Personality, Somatic, and Eating Disorders - Revision Notes
This chapter covers three major groups of psychiatric disorders frequently tested in the Philippine Nursing Licensure Examination (NLE): Personality Disorders, Somatic Symptom and Related Disorders, and Eating Disorders. Together, they share a common theme — maladaptive patterns of thinking, feeling, and behaving that cause significant distress and impairment. As a Filipino BSN graduate, you must be able to identify clinical presentations, prioritize nursing diagnoses using Maslow's hierarchy, apply the nursing process, and deliver care guided by the Philippine Mental Health Act (Republic Act No. 11036) and your professional standards under RA 9173. Note that eating disorders carry the HIGHEST mortality rate of any psychiatric illness — making early recognition and medical stabilization a top nursing priority.
Personality Disorders — Overview and Clusters
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
Personality Disorder
An enduring, pervasive, inflexible pattern of inner experience and behavior that deviates markedly from cultural expectations, begins by adolescence or early adulthood, and causes clinically significant distress or functional impairment.
Importance
High — NLE frequently asks you to distinguish clusters and identify priority nursing interventions based on the specific disorder.
Ego-Syntonic
The characteristic of personality disorders where the client views their behavior, thoughts, and feelings as natural and consistent with their self-image — they do not perceive themselves as abnormal.
Importance
Explains why clients with personality disorders often resist treatment and lack insight — a key concept for understanding therapeutic challenges.
Splitting
A primitive defense mechanism most characteristic of Borderline Personality Disorder where the client views people and situations as entirely all-good or all-bad, with no middle ground. May cause staff conflict.
Importance
Critical NLE point — recognizing splitting guides the nurse to use a UNIFIED TEAM APPROACH and consistent communication to prevent manipulation.
Dialectical Behavior Therapy (DBT)
A specialized form of cognitive-behavioral therapy developed specifically for Borderline Personality Disorder that teaches distress tolerance, emotion regulation, mindfulness, and interpersonal effectiveness.
Importance
The TREATMENT OF CHOICE for Borderline PD — frequently tested in the NLE.
OCPD vs. OCD
Obsessive-Compulsive Personality Disorder (OCPD) is a personality style characterized by perfectionism, orderliness, and rigidity — NOT the same as OCD (Obsessive-Compulsive Disorder), which involves unwanted intrusive obsessions and compulsions causing distress.
Importance
A classic NLE trap — students confuse OCPD (Cluster C personality disorder) with OCD (anxiety/obsessive-compulsive spectrum disorder). Know the distinction.
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.
Cluster B Deep Dive — Borderline and Antisocial Personality Disorders
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
Fear of Abandonment (BPD)
A central feature of Borderline PD — frantic efforts to avoid real or imagined abandonment, which drives unstable and intense interpersonal relationships.
Importance
Explains the client's extreme reactions to perceived rejection (e.g., a nurse going on day off) — understanding this guides therapeutic communication.
Parasuicidal Behavior
Deliberate self-harm behaviors (e.g., cutting, burning) that may or may not be intended to cause death, commonly seen in Borderline PD. Serves as a maladaptive coping mechanism for emotional pain.
Importance
Critical safety priority — always assess intent and lethality; never dismiss self-harm as 'attention-seeking' without thorough assessment.
Antisocial Personality Disorder
A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 (though diagnosis requires age ≥18), including deceitfulness, manipulation, and lack of remorse.
Importance
Frequently tested — NLE questions often present clients who are charming but manipulative, have legal problems, and show no remorse.
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.
Somatic Symptom and Related Disorders
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
La Belle Indifférence
A striking lack of concern or distress about significant neurological symptoms (e.g., paralysis, blindness) seen in Conversion Disorder — the client seems surprisingly unbothered by their physical deficit.
Importance
High-yield NLE distinguishing feature of Conversion Disorder — if a question describes a client with paralysis who seems calm and unconcerned, think Conversion Disorder.
Secondary Gain
The indirect benefits a client receives from being sick, such as attention, sympathy, avoidance of responsibilities, or financial support. Excessive secondary gain reinforces somatic symptoms.
Importance
Key nursing intervention concept — limiting secondary gain reduces reinforcement of somatic behavior without dismissing the client's experience.
Factitious Disorder
A disorder where symptoms are DELIBERATELY fabricated or induced to assume the sick role — motivated by the psychological need to be a patient, NOT for external reward (unlike malingering).
Importance
Critical distinction: Somatic disorders = unintentional symptoms; Factitious Disorder = deliberate, for sick role; Malingering = deliberate, for external gain. NLE may test this distinction.
Illness Anxiety Disorder
Formerly called Hypochondriasis — characterized by excessive preoccupation with having or acquiring a serious illness, with high health anxiety but minimal or no actual physical symptoms.
Importance
Know the distinction from Somatic Symptom Disorder, which features actual physical symptoms.
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.
Eating Disorders — Anorexia Nervosa and Bulimia Nervosa
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
Anorexia Nervosa
An eating disorder characterized by restriction of energy intake leading to significantly low body weight, an intense fear of gaining weight, and a disturbed body image (perceiving oneself as fat despite being underweight).
Importance
High-yield — know the physical complications: amenorrhea, bradycardia, hypotension, hypothermia, lanugo, electrolyte imbalances, and cardiac arrhythmias.
Lanugo
Fine, soft downy body hair that appears on the body of clients with severe anorexia nervosa — a physiologic response to insulation loss from absence of subcutaneous fat due to starvation.
Importance
A classic NLE physical assessment finding specific to anorexia nervosa — must recognize it as a sign of severe malnutrition.
Bulimia Nervosa
An eating disorder characterized by recurrent episodes of binge eating (consuming a large amount of food in a short time with a sense of loss of control) followed by compensatory behaviors to prevent weight gain.
Importance
Know the distinguishing features: normal weight, Russell's sign, dental erosion, parotid swelling, hypokalemia, metabolic alkalosis — all from repeated purging.
Russell's Sign
Calluses, abrasions, or scarring on the knuckles or dorsum of the hand caused by repeatedly inducing vomiting by inserting the hand into the mouth. Pathognomonic of purging behavior in Bulimia Nervosa.
Importance
A unique, highly testable physical sign of Bulimia Nervosa — if the NLE mentions scarred knuckles, think Bulimia.
Refeeding Syndrome
A potentially fatal metabolic complication that occurs when nutrition is reintroduced TOO RAPIDLY to a severely malnourished client. As the body shifts from catabolism to anabolism, insulin surges drive electrolytes into cells, causing profound hypophosphatemia (the hallmark), hypokalemia, and hypomagnesemia, leading to cardiac arrhythmias, heart failure, respiratory failure, and seizures.
Importance
CRITICAL NLE point — know the cause (too rapid refeeding), the hallmark lab finding (hypophosphatemia), the complications (cardiac/respiratory failure, seizures, death), and the prevention (slow, gradual nutrition reintroduction with close electrolyte monitoring).
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.
Refeeding Syndrome — Critical Safety Concept
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
Hypophosphatemia
Abnormally low serum phosphate level — the HALLMARK electrolyte disturbance of refeeding syndrome. Phosphate is essential for energy production (ATP), and its depletion causes cellular dysfunction across cardiac, respiratory, and neurologic systems.
Importance
The single most important lab value to monitor in refeeding syndrome — if the NLE asks 'Which electrolyte is the priority to monitor during nutritional rehabilitation?', the answer is PHOSPHATE.
Catabolic to Anabolic Shift
The metabolic transition that occurs when a malnourished client begins eating — the body switches from breaking down its own stores (catabolism) to building new tissue (anabolism), triggering insulin release and intracellular shifts of electrolytes.
Importance
Understanding this mechanism explains WHY refeeding is dangerous — it is not the malnutrition itself but the sudden shift when refeeding begins.
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.
Nursing Management Summary and Philippine Legal Framework
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
Republic Act No. 11036 (Philippine Mental Health Act)
The Philippine law that establishes a national mental health policy, protects the rights of persons with mental health conditions, promotes access to mental health services, and mandates community-based, humane, and rights-based mental health care.
Importance
The legal framework for ALL psychiatric nursing care in the Philippines — NLE may test knowledge of patient rights and legal obligations under this act.
RA 9173 (Philippine Nursing Act of 2002)
The law that regulates nursing practice in the Philippines, establishes the scope of nursing practice, sets standards for nursing education, and created the Board of Nursing under the PRC.
Importance
The foundational law governing what nurses are authorized to do — relevant to psychiatric nursing as nurses must practice within their legal scope.
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.
Connections
- Personality Disorders ↔ Therapeutic Communication: Clients with personality disorders challenge therapeutic boundaries — understanding the specific disorder guides the appropriate communication approach (e.g., consistent limits for Cluster B, gradual encouragement for Cluster C).
- Borderline PD ↔ Crisis Intervention: The self-harm and suicidal behavior in BPD connects to crisis intervention nursing — safety assessment and de-escalation skills are directly applicable.
- Eating Disorders ↔ Fluid and Electrolyte Balance (NCM): The physiologic complications of Anorexia and Bulimia (hypokalemia, hypophosphatemia, metabolic alkalosis) directly connect to Medical-Surgical Nursing electrolyte concepts.
- Refeeding Syndrome ↔ Enteral/Parenteral Nutrition Nursing: Refeeding syndrome is a critical complication relevant to any malnourished patient receiving nutritional rehabilitation — connects to critical care and medical-surgical nursing.
- Somatic Disorders ↔ Doctor-Shopping and Philippine Healthcare: In the Philippine context, clients with somatic disorders often overuse primary care and emergency services — community health nurses play a key role in maintaining consistent care and limiting unnecessary consultations.
- Eating Disorders ↔ Adolescent Health (NCM 104): Eating disorders predominantly affect adolescents and young adults — connects to pediatric/adolescent nursing concepts including growth, development, and family-centered care.
- Psychiatric Nursing ↔ RA 11036 and RA 9173: All psychiatric nursing care must be legally grounded — patient rights under the Mental Health Act and nursing scope under the Nursing Act are testable legal frameworks.
- Bulimia ↔ Dental Health: Dental enamel erosion from purging connects to health promotion and community health nursing — oral health assessment is a relevant nursing skill.
- Antisocial PD ↔ Forensic Nursing: Clients with Antisocial PD frequently have legal involvement — connects to forensic nursing concepts in the Philippines.
- Body Image Disturbance ↔ Mental Health Nursing NANDA Diagnoses: Disturbed Body Image is a key NANDA diagnosis applicable to both Anorexia and Bulimia — connects to the broader mental health nursing diagnoses framework.
Quick review questions
A nurse is caring for a client with Borderline Personality Disorder who tells her: 'You are the only nurse who truly cares about me. The other nurses are cruel and don't care at all.' How should the nurse interpret and respond to this statement?
Answer
This behavior represents SPLITTING — a defense mechanism characteristic of BPD where the client sees people as all-good or all-bad. The nurse should acknowledge the client's feelings without agreeing, maintain consistent limits, and immediately communicate with the team to establish a unified care approach.
Splitting is a hallmark of Borderline PD. The correct response involves not playing into the idealization (which reinforces splitting), not confronting the client harshly, but rather using consistent, matter-of-fact communication and ensuring the ENTIRE TEAM communicates and maintains a consistent care plan. A team meeting should be called to address the splitting behavior.
A client with Anorexia Nervosa is admitted and begins nutritional rehabilitation. On Day 2 of enteral feeding, the client develops cardiac arrhythmia. Which electrolyte disturbance is the PRIORITY to assess?
Answer
HYPOPHOSPHATEMIA — the hallmark electrolyte disturbance of Refeeding Syndrome.
Refeeding syndrome occurs when nutrition is reintroduced too rapidly to a malnourished client. The insulin surge from carbohydrate reintroduction drives phosphate, potassium, and magnesium into cells, causing serum levels to drop. Hypophosphatemia is the hallmark and can cause cardiac arrhythmias, respiratory failure, and seizures. Priority monitoring: Phosphate, Potassium, Magnesium.
A client presents with sudden onset of blindness following an extremely stressful event. Neurological examination finds no anatomical cause for the vision loss. Surprisingly, the client appears calm and unconcerned. What disorder should the nurse suspect?
Answer
Conversion Disorder (Functional Neurological Symptom Disorder), characterized by la belle indifférence.
Conversion Disorder presents with neurological symptoms (paralysis, blindness, seizures, aphonia) that are inconsistent with recognized neurological disease. The key diagnostic feature in this question is 'la belle indifférence' — the client's surprising lack of distress or concern about a significant neurological deficit. This is NOT malingering (which is intentional for external gain) and NOT somatic symptom disorder.
A nurse is assessing a college student for an eating disorder. The client appears to be of normal weight. On physical examination, the nurse notes calluses on the knuckles of both hands and dental enamel erosion. What disorder is most likely, and what do these physical findings indicate?
Answer
Bulimia Nervosa. The calluses on the knuckles (Russell's sign) indicate self-induced vomiting. Dental enamel erosion results from repeated exposure to gastric acid from purging.
Bulimia Nervosa clients are typically of NORMAL WEIGHT, which is why the disorder may be missed without thorough physical assessment. Russell's sign (knuckle calluses from self-induced vomiting) and dental erosion are classic purging-related findings. Other signs include parotid gland swelling, hypokalemia, and metabolic alkalosis.
Which medication is the evidence-based pharmacologic treatment adjunct for Bulimia Nervosa, and which medication is CONTRAINDICATED in clients with eating disorders?
Answer
FLUOXETINE (Prozac) is approved for Bulimia Nervosa. BUPROPION is CONTRAINDICATED in all eating disorders.
Fluoxetine (an SSRI) is FDA-approved and used in the Philippines as an adjunct for Bulimia Nervosa to reduce binge-purge cycles. Bupropion is contraindicated in eating disorders — particularly in purging clients — because it significantly lowers the seizure threshold, increasing the risk of seizures in clients who are already electrolyte-depleted from purging.
What is the evidence-based psychotherapy of choice for Borderline Personality Disorder, and what four skill areas does it address?
Answer
Dialectical Behavior Therapy (DBT) is the treatment of choice. It addresses: Distress Tolerance, Emotion Regulation, Mindfulness, and Interpersonal Effectiveness.
DBT was developed specifically for Borderline PD and is highly effective. It teaches clients to tolerate distress without self-harm, regulate intense emotions, be present and mindful, and improve interpersonal relationships. It directly addresses the core deficits of BPD.
A nurse is developing a care plan for a client with Somatic Symptom Disorder who complains of persistent severe abdominal pain with no identified medical cause. Which nursing intervention is MOST appropriate?
Answer
Acknowledge that the symptoms are real to the client, limit secondary gain from the sick role, maintain a consistent primary provider, and gradually help the client connect stress and emotions to physical symptoms. Do NOT dismiss symptoms or say 'it's all in your head.'
In somatic disorders, symptoms are NOT intentional and feel very real to the client. Dismissing them damages trust and the therapeutic relationship. The correct approach: validate without reinforcing, limit secondary gain, redirect to healthy coping, and — over time — gently help the client recognize the stress-symptom connection. Always rule out real medical illness first.
Arrange the following nursing actions in order of priority for a newly admitted client with severe Anorexia Nervosa: (1) Begin body image therapy, (2) Correct electrolyte imbalances, (3) Establish a structured eating plan, (4) Monitor cardiac rhythm.
Answer
Priority order: (2) Correct electrolyte imbalances → (4) Monitor cardiac rhythm → (3) Establish a structured eating plan → (1) Begin body image therapy.
Using Maslow's hierarchy: Physiologic needs FIRST. Electrolyte correction and cardiac monitoring address immediate life-threatening threats (electrolyte imbalances can cause fatal arrhythmias). Once medically stabilized, a structured eating plan is established. Psychological work (body image therapy) comes after the client is medically stable — psychological needs are addressed at higher Maslow levels.
Diagrams
Overview: Personality, Somatic, and Eating Disorders — Chapter Concept Map
A comprehensive mind map showing all three major disorder groups covered in this chapter — Personality Disorders (Clusters A, B, C), Somatic Symptom and Related Disorders, and Eating Disorders — along with their key subtypes, clinical features, and nursing approaches. Use this as a quick visual orientation before studying each section in depth.
Nursing Priority Decision Flowchart for Eating Disorders
A step-by-step clinical decision flowchart for nursing management of clients with eating disorders. Follows Maslow's hierarchy — physical/medical stabilization (electrolytes, cardiac monitoring, refeeding syndrome prevention) is always the priority before psychological interventions. Includes the critical refeeding syndrome recognition and response pathway.
Refeeding Syndrome — Mechanism and Nursing Response
A mechanistic flowchart showing WHY refeeding syndrome occurs (insulin surge from too-rapid carbohydrate reintroduction → intracellular electrolyte shift → hypophosphatemia/hypokalemia/hypomagnesemia → cardiac/respiratory failure) and HOW nursing prevents it (slow refeeding + close electrolyte and cardiac monitoring). This diagram illustrates the critical pathophysiology needed to answer NLE pharmacology and priority questions.
Approach to Splitting in Borderline Personality Disorder
A decision flowchart illustrating the correct vs. incorrect nursing response to splitting behavior in a client with Borderline Personality Disorder. Shows the critical importance of a unified team approach — when all staff respond consistently, splitting behavior loses effectiveness and the therapeutic environment is maintained. Contrasts the correct response with common nursing errors.
Differentiating Somatic and Related Disorders
A diagnostic and nursing decision flowchart to differentiate the four somatic and related disorders. The key branching points are: (1) Is symptom production intentional or not? and (2) What is the primary feature — actual symptoms, illness preoccupation, neurological symptoms, or motivation? Includes the critical nursing approach for each subtype, helping students select the correct NLE answers.
Progression and Management Timeline for Anorexia Nervosa
A clinical management timeline showing the sequenced nursing and medical priorities for a client with Anorexia Nervosa from admission through discharge. Reinforces the Maslow-based principle that physiologic stabilization (electrolytes, cardiac monitoring, safe refeeding) must precede psychological interventions (body image therapy, DBT). Connects to discharge planning under RA 11036.
Exam strategy
For NLE questions on Personality, Somatic, and Eating Disorders, use this structured approach: (1) IDENTIFY the disorder from clinical clues — memorize the hallmark signs for each (e.g., splitting for BPD, Russell's sign for Bulimia, la belle indifférence for Conversion Disorder, lanugo for Anorexia). (2) PRIORITIZE using Maslow — always address physiologic and safety needs first; in eating disorders, correct electrolytes and monitor cardiac status BEFORE starting therapy. (3) SELECT the intervention that is CONSISTENT, STRUCTURED, and NON-CONFRONTATIONAL — avoid punitive, dismissive, or reactive responses. (4) WATCH for pharmacology traps — Fluoxetine = yes for Bulimia; Bupropion = NO for eating disorders; DBT = treatment of choice for BPD. (5) REMEMBER refeeding syndrome — hypophosphatemia is the hallmark; prevent by feeding SLOWLY and monitoring Phosphate-Potassium-Magnesium. (6) APPLY legal knowledge — RA 11036 for patient rights in psychiatric care; RA 9173 for nursing scope and accountability. (7) For any question about a client with BPD who is splitting staff — the answer involves a TEAM MEETING and CONSISTENT UNIFIED APPROACH. Use the nursing process structure (ADPIE) to organize your thinking when questions present clinical scenarios — Assess first, diagnose with NANDA, plan with Maslow priorities, implement evidence-based interventions, then evaluate.