NLE Psychiatric Disorders — Personality, Somatic, and Eating DisordersRevision Notes

Exam Tips

• MEMORY AID for clusters: Cluster A = 'Weird' (3 Ss: Paranoid, Schizoid, Schizotypal); Cluster B = 'Wild' (BAHN: Borderline, Antisocial, Histrionic, Narcissistic); Cluster C = 'Worried' (DOC: Dependent, Obsessive-compulsive personality, avoidant — or simply 3 anxious types).
• For Borderline PD NLE questions: look for keywords — 'fear of abandonment,' 'self-mutilation,' 'splitting,' 'unstable relationships' → Priority nursing diagnosis is RISK FOR SELF-MUTILATION or RISK FOR SUICIDE → Intervention = set firm consistent limits + unified team approach + DBT.
• For Antisocial PD: keywords = 'no remorse,' 'manipulation,' 'violates rights of others' → Nursing intervention = firm, consistent limits without being punitive; avoid being manipulated.
• Remember that DBT is the evidence-based treatment of choice specifically for Borderline PD — not other personality disorders.
• When an NLE question mentions 'splitting among staff,' the correct nursing action is to hold a TEAM MEETING to establish and enforce a CONSISTENT CARE PLAN.

Key Points

• A personality disorder is an ENDURING, PERVASIVE, INFLEXIBLE pattern of inner experience and behavior that deviates markedly from cultural expectations.
• Onset is typically by adolescence or early adulthood; it must cause distress or functional impairment to qualify as a disorder.
• Clients often have LIMITED INSIGHT — they may not see their behavior as the problem (ego-syntonic), making engagement in treatment challenging.
• Personality disorders are organized into THREE CLUSTERS: A (Odd/Eccentric), B (Dramatic/Erratic), C (Anxious/Fearful).
• Cluster A includes: Paranoid, Schizoid, Schizotypal.
• Cluster B includes: Borderline, Antisocial, Histrionic, Narcissistic.
• Cluster C includes: Avoidant, Dependent, Obsessive-Compulsive Personality Disorder (OCPD).
• Nursing approach must be CONSISTENT, STRUCTURED, and BOUNDARY-SETTING across all clusters.
• Medication targets specific symptoms (mood instability, impulsivity) — not the disorder itself.
• Care is guided by RA 11036 (Philippine Mental Health Act) ensuring humane, rights-based treatment.

Definitions

Section Title

Personality Disorders — Overview and Clusters

Common Mistakes

• Confusing OCPD (Cluster C personality disorder — ego-syntonic) with OCD (obsessive-compulsive disorder — ego-dystonic with true obsessions/compulsions).
• Forgetting that Cluster B disorders — especially Borderline PD — require a UNIFIED TEAM APPROACH; failure to communicate consistently allows the client to split the staff.
• Thinking personality disorders can be 'cured' with medication — medication only targets specific symptoms like mood instability or impulsivity.
• Mixing up which disorders belong to which cluster — use the memory aid: A=Add (Odd), B=Bold (Dramatic), C=Careful (Anxious).
• Being punitive or confrontational with clients who have Antisocial PD — hold them accountable firmly but without anger or retaliation.

Exam Tips

• NLE priority question stem: 'A client with BPD begins cutting her arms. What is the PRIORITY nursing action?' → Answer: Ensure SAFETY (Maslow) — remove harmful objects, stay with the client, assess wound, then engage in therapeutic communication.
• If an NLE question asks about the BEST THERAPY for BPD → Answer: Dialectical Behavior Therapy (DBT).
• For Antisocial PD, the correct nursing stance is to hold the client ACCOUNTABLE for behavior — not to punish, not to reward, and not to lecture about morality.
• A unified team meeting is the correct response when you notice staff disagreeing about how to care for a client with BPD — this addresses splitting.

Key Points

• Borderline Personality Disorder (BPD) is the HIGHEST PRIORITY Cluster B disorder for nursing because of the risk of self-harm and suicide.
• BPD hallmarks (MNEMONIC: 'AEIOU TIPS'): Abandonment fear, Emptiness (chronic), Impulsivity, Outbursts (affective instability), Unstable relationships, Transient paranoid ideation under stress, Identity disturbance, Parasuicidal/self-mutilation behavior, Suicidal behavior.
• Splitting in BPD: client may idealize one nurse ('You are the only one who understands me') and devalue another ('That nurse is terrible') — this is manipulation via splitting.
• Nursing priority for BPD: SAFETY first (Maslow — physiologic/safety needs), then consistent limit-setting, then therapeutic relationship building.
• Antisocial PD: pattern of DISREGARD and VIOLATION of others' rights since age 15; diagnosis requires the person to be at least 18 years old.
• Antisocial PD key features: deceitfulness, manipulation, impulsivity, irritability/aggressiveness, reckless disregard for safety, irresponsibility, LACK OF REMORSE.
• Nursing approach for Antisocial PD: firm, consistent, non-punitive limit setting; do NOT argue, moralize, or be manipulated; document behavior objectively.
• Histrionic PD: excessive emotionality and attention-seeking; nursing approach — acknowledge feelings but set limits on attention-seeking behavior.
• Narcissistic PD: grandiosity, need for admiration, lack of empathy; nursing approach — matter-of-fact care, avoid power struggles, set limits on entitlement behaviors.

Definitions

Section Title

Cluster B Deep Dive — Borderline and Antisocial Personality Disorders

Common Mistakes

• Dismissing self-mutilation in BPD as 'just attention-seeking' — always perform a full safety assessment; self-harm is a real risk and a nursing priority.
• Failing to recognize when a staff team is being split by a client with BPD — if nurses are arguing about whether a client is 'good' or 'bad,' splitting is likely occurring.
• Confusing conduct disorder (childhood) with antisocial PD (adult) — the DSM requires age ≥18 for the diagnosis of Antisocial PD.
• Being seduced by the charm or sob stories of clients with Antisocial PD — always maintain professional therapeutic boundaries and document objectively.

Exam Tips

• MEMORY AID: 'SICK' for somatic disorders approach — Screen for real illness first, I acknowledge (symptoms are real), Consistent primary provider, Keep secondary gain limited.
• La belle indifférence = Conversion Disorder — if an NLE question shows a client with sudden paralysis who is suspiciously calm, this is your clue.
• Somatic Symptom Disorder ≠ Illness Anxiety Disorder: Somatic = actual physical symptoms present; Illness Anxiety = anxiety about having illness, minimal symptoms.
• The nurse's role is to redirect, not reinforce — therapeutic communication focuses on emotions and stress, NOT on discussing the physical symptoms in detail.
• Maintain a CONSISTENT PRIMARY PROVIDER to reduce 'doctor shopping' and repeated unnecessary tests — a key community health nursing intervention under the Philippine healthcare system.

Key Points

• These disorders involve physical symptoms or health-related anxiety that cause significant distress but are NOT intentionally produced and are NOT fully explained by a medical condition.
• The symptoms are REAL to the client — never tell the client 'it's all in your head' or dismiss the symptoms.
• RULE OUT genuine medical illness FIRST before attributing symptoms to a somatic disorder — these clients can also develop real physical illness.
• Four main types: Somatic Symptom Disorder, Illness Anxiety Disorder, Conversion Disorder, and Factitious Disorder.
• Somatic Symptom Disorder: one or more distressing physical symptoms with disproportionate thoughts, feelings, and behaviors about them.
• Illness Anxiety Disorder (formerly Hypochondriasis): preoccupation with having or acquiring a serious illness, HIGH health anxiety, minimal or no actual somatic symptoms.
• Conversion Disorder (Functional Neurological Symptom Disorder): neurological symptoms (paralysis, blindness, seizures, aphonia) that are INCONSISTENT with recognized neurological disease. Key feature: 'la belle indifférence.'
• Factitious Disorder: DELIBERATE falsification or induction of symptoms to ASSUME THE SICK ROLE — this is NOT the same as somatic disorders (which are not intentional) and NOT the same as malingering (which is feigning for external gain like money or avoiding work).
• Key nursing intervention: limit secondary gain, acknowledge symptoms as real to the client, redirect to healthy coping, and maintain a consistent primary provider.
• Help the client make the CONNECTION between stress/emotions and physical symptoms over time.

Definitions

Section Title

Somatic Symptom and Related Disorders

Common Mistakes

• Telling the client with a somatic disorder that their symptoms are 'not real' — this damages the therapeutic relationship and is therapeutically harmful.
• Confusing Factitious Disorder (deliberate, for sick role) with Malingering (deliberate, for external gain) — both are intentional, but motivation differs.
• Forgetting to RULE OUT real medical illness first — clients with somatic disorders CAN develop genuine medical conditions and must not have symptoms dismissed.
• Providing excessive attention to somatic complaints, which reinforces the sick behavior — use matter-of-fact acknowledgment while redirecting to healthy activities.
• Confusing Conversion Disorder with malingering — Conversion Disorder is NOT intentional; malingering is.

Exam Tips

• MEMORY AID for Anorexia physical findings: 'BLATHE' — Bradycardia, Lanugo, Amenorrhea, Thin/low weight, Hypothermia, Electrolyte imbalances.
• MEMORY AID for Bulimia signs: 'PERED' — Parotid swelling, Electrolyte imbalances (hypokalemia/metabolic alkalosis), Russell's sign, Erosion of enamel, Dental caries.
• Refeeding Syndrome triad: Hypophosphatemia + Hypokalemia + Hypomagnesemia → Cardiac/Respiratory failure → PREVENTION = slow refeeding + monitor electrolytes.
• Pharmacology: FLUOXETINE (Prozac) = approved adjunct for Bulimia Nervosa; BUPROPION = CONTRAINDICATED in all eating disorders.
• NLE priority question: 'Client with Anorexia is starting nutritional rehabilitation. What is the PRIORITY assessment?' → Monitor electrolytes (especially phosphate, potassium, magnesium) and cardiac rhythm to detect refeeding syndrome.
• Weight monitoring: same time of day, same scale, same clothing — standardize the measurement to get accurate trends.
• Family therapy is especially important for ADOLESCENT clients with eating disorders — involve the family in treatment planning.

Key Points

• Eating disorders have the HIGHEST MORTALITY RATE of all psychiatric illnesses — this is a frequently tested NLE fact.
• They are NOT simply about food — they are about CONTROL, SELF-WORTH, and DISTORTED BODY IMAGE.
• Most common in adolescent and young adult females, but rising in males.
• ANOREXIA NERVOSA: restriction of food intake → significantly low body weight + intense fear of gaining weight + disturbed body image (sees self as fat even when dangerously underweight).
• Anorexia subtypes: Restricting type (diet/exercise only) and Binge-eating/Purging type.
• BULIMIA NERVOSA: recurrent binge eating followed by compensatory behaviors (purging — vomiting, laxatives, diuretics; non-purging — fasting, excessive exercise).
• Key distinction: Clients with Bulimia are usually NORMAL WEIGHT or slightly overweight — the disorder is less visually obvious than Anorexia.
• Both disorders involve electrolyte imbalances that can cause cardiac arrhythmias and death.
• PRIORITY nursing action: Address LIFE-THREATENING PHYSICAL COMPLICATIONS FIRST (Maslow — physiologic/safety) before psychological work.
• Nursing observation: Supervise meals AND observe for approximately ONE HOUR after meals to prevent purging.

Definitions

Section Title

Eating Disorders — Anorexia Nervosa and Bulimia Nervosa

Common Mistakes

• Forgetting that Bulimia clients are usually NORMAL WEIGHT — never assume eating disorders are only present in visibly underweight clients.
• Failing to prioritize PHYSICAL/MEDICAL stabilization over psychological therapy — electrolyte correction and cardiac monitoring COME FIRST (Maslow).
• Not observing clients after meals — clients with eating disorders may purge, hide, or discard food if not supervised during and for about one hour after eating.
• Prescribing or expecting BUPROPION for eating disorder clients — Bupropion is CONTRAINDICATED in eating disorders because it lowers the seizure threshold, especially dangerous in purging clients.
• Ignoring refeeding syndrome risk — when a severely malnourished client starts eating again, too-rapid refeeding can be fatal; always monitor phosphate, potassium, and magnesium.
• Focusing nursing conversations on food itself — this creates power struggles; instead, address feelings, self-esteem, and healthy coping.

Exam Tips

• NLE stem clue: 'Client with severe Anorexia Nervosa is started on enteral nutrition and develops cardiac arrhythmia on Day 2. Which lab value is the PRIORITY to check?' → PHOSPHATE (hypophosphatemia = hallmark of refeeding syndrome).
• The three electrolytes to monitor in refeeding syndrome: Phosphate (most critical), Potassium, Magnesium — remember as PPM or 'Phos-K-Mag.'
• Prevention = slow and gradual reintroduction of nutrition — this is both a nursing and medical intervention.
• Always monitor cardiac rhythm and respiratory status during nutritional rehabilitation of severely malnourished clients.

Key Points

• Refeeding syndrome occurs when severely malnourished clients (most commonly Anorexia Nervosa) have nutrition reintroduced TOO RAPIDLY.
• Mechanism: As carbohydrates are reintroduced → insulin secretion surges → insulin drives phosphate, potassium, and magnesium INTO cells → serum levels PLUMMET.
• The HALLMARK of refeeding syndrome is HYPOPHOSPHATEMIA (severely low serum phosphate).
• Other electrolyte disturbances: HYPOKALEMIA and HYPOMAGNESEMIA.
• Consequences: Cardiac arrhythmias, Heart failure, Respiratory failure, Seizures, and DEATH.
• Also involves fluid retention and fluid overload — monitor for edema, increased weight, and respiratory distress.
• Prevention: Reintroduce nutrition SLOWLY and advance calories GRADUALLY per protocol.
• Monitoring: Electrolytes (phosphate, potassium, magnesium) must be checked BEFORE and DURING refeeding; replace deficiencies proactively.
• Monitor: cardiac rhythm (ECG), fluid balance (intake-output), daily weights, and signs of respiratory distress.
• Nutritional support team involvement is essential — dietitian, physician, and nursing work collaboratively.

Definitions

Section Title

Refeeding Syndrome — Critical Safety Concept

Common Mistakes

• Assuming that because a client is malnourished, feeding them faster is better — SLOWER is safer to prevent refeeding syndrome.
• Monitoring only potassium and missing phosphate — phosphate is the HALLMARK electrolyte and must be specifically ordered and monitored.
• Missing the fluid overload component — clients in refeeding syndrome can also develop edema and pulmonary edema; monitor weight and respiratory status.
• Waiting for symptoms to appear before checking electrolytes — proactive monitoring before and during refeeding is essential.

Exam Tips

• When an NLE question asks about PRIORITY for a client with Anorexia — choose the option that addresses PHYSIOLOGIC/SAFETY needs (electrolytes, cardiac monitoring) before psychological interventions.
• When a question involves BPD and self-harm — SAFETY is always the priority; ensure physical safety before therapeutic communication.
• For pharmacology questions: Fluoxetine → Bulimia (helpful); Bupropion → Eating disorders (CONTRAINDICATED).
• Know RA 11036 key provisions: right to humane treatment, informed consent, confidentiality, access to mental health services, and community-based care.
• Use the NURSING PROCESS framework to structure your answers — Assess, Diagnose, Plan, Implement, Evaluate — and always prioritize using Maslow's hierarchy.

Key Points

• All psychiatric nursing care in the Philippines is guided by the Mental Health Act — Republic Act No. 11036 — which protects patient rights, promotes humane treatment, and supports community-based mental health services.
• RA 9173 (Philippine Nursing Act of 2002) governs nursing practice — nurses must adhere to professional standards, scope of practice, and ethical obligations in all psychiatric settings.
• Nursing Process (ADPIE) applied consistently: Assess (clinical findings, safety risks), Diagnose (NANDA-based), Plan (Maslow-prioritized goals), Implement (evidence-based interventions), Evaluate (response to care).
• Priority nursing diagnoses by Maslow: Physiologic needs first (correct electrolytes, ensure nutrition, manage cardiac complications) → Safety (self-harm, suicide risk in BPD) → Love/belonging (therapeutic relationship) → Esteem (body image, self-worth).
• For ALL personality disorders: Consistent, structured approach; clear firm limits; unified team communication to prevent splitting; promote insight gradually.
• For ALL somatic disorders: Rule out medical cause first; acknowledge symptoms as real; limit secondary gain; teach stress-symptom connection; maintain consistent provider.
• For ALL eating disorders: Medical stabilization first; structured eating plan; meal supervision (during + 1 hour after); consistent weight monitoring; body image work; family therapy for adolescents.
• Fluoxetine is the pharmacologic adjunct for Bulimia; Bupropion is CONTRAINDICATED in all eating disorders.
• DBT is the evidence-based psychotherapy specifically for Borderline Personality Disorder.
• Patient and family teaching is an essential nursing role — educate about the chronic, relapsing nature of these disorders, warning signs, and community mental health resources under RA 11036.

Definitions

Section Title

Nursing Management Summary and Philippine Legal Framework

Common Mistakes

• Skipping the assessment step and jumping to intervention — always ASSESS FIRST, especially safety risks, before intervening.
• Using a punitive or confrontational approach with any personality disorder client — firm and consistent does NOT mean harsh or judgmental.
• Forgetting family education in eating disorder management — family therapy and education significantly improve outcomes, especially in adolescents.
• Ignoring legal and ethical obligations under RA 11036 — patients with mental health conditions have rights that must be respected even in psychiatric settings.
• Not involving the multidisciplinary team — psychiatric nursing requires collaboration with physicians, dietitians, psychologists, social workers, and family.