Psychiatric Nursing Notes for NORCET and Staff Nurse Exams: MSE, Disorders, Drugs and MHCA 2017

These psychiatric nursing notes cover the whole mental health nursing syllabus in an exam-ready format for AIIMS NORCET, staff nurse, nursing officer, CHO and ANM exams. You will find the mental status examination, defence mechanisms, major disorders, psychopharmacology with drug levels and side effects, ECT, therapeutic communication and the Mental Healthcare Act 2017, each written the way questions are actually asked.

Use this page alongside our pharmacology nursing notes for drug classes and the NORCET preparation strategy to plan your revision.

Psychiatric nursing notes: syllabus scope and weightage

Mental health nursing is a steady scorer. In NORCET and most staff nurse papers it contributes a moderate share of questions, mostly short and fact based, with a growing number of clinical scenarios (a patient on lithium has coarse tremors, a patient hears voices).

• Most asked: defence mechanisms, lithium, antipsychotic side effects (EPS, NMS), alcohol withdrawal, therapeutic communication, ECT care.
• Frequently asked: MSE terms, schizophrenia symptoms, OCD, suicide precautions, Mental Healthcare Act 2017.

Mental status examination (MSE)

The MSE is a cross-sectional assessment of the patient’s mental state at the time of interview. Learn the order and the key terms in each part.

Component	What is assessed	Exam terms
General appearance and behaviour	Grooming, eye contact, rapport, psychomotor activity	Psychomotor retardation (depression), agitation, catatonia, waxy flexibility
Speech	Rate, volume, tone, coherence	Pressure of speech (mania), poverty of speech, mutism
Mood and affect	Mood is the sustained subjective emotion; affect is the observed expression	Blunted, flat, labile, inappropriate affect; euphoria
Thought	Form, stream, content, possession	Flight of ideas, loosening of association, thought block, delusions, obsessions, thought insertion
Perception	Sensory experiences	Hallucination (perception without stimulus), illusion (misinterpretation of a real stimulus)
Cognition	Consciousness, orientation, attention, memory, intelligence, abstract thinking	Orientation to time, place, person; serial 7 subtraction; proverb interpretation
Judgement and insight	Ability to make sound decisions; awareness of illness	Insight is graded from complete denial to true emotional insight

Defence mechanisms table

Defence (ego defence) mechanisms are mostly unconscious ways the ego protects itself from anxiety. The concept comes from Sigmund Freud and was expanded by Anna Freud. Repression is considered the primary defence; sublimation is considered the most mature and healthy.

Mechanism	Meaning	Example
Repression	Unconscious exclusion of painful thoughts from awareness	No memory of childhood abuse
Suppression	Conscious, voluntary putting aside of a thought (the only conscious one in this list)	“I will think about my exam result after the wedding”
Denial	Refusing to accept reality	A patient with MI insists it is only gastritis
Projection	Attributing one’s own unacceptable feelings to others	A man who dislikes his boss says “My boss hates me”
Displacement	Transferring emotion to a less threatening target	Scolded at work, shouts at children at home
Rationalisation	Giving logical but false reasons	“I failed because the paper was out of syllabus”
Reaction formation	Behaving opposite to true feelings	Excessive sweetness to a disliked co-worker
Regression	Returning to an earlier developmental level	A hospitalised 6-year-old starts bed-wetting
Sublimation	Channelling unacceptable impulses into socially accepted activity	Aggressive drive channelled into boxing
Conversion	Anxiety expressed as physical symptoms without organic cause	Sudden paralysis before an exam
Undoing	Acting to cancel an unacceptable act	Buying gifts after an argument; common in OCD

Classification: ICD-11 and DSM-5 basics

• ICD is published by the WHO. ICD-10 placed mental disorders in Chapter V (codes F00 to F99). ICD-11 came into effect on 1 January 2022 and places them in Chapter 6, “Mental, behavioural or neurodevelopmental disorders”.
• DSM is published by the American Psychiatric Association. DSM-5 was released in 2013 and the text revision DSM-5-TR in 2022. DSM-5 removed the multiaxial system of DSM-IV.

Schizophrenia

Emil Kraepelin called it “dementia praecox”; Eugen Bleuler coined the term schizophrenia in 1911. The dopamine hypothesis (excess dopamine activity in the mesolimbic pathway) explains positive symptoms.

• Bleuler’s 4 A’s: Autism, Ambivalence, Affect disturbance (flat or inappropriate), Association disturbance (loosening).
• Schneider’s first rank symptoms: audible thoughts, voices arguing or discussing, voices commenting on actions, thought insertion, thought withdrawal, thought broadcasting, delusional perception, somatic passivity and made feelings, impulses or acts.
• Positive symptoms: hallucinations (auditory most common), delusions, disorganised speech and behaviour. Negative symptoms: alogia, avolition, anhedonia, asociality, affective flattening.
• Duration (DSM-5): brief psychotic disorder lasts less than 1 month; schizophreniform disorder 1 to 6 months; schizophrenia requires continuous signs for at least 6 months.

Nursing care: build trust with short, frequent contacts; do not argue about delusions or agree with them; respond to the feeling behind them; for hallucinations, present reality (“I do not hear the voices, but I understand they are real to you”) and check for command hallucinations, which carry a risk of harm. Ensure drug compliance and watch for side effects.

Mood disorders

Condition	Key feature	Minimum duration (DSM-5)
Major depressive episode	Low mood or anhedonia with sleep, appetite, energy changes, guilt, suicidal thoughts	2 weeks
Manic episode	Elevated or irritable mood, grandiosity, decreased need for sleep, pressure of speech, flight of ideas	1 week (any duration if hospitalised)
Hypomanic episode	Milder mania without marked impairment	4 days
Persistent depressive disorder (dysthymia)	Chronic low-grade depression	2 years in adults
Cyclothymia	Fluctuating hypomanic and depressive symptoms	2 years in adults

Nursing in mania: low-stimulus environment, high-calorie finger foods that can be eaten on the move, firm and consistent limits, avoid competitive games, ensure rest. Nursing in depression: suicide assessment first, simple decisions, encourage self-care in small steps, monitor food and sleep.

Anxiety disorders and OCD

• Generalised anxiety disorder: excessive worry on most days for at least 6 months (DSM-5).
• Panic disorder: recurrent unexpected panic attacks peaking within minutes, with palpitations, choking, fear of dying. Stay with the patient, speak in short calm sentences.
• Phobias: agoraphobia (fear of places where escape is difficult), social phobia, specific phobias such as acrophobia (heights), claustrophobia (closed spaces). Treatment of choice is behaviour therapy: systematic desensitisation (Joseph Wolpe) or flooding.
• Obsessive-compulsive disorder: obsessions are recurrent intrusive thoughts; compulsions are repetitive acts (washing, checking, counting) done to reduce anxiety. The patient recognises them as excessive (ego-dystonic). Treatment: SSRIs (fluvoxamine, fluoxetine), clomipramine, and exposure and response prevention.

OCD nursing trap: do not stop rituals abruptly at the start, as anxiety rises sharply. Allow time for rituals, then gradually limit them while offering alternative activities.

Substance use and withdrawal

Alcohol withdrawal stage	Usual onset after last drink
Tremors, anxiety, sweating, tachycardia	6 to 12 hours
Alcoholic hallucinosis	12 to 48 hours
Withdrawal seizures (generalised)	12 to 48 hours
Delirium tremens (confusion, coarse tremor, visual hallucinations, autonomic instability)	48 to 72 hours

• Drugs of choice for withdrawal are benzodiazepines (chlordiazepoxide; lorazepam or oxazepam in liver disease).
• Give thiamine before glucose to prevent Wernicke encephalopathy (confusion, ataxia, ophthalmoplegia). Korsakoff psychosis shows amnesia with confabulation.
• Deterrent and anti-craving drugs: disulfiram (inhibits aldehyde dehydrogenase, causes flushing, vomiting, palpitations with alcohol), naltrexone, acamprosate.
• Opioids: overdose causes pinpoint pupils, respiratory depression and coma; antidote naloxone. Withdrawal causes dilated pupils, lacrimation, rhinorrhoea, yawning, gooseflesh, diarrhoea. Substitution therapy uses methadone or buprenorphine.

Psychopharmacology for nurses

Group	Examples	Key side effects and nursing points
Typical antipsychotics	Chlorpromazine, haloperidol, fluphenazine	Extrapyramidal symptoms, sedation, hypotension; chlorpromazine causes photosensitivity. Depot forms: fluphenazine decanoate, haloperidol decanoate
Atypical antipsychotics	Risperidone, olanzapine, quetiapine, aripiprazole, clozapine	Weight gain and metabolic syndrome; clozapine causes agranulocytosis (regular blood counts), seizures and sialorrhoea, and is reserved for treatment-resistant schizophrenia
SSRIs	Fluoxetine, sertraline, escitalopram	Nausea, sexual dysfunction, insomnia; first-line for depression, OCD, anxiety
TCAs	Imipramine, amitriptyline, clomipramine	Anticholinergic effects (dry mouth, constipation, urinary retention), cardiac toxicity in overdose
MAO inhibitors	Phenelzine, tranylcypromine	Hypertensive crisis with tyramine-rich food (aged cheese, wine, pickled or fermented foods)
Mood stabilisers	Lithium, sodium valproate, carbamazepine	See lithium box below; valproate is hepatotoxic and teratogenic

Antidepressants take about 2 to 4 weeks for full effect. Suicide risk can rise in early treatment as energy returns before mood improves, so observation must continue.

Lithium: the most tested drug

• Therapeutic serum level: about 0.6 to 1.2 mEq/L (maintenance usually 0.6 to 1.0 mEq/L). Levels above 1.5 mEq/L indicate toxicity.
• Keep normal salt and fluid intake (about 2 to 3 litres a day). Low sodium, dehydration, vomiting and diuretics raise lithium levels.
• Side effects: fine tremor, polyuria, polydipsia, weight gain, hypothyroidism; first-trimester use is linked to Ebstein anomaly. Signs of toxicity: coarse tremor, vomiting, diarrhoea, ataxia, slurred speech, confusion.

Extrapyramidal symptoms and emergencies

Side effect	Typical onset	Management
Acute dystonia (torticollis, oculogyric crisis)	Hours to days	Anticholinergic such as promethazine or benztropine injection
Akathisia (motor restlessness)	Days to weeks	Reduce dose, propranolol
Drug-induced parkinsonism	Weeks	Trihexyphenidyl
Tardive dyskinesia (lip smacking, tongue thrusting)	Months to years	Often irreversible; stop or change drug; anticholinergics can worsen it
Neuroleptic malignant syndrome	Any time, often early	Hyperthermia, lead-pipe rigidity, autonomic instability, altered consciousness, raised CPK. Stop the antipsychotic, cool, hydrate, dantrolene or bromocriptine
Serotonin syndrome	Hours after dose change	Agitation, hyperthermia, clonus, hyperreflexia, diarrhoea; usually from combining serotonergic drugs. Stop drug, supportive care, cyproheptadine

Electroconvulsive therapy (ECT)

ECT was introduced by Ugo Cerletti and Lucio Bini in 1938. Today it is given as modified ECT under anaesthesia with a muscle relaxant.

• Indications: severe depression with high suicide risk or refusal of food, catatonia, treatment-resistant depression or mania, some cases of schizophrenia.
• Contraindication: raised intracranial pressure is classically taught as the only absolute contraindication; recent MI and cerebral aneurysm are high-risk.
• Before ECT: informed consent, nil by mouth for about 6 to 8 hours, remove dentures, hairpins and jewellery, empty bladder, record vital signs, atropine or glycopyrrolate as premedication.
• During: short-acting anaesthetic and succinylcholine as muscle relaxant, mouth gag, oxygenation. A course is commonly 6 to 12 sessions given 2 to 3 times a week.
• After: lateral position, monitor airway and vitals, reorient the patient. Common side effects: transient confusion, headache and memory loss.

Therapeutic communication and the nurse-patient relationship

Hildegard Peplau’s interpersonal theory (1952) describes the nurse-patient relationship in phases: orientation, working (identification and exploitation) and resolution or termination. Termination is planned from the orientation phase itself.

Therapeutic techniques	Non-therapeutic responses
Active listening and using silence	False reassurance (“Everything will be fine”)
Broad openings (“What would you like to talk about?”)	Giving advice (“You should leave your job”)
Restating, reflecting, clarifying	Asking “why” questions, which feel accusatory
Focusing and summarising	Approving or disapproving, judging
Offering self (“I will sit with you”)	Changing the subject, belittling feelings
Presenting reality	Agreeing with delusions or arguing with them

In MCQs, the correct option usually focuses on the patient’s feelings and keeps communication open. These principles also appear in the communication chapter of our fundamentals of nursing notes.

Mental Healthcare Act 2017: key points

• Replaced the Mental Health Act 1987 and came into force on 29 May 2018.
• Gives every person the right to access mental healthcare from government-funded services.
• Advance directive: a person can state how they wish to be treated or not treated for a future mental illness. Nominated representative: a person chosen to support treatment decisions.
• Section 115: a person who attempts suicide is presumed to have severe stress unless proved otherwise and shall not be tried and punished; the government must provide care and rehabilitation.
• ECT without anaesthesia and muscle relaxant is prohibited; ECT is not to be used for minors except with guardian consent and permission of the Mental Health Review Board.
• Chaining, solitary confinement and sterilisation as a treatment for mental illness are prohibited.
• Admission types: independent admission, and supported admission (up to 30 days under Section 89, and beyond 30 days under Section 90). Emergency treatment may be given for up to 72 hours.

National programme links (NMHP, District Mental Health Programme and Tele-MANAS) are covered in our national health programmes notes.

Suicide risk assessment and care

• Ask directly about suicidal thoughts and plans. Asking does not put the idea in the patient’s mind.
• Highest-risk signs: a specific plan with access to means, previous attempts, hopelessness, recent loss, substance use, and sudden calmness after severe depression (may mean a decision has been made).
• Care: one-to-one close observation for high risk, remove sharp objects, belts, glass and cords, check that oral medicines are swallowed, place the patient near the nursing station, be extra vigilant at night, weekends and shift changes.
• Tele-MANAS, the national tele mental health helpline, can be reached on 14416.

High-yield points for quick revision

1. Suppression is the only conscious defence mechanism; repression is unconscious.
2. Sublimation is the most mature defence mechanism.
3. The most common hallucination in schizophrenia is auditory; in delirium tremens it is visual.
4. Lithium therapeutic level is about 0.6 to 1.2 mEq/L; toxicity above 1.5 mEq/L.
5. Low salt intake increases the risk of lithium toxicity.
6. Clozapine requires regular blood counts because of agranulocytosis.
7. Tardive dyskinesia is a late and often irreversible side effect of antipsychotics.
8. Dantrolene and bromocriptine are used in neuroleptic malignant syndrome.
9. MAO inhibitors plus tyramine-rich foods cause hypertensive crisis.
10. Delirium tremens usually begins 48 to 72 hours after the last drink.
11. Pinpoint pupils suggest opioid overdose; antidote naloxone.
12. Succinylcholine is the muscle relaxant commonly used in modified ECT.
13. Mental Healthcare Act 2017 came into force on 29 May 2018.
14. Section 115 of MHCA presumes severe stress in a person who attempts suicide.

Practise these facts with timed questions in our NORCET test series or the staff nurse test series, and revise drug actions from the medical-surgical nursing notes where conditions overlap. Concise question banks are listed under our NORCET books.

Frequently asked questions

How many questions come from psychiatric nursing in NORCET?

The official notice does not fix subject-wise question counts. In recent papers psychiatric nursing has contributed a moderate, consistent share, so it should be prepared fully. See the NORCET exam pattern and syllabus for the overall structure.

Which topics in mental health nursing should I revise first?

Start with defence mechanisms, lithium, antipsychotic side effects, alcohol withdrawal, ECT nursing care and therapeutic communication. These are asked repeatedly across NORCET, RRB and state exams.

What is the difference between NMS and serotonin syndrome?

NMS follows antipsychotic use and shows lead-pipe rigidity with slow onset. Serotonin syndrome follows serotonergic drugs and shows clonus and hyperreflexia with rapid onset. Both cause hyperthermia and autonomic instability.

Is the Mental Healthcare Act 2017 asked in staff nurse exams?

Yes. Questions usually test the year of enforcement, decriminalisation of attempted suicide, advance directives, the ECT restrictions and the types of admission.