CASE BASED DISCUSSION

PSYCHOTIC CASE
Supervisor :
dr. Sabar Parluhutan Siregar,
Sp.KJ

PATIENTS
IDENTITY

Name : Mr. WAM

Place of birth : Magelang
Born date : February, 1st 1990
Age : 26 years old
Address : Muntilan
Gender : Male
Religion : Moslem
Ethnic : Java
Status : Single
Occupation : Unemployment
Education : Junior high school

ALLOANAMNESIS

Name
: Mr.N
Age
: 64 years old
Gender
: Male
Address
: Muntilan
Religion
: Moslem
Education
: Elementery School
Occupation
: Farmer
Relation to patient : Father
Intimacy
: Close

PRIMARY PROBLEM
(the reason patient came to mental hospital)

Patient

Stressor
He can not finished his final test in junior
high school
His ustadz always scolded him at his
Islamic school
His brother died

The patient take a control

medication at poliklinik RSJS soerojo
The histories ;
since 6 years ago (2010), when the patient studied at
Islamic school, the kyai as the head of the school said to
patients father that patient had a confusing mind but
he still can do some work in the Islamic school/pesantren.
4 years ago (2012). Before he came to the hospital to
take a control medication, his brother died because an
accident at the pesantren. Since that tragedy, patient
usually cry and made himself alone in his room.
1 month after his brother passed away, patient got
some changing behavior like didnt want to do some
work, laughing and smiling alone

 3 months after the tragedy, the patient have some

changing behavior such as throwing neighbour
house with stone, easily to get angry without
any reasons, see some shadows of buto ijo
and he felt that the buto ijo can take control
of his body, hear a whispers, affraid to people
beause he feel like people want to pursuit him
and hurt him, and he couldnt sleep at night.
Then the patient was taken to psychiatric hospital
that helped from the pesantren, because in that
time patient didnt have a Jamkesmas. The patient
was hospitalized about 3 weeks (8 31 May 2012)
and then back to his home with better condition
than before.

 1 years ago (2015) the patient have changes his

behavior again such as easily get angry without
any reasons, harm the people in his house,
throwed some house furnitures in his house, and
cannot sleep at night.
Patient usually talk and smile to himself, he can
take a bath about 1 hour. Patient feeling so afraid
because he think that someone is pursuit him.
Patient wasnt use his drugs about 3 months,
the patient was hospitalized again by his family at
RSJS Soerojo about 2 months (23 march 15 may
2015) the patient back to home with a better
condition than before. Patient always took controls
medication in RSJS soerojo every 1 month until now.

DESCRIPTION OF ILLNESS

symptoms
Time
2012

Characters
functions

2013

2014

2015

HISTORY OF PAST ILLNESS

He admitted in hospital 2
Psychiatr times (May 2012 and March
ic
2015)
Medical

He has a history of seizure at

the age of 3

Patient did not have history of

Substanc
e abuse
drugs, cigarettes and alcohol

PERSONAL LIFE
Prenatal and Perinatal Period

Patient is the fourth

children of his family

- He has two older sisters

- One older brother

The patient was born at witchs house, and he borned

normally. And his mother said that she never had an accident
or some illness during pregnancy and her delivery, length of
pregnancy, spontaneity and normality of delivery, birth
trauma, whether the patient was planned or wanted.
The patients parents said that he can walk completely at the
There
no valid data
prenatal
mothers
age
of are
18 months,
and about
can talk
at thehistory
age ofand
3 years
old. His
preganancy
and
delivery,
length
of pregnancy,
parents just
said
that he
born
healthy at spontanity,
the hand and
of the
normality of delivery, birth trauma, whether the patient was
witchs,planned
There and
waswanted,
no valid
dataany
about
the condition of
and also
birth defect.
patient when she was born such as activity (muscle tone),
pulse, grimace (reflex irritability), appearance, and respiration
(APGAR score)

Early Childhood (0-3 years

old)

Developmental History (Gross Motoric)

Ability
Elevating the
head
Moving to supine
position on its
own
Sitting
Standing
Walking
Climbing up the
ladder
Standing 1 foot /
jump

Result
Fulfilled

Normal range
0-3 months

Fulfilled

3-6 months

Fulfilled
Fulfilled
Fulfilled
No Valid Data

6-9 months
9-12 months
12-24 months
24-36 bulan

No Valid Data

36-48 bulan

Developmental History (Fine Motoric)

Ability
Holding a pencil
Holding 2 objects at the
same time
Piling 2 cubes
Inserting objects into
container
Rolling a ball
Doodling
Wearing shirt

Result
No Valid
Data
Fulfilled

Normal range
3-6 months

No Valid
Data
Fulfilled

9-12 months

Fulfilled
No Valid
Data
Fulfilled

18-24 months
24-36 months

6-9 months

12-18 months

36-48 months

Developmental History (Language)

Ability

Result

Normal
range

Oooh-aah

Fulfilled

0-3 months

Turning toward the sound

Fulfilled

3-5 months

High-pitched sound

No Valid
Data

3-6 months

Voice without meaning (mamama,

Bababa)

Fulfilled

6-9 months

Calling 2-3 syllables without meaning

No Valid
Data

9-12 months

Calling 3-6 words that have meaning

No Valid
Data

18-24 months

Talking at least with two words

Fulfilled

24-36 months

Mentioning name, age, and place

Fulfilled

36-48 months

Developmental History (Social &

Personal)
Ability

Result

Normal range

Know their mother

Fulfilled

0-3 months

Reach out

Fulfilled

3-6 months

Clap

No Valid Data 6-9 months

Playing peek a boo

No Valid Data 6-9 months

Know their family

Fulfilled

Appoint what he wants

without crying or whining

No Valid Data 12-18

months

Tidy up toys

No Valid Data 24-36

months
fulfilled
36-48
months

Playing with friends, follow

the rules of the game

9-12 months

There is a histories of
Seisures at the age of 3
years old, and it happens
almost hours, it
happened 3 times during
his 3 years old, and his
parents just do nothing
about this seizures attack.

Intermediate Childhood
(3-11 years old)
Psychomotor (NO VALID DATA)
No valid data on when patient first time climbing the tree or
play hide and seek games, and if patient ever involved in any
kind of sports.
Psychosocial
The patients is a cheery boy and he often plays with new
friends on first day of elementary school.
Communication (NO VALID DATA)
The patients is a cheery boy and he often play with friends in
school, but there is no valid data about how many friends
patient have during her schooling period.
Emotion (NO VALID DATA)
No valid data on patient adaptation under stress
Cognitive
the patients didnt graduate 2 times during his 6th years as
elementary school

Sexual Development Sign and Activity (NO VALID

DATA)
No data on when patient first masturbation, growth hair on
armpits, growth pubic hair, etc.
Psychomotor (NO VALID DATA)
No data if patient had any favorite hobbies or games, if patient
involved in any kind of sports.
Psychosocial
the patients never have a relationship with different gender
because his school forbid him to do so, if patient ever had any
feeling with opposite gender, he just kept it in his hearts and
didnt say it to her.
Communication
The patient have a deep relationship with his young brother,
and he always play together with his brother.
Emotion
Patient never told friend or family regarding any of his
problems

Physical
Physically active
Rule of Three: 3 yrs,3
ft, 33 lbs.
Weight gain: 4-5 lbs
per year
Growth: 3-4 inches
per year
Physically active,
cant sit still for long
Clumsy throwing balls
Refines complex
skills: hopping,
jumping, climbing,
running, ride
bigwheels and
tricycles
Improving fine motor
skills and eye-hand
coordination: cut with
scissors, draw shapes
3 3,5 yr: most toilet

Preschool

Cognitive
Ego-centric, illogical, magical thinking
Explosion of vocabulary;
learning syntax, grammar;
understood by 75% of people by age 3
Poor understanding of time,
value, sequence of events
Vivid imaginations; some
difficulty separating fantasy
from reality
Accurate memory, but more
suggestible than older children
Primitive drawing, cant
represent themselves in drawing till
age 4
Dont realize others have
different perspective
Leave out important facts
May misinterpret visual cues of
emotions
Receptive language better
than expressive till age 4

Social
Play:
Cooperative,imaginati
ve, may involve fantasy
and imaginary friends,
takes turns in games
Develops gross and
fine motor skills; social
skills;
experiment with social
roles;reduces fears
Wants to please adults
Development of
conscience:
Incorporates parental
prohibitions; feels guilty
when disobedient;
simplistic idea of
good and bad
behavior
Curious about his and
others bodies, may

Emotional
Self-esteem based on what
others tell him or her
Increasing ability to control
emotions;
less
emotional
outbursts
Increased frustration tolerance
Better delay gratification
Rudimentary sense of self
Understands concepts of right
and wrong
Self-esteem reflects opinions
of significant others
Curious
Self-directed in many activities

Possible effects of maltreatment

Poor muscle tone, motor coordination
Poor pronunciation, incomplete sentences
Cognitive delays; inability to concentrate
Cannot play cooperatively; lack curiosity, absent
imaginative and fantasy play
Social immaturity: unable to share or negotiate
with peers; overly bossy, aggressive, competitive
Attachment problems: overly clingy, superficial
attachments, show little distress or over-react
when
separated from caregiver
Underweight from malnourishment; small stature
Excessively fearful, anxious, night terrors
Reminders of traumatic experience may trigger
severe anxiety, aggression, preoccupation
Lack impulse control, little ability to delay
gratification
Exaggerated response (tantrums, aggression) to
even mild stressors
Poor self esteem, confidence; absence of
initiative
Blame self for abuse, placement
Physical injuries; sickly, untreated illnesses

School Aged
Physical

Cognitive

normal, steady
growth: 3 -4
inches per year
Use physical
activities
to develop gross
and fine motor
skills
Motor &
perceptual
motor skills better
integrated
10-12 yr: puberty
begins for some
children

Use language as a communication

tool
Perspective taking:
5-8 yr: can recognize others
perspectives, cant assume the
role of the other
810 yr: recognize difference
between behavior and intent; age
10-11 yr: can accurately
recognize and consider
others viewpoints
Concrete operations:
Accurate perception of
events; rational, logical
thought; concrete thinking; reflect
upon self and attributes;
understands concepts of space,
time, dimension
Can remember events
from months, or years
earlier
More effective coping skills
Understands how his

Social
Friendships are situation
specific
Understands concepts
of right and wrong
Rules relied upon to
guide behavior and play, and
provide child with structure and
security
5-6 yr: believe rules can
be changed
7-8 yrs: strict adherence
to rules
9-10 yrs: rules can be
negotiated
Begin understanding social roles;
regards them as inflexible; can
adapt behavior to fit different
situations; practices social roles
Takes on more responsibilities at
home
Less fantasy play, more
team sports, board games
Morality: avoid punishment; self

Emotional

Possible effects of maltreatment

Self esteem based on ability to

perform and produce
Alternative strategies for dealing
with frustrationand expressing
emotions
Sensitive to others opinions
about themselves
6-9 yr: have questions about
pregnancy, intercourse10-12 yr:
games with peeing, sexual
activity (e.g., strip poker,
truth/dare, boy-girl relationships)

Poor social/academic adjustment in school: preoccupied,

easily frustrated, emotional outbursts, difficulty
concentrating, can be overly reliant on teachers; academic
challenges are threatening, cause anxiety
Little impulse control, immediate gratification, inadequate
coping skills, anxiety, easily frustrated, may feel out of
control
Extremes of emotions, emotional numbing; older children
may self-medicate to avoid negative emotions
Act out frustration, anger, anxiety with hitting, fighting,
lying, stealing, breaking objects, verbal outbursts,
swearing
Extreme reaction to perceived danger (i.e.,fight, flight,
freeze response)
May be mistrustful of adults, or overly
solicitous,manipulative
May speak in unrealistically glowing terms about his
parents
Difficulties in peer relationships; feel inadequate around
peers; over-controlling
Unable to initiate, participate in, or complete activities,
give up quickly
Attachment problems: may not be able to trust, tests
commitment of foster and adoptive parent with negative

Adolescents
Physical
Growth spurt:
Girls: 11-14 yrs
Boys: 13-17 yrs
Puberty:
Girls: 11-14 yrs
Boys: 12-15 yrs
Youth acclimate to
changes in body

Cognitive
Formal operations: precursors in early
adolescence, more developed in
middle and
late adolescence, as follows:
Think hypothetically: calculate
consequences of thoughts and
actions without experiencing them;
consider a number of possibilities and
plan behavior accordingly
Think logically: identify and reject
hypotheses or possible outcomes
based on logic
Think hypothetically, abstractly,
logically
Think about thought: leads to
introspection and selfanalysis
Insight, perspective taking:
understand and consider others
perspectives, and perspectives of
social systems
Systematic problem solving: can
attack a problem, consider multiple
solutions, plan a course of action
Cognitive development is uneven,

Social
Young (12 14):
Psychologically distance self
from parents;identify
with peer group; social status
largely related to group
membership; social
acceptance depends on
conformity to observable traits
or roles; need to be
independent from all adults;
ambivalent about
sexual relationships, sexual
behavior is exploratory
Middle (15 17):
friendships based
on loyalty, understanding,
trust; self-revelationis first step
towards intimacy; conscious
choices about
adults to trust; respect honesty
& straight for wardness from
adults; may become sexually
active
Morality: golden rule;

Emotional
Psycho-social task is identity
formation
Young adolescents (12-14):
selfconscious about physical
appearance and early or late
development; body image rarely
objective, negatively affected by
physical and sexual abuse;
emotionally labile; may over-react to
parental questions or criticisms;
engage in activities for intense
emotional experience; risky
behavior; blatant rejections of
parental standards; rely on peer
group for support
Middle adolescents (15-17):
examination of others values,
beliefs; forms identity by organizing
perceptions of ones attitudes,
behaviors, values into coherent
whole; identity includes positive
self image comprised of cognitive and
affective components
Additional struggles with identity

Possible effects of maltreatment

All of the problems listed in school age
section
Identity confusion: inability to trust in self to
be a healthy adult; expect to fail; may
appear immobilized and without
Direction
Poor self esteem: pervasive feelings of guilt,
self-criticism, overly rigid expectations for
self, inadequacy
May overcompensate for negative selfesteem
by being narcissistic,
unrealistically self-complimentary;
grandiose expectations for self
May engage in self-defeating, testing, and
aggressive, antisocial, or impulsive
behavior; may withdraw
Lack capacity to manage intense
emotions; may be excessively labile, with
frequent and violent mood swings
May be unable to form or maintain
satisfactory relationships with peers
Emotional disturbances: depression,
anxiety, post traumatic stress disorder,
attachment problems, conduct disorders

Late Childhood (11-18 years

old)
Patient said that he never
had a girlfriend.

His relationship with other

siblings were also good.
The patient never
complained or told his
problem to his family.

Education History
His last formal education was junior high school then
continue to Islamic school

Occupation History
Patient never work before

Law History
Never has any law conflict

Marital History
Patient is still single

Psychosexual History
He dressed well like a man should.

Millitary History
Never include in millitary

Religious
He do his religious activity

Social Activity
Patient rarely sosializes with his neighbor.
Patient rarely do some social work in his neighborhood

Wishes
Patient had no plans

FAMILY HISTORY
There are a psychiatry history in his
family, his brother and uncle had
same symptoms as him

Eriksons Stages of Psychosocial

Development
Stage

Basic Conflict

Important Events

Infancy
(birth to 18 months)

Trust vs mistrust

Feeding

Early childhood
(2-3 years)

Autonomy vs shame and

doubt

Toilet training

Preschool
(3-5 years)

Initiative vs guilt

Exploration

School age
(6-11 years)

Industry vs inferiority

School

Adolescence
(12-18 years)

Identity vs role confusion

Social relationships

Young Adulthood
(19-40 years)

Intimacy vs isolation

Relationship

Middle adulthood
(40-65 years)

Generativity vs
stagnation

Work and parenthood

Maturity
(65- death)

Ego integrity vs despair

Reflection on life

Conclusion: no clear data

GENOGRAM

having mental
disorder
Passed
away

Man
Woma
n

MENTAL STATE (March, 18th

2016 at 11.00am)
Appearance
A male, appropriate to his age, wear complete
clothes, enough self care
State of Consciousness
Clear
Connection
a. Attention easily attained, sustained
concentration (+)
b. Attention easily attained, unable to sustained
concentration (-)
c. Difficulty to attention, unable to sustained
concentration (-)

Speech
Quantity :
- Increase
- Normal (+)
- Decrease
Quality :
- Normal (+)
- Decrease

BEHAVIOUR
Normoactive
Hypoactive(+)
Hyperactive
Echopraxia
Catatonia
Active negativism
Cataplexy
Stereotypy

Mannerism
Automatism
Bizarre
Command
automatism
Mutism
Acathysia
Tic

Psychomotor
agitation
Compulsive
Ataxia
Mimicry
Aggresive
Impulsive

ATTITUDE
Cooperative (+)
Non-cooperative
Indifferent
Apathy
Tension
Dependent

Infantile
Distrust
Labile
Rigid

Passive negativism
Catalepsy
Cerea flexibility
Excitement

Emotion
Mood

Dysphoric
Euthymic (+)
Elevated
Euphoria
Expansive
Irritable
Agitation

Affect

Inappropriate
Restrictive
Blunted
Flat (+)
Labile

Disturbance of Perception
Hallucination

Auditory
Visual
Olfactory
Gustatory
Tactile

(+)
(+)
(-)
(-)
(-)

Depersonalization (-)

Illusion

Auditory
Visual
Olfactory
Gustatory
Tactile

(-)
(-)
(-)
(-)
(-)

Derealisation (-)

Thought Progression
Quantity

Normal
Logorrhea
Talk active
Remming
Blocking
Mutism

Quality
Coherence
(-)
Irrelevant answer
(-)
Incoherence
(-)
Flight of idea
(-)
Confabulasion
(-)
Verbigerasion
(-)
Preservasion
(-)
Poverty of speech (+)
Slow speech
(-)
Loosening of assosiasion (-)
Sound assosiasion
(-)
Circumstantiality
(-)
Tangential
(-)
Neologism
(-)
Word salad
(-)
Echolalia
(-)

Content of thought
Delusion

of Reference

Preoccupation
Obsession
Phobia

Delusion of Grandiose
Delusion of Control(+)
Delusion of Influence
Delusion of Passivity

Delusion of Perception
of Suspicious (+)
Thought of Echo
Delusion of Envious
Thought Insertion
Delusion of Chasing (+)
Delusion

of magic-mystic (-) Thought of withdrawal

Thought Broadcasting
Fantasy
(+)
Delusion

Form of Thought
Realistic
Non Realistic
(+)
Dereistic
Autistic

Sensorium and Cognition

Level of education
: Enough
General knowledge
: Good
Orientation of time/place/people/situation
good/good/good/good
Working/short/long memory:
Good/Good/Good
Concentration
: Good
Writing and reading skills : Good
Ability to self care
: Enough

Impulse Control When

Examined
Self control
: Enough
Patient response to examiners question :
Enough

Insight
Impaired insight (+)
Intellectual Insight
True insight

Conciousness

: Composmentis

Vital sign
Blood pressure : 120/80 mmHg
Pulse rate
: 86 times / minute
Temperature
: 36,30C
RR
: 20 times / minute
Head
(-),

: normocephali, mouth deviation

anemic conjungtiva (-), icteric
sclera(-),pupil isocore (+),

 Neck : normal, no rigidity, no palpable

lymph nodes
Thorax
Cor : S1 S2 regular, murmur -, gallop Lung : vesicular sound +/+, wh -/-, rh-/Abdomen : Flat, abdominal wall//chest
wall, normal peristaltic, tympany sound,
tenderness -, mass -, liver, spleen and
kidney not palpable
Extremity : Warm acral, cappilary refill
<2, edema (-)

NEUROGICAL EXAMINATON

Interpretation :

Interpretati
NORMAL

Cranial Nerves Examination

Interpretation :

Significant Finding Resume

A male, 26 years old, controlled to policlinic
Symptoms

Often angry
without any
causes
Talking with
himself
Irritable
He heard some
whispers that
reigns
He sees shadows
Throw some stuff
in his house
He denied that he
was sick

Physical examination
and Mental status
Affect: flat
Disturbance of
perception:
hallucination
auditoric & visual.
Tought form : non
realistic
Thought content :

bizarre delusion
(Thought
broadcasting),
delusion of
suspicious,
delusion of magic
mystic, delusion of
control

Impairment

Self care :
decrease, he should
be told before doing
the self care
Social interaction :
decrease
Working : lack of
productivity

Syndrome
Flat affect
Bizarre delusion
(thought
broadcasting)
Auditoric & visual
hallucination

Psycosis Syndrome

Suspicious
justification
Hostility, selfish to
personal rights
Tendency to revenge

Paranoid Syndrome

DIFFERENTIAL
DIAGNOSIS
F20.00 Schizophrenia Paranoid
Sustainable
F20.3 Undifferentiated Schizophrenia

MULTIAXIAL DIAGNOSIS

AXIS I

F20.00 Schizophrenia Paranoid Sustainable

AXIS II

Z0.32 There is no diagnosis of axis II

AXIS III

There is no diagnosis of axis III

AXIS IV

Withdrawal drugs
AXIS V

GAF 20-11 (Admission) | GAF 60-51 (Latest)

PLANNING MANAGEMENT

Hospitalization : Harmful to others

as an indication of hospitalization
(throwing some stuff in the house)
Responsive Phase
The target of therapy was 50%
decrease symptoms
Antipsychotic (initial dosage)
Haloperidol inj 5 mg IM / 12 hours
Diazepam inj 5 mg IV / 12 hours
Haloperidol tab 5 mg / 12 hours

 Remission Phase
The target of therapy was 100% remission
of symptoms
Haloperidol tab 5 mg / 12 hours
Recovery Phase
Target
therapy
was
100%
remission of symptoms
The patient must be taking
medication
regularly
and
control to psychiatric
Haloperidol decanoate inj 50 mg/4
weeks

Family education : tell his

family about his problem and
his mental disorder and how to

PROBLEM RELATED TO THE

PATIENT
Problem about patients mental state (psychology)

Patient
Patient
Patient
Patient
Patient

saw shadows
heard some whispered that reigns
sure that he were chased by other who wants to hurt him
sure that his mind were withdrawn from the outside
sure the his mind and body were being controled

Problem about patients biological state (organobiology)

There was not a biological problem

Problem about patients life (social)

Patient rarely sosializes with his neighbor
Patient rarely do some social work in his neighborhood

PROGNOSIS

PREMORB
ID
History of disease in the family
(-): good
Marital status
: bad
Family support
: good
Socio-economic status (less) :
bad
Stressor
(clear)
: bad
Premorbid personality
: bad

MORBID
Type of disease (schizophrenia)
: bad
Course (chronic)
: bad
Organic disease
: good
Treatment response
: good
Adherence to take medication
: bad

Quo ad vitam
: dubia ad bonam
Quo ad sanationam
: dubia ad malam
Quo ad social funtion : dubia ad malam

Gallery