviors, distorted body image, and profound physical medical complications. They have the HIGHEST MORTALITY RATE of any psychiatric disorder — a fact that is frequently tested on the NLE. Most commonly affecting adolescent and young adult females, though increasingly seen in males, eating disorders are fundamentally about control, self-worth, and identity — not simply about food.
ANOREXIA NERVOSA:
Anorexia nervosa is characterized by three core features:
- Restriction of caloric intake leading to significantly low body weight (below minimum normal for age, sex, and developmental stage)
- Intense fear of gaining weight or becoming fat — even when already dangerously underweight
- Disturbance in the way body weight or shape is experienced — the client genuinely sees herself as fat even when extremely thin (distorted body image)
Subtypes: Restricting type (achieves low weight only through dieting, fasting, excessive exercise) and Binge-eating/Purging type (engages in binge eating and/or purging within the context of anorexia).
Physical Assessment Findings in Anorexia Nervosa (all from starvation):
- Amenorrhea (absence of menstruation — due to hormonal disruption from low body fat)
- Bradycardia (slow heart rate — the heart muscle is also starved)
- Hypotension (low blood pressure)
- Hypothermia (low body temperature — loss of insulating fat)
- Lanugo (fine, soft body hair that grows as an adaptive response to maintain warmth)
- Dry, yellowish skin (from carotenemia and poor nutrition)
- Electrolyte imbalances — particularly hypokalemia, which endangers the heart
- Cardiac arrhythmias — the leading cause of death in anorexia
- Osteoporosis (from low estrogen and poor calcium intake)
- Constipation, cold intolerance, hair loss, muscle wasting
BULIMIA NERVOSA:
Bulimia nervosa is characterized by:
- Recurrent episodes of binge eating — eating an abnormally large amount of food in a discrete period with a sense of lack of control
- Recurrent inappropriate compensatory behaviors to prevent weight gain: self-induced vomiting, misuse of laxatives, diuretics, or enemas, fasting, or excessive exercise
- Binge-purge cycle occurs at least once a week for 3 months
- Self-evaluation is unduly influenced by body shape and weight
Critically, clients with bulimia are usually of normal weight or slightly above normal weight — the disorder is often hidden and can go undetected for years.
Physical Assessment Findings in Bulimia Nervosa (largely from purging behaviors):
- Electrolyte imbalances — hypokalemia and metabolic alkalosis (from loss of gastric acid through vomiting)
- Dental enamel erosion and dental caries (from acid in vomit bathing the teeth)
- Russell's sign — calluses or scars on the dorsum (back) of the hand/knuckles from repeatedly inducing vomiting
- Parotid gland swelling (enlarged salivary glands, giving a 'chipmunk cheek' appearance)
- Esophagitis and risk of esophageal tears (Mallory-Weiss tears) from repeated vomiting
- Cardiac arrhythmias from hypokalemia
- Menstrual irregularities (though less severe than anorexia)
- Callused throat from gagging
Applications
- Nursing care: observe clients DURING meals and for 1 HOUR after — this is a direct intervention to prevent purging and is frequently tested in the NLE
- Monitor weight consistently: same time daily (usually morning, after voiding), same scale, same clothing (to prevent cheating such as hiding weights in clothing)
- Check electrolytes regularly — especially potassium, phosphate, and magnesium; report abnormalities immediately
- Cardiac monitoring is mandatory for both disorders — arrhythmias are the leading cause of death
- Use matter-of-fact, non-punitive approach during meals — avoid excessive focus on food to prevent power struggles
- Family therapy is a key component, especially for adolescents — involve family under RA 11036 with appropriate consent
- In Philippine settings, connect families to PhilHealth outpatient coverage and community mental health services
Common misconceptions
- Misconception: Bulimia is easy to identify because the client looks thin. Fact: Clients with bulimia are usually of normal weight — the disorder is often hidden.
- Misconception: Eating disorders are just 'picky eating' or dieting. Fact: They are serious psychiatric disorders with the highest mortality of any psychiatric illness.
- Misconception: Anorexia nervosa clients refuse to eat because they want attention. Fact: The disorder involves genuine distorted body image — the client truly believes they are overweight.
- Misconception: Russell's sign is found in anorexia. Fact: Russell's sign (calluses on knuckles from self-induced vomiting) is specific to bulimia.
- Misconception: Once the client gains weight, anorexia is cured. Fact: Eating disorders are complex psychiatric conditions requiring long-term treatment; physical restoration is only one component.
Related concepts
- Refeeding syndrome (critical complication of nutritional restoration)
- Electrolyte imbalances: hypokalemia, hypomagnesemia, hypophosphatemia
- Cardiac dysrhythmias in psychiatric nursing
- Body image disturbance (NANDA nursing diagnosis)
- Cognitive-behavioral therapy (CBT) for eating disorders
- Fluid and electrolyte balance monitoring
Common exam questions
Example
The nurse assessing a client with anorexia nervosa would MOST LIKELY find: A) Russell's sign B) Parotid swelling C) Lanugo D) Metabolic alkalosis. Answer: C) Lanugo — fine body hair from starvation-induced cold intolerance.
Approach
Memorize the specific physical findings for each disorder — lanugo for anorexia, Russell's sign and dental erosion for bulimia, electrolyte imbalances for both. NLE may show a photograph description or ask you to identify which finding belongs to which disorder.
Example
A client with anorexia is admitted with serum potassium of 2.8 mEq/L and HR of 44 bpm. The priority nursing action is: A) Initiate a structured meal plan B) Refer to a dietitian C) Apply cardiac monitor and notify the physician D) Discuss body image concerns. Answer: C) Apply cardiac monitor and notify physician — life-threatening dysrhythmia risk.
Approach
Always select the physiological intervention first — correcting electrolytes, cardiac monitoring, addressing malnutrition — before psychosocial interventions.
Example
Which medication is CONTRAINDICATED in a client with bulimia nervosa who purges? A) Fluoxetine B) Sertraline C) Bupropion D) Olanzapine. Answer: C) Bupropion — lowers seizure threshold, dangerous in purging clients.
Approach
Know that fluoxetine is used in bulimia and bupropion is CONTRAINDICATED. This is a classic NLE pharmacology question for eating disorders.
Key points to remember
- Eating disorders = HIGHEST MORTALITY of any psychiatric disorder — always prioritize physical/medical stability
- Anorexia: low body weight + intense fear of weight gain + distorted body image
- Anorexia physical findings: amenorrhea, bradycardia, hypotension, hypothermia, LANUGO, electrolyte imbalance, arrhythmias
- Cardiac arrhythmias (from hypokalemia and malnutrition) are the leading cause of death in anorexia
- Bulimia: binge-purge cycle + usually NORMAL WEIGHT (can be missed visually!)
- Bulimia physical findings: hypokalemia + metabolic alkalosis, dental erosion, RUSSELL'S SIGN, parotid swelling
- Russell's sign = calluses on dorsum of hand from self-induced vomiting — a specific physical assessment finding
- Lanugo = fine body hair = body's attempt to stay warm in anorexia — NLE high-yield finding
- After meals, observe clients for 1 HOUR to prevent purging or hiding food
- Fluoxetine (Prozac) is approved for bulimia; BUPROPION IS CONTRAINDICATED in eating disorders (lowers seizure threshold)
Refeeding Syndrome: A Critical Complication
Examples
A 17-year-old female with anorexia nervosa (BMI 12.8) is started on nasogastric tube feeding on Day 1 at full caloric requirements. On Day 3, she develops confusion, muscle weakness, and the nurse notes irregular cardiac rhythm on the monitor. Serum phosphate is 0.5 mmol/L (critically low).
Solution
This is REFEEDING SYNDROME. The feedings were initiated too rapidly. The nurse should: immediately notify the physician, continue cardiac monitoring, anticipate orders for phosphate replacement (oral or IV), slow or pause the nutritional infusion per physician order, and monitor potassium and magnesium as well.
Refeeding syndrome developed because calories were introduced too quickly. The hallmark finding — critically low phosphate — confirms the diagnosis. The nurse's priority is cardiac monitoring and electrolyte correction (Maslow: physiological safety). This is why nutritional reintroduction in eating disorders should ALWAYS be done gradually.
Refeeding syndrome is a potentially fatal metabolic complication that occurs when nutrition (especially carbohydrates) is reintroduced too rapidly to a severely malnourished client. It is most relevant in anorexia nervosa but can occur in any severely starved individual. Understanding refeeding syndrome is CRITICAL for NLE preparation because it is a high-stakes clinical situation where the nurse's actions can be life-saving.
Pathophysiology (simplified):
During starvation, the body depletes carbohydrates and shifts to burning fat and protein. Electrolytes like phosphate, potassium, and magnesium move out of cells and are excreted — the serum levels may appear 'normal' on a blood test because the losses are spread across compartments. When food (especially carbohydrates) is suddenly reintroduced:
- Insulin surges in response to the glucose load
- Insulin drives glucose INTO cells — and it takes potassium, phosphate, and magnesium WITH it
- Serum levels of these electrolytes DROP SUDDENLY and dramatically
- This causes profound HYPOPHOSPHATEMIA (the hallmark electrolyte of refeeding syndrome), along with hypokalemia and hypomagnesemia
- Additionally, fluid shifts occur causing FLUID OVERLOAD (edema, pulmonary edema)
- These rapid changes can cause: CARDIAC ARRHYTHMIAS, HEART FAILURE, RESPIRATORY FAILURE, SEIZURES, and DEATH
Clinical Signs of Refeeding Syndrome:
- Muscle weakness and fatigue
- Confusion, altered mental status
- Edema (peripheral or pulmonary)
- Cardiac arrhythmias
- Respiratory distress
- Seizures
- Laboratory: low phosphate (hypophosphatemia is the hallmark), low potassium, low magnesium
Prevention and Nursing Management:
- INTRODUCE NUTRITION SLOWLY — advance calories gradually according to protocol (typically starting at 10-20 kcal/kg/day and advancing over 1-2 weeks)
- MONITOR ELECTROLYTES CLOSELY — especially phosphate, potassium, and magnesium — before, during, and after refeeding begins
- REPLACE ELECTROLYTES PROACTIVELY as ordered — do not wait for critical levels
- Monitor fluid balance (intake and output) and daily weights
- Continuous cardiac monitoring — watch for arrhythmias
- Daily weights and assessment for edema
- Monitor for neurological changes (confusion, seizures)
- Collaborate with the dietitian and physician for the nutritional advancement protocol
NLE High-Yield Point: If an NLE question describes a malnourished client who develops cardiac arrhythmias, seizures, or respiratory failure shortly after starting nutritional support — think REFEEDING SYNDROME. The hallmark electrolyte is HYPOPHOSPHATEMIA.
Applications
- In the NLE, refeeding syndrome is tested by: (1) identifying the hallmark electrolyte (hypophosphatemia), (2) recognizing the timing (occurs early in nutritional reintroduction), (3) selecting the correct nursing intervention (monitor electrolytes, go slow with feeding, cardiac monitoring)
- Applies in all clinical settings where severely malnourished clients receive nutritional support: anorexia nervosa, post-operative starvation, severe malnutrition from other causes
- Document electrolyte trends, report abnormal values immediately, and never increase nutritional rate without physician order and electrolyte stability
Common misconceptions
- Misconception: Refeeding syndrome only occurs with IV nutrition. Fact: It can occur with any rapid reintroduction of nutrition — oral, enteral, or parenteral.
- Misconception: The hallmark electrolyte of refeeding syndrome is hypokalemia. Fact: While hypokalemia occurs, HYPOPHOSPHATEMIA is the hallmark electrolyte of refeeding syndrome.
- Misconception: Once a malnourished client starts eating, the focus should be on getting calories in as fast as possible. Fact: Gradual reintroduction is essential — speed kills in refeeding syndrome.
Related concepts
- Fluid and electrolyte balance: phosphate, potassium, magnesium
- Cardiac arrhythmias: electrolyte-related
- Nasogastric tube feeding and enteral nutrition
- Anorexia nervosa: medical complications
- Metabolic alkalosis vs. metabolic acidosis
Common exam questions
Example
A client with severe anorexia nervosa was started on high-calorie IV nutrition 48 hours ago. She now has an irregular heart rhythm and serum phosphate of 0.4 mmol/L. The nurse recognizes this as: A) Hypertensive crisis B) Refeeding syndrome C) Thyroid storm D) Serotonin syndrome. Answer: B) Refeeding syndrome.
Approach
Look for the combination of: severely malnourished client + recently started nutritional support + new onset confusion/arrhythmia/weakness/seizure = refeeding syndrome. The hallmark electrolyte is hypophosphatemia.
Example
To prevent refeeding syndrome in a severely malnourished client, the nurse should: A) Start at full caloric needs immediately B) Introduce nutrition gradually with electrolyte monitoring C) Withhold all nutrition until electrolytes normalize D) Give phosphate supplements only after symptoms appear. Answer: B) Introduce nutrition gradually with electrolyte monitoring.
Approach
The key prevention strategy is gradual nutritional reintroduction with close electrolyte monitoring. Select interventions that involve going slowly and monitoring proactively.
Key points to remember
- Refeeding syndrome = dangerous electrolyte shifts when nutrition is reintroduced TOO RAPIDLY to a malnourished client
- Most relevant in: anorexia nervosa (severely malnourished)
- Hallmark electrolyte = HYPOPHOSPHATEMIA (low phosphate) — this is the key NLE fact
- Also causes: hypokalemia, hypomagnesemia, and FLUID OVERLOAD
- Mechanism: insulin surge drives glucose, potassium, phosphate, and magnesium INTO cells → serum levels DROP
- Complications: cardiac arrhythmias, heart failure, respiratory failure, seizures, DEATH
- Prevention: INTRODUCE NUTRITION SLOWLY, advance calories gradually per protocol
- Nursing monitoring: electrolytes (phosphate, potassium, magnesium), cardiac rhythm, fluid balance, daily weights, neurological status
- Replace electrolytes proactively before starting refeeding — as ordered
- Collaborate with dietitian and physician for safe nutritional protocol
Nursing Management and Patient-Family Teaching for All Three Disorder Groups
Examples
The family of a 16-year-old with anorexia nervosa asks the nurse: 'Should we let her decide what she eats at home? We don't want to make her feel controlled.' The client is currently at 80% of ideal body weight.
Solution
The nurse should explain that at this stage, the client's judgment about food is impaired by the disorder and that supervised eating is necessary to ensure adequate nutrition. Family-based treatment (FBT) involves the family taking an active, supervised role in meals — this is not about control but about life-saving support. As the client gains weight and stability, autonomy is gradually returned.
This is a family education scenario. The nurse bridges clinical knowledge and family understanding. In FBT, the family is temporarily put 'in charge' of ensuring adequate intake — this is evidence-based for adolescents with anorexia. The nurse must be clear and supportive, not judgmental of the family's uncertainty.
Effective nursing management of personality, somatic, and eating disorders requires integrating the nursing process (ADPIE) with therapeutic communication, limit-setting, safety monitoring, and family education. All care in the Philippine context is governed by RA 11036 (Philippine Mental Health Act) and RA 9173 (Philippine Nursing Act of 2002), which require nurses to provide competent, rights-based, and humane care.
For Personality Disorders:
- Maintain a consistent therapeutic environment with clear, enforced limits
- Use a unified team approach: all staff communicate the same plan to prevent manipulation or splitting
- Document behavior objectively
- Prioritize safety in BPD: assess for self-harm and suicidal ideation at every encounter
- Teach the client (and family) about the chronic nature of the disorder, the value of therapy adherence, and the warning signs of self-harm
- Educate families on suicide/self-harm warning signs — especially for BPD
- DBT skills (distress tolerance, emotion regulation) can be taught to both client and family
For Somatic Disorders:
- Guide the family to validate the client's distress WITHOUT reinforcing the sick role
- Teach families NOT to provide excessive attention to physical complaints — this reinforces illness behavior
- Educate on the mind-body connection: stress and emotions can manifest as physical symptoms
- Encourage the client to keep follow-up appointments with a single consistent provider
- Teach adaptive coping: relaxation techniques, journaling, physical activity, social support
For Eating Disorders:
- Teach the family about the medical seriousness and life-threatening nature of the disorder — eating disorders are not 'just dieting'
- Teach warning signs of relapse: resumed restriction, resumed purging behaviors, weight loss, social withdrawal around meals
- Educate on refeeding syndrome: the danger of rapid nutritional restoration
- Family-based treatment (FBT/Maudsley approach) is evidence-based for adolescents — the family takes an active role in nutritional supervision at home
- Connect families to support resources under RA 11036: community mental health centers, barangay mental health programs, PhilHealth benefits for psychiatric care
- Advise on dental follow-up for bulimia clients (acid erosion); orthopedic monitoring for osteoporosis in anorexia
- Emphasize that recovery is possible but requires patience, long-term commitment, and a multidisciplinary team
Applications
- Patient and family education is a core NLE competency — expect scenarios testing whether you can identify appropriate teaching content
- Under RA 11036, patients have the right to refuse treatment (if competent) — nurses must document this and work toward voluntary engagement in care
- Community mental health: know the referral pathways in the Philippine system (barangay health worker → RHU → district hospital → provincial/tertiary hospital → NCMH)
Common misconceptions
- Misconception: Family support means giving the client everything they want to keep them happy. Fact: Consistent limits and validation without reinforcing maladaptive behavior are the therapeutic family roles.
- Misconception: RA 11036 only applies in psychiatric hospitals. Fact: The Philippine Mental Health Act applies across all healthcare settings and community care.
Related concepts
- RA 11036 — Philippine Mental Health Act: client rights, community-based care
- RA 9173 — Philippine Nursing Act: nurse accountability and competence
- Family-based treatment (FBT/Maudsley) for eating disorders
- Discharge planning and community referral pathways
- Multidisciplinary team approach in psychiatric nursing
Common exam questions
Example
The nurse is teaching the family of a client with Borderline PD. Which statement by the family member indicates understanding? A) 'We will give her what she wants to prevent her from hurting herself.' B) 'We will call emergency services if she threatens to hurt herself.' C) 'We should tell her that cutting herself is just for attention.' D) 'We will ignore her calls completely.' Answer: B) Call emergency services for credible self-harm threats — this addresses safety without reinforcing behavior.
Approach
Identify the most important teaching priority for the specific disorder and situation. For eating disorders: medical seriousness. For BPD: safety. For somatic disorders: validating without reinforcing.
Key points to remember
- All psychiatric nursing care in the Philippines is governed by RA 11036 (Mental Health Act) and RA 9173 (Nursing Act)
- For BPD: teach family suicide/self-harm warning signs and consistent limit-setting at home
- For somatic disorders: teach family to validate without reinforcing the sick role
- For eating disorders: treat the medical emergency first, then psychosocial — never reverse this priority
- Family-based treatment (Maudsley/FBT) is evidence-based for adolescents with eating disorders
- Teach clients and families that recovery is a long-term process with potential for relapse
- Under RA 11036, clients have the right to: voluntary admission, informed consent, confidentiality, and access to community-based care
- Multidisciplinary team in eating disorders: nurse, physician, psychiatrist, dietitian, social worker, psychologist, family
- Document all teaching done and the client/family's understanding as part of the nursing process
- Nurses under RA 9173 are accountable for safe, competent, and ethical psychiatric nursing practice
Practice problems
A client with Borderline Personality Disorder tells Nurse Mariana, 'You are the only one who truly cares for me — the other nurses don't even look at me.' Later that day, she tells another nurse that Nurse Mariana is 'completely useless and heartless.' What defense mechanism is the client using, and what is the PRIORITY nursing intervention?
Solution
Defense mechanism: SPLITTING. Priority nursing intervention: Ensure a unified team approach — all nurses and staff must communicate consistently about the care plan and respond uniformly to the client's behavior. Hold a team conference if needed. Nurse Mariana should not be flattered by the idealization, and the other nurse should not be hurt by the devaluation. Both must respond with calm consistency.
Splitting is the hallmark defense mechanism of BPD — the inability to integrate positive and negative perceptions of a person simultaneously. The correct nursing response is NOT to take sides or respond with emotional intensity. A consistent, unified team approach prevents the client from using splitting to manipulate staff and reinforces a healthier pattern of relating.
A 20-year-old female is admitted with a BMI of 13.2 and has not menstruated for 8 months. On assessment: HR 46 bpm, BP 84/52 mmHg, temperature 35.8°C, and fine downy hair on her forearms and abdomen. She insists, 'I am still overweight.' The physician orders nutritional rehabilitation. After 72 hours of refeeding, the client develops confusion, muscle weakness, and cardiac arrhythmia. Serum phosphate is 0.3 mmol/L. What is happening and what should the nurse do?
Solution
The client is experiencing REFEEDING SYNDROME, occurring as a complication of rapid nutritional reintroduction in anorexia nervosa. The hallmark finding is critically low phosphate (hypophosphatemia: 0.3 mmol/L). Nursing actions: (1) Immediately notify the physician; (2) Apply continuous cardiac monitoring; (3) Prepare for IV phosphate replacement as ordered; (4) Anticipate order to slow or pause nutritional infusion; (5) Also monitor potassium and magnesium levels; (6) Monitor fluid balance and assess for edema; (7) Document all findings and interventions.
When carbohydrates are reintroduced, insulin drives phosphate, potassium, and magnesium into cells, causing serum levels to drop precipitously. This metabolic shift can cause cardiac arrhythmias, respiratory failure, seizures, and death. The nursing priority is cardiac monitoring and electrolyte correction (Maslow Level 1 — physiological safety). The physical findings described earlier (lanugo, bradycardia, hypothermia, amenorrhea) are all consistent with anorexia nervosa from starvation.
During a physical assessment of a 24-year-old female of normal weight referred by her dentist for severe tooth enamel erosion, the nurse notices small, thickened scars on the knuckles of the client's right hand. When asked about her eating habits, the client becomes tearful and admits to 'sometimes eating too much and making myself vomit.' Which disorder does this presentation suggest, and what should the nurse assess next?
Solution
This presentation is consistent with BULIMIA NERVOSA. The key findings are: (1) Normal weight — bulimia often presents in clients of normal or slightly above normal weight; (2) Dental enamel erosion — from repeated acid exposure of vomit; (3) Scars/calluses on knuckles = RUSSELL'S SIGN — from repeatedly using the hand to induce vomiting. Next assessments: Serum electrolytes — especially potassium (hypokalemia) and assess for metabolic alkalosis; cardiac rhythm assessment (arrhythmia risk from hypokalemia); frequency and duration of binge-purge episodes; assessment for depression, anxiety, and self-esteem issues; menstrual history; and presence of other compensatory behaviors (laxative use, excessive exercise).
Russell's sign and dental erosion are objective physical findings specific to bulimia nervosa from purging. Since the client is of normal weight, the disorder may have been undetected. The nurse's role is to assess without judgment, validate the client's experience, and prioritize medical stability (electrolytes, cardiac status) before psychosocial interventions.
A client admitted with multiple physical complaints (headache, abdominal pain, and limb weakness) has had extensive workup including MRI, CT scan, endoscopy, and multiple lab tests — all negative. When the physician tells her the tests are normal, she becomes more distressed and says, 'There must be something wrong — I feel terrible.' She has seen five different doctors in the past six months. Which type of somatic disorder might this represent, and what is the BEST nursing response?
Solution
This presentation suggests ILLNESS ANXIETY DISORDER (formerly Hypochondriasis) — characterized by persistent preoccupation with having a serious illness despite minimal or absent physical findings, high health anxiety, and NOT being reassured by negative test results. The pattern of seeing multiple doctors is 'doctor-shopping.' Best nursing response: 'I can see that these symptoms are causing you real distress, and I understand how frightening this must feel. I want to work with you to help you manage these concerns and find ways to feel better.' Do NOT: say 'There is nothing wrong with you' or 'It is all in your mind' — this invalidates the experience and damages therapeutic rapport.
The correct therapeutic response validates the client's distress without reinforcing illness behavior or medicalizing the problem further. The nurse should then work toward: limiting unnecessary reassurance (which temporarily reduces anxiety but worsens the pattern), helping the client identify stress-symptom connections, teaching coping strategies, and establishing a consistent single provider to reduce doctor-shopping.
A client with anorexia nervosa (BMI 14.0) is ready for discharge after gaining weight to 85% of ideal body weight. The client's mother asks: 'What medication can she take to help? I heard bupropion (Wellbutrin) is good for weight management — can she take that?' How should the nurse respond?
Solution
BUPROPION IS CONTRAINDICATED in clients with eating disorders. The nurse should explain: 'Bupropion is not safe for clients with anorexia or bulimia because it significantly lowers the seizure threshold, especially in clients who have electrolyte imbalances from purging or malnutrition. The risk of seizures is too high.' The nurse should also clarify that the goal of treatment is NOT weight management in the same sense as weight-loss drugs — the goal is healthy nutrition and psychological recovery. For appropriate pharmacotherapy, the physician may consider other options. In BULIMIA specifically, FLUOXETINE (Prozac) is FDA-approved and the medication of choice.
Bupropion is a classic NLE pharmacology question for eating disorders. Its contraindication is due to the seizure risk, which is compounded by electrolyte disturbances common in purging clients. This tests both pharmacology knowledge and patient/family education competencies. Fluoxetine is specifically approved for bulimia nervosa — not typically the first choice in anorexia.
Exam preparation tips
- CLUSTER MEMORY TRICK: A = Odd/Eccentric (think: All Alone); B = Dramatic/Erratic (think: Bold and Borderline); C = Anxious/Fearful (think: Can't Cope). Use these associations to quickly classify disorders under exam pressure.
- SPLITTING RECOGNITION: In NLE scenarios, look for a client who alternates between extreme praise and extreme criticism of the same nurse or staff member. This always points to Borderline PD and the defense mechanism of splitting.
- EATING DISORDER MORTALITY: Commit to memory — eating disorders have the HIGHEST mortality rate of any psychiatric disorder. This fact appears in priority-setting questions where you must address physiological complications BEFORE psychosocial interventions.
- ANOREXIA PHYSICAL FINDINGS MNEMONIC — 'ABCDELH': Amenorrhea, Bradycardia, Cold intolerance, Dry skin, Electrolyte imbalance, Lanugo, Hypotension/Hypothermia. Lanugo (fine body hair) is the most frequently tested finding — know it well.
- BULIMIA KEY TRIAD: Russell's Sign (knuckle calluses) + Dental erosion + Parotid swelling. These three findings are specific to purging behaviors and high-yield for NLE.
- REFEEDING SYNDROME: Remember the sequence — Rapid refeeding → Insulin surge → Electrolytes shift into cells → HYPOPHOSPHATEMIA (hallmark), hypokalemia, hypomagnesemia → Cardiac arrhythmia/seizures/death. The hallmark is PHOSPHATE, not potassium.
- AFTER-MEAL OBSERVATION: In eating disorder management, the nurse observes clients during meals AND for approximately ONE HOUR after to prevent purging, hiding, or discarding food. This specific timeframe appears in NLE options.
- MEDICATION SAFETY: Fluoxetine = YES for bulimia. Bupropion = ABSOLUTELY CONTRAINDICATED in eating disorders (seizure risk). This is a classic pharmacology NLE item.
- SOMATIC DISORDERS — THERAPEUTIC COMMUNICATION: The correct NLE response always validates the client's experience without reinforcing illness behavior or confronting the psychological nature. Avoid: 'It's all in your head.' Use: 'I can see you are experiencing real distress.'
- LA BELLE INDIFFÉRENCE: This French term means 'beautiful indifference' — the client's surprisingly calm acceptance of a disabling symptom (paralysis, blindness) in Conversion Disorder. If the NLE describes a client who seems unconcerned about their inability to walk, think Conversion Disorder.
- FACTITIOUS vs. MALINGERING: Factitious = INTERNAL gain (sick role/attention), deliberate. Malingering = EXTERNAL gain (money, legal benefit), deliberate — NOT a mental disorder. Somatic disorders = unintentional symptoms.
- LEGAL FRAMEWORK: Know that RA 11036 (Philippine Mental Health Act) governs psychiatric nursing practice in the Philippines. It emphasizes voluntary care, community-based treatment, informed consent, and protection of client rights. RA 9173 (Nursing Act) governs nurse accountability and scope of practice.
- DBT FOR BPD: Dialectical Behavior Therapy teaches four skill sets — Distress Tolerance, Emotion Regulation, Mindfulness, and Interpersonal Effectiveness. DBT is the treatment of choice for Borderline PD. This appears in NLE treatment modality questions.
- WEIGHT MONITORING CONSISTENCY: In eating disorders, always weigh at the SAME time (morning, after voiding), SAME scale, SAME clothing. This prevents the client from manipulating results (e.g., hiding weights in clothing, drinking water before weighing). The nurse must supervise the weighing process.
- MASLOW PRIORITY IN ALL THREE GROUPS: In personality disorders — Safety (self-harm) first. In somatic disorders — Rule out real medical illness first. In eating disorders — Correct electrolytes and cardiac monitoring first. Psychosocial interventions always come AFTER physiological stability is established.
Diagrams
Personality Disorder Clusters: Classification Overview
This mind map classifies all ten personality disorders into their three DSM-5 clusters with their defining characteristics. Use this to quickly recall which disorder belongs to which cluster and the key features of each — essential for NLE multiple-choice items that ask you to match a clinical scenario to a specific personality disorder.
Nursing Management of Borderline Personality Disorder: Priority Decision Tree
This flowchart shows the step-by-step priority decision-making process for nursing management of a client with Borderline Personality Disorder. It illustrates how safety is always assessed first (Maslow), followed by identification and management of splitting behavior, and then therapeutic interventions. Use this to answer NLE priority-setting and nursing intervention questions.
Somatic Disorders: Differentiating the Types
This flowchart differentiates the four types of somatic and related disorders based on two key decision points: whether symptoms are intentional and whether external gain is present. It also includes the nursing management pathway. Use this to quickly distinguish between Somatic Symptom Disorder, Illness Anxiety Disorder, Conversion Disorder, Factitious Disorder, and Malingering — a frequently tested differentiation in the NLE.
Eating Disorders: Clinical Features and Priority Nursing Actions
This comprehensive flowchart compares the clinical features of anorexia nervosa and bulimia nervosa side by side, then shows the unified priority nursing management pathway. It highlights the critical refeeding syndrome risk and the 1-hour post-meal observation requirement. This diagram is ideal for studying before NLE priority-setting and pharmacology questions on eating disorders.
Refeeding Syndrome: Pathophysiology and Nursing Prevention
This flowchart illustrates the pathophysiology of refeeding syndrome from starvation through the dangerous electrolyte shifts caused by rapid nutritional reintroduction, showing both the dangerous pathway and the safe prevention pathway. The hallmark electrolyte — hypophosphatemia — is clearly highlighted. Use this to understand and remember the mechanism, complications, and nursing prevention strategies for refeeding syndrome.
High-Yield NLE Facts: Eating Disorders and Somatic Disorders
This comprehensive mind map organizes all high-yield NLE facts for eating disorders, somatic disorders, and the legal framework into one visual reference. Use this for final review before the NLE to quickly recall the most commonly tested facts, physical findings, medications, and legal references across all three disorder groups covered in this chapter.
In summary
This chapter covers three groups of psychiatric disorders that are heavily tested in the Philippine Nursing Licensure Examination: personality disorders, somatic symptom disorders, and eating disorders. The key to mastering this content is understanding the defining features of each disorder, recognizing the specific physical assessment findings, knowing the correct therapeutic communication responses, and applying Maslow's hierarchy to prioritize nursing interventions. Remember: physiological safety and medical stability ALWAYS come first before psychosocial interventions — this principle governs priority questions across all three groups. For personality disorders, the core nursing skill is consistent limit-setting and a unified team approach, particularly for Borderline PD with its risk of self-harm. For somatic disorders, the therapeutic principle is validation without reinforcement — never dismiss, never confront. For eating disorders, the critical facts are the highest psychiatric mortality rate, specific physical findings (lanugo, Russell's sign), the danger of refeeding syndrome (hallmark: hypophosphatemia), the one-hour post-meal observation, and the contraindication of bupropion. All psychiatric nursing practice in the Philippines is guided by RA 11036 (Philippine Mental Health Act) and RA 9173 (Philippine Nursing Act), which mandate humane, rights-based, and competent care. With systematic study of these concepts, thorough practice with application-type questions, and clear visual organization of the key facts, you will be well-prepared to answer NLE items on personality, somatic, and eating disorders with confidence and precision. Kaya mo ito — good luck on your NLE!