NLE Psychiatric Disorders — Personality, Somatic, and Eating DisordersSummary

A personality disorder is an enduring, pervasive, and inflexible pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture, begins by adolescence or early adulthood, is stable over time, and leads to clinically significant distress or functional impairment. Unlike acute psychiatric episodes, these patterns are deeply ingrained and the client often has limited insight into how their behavior affects others. The etiology involves complex interactions among genetic predisposition, temperament, early attachment relationships, trauma, and learned maladaptive coping strategies. Neurobiologically, research suggests altered neurotransmitter activity (particularly serotonin and dopamine dysregulation) and structural brain differences in regions associated with emotion regulation and impulse control.

Cluster A includes three personality disorders: (1) Paranoid personality disorder—characterized by pervasive distrust and suspiciousness of others' motives, interpreting benign events as threatening, reluctance to confide in others, and bearing grudges; (2) Schizoid personality disorder—marked by detachment from social relationships, restricted emotional expression, indifference to praise or criticism, and a strong preference for solitude, with individuals appearing cold and aloof; and (3) Schizotypal personality disorder—featuring social discomfort and anxiety in social situations, cognitive-perceptual distortions (odd beliefs, magical thinking, ideas of reference), eccentric appearance or behavior, and limited close relationships. These individuals often appear strange or peculiar to others and may have transient psychotic-like symptoms under stress. They typically do NOT seek treatment voluntarily and may only present when legal or family pressures mandate evaluation.

Cluster B comprises four personality disorders characterized by dramatic, emotional, or unpredictable presentation: (1) BORDERLINE PERSONALITY DISORDER (BPD)—the most clinically significant for nursing and NLE purposes—marked by instability in relationships (intense oscillation between idealization and devaluation; 'splitting'), unstable self-image, impulsive and harmful behaviors (substance abuse, binge eating, reckless driving), affective instability (rapid mood shifts), chronic feelings of emptiness, intense fear of abandonment (real or imagined), and recurrent self-harm or suicidal behavior; (2) Antisocial personality disorder—characterized by disregard for and violation of others' rights, deceitfulness and manipulation, impulsivity, irritability, aggression, reckless disregard for safety, consistent irresponsibility (legal/financial/occupational), and markedly diminished remorse; (3) Histrionic personality disorder—excessive emotionality, attention-seeking behavior, suggestibility, provocative behavior, and interpersonal relationships viewed as more intimate than they are; and (4) Narcissistic personality disorder—grandiosity, excessive need for admiration, preoccupation with fantasies of unlimited success or power, belief in being special or unique, interpersonally exploitative, lack of empathy, and envy of others. Of these, BPD and antisocial PD present the greatest nursing challenges and risks.

Cluster C includes three personality disorders centered on anxiety and fearful cognitions: (1) Avoidant personality disorder—characterized by social inhibition, feelings of inadequacy and inferiority, hypersensitivity to rejection and criticism, reluctance to take interpersonal risks, restricted social circle due to fear, and physical avoidance of activities they fear; (2) Dependent personality disorder—excessive need to be taken care of, submissive and clinging behaviors, difficulty making everyday decisions without reassurance, willingness to tolerate mistreatment to maintain relationships, and fear of abandonment or being left alone; and (3) Obsessive-compulsive personality disorder (OCPD)—DISTINCT from OCD—characterized by preoccupation with orderliness, perfectionism, and control at the expense of flexibility and efficiency, difficulty delegating tasks, overdevotedness to productivity/tasks at the expense of relationships, reluctance to discard worn-out objects, rigidity in thinking and ethics, and restricted emotional expression. Clients with Cluster C disorders often present with comorbid anxiety or depressive disorders and are more likely to seek treatment voluntarily because they recognize their distress.

Across all personality disorder clusters, effective nursing care rests on several core principles: (1) CONSISTENCY—all team members (nurses, physicians, therapists, social workers) must follow the same treatment plan and reinforce the same limits to prevent manipulation and splitting; (2) CLEAR BOUNDARIES—limits must be stated explicitly, explained rationally, and enforced consistently without anger or judgment; (3) STRUCTURED ENVIRONMENT—predictable routines reduce anxiety and provide security; (4) AVOIDING RESCUE FANTASIES—nurses must not attempt to 'cure' the disorder or become the special provider who 'truly understands' the client; (5) HOLDING CLIENTS ACCOUNTABLE—without being punitive—for their behavior and its consequences; (6) VALIDATION OF FEELINGS WHILE REDIRECTING BEHAVIOR—acknowledging that the client's emotions are real while setting limits on acting-out; and (7) DOCUMENTATION AND TEAM COMMUNICATION—detailed charting about what happened, nursing response, and client outcome ensures continuity and prevents the client from receiving contradictory messages. For BPD specifically, the approach also includes SAFETY MONITORING (frequent observation, removal of harmful objects, suicide risk assessment), DIALECTICAL BEHAVIOR THERAPY (or similar skills training), and EMOTION REGULATION/DISTRESS TOLERANCE coaching.

Somatic symptom and related disorders form a group where physical symptoms or health concerns dominate the clinical picture, but the symptoms are NOT intentionally produced and are not fully explained by a medical condition. The key distinction from malingering is that the client is NOT consciously faking; the symptoms are REAL to them. The pathophysiology involves complex mind-body interactions: chronic stress and unresolved emotions trigger or amplify physical sensations; learned associations (e.g., a pain that once followed anxiety now triggers anxiety whenever it recurs, creating a cycle); and heightened bodily awareness (hypervigilance to internal sensations). Brain imaging in some somatic disorders shows altered neural processing of pain and interoception (awareness of internal body states). These disorders often develop after significant life stressors, losses, or trauma. Unlike factitious disorder, there is NO conscious deception; unlike malingering, there is NO pursuit of external reward (money, time off work, legal advantage).

Somatic symptom disorder is characterized by one or more distressing physical symptoms that are prominent and persistent (lasting at least 6 months), accompanied by EXCESSIVE thoughts, feelings, and behaviors related to the symptoms. The client devotes disproportionate time and energy to health concerns, constantly researching symptoms, checking their body, visiting multiple physicians (doctor-shopping), or avoiding situations they fear will trigger symptoms. The physical complaints may be specific and localized (chest pain, headache, joint pain) or diffuse (fatigue, multiple body aches). Unlike illness anxiety disorder, clients with SSD have noticeable somatic symptoms; however, the DEGREE of concern is excessive relative to the medical findings. For example, a client with mild reflux may become preoccupied with fears of cancer, undergo extensive investigations, and modify their life significantly. The distress and impairment come not just from the symptom itself but from the client's response to it.

Illness anxiety disorder is characterized by preoccupation with having or acquiring a serious illness, with MINIMAL OR NO somatic symptoms (or only mild symptoms). The client experiences HIGH HEALTH ANXIETY and repeatedly checks their body for signs of illness, seeks reassurance from healthcare providers, or excessively researches diseases online. Unlike somatic symptom disorder, there is no prominent pain or fatigue; instead, the client might have a slightly elevated heart rate or a minor cough and become convinced they have a serious condition. The preoccupation persists despite medical evaluation and reassurance that no serious illness is present. Often, reassurance provides only temporary relief (hours to days) before anxiety resurges. High internet usage and 'medical student syndrome' (reading medical information and applying it to oneself) are risk factors.

Conversion disorder is characterized by neurologic symptoms—such as paralysis, blindness, seizures, aphonia (inability to speak), or numbness—that are INCONSISTENT WITH RECOGNIZED DISEASE and do not follow anatomical pathways. For example, a client might experience 'paralysis' of one leg with intact reflexes and strength when tested indirectly (e.g., strong leg movements in bed), which contradicts true neurological disease. The neurologic examination findings are inconsistent or change with testing. Neuroimaging and electroencephalography are normal. The symptoms usually develop AFTER a significant psychosocial stressor. A striking feature is that clients may display surprising LACK OF CONCERN about what would typically be disabling symptoms—called 'la belle indifférence' (beautiful indifference)—though not all clients show this. The symptoms are NOT intentionally produced (unlike factitious disorder); they are an unconscious expression of psychological conflict or trauma.

Factitious disorder is characterized by the DELIBERATE FALSIFICATION or INDUCTION of symptoms to ASSUME THE SICK ROLE—despite the absence of obvious external incentives (money, time off, legal advantage). Unlike malingering, where the deception is for clear external gain, clients with factitious disorder deceive for the internal reward of being cared for and the identity of 'patient.' They may inject infected material to cause infection, claim false symptoms, alter laboratory results, or manipulate healthcare encounters. Factitious Disorder Imposed on Another (formerly Munchausen syndrome by proxy) involves falsifying or inducing symptoms in another person (typically a child or dependent adult) to gain care and attention—constituting abuse. Clients with factitious disorder often have a history of early abuse, loss, or abandonment, and the sick role becomes an unconscious way to secure attention and belonging.

Eating disorders are severe disturbances in eating behavior and related thoughts and emotions, centered on food intake, body shape, and weight. The two primary types are anorexia nervosa and bulimia nervosa; binge eating disorder is also recognized. These disorders are NOT about vanity or desire to look good; they involve deep issues of control, self-worth, identity, and coping with distress. Epidemiology shows peak onset in adolescence and young adulthood (ages 13–25), with higher prevalence in females, though incidence in males is rising (approximately 10–25% of cases). Risk factors include perfectionism, low self-esteem, family history, cultural emphasis on thinness, history of trauma, and other psychiatric comorbidities (depression, anxiety, obsessive-compulsive disorder, substance use). Eating disorders have the HIGHEST MORTALITY RATE OF ANY PSYCHIATRIC ILLNESS—roughly 5–15% lifetime mortality depending on severity and comorbidities, with death resulting from medical complications (cardiac arrhythmia, electrolyte imbalance, infection from purging) or suicide. Early intervention and comprehensive medical-psychiatric management significantly improve outcomes.

Anorexia nervosa is characterized by THREE KEY FEATURES: (1) Restriction of energy intake leading to SIGNIFICANTLY LOW BODY WEIGHT (typically BMI < 17.5, or below 85% of expected weight for age/height); (2) INTENSE FEAR OF GAINING WEIGHT even while underweight, driven by deep-seated body image distortion; and (3) DISTORTED BODY IMAGE—clients perceive themselves as overweight or fat despite being objectively underweight or even skeletal. Subtypes include: RESTRICTING TYPE (weight loss through dieting and exercise alone) and BINGE-EATING/PURGING TYPE (weight loss through binge eating followed by purging via vomiting or laxative misuse). Clients are often perfectionistic, high-achieving, and controlling. CLINICAL PRESENTATION includes extreme thinness, preoccupation with food and calorie counting, excessive exercise, wearing loose clothing to hide weight loss, social withdrawal, and denying the seriousness of low weight. MEDICAL COMPLICATIONS reflect SEVERE STARVATION: Amenorrhea or irregular menses (from low estrogen due to malnutrition)—a hallmark finding; Bradycardia and hypotension (cardiac adaptation to reduced metabolic demands); Hypothermia (low core body temperature); Dry skin, hair loss, and LANUGO (fine, downy body hair—a primitive reactivation of fetal hair); Electrolyte imbalances (hypokalemia, hyponatremia, hypophosphatemia) leading to cardiac arrhythmias; Osteoporosis and bone density loss (calcium/vitamin D depletion and estrogen deficiency); Dehydration; Constipation and gastrointestinal dysmotility; Cognitive impairment and poor concentration (brain energy deficit); Delayed gastric emptying (refeeding risk factor). LIFE-THREATENING COMPLICATIONS: Sudden cardiac death from electrolyte disturbances or cardiac atrophy; Aspiration pneumonia; Multi-organ failure from severe malnutrition; Suicide (approximately 20% of anorexia deaths are from suicide).

Bulimia nervosa is characterized by TWO DEFINING FEATURES: (1) RECURRENT BINGE EATING (rapid consumption of a large amount of food in a short time, accompanied by a sense of loss of control); and (2) RECURRENT COMPENSATORY BEHAVIORS to prevent weight gain—self-induced vomiting (the most common), misuse of laxatives or diuretics, fasting for extended periods, or excessive exercise. Unlike anorexia, clients with bulimia typically maintain NORMAL WEIGHT or are SLIGHTLY OVERWEIGHT—making the disorder less visually obvious and sometimes delayed in diagnosis. Clients report a loss of control during binges (unable to stop eating) followed by shame and guilt, leading to compensatory purging. The cycle of binge-purge may occur multiple times daily. CLINICAL PRESENTATION includes: visits to the bathroom immediately after meals (to purge), denial of binge eating, evidence of hidden food wrappers, excessive concern about body shape and weight (but less extreme body image distortion than anorexia), and impulsivity in other areas (substance abuse, risky sexual behavior). Unlike anorexia restricters, clients with bulimia often maintain a more normal social facade. MEDICAL COMPLICATIONS (largely from repeated purging): ELECTROLYTE IMBALANCES, especially HYPOKALEMIA (low potassium) and METABOLIC ALKALOSIS (from loss of stomach acid during vomiting)—these are life-threatening as potassium is essential for cardiac function; Dental ENAMEL EROSION and DENTAL CARIES (from stomach acid exposure); RUSSELL'S SIGN (calluses or scarring on the knuckles from teeth scraping during self-induced vomiting—a pathognomonic sign); Parotid gland enlargement (swelling of salivary glands from vomiting); Esophagitis and potential esophageal tears/rupture (rare but life-threatening); Gastric rupture (rare, from large binge eating); CARDIAC ARRHYTHMIAS from electrolyte loss (can cause sudden cardiac death); Dehydration; Gastrointestinal dysmotility and constipation. Bulimia is also associated with depression, anxiety, and PERSONALITY DISORDERS (particularly borderline traits).

Refeeding syndrome is a POTENTIALLY FATAL complication occurring when nutrition is reintroduced TOO RAPIDLY to a severely malnourished client (most relevant in anorexia nervosa but also seen in starvation from other causes). PATHOPHYSIOLOGY: During prolonged starvation, the body shifts to a catabolic (breakdown) state, relying on fat and protein for energy. When feeding resumes, the body suddenly switches to an ANABOLIC (building) state. Insulin surges as carbohydrate intake increases, driving ELECTROLYTES—particularly PHOSPHATE (the hallmark), POTASSIUM, and MAGNESIUM—INTO CELLS for ATP production and anabolic processes. This causes PROFOUND HYPOPHOSPHATEMIA (low blood phosphate), HYPOKALEMIA, and HYPOMAGNESEMIA. CLINICAL PRESENTATION typically emerges within 3–7 days of initiating feeding: Weakness and fatigue (from electrolyte shifts); Cardiac arrhythmias and palpitations (from potassium and phosphate deficiency); Confusion, delirium, or altered consciousness; Respiratory muscle weakness and potential respiratory failure; Seizures (from electrolyte abnormalities); Pulmonary edema and heart failure (from fluid shifts); Hypoglycemia (rebound insulin secretion). COMPLICATIONS: Sudden cardiac death; Rhabdomyolysis (muscle breakdown from phosphate deficiency, worsening renal function); Hemolytic anemia; Infection susceptibility (immune dysfunction). PREVENTION: (1) Reintroduce nutrition SLOWLY—initial calories typically 1000–1200 kcal/day for severely malnourished clients, advancing by 200–300 kcal every 3–5 days per protocol; (2) Monitor ELECTROLYTES closely—baseline phosphate, potassium, magnesium, and calcium; repeat labs every 1–3 days initially, then daily once refeeding begins; (3) Phosphate supplementation is OFTEN NEEDED and is more important than many clinicians realize (IV or oral replacement per protocol); (4) Monitor cardiac rhythm continuously if severe electrolyte depletion; (5) Daily weights (same scale, time, and clothing) to detect fluid shifts; (6) Fluid balance monitoring (intake/output) as fluid shifts can precipitate pulmonary or peripheral edema; (7) Monitor for signs of heart failure or respiratory compromise.

Nursing management of eating disorders follows the NURSING PROCESS and MASLOW'S HIERARCHY, with PHYSIOLOGIC SAFETY as the priority due to life-threatening complications. ASSESSMENT: (1) THOROUGH MEDICAL HISTORY AND PHYSICAL EXAM—vital signs (orthostatic blood pressure, heart rate regularity), weight and height (calculate BMI and compare to healthy range), skin (turgor, temperature, lanugo), hair (texture, loss), teeth (erosion, caries), abdomen (distension, tenderness, bowel sounds), cardiovascular exam (murmurs, S3 gallop, arrhythmias), and neurologic exam (mental status, reflexes). (2) LABORATORY ASSESSMENT—complete metabolic panel (electrolytes, glucose, kidney function, liver function), phosphate, magnesium, calcium, complete blood count (anemia?), albumin/prealbumin (protein status), electrocardiogram (arrhythmia risk), and consider imaging (chest X-ray for aspiration risk, bone density scan for osteoporosis). (3) PSYCHIATRIC ASSESSMENT—body image distortion (ask 'How do you see your body?' and compare to objective appearance), thoughts about food and body (obsessive content?), binge-purge frequency and methods, exercise patterns, suicidal ideation, comorbid depression/anxiety, and insight into illness severity. NURSING DIAGNOSES (NANDA-I aligned with Maslow): Priority 1—Imbalanced Nutrition: Less Than Body Requirements (physiologic need); Risk for Injury related to electrolyte imbalance and refeeding syndrome; Risk for Cardiac Dysrhythmia; Risk for Suicide or Self-Harm (for purging, restrictive behavior). Priority 2—Disturbed Body Image; Chronic Low Self-Esteem. Priority 3—Social Isolation; Ineffective Coping. INTERVENTIONS—STRUCTURED EATING PLAN: (1) ESTABLISH A DEFINED MEAL PLAN with specific calorie intake per protocol (typically 2000–3000 kcal/day for anorexia, individualized based on medical stability and baseline metabolic rate). (2) OBSERVATION DURING AND AFTER MEALS—Assign nursing staff to sit with the client during meals and FOR APPROXIMATELY ONE HOUR AFTERWARD to prevent food hiding, discarding, or (in bulimia) purging. For bulimia, accompany to the bathroom or make bathroom inaccessible during the observation window. Document food consumed. (3) WEIGH CLIENT REGULARLY—same scale, time (usually early morning after voiding), and clothing (hospital gown) for consistency; compare to baseline and expected weight goal; note rapid weight changes (may indicate fluid shifts or hidden loss). (4) MONITOR INTAKE AND OUTPUT—strict I&O to detect fluid imbalances; watch for signs of dehydration or fluid overload (edema, dyspnea). (5) ELECTROLYTE MONITORING—Labs per protocol (typically every 1–3 days initially); report abnormalities immediately; phosphate, potassium, magnesium replacement per provider orders. (6) PREVENT REFEEDING SYNDROME—Caloric advancement SLOW and GRADUAL; educate the medical team if calorie increases are too rapid. (7) NUTRITION EDUCATION—Teach normal eating patterns, balanced nutrition, and the difference between hunger cues and emotional eating (without overwhelming the client early in treatment). BEHAVIORAL APPROACH: (1) USE A MATTER-OF-FACT, NON-PUNITIVE TONE—present the eating plan as medical necessity, not punishment. Avoid power struggles and excessive focus on food itself, which can inadvertently reinforce obsession. (2) AVOID PRAISE FOR EATING—Instead, acknowledge completion neutrally ('You consumed 80% of your meal plan'). Excessive praise can trigger guilt or resistance. (3) SET CLEAR CONSEQUENCES AND REWARDS—Per facility protocol, behavioral contracts may outline privileges contingent on adherence (e.g., access to visitors or outings if nutritional goals are met). (4) AVOID COLLUSION—Do NOT hide food for the client, do NOT allow clients to weigh themselves multiple times daily, do NOT engage in lengthy discussions about calories or body appearance. (5) SUPPORT WITHOUT ENABLING—Validate the client's distress ('I know eating is difficult and scary for you') while firmly maintaining the treatment plan. PSYCHOLOGICAL SUPPORT: (1) BUILD SELF-ESTEEM through highlighting STRENGTHS, not appearance; reinforce identity beyond food/body/weight. (2) TEACH EMOTION REGULATION—Help clients identify emotions and develop alternative coping (journaling, art, progressive muscle relaxation) rather than eating/purging. (3) BODY IMAGE WORK—Gentle reality-testing ('What does the scale and tape measure say about your body? How does that compare to what you see in the mirror?') and exposure to avoided situations (mirrors, fitting clothes) with support. (4) INVOLVE FAMILY—Family therapy, psychoeducation, and skill-building are evidence-based interventions, especially for adolescents; educate family on the seriousness, the need for patience, and warning signs of relapse. PSYCHOPHARMACOLOGY: (1) FLUOXETINE (SSRI) is FDA-approved for bulimia nervosa and helps reduce binge-purge frequency and comorbid depression; used adjunctively with behavioral treatment. (2) BUPROPION (Wellbutrin) is CONTRAINDICATED in eating disorders because it LOWERS THE SEIZURE THRESHOLD, and clients with eating disorders (especially bulimia and those with electrolyte imbalances) are at increased seizure risk. (3) Antipsychotics may be used off-label for severe body image distortion or comorbid psychotic features but are not first-line. (4) No medication replaces behavioral and nutritional intervention. MONITORING FOR RELAPSE: Signs include preoccupation with food/weight, exercise increases, social withdrawal, and weight loss or vomiting resumption; rapid intervention prevents hospitalization.

Nursing management of somatic symptom disorders emphasizes a different approach than eating disorders, as medical emergencies are less likely but the risk of unnecessary testing and reinforcement of sick role is high. ASSESSMENT: (1) COMPLETE MEDICAL HISTORY AND PHYSICAL—Rule out organic causes of symptoms; take the complaint seriously ('Tell me about this pain. When did it start? What makes it better or worse? What do you think is causing it?'). (2) IDENTIFY THE SYMPTOM PATTERN—Symptoms often worsen with stress or emotional triggers; clients may report multiple, diffuse symptoms or focus intensely on one symptom. (3) ASSESS HEALTH ANXIETY LEVEL—How much time does the client spend worried about illness? Do they doctor-shop or research symptoms excessively online? (4) PSYCHIATRIC ASSESSMENT—Comorbid depression, anxiety, or trauma; coping mechanisms; secondary gains (attention, avoidance of responsibilities, excuse for poor performance). (5) PSYCHOSOCIAL STRESSORS—Recent losses, conflicts, changes; history of abuse or neglect (especially in childhood). NURSING DIAGNOSES (NANDA-I): Acute or Chronic Pain (or other somatic symptom) related to psychological factors; Anxiety related to health concerns; Ineffective Coping related to emotional distress; Risk for Complicated Grieving or Traumatic Stress (if recent loss or trauma precipitated onset). INTERVENTIONS: (1) RULE OUT MEDICAL CAUSES—Perform thorough initial assessment; coordinate with providers to complete necessary investigations (labs, imaging) ONCE; avoid repeatedly testing the same complaint, which reinforces health anxiety. Establish in the chart that organic causes have been ruled out, reducing staff tendency to investigate repeatedly. (2) ACKNOWLEDGE SYMPTOMS WITHOUT COLLUDING—'I believe you are experiencing pain/fatigue. Your symptom is real to you.' AVOID saying 'It's all in your head' or 'There's nothing wrong with you,' which invalidates and damages trust. Also AVOID excessive reassurance ('Don't worry, you definitely don't have cancer'), which provides temporary relief but then anxiety resurges because the reassurance is sought repeatedly. (3) FOCUS ON FUNCTION, NOT SYMPTOMS—Instead of 'How is your pain?' ask 'What activities did you do today?' or 'Are you able to go for a walk?' Redirect attention from the symptom to capability and activity. (4) ESTABLISH ONE CONSISTENT PRIMARY CARE PROVIDER—Reduces fragmented care, repeated tests, and the client's ability to doctor-shop or play providers against one another. A continuity relationship allows gradual exploration of stressors. (5) SCHEDULE REGULAR, BRIEF VISITS—For example, every Tuesday at 2 PM, a 15-minute appointment with the nurse or provider, regardless of symptoms. This removes the incentive to exaggerate symptoms to 'earn' an appointment and provides consistent, predictable contact. (6) TEACH THE MIND-BODY CONNECTION—Over time, gently link symptom increases to stressful events: 'I notice your stomach pain flares when you're worried about work. Does that match your experience?' Avoid forcing this connection early; allow the client to discover it. (7) REDIRECT TO COPING AND STRESS MANAGEMENT—Teach relaxation techniques (progressive muscle relaxation, deep breathing), exercise (even gentle walking), sleep hygiene, and meaningful activities. Help the client identify and address life stressors (relationship conflict, occupational stress, grief). (8) LIMIT SECONDARY GAINS—While sympathetic, avoid reinforcing the sick role. For example, if the client avoids all work/social activities due to symptoms, gently encourage incremental participation: 'I think a short walk might actually help your energy. How about we start with 5 minutes today?' (9) INVOLVE FAMILY EDUCATION—Teach family NOT to excessively focus on the symptom, NOT to reinforce disability ('No, you're too sick to attend that event'), and NOT to engage in repetitive reassurance-seeking. Encourage normal expectations and emotional support. (10) PSYCHOTHERAPY—Cognitive-behavioral therapy (CBT) and mindfulness-based approaches are evidence-based; referral to psychology/psychiatry is essential for underlying depression, anxiety, trauma, or unresolved grief. AVOID PSYCHOPHARMACOLOGY as first-line (though SSRIs for comorbid depression/anxiety are appropriate). The goal is RESTORATION OF FUNCTION, not symptom elimination, and recognition that emotions and life experiences are valid and addressable.